Sarcopenia and muscle weakness are prevalent complications of ischemic stroke (IS), with limited pharmacological options. This study identifies high-dose extracts of Chrysanthemum Flos (ECF) as a potential therapy for post-stroke muscle dysfunction by targeting PANoptosis-a pro-inflammatory programmed cell death pathway. Through its anti-inflammatory and antioxidant properties, ECF attenuates muscle atrophy and enhances functional recovery, offering novel insights into ISS treatment.

To evaluate the therapeutic efficacy of high-dose ECF in ischemic stroke-induced sarcopenia (ISS) and elucidate its regulatory role in PANoptosis-mediated muscle degeneration and protein homeostasis.

Preparation of a rat middle cerebral artery occlusion (MCAO) model using intravascular wire thrombus blockade. Cerebral injury was assessed using laser speckle contrast imaging, triphenyltetrazolium chloride (TTC) staining, and Zea-Longa neurological scoring. ECF's effects on muscle function were evaluated through gait analysis, muscle morphology (length and weight), grip strength, electromyography, and H&E staining. RNA sequencing was conducted to elucidate transcriptomic alterations and enriched pathways associated with ECF in ISS. PANoptosis-mediated myofiber and L6 cell damage was analyzed by flow cytometry (FC), immunofluorescence (IF), immunohistochemistry (IHC), and western blotting (WB). ECF composition and quality were validated using liquid chromatography-mass spectrometry (LC-MS).

ISS rats showed 83 % reductions in endurance, grip strength, and EMG signals compared to sham (p < 0.01), which improved to 70 % of normal after ECF treatment. ECF significantly increased muscle fiber area, alleviated mitochondrial damage, and improved sarcomere structure (p < 0.001). RNA-seq identified TNF signaling and PANoptosis (apoptosis, pyroptosis, necroptosis) as key drivers of ISS-induced muscle injury. The TNF-targeted inhibitor R7050 further confirmed TNF-α as a critical activator of Z-DNA binding protein 1 (ZBP1). ECF treatment significantly reduced tissue inflammation (p < 0.01) and inhibited ZBP1 expression (p < 0.01). Following ISS, key PANoptosis-related proteins, including ZBP1, Gasdermin D N-terminal fragment (GSDMD-N), Cleaved-Caspase3, Caspase6, Caspase8, phosphorylated mixed-lineage kinase domain-like (p-MLKL), Phosphorylated Receptor-Interacting Protein Kinase 1 (p-RIPK1), Phosphorylated Receptor-Interacting Protein Kinase 3 (p-RIPK3), and NOD-like receptor family pyrin domain containing 3 (NLRP3), were significantly upregulated (p < 0.05), while ECF-H treatment significantly suppressed their expression (p < 0.05, p < 0.01). Additionally, ECF significantly promoted the expression of muscle protein synthesis factors (myogenic differentiation 1 (MyoD1) and recombinant myosin heavy chain 1 (MYH), p < 0.01) and inhibited protein degradation factors (muscle RING-finger protein-1 (MuRF1) and muscle atrophy F-Box protein (MAFbx), p < 0.01), thus maintaining muscle protein homeostasis. The results from PCR, WB, IHC, IF, and FC experiments were consistent with RNA-seq findings.

ECF ameliorates ISS in MCAO rats by inhibiting muscle PANoptosis, which simultaneously reduces protein degradation and enhances protein synthesis.

Benzodiazepine (BZD) use in older adults after acute ischemic stroke (AIS) is common. We aimed to assess the risk of falls or fall-related injuries (FRIs) in older adults after the use of BZDs during the acute poststroke recovery period.

We emulated a hypothetical randomized trial of BZD use during the acute poststroke recovery period using linked data from the Get With the Guidelines Stroke Registry and Mass General Brigham's electronic health records. Our cohort included patients aged 65 years and older with an AIS admission between 2014 and 2021, no documented previous stroke, and no BZD prescriptions in the 3 months before admission. The potential for immortal time and confounding bias was addressed separately using inverse probability weighting.

We analyzed data from 495 patients who initiated inpatient BZDs within 3 days of admission and 2,564 who did not. After standardization, the estimate was 694 events per 1,000 (95% CI 676-709) for the BZD initiation strategy and 584 events per 1,000 (95% CI 575-595) for the noninitiation strategy. Subgroup analyses showed risk differences of 142 events per 1,000 (95% CI 111-165) and 85 events per 1,000 (95% CI 64-107) for patients aged 65-74 years and 75 years and older, respectively. Risk differences were 187 events per 1,000 (95% CI 159-206) for patients with minor (NIH Stroke Severity Scale score ≤ 4) AIS and 32 events per 1,000 (95% CI 10-58) for those with moderate-to-severe AIS.

Initiating BZDs within 3 days of an AIS is associated with an elevated ten-day risk of falls or FRIs, particularly for patients aged 65-74 years and for those with mild stroke. This underscores the need for caution when initiating BZDs, especially among individuals likely to be ambulatory during the acute and subacute poststroke period.

Evidence-based rehabilitation and secondary prevention interventions improve poststroke functional recovery and reduce secondary complications. However, stroke rehabilitation expertise, processes of care, and educational resources vary among sites where postacute care (PAC) is delivered. The American Heart Association developed quality standards based on the American Heart Association 2016 Guidelines for Adult Stroke Rehabilitation and Recovery to address these gaps. An interdisciplinary PAC standards writing committee identified key areas for PAC: quality improvement, medical management, care coordination, patient/caregiver and personnel education, and program management. Subgroups developed draft standards, combining results from a national landscape survey of PAC sites with clinical practice guidelines. The committee then refined the draft standards using a consensus-based process. American Heart Association staff and PAC sites in Montana convened a learning collaborative to gather feedback and provide gap analyses of the standards relative to current practices. Qualitative input from beta testing in Montana and quantitative results from the nationwide survey and Montana sites were analyzed and used to refine the standards further. The national landscape survey demonstrated that most sites do not meet the proposed standards: stroke program oversight structure (78% fall short), stroke rehabilitation leadership (70%), stroke-specific order sets/protocols (61%), and policies requiring staff stroke education (66%). Regarding Montana findings, 41% of the PAC sites have no mechanisms to identify areas of quality improvement specific to their stroke rehabilitation programs, and 59% do not use standardized tools to ensure that performance improvement initiatives are followed. However, with adequate support and resources, most Montana sites stated that they would be able to meet the proposed standards. We conclude that the Stroke PAC Quality Standards are applicable in PAC settings and provide a pathway to improving access to high-quality care for stroke survivors. Outcome studies are needed to confirm anticipated improvements in medical and functional outcomes.

Despite remarkable progress in robotic exoskeletons, exoskeletons are still far from matching human-level guidance and locomotion performance in gait training or movement enhancement. A desirable exoskeleton would first provide a standard gait profile by learning from human operators while requiring body weight support with active human-following to govern dynamic locomotion synchronization. To address these issues, in this article, we propose a human operator-involved dynamic locomotion synchronization control framework for the lower limb exoskeleton actively following gait training with gravity-supporting. First, we designed a human motion capture system based on a five-link model for the locomotion of a human operator. To reproduce human-level motor skills, we use whole-body teleoperation to leverage human control intelligence to command the locomotion of a robotic exoskeleton system. Specifically, using the linear inverted pendulum (LIP) model, the human operator's divergent component of motion (DCM) is obtained by the human motion capture system. The dynamic similarity is used to generate a reference DCM for the robotic exoskeleton to synchronize the human operator's movement. Finally, a fuzzy-based adaptive controller is designed to track the synchronous trajectory for the exoskeleton in the presence of robotic dynamics uncertainties with input saturation. Experiments on the human subject are carried out to demonstrate the effectiveness of the proposed method.

The international incidence of stroke in people of working age is rising. As such, meaningful work return is a major rehabilitation goal for many individuals, including those with aphasia. This scoping review aimed to outline the post-stroke aphasia evidence related to work outcomes, factors influencing employment along with contemporary vocational-language and communication rehabilitation practice. The review employed terms related to aphasia, stroke, rehabilitation, and return to work in publications preceding 25.6.2023. Data were descriptively analysed, and vocational outcomes were summarized at defined timepoints. Of the 908 articles reviewed, 31 papers were included. Individuals with post-stroke aphasia consistently have lower rates of return to work than those post-stroke without aphasia. Employment at one year was 34.29% for those with aphasia compared to 58.46% for people without aphasia. No literature reported vocational-language assessment practices and there were minimal work-focused aphasia interventions identified. There was insufficient evidence to clearly identify person-related, rehabilitation, workplace or other factors influencing work return. This scoping review has identified that there are gaps in knowledge about the factors that influence work return and targeted vocational rehabilitation for this group. Future research to optimize return to work for individuals with aphasia is recommended.

Few studies have been focused on rehabilitation after an acute intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH), and the benefits remain unclear since mixed results have been reported. The objective of this systematic review was to determine whether early rehabilitation, started within 7 days of stroke onset after ICH or SAH improves recovery (e.g. the proportion of independent survivors) compared with usual care.

Searches of PubMed and CINAHL for terms including hemorrhage stroke, ICH, SAH, stroke, Randomized Controlled Trial (RCT), early rehabilitation. And contacted authors as required between 1 January 2005 to 31 October 2021. Selection criteria included only RCTs of people in China with acute ICH or SAH, comparing an intervention group that started early rehabilitation (i.e. within 7 days of admission) with usual care. The primary outcome was activities of daily living (Barthel Index Score). The secondary outcome was stroke severity (National Institute of Health Stroke Scale [NIHSS] or Fugl-Meyer motor assessment scale). Two review authors independently selected the eligible publications, extracted the data, assessed the risk of bias, and applied the GRADE approach to assess the quality of the evidence.

From 1777 retrieved references, 211 citations included potentially appropriate RCTs, 11 articles were eligible (approximately 44% female; the ages across the trials ranged from 28 to 82 years). We found that timing of rehabilitation interventions after hemorrhagic stroke varied (from 1 to 7 days after admission). Average hospital lengths of stay were 14 days to 1 month. Compared with controls, at 6 months patients who received early rehabilitation showed improvements in the Barthel Index (standardized mean difference: 2.11, 95% confidence interval (CI): 0.87,3.43, P<0.001, I2=100%), the NIHSS, (standardized mean difference: -1.26, 95%CI: -2.53,0.01, P<0.001, I2=99%), or Fugl-Meyer Score (standardized mean difference: 2.72, 95%CI: 1.12, 4.32, P<0.001, I2=100%).

Early rehabilitation after hemorrhagic stroke may improve patients' quality of life compared with usual care. However, implementation is hampered by fragmented resources and lack of standardized protocols in China. Future research should focus on developing culturally adapted protocols and addressing resource shortages and systemic barriers.

CRD 42022342653.

Physical, cognitive, and psychosocial impairments experienced by individuals post-stroke detrimentally impact health-related quality of life (HRQoL). Rehabilitation interventions targeting the recovery of motor function aim to improve community reintegration and HRQoL. Aerobic exercise has also been shown to have global effects in individuals post-stroke, positively affecting motor and mood-related outcomes.

To determine the effects of forced-rate aerobic exercise (FE) coupled with upper extremity repetitive task practice (RTP) on HRQoL and mood in individuals post-stroke.

A rater blinded randomized clinical trial was conducted. Individuals ≥6 months post-stroke received 90-minute sessions of FE+RTP or time-matched RTP alone, 3×/week for 8 weeks. The Stroke Impact Scale (SIS), Patient-Reported Outcomes Measurement Information System (PROMIS-29), and Centers For Epidemiology Studies-Depression Scale (CES-D) were administered at baseline, end of treatment (EOT), EOT+6 months, and EOT+12 months.

Sixty participants enrolled in the study and 57 completed the self-reported questionnaires (FE + RTP, N = 29; RTP alone, N = 28). Both groups improved significantly at each time point in the following SIS domains: physical problems, feelings, activities of daily living, mobility, hand use, meaningful activities, and overall recovery; and in the participation domain of PROMIS-29. Depressive symptomology as measured by CES-D improved from baseline to EOT+6. There were no significant group differences in any of the outcomes.

Both interventions were comparably effective in improving HRQoL despite the FE+RTP group receiving only half the dose of RTP compared to the control group (RTP only). Improvements were maintained up to 1 year post-intervention.

Motor rehabilitation aims to help people after stroke to gain optimal motor functioning, independence and quality of life. This European Stroke Organisation (ESO) guideline provides updated, evidence-based support for clinical practice in six agreed critical areas: dose for upper limb and gait therapy, high-intensity gait training, effect of therapy transfer package, group versus individual therapy and sit-to-stand training. The guideline was developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development and Evaluation (GRADE). Expert consensus statements are provided where a GRADE recommendation cannot be made due to insufficient evidence. For therapy dose, very low quality evidence supports a weak recommendation to provide an additional minimal dose of 20 h of repetitive upper limb practice to improve arm capacity. For gait, expert consensus suggests that an additional minimal dose of 20 h of walking practice could be beneficial for walking capacity. For high-intensity gait training, moderate quality evidence supports a strong recommendation for high-intensity gait training to improve walking endurance in people with chronic stroke and stable cardiovascular status, while low quality evidence supports a weak recommendation for improving walking speed. An expert consensus suggests using a transfer package when providing upper limb task-specific training to enhance transfer to daily life. For group therapy, a weak recommendation based on very low quality evidence suggests that task-specific group-based therapy is non-inferior to individual therapy for improving balance, gait speed and walking endurance. A weak recommendation based on moderate quality evidence suggests additional sit-to-stand training to improve balance.

BackgroundThe post-thrombectomy recovery phase has significant influence on long-term patient outcomes. Our study aims to explore the effect of post-thrombectomy rehabilitation strategies on modified Rankin Scale (mRS) at 90-day.MethodsA search of PubMed, Scopus, Web of Science, ClinicalTrials.gov, and the Cochrane Library from inception to April 2024. Randomized controlled trials (RCTs) were included and assessed for quality using the Cochrane risk of bias tool. The rehabilitation strategies were divided into three groups: as per institutional care, as per national guideline, or not specified. We performed meta-regression to identify the association between rehabilitation strategy used and 90-day outcome defined using mRS.Results23 RCTs were included with 6649 patients (mean age 67 and 26% of patients were men). Rehabilitation "as per institutional care" was the most common (52%, 95% confidence interval (CI):31%-72%), followed by "as per national guidelines" (17%, 95% CI:5%-39%). We found statistically significant variations in proportions of rehabilitation strategies (F(2,97) = 0.035, p = 0.01). A two-proportion z-test indicated a borderline significant difference between "as per institutional care" (52%) and "as per national guidelines" (17%) (χ2(1) = 3.52, p = 0.06). In meta-regression, rehabilitation strategies used in the RCT significantly influenced the proportion of patients enrolled in the RCT who achieved mRS 0-2 at 90 days post-thrombectomy (QM (df = 1) = 5.06, p = 0.025). Trials using rehabilitation "as per institutional care" (log odds ratio (OR) = 0.64, 95% CI [0.42, 0.87], p < 0.01) and those using rehabilitation "as per national guidelines" (log odds ratio = 0.58, 95% CI [0.07-1.08], p = 0.02) were associated with statistical significantly higher odds of having higher proportion of patients with mRS 0-2 at 90 days.ConclusionsThere is variation in rehabilitation strategies utilized post-thrombectomy which influences functional outcomes at 90 days. Rehabilitation protocols should be standardized in RCTs evaluating thrombectomy in acute ischemic stroke patients.

To pool and rank the efficacy of various stimulation therapies, including repetitive peripheral magnetic stimulation (rPMS), neuromuscular electrical stimulation (NMES), functional electrical stimulation (FES), transcranial magnetic stimulation (TMS), and combinations of these interventions on upper extremity function, activities of daily living (ADL), and spasticity after stroke relative to sham/conventional rehabilitation.

MEDLINE, Scopus, Physiotherapy Evidence Database, Cochrane Central Register of Controlled Clinical Trials, and Google Scholar were searched from inception to July 2022.

Randomized controlled trials comparing any of the interventions mentioned above (rPMS, NMES, FES, TMS, NMES+rPMS, NMES+TMS, FES+TMS, and conventional rehabilitation) on upper extremity function, ADL, or spasticity from five databases were systematically reviewed and collected. Two-stage network meta-analysis was applied.

Thirty-four studies involving 1476 patients reporting upper extremity function with the Fugl-Meyer Assessment were pooled. NMES combined with rPMS, NMES, NMES combined with TMS, TMS, and FES showed significantly higher improvement than conventional rehabilitation, with pooled mean differences (95% confidence intervals) of 14.69 (9.94-19.45), 9.09 (6.01-12.18), 6.10 (2.51-9.69), 4.07 (0.33-7.81), and 3.61 (0.14-7.07) respectively. NMES combined with rPMS had the highest probability for improving upper extremity function. NMES plus TMS had the highest probability for improving ADL, but none of the interventions showed significant differences in spasticity.

NMES plus rPMS might be the best intervention to improve upper extremity functions, with NMES plus TMS most likely to lead to improved ADL but the quality of the evidence is low.

Stroke is one of the most complex diseases of our time; it impacts individuals across many facets of functioning, depending on the areas of the brain that have been damaged [...].

The triglyceride-glucose body mass index (TyG-BMI) is acknowledged as a dependable surrogate biomarker for the evaluation of insulin resistance (IR). Current research indicates a significant correlation between TyG-BMI and the risk of subsequent cardiovascular events in individuals diagnosed with cardiovascular-kidney-metabolic syndrome (CKM) at stages 0-3. Nevertheless, the prognostic significance of TyG-BMI in patients with CKM stage 4 has not been extensively investigated, and there is a paucity of evidence available on this topic. The study utilized patient data from the Medical Information Mart for Intensive Care (MIMIC-IV) database, categorizing the data into quartiles based on the TyG-BMI index. The primary outcomes of interest were all-cause mortality at 180 days and at one year. To assess the relationship between the TyG-BMI index and these outcomes in patients diagnosed with stage 4 CKM, a Cox proportional hazards model was employed. Additionally, a restricted cubic splines(RCS) model was applied to further investigate the associations between the TyG-BMI index and the specified outcomes. A total of 1,885 patients participated in the study, with 62.49% of the cohort being male. The all-cause mortality rates were recorded at 30.50% at 180 days and 35.12% at one year. Analysis using a multivariate Cox proportional hazards model revealed that an increase in the TyG-BMI index was significantly correlated with a reduction in the risk of all-cause mortality at both the 180-day and one-year marks. Specifically, for each standard deviation increase in the TyG-BMI index, the risk of all-cause mortality decreased by 17% within 180 days (HR = 0.83, 95% CI: 0.76-0.91) and by 21% within one year (HR = 0.79, 95% CI: 0.71-0.87). Furthermore, regression analysis utilizing RCS indicated a linear decrease in all-cause mortality rates associated with increasing TyG-BMI index values over both the 180-day and one-year periods (P for nonlinearity = 0.171 and P for nonlinearity = 0.141, respectively). In patients diagnosed with stage 4 CKM syndrome, a reduced TyG-BMI index was found to be significantly correlated with a heightened risk of all-cause mortality within both 180 days and one year. Consequently, the TyG-BMI index may be utilized as an effective instrument for risk stratification and prognostic assessment in this patient population.

Gait impairment post-stroke is highly heterogeneous. Prior studies classified heterogeneous gait patterns into subgroups using peak kinematics, kinetics, or spatiotemporal variables. A limitation of this approach is the need to select discrete features in the gait cycle. Using continuous gait cycle data, we accounted for differences in magnitude and timing of kinematics. Here, we propose a machine-learning pipeline combining supervised and unsupervised learning. We first trained a Convolutional Neural Network and a Temporal Convolutional Network to extract features that distinguish impaired from neurotypical gait. Then, we used unsupervised time-series k-means and Gaussian Mixture Models to identify gait clusters. We tested our pipeline using kinematic data of 28 neurotypical and 39 individuals post-stroke. We assessed differences between clusters using ANOVA. We identified two neurotypical gait clusters (C1, C2). C1: normative gait pattern. C2: shorter stride time. We observed three post-stroke gait clusters (S1, S2, S3). S1: mild impairment and increased bilateral knee flexion during loading response. S2: moderate impairment, slow speed, short steps, increased knee flexion during stance bilaterally, and reduced paretic knee flexion during swing. S3: mild impairment, asymmetric swing time, increased ankle abduction during the gait cycle, and reduced dorsiflexion bilaterally. Our results indicate that joint kinematics post-stroke are mostly distinct from controls, and highlight kinematic impairments in the non-paretic limb. The post-stroke clusters showed distinct impairments that would require different interventions, providing additional information for clinicians about rehabilitation targets.

Walking difficulties are common after a stroke. During rehabilitation, electromechanical and robotic gait-training devices can help improve walking. As the evidence and certainty of the evidence may have changed since our last update in 2020, we aimed to update the scientific evidence on the benefits and acceptability of these technologies to ensure they remain a viable option for stroke rehabilitation.

Primary • To determine whether electromechanical- and robot-assisted gait training versus physiotherapy (or usual care) improves walking in adults after stroke. Secondary • To determine whether electromechanical- and robot-assisted gait training versus physiotherapy (or usual care) after stroke improves walking velocity, walking capacity, acceptability, and death from all causes until the end of the intervention phase.

We searched CENTRAL, MEDLINE, Embase, and seven other databases. We handsearched relevant conference proceedings, searched trials and research registers, checked reference lists, and contacted trial authors to identify further published, unpublished, and ongoing trials. The date of the latest search was December 2023.

We included all randomised controlled trials and randomised controlled cross-over trials in people over the age of 18 years diagnosed with stroke of any severity, at any stage, in any setting, evaluating electromechanical- and robot-assisted gait training versus physiotherapy (or usual care).

Our critical outcome was the ability to walk independently, measured with the Functional Ambulation Category (FAC). An FAC score of 4 or 5 indicated independent walking over a 15-metre surface, irrespective of aids used, such as a cane. An FAC score less than 4 indicates dependency in walking (supervision or assistance, or both, must be given in performing walking). Important outcomes included walking velocity and capacity, as well as dropouts.

We used Cochrane's RoB 1 tool.

Two review authors independently selected trials for inclusion, assessed methodological quality and risk of bias, and extracted data. We used random-effects models for the meta-analysis. We assessed the certainty of evidence using the GRADE approach.

We included 101 studies (39 new studies plus 62 studies from previous versions) with a total of 4224 participants after stroke in our review update.

Electromechanical-assisted gait training in combination with physiotherapy probably increases the odds of participants becoming independent in walking (odds ratio (OR) 1.65, 95% confidence interval (CI) 1.21 to 2.25; P = 0.001; I² = 31%; 51 studies, 2148 participants; moderate-certainty evidence); probably does not increase mean walking velocity (mean difference (MD) 0.05 m/s, 95% CI 0.02 to 0.08; P < 0.001; I² = 58%; 73 studies, 3043 participants; moderate-certainty evidence); and does not increase mean walking capacity (MD 11 metres walked in 6 minutes, 95% CI 1.8 to 20.3; P = 0.02; I² = 43%; 42 studies, 1966 participants; high-certainty evidence). Electromechanical-assisted gait training does not increase or decrease the risk of loss to the study during the intervention or the risk of death from all causes (high-certainty evidence). At follow-up after study end, electromechanical-assisted gait training in combination with physiotherapy may not increase the odds of participants becoming independent in walking (OR 1.64, 95% CI 0.77 to 3.48; P = 0.20; I² = 69%; 8 studies, 569 participants; low-certainty evidence), and probably does not increase mean walking velocity (MD 0.05 m/s, 95% CI -0.03 to 0.13; P = 0.22; I² = 66%; 17 studies, 857 participants; moderate-certainty evidence) or mean walking capacity (MD 9.6 metres walked in 6 minutes, 95% CI -14.6 to 33.7; P = 0.44; I² = 53%; 15 studies, 736 participants; moderate-certainty evidence). Our results must be interpreted with caution because (1) some trials investigated people who were independent in walking at the start of the study; and (2) there was variation between trials with respect to the devices used and duration and frequency of treatment.

Moderate-certainty evidence shows that people who receive electromechanical-assisted gait training in combination with physiotherapy after stroke are probably more likely to achieve independent walking than people who receive gait training without these devices.We concluded that nine patients need to be treated to prevent one dependency in walking. Further research should consist of large, definitive pragmatic phase 3 trials undertaken to address specific questions about the most effective frequency and duration of electromechanical-assisted gait training, as well as how long any benefit may last. Future trials should consider time poststroke in their trial design.

This Cochrane review had no dedicated funding.

Protocol (2006): doi:10.1002/14651858.CD006185 Original review (2007): doi:10.1002/14651858.CD006185.pub2 Review update (2013): doi:10.1002/14651858.CD006185.pub3 Review update (2017): doi:10.1002/14651858.CD006185.pub4 Review update (2020): doi:10.1002/14651858.CD006185.pub5.

App. 25% of stroke survivors develop post-stroke spasticity (PSS) over the first year after a stroke, and they also experience motor weakness, which may prevent effective recovery by restricting mobility and participating in exercise programmes. Patients generally experience rapid improvement with Botulinum Toxin Type A (BoNT-A) therapy for PSS. Unfortunately, clinical trials demonstrating benefits from BoNT-A treatment are of short duration. Consequently, it is not known if treatment-related improvements in mobility could also contribute to lowering the risks of secondary cardiovascular (CV) events and all-cause death. To assess if BoNT-A injections could also have an impact on long-term outcomes, we developed a 10-year survival model comparing the effects of AbobotulinumtoxinA (aboBoNT-A) injections and rehabilitation therapy (aboBoNT-A+RT) with rehabilitation therapy (RT) alone. The Functional Independence Measure (FIM) appeared to be the only functional outcome allowing us to model the effect of aboBoNT-A injections on all-cause mortality. Stroke survivors who reported better improvement in FIM score during rehabilitation had lower risk of all-cause mortality during follow-up. Patients treated with aboBoNT-A injections + RT showed better improvement in FIM score than patients treated without aboBoNT-A injections. Our modelling results showed that the addition of aboBoNT-A injections to RT led to a reduction of 8.8% in the risk of all-cause mortality, and a relative increase of 12.8% in discounted life-years. The addition of aboBoNT-A injections to RT led to an increase in total costs of £42.328 over 10 years (based on National Health Service (NHS) UK cost collection 2018/2019). In the base-case scenario, incremental costs were driven by the increased number of hours of home care and RT for patients treated with aboBoNT-A injections compared with RT alone. Assuming an incremental cost-effectiveness ratio (ICER) threshold of £30.000, the probabilistic sensitivity analysis found a 73% likelihood that aboBoNT-A+RT demonstrated cost-effectiveness compared with RT alone. Our work advocates for the need to consider and to capture the impact of BoNT-A injections on all-cause mortality and secondary events, such as CV events and recurrent stroke, which are prevalent in stroke survivors.

Stroke recovery is a critical global-health priority; there is growing interest alternative therapies in scalp acupuncture (SA) to overcome the limitations of conventional treatments and improve outcomes. This study provides an overview of systematic reviews to evaluate the evidence on the effectiveness and safety of SA and to compare its therapeutic potential with traditional acupuncture (TA).

A systematic search of 12 databases was conducted to identify systematic reviews and meta-analyses, completed on September 30, 2023, was performed without language restrictions. Selection criteria included adult stroke patients treated with SA, focusing on comparisons of effectiveness and safety in neurological deficits, motor function, disability, and total efficacy rate. Two reviewers independently screened studies and assessed methodological quality using AMSTAR-2, ROBIS, PRISMA-A, and GRADE frameworks. Data were synthesized to compare SA and TA for stroke outcomes, using total searched SA studies and TA data from the Cochrane review, followed by an analysis of high-quality studies to enhance evidence reliability.

After overviewing seven systematic reviews, the certainty of evidence supporting the standalone effectiveness and safety of SA remains low owing to methodological shortcomings. However, SA showed a greater effect size in the neurological deficits (-0.96 vs -0.53) in total studies and high-quality studies (-0.92 vs -0.48). Regarding motor function, SA had a higher effect size in total studies (0.94 vs 0.70), but TA outperformed it in high-quality studies (0.39 vs 0.82). Regarding disability outcomes, TA had a slightly larger effect size in total studies (1.27 vs 1.06), whereas SA surpassed it in high-quality studies (1.65 vs. 1.16).

This overview highlights the potential of SA as an effective alternative therapy for stroke recovery, with high-quality studies demonstrating its effectiveness in improving neurological deficits and disability outcomes. This work guides clinicians on integrating SA for stroke recovery and offers insights for improving public health rehabilitation strategies. Despite limitations in the overall evidence owing to methodological shortcomings, the positive results from high-quality studies support SA as a possible approach for stroke recovery, underscoring the need for further rigorous research to strengthen its clinical application.

Objective.Recently, a novel language training using an auditory brain-computer interface (BCI) based on electroencephalogram recordings has been proposed for chronic stroke patients with aphasia. Tested with native German patients, it has shown significant and medium to large effect sizes in improving multiple aspects of language. During the training, the auditory BCI system delivers word stimuli using six spatially arranged loudspeakers. As delivering the word stimuli via headphones reduces spatial cues and makes the attention to target words more difficult, we investigate the influence of added pitch information. While pitch modulations have shown benefits for tone stimuli, they have not yet been investigated in the context of language stimuli.Approach.The study translated the German experimental setup into Dutch. Seventeen native Dutch speakers participated in a single session of an exploratory study. An incomplete Dutch sentence cued them to listen to a target word embedded into a sequence of comparable non-target words while an electroencephalogram was recorded. Four conditions were compared within-subject to investigate the influence of pitch modulation: presenting the words spatially from six loudspeakers without (6D) and with pitch modulation (6D-Pitch), via stereo headphones with simulated spatial cues and pitch modulation (Stereo-Pitch), and via headphones without spatial cues or pitch modulation (Mono).Main results.Comparing the 6D conditions of both language setups, the Dutch setup could be validated. For the Dutch setup, the binary AUC classification score in the 6D and the 6D-Pitch condition were 0.75 and 0.76, respectively, and adding pitch information did not significantly alter the binary classification accuracy of the event-related potential responses. The classification scores in the 6D condition and the Stereo-Pitch condition were on the same level.Significance.The competitive performance of pitch-modulated word stimuli suggests that the complex hardware setup of the 6D condition could be replaced by a headphone condition. If future studies with aphasia patients confirm the effectiveness and higher usability of a headphone-based language rehabilitation training, a simplified setup could be implemented more easily outside of clinics to deliver frequent training sessions to patients in need.

Impaired postural alignment is commonly observed following acquired brain injury (ABI), and improved postural alignment is associated with mobility recovery in the pre-ambulant phase (i.e. sitting and standing) following ABI. It is unknown whether this association exists for walking.

This study aimed to; i) determine whether the postural alignment and dispersion (PAD) score, previously validated in sitting and standing, can be applied to quantify postural alignment during walking in people with ABI, and ii) whether the PAD discriminates those with slower and faster self-selected walking speed.

Forty-two adults with mobility limitations following ABI, who could walk without assistance for 10 m, and 34 healthy controls (HCs) underwent three-dimensional gait analysis at their self-selected walking speed. Outcome measures were the PAD score (whole-body postural alignment), walking speed (m/s), lateral centre of mass displacement (dynamic postural control), and the Gait Profile Score (walking quality). Outcome measures were evaluated for between-group differences (t-tests and Cohen's d effect size) and individual incidence of abnormality.

Adults with ABI had significantly higher PAD scores compared to HCs (p < 0.05; ES > 0.49). Within the ABI cohort, PAD scores were not significantly different at both more affected (p > 0.05; ES 0.37) and less affected (p > 0.05; ES 0) midstance between faster (≥ 0.8 m/s) and slower walkers (< 0.8 m/s). In contrast, dynamic postural control and walking quality were significantly worse in those participants who walked slower (p < 0.01; ES > 0.80). Prevalence of abnormality was low, capturing 19 % and 26 % of participants for the more affected and less affected lower limb PAD scores.

Preliminary evidence suggests postural alignment may be impaired during walking in people with ABI. The PAD did not discriminate between slower or faster walkers within the ABI cohort. Further research is required to determine the optimal method for measuring postural alignment during walking.

Digital health innovations (DHI) in medicine have led to remarkable progress in stroke prevention and management worldwide. For example, education regarding the knowledge and awareness of stroke, risk scores for stroke incidence, and wearable devices have been used for primary prevention. Automatic telemedicine and diagnostic imaging have been introduced for the treatment of acute stroke. Rehabilitation using robot-assisted training, virtual reality systems, and other applications has been attempted. Information sharing using the DHI may be expected in secondary prevention. Although these DHI technologies likely assist in stroke prevention and management, their usage remains insufficient, partly because of insufficient evidence. Here, we report the current status and problems associated with the effective and widespread use of DHI in Japan.

An accurate and reliable functional prognosis is vital to stroke patients addressing rehabilitation, to their families, and healthcare providers. This study aimed at developing and validating externally patient-wise prognostic models of the global functional outcome at discharge from intensive inpatient post-acute rehabilitation after stroke, based on a standardized comprehensive multidimensional assessment performed at admission to rehabilitation. Patients addressing intensive inpatient rehabilitation pathways within 30 days from stroke were prospectively enrolled in two consecutive multisite studies. Demographics, description of the event, clinical/functional, and psycho-social data were collected. The outcome of interest was disability in basic daily living activities at discharge, measured by the modified Barthel Index (mBI). Machine learning-based prognostic models were developed, internally cross-validated, and externally validated. Interpretability techniques were applied for the analysis of predictors. 385 patients were considered, 220 (165) for training (external test) sets. A 50.9% (55.8%) of women, 79.5% (80.0%) of ischemic, and a median [interquartile range- IQR] age of 80.0[15.0] (79.0[17.0]) were registered. The Support Vector Machine obtained the best validation performances and a median absolute error [IQR] on discharge mBI estimation of 11.5[15.0] and 9.2[13.0] points on the internal and external testing, respectively. The baseline variables providing the main contributions to the predictions were mBI, motor upper-limb score, age, and cognitive screening score. We achieved a solution to support the formulation of a functional prognosis at intensive rehabilitation admission. The interpretability analysis confirms the relevance of easily collected motor and cognitive dataat admission and of the patient's age.Trial registration: Prospectively registered on ClinicalTrials.gov (registration numbers RIPS NCT03866057, STRATEGY NCT05389878).

Sarcopenia is a prevalent and debilitating condition among stroke survivors, characterized by the progressive loss of muscle mass and function. This multicenter, randomized controlled trial aims to evaluate the effects of a community-based high-speed power training (HSPT) program tailored for individuals with post-stroke sarcopenia. The intervention bridges the gap between hospital-based rehabilitation and long-term community reintegration by offering physician-supervised, progressive resistance training sessions conducted twice weekly for eight weeks. Participants are assessed on muscle strength, physical performance, balance, body composition, and gait before and after the intervention. The study utilizes validated tools such as handgrip dynamometry, dual-energy X-ray absorptiometry (DXA), short physical performance battery (SPPB), and timed up and go (TUG) to comprehensively evaluate outcomes. Through stratified randomization and a double-blind design, the trial seeks to minimize bias and maximize clinical relevance. The results from this protocol are expected to inform evidence-based guidelines for stroke rehabilitation and support scalable community-based exercise programs aimed at improving functional recovery and quality of life in this population.

Early out-of-bed mobilization is recommended for individuals with severe acquired brain injury and impaired consciousness to promote recovery. Robot-assisted gait training (RAGT) utilizes robotic assistance to facilitate neuroplastic changes through repetitive training and feedback. We aimed to map the evidence of RAGT in non-ambulatory individuals with impaired consciousness or cognitive functioning, focusing on the rationales underpinning its use and the assessment methods employed.

Following the Joanna Briggs Institute and PRISMA scoping review guidelines, we systematically searched for studies involving adults with severe acquired brain injury. Source selection, data extraction, and charting were performed in duplicate.

Out of 10 444 records screened, seven were included, involving 162 participants. The studies included one randomized and two non-randomized clinical trials, two retrospective studies, and two case reports. RAGT aimed to improve physical recovery (n = 6), arousal stimulation (n = 4), and safety (n = 4). Twenty-six outcome measures were reported.

Our review highlights a research gap in RAGT for individuals with severe brain injury and cognitive impairments. Specifically, the underlying rationales need investigation, and standardized outcome measures must be established. RAGT shows potential in improving functional recovery and consciousness, but future studies must address safety, and feasibility while navigating ethical challenges.

Stroke remains a leading cause of morbidity and mortality worldwide, contributing significantly to public health burdens. Cardiovascular and metabolic risk factors such as diabetes, hypertension, obesity, and dyslipidaemia are strongly associated with an increased risk of stroke. The cardio-metabolic index (CMI), which integrates these factors into a single measure, has emerged as a potential predictor of stroke. This systematic review and meta-analysis intended to examine the link between CMI and risk of stroke, offering an in-depth evaluation of its predictive value METHODS: A systematic search was conducted in PubMed, Embase, and Web of Science until 10 December 2024. The inclusion criteria focused on observational studies (cohort, cross-sectional, and case-control) that reported original data on the association of CMI and stroke risk. Data extraction was standardized, and quality was assessed using the Newcastle-Ottawa Scale. Meta-analysis was performed using a random effects model in R software version 4.4 RESULTS: From 545 articles initially retrieved, with 5 studies met inclusion criteria, encompassing over 100,000 participants. Meta-analysis showed a significant association between elevated CMI and stroke risk with a pooled RR of 1.66 (95 % CI: 1.25 to 2.20). A subgroup analysis of cohort studies yielded a pooled HR of 1.63 (95 % CI: 1.21 to 2.21). There was no significant heterogeneity across studies (I² = 0 %).

Our findings demonstrated a strong association between elevated CMI and an increased risk of stroke. CMI, by integrating multiple cardiovascular and metabolic factors, serves as a comprehensive predictor of stroke risk. Incorporating CMI into routine health screenings could enhance early identification and prevention efforts, ultimately aiding in the reduction of stroke incidence.

To synthesise evidence on the effectiveness of modified constraint-induced movement therapy on upper limb function in stroke survivors within inpatient hospital settings.

A systematic review was pre-registered in PROSPERO (CRD42023421715b) and searched six databases (EMBASE, AMED, MEDLINE, CINAHL, Cochrane Library, OTseeker) up to November 2024.

Articles included adults with stroke undergoing modified constraint-induced movement therapy in inpatient hospital settings. Article quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. Homogenous data was synthesised in a meta-analysis and assessed using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Remaining data was synthesised descriptively.

Ten randomised controlled trials (364 participants) were included. Four (191 participants) were analysed in a meta-analysis, showing modified constraint-induced movement therapy improved upper limb function (standardised mean difference (SMD) 0.94, 95% confidence interval (CI) 0.40 to 1.48), based on low-quality evidence. Five articles included follow-up, with two (90 participants) reporting sustained improvements. Five articles assessed activities of daily living, with two (136 participants) reporting positive effects.

Modified constraint-induced movement therapy improves upper limb function in the acute and sub-acute stages of stroke recovery within inpatient hospital settings. Sustainability of improvements and the impact on activities of daily living remains uncertain.

We present the guidelines for pain management in neurorehabilitation of brain injury in adults of the Spanish Society of Neurorehabilitation based on the review and analysis of the available literature on the subject. We establish recommendations according to the level of evidence offered by the reviewed studies.

The methodology followed by the Spanish Society of Neurorehabilitation for the elaboration of the present guide is based on the analysis of the national and international clinical practice guidelines of the last seven years, carried out according to the management considerations dictated by the evidence for the usual types of pain in the population of people who have suffered an acquired brain injury.

Pain is a common symptom in patients who have suffered brain damage, having a negative impact on quality of life and adherence to the rehabilitation process. When classifying the type of pain according to etiological characteristics, in order to optimise the type of therapeutic approach, we usually refer to pain as nociceptive, and neuropathic pain, although pain in such patients often has "mixed" characteristics. The most common type of pain is nociceptive ahead of neuropathic. The most common pain syndromes in this population are headache, hemiplegic shoulder pain and poststroke central pain. As pain is a subjective experience, people with impaired level of consciousness, severe cognitive impairment and/or severe language problems may have greater difficulty or even being unable to communicate it. An adequate clinical history and a directed physical examination, as well as the use of specific scales for its correct diagnosis are therefore important. Finally, many of the drugs used for its management have a negative impact on rehabilitation, affecting cognitive processes, and/or worsening other neurological symptoms. Furthermore, these patients often have several comorbidities and are frequently on several drugs which means that the approach to pain management must be carefully elaborated by a multidisciplinary team approach.

Upper-extremity dysfunction significantly affects dependence in the daily lives of stroke survivors, limiting their participation in the social environment and reducing their quality of life.

This study aimed to investigate the effect of end-effector robotic arm reach training (RAT) with functional electrical stimulation (FES) on upper-limb motor recovery in chronic stroke survivors.

In this single-blinded randomized controlled trial, 28 chronic stroke survivors were randomized to receive RAT-with-FES and RAT-without-FES for 40 min/day, three times per week over a 4-week period, and the data of 26 participants were used in the final analysis. Upper-limb motor recovery was measured using the Fugl-Meyer assessment (FMA), and kinematics (movement time, speed, and distance) during reaching movements toward targets placed in three directions (ipsilateral, median, and contralateral sides) were measured using a robotic arm.

The upper-limb motor recovery (FMA and kinematics) improvement for the within-group comparisons tended to be greater in the RAT-with-FES group than in the RAT-without-FES group. However, in the between-group comparison, no significant differences were found in FMA, and significant differences were observed only for 2 distance parameters of kinematic factors: total (23.0% vs. 1.7%) and straight total (25.5% vs. 2.6%) distance on the ipsilateral side (p < 0.05).

This study was unable to clearly reveal the positive effects of electrical stimulation combined with robotic arm training. However, we believe that it provides basic data that furthers our understanding of the role of hybrid neuroprostheses in stroke rehabilitation and the factors determining successful treatment.

Ischemic stroke (IS)-associated pneumonia is a leading cause of mortality after stroke, driven by peripheral immune imbalance. This systematic review evaluates immunosuppression markers associated with pneumonia following IS in clinical studies.

Following PRISMA guidelines, we searched PubMed/MEDLINE, EMBASE, and LILACS databases until March 2024. Inclusion criteria comprised clinical studies assessing IS-related immunosuppression and pneumonia, excluding in vitro and animal studies. Study quality was assessed using the Newcastle-Ottawa Scale.

A total of 32 studies met the inclusion criteria, analyzing 1,833 post-stroke patients. Findings indicate that increased interleukin-6 (IL-6), interleukin-10 (IL-10), and C-reactive protein (CRP) levels, alongside decreased repulsive guidance molecule A (RGM-A), are early indicators of post-stroke pneumonia. Meta-analysis was not conducted due to heterogeneity in study methodologies and populations.

Elevated IL-6, IL-10, and CRP levels, along with reduced RGM-A, are associated with post-stroke pneumonia, emphasizing the role of immune dysregulation in its pathophysiology. Despite promising findings, further studies with standardized detection techniques are needed to enhance diagnostic accuracy and improve patient prognosis. The variability in study methodologies presents a limitation to drawing definitive conclusions.Registration: PROSPERO CRD42024543108.

Effective treatments for restoring visual field defects (VFDs) in patients with stroke necessitate validation through randomized clinical trials.

To evaluate the efficacy and safety of a personalized digital therapeutic based on visual perceptual learning for treating poststroke VFDs.

A multicenter randomized clinical trial was conducted from October 19, 2022, to November 8, 2023, at 12 hospitals in South Korea. The study included poststroke outpatients 19 years or older with persistent VFDs (>3 months after stroke) and neuroimaging-confirmed stroke lesions in the visual pathway.

The training group underwent personalized visual discrimination tasks (orientation and rotation) using a mobile virtual reality headset 5 days a week for 12 weeks, with 360 trials per day. The control group received no intervention.

The primary outcome was improved visual areas (defined as sensitivity increased by ≥6 decibels [dB] during 12 weeks) assessed using Humphrey visual field tests at baseline and 12 weeks.

Of 93 enrolled stroke outpatients with VFDs, 82 were included in the final analysis (41 in the intervention group and 41 in the control group; median [IQR] age, 52 [42-65] years; 57 male [69.5%]). As primary measures, the training group, with a high adherence rate, showed significantly greater improvement (sensitivity increased by ≥6 dB) in the whole field (median difference, 72 [95% CI, 36-108] degrees squared; P = .003; mean [SD], 194.1 [197.3] vs 82.5 [95.0] degrees squared) and defective hemifield (median difference, 72 [95% CI, 36-108] degrees squared; P = .002; mean [SD], 158.9 [159.0] vs 72.0 [91.4] degrees squared) compared with the control group. As secondary measures, mean (SD) Humphrey visual field test scores improved after 12 weeks in the training group (whole field: 0.72 [1.55] dB; P = .005; defective hemifield: 1.20 [2.08] dB; P < .001) but not in the control group (whole field: 0.03 [1.30] dB; P = .88; defective hemifield: 0.06 [1.85] dB; P = .84).

In this randomized clinical trial of a digital therapeutic for chronic poststroke VFDs, the visual perceptual learning-based training demonstrated significant improvements in the whole field and defective hemifield.

ClinicalTrials.gov Identifier: NCT05525949.

Alzheimer's disease is a progressive neurodegenerative disorder that primarily affects the elderly population; and is characterized by the gradual loss of memory, cognition, and ability to carry out daily activities. However, a growing body of research indicates that there exists a subtype of Alzheimer's disease known as Atypical Alzheimer's disease. Atypical Alzheimer's disease is a rare form of dementia that differs from the typical presentation of Alzheimer's disease, such as variations in the age of onset, distribution of brain pathology, and clinical symptoms. The patients affected have a younger age of onset and have predominantly visual, language, executive function, motor, and behavioral dysfunction. The diagnosis requires a comprehensive neurological evaluation with specific attention to cognitive and behavioral changes while ruling out other potential causes of dementia. Emerging biomarkers including CSF profiles, amyloid and tau PET imaging, and advanced neuroimaging techniques offer promising avenues for improving diagnostic accuracy and understanding disease mechanisms. In this article, we focus on atypical presentations seen in the posterior cortical variant, frontal variant, progressive aphasic variant, corticobasal syndrome and look at the specific biomarkers used in the diagnosis of each variant along with focusing on the treatment of the disease. We also aim to provide an understanding of Atypical Alzheimer's disease, its clinical features, the biomarkers helping in diagnosing the disease, the current treatment guidelines, and the current scientific advancements in the field.

BackgroundThe combination of speech and language therapy (SLT) with acupuncture, electroacupuncture, and non-invasive brain stimulation is commonly used in clinical practice and scientific research for post-stroke aphasia (PSA).ObjectiveThis study assesses the therapeutic effectiveness of SLT-based combination therapies in improving language function in patients with PSA.MethodsPubMed, CBM, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wan Fang Data and Chinese Scientific Journals Database (VIP) were searched through 2 December, 2024. This study included randomized controlled trials (RCTs) that compared the influence of SLT-based combination treatments and controls on language function in patients with PSA. The meta-analysis was conducted using random effects NMA.ResultsA total of 66 studies were included. The NMA assessing the effectiveness of various interventions for improving speech, repetition, and listening comprehension skills following SLT revealed that combined therapies generally outperformed SLT alone. For speaking skills, SLT + Electroacupuncture demonstrated the highest likelihood of improvement (SUCRA = 84.6). For repetition scores, SLT + Electroacupuncture was effective (SUCRA = 92.0). In listening comprehension, SLT + tDCS showed the greatest potential for improvement (SUCRA = 89.8).ConclusionsThe results revealed that any type of SLT-based combination intervention was more effective than SLT alone.

The devastating physical, emotional, and social effects of stroke can disrupt all aspects of life for the stroke survivor. Ensuring that survivor and caregiver needs are met after a stroke is essential in ongoing care to ensure optimal quality of life. Despite health care professionals making significant strides in poststroke symptom management, education, and rehabilitative support, the common poststroke symptom of sexual dysfunction is rarely addressed. Multiple barriers across health care settings and systems have contributed to this gap. The purpose of this article is to provide evidence that supports the importance of addressing sexual health by health care providers with the stroke survivor and their partner as they transition through the recovery process. We have the following recommendations to optimize care and quality of life for stroke survivors: (1) comprehensive sex education must include information on healthy sex and sexuality for people with neurological disabilities; (2) rehabilitation programs offered in postacute settings should include a structured culturally sensitive interprofessional sexual rehabilitation component that addresses sexuality of the stroke survivor in collaboration with their intimate partners; (3) sexual rehabilitation programs should be tailored for each person based on a thorough assessment of the person's health literacy and learning needs; and (4) the American Heart Association should develop an extensive toolkit for health care providers and survivors that is easily and readily available to the public. Health care providers, survivors, and their partners have a stake in optimal stroke recovery. Sexuality and sexual function are important quality of life indicators thus conversations addressing issues must be included as part of the recovery process. This discussion is best initiated by a health care provider to address system barriers and misconceptions across care transitions. Likewise, survivors and their partners must be encouraged to take ownership to address sexuality issues and initiate the conversation with their health care partners to achieve full recovery.

Transcranial direct current stimulation (tDCS) has a priming effect on post- stroke motor rehabilitation.

We verified whether tDCS combined with task-specific training was superior to nonintervention, task-specific training, or simulated intervention in improving spatio-temporal gait parameters and functional mobility in stroke patients.

We searched MEDLINE, EMBASE, CINAHL, Scopus, Cochrane Central, Web of Science, and LILACS for articles published until May 2024, using terms related to stroke, tDCS, and task-specific training. The risk of bias was assessed using the PEDro scale. The Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to classify the certainty of the evidence for each outcome. Meta-analysis was performed using a random-effects model.

A total of 1,685 studies were identified, of which 18 were included in the qualitative analysis. Seven studies were included in the meta-analysis; all outcomes were classified as "very low quality." Improvements in walking speed only were associated with tDCS combined with task-specific training (mean difference [MD], 0.06; 95% confidence interval [CI]: 0.04, 0.07; p < 0.001; I  = 0%). There were no differences in other spatio-temporal gait parameters or functional mobility.

This systematic review provides low-quality evidence that tDCS, in combination with task-specific training, increases speed in individuals after stroke. Both interventions, tDCS and task-specific training, are inexpensive and easy to implement; therefore, the mean estimate may be considered clinically worthwhile, although the CIs spans both clinically trivial and worthwhile effects.

International Prospective Register of Systematic Reviews (PROSPERO; number CRD42023396021).

Current therapeutic strategies for ischemic stroke fall short of the desired objective of neurological functional recovery. Therefore, there is an urgent need to develop new methods for the treatment of this condition. Exosomes are natural cell-derived vesicles that mediate signal transduction between cells under physiological and pathological conditions. They have low immunogenicity, good stability, high delivery efficiency, and the ability to cross the blood-brain barrier. These physiological properties of exosomes have the potential to lead to new breakthroughs in the treatment of ischemic stroke. The rapid development of nanotechnology has advanced the application of engineered exosomes, which can effectively improve targeting ability, enhance therapeutic efficacy, and minimize the dosages needed. Advances in technology have also driven clinical translational research on exosomes. In this review, we describe the therapeutic effects of exosomes and their positive roles in current treatment strategies for ischemic stroke, including their anti-inflammation, anti-apoptosis, autophagy-regulation, angiogenesis, neurogenesis, and glial scar formation reduction effects. However, it is worth noting that, despite their significant therapeutic potential, there remains a dearth of standardized characterization methods and efficient isolation techniques capable of producing highly purified exosomes. Future optimization strategies should prioritize the exploration of suitable isolation techniques and the establishment of unified workflows to effectively harness exosomes for diagnostic or therapeutic applications in ischemic stroke. Ultimately, our review aims to summarize our understanding of exosome-based treatment prospects in ischemic stroke and foster innovative ideas for the development of exosome-based therapies.

BackgroundExtensive rehabilitation following a stroke is crucial. It could be provided as home health care (HHC) and is critical in aiding patients' recovery at home and promoting independence. Home-based rehabilitation has proven effective for patients with stroke and enhances their quality of life. Further research is necessary to support recovery at home for patients with stroke in Saudi Arabia.ObjectiveThe study aims to explore the barriers and facilitators of physical therapy homecare services for patients with stroke in Saudi Arabia.MethodsA cross-sectional study using a self-administered questionnaire was distributed among 150 licensed physical therapists. Descriptive and inferential statistics were used to describe the participants' characteristics, barriers, and facilitators.ResultsThe physical therapists showed high confidence in stroke rehabilitation, with a mean score (16.49 + 2.37). Most of our respondents reported that patients' refusal of service was considered the most common barrier to homecare, with a mean score of (2.78 + 0.43). The barrier scores were significantly associated with the workplace region (p = 0.04). On a positive note, (84%) identified effective communication as a facilitator, with a mean score of (2.82 + 0.43). A significant association was found among specialists working in the homecare department compared to those working at usual rehabilitation clinics (p = 0.02).ConclusionsThe primary challenges were patients refusing services and inadequate communication. Overcoming these barriers is crucial. Effective communication and involving a family member in the treatment program were critical factors for facilitating home care and ensuring a high level of service.

The quest for scientifically effective rehabilitation methods for stroke recovery constitutes an urgent need. However, due to the inadequacies of longitudinal studies and multimodal assessment methods, the rehabilitation mechanisms of methods such as Acupuncture Treatment (AT) and Motor Imagery (MI) remain unclear. Consequently, this study presents both AT and Acupuncture Synchronized with MI (ASMI) therapies, utilizing a combination of subjective and objective approaches to evaluate the long-term impacts of these two treatment modalities.

A longitudinal design was adopted for a duration of two weeks. Clinical improvement in patients was assessed using scale data, while Functional Near-infrared spectroscopy (fNIRS) and Electroencephalogram (EEG) data were collected to analyze changes in brain function. This study proposed the Cluster-Span Threshold for Directed Networks (CSTDN) algorithm for identifying key connections within the brain network and conducted in-depth analysis using graph theory metrics.

Scale data indicated improvements in behavioral capabilities in both groups post-treatment. EEG and fNIRS data revealed significant variations in specific frequency bands between the two groups.

This study not only validates the efficacy of AT and ASMI in stroke rehabilitation but also unveils the underlying neurobiological mechanisms through multimodal data analysis. The proposed CSTDN algorithm and graph theory analysis offer new perspectives for understanding changes in the brain network.

This research contributes to the optimization of future rehabilitation treatment strategies and the formulation of personalized treatment plans.

Poststroke osteoporosis, particularly of the hip, and an increased risk of fractures due to accidental falls are well known in people with stroke. Only a few of the current stroke guidelines recommend bone mineral density (BMD) measurements during follow-up in this population and measurements are often performed unilaterally.

To compare femoral hip BMD between fallers and nonfallers among patients with stroke, while also assessing differences in balance, mobility, fear of falling, and exploring discrepancies between paretic and nonparetic sides within each group.

Cross-sectional.

Inpatient stroke rehabilitation unit of a tertiary university hospital.

Patients with unilateral hemiplegia hospitalized as a result of stroke.

Not applicable.

The primary outcome was the femoral neck BMD measurement. Dual-energy x-ray absorptiometry was used to measure BMD. Secondary outcomes included Berg balance scale (BBS), timed up-and-go test (TUGT), functional ambulation classification (FAC), and falls efficacy scale-international (FES-I).

A total of 44 patients were enrolled. Twenty-two participants (50%) reported falling. There were no statistically significant differences in BMD (p = .504, p = .197, p = .667, respectively) and T-scores (p = .457, p = .194, p = .693, respectively) of paretic, nonparetic femoral neck, and lumbar spine between nonfallers and fallers. The BBS (p = .033, 95% confidence interval [CI] 0.17-19.05) was significantly lower in the fallers. The FES-I was statistically significantly higher in the fallers (p = .001, 95% CI -22.40 to -6.50). The BMD and T-scores of femoral neck between the paretic and the nonparetic limbs did not differ significantly in the nonfallers (n = 22) (p = .908, 95% CI -0.03-0.03; p = .886, 95% CI -0.27-0.24) but did differ in the fallers (n = 22) (p = .007, 95% CI -0.06 to -0.01; p = .006, 95% CI -0.51 to -0.09).

This study emphasizes that hip BMD may differ on paretic and nonparetic sides, especially in patients with stroke and a history of falls and balance problems. Fall-related self-efficacy and balance may be determinants of falls in these patients.

To summarize current reports in the literature on disparities in rehabilitation after stroke; identify gaps in our understanding of rehabilitation disparities; and make recommendations for future research.

A health sciences librarian developed a search string based on an a priori protocol and searched Medline (Ovid) Embase (Elsevier), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL and EBSCO).

A 2-step screening process of titles and abstracts followed by full-text review was conducted. Primary observational studies conducted in the United States that reported on disparities in rehabilitation (ie, physical, occupational, or speech therapy) among adults after stroke were retained. Eligible disparity populations included racial minorities; ethnic minorities; sex and gender minorities; older populations; socioeconomically disadvantaged populations; and geographic minorities (inner city/rural).

Data extracted from retained articles included: aims/objectives; data source; sample characteristics, rehabilitation outcomes examined; types of disparities examined; statistical methods used; and disparity findings.

Seven thousand eight hundred fifty-three titles and abstracts were screened, and 473 articles underwent full-text review. Forty-nine articles were included for data extraction and analysis. Many articles examined more than 1 disparity type with most examining disparities in race and/or ethnicity (n=43, 87.7%), followed by sex (n=25, 53.0%), age (n=23, 46.9%), socioeconomic status (n=22, 44.9%), and urban/rural status (n=8, 16.3%). Articles varied widely by sample characteristics, data sources, rehabilitation outcomes, and methods of examining disparities.

Although we found some consistent evidence of disparities in rehabilitation for older individuals, non-White races, and individuals of lower socioeconomic status, the variability in methods made the synthesis of findings challenging. Further work, including additional well-designed studies and systematic reviews, and/or meta-analyses of current studies, is needed to better understand the extent of rehabilitation disparities after stroke.

Motor impairments contribute substantially to long-term disability following stroke. Studies of transcranial direct current stimulation (tDCS), combined with various rehabilitation therapies, have shown promising results in reducing motor impairment. We aimed to evaluate the safety and efficacy of three doses of tDCS in combination with modified constraint-induced movement therapy (mCIMT) in people who have had their first ischaemic stroke in the preceding 1-6 months.

We conducted a phase 2, multicentre, randomised, triple-blind, sham-controlled study with a blinded centrally scored primary outcome. The trial was conducted at 15 medical centres in the USA. Eligible participants were enrolled between 1 month and 6 months after their first ischaemic stroke. Inclusion criteria required participants to have a persistent motor deficit, defined as a Fugl-Meyer Upper-Extremity (FM-UE) score of 54 or lower (out of 66), and two consecutive baseline visits (separated by 7-14 days) with an absolute difference of 2 or fewer points on the FM-UE scale. Participants were randomly assigned to treatment groups by an adaptive randomisation algorithm hosted on the TRANSPORT2 WebDCU study website. Participants received either sham, 2 mA, or 4 mA of bi-hemispheric tDCS for the first 30 min and mCIMT with 120 min of active therapy time per session, administered over ten sessions during a 2-week period. The primary endpoint was the change in FM-UE score from baseline to day 15, which was analysed in all participants who have data both at baseline and post-baseline (modified intention-to-treat group). Safety outcomes were analysed in all participants. TRANSPORT2 is registered at clinicaltrials.gov (NCT03826030) and its status is completed.

129 participants were recruited between Sept 9, 2019, and June 14, 2024, and 43 participants were randomly assigned to each group. 54 (42%) of 129 participants were female, and 69 (53%) were White. Two participants in the sham plus mCIMT group withdrew consent before the day 15 assessment and were excluded from the primary analysis. The median baseline FM-UE score was 39·0 (IQR 30·0-46·0) in the sham plus mCIMT group, 39·0 (27·0-48·0) in the 2 mA plus mCIMT group, and 40·0 (27·0-48·0) in the 4 mA plus mCIMT group. For the primary outcome, the adjusted mean change from baseline to day 15 in FM-UE was 4·91 (3·00-6·82) for sham plus mCIMT, 3·87 (2·00-5·74) for 2 mA plus mCIMT, and 5·53 (3·64-7·42) for 4 mA plus mCIMT (p=0·39). No clinically important adverse events were observed in any group and no deaths were reported.

tDCS at doses of 2 mA or 4 mA, in addition to mCIMT, did not lead to further reduction in motor impairment in patients 1-6 months after stroke, but it was safe, well tolerated, and feasible for clinical practice. tDCS at higher doses (ie, >4 mA) might be a consideration for future trials in addition to balancing known covariates affecting stroke recovery during the group allocation.

National Institute of Neurological Disorders and Stroke.

Endovascular therapy (EVT) now penetrates the once obscure realm of large infarct core volume acute ischaemic stroke (LICV-AIS). This research aimed to investigate the potential correlation between different anaesthetic approaches and post-EVT outcomes in LICV-AIS patients.

Between October 2020 and May 2022, the China ANGEL-Alberta Stroke Programme Early CT Score (ASPECT) trial studied patients with LICV-AIS, randomly assigning them to the best medical management (BMM) or BMM with EVT. This post hoc subgroup analysis categorised subjects receiving BMM with EVT into general anaesthesia (GA) and non-GA groups based on anaesthesia type. We applied multivariable logistic regression to evaluate the relationship between anaesthesia during EVT and patient functional outcomes, as measured by the modified Rankin scale (mRS), in addition to the occurrence of complications. Further adjustment for selection bias was achieved through propensity score matching (PSM).

In total, 230 patients with LICV-AIS were enrolled (GA 84 vs Non-GA 146). No significant difference was observed between the two groups in terms of the proportion of patients who achieved an mRS score of 0-2 at 90 days (27.4% for the GA group vs 31.5% for the non-GA group, p=0.51). However, the GA group had significantly longer median surgical times (142 min vs 122 min, p=0.03). Furthermore, GA was associated with an increased risk of postoperative pneumonia (adjusted OR 2.03, 95% CI 1.04 to 3.98). The results of PSM analysis agreed with the results of the multivariate regression analysis. No significant difference in intracranial haemorrhage incidence or mortality rate was observed between the groups.

This post hoc analysis of subgroups of the ANGEL-ASPECT trial suggested that there may be no significant association between the choice of anaesthesia and neurological outcomes in LICV-AIS patients. However, compared with non-GA, GA prolongs the duration of EVT and is associated with a greater postoperative pneumonia risk.

NCT04551664.