Effects of controlled inspiratory muscle training in patients with COPD: a meta-analysis

The purpose of this meta-analysis is to review studies investigating the efficacy of inspiratory muscle training (IMT) in chronic obstructive pulmonary disease (COPD) patients and to find out whether patient characteristics influence the efficacy of IMT. A systematic literature search was performed using the Medline and Embase databases. On the basis of a methodological framework, a critical review was performed and summary effect-sizes were calculated by applying fixed and random effects models. Both IMT alone and IMT as adjunct to general exercise reconditioning significantly increased inspiratory muscle strength and endurance. A significant effect was found for dyspnoea at rest and during exercise. Improved functional exercise capacity tended to be an additional effect of IMT alone and as an adjunct to general exercise reconditioning, but this trend did not reach statistical significance. No significant correlations were found for training effects with patient characteristics. However, subgroup analysis in IMT plus exercise training revealed that patients with inspiratory muscle weakness improved significantly more compared to patients without inspiratory muscle weakness. From this review it is concluded that inspiratory muscle training is an important addition to a pulmonary rehabilitation programme directed at chronic obstructive pulmonary disease patients with inspiratory muscle weakness. The effect on exercise performance is still to be determined

Effects of circuit training as alternative to usual physiotherapy after stroke: randomised controlled trial

Objective To analyse the effect of task oriented circuit training compared with usual physiotherapy in terms of self reported walking competency for patients with stroke discharged from a rehabilitation centre to their own home

Predicting Upper Limb Motor Impairment Recovery after Stroke: A Mixture Model

Objective: Spontaneous recovery is an important determinant of upper extremity recovery after stroke and has been described by the 70% proportional recovery rule for the Fugl–Meyer motor upper extremity (FM-UE) scale. However, this rule is criticized for overestimating the predictability of FM-UE recovery. Our objectives were to develop a longitudinal mixture model of FM-UE recovery, identify FM-UE recovery subgroups, and internally validate the model predictions. Methods: We developed an exponential recovery function with the following parameters: subgroup assignment probability, proportional recovery coefficient rk, time constant in weeks τk, and distribution of the initial FM-UE scores. We fitted the model to FM-UE measurements of 412 first-ever ischemic stroke patients and cross-validated endpoint predictions and FM-UE recovery cluster assignment. Results: The model distinguished 5 subgroups with different recovery parameters (r1 = 0.09, τ1 = 5.3, r2 = 0.46, τ2 = 10.1, r3 = 0.86, τ3 = 9.8, r4 = 0.89, τ4 = 2.7, r5 = 0.93, τ5 = 1.2). Endpoint FM-UE was predicted with a median absolute error of 4.8 (interquartile range [IQR] = 1.3–12.8) at 1 week poststroke and 4.2 (IQR = 1.3–9.8) at 2 weeks. Overall accuracy of assignment to the poor (subgroup 1), moderate (subgroups 2 and 3), and good (subgroups 4 and 5) FM-UE recovery clusters was 0.79 (95% equal-tailed interval [ETI] = 0.78–0.80) at 1 week poststroke and 0.81 (95% ETI = 0.80–0.82) at 2 weeks. Interpretation: FM-UE recovery reflects different subgroups, each with its own recovery profile. Cross-validation indicates that FM-UE endpoints and FM-UE recovery clusters can be well predicted. Results will contribute to the understanding of upper limb recovery patterns in the first 6 months after stroke. ANN NEUROL 2020

Early prediction of outcome of activities of daily living after stroke: a systematic review

Background and Purpose-Knowledge about robust and unbiased factors that predict outcome of activities of daily living (ADL) is paramount in stroke management. This review investigates the methodological quality of prognostic studies in the early poststroke phase for final ADL to identify variables that are predictive or not predictive for outcome of ADL after stroke. Methods-PubMed, Ebsco/Cinahl and Embase were systematically searched for prognostic studies in which stroke patients were included = 3 months poststroke. Risk of bias scores were used to distinguish high-and low-quality studies and a qualitative synthesis was performed. Results-Forty-eight of 8425 identified citations were included. The median risk of bias score was 17 out of 27 (range, 6-22) points. Most studies failed to report medical treatment applied, management of missing data, rationale for candidate determinants and outcome cut-offs, results of univariable analysis, and validation and performance of the model, making the predictive value of most determinants indistinct. Six high-quality studies showed strong evidence for baseline neurological status, upper limb paresis, and age as predictors for outcome of ADL. Gender and risk factors such as atrial fibrillation were unrelated to this outcome. Conclusions-Because of insufficient methodological quality of most prognostic studies, the predictive value of many clinical determinants for outcome of ADL remains unclear. Future cohort studies should focus on early prediction using simple models with good clinical performance to enhance application in stroke management and research. (Stroke. 2011;42:1482-1488.

Impact of early applied upper limb stimulation: The EXPLICIT-stroke programme design

Main claims of the literature are that functional recovery of the paretic upper limb is mainly defined within the first month post stroke and that rehabilitation services should preferably be applied intensively and in a task-oriented way within this particular time window. EXplaining PLastICITy after stroke (acronym EXPLICIT-stroke) aims to explore the underlying mechanisms of post stroke upper limb recovery. Two randomized single blinded trials form the core of the programme, investigating the effects of early modified Constraint-Induced Movement Therapy (modified CIMT) and EMG-triggered Neuro-Muscular Stimulation (EMG-NMS) in patients with respectively a favourable or poor probability for recovery of dexterity.BioMechanical EngineeringMechanical, Maritime and Materials Engineerin

Comparing unilateral and bilateral upper limb training: The ULTRA-stroke program design

<p>Abstract</p> <p>Background</p> <p>About 80% of all stroke survivors have an upper limb paresis immediately after stroke, only about a third of whom (30 to 40%) regain some dexterity within six months following conventional treatment programs. Of late, however, two recently developed interventions - constraint-induced movement therapy (CIMT) and bilateral arm training with rhythmic auditory cueing (BATRAC) - have shown promising results in the treatment of upper limb paresis in chronic stroke patients. The ULTRA-stroke (acronym for Upper Limb TRaining After stroke) program was conceived to assess the effectiveness of these interventions in subacute stroke patients and to examine how the observed changes in sensori-motor functioning relate to changes in stroke recovery mechanisms associated with peripheral stiffness, interlimb interactions, and cortical inter- and intrahemispheric networks. The present paper describes the design of this single-blinded randomized clinical trial (RCT), which has recently started and will take several years to complete.</p> <p>Methods/Design</p> <p>Sixty patients with a first ever stroke will be recruited. Patients will be stratified in terms of their remaining motor ability at the distal part of the arm (i.e., wrist and finger movements) and randomized over three intervention groups receiving modified CIMT, modified BATRAC, or an equally intensive (i.e., dose-matched) conventional treatment program for 6 weeks. Primary outcome variable is the score on the Action Research Arm test (ARAT), which will be assessed before, directly after, and 6 weeks after the intervention. During those test sessions all patients will also undergo measurements aimed at investigating the associated recovery mechanisms using haptic robots and magneto-encephalography (MEG).</p> <p>Discussion</p> <p>ULTRA-stroke is a 3-year translational research program which aims (1) to assess the relative effectiveness of the three interventions, on a group level but also as a function of patient characteristics, and (2) to delineate the functional and neurophysiological changes that are induced by those interventions.</p> <p>The outcome on the ARAT together with information about changes in the associated mechanisms will provide a better understanding of how specific therapies influence neurobiological changes, and which post-stroke conditions lend themselves to specific treatments.</p> <p>Trial Registration</p> <p>The ULTRA-stroke program is registered at the Netherlands Trial Register (NTR, <url>http://www.trialregister.nl</url>, number NTR1665).</p

Cost-effectiveness of a structured progressive task-oriented circuit class training programme to enhance walking competency after stroke: The protocol of the FIT-Stroke trial

<p>Abstract</p> <p>Background</p> <p>Most patients who suffer a stroke experience reduced walking competency and health-related quality of life (HRQoL). A key factor in effective stroke rehabilitation is intensive, task-specific training. Recent studies suggest that intensive, patient-tailored training can be organized as a circuit with a series of task-oriented workstations.</p> <p>Primary aim of the FIT-Stroke trial is to evaluate the effects and cost-effectiveness of a structured, progressive task-oriented circuit class training (CCT) programme, compared to usual physiotherapeutic care during outpatient rehabilitation in a rehabilitation centre. The task-oriented CCT will be applied in groups of 4 to 6 patients. Outcome will be defined in terms of gait and gait-related ADLs after stroke. The trial will also investigate the generalizability of treatment effects of task-oriented CCT in terms of perceived fatigue, anxiety, depression and perceived HRQoL.</p> <p>Methods/design</p> <p>The multicentre single-blinded randomized trial will include 220 stroke patients discharged to the community from inpatient rehabilitation, who are able to communicate and walk at least 10 m without physical, hands-on assistance. After discharge from inpatient rehabilitation, patients in the experimental group will receive task-oriented CCT two times a week for 12 weeks at the physiotherapy department of the rehabilitation centre. Control group patients will receive usual individual, face-to-face, physiotherapy. Costs will be evaluated by having each patient keep a cost diary for the first 24 weeks after randomisation. Primary outcomes are the mobility part of the Stroke Impact Scale (SIS-3.0) and the EuroQol. Secondary outcomes are the other domains of SIS-3.0, lower limb muscle strength, walking endurance, gait speed, balance, confidence not to fall, instrumental ADL, fatigue, anxiety, depression and HRQoL.</p> <p>Discussion</p> <p>Based on assumptions about the effect of intensity of practice and specificity of treatment effects, FIT-Stroke will address two key aims. The first aim is to investigate the effects of task-oriented CCT on walking competency and HRQoL compared to usual face-to-face physiotherapy. The second aim is to reveal the cost-effectiveness of task-oriented CCT in the first 6 months post stroke. Both aims were recently recommended as priorities by the American Hearth Association and Stroke Council.</p> <p>Trial registration</p> <p>This study is registered in the Dutch Trial Register as NTR1534.</p

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. Conclusio

Dynamic Information Flow Based on EEG and Diffusion MRI in Stroke: A Proof-of-Principle Study

In hemiparetic stroke, functional recovery of paretic limb may occur with the reorganization of neural networks in the brain. Neuroimaging techniques, such as magnetic resonance imaging (MRI), have a high spatial resolution which can be used to reveal anatomical changes in the brain following a stroke. However, low temporal resolution of MRI provides less insight of dynamic changes of brain activity. In contrast, electro-neurophysiological techniques, such as electroencephalography (EEG), have an excellent temporal resolution to measure such transient events, however are hindered by its low spatial resolution. This proof-of-principle study assessed a novel multimodal brain imaging technique namely Variational Bayesian Multimodal Encephalography (VBMEG), which aims to improve the spatial resolution of EEG for tracking the information flow inside the brain and its changes following a stroke. The limitations of EEG are complemented by constraints derived from anatomical MRI and diffusion weighted imaging (DWI). EEG data were acquired from individuals suffering from a stroke as well as able-bodied participants while electrical stimuli were delivered sequentially at their index finger in the left and right hand, respectively. The locations of active sources related to this stimulus were precisely identified, resulting in high Variance Accounted For (VAF above 80%). An accurate estimation of dynamic information flow between sources was achieved in this study, showing a high VAF (above 90%) in the cross-validation test. The estimated dynamic information flow was compared between chronic hemiparetic stroke and able-bodied individuals. The results demonstrate the feasibility of VBMEG method in revealing the changes of information flow in the brain after stroke. This study verified the VBMEG method as an advanced computational approach to track the dynamic information flow in the brain following a stroke. This may lead to the development of a quantitative tool for monitoring functional changes of the cortical neural networks after a unilateral brain injury and therefore facilitate the research into, and the practice of stroke rehabilitation