Team Golf:

Right-Sided CVA
with Hemiplegia
Kyle Bailey, Chris McDowell,
Lara Nasser, Mike Neal, Max
Patterson, and Perla Perez
 Early and long-term outcome of rehabilitation in stroke
patients: the role of patient characteristics, time of
initiation, and duration of interventions.

Musicco M, Emberti L, Nappi G, Caltagirone C. Early and long-term outcome of rehabilitation in stroke patients: The role of patient characteristics, time
of initiation, and duration of interventions. Archives of Physical Medicine and Rehabilitation. 2003;84(4):551-558. doi:10.1053/apmr.2003.50084.
Relevance and Study Specifics
● Relevance: Marc is an older patient who suffered a CVA with previous history of several
medical problems. In order to determine his capability to return to work soon, it is necessary to
examine multiple factors in stroke recovery.
● Design: Cohort study
● Participants: 1716 stroke patients (almost 50:50 men:women) in Italy between 1997-1998
● Patients were examined over time across multiple hospitals examining the impact between
multiple factors (gender, age, presence of comorbidities, etc.) and stroke recovery
Validity
Internal Validity

● Patients were not assigned to group for treatment but were examined based on
functional outcomes
● Multiple variables related to stroke recovery were examined to give general results
of the outcomes

External Validity

● Inclusion criteria
○ Patients with stabilized CVA
○ Patient has not undergone rehabilitation during hospitalization
● Exclusion criteria
○ Patients with mild disability
○ Patients who have undergone rehabilitation for more than 1 month
Results and Discussion
Patients in this study tended to have a higher potential for
survival and improved outcomes if the patients were:
● Less disabled
● Younger
● Did not have dementia or ulcers on admission
● Initiated in rehabilitation within 7 days after CVA
In this study, gender and the side of the brain lesion did
not show significant differences
Discussion
● This study provides good evidence that rehab
earlier in the healing process is beneficial
● Age and presence of co-morbidities are good
predictors of eventual outcomes of therapy
● This study does not give suggestions about the
proper length of therapy; more research needs to be
done
Study Limitations and Future Considerations
● This study does not examine a specific standardized technique for stroke recovery, so
variations between protocols can lead to differences
● Study was highly generalized, and the confounding variables can skew information for other
variables
● Future studies should examine specific variables closer to get a better idea of how much each
variable impacts stroke recovery and outcomes
● Future studies should also ensure that each patient follows the same protocol to get rid of that
confounding variable
Duncan PW, Sullivan KJ, Behrman AL et al. Body Weight Supported Treadmill Rehabilitation after
Stroke. N Engl J Med. May 2011:2026-2036. doi:10.1056/NEJMoa1010790.
Study Design: single blinded randomized controlled study

➔ 408 participants
➔ Assignment to three groups; early locomotion training at 2 months post-stroke, late locomotion
training beginning after 6 months, and home exercise that began at 2 months post-stroke.
➔ 139 assigned to early locomotion, 143 assigned to late locomotion training and 126 assigned to
home exercise.
➔ Participants were assessed prior to randomization and at 6 and 12 months by physical
therapists who were unaware of the participants’ group assignment.
➔ Outcome measures such as berg balance scale, stroke impact scale, fugl-meyer and ABC were
used.
 Validity
External Validity
Inclusion Criteria:
age 18 years or older, a
stroke within 45 days
before study entry,
residual paresis in the leg
affected by stroke, ability
to walk 3m with
assistance from no more
than 1 person.
Exclusion Criteria:
dependency on
assistance in ADLs
before the stroke,
contraindications to
exercise and pre-existing
neurologic disorders.
Variables
Internal Validity
Dependent
Participants were Independent Confounding
randomly assigned to
early locomotor ● Level of stroke
3 Training Groups ● Transportation
training, late severity
locomotor training, or ●Gait speed availability
●Early locomotor ● adverse events:
home exercise. ●Distance
training: 2 months hospital
traveled
after the stroke. readmission,
Treatment
assignments were ●Late locomotor fall without a
stratified according to training: 6 months fracture, dyspnea
after the stroke. during treatment,
severity of impairment
at baseline to ensure ●Home exercise and dizziness
program: began 2
balance among the
three groups. months after the
stroke.
Results: At 1 year after stroke, researchers did not establish the superiority of locomotor training on
a treadmill that included body-weight support over home-based physical therapy regardless of
whether locomotor training was started at 2 or 6 months after the stroke. Results also suggested
that home exercise was a more pragmatic form of therapy with fewer risks.

Weaknesses/Limitations: Research study lacked a group receiving no physical therapy treatment

(control) for comparison, difficult to compare the effectiveness of home exercise and locomotor
training. The duration of a single home-exercise session was significantly less than that of early/late
locomotor training.

Future Research: will include a control group for comparison, assess

improvements beyond 1 year.
 Cognitive training on stroke patients via virtual
reality-based serious games
Gamito P, Oliveira J, Coelho C, Morais D, Lopes P, Pacheco J, Brito R, Soares F, Santos N, Barata AF. Cognitive training on stroke patients via virtual
reality-based serious games. Disability and Rehabilitation. 2015;39(4):385-388. doi:10.3109/09638288.2014.934925
Relevance
● Marc is currently easily distracted and has deficits in maintaining attention with inconsistent
sustained concentration

● Marc currently struggling with impaired short term memory and immediate recall

● Marc has impaired sequencing ability and shows cognitive insufficiencies in judgement and
insight.

● There is evidence supplied that the use of virtual reality environments in cognitive
rehabilitation offers benefits in both attention and memory function in patients suffering from
stroke
Study Design
Type: Randomized control design

Subjects: 20 stroke patients (9 male) with a mean age of 55 years (SD ¼ 13.5)
10 were assigned to intervention group and 10 were assigned to control group

Intervention: 60-minutes sessions of cognitive stimulation with mobile technology using Serious
Games involving simulations of daily activities (two to three sessions per week over the usual 4–6
week period of treatment).

Measures: The neuropsychological evaluation was based on the Wechsler Memory Scale, Toulouse–
Pie´ron Test, and the Rey Complex Figure.
Validity
Internal Validity External Validity
● Each of the patients was randomly assigned to their group ● Inclusion criteria
based on simple randomization with random number ○ Patients with stabilized CVA
generator ○ CVA is primary reason for admission
● Each patient interacted with a single therapist throughout
the entirety of the experiment
● Exclusion criteria
● No institutional affiliations were presented in the e-
○ Previous history of neurological or psychiatric
health media.
disorders other than the stroke condition
● The executive training exercises performed were selected
○ Substance or alcohol abuse
in order to develop cognitive abilities related to executive
○ Scores below the cutoff values in the Mini-Mental
functioning.
State Examination
○ Uncorrected visual deficiencies.
Variables
Independent
Dependent
Receiving cognitive rehabilitation through virtual
reality training vs. not receiving cognitive Ability to perform task testing:
rehabilitation training
○ Recognition memory tasks
○ Calculations
○ Working memory tasks
○ Visuospatial orientation
tasks
○ Selective attention tasks
Results
● These results support the effectiveness of VR-based training for cognitive rehabilitation of memory and attention functions in
stroke patients.

● Control group showed no significant improvements

● This indicates that the group receiving cognitive stimulation with mobile technology using Serious Games involving simulations of
daily activities had more improvements than a group with no interventions.

Clinical Significance:
The use of virtual reality environments in cognitive rehabilitation offers cost benefits and other advantages and is able to increase the
ability of patients with stroke to perform memory oriented tasks. It is undetermined how this memory intervention would compare to other
common interventions
Limitations and Further Research
Researcher’s Conclusion:

● It was assumed that there is a greater adherence to training process due to the gaming characteristics of the process, but
this assumption has not yet been tested.

● Other assumed advantages of VR-based cognitive therapy, such as shorter periods of training required for rehabilitation
need to be tested

My Thoughts:

● Further research is needed to clarify if it does this more effectively than traditional forms of cognitive training.

● Since the experimentation was done utilizing one specific VR program, it is impossible to know if these results apply to all
VR systems
 Meaningful Task-Specific Training (MTST) for
Stroke Rehabilitation: A Randomized Controlled
Trial
Arya KN, Verma R, Garg RK et al. Meaningful task-specific training for stroke rehabilitation: A randomized controlled trial. Topics in Stroke
Rehabilitation. 2012; 19(3); 193-211. doi: 10.1310/tsr1903-193
Relevance
● There is no active return in Marc’s LUE, which is limiting his daily functioning and quality of
life.
● His ultimate goal is to regain maximal functional abilities and he hopes to return to work.
● For Marc to return to his prior level of function, UE training is going to be required.
● MTST is a type of rehabilitation program that brings about enduring motor learning and
associated cortical reorganization, and evidence shows that it is beneficial in UE motor
recovery following stroke.
Study Design
● Randomized, Controlled, Double-blinded Trial
● Participants: 103 total participants (62 men, 41 women) who had hemiparesis following a
stroke
○ 51 were assigned to a MTST program
○ 52 were assigned to a dose-matched standard stroke recovery program based on Brunnstrom movement
therapy and Bobath neurodevelopmental technique

● Independent Variables: ● Dependent Variables : ● Confounding Variables :

○ MTST Program vs. dose-
matched standard stroke
recovery program
○ Upper extremity motor recovery
measured through Fugl-Meyer
Assessment, Action Research Arm
Test, Graded Wolf Motor Function
Test, and Motor Activity Log
○ Motivation Level
○ Level of function prior to the stroke
○ Time since stroke
Internal Validity External Validity
● Inclusion Criteria
● Patients were randomly assigned to either the ○ First episode of unilateral stroke with hemiparesis, 4 to
24 weeks post stroke
experimental group or the control group using ○ Functional ambulation classification - Level 1 or above
computer-generated random numbers. ○ Ability to understand directions and cope with intensive
training program
○ Brunnstrom stage of arm recovery of 2 to 5
● All assessors were blinded and trained to
administer the outcome measures properly. ● Exclusion Criteria:
○ Perceptual deficits such as neglect or apraxia
○ Dementia
○ Depression
○ Impaired vision
○ Impaired conscious level
○ Associated medical illness
○ Unstable cardiovascular health
○ Shoulder subluxation
○ Aphasia
○ Sensory loss
MTST Protocol - General Guidelines
Common Meaningful Task Practice
● 10 tasks to perform each week
● Progression to more challenging task if
mastery/plateau achieved in 50% of tasks
● Instructed to relax and mentally imagine
how to perform task
● 45 minutes -- 2 minutes rest time
● 4 targeted movements expected to occur
with each task
Individualized Meaningful Task Practice
● Consider patient’s
occupational/performance experience
● Involve patient in goal setting
● Identify patient’s strengths and
weaknesses
● Select any 4 meaningful tasks related to
patient’s life each week
● Task must be different than common
meaningful tasks
● 15 minutes long -- 1 minute rest time
 Results
● MTST was more beneficial in improving UE recovery

● The patients within the MTST showed significant

improvements in scores of Fugl-Meyer assessment, Action
Research Test, Graded Wolf Motor Function Test, and
Motor Activity Log.
Conclusion
Clinical Significance: MTST can be used to enhance motor recovery, activity limitation, time and quality of
movement, and amount and quality of arm and hand use, and should be considered when treating patients
with hemiparesis following subacute stroke.

Limitations and Future Research:

● The MTST protocol utilized multiple neuroplastic principles, but time, salience, age,
transference, and interference were not included.
● Further studies should continue to refine the MTST protocol by incorporating these
neuroplastic principles.
Effects of Home-Based Versus Clinic-Based Rehabilitation Combining
Mirror Therapy
and Task-Specific Training for Patients With Stroke: A Randomized
Crossover Trial

Hsieh, Y., Chang, K., Hung, J., Wu, C., Fu, M., & Chen, C. (2018). Effects of Home-Based Versus Clinic-Based Rehabilitation
Combining Mirror Therapy and Task-Specific Training for Patients With Stroke: A Randomized Crossover Trial.
Archives of Physical Medicine and Rehabilitation,99(12), 2399-2407. doi:10.1016/j.apmr.2018.03.017
Study Design
● A single-blinded, 2-sequence, 2-period, crossover-designed study.
External Validity
Inclusion Criteria:
● stroke with 1 month to 5 years,
● able to follow instructions
● modified rankin scale showing severe
to slight disability
● Fugl-Meyer showing severe to mild
impairments
● no severe muscle spasticity
Exclusion Criteria:
● Cerebellum stroke
● Other neurologic diseases
● Serious pain/inflammation/pain in
affected arm
● Global or receptive aphasia
● Other major medical problems
Internal Validity
● Single blinded study
● Randomized using an online generator by a technician not affiliated with the study
● Two therapists conducted all therapy sessions to keep consistency throughout
Variables
● Independent: Home-based vs. clinic-based Outcome measures:
rehabilitation
● Dependent: Impairment level, activity and ● Impairment Level: Fugl-Meyer Assessment
participation level (UE section), Revised Nottingham Sensory
● Confounding: Pain level, motivation level, Assessment Box and block Test
transportation cost ● Activity and Participation Level: Motor
Activity Log, 10m Walk Test, Sit-to-Stand
Test (30 seconds), COPM, and EQ-5D
Results
● Home-based group improved amount of use of affected UE and LE force.
● Clinic-based group showed improved perceived health status
● Both groups showed improvement in impairment level and COPM

Clinical Significance: Both settings are shown to be beneficial to improving patient outcomes when
using an intervention strategy of mirror therapy and task-specific training.
Limitations and Future Research
● Small Sample size: 18 participants finished
● Home-based therapy: 3 times a week for a 75-105 minutes
○ Possibly impractical
● The study did not account for the cost of home based therapy on the patient
● 1 month to 5 years post stroke is large range
○ Group in chronic vs. acute stroke
Unilateral Spatial Neglect: Relation to Rehabilitation Outcomes in
Patients With Right Hemisphere Stroke

Gillen R., Tennen H., Mckee T. Unilateral spatial neglect: Relation to rehabilitation outcomes in
patients with right hemisphere stroke. Arch Phys Med Rehabil. 2005; 86:763-767.
ttps://doi.org/10.1016/j.apmr.2004.10.029
 Relevance
● R CVA → L unilateral Spatial Neglect
- influences rehab outcomes
- influences interventions
- unique patient factor
- higher risk for falls
 Retrospective Study (N=175)
Independent ● Unilateral Spatial Neglect
Variable

● Rehabilitation Outcomes
Dependent Variable ●
●
Length of stay
Functional improvement

Confounding Interventions unidentified; exclusion of visual deficits

Variable
 Validity
External Validity Internal Validity
•Generalizability: about one third of pt. admitted with R •Matched non-USN with USN pts. post R CVA for stroke
CVA were excluded due to inability to complete severity
assessments because of visual acuity or perceptual
deficits. •All subjects received same tests in same manner

- Pts were mostly older ~ 72.25- 77.25 and more severely •Subjects randomly selected from database over 5 year
impaired FIM scores period
 Results
•Pts. with USN…
- Had longer rehabilitation hospital stays (5-11 days more)
- Showed less daily functional improvement
- Slower progression & lower level of functional capacity
- Lower neuropsychological scores
- Associated with less improvement incertain key functions (grooming, bathing, walking, etc.) – important to design interventions
targeting USN in relation to functional activities
- USN associated with higher rate of depressive symptoms

***important to consider when planning for resource allocation for treatment and
prospective reimbursement system***
 - Limitations
● study completed on older population
● no integral assessment of peripheral visual fields
● USN is multifactorial (external space vs
personal/own body vs Motor vs sensory)
-Only focused on spatial neglect
- Future Research
● Include other age groups
● Asses and analyze for visual fields/deficits
● Incorporate other USN factors
● Consider other functional measures
Clinical Pearls
Factors in Stroke Recovery
● Multiple factors can be related to stroke recovery,
including age, presence of comorbidities, and the
amount of time the patient waits to start
rehabilitation
● Participants who started interventions earlier than
7 days after the initial CVA had much better
outcomes compared to patients who waited more
than 7 days
● Age plays a significant role in predicting outcomes
of stroke recovery, with this study showing patients
doing much better if they were younger than 65,
but other studies have other age cutoffs for
improvment
Body-Weight-Supported Treadmill Rehab
● Locomotor Experience Applied Post-Stroke (LEAPS)
trial suggested a benefit to locomotor training and
was quickly adopted resulting in an increased use
of commercial lifts and robot-assisted stepping on
a treadmill
● Participants in the early interventions (HEP and
early locomotor) had improvements at 6 months
that were sustained at 1 year. At 6 months, the late
locomotor group had less recovery. But, at 1 year
had similar outcomes to the other two groups.
● All groups had a similar improvement from baseline
to 1 year in the distance walked in 6 minutes, the
number of steps taken in the community, ADLs and
balance.
Clinical Pearls
Cognitive training on stroke patients via virtual
reality-based serious games
● VR-based training has been shown to be effective for
cognitive rehabilitation of memory and attention
functions in stroke patients.
● During the course of this study, stroke patients who did
not receive intervention showed no significant
improvement in memory or attention ability.
● Significant improvements were shown in the
experimental group within just 6 weeks of training
Meaningful Task Specific Training (MTST)
● MTST was beneficial in improving UE recovery in
individuals with hemiparesis following a stroke
● The patients within the MTST showed significant
improvements in scores of Fugl-Meyer assessment,
Action Research Test, Graded Wolf Motor Function Test,
and Motor Activity Log.
● MTST can be used to enhance motor recovery, activity
limitation, time and quality of movement, and amount
and quality of arm and hand use.
Clinical Pearls
Mirror Therapy
and Task-Specific Training
● Both home-based and clinic-based are shown to be
beneficial to improving stroke patient outcomes
when using an intervention strategy of mirror
therapy and task-specific training with differing
effects of outcomes for activity and participation
level.
Unilateral Spatial Neglect
● Patients who have had a stroke and present with
unilateral spatial neglect have unique and non-
favorable outcome predictors; requiring longer
length of stay, showing slower rehabilitation
progression, and less improvement in ADLs.
● Patients with unilateral spatial neglect are
associated with higher rates of depressive
symptoms.
Quiz Questions
Factors in Stroke Recovery Questions Body-Weight-Supported Treadmill Rehab Questions

T/F Predictions in stroke recovery are multifactorial and
cannot be predicted by one specific variable.
According the the Mussico article about stroke recovery
factors, which factor did not show significant differences?
T/F Research has shown that body-weight supported
treadmill rehabilitation was superior to home exercise
when assessing functional walking gains?
Duncan, Sullivan, Behrman et al. concluded…

a) Age a) Home exercise is a more pragmatic form of therapy

b) Presence of Comorbidities with fewer risks.
c) Gender b) The timing of locomotor training (early/late)
d) Initiating Therapy services by the 7th day post- affected the outcome after 1 year.
stroke c) All groups had similar improvements in walking
speeds, motor recovery, balance and QoL.
d) a&c
Quiz Questions
Cognitive training on stroke patients via virtual Meaningful Task Specific Training (MTST)
reality-based serious games
T/F. MTST was shown to be beneficial in improving UE recovery
T/F. In this study by Gamito P, Oliveira J, et. al, the researchers were in individuals with hemiparesis following a stroke
able to see improvements in the experimental group by simulating a
single functional task through reality-based serious games The patients within the MTST group showed significant
In this study by Gamito, P. Oliveira J, et. al, the researchers utilized improvements in what outcome measure scores
outcome measures to test which dependent variables?
a. Fugl-Meyer Assessment
a. Calculations b. Action Research Test
b. Working memory tasks c. Graded Wolf Motor Function Test
c. Visuospatial orientation tasks d. Motor Activity Log
d. Selective attention tasks e. All of the Above
e. All the above
Quiz Questions
Mirror Therapy Unilateral Spatial Neglect
and Task-Specific Training
Patient’s with a Unilateral spatial neglect after a stroke
Home-based therapy showed more improvement in had lower rates of depressive symptoms.
impairment level when compared to clinic-based therapy? -True
-True -False
-False

Which therapy setting showed greater improvement in Patients with unilateral spatial neglect were found to have
_________.
perceived health status?
a. Higher daily functional improvements
-Home-based b. Higher neuropsychological scores
-ICU c. Longer hospital stays
-Clinic-based
-Acute Care