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Rationale: Clinical practice guidelines support structured, progressive protocols for improving walking after stroke. Yet, practice is slow to change, evidenced by the little amount of walking activity in stroke rehabilitation units. Our recent study (n = 75) found that a structured, progressive protocol integrated with typical daily physical therapy improved walking and quality-of-life measures over usual care. Research therapists progressed the intensity of exercise by using heart rate and step counters worn by the participants with stroke during therapy. To have the greatest impact, our next step is to undertake an implementation trial to change practice across stroke units where we enable the entire unit to use the protocol as part of standard of care., Aims: What is the effect of introducing structured, progressive exercise (termed the Walk 'n Watch protocol) to the standard of care on the primary outcome of walking in adult participants with stroke over the hospital inpatient rehabilitation period? Secondary outcomes will be evaluated and include quality of life., Methods and Sample Size Estimates: This national, multisite clinical trial will randomize 12 sites using a stepped-wedge design where each site will be randomized to deliver Usual Care initially for 4, 8, 12, or 16 months (three sites for each duration). Then, each site will switch to the Walk 'n Watch phase for the remaining duration of a total 20-month enrolment period. Each participant will be exposed to either Usual Care or Walk 'n Watch. The trial will enroll a total of 195 participants with stroke to achieve a power of 80% with a Type I error rate of 5%, allowing for 20% dropout. Participants will be medically stable adults post-stroke and able to take five steps with a maximum physical assistance from one therapist. The Walk 'n Watch protocol focuses on completing a minimum of 30 min of weight-bearing, walking-related activities (at the physical therapists' discretion) that progressively increase in intensity informed by activity trackers measuring heart rate and step number., Study Outcome(s): The primary outcome will be the change in walking endurance, measured by the 6-Minute Walk Test, from baseline (T1) to 4 weeks (T2). This change will be compared across Usual Care and Walk 'n Watch phases using a linear mixed-effects model. Additional physical, cognitive, and quality of life outcomes will be measured at T1, T2, and 12 months post-stroke (T3) by a blinded assessor., Discussion: The implementation of stepped-wedge cluster-randomized trial enables the protocol to be tested under real-world conditions, involving all clinicians on the unit. It will result in all sites and all clinicians on the unit to gain expertise in protocol delivery. Hence, a deliberate outcome of the trial is facilitating changes in best practice to improve outcomes for participants with stroke in the trial and for the many participants with stroke admitted after the trial ends.

Background: While higher therapeutic intensity improves motor recovery after stroke, translating findings from successful studies is challenging without clear exercise intensity targets. We show in the DOSE trial 1 more than double the steps and aerobic minutes within a session can be achieved compared with usual care and translates to improved long-term walking outcomes., Objective: We modeled data from this successful higher intensity multi-site RCT to develop targets for prescribing and progressing exercise for varying levels of walking impairment after stroke., Methods: In twenty-five individuals in inpatient rehabilitation, twenty sessions were monitored for a total of 500 one-hour physical therapy sessions. For the 500 sessions, step number and aerobic minute progression were modeled using linear mixed effects regression. Using formulas from the linear mixed effects regression, targets were calculated., Results: The model for step number included session number and baseline walking speed, and for aerobic minutes, session number and age. For steps, there was an increase of 73 steps per session. With baseline walking speed, for every 0.1 m/s increase, a corresponding increase of 302 steps was predicted. For aerobic minutes, there was an increase of .56 minutes of aerobic activity (ie, 34 seconds) per session. For every year increase in age, a decrease of .39 minutes (ie, 23 seconds) was predicted., Conclusions: Using data associated with better walking outcomes, we provide step number and aerobic minute targets that future studies can cross-validate. As walking speed and age are collected at admission, these models allow for uptake of routine measurement of therapeutic intensity.Registration: www.clinicaltrials.gov; NCT01915368.

Background and Purpose: Therapeutic exercise improves balance and walking ability in individuals after stroke. The extent to which motor planning improves with therapeutic exercise is unknown. This case series examined how outpatient physical therapy affects motor planning and motor performance for stepping., Case Description: Individuals poststroke performed self-initiated stepping before (baseline), after (postintervention), and 1 month after (retention) intervention. Amplitude and duration of the movement-related cortical potential (MRCP) was measured using an electroencephalograph from the Cz electrode. Electromyography (EMG) of biceps femoris (BF) was collected. Additionally, clinical measures of motor impairment and function were evaluated at all 3 time points by a blinded assessor., Intervention: Two types of outpatient physical therapy were performed for 6 weeks: CONVENTIONAL (n = 3) and FAST (n = 4, Fast muscle Activation and Stepping Training)., Outcomes: All 7 participants reduced MRCP duration, irrespective of the type of physical therapy. The MRCP amplitude and BF EMG onset changes were more variable. Clinical outcomes improved or were maintained for all participants. The extent of motor impairment was associated with MRCP amplitude., Discussion: Changes in MRCP duration suggest that outpatient physical therapy may promote neuroplasticity of motor planning of stepping movements after stroke; however, a larger sample is needed to determine whether this finding is valid.This case series suggests motor planning for initiating stepping may improve after 6 weeks of outpatient physical therapy for persons with stroke.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A307).

Background and Aims: In addition to overt stroke lesions, co-occurring covert lesions, including white matter hyperintensities (WMH) and covert lacunar infarcts (CLI), contribute to poststroke outcome. The purpose of this study was to examine the relationship between covert lesions, and motor and cognitive outcomes in individuals with chronic stroke., Methods: Volumetric quantification of clinically overt strokes, covert lesions (periventricular and deep: pWMH, dWMH, pCLI, dCLI), ventricular and sulcal CSF (vCSF, sCSF), and normal appearing white (NAWM) and gray matter (NAGM) was performed using structural magnetic resonance imaging. We assessed motor impairment and function, and global cognition, memory, and other cognitive domains. When correlation analysis identified more than one MR parameter relating to stroke outcomes, we used regression modeling to identify which factor had the strongest impact., Results: Neuropsychological and brain imaging data were collected from 30 participants at least 6 months following a clinically diagnosed stroke. Memory performance related to vCSF (r = -0.52, P = .004). The strongest predictor of nonmemory domains was pCLI (r 2 = 0.28, P = .004). Motor impairment and function were most strongly predicted by the volume of stroke and NAWM (r 2 = 0.36; P = .001), and dWMH (r 2 = 0.39; P = .001) respectively., Conclusions: Covert lesion type and location have important consequences for post-stroke cognitive and motor outcome. Limiting the progression of covert lesions in aging populations may enhance the degree of recovery post-stroke., (Copyright © 2018. Published by Elsevier Inc.)

Background: Severity of arm impairment alone does not explain motor outcomes in people with severe impairment post stroke., Objective: Define the contribution of brain biomarkers to upper limb motor outcomes in people with severe arm impairment post stroke., Methods: Paretic arm impairment (Fugl-Meyer upper limb, FM-UL) and function (Wolf Motor Function Test rate, WMFT-rate) were measured in 15 individuals with severe (FM-UL ≤ 30/66) and 14 with mild-moderate (FM-UL > 40/66) impairment. Transcranial magnetic stimulation and diffusion weight imaging indexed structure and function of the corticospinal tract and corpus callosum. Separate models of the relationship between possible biomarkers and motor outcomes at a single chronic (≥6 months) time point post stroke were performed., Results: Age (Δ R 2 0.365, p = 0.017) and ipsilesional-transcallosal inhibition (Δ R 2 0.182, p = 0.048) explained a 54.7% ( p = 0.009) variance in paretic WMFT-rate. Prefrontal corpus callous fractional anisotropy (PF-CC FA) alone explained 49.3% ( p = 0.007) variance in FM-UL outcome. The same models did not explain significant variance in mild-moderate stroke. In the severe group, k-means cluster analysis of PF-CC FA distinguished two subgroups, separated by a clinically meaningful and significant difference in motor impairment ( p = 0.049) and function ( p = 0.006) outcomes., Conclusion: Corpus callosum function and structure were identified as possible biomarkers of motor outcome in people with chronic and severe arm impairment.

Background: Rehabilitation after severe stroke is often limited because of impairments in sensorimotor function. Functional and physiological recovery after severe stroke is poorly understood and has not been studied extensively., Objective: This study's purpose was to examine functional and physiological recovery of standing balance during inpatient rehabilitation in people with severe impairments after stroke., Methods: A total of 10 participants with severe impairments after stroke were evaluated monthly in a stroke rehabilitation unit with the following functional outcome measures: Berg Balance Scale (BBS), Clinical Outcome Variables Scale (COVS), and Chedoke McMaster Stroke Assessment (CMSA). Weight bearing (WB), center of pressure (COP) velocity, and electromyography (EMG) data were collected during quiet standing and during internal perturbation with a rapid nonparetic arm raise., Results: Cross-sectionally, there were moderate to strong correlations for EMG area and WB with CMSA and COVS. Additionally, the BBS was correlated with WB on the paretic side. Longitudinally, statistically significant improvement was found for functional measures but not for physiological measures. The mean BBS and COVS improved by 23 and 21 points, respectively. COP velocity decreased by 60.1% on the paretic leg but not significantly., Conclusions: During stroke rehabilitation, all participants improved functionally. Some patients improved physiologically, though near discharge, all participants remained very impaired. Future studies with larger sample sizes are needed to explore the capacity for physiological recovery in this population., (© The Author(s) 2014.)

Background: The majority of stroke survivors experience motor impairment which benefits from rehabilitation treatment. Telerehabilitation, remote delivery of rehabilitation services, is a possible solution providing access to rehabilitation for stroke survivors living in rural areas or in situations like the COVID-19 pandemic where face-to-face treatment may be risky. However, valid and reliable motor impairment measures have not yet been established over a telerehabilitation platform. The Fugl-Meyer (FM) lower extremity assessment is widely used clinically and in research. Thus, the aim was to develop a modified FM for telerehabilitation (FM-tele) and assess the feasibility and preliminary agreement of FM-tele scores with the FM. Methods: Three phases were employed: phase 1 development, phase 2 feasibility, and phase 3 preliminary agreement. Literature review and consultation with clinicians were employed to develop the FM-tele. Community-dwelling individuals with stroke and FM evaluators were consulted to provide feedback via questionnaires on the feasibility of the FM-tele. To assess the preliminary agreement of the FM-tele, individuals with stroke participated in two sessions, one in-person and one via telerehabilitation. The standard version of the FM was administered during the in-person session. The FM-tele was administered in both sessions. Results: From phase 1, clinician consultation identified the following key principles: safety of the client, clear lower extremity visualization, and minimization of position changes which guided FM-tele development (n = 7). Feasibility was established in phase 2 where participants with stroke indicated that they felt safe and experienced ease following the standardized instructions, despite some technological concerns (n = 5). FM evaluators agreed that participants were safe and indicated effective standardized instructions. Phase 3 (n = 5) indicated preliminary agreement of the FM-tele compared with the FM. Conclusions: Participants with stroke and clinical consultation indicated the FM-tele developed for telerehabilitation is feasible. A lower extremity motor assessment tool for telerehabilitation is urgently needed for stroke survivors living in rural areas or when face-to-face visits are impossible. This pilot study provides preliminary support for a future study. [ABSTRACT FROM AUTHOR]

In the article, the authors discuss the effectiveness of using mobile brain/body imaging (MoBI) to analyze the underlying neurophysiology linked to behavior of functional, real-world movements supplementing clinician-reported outcomes and patient-reported outcome measures (PROM) in people with stroke. Other topics include the mobile neuroimaging methods like electroencephalography (EEG), magnetic resonance imaging (MRI), and functional near-infrared spectroscopy (fNIRS).

Attention and planning can be altered by stroke, which can influence motor performance. Although the influence of these factors on recovery from stroke has been explored for the upper extremity (UE), their impact on balance and gait are unknown. This perspective article presents evidence that altered motor and visuospatial attention influence motor planning of voluntary goal-directed movements poststroke, potentially affecting balance and gait. Additionally, specific strategies for rehabilitation of balance and gait poststroke in the presence of these factors are discussed. Visuospatial attention selects relevant sensory information and supports the preparation of responses to this information. Motor attentional impairments may produce difficulty with selecting appropriate motor feedback, potentially contributing to falls. An original theoretical model is presented for a network of brain regions supporting motor and visuospatial attention, as well as motor planning of voluntary movements. Stroke may influence this functional network both locally and distally, interfering with input or output of the anatomical or functional regions involved and affecting voluntary movements. Although there is limited research directly examining leg function, evidence suggests alterations in motor and visuospatial attention influence motor planning and have a direct impact on performance of gait and balance. This model warrants testing comparing healthy adults with individuals with stroke. [ABSTRACT FROM AUTHOR]