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Neues zur Neurorehabilitation: Motorik und Sprache
Abstract
Dank der Fortschritte der modernen Medizin ist die unmittelbare Mortalitätsrate nach einem Schlaganfall in den vergangenen Jahrzehnten kontinuierlich gesunken. Kehrseite dieser Entwicklung ist, dass die den Schlaganfall überlebenden Patienten für die verbliebene Lebensspanne teilweise erhebliche funktionelle motorische und/oder sprachliche Einschränkungen aufweisen. Im vorliegenden Beitrag werden evidenzbasierte Methoden der Neurorehabilitation zur Förderung motorischer und sprachlicher Funktionen in der akuten sowie chronischen Phase nach einem Schlaganfall vorgestellt. Neben intensiv durchgeführten Trainingsansätzen zählen dazu neuropharmakologische Ansätze und nichtinvasive Hirnstimulationstechniken, wie die transkranielle Magnet- oder Gleichstromstimulation (TMS, tDCS). Zusätzlich erfolgt ein Ausblick auf vielversprechende, derzeit noch als experimentell anzusehende Interventionen.
Von elektronischen Hilfen sind Fitness-Apps durch Förderung einer gesunden Lebensweise zur Prävention geeignet. Mobile EKG-Geräte auf dem Smartphone bewähren sich bei der Sekundärprävention von Patienten mit Herzinfarkt. Diagnose-Apps in Patientenhand sind ohne wissenschaftliche Evidenz. Als organisatorische Hilfen sind der elektronische Arztbrief (eA) sowie die Krankenakte (eKA) und die eSignatur auf dem Vormarsch; die elektronische Patientenakte (ePA) bedarf aber noch der Umsetzung auf eine Gesundheitskarte (eGK) oder das Smartphone. Medizinische Hilfen wie das Telemonitoring von Herz- und Diabetespatienten sowie Apps zum Gleichgewichtstraining oder für Parkinson-Kranke entlasten den Arztalltag. In der Notfallmedizin sind App-basierte Rettungsdienste und teleneuroradiologische Beratungen anerkannt. Ärztliche Online-Beratung kann auch als Zweitmeinung die medizinische Versorgung verbessern. Zukunftsmodelle der elektronischen Vernetzung stützen sich auf Fortschritte der Sensoren zur Erfassung von Motorik und Vigilanz zur Diagnostik bei Anfällen oder dem Schlafapnoe-Syndrom. Das digitalisierte Krankenzimmer könnte pflegeentlastend sein. Online-gestützte Interventionen bei Angstpatienten oder neuropsychiatrisches Telemonitoring von Psychosen zeigen in Studien interessante Ergebnisse.
Künstliche Intelligenz (KI) befasst sich mit der Automatisierung intelligenten Verhaltens mithilfe von Computern. Große Datenmengen, sogenannte Big Data, bedeuten beim Einsatz diagnostischer Suchmaschinen die größten Chancen für seltene Erkrankungen und neueste Therapieformen. Die KI umfasst neben der künstlichen Datenintelligenz die Bild- und die Spracherkennung. Die Bilderkennung hat in der Online-Videosprechstunde vom Dermatologen ihre Berechtigung. Radiologen und Onkologen nutzen diese Bilderkennungstechnik zu früheren Diagnosen im CT und MRT. Vor- und Nachteile der Spracherkennung sind dem Laien mit Alexa und Siri bekannt. Roboter werden in der Medizin von Computern mit KI-Programmen gesteuert. Neben Transport- und Tierrobotern spielen humanoide Roboter in der Medizin die Hauptrolle. Dazu zählen Assistenzroboter im Operationssaal der Neurochirurgen, Urologen und Bauchchirurgen sowie der Care-O-bot-Roboter in der Pflege. Der Pflegenotstand lässt sich lindern, wenn zumindest körperlich schwere Arbeiten automatisiert und robotisiert werden. Zu elektromechanischen und robotergestützten Therapien gehören die Arm-Robot-Therapie und der Roboterball sowie der Einsatz von Exoskeletten. Neurotechnik mit BCIs sind noch Zukunftsmodelle.
Despite preserved or recovered movement ability after stroke, often people do not fully realize this ability in their everyday activities. Constraint-induced movement therapy (CIMT) is an approach to stroke rehabilitation that involves the forced use of the affected arm by restraining the less affected arm combined to several hours of exercise. Modified forms of CIMT exist, reducing the training during the period of restraint, or concentrating only on the use of restraint.
We assessed the efficacy of CIMT and its modified forms for arm management in people with hemiparesis after stroke.1
In January 2015, we searched multiple databases, ongoing trials registers and reference lists of relevant papers. …
Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics related to heart disease, stroke, and other cardiovascular and metabolic diseases and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, and others seeking the best available data on these conditions. Together, cardiovascular disease (CVD) and stroke produce immense health and economic burdens in the United States and globally. The Statistical Update brings together in a single document up-to-date information on the core health behaviors (including diet, physical activity [PA], smoking, and energy balance) and health factors (including blood pressure, cholesterol, and glucose) that define cardiovascular health; a range of …
Based on a large multicenter/intercontinental patient population, the A Very Early Rehabilitation Trial (AVERT) suggests that early intensive mobilization procedures negatively affect 3-month outcome in severely affected stroke victims and in patients with intracerebral hemorrhage. This unexpected finding is interpreted in view of the limitations of the trial. It is argued that these results should not lead to prolonging immobilization and inactivity after stroke and to a cessation of clinical research that aims at integrating rehabilitative intervention into acute stroke care.
The AVERT trial is the largest randomized multicenter trial conducted in stroke rehabilitation to date. It compares very early mobilization within 24 hours after symptom onset with usual care in patients with ischemic or hemorrhagic stroke without significant coexisting comorbidity or premorbid disability.
The authors are to be complimented to have achieved this high quality collection of data across 5 countries in 3 continents (Australia/New Zealand, Europe, and Asia). Rehabilitation interventions are difficult to test in multicenter trials because they often lack standardization and involve a great deal of human effort on the side of the therapist and the patient. This complexity is even higher in the acute phase after stroke where time is short for meeting all acute care requirements, that is, treating the acute event, finding its cause, and preventing complications. The …
Background
Electromechanical and robot-assisted armtraining devices are used in rehabilitation, and may help to improve arm function after stroke.
Objectives
To assess the effectiveness of electromechanical and robot-assisted arm training for improving activities of daily living, arm function,
and arm muscle strength in people after stroke. We also assessed the acceptability and safety of the therapy.
Search methods
We searched the Cochrane Stroke Group’s Trials Register (last searched February 2015), the Cochrane Central Register of Controlled
Trials (CENTRAL) (the Cochrane Library 2015, Issue 3), MEDLINE (1950 to March 2015), EMBASE (1980 to March 2015),
CINAHL (1982 to March 2015), AMED (1985 to March 2015), SPORTDiscus (1949 to March 2015), PEDro (searched April
2015), Compendex (1972 toMarch 2015), and Inspec (1969 toMarch 2015). We also handsearched relevant conference proceedings,
searched trials and research registers, checked reference lists, and contacted trialists, experts, and researchers in our field, as well as
manufacturers of commercial devices.
Selection criteria
Randomised controlled trials comparing electromechanical and robot-assisted arm training for recovery of arm function with other
rehabilitation or placebo interventions, or no treatment, for people after stroke.
Data collection and analysis
Two review authors independently selected trials for inclusion, assessed trial quality and risk of bias, and extracted data. We contacted
trialists for additional information. We analysed the results as standardised mean differences (SMDs) for continuous variables and risk
differences (RDs) for dichotomous variables.
Main results
We included 34 trials (involving 1160 participants) in this update of our review. Electromechanical and robot-assisted arm training
improved activities of daily living scores (SMD 0.37, 95% confidence interval (CI) 0.11 to 0.64, P = 0.005, I² = 62%), arm function
(SMD 0.35, 95% CI 0.18 to 0.51, P < 0.0001, I² = 36%), and arm muscle strength (SMD 0.36, 95% CI 0.01 to 0.70, P = 0.04, I² =
72%), but the quality of the evidence was low to very low. Electromechanical and robot-assisted arm training did not increase the risk
of participant drop-out (RD 0.00, 95% CI -0.02 to 0.03, P = 0.84, I² = 0%) with moderate-quality evidence, and adverse events were
rare.
Authors’ conclusions
People who receive electromechanical and robot-assisted arm and hand training after stroke might improve their activities of daily
living, arm and hand function, and arm and hand muscle strength. However, the results must be interpreted with caution because
the quality of the evidence was low to very low, and there were variations between the trials in the intensity, duration, and amount of
training; type of treatment; and participant characteristics.
Transcranial direct current stimulation (tDCS) is an attractive protocol for stroke motor recovery. The current systematic review and meta-analysis investigated the effects of tDCS on motor learning post-stroke. Specifically, we determined long-term learning effects by examining motor improvements from baseline to at least 5 days after tDCS intervention and motor practise. 17 studies reported long-term retention testing (mean retention interval=43.8 days; SD=56.6 days) and qualified for inclusion in our meta-analysis. Assessing primary outcome measures for groups that received tDCS and motor practise versus sham control groups created 21 valid comparisons: (1) 16 clinical assessments and (2) 5 motor skill acquisition tests. A random effects model meta-analysis showed a significant overall effect size=0.59 (p<0.0001; low heterogeneity, T(2)=0.04; I(2)=22.75%; and high classic fail-safe N=240). 4 moderator variable analyses revealed beneficial effects of tDCS on long-term motor learning: (1) stimulation protocols: anodal on the ipsilesional hemisphere, cathodal on the contralesional hemisphere, or bilateral; (2) recovery stage: subacute or chronic stroke; (3) stimulation timing: tDCS before or during motor practise; and (4) task-specific training or conventional rehabilitation protocols. This robust meta-analysis identified novel long-term motor learning effects with tDCS and motor practise post-stroke.
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Objective. To develop a systematic review of the literature, to describe the different virtual reality (VR) interventions and interactive
videogames applied to the lower extremity (LE) of stroke patients, and to analyse the results according to the most frequently
used outcome measures. Material and Methods. An electronic search of randomized trials between January 2004 and January
2014 in different databases (Medline, Cinahl, Web of Science, PEDro, and Cochrane) was carried out. Several terms (virtual reality,
feedback, stroke, hemiplegia, brain injury, cerebrovascular accident, lower limb, leg, and gait) were combined, and finally 11 articles
were included according to the established inclusion and exclusion criteria. Results.The reviewed trials showed a high heterogeneity
in terms of study design and assessment tools, which makes it difficult to compare and analyze the different types of interventions.
However, most of them found a significant improvement on gait speed, balance and motor function, due to VR intervention.
Conclusions. Although evidence is limited, it suggests that VR intervention (more than 10 sessions) in stroke patients may have
a positive impact on balance, and gait recovery. Better results were obtained when a multimodal approach, combining VR and
conventional physiotherapy, was used. Flexible software seems to adapt better to patients’ requirements, allowingmore specific and
individual treatments.
Question:
In people after stroke, does virtual reality based rehabilitation (VRBR) improve walking speed, balance and mobility more than the same duration of standard rehabilitation? In people after stroke, does adding extra VRBR to standard rehabilitation improve the effects on gait, balance and mobility?
Design:
Systematic review with meta-analysis of randomised trials.
Participants:
Adults with a clinical diagnosis of stroke.
Intervention:
Eligible trials had to include one these comparisons: VRBR replacing some or all of standard rehabilitation or VRBR used as extra rehabilitation time added to a standard rehabilitation regimen.
Outcome measures:
Walking speed, balance, mobility and adverse events.
Results:
In total, 15 trials involving 341 participants were included. When VRBR replaced some or all of the standard rehabilitation, there were statistically significant benefits in walking speed (MD 0.15 m/s, 95% CI 0.10 to 0.19), balance (MD 2.1 points on the Berg Balance Scale, 95% CI 1.8 to 2.5) and mobility (MD 2.3 seconds on the Timed Up and Go test, 95% CI 1.2 to 3.4). When VRBR was added to standard rehabilitation, mobility showed a significant benefit (0.7 seconds on the Timed Up and Go test, 95% CI 0.4 to 1.1), but insufficient evidence was found to comment about walking speed (one trial) and balance (high heterogeneity).
Conclusion:
Substituting some or all of a standard rehabilitation regimen with VRBR elicits greater benefits in walking speed, balance and mobility in people with stroke. Although the benefits are small, the extra cost of applying virtual reality to standard rehabilitation is also small, especially when spread over many patients in a clinic. Adding extra VRBR time to standard rehabilitation also has some benefits; further research is needed to determine if these benefits are clinically worthwhile.
Background:
Early mobilisation after stroke is thought to contribute to the effects of stroke-unit care; however, the intervention is poorly defined and not underpinned by strong evidence. We aimed to compare the effectiveness of frequent, higher dose, very early mobilisation with usual care after stroke.
Methods:
We did this parallel-group, single-blind, randomised controlled trial at 56 acute stroke units in five countries. Patients (aged ≥18 years) with ischaemic or haemorrhagic stroke, first or recurrent, who met physiological criteria were randomly assigned (1:1), via a web-based computer generated block randomisation procedure (block size of six), to receive usual stroke-unit care alone or very early mobilisation in addition to usual care. Treatment with recombinant tissue plasminogen activator was allowed. Randomisation was stratified by study site and stroke severity. Patients, outcome assessors, and investigators involved in trial and data management were masked to treatment allocation. The primary outcome was a favourable outcome 3 months after stroke, defined as a modified Rankin Scale score of 0-2. We did analysis on an intention-to-treat basis. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12606000185561.
Findings:
Between July 18, 2006, and Oct 16, 2014, we randomly assigned 2104 patients to receive either very early mobilisation (n=1054) or usual care (n=1050); 2083 (99%) patients were included in the 3 month follow-up assessment. 965 (92%) patients were mobilised within 24 h in the very early mobilisation group compared with 623 (59%) patients in the usual care group. Fewer patients in the very early mobilisation group had a favourable outcome than those in the usual care group (n=480 [46%] vs n=525 [50%]; adjusted odds ratio [OR] 0·73, 95% CI 0·59-0·90; p=0·004). 88 (8%) patients died in the very early mobilisation group compared with 72 (7%) patients in the usual care group (OR 1·34, 95% CI 0·93-1·93, p=0·113). 201 (19%) patients in the very early mobilisation group and 208 (20%) of those in the usual care group had a non-fatal serious adverse event, with no reduction in immobility-related complications with very early mobilisation.
Interpretation:
First mobilisation took place within 24 h for most patients in this trial. The higher dose, very early mobilisation protocol was associated with a reduction in the odds of a favourable outcome at 3 months. Early mobilisation after stroke is recommended in many clinical practice guidelines worldwide, and our findings should affect clinical practice by refining present guidelines; however, clinical recommendations should be informed by future analyses of dose-response associations.
Funding:
National Health and Medical Research Council, Singapore Health, Chest Heart and Stroke Scotland, Northern Ireland Chest Heart and Stroke, UK Stroke Association, National Institute of Health Research.
Chronic communication impairment is common after stroke, and conventional speech and language therapy (SLT) strategies have limited effectiveness in post-stroke aphasia. Neurorehabilitation with non-invasive brain stimulation techniques (NIBS)—particularly repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS)—may enhance the effects of SLT in selected patients. Applying inhibitory NIBS to specific homologous language regions may induce neural reorganization and reduce interhemispheric competition. This mini review highlights randomized controlled trials (RCTs) and randomized cross-over trials using low-frequency rTMS or cathodal tDCS over the non-lesioned non-language dominant hemisphere and performs an exploratory meta-analysis of those trials considered combinable. Using a random-effects model, a meta-analysis of nine eligible trials involving 215 participants showed a significant mean effect size of 0.51 (95% CI = 0.24–0.79) for the main outcome “accuracy of naming” in language assessment. No heterogeneity was observed (I² = 0%). More multicenter RCTs with larger populations and homogenous intervention protocols are required to confirm these and the longer-term effects.
Aphasia is an important stroke sequel that impacts negatively on the HQoL of stroke patients. Although a number of stroke patients with aphasia will have good functional recovery, many are left with language deficits.
Papers were identified through PubMed and MEDLINE search, with keywords such as: 'stroke', 'aphasia', 'post-stroke aphasia', 'factors that predict aphasia recovery', 'aphasia outcomes' and 'aphasia prognosis'.
The most important factors that determine recovery are the lesion location and size, aphasia type and severity and to some extent the nature of early haemodynamic response, and treatment received. Anagraphic factors like gender, age, handedness and education have not been found to be robust predictors of recovery.
Predicting post-stroke aphasia recovery is difficult, because of the interplay between lesion, anagraphic, and treatment-related factors, in addition to the role of neuroplasticity.
Copyright © 2015 Elsevier B.V. All rights reserved.
Background:
Different therapeutic methods are being used to prevent or decrease long-term impairments of the upper arm in stroke patients. Functional electrical stimulation (FES) is one of these methods, which aims to stimulate the nerves of the weakened muscles so that the resulting muscle contractions resemble those of a functional task.
Objectives:
The objective of this study was to review the evidence for the effect of FES on (1) shoulder subluxation, (2) pain, and (3) upper arm motor function in stroke patients, when added to conventional therapy.
Methods:
From the 727 retrieved articles, 10 (9 RCTs, 1 quasi-RCT) were selected for final analysis and were rated based on the PEDro (Physiotherapy Evidence Database) scores and the Sackett's levels of evidence. A meta-analysis was performed for all three considered outcomes.
Results:
The results of the meta-analyses showed a significant difference in shoulder subluxation in experimental groups compared to control groups, only if FES was applied early after stroke. No effects were found on pain or motor function outcomes.
Conclusion:
FES can be used to prevent or reduce shoulder subluxation early after stroke. However, it should not be used to reduce pain or improve upper arm motor function after stroke.
Noninvasive brain stimulation (NIBS) techniques can be used to monitor and modulate the excitability of intracortical neuronal circuits. Long periods of cortical stimulation can produce lasting effects on brain function, paving the way for therapeutic applications of NIBS in chronic neurological disease. The potential of NIBS in stroke rehabilitation has been of particular interest, because stroke is the main cause of permanent disability in industrial nations, and treatment outcomes often fail to meet the expectations of patients. Despite promising reports from many clinical trials on NIBS for stroke recovery, the number of studies reporting a null effect remains a concern. One possible explanation is that the interhemispheric competition model-which posits that suppressing the excitability of the hemisphere not affected by stroke will enhance recovery by reducing interhemispheric inhibition of the stroke hemisphere, and forms the rationale for many studies-is oversimplified or even incorrect. Here, we critically review the proposed mechanisms of synaptic and functional reorganization after stroke, and suggest a bimodal balance-recovery model that links interhemispheric balancing and functional recovery to the structural reserve spared by the lesion. The proposed model could enable NIBS to be tailored to the needs of individual patients.
Mirror visual feedback (MVF), a phenomenon where movement of one limb is perceived as movement of the other limb, has the capacity to alleviate phantom limb pain or promote motor recovery of the upper limbs after stroke. The tool has received great interest from health professionals; however, a clear understanding of the mechanisms underlying the neural recovery owing to MVF is lacking.
Objective. We performed a systematic review to assess the effect of MVF on brain activation during a motor task.
Methods. We searched PubMed, CINAHL, and EMBASE databases for neuroimaging studies investigating the effect of MVF on the brain. Key details for each study regarding participants, imaging methods, and results were extracted.
Results. The database search yielded 347 article, of which we identified 33 suitable for inclusion. Compared with a control condition, MVF increases neural activity in areas involved with allocation of attention and cognitive control (dorsolateral prefrontal cortex, posterior cingulate cortex, S1 and S2, precuneus). Apart from activation in the superior temporal gyrus and premotor cortex, there is little evidence that MVF activates the mirror neuron system. MVF increases the excitability of the ipsilateral primary motor cortex (M1) that projects to the “untrained” hand/arm. There is also evidence for ipsilateral projections from the contralateral M1 to the untrained/affected hand as a consequence of training with MVF.
Conclusion. MVF can exert a strong influence on the motor network, mainly through increased cognitive penetration in action control, though the variance in methodology and the lack of studies that shed light on the functional connectivity between areas still limit insight into the actual underlying mechanisms.
The estimated prevalence of aphasia in the UK and the USA is 250 000 and 1 000 000, respectively. The commonest aetiology is stroke. The impairment may improve with behavioural therapy, and trials using cortical stimulation or pharmacotherapy are undergoing proof-of-principle investigation, but with mixed results. Aphasia is a heterogeneous syndrome, and the simple classifications according to the Broca-Wernicke-Lichtheim model inadequately describe the diverse communication difficulties with which patients may present. Greater knowledge of how intact neural networks promote recovery after aphasic stroke, either spontaneously or in response to interventions, will result in clearer hypotheses about how to improve the treatment of aphasia. Twenty-five years ago, a pioneering study on healthy participants heralded the introduction of functional neuroimaging to the study of mechanisms of recovery from aphasia. Over the ensuing decades, such studies have been interpreted as supporting one of three hypotheses, which are not mutually exclusive. The first two predate the introduction of functional neuroimaging: that recovery is the consequence of the reconstitution of domain-specific language systems in tissue around the lesion (the 'perilesional' hypothesis), or by homotopic cortex in the contralateral hemisphere (the 'laterality-shift' hypothesis). The third is that loss of transcallosal inhibition to contralateral homotopic cortex hinders recovery (the 'disinhibition' hypothesis). These different hypotheses at times give conflicting views about rehabilitative intervention; for example, should one attempt to activate or inhibit a contralateral homotopic region with cortical stimulation techniques to promote recovery? This review proposes that although the functional imaging data are statistically valid in most cases, their interpretation has often favoured one explanation while ignoring plausible alternatives. In our view, this is particularly evident when recovery is attributed to activity in 'language networks' occupying sites not observed in healthy participants. In this review we will argue that much of the distribution of what has often been interpreted as language-specific activity, particularly in midline and contralateral cortical regions, is an upregulation of activity in intact domain-general systems for cognitive control and attention, responding in a task-dependent manner to the increased 'effort' when damaged downstream domain-specific language networks are impaired. We further propose that it is an inability fully to activate these systems that may result in sub optimal recovery in some patients. Interpretation of the data in terms of activity in domain-general networks affords insights into novel approaches to rehabilitation.
Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT.
Randomized controlled trials (RCTs) regarding PT in stroke rehabilitation were retrieved through a systematic search. Outcomes were classified according to the ICF. RCTs with a low risk of bias were quantitatively analyzed. Differences between phases poststroke were explored in subgroup analyses. A best evidence synthesis was performed for neurological treatment approaches. The search yielded 467 RCTs (N = 25373; median PEDro score 6 [IQR 5-7]), identifying 53 interventions. No adverse events were reported. Strong evidence was found for significant positive effects of 13 interventions related to gait, 11 interventions related to arm-hand activities, 1 intervention for ADL, and 3 interventions for physical fitness. Summary Effect Sizes (SESs) ranged from 0.17 (95%CI 0.03-0.70; I(2) = 0%) for therapeutic positioning of the paretic arm to 2.47 (95%CI 0.84-4.11; I(2) = 77%) for training of sitting balance. There is strong evidence that a higher dose of practice is better, with SESs ranging from 0.21 (95%CI 0.02-0.39; I(2) = 6%) for motor function of the paretic arm to 0.61 (95%CI 0.41-0.82; I(2) = 41%) for muscle strength of the paretic leg. Subgroup analyses yielded significant differences with respect to timing poststroke for 10 interventions. Neurological treatment approaches to training of body functions and activities showed equal or unfavorable effects when compared to other training interventions. Main limitations of the present review are not using individual patient data for meta-analyses and absence of correction for multiple testing.
There is strong evidence for PT interventions favoring intensive high repetitive task-oriented and task-specific training in all phases poststroke. Effects are mostly restricted to the actually trained functions and activities. Suggestions for prioritizing PT stroke research are given.
. Recent neuroimaging studies on poststroke aphasia revealed maladaptive cortical changes in both hemispheres, yet their functional contribution in language recovery remains elusive. The aim of this study was to evaluate the long-term efficacy of dual-hemisphere repetitive transcranial magnetic stimulation (rTMS) on poststroke aphasia.
. Thirty patients with subacute poststroke nonfluent aphasia were randomly allocated to receive real or sham rTMS. Each patient received 1000 rTMS pulses (1 Hz at 110% of resting motor threshold [rMT] over the right unaffected Broca's area and 1000 pulses (20 Hz at 80% rMT) over the left affected Broca's area for 10 consecutive days followed by speech/language training. The language section of the Hemispheric Stroke Scale (HSS), the Stroke Aphasic Depression Questionnaire-Hospital Version (SADQ-H), and the National Institutes of Health Stroke Scale (NIHSS) were measured before, immediately after the 10 sessions, and 1 and 2 months after the last session.
. At baseline, there were no significant differences between groups in demographic and clinical rating scales. However, there was a significantly greater improvement in the HSS language score as well as in the SADQ-H after real rTMS compared with sham rTMS, which remained significant 2 months after the end of the treatment sessions.
. This is the first clinical study of dual-hemisphere rTMS in poststroke aphasia. Combining dual-hemisphere rTMS with language training might be a feasible treatment for nonfluent aphasia; further multicenter studies are needed to confirm this result.
Treadmill training, with or without body weight support using a harness, is used in rehabilitation and might help to improve walking after stroke. This is an update of a Cochrane review first published in 2005.
To determine if treadmill training and body weight support, individually or in combination, improve walking ability, quality of life, activities of daily living, dependency or death, and institutionalisation or death, compared with other physiotherapy gait training interventions after stroke. The secondary objective was to determine the safety and acceptability of this method of gait training.
We searched the Cochrane Stroke Group Trials Register (last searched June 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Reviews of Effects (DARE) (The Cochrane Library 2013, Issue 7), MEDLINE (1966 to July 2013), EMBASE (1980 to July 2013), CINAHL (1982 to June 2013), AMED (1985 to July 2013) and SPORTDiscus (1949 to June 2013). We also handsearched relevant conference proceedings and ongoing trials and research registers, screened reference lists and contacted trialists to identify further trials.
Randomised or quasi-randomised controlled and cross-over trials of treadmill training and body weight support, individually or in combination, for the treatment of walking after stroke.
Two authors independently selected trials, extracted data and assessed methodological quality. The primary outcomes investigated were walking speed, endurance and dependency.
We included 44 trials with 2658 participants in this updated review. Overall, the use of treadmill training with body weight support did not increase the chances of walking independently compared with other physiotherapy interventions (risk difference (RD) -0.00, 95% confidence interval (CI) -0.02 to 0.02; P = 0.94; I² = 0%). Overall, the use of treadmill training with body weight support in walking rehabilitation for patients after stroke increased the walking velocity and walking endurance significantly. The pooled mean difference (MD) (random-effects model) for walking velocity was 0.07 m/s (95% CI 0.01 to 0.12; P = 0.02; I² = 57%) and the pooled MD for walking endurance was 26.35 metres (95% CI 2.51 to 50.19; P = 0.03; I² = 60%). Overall, the use of treadmill training with body weight support in walking rehabilitation for patients after stroke did not increase the walking velocity and walking endurance at the end of scheduled follow-up significantly. The pooled MD (random-effects model) for walking velocity was 0.04 m/s (95% CI -0.06 to 0.14; P = 0.40; I² = 40%) and the pooled MD for walking endurance was 32.36 metres (95% CI -3.10 to 67.81; P = 0.07; I² = 63%). However, for ambulatory patients improvements in walking endurance lasted until the end of scheduled follow-up (MD 58.88 metres, 95% CI 29.10 to 88.66; P = 0.0001; I² = 0%). Adverse events and drop outs did not occur more frequently in people receiving treadmill training and these were not judged to be clinically serious events.
Overall, people after stroke who receive treadmill training with or without body weight support are not more likely to improve their ability to walk independently compared with people after stroke not receiving treadmill training, but walking speed and walking endurance may improve. Specifically, stroke patients who are able to walk (but not people who are not able to walk) appear to benefit most from this type of intervention. This review found that improvements in walking endurance in people able to walk may have persisting beneficial effects. Further research should specifically investigate the effects of different frequencies, durations or intensities (in terms of speed increments and inclination) of treadmill training, as well as the use of handrails, in ambulatory patients, but not in dependent walkers.
Aphasia is a highly disabling language disorder usually caused by a left-lateralized brain damage. Even if traditional linguistic-based therapies have been proved to induce an adequate clinical improvement, a large percentage of patients are left with some degree of language impairments. Therefore, new approaches to common speech therapies are urgently needed in order to maximize the recovery from aphasia. The recent application of non-invasive neurostimulation techniques to language rehabilitation has already provided promising results particularly for the recovery of word-retrieval deficits in chronic stroke aphasic patients. Positive outcomes also come from action observation therapy. Indeed, some very recent studies have shown that the observation and/or execution of gestures positively influences language recovery especially for words related to human actions. This article gives an overview of the most important results achieved using these two approaches and discusses how the application of these treatments might potentiate aphasia recovery.
Recovery after stroke can occur either via reductions in impairment or through compensation. Studies in humans and nonhuman animal models show that most recovery from impairment occurs in the first 1-3 months after stroke as a result of both spontaneous reorganization and increased responsiveness to enriched environments and training. Improvement from impairment is attributable to a short-lived sensitive period of postischemic plasticity defined by unique genetic, molecular, physiological, and structural events. In contrast, compensation can occur at any time after stroke. Here, we address both the biology of the brain's postischemic sensitive period and the difficult question of what kind of training (task-specific vs. a stimulating environment for self-initiated exploration of various natural behaviors) best exploits this period.
Data suggest that three important variables determine the degree of motor recovery from impairment: the timing, intensity, and approach to training with respect to stroke onset; the unique postischemic plasticity milieu; and the extent of cortical reorganization.
Future work will need to further characterize the unique interaction between types of training and postischemic plasticity, and find ways to augment and prolong the sensitive period using pharmacological agents or noninvasive brain stimulation.
Die S3-Leitlinie „Rehabilitative Therapie bei Armparese nach Schlaganfall“ vom 23.04.2020 (gültig bis 22.04.2025) beschreibt die Effekte der rehabilitativen Therapie bei Patienten mit einem Schlaganfall und einer Armparese.
Background Early mobilisation after stroke is thought to contribute to the eff ects of stroke-unit care; however, the intervention is poorly defined and not underpinned by strong evidence. We aimed to compare the effectiveness of frequent, higher dose, very early mobilisation with usual care after stroke.Methods
We did this parallel-group, single-blind, randomised controlled trial at 56 acute stroke units in five countries. Patients (aged ≥18 years) with ischaemic or haemorrhagic stroke, first or recurrent, who met physiological criteriawere randomly assigned (1:1), via a web-based computer generated block randomisation procedure (block size of six), to receive usual stroke-unit care alone or very early mobilisation in addition to usual care. Treatment with recombinant tissue plasminogen activator was allowed. Randomisation was stratified by study site and stroke severity. Patients, outcome assessors, and investigators involved in trial and data management were masked to treatment allocation. The primary outcome was a favourable outcome 3 months after stroke, defined as a modified Rankin Scale score of 0–2. We did analysis on an intention-to-treat basis. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12606000185561.FindingsBetween July 18, 2006, and Oct 16, 2014, we randomly assigned 2104 patients to receive either very early mobilisation (n=1054) or usual care (n=1050); 2083 (99%) patients were included in the 3 month follow-up assessment. 965 (92%) patients were mobilised within 24 h in the very early mobilisation group compared with 623 (59%) patients in the usual care group. Fewer patients in the very early mobilisation group had a favourable outcome than those in the usual care group (n=480 [46%] vs n=525 [50%]; adjusted odds ratio [OR] 0·73, 95% CI 0·59–0·90; p=0·004). 88 (8%) patients died in the very early mobilisation group compared with 72 (7%) patients in the usual care group (OR 1·34, 95% CI 0·93–1·93, p=0·113). 201 (19%) patients in the very early mobilisation group and 208 (20%) of those in the usual care group had a non-fatal serious adverse event, with no reduction in immobility-related complications with very early mobilisation.InterpretationFirst mobilisation took place within 24 h for most patients in this trial. The higher dose, very early mobilisation protocol was associated with a reduction in the odds of a favourable outcome at 3 months. Early mobilisation after stroke is recommended in many clinical practice guidelines worldwide, and our findings should affect clinical practice by refi ning present guidelines; however, clinical recommendations should be informed by future analyses of dose–response associations.
Background:
Constraint-induced aphasia therapy (CIAT) has proven effective in patients with subacute and chronic forms of aphasia. It has remained unclear, however, whether intensity of therapy or constraint is the relevant factor. Data about intensive speech and language therapy (SLT) are conflicting.
Objective:
To identify the effective component of CIAT and assess the feasibility of SLT in the acute stage after stroke.
Method:
A total of 60 patients with aphasia (68.2 ± 11.7 years) were enrolled 18.9 days after first-ever stroke. They were randomly distributed into 3 groups: (1) CIAT group receiving therapy for 3 hours per day (10 workdays, total 30 hours); (2) conventional communication treatment group, with same intensity without constraints; and (3) control group receiving individual therapy twice a day as well as group therapy (total 14 hours). Patients were assessed pretreatment and posttreatment using the Aachener Aphasia Test (primary end point: token test) and the Communicative Activity Log (CAL).
Results:
Pretreatment, there were no between-group differences. Posttreatment, all groups showed significant improvements without between-group differences.
Conclusion:
It was found that 14 hours of aphasia therapy administered within 2 weeks as individual therapy, focusing on individual deficits, combined with group sessions has proven to be most efficient. This approach yielded the same outcome as 30 hours of group therapy, either in the form of CIAT or group therapy without constraints. SLT in an intensive treatment schedule is feasible and was well tolerated in the acute stage after stroke.
Background:
Aphasia is an acquired language impairment following brain damage that affects some or all language modalities: expression and understanding of speech, reading, and writing. Approximately one third of people who have a stroke experience aphasia.
Objectives:
To assess the effects of speech and language therapy (SLT) for aphasia following stroke.
Search methods:
We searched the Cochrane Stroke Group Trials Register (last searched 9 September 2015), CENTRAL (2015, Issue 5) and other Cochrane Library Databases (CDSR, DARE, HTA, to 22 September 2015), MEDLINE (1946 to September 2015), EMBASE (1980 to September 2015), CINAHL (1982 to September 2015), AMED (1985 to September 2015), LLBA (1973 to September 2015), and SpeechBITE (2008 to September 2015). We also searched major trials registers for ongoing trials including ClinicalTrials.gov (to 21 September 2015), the Stroke Trials Registry (to 21 September 2015), Current Controlled Trials (to 22 September 2015), and WHO ICTRP (to 22 September 2015). In an effort to identify further published, unpublished, and ongoing trials we also handsearched the International Journal of Language and Communication Disorders (1969 to 2005) and reference lists of relevant articles, and we contacted academic institutions and other researchers. There were no language restrictions.
Selection criteria:
Randomised controlled trials (RCTs) comparing SLT (a formal intervention that aims to improve language and communication abilities, activity and participation) versus no SLT; social support or stimulation (an intervention that provides social support and communication stimulation but does not include targeted therapeutic interventions); or another SLT intervention (differing in duration, intensity, frequency, intervention methodology or theoretical approach).
Data collection and analysis:
We independently extracted the data and assessed the quality of included trials. We sought missing data from investigators.
Main results:
We included 57 RCTs (74 randomised comparisons) involving 3002 participants in this review (some appearing in more than one comparison). Twenty-seven randomised comparisons (1620 participants) assessed SLT versus no SLT; SLT resulted in clinically and statistically significant benefits to patients' functional communication (standardised mean difference (SMD) 0.28, 95% confidence interval (CI) 0.06 to 0.49, P = 0.01), reading, writing, and expressive language, but (based on smaller numbers) benefits were not evident at follow-up. Nine randomised comparisons (447 participants) assessed SLT with social support and stimulation; meta-analyses found no evidence of a difference in functional communication, but more participants withdrew from social support interventions than SLT. Thirty-eight randomised comparisons (1242 participants) assessed two approaches to SLT. Functional communication was significantly better in people with aphasia that received therapy at a high intensity, high dose, or over a long duration compared to those that received therapy at a lower intensity, lower dose, or over a shorter period of time. The benefits of a high intensity or a high dose of SLT were confounded by a significantly higher dropout rate in these intervention groups. Generally, trials randomised small numbers of participants across a range of characteristics (age, time since stroke, and severity profiles), interventions, and outcomes.
Authors' conclusions:
Our review provides evidence of the effectiveness of SLT for people with aphasia following stroke in terms of improved functional communication, reading, writing, and expressive language compared with no therapy. There is some indication that therapy at high intensity, high dose or over a longer period may be beneficial. HIgh-intensity and high dose interventions may not be acceptable to all.
Background
Aphasia is a common symptom in post-stroke patients. Piracetam is a commonly used nootropic agent that promises various benefits to brain function, including language improvement. Objective
We performed a systematic review and meta-analysis to assess whether piracetam facilitates the rehabilitation of language performance in post-stroke patients. Methods
Randomized controlled trials (RCTs) of piracetam treatment in post-stroke patients published in any language were included, excluding those involving pre-existing cognitive disorders such as dementia and mood disturbances. We searched several databases including PubMed, EMBASE, Cochrane Central, CINAHL, Web of Science, and PsycINFO for RCTs published up to 31 December 2015. We conducted a meta-analysis using RevMan (version 5.3), with standardized mean differences (SMDs) and fixed-effect models, and used StataSE (version 13) for the detection of publication bias. This study has been submitted to PROSPERO, and its registration number is CRD42016034088. ResultsWe identified 1180 titles and abstracts, and finally included seven RCTs in this meta-analysis. The number of participants in each study ranged from 19 to 66, summing up to 261 patients overall. The dose of piracetam was consistent while the frequency and time of therapy varied. The assessment of the language at the end of trials showed no significant improvement in overall severity of aphasia [SMD 0.23, 95 % confidence interval (CI) −0.03 to 0.49, P = 0.08], but written language (SMD 0.35, 95 % CI 0.04 to 0.66, P = 0.03) showed pronounced improvement. Subgroup analyses indicated a dissociation of effectiveness between short- and long-term assessment in overall severity (P = 0.008, I2 = 85.6 %) in terms of tests for subgroup differences, and a mild trend toward dissociation in written subtests (P = 0.30, I2 = 5.1 %). Funnel plots and Egger’s test identified no obvious publication bias in the primary variable. Conclusions
Piracetam plays a limited role in the rehabilitation of overall language impairment and only benefits written language ability at the end of trials. Its effect on overall linguistic level and written language tends to emerge within a short period and declines thereafter.
P59
Background: Although patterns of stroke occurrence and mortality have been well studied, little epidemiologic data are available regarding the clinical characteristics of stroke events. Methods: We evaluated hospitalized stroke events reported in the Atherosclerosis Risk in Communities Study to describe the clinical characteristics of incident stroke. Incident confirmed stroke cases (n=474) were evaluated for stroke symptoms including headache, vertigo, gait disturbance, and convulsions. Cases were also evaluated for stroke signs including hemianopia, diplopia, speech deficits, paresis, and parasthesia/sensory deficits. Stroke characteristics were also evaluated for univariate associations with race, gender, and stroke subtype. Results: Over an average follow-up of 9.2 years, 407 (86%) ischemic and 67 (14%) hemorrhagic strokes occurred. Stroke symptoms in order of decreasing frequency (95% confidence intervals) were headache (27.4%, 23.4%-31.4%), gait disturbance (10.8%, 7.9%-13.6%), convulsions (4.4%, 2.6%-6.3%), and vertigo (2.1%, 0.8%-3.4%). Speech deficits occurred in 64.1% (59.8%-68.5%), hemianopia in 14.6% (11.4%-17.7%), and diplopia in 5.5% (3.4%-7.5%) of cases. Most cases involved paresis (81.6%, 78.1%-85.1%), predominantly of the arms (75.5%, 71.6%-79.4%). Fewer subjects experienced sensory deficits (44.5%, 40.0%-49.6%), predominantly in the arms (38.6%, 34.2%-43.0%). Blacks were more likely than whites to experience paresis (85.8% vs 77.9%, p=0.03). Men were more likely than women to experience a gait disturbance (14.3% vs 6.7%, p=0.001). As expected, persons with hemorrhagic strokes had a higher proportion of headaches (59.7% vs 22.1%, p=0.001) and convulsions (11.9% vs 3.2%, p=0.001) than those with ischemic events, while speech deficits were more common in ischemic strokes (68.1% vs 40.3%, p=0.001). Conclusions: We present epidemiologic data concerning the clinical characteristics of incident stroke in a population-based cohort. While minor differences by race, gender, and stroke subtype were observed, data from additional follow-up is required to confirm observed variation.
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See Fink et al . (doi: 10.1093/aww034 ) for a scientific commentary on this article.
Transcranial direct-current stimulation (tDCS) has shown beneficial effects in post-stroke aphasia, but selecting stimulation sites is challenging. In a randomised controlled trial, Meinzer et al . demonstrate that motor cortex tDCS induces long-lasting improvement of language and everyday communication in patients, and may be a clinically feasible way to enhance recovery.
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See Fink et al . (doi: 10.1093/aww034 ) for a scientific commentary on this article.
Transcranial direct-current stimulation (tDCS) has shown beneficial effects in post-stroke aphasia, but selecting stimulation sites is challenging. In a randomised controlled trial, Meinzer et al . demonstrate that motor cortex tDCS induces long-lasting improvement of language and everyday communication in patients, and may be a clinically feasible way to enhance recovery.
Background and objective:
Favorable prognosis of the upper limb depends on preservation or return of voluntary finger extension (FE) early after stroke. The present study aimed to determine the effects of modified constraint-induced movement therapy (mCIMT) and electromyography-triggered neuromuscular stimulation (EMG-NMS) on upper limb capacity early poststroke.
Methods:
A total of 159 ischemic stroke patients were included: 58 patients with a favorable prognosis (>10° of FE) were randomly allocated to 3 weeks of mCIMT or usual care only; 101 patients with an unfavorable prognosis were allocated to 3-week EMG-NMS or usual care only. Both interventions started within 14 days poststroke, lasted up until 5 weeks, focused at preservation or return of FE.
Results:
Upper limb capacity was measured with the Action Research Arm Test (ARAT), assessed weekly within the first 5 weeks poststroke and at postassessments at 8, 12, and 26 weeks. Clinically relevant differences in ARAT in favor of mCIMT were found after 5, 8, and 12 weeks poststroke (respectively, 6, 7, and 7 points; P < .05), but not after 26 weeks. We did not find statistically significant differences between mCIMT and usual care on impairment measures, such as the Fugl-Meyer assessment of the arm (FMA-UE). EMG-NMS did not result in significant differences.
Conclusions:
Three weeks of early mCIMT is superior to usual care in terms of regaining upper limb capacity in patients with a favorable prognosis; 3 weeks of EMG-NMS in patients with an unfavorable prognosis is not beneficial. Despite meaningful improvements in upper limb capacity, no evidence was found that the time-dependent neurological improvements early poststroke are significantly influenced by either mCIMT or EMG-NMS.
Almost 7 million adult Americans have had a stroke. There is a growing need for more effective treatment options as add-ons to conventional therapies. This article summarizes the published literature for pharmacologic agents used for the enhancement of motor and speech recovery after stroke. Amphetamine, levodopa, selective serotonin reuptake inhibitors, and piracetam were the most commonly used drugs. Pharmacologic augmentation of stroke motor and speech recovery seems promising but systematic, adequately powered, randomized, and double-blind clinical trials are needed. At this point, the use of these pharmacologic agents is not supported by class I evidence.
Pathologisch veranderte Neuroplastizitat wird zunehmend als pathophysiologische Grundlage verschiedenster neurologischer und psychiatrischer Erkrankungen identifiziert. Nicht-invasive Hirnstimulationsverfahren bieten zum einen die Moglichkeit, Neuroplastizitat und kortikale Exzitabilitat am Patienten zu untersuchen und zum anderen pathologische Neuroplastizitat therapeutisch zu modulieren. In den letzten Jahrzehnten wurden verschiedene Verfahren zur Beeinflussung von Neuroplastizitat im Menschen etabliert. Hierzu gehoren die repetitive transkranielle Magnetstimulation, die gepaarte assoziative Stimulation, die transkranielle Gleichstromstimulation, und oszillatorische elektrische Stimulationsverfahren wie die transkranielle Wechselstromstimulation oder Random Noise Stimulation. Im klinischen Alltag regelmasig eingesetzt und in den USA von der FDA bei schweren Depressionen zur Behandlung zugelassen ist bisher die repetitive transkranielle Magnetstimulation, die ubrigen Verfahren haben gegenwartig einen experimentellen Charakter. Im folgenden Artikel geben wir einen Uberblick uber die Methodik der unterschiedlichen Stimulationsverfahren, die bisherigen klinischen Daten zum therapeutischen Einsatz und Zukunftsperspektiven.
Purpose of review:
Prescribing the most appropriate dose of motor therapy for individual patients is a challenge because minimal data are available and a large number of factors are unknown. This review explores the concept of dose and reviews the most recent findings in the field of neurorehabilitation, with a focus on relearning motor skills after stroke.
Recent findings:
Appropriate dosing involves the prescription of a specific amount of an active ingredient, at a specific frequency and duration. Dosing parameters, particularly amount, are not well defined or quantified in most studies. Compiling data across studies indicates a positive, moderate dose-response relationship, indicating that more movement practice results in better outcomes. This relationship is confounded by time after stroke, however, wherein longer durations of scheduled therapy may not be beneficial in the first few hours, days, and/or weeks.
Summary:
These findings suggest that substantially more movement practice may be necessary to achieve better outcomes for people living with the disabling consequences of stroke. Preclinical investigations are needed to elucidate many of the unknowns and allow for a more biologically driven rehabilitation prescription process. Likewise, clinical investigations are needed to determine the dose-response relationships and examine the potential dose-timing interaction in humans.
Among the therapeutic strategies under study to improve long-term outcome after stroke are drugs targeting events that underlie recovery. Drugs that enhance recovery are separate from those that promote neuroprotection or reperfusion in patients with stroke. Recovery-based drugs have distinct therapeutic targets that are related to plasticity and growth after stroke, and in general, improvements in behavioral outcome are not accompanied by a reduction in infarct volume. Interventions targeting recovery have a time window measured in days or sometimes weeks-months, suggesting potential utility for a large percentage of patients with stroke. Currently, among drugs that enhance motor recovery after stroke in humans, the strongest evidence exists for serotonergic and dopaminergic agents. Restorative therapies generally target the brain directly, in contrast to approved stroke therapeutics that target arteries, clots, platelets, glucose, or cholesterol. Targeting the brain has wide-ranging implications, for example, in relation to drug delivery. In addition, because restorative drugs aim to change brain structure and function, their effects are influenced by concomitant behavioral experience, a finding that informs selection of entry criteria, outcome measures, and biomarkers in a clinical trial setting. These points underscore the importance of a neural systems approach in studying stroke recovery.
© 2015 American Heart Association, Inc.
Constraint-induced movement therapy (CIMT) is recommended for patients with upper limb dysfunction after stroke, yet evidence to support the implementation of CIMT in ambulatory care is insufficient. We assessed the efficacy of home CIMT, a modified form of CIMT that trains arm use in daily activities within the home environment.
In this parallel, cluster-randomised controlled trial, we selected 71 therapy practices in northern Germany that treat adult patients with upper limb dysfunction after stroke. Practices were stratified by region and randomly allocated by an external biometrician (1:1, block size of four) using a computer-generated sequence. 37 practices were randomly assigned to provide 4 weeks of home CIMT and 34 practices to provide 4 weeks of standard therapy. Eligible patients had mild to moderate impairment of arm function at least 6 months after stroke and a friend or family member willing to participate as a non-professional coach. Patients of both groups received 5 h of professional therapist contact in 4 weeks. In the home CIMT group, therapists used the contact time to instruct and supervise patients and coaches in home CIMT. Patients in the standard therapy group received conventional physical or occupational therapy, but additional home training was not obligatory. All assessments were done by masked outcome assessors at baseline, after 4 weeks of intervention, and at 6 month follow-up. The primary outcomes were quality of movement, assessed by the Motor Activity Log (MAL-QOM, assessor-assisted self-reported), and performance time, assessed by the Wolf Motor Function Test (WMFT-PT, assessor-reported). Primary outcomes were tested hierarchically after 4 weeks of intervention and analysed by intention to treat, using mixed linear models. This trial is registered with ClinicalTrials.gov, NCT01343602.
Between July 11, 2011, and June 4, 2013, 85 of 156 enrolled patients were assigned home CIMT and 71 patients were assigned standard therapy. 82 (96%) patients in the home CIMT group and 71 (100%) patients in the standard therapy group completed treatment and were assessed at 4 weeks. Patients in both groups improved in quality of movement (MAL-QOM; change from baseline 0·56, 95% CI 0·41-0·71, p<0·0001 for home CIMT vs 0·31, 0·15-0·46, p=0·0003 for standard therapy). Patients in the home CIMT group improved more than patients in the standard therapy group (between-group difference 0·26, 95% CI 0·05-0·46; p=0·0156). Both groups also improved in motor function performance time (WMFT-PT; change from baseline -25·60%, 95% CI -36·75 to -12·49, p=0·0006 for home CIMT vs -27·52%, -38·94 to -13·94, p=0·0004 for standard therapy), but the extent of improvement did not differ between groups (2·65%, -17·94 to 28·40; p=0·8152). Nine adverse events (of which six were serious) were reported in the home CIMT group and ten (of which seven were serious) in the standard therapy group; however, none was deemed related to the study intervention.
Home-based CIMT can enhance the perceived use of the stroke-affected arm in daily activities more effectively than conventional therapy, but was not superior with respect to motor function. Further research is needed to confirm whether home CIMT leads to clinically significant improvements and if so to identify patients that are most likely to benefit.
German Federal Ministry of Education and Research.
Copyright © 2015 Elsevier Ltd. All rights reserved.
Neuromuscular electric stimulation (NMES) has been used to reduce spasticity and improve range of motion in patients with stroke. However, contradictory results have been reported by clinical trials. A systematic review of randomized clinical trials was conducted to assess the effect of treatment with NMES with or without association to another therapy on spastic muscles after stroke compared with placebo or another intervention.
We searched the following electronic databases (from inception to February 2015): Medline (PubMed), EMBASE, Cochrane Central Register of Controlled Trials and Physiotherapy Evidence Database (PEDro). Two independent reviewers assessed the eligibility of studies based on predefined inclusion criteria (application of electric stimulation on the lower or upper extremities, regardless of NMES dosage, and comparison with a control group which was not exposed to electric stimulation), excluding studies with <3 days of intervention. The primary outcome extracted was spasticity, assessed by the Modified Ashworth Scale, and the secondary outcome extracted was range of motion, assessed by Goniometer.
Of the total of 5066 titles, 29 randomized clinical trials were included with 940 subjects. NMES provided reductions in spasticity (-0.30 [95% confidence interval, -0.58 to -0.03], n=14 randomized clinical trials) and increase in range of motion when compared with control group (2.87 [95% confidence interval, 1.18-4.56], n=13 randomized clinical trials) after stroke.
NMES combined with other intervention modalities can be considered as a treatment option that provides improvements in spasticity and range of motion in patients after stroke.
URL: http://www.crd.york.ac.uk/PROSPERO. Unique identifier: CRD42014008946.
© 2015 American Heart Association, Inc.
Background: Speech pathologists face the clinical obstacle of providing an intensive service for individuals with aphasia. Computer therapy potentially offers a solution to the dilemma of increasing therapy frequency while maintaining or reducing the load on therapists’ resources.
The purpose of this systematic review was to summarize the effect of daily use of single-channel foot drop stimulation among persons with stroke. Randomized controlled trials were searched using electronic databases through May 2014. Six randomized controlled trials were included, involving 820 participants. Gait speed was the most common outcome measured. Other common outcomes included Timed Up and Go, modified Emory Functional Ambulation Profile, Berg Balance Scale, Physiologic Cost Index, Six-Minute Walk Test, quality-of-life, and lower extremity Fugl-Meyer. In summary, foot drop stimulation and ankle foot orthoses seem effective and "equivalent" for increasing gait speed. Other outcomes that consistently improved in both groups were the Timed Up and Go and Six-Minute Walk Test. Foot drop stimulation was more effective compared with ankle foot orthosis for decreasing Physiologic Cost Index and seemed to be preferred by participants. Physical therapy may facilitate improvement in both foot drop stimulation and ankle foot orthosis groups.
Neuromodulation with pharmacological agents, including drugs of abuse such as amphetamine, when paired with behavioral experience, has been shown to positively modify outcomes in animal models of stroke. A number of clinical studies have tested the efficacy of a variety of drugs to enhance recovery of language deficits post stroke. The purpose of this paper is to : (1) present pertinent animal studies supporting the use of dextro-amphetamine sulphate (AMPH) to enhance recovery after experimental lesions with emphasis on the importance of learning dependent activity for lasting recovery; (2) briefly review neuropharmacological explorations in the treatment of aphasia; (3) present a pilot study in aphasia exploring a drug combination of AMPH and donepezil hydrochloride paired with behavioral treatment to facilitate recovery; and (4) conclude with comments regarding the role of adjunctive pharmacotherapy in the rehabilitation of aphasia, particularly AMPH.
Copyright © 2015. Published by Elsevier Inc.
The PLORAS Database is a relational repository of anatomical and functional imaging data that has primarily been acquired from stroke survivors, along with standardised scores on a wide range of sensory, motor and cognitive abilities, demographic details and medical history. As of January 2015, we have data from 750 patients with an expected accrual rate of 200 patients per year. Expansion will accelerate as we extend our collaborations. The main aim of the Database is to Predict Language Outcome and Recovery after Stroke (PLORAS) on the basis of a single structural (anatomical) brain scan that indexes the stereotactic location and extent of brain damage. Predictions are made for individual patients by indicating how other patients with the most similar brain damage, cognitive abilities and demographic details recovered their language skills over time. Predictions are validated by longitudinal follow ups of patients who initially presented with speech and language difficulties. The PLORAS Database can also be used to predict recovery of other cognitive abilities on the basis of anatomical brain scans. The functional imaging data can be used to understand the neural mechanisms that support recovery from brain damage; and all the data can be used to understand the main sources of inter-subject variability in structure-function mappings in the human brain. Data will be made available for sharing, subject to: funding, ethical approval and patient consent.
Copyright © 2015. Published by Elsevier Inc.
Constraint-induced movement therapy (CIMT) was developed to overcome upper limb impairments after stroke and is the most investigated intervention for the rehabilitation of patients. Original CIMT includes constraining of the non-paretic arm and task-oriented training. Modified versions also apply constraining of the non-paretic arm, but not as intensive as original CIMT. Behavioural strategies are mostly absent for both modified and original CIMT. With forced use therapy, only constraining of the non-paretic arm is applied. The original and modified types of CIMT have beneficial effects on motor function, arm-hand activities, and self-reported arm-hand functioning in daily life, immediately after treatment and at long-term follow-up, whereas there is no evidence for the efficacy of constraint alone (as used in forced use therapy). The type of CIMT, timing, or intensity of practice do not seem to affect patient outcomes. Although the underlying mechanisms that drive modified and original CIMT are still poorly understood, findings from kinematic studies suggest that improvements are mainly based on adaptations through learning to optimise the use of intact end-effectors in patients with some voluntary motor control of wrist and finger extensors after stroke.
Copyright © 2015 Elsevier Ltd. All rights reserved.
To investigate (i) the effect of functional electrical stimulation (FES) in improving activity and (ii) whether FES is more effective than training alone? Review protocol available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42012003054.
Cochrane Central Register of Controlled Trials, Ovid MEDLINE, EBSCO CINHAL, Ovid EMBASE, Physiotherapy Evidence Database and Occupational Therapy Systematic Evaluation of Effectiveness database.
Randomized and controlled trials up to 22(nd) June 2014 were included following pre-determined search and selection criteria.
Data extraction occurred by two people independently using a pre-determined data collection form. Methodological quality was assessed by 2 reviewers using the PEDro methodological rating scale. Meta-analysis was conducted separately for the two research questions.
Eighteen trials (19 comparisons) were eligible for inclusion in the review. FES had a moderate effect on activity (SMD 0.40, 95% CI 0.09 to 0.72) compared with no or placebo intervention. FES had a moderate effect on activity (SMD 0.56, 95% CI 0.29 to 0.92) compared with training alone. When subgroup analyses were performed, FES had a large effect on upper limb activity (SMD 0.69, 95% CI 0.33 to 1.05) and a small effect on walking speed (MD 0.08 m/s, 95% CI 0.02 to 0.15) compared with any control.
FES appears to moderately improve activity compared with both no intervention and training alone. These findings suggest that FES should be used in stroke rehabilitation to improve the ability to perform activities.
Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
Purpose:
L-dopa has been shown to improve outcome of moderate-intensity language training after stroke in acute aphasia. Given the critical role of training intensity we probed the effect of l-dopa in combination with high-intensity language training in chronic post-stroke aphasia.
Methods:
In this prospective, randomized, placebo-controlled, double-blind study, aphasia patients (>1 year post stroke) were administered 100/25 mg of l-dopa/carbidopa or placebo daily prior to four hours of language training for two weeks. Conditions were crossed-over after a wash-out period of 4 weeks.
Results:
An a-priori planned interim analysis (n = 10) showed that naming performance and verbal communication improved significantly and persistently for at least 6 months in every patient, but l-dopa had no incremental effect to intensive training.
Conclusion:
High-intensity language training in chronic aphasia may take learning to a ceiling that precludes additive benefits from l-dopa. Effects of l-dopa on post-stroke recovery during less intense treatment in chronic aphasia remain to be evaluated.
Background:
Improving upper limb function is a core element of stroke rehabilitation needed to maximise patient outcomes and reduce disability. Evidence about effects of individual treatment techniques and modalities is synthesised within many reviews. For selection of effective rehabilitation treatment, the relative effectiveness of interventions must be known. However, a comprehensive overview of systematic reviews in this area is currently lacking.
Objectives:
To carry out a Cochrane overview by synthesising systematic reviews of interventions provided to improve upper limb function after stroke.
Methods:
Search methods:
We comprehensively searched the Cochrane Database of Systematic Reviews; the Database of Reviews of Effects; and PROSPERO (an international prospective register of systematic reviews) (June 2013). We also contacted review authors in an effort to identify further relevant reviews.
Selection criteria:
We included Cochrane and non-Cochrane reviews of randomised controlled trials (RCTs) of patients with stroke comparing upper limb interventions with no treatment, usual care or alternative treatments. Our primary outcome of interest was upper limb function; secondary outcomes included motor impairment and performance of activities of daily living. When we identified overlapping reviews, we systematically identified the most up-to-date and comprehensive review and excluded reviews that overlapped with this.
Data collection and analysis:
Two overview authors independently applied the selection criteria, excluding reviews that were superseded by more up-to-date reviews including the same (or similar) studies. Two overview authors independently assessed the methodological quality of reviews (using a modified version of the AMSTAR tool) and extracted data. Quality of evidence within each comparison in each review was determined using objective criteria (based on numbers of participants, risk of bias, heterogeneity and review quality) to apply GRADE (Grades of Recommendation, Assessment, Development and Evaluation) levels of evidence. We resolved disagreements through discussion. We systematically tabulated the effects of interventions and used quality of evidence to determine implications for clinical practice and to make recommendations for future research.
Main results:
Our searches identified 1840 records, from which we included 40 completed reviews (19 Cochrane; 21 non-Cochrane), covering 18 individual interventions and dose and setting of interventions. The 40 reviews contain 503 studies (18,078 participants). We extracted pooled data from 31 reviews related to 127 comparisons. We judged the quality of evidence to be high for 1/127 comparisons (transcranial direct current stimulation (tDCS) demonstrating no benefit for outcomes of activities of daily living (ADLs)); moderate for 49/127 comparisons (covering seven individual interventions) and low or very low for 77/127 comparisons.Moderate-quality evidence showed a beneficial effect of constraint-induced movement therapy (CIMT), mental practice, mirror therapy, interventions for sensory impairment, virtual reality and a relatively high dose of repetitive task practice, suggesting that these may be effective interventions; moderate-quality evidence also indicated that unilateral arm training may be more effective than bilateral arm training. Information was insufficient to reveal the relative effectiveness of different interventions.Moderate-quality evidence from subgroup analyses comparing greater and lesser doses of mental practice, repetitive task training and virtual reality demonstrates a beneficial effect for the group given the greater dose, although not for the group given the smaller dose; however tests for subgroup differences do not suggest a statistically significant difference between these groups. Future research related to dose is essential.Specific recommendations for future research are derived from current evidence. These recommendations include but are not limited to adequately powered, high-quality RCTs to confirm the benefit of CIMT, mental practice, mirror therapy, virtual reality and a relatively high dose of repetitive task practice; high-quality RCTs to explore the effects of repetitive transcranial magnetic stimulation (rTMS), tDCS, hands-on therapy, music therapy, pharmacological interventions and interventions for sensory impairment; and up-to-date reviews related to biofeedback, Bobath therapy, electrical stimulation, reach-to-grasp exercise, repetitive task training, strength training and stretching and positioning.
Authors' conclusions:
Large numbers of overlapping reviews related to interventions to improve upper limb function following stroke have been identified, and this overview serves to signpost clinicians and policy makers toward relevant systematic reviews to support clinical decisions, providing one accessible, comprehensive document, which should support clinicians and policy makers in clinical decision making for stroke rehabilitation.Currently, no high-quality evidence can be found for any interventions that are currently used as part of routine practice, and evidence is insufficient to enable comparison of the relative effectiveness of interventions. Effective collaboration is urgently needed to support large, robust RCTs of interventions currently used routinely within clinical practice. Evidence related to dose of interventions is particularly needed, as this information has widespread clinical and research implications.
Objective:
We explored the effectiveness of mirror therapy (MT) in the treatment of unilateral neglect in stroke patients.
Methods:
This is an open, blinded endpoint, randomized controlled trial carried out from January 2011 to August 2013. We included stroke patients with thalamic and parietal lobe lesions with unilateral neglect 48 hours after stroke. Patients were randomized to the MT group or the control group (sham MT), and both the groups received limb activation. Patients received treatment for 1-2 hours a day 5 days a week for 4 weeks. The primary outcome was unilateral neglect assessed by a blinded assessor using the star cancellation test, the line bisection test, and a picture identification task at 1, 3, and 6 months. This study was registered at http://clinicaltrials.gov (NCT 01735877).
Results:
Forty-eight patients were randomized to MT (n = 27) or the control group (n = 21). Improvement in scores on the star cancellation test over 6 months was greater in the MT group (mean difference 23, 95% confidence interval [CI] 19-28; p < 0.0001). Similarly, improvement in the MT group was observed in the scores on the picture identification task (mean difference 3.2, 95% CI 2.4-4.0; p < 0.0001) and line bisection test (mean difference 8.6, 95% CI 2.7-14.6; p = 0.006).
Conclusions:
In patients with stroke, MT is a simple treatment that improves unilateral neglect.
Classification of evidence:
This study provides Class I evidence that for patients with neglect from thalamic and parietal lobe strokes, MT improves neglect.
Background and purpose:
Neurophysiological models of rehabilitation and recovery suggest that a large volume of specific practice is required to induce the neuroplastic changes that underlie behavioral recovery. The primary objective of this meta-analysis was to explore the relationship between time scheduled for therapy and improvement in motor therapy for adults after stroke by (1) comparing high doses to low doses and (2) using metaregression to quantify the dose-response relationship further.
Methods:
Databases were searched to find randomized controlled trials that were not dosage matched for total time scheduled for therapy. Regression models were used to predict improvement during therapy as a function of total time scheduled for therapy and years after stroke.
Results:
Overall, treatment groups receiving more therapy improved beyond control groups that received less (g=0.35; 95% confidence interval, 0.26-0.45). Furthermore, increased time scheduled for therapy was a significant predictor of increased improvement by itself and when controlling for linear and quadratic effects of time after stroke.
Conclusions:
There is a positive relationship between the time scheduled for therapy and therapy outcomes. These data suggest that large doses of therapy lead to clinically meaningful improvements, controlling for time after stroke. Currently, trials report time scheduled for therapy as a measure of therapy dose. Preferable measures of dose would be active time in therapy or repetitions of an exercise.
The purpose of this article was to investigate the effects of repetitive transcranial magnetic stimulation (rTMS) on hand function recovery and the plasticity of the cortex in stroke patients.
A search was conducted in electronic databases for randomized controlled trials exploring the effects of rTMS on hand motor function rehabilitation published from 1990 to January 30, 2012. The authors summarized the effect size on finger coordination, hand function, cortical excitement, and activities of daily living by calculating the standardized mean difference. Adverse effects were also discussed.
Of 1668 articles identified, 8 articles (N = 273) were included in this study. The summary effect size indicated positive effects of rTMS on finger motor ability (standardized mean difference, 0.58) and hand function (standardized mean difference, -0.82). However, this study showed that the changes of neurophysiologic measurements were not significant in the included studies. Even so, the trend of these changes was positive. Few adverse events were observed.
rTMS can improve patients' recovery after stroke. The authors suggest that future trials can concentrate on the effects of rTMS for different types of stroke patients in response to stimulation at different sites and explore optimal rTMS parameters for individual treatment.
Background:
Stroke is one of the leading causes of disability worldwide. Functional impairment resulting in poor performance in activities of daily living (ADLs) among stroke survivors is common. Current rehabilitation approaches have limited effectiveness in improving ADL performance and function after stroke, but a possible adjunct to stroke rehabilitation might be non-invasive brain stimulation by transcranial direct current stimulation (tDCS) to modulate cortical excitability and hence to improve ADL performance and function.
Objectives:
To assess the effects of tDCS on generic activities of daily living (ADLs) and motor function in people with stroke.
Search methods:
We searched the Cochrane Stroke Group Trials Register (March 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, May 2013), MEDLINE (1948 to May 2013), EMBASE (1980 to May 2013), CINAHL (1982 to May 2013), AMED (1985 to May 2013), Science Citation Index (1899 to May 2013) and four additional databases. In an effort to identify further published, unpublished and ongoing trials, we searched trials registers and reference lists, handsearched conference proceedings and contacted authors and equipment manufacturers.
Selection criteria:
We included only randomised controlled trials (RCTs) and randomised controlled cross-over trials (from which we analysed only the first period as a parallel-group design) that compared tDCS versus control in adults with stroke for improving ADL performance and function.
Data collection and analysis:
Two review authors independently assessed trial quality (JM and MP) and extracted data (BE and JM). If necessary, we contacted study authors to ask for additional information. We collected information on dropouts and adverse events from the trial reports.
Main results:
We included 15 studies involving a total of 455 participants. Analysis of six studies involving 326 participants regarding our primary outcome, ADL, showed no evidence of an effect in favour of tDCS at the end of the intervention phase (mean difference (MD) 5.31 Barthel Index (BI) points; 95% confidence interval (CI) -0.52 to 11.14; inverse variance method with random-effects model), whereas at follow-up (MD 11.13 BI points; 95% CI 2.89 to 19.37; inverse variance method with random-effects model), we found evidence of an effect. However, the confidence intervals were wide and the effect was not sustained when only studies with low risk of bias were included. For our secondary outcome, upper limb function, we analysed eight trials with 358 participants, which showed evidence of an effect in favour of tDCS at the end of the intervention phase (MD 3.45 Upper Extremity Fugl-Meyer Score points (UE-FM points); 95% CI 1.24 to 5.67; inverse variance method with random-effects model) but not at the end of follow-up three months after the intervention (MD 9.23 UE-FM points; 95% CI -13.47 to 31.94; inverse variance method with random-effects model). These results were sensitive to inclusion of studies at high risk of bias. Adverse events were reported and the proportions of dropouts and adverse events were comparable between groups (risk difference (RD) 0.00; 95% CI -0.02 to 0.03; Mantel-Haenszel method with random-effects model).
Authors' conclusions:
At the moment, evidence of very low to low quality is available on the effectiveness of tDCS (anodal/cathodal/dual) versus control (sham/any other intervention) for improving ADL performance and function after stroke. Future research should investigate the effects of tDCS on lower limb function and should address methodological issues by routinely reporting data on adverse events and dropouts and allocation concealment, and by performing intention-to-treat analyses.