Stroke is a common, serious, and disabling global health-care problem, and rehabilitation is a major part of patient care. There is evidence to support rehabilitation in well coordinated ...multidisciplinary stroke units or through provision of early supported provision of discharge teams. Potentially beneficial treatment options for motor recovery of the arm include constraint-induced movement therapy and robotics. Promising interventions that could be beneficial to improve aspects of gait include fitness training, high-intensity therapy, and repetitive-task training. Repetitive-task training might also improve transfer functions. Occupational therapy can improve activities of daily living; however, information about the clinical effect of various strategies of cognitive rehabilitation and strategies for aphasia and dysarthria is scarce. Several large trials of rehabilitation practice and of novel therapies (eg, stem-cell therapy, repetitive transcranial magnetic stimulation, virtual reality, robotic therapies, and drug augmentation) are underway to inform future practice.
To report and synthesize the perspectives, experiences, and preferences of stroke survivors undertaking inpatient physical rehabilitation through a systematic review of qualitative studies.
MEDLINE, ...CINAHL, Embase, and PsycINFO were searched from database inception to February 2014. Reference lists of relevant publications were searched. All languages were included.
Qualitative studies reporting stroke survivors' experiences of inpatient stroke rehabilitation were selected independently by 2 reviewers. The search yielded 3039 records; 95 full-text publications were assessed for eligibility, and 32 documents (31 studies) were finally included. Comprehensiveness and explicit reporting were assessed independently by 2 reviewers using the consolidated criteria for reporting qualitative research framework. Discrepancies were resolved by consensus.
Data regarding characteristics of the included studies were extracted by 1 reviewer, tabled, and checked for accuracy by another reviewer. All text reported in studies' results sections were entered into qualitative data management software for analysis.
Extracted texts were inductively coded and analyzed in 3 phases using thematic synthesis. Nine interrelated analytical themes, with descriptive subthemes, were identified that related to issues of importance to stroke survivors: (1) physical activity is valued; (2) bored and alone; (3) patient-centered therapy; (4) recreation is also rehabilitation; (5) dependency and lack of control; (6) fostering autonomy; (7) power of communication and information; (8) motivation needs nurturing; and (9) fatigue can overwhelm.
The thematic synthesis provides new insights into stroke survivors' experiences of inpatient rehabilitation. Negative experiences were reported in all studies and include disempowerment, boredom, and frustration. Rehabilitation could be improved by increasing activity within formal therapy and in free time, fostering patients' autonomy through genuinely patient-centered care, and more effective communication and information. Future stroke rehabilitation research should take into account the experiences and preferences of stroke survivors.
Early rehabilitation after stroke Bernhardt, Julie; Godecke, Erin; Johnson, Liam ...
Current opinion in neurology,
02/2017, Letnik:
30, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Early rehabilitation is recommended in many guidelines, with limited evidence to guide practice. Brain neurobiology suggests that early training, at the right dose, will aid recovery. In this review, ...we highlight recent trials of early mobilization, aphasia, dysphagia and upper limb treatment in which intervention is commenced within 7 days of stroke and discuss future research directions.
Trials in this early time window are few. Although the seminal AVERT trial suggests that a cautious approach is necessary immediately (<24 h) after stroke, early mobility training and mobilization appear well tolerated, with few reasons to delay initiating some rehabilitation within the first week. The results of large clinical trials of early aphasia therapy are on the horizon, and examples of targeted upper limb treatments with better patient selection are emerging.
Early rehabilitation trials are complex, particularly those that intervene across acute and rehabilitation care settings, but these trials are important if we are to optimize recovery potential in the critical window for repair. Concerted efforts to standardize 'early' recruitment, appropriately stratify participants and implement longer term follow-up is needed. Trial standards are improving. New recommendations from a recent Stroke Recovery and Rehabilitation Roundtable will help drive new research.
Mobilising patients early after stroke early mobilisation (EM) is thought to contribute to the beneficial effects of stroke unit care but it is poorly defined and lacks direct evidence of benefit.
We ...assessed the effectiveness of frequent higher dose very early mobilisation (VEM) after stroke.
We conducted a parallel-group, single-blind, prospective randomised controlled trial with blinded end-point assessment using a web-based computer-generated stratified randomisation.
The trial took place in 56 acute stroke units in five countries.
We included adult patients with a first or recurrent stroke who met physiological inclusion criteria.
Patients received either usual stroke unit care (UC) or UC plus VEM commencing within 24 hours of stroke.
The primary outcome was good recovery modified Rankin scale (mRS) score of 0-2 3 months after stroke. Secondary outcomes at 3 months were the mRS, time to achieve walking 50 m, serious adverse events, quality of life (QoL) and costs at 12 months. Tertiary outcomes included a dose-response analysis.
Patients, outcome assessors and investigators involved in the trial were blinded to treatment allocation.
We recruited 2104 (UK,
= 610; Australasia,
= 1494) patients: 1054 allocated to VEM and 1050 to UC. Intervention protocol targets were achieved. Compared with UC, VEM patients mobilised 4.8 hours 95% confidence interval (CI) 4.1 to 5.7 hours;
< 0.0001 earlier, with an additional three (95% CI 3.0 to 3.5;
< 0.0001) mobilisation sessions per day. Fewer patients in the VEM group (
= 480, 46%) had a favourable outcome than in the UC group (
= 525, 50%) (adjusted odds ratio 0.73, 95% CI 0.59 to 0.90;
= 0.004). Results were consistent between Australasian and UK settings. There were no statistically significant differences in secondary outcomes at 3 months and QoL at 12 months. Dose-response analysis found a consistent pattern of an improved odds of efficacy and safety outcomes in association with increased daily frequency of out-of-bed sessions but a reduced odds with an increased amount of mobilisation (minutes per day).
UC clinicians started mobilisation earlier each year altering the context of the trial. Other potential confounding factors included staff patient interaction.
Patients in the VEM group were mobilised earlier and with a higher dose of therapy than those in the UC group, which was already early. This VEM protocol was associated with reduced odds of favourable outcome at 3 months cautioning against very early high-dose mobilisation. At 12 months, health-related QoL was similar regardless of group. Shorter, more frequent mobilisation early after stroke may be associated with a more favourable outcome.
These results informed a new trial proposal A Very Early Rehabilitation Trial - DOSE (AVERT-DOSE) aiming to determine the optimal frequency and dose of EM.
The trial is registered with the Australian New Zealand Clinical Trials Registry number ACTRN12606000185561, Current Controlled Trials ISRCTN98129255 and ISRCTN98129255.
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in
; Vol. 21, No. 54. See the NIHR Journals Library website for further project information. Funding was also received from the National Health and Medical Research Council Australia, Singapore Health, Chest Heart and Stroke Scotland, Northern Ireland Chest Heart and Stroke, and the Stroke Association. In addition, National Health and Medical Research Council fellowship funding was provided to Julie Bernhardt (1058635), who also received fellowship funding from the Australia Research Council (0991086) and the National Heart Foundation (G04M1571). The Florey Institute of Neuroscience and Mental Health, which hosted the trial, acknowledges the support received from the Victorian Government via the Operational Infrastructure Support Scheme.
Abstract
Background. Mobility limitations are common following stroke and frequently lead to poor participation in physical activity (PA).
Purpose. The purpose of this study was to describe PA across ...the various stages following stroke (acute, subacute, and chronic).
Data Sources. Searches were conducted in 5 databases.
Study Selection. Eligible studies included participants with stroke whose PA was quantitatively measured for at least 4 hours in a single session. Two reviewers independently reviewed titles and abstracts.
Data Extraction. One reviewer extracted data and assessed quality using the Downs and Black checklist. Weighted means were calculated for PA outcomes.
Data Synthesis. Searches yielded 103 eligible papers including 5306 participants aged 21 to 96 years. Devices (eg, activity monitors) were used in 73 papers, and behavioral mapping (observational monitoring) in 30. Devices show that people with stroke took on average 5535 steps per day (n = 406, 10 studies) in the subacute phase and 4078 steps (n = 1280, 32 studies) in the chronic phase. Average daily walking duration (% measured time) was higher in the chronic phase (9.0%, n = 100) than subacute (1.8%, n = 172), and sedentary time was >78% regardless of time post stroke. Acute data were lacking for these variables. Matched healthy individuals took an average of 8338 steps per day (n = 129). Behavioral mapping showed time in bed was higher in the acute than subacute phase (mean 45.1% versus 23.8%), with similar time spent sitting (mean 37.6% versus 32.6%).
Limitations. Limitations of this review include not pooling data reported as medians.
Conclusions. Physical activity levels do not meet guidelines following stroke. Time spent inactive and sedentary is high at all times. Increasing PA and developing standardized activity targets may be important across all stages of stroke recovery.
To systematically review the evidence to determine energy expenditure (EE) in volume of oxygen uptake (V̇O2) (mL/kg/min) and energy cost in oxygen uptake per meter walked (V̇O2/walking speed; ...mL/kg/m) during walking poststroke and how it compares with healthy controls; and to determine how applicable current exercise prescription guidelines are to stroke survivors.
Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and CINAHL were searched on October 9, 2014, using search terms related to stroke and EE. Additionally, we screened reference lists of eligible studies.
Two independent reviewers screened titles and abstracts of 2115 identified references. After screening the full text of 144 potentially eligible studies, we included 29 studies (stroke survivors: n=501, healthy controls: n=123), including participants with confirmed stroke and a measure of V̇O2 during walking using breath-by-breath analysis. Studies with (9 studies) and without (20 studies) a healthy control group were included.
Two reviewers independently extracted data using a standard template, including patient characteristics, outcome data, and study methods.
Mean age of stroke survivors was 57 years (range, 40-67y). Poststroke EE was highly variable across studies and could not be pooled because of high heterogeneity. EE during steady-state overground walking at matched speeds was significantly higher in stroke survivors than healthy controls (mean difference in V̇O2, 4.06 mL/kg/min; 95% confidence interval CI, 2.21-5.91; 1 study; n=26); there was no significant group difference at self-selected speeds. Energy cost during steady-state overground walking was higher in stroke survivors at both self-selected (mean difference, .47 mL/kg/m; 95% CI, .29-.66; 2 studies; n=38) and matched speeds compared with healthy controls (mean difference, .27 mL/kg/m; 95% CI, .03-.51; 1 study; n=26).
Stroke survivors expend more energy during walking than healthy controls. Low-intensity exercise as described in guidelines might be at a moderate intensity level for stroke survivors; there is a need for stroke-specific exercise guidelines.
Regular physical activity is vital for cardiovascular health. Time spent in sedentary behaviors (eg, sitting, lying down) also is an independent risk factor for cardiovascular disease. The pattern in ...which sedentary time is accumulated is important-with prolonged periods of sitting time being particularly deleterious. People with stroke are at high risk for cardiovascular disease, including recurrent stroke.
This systematic review aimed to update current knowledge of physical activity and sedentary behaviors among people with stroke living in the community. A secondary aim was to investigate factors associated with physical activity levels.
The data sources used were MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complimentary Medicine Database (AMED), EMBASE, and the Cochrane Library.
Studies involving people with stroke living in the community and utilizing objective measures of physical activity or sedentary behaviors were included.
Data were extracted by one reviewer and checked for accuracy by a second person.
Twenty-six studies, involving 983 participants, were included. The most common measure of activity was steps per day (22 studies), which was consistently reported as less than half of age-matched normative values. Only 4 studies reported on sedentary time specifically. No studies described the pattern by which sedentary behaviors were accumulated across the day. Walking ability, balance, and degree of physical fitness were positively associated with higher levels of physical activity.
This review included only studies of people living in the community after stroke who were able to walk, and the majority of included participants were aged between 65 and 75 years of age.
Little is known about the time people with stroke spend being sedentary each day or the pattern in which sedentary time is accumulated. Studies using objective, reliable, and valid measures of sedentary time are needed to further investigate the effects of sedentary time on the health of people with stroke.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
The first Stroke Recovery and Rehabilitation Roundtable established a game changing set of new standards for stroke recovery research. Common language and definitions were required to develop an ...agreed framework spanning the four working groups: translation of basic science, biomarkers of stroke recovery, measurement in clinical trials and intervention development and reporting. This paper outlines the working definitions established by our group and an agreed vision for accelerating progress in stroke recovery research.
The aim of this paper was to examine the amount and type of physical activity engaged in by people hospitalised after stroke. Method. We systematically reviewed the literature for observational ...studies describing the physical activity of stroke patients. Results. Behavioural mapping, video recording and therapist report are used to monitor activity levels in hospitalised stroke patients in the 24 included studies. Most of the patient day is spent inactive (median 48.1%, IQR 39.6%–69.3%), alone (median 53.7%, IQR 44.2%–60.6%) and in their bedroom (median 56.5%, IQR 45.2%–72.5%). Approximately one hour per day is spent in physiotherapy (median 63.2 minutes, IQR 36.0–79.5) and occupational therapy (median 57.0 minutes, IQR 25.1–58.5). Even in formal therapy sessions limited time is spent in moderate to high level physical activity. Low levels of physical activity appear more common in patients within 14 days post-stroke and those admitted to conventional care. Conclusions. Physical activity levels are low in hospitalised stroke patients. Improving the description and classification of post stroke physical activity would enhance our ability to pool data across observational studies. The importance of increasing activity levels and the effectiveness of interventions to increase physical activity after stroke need to be tested further.
Finding, testing and demonstrating efficacy of new treatments for stroke recovery is a multifaceted challenge. We believe that to advance the field, neurorehabilitation trials need a conceptually ...rigorous starting framework. An essential first step is to agree on definitions of sensorimotor recovery and on measures consistent with these definitions. Such standardization would allow pooling of participant data across studies and institutions aiding meta-analyses of completed trials, more detailed exploration of recovery profiles of our patients and the generation of new hypotheses. Here, we present the results of a consensus meeting about measurement standards and patient characteristics that we suggest should be collected in all future stroke recovery trials. Recommendations are made considering time post stroke and are aligned with the international classification of functioning and disability. A strong case is made for addition of kinematic and kinetic movement quantification. Further work is being undertaken by our group to form consensus on clinical predictors and pre-stroke clinical data that should be collected, as well as recommendations for additional outcome measurement tools. To improve stroke recovery trials, we urge the research community to consider adopting our recommendations in their trial design.
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