Evaluation of the Victorian Healthy Homes Program: protocol for a randomised controlled trial.

INTRODUCTION: The evaluation of the Victorian Healthy Homes Program (VHHP) will generate evidence about the efficacy and cost-effectiveness of home upgrades to improve thermal comfort, reduce energy use and produce health and economic benefits to vulnerable households in Victoria, Australia. METHODS AND ANALYSIS: The VHHP evaluation will use a staggered, parallel group clustered randomised controlled trial to test the home energy intervention in 1000 households. All households will receive the intervention either before (intervention group) or after (control group) winter (defined as 22 June to 21 September). The trial spans three winters with differing numbers of households in each cohort. The primary outcome is the mean difference in indoor average daily temperature between intervention and control households during the winter period. Secondary outcomes include household energy consumption and residential energy efficiency, self-reported respiratory symptoms, health-related quality of life, healthcare utilisation, absences from school/work and self-reported conditions within the home. Linear and logistic regression will be used to analyse the primary and secondary outcomes, controlling for clustering of households by area and the possible confounders of year and timing of intervention, to compare the treatment and control groups over the winter period. Economic evaluation will include a cost-effectiveness and cost-benefit analysis. ETHICS AND DISSEMINATION: Ethical approval was received from Victorian Department of Human Services Human Research Ethics Committee (reference number: 04/17), University of Technology Sydney Human Research Ethics Committee (reference number: ETH18-2273) and Australian Government Department of Veterans Affairs. Study results will be disseminated in a final report and peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12618000160235.

Mood and Cognitive Trajectories Over the First Year after Mild Ischemic Stroke.

OBJECTIVES: Cognitive and mood dysfunction are major contributors to post-stroke disability. The longer-term trajectories of mood and cognition post-stroke remain unclear, as do which cognitive domains decline, improve, or remain stable after stroke, and in which patients. We aimed to characterize the cognitive trajectories of mild ischemic stroke survivors over one year compared to stroke-free controls, and to investigate whether symptoms of anxiety and depression were associated with cognitive function. MATERIALS AND METHODS: All participants were tested with a neuropsychological test battery at 3-months and 12-months post-stroke, assessing attention/processing speed, memory, visuospatial function, executive function, and language. Anxiety and depression symptomatology were also assessed at both timepoints. RESULTS: Stroke participants (N=126, mean age 68.44 years ±11.83, 87 males, median [Q1, Q3] admission NIHSS=2 [1, 4]) performed worse on cognitive tests and endorsed significantly higher depression and anxiety symptomatology than controls (N=40, mean age=68.82 years ±6.33, 25 males) at both timepoints. Mood scores were not correlated with cognitive performance. Stroke participants' scores trended higher across cognitive domains from 3- to 12-months but statistically significant improvement was only observed on executive function tasks. CONCLUSION: Stroke participants performed significantly worse than controls on all cognitive domains following mild ischemic stroke. Stroke participants only exhibited statistically significant improvement on executive function tasks between 3- and 12- months. Whilst anxiety and depression symptoms were higher in stroke participants, this was not correlated with cognitive performance. Further studies are needed to understand factors underlying cognitive recovery and decline after stroke.

The stroke exercise preference inventory is feasible to use in a community rehabilitation setting.

Exploring exercise preferences may help people to adhere to exercise programs by promoting customized programs to suit the person's choices and concerns. We investigated if the Stroke Exercise Preference Inventory, a questionnaire designed to explore stroke survivors' preferences for exercise and potential barriers, was feasible to use, and whether it assisted physiotherapists to design ongoing exercise programs in a mixed diagnostic convenience sample attending community rehabilitation. Physiotherapy staff interviewed 42 participants, and sought feedback about the questionnaire. Participant responses for exercise preferences and perceived barriers were then summarized. The questionnaire was quick to administer, readily understood, and considered relevant to consider when discussing options for exercise. Clinicians reported the questionnaire was useful for 48% (20/42) of participants, as it engaged the participant, clarified their preferences and allowed problem solving of potential barriers to exercise. Participants expressed strong preferences to be challenged, and to receive supervision and support. Preferences regarding environmental and social context of exercise varied widely. Difficulty getting started was the most common barrier reported. The Stroke Exercise Preference Inventory was feasible to use with a mixed diagnostic group during community rehabilitation, and provides structure to explore preferences and barriers to exercise. It remains to be tested whether use of the questionnaire promotes adherence to exercise programs.

Neurodegeneration Over 3 Years Following Ischaemic Stroke: Findings From the Cognition and Neocortical Volume After Stroke Study.

Background: Stroke survivors are at high risk of dementia, associated with increasing age and vascular burden and with pre-existing cognitive impairment, older age. Brain atrophy patterns are recognised as signatures of neurodegenerative conditions, but the natural history of brain atrophy after stroke remains poorly described. We sought to determine whether stroke survivors who were cognitively normal at time of stroke had greater total brain (TBV) and hippocampal volume (HV) loss over 3 years than controls. We examined whether stroke survivors who were cognitively impaired (CI) at 3 months following their stroke had greater brain volume loss than cognitively normal (CN) stroke participants over the next 3 years. Methods: Cognition And Neocortical Volume After Stroke (CANVAS) study is a multi-centre cohort study of first-ever or recurrent adult ischaemic stroke participants compared to age- and sex-matched community controls. Participants were followed with MRI and cognitive assessments over 3 years and were free of a history of cognitive impairment or decline at inclusion. Our primary outcome measure was TBV change between 3 months and 3 years; secondary outcomes were TBV and HV change comparing CI and CN participants. We investigated associations between group status and brain volume change using a baseline-volume adjusted linear regression model with robust standard error. Results: Ninety-three stroke (26 women, 66.7 ± 12 years) and 39 control participants (15 women, 68.7 ± 7 years) were available at 3 years. TBV loss in stroke patients was greater than controls: stroke mean (M) = 20.3 cm3 ± SD 14.8 cm3; controls M = 14.2 cm3 ± SD 13.2 cm3; [adjusted mean difference 7.88 95%CI (2.84, 12.91) p-value = 0.002]. TBV decline was greater in those stroke participants who were cognitively impaired (M = 30.7 cm3; SD = 14.2 cm3) at 3 months (M = 19.6 cm3; SD = 13.8 cm3); [adjusted mean difference 10.42; 95%CI (3.04, 17.80), p-value = 0.006]. No statistically significant differences in HV change were observed. Conclusions: Ischaemic stroke survivors exhibit greater neurodegeneration compared to stroke-free controls. Brain atrophy is greater in stroke participants who were cognitively impaired early after their stroke. Early cognitive impairment was associated greater subsequent atrophy, reflecting the combined impacts of stroke and vascular brain burden. Atrophy rates could serve as a useful biomarker for trials testing interventions to reduce post-stroke secondary neurodegeneration. Clinical Trail Registration: http://www.clinicaltrials.gov, identifier: NCT02205424.

Cognitive Recovery After Stroke: A Meta-analysis and Metaregression of Intervention and Cohort Studies.

BACKGROUND: Cognition affects poststroke recovery, but meta-analyses of cognition have not yet provided a comparison of observational and intervention evidence. OBJECTIVE: To describe the trajectory of poststroke cognition and the factors that moderate it across intervention and observational cohorts. METHODS: Six databases were searched up to January 2020. Studies describing quantitative changes in cognition in adults poststroke were included. Interventions were classified into pharmacological, therapist-led, nonroutine/alternative, and usual care. Summary estimates were compared via hierarchical mixed-effects models. Age, recovery stage, stroke etiology, cognitive domain targeted in studies, and intervention types were investigated as moderators of cognition. Recovery stage and intervention were further analyzed in a multiplicative metaregression model. RESULTS: A total of 43 intervention trials and 79 observation cohorts involving 28 222 stroke participants were included. Heterogeneity was significant (τ2 = 0.09; CI = 0.01-0.21, P < .001) with no evidence of publication bias. Cognitive recovery was greater in intervention trials (g = 0.47; CI = 0.37-0.58) than observational cohorts (g = 0.28; CI = 0.20-0.36) across all moderators analyzed. Nonroutine/alternative and pharmacological trials achieved the best overall results (g = 0.57, CI = 0.42-0.73, and g = 0.52, CI = 0.30-0.74, respectively), followed by therapist-led (g = 0.46; CI = 0.17-0.74), and usual care (g = 0.28; CI = 0.11-0.45) interventions. Medium recovery effects (ie, g ≥ 0.5) were observed in examining first-ever stroke, executive function, visuo-perceptual, consciousness, and psychomotor skills, 61 to 180 days poststroke, in participants aged 65 to 70 years. CONCLUSION: Cognitive recovery is possible using different controlled interventions in all recovery stages, with smaller benefits ≥2 years poststroke. Longer-term studies are needed to determine the role of nonroutine/alternative therapies and the association between cognitive recovery and performance in everyday activities.

Hippocampal Volume and Amyloid PET Status Three Years After Ischemic Stroke: A Pilot Study.

Hippocampal atrophy is seen in many neurodegenerative disorders and may be a cardinal feature of vascular neurodegeneration. We examined hippocampal volume (HV) in a group of ischemic stroke survivors with amyloid 18F-NAV4694 PET imaging three years after stroke. We compared HV between the amyloid-positive (n = 4) and amyloid-negative (n = 29) groups, and associations with co-morbidities using Charlson Comorbidity Indices and multi-way ANOVA. Amyloid status was not associated with verbal or visual delayed free recall memory indices or cognitive impairment. We found no association between amyloid status and HV in this group of ischemic stroke survivors.

Sedentary time and activity behaviors after stroke rehabilitation: Changes in the first 3 months home.

BACKGROUND: Sedentary time is prevalent following stroke, limiting functional improvement, and increasing cardiovascular risk. At discharge we examined: 1) change in sedentary time and activity over the following 3 months' and 2) physical, psychological or cognitive factors predicting any change. A secondary aim examined cross-sectional associations between factors and activity at 3 months. METHODS: People with stroke (n = 34) were recruited from two rehabilitation units. An activity monitor (ActivPAL3) was worn for 7 days during the first week home and 3 months later. Factors examined included physical, psychological, and cognitive function. Linear mixed models (adjusted for waking hours) were used to examine changes in sedentary time, walking, and step count over time. Interaction terms between time and each factor were added to the model to determine if they modified change over time. Linear regression was performed to determine factors cross-sectionally associated with 3-month activity. RESULTS: ActivPAL data were available at both time points for 28 (82%) participants (mean age 69 [SD 12] years). At 3 months, participants spent 39 fewer minutes sedentary (95%CI -70,-8 p = .01), 21 minutes more walking (95%CI 2,22 p = .02) and completed 1112 additional steps/day (95%CI 268,1956 p = .01), compared to the first week home. No factors predicted change in activity. At 3 months, greater depression (ß 22 mins (95%CI 8,36) p = .004) and slower gait speed (ß - 43 mins 95%CI -59,-27 p ≤ 0.001) were associated with more sedentary time and less walking activity, respectively. CONCLUSIONS: Sedentary time reduced and walking activity increased between discharge home and 3 months later. Interventions targeting mood and physical function may warrant testing to reduce sedentary behavior 3 months following discharge.

Determining Maximal Tolerable Aerobic Training Intensity in the Acute Phase after Stroke: a Novel Dose Ranging Trial Protocol.

INTRODUCTION: There is strong evidence that cardiorespiratory fitness (CRF) training improves fitness and mobility after stroke. Despite the large number of studies, the most efficacious dose is yet to be determined. Furthermore, the safety of early post-stroke training, while theoretically beneficial, remains uncertain. The aim of this study is to determine the maximum safe and tolerable intensity of CRF training early post-stroke. METHODS: This is a stratified (low to moderate exercise capacity), Phase I, 5+5 dose ranging trial protocol. Participants will be recruited within one month post-stroke and stratified by their exercise-capacity (i.e. low and moderate capacity). Cohorts of five participants will perform 12 interval-based training sessions for four-weeks at a pre-determined target-intensity. The intensity will increase in each consecutive cohort, in each stratum according to pre-defined rules until the maximum safe and tolerable intensity is reached, as determined by the occurrence of dose-limiting events and occurrence of adverse events. Dose-limiting events are defined as symptoms indicative of over-training including pain and inability to perform usual activities. STUDY OUTCOME: Maximum safe and tolerable intensity of CRF training in stroke survivors with low and moderate exercise capacity. DISCUSSION: This study is a first step in the systematic development of a CRF training intervention. We believe similar dose ranging designs may be useful for development of other rehabilitation interventions in different study populations.

The AVERT MoCA Data: Scoring Reliability in a Large Multicenter Trial.

The Montreal Cognitive Assessment (MoCA) is a widely used cognitive screening tool in stroke. As scoring the visuospatial/executive MoCA items involves subjective judgement, reliability is important. Analyzing data on these items from A Very Early Rehabilitation Trial (AVERT), we compared the original scoring of assessors (n = 102) to blind scoring by a single, independent rater. In a sample of scoresheets from 1,119 participants, we found variable interrater reliability. The match between original assessors and the independent rater was the following: trail-making 97% (κ = 0.94), cube copy 90% (κ = 0.80), clock contour 92% (κ = 0.49), clock numbers 89% (κ = 0.67), and clock hands 72% (κ = 0.46). For all items except clock contour, the independent rater was "stricter" than the original assessors. Discrepancies were typically errors in original scoring, rather than borderline differences in subjective judgement. In trials that include the MoCA, researchers should emphasize scoring rules to assessors and implement independent data checking, especially for clock hands, to maximize accuracy.

Safety of Performing a Graded Exercise Test Early after Stroke and Transient Ischemic Attack.

BACKGROUND: Low cardiorespiratory fitness (CRF) is a predictor of stroke risk and poor outcome poststroke. Fitness levels are rarely assessed in the acute phase and it is unclear if it is safe for stroke survivors and people with transient ischemic attack (TIA) to perform a graded exercise test to assess fitness. OBJECTIVE: To determine if people within 14 days post stroke can safely perform a graded exercise test. DESIGN: Observational study. SETTING: Research institute. PARTICIPANTS: People with stroke or TIA admitted to an acute stroke unit. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Safety of performing a graded exercise test early post stroke. Safety outcomes were (1) occurrence of an adverse event or (2) <85% blood oxygen saturation (SpO2 ). Participants performed a graded exercise test on a recumbent stepper at a research institute <2 weeks postevent. CRF was determined by measuring peak volume of oxygen uptake (VO2peak ) using a metabolic cart. RESULTS: Twenty-nine participants were enrolled in the study (median age 69 years; interquartile range 58-75). Sixteen were diagnosed with TIA and 13 with a mild stroke. Twenty-eight participants completed the test; one participant was unable to perform the test due to back pain. The test was terminated due to standardized stopping criteria in 26 cases (5 = volitional fatigue, 6 = unable to keep required cadence, 15 = reaching 85% HRmax ), one due to safety (ie, SpO2 < 85%), and one was inadvertently terminated before stopping criteria were reached. Average CRF determined by the exercise test was low; mean VO2peak of 16.2 ± 4.5 mL/kg/min for men (n = 20) and 12.4 ± 3.6 mL/kg/min for women (n = 8). CONCLUSIONS: Determining exercise capacity early post stroke and TIA using a graded exercise test appears to be safe in patients with mild deficits. This information should be useful to plan tailored exercise programs. Further research should focus on determining safety of exercise testing in more severely affected stroke survivors.

Relationship between pre-stroke physical activity and symptoms of post-stroke anxiety and depression: An observational study.

OBJECTIVES: To explore mechanisms affecting mental health in patients with stroke. The aims were to investigate the association between pre-stroke physical activity and symptoms of anxiety and depression 3 months after stroke, and to investigate how self-reported physical activity changed from before to 3 months after the stroke. DESIGN: Secondary analyses of a prospective observational multicentre study. PATIENTS: Stroke patients from 11 Norwegian stroke units. METHODS: Symptoms of anxiety and depression were measured using the Hospital Anxiety and Depression Scale, and physical activity was assessed by self-report. Negative binomial regression was used to analyse associations. RESULTS: The analysed sample consisted of 205 patients; mean age was 74 years (standard deviation (SD) 11.5); 46% were women. Higher activity levels before stroke were associated with fewer symptoms of depression in multivariable analyses with regression coefficient of 0.84 (95% confidence interval 0.73-0.97), p = 0.015. Eighty-five (41.5%) patients reported similar activity levels before and after stroke. CONCLUSION: In this group of patients with mild symptoms of emotional distress, it seems that pre-stroke physical activity might be protective against post-stroke depression, but not anxiety. Many patients with mild-to-moderate stroke report being equally active before and after the stroke.

Longitudinal evaluation of cognition after stroke - A systematic scoping review.

BACKGROUND: Cognitive impairment affects up to 80 percent of the stroke population, however, both the available evidence about post-stroke cognition and the measures used to evaluate it longitudinally have not been well described. The aims of this systematic scoping review were: to identify and characterize studies evaluating cognition longitudinally after stroke; to summarize the cognitive instruments used and the domains they target; and to organize cognitive domains assessed using the International Classification of Functioning, Disability and Health (ICF). METHODS: We used a systematic scoping approach to search for peer-reviewed articles involving adults with stroke that evaluated cognition longitudinally. Screening of titles, abstracts, and full reports was completed independently by two reviewers, across six electronic databases (PubMed, PsycInfo, Medline, Cinahl Plus, Embase, and Web of Science). Cognitive domains were mapped to an ICF function independently by the same two reviewers, using a previously tested, standardized approach. RESULTS: A total of 5,540 records were found; 257 were included, representing a total pooled sample of 120,860 stroke survivors. Of these studies, 200 (78%) provided specific cognitive outcomes from the longitudinal evaluations, 57 (22%) reported model predictions, and 77 (30%) included interventions. Cognition was evaluated with 356 unique instruments, targeting 95 distinct cognitive domains, and 17 mental functions from the ICF. The Mini-Mental State Examination was the most frequently used instrument (117 reports, 46%). Other tools used longitudinally were the Trail Making Test (17% of reports), tests of verbal fluency (14%), the Functional Independence Measure (14%), the Montreal Cognitive Assessment (13%), the Digit Span (11%), and the Stroop test (10%). Global cognition was evaluated in 170 reports (66%), followed by higher-level cognitive functioning (29%), memory (28%), language (21%), attention (21%), and perceptual skills (14%). Studies using functional (or performance-based) cognitive assessments over time were scarce (< 1%). CONCLUSION: Our findings indicate that whilst there is a substantial number of studies available that report longitudinal evaluations of cognition after stroke, there is large variability in the measures used and the cognitive domains they target. Nonetheless, the available data for evaluation of cognition over time after stroke can be organized and described systematically.

APOE ɛ4 Carriers Show Delayed Recovery of Verbal Memory and Smaller Entorhinal Volume in the First Year After Ischemic Stroke.

BACKGROUND: The apolipoprotein E (APOE) gene ɛ4 allele is a risk factor for Alzheimer's disease and cardiovascular disease. However, its relationship with cognition and brain volume after stroke is not clear. OBJECTIVE: We compared cognition and medial temporal lobe volumes in APOEɛ4 carriers and non-carriers in the first year after ischemic stroke. METHODS: We sampled 20 APOEɛ4 carriers and 20 non-carriers from a larger cohort of 135 ischemic stroke participants in the longitudinal CANVAS study. Participants were matched on a range of demographic and stroke characteristics. We used linear mixed-effect models to compare cognitive domain z-scores (attention, processing speed, executive function, verbal and visual memory, language, visuospatial function) and regional medial temporal lobe volumes (hippocampal, entorhinal cortex) between groups at each time-point (3, 12-months post-stroke), and within groups across time-points. APOE gene single nucleotide polymorphisms (SNPs; rs7412, rs429358) were genotyped on venous blood. RESULTS: APOEɛ4 carriers and non-carriers did not differ on any demographic, clinical, or stroke variable. Carriers performed worse than non-carriers in verbal memory at 3 months post-stroke (p = 0.046), but were better in executive function at 12 months (p = 0.035). Carriers demonstrated a significant improvement in verbal memory (p = 0.012) and executive function (p = 0.015) between time-points. Non-carriers demonstrated a significant improvement in visual memory (p = 0.0005). Carriers had smaller bilateral entorhinal cortex volumes (p < 0.05), and larger right sided and contralesional hippocampal volumes, at both time-points (p < 0.05). CONCLUSION: APOE ɛ4 is associated with delayed recovery of verbal memory function and reduced entorhinal cortex volumes in the first year after ischemic stroke.

Early mobilization and quality of life after stroke: Findings from AVERT.

OBJECTIVE: To determine whether early and more frequent mobilization after stroke affects health-related quality of life. METHODS: A Very Early Rehabilitation Trial (AVERT) was an international, multicenter (56 sites), phase 3 randomized controlled trial, spanning 2006-2015. People were included if they were aged ≥18 years, presented within 24 hours of a first or recurrent stroke (ischemic or hemorrhagic), and satisfied preordained physiologic criteria. Participants were randomized to usual care alone or very early and more frequent mobilization in addition to usual care. Quality of life at 12 months was a prespecified secondary outcome, evaluated using the Assessment of Quality of Life 4D (AQoL-4D). This utility-weighted scale has scores ranging from -0.04 (worse than death) to 1 (perfect health). Participants who died were assigned an AQoL-4D score of 0. RESULTS: No significant difference in quality of life at 12 months between intervention (median 0.47, interquartile range [IQR] 0.07-0.81) and usual care (median 0.49, IQR 0.08-0.81) groups was identified (p = 0.86), nor were there any group differences across the 4 AQoL-4D domains. The same lack of group difference in quality of life was observed at 3 months. When cohort data were analyzed (both groups together), quality of life was strongly associated with acute length of stay, independence in activities of daily living, cognitive function, depressive symptoms, and anxiety symptoms (all p < 0.001). Quality of life in AVERT participants was substantially lower than population norms, and the gap increased with age. CONCLUSIONS: Earlier and more frequent mobilization after stroke did not influence quality of life. CLINICAL TRIAL REGISTRATION: anzctr.org.au; ACTRN12606000185561 CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that for people with stroke, earlier and more frequent mobilization did not influence quality of life over the subsequent year.

Television Viewing Time and Stroke Risk: Australian Diabetes Obesity and Lifestyle Study (1999-2012).

INTRODUCTION: Having a low level of physical activity is an established risk factor for stroke, but little is known about the importance of common sedentary behavior-television viewing-to stroke risk. METHODS: We conducted a retrospective analysis of data that were collected as part of the longitudinal Australian Diabetes, Obesity, and Lifestyle study. Stroke events reported during the study (between baseline assessment in 1999-2000 and April 2011) were confirmed using adjudication based on medical records. Baseline data on minutes per week spent watching television were used as the exposure variable. Other variables were collected in assessments at wave 2 (2004-05) and wave 3 (2011-2012). Univariable and multivariable logistic regression analyses were performed. RESULTS: Among the full Australian Diabetes, Obesity, and Lifestyle study population (n = 11,247), there were 153 participants with confirmed stroke during the study period, and 9207 participants with no stroke in this period. Participants who went on to have their first stroke during the study had significantly higher levels of TV viewing time at baseline than those who did not have a stroke (P = .001). This association was not present (P = .83), however, when age and sex were included in the regression model. CONCLUSION: In the Australian Diabetes, Obesity, and Lifestyle study dataset, there was no evidence that more TV viewing is independently associated with risk of stroke, although analyses may have been underpowered.

Early Mobilization After Stroke Is Not Associated With Cognitive Outcome.

Background and Purpose- We aimed to determine whether early mobilization after stroke affects subsequent cognitive function. Methods- AVERT (A Very Early Rehabilitation Trial) was an international, 56-site, phase 3 randomized controlled trial, conducted from 2006 to 2015. Participants were included if they were aged 18+, presented within 24 hours of stroke, and satisfied physiological limits for blood pressure, heart rate, and temperature. Participants were randomized to receive either usual stroke unit care or very early and more frequent mobilization in addition to usual stroke unit care. The Montreal Cognitive Assessment, scored 0 to 30, was introduced as a 3-month outcome during 2008. Results- Of the 2104 patients included in AVERT, 317 were assessed before the Montreal Cognitive Assessment's introduction. Of the remaining 1787, 1189 (66.5%) had complete Montreal Cognitive Assessment data, 456 (25.5%) had partially or completely missing data, 136 (7.6%) had died, and 6 (0.3%) were lost to follow-up. In surviving participants with complete data, adjusting for age and stroke severity, total Montreal Cognitive Assessment score was no different in the intervention (n=595; median, 23; interquartile range, 19-26; mean, 21.9; SD, 5.9) and usual care (n=594; median, 23; interquartile range, 19-26; mean, 21.8; SD, 5.9) groups ( P=0.68). Conclusions- Exposure to earlier and more frequent mobilization in the acute stage of stroke does not influence cognitive outcome at 3 months. This stands in contrast to the primary outcome from AVERT (modified Rankin Scale), where the intervention group had less favorable outcomes than controls. Clinical Trial Registration- URL: https://www.anzctr.org.au . Unique identifier: ACTRN12606000185561.

Investigating post-stroke fatigue: An individual participant data meta-analysis.

OBJECTIVE: The prevalence of post-stroke fatigue differs widely across studies, and reasons for such divergence are unclear. We aimed to collate individual data on post-stroke fatigue from multiple studies to facilitate high-powered meta-analysis, thus increasing our understanding of this complex phenomenon. METHODS: We conducted an Individual Participant Data (IPD) meta-analysis on post-stroke fatigue and its associated factors. The starting point was our 2016 systematic review and meta-analysis of post-stroke fatigue prevalence, which included 24 studies that used the Fatigue Severity Scale (FSS). Study authors were asked to provide anonymised raw data on the following pre-identified variables: (i) FSS score, (ii) age, (iii) sex, (iv) time post-stroke, (v) depressive symptoms, (vi) stroke severity, (vii) disability, and (viii) stroke type. Linear regression analyses with FSS total score as the dependent variable, clustered by study, were conducted. RESULTS: We obtained data from 14 of the 24 studies, and 12 datasets were suitable for IPD meta-analysis (total n = 2102). Higher levels of fatigue were independently associated with female sex (coeff. = 2.13, 95% CI 0.44-3.82, p = 0.023), depressive symptoms (coeff. = 7.90, 95% CI 1.76-14.04, p = 0.021), longer time since stroke (coeff. = 10.38, 95% CI 4.35-16.41, p = 0.007) and greater disability (coeff. = 4.16, 95% CI 1.52-6.81, p = 0.010). While there was no linear association between fatigue and age, a cubic relationship was identified (p < 0.001), with fatigue peaks in mid-life and the oldest old. CONCLUSION: Use of IPD meta-analysis gave us the power to identify novel factors associated with fatigue, such as longer time since stroke, as well as a non-linear relationship with age.

Go Home, Sit Less: The Impact of Home Versus Hospital Rehabilitation Environment on Activity Levels of Stroke Survivors.

OBJECTIVE: To examine whether change in rehabilitation environment (hospital or home) and other factors influence time spent sitting upright and walking after stroke. DESIGN: Observational study. SETTING: Two inpatient rehabilitation units and community residences following discharge. PARTICIPANTS: Participants (N=34) with stroke were recruited. MAIN OUTCOME MEASURE: An activity monitor was worn continuously for 7 days during the final week in the hospital and the first week at home. Other covariates included mood, fatigue, physical function, pain, and cognition. Linear mixed models were performed to examine the associations between the environment (exposure) and physical activity levels (outcome) in the hospital and at home. Interaction terms between the exposure and other covariates were added to the model to determine whether they modified activity with change in environment. RESULTS: The mean age of participants was 68±13 years and 53% were male. At home, participants spent 45 fewer minutes sitting (95% CI -84.8, -6.1; P=.02), 45 more minutes upright (95% CI 6.1, 84.8; P=.02), and 12 more minutes walking (95% CI 5, 19; P=.001), and completed 724 additional steps (95% CI 199, 1250; P=.01) each day compared to in the hospital. Depression at discharge predicted greater sitting time and less upright time (P=.03 respectively) at home. CONCLUSIONS: Environmental change from hospital to home was associated with reduced sitting time and increased the time spent physically active, though depression modified this change. The rehabilitation environment may be a target to reduce sitting and promote physical activity.

Validity of Multisensor Array for Measuring Energy Expenditure of an Activity Bout in Early Stroke Survivors.

Introduction. Stroke survivors use more energy than healthy people during activities such as walking, which has consequences for the way exercise is prescribed for stroke survivors. There is a need for wearable device that can validly measure energy expenditure (EE) of activity to inform exercise prescription early after stroke. We aimed to determine the validity and reliability of the SenseWear-Armband (SWA) to measure EE and step-counts during activity <1 month after stroke. Materials and Methods. EE was measured using the SWA and metabolic cart and steps-counts were measured using the SWA and direct observation. Based on walking ability, participants performed 2x six-minute walks or repeated sit-to-stands. Concurrent validity and test-retest reliability were determined by calculating intraclass and concordance correlation coefficients. Results and Discussion. Thirteen participants walked; nine performed sit-to-stands. Validity of the SWA measuring EE for both activities was poor (ICC/CCC < 0.40). The SWA overestimates EE during walking and underestimated EE during sit-to-stands. Test-retest agreement showed an ICC/CCC of <0.40 and >0.75 for walking and sit-to-stand, respectively. However, agreement levels changed with increasing EE levels (i.e., proportional bias). The SWA did not accurately measure step-counts. Conclusion. The SWA should be used with caution to measure EE of activity of mild to moderate stroke survivors <1 month after stroke.

Lower cognitive control network connectivity in stroke participants with depressive features.

Around one-third of people develop depression following ischaemic stroke, yet the underlying mechanisms are poorly understood. Post-stroke depression has been linked to frontal infarcts, mainly lesions in the left dorsolateral prefrontal cortex (DLPFC). But depression is a network disorder that cannot be fully characterised through lesion-symptom mapping. Researchers of depression in non-stroke populations have successfully tapped into the cognitive control network (CCN) using the bilateral DLPFC as a seed, and found that CCN resting-state connectivity is reduced in even mildly depressed subjects, compared to healthy controls. Hence, we aimed to investigate the association between post-stroke depressive features and the CCN resting-state connectivity in a stroke population. We analysed DLPFC resting-state connectivity in 64 stroke participants, 20 of whom showed depressive features assessed with the Patient Health Questionnaire (PHQ-9) at 3 months after stroke. We directly compared groups showing symptoms of depression with those who did not, and performed a regression with PHQ-9 scores in all participants, controlling for age, gender, lesion volume and stroke severity. Post-stroke depression was associated with lower connectivity between the left DLPFC and the right supramarginal gyrus (SMG) in both group and regression analyses. Neither the seed nor the results overlapped with stroke lesions. These findings confirm an important role of the left DLPFC in post-stroke depression, but now show that large-scale network disruptions following stroke associated with depressive features occur without lesions in the DLPFC.