Gait Device Treatment Using Telehealth for Individuals With Stroke During the COVID-19 Pandemic: Nonrandomized Pilot Feasibility Study.

BACKGROUND: During the COVID-19 pandemic, rehabilitation providers and consumers adopted telehealth practices at unprecedented rates. Multiple prepandemic studies demonstrate the feasibility and comparable efficacy between in-clinic and remote treatment for certain impairments caused by stroke, such as upper extremity weakness and impaired motor function. However, less guidance has been available regarding gait assessment and treatment. Despite this limitation, safe and effective gait treatment is fundamental to optimizing health and well-being after stroke and should be considered a treatment priority, including during the COVID-19 pandemic. OBJECTIVE: This study explores the feasibility of using telehealth to deliver gait treatment using a wearable gait device, the iStride device, to stroke survivors during the 2020 pandemic. The gait device is used to treat hemiparetic gait impairments caused by stroke. The device alters the user's gait mechanics and creates a subtle destabilization of the nonparetic limb; therefore, supervision is required during its usage. Before the pandemic, treatment with the gait device had been provided in person to appropriate candidates using a combination of physical therapists and trained personnel. However, upon the emergence of the COVID-19 pandemic, in-person treatment was halted in adherence to pandemic guidelines. This study investigates the feasibility of 2 remote delivery treatment models with the gait device for stroke survivors. METHODS: Participants were recruited during the first half of 2020 after the onset of the pandemic and included 5 individuals with chronic stroke (mean age 72 years; 84 months post stroke). Four participants were previous gait device users who transitioned to the telehealth delivery model to continue their gait treatment remotely. The fifth participant performed all study-related activities, from recruitment through follow-up, remotely. The protocol included virtual training for the at-home care partner, followed by 3 months of remote treatment with the gait device. Participants were instructed to wear gait sensors during all treatment activities. To assess feasibility, we monitored the safety of the remote treatment, compliance with protocol activities, acceptability of the telehealth treatment delivery, and preliminary efficacy of the gait treatment. Functional improvement was measured using the 10-Meter Walk Test, the Timed Up and Go Test, and the 6-Minute Walk Test, and quality of life was assessed using the Stroke-Specific Quality of Life Scale. RESULTS: No serious adverse events occurred, and participants rated high acceptance of the telehealth delivery. Protocol compliance averaged 95% of treatment sessions, 100% of assessments, and 85% of sensor usage during treatment. After 3 months of treatment, the average improvement in each functional outcome exceeded the minimal clinically important difference or minimal detectable change value. CONCLUSIONS: Remote treatment delivery with the gait device appeared feasible with care partner support. Gait treatment using telehealth may be useful to offset negative immobility impacts for those requiring or preferring remote care during the pandemic or otherwise. TRIAL REGISTRATION: ClinicalTrials.gov NCT04434313; https://clinicaltrials.gov/ct2/show/NCT04434313.

An investigation into the effects of Omicron and winter pressures on stroke rehabilitation services across the East of England

Introduction: A service impact assessment was undertaken to understand the influence of winter pressures and omicron on stroke rehabilitation service delivery in November and December 2021. This followed concerns regarding rehabilitation provision raised by clinicians and stroke service managers including acute providers, community in patient teams and early supported discharge (ESD) teams across the East of England. Method(s): Questionnaires were distributed to all acute, community and ESD stroke services within the North and South Integrated Stroke Delivery Networks (ISDN), covering physiotherapy, occupational therapy, speech and language therapy and psychology disciplines. Ratings were made against the key themes that had been raised anecdotally as concerns to service delivery. (0=no impact, 1=some impact 2=significant impact) Follow up meetings were arranged for each Integrated Care System (ICS) to provide narrative around the rated themes. Allied Health Professional (AHP) representatives from each stroke service within the ICS were invited to these meetings. Finally, the ratings and narrative were taken back to the Rehabilitation Clinical Advisory Group (CAG) for solutionbased discussions to formulate a potential action plan to report to the Clinical Reference Group (CRG). In total 61 responses were received from professional leads across the four disciplines. Result(s): Issues, themes and recommendations have been established relating to: * Workforce. * Increased referral rates and caseloads. * Rehabilitation Intensity. * Access to care packages and equipment. * Visiting arrangements and the direct impact on discharge planning. * Perceived patient and family experience. Conclusion(s): Analysis is ongoing;however, ten recommendations are being prepared to enable increased robustness of service delivery in preparation for next winter.

High-Tech Home-Based Rehabilitation after Stroke: A Systematic Review and Meta-Analysis.

(1) Background: To improve existing rehabilitation technologies, we conducted a systematic review and meta-analysis to identify the effect size of home-based rehabilitation using robotic, virtual reality, and game devices on physical function for stroke survivors. (2) Methods: Embase, PubMed, Cochrane Library, ProQuest, and CINAHL were used to search the randomized controlled trials that applied technologies via home-based rehabilitation, such as virtual reality, robot-assisted devices, and games. The effect size (Hedges's g) of technology type and affected limb on physical function were calculated. (3) Results: Ten studies were included. The effect size of home-based rehabilitation in virtual reality had the greatest value (Hedges's g, 0.850; 95% CI, 0.314-1.385), followed by robot-assisted devices (Hedges's g, 0.120; 95% CI, 0.003-0.017) and games (Hedges's g, -0.162; 95% CI, -0.036 to -0.534). The effect size was larger in the upper limbs (Hedges's g, 0.287; 95% CI, 0.128-0.447) than in the lower limbs (Hedges's g, -0.113; 95% CI, -0.547 to 0.321). (4) Conclusions: Virtual reality home rehabilitation was highly effective for physical function compared to other rehabilitation technologies. Interventions that consisted of a pre-structured and tailored program applied to the upper limbs were effective for physical function and psychological outcomes.

A pilot study implementing mood intervention in inpatient stroke rehabilitation with people with aphasia

Introduction: Psychological distress is common in people with aphasia, it causes avoidable suffering and impacts on healthcare outcomes and length of hospital stays. This pilot aimed to implement and evaluate a stepped psychological care approach for people with post-stroke aphasia in inpatient stroke rehabilitation. Method(s): A pathway was created to trial;[1] assessing mood using the Distress Thermometer [2] establishing goals to either improve or maintain mood, [3] creating an intervention plan in line with levels 1-2 of the stepped psychological care approach including mindfulness, behavioural activation, education, peer-group experience, and opportunities for mood discussion. Between June-September 2021, data was collected for all patients with aphasia admitted to the rehabilitation unit including Signs of Depression Screening Scale (SDSS) scores, and therapy assistant/researcher reflections. Result(s): Data was collected for nine patients;due to missing data five complete data sets were included. The pre-intervention median SDSS=3, and post-intervention SDSS=1. Reflection notes indicated positive feedback from two patients, increased rapport, greater role satisfaction, short term mood improvements within sessions. Several interventions were declined;mindfulness (3 patients), group/peer sessions (2 ), behavioural activation (2) and any mood intervention (3). Mood interventions had to be deprioritised at times due to workload. The COVID-19 pandemic also meant some activities were unavailable. Conclusion(s): This pilot showed that not all patients wanted to engage with specific or all mood interventions at this early rehabilitation stage. Further research is needed to establish which patients benefit from which intervention and at what stage it should be offered.

An exploration of the role telerehabilitation could play in meeting the needs of stroke survivors post hospital discharge

Introduction: Stroke is a leading cause of disability in the UK. Survivors often report feeling 'abandoned and alone' post hospital discharge. In 2020 the Covid-19 pandemic had a profound effect on NHS service delivery, resulting in reduced national access to stroke rehabilitation. A synchronous telerehabilitation service was established by the Oxfordshire Stroke Rehabilitation Unit to deliver ongoing support for stroke survivors post hospital discharge. This study explores the delivery and outcomes of the telerehabilitation service Method: Retrospective analysis of service data collected between April 2020 and January 2021 was completed. All patients discharged from the inpatient unit were contacted by the service. Appointment content and frequency were dictated by patient need. Result(s): Of 90 patients contacted, 63 participated in telerehabilitation intervention (defined as two or more sessions). Patients who received intervention were significantly (p=<0.05) more functionally independent than those who received a single session, as measured by a Modified Rankin Scale score of less than four. Telerehabilitation content was 45% exercise sessions and 55% advice and support. Those who participated in telerehabilitation saw significant improvement (p=<0.05) on one or more functional measures during the intervention period and 93% of patients would choose this model of rehabilitation again. Conclusion(s): Synchronous telerehabilitation may be able to meet the initial needs of some stroke survivors post hospital discharge. Those residing at home who can mobilise without assistance appear most likely to benefit. Education, advice, and support are important post discharge, alongside physical rehabilitation. Telerehabilitation appears to be acceptable for some stroke survivors.

An exploration into physiotherapists' views of the impact of the COVID-19 pandemic on the delivery of acute stroke rehabilitation in England

Introduction: Post-stroke morbidity and mortality is reduced by timedependent medical interventions and multidisciplinary rehabilitation, both of which have been impacted by the Coronavirus pandemic (COVID-19). Research studies exploring the impact of COVID-19 on the delivery of acute stroke rehabilitation are lacking. The aim of this survey was to understand how COVID-19 had impacted stroke rehabilitation from physiotherapists' perspective. Method(s): An online survey was designed and piloted prior to dissemination. Participants were recruited on a voluntary basis following advertisement via a specialist interest group and social media. Data were analysed using reflexive thematic analysis. The project received approval by the university's ethics committee (no.2584). Result(s): The survey was completed by 45 physiotherapists, with a range of clinical experience from a variety of stroke rehabilitation units across England. Thematic analysis revealed four themes: 1. The availability of personal protective equipment (PPE), the experience of wearing PPE and associated difficulties communicating with patients;2. The quality and quantity of rehabilitation due to staffing shortages and access to appropriate rehabilitation spaces;3. Difficulties with discharge planning due to pressure to facilitate discharge from hospital, alongside variations in access to appropriate community rehabilitation;4. The impact of visiting restrictions on patients' mood and morale, engaging friends and family in rehabilitation and the challenges this created when planning hospital discharge. Conclusion(s): This survey highlights the main challenges encountered by physiotherapists providing stroke rehabilitation during COVID-19. Given the ongoing nature of the pandemic, these findings may assist in optimising staff experience and the quality of stroke rehabilitation.

Stroke Service Redesign to Facilitate Hospital Flow during the Covid-19 Pandemic

Introduction: During the Covid-19 pandemic it was recognised by MTW, a reconfiguration of the acute hospital would be required to create extra bed capacity and protect vulnerable patient groups. Alongside the pandemic the Kent and Medway stroke reconfiguration occurred (Winidbank, 2015). Since July 2020, MTW Stroke Unit admission data shows an average rise of 107% in activity. In December 2020, 'The Hilton Stroke Pathway' (HSP) was developed as a 6 month rehabilitation pilot to increase the MTW bed-base away from the acute site . The pathway consisted of an innovative virtual and homecare rehabilitation service in collaboration with Hilton Nursing Partners. Method(s): The pilots were evaluated using 5 key criteria: financial performance, clinical service delivery, quality of care, patient experience and stakeholder feedback. The pathway is overseen by MTW therapists, discharge liaison services and Hilton care. The aim of the pathway: Enable safe discharge home for stroke patients requiring specialist rehabilitation as soon as they were medically fit. Ensure patients rehabilitation was delivered safely and effectively. Provide a flexible service supporting patients with a range of therapy need. Provide nursing and care support as required. There are 3 levels of support: recovery, moderate and intensive. The MDT discussed which level was most appropriate for the patient. This was then reviewed as patients improved. Initially the therapy was overseen virtually by the OT, PT and SALT team. However, due to complexity of some of the patients' rehabilitation needs, therapy staff shifted to face-to-face therapy sessions. Due to the success of the pilot phase MTW decided to transition the pathway to business as usual. As part of this the pathway was reviewed in collaboration with KCFHT and therapy outcome measures were collected. Monthly monitoring meetings continue with Hilton, to ensure ongoing quality of care and effectiveness of the pathway Results: Since the beginning of the pilot the pathway has achieved positive results in SSNAP. Between January and June 2021 92.2% required OT, 84.4% required PT and 63.3% required SALT. The results in chart 1-2 are from Jan - April 2022. Chart 1 shows patient outcomes for destination on discharge. Chart 2 shows the difference in Therapy Outcome Measure (TOMs) admission and discharge scores. There has been a significant difference in the TOMS in three domains (significant difference=0.5)(Enderby and John, 2019), impairments, activity and participation. The biggest improvements has been seen in activity and participation meaning the HSP are enabling patients to integrate back into society and their occupational roles in life. The pilot evidenced using multi-organisational working has enabled earlier and safer discharges home. The new pathway has allowed for flexible acute bed capacity following the closure of stroke services at Medway hospital and during the challenges that accompanied the Covid-19 pandemic. The HSP has shown significant improvement with functional outcomes and integration back into occupational roles. In 2022 52% of the patients did not require further social care at the end of the pathway. SSNAP data shows a higher intensity of therapy was provided with an average of 34 minutes of OT, 37 minute of PT and 14 mins of SALT per day, whilst on the pathway. Therefore, MTW and Hilton Nursing Partners are keen for continuation of this pathway into future stroke development. Additionally, collaboration with KCHFT community neurorehabiliation team enabled the West Kent stroke rehabilitation pathways to be defined seen in Chart 3. The integration of Hilton Nursing Partners and the MTW MDT enabled safe and effective facilitation for stroke patients into their homes, whilst achieving high levels of independence. Conclusion(s): The stroke service demonstrated what can be achieved in a short timeframe and in challenging circumstances. The implementation was robust and a positive use of NHS resources to proactively enable changes in stroke service provision required across West Kent The pathway was well received by patients and staff, providing a direction of travel towards community-based stroke rehabilitation services which reflect the national guidelines for stroke services (RCP, 2016;NICE, 2013).

'Exploring the Effect of Mirror Therapy versus Constraint Induced Movement Therapy in an Older Adult Post Stroke Population'

Introduction: The Covid-19 pandemic resulted in the closure of community therapy services in Ireland. The need for the provision of upper limb rehabilitation for stroke survivors remained. A new method of service provision was developed and evaluated. Aim- To deliver an upper limb rehabilitation programme to older adults post stroke through virtual means and to compare the stroke interventions of mirror therapy (MT) and constraint induced movement therapy (CIMT). Method(s): 21 participants recruited. The investigator recorded 36 upper limb rehabilitation sessions (12 MT, 12 CIMT and 12 control) which were sent electronically to participants- 6 week therapy programme. Participants were assessed pre and post intervention using the DASH, OSA-SF, JAMAR Hand Function Test, 9 Hole Peg Test and Dynamometer. Statistical significance for CIMT group in grip strength and minimal fine motor skills improvement. MT showed significance in both fine and gross motor skills, grip and pinch strength and overall participants self-perceptions of function. Result(s): 21 participants completed upper limb rehabilitation programmes in their own homes successfully. The MT group showed greater significance than CIMT when completed through virtual means. Telehealth may be a means of service delivery going forward and MT has proven effective as virtual intervention. Conclusion(s): Further evaluation of this intervention through virtual means is needed. Implications for practice- The incorporation of telehealth into upper limb stroke rehabilitation practice can alleviate waiting lists through allowing multiple patients access to interventions at once and also can provide a stroke service in a timely manner.

Augmented reality for stroke rehabilitation during COVID-19.

BACKGROUND: The lack of the rehabilitation professionals is a global issue and it is becoming more serious during COVID-19. An Augmented Reality Rehabilitation System (AR Rehab) was developed for virtual training delivery. The virtual training was integrated into the participants' usual care to reduce the human trainers' effort so that the manpower scarcity can be eased. This also resulted in the reduction of the contact rate in pandemics. OBJECTIVE: To investigate the feasibility of the AR Rehab-based virtual training when integrated into the usual care in a real-world pandemic setting, by answering questions of whether the integrated trials can help fulfill the training goal and whether the trials can be delivered when resources are limited because of COVID-19. METHODS: Chronic stroke participants were randomly assigned to either a centre-based group (AR-Centre) or a home-based group (AR-Home) for a trial consisting of 20 sessions delivered in a human-machine integrated intervention. The trial of the AR-Centre was human training intensive with 3/4 of each session delivered by human trainers (PTs/OTs/Assistants) and 1/4 delivered by the virtual trainer (AR Rehab). The trial of the AR-Home was virtual training intensive with 1/4 and 3/4 of each session delivered by human and virtual trainers, respectively. Functional assessments including Fugl-Meyer Assessment for Upper Extremity (FMA-UE) and Lower Extremity (FMA-LE), Functional Ambulation Category (FAC), Berg Balance Scale (BBS), Barthel Index (BI) of Activities of Daily Living (ADL), and Physical Component Summary (SF-12v2 PCS) and Mental Component Summary (SF-12v2 MCS) of the 12-Item Short Form Health Survey (SF-12v2), were conducted before and after the intervention. User experience (UX) using questionnaires were collected after the intervention. Time and human resources required to deliver the human and virtual training, respectively, and the proportion of participants with clinical significant improvement were also used as supplementary measures. RESULTS: There were 129 patients from 10 rehabilitation centres enrolled in the integrated program with 39 of them were selected for investigation. Significant functional improvement in FMA-UE (AR-Centre: p = 0.0022, AR-Home: p = 0.0043), FMA-LE (AR-Centre: p = 0.0007, AR-Home: p = 0.0052), SF-12v2 PCS (AR-Centre: p = 0.027, AR-Home: p = 0.036) were observed in both groups. Significant improvement in balance ability (BBS: p = 0.0438), and mental components (SF-12v2 MCS: p = 0.017) were found in AR-Centre group, while activities of daily living (BI: p = 0.0007) was found in AR-Home group. Contact rate was reduced by 30.75-72.30% within AR-All, 0.00-60.00% within AR-Centre, and 75.00-90.00% within AR-Home. CONCLUSION: The human-machine integrated mode was effective and efficient to reduce the human rehabilitation professionals' effort while fulfilling the training goals. It eased the scarcity of manpower and reduced the contact rate during the pandemics.

Inpatient rehabilitation therapy in stroke patients with reperfusion therapy: a national prospective registry study.

BACKGROUND: Little is known about the rate of real-world inpatient rehabilitation therapy (IRT) after stroke. We aimed to determine the rate of inpatient rehabilitation therapy and its associated factors in patients who undergo reperfusion therapy in China. METHODS: This national prospective registry study included hospitalized ischemic stroke patients aged 14-99 years with reperfusion therapy between January 1, 2019, and June 30, 2020, collecting hospital-level and patient-level demographic and clinical data. IRT included acupuncture or massage, physical therapy, occupational therapy, speech therapy, and others. The primary outcome was the rate of patients receiving IRT. RESULTS: We included 209,189 eligible patients from 2191 hospitals. The median age was 66 years, and 64.2% were men. Four in five patients received only thrombolysis, and the rest 19.2% underwent endovascular therapy. The overall rate of IRT was 58.2% (95% CI, 58.0-58.5%). Differences in demographic and clinical variables existed between patients with and without IRT. The rates of acupuncture or massage, physical therapy, occupational therapy, speech therapy, and other rehabilitation interventions were 38.0%, 28.8%, 11.8%, 14.4%, and 22.9%, respectively. The rates of single and multimodal interventions were 28.3% and 30.0%, respectively. A lower likelihood of receiving IRT was associated with being 14-50 or 76-99 years old, female, from Northeast China, from Class-C hospitals, receiving only thrombolysis, having severe stroke or severe deterioration, a short length of stay, Covid-19 pandemic and having intracranial or gastrointestinal hemorrhage. CONCLUSION: Among our patient population, the IRT rate was low with limited use of physical therapy, multimodal interventions, and rehabilitation centers and varied by demographic and clinical features. The implementation of IRT remains a challenge for stroke care, warranting urgent and effective national programs to enhance post-stroke rehabilitation and the adherence to guidelines.

[Effect of rehabilitation on functionality/quality of life in stroke due to COVID-19]

Background: COVID-19 can present neurological complications of the central nervous system. Ischemic-type strokes have been reported in this population. Neurological rehabilitation participates in the functional recovery and improvement of the quality of life of these patients.

Designing Spellcasters from Clinician Perspectives: A Customizable Gesture-Based Immersive Virtual Reality Game for Stroke Rehabilitation

Developing games is time-consuming and costly. Overly clinical therapy games run the risk of being boring, which defeats the purpose of using games to motivate healing in the first place [10, 23]. In this work, we adapt and repurpose an existing immersive virtual reality (iVR) game, Spellcasters, originally designed purely for entertainment for use as a stroke rehabilitation game-which is particularly relevant in the wake of COVID-19, where telehealth solutions are increasingly needed [4]. In preparation for participatory design sessions with stroke survivors, we collaborate with 14 medical professionals to ensure Spellcasters is safe and therapeutically valid for clinical adoption. We present our novel VR sandbox implementation that allows medical professionals to customize appropriate gestures and interactions for each patient's unique needs. Additionally, we share a co-designed companion app prototype based on clinicians' preferred data reporting mechanisms for telehealth. We discuss insights about adapting and repurposing entertainment games as serious games for health, features that clinicians value, and the potential broader impacts of applications like Spellcasters for stroke management.

Monitoring Post-Stroke Fatigue, Sleep Quality and Therapy Participation during in-Patient Rehabilitation: A Feasibility Study

Background: Despite similar motor recovery of limbs in research, clinically the lower limb is observed to demonstrate greater recovery than the upper limb (UL). Understanding the relation between the post-stroke rehabilitation experience in the hospital environment and neuroplasticity and motor recovery of the UL may provide insight into how to optimize the hospital and promote recovery. Aim(s): This feasibility study aimed to collect cross-sectional data from inpatients who were clinically receiving UL motor training within a rehabilitation hospital to determine the feasibility of our protocol as well as describe the factors and potential associations between motor performance and therapy participation, fatigue, stress and sleep. Method(s): Inpatients were recruited across two rehabilitation wards;inclusion criteria were broad (stroke diagnosis and clinically identified UL motor impairment). Therapy session duration and frequencies were recorded prior to assessing sleep quality and amount over one night (Actiwatch, Phillips Respironics, USA)). Participants rated their perceived fatigue (Fatigue Severity Scale-FSS) and sleep quality (Leeds Sleep Evaluation Questionnaire-LSEQ), and overnight nursing documentation of sleep was extracted from the medical record. Motor performance was assessed via the box and block test. All data were collected across a 24h period. Result(s): N=14 participants participated (age 71+/-11y) at a mean+/-SD 32+/-23 days post-stroke and 22+/-21 days since admission to rehabilitation. Participants received motor training 10+/-3 times per week, and sessions were 51+/-18min in length. Mean+/-SD sleep duration was 9.5+/-1.9h with 1.1+/-0.7h awake-time during the night. All participants reported fatigue, with mean FSS (37+/-16), and identified issues with respect to getting to sleep as well as quality of sleep on the LSEQ. All data were feasible to collect, however COVID restrictions and bed-numbers influenced recruitment rate. Conclusion(s): Findings provide key feasibility data to better understand targetable factors to optimise the post-stroke rehabilitation experience, neuroplasticity and UL motor recovery after stroke.

A Review for Designing a Low-Cost Online Lower Limb Monitoring System of a Post-stroke Rehabilitation

The physical therapy generally requires direct assistance from therapists continuously, however, the time is very limited. Moreover, the social distancing policy in the COVID-19 pandemic period made the patient could not come to rehabilitation center for physical therapy. Remote physical therapy is suggested to reduce dependency of therapist for conducting the physical therapy. However, there is few information about the necessary parameters in lower limb monitoring of post-stroke patient. Therefore, in this paper, a review for designing a low-cost online homecare physical therapy monitoring system is proposed. Article finding had been done using online search engine Google Scholars to conclude the design of the online monitoring system. Several keywords had been used, such as “online stroke rehabilitation monitoring,” “stroke rehabilitation parameters,” “stroke monitoring Internet of Things,” and “lower limb stroke monitoring.” The results show that the necessary monitor parameters are lower limb kinematics and dynamics, which can be complimented by bio-signal data, such as EMG. The lower limb monitoring system can use IMU, muscle sensor, and footswitches to measure the necessary parameters. IMU measures the lower limb kinematics because it provides wide range of measurement. Muscle sensor, which compatible to microcontroller, measures the EMG. Lastly, the footswitches detect the gait phases, which classify the measured data for more in-depth analysis. The mentioned sensors are cheap and available in the online market of Indonesia, which is suitable to realize a low-cost lower limb monitoring system. The research finding also suggests quick and accurate feedback mechanism for improving the training quality, which the feedback is combination of therapist opinion and artificial intelligence prediction. © 2022, The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd.

ENHANCEMENT OF STROKE REHABILITATION WITH LEVODOPA (ESTRELSTUDY) - DESIGN AND PROGRESS OF THE ONGOING MULTICENTER PLACEBOCONTROLLED RANDOMIZED TRIAL

Background: In this multicenter, randomized, placebo-controlled trial we study whether Levodopa given in addition to usual rehabilitative therapies is associated with a patient-relevant enhancement of motor recovery after acute stroke. Methods: ESTREL (Enhancement of Stroke REhabilitation with Levodopa) is a multicenter, placebo-controlled randomized superiority trial. Patients with an acute ischemic or hemorrhagic stroke ≤7 days leading to a clinically meaningful hemiparesis in need of in-hospital rehabilitation are enrolled in stroke units and later transferred to experienced neurorehabilitation centers. Participants receive Levodopa 100mg/Carbidopa 25mg three times daily or matching placebo for 5 weeks in addition to standardized rehabilitative therapy. The primary outcome is the Fugl-Meyer- Motor Assessment score 3 months after randomization. We present the characteristics of the first 200 of 610 patients to be enrolled. Results: 13 certified stroke units and 13 neurorehabilitation centers are involved (“stroke-pathway-trial”). The first 200 participants had a median age of 73 [IQR 64-82] years and 43.5 % were female. 169 patients (84.5%) had ischemic stroke. At baseline, the median NIH-Stroke scale score was 8 [5-10]. Successful 3-month assessment was performed in 183 patients (91.5%);11 (5%) died, 5 (2.5%) withdrew from the study and 1 patient missed the clinical 3 months-visit due to the COVID-19 pandemic. Conclusions: The ESTREL study will provide evidence whether the additional use of Levodopa in the rehabilitation process of stroke patients is safe and effective. The ESTREL-study started successfully due to the good cooperation between acute stroke units and rehabilitation centers, as well as the high acceptance rate among patients.

EXAMINING CHANGES IN STROKE RESEARCH RECRUITMENT TRENDS PRE AND POST COVID-19

Background and aims: Covid-19 has disrupted essential stroke prevention and treatment services, stroke rehabilitation and support services and delivery of stroke research. We examine recruitment data for two stroke rehabilitation trials recruiting within a single centre in November 2019 and November 2021, to identify if/how Covid-19 impacted upon recruitment rates and processes. Both studies were managed by the same research team and comprised of comparable protocols and selection criteria. Methods: Recruitment data from the two corresponding time periods, are reported using descriptive statistics. Field notes and direct researcher experiences are used to support observations derived from the data. Results: Patients screened reduced by >40% in November 2021 compared to the same period in 2019, despite an almost 20% increase in admissions, recruitment reduced by 75%. Research staffing issues (sickness) resulted in missed recruitment data and opportunities in November 2021. There were changes in participant identification methods, resulting from restricted researcher screening within clinical areas;more remote screening, less attendance at clinical meetings and increased initiation of referrals from the clinical staff (Table 1). While the centre's clinical trials portfolio expanded between 2019 and 2021 (from 11 to 17), we noted a reduction in research co-enrolment;reasons for this are unclear, however lower recruitment rates more broadly may have contributed to this. Conclusions: Covid-19 has changed how we engage with/in clinical research. Understanding the ways in which Covid-19 has altered the research recruitment landscape will be important in the continued delivery of vital stroke research, driving clinical advancements in the field.

Rehabilitation of Upper Extremity by Telerehabilitation Combined With Exergames in Survivors of Chronic Stroke: Preliminary Findings From a Feasibility Clinical Trial.

BACKGROUND: Exergames are increasingly being used among survivors of stroke with chronic upper extremity (UE) sequelae to continue exercising at home after discharge and maintain activity levels. The use of virtual reality exergames combined with a telerehabilitation app (VirTele) may be an interesting alternative to rehabilitate the UE sequelae in survivors of chronic stroke while allowing for ongoing monitoring with a clinician. OBJECTIVE: This study aimed to determine the feasibility of using VirTele in survivors of chronic stroke at home and explore the impact of VirTele on UE motor function, quantity and quality of use, quality of life, and motivation in survivors of chronic stroke compared with conventional therapy. METHODS: This study was a 2-arm feasibility clinical trial. Eligible participants were randomly allocated to an experimental group (receiving VirTele for 8 weeks) or a control group (receiving conventional therapy for 8 weeks). Feasibility was measured from the exergame and intervention logs completed by the clinician. Outcome measurements included the Fugl-Meyer Assessment-UE, Motor Activity Log-30, Stroke Impact Scale-16, and Treatment Self-Regulation Questionnaire-15, which were administered to both groups at four time points: time point 1 (T1; before starting the intervention), time point 2 (after the intervention), time point 3 (1 month after the intervention), and time point 4 (T4; 2 months after the intervention). RESULTS: A total of 11 survivors of stroke were randomized and allocated to an experimental or a control group. At the onset of the COVID-19 pandemic, participants pursued the allocated treatment for 3 months instead of 8 weeks. VirTele intervention dose was captured in terms of time spent on exergames, frequency of use of exergames, total number of successful repetitions, and frequency of videoconference sessions. Technical issues included the loss of passwords, internet issues, updates of the system, and problems with the avatar. Overall, most survivors of stroke found the technology easy to use and useful, except for 9% (1/11) of participants. For the Fugl-Meyer Assessment-UE and Motor Activity Log-30, both groups exhibited an improvement in >50% of the participants, which was maintained over time (from time point 3 to T4). Regarding Stroke Impact Scale-16 scores, the control group reported improvement in activities of daily life (3/5, 60%), hand function (5/5, 100%), and mobility (2/5, 40%), whereas the experimental group reported varied and inconclusive results (from T1 to T4). For the Treatment Self-Regulation Questionnaire-15, 75% (3/4) of the experimental group demonstrated an increase in the autonomous motivation score (from T1 to time point 2), whereas, in the control group, this improvement was observed in only 9% (1/11) of participants. CONCLUSIONS: The VirTele intervention constitutes another therapeutic alternative, in addition to conventional therapy, to deliver an intense personalized rehabilitation program for survivors of chronic stroke with UE sequelae. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/14629.

IOT BASED STROKE REHABILITATION MONITORING SYSTEM

Stroke is a perplexing and lethal neurological condition and is the second leading cause of death worldwide. One of the severe repercussions induced by stroke is hemi paresis. It causes weakness or loss of function on one side of the body. It can be challenging to live with such a disability as it hinders normal day-to-day activities. It takes a multidisciplinary team of physicians, psychiatrists, and caretakers to treat patients suffering from this disorder. Therefore, it is of the utmost importance to constantly monitor and treat the patients to improve their chances of recovery. This process can be complicated due to patient safety concerns during a pandemic such as covid 19. It increases the risk as it increases the possibility of another stroke attack. It also decreases the treatment's effectiveness as physical contact between doctor and patients has been reduced to ensure safety from covid 19. In our work, we developed a remote IoT-based stroke monitoring system that measures the patient's movement. This data is then sent to the cloud servers, where the concerned medical professionals can remotely access them to analyze and monitor the patient's progress.

I PREDICT A RIOT: A SCOPING REVIEW OF THE USE CASES OF REHABILITATION INTERNET OF THINGS (RIOT) APPLIANCES

The Internet of things (IoT) describes the network of physical objects that are embedded with sensors, software, and other technologies for the purpose of connecting and exchanging data with other devices over the internet [1]. This ecosystem is one that has potential to be an important tool in long-term rehabilitation care and to break down physical barriers in access to care. RIoT is an incredibly relevant subject in rehabilitation medicine, especially in the context of the current COVID-19 pandemic. This scoping review was created to look at the current literature available on the application of IoT in the context of rehabilitation, charting both areas of interest and the gaps present in the research. We devised a search strategy, inclusion/exclusion criteria and a data extractionmethod according to the PRISMA-SCR guidelines. The results of this scoping review found that research into RIoT applications in clinical care is an area of increasing interest. This is especially true for stroke rehabilitation, and of the use of wearables for physiological monitoring. This review also found that gaps do remain in the field, as many projects are in the early stages of development and clinical feasibility is still unknown due to small study sizes.

Stroke Recovery During the COVID-19 Pandemic: A Position Paper on Recommendations for Rehabilitation.

Health care delivery shifted and adapted with the COVID-19 pandemic caused by the novel severe acute respiratory syndrome coronavirus 2. Stroke care was negatively affected across the care continuum and may lead to poor community living outcomes in those who survived a stroke during the ongoing pandemic. For instance, delays in seeking care, changes in length of stays, and shifts in discharge patterns were observed during the pandemic. Those seeking care were younger and had more severe neurologic effects from stroke. Increased strain was placed on caregivers and public health efforts, and community-wide lockdowns, albeit necessary to reduce the spread of COVID-19, had detrimental effects on treatment and recommendations to support community living outcomes. The American Congress of Rehabilitation Medicine Stroke Interdisciplinary Special Interest Group Health and Wellness Task Force convened to (1) discuss international experiences in stroke care and rehabilitation and (2) review recently published literature on stroke care and outcomes during the pandemic. Based on the findings in the literature, the task force proposes recommendations and interdisciplinary approaches at the (1) institutional and societal level; (2) health care delivery level; and (3) individual and interpersonal level spanning across the care continuum and into the community.