TMS-Induced Central Motor Conduction Time at the Non-Infarcted Hemisphere Is Associated with Spontaneous Motor Recovery of the Paretic Upper Limb after Severe Stroke

Background: Stroke affects the neuronal networks of the non-infarcted hemisphere. The central motor conduction time (CMCT) induced by transcranial magnetic stimulation (TMS) could be used to determine the conduction time of the corticospinal tract of the non-infarcted hemisphere after a stroke. Objectives: Our primary aim was to demonstrate the existence of prolonged CMCT in the non-infarcted hemisphere, measured within the first 48 h when compared to normative data, and secondly, if the severity of motor impairment of the affected upper limb was significantly associated with prolonged CMCTs in the non-infarcted hemisphere when measured within the first 2 weeks post stroke. Methods: CMCT in the non-infarcted hemisphere was measured in 50 patients within 48 h and at 11 days after a first-ever ischemic stroke. Patients lacking significant spontaneous motor recovery, so-called non-recoverers, were defined as those who started below 18 points on the FM-UE and showed less than 6 points (10%) improvement within 6 months. Results: CMCT in the non-infarcted hemisphere was prolonged in 30/50 (60%) patients within 48 h and still in 24/49 (49%) patients at 11 days. Sustained prolonged CMCT in the non-infarcted hemisphere was significantly more frequent in non-recoverers following FM-UE. Conclusions: The current study suggests that CMCT in the non-infarcted hemisphere is significantly prolonged in 60% of severely affected, is-chemic stroke patients when measured within the first 48 h post stroke. The likelihood of CMCT is significantly higher in non-recoverers when compared to those that show spontaneous motor recovery early post stroke

EVIDENCE FOR PEER SUPPORT IN REHABILITATION FOR INDIVIDUALS WITH ACQUIRED BRAIN INJURY: A SYSTEMATIC REVIEW

Objective: To systematically review the literature on evidence for the application of peer support in the rehabilitation of persons with acquired brain injury. Data sources: PubMed, Embase.com, Ebsco/Cinahl, Ebsco/PsycInfo and Wiley/Cochrane Library were searched from inception up to 19 June 2015. Study selection: Randomized controlled trials were included describing participants with acquired brain injury in a rehabilitation setting and peer supporters who were specifically assigned to this role. Data extraction: Two independent reviewers assessed metho-dological quality using the PEDro scale. Cohen’s kappa was calculated to assess agreement between the reviewers. Data synthesis: Two randomized controlled trials could be included, both focussing on patients with traumatic brain injury. The randomized controlled trials included a total of 126 participants with traumatic brain injury and 62 care-givers and suggest a positive influence of peer support for traumatic brain injury survivors and their caregivers in areas of social support, coping, behavioural control and physical quality of life. Conclusion: The evidence for peer support is limited and restricted to traumatic brain injury. Randomized controlled trials on peer support for patients with other causes of acquired brain injury are lacking. It is important to gain more insight into the effects of peer support and the influence of patient and peer characteristics and the intervention protocol

Is Recovery of Somatosensory Impairment Conditional for Upper-Limb Motor Recovery Early After Stroke?

Background. Spontaneous recovery early after stroke is most evident during a time-sensitive window of heightened neuroplasticity, known as spontaneous neurobiological recovery. It is unknown whether poststroke upper-limb motor and somatosensory impairment both reflect spontaneous neurobiological recovery or if somatosensory impairment and/or recovery influences motor recovery. Methods. Motor (Fugl-Meyer upper-extremity [FM-UE]) and somatosensory impairments (Erasmus modification of the Nottingham Sensory Assessment [EmNSA-UE]) were measured in 215 patients within 3 weeks and at 5, 12, and 26 weeks after a first-ever ischemic stroke. The longitudinal association between FM-UE and EmNSA-UE was examined in patients with motor and somatosensory impairments (FM-UE ≤ 60 and EmNSA-UE ≤ 37) at baseline. Results. A total of 94 patients were included in the longitudinal analysis. EmNSA-UE increased significantly up to 12 weeks poststroke. The longitudinal association between motor and somatosensory impairment disappeared when correcting for progress of time and was not significantly different for patients with severe baseline somatosensory impairment. Patients with a FM-UE score ≥18 at 26 weeks (n = 55) showed a significant positive association between motor and somatosensory impairments, irrespective of progress of time. Conclusions. Progress of time, as a reflection of spontaneous neurobiological recovery, is an important factor that drives recovery of upper-limb motor as well as somatosensory impairments in the first 12 weeks poststroke. Severe somatosensory impairment at baseline does not directly compromise motor recovery. The study rather suggests that spontaneous recovery of somatosensory impairment is a prerequisite for full motor recovery of the upper paretic limb

Moving stroke rehabilitation forward: The need to change research

BACKGROUND: Stroke rehabilitation aims to reduce impairments and promote activity and participation among patients. A major challenge for stroke rehabilitation research is to develop interventions that can reduce patients' neurological impairments. Until now, there has been no breakthrough in this research field. To move stroke rehabilitation forward, we need more knowledge about underlying mechanisms that drive spontaneous (i.e., reactive) neurobiological recovery after stroke and factors that can be used to optimize its prediction early after stroke onset. OBJECTIVE: The aim of the present invited review was therefore to elaborate on the time window of reactive neurobiological recovery, the proportional recovery rule and its generalizability to other neurological impairments, as well as to discuss the consequences for designing stroke recovery and rehabilitation trials. METHODS: In this narrative review, we offer suggestions to optimize the research designs of future stroke rehabilitation and recovery trials post stroke, in order to overcome the current prognostic heterogeneity introduced by variations in the potential for reactive neurobiological recovery. FINDINGS AND CONCLUSIONS: There is an urgent need for high-quality, explanatory trials in the first three months post stroke. These trials should preferably stratify patients based on their initial potential for reactive neurobiological recovery, measure recovery repeatedly at fixed times post stroke, and differentiate in their outcomes between behavioural restitution and compensation of functions

Comparison of self-reported vs observational clinical measures of improvement in upper limb capacity in patients after stroke

Objective: Recovery of the paretic arm post-stroke can be assessed using observational and self-reported measures. The aim of this study was to determine whether the correspondence (match) or non-correspondence (mismatch) between observational and self-reported improvements in upper limb capacity are significantly different at 0-3 months compared with 3-6 months post-stroke. Methods: A total of 159 patients with ischaemic stroke with upper limb paresis were included in the study. Recovery of arm capacity was measured with observational (Action Research Arm Test; ARAT) and self-reported measures (Motor Activity Log Quality of Movement; MAL-QOM and Stroke Impact Scale Hand; SIS-Hand) at 0-3 and 3-6 months post-stroke. The proportion of matches was defined (contingency tables and Fisher's exact test) and compared across the different time-windows using McNemar's test. Results: The proportion of matches was not significantly different at 0-3 months compared with 3-6 months post-stroke for the ARAT vs MAL-QOM and SIS-Hand (all p > 0.05). In case of mismatches, patients' self-reports were more often pessimistic (86%) in the first 3 months post-stroke compared with the subsequent 3 months (39%). Conclusion: The match between observational and self-reported measures of upper limb capacity is not dependent on the timing of assessment post-stroke. Assessment of both observational and self-reported measures may help to recognize possible over- or under-estimation of improvement in upper limb capacity post-stroke

Caregiver-mediated exercises with e-health support for early supported discharge after stroke (CARE4STROKE): A randomized controlled trial.

Background and purposeWe designed an 8-week caregiver-mediated exercise program with e-health support after stroke (CARE4STROKE) in addition to usual care with the aim to improve functional outcome and to facilitate early supported discharge by increasing the intensity of task specific training.MethodsAn observer-blinded randomized controlled trial in which 66 stroke patient-caregiver couples were included during inpatient rehabilitation. Patients allocated to the CARE4STROKE program trained an additional amount of 150 minutes a week with a caregiver and were compared to a control group that received usual care alone. Primary outcomes: self-reported mobility domain of the Stroke Impact Scale 3.0 (SIS) and length of stay (LOS). Secondary outcomes: motor impairment, strength, walking ability, balance, mobility and (Extended) Activities of Daily Living of patients, caregiver strain of caregivers, and mood, self-efficacy, fatigue and quality of life of both patients and caregivers. Outcomes were assessed at baseline, 8 and 12 weeks after randomization.ResultsNo significant between-group differences were found regarding SIS-mobility after 8 (β 6.21, SD 5.16; P = 0.229) and 12 weeks (β 0.14, SD 2.87; P = 0.961), and LOS (P = 0.818). Significant effects in favor of the intervention group were found for patient's anxiety (β 2.01, SD 0.88; P = 0.023) and caregiver's depression (β 2.33, SD 0.77; P = 0.003) post intervention. Decreased anxiety in patients remained significant at the 12-week follow-up (β 1.01, SD 0.40; P = 0.009).ConclusionsThis proof-of concept trial did not find significant effects on both primary outcomes mobility and LOS as well as the secondary functional outcomes. Treatment contrast in terms of total exercise time may have been insufficient to achieve these effects. However, caregiver-mediated exercises showed a favorable impact on secondary outcome measures of mood for both patient and caregiver.Clinical trial registrationNTR4300, URL- http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4300

Does Transcranial Magnetic Stimulation Have an Added Value to Clinical Assessment in Predicting Upper-Limb Function Very Early After Severe Stroke?

BACKGROUND: The added prognostic value of transcranial magnetic stimulation (TMS)-induced motor-evoked potentials (MEPs) to clinical modeling for the upper limb is still unknown early poststroke. OBJECTIVE: To determine the added prognostic value of TMS of the adductor digiti minimi (TMS-ADM) to the clinical model based on voluntary shoulder abduction (SA) and finger extension (FE) during the first 48 hours and at 11 days after stroke. METHODS: This was a prospective cohort study with 3 logistic regression models, developed to predict upper-limb function at 6 months poststroke. The first model showed the predictive value of SA and FE measured within 48 hours and at 11 days poststroke. The second model included TMS-ADM, whereas the third model combined clinical and TMS-ADM information. Differences between derived models were tested with receiver operating characteristic curve analyses. RESULTS: A total of 51 patients with severe, first-ever ischemic stroke were included. Within 48 hours, no significant added value of TMS-ADM to clinical modeling was found ( P = .369). Both models suffered from a relatively low negative predictive value within 48 hours poststroke. TMS-ADM combined with SA and FE (SAFE) showed significantly more accuracy than TMS-ADM alone at 11 days poststroke ( P = .039). CONCLUSION: TMS-ADM showed no added value to clinical modeling when measured within first 48 hours poststroke, whereas optimal prediction is achieved by SAFE combined with TMS-ADM at 11 days poststroke. Our findings suggest that accuracy of predicting upper-limb motor function by TMS-ADM is mainly determined by the time of assessment early after stroke onset

Computerised patient-specific prediction of the recovery profile of upper limb capacity within stroke services: the next step

Introduction Predicting upper limb capacity recovery is important to set treatment goals, select therapies and plan discharge. We introduce a prediction model of the patient-specific profile of upper limb capacity recovery up to 6 months poststroke by incorporating all serially assessed clinical information from patients. Methods Model input was recovery profile of 450 patients with a first-ever ischaemic hemispheric stroke measured using the Action Research Arm Test (ARAT). Subjects received at least three assessment sessions, starting within the first week until 6 months poststroke. We developed mixed-effects models that are able to deal with one or multiple measurements per subject, measured at non-fixed time points. The prediction accuracy of the different models was established by a fivefold cross-validation procedure. Results A model with only ARAT time course, finger extension and shoulder abduction performed as good as models with more covariates. For the final model, cross-validation prediction errors at 6 months poststroke decreased as the number of measurements per subject increased, from a median error of 8.4 points on the ARAT (Q1-Q3:1.7-28.1) when one measurement early poststroke was used, to 2.3 (Q1-Q3:1-7.2) for seven measurements. An online version of the recovery model was developed that can be linked to data acquisition environments. Conclusion Our innovative dynamic model can predict real-time, patient-specific upper limb capacity recovery profiles up to 6 months poststroke. The model can use all available serially assessed data in a flexible way, creating a prediction at any desired moment poststroke, stand-alone or linked with an electronic health record system

Computerised patient-specific prediction of the recovery profile of upper limb capacity within stroke services: The next step

Introduction Predicting upper limb capacity recovery is important to set treatment goals, select therapies and plan discharge. We introduce a prediction model of the patient-specific profile of upper limb capacity recovery up to 6 months poststroke by incorporating all serially assessed clinical information from patients. Methods Model input was recovery profile of 450 patients with a first-ever ischaemic hemispheric stroke measured using the Action Research Arm Test (ARAT). Subjects received at least three assessment sessions, starting within the first week until 6 months poststroke. We developed mixed-effects models that are able to deal with one or multiple measurements per subject, measured at non-fixed time points. The prediction accuracy of the different models was established by a fivefold cross-validation procedure. Results A model with only ARAT time course, finger extension and shoulder abduction performed as good as models with more covariates. For the final model, cross-validation prediction errors at 6 months poststroke decreased as the number of measurements per subject increased, from a median error of 8.4 points on the ARAT (Q1-Q3:1.7-28.1) when one measurement early poststroke was used, to 2.3 (Q1-Q3:1-7.2) for seven measurements. An online version of the recovery model was developed that can be linked to data acquisition environments. Conclusion Our innovative dynamic model can predict real-time, patient-specific upper limb capacity recovery profiles up to 6 months poststroke. The model can use all available serially assessed data in a flexible way, creating a prediction at any desired moment poststroke, stand-alone or linked with an electronic health record system