Background Technology is being increasingly investigated as an option to allow stroke survivors to exploit their full potential for recovery by facilitating home-based upper limb practice. This review seeks to explore the factors that influence perseverance with technology-facilitated home-based upper limb practice after stroke. Methods A systematic mixed studies review with sequential exploratory synthesis was undertaken. Studies investigating adult stroke survivors with upper limb disability undertaking technology-facilitated home-based upper limb practice administered ≥ 3 times/week over a period of ≥ 4 weeks were included. Qualitative outcomes were stroke survivors’ and family members’ perceptions of their experience utilising technology to facilitate home-based upper limb practice. Quantitative outcomes were adherence and dropouts, as surrogate measures of perseverance. The Mixed Methods Appraisal Tool was used to assess quality of included studies. Results Forty-two studies were included. Six studies were qualitative and of high quality; 28 studies were quantitative and eight were mixed methods studies, all moderate to low quality. A conceptual framework of perseverance with three stages was formed: (1) getting in the game; (2) sticking with it, and; (3) continuing or moving on. Conditions perceived to influence perseverance, and factors mediating these conditions were identified at each stage. Adherence with prescribed dose ranged from 13 to 140%. Participants were found to be less likely to adhere when prescribed sessions were more frequent (6–7 days/week) or of longer duration (≥ 12 weeks). Conclusion From the mixed methods findings, we propose a framework for perseverance with technology-facilitated home-based upper limb practice. The framework offers opportunities for clinicians and researchers to design strategies targeting factors that influence perseverance with practice, in both the clinical prescription of practice and technology design. To confirm the clinical utility of this framework, further research is required to explore perseverance and the factors influencing perseverance. Registration: PROSPERO CRD42017072799—https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=72799

Background. Recent studies have reported lower statistics of upper limb (UL) weakness (48-57%) compared to widely cited values collected over 2 decades ago (70-80%). Objective. To explore potential factors contributing to the accuracy of prevalence values of UL weakness using a case study from a single regional centre. Methods. All patients admitted to the acute stroke unit with suspected diagnosis of stroke were screened from February 2016 to August 2017. Upper limb weakness was captured (a) prospectively using the Shoulder Abduction and Finger Extension (SAFE) score performed by unit physical therapists within 7 days post-stroke and (b) retrospectively via chart review using the National Institutes of Health Stroke Scale (NIHSS) arm score at admission and 24 hours post-admission. Results. A total of 656 patients were admitted with a first-ever stroke, and 621 (95%) individuals were administered the SAFE score. A total of 40% of individuals had UL weakness using the SAFE score (SAFE ≤8) at a mean time of 1.9 (SD 1.5) days post-stroke. In the same sample, 57% and 49% had UL weakness using the admission and 24-hour post-admission NIHSS arm score, respectively. Conclusions. The accuracy of population-level UL weakness prevalence values can be affected by weakness measure and score cut-off, time post-stroke weakness is captured, sample characteristics and use of single or multiple sites. Researchers using prevalence values for clinical trial planning should consider these attributes when using prevalence data for estimating recruitment rates and resource needs.

Background Little is known about diet quality with a reduced-energy, low-fat, partial meal replacement (PMR) plan, especially in individuals with type 2 diabetes. The Action for Health in Diabetes (Look AHEAD) trial implemented a PMR plan in the intensive lifestyle intervention (ILI). Objective Compare dietary intake and percent meeting fat-related and food group dietary recommendations in ILI and diabetes support and education (DSE) groups at 12 months. Design Randomized controlled trial, comparing ILI to DSE, at 0- and 12-months. Participants/setting From 16 United States sites, the first 50% of participants (aged 45 to 76 years, overweight or obese, with type 2 diabetes) were invited to complete dietary assessments. Complete 0- and 12-month dietary assessments (collected between 2001 and 2004) were available on 2,397 participants (46.6% of total participants), with 1,186 randomized to DSE and 1,211 randomized to ILI. Main outcome measures A food frequency questionnaire assessed intake: energy; percent energy from protein, fat, carbohydrate, polyunsaturated fatty acids (PUFA), and saturated fats; trans fatty acids; cholesterol; fiber; weekly meal replacements (MRs); and daily servings from food groups from the Food Guide Pyramid. Statistical analyses performed Mixed-factor analyses of covariance (ANCOVA), using Proc MIXED with a repeated statement, with age, sex, race/ethnicity, education, and income controlled. Unadjusted chi-square tests compared percent meeting fat-related and food group recommendations at 12 months. Results At 12 months, ILI had a significantly lower fat and cholesterol intake and greater fiber intake than DSE. ILI consumed more servings/day of fruits; vegetables; and milk, yogurt & cheese; and fewer servings/day of fats, oils & sweets than DSE. A greater percentage of ILI than DSE participants met fat-related and most food group recommendations. Within ILI, a greater percentage of participants consuming ≥ 2 MRs/day than < 1 MR/day met most fat-related and food group recommendations. Conclusions The PMR plan consumed by ILI was related to superior diet quality.

Introduction: Acute exercise can modulate the excitability of the nonexercised upper limb representation in the primary motor cortex (M1). Measures of M1 excitability using transcranial magnetic stimulation (TMS) are modulated after various forms of acute exercise in young adults, including high-intensity interval training (HIIT). However, the impact of HIIT on M1 excitability in older adults is currently unknown. Therefore, the purpose of the current study was to investigate the effects of lower limb cycling HIIT on bilateral upper limb M1 excitability in older adults. Methods: We assessed the impact of acute lower limb HIIT or rest on bilateral corticospinal excitability, intracortical inhibition and facilitation, and interhemispheric inhibition of the nonexercised upper limb muscle in healthy older adults (mean age 66 ± 8 yr). We used single and pairedpulse TMS to assess motor evoked potentials, short-interval intracortical inhibition, intracortical facilitation, and the ipsilateral silent period. Two groups of healthy older adults completed either HIIT exercise or seated rest for 23 min, with TMS measures performed before (T0), immediately after (T1), and 30 min after (T2) HIIT/rest. Results: Motor evoked potentials were significantly increased after HIIT exercise at T2 compared with T0 in the dominant upper limb. Contrary to our hypothesis, we did not find any significant change in short-interval intracortical inhibition, intracortical facilitation, or ipsilateral silent period after HIIT. Conclusions: Our findings demonstrate that corticospinal excitability of the nonexercised upper limb is increased after HIIT in healthy older adults. Our results indicate that acute HIIT exercise impacts corticospinal excitability in older adults, without affecting intracortical or interhemispheric circuitry. These findings have implications for the development of exercise strategies to potentiate neuroplasticity in healthy older and clinical populations.

Up to two-thirds of stroke survivors experience persistent sensorimotor impairments. Recovery relies on the integrity of spared brain areas to compensate for damaged tissue. Deep grey matter structures play a critical role in the control and regulation of sensorimotor circuits. The goal of this work is to identify associations between volumes of spared subcortical nuclei and sensorimotor behaviour at different timepoints after stroke. We pooled high-resolution T 1 -weighted MRI brain scans and behavioural data in 828 individuals with unilateral stroke from 28 cohorts worldwide. Cross-sectional analyses using linear mixed-effects models related post-stroke sensorimotor behaviour to non-lesioned subcortical volumes (Bonferroni-corrected, P < 0.004). We tested subacute (≤90 days) and chronic (≥180 days) stroke subgroups separately, with exploratory analyses in early stroke (≤21 days) and across all time. Sub-analyses in chronic stroke were also performed based on class of sensorimotor deficits (impairment, activity limitations) and side of lesioned hemisphere. Worse sensorimotor behaviour was associated with a smaller ipsilesional thalamic volume in both early ( n = 179; d = 0.68) and subacute ( n = 274, d = 0.46) stroke. In chronic stroke ( n = 404), worse sensorimotor behaviour was associated with smaller ipsilesional putamen ( d = 0.52) and nucleus accumbens ( d = 0.39) volumes, and a larger ipsilesional lateral ventricle ( d = −0.42). Worse chronic sensorimotor impairment specifically (measured by the Fugl-Meyer Assessment; n = 256) was associated with smaller ipsilesional putamen ( d = 0.72) and larger lateral ventricle ( d = −0.41) volumes, while several measures of activity limitations ( n = 116) showed no significant relationships. In the full cohort across all time ( n = 828), sensorimotor behaviour was associated with the volumes of the ipsilesional nucleus accumbens ( d = 0.23), putamen ( d = 0.33), thalamus ( d = 0.33) and lateral ventricle ( d = −0.23). We demonstrate significant relationships between post-stroke sensorimotor behaviour and reduced volumes of deep grey matter structures that were spared by stroke, which differ by time and class of sensorimotor measure. These findings provide additional insight into how different cortico-thalamo-striatal circuits support post-stroke sensorimotor outcomes.

Objective This study aimed to investigate factors related to paretic upper limb use within the first 4 wks after stroke. Design Sixty inpatients within 4 wks of first-time stroke were stratified by severity defined by Fugl-Meyer Upper Limb scores: severe = 0–22, moderate = 23–50, and mild = 51–66. All wore a wrist accelerometer on the paretic upper limb (24 hrs). Factors investigated were the following measures: upper limb motor impairment; mobility; balance; functional independence; sensory impairment; cognitive function; social factors; environmental restriction; and knowledge. Individual and multivariate quantile regression analyses were performed. Results Upper limb motor impairment, mobility, balance, functional independence, self-efficacy, and knowing how to use the paretic upper limb were significantly related to upper limb use across the three impairment groups (pseudo R 2 = 0.079–0.492, P < 0.02). Multivariate regression showed the only significant factor in moderate and mild group was Fugl-Meyer Upper Limb score (moderate pseudo R 2 = 0.55, mild pseudo R 2 = 0.54, P < 0.001). For the severe group, Fugl-Meyer upper limb score and step count were significant (severe pseudo R 2 = 0.47, P ≤ 0.030). Conclusions Upper limb motor impairment is significantly associated with paretic upper limb use across three impairment groups and step count with the severe group. Strategies to improve upper limb motor impairment and increase mobility may be required to increase upper limb use.

Importance: Early mobilization, out-of-bed activity, is a component of acute stroke unit care; however, stroke patient heterogeneity requires complex decision-making. Clinically credible and applicable CPGs are needed to support and optimize the delivery of care. In this study, we are specifically exploring the role of clinical practice guidelines to support individual patient-level decision-making by stroke clinicians about early mobilization post-stroke.Methods: Our study uses a novel, two-pronged approach. (1) A review of CPGs containing recommendations for early mobilization practices published after 2015 was appraised using purposely selected items from the Appraisal of Guidelines Research and Evaluation–Recommendations Excellence (AGREE-REX) tool relevant to decision-making for clinicians. (2) A cross-sectional study involving semi-structured interviews with Australian expert stroke clinicians representing content experts and CPG target users. Every CPG was independently assessed against the AGREE-REX standard by two reviewers. Expert stroke clinicians, invited via email, were recruited between June 2019 to March 2020.The main outcomes from the review was the proportion of criteria addressed for each AGREE-REX item by individual and all CPG(s). The main cross-sectional outcomes were the distributions of stroke clinicians' responses about the utility of CPGs, specific areas of uncertainty in early mobilization decision-making, and suggested parameters for inclusion in future early mobilization CPGs.Results: In 18 identified CPGs, many did not adequately address the “Evidence” and “Applicability to Patients” AGREE-REX items. Out of 30 expert stroke clinicians (11 physicians [37%], 11 physiotherapists [37%], 8 nurses [26%]; median [IQR] years of experience, 14 [10–25]), 47% found current CPGs “too broad or vague,” while 40% rely on individual clinical judgement and interpretation of the evidence to select an evidence-based choice of action. The areas of uncertainty in decision-making revealed four key suggestions: (1) more granular descriptions of patient and stroke characteristics for appropriate tailoring of decisions, (2) clear statements about when clinical flexibility is appropriate, (3) detailed description of the intervention dose, and (4) physical assessment criteria including safety parameters.Conclusions: The lack of specificity, clinical applicability, and adaptability of current CPGs to effectively respond to the heterogeneous clinical stroke context has provided a clear direction for improvement.

Look AHEAD was a randomized clinical trial designed to examine the long-term health effects of weight loss in overweight and obese individuals with type 2 diabetes. The primary result was that the incidence of cardiovascular events over a median follow up of 9.6 years was not reduced in the intensive lifestyle group relative to the control group. This finding is discussed, with emphasis on its implications for design of clinical trials and clinical treatment of obese people with type 2 diabetes.