Alex Pollock

Motor recovery after stroke: a systematic review

Loss of functional movement is a common consequence of stroke for which a wide range of interventions has been developed. In this Review, we aimed to provide an overview of the available evidence on interventions for motor recovery after stroke through the evaluation of systematic reviews, supplemented by recent randomised controlled trials. Most trials were small and had some design limitations. Improvements in recovery of arm function were seen for constraint-induced movement therapy, electromyographic biofeedback, mental practice with motor imagery, and robotics. Improvements in transfer ability or balance were seen with repetitive task training, biofeedback, and training with a moving platform. Physical fitness training, high-intensity therapy (usually physiotherapy), and repetitive task training improved walking speed. Although the existing evidence is limited by poor trial designs, some treatments do show promise for improving motor recovery, particularly those that have focused on high-intensity and repetitive task-specific practice.

Predictors of upper limb recovery after stroke:a systematic review and meta-analysis

Objective: To systematically review and summarize the current available literature on prognostic variables relating to upper limb recovery following stroke. To identify which, if any variables predict upper limb recovery following stroke. Data sources: We completed searches in MEDLINE, EMBASE, AMED, CINAHL and Cochrane CENTRAL databases. Searches were completed in November 2010. Review methods: Studies were included if predictor variables were measured at baseline and linked to an outcome of upper limb recovery at a future time point. Exclusion criteria included predictor variables relating to response to treatment and outcome measurements of very specific upper limb impairments such as spasticity or pain. Two independent reviewers completed data extraction and assessed study quality. Results: Fifty-eight studies met the inclusion criteria. Predictor variables which have been considered within these studies include; age, sex, lesion site, initial motor impairment, motor-evoked potentials andsomatosensory-evoked potentials. Initial measures of upper limb impairment and function were found to be the most significant predictors of upper limb recovery; odds ratio 14.84 (95% confidence intervals (CI) 9.08–24.25) and 38.62 (95% CI 8.40–177.53), respectively. Conclusions: Interpretation of these results is complicated by methodological factors including variations in study populations, upper limb motor outcome scales, timing of baseline and outcome assessments and predictors selected. The most important predictive factors for upper limb recovery following stroke appears to the initial severity of motor impairment or function.

Top 10 research priorities relating to life after stroke – consensus from stroke survivors, caregivers, and health professionals

Background Research resources should address the issues that are most important to people affected by a particular healthcare problem. Systematic identification of stroke survivor, caregiver, and health professional priorities would ensure that scarce research resources are directed to areas that matter most to people affected by stroke. Aims We aimed to identify the top 10 research priorities relating to life after stroke, as agreed by stroke survivors, caregivers, and health professionals. Methods Key stages involved establishing a priority setting partnership; gathering treatment uncertainties from stroke survivors, caregivers, and health professionals relating to life after stroke (using surveys administered by e-mail, post, and at face-to-face meetings); checking submitted treatment uncertainties to ensure that they were clear, unanswered questions about the effects of a treatment/intervention; interim prioritization to identify the highest priority questions (objectively identified from ranking of personal priorities by original survey respondents); and a final consensus meeting to reach agreement on the top 10 research priorities. Results We gathered 548 research questions that were refined into 226 unique unanswered treatment uncertainties. Ninety-seven respondents completed the interim prioritization process, objectively identifying 24 shared priority treatment uncertainties. A representative group of 28 stroke survivors, caregivers, and health professionals attended a final meeting, reaching consensus on the top 10 research priorities relating to life after stroke. Six of the agreed top 10 research priorities related to specific stroke-related impairments, including cognition, aphasia, vision, upper limb, mobility, and fatigue. Three related to more social aspects of ‘living with stroke’ including coming to terms with long-term consequences, confidence, and helping stroke survivors and their families ‘cope’ with speech problems. One related to the secondary consequences of stroke and subsequent stroke prevention. Conclusions The top 10 research priorities relating to life after stroke have been identified using a rigorous and person-centered approach. These should be used to inform the prioritization and funding of future research relating to life after stroke.

Visual neglect following stroke: current concepts and future focus.

Visual neglect is a common, yet frequently overlooked, neurological disorder following stroke characterized by a deficit in attention and appreciation of stimuli on the contralesional side of the body. It has a profound functional impact on affected individuals. A assessment and management of this condition are hindered, however, by the lack of professional awareness and clinical guidelines. Recent evidence suggests that the underlying deficit in visual attention is due to a disrupted internalized representation of the outer world rather than a disorder of sensory inputs. Dysfunction of the cortical domains and white-matter tracts, as well as inter-hemispheric imbalance, have been implicated in the various manifestations of visual neglect. Optimal diagnosis requires careful history-taking from the patient, family, and friends, in addition to clinical assessment with the line bisection test, the star cancellation test, and the Catherine Bergego Scale. Early recognition and prompt rehabilitation employing a multidisciplinary approach is desirable. Although no treatment has been definitively shown to be of benefit, those with promise include prism adaptation, visual scanning therapy, and virtual reality-based techniques. Further high quality research to seek optimum short- and long-term rehabilitative strategies for visual neglect is required.

Recovery From Poststroke Visual Impairment Evidence From a Clinical Trials Resource

Introduction. Limited evidence suggests that visual impairments may influence outcome after stroke. The degree of recovery from these impairments is poorly characterized. Objectives. To describe recovery and to determine whether visual impairments influence functional outcome and quality of life. Methods. We extracted demographic and outcome data from the Virtual International Stroke Trials Archive (VISTA). We examined horizontal eye movement disorders and hemianopia using the Best Gaze and Visual domains of the National Institutes of Health Stroke Scale (NIHSS) and described recovery at 30 and 90 days. Proportional odds modelling was used to examine the association between impairments at baseline, modified Rankin Scale (mRS), and European Quality of Life Score (EQ-5D) at 90 days. Results. Visual impairments were reported in 7,204/11,900 (60.5%) patients at baseline. Complete recovery occurred in 1,398/3,285 (42.6%) and 3,243/7,204 (45.0%) patients by 30 and 90 days respectively. The burden of persistent visual impairment in survivors was 1,135/4,028 (28.2%) at 30 days and 1,915/9,338 (20.5%) at 90 days. Partial gaze palsy (P < .0001; OR = 0.81; 95% CI = 0.74-0.87), forced deviation (P < .0001; OR = 0.48; 95% CI = 0.43-0.53), and complete homonymous hemianopia (P < .0001; OR = 0.67; 95% CI = 0.62-0.73) at baseline were associated with poor mRS at 90 days. Conclusions. The rate of recovery was greater in the first month after stroke, suggesting a potential time frame for interventions. The associations between visual impairments and poor mRS suggest that these impairments should be considered in multidisciplinary assessments and interventions.

Rehabilitation for post-stroke cognitive impairment: an overview of recommendations arising from systematic reviews of current evidence

Background: Although cognitive impairments are common following stroke, there is considerable uncertainty about the types of interventions that can reduce activity restrictions and improve quality of life. Indeed, a recent project to identify priorities for research into life after stroke determined that the top priority for patients, carers and health professionals was how to improve cognitive impairments. Objective: To provide an overview of the evidence for the effectiveness of cognitive rehabilitation for patients with stroke and to determine the main gaps in the current evidence base. Methods: Evidence was synthesised for the six Cochrane reviews relating to rehabilitation for post-stroke cognitive impairment and any subsequently published randomized controlled trials to February 2012. Results: Data arising from 44 trials involving over 1500 patients was identified. Though there was support for the effectiveness of cognitive rehabilitation for some cognitive impairments, significant gaps were found in the current evidence base. All of the Cochrane reviews identified major limitations within the evidence they identified. Conclusions: There is currently insufficient research evidence, or evidence of insufficient quality, to support clear recommendations for clinical practice. Recommendations are made as to the research required to strengthen the evidence base, and so facilitate the delivery of effective interventions to individuals with cognitive impairment after stroke.

Physiotherapy Treatment Approaches for Stroke

Graeme J. Hankey MD, FRCP Section Editor: There are several different approaches to physiotherapy treatment after stroke. These can broadly be divided into approaches that are based on neurophysiological, motor learning, or orthopaedic principles. Some physiotherapists base their treatment on a single approach, whereas others use a mixture of components from a number of different approaches. The practical application of these approaches can result in substantial differences in patient treatment. At present, the Bobath Approach, based on neurophysiological principles, probably remains the most widely used approach in the Western world.1–5 However, there is a lack of convincing evidence to support any specific physiotherapy treatment approach.3,6 This systematic review aims to assess the effects of physiotherapy treatment if it is based on orthopaedic, motor learning, or neurophysiological principles, or on a mixture of these treatment principles. We searched the Cochrane Stroke Group Trials Register …

Development of a new model to engage patients and clinicians in setting research priorities.

Objectives Equitable involvement of patients and clinicians in setting research and funding priorities is ethically desirable and can improve the quality, relevance and implementation of research. Survey methods used in previous priority setting projects to gather treatment uncertainties may not be sufficient to facilitate responses from patients and their lay carers for some health care topics. We aimed to develop a new model to engage patients and clinicians in setting research priorities relating to life after stroke, and to explore the use of this model within a James Lind Alliance (JLA) priority setting project. Methods We developed a model to facilitate involvement through targeted engagement and assisted involvement (FREE TEA model). We implemented both standard surveys and the FREE TEA model to gather research priorities (treatment uncertainties) from people affected by stroke living in Scotland. We explored and configured the number of treatment uncertainties elicited from different groups by the two approaches. Results We gathered 516 treatment uncertainties from stroke survivors, carers and health professionals. We achieved approximately equal numbers of contributions; 281 (54%) from stroke survivors/carers; 235 (46%) from health professionals. For stroke survivors and carers, 98 (35%) treatment uncertainties were elicited from the standard survey and 183 (65%) at FREE TEA face-to-face visits. This contrasted with the health professionals for whom 198 (84%) were elicited from the standard survey and only 37 (16%) from FREE TEA visits. Conclusions The FREE TEA model has implications for future priority setting projects and user-involvement relating to populations of people with complex health needs. Our results imply that reliance on standard surveys may result in poor and unrepresentative involvement of patients, thereby favouring the views of health professionals.

Physical Rehabilitation Approaches for the Recovery of Function and Mobility After Stroke: Major Update

Various physical rehabilitation approaches may be used to promote recovery of function and mobility after stroke. Controversy and debate about the relative effectiveness of approaches persist. We aimed to determine whether physical rehabilitation approaches are effective in recovery of function and mobility in people with stroke, and to assess whether any one physical rehabilitation approach is more effective than any other approach. A stakeholder group, comprising stroke survivors, caregivers, and physiotherapists, made decisions using consensus-making techniques relating to the scope and focus of this updated review.1 We performed a comprehensive search (to December 2012), …

Cognitive Rehabilitation for Executive Dysfunction in Adults With Stroke or Other Adult Nonprogressive Acquired Brain Damage

Executive functions are cognitive processes essential for controlling goal-oriented behavior and responding to new and novel situations. Executive function includes the processes of planning, initiation, organization, inhibition, problem solving, self-monitoring, and error correction. It has been estimated that ≈75% of stroke survivors experience impaired executive function (executive dysfunction), resulting in reduced capacity to regain independence in activities of daily living, particularly when new movement strategies are necessary to compensate for limb weakness. A variety of cognitive rehabilitation interventions are implemented within clinical practice in an attempt to improve executive function and, consequently, independence with activities of daily living.1 To determine the effects of cognitive rehabilitation on executive dysfunction for adults with stroke or other nonprogressive acquired brain injuries. We searched: …