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Pharmacological Interventions+ Rehab vs. Rehab to address Unilateral Spatial Neglect
low-quality evidence of RCT; effectiveness and safety uncertain.

Pharm interventions examined: dopamine, noradrenergic agonists, pro-cholinergic, transdermal nicotine

Outcomes measures used: barrage, letter cancellation, sentence reading, Wundt-Jastrow

Cognitive Rehab for attention
- no change from 2000>2013
-minor improvements in divided attention immediately, uncertain in they persist
-no evidence to support meaningful change to alertness, selective attention, sustained attention

From reference list:

14. EBRSR Clinician Handbook: Rehabilitation of Cognitive Impairment Post Stroke14
-less cognitive rehab evidence compared to motor rehab
-compensatory strategies to inc memory function - assistive devices, electronic devices, computer programs
-exercise is beneficial in improving learning and memory - can be high or low intensity

15. A Systematic Review and Meta-Analysis of Rehabilitative Interventions for Unilateral Spatial Neglect and Hemianopia Poststroke from 2006 Through 201615
-activity-based intervention show to improve visual search
-visual exploration training - compensate, scanning eye and head movement
-smooth pursuit training
-restoration therapy - insufficient evidence to support

Article on Risk factors for post stroke depression (PSD):
post stroke depression is most frequent and serious neuropsychiatric consequence of stroke. Patient with PSD have more functional disability, poor rehabilitation outcomes and increased morbidity and mortality in the first year after stroke.
Risk factors for post stroke depression include: history of psychiatric history, neuroticism personality trait, female gender and severity of stroke.
Prevention of PSD requires social and family participation.

Article "Patients with neuro psychological disorders short after stroke have worse functional outcomes: a systematic review and meta-analysis:
-Neuro psychological disorders were referred to as neglect, aphasia and cognitive dysfunction in this article.
-Article states that patients with neglect, especially aphasia with comprehensive deficits short after stroke have worse functional outcomes.
-Clinicians should perform extensive screening for neglect, aphasia and cognitive deficits to make sure we are accurately diagnosing the different neuropsychological disorders.
-We can anticipate that patients with neuropsychological
disorders will require longer rehabilitation stays.

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Not a lot of research.

Various equipment:
exoskeleton
Armeo

Dosage: ranges from 10-60 mins
3 to 5 times a week for 4 to 11 weeks period

One study showed dose of 35-40 mins in 60 min therapy for exoskeleton use

outcome measures used:
Fugl Meyer
ARAT

(ebrsr website)
One study shows:
Esquenazi et al. (2020) RCT (6) Nstart= 45 Nend= 40 TPS= Acute
E: Robot assisted therapy (Armeo) C: Conventional table top exercise Duration: 1hr, 4x/wk until discharge (~3wks)
• Functional Independence Measure: (-) • Fugl-Meyer Assessment Upper Extremity: (-) • Modified Ashworth Scale • Elbow flexion: (-) • Elbow extension: (-) • Active Range of Motion: • Elbow flexion: (+exp) • Elbow extension: (-) • Passive Range of Motion • Elbow flexion: (+exp) • Elbow extension: (-)

Another study shows:
Carpinella et al. (2020) RCT (8) Nstart= 40 Nend= 38 TPS= Subacute/Chronic
E: Robot arm end effector (braccio di ferro) C: Conventional therapy Duration: 45min, 5d/wk, 4wks
• Elbow: Flexion (-) & Extension (+exp) • Trunk compensation index: (+exp) • Fugl-Meyer Assessment Upper Extremity: (-) • Proximal (-) • Distal (-) • Reaching performance scale: (-) • Proximal Modified Ashworth Scale: (+exp) • Distal Modified Ashworth Scale: (-) • Functional Independence Measure (-)

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Balance Interventions In the 21 studies done in study given us: T'ai Chi showed a positive effect on ADL, balance, limb motor function and gait.  

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Balance Interventions In the 21 studies done in study given us: T'ai Chi showed a positive effect on ADL, balance, limb motor function and gait.  

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Stroke engine:
effective: aquatic, bobath, cycling, force platform training, multisensory training, perceptual exercises, tai chi, vision deprived training.
not-effective:  independent practice, mechanical balance training devices, speed-dependent treadmill training, standing practice, task-oriented walking, task-specific reaching, thermal therapy, vibration therapy,  virtual reality
conflicting: trunk exercise

EBRSR: Sit-to-stand training may be beneficial for improving gait and muscle strength, but not functional ambulation. Sit-to-stand training with asymmetrical foot position may be beneficial for improving balance
sit to stands, perturbations, acupuncture, trunk training with visual feedback, tai chi, body weight support, pool therapy, cycle ergometer training, gait training with movement or posture control visual feedback, strength training, treadmill training with virtual reality

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-Split belt training: shorter step length on faster belt has potential to increase step length symmetry post-stroke when long term training is performed

-mod to high intensity walking training can increase gait speed and distance in individuals greater than 6 months; 30secs bursts with 30-60sec breaks, 3x/wk 12 sessions 20-25mins per session; another study 3x/wk for 50-60mins for 3 mo
-virtual reality with walking training can improve gait speed and distance
-strong evidence that body weight supported treadmill training, robotic assisted training, or sitting/standing balance training without virtual reality training should not be used to improve walking speed or distance in patients who are ambulatory 6months post stroke

-interventions that include at least 1 behavioral modification in addition to exercise or real world walking practice is more effective than exercise alone. goal setting, barrier identification, self-monitoring are considered behavioral modifications

-the amount of task-specific practices is an important variable - high intensity stepping training and VR-enhanced walking were beneficial. Freq: 2-3x/wk for 1-1.5hr sessions.

-for those with mild walking deficits, high quality studies have not found that BWS treadmill training is more effective than usual walking training. For those with serious walking deficits, a number of high quality research studies have shown that BWS treadmill training is more effective than usual walking training for improving sped of walking, endurance, balance, motor recovery and functional walking

-evidence for use of cycling/recumbent bike at high intensity    to improve gait speed. 60-80% of HR reserve or 70-85% of HR max

-CPG recommend use of following for outcome measures post-stroke: Berg, ABC, FGA, 10MWT, 6MWT

-use of Exoskeleton is most beneficial for acute phase non-ambulators. Does not increase gait speed or endurance but can improve likelihood of return to independent walking.

-Dual task training with walking improves walking distance, functional ambulation and LE function for up to 6 months regardless of stroke onset.

In clinic:
-hemiparetic limb stance training for proprioceptive training
-strengthening for force production in gait/push off > gluteal strengthening, gastroc strength

Challenges in the clinic: variability of patients

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Leg Interventions PLUS AFO's and Neuroprostheses

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Leg Interventions PLUS AFO's and Neuroprostheses

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-body-weight supported treadmill walking combined with limb loaded cycling improved hip and knee extension motions throughout stance and swing while walking, however ankle motion showed no noticeable change. As well, a strong correlation was found between gait improvement and magnitude of paretic leg gluteus maximus and gluteus medius activation during gait (measured by EMG).
- change in gait speed AFO vs FES: no evidence showing superiority of one over the other. Factors for decision making include funding, pf spasticity, cognition. AFO may lead to more compensatory effects and FES may result in more muscle re-training.
- initiate AFO within 5 days of stroke for best results
- custom AFO has greater benefit than pre-fabricated. (need for further investigation on need for AFO for early mobilization - so in the hospital do they need an AFO for early mobilization and since they need SOMETHING they need to get a prefab at that level of care
- look at quad strength and knee ROM in swing as considerations for determining use of AFO (if they are weaker in the quad may want to choose AFO vs FES if they are weak at the knee).
- interestingly, Lauren said that more patients come to acute rehab with a device who were higher level and only in the hospital a few days, vs the more low level strokes (who acute rehab is just getting up for the first time)
- FES depends on the device when it activates - patient gait performance may limit their ability to successfully use FES (tibial inclination, heel switch, gyroscope, etc)
setting AFO in 5 degrees of df assists with foot clearance in swing and decreases knee hyperextension in stance.
-strengthening vs strengthening show a positive effect on transfers and gait.
- task specific - if you want to improve walking, work on walking - there is no specific strengthening - just walk

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kinesiotaping:  reduces shoulder subluxation, improves motor function of the upper limb and activities of daily living in patients with hemiplegic shoulder pain post-intervention, and reduced pain for patients with chronic stroke. AOTA article supported the california tri-pole taping method (using leukotape) for subluxation post stroke. inclusion criteria was at least 5mm subluxation. intervention phase: 3 taping applications per week x 3 weeks. OMs: goniometer measurements, Katz Index for ADL performance, 10pt pain and comfort of tape, finger width & tape measure for subluxation measurement. Results: significant decrease in: amount of subluxation, pain; significant increase in: active shoulder flexion and abduction, ADL function

action observation therapy: had a moderate to large effect size on arm and hand motor outcomes as well as daily activity performance. moderate to large effect size for both acute/subacute stroke and chronic stroke patients. Action observation is a form of therapy whereby a motor task is performed by an individual while watching
a mirror image of another individual perform the same task

4 weeks post stroke for Upper Limb function: mCIMT and task specific training with supplementary use of biofeedback and electrical stimulation during acute phase of stroke
task specific training yields long lasting cortical reorganization vs traditional stroke rehab

stretching and joint stabilization: one group 30 min traditional exercise, one group 30 min stretching, and one group 15 min/15min joint stabilization exercises. before, 4wks post, 8wks post. stretching and joint stabilization group showed significant improvements in shoulder function compared to traditional and stretching only groups, and decreased pathological thickness of tendons.

FES (from stroke engine): can help with weak or painful hand. helpful in retraining hand function and dexterity in acute and chronic stroke. FES for arm/hand not effective in improving functional independence. inconclusive for strengthening hand post stroke. limited evidence for reducing spasticity for chronic stroke patients. not effective for increasing hand/arm movements in the acute phase, but applied to specific muscles in subacute or chronic phase was effective increasing ROM compared to regular therapy. conflicting evidence of FES + conventional therapy in improving motor function for acute stroke. FES + task specific phase in subacute phase improves motor function. reaction time: improved in those with acute stroke. used for at least 6wks

robotics: used the bimanutrack robotic device. unilateral robotic therapy, bilateral, control group (routine OT). all 3 groups got 90-105 min/day 5days/wk x 4wks. unilateral and bilateral robotic training group showed greater improvements in motor impairment, muscle power, and strength than the control. unilateral group more effective for improvements at distal joints. bilateral group showed greater muscle power at proximal joints. OMs: fugl meyer (motor impairment), Medical Research Council Instrument (muscle power), dynamometer (grip strength)

mirror therapy: may improve motor function, dexterity, proprioceptive, and stroke severity, but mixed results regarding improvements in ADLs, spasticity and muscle strength. 2-5 hr/day, 5 days/wk x 4wks
mental practice: may improve motor function, muscle strength; mixed evidence for ADL improvement; 45 min/day 3 days/wk x 4 wks
bilateral arm training: may improve motor function, not strength. mixed evidence for dexterity and ADLs. 20 min/day 3-5 days/wk x 6wks
TENS, FES
Orthosis