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INTRODUCTION: The evidence on the utility and effectiveness of rehabilitation interventions delivered via telerehabilitation is growing rapidly. Telerehabilitation is expected to have a key role in rehabilitation in the future.

AIM: The aim of this evidence-based position paper (EBPP) is to improve PRM physicians' professional practice in telerehabilitation to be delivered to improve functioning and to reduce activity limitations and/or participation restrictions in individuals with a variety of disabling health conditions.

METHODS: To produce recommendations for PRM physicians on telerehabilitation, a systematic review of the literature and a consensus procedure by means of a Delphi process have been performed involving the delegates of all European countries represented in the UEMS PRM Section. RESULTS: The systematic literature review is reported together with the 32 recommendations resulting from the Delphi procedure.

CONCLUSIONS: It is recommended that PRM physicians deliver rehabilitation services remotely, via digital means or using communication technologies to eligible individuals, whenever required and feasible in a variety of health conditions in favor of the patient and his/her family, based on evidence of effectiveness and in compliance with relevant regulations. This EBPP represents the official position of the European Union through the UEMS PRM Section and designates the professional role of PRM physicians in telerehabilitation.

Objective: To investigate whether high-intensity lower extremity constraint-induced movement therapy can improve balance, leg strength, and dual-task ability.

Design: A longitudinal cohort study in a real-world outpatient clinic.

Patients: 147 community-dwelling participants in the subacute and chronic poststroke phases.

Methods: Participants received lower extremity constraint-induced movement therapy for 6 hours/day during 2 consecutive weeks, including balance, strength, and functional training. The Berg Balance Scale (BBS), Single-Leg-Stance (SLS) bilaterally, one Repetition Maximum (1RM) in a leg press, symmetry of leg strength (Diff-1RM), Timed Up and Go (TUG), and the TUG Manual test were assessed before, after, and 3 months after lower extremity constraint-induced movement therapy.

Results: Compared with preintervention data, statistically significant improvements after lower extremity constraint-induced movement therapy (p < 0.001) were demonstrated for balance with an absolute value in BBS at 1.9 points (effect size 0.38) and SLS at 2.4 s (effect size 0.24), and for leg strength at 10.2 kg (effect size 0.54) for the affected leg. Diff 1RM decreased significantly at 5.8 kg (effect size 0.39) and improvements on dual-task ability at 2.7 s were significant (effect size 0.14). The effects persisted at the 3-month follow-up.

Conclusions: High-intensity lower extremity constraint-induced movement therapy may be a feasible treatment option for middle-aged stroke patients to affect balance, leg strength, and dual-task ability positively in an out-patient clinical setting.

Background and objective: We recently reported improvements of working memory across 10 years post stroke among middle-aged individuals. However, the mechanisms underlying working-memory recovery are largely unknown. This study investigated the associations between long-term improvement of working memory and resting-state functional connectivity in two frontoparietal networks: the frontoparietal network and the dorsal attention network.

Methods: Working memory was repeatedly assessed by the Digit Span Backwards task in 21 persons, within 1 year after stroke onset and again 10 years post stroke onset. Brain functional connectivity was examined by resting state functional magnetic resonance imaging at the 10-year follow-up.

Results: A significant improvement of working memory was found among 21 persons after stroke (median age = 64) at the 10-year follow-up compared to the within-one-year assessment. The magnitude of performance improvement on the Digit Span Backwards task was significantly positively correlated with stronger brain connectivity in the frontoparietal network (r = 0.51, p = 0.018) measured at the 10-year follow-up only. A similar association was observed in the dorsal attention network (r = 0.43, p = 0.052) but not in a visual network (r = -0.17, p = 0.46) that served as a control network. The association between functional connectivity within the above-mentioned networks and Digit Span Backwards scores at 10-year after stroke was in the same direction but did not reach significance.

Conclusions: The present work relate stronger long-term performance improvement on the Digit Span Backwards task with higher integrity of frontoparietal network connectivity.

BACKGROUND: To regain the ability to walk is one of the most commonly stated goals for people who have had a stroke due to its importance in everyday life. Walking ability affects patients’ mobility, self-care, and social lives. Constraint-induced movement therapy (CIMT) is known to be effective in improving upper extremity outcomes post-stroke. However, there is insufficient evidence regarding its efficacy in improving lower extremity outcomes.AIM: To investigate whether a highly intensive CIMT for lower extremity (LE-CIMT) function post-stroke can improve motor function, functional mobility, and walking ability. Furthermore, it also aimed to investigate whether age, gender, stroke type, more-affected side, or time after stroke onset affect the efficacy of LE-CIMT on walking ability outcomes.

DESIGN: Longitudinal cohort study.

SETTING: Outpatient clinic in Stockholm, Sweden.

POPULATION: A total of 147 patients mean age 51 years (68% males; 57% right-sided hemiparesis), at the sub-acute or chronic phases post-stroke who had not previously undergone LE-CIMT.

METHODS: All patients received LE-CIMT for 6 hours per day over 2 weeks. The Fugl-Meyer Assessment (FMA) of the lower extremity, Timed Up and Go (TUG) test, Ten-Meter Walk Test (10MWT), and six-Minute Walk Test (6MWT) were used to assess functional outcomes before and directly after the 2-week treatment was complete as well at 3-month post-intervention.

RESULTS: Compared to baseline values, FMA (P<0.001), TUG (P<0.001), 10MWT (P<0.001) and 6MWT (P<0.001) scores were statistically significantly improved directly after the LE-CIMT intervention. These improvements persisted at the 3-month post-intervention follow-up. Those who completed the intervention 1-6 months after stroke onset had statistically significant larger improvements in 10MWT compared to those who received the intervention later than 6 months after stroke onset. Age, gender, stroke type, and more-affected side did not impact 10MWT results.

CONCLUSIONS: In an outpatient clinic setting, high-intensity LE-CIMT statistically significant improved motor function, functional mobility, and walking ability in middle-aged patients in the sub-acute and chronic post-stroke phases. However, studies with more robust designs need to be conducted to deepen the understanding of the efficacy of LE-CIMT.

CLINICAL REHABILITATION IMPACT: High-intensity LE-CIMT may be a feasible and useful treatment option in outpatient clinics to improve post-stroke walking ability.

Background: We have recently demonstrated significant general cognitive recovery with delayed improvement of working memory 10 years after stroke in a unique longitudinal cohort.Aim: This study investigated demographic and clinical characteristics relevant to improved cognitive functions 10-year after a first-ever stroke.   

Materials and Methods: A prospective longitudinal cohort study was carried out in 38 middle-aged (mean age =54 at stroke onset) stroke survivors. Cognition was assessed thrice at one week, seven months, and ten years after the stroke. Working memory and visuospatial function were assessed with the Digit Span and Block Design subtests, respectively. General cognition was evaluated with the Mini-Mental State Examination at the two later time points. Multivariate linear regression was used to identify the variables that may significantly predict improved cognitive functions at 10-year follow-up.

Results: We found that having a full-time job prior to the stroke, suffering an ischemic (as opposed to a hemorrhagic) stroke, and having a university education predicted significantly superior general cognitive function 10 years after stroke (R2 of 0.77, p <0.001), while working memory and visuospatial function at 1 week after stroke significantly predicted their respective functions at 10-year follow-up (R2 of 0.41, p = 0.003). 

Conclusions: Our results indicate that premorbid employment status and higher education as well as having suffered from an ischemic rather than a hemorrhagic stroke might predict superior cognitive recovery among middle-aged individuals 10 years after stroke. 

Background: Stroke is a leading cause of disability among adults worldwide. A timely structured follow-up tool to identify patients’ rehabilitation needs and develop patient-tailored rehabilitation regimens to decrease disability is largely lacking in current stroke care. The overall purpose of this study is to evaluate the effectiveness of a novel digital follow-up tool, Rehabkompassen®, among persons discharged from acute care settings after a stroke.

Methods: This multicentre, parallel, open-label, two-arm pragmatic randomized controlled trial with an allocation ratio of 1:1 will be conducted in Sweden. A total of 1106 adult stroke patients will have follow-up visits in usual care settings at 3 and 12 months after stroke onset. At the 3-month follow-up, participants will have a usual outpatient visit without (control group, n = 553) or with (intervention group, n = 553) the Rehabkompassen® tool. All participants will receive the intervention at the 12-month follow-up visit. Feedback from the end-users (patient and health care practitioners) will be collected after the visits. The primary outcomes will be the patients’ independence and social participation at the 12-month visits. Secondary outcomes will include end-users’ satisfaction, barriers and facilitators for adopting the instrument, other stroke impacts, health-related quality of life and the cost-effectiveness of the instrument, calculated by incremental cost per quality-adjusted life year (QALY).

Discussion: The outcomes of this trial will inform clinical practice and health care policy on the role of the Rehabkompassen® digital follow-up tool in the post-acute continuum of care after stroke.

Trial registration: ClinicalTrials.gov NCT04915027. Registered on 4 June 2021. ISRCTN registry ISRCTN63166587. Registered on 21 August 2023.

Despite the promising benefits of virtual reality (VR) cognitive rehabilitation and the affordable VR systems currently on the market, few VR tools have found their way into the clinic. The purpose of this Information and Education page is to assist clinicians in deciding which VR systems are useful for cognitive rehabilitation.

Background: There is a need for an overview of systematic reviews (SRs) examining randomized clinical trials (RCTs) of pharmacological interventions in the treatment of intracranial pressure (ICP) post-TBI.

Objectives: To summarize pharmacological effectiveness in decreasing ICP in SRs with RCTs and evaluate study quality.

Methods: Comprehensive literature searches were conducted in MEDLINE, PubMed, EMBASE, PsycINFO, and Cochrane Library databases for English SRs through October 2020. Inclusion criteria were SRs with RCTs that examined pharmacological interventions to treat ICP in patients post-TBI. Data extracted were participant characteristics, pharmacological interventions, and ICP outcomes. Study quality was assessed with AMSTAR-2.

Results: Eleven SRs between 2003 and 2020 were included. AMSTAR-2 ratings revealed 3/11 SRs of high quality. Pharmacological interventions included hyperosmolars, neuroprotectives, anesthetics, sedatives, and analgesics. Study samples ranged from 7 to 1282 patients. Hyperosmolar agents and sedatives were beneficial in lowering elevated ICP. High bolus dose opioids had a more deleterious effect on ICP. Neuroprotective agents did not show any effects in ICP management. RCT sample sizes and findings in the SRs varied. A lack of detailed data syntheses was noted. AMSTAR-2 analysis revealed moderate-to-high quality in most SRs. Future SRs may focus on streamlined reporting of dosing and clearer clinical recommendations.

Conclusions: PROSPERO-Registration: CRD42015017355.

Introduction: It remains a huge challenge to identify individual rehabilitation needs in a time-efficient manner for providing patient-tailored rehabilitation during the continuum of stroke care. We have recently demonstrated the usefulness of a paper-version Rehab-Compass as a follow-up tool. The aim of the current study was to develop a digital version of the Rehab-Compass and evaluate its usability and feasibility.

Methods: The novel digital tool Rehabkompassen® was developed by an iterative and participatory design process. Patients' rehabilitation needs were visualized by the tool and used before, during, and after the consultation. The usability and feasibility of the tool was assessed by task completion rate, the System Usability Scale, and satisfaction questionnaires among 2 physicians and 24 adult stroke patients in an outpatient clinical setting.

Results: Rehabkompassen® identified and graphically visualized a panoramic view of the stroke patients' multidimensional needs in individual- and group levels. The instrument appeared to be feasible and time efficient in clinical use with a 100% overall task completion rate for both patients and physicians. A majority of the patients reported that it was very easy or fairly easy to answer the digital questionnaires and to understand their own digital Rehab-Compass graph. Two physicians reported a high mean score on the System Usability Scale (95/100) and were positive about using the tool in the future.

Conclusions: The current results indicated that Rehabkompassen® was a feasible, useful, and time-saving follow-up tool for the identification of rehabilitation needs among stroke survivors in the post-acute continuum of care after stroke. Further research is needed to evaluate the efficacy of the digital instrument among stroke patients.

Background: Stroke is a leading cause of disability among adults, with heavy social and economic burden worldwide. A cost-effective solution is urgently needed to facilitate the identification of individual rehabilitation needs and thereby provide tailored rehabilitations to reduce disability among people who have had a stroke. A novel digital graphic follow-up tool Rehabkompassen has recently been developed to facilitate capturing the multidimensional rehabilitation needs of people who have had a stroke.

Objective: The aim of this study was to evaluate the feasibility and acceptability of conducting a definitive trial to evaluate Rehabkompassen as a digital follow-up tool among people who have had a stroke in outpatient clinical settings.

Methods: This pilot study of Rehabkompassen was a parallel, open-label, 2-arm prospective, proof-of-concept randomized controlled trial (RCT) with an allocation ratio of 1:1 in a single outpatient clinic. Patients who have had a stroke within the 3 previous months, aged ≥18 years, and living in the community were included. The trial compared usual outpatient visits with Rehabkompassen (intervention group) and without Rehabkompassen (control group) at the 3-month follow-up as well as usual outpatient visit with Rehabkompassen at the 12-month follow-up. Information on the recruitment rate, delivery, and uptake of Rehabkompassen; assessment and outcome measures completion rates; the frequency of withdrawals; the loss of follow-up; and satisfaction scores were obtained. The key outcomes were evaluated in both groups.

Results: In total, 28 patients (14 control, 14 Rehabkompassen) participated in this study, with 100 patients screened. The overall recruitment rate was 28% (28/100). Retention in the trial was 86% (24/28) at the 12-month follow-up. All participants used the tool as planned during their follow-ups, which provided a 100% (24/24) task completion rate of using Rehabkompassen and suggested excellent feasibility. Both patient- and physician-participants reported satisfaction with the instrument (19/24, 79% and 2/2, 100%, respectively). In all, 2 (N=2, 100%) physicians and 18 (N=24, 75%) patients were willing to use the tool in the future. Furthermore, modified Rankin Scale as the primary outcome and various stroke impacts as secondary outcomes were both successfully collected and compared in this study.

Conclusions: This study demonstrated the high feasibility and adherence of the study protocol as well as the high acceptability of Rehabkompassen among patients who have had a stroke and physicians in an outpatient setting in comparison to the predefined criterion. The information collected in this feasibility study combined with the amendments of the study protocol may improve the future definitive RCT. The results of this trial support the feasibility and acceptability of conducting a large definitive RCT.