Persistent difficulty in using the upper limb remains a major contributor to physical disability post-stroke. There is a nihilistic view about what clinically relevant changes are possible after the ...early post-stroke phase. The Queen Square Upper Limb Neurorehabilitation programme delivers high-quality, high-dose, high-intensity upper limb neurorehabilitation during a 3-week (90 hours) programme. Here, we report clinical changes made by the chronic stroke patients treated on the programme, factors that might predict responsiveness to therapy and the relationship between changes in impairment and activity.
Upper limb impairment and activity were assessed on admission, discharge, 6 weeks and 6 months after treatment, with modified upper limb Fugl-Meyer (FM-UL, max-54), Action Research Arm Test (ARAT, max-57) and Chedoke Arm and Hand Activity Inventory (CAHAI, max-91). Patient-reported outcome measures were recorded with the Arm Activity Measure (ArmA) parts A (0-32) and B (0-52), where lower scores are better.
224 patients (median time post-stroke 18 months) completed the 6-month programme. Median scores on admission were as follows: FM-UL = 26 (IQR 16-37), ARAT=18 (IQR 7-33), CAHAI=40 (28-55), ArmA-A=8 (IQR 4.5-12) and ArmA-B=38 (IQR 24-46). The median scores 6 months after the programme were as follows: FM-UL=37 (IQR 24-48), ARAT=27 (IQR 12-45), CAHAI=52 (IQR 35-77), ArmA-A=3 (IQR 1-6.5) and ArmA-B=19 (IQR 8.5-32). We found no predictors of treatment response beyond admission scores.
With intensive upper limb rehabilitation, chronic stroke patients can change by clinically important differences in measures of impairment and activity. Crucially, clinical gains continued during the 6-month follow-up period.
Cortical Reorganization After Stroke Grefkes, Christian; Ward, Nick S.
The Neuroscientist (Baltimore, Md.),
02/2014, Letnik:
20, Številka:
1
Journal Article
Recenzirano
The brain has an intrinsic capacity to compensate for structural damage through reorganizing of surviving networks. These processes are fundamental for recovery of function after many forms of brain ...injury, including stroke. Functional neuroimaging techniques have allowed the investigation of these processes in vivo. Here, we review key advances over the past two decades that have shed light on the neural mechanisms enabling recovery of motor function after stroke. We first provide an overview on invasive stroke models in non-human primates that provided insights into lesion-induced changes in the cortical representations of the upper limb. We then present key findings from neuroimaging studies in human stroke patients, which suggest that the role of contralesional motor hemisphere in supporting recovered function depends on factors such as time since stroke, lesion location and anatomical region. More recently, research has been directed at understanding how surviving brain regions influence one another during movement. It appears that it is not only the corticospinal tract but also brainstem pathways and interhemispheric connections that affect cortical reorganization patterns and functional recovery. In summary, neuroimaging opens the way for greater understanding of the mechanisms of recovery and potentially improves our ability to deliver effective restorative therapy.
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 identification of human broadly neutralizing antibodies (bnAbs) targeting the hemagglutinin (HA) stem revitalized hopes of developing a universal influenza vaccine. Using a rational design and ...library approach, we engineered stable HA stem antigens ("mini-HAs") based on an H1 subtype sequence. Our most advanced candidate exhibits structural and bnAb binding properties comparable to those of full-length HA, completely protects mice in lethal heterologous and heterosubtypic challenge models, and reduces fever after sublethal challenge in cynomolgus monkeys. Antibodies elicited by this mini-HA in mice and nonhuman primates bound a wide range of HAs, competed with human bnAbs for HA stem binding, neutralized H5N1 viruses, and mediated antibody-dependent effector activity. These results represent a proof of concept for the design of HA stem mimics that elicit bnAbs against influenza A group 1 viruses.
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 most difficult clinical questions in stroke rehabilitation are “What is this patient’s potential for recovery?” and “What is the best rehabilitation strategy for this person, given her/his ...clinical profile?” Without answers to these questions, clinicians struggle to make decisions regarding the content and focus of therapy, and researchers design studies that inadvertently mix participants who have a high likelihood of responding with those who do not. Developing and implementing biomarkers that distinguish patient subgroups will help address these issues and unravel the factors important to the recovery process. The goal of the present paper is to provide a consensus statement regarding the current state of the evidence for stroke recovery biomarkers. Biomarkers of motor, somatosensory, cognitive and language domains across the recovery timeline post-stroke are considered; with focus on brain structure and function, and exclusion of blood markers and genetics. We provide evidence for biomarkers that are considered ready to be included in clinical trials, as well as others that are promising but not ready and so represent a developmental priority. We conclude with an example that illustrates the utility of biomarkers in recovery and rehabilitation research, demonstrating how the inclusion of a biomarker may enhance future clinical trials. In this way, we propose a way forward for when and where we can include biomarkers to advance the efficacy of the practice of, and research into, rehabilitation and recovery after stroke.
This review examines recent brain imaging studies that might contribute to delivering better recovery of motor function after stroke.
Most recent studies characterize differences in structural and ...functional organization of the poststroke brain in relation to impairment, or measure alterations in brain organization as the result of one form of therapy or another. These studies have not altered clinical practice. New approaches can test specific models of motor recovery after stroke. Firstly, anatomical assessment of key motor pathways, particularly corticospinal tract, may be useful in predicting long-term outcomes if used in combination with early clinical scores. Secondly, assessment of neuronal oscillations with electro or magneto-encephalography may provide a novel way of assessing the balance between excitatory and inhibitory cortical processes and thereby provide biomarkers of the potential for experience-dependent plasticity.
Most recent studies are observational and do not test a plausible model of motor recovery after stroke. Brain imaging studies of stroke recovery need to consider how to provide tools to aid prediction of long-term outcome or response to treatment, or describe potential therapeutic targets for novel recovery promoting interventions, if they are to be clinically useful.
Stroke is the most common cause of physical disability in the world today. While the key element of rehabilitative therapy is training, there is currently much interest in approaches that "prime" the ...primary motor cortex to be more excitable, thereby increasing the likelihood of experience-dependent plasticity. Cortical oscillations reflect the balance of excitation and inhibition, itself a key determinant of the potential for experience-dependent plasticity. In the motor system, beta-band oscillations are important and are thought to maintain the resting sensorimotor state. Here we examined motor cortex beta oscillations during rest and unimanual movement in a group of stroke patients and healthy control subjects, using magnetoencephalography. Movement-related beta desynchronization (MRBD) in contralateral primary motor cortex was found to be significantly reduced in patients compared with control subjects. Within the patient group, smaller MRBD was seen in those with more motor impairment. We speculate that impaired modulation of beta oscillations during affected hand grip is detrimental to motor control, highlighting this as a potential therapeutic target in neurorehabilitation.
Purpose: To assess the key features of group self-management interventions for stroke and explore the role of peer support in this setting.
Method: A segregated mixed research synthesis was ...conducted. A literature search was performed in OvidSP, EMBASE, AMED and EBSCO (up to January 2018). Studies were included if they delivered group interventions containing self-management principles to stroke survivors on more than two consecutive occasions. The bias of included studies was assessed using NICE guidelines. Quantitative data were analyzed using frequency counts and qualitative data were analyzed thematically.
Results: Twelve studies were included in the review including a total of 3298 participants (age range 56-89) and eight different self-management interventions. Key features of group self-management interventions were identified as increasing knowledge, collaboration and/or communication, accessing resources, goal setting, and problem solving. Peer support facilitated the sharing of experiences, social comparison, vicarious learning, and increased motivation.
Conclusion: Future self-management interventions should be designed to maximize peer support and incorporate techniques which facilitate, knowledge building, goal setting, access to resources, problem solving, and communication.
Implications for rehabilitation
Group self-management interventions offer a way to provide peer support to stroke survivors and should be utilized in practice.
Peer support is seen by stroke survivors as valuable because it can facilitate the sharing of experiences, social comparison, vicarious learning, and increase motivation.
Knowledge building, goal setting, problem solving, collaborative skills, and the ability to access resources should be incorporated into interventions aiming to enhance self-management behaviors in the stroke population.
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