Marilyn MacKay-Lyons

In accelerometer-based measurement, the inclusion of upper extremity (UE) activity during walking can overestimate real-world functional UE use in people post-stroke. This study introduces a comprehensive, accelerometer-based approach to examining real-world UE use, including the contribution of UE activity during walking, and compares UE use during walking versus ADL-based activities. People with subacute stroke wore bilateral wrist and ankle inertial measurement units (IMU) for one week (24 h/day). Agreement between UE-Total, UE-Continuous Walking and UE-ADL measures were assessed using Bland–Altman analyses. Variables were modeled using linear regression to explore step count, mobility aid use and UE motor impairment as predictors of IMU measures of real-world UE use. Agreement between UE-Total and UE-ADL measures showed minimal bias. Differences between UE-Continuous Walking and UE-ADL varied by mobility aid. UE-Continuous Walking was associated with increased UE activity and relatively greater paretic arm use compared with UE-ADL. Across UE-Continuous Walking and UE-ADL, step count was the strongest predictor of real-world UE use. UE activity during continuous walking exhibits different use patterns as compared to ADL-based activity. Accordingly, separating continuous walking-related UE activity from ADL-based UE use may improve clinical interpretation of IMU measures of real-world UE use in individuals with subacute stroke.

In accelerometer-based measurement, inclusion of upper extremity (UE) activity during walking can overestimate real-world functional UE use in people post-stroke. This study introduces a comprehensive, accelerometer-based approach to examine real-world UE use, including contribution of UE activity during walking, and compares UE use during walking versus ADL-based activities. People with subacute stroke wore bilateral wrist and ankle inertial measurement units (IMU) for one week (24 hrs/day). Agreement between UE-Total, UE-Continuous Walking, and UE-ADL measures were assessed using Bland–Altman analyses. Variables were modeled using linear regression to explore step count, mobility aid use and UE motor impairment as predictors of IMU measures of real-world UE use. Agreement between UE-Total and UE-ADL measures showed minimal bias. Differences between UE-Continuous Walking and UE-ADL varied by mobility aid. UE-Continuous Walking was associated with increased UE activity and relatively greater paretic arm use compared with UE-ADL. Across UE-Continuous Walking and UE-ADL, step count was the strongest predictor of real-world UE use. UE activity during continuous walking exhibits different use patterns as compared to ADL-based activity. Accordingly, separating continuous walking-related UE activity from ADL-based UE use may improve clinical interpretation of IMU measures of real-world UE use in individuals with subacute stroke.

Background: Corticospinal excitability (CSE) is a surrogate measure of neuroplasticity within the corticospinal tract measured with transcranial magnetic stimulation (TMS). A single bout of high-intensity interval training (HIIT) and moderate-intensity continuous training (MICT) cardiovascular exercise (CE) have been both demonstrated to transiently augment CSE in people with stroke. However, the effect of multiple sessions of CE and exercise intensity is unknown. Objectives: We conducted a randomized controlled trial (NCT03614585) to examine the effect of a HIIT vs. MICT CE program on CSE measures obtained using TMS applied on the ipsilesional (ILH) and contralesional (CLH) hemispheres. Methods: Fifty-six individuals with cortical and/or subcortical stroke lesions in the chronic phase of stroke recovery (>6 months) were randomly assigned to a 12-week HIIT (n = 28) or MICT (n = 28) program. CSE measures were obtained at baseline and post-intervention. Linear mixed model analyses were conducted to compare changes in CSE measures and their respective interhemispheric ratios. Results: CSE changes were not significantly different between HIIT and MICT but exploratory analyses showed that, when analyzed together, both groups increased resting motor evoked potential (MEP) amplitude ( P = .003), decreased resting motor threshold (rMT) ( P = .030), and reduced intracortical facilitation (ICF) ( P = .049) in the ILH. No CSE changes in the CLH were observed. HIIT and MICT rebalanced interhemispheric rMT ( P = .020) and ICF ratios ( P = .040), and increased resting MEP amplitude ratio ( P = .020). Conclusions: Chronic CE increases excitatory ILH CSE measures and reduces interhemispheric imbalances but intensity does not have a moderating effect. More studies are needed to determine the functional relevance of exercise-induced changes in CSE in post-stroke recovery.

Background: Upper limb activity following stroke is low, which may limit recovery. We investigated whether a virtually-delivered upper limb program, that included a wearable device with reach-to-grasp feedback, would increase upper limb activity after stroke. Methods: This was a parallel-group, assessor-blinded, randomized control trial conducted at 6 sites across 5 provinces of the CanStroke Recovery Trials Platform between 2020 to 2022. Participants (n = 73) were community-living, less than 1 year post stroke, and had residual arm movement and upper limb use limitations. Participants were randomized via a central web-based randomization service to receive a virtually delivered program (Virtual Arm Boot Camp [V-ABC], n = 36) or waitlist control (n = 37) receiving usual care. V-ABC consisted of a home exercise program, feedback from a wrist-worn device to monitor reach-to-grasp counts, and 6 virtual sessions with a trained therapist over 3 weeks. The primary outcome was the average daily reach-to-grasp counts over 3 days at 4 weeks post baseline assessment. Secondary outcomes included upper limb function, self-reported use, and quality of life. Within-subject changes between pre, post treatment, and 2 months follow up for all participants were also examined as a tertiary analysis. Results: The V-ABC group demonstrated greater average daily reach-to-grasp counts (primary outcome) at 4 weeks compared to control (mean difference = 368, 95% confidence interval = 6-730, P = .046). Conclusions: This study provided evidence that a virtually delivered upper limb program that consists of exercise, feedback from a wearable device, and therapist support can increase real-world upper limb activity following stroke. Clinical Trial Registration: NCT04232163.

BACKGROUND: Limited evidence supports the effects of short-interval high-intensity interval training (HIIT) for improving cardiorespiratory fitness (V̇O ₂ peak) after stroke. We aimed to compare the effects of 12 weeks of short-interval HIIT versus moderate-intensity continuous training (MICT) on V̇O ₂ peak, cardiovascular risk factors, and mobility outcomes among individuals ≥6 months poststroke. METHODS: This study was a multi-site, 12-week randomized controlled trial (NCT03614585) with an 8-week follow-up. Participants were randomized into 3 d/wk of HIIT (10×1 minute 80%–100% heart rate reserve interspersed with 1 minute 30% heart rate reserve [19 minutes]) or MICT (20–30 minutes 40%–60% heart rate reserve). Secondary outcomes of the trial, including V̇O ₂ peak, cardiovascular risk factors (carotid-femoral pulse wave velocity, blood pressure, and waist-hip ratio), and mobility (6-minute walk test, 10 m gait speed), were reported. Linear mixed model analyses with a group×study time point interaction evaluated between-group differences. RESULTS: Of the 305 potential participants, 82 consented (mean [SD] age 64.9 [9.3] years, 32 females [39%], 1.8 [1.2] years poststroke) and were randomized to HIIT (n=42, mean [SD] baseline V̇O ₂ peak 17.3 [5.9] mL/kg·min) or MICT (n=40, mean [SD] baseline V̇O ₂ peak 17.2 [6.0] mL/kg·min). Participants attended 82% of visits (n=2417/2952). No adverse events occurred during the study period. A significant group×study time point interaction was found (χ ² =8.46; P =0.015) for V̇O ₂ peak at 12 weeks (mean difference, 1.81 [95% CI, 0.58–3.04]; P =0.004) whereby the HIIT group had greater gains in V̇O ₂ peak (∆3.52 mL/kg·min [95% CI, 2.47–4.57]; P P =0.001). There was no between-group difference in V̇O ₂ peak (mean difference, 1.08 [95% CI, −0.26 to 2.42]; P =0.11) at 8-week follow-up. No group×study time point interactions were found for cardiovascular risk factors or mobility outcomes. CONCLUSIONS: Short-interval HIIT may be an effective alternative to MICT for improving V̇O ₂ peak at 12 weeks postintervention. REGISTRATION: URL: https://clinicaltrials.gov ; Unique identifier: NCT03614585.

Background and Purpose: While underutilized, poststroke administration of the 10-m walk test (10mWT) and 6-minute walk test (6MWT) can improve care and is considered best practice. We aimed to evaluate provision of a toolkit designed to increase use of these tests by physical therapists (PTs). Methods: In a before-and-after study, 54 PTs and professional leaders in 9 hospitals were provided a toolkit and access to a clinical expert over a 5-month period. The toolkit comprised a guide, smartphone app, and video, and described how to set up walkways, implement learning sessions, administer walk tests, and interpret and apply test results clinically. The proportion of hospital visits for which each walk test score was documented at least once (based on abstracted health records of ambulatory patients) were compared over 8-month periods pre- and post-intervention using generalized mixed models. Results: Data from 347 and 375 pre- and postintervention hospital visits, respectively, were analyzed. Compared with preintervention, the odds of implementing the 10mWT were 12 times greater (odds ratio [OR] = 12.4, 95% confidence interval [CI] 5.8, 26.3), and of implementing the 6MWT were approximately 4 times greater (OR = 3.9, 95% CI 2.3, 6.7), post-intervention, after adjusting for hospital setting, ambulation ability, presence of aphasia and cognitive impairment, and provider-level clustering. Unadjusted change in the percentage of visits for which the 10mWT/6MWT was documented at least once was smallest in acute care settings (2.0/3.8%), and largest in inpatient and outpatient rehabilitation settings (28.0/19.9% and 29.4/23.4%, respectively). Discussion and Conclusions: Providing a comprehensive toolkit to hospitals with professional leaders likely contributed to increasing 10mWT and 6MWT administration during inpatient and outpatient stroke rehabilitation. Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A390).

Background: Encouraging upper limb use and increasing intensity of practice in rehabilitation are two important goals for optimizing upper limb recovery post stroke. Feedback from novel wearable sensors may influence practice behaviour to promote achieving these goals. A wearable sensor can potentially be used in conjunction with a virtually monitored home program for greater patient convenience, or due to restrictions that preclude in-person visits, such as COVID-19. This trial aims to (1) determine the efficacy of a virtual behaviour change program that relies on feedback from a custom wearable sensor to increase use and function of the upper limb post stroke; and (2) explore the experiences and perceptions of using a program coupled with wearable sensors to increase arm use from the perspective of people with stroke. Methods: This mixed-methods study will utilize a prospective controlled trial with random allocation to immediate or 3-week delayed entry to determine the efficacy of a 3-week behaviour change program with a nested qualitative description study. The intervention, the Virtual Arm Boot Camp (V-ABC) features feedback from a wearable device, which is intended to increase upper limb use post stroke, as well as 6 virtual sessions with a therapist. Sixty-four adults within 1-year post stroke onset will be recruited from seven rehabilitation centres. All outcomes will be collected virtually. The primary outcome measure is upper limb use measured by grasp counts over 3 days from the wearable sensor (TENZR) after the 3-week intervention. Secondary outcomes include upper limb function (Arm Capacity and Movement Test) and self-reported function (Hand Function and Strength subscale from the Stroke Impact Scale). Outcome data will be collected at baseline, post-intervention and at 2 months retention. The qualitative component will explore the experiences and acceptability of using a home program with a wearable sensor for increasing arm use from the point of view of individuals with stroke. Semi-structured interviews will be conducted with participants after they have experienced the intervention. Qualitative data will be analysed using content analysis. Discussion: This study will provide novel information regarding the efficacy and acceptability of virtually delivered programs to improve upper extremity recovery, and the use of wearable sensors to assist with behaviour change. Trial registration: ClinicalTrials.govNCT04232163. January 18, 2020.

Background: Non-disabling stroke (NDS) and transient ischemic attack (TIA) herald the possibility of future, more debilitating vascular events. Evidence is conflicting about potency of exercise and education in reducing risk factors for second stroke. Methods: Three-site, single-blinded, randomized controlled trial with 184 participants 2peak) was measured at baseline, post-intervention, 12-month assessments. Results: Significant between-group differences at post-intervention favored PREVENT group over UC: DBPrest (mean difference [MD]: −3.2 mmHg, 95% confidence interval [CI]: −6.3, −.2, P = .04) and LDL-C (MD: −.31 mmol/L, 95% CI: −.42, −.20, P = .02). Trends of improvement in PREVENT group were noted in several variables between baseline and 6-month follow-up but not sustained at 12-month follow-up. Of note, VO₂ peak did not change over time in either group. Conclusion: Impact of PREVENT on vascular risk factor reduction was more modest than anticipated, possibly because several outcome variables approximated normative values at baseline and training intensity may have been sub-optimal. Further investigation is warranted to determine when exercise and education programs are viable adjuncts to pharmaceutical management for reduction of risk factors for second stroke. Clinical Trial Registration-URL: http://www.clinicaltrials.gov . Unique identifier: #NCT00885456

Background. The COVID-19 pandemic attributable to the severe acute respiratory syndrome virus (SARS-CoV-2) has had a significant and continuing impact across all areas of healthcare including stroke. Individuals post-stroke are at high risk for infection, disease severity, and mortality after COVID-19 infection. Exercise stroke rehabilitation programs remain critical for individuals recovering from stroke to mitigate risk factors and morbidity associated with the potential long-term consequences of COVID-19. There is currently no exercise rehabilitation guidance for people post-stroke with a history of COVID-19 infection. Purpose. To (1) review the multi-system pathophysiology of COVID-19 related to stroke and exercise; (2) discuss the multi-system benefits of exercise for individuals post-stroke with suspected or confirmed COVID-19 infection; and (3) provide clinical considerations related to COVID-19 for exercise during stroke rehabilitation. This article is intended for healthcare professionals involved in the implementation of exercise rehabilitation for individuals post-stroke who have suspected or confirmed COVID-19 infection and non-infected individuals who want to receive safe exercise rehabilitation. Results. Our clinical considerations integrate pre-COVID-19 stroke (n = 2) and COVID-19 exercise guidelines for non-stroke populations (athletic [n = 6], pulmonary [n = 1], cardiac [n = 2]), COVID-19 pathophysiology literature, considerations of stroke rehabilitation practices, and exercise physiology principles. A clinical decision-making tool for COVID-19 screening and eligibility for stroke exercise rehabilitation is provided, along with key subjective and physiological measures to guide exercise prescription. Conclusion. We propose that this framework promotes safe exercise programming within stroke rehabilitation for COVID-19 and future infectious disease outbreaks.

Objective: The iWalk study showed significant increase in use of the 10-Meter Walk Test (10MWT) and 6-Minute Walk Test (6MWT) poststroke following provision of a toolkit. This paper examined the influence of contextual circumstances on use of the toolkit and implementation strategy across acute care and inpatient and outpatient rehabilitation settings.Methods: A theory-based toolkit and implementation strategy was designed to support guideline recommendations to use standardized tools for evaluation of walking, education, and goal-setting poststroke. The toolkit comprised a mobile app, video, and educational guide outlining instructions for 3 learning sessions. After completing learning sessions, 33 physical therapists and 7 professional leaders participated in focus groups or interviews. As part of a realist evaluation, the study compared and synthesized site-specific context-mechanism-outcome descriptions across sites to refine an initial theory of how the toolkit would influence practice.Results: Analysis revealed 3 context-mechanism-outcomes: (1) No onsite facilitator? No practice change in acute care: Without an onsite facilitator, participants lacked authority to facilitate and coordinate the implementation strategy; (2) Onsite facilitation fostered integration of select practices in acute care: When onsite facilitation occurred in acute care, walk test administration and use of reference values for patient education were adopted variably with high functioning patients; (3) Onsite facilitation fostered integration of most practices in rehabilitation settings: When onsite facilitation occurred, many participants incorporated 1 or both tests to evaluate and monitor walking capacity, and reference values were applied for inpatient and outpatient education and goal setting. Participants preferentially implemented the 10MWT over the 6MWT because set-up and administration were easier and a greater proportion of patients could walk 10 m.Conclusion: Findings underscore contextual factors and activities essential to eliciting change in assessment practice in stroke rehabilitation across care settings.Impact: This study shows that to foster recommended walking assessment practices, an onsite facilitator should be present to enable learning sessions and toolkit use.