Bilateral movement training and stroke rehabilitation: A systematic review and meta-analysis

Motor extinction: a deficit of attention or intention?

Motor extinction refers to a deficit of motor production on the side opposite a brain lesion that either only becomes apparent or disproportionately worsens during bilateral motor activity. It may arise due either to a contralesional deficit in setting the motor activation level (an intentional deficit) or a deficit in contralesional awareness of the sensory consequences of movement (an attentional deficit). In this study, we investigate the nature of motor extinction in a patient (LR) with a right fronto-temporal lesion through the kinematic analysis of unimanual and bimanual circle-drawing movements. While the ipsi- and contralesional limbs performed comparably for unimanual movements, the contralesional limb demonstrated marked bradykinesia and hypometria during bimanual movements. Furthermore, these deficits were not overcome when visual feedback of the contralesional limb was provided (Experiment 1). However, when performing bimanual movements in the presence of a visual template (Experiment 2), LR was able to overcome the contralesional hypometria but not the bradykinesia which proved intractable across both experiments. Both the bradykinesia and hypometria could result from an intentional deficit of motor production. However, in Experiment 2, LR also demonstrated an abnormal level of positional drift in the contralesional limb for bimanual movements indicative of an additional attentional deficit. We conclude that LR’s presentation of motor extinction is the result of a primary intentional deficit and a secondary attentional deficit.

The effect of altering a single component of a rehabilitation programme on the functional recovery of stroke patients: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of altering a single component of a rehabilitation programme (e.g. adding bilateral practice alone) on functional recovery after stroke, defined using a measure of activity.

DATA SOURCES

A search was conducted of Medline/Pubmed, CINAHL and Web of Science.

REVIEW METHODS

Two reviewers independently assessed eligibility. Randomized controlled trials were included if all participants received the same base intervention, and the experimental group experienced alteration of a single component of the training programme. This could be manipulation of an intrinsic component of training (e.g. intensity) or the addition of a discretionary component (e.g. augmented feedback). One reviewer extracted the data and another independently checked a subsample (20%). Quality was appraised according to the PEDro scale.

RESULTS

Thirty-six studies (n = 1724 participants) were included. These evaluated nine training components: mechanical degrees of freedom, intensity of practice, load, practice schedule, augmented feedback, bilateral movements, constraint of the unimpaired limb, mental practice and mirrored-visual feedback. Manipulation of the mechanical degrees of freedom of the trunk during reaching and the addition of mental practice during upper limb training were the only single components found to independently enhance recovery of function after stroke.

CONCLUSION

This review provides limited evidence to support the supposition that altering a single component of a rehabilitation programme realises greater functional recovery for stroke survivors. Further investigations are required to determine the most effective single components of rehabilitation programmes, and the combinations that may enhance functional recovery.

Robotic unilateral and bilateral upper-limb movement training for stroke survivors afflicted by chronic hemiparesis

Stroke is the leading cause of long-term neurological disability and the principle reason for seeking rehabilitative services in the US. Learning based rehabilitation training enables independent mobility in the majority of patients post stroke, however, restoration of fine manipulation, motor function and task specific functions of the hemiplegic arm and hand is noted in fewer than 15% of the stroke patients. Brain plasticity is the innate mechanism enabling the recovery of motor skills through neurological reorganization of the brain as a response to limbs' manipulation. The objective of this research was to evaluate the therapeutic efficacy for the upper limbs with a dual arm exoskeleton system (EXO-UL7) using three different modalities: bilateral mirror image with symmetric movements of both arms, unilateral movement of the affected arm and standard care. Five hemiparetic subjects were randomly assigned to each therapy modality. An upper limb exoskeleton was used to provide bilateral and unilateral treatments. Standard care was provided by a licensed physical therapist. Subjects were evaluated before and after the interventions using 13 different clinical measures. Following these treatments all of the subjects demonstrated significant improved of their fine motor control and gross control across all the treatment modalities. Subjects exhibited significant improvements in range of motion of the shoulder, and improved muscle strength for bilateral training and standard care, but not for unilateral training. In conclusion, a synergetic approach in which robotic treatments (unilateral and bilateral depending on the level of the motor control) are supplemented by the standard of care may maximize the outcome of the motor control recover following stroke.

A multi-site study of functional outcomes following a themed approach to hand-arm bimanual intensive therapy for children with hemiplegia

AIM

This study investigated the effects of a theme-based ('magic') variation of the hand-arm bimanual intensive therapy programme, in two different countries, in improving activity performance for children with hemiplegia, including those with severe movement restrictions.

METHOD

Twenty-three children with spastic hemiplegia (13 males, 10 females; mean age 10y 7mo, range 7-15y; Manual Ability Classification System level I, two; level II, 13; level III, eight), participated in one of three, 2-week, summer camps. A within-participant experimental design was used with the Assisting Hand Assessment and Children's Hand Experience Questionnaire as primary outcome measures. Evaluations occurred immediately before the first day, on the last day, and 3 months after intervention. Two groups underwent additional assessments 2 weeks before the camp.

RESULTS

Significant intervention effects were seen on the Assisting Hand Assessment (p=0.002) and on the Children's Hand Experience Questionnaire (p<0.001), the latter maintained at follow-up. The affected hand was reported to be used in 25% of bimanual activities before the camp, progressing to 93% after camp, and decreasing to 86% at follow-up. Severity of impairment did not influence progress.

INTERPRETATION

This themed approach to intensive intervention showed positive results in bimanual use, with improvements in independence sustained at follow-up. Although children across camps and motor severity made progress, some questions remain about intensity and duration of intervention to optimize longer-term outcomes.

Transfer of ballistic motor skill between bilateral and unilateral contexts in young and older adults: neural adaptations and behavioral implications

Bilateral movement rehabilitation is gaining popularity as an approach to improve the recovery not only of bimanual function but also of unilateral motor tasks. While the neural mechanisms mediating the transfer of bilateral training gains into unimanual contexts are not fully understood, converging evidence from behavioral, neurophysiological, and imaging studies suggests that bimanual movements are not simply the superposition of unimanual tasks undertaken with both (upper) limbs. Here we investigated the neural responses in both hemispheres to bilateral ballistic motor training and the extent to which performance improvements transferred to a unimanual task. Since aging influences interhemispheric interactions during movement production, both young (n = 9; mean age 19.4 yr; 6 women, 3 men) and older (n = 9; 66.3 yr; 7 women, 2 men) adults practiced a bilateral motor task requiring simultaneous "fast-as-possible" abductions of their left and right index fingers. Changes in bilateral and unilateral performance, and in corticospinal excitability and intracortical inhibition, were assessed. Strong transfer was observed between bimanual and unimanual contexts for both age groups. However, in contrast to previous reports of substantial bilateral cortical adaptations following unilateral training, increases in corticospinal excitability following bilateral training were not statistically reliable, and a release of intracortical inhibition was only observed for older adults. The results indicate that the neural mechanisms of motor learning for bilateral ballistic tasks differ from those that underlie unimanual ballistic performance improvement but that aging results in a greater overlap of the neural mechanisms mediating bilateral and unilateral ballistic motor performance.

Substantial generalization of sensorimotor learning from bilateral to unilateral movement conditions

Controversy exists regarding whether bimanual skill learning can generalize to unimanual performance. For example, some investigators showed that dynamic adaptation could only partially generalize between bilateral and unilateral movement conditions, while others demonstrated complete generalization of visuomotor adaptation. Here, we identified three potential factors that might have contributed to the discrepancy between the two sets of findings. In our first experiment, subjects performed reaching movements toward eight targets bilaterally with a novel force field applied to both arms, then unilaterally with the force field applied to one arm. Results showed that the dynamic adaptation generalized completely from bilateral to unilateral movements. In our second experiment, the same force field was only applied to one arm during both bilateral and unilateral movements. Results indicated complete transfer again. Finally, our subjects performed reaching movements toward a single target with the force field or a novel visuomotor rotation applied only to one arm during both bilateral and unilateral movements. The reduced breadth of experience obtained during bilateral movements resulted in incomplete transfer, which explains previous findings of limited generalization. These findings collectively suggest a substantial overlap between the neural processes underlying bilateral and unilateral movements, supporting the idea that bilateral training, often employed in stroke rehabilitation, is a valid method for improving unilateral performance. However, our findings also suggest that while the neural representations developed during bilateral training can generalize to facilitate unilateral performance, the extent of generalization may depend on the breadth of experience obtained during bilateral training.

A systematic review of bilateral upper limb training devices for poststroke rehabilitation

Introduction. In stroke rehabilitation, bilateral upper limb training is gaining ground. As a result, a growing number of mechanical and robotic bilateral upper limb training devices have been proposed. Objective. To provide an overview and qualitative evaluation of the clinical applicability of bilateral upper limb training devices. Methods. Potentially relevant literature was searched in the PubMed, Web of Science, and Google Scholar databases from 1990 onwards. Devices were categorized as mechanical or robotic (according to the PubMed MeSH term of robotics). Results. In total, 6 mechanical and 14 robotic bilateral upper limb training devices were evaluated in terms of mechanical and electromechanical characteristics, supported movement patterns, targeted part and active involvement of the upper limb, training protocols, outcomes of clinical trials, and commercial availability. Conclusion. Initial clinical results are not yet of such caliber that the devices in question and the concepts on which they are based are firmly established. However, the clinical outcomes do not rule out the possibility that the concept of bilateral training and the accompanied devices may provide a useful extension of currently available forms of therapy. To actually demonstrate their (surplus) value, more research with adequate experimental, dose-matched designs, and sufficient statistical power are required.

Aberrant Oscillatory Activity during Simple Movement in Task-Specific Focal Hand Dystonia

In task-specific focal hand dystonia (tspFHD), the temporal dynamics of cortical activity in the motor system and how these processes are related to impairments in sensory and motor function are poorly understood. Here, we use time-frequency reconstructions of magnetoencephalographic (MEG) data to elaborate the temporal and spatial characteristics of cortical activity during movement. A self-paced finger tapping task during MEG recording was performed by 11 patients with tspFHD and 11 matched healthy controls. In both groups robust changes in beta (12-30 Hz) and high gamma (65-90 Hz) oscillatory activity were identified over sensory and motor cortices during button press. A significant decrease [p < 0.05, 1% False Discovery Rate (FDR) corrected] in high gamma power during movements of the affected hand was identified over ipsilateral sensorimotor cortex in the period prior to (-575 ms) and following (725 ms) button press. Furthermore, an increase (p < 0.05, 1% FDR corrected) in beta power suppression following movement of the affected hand was identified over visual cortex in patients with tspFHD. For movements of the unaffected hand, a significant (p < 0.05, 1% FDR corrected) increase in beta power suppression was identified over secondary somatosensory cortex (S2) in the period following button press in patients with tspFHD. Oscillatory activity within in the tspFHD group was however not correlated with clinical measures. Understanding these aberrant oscillatory dynamics can provide the groundwork for interventions that focus on modulating the timing of this activity.

Effect of therapist-based versus robot-assisted bilateral arm training on motor control, functional performance, and quality of life after chronic stroke: a clinical trial

BACKGROUND

Although bilateral arm training (BAT) has been widely studied, the comparative effects of therapist-based BAT (TBAT) versus robot-assisted BAT (RBAT) remains unknown.

OBJECTIVE

This study compared the efficacy of TBAT, RBAT, and a control treatment (CT) on motor control, functional performance, and quality of life after chronic stroke.

DESIGN

A randomized, pretest-posttest, control group design was used.

METHODS

Forty-two patients (mean age=54.49 years, SD=9.69; mean length of time since stroke onset=17.62 months, SD=10.50) were randomly assigned to TBAT, RBAT, and CT groups. Each group received treatment for 90 to 105 minutes per session, 5 sessions on weekdays, for 4 weeks. Outcome measures included kinematic analyses, the Fugl-Meyer Assessment (FMA), the Motor Activity Log, and the Stroke Impact Scale (SIS).

RESULTS

Large and significant effects were found in the kinematic variables, distal part of upper-limb motor impairment, and certain aspects of quality of life in favor of TBAT or RBAT. Specifically, the TBAT group demonstrated significantly better temporal efficiency and smoothness, straighter trunk motion, and less trunk compensation compared with the CT and RBAT groups. The RBAT group had increased shoulder flexion compared with the CT and TBAT groups. On the FMA, the TBAT group showed higher distal part scores than the CT group. On the SIS, the RBAT group had better strength subscale, physical function domain, and total scores than the CT group. Limitations This study recruited patients with mild spasticity and without cognitive impairment.

CONCLUSIONS

Compared with CT, TBAT and RBAT exhibited differential effects on outcome measures. Therapist-based BAT may improve temporal efficiency, smoothness, trunk control, and motor impairment of the distal upper limb. Robot-assisted BAT may improve shoulder flexion and quality of life.

Maladaptive plasticity for motor recovery after stroke: mechanisms and approaches

Many studies in human and animal models have shown that neural plasticity compensates for the loss of motor function after stroke. However, neural plasticity concerning compensatory movement, activated ipsilateral motor projections and competitive interaction after stroke contributes to maladaptive plasticity, which negatively affects motor recovery. Compensatory movement on the less-affected side helps to perform self-sustaining activity but also creates an inappropriate movement pattern and ultimately limits the normal motor pattern. The activated ipsilateral motor projections after stroke are unable to sufficiently support the disruption of the corticospinal motor projections and induce the abnormal movement linked to poor motor ability. The competitive interaction between both hemispheres induces abnormal interhemispheric inhibition that weakens motor function in stroke patients. Moreover, widespread disinhibition increases the risk of competitive interaction between the hand and the proximal arm, which results in an incomplete motor recovery. To minimize this maladaptive plasticity, rehabilitation programs should be selected according to the motor impairment of stroke patients. Noninvasive brain stimulation might also be useful for correcting maladaptive plasticity after stroke. Here, we review the underlying mechanisms of maladaptive plasticity after stroke and propose rehabilitation approaches for appropriate cortical reorganization.

Relationship between arm usage and instrumental activities of daily living after unilateral stroke

OBJECTIVE

To determine whether the preferred pattern of arm use after unilateral hemispheric damage was associated with better everyday functioning. Our previous work showed that right-handed stroke patients with right hemisphere damage (RHD) used their right, ipsilesional arm most frequently, while those with left hemisphere damage (LHD) used both arms together most frequently. This effect was explained by right-hand preference, but its relationship to functional performance is not known.

DESIGN

Observational cohort.

SETTING

Research laboratory.

PARTICIPANTS

Stroke patients (n=60; 30 RHD, 30 LHD) and healthy controls (n=52).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Functional Impact Assessment was used to assess performance on instrumental activities of daily living (IADLs).

RESULTS

The preferred patterns of arm use were similar to those in our previous report. However, it was the greater use of both arms together that was associated with better IADL performance in both stroke groups. Ipsilesional arm use alone was not significantly associated with IADL performance in the RHD group and was associated with poorer performance in the LHD group.

CONCLUSIONS

The modal arm use pattern did not always optimize IADL functioning. Better IADL functioning in both stroke groups was associated with the use of both arms together, which is the most common arm use pattern of healthy individuals doing these same IADLs. An important practical question that arises from these findings is whether bilateral arm rehabilitation should be emphasized, because using both arms together is the best predictor of better performance on everyday tasks.

A pilot study of contralateral homonymous muscle activity simulated electrical stimulation in chronic hemiplegia

OBJECTIVE

For the recovery of hemiparetic hand function, a therapy was developed called contralateral homonymous muscle activity stimulated electrical stimulation (CHASE), which combines electrical stimulation and bilateral movements, and its feasibility was studied in three chronic stroke patients with severe hand hemiparesis.

METHODS

Patients with a subcortical lesion were asked to extend their wrist and fingers bilaterally while an electromyogram (EMG) was recorded from the extensor carpi radialis (ECR) muscle in the unaffected hand. Electric stimulation was applied to the homonymous wrist and finger extensors of the affected side. The intensity of the electrical stimulation was computed based on the EMG and scaled so that the movements of the paretic hand looked similar to those of the unaffected side. The patients received 30-minutes of therapy per day for 2 weeks.

RESULTS

Improvement in the active range of motion of wrist extension was observed for all patients. There was a decrease in the scores of modified Ashworth scale in the flexors. Fugl-Meyer assessment scores of motor function of the upper extremities improved in two of the patients.

CONCLUSIONS

The results suggest a positive outcome can be obtained using the CHASE system for upper extremity rehabilitation of patients with severe hemiplegia.

Systematic reviews identify important methodological flaws in stroke rehabilitation therapy primary studies: review of reviews

OBJECTIVE

A "review of reviews" was undertaken to assess methodological issues in studies evaluating nondrug rehabilitation interventions in stroke patients.

STUDY DESIGN AND SETTING

MEDLINE, CINAHL, PsycINFO, and the Cochrane Database of Systematic Reviews were searched from January 2000 to January 2008 within the stroke rehabilitation setting. Electronic searches were supplemented by reviews of reference lists and citations identified by experts. Eligible studies were systematic reviews; excluded citations were narrative reviews or reviews of reviews. Review characteristics and criteria for assessing methodological quality of primary studies within them were extracted.

RESULTS

The search yielded 949 English-language citations. We included a final set of 38 systematic reviews. Cochrane reviews, which have a standardized methodology, were generally of higher methodological quality than non-Cochrane reviews. Most systematic reviews used standardized quality assessment criteria for primary studies, but not all were comprehensive. Reviews showed that primary studies had problems with randomization, allocation concealment, and blinding. Baseline comparability, adverse events, and co-intervention or contamination were not consistently assessed. Blinding of patients and providers was often not feasible and was not evaluated as a source of bias.

CONCLUSIONS

The eligible systematic reviews identified important methodological flaws in the evaluated primary studies, suggesting the need for improvement of research methods and reporting.

Mirror symmetric bimanual movement priming can increase corticomotor excitability and enhance motor learning

Repetitive mirror symmetric bilateral upper limb may be a suitable priming technique for upper limb rehabilitation after stroke. Here we demonstrate neurophysiological and behavioural after-effects in healthy participants after priming with 20 minutes of repetitive active-passive bimanual wrist flexion and extension in a mirror symmetric pattern with respect to the body midline (MIR) compared to an control priming condition with alternating flexion-extension (ALT). Transcranial magnetic stimulation (TMS) indicated that corticomotor excitability (CME) of the passive hemisphere remained elevated compared to baseline for at least 30 minutes after MIR but not ALT, evidenced by an increase in the size of motor evoked potentials in ECR and FCR. Short and long-latency intracortical inhibition (SICI, LICI), short afferent inhibition (SAI) and interhemispheric inhibition (IHI) were also examined using pairs of stimuli. LICI differed between patterns, with less LICI after MIR compared with ALT, and an effect of pattern on IHI, with reduced IHI in passive FCR 15 minutes after MIR compared with ALT and baseline. There was no effect of pattern on SAI or FCR H-reflex. Similarly, SICI remained unchanged after 20 minutes of MIR. We then had participants complete a timed manual dexterity motor learning task with the passive hand during, immediately after, and 24 hours after MIR or control priming. The rate of task completion was faster with MIR priming compared to control conditions. Finally, ECR and FCR MEPs were examined within a pre-movement facilitation paradigm of wrist extension before and after MIR. ECR, but not FCR, MEPs were consistently facilitated before and after MIR, demonstrating no degradation of selective muscle activation. In summary, mirror symmetric active-passive bimanual movement increases CME and can enhance motor learning without degradation of muscle selectivity. These findings rationalise the use of mirror symmetric bimanual movement as a priming modality in post-stroke upper limb rehabilitation.

Externally cued inphase bimanual training enhances preparatory premotor activity

OBJECTIVE

Previous studies have demonstrated that cortical potentials representing motor preparation for visually-cued movements are enhanced following a single session of visually-cued bimanual movement training (BMT). The neuroanatomical sources that contribute to these rapid training-induced adaptations were unclear. To address this, we compared cortical potentials associated with motor preparation for visually-cued (movement-related potential, MRP) and self-paced (Bereitschaftspotential, BP) movements and investigated adaptations of these following BMT.

METHODS

EEG recorded the cued MRP and self-paced BP during two experiments. In experiment one, pre and post self-paced unimanual trials were interspersed with cued inphase BMT. In experiment two, self-paced and visually-cued movement trials were performed to assess the differences between and the contributing neural sources to the cued MRP and self-paced BP.

RESULTS

Inphase BMT does not affect the early BP. Source localization analysis revealed that the preparatory portion of the cued MRP and self-paced BP are generated by the lateral premotor cortex and the supplementary motor area, respectively.

CONCLUSIONS

The early cued MRP and self-paced BP have unique cortical generators and are independently modulated by specific training types.

SIGNIFICANCE

These novel findings have implications for interpreting rapid, single-session, training adaptations previously observed. These cortical potentials may also be useful measurement tools to gauge within-session cortical modulations in response to specific modes of rehabilitative training in the stroke population.

Physical activity in the prevention and treatment of stroke

The role of physical activity in the prevention of stroke is of great interest due to the high mortality and significant impact of stroke-related morbidity on the individual and on healthcare resources. The use of physical activity as a therapeutic strategy to maximise functional recovery in the rehabilitation of stroke survivors has a growing evidence base. This narrative review examines the existing literature surrounding the use of exercise and physical therapy in the primary and secondary prevention of stroke. It explores the effect of gender, exercise intensities and the duration of observed benefit. It details the most recent evidence for physical activity in improving functional outcome in stroke patients. The review summaries the current guidelines and recommendations for exercise therapy and highlights areas in which further research and investigation would be useful to determine optimal exercise prescription for effective prevention and rehabilitation in stroke.

Bilateral assessment of functional tasks for robot-assisted therapy applications

This article presents a novel evaluation system along with methods to evaluate bilateral coordination of arm function on activities of daily living tasks before and after robot-assisted therapy. An affordable bilateral assessment system (BiAS) consisting of two mini-passive measuring units modeled as three degree of freedom robots is described. The process for evaluating functional tasks using the BiAS is presented and we demonstrate its ability to measure wrist kinematic trajectories. Three metrics, phase difference, movement overlap, and task completion time, are used to evaluate the BiAS system on a bilateral symmetric (bi-drink) and a bilateral asymmetric (bi-pour) functional task. Wrist position and velocity trajectories are evaluated using these metrics to provide insight into temporal and spatial bilateral deficits after stroke. The BiAS system quantified movements of the wrists during functional tasks and detected differences in impaired and unimpaired arm movements. Case studies showed that stroke patients compared to healthy subjects move slower and are less likely to use their arm simultaneously even when the functional task requires simultaneous movement. After robot-assisted therapy, interlimb coordination spatial deficits moved toward normal coordination on functional tasks.

The effect of rhythmic exercises on cognition and behaviour of maltreated children: a pilot study

OBJECTIVES

This study assesses the effect of rhythmic exercises using Rhythmex(®) program on the cognitive function and behaviour of maltreated children living in a group residential facility.

METHOD

School age children (ages 6-9) participated in the study, one group of 23 children exercised with Rhythmex rhythmic exercise program for eight weeks, 2-3 times a week, for 5 min, while a second group of 14 children did not exercise. Both groups took the Visual-Motor Integration (VMI) test pre- and post-intervention and social workers evaluated their behaviour on the Achenbach's Child Behaviour Checklist (CBCL) pre-intervention and then 12 months later.

RESULTS

Improvement of 12 months on average in the VMI scores from pre- to post-intervention among the exercise group participants was observed compared with the control group. Aggressive behaviour was significantly lower on the Achenbach's CBCL aggression subscale among the exercise group participants compared with the control group.

CONCLUSION

Rhythmic exercises for 5 min, 2-3 times a week for 8 weeks appear to be effective in improving VMI scores and lowering aggressive behaviour among maltreated children when compared to children of the same age who did not participate in the rhythmic exercises program.

Interaction of electrical stimulation and voluntary hand movement in SII and the cerebellum during simulated therapeutic functional electrical stimulation in healthy adults

The therapeutic application of functional electrical stimulation (FES) has shown promising clinical results in the rehabilitation of post-stroke hemiplegia. It appears that the effect is optimal when the patterned electrical stimulation is used in close synchrony with voluntary movement, although the neural mechanisms that underlie the clinical successes reported with therapeutic FES are unknown. One possibility is that therapeutic FES takes advantage of the sensory consequences of an internal model. Here, we investigate fMRI cortical activity when FES is combined with voluntary effort (FESVOL) and we compare this activity to that produced when FES and voluntary activity (VOL) are performed alone. FESVOL revealed greater cerebellar activity compared with FES alone and reduced activity bilaterally in secondary somatosensory areas (SII) compared with VOL alone. Reduced activity was also observed for FESVOL compared with FES alone in the angular gyrus, middle frontal gyrus and inferior frontal gyrus. These findings indicate that during the VOL condition the cerebellum predicts the sensory consequences of the movement and this reduces the subsequent activation in SII. The decreased SII activity may reflect a better match between the internal model and the actual sensory feedback. The greater cerebellar activity coupled with reduced angular gyrus activity in FESVOL compared with FES suggests that the cortex may interpret sensory information during the FES condition as an error-like signal due to the lack of a voluntary component in the movement.

Current trends in stroke rehabilitation. A review with focus on brain plasticity

Current understanding of brain plasticity has lead to new approaches in ischemic stroke rehabilitation. Stroke units that combine good medical and nursing care with task-oriented intense training in an environment that provides confidence, stimulation and motivation significantly improve outcome. Repetitive trans-cranial magnetic stimulation (rTMS), and trans-cranial direct current stimulation (tDCS) are applied in rehabilitation of motor function. The long-term effect, optimal way of stimulation and possibly efficacy in cognitive rehabilitation need evaluation. Methods based on multisensory integration of motor, cognitive, and perceptual processes including action observation, mental training, and virtual reality are being tested. Different approaches of intensive aphasia training are described. Recent data on intensive melodic intonation therapy indicate that even patients with very severe non-fluent aphasia can regain speech through homotopic white matter tract plasticity. Music therapy is applied in motor and cognitive rehabilitation. To avoid the confounding effect of spontaneous improvement, most trials are preformed ≥3 months post stroke. Randomized controlled trials starting earlier after strokes are needed. More attention should be given to stroke heterogeneity, cognitive rehabilitation, and social adjustment and to genetic differences, including the role of BDNF polymorphism in brain plasticity.

Bilateral transfer in active and passive guidance-reproduction based bimanual tasks: effect of proprioception and handedness

Recently, bilateral movement training based on robot-assisted rehabilitation systems has been attracting a lot of attention as a post-stroke motor rehabilitation protocol. Since humans generate coordinated motions based on their motor and sensory systems, investigation of the innate properties of human motor or sensory systems may provide insight into planning of effective bilateral movement training. In this study, we investigate the effects of proprioception and handedness on the movement of the contra-lateral upper limb, under both active and passive guidance conditions of the robot manipulators. Active and passive guidance-reproduction based bimanual tasks were used in this study; in these the subject is asked to hold both the right and left knobs installed at the end-effectors of two robot manipulators. The results indicate that better reproducing performance was obtained when the proprioceptive input was acquired from the active guidance condition.

ZigBee-based Wireless Neuro-Stimulator for Improving Stroke Recovery

Stroke is a leading cause of adult disability and the second-leading cause of death in Korea. It is also the third-leading cause of death in the United States, leading to a serious demand for new interventions to improve the quality of life in stroke survivors. To this end, direct cortical stimulation using an epidural electrode has been reported with promising results in animal and human studies, showing the potential for enhancing the recovery in chronic stroke patients. For optimal results, doctors must be able to modify the stimulation pattern as frequently as needed over a period of time for a given patient. However, severe aftereffects caused by stroke limit patients' activities, making regular doctor visits for treatment difficult. This study aims to develop a prototype of a telemedicine system to enhance stroke recovery by using a ZigBeebased wireless neuro-stimulator. The ZigBee is a stable platform for many low-power wireless applications. To allow stroke patients to remotely obtain neuro-stimulation treatments from their doctors, we connected the ZigBee to the internet. The system also allows doctors to personalize treatment based on the history of the stimulation parameters. The system developed here can also be beneficial as a common platform for a wide range of brain diseases and clinical care for which electric stimulation is used.

Relevance of structural brain connectivity to learning and recovery from stroke

The physical structure of white matter fiber bundles constrains their function. Any behavior that relies on transmission of signals along a particular pathway will therefore be influenced by the structural condition of that pathway. Diffusion-weighted magnetic resonance imaging provides localized measures that are sensitive to white matter microstructure. In this review, we discuss imaging evidence on the relevance of white matter microstructure to behavior. We focus in particular on motor behavior and learning in healthy individuals and in individuals who have suffered a stroke. We provide examples of ways in which imaging measures of structural brain connectivity can inform our study of motor behavior and effects of motor training in three different domains: (1) to assess network degeneration or damage with healthy aging and following stroke, (2) to identify a structural basis for individual differences in behavioral responses, and (3) to test for dynamic changes in structural connectivity with learning or recovery.

Randomized trial of distributed constraint-induced therapy versus bilateral arm training for the rehabilitation of upper-limb motor control and function after stroke

BACKGROUND AND OBJECTIVE

This study compared the efficacy of distributed constraint-induced therapy (dCIT), bilateral arm training (BAT), and control treatment (CT) on motor control and functional performance of the upper limb in stroke patients.

METHODS

A total of 66 patients with mean stroke onset of 16.20 months and mild to moderate motor impairment were randomized to dCIT, BAT, or CT groups. Each group received treatment for 2 h/d and 5 d/wk for 3 weeks. Pretreatment and posttreatment measures included reaching kinematic variables in unilateral and bilateral tasks, the Wolf Motor Function Test (WMFT), and the Motor Activity Log (MAL).

RESULTS

The dCIT and BAT groups had smoother reaching trajectories in the unilateral and bilateral tasks than the CT group. The BAT group, but not the dCIT group, generated greater force at movement initiation than the CT group during the unilateral and bilateral tasks. The dCIT patients had decreased WMFT time and higher functional ability scores than the CT patients. MAL results pointed to better performance in the amount and quality of use of the affected arm than BAT and CT patients.

CONCLUSIONS

BAT and dCIT exhibited similar beneficial effects on movement smoothness but differential effects on force at movement initiation and functional performance. Therefore, BAT is a better option if improvement of force generation is the treatment goal, and dCIT is more appropriate for improving functional ability and use of the affected arm in daily life. These findings may assist in the planning of individually tailored rehabilitation therapies.

Bilateral and unilateral arm training improve motor function through differing neuroplastic mechanisms: a single-blinded randomized controlled trial

BACKGROUND AND PURPOSE

This randomized controlled trial tests the efficacy of bilateral arm training with rhythmic auditory cueing (BATRAC) versus dose-matched therapeutic exercises (DMTEs) on upper-extremity (UE) function in stroke survivors and uses functional magnetic resonance imaging (fMRI) to examine effects on cortical reorganization.

METHODS

A total of 111 adults with chronic UE paresis were randomized to 6 weeks (3×/week) of BATRAC or DMTE. Primary end points of UE assessments of Fugl-Meyer UE Test (FM) and modified Wolf Motor Function Test Time (WT) were performed 6 weeks prior to and at baseline, after training, and 4 months later. Pretraining and posttraining, fMRI for UE movement was evaluated in 17 BATRAC and 21 DMTE participants.

RESULTS

The improvements in UE function (BATRAC: FM Δ = 1.1 + 0.5, P = .03; WT Δ = -2.6 + 0.8, P < .00; DMTE: FM Δ = 1.9 + 0.4, P < .00; WT Δ = -1.6 + 0.7; P = .04) were comparable between groups and retained after 4 months. Satisfaction was higher after BATRAC than DMTE (P = .003). BATRAC led to significantly higher increase in activation in ipsilesional precentral, anterior cingulate and postcentral gyri, and supplementary motor area and contralesional superior frontal gyrus (P < .05). Activation change in the latter was correlated with improvement in the WMFT (P = .01).

CONCLUSIONS

BATRAC is not superior to DMTE, but both rehabilitation programs durably improve motor function for individuals with chronic UE hemiparesis and with varied deficit severity. Adaptations in brain activation are greater after BATRAC than DMTE, suggesting that given similar benefits to motor function, these therapies operate through different mechanisms.

The surface electromyography analysis of the non-plegic upper limb of hemiplegic subjects

Many authors have studied physical and functional changes in individuals post-stroke, but there are few studies that assess changes in the non-plegic side of hemiplegic subjects. This study aimed to compare the electromyographic activity in the forearm muscles of spastic patients and clinically healthy individuals, to determine if there is difference between the non-plegic side of hemiplegics and the dominant member of normal individuals. 22 hemiplegic subjects and 15 clinically healthy subjects were submitted to electromyography of the flexor and extensor carpi ulnaris muscles during wrist flexion and extension. The flexor muscles activation of stroke group (average 464.6 u.n) was significantly higher than the same muscles in control group (mean: 106.3 u.n.) during the wrist flexion, what shows that the non affected side does not present activation in the standard of normality found in the control group.

Cortical and behavioral adaptations in response to short-term inphase versus antiphase bimanual movement training

Bimanual movement training (BMT) may be an effective rehabilitative protocol for movement-related deficits following a stroke; however, it is unclear how varying types of BMT induce cortical adaptations in the healthy population. Moreover, we lack a methodology to measure cortical adaptations in response to modes of movement training. Therefore, the present study measured the cued movement-related potential (MRP) to investigate cortical adaptations during cued inphase versus antiphase BMT that transferred to a unimanual task and how cortical modulations related to behavior. Three specific hypotheses were investigated: (1) cued inphase BMT would induce cortical adaptations within regions subserving motor preparation and movement execution, (2) repetitive cued unimanual training would induce cortical activity modulations associated with motor execution, and (3) increased cortical activity would be associated with enhanced performance. On three separate days, EEG was recorded from 22 electrodes during three types of cued movement training: inphase BMT, antiphase BMT and repetitive unimanual movement, in addition to pre- and post-training unimanual movement trials involving cued right wrist flexion. The MRP was measured for each repetition during each trial. Results showed a significant training-related increase in preparatory activation correlated with a behavioral enhancement following cued inphase BMT. This effect was not attributable to a change in arousal. No significant training-related modulation occurred in response to cued antiphase BMT or repetitive unimanual movement training. These results suggest that cortical adaptations in relation to the preparation of a cued movement enhance in response to cued inphase BMT, and the MRP is an effective measurement tool to assess training-related adaptations in response to inphase BMT specifically.

The neural control of bimanual movements in the elderly: Brain regions exhibiting age-related increases in activity, frequency-induced neural modulation, and task-specific compensatory recruitment

Coordinated hand use is an essential component of many activities of daily living. Although previous studies have demonstrated age-related behavioral deficits in bimanual tasks, studies that assessed the neural basis underlying such declines in function do not exist. In this fMRI study, 16 old and 16 young healthy adults performed bimanual movements varying in coordination complexity (i.e., in-phase, antiphase) and movement frequency (i.e., 45, 60, 75, 90% of critical antiphase speed) demands. Difficulty was normalized on an individual subject basis leading to group performances (measured by phase accuracy/stability) that were matched for young and old subjects. Despite lower overall movement frequency, the old group "overactivated" brain areas compared with the young adults. These regions included the supplementary motor area, higher order feedback processing areas, and regions typically ascribed to cognitive functions (e.g., inferior parietal cortex/dorsolateral prefrontal cortex). Further, age-related increases in activity in the supplementary motor area and left secondary somatosensory cortex showed positive correlations with coordinative ability in the more complex antiphase task, suggesting a compensation mechanism. Lastly, for both old and young subjects, similar modulation of neural activity was seen with increased movement frequency. Overall, these findings demonstrate for the first time that bimanual movements require greater neural resources for old adults in order to match the level of performance seen in younger subjects. Nevertheless, this increase in neural activity does not preclude frequency-induced neural modulations as a function of increased task demand in the elderly.

Simultaneous bilateral training for improving arm function after stroke

BACKGROUND

Simultaneous bilateral training, the completion of identical activities with both arms simultaneously, is one intervention to improve arm function and reduce impairment.

OBJECTIVES

To determine the effects of simultaneous bilateral training for improving arm function after stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Trials Register (last searched August 2009) and 10 electronic bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2009), MEDLINE, EMBASE, CINAHL and AMED (August 2009). We also searched reference lists and trials registers.

SELECTION CRITERIA

Randomised trials in adults after stroke, where the intervention was simultaneous bilateral training compared to placebo or no intervention, usual care or other upper limb (arm) interventions. PRIMARY OUTCOMES were performance in activities of daily living (ADL) and functional movement of the upper limb. SECONDARY OUTCOMES were performance in extended activities of daily living and motor impairment of the arm.

DATA COLLECTION AND ANALYSIS

Two authors independently screened abstracts, extracted data and appraised trials. Assessment of methodological quality was undertaken for allocation concealment, blinding of outcome assessor, intention-to-treat, baseline similarity and loss to follow up.

MAIN RESULTS

We included 18 studies involving 549 relevant participants, of which 14 (421 participants) were included in the analysis (one within both comparisons). Four of the 14 studies compared the effects of bilateral training with usual care.

PRIMARY OUTCOMES

results were not statistically significant for performance in ADL (standardised mean difference (SMD) 0.25, 95% confidence interval (CI) -0.14 to 0.63); functional movement of the arm (SMD -0.07, 95% CI -0.42 to 0.28) or hand (SMD -0.04, 95% CI -0.50 to 0.42).

SECONDARY OUTCOMES

no statistically significant results. Eleven of the 14 studies compared the effects of bilateral training with other specific upper limb (arm) interventions.

PRIMARY OUTCOMES

no statistically significant results for performance of ADL (SMD -0.25, 95% CI -0.57 to 0.08); functional movement of the arm (SMD -0.20, 95% CI -0.49 to 0.09) or hand (SMD -0.21, 95% CI -0.51 to 0.09).

SECONDARY OUTCOMES

one study reported a statistically significant result in favour of another upper limb intervention for performance in extended ADL. No statistically significant differences were found for motor impairment outcomes.

AUTHORS' CONCLUSIONS

There is insufficient good quality evidence to make recommendations about the relative effect of simultaneous bilateral training compared to placebo, no intervention or usual care. We identified evidence that suggests that bilateral training may be no more (or less) effective than usual care or other upper limb interventions for performance in ADL, functional movement of the upper limb or motor impairment outcomes.

A review of bilateral training for upper extremity hemiparesis

Upper extremity hemiparesis is the most common post-stroke disability. Longitudinal studies have indicated that 30-66% of stroke survivors do not have full arm function 6 months post-stroke. The current gold standard for treatment of mild post-stroke upper limb impairment is constraint-induced therapy but, because of the inclusion criteria, alternative treatments are needed which target more impaired subjects. Bilateral arm training has been investigated as a potential rehabilitation intervention. Bilateral arm training encompasses a number of methods including: (1) bilateral isokinematic training; (2) mirror therapy using bilateral training; (3) device-driven bilateral training; and (4) bilateral motor priming. Neural mechanisms mediating bilateral training are first reviewed. The key bilateral training studies that have demonstrated evidence of efficacy will then be discussed. Finally, conclusions are drawn concerning clinical implications based on the reviewed literature.

Bilateral movement therapy post-stroke: underlying mechanisms and review

Aims

Up to 66% of individuals with stroke never regain functional use of their upper extremities. Bilateral movement training (BMT) is a task-specific rehabilitation technique that has recently been investigated for its influence on upper extremity recovery in individuals post-stroke. BMT is thought to affect the hemiparetic upper extremity by a phenomenon referred to as cross education, or the cross transfer effect.

Methods

This article reviews the theoretical accounts underlying the cross transfer effect and explain the means by which BMT may facilitate recovery of function in the hemiparetic arm. The current research evidence supporting the use of BMT as a therapeutic approach to stroke rehabilitation is discussed, and implications for clinical practice and recommendations for further research are presented.

Findings

Evidence is emerging that BMT improves impairments and function in people with hemiparesis after stroke. The main limitations of existing research on BMT include small sample sizes, varying initial impairment levels, and lack of control groups.

Conclusions

Future research needs to establish which individuals are most likely to benefi tfrom BMT, as well as the optimal dose of BMT, and whether BMT can be used as an adjunct to existing rehabilitation approaches for upper extremity rehabilitation.

Bilateral movement training and stroke motor recovery progress: a structured review and meta-analysis

The purpose was to conduct a structured review and meta-analysis to determine the cumulative effect of bilateral arm training on motor capabilities post stroke. Forty-eight stroke studies were selected from three databases with 25 comparisons qualifying for inclusion in our meta-analysis. We identified and coded four types of bilateral arm interventions with 366 stroke patients. A random effects model using the standardized mean difference technique determined a large and significant effect size (0.734; SE=0.125), high fail-safe N (532), and medium variability in the studies (I(2)=63%). Moderator variable analysis on the type of bilateral training revealed two large and significant effects: (a) BATRAC (0.842; SE=0.155) and (b) coupled bilateral and EMG-triggered neuromuscular stimulation (1.142; SE=0.176). These novel findings provide strong evidence supporting bilateral arm training with the caveat that two coupled protocols, rhythmic alternating movements and active stimulation, are most effective.

Incorporating haptic effects into three-dimensional virtual environments to train the hemiparetic upper extremity

Current neuroscience has identified several constructs to increase the effectiveness of upper extremity rehabilitation. One is the use of progressive, skill acquisition-oriented training. Another approach emphasizes the use of bilateral activities. Building on these principles, this paper describes the design and feasibility testing of a robotic/virtual environment system designed to train the arm of persons who have had strokes. The system provides a variety of assistance modes, scalable workspaces and hand-robot interfaces allowing persons with strokes to train multiple joints in three dimensions. The simulations utilize assistance algorithms that adjust task difficulty both online and offline in relation to subject performance. Several distinctive haptic effects have been incorporated into the simulations. An adaptive master-slave relationship between the unimpaired and impaired arm encourages active movement of the subject's hemiparetic arm during a bimanual task. Adaptive anti-gravity support and damping stabilize the arm during virtual reaching and placement tasks. An adaptive virtual spring provides assistance to complete the movement if the subject is unable to complete the task in time. Finally, haptically rendered virtual objects help to shape the movement trajectory during a virtual placement task. A proof of concept study demonstrated this system to be safe, feasible and worthy of further study.

The effects of bilateral arm training on motor control and functional performance in chronic stroke: a randomized controlled study

BACKGROUND

Most studies of bilateral arm training (BAT) did not employ a randomized controlled trial design and involved very limited functional training tasks.

OBJECTIVE

Compare the effects of BAT with control intervention (CI) on motor control and motor performance of the upper extremity and also functional gains in patients with chronic stroke.

METHODS

. This 2-group randomized controlled trial with pretreatment and posttreatment measures enrolled 33 stroke patients (mean age = 53.85 years) 6 to 67 months after onset of a first stroke. They received either a BAT program concentrating on both upper extremities moving simultaneously in functional tasks by symmetric patterns or CI (control treatment) for 2 hours on weekdays for 3 weeks. Outcome measures included kinematic analyses assessing motor control strategies for unilateral and bimanual reaching and clinical measures involving the Fugl-Meyer Assessment (FMA) of motor-impairment severity and the Functional Independence Measure (FIM) and the Motor Activity Log (MAL) evaluating functional ability.

RESULTS

After treatment, the BAT group showed better temporal and spatial efficiency during unilateral and bilateral tasks and less online error correction only during the bilateral task than the control group. The BAT group showed a significantly greater improvement in the FMA than the control group but not in the FIM and MAL.

CONCLUSIONS

Relative to CI, BAT improved the spatiotemporal control of the affected arm in both bilateral and unilateral tasks, decreased online corrections to perform bilateral tasks, and reduced motor impairment. These findings support the use of BAT to improve motor control and motor function of the affected upper limb in stroke patients.

Motor recovery after stroke: a systematic review

Loss of functional movement is a common consequence of stroke for which a wide range of interventions has been developed. In this Review, we aimed to provide an overview of the available evidence on interventions for motor recovery after stroke through the evaluation of systematic reviews, supplemented by recent randomised controlled trials. Most trials were small and had some design limitations. Improvements in recovery of arm function were seen for constraint-induced movement therapy, electromyographic biofeedback, mental practice with motor imagery, and robotics. Improvements in transfer ability or balance were seen with repetitive task training, biofeedback, and training with a moving platform. Physical fitness training, high-intensity therapy (usually physiotherapy), and repetitive task training improved walking speed. Although the existing evidence is limited by poor trial designs, some treatments do show promise for improving motor recovery, particularly those that have focused on high-intensity and repetitive task-specific practice.

An assessment of robot-assisted bimanual movements on upper limb motor coordination following stroke

Robot-assisted training is increasingly being investigated in upper limb rehabilitation for individuals with stroke. Many studies have suggested that an appropriate synchronization of voluntary motor commands and limb movement is critical for long-term efficacy. Bimanual training is one method for enhancing this synchronization or motor coordination. The purpose of the study was to evaluate the potential efficacy of bimanual robot-assisted movements by comparing the relative timing of muscle activation and forces to those generated during unimanual robot-assisted movement. A secondary goal was to compare bimanual robot-assisted movement to bimanual voluntary movement, where both limbs moved independently without robotics. Subjects performed reaching tasks while attached to one or two robotic manipulators. A predefined movement trajectory was prescribed during unimanual robot-assisted movement; in bimanual robot-assisted movement the paretic limb trajectory mirrored the nonparetic limb. Relative to unimanual movements, during bimanual movements the timing of muscle activation and initial interface forces was more similar to the nonparetic limb. However, there were limited differences in these measures between bimanual voluntary and bimanual robot-assisted movements. Bimanual robot-assisted movements resulted in superior motor coordination compared to unimanual movements and could be beneficial for individuals with a restricted movement range. Bimanual movements without robotics were just as efficacious and may be preferred for individuals who can generate movement without assistance.

Rhythmic exercises in rehabilitation of TBI patients: a case report

SUMMARY

Patients who have sustained traumatic brain injury (TBI) often present with a multiplicity of dysfunctions making rehabilitation challenging. Patients who have taken part in studies of rehabilitation exercises that incorporated monotonous timed auditory cues (using a metronome) following cerebrovascular events demonstrated improvement in gait and motor functions. The purpose of this case report is to describe the efficacy of Rhythmic Exercises with Auditory Cues (REAC) to improve functions in a patient, years after their traumatic brain injury.

METHODS

A single case report of a 24-year-old female patient, nine years post hemispherectomy following TBI that resulted in right hemiparesis. The patient was taught to perform REAC exercises at home. These exercises were designed to activate the body while Alternating hands and feet Bilaterally with Cross-midline movements for a short Duration while synchronizing the movements with a metronome as a Rhythm regulator. Outcome measurements included gait and functional assessment and cognitive and psychological instrument scores that were compared pre and post treatment. Clinical improvement was observed in the patient's gait pattern with reduced hip hiking motion and increased cadence. There was a decrease in spasticity in the right arm and leg with some isolated volitional movements of the hand and fingers returning. She also regained sensation in her right arm and leg. Cognitive improvement was demonstrated by increased IQ scores from 78 to 94.

Unilateral and bilateral upper extremity weight-bearing effect on upper extremity impairment and functional performance after brain injury

The purpose of the study was to investigate the effect of upper extremity (UE) weight bearing on UE impairment functional performance of persons with acquired brain injury (BI). A quasi-experimental design was used to examine a convenience sample of 99 persons with acquired BI and 22 without BI (WBI) living in a community re-entry centre. A computerized force-sensing array pressure map system was used to determine the UE pressure during unilateral and bilateral conditions. Differences between groups were examined using t-tests. Correlations were computed between UE weight bearing and hand function, and functional performance as measured by the Fugl-Meyer scale and functional independence measure (FIM) scale. The group of people with BI exerted significantly lower UE weight bearing during unilateral conditions as compared with persons WBI [left: t (119) = 2.34, p = 0.021; right: t (119) = 4.79, p = 0.043). UE weight-bearing measures correlated strongly with FIM motor scores with bilateral UE conditions yielded the highest significant correlation (bilateral left r = 0.487, p < 0.001; bilateral right r = 0.469, p < 0.01). The results indicated that UE weight-bearing pressure differs in unilateral and bilateral conditions, between persons with and WBI and between persons with stroke and traumatic brain injury. These findings may have implications for occupational therapists that use unilateral versus bilateral motor training for rehabilitation. There is a need to replicate the study design with a randomized and stratified sample of persons with BI.

Effects of Constraint-Induced Therapy Versus Bilateral Arm Training on Motor Performance, Daily Functions, and Quality of Life in Stroke Survivors

Background and Objective. This study investigated the relative effects of distributed constraint-induced therapy (CIT) and bilateral arm training (BAT) on motor performance, daily function, functional use of the affected arm, and quality of life in patients with hemiparetic stroke. Methods. A total of 60 patients were randomized to distributed CIT, BAT, or a control intervention of less specific but active therapy. Each group received intensive training for 2 hours/day, 5 days/week, for 3 weeks. Pretreatment and posttreatment measures included the Fugl—Meyer Assessment (FMA), Functional Independence Measure (FIM), Motor Activity Log (MAL), and Stroke Impact Scale (SIS). The proximal and distal scores of FMA were used to examine separate upper limb (UL) elements of movement. Results . The distributed CIT and BAT groups showed better performance in the overall and the distal part score of the FMA than the control group. The BAT group exhibited greater gains in the proximal part score of the FMA than the distributed CIT and control groups. Enhanced performance was found for the distributed CIT group in the MAL, the subtest of locomotion in the FIM, and certain domains of the SIS (eg, ADL/IADL). Conclusion. BAT may uniquely improve proximal UL motor impairment. In contrast, distributed CIT may produce greater functional gains for the affected UL in subjects with mild to moderate chronic hemiparesis.

Bilateral upper limb training with functional electric stimulation in patients with chronic stroke

BACKGROUND

The recovery rate of upper limb function after stroke is poor when compared with independent walking. Therefore, effective methods are warranted for upper limb rehabilitation.

OBJECTIVE

The aim of this study was to investigate the effectiveness of functional electric stimulation (FES) with bilateral activities training on upper limb function.

METHODS

This study was a double-blinded randomized controlled trial. Twenty patients were recruited 6 months after the onset of stroke and completed 15 training sessions. Participants were randomly assigned to the FES group or to the control group. Each session consisted of stretching activities (10 minutes), FES with bilateral tasks (20 minutes), and occupational therapy treatment (60 minutes). The participants used a self-trigger mechanism, with an accelerometer as a motion detector, for generating an electric stimulation pattern that was synchronized with the bilateral upper limb activities during the training. The participants in the control group received the same duration of stretching and occupational therapy training except that they just received placebo stimulation with the bilateral tasks. The outcome measures included Functional Test for the Hemiplegic Upper Extremity (FTHUE), Fugl-Meyer Assessment (FMA), grip power, forward reaching distance, active range of motion of wrist extension, Functional Independence Measure, and Modified Ashworth Scale.

RESULTS

At baseline comparison, there was no significant difference in both groups. After 15 training sessions, the FES group had significant improvement in FMA (P = .039), FTHUE (P = .001), and active range of motion of wrist extension (P = .020) when compared with the control group.

CONCLUSIONS

Bilateral upper limb training with FES could be an effective method for upper limb rehabilitation of stroke patients after 15 training sessions.

A novel functional electrical stimulation treatment for recovery of hand function in hemiplegia: 12-week pilot study

BACKGROUND

Loss of finger extension is common after stroke and can severely limit hand function. Contralaterally controlled functional electrical stimulation (CCFES) is a new treatment aimed at restoring volitional finger and thumb extension. A previous pilot study showed reductions in hand impairment after 6 weeks of CCFES, but the effect did not persist after end of treatment.

OBJECTIVE

This study aimed to evaluate the feasibility of achieving greater and more persistent gains with CCFES by increasing the treatment period to 12 weeks.

METHODS

CCFES uses neuromuscular electrical stimulation to open the paretic hand in direct proportion to the degree of volitional opening of the unimpaired contralateral hand, which is detected by an instrumented glove. Three subjects with chronic hemiplegia participated in a 12-week CCFES treatment, which consisted of daily CCFES-assisted active repetitive hand-opening exercises and twice weekly functional task practice with CCFES.

RESULTS

Maximum voluntary finger extension increased by 101 degrees and 68 degrees for subjects 1 and 2, respectively, but subject 3 had no improvement in finger extension. Box and Block score increased by 6, 15, and 7 blocks, and upper extremity Fugl-Meyer score increased by 11, 15, and 7 points for subjects 1, 2, and 3, respectively. The finger extension gains declined at the 1-month and 3-month follow-up for subjects 1 and 2, but the gains in Box and Block and Fugl-Meyer scores persisted at follow-up.

CONCLUSIONS

Greater reductions in hand impairment were achieved by extending the treatment period. The effect and its longevity may be related to baseline impairment level.

Impact of EMG-triggered neuromuscular stimulation of the wrist and finger extensors of the paretic hand after stroke: a systematic review of the literature

OBJECTIVE

To assess whether EMG-triggered neuromuscular electrical stimulation (EMG-NMES) applied to the extensor muscles of the forearm improves hand function after stroke.

DESIGN

Systematic review of randomized controlled trials.

METHODS

A computer-aided literature search up to June 2006 identified articles comparing EMG-NMES of the upper extremity with usual care. Methodological quality was rated on the Physiotherapy Evidence Database scale (PEDro), and the Hedges' g model was used to calculate the summary effect sizes (SES) using fixed or random models depending on heterogeneity.

RESULTS

Eight studies, selected out of 192 hits and presenting 157 patients, were included in quantitative and qualitative analyses. The methodological quality ranged from 2 to 6 points. The meta-analysis revealed non-significant effect sizes in favour of EMG-NMES for reaction time, sustained contraction, dexterity measured with the Box and Block manipulation test, synergism measured with the Fugl-Meyer Motor Assessment Scale and manual dexterity measured with the Action Research Arm test.

CONCLUSION

No statistically significant differences in effects were found between EMG-NMES and usual care. Most studies had poor methodological quality, low statistical power and insufficient treatment contrast between experimental and control groups. In addition, all studies except two investigated the effects of EMG-NMES in the chronic phase after stroke, whereas the literature suggests that an early start, within the time window in which functional outcome of the upper limb is not fully defined, is more appropriate.