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An online, Langerian mindfulness intervention promoting attention to symptom variability was highly satisfied with by stroke survivors and their caregivers, a small study suggests.
M. Demers et al. (2021) described development of an online Langerian mindfulness program for stroke survivors and caregivers. Stroke is a heterogeneous condition with possible sensorimotor, cognitive, perceptual, social, and psychological sequelae. Caregivers are crucial in preserving rehabilitation gains and independence levels. This study supports the feasibility of a three-week online mindfulness intervention for stroke survivors and caregivers. Stroke survivors and caregivers participated in a three-week, online, Langerian mindfulness intervention promoting attention to variability. The experience from the mindfulness intervention was positive overall, with high levels of satisfaction and good adherence to the daily exercises.
11 stroke survivors were included in the research. However, “The small sample size and large inter-individual baseline variability may explain why changes were not detected. The evaluation timeline may be too short to observe changes in quality of life and psychological well-being. Participants reported implementing mindfulness strategies in their daily lives,” say the researchers.
There is a lack of a targeted approach to stroke rehabilitation.
In ‘Finding effective therapeutic approaches for motor rehabilitation after stroke’, a group led by R. Ranganathan from the Department of Kinesiology (2021) reported that with several recent Phase 3 clinical trials of motor rehabilitation for stroke showing no differences between the treatment and the control group, there is an urgent need to find more effective therapeutic interventions. The purpose of this review was to more closely examine the basis for current therapeutic approaches in stroke rehabilitation. A majority of studies did not provide an explicit rationale for why the treatment would be expected to work. There was not a close correspondence between the active ingredients mentioned versus those reported or measured in the study. There is an urgent need to find more effective therapeutic interventions. There was a relatively even split between studies that used multimodal therapy and those that focused on a single mode of therapy.
The researchers evaluated 539 studies. Some of the results claim to reinforce previous work in this topic: “A recent review that examined 194 randomized controlled trials from 1979 to 2013 found that only about 31% of the trials described a clear rationale. The inclusion of a rationale was associated with increased odds of a positive finding,” Ranganathan posited. However, “Many rehabilitation interventions currently address a small fraction of the stroke population. The recruitment rate for most large Phase 3 clinical trials tends to be smaller than 10% of the screened population. This suggests the need to find therapies that are applicable to a wider population,” note the authors. They propose that recommendations for future research. In light of these findings, they suggest three recommendations for future work in order to facilitate the search for effective therapeutic interventions. The authors have provided data and code at: https://osf.io/vg46a.
Transcranial magnetic stimulation (TMS) has been used to improve the recovery of patients with glioma who experienced motor or language deficits following craniotomy.
In ‘Interventional Neurorehabilitation for Promoting Functional Recovery Post-Craniotomy’, A. Poologaindran and colleagues (2021) reported that for the first time, they demonstrate the safety profile and ability to recruit, enrol, and complete Transcranial Magnetic Stimulation acutely post-craniotomy in a high seizure risk population. Patients with supratentorial gliomas developed a significant post-operative neurological deficit related to motor or language function. In glioma patients who experienced post-operative motor or language deficits, they used connectomics to construct single-subject cortical networks. Based on their clinical and connectivity deficit, patients underwent network-specific Transcranial Magnetic Stimulation (TMS) sessions daily over five consecutive days. Patients were assessed for TMS-related side effects and improvements.
The research involved 34 glioma patients. Their results seem to corroborate previous studies in this field: “Transient tingling was reported at the site of stimulation during stimulation onset, but also resolved immediately. These results are consistent with well-documented side-effects during rTMS of non-craniotomy patients,” Poologaindran said. However, “The uncontrolled and early nature of our intervention raises the possibility whether these patients would have improved without treatment. Future trials should employ prospective, randomised, doubleblinded active- and sham-controlled TMS,” note the authors. The team propose that they elucidate the role of individualized TMS in standard inpatient rehabilitation and discuss implications for future study on rTMS to optimize clinical outcomes.
Early, activity-intensive therapy for young children with perinatal ischemic stroke improves gross motor function, as compared to usual care.
In ‘Early, intensive rehabilitation improves gross motor function after perinatal stroke’, C. Hurd and colleagues (2021) reported that perinatal stroke is a cerebrovascular event that occurs between gestational age of 20 weeks and 28 days postnatal. They showed that intensive activity-based rehabilitation for the lower extremity in children with hemiparesis under the age of two resulted in large improvements in walking. Intensive, child-initiated therapy would result in greater improvements in motor function than usual care. The improvement in Gross Motor Function Measure-66 over 12 weeks was greater for the Immediate than the Delay Group and greater in younger children.
The research involved 34 children. The investigators admit that “Despite randomization there was a difference in age between the control and intervention groups. One 3-month bout of intensive training may not be sufficient to have a significant impact on long-term motor function. Determining the ideal time for additional training is needed.”
Partnered dance with a leader and a follower can improve motor function in Parkinsons disease, but which strategy is more effective in remediating effects of the disease?
A. Kashyap et al. (2021) reported in ‘Neural Correlates of Effects of Internally versus Externally Guided Partnered Rehabilitative Tango for People with Parkinson's Disease’ that neurorehabilitation using motor therapies has come into increasing focus as an alternate treatment to pharmacological and surgical methods for neurological disorders. Successful motor therapies in Parkinson’s Disease (PD) have focused on improving motor symptoms by engaging participants in a wide range of motor activities. This study was designed to determine whether internally guided (IG) or externally guided (EG( training results in differential engagement of pathways in people with mild to moderate PD. The externally guided group improved on Freezing of gait, 6MWT, Corsi Blocks, Brooks Spatial Memory and Beck depression. The study showed no enhanced activity in the STC pathway following IG training in the defined Parkinson's Disease groups.
58 participants were included in the study. Their conclusions may support what was previously known about this field: “The leader group showed significant clinical improvement in UPDRS III and motor measures such as the balance and distance they are able to walk during a six-minute interval. The IG dance training had positive benefits to the PD participants,” Kashyap suggested. However, “The in-scanner foot tapping task showed very few behavioral differences between the individuals. Small, and unequal sample sizes may have reduced power to detect effects. Larger samples are necessary to produce more definitive results,” admit the researchers.
A systematic review and meta-analysis of 66 studies investigating the effect of exercise on bone mineral density in postmenopausal women.
A research team from the Department of Rehabilitation Medicine led by Y. Li (2021) reported on comparative effectiveness of different exercises on bone mineral density in postmenopausal women. In the early years after menopause, postmenopausal women experience dramatic decreases in bone mineral density (BMD). This may increase the likelihood of developing osteoporosis and fragility fractures. Osteoporotic fracture is associated with substantial morbidity and mortality. Different types of physical exercise, including aerobic exercise, impact exercise, strength training and balance training are used in clinical practice to maintain or increase BMD. Exercise therapy has clear benefits on bone mineral density in postmenopausal women. The magnitude of effect varies depending on the outcome of interest, the age of participants, and the duration of intervention. Clinicians might consult the ranking of the exercise intervention presented in this study when designating an optimal, individualized exercise prescription to improve BMD.
The research involved 66 studies with a total number of 4336 participants. Aspects of the authors’ results appear to corroborate previous work in this subject: “The results indicate that depending on outcome of interest, multicomponent exercise, and resistance training were the most effective interventions. No matter the age of postmenopausal women, and the duration of intervention, some certain kinds of exercise could be performed to improve BMD at the lumbar spine and femoral neck,” Li claimed. Discussing possible improvements, “There were only three trials for this intervention and the results were limited by wide 95% CrIs. High impact exercise was the best exercise intervention followed by multicomponent exercise and flexibility exercise,” they say.
The gait of patients with knee osteoarthritis may be more unstable than that of healthy individuals.
T. Akimoto et al. (2021) described evaluation of gait cycle time variability in patients with knee osteoarthritis using a triaxial accelerometer. Knee osteoarthritis is a common disease that imposes an enormous personal and social burden. Unstable gait may be associated with gait speed and quality of life. They believe that rehabilitation to improve unstable gait can enhance thequality of life of patients with knee OA. This study recruited participants in two groups: patients with knee OA and healthy elderly women. Gait cycle variability, gait speed on the treadmill, Borg's 6–20 scale, knee extension strength and knee extension ROM were examined.
The research involved 24 female patients. Some of their findings seem to reinforce previous studies in this subject: “Knee joint function, gait speed, and WOMAC scores were lower in the knee OA group than in the healthy group. Previous studies have reported reduced knee extensor strength in patients with knee Oa compared to those in healthy subjects,” Akimoto suggested.
A study has found no effect of transcranial direct current stimulation (tDCS) on fatigue or depression in chronic phase stroke survivors.
A research group led by K. Ulrichsen at the Oslo University Hospital & Institute of Clinical Medicine (2021) reported that, in a sample of chronic stroke patients, they tested the effect of tDCS combined with computerized cognitive training on fatigue and depressive symptoms. Bayes factor estimations for linear correlations provided anecdotal to moderate evidence for no association between fatigue, depression and measures of cognitive function at baseline. Both fatigue severity scale (FSS) and PHQ were negatively associated with training gain in two and three of six included subtests, respectively. tDCS treatment response may interact with individual characteristics such as time since stroke onset, lesion location or lesion size. Future well-powered studies including patients sampled from a wide severity spectrum may be able to discern associations between treatment response and clinical stroke and lesion characteristics.
The analysis involved 74 patients. The researchers’ findings potentially strengthen what was previously known about this area: “This accords with previous reports of poor psychometric properties for item 1 and 2 and improved potential to detect fatigue changes across time. Our results support that these items could be removed in future studies targeting temporal changes in fatigue,” Ulrichsen argued. Discussing potential shortcomings, “The patients suffered from relatively mild strokes, as reflected in the low NIHSS scores. However, both fatigue and depressive complaints were comparable to previous chronic phase stroke studies. Future studies should aim to evaluate long-term effects in addition to immediate response,” they observe. The researchers suggest that the results support that these items could be removed in future studies targeting temporal changes in fatigue.
For the first time, a study in Nepal has tested the feasibility and acceptability of telerehabilitation to provide long-term follow-up of individuals with spinal injuries.
R. Dhakal and colleagues (2021) described TEleRehabilitation Nepal to improve quality of life of people with spinal cord injury and acquired brain injury. The disabilities an individual experiences after Spinal Cord Injury and ABI often results in entering a spiral of unemployment, poverty, and ill-health. Outcomes are poor in low- and middle-income countries due to paucity of specialist rehabilitative services. This study assessed the feasibility of a telerehabilitation approach for following up and providing interventions to those with physical, cognitive, and psychological problems. In Nepal, telemedicine and telephysiotherapy has been shown to be effective and cost saving.
The study involved 82 participants with spinal cord injury. Aspects of their findings potentially confirm previous work in this subject: “The literature demonstrates the possibility to collaborate among the providers so that in a situation where there is scarcity of rehabilitation professionals, there is a possibility of connecting to national and international professionals to provide telerehabilitation. The study has flagged up the need for a specific criterion forming decision making for deciding interventions in future,” Dhakal suggested. “Telerehabilitation showed significant improvement in balance and mobility, MBI scores, balance among stroke survivors. In a Nepalese feasibility study of telephysiotherapy, delivered for four weeks, there was a significant reduction in musculoskeletal pain,” say the investigators. However, the researchers note that there was no control arm to compare the treatment to. Participants were not followed-up long-term, a future study needs to identify effects. Many outcomes were self-reported, which may have introduced response bias.
A questionnaire that can be used to assess locomotor function in children with cerebral palsy (CP) has been developed and tested by a team of researchers in the US.
A team from the University of Minnesota Department of Orthopedic Surgery led by M. Schwartz (2021) reported on a patient-reported measure of locomotor function derived from the functional assessment questionnaire (FAQ). Locomotor function is often impaired in children diagnosed with cerebral palsy. The researchers defined the functional assessment questionnaire transform (FAQt) as a weighted sum of overall walking ability and ability to perform 22 complex locomotor skills. Schwartz and colleagues showed that this measure exhibited strong concurrent validity compared to the gross motor function measure and external validity across two centers. The FAQt is proposed as a new measure of locomotor function based on patient reported skills. The authors believe the ease of administration, the simple interpretation, and the sensible ‘growth-curves’ included in this study make the FAQt a valuable addition for both clinical assessment and research.
The research involved 350 consecutive individuals. Some of the researchers’ findings potentially consolidate previous studies in this area: “To test concurrent validity, we compared the FAQt to the GMFM-66. We further demonstrated that FAQt evolves with age in a manner like GMFM-66 when stratified by GMFCS level,” Schwartz argued. However, “The primary limitation is the list of activities included in the FAQ questionnaire. These questions span a variety of locomotor skills but are not intended to capture function broadly across activities of daily living. The FAQ does not ask about items related to domains A, B, and C of the GMFM-66,” note the researchers.
Physical activity during the hospital stay post-stroke may support cerebrovascular health after discharge.
In ‘Walking Activities during the Acute Stroke Hospital Stay May Benefit Cerebrovascular Health’, A. Whitaker et al. (2021) noted that light to moderate physical activity is recommended during the acute hospital stay to improve cardiovascular and musculoskeletal health. Stroke rehabilitation research should include measures of cerebrovascular health to increase the understanding regarding the relationship between physical activity and brain health. This study suggests that physical therapists may impact motor function as well as brain health by providing the motivation, support, and patient education. There were no significant differences between groups for stroke characteristics or treatment interventions.
The authors divided individuals based on average farthest walking distance,. Participants were 63 +/- 15 years. Baseline middle cerebral artery blood velocity (MCAv) was not different between groups. Some of the results may corroborate previous work in this subject: “Due to a small sample size, confounding factors such as age, sex, and medications were not statistically controlled. MCAv is linearly related to blood flow when a constant MCA diameter is maintained,” Whitaker suggested. However, “While this study provides an important future direction for prospectively collecting physical activity during the acute hospital and cerebrovascular health during stroke recovery, there are several limitations to consider due to the retrospective study design,” note the authors. The team argue that physical therapists and physical therapy assistants have instrumental roles in advocating for and providing out-of-bed activities that may contribute to long-term cerebrovascular health. They suggest that further research is needed to determine whether performing physical activity and walking farther distances within the acute hospital to increase measures of MCAv is associated with improved functional recovery.
The ability to assess upper-extremity motor function remotely is feasible and reliable in community-dwelling older adults.
In ‘Remote, unsupervised functional motor task evaluation in older adults across the United States using the MindCrowd electronic cohort’, A. Hooyman et al. (2021) reported that assessing motor function in older adults is essential, as it is affected by neurologic conditions like stroke, Mild Cognitive Impairment. The purpose of this study was to validate a remote, unsupervised version of a functional motor assessment within an in-home setting. Results showed that motor performance collected in-home without supervision was not significantly different from data collected face-to-face in a laboratory setting. This suggests that older adults nationwide can reliably perform this motor assessment remotely without supervision or clinical oversight. The feasibility and reliability of assessing motor function at home and unsupervised allows for clinical trial enrichment.
There were 679 participants in the analysis. Discussing possible shortcomings, “Electronic cohorts allow for more extensive and distributed samples and enable a much more robust set of data to be collected than typical face-to-face laboratory research. With the remote version of this motor assessment validated, future studies can investigate how other factors, such as race/ethnicity, socioeconomic status and socioeconomic status, affect motor function and motor decline in older adults,” they observe. They recommend that remote version of this motor assessment validated. Future studies can investigate how other factors, such as race/ethnicity, socioeconomic status, former occupation, marital status, comorbidities, polypharmacology, and genetics affect motor function and motor decline.
An Ideal battery of testing for function would be inexpensive, easily administered, standardized and validated for multiple health issues, such as chronic pain, according to a Canadian study.
In ‘Comparing Patient Reported Outcomes to Objective Measures of Function in patients with Chronic Pain’, a research group led by G. Gupta at the Forces Health Service Centre Ottawa (2021) noted that the current assessment of functional status in patients with chronic pain relies primarily on patient reported outcomes. The authors noted that high catastrophizing may promote a feeling of reduced ability to do meaningful, daily activities. This study aims to collect this data using SF-12 and 2-minute walk test (2MWT) and newly created Elevation & Movement Lift test (EMLi). SF-12 physical function score negatively correlated with perceived exertion but not performance with no impact correlation with Mental Health sub score. EMLi performance correlated with perception and upper extremity pain.
The study involved 102 patients with chronic pain. Discussing possible shortcomings, “Limitations include the relatively small sample size, the heterogeneity of chronic pain conditions and the inability to control for various comorbid health conditions. In the future, more strict performance examples by testers would be favorable,” they observe. They suggest that future studies can look to validate the EMLi in various other populations including patients with various spinal pain and localized joint dysfunction/musculoskeletal issues. Specific parameters such as the amount of weight required, timing of trials, reproducibility, validity and validity need to be established as well.
Demers, M., Pagnini, F., Phillips, D., Chang, B., Winstein, C., & Langer, E. (2021). Development of an online Langerian mindfulness program for stroke survivors and caregivers. doi:10.1101/2021.08.05.21261674 [Link]
Ranganathan, R., Doherty, C., Gussert, M., Kaplinski, E., Koje, M., & Krishnan, C. (2021). Finding effective therapeutic approaches for motor rehabilitation after stroke: Insights from a thematic analysis. doi:10.1101/2021.08.01.21261366 [Link]
Poologaindran, A., Profyris, C., Young, I. M., Dadario, N. B., Ahsan, S. A., Chendeb, K., … Sughrue, M. E. (2021). Interventional Neurorehabilitation for Promoting Functional Recovery Post-Craniotomy: A Proof-of-Concept. doi:10.1101/2021.07.27.21260088 [Link]
Hurd, C., Livingstone, D., Brunton, K., Smith, A., Gorassini, M., Watt, M.-J., … Yang, J. F. (2021). Early, intensive rehabilitation improves gross motor function after perinatal stroke: results of a randomized controlled trial. doi:10.1101/2021.07.21.21260801 [Link]
Kashyap, A., Crosson, B., Krishnamurthy, V., McGregor, K. M., Bozzorg, A., Gopinath, K., … Hackney, M. E. (2021). Neural Correlates of Effects of Internally versus Externally Guided Partnered Rehabilitative Tango for People with Parkinson’s Disease. doi:10.1101/2021.07.16.21260219 [Link]
Li, Y., Wang, X., Zhang, R., Zhu, S., Wang, L., Huang, J., … He, C. (2021). Comparative effectiveness of different exercises on bone mineral density in postmenopausal women: a systematic review and network meta-analysis of randomized controlled trials. doi:10.1101/2021.07.12.21260370 [Link]
Akimoto, T., Kawamura, K., Wada, T., Ishihara, N., Yokota, A., Suginoshita, T., & Yokoyama, S. (2021). Evaluation of gait cycle time variability in patients with knee osteoarthritis using a triaxial accelerometer. doi:10.1101/2021.07.02.21259710 [Link]
Ulrichsen, K. M., Kolskår, K. K., Richard, G., Pedersen, M. L., Alnæs, D., Dørum, E. S., … Westlye, L. T. (2021). No effect of tDCS on fatigue and depression in chronic stroke patients: an exploratory randomized sham-controlled trial combining tDCS with computerized cognitive training. doi:10.1101/2021.06.22.21258133 [Link]
Dhakal, R., Baniya, M., Solomon, R. M., Rana, C., Ghimire, P., Hariharan, R., … Sivan, M. (2021). TEleRehabilitation Nepal (TERN) to improve quality of life of people with spinal cord injury and acquired brain injury. A proof-of-concept study. doi:10.1101/2021.06.21.21257001 [Link]
Schwartz, M. H., Aldahondo, N., & MacWilliams, B. A. (2021). A Patient-Reported Measure of Locomotor Function Derived from the Functional Assessment Questionnaire. doi:10.1101/2021.06.12.21258826 [Link]
Whitaker, A. A., Henry, M. L., Morton, A., Ward, J. L., Eickmeyer, S. M., Abraham, M. G., & Billinger, S. A. (2021). Walking Activities during the Acute Stroke Hospital Stay May Benefit Cerebrovascular Health. doi:10.1101/2021.06.10.21258640 [Link]
Hooyman, A., Talboom, J. S., DeBoth, M. D., Ryan, L., Huentelman, M., & Schaefer, S. Y. (2021). Remote, unsupervised functional motor task evaluation in older adults across the United States using the MindCrowd electronic cohort. doi:10.1101/2021.05.17.21257333 [Link]
Gupta, G., Paquet-Proulx, E., Besemann, Lc. M., Burton, K., Lalonde, S., & Minerbi, A. (2021). Comparing Patient Reported Outcomes to Objective Measures of Function in patients with Chronic Pain: Using the SF-12, 2 minute walk test and Elevation and Movement Lift test. doi:10.1101/2021.05.07.21256342 [Link]