Effect of Stroke on Fall Rate, Location and Predictors: A Prospective Comparison of Older Adults with and without Stroke

BACKGROUND: The literature suggests that stroke is a major risk factor for falls, but there is a lack of prospective, controlled studies which quantify fall-risk after stroke. The purpose of this study was to compare the rates, location and predictors among individuals recently discharged home from stroke rehabilitation to age and sex matched controls. METHODOLOGY/PRINCIPAL FINDINGS: A sample of 80 people with stroke and 90 controls received baseline assessments of balance, mobility and balance confidence. Falls were recorded prospectively over 13 months for both groups. Group differences in fall rates and contribution of clinical measures to falls were determined using negative binomial regression. Fall location was compared between groups using χ(2) statistics. The rate of falls for individuals with stroke was 1.77 times the rate for the control group. People with stroke were more likely to fall at home. Poorer balance (Berg Balance Scale) was associated with greater falls for both stroke and control groups (incidence rate ratio [IRR]: 0.908 and IRR: 0.877 respectively). A faster Timed Up and Go Test was associated with greater falls for the stroke group (IRR: 0.955) while better walking endurance (Six Minute Walk Test) was associated with greater falls for the controls (IRR: 1.004). Balance confidence was not an independent predictor in either group. CONCLUSIONS: Individuals recently discharged home are at greater risk of falling than individuals without stroke. Attention to home environment is warranted. Balance function can predict falls for both people with stroke and age and sex matched controls. Increased mobility may increase exposure to fall opportunities

Sex differences in the effects of exercise on cognition post-stroke: Secondary analysis of a randomized controlled trial

OBJECTIVE: To determine whether there are differences in exercise-associated changes in cognitive func-tion between males and females living with stroke. DESIGN: Secondary analysis of data from a prospective assessor-blinded randomized controlled trial. PARTICIPANTS: Fifty participants (50-80 years, \u3e 1 year post-stroke, able to walk ≥ 5 m). METHODS: Participants were allocated into a 6-month aerobic exercise programme (14 males, 11 females) or balance and flexibility programme (15 males, 10 females). Working memory (Verbal Digit Span Backwards Test), selective attention and conflict resolution (Stroop Colour-Word Test), and set shifting/cognitive flexibility (Trail-Making Test B) were assessed before and after the programmes. RESULTS: There was a group × time interaction in females (effect size 0.28, p = 0.03), which was not observed in males (effect size 0.01, p = 0.62). Females demonstrated a Stroop Colour-Word Interference test change of -2.3 s, whereas males demonstrated a change of +5.5 s following aerobic exercise. There were no differences between exercise groups in either sex for any of the other outcomes (working memory and set-shifting/cognitive flexibility). CONCLUSION: Females living with stroke may demonstrate a greater response to exercise on selective attention and conflict resolution compared with males with stroke. These findings suggest that there may be sex-specific effects of exercise on cognitive func-tion in individuals with stroke

Predicting interest to use mobile-device telerehabilitation (mRehab) by baby-boomers with stroke

Context and purpose: Demand for stroke rehabilitation services are reaching unprecedented levels due to an overall population aging, driven by the aging of the baby-boomer generation. Delivery of rehabilitation via mobile-device technologies may provide advantages towards meeting the increasing demands on the rehabilitation system by providing individuals with rehabilitation services in their homes and communities. The aim of this paper is to gain an understanding of the interest of current baby-boomers with stroke to use mobile-device technology to receive rehabilitation services such as education, assessments and exercise programs (mRehab). Methods: People living in the community with stroke born between 1946 and 1964 (i.e., baby-boomer generation) who participated in a larger telerehabilitation survey were included in this study. Regression modeling was used to evaluate personal, health/disability and technological predictors of interest to use mobile-devices for telerehabilitation. Results and significance: Fifty people with stroke, mean age 62.7 (4.4) years, 58% male, 54.2% with moderate or moderately severe disability were included; 86% had access to a mobile phone or tablet. Regression analysis resulted in statistically significant personal (education, β = 0.29 [95% CI = 0.05 to 1.11], population of residence, β = 0.30 [95% CI = 0.07 to 0.69]), health (comorbid conditions, β = 0.30 [95% CI = 0.02 to 0.20]) technology (ownership, β = 0.26 [95% CI = 0.01 to 0.86] and attitude towards telerehabilitation, β = 0.25 [95% CI = 0.01 to 0.79]) predictors of interest to use mobile-devices for telerehabilitation (R2 = 33.1%).This study identifies personal, health and technological factors which predict interest of baby-boomers with stroke with ongoing and complex health needs to use mRehab. Health professionals can use this information as they integrate mRehab into their practice and inform future development of mRehab solutions

Phase-dependent Brain Activation of the Frontal and Parietal Regions During Walking After Stroke - An fNIRS Study

Background: Recovery of walking post-stroke is highly variable. Accurately measuring and documenting functional brain activation characteristics during walking can help guide rehabilitation. Previous work in this area has been limited to investigations of frontal brain regions and have not utilized recent technological and analytical advances for more accurate measurements. There were three aims for this study: to characterize the hemodynamic profile during walking post-stroke, to investigate regional changes in brain activation during different phases of walking, and to related brain changes to clinical measures. Methods: Functional near-infrared spectroscopy (fNIRS) along the pre-frontal, premotor, sensorimotor, and posterior parietal cortices was used on twenty individuals greater than six months post-stroke. Individual fNIRS optodes were digitized and used to estimate channel locations on each participant and short separation channels were used to control for extracerebral hemodynamic changes. Participants walked at their comfortable pace several times along a hallway while brain activation was recorded. Exploratory cluster analysis was conducted to determine if there was a link between brain activation and clinical measures. Results: Sustained activation was observed in the pre-frontal cortex with the ipsilesional hemisphere showing greater activation compared to the contralesional side. Sensorimotor cortex was active during the early, acceleration stage of walking only. Posterior parietal cortex showed changes in activation during the later, steady-state stage of walking. Faster gait speeds also related to increased activation in contralesional sensorimotor and posterior parietal cortices. Exploratory analysis clustered participants into two distinct groups based on their brain activation profiles and generally showed that individuals with greater activation tended to have better physical outcomes. Conclusions: These findings can guide future research for obtaining adequate power and determining factors that can be used as effect modifiers to reduce inter-subject variability. Overall, this is the first study to report specific oxygenated and deoxygenated hemoglobin changes in frontal to parietal regions during walking in the stroke population. Our results shed light on the importance of measuring brain activation across the cortex and show the importance of pre-frontal, sensorimotor, and posterior parietal cortices in walking after a stroke

Frontal, Sensorimotor, and Posterior Parietal Regions Are Involved in Dual-Task Walking After Stroke

Background: Walking within the community requires the ability to walk while simultaneously completing other tasks. After a stroke, completing an additional task while walking is significantly impaired, and it is unclear how the functional activity of the brain may impact this. Methods: Twenty individual in the chronic stage post-stroke participated in this study. Functional near-infrared spectroscopy (fNIRS) was used to measure prefrontal, pre-motor, sensorimotor, and posterior parietal cortices during walking and walking while completing secondary verbal tasks of varying difficulty. Changes in brain activity during these tasks were measured and relationships were accessed between brain activation changes and cognitive or motor abilities. Results: Significantly larger activations were found for prefrontal, pre-motor, and posterior parietal cortices during dual-task walking. Increasing dual-task walking challenge did not result in an increase in brain activation in these regions. Higher general cognition related to lower increases in activation during the easier dual-task. With the harder dual-task, a trend was also found for higher activation and less motor impairment. Conclusions: This is the first study to show that executive function, motor preparation/planning, and sensorimotor integration areas are all important for dual-task walking post-stroke. A lack of further brain activation increase with increasing challenge suggests a point at which a trade-off between brain activation and performance occurs. Further research is needed to determine if training would result in further increases in brain activity or improved performance

Factors Influencing the Delivery of Intensive Rehabilitation in Stroke: Patient Perceptions Versus Rehabilitation Therapist Perceptions

Background Despite increasing evidence on intensive task-specific practice and aerobic exercise in stroke rehabilitation, implementation remains difficult. The factors influencing implementation have been explored from therapists’ perspectives; however, despite an increased emphasis on patient involvement in research, patients’ perceptions have not yet been investigated. Objective The study aimed to investigate factors influencing implementation of higher intensity activity in people with stroke and to compare this with therapists’ perspectives. Design The design was a cross-sectional qualitative study. Methods The study used semi-structured interviews with people with stroke who were part of a randomized clinical trial, the Determining Optimal post-Stroke Exercise (DOSE) study, which delivered a higher intensity intervention. An interview guide was developed and data analyzed using implementation frameworks. Factors emerging from people with stroke were compared and contrasted to factors perceived by rehabilitation therapists. Results Ten people with stroke were interviewed before data saturation was reached. Participants had a positive attitude regarding working hard, and were satisfied with the graded exercise test, high intensity intervention, and the feedback monitoring devices. Therapists and patients had contrasting perceptions about their beliefs of intensive exercise and the content of the intervention, with therapists more focused on the methods and patients more focused on the personal interactions stemming from the therapeutic relationship. Conclusions People with stroke perceived no barriers regarding the implementation of higher intensity rehabilitation in practice and were positive towards working at more intense levels. Contrastingly, from the therapists’ perspective, therapists’ beliefs about quality of movement and issues around staffing and resources were perceived to be barriers. In addition, therapists and people with stroke perceived the contents of the intervention differently, highlighting the importance of involving patients and clinicians in the development and evaluation of rehabilitation interventions

Phase-dependent Brain Activation of the Frontal and Parietal Regions During Walking After Stroke - An fNIRS Study

BackgroundRecovery of walking post-stroke is highly variable. Accurately measuring and documenting functional brain activation characteristics during walking can help guide rehabilitation. Previous work in this area has been limited to investigations of frontal brain regions and have not utilized recent technological and analytical advances for more accurate measurements. There were three aims for this study: to characterize the hemodynamic profile during walking post-stroke, to investigate regional changes in brain activation during different phases of walking, and to related brain changes to clinical measures.MethodsFunctional near-infrared spectroscopy (fNIRS) along the pre-frontal, premotor, sensorimotor, and posterior parietal cortices was used on twenty individuals greater than six months post-stroke. Individual fNIRS optodes were digitized and used to estimate channel locations on each participant and short separation channels were used to control for extracerebral hemodynamic changes. Participants walked at their comfortable pace several times along a hallway while brain activation was recorded. Exploratory cluster analysis was conducted to determine if there was a link between brain activation and clinical measures.ResultsSustained activation was observed in the pre-frontal cortex with the ipsilesional hemisphere showing greater activation compared to the contralesional side. Sensorimotor cortex was active during the early, acceleration stage of walking only. Posterior parietal cortex showed changes in activation during the later, steady-state stage of walking. Faster gait speeds also related to increased activation in contralesional sensorimotor and posterior parietal cortices. Exploratory analysis clustered participants into two distinct groups based on their brain activation profiles and generally showed that individuals with greater activation tended to have better physical outcomes.ConclusionsThese findings can guide future research for obtaining adequate power and determining factors that can be used as effect modifiers to reduce inter-subject variability. Overall, this is the first study to report specific oxygenated and deoxygenated hemoglobin changes in frontal to parietal regions during walking in the stroke population. Our results shed light on the importance of measuring brain activation across the cortex and show the importance of pre-frontal, sensorimotor, and posterior parietal cortices in walking after a stroke

Blood pressure trajectory of inpatient stroke rehabilitation patients from the Determining Optimal Post-Stroke Exercise (DOSE) trial over the first 12 months post-stroke

BackgroundHigh blood pressure (BP) is the primary risk factor for recurrent strokes. Despite established clinical guidelines, some stroke survivors exhibit uncontrolled BP over the first 12 months post-stroke. Furthermore, research on BP trajectories in stroke survivors admitted to inpatient rehabilitation hospitals is limited. Exercise is recommended to reduce BP after stroke. However, the effect of high repetition gait training at aerobic intensities (>40% heart rate reserve; HRR) during inpatient rehabilitation on BP is unclear. We aimed to determine the effect of an aerobic gait training intervention on BP trajectory over the first 12 months post-stroke.MethodsThis is a secondary analysis of the Determining Optimal Post-Stroke Exercise (DOSE) trial. Participants with stroke admitted to inpatient rehabilitation hospitals were recruited and randomized to usual care (n = 24), DOSE1 (n = 25; >2,000 steps, 40–60% HRR for >30 min/session, 20 sessions over 4 weeks), or DOSE2 (n = 25; additional DOSE1 session/day) groups. Resting BP [systolic (SBP) and diastolic (DBP)] was measured at baseline (inpatient rehabilitation admission), post-intervention (near inpatient discharge), 6- and 12-month post-stroke. Linear mixed-effects models were used to examine the effects of group and time (weeks post-stroke) on SBP, DBP and hypertension (≥140/90 mmHg; ≥130/80 mmHg, if diabetic), controlling for age, stroke type, and baseline history of hypertension.ResultsNo effect of intervention group on SBP, DBP, or hypertension was observed. BP increased from baseline to 12-month post-stroke for SBP (from [mean ± standard deviation] 121.8 ± 15.0 to 131.8 ± 17.8 mmHg) and for DBP (74.4 ± 9.8 to 78.5 ± 10.1 mmHg). The proportion of hypertensive participants increased from 20.8% (n = 15/72) to 32.8% (n = 19/58). These increases in BP were statistically significant: an effect [estimation (95%CI), value of p] of time was observed on SBP [0.19 (0.12–0.26) mmHg/week, p < 0.001], DBP [0.09 (0.05–0.14) mmHg/week, p < 0.001], and hypertension [OR (95%CI): 1.03 (1.01–1.05), p = 0.010]. A baseline history of hypertension was associated with higher SBP by 13.45 (8.73–18.17) mmHg, higher DBP by 5.57 (2.02–9.12) mmHg, and 42.22 (6.60–270.08) times the odds of being hypertensive at each timepoint, compared to those without.ConclusionBlood pressure increased after inpatient rehabilitation over the first 12 months post-stroke, especially among those with a history of hypertension. The 4-week aerobic gait training intervention did not influence this trajectory