ObjectiveAn in-depth exploration of neighborhood environmental impact on post-discharge stroke outcomes is lacking yet essential for identifying populations at high risk. We assess neighborhood economic and demographic characteristics associated with 90-day death or readmission post-stroke hospitalization.MethodsWe prospectively analyzed 1,329 acute stroke survivors in the Florida Stroke Registry's Transition of Care Stroke Disparities Study (91% ischemic, 56% male, 52% non-Hispanic White, 23% non-Hispanic Black, 22% Hispanic, median age 64). Neighborhood characteristics at the ZIP+4 level, including socioeconomic status (NSES), racial/ethnic composition, and business densities (food, tobacco/alcohol, gyms, medical services), were analyzed using factor analysis to generate four factors with eigenvalues greater than 1. Outcomes (death or readmission) were assessed through structured telephone interviews 90 days post-discharge. Logistic regression evaluated associations between neighborhood characteristics and outcomes, adjusting for demographics (race/ethnicity, sex, age), vascular risk factors, stroke severity from Get With The Guidelines-Stroke®, and social or economic conditions such as insurance, support, and living arrangements.ResultsWithin 90 days, 208 patients experienced death or readmission. Four factors explained 59% of the variance in 24 neighborhood characteristics. Factor 1, defined by lower NSES, higher population density, and urbanization (RUCA code 1, greater densities of tobacco/alcohol outlets, restaurants, grocery stores, gyms, and pharmacies), was associated with a 20% increased risk.ConclusionsLiving in densely populated, highly urbanized neighborhoods with lower SES and greater commercial density predicted poor stroke outcomes independent of individual health or SES. These findings can guide community interventions to reduce stroke mortality and readmission.

Introduction: Gait speed is a functional vital sign used to categorize community ambulation after stroke. The relationship between gait speed and quantity (i.e., step counts) of community ambulation post-stroke has been established. Yet, quantity alone does not depict a complete picture of community function. Gait quality metrics, such as symmetry, play a role in falls risk, and speak to functional motor impairments post-stroke. However, the relationship between gait speed and community-measured gait quality remains unknown. The purpose of this study was to investigate the relationship between gait speed and gait quality in a community setting after stroke. Methods: A 10-meter walk test was used to evaluate each preferred gait speed (PGS) and fastest gait speed (FGS). The mean of three trials for each PGS/FGS was used. Participants then wore inertial measurement units (IMUs) over a one-week period in their home/community setting. IMUs recorded both step counts (quantity) and time in stance phase of each the paretic and non-paretic lower limb during the gait cycle. Symmetry (quality) was calculated by dividing the stance time of the paretic by the non-paretic limb, yielding a symmetry index (SI). To assess the relationship between gait speed and gait quality, we first standardized the magnitude of asymmetry by subtracting SI from one. We used a linear regression model to determine whether gait speed predicted gait asymmetry, controlling for NIHSS. Results: Of 32 participants, the mean±SD age was 61±9 years, and time since stroke was 66±104 months. The sample included 15 (47%) females and 13 (41%) left CVAs. In our cohort, 22 (69%) had mild strokes (NIHSS 0-5) and 10 (31%) had moderate strokes (NIHSS 6-14). After controlling for NIHSS, each PGS (β = -0.237, SE = 0.085, t = -2.796, p = 0.009, CI [-0.411, -0.063]) and FGS (β = –0.141, SE = 0.050, t = -2.842, p = 0.008, CI [-0.243, -0.039]) significantly predicted gait quality. PGS model explained 17%, while FGS model explained 18% of the variance in gait quality. Figure 1 shows the linear relationship between each PGS (A) and FGS (B) to the amount of gait asymmetry. Regarding gait quantity, no significant relationship was found between PGS and FGS to gait quantity within our sample. Conclusions: Both PGS and FGS are significant predictors of gait quality, but not quantity, in a community setting after stroke. Our results are limited by the small sample size. Future work with a larger sample is warranted.

Objectives Community health workers (CHWs) help patients navigate community resources and support healthier lifestyles. Although stroke transitions of care require navigating complex clinical services and behavioral changes, there is no established formal training for CHWs in stroke care across Florida. We describe the impact of a comprehensive stroke training course designed and tailored for community health workers. Methods We developed a CHW stroke care curriculum with input from the Florida CHW Coalition, vascular neurologists, epidemiologists, and Florida Stroke Registry stakeholders. The course, featuring a 12-credit continuing medical education curriculum, was a hybrid of live and recorded lectures, modules, and community engagement exercises. Free registrations were promoted via the Florida CHW Coalition advertisements, Florida Stroke Registry Web site and listserv, and stakeholder meetings. Results Three separate cohorts accomplished the course. Across 3 years (2022-2024), a total of 75 participants (54 of whom completed the course) were included in this analysis. The median age was 44 years (interquartile range 35-54), with 74% of participants aged 54 years or younger. The racial/ethnic distribution was 33% Hispanic, 30% White, and 26% Black. The majority were female (n = 50, 93%). The mean pretraining score was 72% (standard deviation 15.2%), which increased to 91% (standard deviation 6.2%) posttraining. Due to the nonnormal distribution of score differences, we used the Wilcoxon signed-rank test (S) which confirmed a statistically significant improvement in scores post training (S = 735.5, p < 0.001) indicating higher post-training scores and reduced variability, indicating both effectiveness and consistency of learning gains. Conclusions The formal training of CHWs to recognize stroke risk factors, promote self-management, and support stroke care equipped CHWs with the essential skills and knowledge to confidently foster meaningful partnerships with the community aimed at improving stroke outcomes.

Background: Optimization of stroke care plays a critical role in post-stroke outcomes. The stroke coordinator role includes leadership of stroke care teams, education of staff, patients, and emergency personnel, and stroke care quality improvement initiatives. The current study aimed to characterize Florida stroke coordinator responsibilities, stroke coordinators roles, and resources available and job satisfaction through a statewide hospital survey. Methods: We report on a 20-item Stroke Coordinator Roles and Responsibility Survey that was administered to stroke coordinators from participating Florida hospitals. Topics included description of stroke center (i.e., size and type); experience of stroke coordinator; roles/responsibilities (data abstraction details, number of sites covered, description of additional duties); resources available; adequacy of training; satisfaction with compensation. We characterized various roles and resources available to coordinators and examined their variations by center type, size, and additionally by years in current position using the Chi square test. Results: Surveys were deployed to 148 stroke coordinators covering 180 stroke hospitals from August to December 2023. A total of 55 responses (response rate 37 %) were available for analysis from 25 comprehensive/thrombectomy capable and 24 primary stroke centers with some coordinators covering multiple sites. Stroke coordinators who have been in their current role >5 years were more likely to work in large (63 % vs 29 %, p = 0.02), comprehensive (75 % vs 33 % p = 0.03) stroke centers. Coordinators reported spending on average 45 to 60 min per chart for data abstraction, which was unrelated to center type (p = 0.57), size (p = 0.99) or coordinator experience (p = 0.81). The longer the stroke coordinator was in their role (>5 years vs. <5 years) the more likely they had additional duties (>2 additional duties, 69 % vs 49 %, p = 0.04), and less likely to have extra resources (88 % vs 67 % p = 0.05). The majority (61 %) of stroke coordinators indicated dissatisfaction with their training and compensation. Conclusions: Stroke coordinators face challenges with chart abstraction workload, fulfilling multiple roles, and limited available resources. Dissatisfaction is present with perceptions of inadequate training and compensation. Organizations should focus on addressing these concerns to stabilize and strengthen the stroke coordinator role, enhancing the quality and performance of the stroke program.

Gait recovery after stroke is a primary goal of rehabilitation, therefore it is imperative to develop technologies that accurately identify gait impairments after stroke. Markerless motion capture (MMC) is an emerging technology that has been validated in healthy individuals. Our study aims to evaluate the validity of MMC against an instrumented walkway system (IWS) commonly used to evaluate gait in stroke survivors. Nineteen participants performed three comfortable speed (CS) and three fastest speed (FS) walking trials simultaneously recorded with IWS and MMC system, KinaTrax (HumanVersion 8.2, KinaTrax Inc., Boca Raton, FL, USA). Pearson’s correlation coefficient and intraclass correlation coefficient (ICC (3,1), 95%CI) were used to evaluate the agreement and consistency between systems. Furthermore, Bland–Altman plots were used to estimate bias and Limits of Agreement (LoA). For both CS and FS, agreements between MMC and IWS were good to excellent in all parameters except for non-paretic single-limb support time (SLS), which revealed moderate agreement during CS. Additionally, stride width and paretic SLS showed poor agreement in both conditions. Biases eliminated systematic errors, with variable LoAs in all parameters during both conditions. Findings indicated high validity of MMC in measuring spatiotemporal gait parameters in stroke survivors. Further validity work is warranted.

OBJECTIVE:Poststroke rehabilitation provides skilled services that target motor impairments to improve function and maximize independence after stroke. Our objectives are to first describe functional outcomes for those who participated in rehabilitation services, then to identify race/ethnic disparities in rehabilitation services after stroke and characterize the independent association of race/ethnicity to functional recovery after stroke. DESIGN:Observational data were extracted from the American Heart Association's Get-With-The-Guidelines-Stroke dataset. Rehabilitation services and modified Rankin Scale were recorded at hospital discharge and via follow-up phone calls at 30 and 90 days after. SETTING:Large, comprehensive stroke centers. PARTICIPANTS:Stroke survivors throughout the state of Florida (n=1083). INTERVENTIONS:Not applicable. MAIN OUTCOME MEASURES:Descriptive statistics characterize functional change in those who received rehabilitation services. Logistic regression models adjusted for potential confounders were used to determine (1) race/ethnic differences in rehabilitation services received and (2) race/ethnic differences in functional change from discharge to 30 and 90 days, respectively. RESULTS:Of 1083 individuals, 43% were women, 54% were non-Hispanic White (NHW), 23% non-Hispanic Black (NHB), and 23% Hispanic. At a short-term (30d) follow-up after hospital discharge, 14% of individuals who received rehabilitation services showed functional gains, 68% no change in function, and 18% functional decline. Yet, 30 days is likely inadequate for the full functional benefit of rehabilitation efforts. At 90 days after hospital discharge, 26% showed functional improvements, 58% no change, and 16% functional decline. Irrespective of type of rehabilitation services received, there were no differences in functional change between NHW and NHB individuals, yet Hispanic individuals were less likely to improve (adjusted odds ratio [aOR]=0.647, 95% CI [0.425-0.983]) compared with NHW. In addition, Hispanic individuals were significantly less likely to receive any rehabilitation services (aOR=0.626, 95% CI [0.442-0.886]) and were half as likely to receive outpatient services (aOR=0.543, 95% CI [0.368-0.800]) compared with NHW. CONCLUSIONS:Rehabilitation is key to functional improvement after stroke. We are making strides in health equity between NHW and NHB individuals, yet there remain disparities in functional outcomes and in rehabilitation services particularly for Hispanic individuals after stroke.

Objective: A thorough exploration of neighborhood environmental impacts on post-discharge stroke outcomes is lacking and crucial to identifying populations at high risk. We assess neighborhood economic and demographic characteristics associated with 90-day death or readmission post-stroke hospitalization. Methods: The study population included 1329 stroke survivors in the prospective Florida Stroke Registry’s Transition of Care Stroke Disparities Study (91% ischemic stroke, 56% males, 51.5% Non-Hispanic White, 22.6% non-Hispanic Black, 21.8% Hispanic, median age 64). Publicly available data on the neighborhood (Zip+4) characteristics included socioeconomic status (NSES), race/ethnic composition, and business densities (food, tobacco/alcohol, gyms, medical services), which were used in factor analysis to create four main factors. Structured telephone interviews at 90 days post-discharge assessed stroke outcomes (death or readmission). Logistic regression models examined associations between the neighborhood characteristics and death/readmission, adjusting for individual demographics (race/ethnicity, sex, age), vascular risk factors and stroke severity obtained from Get with the Guidelines-Stroke®, and individual social/economic conditions (insurance, social support, living arrangement) from patient interviews. Results: Within 90 days post-discharge, 208 patients experienced death or readmission. Four main factors explained 56% of the variance in 24 neighborhood characteristics, of which factor 1 was associated with a 20% increased risk of death/readmission. Factor 1 was characterized by Hispanic dominance (above median %Hispanic), lower NSES (higher %below the poverty line, densely populated), and highly urbanized (primary Rural-Urban Commuting Area (RUCA) code of 1, higher densities of tobacco outlets, alcohol outlets, restaurants, grocery stores, gyms, and pharmacies). Conclusions: Living in predominantly Hispanic, highly urbanized, crowded neighborhoods with lower SES, predicted poor stroke outcomes independent of individual health or SES conditions. These findings can help inform the target population for community interventions aimed at improving stroke mortality and readmission rates.

OBJECTIVE:Poor socioeconomic conditions are linked to increased stroke-related mortality and worse clinical outcomes post-stroke. This study examines the association between neighborhood socio-demographic (NSD) profile and adequate transitions of care (ATOC) in acute ischemic stroke patients one month after discharge. METHODS:The Transitions of Care Stroke Disparities Study (TCSD-S) is an observational prospective cohort investigating disparities in stroke care transitions. Data from 1132 acute ischemic stroke (AIS) patients was obtained from three sources: 1) publicly available NSD data using participants' ZIP codes, 2) Structured telephone interviews at 30 days post-discharge to ascertain participants' behavior in six categories, and 3) covariates obtained from Get with the Guidelines-Stroke® (GWTG-S). Logistic regression models examined the relationship between NSDs and achieving ATOC, defined as adherence to at least 75 % of the six behavioral modifications for ATOC, adjusting for patient demographics, social determinants of health, and stroke severity. RESULTS:The sample included 56 % males, 51.5 % non-Hispanic White, 22.6 % non-Hispanic Black, and 21.8 % Hispanic individuals, with a median age of 64 (IQR = 55-74 years). ATOC was achieved in 994 (88 %) participants. While NSDs did not independently predict the overall ATOC success, we observed a direct association of NSD profile (education level and median income) with patients' adherence to rehabilitation follow-up (p = 0.03), toxic habit cessation (p = 0.04), and medical appointment attendance (p = 0.04), independent of the effects of individual socioeconomic status. CONCLUSIONS:Neighborhood socioeconomic status directly impacts protective behaviors. This finding can inform future community-level interventions aimed at improving patients' adherence to behavioral modifications.

OBJECTIVES:We explore patient-reported behaviors and activities within 30-days post-stroke hospitalization and their role in reducing death or readmissions within 90-days post-stroke. METHODS:We constructed the adequate transitions of care (ATOC) composite score, measuring patient-reported participation in eligible behaviors and activities (diet modification, weekly exercise, follow-up medical appointment attendance, medication adherence, therapy use, and toxic habit cessation) within 30 days post-stroke hospital discharge. We analyzed ATOC scores in ischemic and intracerebral hemorrhage stroke patients discharged from the hospital to home or rehabilitation facilities and enrolled in the NIH-funded Transitions of Care Stroke Disparities Study (TCSD-S). We utilized Cox regression analysis, with the progressive adjustment for sociodemographic variables, social determinants of health, and stroke risk factors, to determine the associations between ATOC score within 30-days and death or readmission within 90-days post-stroke. RESULTS:In our sample of 1239 stroke patients (mean age 64 +/- 14, 58 % male, 22 % Hispanic, 22 % Black, 52 % White, 76 % discharged home), 13 % experienced a readmission or death within 90 days (3 deaths, 160 readmissions, 3 readmissions with subsequent death). Seventy percent of participants accomplished a ≥75 % ATOC score. A 25 % increase in ATOC was associated with a respective 20 % (95 % CI 3-33 %) reduced risk of death or readmission within 90-days. CONCLUSION:ATOC represents modifiable behaviors and activities within 30-days post-stroke that are associated with reduced risk of death or readmission within 90-days post-stroke. The ATOC score should be validated in other populations, but it can serve as a tool for improving transitions of stroke care initiatives and interventions.

Objective:To establish short-term feasibility and usability of wrist-worn wearable sensors to capture arm/hand activity of stroke survivors and to explore the association between factors related to use of the paretic arm/hand. Methods:30 chronic stroke survivors were monitored with wrist-worn wearable sensors during 12h/day for a 7-day period. Participants also completed standardized assessments to capture stroke severity, arm motor impairments, self-perceived arm use and self-efficacy. Usability of the wearable sensors was assessed using the adapted System Usability Scale and an exit interview. Associations between motor performance and capacity (arm/hand impairments and activity limitations) were assessed using Spearman's correlations. Results:Minimal technical issues or lack of adherence to the wearing schedule occurred, with 87.6% of days procuring valid data from both sensors. Average sensor wear time was 12.6 (standard deviation: 0.2) h/day. Three participants experienced discomfort with one of the wristbands and three other participants had unrelated adverse events. There were positive self-reported usability scores (mean: 85.4/100) and high user satisfaction. Significant correlations were observed for measures of motor capacity and self-efficacy with paretic arm use in the home and the community (Spearman's correlation ρs: 0.44-0.71). Conclusions:This work demonstrates the feasibility and usability of a consumer-grade wearable sensor to capture paretic arm activity outside the laboratory. It provides early insight into stroke survivors' everyday arm use and related factors such as motor capacity and self-efficacy. Impact:The integration of wearable technologies into clinical practice offers new possibilities to complement in-person clinical assessments and to better understand how each person is moving outside of therapy and throughout the recovery and reintegration phase. Insights gained from monitoring stroke survivors arm/hand use in the home and community is the first step towards informing future research with an emphasis on causal mechanisms with clinical relevance.

Background and Purpose: Social determinants of health (SDOH), including social networks, impact disability and quality of life post-stroke, yet the direct influence of SDOH on functional change remains undetermined. We aimed to identify which SDOH predict change on the modified Rankin Scale (mRS) within 90 days after stroke hospitalization.Methods: Stroke patients from the Transitions of Care Stroke Disparities Study (TCSDS) were enrolled from 12 hospitals in the Florida Stroke Registry. TCSDS aims to identify disparities in hospital-to-home transitions after stroke. SDOH were collected by trained interviewers at hospital discharge. The mRS was assessed at discharge, 30- and 90-day post-stroke. Multinomial logistic regression models examined contributions of each SDOH to mRS improvement or worsening (compared to no change) from discharge to 30- and 90-day, respectively.Results: Of 1190 participants, median age was 64 years, 42% were women, 52% were non-Hispanic White, and 91% had an ischemic stroke. Those with a limited social support network had greater odds of functional decline at 30 days (aOR = 1.39, 1.17-1.66), adjusting for age and onset to arrival time and at 90 days (aOR = 1.50, 1.10-2.05) after adjusting for age. Results were consistent after further adjustment for additional SDOH and participant characteristics. Individuals living with a spouse/partner had reduced odds of functional decline at 90 days (aOR = 0.74, 0.57-0.98); however, results were inconsistent with more conservative modeling approaches.Conclusion: The findings highlight the importance of SDOH, specifically having a greater number of individuals in your social network in functional recovery after stroke.

Objective: Transition of Care Stroke Disparities Study is an observational prospective cohort aimed to investigate disparities in the transition of stroke care (TOSC) post-hospitalization to home and to identify factors associated with adequate TOSC and stroke outcomes. we have demonstrated that higher individual socioeconomic status is associated with adequate TOSC. The present study explores the association between neighborhood-level characteristics (NLC) and adequate TOSC in ischemic stroke patients 1 month after discharge. Methods: Data from 925 ischemic stroke patients discharged from 10 Comprehensive Stroke Centers (CSCs) was obtained from three sources: a. NLC: demographic composition, level of education, and median household income from publicly available data using participants’ Zip codes (independent variables); b. 30-day post-discharge data for 6 categories of TOSC-related behaviors (dependent variables) including medication adherence, weekly exercise, medical follow-up, rehabilitation attendance, toxic habit cessation, diet modification. c. Clinical characteristics from Get with the Guidelines-Stroke (covariates). The primary outcome was 100% adequate transition of care (ATOC), a combined index of ideal adherence to all applicable behavior modifications. Results: The sample included 46% Women, 23% Non-Hispanic Black and 22% Hispanic, the average age was 64 years. NLC ranged as follows: % Black (0-93.9, median 9.1), %Hispanic (3-99.9, median 82.3), % bachelor’s degree (6.3-77.3, median 26.2), and median household income ($18,920-159,914, median $48,816). Almost a third (34%) of participants achieved 100% ATOC. In the adjusted analysis of NLC variables, higher %Hispanic (OR=1.45, 95% CI=1.03-2.04), higher %bachelor's degree recipients (OR=1.62, 95% CI=1.21-2.18), and higher median income (OR=1.12, 95%CI=1.04-1.21) were significantly associated with achieving 100% ATOC. Conclusions: Results suggest that NLC plays a crucial role in adherence to care transition instructions, underscoring the importance of interventions targeted at lower socioeconomic status populations. Future work will determine the impacts of NLC on stroke recurrence and readmission.

ObjectiveTo establish the concurrent validity, acceptability, and sensor optimization of a consumer-grade, wearable, multi-sensor system to capture quantity and quality metrics of mobility and upper limb movements in stroke survivors.DesignSingle-session, cross-sectional.SettingClinical research laboratory.ParticipantsThirty chronic stroke survivors (age 57 (10) years; 33% female) with mild to severe motor impairments participated.InterventionsNot Applicable.Main Outcome MeasuresParticipants donned 5 sensors and performed standardized assessments of mobility and upper limb (UL) movement. True/false, positive/negative time in active movement for the UL were calculated and compared to criterion-standards using an accuracy rate. Bland-Altman plots and linear regression models were used to establish concurrent validity of UL movement counts, step counts, and stance time symmetry of MiGo against established criterion-standard measures. Acceptability and sensor optimization were assessed through an end-user survey and decision matrix.ResultsMobility metrics showed excellent association with criterion-standards for step counts (video: r=0.988, P<.001, IMU: r=0.921, P<.001) and stance-time symmetry (r=0.722, P<.001). In the UL, movement counts showed excellent to good agreement (paretic: r=0.849, P<.001, nonparetic: r=0.672, P<.001). Accuracy of active movement time was 85.2% (paretic) and 88.0% (nonparetic) UL. Most participants (63.3%) had difficulty donning/doffing the sensors. Acceptability was high (4.2/5).ConclusionsThe sensors demonstrated excellent concurrent validity for mobility metrics and UL movements of stroke survivors. Acceptability of the system was high, but alternative wristbands should be considered.

BACKGROUNDThe ability to objectively measure spatiotemporal metrics within individuals post-stroke is integral to plan appropriate intervention, track recovery, and ultimately improve efficacy of rehabilitation programs. Inertial measurement units (IMUs) provide a means to systematically collect gait-specific metrics that could not otherwise be obtained from clinical outcomes. However, the use of IMUs to measure spatiotemporal parameters in stroke survivors has yet to be validated. The purpose of this study is to determine the validity and reliability of IMU-recorded spatiotemporal gait metrics as compared to a motion capture camera system (MCCS) in individuals post-stroke.METHODSParticipants (n = 23, M/F = 12/11, mean (SD) age = 50.2(11.1) spatiotemporal data were collected simultaneously from a MCCS and APDM Opal IMUs during a five-minute treadmill walking task at a self-selected speed. Criterion validity and test-retest reliability were assessed using Lin's concordance correlation coefficients (CCCs) and intraclass correlation coefficients (ICCs), respectively. Spatiotemporal values from MCCS and IMU were used to calculate gait asymmetry, and a t-test was used to assess the difference between asymmetry values.RESULTSThere were fair-to-excellent agreement between IMU and MCCS of temporal parameters (CCC 0.56-0.98), excellent agreement of spatial parameters (CCC >0.90), and excellent test-retest reliability for all parameters (ICC >0.90).CONCLUSIONSCompared to motion capture, the APDM Opal IMUs produced accurate and reliable measures of spatiotemporal parameters. Findings support the use of IMUs to assess spatiotemporal parameters in individual's post-stroke.

Objectives: This study identifies the association between patient perception of discharge education/resources and adequate transitions of care (ATOC) (i.e., patient achievement of at least 75% of recommended positive behaviors and activities within 30 days post-stroke hospitalization). Methods: The analysis measured the association between sufficient discharge communication (SDC) (i.e., patient receipt of sufficient diet education, sufficient toxic habit cessation education, if applicable, and scheduled medical follow-up appointment) and ATOC within 30 days post-discharge overall and by race/ethnicity [non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic] in the Transitions of Care Stroke Disparities Study (TCSD-S) (2018-2023). Results: In our sample (N = 1151, Average Age 64+/-14 years, 57% Men, 54% NHW, 24% NHB, 23% Hispanic), 31% overall, as well as 22% of NHW, 43% of NHB, and 41% of Hispanics reported SDC. After covariate adjustment, patients reporting SDC had increased likelihood of accomplishing ATOC when compared to patients not reporting SDC overall (OR = 1.97; 95% CI: 1.42-2.74) and among NHW (OR = 2.76; 95% CI: 1.64-4.64) and NHB (OR = 2.29; 95% CI: 1.16-4.53). The association among Hispanic participants was not statistically significant. Conclusion: Our findings reinforce the importance of providing quality communication to patients to ensure a successful transition of care from hospital to home or rehabilitation facility.

Introduction: Historically, non-Hispanic black (NHB) and Hispanic stroke survivors have been discharged at a poorer functional level than non-Hispanic whites (NHW). The purpose of this study was to examine race and ethnic differences in rehabilitation prescription and participation at time of discharge (DC) and in modified Rankin Scale (mRS) at 30- and 90-days post-stroke. Methods: The Transitions of Stroke Care Disparities Study is designed to reduce disparities and optimize post-stroke care in hospital-to-home transitions. Survivors of ischemic stroke and intracerebral hemorrhage from a subset of 165 hospitals in the Florida Stroke Registry were included in the Get with the Guidelines-Stroke® (GWTG-S) database. Race and ethnicity, therapy prescription and participation, and mRS were extracted from GWTG-S, and by self-report at 30- and 90-days after DC. Race and ethnic differences were assessed in therapy prescription, participation, and mRS using binary logistic regression adjusted for age, sex, stroke severity (NIHSS), and DC walking ability. Results: In 1,129 stroke survivors (mean age 64y, 45% women, 55% NHW, 23% NHB, 22% Hispanic, 76% independent walkers at DC), 29% were prescribed inpatient and 50% outpatient rehabilitation at DC. Multivariable analysis showed NHW were significantly less likely to be prescribed inpatient therapy compared to NHB [OR 0.56, 95%CI (0.35-0.88)] or Hispanics [OR 0.50, 95%CI (0.31-0.80)]. Hispanic individuals [OR 1.69, 95%CI (1.20-2.38)] were significantly less likely to be prescribed outpatient therapy compared to NHW or NHB. No differences in therapy participation were seen between NHW and NHB [OR 1.16, 95%CI (0.69-1.97)] or Hispanics [OR 1.41, 95%CI (0.82-2.43)]. No differences in mRS were seen between NHW and NHB [30-days, OR 0.85, 95% CI (0.52-1.39); 90-days, OR 0.68, 95%CI (0.42-1.11)] or Hispanics [30-days, OR 0.63, 95% CI (0.37-1.10); 90-days, OR 0.61, 95%CI (0.36-1.03)]. Conclusions: Although there were significant race and ethnic differences in therapy prescription setting, no race and ethnic differences were seen in therapy participation or in mRS at either 30- or 90-days. Further research is warranted to examine race and ethnic differences in stroke recurrence and readmission rates.

Introduction: Descending motor pathways, namely the corticospinal (CST) and corticoreticular tracts (CRT), are important for normal gait function and have been implicated in gait recovery after stroke. However, the relationship of structural injury to these tracts and gait function in the acute and chronic stage post-stroke remains unclear. Methods: Gait velocity was recorded the first week (acute) after stroke (n=127) and one year later (n= 50). CST and CRT injury were measured using weighted lesion load (wLL). The impact of CST and CRT injury on ambulation status (non-ambulatory vs. ambulatory) and gait velocity was assessed with multivariate logistic and linear regression models, respectively, acutely and chronically, controlling for wLL and lesion size. Results: Greater CRT injury resulted in a higher odds of ambulation loss acutely post-stroke (odds ratio [95% CI, p value]: CRT wLL, 1.06 [1.02-1.12, 0.007]; CST wLL 0.97 [0.95-0.99, 0.04]; lesion volume 1.00 [0.99-1.00, 0.96]). Conversely, greater CST injury had higher odds of ambulation loss at one-year (CST wLL, 1.09 [1.01-1.21, 0.04]; CRT wLL, 0.98 [0.84-1.13, 0.75]; lesion volume, 1.00 [0.99-1.00, 0.81]). For walkers (N=51 [acute] and 46 [chronic]), gait velocity was not significantly associated with CRT nor CST wLL at either time. Multicollinearity results denoted lesion measures provided independent information (maximum variance inflation factors 3.4 (acute), 4.2 (one-year)). Conclusion: Results suggest CRT injury is the dominant correlate of ambulation loss acutely, with CST the dominant correlate of persistent loss after one-year. Gait velocity is not well explained by damage to either tract. The results imply that the CRT may be the primary cortical projection for normal (pre-stroke) gait. Yet, the nervous system has sufficient redundancy to compensate for unilateral CRT injury, while CST injury may have a more enduring negative impact on gait function.

Background In stroke rehabilitation, wearable technology can be used as an intervention modality by providing timely, meaningful feedback on motor performance. Stroke survivors’ preferences may offer a unique perspective on what metrics are intuitive, actionable, and meaningful to change behavior. However, few studies have identified feedback preferences from stroke survivors. This project aims to determine the ease of understanding and movement encouragement of feedback based on wearable sensor data (both arm/hand use and mobility) for stroke survivors and to identify preferences for feedback metrics (mode, content, frequency, and timing). Methods A sample of 30 chronic stroke survivors wore a multi-sensor system in the natural environment over a 1-week monitoring period. The sensor system captured time in active movement of each arm, arm use ratio, step counts and stance time symmetry. Using the data from the monitoring period, participants were presented with a movement report with visual displays of feedback about arm/hand use, step counts and gait symmetry. A survey and qualitative interview were used to assess ease of understanding, actionability and components of feedback that users found most meaningful to drive lasting behavior change. Results Arm/hand use and mobility sensor-derived feedback metrics were easy to understand and actionable. The preferred metric to encourage arm/hand use was the hourly arm use bar plot, and similarly the preferred metric to encourage mobility was the hourly steps bar plot, which were each ranked as top choice by 40% of participants. Participants perceived that quantitative (i.e., step counts) and qualitative (i.e., stance time symmetry) mobility metrics provided complementary information. Three main themes emerged from the qualitative analysis: (1) Motivation for behavior change, (2) Real-time feedback based on individual goals, and (3) Value of experienced clinicians for prescription and accountability. Participants stressed the importance of having feedback tailored to their own personalized goals and receiving guidance from clinicians on strategies to progress and increase functional movement behavior in the unsupervised home and community setting. Conclusion The resulting technology has the potential to integrate engineering and personalized rehabilitation to maximize participation in meaningful life activities outside clinical settings in a less structured environment.

Background We previously characterized hemisphere-specific motor control deficits in the ipsilesional, less-impaired arm of unilaterally lesioned stroke survivors. Our preliminary data indicate these deficits are substantial and functionally limiting in patients with severe paresis. Methods We have designed an intervention (“IPSI”) to remediate the hemisphere-specific deficits in the ipsilesional arm, using a virtual-reality platform, followed by manipulation training with a variety of real objects, designed to facilitate generalization and transfer to functional behaviors encountered in the natural environment. This is a 2-site (primary site – Penn State College of Medicine, secondary site – University of Southern California), two-group randomized intervention with an experimental group, which receives unilateral training of the ipsilesional arm throughout 3 one-hour sessions per week for 5 weeks, through our Virtual Reality and Manipulation Training (VRMT) protocol. Our control group receives a conventional intervention on the contralesional arm, 3 one-hour sessions per week for 5 weeks, guided by recently released practice guidelines for upper limb rehabilitation in adult stroke. The study aims to include a total of 120 stroke survivors (60 per group) whose stroke was in the territory of the middle cerebral artery (MCA) resulting in severe upper-extremity motor impairments. Outcome measures (Primary: Jebsen-Taylor Hand Function Test, Fugl-Meyer Assessment, Abilhand, Barthel Index) are assessed at five evaluation points: Baseline 1, Baseline 2, immediate post-intervention (primary endpoint), and 3-weeks (short-term retention) and 6-months post-intervention (long-term retention). We hypothesize that both groups will improve performance of the targeted arm, but that the ipsilesional arm remediation group will show greater improvements in functional independence. Discussion The results of this study are expected to inform upper limb evaluation and treatment to consider ipsilesional arm function, as part of a comprehensive physical rehabilitation strategy that includes evaluation and remediation of both arms. Trial Registration This study is registered with ClinicalTrials.gov (Registration ID: NCT03634397 ; date of registration: 08/16/2018).