Predicting motor gains with home-based telerehabilitation after stroke

2021 ◽  
pp. 1357633X2110233
Author(s):  
Sang Min Paik ◽  
Steven C Cramer
Keyword(s):  
Secondary Analysis ◽  
Arm Movement ◽  
Visual Field Defects ◽  
Motor Deficits ◽  
Total N ◽  
Rehabilitation Therapy ◽  
Post Stroke ◽  
Female Sex ◽  
Home Based ◽  
Affective Deficits

Introduction Telerehabilitation (TR) may be useful for rehabilitation therapy after stroke. However, stroke is a heterogeneous condition, and not all patients can be expected to derive the same benefit from TR, underscoring the need to identify predictors of response to TR. Methods A prior trial provided patients with 6 weeks of intensive rehabilitation therapy targeting arm movement, randomly assigned to be provided in the home via TR (current focus) or in clinic. Eligible patients had moderate arm motor deficits and were in the subacute–chronic stage post stroke. Behavioral gains were measured as change in the arm motor Fugl-Meyer score from baseline to 30 days post therapy. To delineate predictors of TR response, multivariable linear regression was performed, advancing the most significant predictor from each of eight categories: patient demographics, stroke characteristics, medical history, rehabilitation therapy outside of study procedures, motivation, sensorimotor impairment, cognitive/affective deficits, and functional status. Results The primary focus was on patients starting TR >90 days post stroke onset ( n = 44), among whom female sex, less spasticity, and less visual field defects predicted greater motor gains. This model explained 39.3% of the variance in treatment-related gains. In secondary analysis that also included TR patients enrolled ≤90 days post stroke (total n = 59), only female sex was a predictor of treatment gains. A separate secondary analysis examined patients >90 days post stroke ( n = 34) randomized to in-clinic therapy, among whom starting therapy earlier post stroke and less ataxia predicted greater motor gains. Discussion Response to TR varies across patients, emphasizing the need to identify characteristics that predict treatment-related behavioral gain. The current study highlights factors that might be important to patient selection for home-based TR after stroke.

scholarly journals A Feasibility Study of Expanded Home-Based Telerehabilitation After Stroke

2021 ◽  
Vol 11 ◽  
Author(s):  
Steven C. Cramer ◽  
Lucy Dodakian ◽  
Vu Le ◽  
Alison McKenzie ◽  
Jill See ◽  
...  
Keyword(s):  
Feasibility Study ◽  
Holistic Approach ◽  
Motor Deficits ◽  
Limb Weakness ◽  
Clinical Trial Registration ◽  
Rehabilitation Care ◽  
Rehabilitation Therapy ◽  
Post Stroke ◽  
Home Based ◽  
Real Objects

Introduction: High doses of activity-based rehabilitation therapy improve outcomes after stroke, but many patients do not receive this for various reasons such as poor access, transportation difficulties, and low compliance. Home-based telerehabilitation (TR) can address these issues. The current study evaluated the feasibility of an expanded TR program.Methods: Under the supervision of a licensed therapist, adults with stroke and limb weakness received home-based TR (1 h/day, 6 days/week) delivered using games and exercises. New features examined include extending therapy to 12 weeks duration, treating both arm and leg motor deficits, patient assessments performed with no therapist supervision, adding sensors to real objects, ingesting a daily experimental (placebo) pill, and generating automated actionable reports.Results: Enrollees (n = 13) were median age 61 (IQR 52–65.5), and 129 (52–486) days post-stroke. Patients initiated therapy on 79.9% of assigned days and completed therapy on 65.7% of days; median therapy dose was 50.4 (33.3–56.7) h. Non-compliance doubled during weeks 7–12. Modified Rankin scores improved in 6/13 patients, 3 of whom were >3 months post-stroke. Fugl-Meyer motor scores increased by 6 (2.5–12.5) points in the arm and 1 (−0.5 to 5) point in the leg. Assessments spanning numerous dimensions of stroke outcomes were successfully implemented; some, including a weekly measure that documented a decline in fatigue (p = 0.004), were successfully scored without therapist supervision. Using data from an attached sensor, real objects could be used to drive game play. The experimental pill was taken on 90.9% of therapy days. Automatic actionable reports reliably notified study personnel when critical values were reached.Conclusions: Several new features performed well, and useful insights were obtained for those that did not. A home-based telehealth system supports a holistic approach to rehabilitation care, including intensive rehabilitation therapy, secondary stroke prevention, screening for complications of stroke, and daily ingestion of a pill. This feasibility study informs future efforts to expand stroke TR.Clinical Trial Registration:Clinicaltrials.gov, # NCT03460587.

Abstract P196: Patients Most Likely to Benefit From Home-Based Telerehabilitation After Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Sang Min Paik ◽  
Steven C Cramer
Keyword(s):  
Visual Field ◽  
Linear Regression Analysis ◽  
Multivariable Analysis ◽  
Secondary Analysis ◽  
Visual Field Defects ◽  
High Dose ◽  
Post Stroke ◽  
Home Based ◽  
Multivariable Linear Regression Analysis ◽  
Field Defects

Introduction: Higher doses of rehabilitation therapy are associated with better outcomes after stroke. Many patients do not receive high-dose therapy, however, e.g., due to limited availability and access, especially in the COVID era. Telehealth approaches can overcome many barriers, and evidence suggests that some forms of telerehabilitation are efficacious after stroke. However, uncertainty exists as to which patients are most likely to benefit from telerehabilitation. This issue was examined in the current study. Methods: Data are from patients randomized to telerehabilitation (TR) in an 11-site, assessor-blind trial (JAMA Neurol 76:1079) that provided 6 weeks of intensive arm motor therapy to hemiparetic patients with stroke 4-36 weeks prior. The primary endpoint was change in arm motor Fugl-Meyer (FM) from pre-treatment to 1-month post-treatment. Predictors of TR-related FM gain were identified using forward stepwise multivariable linear regression analysis, advancing the most significant predictor from each of 8 categories (demographics, stroke characteristics, medical history, amount of outside therapy, motivation, sensorimotor impairment, cognitive/affective status, and functional status) if it survived bivariate screening with p<0.1. Results: In patients >90 days post-stroke onset (n=44), sex (r=.33, p=.028), # hours of outside therapy post-randomization (r=.36, p=.019), spasticity (r=-.37, p=.014), and NIHSS visual field score (r=-.28, p=.068) were bivariate predictors of TR-related FM gain. In multivariable analysis, all except therapy hours survived as significant (P<0.05) predictors: TR-related FM gains were higher in females and lower in patients with spasticity or visual field defects. When the 15 patients randomized to TR ≤90 days post-stroke were added in secondary analysis, multivariable analysis found that sex, # hours of therapy post-randomization, and NIHSS neglect score were significant predictors. Conclusions: In patients with stable motor status >90 days post-stroke, behavioral gains from home-based TR were greatest in patients who were female and who had less spasticity and visual field defects. These results might be useful for patient selection and for design of future TR-based therapeutic approaches.

Abstract WP193: A Pilot Study of Expanded Home-Based Telerehabilitation After Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Steven C Cramer ◽  
Lucy Dodakian ◽  
Vu Le ◽  
Alison McKenzie ◽  
JIll See ◽  
...  
Keyword(s):  
Social Networks ◽  
Augmented Reality ◽  
Current System ◽  
Geriatric Depression Scale ◽  
Depression Scale ◽  
Smart Devices ◽  
Motor Deficits ◽  
Post Stroke ◽  
Home Based ◽  
High Doses

Introduction: High doses of activity-based rehabilitation therapy help but many patients do not receive this, e.g., due to access, cost, and low compliance. Home-based telerehabilitation (TR) can address these issues. A prior study found 6 weeks of TR targeting arm motor deficits after stroke comparably efficacious vs. therapy delivered in-clinic. Here, we evaluated a program expanded in TR dose and scope. Methods: Adults with stroke and arm motor deficits saw a licensed OT/PT who performed a live exam then supervised home-based TR (6 days/week, 1 hour/day) through games, exercises, and education. New features examined herein included (a) extending therapy to 12 weeks, (b) treating both arm and leg motor deficits, (c) augmented reality games, (d) wireless smart devices, (e) ingesting a daily experimental (placebo) pill, (f) using functional objects, (g) evaluating social networks, and (h) automated actionable reports. Results: Patients (n=13) were median age 61 [IQR=52-65.5], and 129 [52-486] days post-stroke. Patients initiated therapy on 79.9% of the 72 assigned days and completed >30 min on 65.7% of days, for a 12-week total therapy dose of 50.4 [33.3 - 56.7] hours. Non-compliant days during weeks 7-12 were double those of weeks 1-6. Modified Rankin scores improved by 1 level in 6/13 patients, 3 of whom were > 3month post-stroke. Fugl-Meyer motor scores increased by 6 [2.5-12.5] points in the arm and 1 [-0.5 - 5] point in the leg, mainly in weeks 1-6. Geriatric Depression Scale scores fell from 3 [1-5] at baseline (3/13 with depression) to 1 [0-4] (0/13 with depression) at week 12. Augmented reality gaming and functional objects were well received. Communication with smart devices was challenging. The experimental pill was taken, with photo verification, on 90.9% of days. Enrollees had large social networks. Automatic reports reliably notified study personnel when compliance was low or behavioral scores were concerning. Conclusions: High doses of home-based TR targeting arm and leg motor deficits are feasible and improve functional outcomes, motor deficits, and mood. The current system automates experimental pill ingestion and actionable reports to clinicians. Compliance declined over time, suggesting the need for novel approaches to extended periods of TR.

scholarly journals Stroke promotes the development of brain atrophy and delayed cell death in hypertensive rats

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Mohammed A. Sayed ◽  
Wael Eldahshan ◽  
Mahmoud Abdelbary ◽  
Bindu Pillai ◽  
Waleed Althomali ◽  
...  
Keyword(s):  
Cell Death ◽  
Fold Increase ◽  
Magnetic Resonance Images ◽  
Protein Quantification ◽  
Motor Deficits ◽  
Long Term Memory ◽  
Delayed Presentation ◽  
Hypertensive Rats ◽  
Post Stroke ◽  
Delayed Cell Death

AbstractPost-stroke cognitive impairment (PSCI) is a major source of disability, affecting up to two thirds of stroke survivors with no available therapeutic options. The condition remains understudied in preclinical models due to its delayed presentation. Although hypertension is a leading risk factor for dementia, how ischemic stroke contributes to this neurodegenerative condition is unknown. In this study, we used a model of hypertension to study the development of PSCI and its mechanisms. Spontaneously hypertensive rats (SHR) were compared to normotensive rats and were subjected to 1-h middle cerebral artery occlusion or sham surgery. Novel object recognition, passive avoidance test and Morris water maze were used to assess cognition. In addition, brain magnetic resonance images were obtained 12-weeks post-stroke and tissue was collected for immunohistochemistry and protein quantification. Stroked animals developed impairment in long-term memory at 4-weeks post-stroke despite recovery from motor deficits, with hypertensive animals showing some symptoms of anhedonia. Stroked SHRs displayed grey matter atrophy and had a two-fold increase in apoptosis in the ischemic borderzone and increased markers of inflammatory cell death and DNA damage at 12 weeks post-stroke. This indicates that preexisting hypertension exacerbates the development of secondary neurodegeneration after stroke beyond its acute effects on neurovascular injury.

scholarly journals A Case Report on Treating Post-stroke Visual Impairment with Gami-banhabakchulchunma-tang and Acupuncture

2021 ◽  
Vol 42 (5) ◽  
pp. 1045-1053
Author(s):  
Jeong-hui Kim ◽  
Hae-yoong Kim ◽  
Seo-young Won ◽  
Ju-young Ryu ◽  
Eun-sun Jung ◽  
...  
Keyword(s):  
Visual Field ◽  
Herbal Medicine ◽  
Visual Impairment ◽  
Rating Scale ◽  
Numerical Rating Scale ◽  
Visual Field Defects ◽  
Blurred Vision ◽  
Post Stroke ◽  
Numerical Rating ◽  
Field Defects

Objectives: This study investigated the effectiveness of acupuncture and herbal medicine (Gami-banhabakchulchunma-tang) for post-stroke visual impairment.Methods: A 79-year-old male with headache, dizziness, visual field defects, and blurred vision caused by a posterior cerebral infarction was treated with acupuncture and Gami-banhabakchulchunma-tang for three months. We used the Numerical Rating Scale (NRS) for each symptom and measured the patient’s eye-movement range.Results: Following treatment, the NRS score for headache decreased from 5 to 0, and for dizziness and blurred vision, it decreased from 5 to 1. The NRS score for visual field defects decreased from 5 to 2. The range of the patient’s left and right eye movements both improved, and no adverse side effects were observed during the admission period.Conclusions: Korean medical treatment with acupuncture and herbal medicine (Gami-banhabakchulchunma-tang) could effectively treat post-stoke visual impairment.

Abstract 11: Targeted Training of a Motor-parietal Circuit Improves Its Behavioral Output

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Steven C Cramer ◽  
Robert Zhou ◽  
Morgan Ingemanson ◽  
John J Choi ◽  
Katherine M Wu ◽  
...  
Keyword(s):  
Primary Motor Cortex ◽  
Brain Connectivity ◽  
Secondary Analysis ◽  
Visuomotor Learning ◽  
Visuomotor Tracking ◽  
Home Based ◽  
Eeg Connectivity ◽  
Hemiparetic Stroke ◽  
Chronic Hemiparetic Stroke ◽  
High Beta

Introduction: Emerging brain mapping methods measure function of individual brain circuits and have the potential to predict a patient’s gains and needs in the context of stroke rehabilitation. We recently described a motor-parietal circuit underlying visuomotor tracking and defined an EEG coherence measure (reflecting connectivity) that predicts visuomotor learning. Here we test the hypothesis that this EEG metric predicts visuomotor learning after stroke. Methods: After baseline dense-array resting EEG, patients with chronic hemiparetic stroke were provided with a home-based gaming system. During 9 half-hour training sessions, patients played games in which the stroke-affected arm tracked objects moving on the tabletop. Games were implemented using augmented reality, which we have found has advantages for motor training and in which virtual objects are projected into the real world and modified during game play. Results: Subjects (n=12) had affected arm Box&Blocks score of 15±12 and were 35±26 mo post-stroke. Visuomotor tracking improved significantly: on a standardized visuomotor test using the gaming system, scores increased from 60.5±11.5% to 74.0±3.2% (p=0.003). Gains were specific, as other behaviors were unchanged. Individual gains in visuomotor tracking score were predicted by the EEG connectivity metric from our prior study, coherence between leads overlying ipsilesional primary motor cortex (M1i) and ipsilesional lateral parietal region in the high beta (20-30 Hz) range, with higher connectivity predicting greater visuomotor tracking gains (r=0.61, p=0.037). This too was specific, as connectivity between M1i and other brain areas did not predict gains. Secondary analysis found that baseline visuomotor tracking scores correlated with several EEG connectivity measures, all inversely and all between M1i and contralesional regions. Conclusions: We found that (1) training that targets a specific brain circuit improves behavioral output of that circuit, and (2) an EEG measure of brain connectivity within that circuit predicts these behavioral gains--both with specificity. This approach may be useful for many neural circuits and their respective rehabilitation-related behaviors.

Abstract TP318: The Circumstances and Consequences of Post-stroke Falls

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Arlene A Schmid ◽  
H. Klar Yaggi ◽  
Nicolas Burrus ◽  
Vincent McClain ◽  
Charles Austin ◽  
...  
Keyword(s):  
Medical Care ◽  
Mental State ◽  
Fall Prevention ◽  
Secondary Analysis ◽  
Stroke Recovery ◽  
Large Trial ◽  
Post Stroke ◽  
Falling Asleep ◽  
One Year ◽  
The One

Introduction: Three-quarters of people with stroke sustain a fall. Fall risk and risk for injury persists into the chronics phases of stroke recovery. Currently, the circumstances surrounding post-stroke falls are not well understood; identifying these circumstances is a key step in the development of fall prevention programs. Likewise, the consequences of falls during the chronic phases of stroke are largely unexplored. Objectives: The objectives of the study were to identify the circumstances and consequences of post-stroke fall events. Methods: This is a secondary analysis of data derived from a large trial. To be included in the trial and these analyses, participants had to have survived a stroke and had a diagnosis of hypertension or blood pressure >140/90 mmHg. Demographics and stroke characteristics were recorded. Patients were asked about falls prospectively over the one-year study period. Once a fall event was identified, chart review and interviews were used to obtain information regarding circumstances and consequences of the fall. Fall circumstances were separated into intrinsic/personal and environmental categories including: falls with activity; falls with movement; falls due to trips or slips; falls related to a physical or mental state; location of the fall; and the season when the fall occurred. Consequences of falls were classified according to type of injury (laceration, fracture) and medical care received. Results: A total of 53 of the 225 (33%) participants reported a fall; 70% of falls occurred at home and 40% of falls were associated with impaired physical or mental state (e.g., falling asleep and falling out of a chair or inattention to tying shoes, or forgetting to use a device). Additionally, 21% of falls were associated with activities, 21% with mobility, and 34% with slips or trips. The majority of people who fell sustained an injury (72%); injuries ranged from bruising to fractures and 55% of those with an injury sought medical care (32% to emergency). Conclusion: Post-stroke falls are associated with an alarming rate of injury and healthcare utilization. Targeting mental and physical states may be key to fall prevention programming for people with chronic stroke.

Smartphone-Based Ecological Momentary Assessment as the New Standard Measure for Post-Stroke Functioning (Preprint)

2021 ◽  
Author(s):  
Quoc Bui ◽  
Katherine J. Kaufman ◽  
Vy Pham ◽  
Eric J. Lenze ◽  
Jin-Moo Lee ◽  
...  
Keyword(s):  
Ecological Momentary Assessment ◽  
Functional Disability ◽  
Longitudinal Research ◽  
Everyday Functioning ◽  
Post Stroke ◽  
Home Based ◽  
Mobility Devices ◽  
Ecological Momentary ◽  
Cognitive Problems ◽  
Momentary Assessment

BACKGROUND Functional disability is common after stroke. To inform new treatments, better measures are needed to advance our understanding of post-stroke functioning. Ecological momentary assessment (EMA) provides a putatively valid measure of everyday functioning by assessing patients during their lived experiences. OBJECTIVE This study aims to validate the smartphone-based EMA to characterize post-stroke everyday functioning and symptoms. METHODS Participants (N=212) with mild to moderate stroke were assessed five times daily for 14 days with EMA surveys to appraise mental, somatic, and cognitive symptoms, and what, with whom, and where participants were doing activities. Participants also completed standardized assessments during lab visits. RESULTS Most participants (median age = 60 years) were ischemic stroke (90%) and neurologically mild (median NIHSS = 2). Total 14,140 EMA surveys were analyzed. Participants were home 78% of the time and primarily participated in passive, unproductive activities, especially watching television and resting. EMA was sensitive to indicators of post-stroke disability; unemployed participants reported fewer vocational activities (W =12183.5, P < .001) but more activities of daily living (ADL) (W =6995, P < .001) and passive activities (W =7499.5, P =.003) than employed counterparts. Users of mobility devices and participants with cognitive problems spent significantly less time on vocational activities (W =2717, P< .0001 for mobility devices; W =7278, P= .03 for cognitive problems) and more on ADL (W =4807.5, P= .010 for mobility devices; W =9516.5, P< .001 for cognitive problems) than non-users and those without cognitive problems. Our data supported the validity of EMA methods in stroke, with small-to-moderate correlations of EMA with in-lab measures of daily functioning and very large correlations between EMA and in-lab measures of symptoms, especially those measuring the same constructs. CONCLUSIONS Our findings reveal that EMA tracked post-stroke functioning precisely. EMA may be beneficial in examining post-stroke functional recovery, monitoring patients for home-based interventions, and for longitudinal research. CLINICALTRIAL NA

Muscle torques and joint accelerations provide more sensitive measures of post-stroke movement deficits than joint angles.

2021 ◽  
Author(s):  
Ariel B Thomas ◽  
Erienne V Olesh ◽  
Amelia Adcock ◽  
Valeriya Gritsenko
Keyword(s):  
Motor Control ◽  
Motion Capture ◽  
Reaching Movements ◽  
Motor Deficits ◽  
Joint Angles ◽  
Active Joint ◽  
Joint Torques ◽  
Post Stroke ◽  
Muscle Moments ◽  
Muscle Torques

The whole repertoire of complex human motion is enabled by forces applied by our muscles and controlled by the nervous system. The impact of stroke on the complex multi-joint motor control is difficult to quantify in a meaningful way that informs about the underlying deficit in the active motor control and intersegmental coordination. We tested whether post-stroke deficit can be quantified with high sensitivity using motion capture and inverse modeling of a broad range of reaching movements. Our hypothesis is that muscle moments estimated based on active joint torques provide a more sensitive measure of post-stroke motor deficits than joint angles. The motion of twenty-two participants was captured while performing reaching movements in a center-out task, presented in virtual reality. We used inverse dynamics analysis to derive active joint torques that were the result of muscle contractions, termed muscle torques, that caused the recorded multi-joint motion. We then applied a novel analysis to separate the component of muscle torque related to gravity compensation from that related to intersegmental dynamics. Our results show that muscle torques characterize individual reaching movements with higher information content than joint angles do. Moreover, muscle torques enable distinguishing the individual motor deficits caused by aging or stroke from the typical differences in reaching between healthy individuals. Similar results were obtained using metrics derived from joint accelerations. This novel quantitative assessment method may be used in conjunction with home-based gaming motion-capture technology for remote monitoring of motor deficits and inform the development of evidence-based robotic therapy interventions.

Sign in / Sign up

Export Citation Format

Share Document