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Systems for stroke rehabilitation and recovery are variable and fragmented; stroke survivors often experience gaps in care with detrimental effects on their recovery. We designed and hosted a multidisciplinary and interactive workshop to discuss challenges facing patients recovering from stroke and to brainstorm solutions. Forty-one participants including clinicians, researchers, and stroke survivors attended the workshop. Participants were surveyed beforehand about challenges facing stroke recovery and results were tabulated as a word cloud. An interactive, design-thinking exercise was conducted that involved completing workbooks, hands-on prototype designing, and presentations, which were then analyzed through qualitative content analysis using an inductive approach. High frequency words in the word cloud of survey responses included access, fragmented, and uncertainty. Qualitative analysis revealed 6 major challenge themes including poor (1) transitions in and (2) access to care; (3) barriers to health insurance; (4) lack of patient support; (5) knowledge gaps; and (6) lack of standardized outcomes. Eleven unique solutions were proposed that centered around new technologies, health care system changes, and the creation of new support roles. Analysis of the alignment between the challenges and solutions revealed that the single proposed solution that solved the most identified challenges was a "comprehensive stroke clinic with follow-up programs, cutting edge treatments, patient advocation and research." Through our interactive design-thinking workshop process and inductive thematic analysis, we identified major challenges facing patients recovering from stroke, collaboratively proposed solutions, and analyzed their alignment. This process offers an innovative approach to reaching consensus among interdisciplinary stakeholders.

ObjectiveTo test the hypothesis that cognitive demands influence motor performance during recovery from acute stroke, we tested patients with acute stroke on 2 motor tasks with different cognitive demands and related task performance to cognitive impairment and neuroanatomic injury.MethodsWe assessed the contralesional and ipsilesional upper extremities of a cohort of 50 patients with weakness after unilateral acute ischemic stroke at 3 time points with 2 tasks: the Box & Blocks Test, a task with greater cognitive demand, and Grip Strength, a simple and ballistic motor task. We compared performance on the 2 tasks, related motor performance to cognitive dysfunction, and used voxel-based lesion symptom mapping to determine neuroanatomic sites associated with motor performance.ResultsConsistent across contralesional and ipsilesional upper extremities and most pronounced immediately after stroke, Box & Blocks scores were significantly more impaired than Grip Strength scores. The presence of cognitive dysfunction significantly explained up to 33% of variance in Box & Blocks performance but was not associated with Grip Strength performance. While Grip Strength performance was associated with injury largely restricted to sensorimotor regions, Box & Blocks performance was associated with broad injury outside sensorimotor structures, particularly the dorsal anterior insula, a region known to be important for complex cognitive function.ConclusionsTogether, these results suggest that cognitive demands influence upper extremity motor performance during recovery from acute stroke. Our findings emphasize the integrated nature of motor and cognitive systems and suggest that it is critical to consider cognitive demands during motor testing and neurorehabilitation after stroke.

Background: Studies of movement of the upper extremity for stroke patients currently require assessments with special equipment and trained assessors, limiting the accessibility. Hevelius is an experimental online platform designed to study human interaction with technology at a large scale. Our aim was to demonstrate the feasibility of using Hevelius for testing arm kinematics in stroke patients. Methods: Stroke patients (time from stroke 6 weeks to 1 year) with upper extremity weakness with an NIH Stroke Scale contralesional arm motor (5A or 5B) score of 2 or less were tested on Hevelius. Participants engaged in a Point-And-Click task. Thirty-two kinematic features of movement from continuous, target-driven mouse movement were collected in the arms contralesional and ipsilesional to stroke and compared to data from with health controls. Upper extremity Fugl-Meyer (UE-FM), NIH Stroke Scale (NIHSS), 9-Hole-Peg as well as patient reported outcomes (via Stroke Impact Scale) were collected during the same research visits. Results: In a total sample of N = 19 patients with upper extremity weakness after stroke who performed Hevelius testing, the median age was 66 (range 47 - 81) with 70% male participants. Nine participants had strokes affecting their dominant arm. LASSO method was used for regression to simultaneously performs feature selection and fitting of a linear model. Score estimates on Hevelius platform correlated strongly on linear regression modeling with clinical scores (from r=0.675 for arm portion of NIHSS ). There was also correlation with 9-Hole-Peg (r=0.581) and no clear correlation with UE-FM, modified Rankin score and Stroke Impact Scale. Five of the 9 patients with dominant arm affected by stroke had NIHSS of 0 and UE-FM of 66. Abnormal movement kinematics were detected in both the contralesional and ipsilesional arms when compared to healthy controls. Conclusions: Characteristics of arm movement are essential to the understanding of motor recovery after stroke. Our study demonstrates subtle deficits of arm movement in task-directed testing that were not captured with traditional measures of stroke recovery.

Background: Return to driving and employment are goals for many stroke survivors. There are few reports of patient centered outcomes including return to employment, driving, self-efficacy, functional outcomes, stroke knowledge or characteristics of survivors who achieve these goals. Methods: Prospective observational study of stroke patients treated in an interdisciplinary outpatient rehabilitation program addressing physical, cognitive, communicative, risk factor/stroke knowledge, self-efficacy, psychosocial, driving and vocational issues. Results: 190 consecutive patients(117 men, 73 women, average age 62(18-90), 66 aphasic) with baseline modified Rankin Scores of 5(1%); 4(25%); 3(56%); 2(15%); 1(3%), and average NIHSS score of 6(range 0-18) were treated between 12/2011-7/2019. 136 Patients suffered ischemic strokes and 54 had hemorrhages. Locations were: 65 left, 69 right, 26 bilateral hemisphere, 30 brainstem. 41% had MCA territory strokes. Of 104 patients working pre-stroke, 50% returned to work and an additional 7% were work capable upon completion of program. 95% of patients driving pre-stroke could not drive on admission. After training, 43%(67/157) returned to driving. Patients had improvements in all 9 domains of Stroke Impact Scale with SIS total score improving an average of 23%. Patients received an average of 33 physical therapy visits with average percent improvement of 72% and 41% on 6” walk and Berg Balance scores. Average percent improvement in Stroke Self Efficacy Scores was 29%. After individualized cardiovascular risk, stroke and medication education sessions with the Nurse Practitioner based on AHA guidelines and Life’s Simple 7’s curriculum, stroke and risk factor knowledge quiz scores improved an average of 29%. Average length of stay was 5(range .5-24) months. Multiple other demographic and outcome measures are collected. Conclusions: Outcome data show a community-based team rehabilitation program can successfully combine CV/stroke education with rehabilitation services to maximize patient centered outcomes including return to work, driving, overall stroke recovery, physical functioning, stroke knowledge, and self-efficacy for many types of stroke survivors with moderate to severe disability.

Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations. Upper extremity (UE) functional recovery after stroke requires the integration of motor and sensory systems. We describe the relationship among recovery of somatosensation, motor impairment, and manual dexterity from acute to 3 months poststroke. Sensory retraining emphasized in conjunction with motor interventions after stroke may improve functional UE outcomes. Primary Author and Speaker: Isha Vora Contributing Authors: David Lin, Julie DiCarlo, Jessica Ranford, and Teresa J. Kimberley