Defining Optimal Aerobic Exercise Parameters to Affect Complex Motor and Cognitive Outcomes after Stroke: A Systematic Review and Synthesis

Although poststroke aerobic exercise (AE) increases markers of neuroplasticity and protects perilesional tissue, the degree to which it enhances complex motor or cognitive outcomes is unknown. Previous research suggests that timing and dosage of exercise may be important. We synthesized data from clinical and animal studies in order to determine optimal AE training parameters and recovery outcomes for future research. Using predefined criteria, we included clinical trials of stroke of any type or duration and animal studies employing any established models of stroke. Of the 5,259 titles returned, 52 articles met our criteria, measuring the effects of AE on balance, lower extremity coordination, upper limb motor skills, learning, processing speed, memory, and executive function. We found that early-initiated low-to-moderate intensity AE improved locomotor coordination in rodents. In clinical trials, AE improved balance and lower limb coordination irrespective of intervention modality or parameter. In contrast, fine upper limb recovery was relatively resistant to AE. In terms of cognitive outcomes, poststroke AE in animals improved memory and learning, except when training was too intense. However, in clinical trials, combined training protocols more consistently improved cognition. We noted a paucity of studies examining the benefits of AE on recovery beyond cessation of the intervention

Translingual neurostimulation combined with physical therapy to improve walking and balance in multiple sclerosis (NeuroMSTraLS): Study protocol for a randomized controlled trial

INTRODUCTION: Physical rehabilitation restores lost function and promotes brain plasticity in people with Multiple Sclerosis (MS). Research groups worldwide are testing the therapeutic effects of combining non-invasive neuromodulation with physical therapy (PT) to further improve functional outcomes in neurological disorders but with mixed results. Whether such devices enhance function is not clear. We present the rationale and study design for a randomized controlled trial evaluating if there is additional benefit to the synergistic pairing of translingual neurostimulation (TLNS) with PT to improve walking and balance in MS. METHODS AND ANALYSIS: A parallel group [PT + TLNS or PT + Sham], quadruple-blinded, randomized controlled trial. Participants (N = 52) with gait and balance deficits due to relapsing-remitting or progressive MS, who are between 18 and 70 years of age, will be recruited through patient registries in Newfoundland & Labrador and Saskatchewan, Canada. All participants will receive 14 weeks of PT while wearing either a TLNS or sham device. Dynamic Gait Index is the primary outcome. Secondary outcomes include fast walking speed, subjective ratings of fatigue, MS impact, and quality of life. Outcomes are assessed at baseline (Pre), after 14 weeks of therapy (Post), and 26 weeks (Follow Up). We employ multiple methods to ensure treatment fidelity including activity and device use monitoring. Primary and secondary outcomes will be analyzed using linear mixed-effect models. We will control for baseline score and site to test the effects of Time (Post vs. Follow-Up), Group and the Group x Time interaction as fixed effects. A random intercept of participant will account for the repeated measures in the Time variable. Participants must complete the Post testing to be included in the analysis. ETHICS AND DISSEMINATION: The Human Research Ethics Boards in Newfoundland & Labrador (HREB#2021.085) & Saskatchewan (HREB Bio 2578) approved the protocol. Dissemination avenues include peer-reviewed journals, conferences and patient-oriented communications

The MoxFo initiative-Mechanisms of action: Biomarkers in multiple sclerosis exercise studies

background: as exercise exerts neurobiological and immunomodulatory effects, it might also act as a disease-modifying intervention in MS. however, a clear mechanistic link between exercise and disease-modifying effects in MS has yet to be established.objective: establish recommendations for future mechanistic exercise studies in MS.Methods: In regular meetings, members of the mechanisms of action group within the MoXFo (Moving eXercise research Forward in MS) initiative evaluated gaps of knowledge and discussed unmet needs in mechanistic MS research.results: we concluded that biomarkers assessed in translational studies in humans and animals are essential to decipher the underlying mechanisms of exercise in MS. consequently, we defined clear definitions of different types of biomarkers examined in MS exercise studies and operationalized their use to align with the research question and optimal testing time points. Furthermore, we provide key considerations to improve the rigor of translational studies and defined minimal reporting criteria for animal studies.conclusion: the resulting recommendations are intended to improve the quality of future mechanistic exercise studies in MS and consequently lead to a better understanding of therapeutic approaches

Exercise-Based Stroke Rehabilitation: Clinical Considerations Following the COVID-19 Pandemic

Background. The COVID-19 pandemic attributable to the severe acute respiratory syndrome virus (SARS-CoV-2) has had a significant and continuing impact across all areas of healthcare including stroke. Individuals post-stroke are at high risk for infection, disease severity, and mortality after COVID-19 infection. Exercise stroke rehabilitation programs remain critical for individuals recovering from stroke to mitigate risk factors and morbidity associated with the potential long-term consequences of COVID-19. There is currently no exercise rehabilitation guidance for people post-stroke with a history of COVID-19 infection. Purpose. To (1) review the multi-system pathophysiology of COVID-19 related to stroke and exercise; (2) discuss the multi-system benefits of exercise for individuals post-stroke with suspected or confirmed COVID-19 infection; and (3) provide clinical considerations related to COVID-19 for exercise during stroke rehabilitation. This article is intended for healthcare professionals involved in the implementation of exercise rehabilitation for individuals post-stroke who have suspected or confirmed COVID-19 infection and non-infected individuals who want to receive safe exercise rehabilitation. Results. Our clinical considerations integrate pre-COVID-19 stroke (n = 2) and COVID-19 exercise guidelines for non-stroke populations (athletic [n = 6], pulmonary [n = 1], cardiac [n = 2]), COVID-19 pathophysiology literature, considerations of stroke rehabilitation practices, and exercise physiology principles. A clinical decision-making tool for COVID-19 screening and eligibility for stroke exercise rehabilitation is provided, along with key subjective and physiological measures to guide exercise prescription. Conclusion. We propose that this framework promotes safe exercise programming within stroke rehabilitation for COVID-19 and future infectious disease outbreaks

A Bout of High Intensity Interval Training Lengthened Nerve Conduction Latency to the Non-exercised Affected Limb in Chronic Stroke

Objective: Evaluate intensity-dependent effects of a single bout of high intensity interval training (HIIT) compared to moderate intensity constant-load exercise (MICE) on corticospinal excitability (CSE) and effects on upper limb performance in chronic stroke.Design: Randomized cross-over trial.Setting: Research laboratory in a tertiary rehabilitation hospital.Participants: Convenience sample of 12 chronic stroke survivors.Outcome measures: Bilateral CSE measures of intracortical inhibition and facilitation, motor thresholds, and motor evoked potential (MEP) latency using transcranial magnetic stimulation. Upper limb functional measures of dexterity (Box and Blocks Test) and strength (pinch and grip strength).Results: Twelve (10 males; 62.50 ± 9.0 years old) chronic stroke (26.70 ± 23.0 months) survivors with moderate level of residual impairment participated. MEP latency from the ipsilesional hemisphere was lengthened after HIIT (pre: 24.27 ± 1.8 ms, and post: 25.04 ± 1.8 ms, p = 0.01) but not MICE (pre: 25.49 ± 1.10 ms, and post: 25.28 ± 1.0 ms, p = 0.44). There were no significant changes in motor thresholds, intracortical inhibition or facilitation. Pinch strength of the affected hand decreased after MICE (pre: 8.96 ± 1.9 kg vs. post: 8.40 ± 2.0 kg, p = 0.02) but not after HIIT (pre: 8.83 ± 2.0 kg vs. post: 8.65 ± 2.2 kg, p = 0.29). Regardless of type of aerobic exercise, higher total energy expenditure was associated with greater increases in pinch strength in the affected hand after exercise (R2 = 0.31, p = 0.04) and decreases in pinch strength of the less affected hand (R2 = 0.26 p = 0.02).Conclusion: A single bout of HIIT resulted in lengthened nerve conduction latency in the affected hand that was not engaged in the exercise. Longer latency could be related to the cross-over effects of fatiguing exercise or to reduced hand spasticity. Somewhat counterintuitively, pinch strength of the affected hand decreased after MICE but not HIIT. Regardless of the structure of exercise, higher energy expended was associated with pinch strength gains in the affected hand and strength losses in the less affected hand. Since aerobic exercise has acute effects on MEP latency and hand strength, it could be paired with upper limb training to potentiate beneficial effects

Conditions and strategies influencing sustainability of a community-based exercise program incorporating a healthcare-community partnership for people with balance and mobility limitations in Canada: A collective case study of the Together in Movement and Exercise (TIME™) program

BackgroundCommunity-based exercise programs delivered through healthcare-community partnerships (CBEP-HCPs) are beneficial to individuals with balance and mobility limitations. For the community to benefit, however, these programs must be sustained over time.PurposeTo identify conditions influencing the sustainability of CBEP-HCPs for people with balance and mobility limitations and strategies used to promote sustainability based on experiences of program providers, exercise participants, and caregivers.MethodsUsing a qualitative collective case study design, we invited stakeholders (program providers, exercise participants, and caregivers) from sites that had been running a CBEP-HCP for people with balance and mobility limitations for ≥4 years; and sites where the CBEP-HCP had been discontinued, to participate. We used two sustainability models to inform development of interview guides and data analysis. Qualitative data from each site were integrated using a narrative approach to foster deeper understanding of within-organization experiences.ResultsTwenty-nine individuals from 4 sustained and 4 discontinued sites in Ontario (n = 6) and British Columbia (n = 2), Canada, participated. Sites with sustained programs were characterized by conditions such as need for the program in the community, presence of secure funding or cost recovery mechanisms, presence of community partners, availability of experienced and motivated instructors, and the capacity to allocate resources towards program marketing and participant recruitment. For sites where programs discontinued, diminished participation and/or enrollment and an inability to allocate sufficient financial, human, and logistical resources towards the program affected program continuity. Participants from discontinued sites also identified issues such as staff with low motivation and limited experience, and presence of competing programs within the organization or the community. Staff associated the absence of referral pathways, insufficient community awareness of the program, and the inability to recover program cost due to poor participation, with program discontinuation.ConclusionSustainability of CBEP-HCPs for people with balance and mobility limitations is influenced by conditions that exist during program implementation and delivery, including the need for the program in the community, and organization and community capacity to bear the program's financial and resource requirements. Complex interactions among these factors, in addition to strategies employed by program staff to promote sustainability, influence program sustainability

Rehabilitation Gaps and Needs Assessment, Eastern Health

Rehabilitation is aimed at enabling people disabled by injury or disease to obtain their optimal physical, intellectual, psychological and social functioning. It requires an integrated team of health professionals using a bio-psycho-social model of health across the continuum of care. An aging population, emphasis on chronic disease management, and the move towards community living for people with disabilities requires the re-evaluation of rehabilitation services. The purpose of the Rehabilitation Gaps and Needs Assessment was to outline existing rehabilitation services, identify areas to improve care, and to provide the foundation for a strategic plan for rehabilitation within Eastern Health. Due to the tertiary role of Eastern Health, provincial input was sought and some recommendations made for other health authorities that would help improve services throughout the province. -- Primary data was gathered from patients, families, managers, administrators, and rehabilitation providers using surveys, focus groups and key informant interviews. Secondary data was analyzed from provincial and regional health indicators and databases, previously completed human resources and rehabilitation reports, and rehabilitation reports from other provinces. The research process and results were directed by community stakeholders, managers and other experts in the field. -- The results showed that, other than the physical facilities, existing inpatient and outpatient services at the L.A. Miller Centre were adequate overall. The greatest need identified was community-based rehabilitation; rehabilitation in homes, long term care facilities and personal care homes. Findings suggested that there is a need for inpatient restorative care for the elderly, for community-based management programs for people with chronic disease (cardiac, pulmonary, arthritis, obesity, etc.) and for vocational and cognitive rehabilitation for people with brain injury. Access to rehabilitation is polarized along rural and urban lines with rural areas having very limited access to inpatient, outpatient and community rehabilitation. We found that for people with rehabilitation needs, over half were readmitted to hospital within a year. There were 19,418 alternate level of care days for rehabilitation patients in 2005-2006. Gaps in rehabilitative care cause impairment in patient flow through the system and ultimately limit the person’s ability to live independently at home. These substantial improvements in rehabilitation services would require an action plan over a period of 5-6 years. -- There are ways to improve recruitment and retention of rehabilitation providers, including therapists, nurses and physical medicine and rehabilitation specialists across the province. There are also methods such as reducing clerical duties and improving health record and patient information technology that have the potential to improve efficiency. -- We found that gaps in the system can be improved through enhanced communication, patient navigation and development of a coordinated provincial rehabilitation network. Admission criteria designed to identify the most appropriate patients for a service, especially at the L.A. Miller Centre, causes confusion for health providers, patients and families and ultimately creates gaps. It is essential that we avoid a silo approach to care and ensure that patients and their families find the most appropriate rehabilitation service for them

An examination of constraint-induced therapy as a method to intensify intervention and improve functional outcome during the rehabilitation phase of stroke

Studies have shown that constraint-induced therapy (CIT) improves recovery of the impaired upper extremity and influences neuroplastic changes in the recovering brain, primarily in chronic stroke populations and when paired with six hours of additional therapy per day. A protocol of mitten constraint was developed in which subjects, during the rehabilitation phase of stroke, wore a mitten on the sound hand rather than a sling and splint as used previously, gradually increasing wearing time, without hours of additional therapy. The purpose of this exploratory study was to evaluate the effectiveness of this constraint protocol and compliance to the treatment. Subjects were randomly assigned to CIT plus conventional therapy or conventional therapy only. Upper extremity, lower extremity and trunk motor control and strength were evaluated along with shoulder pain, compliance and level of dependence on caregivers. CIT appeared to significantly improve recovery of postural control and augmented recovery of the impaired upper extremity. The constraint protocol was most effective in male subjects and subjects with left hemiplegia. Compliance varied according to level of disability on admission but was not related to overall recovery. CIT did not induce increased dependence on caregivers and was not associated with adverse events however there was a trend toward increased hemiplegic shoulder pain in some subgroups that was associated with poorer outcome. It was concluded that this constraint protocol was a clinically relevant and practical method to apply CIT in the acute rehabilitation setting

Building an Evidence-Based Framework for the Development of a Newfoundland and Labrador Centre on Aging

Life expectancies are increasing and populations are aging in all western industrialized countries. Given the demographics, the health and well-being of older adults and the provision of services for seniors are major priorities for all levels of government and will become increasingly so. Newfoundland and Labrador (NL) has one of the highest proportions (13.9%) of seniors of any province and that percentage is expected to increase to 20% by 2017 (Provincial Healthy Aging Policy Framework, 2007). Statistics Canada has recently projected that by 2031, NL will have the highest proportion of older adults in Canada. The Government of Newfoundland and Labrador has acknowledged the need to address the challenges of an aging population in the Healthy Aging Policy Framework. There are approximately 18 Canadian research centres involved in the study of aging. The only province without a centre dedicated to the study of aging is NL1. The establishment of a NL Centre on Aging would be an important development given the demographics and the unique circumstances of the province and its people. A NL Centre on Aging would facilitate aging-related research and education, thereby assisting the government of NL in achieving the goals of the Healthy Aging Policy Framework. The present document describes a qualitative descriptive investigation funded by the Healthy Aging Research Program (HARP) of the NL Centre for Applied Health Research (NLCAHR) and by the Grenfell Campus of Memorial University