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Objective To evaluate whether ankle-foot orthosis (AFO) has a beneficial effect on dorsiflexion angle increase during the swing phase among individuals with stroke and patient-important outcomes in individuals with stroke. Literature survey Randomized controlled trials (RCTs), randomized crossover trials, and cluster RCTs until May 2020 were researched through CENTRAL, MEDLINE, EMBASE, PEDro, CINAHL, and REHABDATA databases. Studies reporting on AFO use to improve walking, functional mobility, quality of life, and activity limitations and reports of adverse events in individuals with stroke were included. Methodology Two independent reviewers extracted the data and assessed the risk of bias. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach. Synthesis Fourteen trials that enrolled 282 individuals with stroke and compared AFO with no AFO were included. Compared with no AFO, AFO could increase the dorsiflexion angle of ankle joints during walking (mean difference [MD], 3.7[°]; 95% confidence interval [CI], 2.0-5.3; low certainty of evidence). Furthermore, AFO could improve walking ability (walking speed) (MD, 0.09[m/s]; 95% CI, 0.06-0.12; low certainty of evidence). No study had reported the effects of AFO on QOL, adverse events, fall frequency, and activities of daily life. Conclusions Our findings suggest that AFO improved ankle kinematics and walking ability in the short term; nonetheless, the evidence was characterized by a low degree of certainty. Systematic review registration PROSPERO, registration no. CRD42020183778. This article is protected by copyright. All rights reserved.

Objective To examine the relationship between the time constant of oxygen uptake kinetics during the onset of exercise (τVO2) estimated from a single exercise bout and that obtained from three averaged exercise bouts in individuals with stroke.Methods Twenty participants with stroke performed three bouts of a constant-load pedaling exercise at approximately 80% of the workload corresponding to the ventilatory threshold to estimate τVO2. The VO2 data from the first trial of three bouts were used to estimate τVO2 for a single bout. Additionally, data collected from three bouts were ensemble-averaged to obtain τVO2 for three averaged bouts as the criterion.Results There was a very high correlation between τVO2 for a single bout (34.8±14.0 seconds) and τVO2 for three averaged bouts (38.5±13.4 seconds) (r=0.926, p

Recent advances in wearable technology have enabled us to visualize how stroke patients spend time and how they behave during physical activity over a period of 24-h. This capability is expected to provide new insights into rehabilitation research. However, wearable electrocardiograph (ECG) monitoring devices generate noise and artifacts from external factors such as body movements, which causes misdetection of the R wave. To compensate for the loss of heart rate data due to misdetection, the present study focused on ensemble averaging as a method to impute missing data and validated this method of data imputation on 24-h recordings. First, to investigate the measurement period for data imputation, we continuously measured heart rates of six healthy participants for four days and applied ensemble averaging to the first two, three and all four days of measurement data. Next, we validated the imputation by ensemble averaging with 218 measurement data from 63 stroke inpatients in a rehabilitation ward. For the healthy participants, the period with data losses decreased from 115 min (8.3% of the 24-h) to 5.5 min (0.4%), 0 min (0%), and 0 min (0%) when ensemble averaging was applied to two, three, and four days of measurement data, respectively. For data of stroke patients acquired in a two-day measurement session, ensemble averaging decreased the period with data losses more than the conventional method that selects data of the day with the least missing data among the measurement days did (0.17 and versus 1.7% of the 24-h). The median and maximum heart rate when ensemble averaging was applied was strongly correlated to the median and maximum heart rate when ensemble averaging was not applied. The results suggest that ensemble averaging is useful for imputing missing vital data such as heart rate.

BackgroundThe International Classification of Functioning, Disability, and Health (ICF) Generic-30 (Rehabilitation) Set is a tool used to assess the functioning of a clinical population in rehabilitation. The ICF Generic-30 consists of nine ICF categories from the component “body functions” and 21 from the component “activities and participation”. This study aimed to develop a rating reference guide for the nine body function categories of the ICF Generic-30 Set using a predefined, structured process and to examine the interrater reliability of the ratings using the rating reference guide.MethodsThe development of the first version of the rating reference guide involved the following steps: (1) a trial of rating patients by several raters; (2) cognitive interviews with each rater to analyze the thought process involved in each rating; (3) the drafting of the rating reference guide by a multidisciplinary panel; and (4) a review by ICF specialists to confirm consistency with the ICF. Subsequently, we conducted a first field test to gain insight into the use of the guide in practice. The reference guide was modified based on the raters’ feedback in the field test, and an inter-rater reliability test was conducted thereafter. Interrater agreement was evaluated using weighted kappa statistics with linear weights.ResultsThe first version of the rating reference guide was successfully developed and tested. The weighted kappa coefficient in the field testing ranged from 0.25 to 0.92. The interrater reliability testing of the rating reference guide modified based on the field test results yielded an improved weighted kappa coefficient ranging from 0.53 to 0.78. Relative improvements in the weighted kappa coefficients were observed in seven out of the nine categories. Consequently, seven out of nine categories were found to have a weighted kappa coefficient of 0.61 or higher.ConclusionsIn this study, we developed and modified a rating reference guide for the body function categories of the ICF Generic-30 Set. The interrater reliability test using the final version of the rating reference guide showed moderate to substantial interrater agreement, which encouraged the use of the ICF in rehabilitation practice.

Aim This study aimed to investigate body composition in Japanese patients with psychiatric disorders. Methods A cross‐sectional study was conducted to assess the body composition in Japanese patients with psychiatric disorders and healthy controls. InBody470 was used to measure the body composition of the participants. For the primary analysis, measures of body composition between patients and healthy controls were compared. Moreover, the following patient subgroups were also compared with the healthy controls: (a) patients with psychotic disorders only, (b) patients with mood disorders only, (c) patients receiving antipsychotics, (d) patients receiving conventional mood stabilizers, (e) patients receiving antidepressants only but not any antipsychotics and/or mood stabilizers, and (f) patients receiving hypnotics/anxiolytics. Results This study included 205 individuals (105 patients and 100 healthy controls). It was found that patients had a significantly higher body mass index, waist‐hip ratio, body fat mass, and percent body fat compared with the healthy controls. Moreover, significant differences were noted in the waist‐hip ratio, body fat mass, and percent body fat between all patient subgroups other than patients receiving conventional mood stabilizers subgroup and healthy controls. Conclusion This is the first cross‐sectional study to examine body composition in Japanese patients with psychiatric disorders. No difference in the skeletal muscle volume was noted although patients had higher body fat than healthy controls. A longitudinal and large cohort study in the future, controlling for medication and diagnosis, will need to determine why body fat is increased in Japanese patients with psychiatric disorders., This study aimed to investigate body composition in psychiatric disorders patients. Patients had higher body fat than healthy controls. No difference in the skeletal muscle volume between patients and healthy controls was found.

Objectives The primary objective was to provide a list of effective motivational strategies based on consensus among rehabilitation experts, generated using the Delphi technique. The secondary objective was to identify the types of information that are important when selecting motivational strategies. Design Delphi study. Setting On-site survey at academic conferences and web-based survey. Participants Rehabilitation experts (N=198) including physicians, physical therapists, occupational therapists, and speech-language-hearing therapists who had worked in stroke rehabilitation for at least 5 years. Intervention Not applicable. Main Outcome Measures Panelists were asked to rate the effectiveness of motivational strategies and to rate the importance of different types of information using a 5-point Likert scale. Consensus was defined as having been reached for items with an interquartile range of 1 or less. Results A total of 116 experts (58.6%) completed the third round of the Delphi survey. Consensus was reached on all of the 26 presented strategies. Seven strategies, such as control of task difficulty and goal setting, were considered to be very effective in increasing patient motivation. In addition, all 11 of the presented types of information regarding patient health status, environmental factors, and personal factors were deemed very important or important in determining which motivational strategies to use. Conclusions We generated a list of effective motivational strategies for stroke rehabilitation based on expert consensus. Our results suggest that experts consider a comprehensive range of patient information when choosing motivational strategies. These findings represent a group of consensus-based recommendations for increasing patient adherence to stroke rehabilitation programs, which may be beneficial to many medical professionals working in stroke rehabilitation.

Introduction Transferring is a basic skill that is essential for mobility independence and indispensable for expanding activities of daily living of stroke patients using a wheelchair. Therefore, transfer independence is an important issue that greatly affects daily life in the hospital and at home. To offer an effective intervention to acquire a skill, developing an assessment for individual subtasks that comprise transferring would assist the identification of specific tasks that prevent independence in patients and facilitate interventions to improve transferring independence. Objective To examine the reliability and validity of a newly developed transfer assessment form, the Bed-wheelchair transfer Tasks Assessment Form (BTAF), for stroke patients to evaluate subtasks required for transferring. Design Validation and test-retest studies. Setting Subacute rehabilitation wards in Japan. Participants A total of 82 therapists for verifying content validity; 30 patients for validation and test-retest study. Interventions Not applicable. Main outcome measures The content validity was initially assessed based on a questionnaire. Subsequently, four occupational therapists used the form to evaluate the video-recorded transferring performances of stroke participants. Two assessors evaluated each performance once and then 2 weeks later. The inter-rater reliability, intra-rater reliability, internal consistency, and concurrent validity were examined. Results Fleiss's κ coefficient for inter-rater reliability for each item of the form was 0.66 or more. Cohen's κ coefficient for intra-rater reliability for each item was 0.73 or more. Cronbach's coefficient alpha ranged from 0.90 to 0.93. Spearman's rank correlation coefficients between the mean scores of our form and scores of the functional independence measure item "transfer to bed/chair/wheelchair" ranged from 0.53 to 0.78 (P Conclusions The form demonstrated good reliability and validity. Its usefulness and efficacy should be further investigated in stroke patients to facilitate rehabilitation.

Cranial nerve involvement is a finding often observed in patients infected with severe acute respiratory syndrome coronavirus 2 during the pandemic outbreak of coronavirus disease 2019 (COVID-19). To our knowledge, this is the first report of oropharyngeal dysphagia associated with COVID-19. A 70-year-old male developed dysphagia and consequent aspiration pneumonia during recovery from severe COVID-19. He had altered sense of taste and absent gag reflex. Videoendoscopy, videofluorography, and high-resolution manometry revealed impaired pharyngolaryngeal sensation, silent aspiration, and mesopharyngeal contractile dysfunction. These findings suggested that glossopharyngeal and vagal neuropathy might have elicited dysphagia following COVID-19. The current case emphasizes the importance of presuming neurologic involvement and concurrent dysphagia, and that subsequent aspiration pneumonia might be overlooked in severe respiratory infection during COVID-19.

Background Owing to musculoskeletal dysfunction, locomotive syndrome elevates the risk of requiring nursing care. Among degenerative musculoskeletal disorders, lumbar spinal canal stenosis (LSS) associates with locomotive syndrome; however, whether lumbar spinal surgery for LSS improves locomotive syndrome remains unclear. Hence, this study aimed to identify the efficacy of lumbar spinal surgery on locomotive syndrome among elderly patients with LSS. Methods We prospectively collected the clinical data from multiple institutions of patients (age >65 years) who underwent lumbar spinal surgery. Patients were examined for the locomotive syndrome risk test, including the stand-up Test, the two-step Test, and the 25-question risk assessment, 1-day preoperatively and 6-month and 1-year postoperatively. Using a logistic regression model, we identified factors associated with improvement of locomotive syndrome in the total assessment. Results Overall, we examined the data of 166 patients in this study. Upon converting each score of three tests to the stage of locomotive syndrome, the two-step test and the 25-question risk assessment revealed marked improvement in the postoperative distribution of stages. However, the stand-up test revealed a comparable distribution of stages pre- and postoperatively. In the total assessment, the postoperative distribution of stages was significantly improved than that preoperatively. The multivariable analysis revealed that failed back surgery syndrome [odds ratio (OR), 0.2; 95% confidence interval (CI): 0.04–1.05; P = 0.057)] and preoperative stage of 2 in stand-up test (OR, 0.2; 95% CI: 0.05–1.02; P = 0.054) tended to have inverse association with postoperative improvement of locomotive syndrome in the total assessment. Conclusions Lumbar spinal surgery improved the stage of locomotive syndrome among elderly patients with LSS. This study suggests that lumbar spinal surgery for LSS could be beneficial in alleviating locomotive syndrome.

Hemiparesis resulting from stroke presents characteristic spatiotemporal gait patterns. This study aimed to clarify the spatiotemporal gait characteristics of hemiparetic patients by comparing them with height-, speed-, and age-matched controls while walking at various speeds. The data on spatiotemporal gait parameters of stroke patients and that of matched controls were extracted from a hospital gait analysis database. In total, 130 pairs of data were selected for analysis. Patients and controls were compared for spatiotemporal gait parameters and the raw value (RSI) and absolute value (ASI) of symmetry index and coefficient of variation (CV) of these parameters. Stroke patients presented with prolonged nonparetic stance (patients vs. controls: 1.01 ± 0.41 vs. 0.83 ± 0.25) and paretic swing time (0.45 ± 0.12 vs. 0.39 ± 0.07), shortened nonparetic swing phase (0.35 ± 0.07 vs. 0.39 ± 0.07), and prolonged paretic and nonparetic double stance phases [0.27 ± 0.13 (paretic)/0.27 ± 0.17 (nonparetic) vs. 0.22 ± 0.10]. These changes are especially seen in low-gait speed groups (

Background Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that has the potential to induce motor cortical plasticity in humans. It is well known that motor cortical plasticity plays an essential role in motor learning and recovery in patients with stroke and neurodegenerative disorders. However, it remains unclear how cognitive function influences motor cortical plasticity induced by tDCS. The present study aimed to investigate whether anodal tDCS combined with attention to a target muscle could enhance motor cortical plasticity and improve motor learning in healthy individuals. Methods Thirty-three healthy volunteers were assigned to two experiments. In experiment 1, there were three interventional conditions: 1) anodal tDCS was applied while participants paid attention to the first dorsal interosseous (FDI) muscle, 2) anodal tDCS was applied while participants paid attention to the sound, and 3) anodal tDCS was applied without the participants paying attention to the FDI muscle or the sound. Anodal tDCS (2 mA, 10 min) was applied over the primary motor cortex (M1). Changes in motor evoked potentials (MEPs), short-interval intracortical inhibition (SICI), and intracortical facilitation (ICF) were assessed before and immediately after (0 min), and then 10 min, 30 min, and 60 min after each intervention. In experiment 2, we investigated whether the combination of anodal tDCS and attention to the abductor pollicis brevis (APB) muscle could facilitate the learning of a ballistic thumb movement. Results Anodal tDCS increased cortical excitability in all conditions immediately after the stimulation. Significant increases in MEPs and significant decreases in SICI were observed for at least 60 min after anodal tDCS, but only when participants paid attention to the FDI muscle. In contrast, no significant changes in ICF were observed in any condition. In experiment 2, the combination of tDCS and attention to the APB muscle significantly enhanced the acquisition of a ballistic thumb movement. The higher performance was still observed 7 days after the stimulation. Conclusions This study shows that anodal tDCS over M1 in conjunction with attention to the target muscle enhances motor cortex plasticity and improves motor learning in healthy adults. These findings suggest that a combination of attention and tDCS may be an effective strategy to promote rehabilitation training in patients with stroke and neurodegenerative disorders. Trial registration Retrospectively registered (UMIN000036848).

Background: A self-monitoring approach utilizing fitness trackers that provide feedback regarding physical activities has been recently applied to rehabilitation patients to promote voluntary walking activities. Although this approach has been proven to increase physical activity, it is uncertain whether the intervention improves walking ability.Aim: This review investigated whether the additional self-monitoring approach using activity trackers would improve walking ability in any type of rehabilitation setting.Methods: A systematic search was performed in four databases [PubMed (MEDLINE), The Cochrane Library, SPORTDiscus, and Cumulative Index to Nursing and Allied Health Literature] to identify studies that examined the self-monitoring approach combined with rehabilitative intervention vs. the same rehabilitative intervention only in participants with any unhealthy conditions. Two review authors independently assessed the eligibility of all the retrieved English literature published from 2009 to 2019, then discussed the final inclusion. The risk of bias was assessed referring to the criteria of the Cochrane Risk of Bias tool. The key findings were synthesized using narrative synthesis. In addition, a quantitative synthesis was conducted when more than two studies investigating the same disease were identified.Results: Eleven randomized controlled trials satisfied the eligibility criteria, nine of which had a lower risk of bias. The types of diseases included stroke, chronic obstructive pulmonary disease (COPD), cancer, Parkinson's disease, hemophilia, peripheral artery disease, post-total knee arthroplasty, and geriatric rehabilitation. Eight studies reported measures of walking endurance and four reported measures of gait speed. In the quantitative synthesis of two studies investigating COPD, there was a significant between-group difference in terms of changes in the 6-min walking distance from the baseline, which was favorable to the additional self-monitoring intervention group (mean difference: 13.1 m; 95% confidence interval, 1.8–24.5; 2 studies, 124 participants; p = 0.02; I2 = 0%). Other available data revealed no consistent evidence regarding effectiveness of the intervention.Conclusions: The findings indicate that there is little evidence suggesting the effectiveness of the self-monitoring approach in improving walking ability in rehabilitation settings. However, a weak recommendation for patients with stable COPD was implicated in the quantitative synthesis. Further research would be required to explore the best indications for this self-monitoring approach.Systematic Review Registration: CRD 42020157695.

Background Transcranial direct current stimulation (tDCS) is a technique that can noninvasively modulate neural states in a targeted brain region. As cerebellar activity levels are associated with upper limb motor improvement after stroke, the cerebellum is a plausible target of tDCS. However, the effect of tDCS remains unclear. Here, we designed a pilot study to assess: (1) the feasibility of a study that aims to examine the effects of cerebellar tDCS combined with an intensive rehabilitation approach based on the concept of constraint-induced movement therapy (CIMT) and (2) the preliminary outcome of the combined approach on upper limb motor function in patients with stroke in the chronic stage. Methods This pilot study has a double-blind randomized controlled design. Twenty-four chronic stroke patients with mild to moderate levels of upper limb motor impairment will be randomly assigned to an active or sham tDCS group. The participants will receive 20 min of active or sham tDCS to the contralesional cerebellum at the commencement of 4 h of daily intensive training, repeatedly for 5 days per week for 2 weeks. The primary outcomes are recruitment, enrollment, protocol adherence, and retention rates and measures to evaluate the feasibility of the study. The secondary outcome is upper limb motor function which will be evaluated using the Action Research Arm Test, Fugl-Meyer Assessment, for the upper extremity and the Motor Activity Log. Additionally, neurophysiological and neuroanatomical assessments of the cerebellum will be performed using transcranial magnetic stimulation and magnetic resonance imaging. These assessments will be conducted before, at the middle, and after the 2-week intervention, and finally, 1 month after the intervention. Any adverse events that occur during the study will be recorded. Discussion Cerebellar tDCS combined with intensive upper limb training may increase the gains of motor improvement when compared to the sham condition. The present study should provide valuable evidence regarding the feasibility of the design and the efficacy of cerebellar tDCS for upper limb motor function in patients with stroke before a future large trial is conducted. Trial registration This study has been registered at the Japan Registry of Clinical Trials (jRCTs042200078). Registered 17 December 2020

OBJECTIVE The sit-up test is used to assess orthostatic hypotension, without the use of a tilt table, in populations who are unable to stand. The primary objective of this study was to determine the differences in blood pressure and hemodynamic responses between the sit-up and head-up tilt tests. The secondary objective was to determine the hemodynamic responses related to changes in blood pressure during each test. METHODS Nineteen healthy volunteers (nine males, aged 24.3 ± 2.4 years) underwent the sit-up and head-up tilt tests. Systolic and diastolic blood pressure, heart rate, stroke volume, cardiac output, and total peripheral resistance were measured. RESULTS The increase in systolic blood pressure (15 ± 9 vs. 8 ± 8 mmHg) was greater, while the increase in heart rate (8 ± 5 vs. 12 ± 8 bpm) and reduction in stroke volume (-17 ± 10 vs. -21 ± 10 ml) were smaller during the sit-up test than during the head-up tilt test (P < 0.05). Additionally, the increases in blood pressure variables were significantly associated with the increase in total peripheral resistance (P < 0.05), but not with changes in other hemodynamic variables in both tests. CONCLUSION Although the magnitudes of changes in systolic blood pressure, heart rate, and stroke volume differed between the tests, the hemodynamic variable related to changes in blood pressure was the same for both tests. These results may contribute to the clinical application of the sit-up test for identifying the presence and hemodynamic mechanisms of orthostatic hypotension.

BACKGROUND: Ankle-foot orthoses are used to improve gait stability in patients with post-stroke gait; however, there is not enough evidence to support their beneficial impact on gait stability. AIM: To investigate the effects of ankle-foot orthoses on post-stroke gait stability. DESIGN: An experimental study with repeated measurements of gait parameters with and without orthosis. SETTING: Inpatients and outpatients in the Fujita Health University Hospital, Toyoake, Japan. POPULATION: Thirty-two patients (22 males; mean age 48.3±20.0 years) with post-stroke hemiparesis participated in the study. METHODS: Three-dimensional treadmill gait analysis was performed with and without ankle-foot orthosis for each participant. Spatiotemporal parameters, their coefficient of variation, and margin of stability were evaluated. Toe clearance, another major target of orthosis, was also examined. The effect of orthosis in the patients with severe (not able to move within the full range of motion, defying gravity) and mild ankle impairment (able to move within the full range but have problem with speed and/or smoothness of the ankle movement) was compared. RESULTS: In the total group comparison, the decrease in the coefficient of variation of step width (P=0.012), and margin of stability on the paretic side (P=0.023) were observed. In the severe ankle impairment groups, the decreased in the coefficient of variation of the non-paretic step length (P=0.007), stride length (P=0.037), and step width (P=0.033) and margin of stability on the paretic side (P=0.006) were observed. No significant effects were observed in the mild ankle impairment group; rather, the coefficient of variation of non-paretic step length increased with the use of orthosis in this group (P=0.043); however, toe clearance increased with the use of ankle-foot orthosis (P=0.041). CONCLUSIONS: Ankle-foot orthoses improved gait stability indices; however, the effect was either not significant or showed possible worsening in the patients with mild ankle impairment, while the effect on toe clearance was significant. These results suggest that the effects of using orthoses in patients with mild impairment should be carefully evaluated. CLINICAL REHABILITATION IMPACT: Understanding the effects of ankle-foot orthoses on the stability of post-stroke gait and their relationship with ankle impairment severity may support clinical decision-making while prescribing orthosis for post-stroke hemiparesis.

Introduction: There is growing evidence supporting the relationship of vertical misperception and poor balance control with asymmetrical standing posture in patients with stroke. Although the vestibular system has been shown to be responsible for vertical misperception and balance disorders, the effect of galvanic vestibular stimulation (GVS) on both vertical misperception and postural asymmetry after stroke remains elusive. The aim of this study was to investigate the effects of GVS on visual verticality and postural asymmetry after stroke and to clarify whether the effects differ depending on the polarity of the stimulation and hemispheric lesion side.Methods: We measured the subjective visual vertical (SVV) and body weight distribution on each foot in an upright stance in 24 patients with a hemispheric stroke (10 with a left hemisphere lesion and 14 with a right hemisphere lesion) and nine age-matched healthy controls. During the measurements, bipolar GVS (1.5 mA) was applied over the bilateral mastoid processes in three stimulation conditions: contralesional-anodal and ipsilesional-cathodal vestibular stimulation, ipsilesional-anodal and contralesional-cathodal vestibular stimulation, and no stimulation. To examine whether GVS modulates visual verticality and standing posture, SVV and weight-bearing in the three conditions were analyzed.Results: During no stimulation, the SVV deviated to the contralesional side in patients with a right hemisphere lesion, while more weight-bearing was observed on the ipsilesional limb than on the contralesional limb in both patient groups than in the controls. The SVV was modulated by reversing the polarity of GVS in all the groups when the cathodal stimulus side was either ipsilateral or contralateral to the lesion while the ipsilesional-cathodal vestibular stimulation reduced weight-bearing asymmetry in only the patients with a right hemisphere lesion.Conclusions: These findings demonstrate that the effects of GVS on the SVV and standing posture differ depending on the polarity of GVS and the hemispheric lesion side. Patients with a right hemisphere lesion have difficulty maintaining their preferred standing posture under visual verticality modulation evoked by GVS. The application of GVS may clarify whether the vestibular system has neural redundancy after stroke to suppress any effects of the stimulation, including modulation of the visual verticality, on balance.

BACKGROUND Stroke patients often suffer from dysphagia during their recovery. We hypothesised that subacute stroke patients with dysphagia had more deteriorated oral health status including muscle strength and motor function. OBJECTIVE Quantitatively investigate oral health status and identify associations with oral feeding status in stroke patients admitted to a convalescent rehabilitation unit. METHODS We prospectively recruited 187 stroke patients admitted to a convalescent rehabilitation unit. Oral feeding status was examined using the Functional Oral Intake Scale (FOIS), and the cohort was divided into three groups based on FOIS score as non-oral feeding (FOIS-123; 22 patients), dysphagic diet (FOIS-45; 74 patients), and regular diet (FOIS-67; 91 patients) groups. Activities of daily living (ADL) were assessed with the Functional Independence Measure (FIM). Oral health status was measured quantitatively in six oral function parameters and Oral Health Assessment Tool (OHAT), and differences according to the FOIS, age and FIM were statistically tested. RESULTS In bivariate analysis, two parameters, tongue pressure and tongue-lip motor functions were significantly higher in the regular diet group than in the other groups (P

Objective: To elucidate the characteristics of sub-acute stroke survivors with post-stroke cognitive impairment, and examine the factors associated with cognitive improvement. Design: Retrospective cohort study. Participants: A total of 218 consecutive stroke sur-vivors, who were admitted to a rehabilitation hospital between April 2014 and March 2015, were included. Methods: The prevalence of post-stroke cognitive impairment, defined as having a Mini-Mental State Examination (MMSE) score

Physical deconditioning after stroke may induce post-stroke fatigue. However, research on this association is limited. Our primary objective was to investigate the associations of post-stroke fatigue severity with oxygen uptake ($$\dot{\mathrm{V}}$$ V ˙ O2) at peak exercise and the time constant of $$\dot{\mathrm{V}}$$ V ˙ O2 kinetics (τ$$\dot{\mathrm{V}}$$ V ˙ O2) at exercise onset. The secondary objective was to examine the associations between fatigue and cardiorespiratory variables potentially affecting $$\dot{\mathrm{V}}$$ V ˙ O2 during exercise. Twenty-three inpatients from a subacute rehabilitation ward were enrolled in this study. The median (interquartile range) Fatigue Severity Scale (FSS) score, as a measure of fatigue, was 32 (range 27–42) points. The FSS score was not associated with $$\dot{\mathrm{V}}$$ V ˙ O2 at peak exercise during a symptom-limited graded exercise test (rho = − 0.264; p = 0.224), whereas it was significantly associated with τ$$\dot{\mathrm{V}}$$ V ˙ O2 during a submaximal constant-load exercise test (rho = 0.530; p = 0.009). A higher FSS score also significantly correlated with a longer time constant of cardiac output (CO) kinetics (rho = 0.476; p = 0.022). Our findings suggest that severe post-stroke fatigue is associated with delayed increases in $$\dot{\mathrm{V}}$$ V ˙ O2 and CO at the onset of exercise. Our findings can contribute to the development of an appropriate rehabilitation programme for individuals with post-stroke fatigue.

Purpose Movement repetition is known to play a key role in promoting functional improvements or maintaining functional levels in post-stroke hemiparetic patients. However, repetitive movements tend to be monotonous, making it challenging for patients to continue. Here, we developed a new gamified system to allow patients perform repetitive movements with enjoyment. The present study aimed to examine the usability of the system in subacute stroke patients. Method The exercise system comprised an electromyography-controlled operating system that enabled users to play a virtual game by repetitive finger and wrist movements on the affected side. A total of 13 patients with upper-limb hemiparesis underwent a single bout of exercise using the system and assessed its usability, satisfactoriness, enjoyability, etc. using the System Usability Scale (SUS), Quebec User Evaluation of Satisfaction with assistive Technology (QUEST)-like questionnaire, and numerical rating scale (NRS). Results All the participants, who had a wide range of paretic levels, were able to perform the exercise using the system. Participants scored the system a median of 85.0 for SUS and 4.2 for the QUEST-like questionnaire, with an "excellent" in usability and "satisfied" in user satisfaction with the system. The median NRS scores for enjoyability, potential for continuous use, and effectiveness were 8.0, 9.0, and 9.0, respectively, which were greater than the scores for usual rehabilitation training for the upper extremity. Conclusions The novel electromyography-controlled gamified exercise system may have sufficient usability and enjoyability to motivate patients with a wide range of paretic levels to perform repetitive finger and wrist movements.IMPLICATIONS FOR REHABILITATIONThe electromyography-controlled gamified exercise system had overall positive perspectives on the usability of the system.This exercise system could help motivate patients with a wide range of paretic levels to perform repetitive finger and wrist movements.

Background:Motivation is essential for patients with subacute stroke undergoing intensive rehabilitation. Although it is known that motivation induces behavioral changes toward rehabilitation, detailed description has been lacking. Motivation can be intrinsic or extrinsic; however, it is unclear which type of factors mainly motivates patients' daily rehabilitation.Purpose:This study aimed to examine the factors influencing patients' motivation and to explore the behavioral changes induced by motivation, especially age-related differences.Method:Twenty participants (mean age 65.8 years [standard deviation 13.7]) who had a subacute stroke and underwent rehabilitation at a convalescent hospital were recruited using convenience sampling. Semi-structured interviews were conducted by an occupational therapist with an interview topic guide regarding factors influencing motivation and how it affects behavioral change. Interviews were recorded, transcribed to text, and analyzed by three occupational therapists using thematic analysis. The participants were divided into two groups: aged patients (aged ≥ 65 years) and middle-aged patients (aged < 65 years), and data were analyzed according to the groups. This study was conducted according to the consolidated criteria for reporting qualitative research.Results:Seven core categories were identified as factors influencing patients' motivation: patients' goals, experiences of success and failure, physical condition and cognitive function, resilience, influence of rehabilitation professionals, relationships between patients, and patients' supporters. The first four and last three core categories were further classified as personal and social-relationship factors, respectively. The categories related to intrinsic motivation such as enjoyment of rehabilitation itself were not derived. In both age-groups, motivation affected the frequency of self-training and activity in daily lives. In some aged patients, however, high motivation restrained their self-training to conserve their physical strength for rehabilitation by professionals. Some aged patients do not express their high motivation through their facial expressions and conversations compared to middle-aged patients; therefore, motivation is not always observable in aged patients.Conclusions:Interventions tailored to extrinsic factors are important for maintaining patients' motivation. Observational evaluation may lead to mislabeling of their motivation, especially for aged patients. Rehabilitation professionals should use validated evaluation scales or patients' narratives to assess patients' motivation.

Short stride length is one of clinical symptoms associated with lumbar spinal stenosis (LSS). Short stride is a risk factor for falls; therefore, identification of factors associated with short stride is critical for fall prevention in LSS patients. Although the Two-Step test can conveniently assess maximal stride length, it has not become widely used; therefore, its data are limited. We identified the potential factors associated with short stride of elderly LSS patients using Two-Step test.Clinical data of patients aged65 years who planned to undergo surgery for LSS were prospectively collected at multiple institutions. Patients were assessed with the Two-Step test and Timed Up-and-Go Test prior to surgery; 357 consecutive patients were enrolled. We determined the cut-off value of the Two-Step test score for short stride, referring to the Timed Up-and-Go Test score of 13.5 s, used to indicate high risk of falls in elderly individuals. Logistic regression model was constructed to identify factors associated with short stride.The Two-Step test score showed moderate-to-strong inverse correlation with that of Timed Up-and-Go Test (r = -0.65, p 0.001). Using the tentative Two-Step test cut-off value (0.93) for short stride, multivariable analysis showed that age ≥80 years (OR = 2.3, 95% CI:1.1-4.8), a score of60 for lumbar function in Japanese Orthopedic Association Back Pain Evaluation Questionnaire (OR = 2.7, 95% CI:1.5-4.7), motor deficit (OR = 2.7, 95% CI:1.2-6.1), and sagittal vertical axis ≥50 mm (OR = 2.1, 95% CI:1.2-3.5) were factors significantly associated with short stride in elderly patients with LSS.Using the Two-Step test, we found that 80 years old and over, lumbar dysfunction, motor deficit of the lower extremities, and forward-bent posture were associated with short stride in LSS patients. Therefore, elderly LSS patients with these conditions may have a higher risk for falls.

To determine the level of limitations in activities of daily living (ADL) and instrumental ADL, and identify related factors to instrumental ADL among elderly persons with severe aortic stenosis (AS). We prospectively enrolled 112 consecutive elderly persons (mean age, 84.6 ± 4.4 y) with severe AS. We assessed ADL and instrumental ADL using the Barthel index (BI) and the Frenchay activities index (FAI), respectively. Cardiac, physical, cognitive and kidney functions, nutritional status, medical histories, and comorbidities were assessed. A multiple logistic analysis was developed to explore related factors to the FAI. The medians (ranges) of BI and FAI were 100 (15–100) and 21 (0–38), respectively. The multiple logistic analysis revealed that a history of heart failure (sβ = −0.189), a history of cerebrovascular disease (sβ = −0.233), the short physical performance battery score ≤ 8 (sβ = −0.272), the mini-mental state examination score ≤ 23 (sβ = -0.168) were significantly related to the FAI (p Physical frailty, a history of heart failure, cerebrovascular disease, and cognitive decline were independently related to declined instrumental ADL.IMPLICATIONS FOR REHABILIATIONActivities of daily living was well-preserved among elderly persons with severe aortic stenosis.Instrumental activities of daily living varied among patients with aortic stenosis and was sometimes impaired.Physical frailty, a history of heart failure, and a history of cerebrovascular disease were independently associated with instrumental activities of daily living in elderly persons with severe aortic stenosis. Activities of daily living was well-preserved among elderly persons with severe aortic stenosis. Instrumental activities of daily living varied among patients with aortic stenosis and was sometimes impaired. Physical frailty, a history of heart failure, and a history of cerebrovascular disease were independently associated with instrumental activities of daily living in elderly persons with severe aortic stenosis.

AIM To elucidate the incidences and circumstances of falls and fall-related injuries, and to explore the physical characteristics of community-dwelling ambulatory stroke survivors who experienced falls. METHODS A total of 144 community-dwelling ambulatory survivors of hemiparetic stroke (mean age 68.0 years [SD 10.4 years]) who were undergoing rehabilitation in an adult daycare center participated in this prospective study. The mean duration from stroke onset was 5.21 years (SD 3.15 years). The occurrence of falls was collected for 1 year with a fall diary. The incidence rates of falls and fall-related injuries, and the detailed circumstances of falls were descriptively analyzed. The characteristics of fallers were explored by comparing background information, motor impairments and results of physical function tests, including the 10-m walk test, Timed Up and Go test and five-times-sit-to-stand test, between fallers and non-fallers. RESULTS The incidence rates of falls and fall-related fractures were 0.88 per person-year and 2.8 per 100 person-years, respectively. Falls occurred more frequently during daytime and in winter. Falls were caused most often by losing balance while walking indoors, especially on the way to the toilet. After falling, 34.1% of individuals who fell could not stand up by themselves. The time of the five-times-sit-to-stand test was significantly longer in fallers than in non-fallers (P < 0.05). CONCLUSIONS The incidence rate of falls was high among community-dwelling ambulatory survivors of hemiparetic stroke. Appropriate approaches, including mastering the skills to cope with falling, are required, especially for individuals with reduced lower limb muscle strength. Geriatr Gerontol Int 2019; 19: 240-244.

The study aimed to identify factors related to bone mineral density (BMD) among older patients with heart failure (HF). A total of 70 consecutive patients with HF aged 65 years or older who were admitted to an acute hospital due to worsening condition were enrolled before discharge. BMD of the femoral neck was evaluated using the DEXA method. Physical function, as well as echocardiographic and laboratory findings including biomarker of HF severity were collected. Bivariate and multiple regression analyses were employed to determine the association between BMD and the clinical variables. Bivariate analysis determined that age, grip strength, walking speed, serum albumin, and N-terminal pro B-type natriuretic peptide (NT-proBNP) were significantly correlated with BMD (P

Physical deconditioning after stroke may induce post-stroke fatigue. However, research on this association is limited. Our primary objective was to investigate the associations of post-stroke fatigue with oxygen uptake (⩒O2) at peak exercise and the time constant of ⩒O2 kinetics (τ⩒O2) at the onset of exercise. The secondary objective was to examine the associations between fatigue and cardiorespiratory variables potentially affecting ⩒O2 during exercise. Twenty-three inpatients from a subacute rehabilitation ward were enrolled in this study. The median (interquartile range) Fatigue Severity Scale (FSS) score as a measure of fatigue was 32 (27, 42) points. The FSS score was not associated with ⩒O2 at peak exercise during a symptom-limited graded exercise test (rho = −0.264; p = 0.224), while it was significantly associated with τ⩒O2 during a submaximal constant-load exercise test (rho = 0.530; p = 0.009). A higher FSS score was also significantly correlated with a longer time constant of cardiac output kinetics (rho = 0.476, p = 0.022). These results suggest that the ability of the cardiorespiratory system to adapt to exercise is impaired in individuals with severe post-stroke fatigue. Our findings can contribute to the development of an appropriate rehabilitation program for such individuals.

Welwalk WW-1000 is a gait exercise robotic assist system that allows subjects to walk on treadmill by attaching a knee-ankle-foot robot to a paralyzed limb. Abnormal gait patterns during exercise using Welwalk WW-1000 are evaluated by gait observation or marker-based motion analysis systems. However, gait observation is a subjective and ordinal measure, and marker-based motion analysis systems are challenging to implement due to the complexity of preparing equipment and attaching markers to subjects. In this study, we propose the Welwalk WW-2000 system, which incorporated a marker-less motion analysis system that detects abnormal gait patterns during exercise using the robotic system. Using this system, it is expected that a gait exercise program can be planned from easily obtainable, objective information. This system detects the features of abnormal gait patterns using the body position coordinates of the subject obtained from three-dimensional, inertial, knee angle, and load sensors. The purpose of this study was to validate the marker-less motion analysis system against marker-based motion analysis systems. One healthy male simulated the seven abnormal gait patterns which occur frequently in stroke patients, with four grades of severity. Spearman"s rank correlation coefficients were calculated for the relationship between the abnormal gait pattern parameters calculated by each motion analysis system. The correlations between the two systems ranged from 0.81 to 0.95. Therefore, it was confirmed that the marker-less motion analysis system of the Welwalk WW-2000 was valid.

The purpose of this study was to clarify whether the novel lateral transfer assist robot facilitates easier transfers compared with a wheelchair in post-stroke hemiparesis patients.This cross-sectional study enrolled 20 post-stroke hemiparesis patients, and the task difficulty of transfers was compared between a wheelchair and lateral transfer assist robot. All participants were asked to transfer from either wheelchair or lateral transfer assist robot to a platform table and back. The primary outcome was the transfer score of the Functional Independence Measure. The secondary outcome was the time required for transfer.The transfer score of the Functional Independence Measure was significantly higher with lateral transfer assist robot than with wheelchair (Transfer with a lateral transfer assist robot is easier than with wheelchair and facilitates independence in post-stroke hemiparesis patients.IMPLICATIONS FOR REHABILITATIONTransfer skill influences the functional independence and quality of life of a wheelchair userA novel structural mobility device-the lateral transfer assist robot (LTAR)-can facilitate transfersThe LTAR could improve the degree of independence for transfers than the wheelchair, without any time loss, in post-stroke hemiparesis patientsThe LTAR could potentially reduce the risk for falls in various medical and care facilities.

To determine whether poststroke fatigue at admission is associated with the degree of independence in activities of daily living in patients with stroke at discharge from subacute rehabilitation wards.Retrospective cohort study.Subacute rehabilitation hospital.A consecutive sample of patients (N=156) with stroke who were admitted to a subacute rehabilitation ward between December 2012 and November 2013 were enrolled in the study.Not applicable.Poststroke fatigue was assessed using the Fatigue Severity Scale within 2 weeks of admission. Poststroke fatigue was defined as the mean score of 4 points or more from among 9 items in the Fatigue Severity Scale. Functional outcome was assessed by using FIM motor items.Fifty-six (35.9%) of the 156 participants had poststroke fatigue at admission. The scores of the FIM motor items at admission and discharge were significantly lower in the fatigue group than in the nonfatigue group (P.05). Multiple regression analysis with potentially confounding variables revealed that poststroke fatigue was a significant independent factor for discharge FIM motor items score (P.05).Poststroke fatigue at admission was significantly associated with functional outcome at discharge from subacute rehabilitation wards. Our findings emphasize that rehabilitation professionals need to manage poststroke fatigue in addition to providing the interventions to improve daily activities in patients with subacute stroke.

ObjectivesTo examine the inter-rater reliability of the thumb localizing test (TLT) and its validity against quantitative measures of proprioception.MethodsThe TLT was assessed by two raters in a standardized manner in 40 individuals with hemiparetic stroke. Inter-rater reliability was examined with weighted Kappa. For the quantitative measures, a bimanual matching task in a planar robotic device was performed. Without vision, each participant moved the unaffected hand to the perceived mirrored location of the affected hand, which was passively moved by the robot. Three measures were taken after 54 trials: Variability, trial-to-trial variability of the mirrored-matched locations; Area, the ratio of the area enclosed by the active hand relative to the passive hand; and Shift, systematic shifts between the passive and active hands. The correlation between the TLT and each robotic measure was examined with Spearman's rank correlation coefficient.ResultsThe overall weighted kappa of the TLT was 0.84 (PConclusionsThe TLT had a high inter-rater reliability, and was validated against quantitative measures of proprioception reflecting the perceived area of movement and variability of the limb location.

Introduction Gait exercise assist robot (GEAR), a gait rehabilitation robot developed for poststroke gait disorder, has been shown to improve walking speed and to improve the poststroke gait pattern. However, the persistence of its beneficial effect has not been clarified. In this matched case-control study, we assessed the durability of the effectiveness of GEAR training in patients with subacute stroke on the basis of clinical evaluation and three-dimensional (3D) gait analysis. Methods Gait data of 10 patients who underwent GEAR intervention program and 10 patients matched for age, height, sex, affected side, type of stroke, and initial gait ability who underwent conventional therapy were extracted from database. The outcome measures were walk score of Functional Independence Measure (FIM-walk), Stroke Impairment Assessment Set total lower limb motor function score (SIAS-L/E), and 3D gait analysis data (spatiotemporal factors and abnormal gait patter indices) at three time points: baseline, at the end of intervention, and within 1 week before discharge. Results In the GEAR group, the FIM-walk score, SIAS-L/E score, cadence, and single stance time of paretic side at discharge were significantly higher than those at post-training (p < 0.05), whereas the stance time and double support time of the unaffected side, knee extensor thrust, insufficient knee flexion, and external rotated hip of the affected side were significantly lower (p < 005). However, no significant differences in these respects were observed in the control group between the corresponding evaluation time points. Conclusion The results indicated significant improvement in the GEAR group after the training period, with respect to both clinical parameters and the gait pattern indices. This improvement was not evident in the control group after the training period. The results possibly support the effectiveness of GEAR training in conferring persistently efficient gait patterns in patients with poststroke gait disorder. Further studies should investigate the long-term effects of GEAR training in a larger sample.

Objective To examine functional outcomes in patients with subacute stroke who are on haemodialysis. Design Observational cohort study. Subjects Patients with stroke who were admitted to rehabilitation wards between April 2011 and August 2016 were retrospectively enrolled. Methods Data on the Functional Independence Measure (FIM) and discharge destination were collected from medical records as outcomes. Outcomes were compared for patients who received haemodialysis and those who did not. Multiple regression analyses were carried out to explore the impact of haemodialysis on functional outcomes. Results Among 859 patients, 34 (mean age 63.6 years (standard deviation (SD) 11.7)) required haemodialysis while staying in rehabilitation wards. One hundred patients not receiving haemodialysis (mean age 70.7 years (SD 13.8) ) were randomly selected as controls. The total FIM score at discharge, FIM gain, FIM efficiency, FIM effectiveness, and discharge destination were not significantly different between the 2 groups (p > 0.05). Multiple regression analysis, adjusted for other confounding factors, found no significant difference in total FIM score between groups at discharge (p = 0.427). Conclusion Dialysis was not an inhibitory factor affecting outcomes during subacute rehabilitation in patients with stroke. Rehabilitation should be considered for patients with subacute stroke requiring haemodialysis, in order to provide every opportunity to achieve adequate functional outcomes.

To characterize each cognitive function per se and to understand the brain as an aggregate of those functions, it is vital to relate dozens of these functions to each other. Knowledge about the relationships among cognitive functions is informative not only for basic neuroscientific research but also for clinical applications and developments of brain-inspired artificial intelligence. In the present study, we propose an exhaustive data mining approach to reveal relationships among cognitive functions based on functional brain mapping and network analysis. We began our analysis with 109 pseudo-activation maps (cognitive function maps; CFM) that were reconstructed from a functional magnetic resonance imaging meta-analysis database, each of which corresponds to one of 109 cognitive functions such as ‘emotion,’ ‘attention,’ ‘episodic memory,’ etc. Based on the resting-state functional connectivity between the CFMs, we mapped the cognitive functions onto a two-dimensional space where the relevant functions were located close to each other, which provided a rough picture of the brain as an aggregate of cognitive functions. Then, we conducted so-called conceptual analysis of cognitive functions using clustering of voxels in each CFM connected to the other 108 CFMs with various strengths. As a result, a CFM for each cognitive function was subdivided into several parts, each of which is strongly associated with some CFMs for a subset of the other cognitive functions, which brought in sub-concepts (i.e., sub-functions) of the cognitive function. Moreover, we conducted network analysis for the network whose nodes were parcels derived from whole-brain parcellation based on the whole-brain voxel-to-CFM resting-state functional connectivities. Since each parcel is characterized by associations with the 109 cognitive functions, network analyses using them are expected to inform about relationships between cognitive and network characteristics. Indeed, we found that informational diversities of interaction between parcels and densities of local connectivity were dependent on the kinds of associated functions. In addition, we identified the homogeneous and inhomogeneous network communities about the associated functions. Altogether, we suggested the effectiveness of our approach in which we fused the large-scale meta-analysis of functional brain mapping with the methods of network neuroscience to investigate the relationships among cognitive functions.

Objectives To examine the relationship between patients’ transfer ability and fall risk in stroke patients during hospitalization. Materials and methods We retrospectively enrolled 237 stroke patients who were transferred to a convalescent rehabilitation ward from acute wards in the same hospital. Using incident reports, we investigated their fall rates and activity status at the falls according to their transfer abilities, which were assessed with Functional Independence Measure (FIM) transfer scores. The bi-weekly time trend of fall rates in all patients and in three subgroups based on FIM transfer scores of 1–3, 4–5, and 6–7, and activity status at the falls, were investigated. In addition, changes of patients’ transfer ability on admission, at the first fall, and at discharge were investigated among falling patients. Results The fall rate was the greatest in patients with a FIM transfer score of 4 (14.3 times/1000 person-days). The majority of falls for patients with a FIM transfer score of 1 occurred at the activity status of “on the bed” and “sitting”, while three quarters of patients with a FIM score of 7 had falls during “standing” and “walking”. No longitudinal trend in fall rates was found overall; however, the fall rate trends differed depending on the FIM transfer score. The majority of the patients who fell required full assistance for transfers upon admission but required no assistance at discharge. Conclusions Fall risk differed among patients with various transfer abilities; the greatest risk was in those who needed minimal assistance for transfers.