A – Clinical & Intervention Studies
Continuous positive airway pressure adherence and depressive symptoms in stroke/TIA patients with obstructive sleep apnea
Hephzibah Ali1,2,
Michelle Gyenes1,2,
Henry T.H. Xie1,2,
Maneesha Kamra1,
David R. Colelli1,
Nardin Kirolos3,
David Gladstone1,
Karl Boyle4,
Arun Sundaram1,
Julia J. Hopyan1,2,
Richard H. Swartz1,2,
Brian J. Murray1,2,
Mark I. Boulos1,2
1Sunnybrook Health Sciences Centre, 2University of Toronto, 3The Hospital for Sick Children, 4Beaumont Hospital
Background: Obstructive sleep apnea (OSA) is highly prevalent among patients with stroke and transient ischemic attack (TIA) and is associated with poorer outcomes including post-stroke depression. Continuous positive airway pressure (CPAP) is the gold standard treatment for OSA; however, adherence remains low. The relationship between CPAP adherence, post-stroke depression, and other outcomes has not been well defined. This study aimed to evaluate whether CPAP adherence was associated with changes in depressive symptoms, daytime sleepiness, functional outcomes, cognition, and stroke recurrence in patients with post-stroke/TIA OSA.
Methods: This was a retrospective cohort study of 112 patients with imaging-confirmed stroke or physician-diagnosed TIA who were diagnosed with OSA via in-laboratory polysomnography or home sleep apnea testing as part of the SLEAP SMART trial (ClinicalTrials.gov ID NCT02454023). CPAP adherence at the 6-month follow-up was evaluated as a dichotomous (i.e. use of CPAP for ⩾4 hours/night for ⩾70% of nights) and continuous variable (i.e. number of hours CPAP was used per week). Changes in outcomes were measured between the baseline and a 6-month follow-up. Outcomes included changes in depressive symptoms (as measured by the Center for Epidemiologic Studies Depression Scale [CES-D]), changes in daytime sleepiness, functional outcomes, cognition, and stroke recurrence. Group comparisons were performed using independent-sample t-tests and chi-square tests. Binary logistic regressions were used to evaluate CPAP adherence dichotomously. Multivariable linear regressions modeled adherence continuously (hours/week), while adjusting for covariates (i.e. age, sex, BMI, stroke severity, hypertension, hyperlipidemia, diabetes, and atrial fibrillation).
Results: Of 112 patients, 36 (32.1%) were adherent to CPAP and 76 (67.9%) were non-adherent. At baseline, groups did not differ significantly in demographics or comorbidities. No significant differences in change in the CES-D or the other outcomes were observed between the adherent and non-adherent groups when CPAP adherence was modeled dichotomously. However, when CPAP adherence was modeled continuously, greater weekly CPAP use was associated with reduced depressive symptoms (β = −0.07 per hour/week; 95% CI −0.14 to −0.003; p=0.04) while controlling for our covariates of interest. Model-based predictions indicated that the estimated change in depressive symptoms became statistically different from no change at approximately 31 hours of CPAP use per week. Stroke recurrence occurred only in the non-adherent group (adherent: 0/36, 0%; non-adherent: 3/76, 3.9%).
Conclusion: A dose-dependent relationship was observed between greater CPAP use and improvement in depressive symptoms, suggesting benefits beyond a conventional CPAP adherence threshold. These findings highlight the importance of encouraging CPAP use in post-stroke/TIA populations as it may confer clinically meaningful mood benefits.
Exploring the acceptability of a fNIRS-neurofeedback intervention within stroke rehabilitation from a practitioner perspective
Christine Ausman1,
Sofia So1,
Diane Mackenzie1,
David Westwood1,
Heather Neyedli1,
Sarah Moore1
1Dalhousie University
Background: Post-stroke neurorehabilitation continues to evolve with advances in technology-based interventions. To promote a successful translation of these interventions from research and development into clinical practice, we must understand the key facilitators and barriers to implementation. Stroke rehabilitation practitioners are key stakeholders as they can provide insights on patient needs, workflow constraints, resource limitations, and complex dynamics within the Canadian healthcare system. We previously developed a prototype functional near-infrared spectroscopy (fNIRS) neurofeedback (NF) intervention. This study explores the perceived acceptability of this newly developed fNIRS-NF intervention among stroke rehabilitation practitioners early in the design cycle.
Methods: Guided by the Technology Acceptance Model and the Theoretical Framework of Acceptability, this interview study used an interpretive description approach to gain insights from physiotherapists, occupational therapists, and recreation therapists currently working in stroke rehabilitation within Nova Scotia, across both urban and rural areas, and working in various settings such as acute care, rehabilitation, and outpatient services.
Results: Eleven (n=11) practitioners shared valuable insights, organized into four themes: 1) From Protocol to Practice, delving into considerations for delivering the intervention within realistic practice settings; 2) The Cost of Implementation, exploring the various costs associated with the intervention; 3) The Human Element, emphasizing the influence of the clients’ and practitioners’ personal characteristics; and 4) For the Hope of It All, highlighting the ongoing hope practitioners hold for continued research, development, and improvements in stroke rehabilitation care.
Conclusion: The successful integration of the intervention into stroke rehabilitation is contingent on addressing various barriers. Practitioners negotiate between the integration of new technology and its associated costs, while holding a ‘spark of hope’ for its potential in improving neurorehabilitation for their clients. Research should continue to consider stakeholder engagement to address real-world constraints.
Effects of exercise and transcranial direct current stimulation on cognitive fatigue and prefrontal cortex activity after stroke
Hamid Barzegarpoor1,
Michelle Ploughman1,
Duane Button1
1Memorial University of Newfoundland
Background: Post-stroke fatigue is a common and debilitating condition affecting up to 80% of stroke survivors and represents one of the most significant unmet needs among individuals living in the community after stroke. Cognitive fatigue, characterized by a reduced capacity to sustain attention, increased mental effort, and decreased productivity and quality of life, is particularly prevalent. Disruptions in the balance of excitation and inhibition within fatigue-related neural circuits have been proposed as a potential underlying mechanism. However, effective non-pharmacological interventions targeting cognitive fatigue after stroke remain limited.
Methods: This study investigates the effects of non-pharmacological interventions on cognitive fatigue in individuals recovering from stroke. Twenty-four participants complete four separate experimental sessions involving transcranial direct current stimulation (tDCS), whole-body exercise, handgrip exercise, and rest. Cognitive fatigue is assessed objectively using the sustained psychomotor vigilance task (PVT) and subjectively using a visual analog scale (VAS). Concurrent changes in cortical activity, with a focus on the prefrontal cortex, are monitored using functional near-infrared spectroscopy (fNIRS).
Results: It is expected that all interventions will result in changes in prefrontal cortical activity from pre- to post-intervention, with greater modulation following tDCS compared to exercise and rest conditions. Additionally, tDCS, whole-body exercise, and handgrip exercise are expected to reduce mean reaction time and the number of lapses on the PVT, as well as subjective cognitive fatigue scores measured by the VAS, compared to rest.
Conclusion: These expected findings suggest that exercise and transcranial direct current stimulation may represent feasible, cost-effective, and non-invasive approaches for mitigating cognitive fatigue following stroke. By targeting both behavioral performance and prefrontal cortical activity, this study may contribute to a better understanding of the neural mechanisms underlying cognitive fatigue and support the development of personalized, non-pharmacological rehabilitation strategies for stroke survivors.
NeuroRecoVR: Safety of split-belt virtual reality treadmill training for subacute stroke
Alexa Boyer1,
Mackenzie Trpcic1,
Zaid Alsaaran2,
Isabelle Poitras3,
John Bertram1,
Sean Dukelow1
1University of Calgary, 2Division of Physical Medicine and Rehabilitation, 3Laval University
Introduction: Up to 80% of stroke survivors have mobility and balance impairments, such as unequal step lengths, which can impede their independence and decrease their quality of life. SBT have shown promise for rehabilitating gait post stroke. Exercise after stroke has shown benefits to improving motor function, but there are still concerns about cardiovascular intensive training after stroke. Previous work has suggested split-belt treadmill (SBT) training can be safe and feasible for chronic stroke survivors. While SBT has been studied in chronic stroke, its impact in the early months post-stroke is still not well understood, especially regarding the safety and feasibility of application into clinical settings. This study aimed to assess the safety and feasibility of the SBT system as a rehabilitation tool for subacute stroke survivors and to establish its preliminary efficacy in improving gait asymmetries, walking speed, and endurance.
Methods: Fifteen participants, with an average age of 55 (range 36-69) and an average of 40 days post-stroke (range 18-86), underwent a 10-day SBT walking intervention. Participants completed 10 sessions, each with 27 minutes of treadmill training and 15 minutes of SBT walking with the affected limb on the fast belt. Heart rate and blood pressure were measured at the start of each session, after 15 minutes of SBT walking, and at the end of the session. Before the intervention, baseline assessments were conducted to measure comfortable walking speed (10-meter walk test), endurance (6-minute walk test), and lower-limb function (Fugl-Meyer Lower Extremity Scale). The assessments were repeated on days 5 and 10. Ground reaction forces were recorded during walking using force plates embedded in the treadmill, allowing for measurement of biomechanical characteristics, including step length asymmetry.
Results: The post-training average cardiovascular measures on day 1 were BP: 126/86 mmHg (range: 110/72-144/116); HR: 91 bpm (range:83-106), and on day 10 were BP: 127/77 mmHg (range: 108/55-134/97); HR: 95 bpm (range:70-114). BP and HR increased after waking on the treadmill but remained within safe limits. Patients completed 100% of sessions without experiencing any falls. Participants improved their initial average SBT walking asymmetry by 0.07 m (±0.02 SD; p = 0.004, t-test) over 10 days, suggesting that patients were learning and retaining a symmetric walking pattern. On average, participants increased their walking speed by 0.24 m/s (±0.24 SD; p=0.002) endurance by 71.1 m (±55.7 SD; p<0.001) and lower limb function by 3.14 points (±2.7 SD: p<0.001).
Conclusion: This research demonstrates the potential of VR-SBT for early post-stroke rehabilitation. The NeuroRecoVR initiative improved post-stroke patients' walking speed and symmetry without significant adverse events and without inducing unsafe BP or HR readings during the 10-day training protocol.
Use of perceived exertion scales to prescribe and monitor resistance training intensity after stroke: A scoping review
Mackenzie Butt1,
Jiwoo Park1,
Juliano Abreu1,
Nicoly Ulium2,
Kenneth Noguchi3,
Brodie Sakakibara3,
Stuart M Phillips1,
Marla K Beauchamp1,
Ada Tang1
1McMaster University, 2Federal University of São Carlos, 3University of British Columbia
Background: After stroke, muscle weakness contributes to impairments in balance, posture, movement control, and force generation. Resistance training (RT) can improve functional performance and independence in people with stroke. Stroke exercise guidelines recommend target intensity for RT at 50-80% of one-repetition maximum (1-RM), the maximum weight a person can lift once with correct technique. However, there are limitations to using 1-RM in the stroke population, including the need for specialized gym equipment and stroke related impairments that make producing a maximal voluntary contraction difficult. Rating of Perceived Exertion (RPE) scales provide a self-reported perceived difficulty during exercise and may be a more accessible alternative to 1-RM testing for monitoring and prescribing intensity; however, their application for guiding RT workloads after stroke is not well established. Therefore, the purpose of this scoping review is to synthesize the literature on prescribing and monitoring exercise intensity using RPE scales in RT interventions after stroke.
Methods: This scoping review followed the frameworks of Arksey and O’Malley with refinements by the Joanna Briggs Institute. Reporting will be in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. A comprehensive search strategy was developed with an academic librarian, including keywords for stroke, RT and RPE. Literatures searches were conducted in MEDLINE, EMBASE, Web of Science, CINAHL, and SPORTDiscus from inception to January 26, 2026. Studies were included if they used any design, involved adults post-stroke (⩾18 years), incorporated any form of resistance to enhance health or fitness (including bodyweight exercises), and reported RT intensity using RPE scales. Mixed samples were eligible if ⩾80% had stroke. Studies were excluded if they: (i) were not primary research (e.g., reviews, editorials, abstracts, opinion pieces), (ii) were not in English, (iii) lacked a RT component or (iv) did not report RPE specific to RT in multi-component interventions. Screening and data extraction will be conducted in pairs, with conflicts resolved by a third author. Methods for prescribing RT intensity and monitoring RPE will be synthesized and compared, with findings summarized in a table.
Results: Analyses are currently ongoing. After de-duplication, 3708 citations were identified. Title and abstract screening are currently underway with four independent reviewers.
Conclusion: Considering the benefits of RT for individuals living with stroke, it is important to encourage its implementation within rehabilitation. Findings from this review will provide evidence on a clinically accessible alternative for measuring RT intensity after stroke. This evidence may help reduce existing barriers to obtaining accurate intensity measurements and further support the integration of RT approaches in a rehabilitative setting.
Back to the desk: Bridging home-to-outpatient occupational therapy for return to work after mild stroke
Sze Neng Chong1
1National University Hospital
Background: Return to work (RTW) after stroke is frequently delayed by gaps during the transition from inpatient discharge to outpatient rehabilitation. A structured occupational therapy (OT) home-to-outpatient workflow may reduce this gap by targeting work-relevant upper-limb performance and confidence early at home, with planned continuation in outpatient care. This retrospective single-case evaluation describes a home-to-outpatient OT approach for RTW readiness after mild subcortical stroke.
Methods: A retrospective review of routine clinical documentation was conducted for a 54-year-old female office-based project manager with right ataxic hemiparesis following left subcortical infarct, who received a home-based OT program with planned outpatient neuro-OT follow-up. Treatment emphasised pragmatic RTW readiness: job-demand mapping (typing/mouse use, handwriting/signature, carrying a work bag, professional grooming for meetings), task-specific practice with graded speed/accuracy targets, ergonomic set-up and positioning strategies, simulation of workplace scenarios (stairs/steps with work bag, carrying food/drinks), and a structured self-managed home program. Outcomes were assessed using routine clinical measures and compared pre–post (initial assessment versus discharge from outpatient OT); including upper-extremity sensorimotor function on the Fugl-Meyer Assessment-Upper Extremity (FMA-UE), grip strength (dynamometer), typing speed (words per minute) relevant to meeting documentation, fine motor skills (grooved pegboard time), and self-reported/observed ability to complete simulated work tasks.
Results: FMA-UE improved from 60 to 62 points. Grip strength improved from 11.2 kg to 15.4 kg. Typing speed improved from 22 to 33 words per minute. Grooved pegboard time improved from 3 min 56 s to 1 min 32 s. The participant progressed to modified independent self-care and demonstrated improved performance in simulated workplace tasks. At the final home-based OT session, she could complete professional grooming using her affected hand (including eye/eyebrow cosmetics) using compensatory positioning strategies to prepare for work meetings. A graded RTW plan was established at outpatient follow-up. By outpatient OT discharge, the participant expressed confidence in managing work demands, and a memo was provided to her employer suggesting minor work accommodations to support her transition back to work.
Conclusion: In this retrospective single-case evaluation, a structured OT process bridging home-based rehabilitation to outpatient care was associated with measurable improvements in upper-limb performance and functional RTW readiness after mild stroke. This workflow provides transferable components that may be integrated into community stroke rehabilitation pathways to reduce transition gaps and better align therapy with real-world work demands.
Understanding barriers and facilitators to equitable recruitment in stroke rehabilitation trials: The protocol for the ORDER qualitative sub study
Melanie Dunlop1,
Gwyn Allin2,
Jennifer Monaghan2,
Adria Quigley3,
Sean Dukelow4,
Mark Bayley5,
Ada Tang6,
Ferne Mardlin-Smith2,
Hanna Fang6,
Jiwoo Park6,
Janet Curran3,
Susan Marzolini7,
Courtney Pollock8,
Ruth Martin-Misener3
1Nova Scotia Health, 2CanStroke, 3Dalhousie University, 4University of Calgary, 5Toronto Rehabilitation Institute, 6McMaster University, 7University Health Network, 8University of British Columbia
Background: Women and individuals with communication challenges remain underrepresented in stroke rehabilitation research. The Optimizing Recruitment to Drive Equitable Research (ORDER) study is a pilot study-within-a-trial embedded in the Canadian Maraviroc Randomized Controlled Trial to Augment Rehabilitation Outcomes after Stroke (CAMAROS). ORDER aims to identify strategies to enhance trial recruitment and includes a qualitative component exploring barriers and facilitators to participation in stroke recovery trials.
Research Question: What are the barriers and facilitators to equitable recruitment of people with lived stroke experience in stroke rehabilitation trials?
Methods: The ORDER interview sub-study uses a qualitative descriptive design guided by the Theoretical Domains Framework (TDF). Semi-structured interviews will be conducted with two groups:
Individuals with lived stroke experience approached for CAMAROS participation (those who enrolled and those who declined); and
Site Coordinators involved in recruitment and consent.
Interviews will be co-facilitated by a PhD student and a peer with lived stroke experience. Thirty individuals with lived stroke experience will be interviewed (15 enrolled, 15 declined) along with all Site Coordinators (n=xxx). Purposive sampling will ensure diversity across sex, gender, and race. At least 15 women and 10 participants identifying as Black, Indigenous, or other racialized individuals will be included, reflecting Canadian demographics (Women: 51%; Racialized: ~30%).
Interviews (~30–40 minutes) will be conducted via Zoom and will explore perceptions of recruitment and consent processes, comprehension of study materials, environmental and social influences, and decision-making supports. Participants with aphasia will be interviewed using supported communication techniques (e.g., simplified language, written keywords, verification of understanding) to ensure inclusion and accurate expression.
All Site Coordinators from active ORDER sites will be invited (N=xxx). Their interviews will explore perceived challenges and enablers to recruitment, the influence of identity (e.g., gender, role, culture), and the impact of ORDER materials on engagement. All interviews will be recorded and transcribed with Otter.ai. Deductive content analysis will map responses to TDF domains. Two researchers will independently code and compare transcripts, reaching consensus through iterative review.
Results: This protocol outlines the qualitative sub-study procedures; no results are yet available. Expected outcomes include identifying multilevel barriers and facilitators shaping equitable recruitment, with particular attention to sex, gender, and contextual factors influencing decision-making in stroke recovery research.
Conclusion: This qualitative component of the ORDER study will enhance understanding of the experiences of individuals living with stroke, particularly perceptions of barriers and facilitators to research engagement. Together with quantitative findings, these results will inform strategies to optimize informed consent and recruitment practices, promoting inclusivity in stroke rehabilitation trials.
Does glial fibrillary acidic protein (GFAP)/D-Dimer point-of-care testing improve the early detection of large/medium vesssel occlusion stroke in the emergency department?
Islam E’Leimat1,
Ehsan Yaghoubi1,
Mahesh Kate1,
Thomas Jeerakathil1,
Laura Gioia2,
Brian Buck1
1University of Alberta, 2University of Montréal
Background: Early and accurate detection of acute ischemic stroke due to large/medium vessel occlusion (LVO/MeVO) in the emergency department (ED) is critical for timely intervention. Prior research has demonstrated that combining clinical assessment scales with serum biomarkers, such as glial fibrillary acidic protein (GFAP) and D-dimer, can improve prehospital LVO identification; however, the role of point-of-care (POC) biomarkers in the ED remains unclear. The aim of this study is to determine whether adding POC GFAP and D-Dimer testing to the established ROSIER (Recognition of Stroke in the Emergency Room) Scale at emergency triage can enhance the identification of potentially treatable LVO/MeVO stroke.
Methods: This ongoing, prospective study enrolled consecutive adult patients presenting to the University of Alberta Hospital ED during daytime hours (Nov 2025–Feb 2026) with an acute code stroke activation, a ROSIER Scale ⩾ 1, and a last-known-well time < 24 hours. D-dimer (semiquantitative 1–10; negative <4, positive ⩾4) and GFAP (qualitative binary) were assessed using the LVOne rapid POC assay (Upfront Diagnostics, UK), A positive test was defined as a negative GFAP result in combination with a D-dimer value ⩾4. Final diagnosis (LVO/MeVO stroke, other stroke [intracerebral hemorrhage and Transient Ischemic Attack], or stroke mimic) was determined by chart and neuroimaging review. Combined diagnostic accuracy was assessed using the logistic regression-based receiver operating characteristic (ROC) curve analysis.
Results: A total of 61 patients were enrolled; the mean age was 72.6 ± 16.9 years, and 29 (47.5%) were male. Median ROSIER Scale was 2 (IQR 1–4). The LVOne test was valid in 55 of 61 (90.1%) patients; among these, 21 (38%) tested positive with a sensitivity of (54.2%) and higher specificity (74.1%) for LVO/MeVO stroke. In multivariable logistic regression adjusted for age, sex, ROSIER (aOR 2.5, 95% CI 1.33- 4.6; p=0.0040) and LVOone test (aOR 6.5, 95% CI 1.5- 29.3; p=0.014) were independently associated with an increased odds of stroke due to LVO/MeVO with a combined adjusted Area Under the Curve (AUC) of 0.79 (Figure1).
Conclusion: Adding POC D-dimer and GFAP to ROSIER Scale modestly increases the specificity for detecting LVO/MEVO stroke at ED triage. Future studies are needed to determine the impact on ED endovascular therapy workflow and patient outcomes.
CONtralesional inhibitory rTMS for recovery of arm function after stroke (ConTRAstroke): A Canadian feasibility trial
Jodi Edwards1,
Dorothy Barthélemy2,
Lara Boyd3,
Sean Dukelow4,
Franziska Hildesheim5,
Catherine Mercier6,
Malo Musende5,
Michelle Ploughman7,
Marc Roig5,
Sue Peters8,
Lisa Sheehy9,
Numa Dancause2,
Tibor Schuster5,
Alexander Thiel5
1University of Ottawa Heart Institute, 2Université de Montréal, 3University of British Columbia, 4University of Calgary, 5McGill University, 6Université Laval, 7Memorial University of Newfoundland, 8Western University, 9Bruyère Health Research Institute
Details
Background: The Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim) developed a standardized consensus protocol for rTMS (repetitive Transcranial Magnetic Stimulation) as an adjunct to standardized therapy for upper limb rehabilitation in sub-acute stroke [Edwards, NNR 2021 35(2)]. Here we report results of ConTRAstroke, a clinical feasibility trial testing the implementation of the CanStim protocol at 8 Canadian sites.
Methods: 83 patients with first ischemic stroke were consented. 77 patients (age 64.0±13.0 years, NIHSS 4.2±2.5, 43% female) were randomized (mean 44.6 days ±20.3). Inclusion criteria were Fugl-Meyer Upper Extremity (FM-UE) score ⩽ 56, and ability to perform the Graded Repetitive Arm Supplementary Program (GRASP). Patients received 15 sessions of 1Hz rTMS to contralesional M1 (at 120% RMT) or sham stimulation followed by 60 minutes GRASP, replacing standard-of care upper extremity task-specific therapy. Feasibility and differences in the exploratory co-primary efficacy outcomes FM-UE and Action Reach ARM Test (ARAT) and patient reported outcomes (Canadian Occupational Performance measure, COPM) are reported for the intention to treat population.
Results: 71% completed 15 sessions, 87% 10 or more 17% were lost to follow-up. There was no difference in mean change in measures of functional impairment (FM-UE and ARAT) between active and sham groups but there was and adjusted treatment effect on COPM (mean 0.86 CI 0.04, 1.68).
Conclusion: Implementing the CanStim consensus protocol in a sub-acute in-patient rehabilitation setting controlling the dose of task-specific therapy is feasible, an add-on effect of rTMS was observed for patient reported outcomes but not for motor impairment.
Effects of movement behaviours on performance and capacity outcomes post-stroke: A systematic review and meta-analysis of wearable sensor-derived walking activities in daily living
Joy Ezeugwa1,
Aiza Khan1,
Deborah Okunsanya1,
Liz Dennett1,
Brain Buck1,
Patricia Manns1,
Victor Ezeugwu1
1University of Alberta
Background: Physical rehabilitation interventions can enhance functional capacity after stroke, but improved ability doesn’t always lead to better real-world performance. Understanding this gap is key to optimizing post-stroke recovery strategies.
Objectives: This research aimed to evaluate the effectiveness of physical rehabilitation interventions specifically exercise, behavior change techniques (BCTs), or their combination on real-world walking measured using wearable sensors and capacity (gait speed and walking endurance) outcomes in stroke survivors.
Methods: This systematic review and meta-analysis followed PRISMA guidelines. Comprehensive searches were conducted in Medline, Embase, CINAHL, and Scopus up to January 2025. Randomized controlled trials involving stroke survivors receiving physical rehabilitation interventions—exercise, BCTs, or both—compared to exercise-only or usual care were included. Outcomes assessed were daily steps, gait speed (comfortable and fastest), and endurance (6-minute walk test). Meta-analyses using random-effects models (STATA 18) reported standardized mean differences (SMDs) and 95% confidence intervals (CIs). Heterogeneity was evaluated using I² statistics.
Results: Of 1,782 references screened, 28 studies met the inclusion criteria, and 23 were included in meta-analyses comprising 2,327 participants. Exercise-only interventions produced a small but significant improvement in daily steps (SMD = 0.23; 95% CI: 0.03 to 0.44; I² = 36.6%; moderate certainty), and moderate improvements in both comfortable gait speed (SMD = 0.38; 95% CI: 0.19 to 0.57; I² = 35.5%; moderate certainty) and endurance (SMD = 0.39; 95% CI: 0.26 to 0.52; I² = 0%; moderate certainty). BCT-only interventions demonstrated a larger effect on daily steps (SMD = 0.41; 95% CI: 0.19 to 0.63; I² = 0%; moderate certainty). In contrast, combined exercise and BCT interventions did not yield significant improvements in any outcomes and were supported by very low to low certainty of evidence.
Conclusion: Exercise-only interventions improve gait speed and endurance after stroke, with small gains in daily steps. BCT-only interventions yield greater improvements in daily walking activity. Combined interventions show limited added benefit.
Protocol registration: This study has been registered in PROSPERO (No. CRD42023411679)
Patterns of 24-hour movement behaviour in acute and subacute phases of recovery after ischemic stroke: A cross-sectional study
Joy Ezeugwa1,
Brian Buck1,
Patricia Manns1,
Victor Ezeugwu1
1University of Alberta
Background: Early stroke recovery is characterised by changes in physical capacity and functional mobility; however, how these changes translate into real-world movement behaviour (sedentary time and physical activity) across the 24-hour activity cycle remains poorly understood. Guided by the 24-hour activity cycle framework, this study examined movement behaviours across the acute care and subacute recovery phases after ischemic stroke. We also examined associations between timed walking tests, movement behaviour, and health-related quality of life.
Methods: This cross-sectional study included adults able to walk 5 meters. Participants were recruited in the acute phase (within 7 days of stroke; n = 18) and subacute recovery phase (within 3 months of stroke; n = 25). Movement behaviours were captured using 24-hour activPAL accelerometry. Functional mobility was assessed via the 6-minute walk test (6MWT), 10-m walk test, and Timed Up and Go (TUG). Health-related quality of life was assessed using the EQ-5D visual analogue scale. Between-group differences for age and NIHSS were examined using independent samples t-tests, and sex was compared using a Pearson chi-square test. All statistical analyses were performed in Stata 14
Results: Participants in the acute group had a mean age of 66.5 years (SD 13.0), were predominantly male (66.7%), and presented with a median NIHSS score of 2 (IQR 0–4). In comparison, the subacute group (mean age 68.0 ± 11.9 years; 48.0% male) exhibited higher stroke severity with a median NIHSS of 7 (IQR 4–8). Total daily sedentary time was high and remained consistent between the groups (708.3 vs. 720.8 min/day, p = 0.79).
While the subacute group showed significantly greater walking endurance (6MWT: 314.2m vs 218.6m, p = 0.004), daily step counts (p = 0.46) and sit-to-stand transitions (p = 0.22) did not differ. Exploratory analysis revealed that walking endurance (6MWT) and EQ-5D VAS were strong predictors of daily activity in the acute phase (rho = 0.75, p < 0.05; rho = 0.80, p < 0.05), yet this relationship was no longer significant in the subacute phase (rho = 0.40, p = 0.10). In contrast, gait speed maintained significant moderate-to-strong associations with daily step counts across both the acute (rho = 0.70) and subacute (rho = 0.50) recovery phases (p < 0.05). Functional mobility, as measured by the Timed Up and Go (TUG) test, showed no significant association with real-world step counts.
Conclusion: Although functional walking capacity is significantly higher in the subacute phase, real-world movement behaviours remain highly sedentary and do not differ from the acute phase. This suggests a disconnect between measured walking capacity and real-world performance. Rehabilitation strategies should address environmental and behavioural barriers to translate functional gains into increased daily activity.
Keywords: Ischemic Stroke; 24-Hour Activity Cycle; Accelerometry; Sedentary Behaviour; Physical Activity; Functional Capacity.
Predictors of favourable modified Rankin scale outcome during inpatient rehabilitation for subacute stroke: A secondary analysis of the Walk ‘n Watch trial
Victor Ezeugwu1,
Sue Peters2,
Stanley Hung3,
Mark Bayley4,
Krista Best5,
Louise Connell6,
Sarah Donkers7,
Sean Dukelow8,
Marie-Hélène Milot9,
Brodie Sakakibara3,
Lisa Sheehy10,
Hubert Wong3,
Yuwei Yang3,
Jennifer Yao11,
Janice J. Eng3
1University of Alberta, 2Western University, 3University of British Columbia, 4Toronto Rehabilitation Institute, 5Université Laval, 6Lancaster University, 7University of Saskatchewan, 8University of Calgary, 9Université de Sherbrooke, 10Bruyère Health Research Institute, 11Vancouver Coastal Health
Background: Identifying prognostic factors associated with favourable outcomes in early subacute stroke may support targeted rehabilitation interventions. This study examined admission clinical characteristics associated with favourable modified Rankin Scale (mRS ⩽2) outcome at discharge following inpatient rehabilitation for early subacute stroke and assessed whether predictors differed by rehabilitation intensity.
Methods: This secondary analysis included 267 participants within 12 weeks post-stroke from the Walk ‘n Watch (WnW) stepped-wedge cluster randomized trial conducted across 12 Canadian inpatient rehabilitation sites. Eligible participants were medically stable adults (⩾18 years) able to walk ⩾5 steps with no more than one-person assistance at admission. Participants received either usual care (n=139; 30–60 minutes/day of physical therapy) or the WnW protocol (n=128), which delivered a similar therapy duration but emphasized higher-intensity walking (40–60% heart rate reserve) guided by activity trackers. Assessments were conducted at admission to inpatient rehabilitation and 4 weeks later (discharge). Admission characteristics included age, sex, time since stroke onset, stroke type, admission mRS, depression (Patient Health Questionnaire-9), cognitive function (Montreal Cognitive Assessment; MoCA), and walking endurance (6-minute walk test; 6MWT). Sequential multivariable logistic regression models examined associations between admission characteristics and favourable mRS outcome at discharge, stratified by rehabilitation intensity. Model performance was evaluated using Area Under the Curve (AUC), Nagelkerke’s pseudo-R², and Akaike’s Information Criterion (AIC).
Results: Participants mean age was 67.9±12.5 years; 39.3% were female, 81.7% had ischemic stroke, and mean time since stroke was 28.3±17.4 days. Mean admission MoCA score was 21.4±6.1 and 6MWT distance was 148.4±107.2 meters. Admission characteristics did not differ between groups. Favourable mRS outcomes at discharge were achieved by 40% of usual care and 44% of WnW participants. Predictors varied by rehabilitation intensity. In usual care, shorter time since stroke, hemorrhagic stroke, and lower admission mRS were associated with favourable mRS (p<0.05). In contrast, higher MoCA score was associated with favourable mRS in the WnW group (p<0.05), with trends for greater walking endurance and male sex. Model discrimination was high and stable in usual care (AUC 0.81–0.82; Nagelkerke R² 0.36–0.39), whereas WnW models showed progressive improvements in model fit (AUC 0.69–0.77) and explained variance (Nagelkerke R² 0.14–0.26) with added variables.
Conclusion: Admission characteristics associated with favourable mRS outcome differed by rehabilitation intensity. Our findings suggest that rehabilitation intensity modifies the relevance of admission characteristics and underscore the importance of considering both patient factors and therapeutic dose in subacute stroke rehabilitation.
A pilot randomized trial of a behavioural intervention with guided stepping training early post-stroke (BIG STEPS)
Victor Ezeugwu1,
Mona Iyizoba2,
Asya Shiloff-Rogers2,
Joy Ezeugwa1,
Sophia Pawelko1,
Andrew Chan2,
Jake Hayward1,
Carmen Tuchak2,
Jaime Yu1
1University of Alberta, 2Glenrose Rehabilitation Hospital
Background: Prolonged sedentary time is common after stroke and is associated with poor health outcomes. Following hospital discharge, access to rehabilitation is often reduced and fragmented, making the transition to home a particularly vulnerable period for people with stroke and their care partners. This pilot study evaluated the feasibility and preliminary effects of a home-based behavioural intervention with guided stepping training early after stroke (BIG STEPS).
Methods: In this single-blind (assessor) randomized waitlist-controlled trial, adults (⩾18 years) within 3 months of ischemic or hemorrhagic stroke were enrolled. Eligible participants were able to walk ⩾5 meters with or without a gait aid and were recruited prior to or shortly after discharge home from hospital. Exclusion criteria included pre-existing mobility-limiting conditions, bedrest orders, or cognitive impairments limiting the ability to follow instructions.
Participants were randomized to early BIG STEPS (n=14) or waitlist control (n=14). The 12-week BIG STEPS intervention targeted reducing prolonged sedentary time and increasing daily steps using behaviour change strategies, including education, outcome expectations, self-monitoring, and action planning. The waitlist group received the intervention after a 12-week delay. All participants received usual care.
Primary outcomes were feasibility, adherence, and safety. Exploratory outcomes assessed at baseline, 3, and 6 months included accelerometer-derived sedentary time and daily steps, timed walking tests (6-minute walk test, Timed Up and Go, gait speed), and patient-reported outcomes.
Data were analyzed using linear mixed-effects models with restricted maximum likelihood and Kenward–Roger adjusted degrees of freedom, including fixed effects for group, time, and group-by-time interaction.
Results: Twenty-eight participants with ischemic or hemorrhagic stroke were enrolled (13 female [46%]; mean age: 67.8 ±13.3 years). Recruitment averaged 2.3 participants per month. Retention exceeded the a priori threshold of 80% at weeks 12 and 24 (86-93%). No intervention-related serious adverse events occurred.
At week 12, the early BIG STEPS group accumulated a mean of 6534 ± 2773 steps/day compared with 4031 ± 2072 steps/day in the delayed BIG STEPS group. Sedentary time decreased by approximately 1.4 hours/day in the early BIG STEPS group and 0.7 hours/day in the delayed BIG STEPS group. Between-group effects favoured the early group for daily steps (Hedges’ g = 1.4) and sedentary time (Hedges’ g = −1.1).
At week 24, outcomes converged after the delayed BIG STEPS group received the intervention. Between-group differences for timed walking tests and patient-reported outcomes were small.
Conclusion: A behavioural intervention combined with guided stepping training early after stroke was feasible and safe, with preliminary effects supporting progression to a fully powered randomized controlled trial.
The application of transcranial direct current stimulation (tDCS) in stroke patients with dysphagia: An umbrella review
Sima Farpour1,
Abel Davtyan2,
Hadi Niaz1,
Kiana Hosseini3,
Paawan Virdi1,
Willow Leahy1,
Neha Saroya1,
Nora Cullen1
1McMaster University, 2University of Limerick, 3York University
Background: Post-stroke dysphagia (PSD) significantly impacts patients' quality of life (QOL) and increases the risk of complications. Transcranial direct current stimulation (tDCS) has emerged as a potential adjunct to enhance recovery, but findings across systematic reviews (SRs) are mixed and inconsistent. This umbrella review aims to synthesize and evaluate existing high-level evidence to clarify the efficacy, effectiveness, and safety of tDCS in post-stroke swallowing rehabilitation, summarize stimulation parameters, identify gaps, and inform clinical practice and future research.
Methods: Seven databases were searched. SRs of randomized clinical trials (RCTs) were included if they discussed tDCS application in PSD. Exclusion criteria were dysphagia attributable to non-stroke ethiologies; Other non-invasive brain stimulations than tDCS; SR of non-RCTs; non-English articles; or not peer-reviewed published journal articles. Two independent reviewers completed screening and data extraction. The disagreements were resolved by the third reviewer. AMSTAR-2 and ROBIS were used for assessment of bias. PROSPERO registration: CRD42025125045.
Results: Twenty-three systematic reviews were included from an initial pool of 1,315 records. The majority of SRs (n=22) reported that tDCS was effective for PSD rehabilitation. Meta-analyses comparing tDCS with control demonstrated moderate to high pooled effect sizes in favor of tDCS (SMD=0.65, 95%CI=0.25–1.04;p=0.00;I²=42%). Significant improvements in QOL were also reported, with a pooled effect size favoring tDCS over control (SMD=1.18,95%CI=0.54–1.83;p< 0.001).
Subgroup analyses across reviews suggested larger effect sizes when tDCS was applied during the acute stroke phase (SMD =1.03,95%CI=0.54–1.52) compared with the chronic phase (SMD=0.56,95%CI=0.28–0.85). Findings regarding hemisphere of stimulation were inconsistent: some meta-analyses favored stimulation of the unaffected hemisphere (SMD= 0.88,95%CI=0.49–1.27;p< 0.0001), while others reported significant pooled effects for both affected (g=0.87,95%CI=0.26–1.48;p =0.005) and unaffected hemispheres (g=0.61,95%CI=0.23–0.99;p=0.002), with substantial heterogeneity reported in some analyses.
Safety outcomes were addressed in three SRs. Where reported, tDCS was well tolerated, with only mild transient adverse effects (e.g., tingling or itching) and no serious or life-threatening adverse events documented.
Conclusion: Current evidence supports tDCS as a safe and effective adjunct to conventional swallowing rehabilitation in PSD, with moderate to large improvements in swallowing function and quality of life. However, substantial heterogeneity across studies—particularly regarding stimulation parameters, timing, and hemisphere of stimulation—limits definitive clinical guidance. These findings highlight a critical need for well-designed feasibility and randomized trials to optimize tDCS protocols and inform evidence-based clinical implementation.
Changes in unimanual and bimanual upper extremity use during the subacute phase post-stroke and the influence of supervised and unsupervised contexts
Léandre Gagné-Pelletier1,
Isabelle Poitras2,
Marc Roig3,
Catherine Mercier4
1Laval University, 2University of Calgary, 3McGill University, 4Université Laval
Background: The subacute phase after stroke is a critical period for recovery, yet the extent to which gains in upper extremity (UE) capacity translate into real-world use remains uncertain. Accelerometry provides an objective way to quantify UE use, but little is known about patterns of unimanual and bimanual use and how they can be influenced by different contextual factors. This longitudinal study aimed to characterize changes in patterns of UE use during the subacute phase and to determine how different contexts influence UE use.
Methods: Forty-one participants were assessed at admission to inpatient rehabilitation (28 ± 8 days post-stroke), before discharge (68 ± 11 days post stroke), and at six months post-stroke. UE use was measured with wrist-worn accelerometers over seven consecutive days in three contexts: daily life, therapy sessions, and functional assessments. Outcomes included the use ratio (paretic/non-paretic) and the percentage of unimanual and bimanual use.
Results: Unimanual use of the non-paretic UE was the most frequent pattern observed at admission, representing 56.8% of the total UE use, while bimanual use represented 29.3%. At 6 months post-stroke, a more mixed pattern was observed with similar proportion of non-paretic unimanual use and bimanual use (44.4% and 39.2%, respectively). Use ratio improved between admission and discharge (from 0.53 to 0.69; p<0.001), indicating a more symmetrical UE use, but no further change was observed after discharge (p=0.09). Percentage of unimanual non-paretic use decreased while bimanual use increased across all time points (p⩽0.03). Percentage of unimanual paretic use remained low (between 14.0 and 16.5%), with no change over time (p=0.37). An effect of context was observed for all accelerometry variables (p⩽0.003), showing more asymmetric UE use outside of supervised clinical contexts (therapies and assessments).
Conclusion: Recovery during the subacute phase is characterized by substantial improvement in UE use during rehabilitation, followed by subtle changes in use patterns during the late subacute phase. At admission, compensation through unimanual use of the non-paretic UE was predominant, gradually evolving toward a mixed strategy of bimanual and unimanual non-paretic use over time. The discrepancy between UE use during supervised clinical contexts and spontaneous use in daily life highlights the need for accelerometry-based monitoring in clinical practice.
Deficits in adapting to novel forces during reaching are common in early stroke recovery
Joshua Garland1,
Camille Eamon1,
Robert Moore1,
Sean Dukelow1,
Tyler Cluff1
1University of Calgary
Background: Motor adaptation is the process of recalibrating movement in response to sensory feedback about changes in the body or environment that cause movement errors. During stroke rehabilitation, therapists often use task-specific practice in which survivors experience movement errors and learn to correct them. For example, when reaching to place a coffee cup on a table, the arm may deviate off target. The nervous system uses the incoming proprioceptive feedback about these errors to adapt movement. While adaptation is a tenet of rehabilitation, most evidence comes from healthy adults or chronic stroke, long after rehabilitation is usually complete. Here, we investigated proprioception-driven adaptation in early stroke recovery, and whether adaptation is correlated with scores on clinical assessments of sensorimotor and functional impairment.
Methods: Forty-five adults with first-time, unilateral stroke (13[3-26] days post-stroke) and 139 control participants completed a motor adaptation task in a Kinarm robotic exoskeleton. In the task, participants made 150 reaching movements to virtual targets presented in their workspace. While reaching, the robot applied small forces to the arm perpendicular to the direction of the reach. Participants completed 24 reaches without forces (Baseline phase), 108 with forces (Adaptation), and 18 without forces (Washout). Stroke participants completed the task with their more affected arm, while controls completed the task with either their dominant or non-dominant arm.
We used three metrics to quantify motor adaptation: the mean peak lateral deviation (PLD) of the hand from a straight line connecting the targets during the first 15 Adaptation trials (Early Adaptation), the mean PLD during the last 15 Adaptation trials (Late Adaptation), and the number of trials needed to adapt to the applied forces (Trials to Adapt). We constructed normative models using healthy control performance, with age, sex, and dominance of the tested arm included as predictors. On each metric, stroke participants were considered impaired if their performance exceeded 95% of the normalized control distribution.
Results: 47% of stroke survivors were impaired in Early Adaptation, 47% in Late Adaptation, and 38% in Trials to Adapt. Performance on each metric showed moderate-to-strong correlations (ρ = -0.62 to -0.41) with the Fugl-Meyer Assessment-Upper Extremity, Medical Research Council strength scale, and Functional Independence Measure (p-values<0.01), but not the Thumb Localization Test (p>0.05).
Conclusion: Adaptation using proprioceptive feedback was impaired in early stroke recovery, and adaptation was correlated with clinical assessments of motor function, strength, and functional independence. These results further our understanding of motor adaptation and its relationship with clinical impairments in subacute stroke. In the future, this may help therapists tailor rehabilitation to a patient’s specific motor adaptation impairments.
Quantitative Hounsfield unit analysis on time-resolved CT angiography: Distinguishing hemodynamically significant carotid webs from non-stenotic plaques
Pranil Gc1,
Jordy Andres Velasco Nieto1,
Janet Halladay1,
Ruba Kiwan2,
Ravinder-Jeet Singh3
1Health Sciences North Research Institute, 2London Health Sciences Centre, 3Health Sciences North
Background: Carotid webs (CW) and non-stenotic plaques are increasingly recognized as causes of "cryptogenic" stroke due to focal flow stagnation and thrombosis. While advanced imaging like CFD and 4D-flow MRI has shown that CWs generate larger recirculation zones, a simple, reproducible imaging biomarker on CT angiography is lacking. We aimed to quantify voxel-level Hounsfield Unit (HU) differences on time-resolved CTA (trCTA) as a proxy for contrast retention and hemodynamic disturbance in CW versus non-stenotic plaques.
Methods: In this prospective pilot study, we analyzed adults with TIA or ischemic stroke and non-stenotic (<50%) carotid bifurcation lesions. Lesions were classified via arterial-phase CTA as CW or non-stenotic plaque based on typical morphology. Using late venous (washout phase) trCTA phases, regions of interest (ROIs) were placed in the post-lesion recirculation zone and a distal common carotid artery as a reference segment. Two blinded reviewers (R1 and R2) independently calculated ΔHU as venous phase HU in the pocket immediately cranial (downstream) to the lesion minus the distal common carotid artery.
Results: Nine patients were analyzed: 4 with carotid webs (mean age 50.8±5.8 years) and 5 with non-stenotic plaques (70.6±9.1 years; p=0.019). Both reviewers showed consistent trends of higher HU differences in CW (pooled: 67±39 vs 38±19, p=0.075). Inter-rater agreement was strong (Pearson r ΔHU=0.87, Cohen’s κ=0.78 binarized). CW demonstrated greater contrast retention, indicating hemodynamic disturbance.
Conclusion: Quantitative trCTA analysis reveals that carotid webs demonstrate greater contrast retention than non-stenotic plaques, suggesting a higher degree of hemodynamic disturbance and status. These ROI-based biomarkers provide a simple, objective measure of disturbed flow that could improve diagnosis and risk stratification of non-stenotic carotid bifurcation lesions.
Impact of the personalized Integrated Cognitive-Somatosensory-Motor (iCOSMO) Intervention to improve upper limb recovery after stroke: Three case reports
Urvashy Gopaul1,
Megha Saini1,
Mark Bayley1
1Toronto Rehabilitation Institute
Background: The integrated Somatosensory-MOtor training using a COgnitive approach (iCOSMO) training intervention aims to improve upper limb recovery in people with chronic stroke. The iCOSMO training combines robotic training using the Kinarm Exoskeleton device with haptic perception exploratory tasks through active touch and movement exploratory procedures during goal-oriented tasks. The iCOSMO intervention is delivered three times per week, two hours per session for 6 weeks. This study explores the impact of the iCOSMO intervention on upper limb recovery in people with chronic stroke.
Methods: Three people (Participant A: Male, 60 years; 12 months post-stroke; Participant B: Male, 42 years, 13 months post-stroke; Participant C: Male, 74 years; 20 months post-stroke) have completed the iCOSMO intervention. The clinical tasks and Kinarm robotic tasks were gradually progressed with increasing levels of difficulty to maintain a sufficient level of challenge to optimize movement and somatosensory re-learning and upper limb recovery. Standardized motor and somatosensory clinical assessments included the Fugl-Meyer- upper extremity (FMA-UE), action research motor test (ARAT), Wolf motor function test (WMFT), box and block (BBT), grip and pinch strength, tactile discrimination test (TDT), wrist position sense test (WPST) and functional tactile object recognition (FTORT). The participants were tested at pre- and post-intervention, and at 1-month follow-up. Three additional participants are currently receiving the iCOSMO intervention.
Results: Participant A and C completed 18 sessions (36 hours) of iCOSMO while Participant B completed 16 sessions (32 hours) of iCOSMO. Participant A improved by 2.2-95.5% in all measures at post-intervention. From post-intervention to follow-up, improvements were observed only in the ARAT, WMFT, BBT and pinch strength. Participant B improved by 8.2-90.8% in all measures, except in the TDT at post-intervention. From post-intervention to follow-up, improvements were observed in all measures, except the FMA-UE and ARAT. Participant C improved by 7.6-78.9% in all measures, except FTORT and grip strength at post-intervention. From post-intervention to follow-up, improvements were observed in pinch strength and WPST only.
Conclusion: iCOSMO is a novel intervention combining somatosensory, motor and cognitive training that demonstrates improvements in movement and somatosensation. Thus, iCOSMO could be a promising neurorestoration intervention to improve upper limb recovery after stroke.
The personalized integrated COgnitive-somatoSensory-Motor(iCOSMO) intervention to improve upper limb function after stroke: Preliminary data on the perspectives of people with stroke
Urvashy Gopaul1,
Mark Bayley1
1Toronto Rehabilitation Institute
Background: The integrated Somatosensory-MOtor training using a COgnitive approach (iCOSMO) training intervention aims to improve upper limb recovery in people with chronic stroke. The iCOSMO intervention includes two treatment modalities: (1) robotic training in the form of eight graded gaming tasks, using the Kinarm Exoskeleton device and (2) restorative clinical tasks through active touch and movement exploratory procedures during goal-oriented tasks. Cognitive strategies that integrate learning theory and motor acquisition to perform daily activities were emphasized during the integrated motor and sensory training tasks. The iCOSMO intervention is delivered three times per week, two hours per session for 6 weeks. This study aims to explore the perspectives of the recipients of iCOSMO about their perspectives on benefits of iCOSMO and barriers that they faced during their participation in the study.
Methods: Three people (Participant A: Male, 60 years; 12 months post-stroke; Participant B: Male, 42 years, 13 months post-stroke; Participant C: Male, 74 years; 20 months post-stroke) completed the iCOSMO intervention. They participated in a semi-structured interview (1 hour) conducted virtually through Microsoft TEAMS. The interview explored their perspectives about the benefits of iCOSMO, the barriers of participation in the iCOSMO trial and their overall level of satisfaction about the iCOSMO intervention. The recordings were transcribed verbatim and analyzed for inductive thematic analysis using implementation theory. Three additional participants are currently receiving the iCOSMO intervention.
Results: The three participants reported improved motor function such as increased range of motion of their upper limbs and fine motor skills of their hands. The participants reported improved tactile touch sensations in their hands. The frequency and duration of the iCOSMO intervention was perceived as sufficient and satisfactory. All three participants found the robotic and exploratory tasks engaging. They reported that the graded challenges of the robotic and exploratory tasks were helpful in improving their upper limb recovery. Two participants reported challenges with accessible public transport to the rehabilitation centre which caused delays in attending appointments in a few instances. The participants were satisfied with the iCOSMO intervention, although they would have preferred to have more sessions of iCOSMO beyond the 18 planned sessions. They also reported that they would recommend the iCOSMO intervention to other people with stroke.
Conclusion: The iCOSMO intervention offers a novel upper limb training integrating cognition, movement and somatosensation for people with stroke. Recipients of iCOSMO are likely to benefit from the intervention by improving movement and touch sensations after stroke. The iCOSMO intervention could be a promising neurorehabilitation program to improve upper limb recovery after stroke.
PROVE-VR: Protocol for a pilot randomized trial using omnidirectional treadmill virtual reality training for chronic stroke
Skeets Greene1,
Bridget Daly1,
Cory Munroe1,
Courtney Pollock2,
Sean Dukelow3,
Anouk Lamontagne4,
Heather Neyedli5,
Alison Mcdonald6,
Melanie Dunlop1,
Mayra Barrera Machuca1,
Janice Eng2,
Adria Quigley1
1Dalhousie University, 2University of British Columbia, 3University of Calgary, 4McGill University, 5Dalhousie University, 6Nova Scotia Health
Background: Virtual reality (VR) has been introduced to neurorehabilitation to promote improvements in cognitive and physical function. Omnidirectional treadmill technology can be integrated with VR (Omni-VR) to allow for immersive rehabilitation. Task-oriented, repetitive, and engaging rehabilitation approaches have been shown to be effective for stroke recovery regardless of recovery stage. Omni-VR enables multidirectional movement while completing challenging rehabilitation activities in VR, which creates a cognitive-motor training environment necessary to simulate community ambulation. To our knowledge, this is the first study to test the feasibility and efficacy of an Omni-VR system among persons living with chronic stroke (PLWCS). Our primary objective is to test the feasibility of Omni-VR among PLWCS. Our secondary objective is to estimate the extent to which cognition, walking, balance, and brain activation during dual task walking change following a 12-week Omni-VR or traditional exercise program.
Methods: For this pilot randomized controlled trial, we are recruiting 23 PLWCS from rehabilitation facilities in Halifax, Nova Scotia. Upon eligibility screening and baseline assessment, participants are randomized 2:1 to the intervention or control groups. All participants will undergo 45-minute training sessions 3 times/week for 12 weeks, with the intervention group using Omni-VR and the control group completing a traditional exercise program. Blinded assessors are evaluating participants at baseline and 12 weeks post-intervention.
Anticipated Results: This is a pilot trial; as such, between group analyses are not indicated. Feasibility outcomes (Consent and retention rates, adherence, system usability, participant burden, technical issues and safety) will be reported on using descriptive statistics and evaluated for success based on a priori criteria. Secondary outcomes (balance, walking, cognition, brain activation during dual task walking, health-related quality of life and motivation) will be assessed based on whether participants meet minimal important change thresholds across outcome measures.
Conclusion: Omni-VR has the potential to provide a low-cost, safe, and engaging method of rehabilitation to supplement current conventional therapies. If successful, we will test the use of Omni-VR training among PLWCS in a full-scale trial.
Trial Registration: clinicaltrials.govw4 NCT06495450
Post-stroke vision impairment is in the eye of the beholder
Alexis Hill1,
Lydia Kuhl1,
Isabelle Poitras2,
Matthew Chilvers1,
Sean Dukelow1
1University of Calgary, 2Université Laval
Background: Recent quantitative evidence suggests that more than 50% of stroke survivors have vision impairment, but less than 20% are identified by clinical assessment during inpatient care. This leads us to believe that vision impairments, including visual fields, attention, or oculomotor dysfunction, often go clinically undetected due to coarse and imprecise bedside vision assessments. Intact visual systems decrease falls and improve independence, making detection of vision impairment imperative for successful stroke rehabilitation. We assessed saccades (voluntary and involuntary rapid ballistic eye movements) in stroke survivors to quantify those with vision impairment but without diagnosis.
Methods: Subacute stroke survivors (n=42 [48±46 days post-stroke, mean ± SD]) completed a saccade task using an eyetracking camera. During the task, participants were instructed to look at a central fixation target. When the fixation target turned off, they were instructed to look to one of two possible peripheral targets as they appeared (10cm to the right or left, presentation order pseudorandomized). Participants completed 60 trials. Additionally, participants completed clinical assessments for visual acuity (Snellen Eye Chart) and visual fields (confrontation testing) to ensure they could identify task targets. We measured the accuracy and latency of the first outward saccade initiated to each peripheral target. Parameters for defining impairment were based on a control model (n=114) and stroke survivor data was age and sex matched to produce normative scores. To collect data on clinical detection of vision impairment, stroke survivor’s charts were reviewed for any record of vision impairment identified during their inpatient stay.
Results: On the saccade task, 42.9% (18/42) of participants were impaired on either accuracy or latency. Of those impaired, 61% (11/18) were identified by eyetracking and undetected clinically. Of those 11, 5 were impaired on accuracy, 3 were impaired on latency, and 3 were impaired on both parameters. During inpatient care, 39% (the remaining 7/18) were identified clinically. Of those 7, 3 were impaired on accuracy, 2 of whom were diagnosed with neglect and 1 with visual field impairment. The other 4 were impaired on both accuracy and latency and had visual field deficits; 1 was also diagnosed with neglect, and 1 with neglect and oculomotor dysfunction.
Conclusion: More than half of stroke survivors with vision impairment may go undiagnosed during inpatient care. Here, we only examined two parameters of saccadic dysfunction and found 61% of visually impaired participants did not receive a diagnosis of vision impairment. This suggests that quantitative vision screening, like the eyetracking camera and saccade task used in this project, has potential to improve sensitivity of vision impairment diagnosis, and subsequently contribute to stroke recovery.
Baseline Stroke severity predicts clinical outcome after thrombolysis in acute ischemic stroke: Results from the AcT trial
Seyed Mojtaba Hosseini1,
Mohammed Almekhlafi2,
Aravind Ganesh2,
Luciana Catanese3,
Brian Buck4,
Aleksander Tkach5,
Richard H. Swartz6,
Tolulope T. Sajobi2,
Bijoy Menon2,
Nishita Singh1
1University of Manitoba, 2University of Calgary, 3McMaster University, 4University of Alberta, 5Interior Health, 6University of Toronto
Background: Baseline stroke severity, measured by the National Institutes of Health Stroke Scale (NIHSS), is associated with outcomes after acute ischemic stroke. We evaluate the association between baseline NIHSS categories with functional, safety outcomes, and health service outcomes among patients enrolled in the Alteplase compared to Tenecteplase (AcT) trial, a pragmatic, multicenter randomized trial.
Methods: Patients were stratified by baseline NIHSS into mild (0-7), moderate (8-15), and severe (³16). Baseline characteristics were compared across groups. Outcomes at 90 days included functional independence (modified Rankin Scale [mRS] 0-1, 0-2), ordinal shift in mRS, return to baseline function, length of hospital stay, and discharge disposition. Safety outcomes included intracranial hemorrhage (ICH), radiological hemorrhage subtypes, and 90-day mortality. Logistic regression was used for binary outcomes, ordinal logistic regression for mRS shift, and negative binomial regression for length of stay, adjusting for age, sex, onset-to-needle time, occlusion location, thrombolytic type, and the interaction between baseline NIHSS and thrombolytic type. Effect sizes are reported as adjusted odds ratios from logistic and ordinal logistic regression models, and incidence rate ratios from negative binomial regression. Interaction between baseline NIHSS strata and thrombolytic type was tested within the fully adjusted models for functional outcomes.
Results: Of 1,570 patients with available baseline NIHSS, 619 (39.4%) had NIHSS 0-7, 504 (32.1%) NIHSS 8-15, and 447 (28.5%) NIHSS ³16. Functional recovery worsened progressively with increasing NIHSS. Compared with NIHSS 0-7, the odds of achieving mRS 0-1 at 90 days were significantly lower for NIHSS 8-15 (aOR 0.46; 95% CI 0.32–0.66) and NIHSS ³16 (aOR 0.38; 95% CI 0.24-0.59). Similar patterns were observed for mRS 0-2 and return to baseline function. Ordinal mRS shift analyses demonstrated worse overall disability with increasing stroke severity (NIHSS 8-15: adjusted common OR 2.14; 95% CI 1.59–2.88, NIHSS ³16: adjusted common OR 3.27; 95% CI 2.87–4.47) when compared with NIHSS 0-7. Length of stay increased with stroke severity, with longer stay in moderate (aIRR 1.21, 95% CI 1.01–1.45) and severe NIHSS groups (aIRR 1.75, 95% CI 1.41–2.18). No significant interaction between baseline NIHSS strata and thrombolytic type was observed for functional outcome (Table 1). Ninety-day mortality was higher with increasing baseline stroke severity (aOR 2.00; 95% CI 1.17-3.45), and NIHSS ³16 (aOR 3.06; 95% CI 1.71-5.56), compared with NIHSS 0-7. Severe parenchymal hemorrhage (PH2) was significantly more frequent with increasing stroke severity, with markedly higher adjusted odds in NIHSS ³16 compared with NIHSS 0-7 (aOR 5.58; 95% CI 1.36-29.42).
Conclusion: Baseline NIHSS independently predicts functional recovery, mortality, and severe hemorrhagic complications after thrombolysis. Compared with mild stroke, moderate and severe stroke have worse outcomes, highlighting NIHSS as a prognostic tool for clinical decision-making and trial interpretation.
Sex-related variation in carotid plaque features and their impact on major adverse cardiovascular event in MESA study
Seyed Mojtaba Hosseini1,
Preethi Srikanthan2,
Tamara B Horwich3,
Karol Watson4,
Nishita Singh1
1University of Manitoba, 2University of California, Los Angeles, 3University of California, Los Angeles, 4University of California, Los Angeles
Background: Sex differences influence atherosclerosis, vascular structure, and plaque characteristics. Sex-specific associations between carotid artery structure, plaque features, and cardiovascular outcomes were examined.
Methods: Participants were drawn from the Multi-Ethnic Study of Atherosclerosis (MESA), a prospective, population-based cohort. Carotid ultrasound measures included wall area (mm²), intima-media thickness (IMT, mm), remodeling index, normalized wall index, and Young’s elastic modulus (kPa), assessed separately for the internal (ICA) and common carotid arteries (CCA). A subset underwent carotid MRI to characterize plaque features (lipid core presence, calcium presence, fibrous cap thickness [mm]). Associations between imaging features and major adverse cardiovascular events (MACE: myocardial infarction, stroke, angina, coronary revascularization, or cardiovascular death) were examined using Cox proportional hazards models. Models were adjusted for age, body mass index, systolic blood pressure, diastolic blood pressure, hypertension, diabetes, total cholesterol, alcohol intake, smoking status, pack-years, cigarettes/day, and time since quitting.
Results: Of 3,447 participants included, 1,826 (52.97%) were women (median age 69 years [IQR 62-77]) and 1,621 (47.02%) were men (median age 70 years [IQR 62-77]). Over approximately 10 years of follow-up, total MACE occurred in 20.6% of men and 13.8% of women (p<0.01). On ultrasound, men had higher common carotid IMT than women (0.80 ± 0.37 vs 0.69 ± 0.29 mm, p<0.01) and lower arterial elasticity (Young’s modulus 175.22 ± 112.55 vs 201.22 ± 143.98 kPa, p<0.01). In adjusted, sex-stratified Cox models, higher ICA IMT and normalized wall index were associated with increased risk of total MACE in both men and women. In contrast, ICA wall area was associated with total MACE in women (adjusted HR 1.19, 95% CI 1.08-1.32) but not in men (adjusted HR 1.06, 95% CI 0.97-1.17). Tests for heterogeneity by sex did not indicate statistically significant differences in these associations (all p-interaction >0.05).
For individual outcomes, significant sex heterogeneity was observed for ICA wall thickness in relation to myocardial infarction (women adjusted HR 1.26, 95% CI 1.08-1.46 vs men adjusted HR 0.99, 95% CI 0.82-1.18; p-interaction = 0.041). Among MRI-derived ICA vulnerable plaque features, lipid core presence was strongly associated with angina in men (adjusted HR 2.44, 95% CI 1.50-3.98) but not in women, with a significant sex interaction (p-interaction = 0.012), while no other plaque feature demonstrated consistent sex-specific associations across outcomes.
Conclusion: Carotid structural and plaque features were associated with cardiovascular events in both sexes. Although some associations differed in magnitude, formal interaction testing did not confirm significant sex heterogeneity. These findings support cautious interpretation of sex-specific associations and highlight the importance of comprehensive risk adjustment when evaluating carotid imaging biomarkers.
Assessing treatment response variance to transcranial magnetic stimulation and multimodal aphasia therapy in chronic stroke survivors
Johanna Jacob1,
Trevor Low1,
Matthew Chilvers1,
Sean Dukelow1
1University of Calgary
Background: Post-stroke aphasia affects up to 52% of chronic stroke survivors, and is treated acutely with speech language therapy. Recently, a successful trial from our lab showed that repetitive transcranial magnetic stimulation (rTMS) delivered with multimodal aphasia therapy (M-MAT) improves speech production outcomes at 15-weeks post-treatment more than M-MAT alone. Despite these group level effects, there was variation in treatment response within groups, which is not yet well understood. As such, we examined lesion features that may explain variance in treatment response to rTMS and M-MAT, and M-MAT alone.
Methods: 41 adults [48±44 months post-stroke] with chronic post-stroke nonfluent aphasia completed 10 days of M-MAT. Each day participants received 20 minutes of either 1 Hz inhibitory rTMS (n = 20) or sham stimulation (n = 21) to the right pars triangularis (right homologue of Broca’s area), followed by 3.5-hours of M-MAT. Participants in both groups completed neuroimaging and speech and language assessments at baseline, and 15-weeks post-treatment. Normalized lesion maps for each participant were used to calculate lesion extent at regions related to speech production using the Harvard-Oxford atlas. The relationship between region-specific damage and treatment response was assessed using linear regression modelling. Treatment response was quantified by the difference in baseline and 15-week aphasia quotient scores on the Western Aphasia Battery (WAB-AQ). These relationships were first assessed across the combined sample (rTMS and sham groups together), and then within the rTMS and sham groups separately.
Results: In the combined sample, no significant relationships were found between region-specific damage and treatment response. However within the rTMS group, regression analysis showed that lesion extent of the left pars triangularis (LPTr) explained 19.2% of variance in treatment response (adjusted R2 = 0.192, F(1,18) = 5.12, p < 0.05). No significant relationships between region-specific damage and treatment response were found within the sham group.
Conclusion: These results suggest that the extent of damage to the LPTr (Broca’s area) in part predicts treatment response to rTMS and M-MAT. Based on these results, stroke survivors with chronic nonfluent aphasia who have less damage to their LPTr would likely be good candidates for rTMS and M-MAT treatment. Further research is required to build a more comprehensive understanding of what other factors influence rTMS and M-MAT treatment response in the context of aphasia recovery.
Therapeutic recreation as a bridge to community rehabilitation and reintegration after stroke
Katie Jacobson-Lang1
1The City of Ottawa
The City of Ottawa’s Inclusive Recreation unit partnered with the Ontario Brain Institute (OBI) through the Gaining Expertise in Evaluation Knowledge (GEEK) program to strengthen evaluation capacity within its existing acquired brain injury (ABI) and post -stroke therapeutic recreation day programs that have been in existence since 1999. This partnership supports community-based therapeutic recreation (TR) services that align with Canadian Stroke Best Practice Guidelines and extend rehabilitation beyond hospital discharge.
These innovative programs serve adults living with ABI, including dedicated programming for stroke survivors, bridging inpatient rehabilitation, outpatient services, and meaningful community reintegration. Programming is guided by the Flourishing Through Leisure (FTL) model, holistically supporting cognitive, physical, social, psychological, spiritual, and leisure functioning. A strengths-based approach centers participant-identified goals focused on identity, participation, and quality of life, translating clinical recovery into sustained community engagement.
Two delivery models increase access and flexibility. Ottawa East focuses on physical and cognitive rehabilitation and adapted leisure exploration. Ottawa Central Link emphasizes strengths discovery, values clarification, and supported transition to independent, meaningful leisure, including structured one-to-one goal meetings. Services are delivered by an interprofessional team including Therapeutic Recreation Specialists, adapted fitness instructors, and consulting physiotherapy and nursing supports. In 2024 to 2025, 52 participants were served across both programs, with demand exceeding capacity.
GEEK funding of $95,000 over two years supported a formal evaluation to strengthen scalability, accountability, and knowledge translation. The study aimed to:
build sustainable evaluation capacity;
improve measurement of qualitative and quantitative outcomes (e.g., wellbeing, life satisfaction);
streamline documentation and progress tracking; and
demonstrate the effectiveness of a therapeutic recreation–led model for post-stroke rehabilitation.
With the support of Prairie Space Consulting, a logic model aligned to FTL domains was developed. The existing Individual Strength-Based Plan (ISBP) tool was redesigned to reduce duplication and integrate assessment, planning, and evaluation. Standardized measures were identified and included emotional health, mobility, endurance, and cognitive functioning.
Early outcomes show improved staff efficiency, clearer documentation, and stronger visibility of participant progress. Participants achieved meaningful goals, with some transitioning fully into independent community leisure such as fitness programs, arts groups, choirs, and peer-led social activities.
A final evaluation report and implementation toolkit will be completed by March 2026 to support knowledge translation and replication across Canada. The toolkit will include a program logic model, ISBP tool including sample goals, objectives and suggestions for adaptations, standardized measurement tools, FTL model and background information, and a sample schedule including programming resources.
Effect of dwell time on cerebral hypoperfusion in hyperacute ischemic stroke patients treated in a mobile stroke unit
Neha Jaswal1,2, Tripthi Sugumar1,3, Islam E’Leimat1, Kimberly Gilbertson4, Jason Opsahl4, Chetan Kashinkunti5, Brian Buck1, Rezan Ashayeriahmadabad1, Ashfaq Shuaib5, Thomas Jeerakathil5, Mahesh Kate6
1University of Alberta, 2Faculty of Medicine and Dentistry, University of Alberta, 3Dalhousie University / Nova Scotia Health, 4Alberta Health Services, 5Faculty of Medicine, University of Alberta, 6Department of Medicine, University of Alberta
Introduction: Previous studies of patients with hyperacute ischemic stroke (HIS) have demonstrated higher rates of angiographic reperfusion with earlier thrombolysis and longer thrombolysis-to-imaging reassessment time (“dwell time”). However, whether longer dwell time is associated with improved tissue-level perfusion, particularly in patients treated in a mobile stroke unit (MSU) within the golden hour, remains unknown.We hypothesize dwell time would be associated with lower ischemic core, lower penumbral volume and lower hypoperfused tissue in patients thrombolysed in an MSU within golden hour using computed tomography perfusion (CTP) performed on arrival at the emergency department.
Methods: We included all HIS patients treated with intravenous thrombolysis (IVT) in the MSU, who underwent CTP upon arrival at the emergency department. Ischemic core, penumbra and hypoperfused tissue were defined as relative Cerebral blood flow (rCBF) <30%, time-to-maximum (Tmax) >6s and Tmax>4s, respectively. MSU dwell time (min) was defined as the time between IVT and CTP in the emergency department. Patients were divided into two groups: golden-hour treated (GH) and non-golden-hour treated (NGH) based on onset to thrombolysis time ⩽60 min or >60 min, respectively. Multivariate linear regression analysis assessed the relationships between MSU-dwell time (min) and cerebral perfusion parameters (rCBF<30%, Tmax>6s, Tmax>4s) in the GH and NGH groups.
Results: A total of 137 patients who received IVT in MSU had an interpretable CTP; 65 (47.4%) were female, with a median [IQR] age of 72.5 years [58-82], and a median pre-IVT NIHSS of 9.5 [6-15.2]. Thirty-six (26.3%) were treated within GH, 63 (46%) had symptomatic intracranial arterial occlusion, 38 (27.8%) had ischemic core, 73 (53.3%) had penumbral tissue, and 106 (77.4%) had hypoperfused tissue. Median MSU door-to-needle time (min) was shorter in GH vs. NGH (21 [18.5-23]) vs (25 [21-30] minutes; p<0.001), as was MSU-dwell time (47 [39.3-55] vs. 55 [44.5-68.5] minutes; p=0.012). MSU-dwell time was not associated with cerebral perfusion parameters (rCBF<30%, Tmax>6s, Tmax>4s) in patients in the GH and NGH groups after adjusting for age and pre-IVT NIHSS. Median 24-hr NIHSS was similar between GH [1.5 (0.25-5)] and NGH [3 (1-9.5)]. The proportion of patients with excellent functional outcome (modified Rankin scale 0-1) at 90 days was similar between the GH (58.3%) and NGH (46.5%) groups.
Conclusion: In patients treated on the MSU with IVT, 26% were treated in the golden hour, and more than three-fourths of patients had persistent hypoperfused tissue on arrival in the emergency department. We did not find a relationship between dwell time and the cerebral perfusion parameters on CTPs completed in the emergency room in patients with HIS. This study demonstrates that higher dwell times was not associated with differences in tissue-level perfusion volumes on ED CTP in patients receiving early thrombolysis on the MSU.
Abnormal gaze patterns underlie limited visual compensation for proprioceptive impairments
Lydia Kuhl1,
Matthew Chilvers1,
Isabelle Poitras2,
Alexis Hill1,
Troy Herter3,
Tyler Cluff1,
Sean Dukelow1
1University of Calgary, 2Université Laval, 3University of South Carolina
Background: Up to 48% of stroke survivors cannot use vision to compensate for impairments in proprioception (sense of limb position/movement). This contradicts compensation behaviour in healthy individuals and is negatively associated with stroke recovery. We examined gaze patterns during an arm position matching (APM) task to better understand why some stroke survivors cannot use vision to compensate for proprioceptive impairments.
Methods: Participants (n = 114 control, n = 54 stroke [46±48 days post-stroke, mean ± SD]) completed an APM task in a robotic exoskeleton with an eye tracker. The robot positioned one arm, and the participant was asked to mirror-match that position with the other arm. Each of the four target locations (square arrangement, 15cm spacing) were pseudo-randomly repeated six times throughout the task. Participants did the task first with vision of their upper limbs occluded (no vision condition) and then with full vision of their arms (vision condition). The robot moved the affected arm for stroke participants, while control participants repeated the task with both arms in each condition. Oculomotor and upper limb kinematic data was collected, and we examined gaze patterns during the APM task with vision. To test for visual impairment (VI), clinical assessments for visual field deficits (Confrontation Test) and neglect (Behavioural Inattention Test), as well as a robotic assessment of saccadic eye movements were done.
Results: The general gaze strategy in the control group was to fixate in two spots along body midline (around the locations of the medial targets) with scanning eye movements between hands. Stroke participants with normal performance on the APM task with vision used this strategy. Participants with impaired performance on both conditions of the task (absent compensation, n = 12) deviated from this strategy, with less concentrated and more stochastic gaze patterning. Seventy-five percent of this group had some form of VI. Seven participants had normal performance on the APM task in the no vision condition but impaired performance on the vision condition (maladaptive compensation). Only two people in this group (29%) had VI, and gaze patterns in this group resembled those of stroke participants who were unimpaired on the APM task using vision.
Conclusion: Gaze patterns in stroke survivors with absent compensation suggested that inability to compensate using vision was due to VI. For stroke survivors with maladaptive compensation, inability to compensate was more likely due to multisensory integration issues. Gaze patterning resembled participants who were unimpaired with vision, but the maladaptive group was impaired on the vision condition instead. Further understanding of gaze behaviour, visual processing, and visual-proprioceptive integration post-stroke may inform specific interventions that will enhance stroke rehabilitation in individuals who cannot use vision to compensate for proprioceptive impairments.
Deficits in force-based adaptation are associated with greater motor impairment in early stroke recovery
Kathryn Lambert1,
Camille Eamon1,
Joshua Garland1,
Sean Dukelow1,
Tyler Cluff1
1University of Calgary
Background: Around 70% of stroke survivors experience motor deficits that impair their ability to perform daily activities. Despite the time and effort invested in therapy, motor recovery remains inconsistent. Some survivors show near full recovery, while others are left with permanent motor deficits. The mechanisms underlying this variability are poorly understood.
Many daily motor tasks require adapting movements based on proprioceptive feedback. Force adaptation, the ability to modify actions in response to errors caused by novel force disturbances, may thus be important for functional recovery. Yet it remains unclear whether impairments in force adaptation are associated with the severity of motor deficits in early stroke recovery, when most therapy occurs. Here, we used the Kinarm robotic exoskeleton to test whether impairments in force adaptation are linked to motor deficits in the early subacute phase of recovery.
Methods: Forty-five individuals with a first-time, unilateral stroke (13 [3-26] days post stroke) participated in the study. We measured motor impairment using a visually guided reaching (VGR) task. In this task, participants moved their affected arm to one of four targets presented in their virtual workspace, for a total of 64 trials. A task score was generated using multiple movement parameters, such as reaction time, movement time, and path length ratio. To measure force adaptation, participants completed a similar reaching task, but with the addition of small forces that displaced their hand lateral to the target. Participants completed 150 reaching movements: 24 without forces (Baseline), 108 with forces (Adaptation), and then another 18 without forces (Washout). We quantified adaptation as the mean peak lateral deviation of the hand relative to a straight path joining the start and end targets on the first 15 (Early Adaptation) and last 15 (Late Adaptation) adaptation trials. Scores for each task were adjusted using normative models constructed from large control datasets, accounting for effects of age, sex, and handedness. Participants were classified as impaired if their performance fell outside the 95th percentile of the normalized control data.
Results: VGR performance was moderately correlated with Early Adaptation (r(43) = 0.456, p = 0.004) and Late Adaptation (r(43) = 0.383, p = 0.009). Participants who were impaired in the VGR task were more likely to be impaired in Early Adaptation (χ2 (1, 45) = 8.571, p = 0.006) and Late Adaptation (χ2 (1, 45) = 7.782, p = 0.006).
Conclusion: We found that stroke survivors with greater motor impairment were more likely to exhibit deficits when adapting to novel force disturbances. Force adaptation may therefore be compromised in survivors with motor deficits. These findings can be used to personalize therapy based on a survivor’s capacity for force adaptation. For example, a clinician may place more emphasis on visual feedback for survivors with more severe motor deficits.
Transcutaneous spinal stimulation to restore upper extremity function post-stroke
Stephanie Larosa1,
Jessica D'amico1,2,
Yoshino Okuma1
1University of Alberta, 2Glenrose Rehabilitation Hospital
Background: Transcutaneous spinal stimulation (TSS) non-invasively activates the spinal network. In individuals with spinal cord injury, TSS safely and effectively improves motor function, spasticity, and sensation. This study aims to determine whether TSS can safely improve upper extremity function in chronic stroke.
Methods: Four males (mean age ± SD: 67 ± 9) with chronic stroke (4 ± 9 years; 2 hemorrhagic and 2 ischemic) and upper-extremity impairments were enrolled in this proof-of-concept study. The intervention included 24 rehabilitation sessions completed over two months. During each session, participants received sub-motor threshold cervical TSS (1ms, modulated biphasic waveform, 10kHz carrier frequency, 20-68 mA) delivered at 30 Hz while participating in 60 minutes of upper-extremity rehabilitation. The cathode was placed between the C3-C4 vertebral levels, with anodes placed bilaterally over the clavicles. Clinical and neurophysiology assessments were completed at baseline and post-intervention. Clinical assessments included the Upper Extremity Fugl-Meyer Assessment (UE-FMA) and the Action Research Arm Test (ARAT). The neurophysiology assessment included transcranial magnetic stimulation motor evoked potentials (MEPs) assessing corticospinal excitability, and TSS-evoked potentials (TEPs) to assess spinal excitability. During this assessment, electromyography was recorded from flexor carpi radialis (FCR), extensor carpi radialis (ECR), first dorsal interosseous (FDI), and abductor digiti minimi (ADM). Participants also reported their impressions of change using the Patient Global Impression of Change (PGIC). Effect size was calculated using Cohen’s d.
Results: All participants completed all sessions with no adverse events reported. Following the intervention, there was a large increase in total UE-FMA scores (d =1.55) and in the following sub-scores: upper extremity (d = 1.38), coordination speed (d =2.60), and motor function (d =2.38). Following the intervention, large increases were also observed in ARAT total scores (d =1.22) and in the grip sub-score (d =1.79). For overall function, two participants reported “much improved,” and two reported “minimally improved”. TMS-evoked MEPs were present at baseline in two participants. Following the intervention, MEPs increased across all recorded muscles in one participant and in ECR only in the second, while a third participant exhibited the emergence of previously absent MEPs across all recorded muscles, indicating improved corticospinal transmission. A small increase in TEPmax was observed in ECR (d =.29), a medium increase in FDI (d =.63), and a large increase in ADM (d =.85), consistent with enhanced spinal excitability.
Conclusion: This proof-of-concept study demonstrates initial feasibility of TSS combined with rehabilitation in the stroke population. Preliminary findings suggest potential improvements in upper limb function post-stroke, warranting a larger randomized controlled trial.
Optimizing the timing of priming exercise to promote cognitive recovery
Vivian Yuwei Li1,
Anna Daoust1,
Anjana Rajendran1,
Justin Andrushko2,
Christopher Lamb1,
Beverley Larssen1,
Payton Ray3,
Cristina Rubino4,
Michelle Ploughman5,
Gail Eskes6,
Lara Boyd1
1University of British Columbia, 2Northumbria University, 3Queen's University, 4York University, 5Memorial University of Newfoundland, 6Dalhousie University
Background: Stroke commonly leads to cognitive impairments, including attentional deficits and executive dysfunction. High-intensity interval training (HIIT) paired with motor training promotes neuroplasticity and improves some cognitive abilities in individuals with chronic stroke. However, the effect of this combined intervention on cognition in the earlier stages post-stroke is unknown. In this preliminary study, we paired HIIT with motor practice in stroke survivors to investigate the potential impacts of timing post-stroke on cognitive function.
Methods: Thirty-one individuals from two sites (Vancouver: n=21 and St. John's: n=10) with post-stroke upper-limb motor impairments completed the study and were included in the analysis (females: 9; mean age (SD): 62.0 (13.8); time post-stroke range (median): 1.7-257.2 (16.4) months; stroke hemisphere: 16 left/15 right). Participants underwent 10 sessions of 3 × 3-minute HIIT cycling (70% maximum resistance) followed by upper-limb motor training. Motor impairment was measured at baseline using the Fugl-Meyer Assessment for upper extremity (FMA-UE). Cognitive measures were assessed at baseline and two post-intervention timepoints (24-hour and 30-day) using five tasks from the Dalhousie Computerized Assessment Battery (DalCAB). Composite scores were created for each of the three attentional domains measured by the DalCAB: vigilance, orienting, and executive control (including working memory), with a lower score indicating better performance in each domain. Linear mixed-effects regression models were used to test the effect of time post-stroke (in months) on changes in attention task scores in the three domains.
Results: HIIT paired with motor practice improved performance in the orienting domain at the 24-hour time point relative to baseline (β = -0.363, 95% CI [-0.635, -0.091], p = 0.010). Increasing stroke chronicity was associated with greater motor impairment (rs = -0.421, p = 0.018), and poorer executive control (β = 0.003, 95% CI [0.00005, 0.005], p = 0.021). For measures involving working memory only, there was an interaction between timepoints and stroke chronicity (24-hour: β = -0.004, p = 0.033; 30-day: β = -0.005, p = 0.009), indicating that individuals with higher stroke chronicity showed greater improvement.
Conclusion: We provided preliminary evidence for an association between stroke chronicity and executive control. While HIIT paired with motor training may benefit orienting of attention regardless of stroke chronicity, it may only preferentially support improvements in working memory for individuals with higher stroke chronicity. These findings may inform rehabilitation strategies for people at different stages post-stroke to maximize their cognitive function.
Feasibility of integrating split-belt walking training with physiotherapist-led gait retraining: A case study
Beier Lin1,
Kaya Yoshida1,
Courtney Pollock1
1University of British Columbia
Background: Split-belt treadmill walking training has been shown to improve between-leg step length symmetry (SLS) post-stroke. However, prior studies focused primarily on implicit locomotor adaptation induced by split-belt walking without integrating physiotherapist (PT)-led explicit gait retraining to address optimized rehabilitation of gait patterns post-stroke. This case study examined the feasibility of integrating split-belt treadmill walking and PT-led gait retraining during a 4-week intervention for a chronic-stroke individual with hemiparesis.
Methods: The participant was a 79-year-old male, 3 years post-stroke, (ischemic, brainstem stroke, with moderate lower-limb impairment, Chedoke McMaster Stroke Assessment foot: 4/7, leg: 5/7) reliant on a 4-wheel walker for ambulation. He completed 12 sessions of alternating blocks of split-belt treadmill walking (four 4-minute split-blocks [2:1 speed ratio] alternated with 2-minute tied-blocks [1:1 speed ratio]; 3 sessions/week) at a 2% incline to induce an error-augmentation paradigm. The shorter step (paretic leg) was placed on the fast belt to drive motor adaptation. Belt speeds were individualized based on 10-Meter Walk Test and increased by 5%/week. During each session, a PT provided gait retraining inclusive of hands-on facilitation and verbal cueing of gait, limited to 3 targeted domains per session. SLS was measured from treadmill-embedded force plates. Participant perspectives regarding the intervention and recommendations were captured throughout the trial.
Results: Integration of PT-led gait retraining during split-belt walking was feasible and safe. The PT observed reduced weight transfer to the paretic leg during stance and use of toe-walking on the non-paretic leg to achieve paretic leg foot clearance. Hands-on and verbal cueing addressed gait pattern quality, specifically push-off, hip flexor activation to initiate paretic leg swing, and stance leg stability with improved weight transfer to the paretic leg, rather than directly targeting SLS. Both feedback types faded as gait improved. Training improved SLS from baseline to post-training at both slow (Δ=0.07) and fast (Δ=0.09) walking speeds, with gains maintained at one-month retention. The participant reported positive perceptions of speed and incline progression; however, suggested further increases to enhance training challenge over the 4 weeks.
Conclusion: This case study demonstrates that integrating PT-led gait retraining during split-belt treadmill walking is feasible and safe in a chronic stroke population. Explicit PT-led gait retraining successfully addressed maladaptive gait patterns used by the participant, while between-leg SLS was addressed implicitly through the split-belt walking paradigm. Overall, integrating both implicit motor adaptation induced by split-belt walking perturbation and explicit clinical gait retraining may represent a complementary and clinically meaningful approach for post-stroke gait rehabilitation.
Clinical predictors of recovery across functional, cognitive, and patient-reported domains after chronic subdural hematoma
Saba Mohammadalinezhad Kolahdouz1,
Susan Alcock1,
Yan Sin Leung1,
Nima Kashani1,
Bill Hao Wang2,
Marlise P. Dos Santos3,
Geneviève Milot4,
Cian O'kelly5,
Daniel Iansu6,
Adela Cora7,
Joseph Silvaggio1,
Namita Sinha1,
Roman Marin1,
Bijoy K Menon8,
Michael E. Kelly9,
Jai Jai Shiva Shankar1
1University of Manitoba, 2McMaster University, 3University of Ottawa, 4Université Laval, 5University of Alberta, 6Université de Montréal, 7Dalhousie University, 8University of Calgary, 9University of Saskatchewan
Background: Chronic subdural hematoma (CSDH) is an increasingly common neurosurgical condition in older adults and is frequently associated with functional impairment, cognitive dysfunction, and reduced quality of life. Treatment often improves neurological status, but recovery varies and key predictors remain unclear. This pre-specified secondary analysis of the EMMA-Can randomized clinical trial examined 90-day functional, cognitive, and patient-reported outcomes following treatment for CSDH and identified clinical factors associated with recovery.
Methods: Participants enrolled in the EMMA-Can trial with available baseline and 90-day outcome data were included in outcome-specific complete-case analyses. Functional outcome was assessed using the modified Rankin Scale (mRS), cognitive outcome using the Montreal Cognitive Assessment (MoCA), and patient-reported health status using EQ-VAS and EQ-5D-5L index. Ordinal logistic regression was used for mRS, and baseline-adjusted linear regression models with HC3 robust standard errors were used for continuous outcomes. Models were adjusted for age group, sex, treatment arm, hematoma size, recurrence within 90 days, and baseline value of the corresponding outcome.
Results: A total of 186 participants were available in the analytic dataset, with sample sizes varying across outcomes due to complete-case analyses. Outcomes improved between baseline and 90 days: median mRS improved from 3.0 (IQR 1.0-3.0) to 1.0 (0-2.0); mean MoCA increased from 14.8 ± 4.2 to 16.9 ± 4.1; mean EQ-VAS increased from 66.3 ± 17.0 to 75.9 ± 18.6; and mean EQ-5D-5L index increased from 0.741 ± 0.216 to 0.827 ± 0.178. Baseline clinical status was the strongest independent predictor across outcome domains. Participants with baseline mRS >3 had significantly lower odds of favourable functional outcome at 90 days compared with baseline mRS 0-1 (OR 0.24, 95% CI 0.11-0.53, p<0.001). Female sex was associated with lower odds of favourable functional outcome at mRS ⩽ 2 (OR 0.49, 95% CI 0.24-0.98, p=0.043) and mRS ⩽ 3 (OR 0.43, 95% CI 0.19-0.95, p=0.038). Baseline MoCA independently predicted 90-day cognition (β=0.60, 95% CI 0.45-0.75, p<0.001), while baseline EQ-VAS (β=0.31, 95% CI 0.14-0.47, p<0.001) and baseline EQ-5D-5L index (β=0.21, 95% CI 0.04-0.37, p=0.014) predicted 90-day outcomes. Age, treatment arm, recurrence, and hematoma size were not independently associated with most outcomes.
Conclusion: Baseline clinical status was the strongest predictor of short-term recovery after CSDH treatment, whereas most demographic and treatment-related factors were not independently associated with outcomes. Baseline disability, cognition, and quality of life independently predicted 90-day outcomes. These findings highlight the importance of multidimensional outcome assessment in CSDH research and support inclusion of cognitive and patient-reported measures alongside traditional functional outcomes.
Carotid-femoral pulse wave velocity is associated with post-stroke cognitive impairment
Kevin Moncion1,
Lynden Rodrigues1,
Bernat De Las Heras1,
Adam Sutoski1,
Kira Sikorska1,
Juliano Abreu2,
Ada Tang2,
Marc Roig1
1McGill University, 2McMaster University
Background: Cardiovascular risk factors are highly prevalent post-stroke and are associated with increased risk of post-stroke cognitive impairment (PSCI). Carotid-femoral pulse wave velocity (cfPWV), the gold-standard measurement of arterial stiffness, may be a sensitive biomarker for vascular aging and PSCI. This study evaluated the association between cfPWV and global cognitive function as measured by the Montreal Cognitive Assessment (MoCA) among individuals ⩾6 months post-stroke.
Methods: This cross-sectional analysis is a secondary analysis of baseline data from an exercise-based randomized controlled trial. Demographic and clinical data were collected, including age, biological sex, medical history, time post-stroke, stroke type, and stroke severity as measured by the National Institutes of Health Stroke Severity Scale (NIHSS). The MoCA was administered by a trained assessor. Resting cfPWV was measured non-invasively using applanation tonometry on the non-paretic side. Logistic regression analyses evaluated the associations between cfPWV and MoCA, adjusting for participants’ age, sex, resting systolic blood pressure, type 2 diabetes status, and NIHSS. The primary outcome was cognitive impairment defined as a MoCA score of <26/30, with secondary cutpoints at <24/30 and <22/30 as more sensitive cognitive impairment cutpoints on the MoCA.
Results: Sixty-seven participants (45 males, age 64.7 ± 9.6 years, 1.8 ± 1.2 years post-stroke) with mild to moderate stroke severity (median NIHSS [IQR] = 1 [2], min-max 0-11) were included in this analysis. cfPWV was 10.3 ± 2.9 m/s at baseline. Of the 67 participants included, 33 (49.3%) were classified as scoring <26/30 on the MoCA. Each 1 m/s increase in cfPWV was significantly associated with 31% greater odds of cognitive impairment at the MoCA <26/30 cutpoint (adjusted OR [aOR] = 1.31; 95% CI 1.03, 1.73; p = 0.04; Area Under the Curve [AUC] = 0.73, 95% CI 0.61, 0.86). Consistent associations were found at both secondary MoCA cutpoints, including <24/30 (aOR = 1.36; 95% CI 1.02, 1.86; p = 0.04; AUC = 0.87, 95% CI 0.76, 0.97) and <22/30 (aOR = 1.30; 95% CI 1.01, 1.72; p = 0.05; AUC = 0.81, 95% CI 0.67, 0.95).
Conclusion: Higher cfPWV is independently associated with PSCI across clinically relevant cutpoints of the MoCA in individuals in the chronic phase of stroke recovery. These findings provide preliminary evidence that cfPWV is a potential biomarker for both vascular events and PSCI. Larger scale studies are needed to corroborate our findings and explore further mechanistic links between vascular biomarkers and cognitive outcomes post-stroke.
Adapting the Health Promoting Lifestyle Profile II to measure self-management skills in people with stroke: A psychometric study
Kenneth Noguchi1,
Janice J Eng1,
Brodie Sakakibara1
1University of British Columbia
Background: The Canadian Stroke Best Practices recommend improving self-management abilities and skills after stroke for ongoing recovery and secondary prevention purposes. However, few measures adequately capture the construct of self-management, making it difficult to assess the effects of self-management interventions. The objectives of this study were to: (1) adapt the 52-item Health Promoting Lifestyle Profile II (HPLP-II) to a measure of self-management ability; (2) examine the factor structure of the self-management measure in people with stroke; and (3) to examine the associations between age, sex, education, stroke severity, physical activity levels, and self-management.
Methods: This was a secondary analysis using data of the Stroke Coach randomized controlled trial. Participants were randomized to a telehealth self-management intervention or memory training attention-control. Individuals were eligible for the present study if they had complete data on the HPLP-II. Nineteen items from the HPLP-II were first conceptually chosen to represent self-management ability based on the domains of a conceptual framework: problem solving (4 items), decision making (3 items), resource utilization (3 items), patient-provider relations (3 items), action planning (4 items), and self-tailoring (2 items). Exploratory factor analysis (EFA) was used to examine the factor structure of the new measure. Univariable analyses explored the relationships between the new measure with age, sex, education, and stroke severity (modified Rankin Scale). Multivariable regression analysis was used to examine the relationships between the final measure with physical activity (steps per day).
Results: All participants in the trial (n=126; age 68.1±9.7 years; time post-stroke 7.1±3.6 months; 31% female) were eligible for the EFA. Parallel analysis, scree plots, and minimum average partial correlations suggested a single factor structure. One item was removed due to low factor loading. The new measure had high internal consistency (alpha=0.86). Univariable analyses showed relationships with sex (female: +4.6 points, 95% confidence interval [CI]: 0.9-8.3, p=0.02), education (r=0.20, p=0.02), and stroke severity (F(3,122)=3.40, p=0.02). There was no relationship with age (r=-0.03, p=0.74). After adjusting for sex, education and stroke severity, the new self-management measure was independently associated with steps per day (b=82.4, 95% CI: 9.9-154.9; p=0.026).
Conclusion: A novel 18-item self-management ability measure was developed. The measure had high internal consistency and was higher in those who were females, more educated, and lower stroke severity. The measure was also independently associated with physical activity levels. Notably, the measure’s items were specific to select health domains such as physical activity, nutrition, and spiritual growth. Future research should adapt and test the psychometric properties of a more generic version of the measure.
Accelerometer-derived patterns of sedentary and upright behaviours in people with stroke and healthcare workers
Oluwatosin Oladimeji1,
Patricia Manns1,
Victor Ezeugwu1
1University of Alberta
Background: Contemporary behaviour change and social–ecological theories emphasize the influence of physical and social environments on health behaviours. In rehabilitation settings, healthcare workers shape the care environment and may implicitly model how sedentary and upright activities are accumulated (i.e., bouts) that influence patients’ activity patterns. Examining correlations between the sedentary and upright behaviours of healthcare professionalsand stroke survivors may provide insight into mechanisms through which rehabilitation cultures are formed. Such knowledge may support the development of strategies that leverage clinician behaviour to optimize activity behaviours. This study aimed to characterise patterns of sedentary and upright behaviours and examine their correlations in stroke survivors and healthcare workers.
Methods: Thirty-four stroke survivors (15 female; mean age ± SD: 64.6 ± 12.6 years; 3.5 ± 1.1 months post-stroke) and 36 healthcare workers (33 female; mean age: 37.3 ± 9.6 years; 8.5 ± 6.2 years of professional experience) were recruited from a rehabilitation hospital. All participants completed up to seven days of activPAL monitoring. Time spent in sedentary and upright bouts was summarised. Associations between age, body mass index (BMI), and bout characteristics were examined using Spearman’s correlation. The effect of age on this characteristic was examined using linear regression.
Results: Time spent in upright bouts <10 min and ⩾10 min was lower in stroke survivors than in healthcare workers (103.9 ± 38.2 vs. 124.1 ± 21.4 min, p = 0.007; 137.8 ± 127.1 vs. 252.5 ± 82.6min, respectively). Time spent in sedentary bouts <30 min was also lower in stroke survivors (213.9 ± 84.3 vs. 294.3 ± 46.5 min, p < 0.001), whereas time spent in prolonged sedentary bouts (⩾0.5 to <1 h; ⩾1 to <2 h; ⩾2 to <4 h; <4 h) was higher (162.4 ± 61.9 vs. 133.6 ± 28.5; 161.4 ± 94.1 vs. 69.4 ± 37.0; 85.0 ± 68.7 vs. 39.3 ± 38.4; 21.3 ± 50.6 vs. 13.2 ± 38.1, respectively). The number of sedentary bouts <30 min was lower in stroke survivors (37.6 ± 20.0 vs. 53.1 ± 11.2).
Among healthcare workers, moderate correlations were observed between age and time spent in upright bouts (⩾10 to <20 min; r = 0.40, p = 0.02) and sedentary bouts (⩾1 to <2 h; r = −0.37, p =0.03). In stroke survivors, BMI was moderately negatively correlated with time spent in upright bouts ⩾20 min (r = −0.45, p = 0.01). Among healthcare workers, BMI was moderately correlated with time spent in sedentary bouts ⩾2 to <4 h (r = 0.41, p = 0.02) and with the number of sedentary bouts <30 min (r = −0.33, p = 0.05). There was no significant effect of age on the upright and sedentary bouts of healthcare workers and stroke survivors.
Conclusion: Stroke survivors accumulated less time in upright activities and more time in prolonged sedentary bouts. These findings underscore the importance of addressing prolonged sedentary behaviour in rehabilitation settings and identified healthcare worker factors that correlate with sedentary and upright behaviour patterns.
Sex differences in movement behaviours and functional outcomes after rehabilitation for subacute stroke
Sophia Pawelko1,
Mona Iyizoba2,
Asya Shiloff-Rogers2,
Andrew Chan2,
Jake Hayward1,
Carmen Tuchak2,
Jaime Yu3,
Patricia Manns1,
Victor Ezeugwu Ezeugwu1
1University of Alberta, 2Glenrose Rehabilitation Hospital, 3Faculty of Medicine & Dentistry, Department of Medicine, University of Alberta, Edmonton, Alberta,
Background: Improving function is a key goal of post-stroke rehabilitation to enhance independence, mobility, and cardiometabolic health. Women often experience poorer post-stroke outcomes than men, yet sex differences in 24-hour movement behaviours (physical activity, sedentary behaviour, and sleep) remain underexplored. This study examined sex differences in movement behaviours and functional outcomes following rehabilitation for subacute stroke (<6 months post-stroke). We hypothesized that women would have lower physical activity, more prolonged sedentary behaviour, and longer sleep duration than men.
Methods: Baseline data were pooled from two behaviour-change intervention studies targeting movement behaviour after rehabilitation for subacute stroke. Participants were ⩾18 years, diagnosed with ischemic or hemorrhagic stroke, able to walk ⩾5 meters (with or without a gait aid), and with ⩾1 valid day of 24-hour activPAL accelerometry data. Movement behaviours included time spent lying, sedentary, upright (<20 steps/min), walking (⩾20 steps/min), sit-to-stand transitions, step counts, and number of sedentary bouts. Functional outcomes were assessed using gait speed and the Timed Up and Go (TUG). Descriptive statistics were calculated, normality assessed using Shapiro–Wilk tests, sex differences examined with Welch’s independent t-tests due to unequal sample size, and associations explored using Spearman correlations.
Results: Sixty-four participants were included (mean age 65.7 ± 13.0 years; 54.7% male; 78.1% Caucasian; 82.9 ± 42.7 days post-stroke), with a median [interquartile range] of 6 [4–6] valid accelerometry days. There were no sex differences in demographic characteristics. Females and males spent comparable average minutes per day in lying (519.8 ± 116.4 vs 546.7 ± 104.2), sedentary (675.9 ± 140.4 vs 663.8 ± 112.6), upright (<20 steps/min; 182.4 ± 117.5 vs 155.5 ± 69.1), and walking (57.5 ± 42.5 vs 68.2 ± 43.3). However, females had greater number of prolonged sedentary bouts ⩾2 hours (0.88 ± 0.55 vs 0.45 ± 0.30; p < .001). Males completed the TUG faster than females (15.1 ± 5.5 vs 21.9 ± 12.4 s; p = .009), with no sex differences in step count, sit-to-stand transitions, or gait speed (p > .05). BMI was negatively correlated with step count in men (ρ = −0.34; p < .05) and with sit-to-stand transitions in women (ρ = −0.45; p < .05). Age was associated with slower TUG performance (ρ = 0.52) and gait speed (ρ = −0.47) in men only (both p < .01). Longer time since stroke was associated with less prolonged sedentary time in women (ρ = −0.45; p < .05) and slower gait speed in men (ρ = −0.42; p < .05).
Conclusion: Although overall movement behaviour volume was similar, females accumulated more prolonged sedentary time following rehabilitation for subacute stroke. Sex-specific associations with BMI, age, and time since stroke underscore the importance of incorporating sex considerations into movement behaviour interventions.
Changes in resting-state connectivity after repetitive transcranial magnetic stimulation relates to motor evoked potential onset latency
Anjana Rajendran1,
Cristina Schaurich1,
Beverley Larssen1,
Justine Magnuson2,
Cristina Rubino1,
Lauren Penko1,
Ronan Denyer3,
Christy Jones1,
Jordan Brocato1,
Christopher Lamb1,
Sarah Kraeutner1,
Lara Boyd1
1University of British Columbia, 2University of British Columbia Okanagan, 3Université Catholique de Louvain
Background: Repetitive transcranial magnetic stimulation (rTMS) is a promising adjunct to post-stroke motor rehabilitation when applied prior to skilled motor practice. rTMS may modulate cortical excitability by reducing contralesional hemispheric inhibition. Continuous theta burst stimulation (cTBS) is a patterned, faster stimulation paradigm; though, individual responses vary. Resting-state fMRI (rsfMRI) has been used to examine sensorimotor network changes following repeated rTMS sessions post-stroke. However, aftereffects of cTBS are not well characterized. Interneuron conduction in the motor cortex (M1) is linked to cTBS response in healthy brains. Single-pulse TMS delivered in the anterior-posterior (AP) direction elicits longer-latency motor evoked potentials (MEPs) than posterior-anterior (PA), reflecting greater synaptic distance from corticospinal neurons. High-intensity lateral-medial (LM) stimulation can index corticospinal activation. Though untested, AP-LM MEP onset latency may help characterize who may benefit from cTBS after stroke. This study examined if cTBS induced changes in rsfMRI is associated with AP-LM MEP onset latency in chronic stroke. We predicted longer contralesional AP-LM MEP latency would be associated with reduced M1-sensorimotor region connectivity after cTBS.
Methods: 32 participants with chronic stroke (10 females; mean age 68.7±12.7 years) completed a TMS mapping session and two MRI sessions consisting of rsfMRI, followed by either active (80% RMT) or sham cTBS over contralesional M1, and a repeat rsfMRI, with session order randomized. AP/PA (110% RMT) and LM (150% RMT) MEPs were assessed to calculate latency differences. Mean MEP onset latencies were calculated and differences between AP-LM were calculated. During rsfMRI, participants rested supine for 10 minutes while fixating their eyes on a cross. Contralesional seed regions (N=4) were defined a priori within the rsfMRI sensorimotor network. Connectivity changes from M1 to the postcentral gyrus, supplementary motor area, superior and middle frontal gyrus were calculated as post-pre cTBS Fisher-Z scores.
Results: A linear mixed-effects model found that AP-LM MEP onset moderated connectivity changes between M1 to the postcentral gyrus (β=0.03, SE=0.015, p=0.023). The interaction did not survive FDR correction for multiple comparisons (padj=0.09); however, a large effect size (=0.15, 95% CI [0.01, 0.39]) suggests a meaningful trend.
Conclusion: Our data suggest that responses to a single cTBS session, specifically connectivity from M1 to postcentral gyrus, may be associated with AP-LM MEP onset latency. Longer latencies were associated with a trend for reduced connectivity after cTBS. Our findings suggest that immediate cTBS responses and individual variability after stroke may be captured using rsfMRI and MEP onset. Our results support investigation of MEP onset time as a marker of cTBS aftereffects, identifying who may benefit from cTBS as an adjunct to motor rehabilitation.
Operationalization of neurodegeneration (N) and vascular (V) criteria in the NIA research biological diagnosis of Alzheimer’s disease and concomitant cerebrovascular pathology
Heidi Riek1,
Ryan Muir1,
Arunima Kapoor2,
Maged Goubran1,
Sean Nestor3,
Joel Ramirez1,
Christopher Scott1,
Sandra Black1,
Richard Swartz1
1Sunnybrook Health Sciences Centre, 2University of California, Irvine, 3University of Toronto
Background: The NIA-AA research criteria for Alzheimer’s disease (AD) provides a biological diagnostic framework for research applications based on amyloid (A) and tau (T) pathology. Additional components describing overall brain atrophy/neurodegeneration (N) and vascular (V) co-pathology have been proposed. However, these components have not been formally integrated or operationalized, and there is a lack of specific, objective, widely adopted cutoffs for categorizing participants as neurodegeneration positive/negative. This has led to uncertainty in application and very limited assessment of vascular pathology in research populations. This project aims to develop and validate structural MRI-based cutoffs for N and V components.
Methods: We used data from the Sunnybrook Dementia Study, a prospective observational cohort study of normal control (NC) participants and patients recruited from a tertiary memory clinic, including those with AD, cognitive impairment-no diagnosis (CIND), vascular dementia (VaD), vascular CIND (VCIND), or AD plus VaD or cerebrovascular disease (CVD). We applied quantile regression in the NC cohort (N=116, mean age=69.3 ± 8.0 years, 61.2% female) to construct normative age- and sex-based 5th or 95th percentile cutoffs for MRI volumes of interest, computed as percentages of total intracranial volume. These included normal-appearing grey matter; sulcal and ventricular CSF; and hippocampal volume (relevant to N), and perivascular spaces; deep, periventricular, and total white matter hyperintensities; total lacune volume; and infarct presence (relevant to V). We then used these cutoffs to categorize patients (N=674, mean age=72.0 ± 9.4 years, 55.3% female), as N+/- or V+/- by requiring at least one relevant abnormal variable for each. This produced four categories: N-/V-, N-/V+, N+/V-, and N+/V+. We characterized clinical diagnoses by category and used ANCOVA, adjusted for age and sex, to compare Mini-Mental State Examination (MMSE) and Dementia Rating Scale (DRS) scores.
Results: Patients were categorized as N-/V- (n=126), N-/V+ (89), N+/V- (242), and N+/V+ (217). The two V+ groups (N-/V+, N+/V+) comprised more patients with vascular-linked diagnoses (VaD, VCIND, AD+VaD/CVD; 52.8% and 51.6% respectively) relative to V- groups (N-/V-: 12.7%; N+/V-: 14.5%). The N+/V- group contained mostly patients with AD (55.4%) followed by CIND (21.1%)), and the N-/V- group mostly CIND (41.3%) followed by AD (32.5%). For both MMSE and DRS scores, including DRS subscales, the two N+ groups (N+/V-, N+/V+) did not differ from one another but had significantly lower scores than the two N- groups (N-/V-, N-/V+), which also did not differ from one another. Normal controls scored significantly higher than all patient groups.
Conclusion: Given its clinical and cognitive correlates, the proposed operationalization method shows promise to define normal and abnormal neurodegeneration and vascular pathology for research purposes. N+/- status predicted cognitive performance across both cognitive tests, highlighting its value in disease staging; although V+/- status was not related to cognition, it should form a critical part of research inclusion/exclusion criteria to facilitate study of vascular and mixed dementias and/or to limit cohort heterogeneity in studies of AD. Future work must validate and/or refine the proposed approach using additional large, diverse cohorts.
Breaking barriers: Navigating life after stroke and the path to reintegration
Eden Samson1, Katrine Sauvé-Schenk2, Hillel Finestone3,4, Lisa Sheehy4
1University of Toronto, 2University of Ottawa, 3Élisabeth Bruyère Hospital, 4Bruyère Health Research Institute
Background: People who have experienced a stroke face significant challenges reintegrating into daily life, due to physical, cognitive, and psychological impairments. These difficulties are compounded by inadequate social support and financial constraints, limiting access to rehabilitation and community resources. While existing research highlights individual barriers to reintegration, there is a gap in understanding the intersection of these challenges over time. The objective of this study was to assess the ability of individuals to reintegrate into society during their first year post-stroke, to examine what and how social and healthcare services were obtained and to identify unmet needs that hindered reintegration.
Methods: A qualitative interpretive description approach was adopted, using semi-structured interviews with 11 people one year post-stroke. Participants were recruited from the Walk ‘n Watch Study (a multi-site pragmatic trial of a structured, progressive walking intervention for inpatient stroke rehabilitation) conducted at Bruyère Health. They shared their experiences regarding community reintegration and access (or lack of access) to needed support services. Thematic analysis was conducted to identify key facilitators and barriers, with attention to demographic factors.
Results: Findings suggest that strong social networks, financial assistance, and access to rehabilitation services supported reintegration. Participants who had strong family involvement and self-motivation, and who engaged with the community reported better psychological and functional recovery. However, barriers such as socioeconomic disparities, psychological distress, and insufficient long-term support services hindered reintegration. Some participants’ ability to resume participation in daily activities was limited by emotional distress, including feelings of emotional isolation, social stigma and depression. Some participants reported challenges in accessing resources that were tailored to their evolving needs, meaning there were gaps in long-term reintegration support.
Conclusion: This study highlighted the need for comprehensive, interdisciplinary rehabilitation strategies that extend beyond initial stroke recovery. They should be accessible to all and include socioeconomic and psychological support. Future research should explore applicable long-term rehabilitation models and evaluate policy changes that can enhance access to resources for effective reintegration of people who have had a stroke.
Feasibility and utility of using videoconferencing compared to in-person administration of performance-based measures of balance, strength and mobility in community-dwelling older adults with mobility limitations
Lisa Sheehy1,
Heidi Sveistrup2,
Elizabeth Inness3,
Navaldeep Kaur4,
Joyce Fung5,
Nancy Salbach3
1Bruyère Health Research Institute, 2University of Ottawa, 3University of Toronto, 4University Health Network, 5McGill University
Background: Adults facing mobility challenges from stroke and other health conditions benefit from targeted rehabilitation to improve balance, strength and mobility. Videoconferencing provides an equitable alternative for patients unable to attend in person due to distance, weather, fatigue, lack of transportation or other factors. Standardized assessment of balance, strength and mobility should be completed to identify deficits, inform treatment and monitor response to therapy. While some evidence supports the validity and reliability of physical assessments via videoconferencing, data on their utility and feasibility in a real-world setting remain limited. The objective of this study was to investigate the utility and feasibility of administering tests of balance, strength and mobility in people with mobility limitations using videoconferencing, compared to in person administration.
Methods: Community-dwelling participants with balance or walking deficits (but able to walk 10m and perform sit-to-stand independently) were recruited from outpatient geriatric and stroke rehabilitation services at a tertiary-care hospital. Participants supplied their own technology device/Internet and had a study partner for the remote assessment. Following a remote orientation session, physical therapists administered 5 standardized assessments (Timed Up-and-Go test, 30-second Sit-to-Stand test, 3-metre Walk test, 7-item Berg Balance Scale, and 2-minute Step test) in-person and remotely. Testing order (in person or remote) was randomized. Utility and feasibility data were collected via questionnaires after each assessment. Remote and in-person tests were compared using paired-sample t-tests.
Results: Seven participants (mean age 70 years, 4 male, 2 with stroke) completed the study. Assessment sessions lasted an average of 36 minutes in person and 47 minutes remotely. Two remote sessions experienced occasional video “freezing”. All outcomes were comparable between in-person and remote assessments (P > 0.05) except for the 3-metre Walk test (P = 0.015), where the remote assessment was a mean of 0.9s longer than in person. Assessors mentioned no safety concerns in person, however during the remote 2-minute Step test there was concern for a potential fall in 1 participant. Participants felt safe during both testing sessions. They indicated a strong interest in future remote assessments but some preferred in-person. Both participants and assessors noted excessive repetition between orientation and assessment sessions and that home set-up took longer than expected. Positioning the camera to capture the entire walkway was difficult for some. One assessor suggested providing participants with consistent devices to allow easier troubleshooting.
Conclusion: Assessments of balance and mobility performed via videoconferencing are feasible and show utility. Streamlining the orientation and testing sessions, and providing consistent technology devices would mitigate most challenges.
Step targets in inpatient stroke rehabilitation: A secondary analysis of the Walk ‘n Watch study
Lisa Sheehy1,
Sarah Donkers2,
Magdalena Ivok3,
Stanley Hung3,
Janice Eng3,
Sue Peters4,
Walk 'N Watch Team3
1Bruyère Health Research Institute, 2University of Saskatchewan, 3University of British Columbia, 4Western University
Background: The Walk ‘n Watch (WnW) protocol provides intense, progressive walking practice during inpatient stroke rehabilitation, and is shown to improve walking endurance, balance and quality of life after stroke compared to usual care. In the WnW protocol, individualized step targets are set based on the patient’s baseline 6-minute walk test (6MWT) distance. Steps are measured with sensors and increase over time. Protocol targets were modeled from pilot data, however, adherence to step targets has not been assessed. In this secondary analysis of the WnW study, the objective was to determine how closely the actual number of steps taken in inpatient physiotherapy sessions matched the step targets for patients who received the WnW protocol.
Methods: 120 participants with subacute stroke who received the WnW protocol were included. Daily inpatient physiotherapy sessions included a minimum of 30 minutes of gait-related activities. Physiotherapists recorded steps using Fitbit step counters (Inspire 2) worn on the non-paretic ankle. Participants were divided into lower, middle and higher-functioning groups based on baseline 6MWT distance, and individualized step count targets were assigned according to these categories. Three progressive step count targets were provided over 4 weeks, and data from the first 10 sessions were analyzed.
Results: Participants (mean age 68 (SD 13), 32% females, 68% males) attended a mean of 15.11 (SD 6.3) WnW sessions during their inpatient rehabilitation stay. The mean number of steps taken for all participants increased from 993 (SD 715) in session 1 to 1325 (SD 857) in session 5, and remained steady thereafter. Baseline 6MWT distance predicted step counts in physiotherapy, with higher-functioning participants having higher step counts. The lower-functioning participants met 65.0% of their step goal at session 5, compared to 56.7% and 61.7% of the middle- and higher-functioning participants. After 10 sessions, the corresponding percentages were 50.7%, 43.7% and 52.4%. The number of steps for females decreased after session 6 while steps for males continued to increase.
Conclusion: Participants achieved only 43.7% to 65.0% of their step count targets, suggesting that the WnW protocol step targets may be difficult to achieve in inpatient rehabilitation. Despite not meeting the prescribed step targets, overall the WnW protocol has demonstrated clinically-meaningful improvements in walking endurance and quality of life over usual care (Peters et al, 2025). Steps taken may have decreased later in the participants’ inpatient stays due to competing rehabilitation goals, which may be more prominent for female participants. Future research should clarify what step counts produce an optimal outcome in real-life inpatient settings.
Virtual reality perimetry as a portable alternative to the Humphrey Field Analyzer
Ben Shi1,
Lydia Kuhl1,
Isabelle Poitras1,2,
Matthew Chilvers1,
Isabella Morrissey1,
Alexis Hill1,
Antoine Sylvestre-Bouchard1,
Fiona Costello1,
Sean Dukelow1
1University of Calgary, 2Université Laval
Background: Half of all stroke survivors experience visual field deficits ranging from partial to near-complete field loss. These deficits can reduce mobility and safety and limit participation in rehabilitation. Accurate assessment of visual field loss is therefore important for effective rehabilitation and recovery. The current gold standard perimetry device, the Humphrey Field Analyzer (HFA), is expensive and requires adequate trunk stability, something that is a challenge for many stroke survivors. This project aims to validate a virtual reality (VR) headset as a cheaper, portable alternative to the HFA.
Methods: First-time stroke survivors (n = 13 [63.7 ± 66.2 days post-stroke, mean ± SD]) completed monocular visual field testing of the left and right eyes (24-2 SITA Standard) and a binocular field test (Esterman) on both the HFA and a PICO 3 VR headset running Retinalogik (Calgary, Canada) software. During testing, participants fixated on a central target and pressed a button when a target flashed in their peripheral vision. Both devices were run within 48 hours of one another, with the starting device counterbalanced across participants. For the 24-2 SITA Standard, the starting eye was randomized between participants but remained constant within each participant. The VR 24-2 SITA Standard was validated using intraclass correlation coefficients (ICC) and Bland–Altman analyses. The Esterman was analyzed using the number of targets detected. Additional metrics, including test duration, fixation losses, and false positive and false negative rates, were compared for both tests using a Wilcoxon signed-rank Test.
Results: ICC(3,1) intraclass correlation revealed moderate-to-good pointwise agreement between the VR and HFA devices (left eye: ICC = 0.732, p < .001; right eye: ICC = 0.762, p < .001) on the 24-2 SITA Standard. Bland–Altman analyses demonstrated a negative pointwise bias, indicating higher mean sensitivity values on the VR device, of –2.40 dB (95% LOA –6.59 to 1.78 dB) for the left eye and –2.29 dB (95% LOA –6.17 to 1.58 dB) for the right eye. When comparing the devices, the VR had significantly shorter test durations (L eye: 305 ± 45 s vs 400 ± 88 s, p = .02; R eye: 292 ± 42 s vs 372 ± 41 s, p = .01, mean ± SD) and lower fixation losses (L eye: 5 ± 6% vs 39 ± 32%, p = .04; R eye: 3 ± 5% vs 29 ± 23%, p = .005, mean ± SD). For the Esterman test, the mean number of targets seen did not differ significantly between devices, but the test durations were significantly shorter for the VR (165 ± 11 s vs 395 ± 85 s, p = .002, mean ± SD). The VR device had a significantly higher mean false negative rate in the Esterman (7 ± 5% vs 2 ± 6%, p = .046, mean ± SD).
Conclusion: VR is a promising tool for both monocular and binocular visual field testing. Especially after stroke, when physical impairments are common, reliable bedside tools to assess visual field deficits have substantial utility.
Inner speech as a cognitive tool in damaged language systems
Tijana Simic1,
Stephanie Long1,
Rudra Patel2,
Erica Eng1,
Chaerin Jang1
1University of Toronto, 2Division of Neurology, Department of Clinical Neurosciences, Cumming School of Medicine, University
Background: Roughly 30% of stroke survivors will have aphasia, a difficulty speaking with- or understanding others1. One factor that may support language processing after stroke is executive control (EC) ability. EC is a set of mental processes that enable goal-directed behaviour (e.g., multitasking, ignoring distractors, and revising existing knowledge). Studies suggest that EC processes support language and communicative functions2 including error detection and repair during speech3, more organized storytelling4, and more effective conversational skills5. Our previous work found that better EC predicted greater long-term maintenance of language treatment effects6. However, it remains unclear to what extent language deficits impact EC task performance. Evidence from healthy controls suggests that language plays an important role in successful completion of EC tasks, through subvocal rehearsal, or inner speech (IS) mechanisms7-10. Described as “the little voice in one’s head”, IS is measured objectively by comparing performance on silent versus overt phonological tasks11. No studies to date have investigated the association between IS and EC measures in individuals with damaged language systems. We aimed to investigate IS as a predictor of overt speech and EC performance in individuals with post-stroke aphasia.
Methods: Ten English-speaking adults (Meanage=67.8, SD=7.3) with chronic post-stroke aphasia (Meanmonths post-stroke=73.6, SD=58.8) participated in this study. Aphasia severity, based on the Western Aphasia Battery12 Aphasia Quotient ranged from 40.1-89.2 (Mean=73.2; SD=14.5), with fluent (n=6) and nonfluent (n=4) aphasia types. Participants completed IS tasks including written and picture rhyme and homophone judgments, and overt and silent naming (pointing to the first sound of a word without speaking or moving the lips). Participants also completed EC tasks measuring inhibition, working memory updating, and shifting abilities. Linear regressions were used to analyze whether IS predicts a) overt naming and b) EC task performance.
Results: IS, EC, and overt naming ability were not associated with age, education, MPO or aphasia severity, nor did they differ as a function of fluency. However, IS was a significant predictor of overt naming (R2=.78, Adjusted R2=.75, F(1,8)=28.0, p<.001) and EC-shifting performance (R2=.79, Adjusted R2=.77, F(1,8)=30.72, p <.001), such that more successful IS predicted better naming, and more efficient shifting between tasks. These relationships remained significant even when controlling for age, education, months post-onset and aphasia severity.
Conclusion: Results suggest that IS supports both overt naming and EC-shifting ability in individuals with post-stroke aphasia. Differences between overt and covert speech may hold important predictive power and help with treatment selection: successful IS words may require therapy for speech output and unsuccessful IS words may require therapy at earlier word-finding stages.
Deficits in cognitive–motor control of the less-affected upper limb in subacute stroke assessed using a robotic exoskeleton: A six-month follow-up study
Segnon Emmanuel Sogbossi1,
Léandre Gagné-Pelletier2,
Catherine Mercier1
1Université Laval, 2Laval University
Background: Most activities of daily living require cognitive–motor integration. Identifying deficits in cognitive–motor control after stroke is important, as motor rehabilitation relies on task-specific motor learning. Robot-based assessments offer precise, quantitative evaluation of these deficits and may be more reliable early after stroke when performed on the less-affected limb, minimizing the impact of paresis. Accordingly, this study aimed to longitudinally assess cognitive–motor control deficits in the less-affected upper limb of adult stroke survivors during the subacute phase. A secondary aim was to examine the effect of lesion side on these deficits.
Methods: Forty-one participants (mean [SD] age: 64.6 [14.4] years; 15 women; 24 with right hemisphere damage; 38 right-handed) were assessed using the KINARM Exoskeleton Lab at approximately 1 month (T1), 2 months (T2), and 6 months (T3) post-stroke. They completed the Visually Guided Reaching (VGR) and Reverse Visually Guided Reaching (RVGR) tasks with their less-affected upper limb to assess motor control and cognitive-motor control, respectively. Global Task scores and Z-scores derived from normative data were used to determine the prevalence of deficits within each task. Linear mixed-effects models examined changes over time and the effect of lesion side.
Results: At T1, 88% of participants were impaired on the RVGR global Task score. When looking at specific variables, the highest impairment rates were observed for the initial direction angle (78%), the correction time (70%) and the speed maxima counts (67%). In contrast, only 12% of participants were impaired on the VGR task score. Performance on the RVGR global Task score improved over time, with a time × lesion side interaction: deficits were more severe for right hemisphere lesions than for left hemisphere lesions at T1, but this difference attenuated over time. Performance on the VGR task remained largely unchanged over time.
Conclusion: Adults with stroke exhibited significant impairments in cognitive–motor control of the less-affected upper limb, independent of pure motor deficits, persisting into the chronic stage. Right hemisphere lesion was associated with greater impairments than left hemisphere lesion, especially early after stroke, indicating a potential hemispheric specialization for cognitive-motor control. These findings highlight the importance of assessing cognitive–motor control and integrating it into post-stroke rehabilitation interventions. Future studies could explore the predictive role of cognitive–motor control in motor learning and stroke recovery.
Global approaches and insights on symptomatic carotid web management: A mixed-methods study
Natalie Williams1,
Michael Avila Salas1,
Federico Carpani2,
Kamran Zahid1,
Seyed Mojtaba Hosseini1,
Nima Kashani1,
Johanna Ospel3,
Raed Joundi4,
Mohammad Almekhlafi3,
Andrew Demchuk5,
Tolulope Sajobi3,
Jai Shankar1,
Aleksander Tkach6,
Dar Dowlatshahi7,
Alexandre Poppe8,
Bijoy Menon9,
Michael Hill3,
Ravinder-Jeet Singh9,
Aravind Ganesh3,
Nishita Singh1
1University of Manitoba, 2University Health Network, 3University of Calgary, 4Hamilton Health Sciences, 5University of Calgary, 6Interior Health, 7The Ottawa Hospital, 8Centre hospitalier de l’Université de Montréal, 9Health Sciences North
Background: Carotid web is a rare and underdiagnosed cause of recurrent embolic stroke with inconsistent clinical management. This study evaluates global practices, diagnostic approaches, willingness to randomize carotid web patients into trials, and determinants of decision-making in carotid web management.
Methods: We used convergent mixed-methods: a survey and qualitative semi-structured interviews. The ACTIVATE-CAS survey was distributed to 169 stroke specialists across 6 continents, which assessed diagnostic preferences, treatment strategies, and attitudes toward trial participation for carotid web using 8 questions. Quantitative data identified patterns in clinician decision-making and trial readiness. Interviews with 21global stroke leaders were conducted using an interview guide to assess clinicians’ approaches to management of carotid web. Thematic analyses were contextualized against the identified patterns in the quantitative data. Integration occurred at the interpretive stage. Survey findings were used to identify patterns of practice variation, while qualitative data were used to understand differences in thinking underlying such variations.
Results: Among 169 respondents (72.7% aged <40 years; 69% male, 58.5% neurologists, 32.5% interventionists) (55.6% North America, 19% Europe, 12.4% Australia, 6.5% Asia), in current practice, 58% treated carotid web patients with single antiplatelet therapy, while 29% favored dual antiplatelet therapy. Furthermore, most respondents (76%) expressed willingness to randomize carotid web patients into trials comparing best medical management with carotid revascularization for first-ever stroke. Clinicians favored carotid revascularization for carotid web, viewing it as a distinct, high-risk embolic entity, despite very “limited evidence” (Table 1). Both the survey results and interview findings displayed unanimous agreement on the unmet need to conduct randomized controlled trials for carotid web management.
Conclusion: Management of carotid web varies across the continents, and clinicians’ willingness to partake in clinical trials highlights the recognized need for high-quality evidence to inform treatment guidelines. The threshold for intervention is lower for carotid web than other non-stenotic carotid conditions due to higher perceived risk, despite the lack of randomized trials or large prospective studies on management.
Sleep-related arousals during polysomnography are associated with white matter hyperintensity burden and cerebral microbleeds after first-ever minor stroke or transient ischemic attack
Henry T.H. Xie1,2,
Mark Boulos2,
Laavanya Dharmakulaseelan2,
Preston Tse2,
Ryan Muir1,
Joel Ramirez1,
Fuqiang Gao1,
Richard Swartz1,
Brian Murray1,
Sandra Black1
1Sunnybrook Health Sciences Centre, 2University of Toronto
Background: Sleep fragmentation has been implicated in cerebrovascular injury, yet the relationship between specific arousal subtypes and radiographic markers of cerebral small vessel disease (CSVD) remains unclear. Arousals may arise due to a variety of factors, including respiratory disturbances and limb movements, and can also occur during different sleep stages, potentially reflecting distinct pathophysiologic processes. We examined whether specific arousal indices were independently associated with CSVD burden following first-ever minor stroke or high-risk transient ischemic attack (TIA).
Methods: We analyzed prospectively collected data from 79 patients with first-ever minor ischemic stroke (NIHSS ⩽3) or high-risk TIA who underwent technologist-monitored in-laboratory polysomnography and brain MRI. Arousal indices were quantified as the total arousal index (events/hour) and stratified by subtype (respiratory- vs limb movement–associated) and sleep stage (REM vs non-REM). White matter hyperintensity burden was quantified using the Age-Related White Matter Changes (ARWMC) scale and analyzed using linear regression. Cerebral microbleeds were quantified using the Microbleed Anatomical Rating Scale (MARS) and analyzed using negative binomial regression. Full adjustment controlled for age, sex, body mass index (BMI), diabetes, hypertension, smoking, and apnea-hypopnea index. False discovery rate correction was applied to account for multiple comparisons.
Results: The mean (standard deviation) age was 62 (15) years, 34% were female, and the median (interquartile range, IQR) BMI was 27.1 (24.2–30.5). The median (IQR) total arousal index was 24.6 (15.6–33.0).
In fully adjusted models, non-REM respiratory-associated arousals (β = 0.172, 95% CI 0.053–0.290; q = 0.026) and non-REM limb movement–associated arousals (β = 0.469, 95% CI 0.230–0.708; q = 0.003) were independently associated with higher ARWMC scores.
For cerebral microbleeds, non-REM respiratory-related arousals were associated with a higher MARS score (IRR 1.071, 95% CI 1.012–1.134; q = 0.035). The total arousal index, but not limb movement–associated arousal indices, was associated with cerebral microbleed burden. REM-specific indices were not associated with ARWMC or MARS scores.
Conclusion: Physiologic arousal subtypes demonstrate differential associations with radiographic markers of cerebral small vessel disease after minor stroke or TIA. Non-REM respiratory- and limb movement–associated arousals were independently associated with white matter hyperintensity burden, whereas respiratory-related arousals, particularly during non-REM sleep, were associated with higher cerebral microbleed burden. These findings suggest that physiologic arousal subtypes may represent distinct pathways linking sleep disturbance to cerebrovascular injury and that arousal subtype characterization, rather than total arousal index alone, may be important in understanding cerebrovascular injury.
Interprofessional collaborative care for the delivery of chronic disease self-management support among people with stroke or TIA – A scoping review protocol
Michelle Yang1,
Krista Best2,
Courtney Pollock1,
Brodie Sakakibara1
1University of British Columbia, 2Université Laval
Background: Interprofessional collaborative care (ICC) is when multiple health professionals from different disciplines work together, along with patients, to deliver collaboratively developed care plans. While evidence suggests that delivery of care from ICC teams – compared to individual providers – within acute care settings leads to improved health outcomes, enhanced patient satisfaction, and more efficient healthcare (e.g., in-patient stroke units), ICC used as a model for the delivery of chronic disease self-management support is just emerging. Here we report on a scoping review protocol that will: (1) characterize ICC interventions that aim to improve patient health outcomes for people with stroke or TIA; (2) examine differences in ICC protocols between acute and chronic care settings; and (3) explore the impact of these interventions on patient outcomes.
Methods: This scoping review will follow Arksey and O’Malley’s (2005) methodological framework and use the Canadian Interprofessional Health Collaborative (CIHC) competency framework to characterize ICC usage. Six databases (MEDLINE, EMBASE, Web of Science, PubMed, PsycINFO and Cochrane Library) will be searched from their inception to present. Comprehensive search strategies for each database will be developed in collaboration with a university librarian. Quantitative studies investigating ICC interventions (i.e., health interventions delivered by two or more health professional workers from different disciplines working together with patients/clients and their families to support patients’/clients’ care) on patient health outcomes will be eligible if they: (1) include adults with stroke or TIA; and (2) are published in peer-reviewed journals in English. Two independent reviewers will screen studies for eligibility and perform data extraction. Data will be recorded in study specific tables, and quantitative information will be summarized descriptively. Studies will be sorted according to acute and chronic care settings, respectively. Intervention information will be summarized descriptively, and ICC elements described will be categorized into the CIHC framework’s six core competencies: relationship-focused care, team communication, role clarification and negotiation, team functioning, team differences processing, and collaborative leadership.
Conclusion: This review will summarize existing literature on the use of ICC to provide health services to people with stroke and TIA, with emphasis of its use in chronic care settings. Our findings may identify research gaps and/or inform the development of ICC models for the delivery of chronic disease self-management support.
Sociodemographic, health, and behavioural predictors of diet quality in people with stroke
Michelle Yang1,
Miranda Smith1,
Sarah Purcell1,
Maureen Ashe1,
Tricia Tang1,
Brodie Sakakibara1
1University of British Columbia
Background: Dietary quality reflects an overall dietary pattern that considers individual dietary components (e.g., fruits and vegetables) and nutrients (e.g., saturated fatty acids and vitamins). Emerging research suggests that overall diet quality may be a more important indicator of health outcomes than individual dietary components or nutrients. Diet quality may be particularly relevant for reducing risk related to metabolic syndrome (MetS)—a common condition among people with stroke and a contributing factor to secondary events following initial stroke onset. However, there is limited understanding of the factors associated with diet quality among people with (i) stroke and (ii) stroke with comorbid MetS. The study objectives were to: (1) identify sociodemographic, health, and behavioural variables that predict overall diet quality in people with stroke; and (2) examine the associations of these predictors among stroke survivors with MetS.
Methods: This secondary analysis of baseline data from a larger randomized controlled trial included individuals aged ⩾50 years, within one-year post-stroke, with mild to moderate stroke severity. Diet quality (dependent variable) was assessed using the Smart Diet food frequency questionnaire and converted into a Prospective Urban Rural Epidemiology (PURE) score. PURE scores ranged from 0–24, with higher scores indicating poorer diet quality (‘better’ = 0–13; ‘poorer’ = 14–24). Independent variables included: (1) sociodemographic (e.g., age, sex, marital status, education level); (2) health (e.g., stroke severity, number of comorbid conditions); and (3) behavioural factors (e.g., stress management, physical activity). Hierarchical linear regression models using forward selection and backward elimination were conducted to develop parsimonious prediction models.
Results: Among the 89 participants included, 59 (66.3%) were male and 56 (62.9%) were categorized as having MetS. Among individuals with MetS (n = 56), the mean age was 68.5 ± 9.6 years, and 36 (64.3%) were male. Regression analyses among all study participants showed that a greater number of comorbid conditions (β = 0.22, p = 0.044) and higher levels of physical activity (β = −0.31, p = 0.006) were significant predictors of diet quality (p < 0.05). Among individuals with MetS, greater stroke severity (β = −0.27, p = 0.044) and greater number of comorbid conditions (β = −0.33, p = 0.017) were significant predictors of diet quality (p < 0.05).
Conclusion: Higher physical activity levels and a greater number of comorbid conditions were associated with better overall diet quality among people with stroke. Increased stroke severity was also associated with diet quality among individuals with MetS. These findings highlight the importance of considering physical activity alongside diet quality, particularly among stroke survivors with greater comorbidity burden and higher stroke severity, to support secondary prevention efforts for future interventions.
Split-belt training with a progressive, individualized, ramped alternating-block approach for adaptation of locomotion in chronic-stroke
Kaya Yoshida1,
Beier Lin1,
Shannon Lim1,
Janice J. Eng1,
Lara Boyd1,
Amy Schneeberg1,
Theodore Huppert2,
Courtney Pollock1
1University of British Columbia, 2University of Pittsburgh
Background: Following a stroke, between-leg asymmetries commonly impact walking function and speed. Split-belt treadmill interventions use error augmentation to improve step length symmetry (SLS) post-stroke. Recent evidence suggests that incorporating incline and alternating between tied-and split-block conditions may enhance SLS gains. However, this potential benefit has not been evaluated across multiple training sessions. Importantly, exposure to walking challenge has been shown to increase attentional demands and sympathetic arousal linked to decreased balance confidence post-stroke. Thus, this study examined locomotor adaptation, together with perceived stability, sympathetic arousal, cortical activation, and resulting functional gait speed following a progressive, individualized, ramped, alternating-block split-belt treadmill program in people with chronic stroke.
Methods: Ten independent ambulators with chronic stroke resulting in hemiparesis (5M; 5F, 55.9 6.8 yrs, 3.6 3.6 yrs post-stroke) with asymmetrical step lengths (baseline SLS=-0.12) and mild-moderate lower-limb impairment (Chedoke McMaster Stroke Assessment foot: 3.7/7, leg: 5.2/7) completed 12 sessions (3x/week) of split-belt treadmill training (2:1 belt speed ratio; 4x4-minute blocks at 2% ramp). Belt speeds were individualized to over-ground walking speed and increased 5% weekly. SLS, electrodermal activity (sympathetic arousal), prefrontal cortex (PFC) activation (functional near-infrared spectroscopy) and rating of perceived stability (RPS) were measured at pre-, post- and one-month retention. Comfortable and fast gait speeds (CGS, FGS) were assessed using the 10-Meter Walk Test. Linear-mixed effects models assessed changes in each measure by timepoint.
Results: Training resulted in increased SLS at slow (Δ=0.049, p=.06) and fast (Δ=–0.115, p=.04) walking speeds at post-training and was maintained at one-month retention. Functionally, training resulted in faster over-ground CGS (Δ=0.19 m/s, p<.001) and FGS (Δ=0.12 m/s, p =.017), also maintained at retention. Participant-reported RPS demonstrated improved perception of stability at post-training and retention (p<.001). Sympathetic arousal response at split onset decreased by 73% following training (p<.001) and was somewhat maintained at retention. Bilateral PFC activation decreased post-training (p<.001) and was maintained at retention, suggesting reduced attentional demand during split-belt walking.
Conclusion: Twelve sessions of progressive, ramped, alternating block split-belt treadmill training resulted in improvements in SLS and gait speed post-stroke that were maintained one-month post training. Patterns of adaptation in SLS showed temporal co-modulation with sympathetic arousal and PFC activation in line with participant-reported decreased perception of challenge associated with split-belt walking. These findings support the potential of split-belt treadmill training as an effective neurorehabilitation intervention.