Mental practice for treating upper extremity deficits in individuals with hemiparesis after stroke

Effectiveness of mental practice for limb dysfunction in patients who have experienced a stroke: a systematic review and meta-analysis

Stroke is the second largest cause of death in adults and the principal cause of long-term severe adult disability worldwide. Approximately 70% of patients present with upper limb weakness following stroke. One intervention for the treatment of upper limb impairment post-stroke is mental practice. This article critically appraises a systematic review which assesses the effectiveness of mental practice for limb dysfunction in patients who have experienced stroke.

Effect of Motor Imagery Training on Motor Learning in Children and Adolescents: A Systematic Review and Meta-Analysis

Background: There is an urgent need to systematically analyze the growing body of literature on the effect of motor imagery (MI) training in children and adolescents. Methods: Seven databases and clinicaltrials.gov were searched. Two reviewers independently screened references and full texts, and extracted data (studies’ methodology, MI elements, temporal parameters). Two studies were meta-analyzed providing the standard mean difference (SDM). Selected studies were evaluated with the risk of bias (RoB) and GRADE tools. Results: A total of 7238 references were retrieved. The sample size of the 22 included studies, published between 1995 and 2021, ranged from 18 to 136 participants, totaling 934 (nine to 18 years). Studies included healthy pupils, mentally retarded adolescents, children with motor coordination difficulties or with mild mental disabilities. The motor learning tasks focused on upper, lower and whole body movements. SMDs for the primary outcome of pooled studies varied between 0.83 to 1.87 (95% CI, I², T² varied 0.33–3.10; p = 0.001; 0–74%; 0–0.59). RoB varied between some concerns and high risk. GRADE rating was low. Conclusions: MI combined with physical practice (PP) might have a high potential for healthy and impaired children and adolescents. However, important reporting recommendations (PETTLEP, TIDieR, CONSORT) should be followed. The systematic review was registered with PROSPERO: CRD42021237361.

A different point of view: the evaluation of motor imagery perspectives in patients with sensorimotor impairments in a longitudinal study

Background

Motor imagery (MI) has been successfully applied in neurological rehabilitation. Little is known about the spontaneous selection of the MI perspectives in patients with sensorimotor impairments. What perspective is selected: internal (first-person view), or external (third-person view)? The aim was to evaluate the MI perspective preference in patients with sensorimotor impairments.

Methods

In a longitudinal study including four measurement sessions, 55 patients (25 stroke, 25 multiple sclerosis, 5 Parkinson’s disease; 25 females; mean age 58 ± 14 years) were included. MI ability and perspective preference in both visual and kinaesthetic imagery modalities were assessed using the Kinaesthetic and Visual Imagery Questionnaire-20 (KVIQ-20), the body rotation task (BRT), and mental chronometry (MC). Additionally, patients’ activity level was assessed. Descriptive analyses were performed regarding different age- (< 45, 45–64, > 64), activity levels (inactive, partially active, active), and KVIQ-20 movement classifications (axial, proximal, distal, upper and lower limb). A mixed-effects model was used to investiage the relationship between the primary outcome (MI perspective: internal, external) with the explanatory variables age, MI modality (visual, kinaesthetic), movement type (axial, proximal, distal), activity levels and the different assessments (KVIQ-20, BRT, MC).

Results

Imagery modality was not a significant predictor of perspective preference. Over the four measurement sessions, patients tended to become more consistent in their perspective selection, however, time point was not a significant predictor. Movement type was a significant predictor: imagination of distal vs. axial and proximal vs. axial movements were both associated with preference for external perspective. Patients with increased physical activity level tend to use internal imagery, however, this effect was borderline not statistically significant. Age was neither a significant precictor. Regarding the MI assessments, the KVIQ- 20 score was a significant predictor. The patients with higher test scores tend to use the external perspective.

Conclusion

It is recommended to evaluate the spontaneous MI perspective selection to design patient-specific MI training interventions. Distal movements (foot, finger) may be an indicator when evaluating the consistency of the MI perspective in patients with sensorimotor impairments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02266-w.

Longer-term health and social care strategies for stroke survivors and their carers: the LoTS2Care research programme including cluster feasibility RCT

Background

It is reported that the longer-term outcomes for stroke survivors are poor, with a range of unmet needs identified.

Objectives

The aims were to develop and test a longer-term stroke care strategy focused on improving the quality of life of stroke survivors and their carers by addressing unmet needs, and maintenance and enhancement of participation (i.e. involvement in life situations).

Design

Five overlapping workstreams were undertaken – (1) refinement of content by semistructured interviews with stroke survivors and their carers and by a review of the literature to inform content and delivery of the care strategy; (2) exploration of service models by national survey and focus groups with purposely selected services; (3) intervention development by interaction with a reference group of stroke survivors, carers, and health and social care professionals; (4) refinement and pilot implementation of the developed intervention in three stroke services (case studies); and (5) a cluster randomised controlled feasibility trial in 10 stroke services across England and Wales.

Setting

The intervention development work and feasibility trial were in stroke services (inclusive of primary, secondary, community and social care provision) across England and Wales.

Participants

Participants were stroke survivors resident in the community and their carers, and health and social care professionals in the included stroke services.

Data sources

Interviews with 28 stroke survivors and their carers at least 9 months post stroke ascertained their needs and the barriers to and facilitators of addressing those needs. Additional literature reviews identified 23 needs. No evidence-based interventions to address these needs were reported; self-management was highlighted as a possible delivery mechanism. In workstream 2, a national survey revealed that the most common model of stroke service provision was care up to 12 months post stroke, reported by 46 (40%) services. Thirty-five (30%) services provided care up to 6 months post stroke and 35 (30%) provided care beyond 12 months, thus identifying 6 months post stroke as an appropriate delivery point for a new intervention. Through focus groups in a range of services, stroke survivors’ perceived unmet needs and the barriers to and enablers of service provision were identified.

Intervention

Using information obtained in workstreams 1 and 2 and working closely with a stakeholder reference group, we developed an intervention based on the unmet needs prioritised by stroke survivors and their carers (workstream 3). In workstream 4, action groups (clinicians, stroke survivors and researchers) were established in three stroke services that led implementation in their service and contributed to the iterative refinement of the intervention, associated training programme and implementation materials. The intervention (called New Start) was delivered at 6 months post stroke. Key components were problem-solving self-management with survivors and carers, help with obtaining usable information, and helping survivors and their carers build sustainable, flexible support networks.

Results

A cluster randomised feasibility trial (workstream 5) was successfully implemented in 10 stroke services across England and Wales, with associated process and health economic evaluations. Five services were randomised to provide New Start, while five continued with usual care; 269 participants were recruited. Progression criteria – in terms of our pre-determined (red, amber, green) criteria for progress to a full trial: target stroke survivor recruitment rates were achieved, on average, across sites (24.1 per site over 6 months, green); 216 (80.3%) registered stroke survivors returned follow-up questionnaires at 9 months (84.1% in the intervention arm and 75.8% in the usual care arm, green); according to data reported by sites, overall, 95.2% of registered stroke survivors were offered at least one session of the intervention (green); all five intervention sites had at least two facilitators deemed competent, delivered the New Start intervention and provided it to stroke survivors (green). However, at some sites, there were concerns regarding the number of stroke survivors being offered, accepting and receiving the intervention. Only small differences in outcomes and costs were observed between the New Start and usual care groups, and considerable uncertainty around the cost-effectiveness remains.

Conclusions

We report a complex programme of work that has described the longer-term needs of stroke survivors and highlighted evidence and service gaps. Working closely with stroke survivors, an intervention was developed that has been refined in three services and feasibility tested in a cluster randomised controlled trial. Further refinement of the target population and optimisation of the intervention materials is required prior to a full randomised controlled trial evaluation.

Future work

Optimisation of the intervention, and clearer specification of recipients, are required prior to a full trial evaluation.

Trial registration

Current Controlled Trials ISRCTN38920246.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.

Motor imagery for gait rehabilitation after stroke

BACKGROUND

Motor imagery (MI) is defined as a mentally rehearsed task in which movement is imagined but is not performed. The approach includes repetitive imagined body movements or rehearsing imagined acts to improve motor performance.

OBJECTIVES

To assess the treatment effects of MI for enhancing ability to walk among people following stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group registry, CENTRAL, MEDLINE, Embase and seven other databases. We also searched trial registries and reference lists. The last searches were conducted on 24 February 2020.

SELECTION CRITERIA

Randomized controlled trials (RCTs) using MI alone or associated with action observation or physical practice to improve gait in individuals after stroke. The critical outcome was the ability to walk, assessed using either a continuous variable (walking speed) or a dichotomous variable (dependence on personal assistance). Important outcomes included walking endurance, motor function, functional mobility, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials according to pre-defined inclusion criteria, extracted the data, assessed the risk of bias, and applied the GRADE approach to evaluate the certainty of the evidence. The review authors contacted the study authors for clarification and missing data.

MAIN RESULTS

We included 21 studies, involving a total of 762 participants. Participants were in the acute, subacute, or chronic stages of stroke, and had a mean age ranging from 50 to 78 years. All participants presented at least some gait deficit. All studies compared MI training versus other therapies. Most of the included studies used MI associated with physical practice in the experimental groups. The treatment time for the experimental groups ranged from two to eight weeks. There was a high risk of bias for at least one assessed domain in 20 of the 21 included studies. Regarding our critical outcome, there was very low-certainty evidence that MI was more beneficial for improving gait (walking speed) compared to other therapies at the end of the treatment (pooled standardized mean difference (SMD) 0.44; 95% confidence interval (CI) 0.06 to 0.81; P = 0.02; six studies; 191 participants; I² = 38%). We did not include the outcome of dependence on personal assistance in the meta-analysis, because only one study provided information regarding the number of participants that became dependent or independent after interventions. For our important outcomes, there was very low-certainty evidence that MI was no more beneficial than other interventions for improving motor function (pooled mean difference (MD) 2.24, 95% CI -1.20 to 5.69; P = 0.20; three studies; 130 participants; I² = 87%) and functional mobility at the end of the treatment (pooled SMD 0.55, 95% CI -0.45 to 1.56; P = 0.09; four studies; 116 participants; I² = 64.2%). No adverse events were observed in those studies that reported this outcome (seven studies). We were unable to pool data regarding walking endurance and all other outcomes at follow-up.

AUTHORS' CONCLUSIONS

We found very low-certainty evidence regarding the short-term benefits of MI on walking speed in individuals who have had a stroke, compared to other therapies. Evidence was insufficient to estimate the effect of MI on the dependence on personal assistance and walking endurance. Compared with other therapies, the evidence indicates that MI does not improve motor function and functional mobility after stroke (very low-certainty evidence). Evidence was also insufficient to estimate the effect of MI on gait, motor function, and functional mobility after stroke compared to placebo or no intervention. Motor Imagery and other therapies used for gait rehabilitation after stroke do not appear to cause significant adverse events.

Critical analysis of evidence about the impacts on surgical teams of 'mental practice' in systematic reviews: a systematic rapid evidence assessment (SREA)

BACKGROUND

Mental Rehearsal (MR) the cognitive act of simulating a task in our heads to pre-experience events imaginatively. It has been used widely to improve individual and collective performance in fields outside healthcare and offers potential for more efficient training in time pressured surgical and medical team contexts. The study aims to review the current systematic review literature to determine the impact of MP on surgical performance and learning.

METHODS

Medline, Embase, British Educational Index, CINAHL, Web of Science PsycINFO, Cochrane databased were searched in the period 1994-2018. The primary outcomes measure were performance improvements in surgical technical skills, stress reduction, confidence and team performance. Study quality of the Systematic Reviews was assessed using AMSTAR 2, a critical appraisal tool for systematic reviews. The reported impacts of MP in all included studies were mapped onto Kirkpatrick's framework for the evaluation of educational interventions.

RESULTS

Six Systematic reviews were identified which met the inclusion criteria, of which all reported positive and varying benefits of MP on surgical performance, confidence, and coping strategies. However, reported impacts on a modified Kirkpatrick's framework did not exceed level 3. Mental practice was described in terms of mental imagery and mental rehearsal with most authors using each of the terms in their search strategies. The impacts on transfer to practice and the long- term acquisition of skills, but also personal uptake of mental practice routines were not reported.

CONCLUSION

The majority of studies demonstrate benefits of MP for technical performance. Overall the systematic reviews were of medium to high quality. However, studies lacked a sufficiently articulated evaluation methodology to examine impacts beyond the immediate experimentations. This is also due to the limitations found in the primary studies. Future research should look at longitudinal mixed method evaluation designs and focus on real clinical teams.

Mental practice for treating upper extremity deficits in individuals with hemiparesis after stroke

BACKGROUND

Stroke is caused by the interruption of blood flow to the brain (ischemic stroke) or the rupture of blood vessels within the brain (hemorrhagic stroke) and may lead to changes in perception, cognition, mood, speech, health-related quality of life, and function, such as difficulty walking and using the arm. Activity limitations (decreased function) of the upper extremity are a common finding for individuals living with stroke. Mental practice (MP) is a training method that uses cognitive rehearsal of activities to improve performance of those activities.

OBJECTIVES

To determine whether MP improves outcomes of upper extremity rehabilitation for individuals living with the effects of stroke. In particular, we sought to (1) determine the effects of MP on upper extremity activity, upper extremity impairment, activities of daily living, health-related quality of life, economic costs, and adverse effects; and (2) explore whether effects differed according to (a) the time post stroke at which MP was delivered, (b) the dose of MP provided, or (c) the type of comparison performed.

SEARCH METHODS

We last searched the Cochrane Stroke Group Trials Register on September 17, 2019. On September 3, 2019, we searched the Cochrane Central Register of Controlled Trials (the Cochrane Library), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Scopus, Web of Science, the Physiotherapy Evidence Database (PEDro), and REHABDATA. On October 2, 2019, we searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We reviewed the reference lists of included studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of adult participants with stroke who had deficits in upper extremity function (called upper extremity activity).

DATA COLLECTION AND ANALYSIS

Two review authors screened titles and abstracts of the citations produced by the literature search and excluded obviously irrelevant studies. We obtained the full text of all remaining studies, and both review authors then independently selected trials for inclusion. We combined studies when the review produced a minimum of two trials employing a particular intervention strategy and a common outcome. We considered the primary outcome to be the ability of the arm to be used for appropriate tasks, called upper extremity activity. Secondary outcomes included upper extremity impairment (such as quality of movement, range of motion, tone, presence of synergistic movement), activities of daily living (ADLs), health-related quality of life (HRQL), economic costs, and adverse events. We assessed risk of bias in the included studies and applied GRADE to assess the certainty of the evidence. We completed subgroup analyses for time since stroke, dosage of MP, type of comparison, and type of arm activity outcome measure.

MAIN RESULTS

We included 25 studies involving 676 participants from nine countries. For the comparison of MP in addition to other treatment versus the other treatment, MP in combination with other treatment appears more effective in improving upper extremity activity than the other treatment without MP (standardized mean difference [SMD] 0.66, 95% confidence interval [CI] 0.39 to 0.94; I² = 39%; 15 studies; 397 participants); the GRADE certainty of evidence score was moderate based on risk of bias for the upper extremity activity outcome. For upper extremity impairment, results were as follows: SMD 0.59, 95% CI 0.30 to 0.87; I² = 43%; 15 studies; 397 participants, with a GRADE score of moderate, based on risk of bias. For ADLs, results were as follows: SMD 0.08, 95% CI -0.24 to 0.39; I² = 0%; 4 studies; 157 participants; the GRADE score was low due to risk of bias and small sample size. For the comparison of MP versus conventional treatment, the only outcome with available data to combine (3 studies; 50 participants) was upper extremity impairment (SMD 0.34, 95% CI -0.33 to 1.00; I² = 21%); GRADE for the impairment outcome in this comparison was low due to risk of bias and small sample size. Subgroup analyses of time post stroke, dosage of MP, or comparison type for the MP in combination with other rehabilitation treatment versus the other treatment comparison showed no differences. The secondary outcome of health-related quality of life was reported in only one study, and no study noted the outcomes of economic costs and adverse events.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that MP in addition to other treatment versus the other treatment appears to be beneficial in improving upper extremity activity. Moderate-certainty evidence also shows that MP in addition to other treatment versus the other treatment appears to be beneficial in improving upper extremity impairment after stroke. Low-certainty evidence suggests that ADLs may not be improved with MP in addition to other treatment versus the other treatment. Low-certainty evidence also suggests that MP versus conventional treatment may not improve upper extremity impairment. Further study is required to evaluate effects of MP on time post stroke, the volume of MP required to affect outcomes, and whether improvement is maintained over the long term.

Brain-computer-interface technology with multisensory feedback for controlled ideomotor training in the rehabilitation of stroke patients

Motor recovery of the upper limb is a priority in the neurorehabilitation of stroke patients. Advances in the brain-computer interface (BCI) technology have significantly improved the quality of rehabilitation. The aim of this study was to explore the factors affecting the recovery of the upper limb in stroke patients undergoing BCI-based rehabilitation with the robotic hand. The study recruited 24 patients (14 men and 10 women) aged 51 to 62 years with a solitary supratentorial stroke lesion. The lesion was left-hemispheric in 11 (45.6%) patients and right-hemispheric in 13 (54.4%) patients. Time elapsed from stroke was 4.0 months (3.0; 12.0). The median MoCa score was 25.0 (23.0; 27.0). The rehabilitation course consisted of 9.5 sessions (8.0; 10.0). We established a significant moderate correlation between motor imagery performance (the MIQ-RS score) and the efficacy of patient-BCI interaction. Patients with high MIQ-RS scores (47.5 (32.0; 54.0) achieved a better control of the BCI-driven hand exoskeleton (63.0 (54.0; 67.0), R = 0.67; p < 0.05). Recovery dynamics were more pronounced in patients with high MIQ-RS scores: the median score on the Fugl-Meyer Assessment scale was 14 (8.0; 16.0) points vs 10 (6.0; 13.0) points in patients with low MIQ-RS scores. However, the difference was not significant. Thus, we established a correlation between a patient’s ability for motor imagery (MIQ-RS) and the efficacy of patient-BCI interaction. A larger patient sample might be necessary to assess the effect of these factors on motor recovery dynamics.

Motor imagery for pain and motor function after spinal cord injury: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVES

To evaluate the therapeutic benefits of motor imagery (MI) for the people with spinal cord injury (SCI).

SETTING

International.

METHODS

We searched electronic bibliographic databases, trial registers, and relevant reference lists. The review included experimental and quasi-experimental study designs as well as observational studies. For the critical appraisal of the 18 studies retrieved (three RCT, seven quasi-RCT, eight observational), we used instruments from the Joanna Briggs Institute. The primary outcome measure was pain. Secondary outcome measures included motor function and neurophysiological parameters. Adverse effects were extracted if reported in the included studies. Because of data heterogeneity, only a qualitative synthesis is offered.

RESULTS

The included studies involved 282 patients. In most, results were an improvement in motor function and decreased pain; however, some reported no effect or an increase in pain. Although protocols of MI intervention were heterogeneous, sessions of 8-20 min were used for pain treatments, and of 30-60 min were used for motor function improvement. Neurophysiological measurements showed changes in brain region activation and excitability imposed by SCI, which were partially recovered by MI interventions. No serious adverse effects were reported.

CONCLUSIONS

High heterogeneity in the SCI population, MI interventions, and outcomes measured makes it difficult to judge the therapeutic effects and best MI intervention protocol, especially for people with SCI with neuropathic pain. Further clinical trials evaluating MI intervention as adjunct therapy for pain in SCI patients are warranted.

Effectiveness of interventions to improve hand motor function in individuals with moderate to severe stroke: a systematic review protocol

INTRODUCTION

The human hand is extremely involved in our daily lives. However, the rehabilitation of hand function after stroke can be rather difficult due to the complexity of hand structure and function, as well as neural basis that supports hand function. Specifically, in individuals with moderate to severe impairment following a stroke, previous evidence for effective treatments that recover hand function in this population is limited, and thus has never been reviewed. With the progress of rehabilitation science and tool development, results from more and more clinical trials are now available, thereby justifying conducting a systematic review.

METHODS AND ANALYSIS

This systematic review protocol is consistent with the methodology recommended by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols and the Cochrane handbook for systematic reviews of interventions. Electronic searches will be carried out in the PubMed, CINAHL, Physiotherapy Evidence Database and Cochrane Library databases, along with manual searches in the reference lists from included studies and published systematic reviews. The date range parameters used in searching all databases is between January 1999 and January 2019. Randomised controlled trials (RCTs) published in English, with the primary outcome focusing on hand motor function, will be included. Two reviewers will screen all retrieved titles, abstracts and full texts, perform the evaluation of the risk bias and extract all data independently. The risk of bias of the included RCTs will be evaluated by the Cochrane Collaboration's tool. A qualitative synthesis will be provided in text and table, to summarise the main results of the selected publications. A meta-analysis will be considered if there is sufficient homogeneity across outcomes. The quality of the included publications will be evaluated by the Grading of Recommendations Assessment, Development and Evaluation system from the Cochrane Handbook for Systematic Reviews of Interventions.

ETHICS AND DISSEMINATION

No ethical approval is needed, and the results of this review will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

CRD42019128285.

Efficacy of motor imagery additional to motor-based therapy in the recovery of motor function of the upper limb in post-stroke individuals: a systematic review

Background. Motor imagery (MI) consists of the mental simulation of repetitive movements with the intention of promoting the learning of a motor skill. It seems to be an additional useful tool for motor-based therapy to potentiate the rehabilitation of the upper limb function of post-stroke individuals. Objective. To investigate whether MI combined with motor-based therapy is effective in recovering motor deficits of upper limbs from post-stroke individuals. Method. A systematic review of the literature was performed in the PEDro, LILACS, Cochrane, SCOPUS, Medline/PubMed and SciELO databases. Randomized controlled trials (RCTs) investigating the efficacy of MI associated with motor-based therapy compared with isolated motor-based therapy were included. The included outcomes were gross motor function and functional activities of the upper limb of post-stroke individuals. The physiotherapy evidence database scale was applied for evaluation of methodological quality. Results. Four RCTs were included, with a total of 104 participants, with methodological quality varying from moderate to high. There was a statistically significant improvement in upper limb motor function in all studies. Gross motor function was higher in MI associated with motor-based therapy compared to controls, but only in one study there was superiority in the results of functional activities of the upper limb. Conclusion. There is evidence showing that MI associated with motor-based therapy is an effective tool in improving the motor function of upper limbs of post-stroke individuals. However, more studies are needed to establish criteria for frequency and duration of intervention, and what better type of MI should be used.

Brain-computer interfaces for post-stroke motor rehabilitation: a meta-analysis

Brain‐computer interfaces (BCIs) can provide sensory feedback of ongoing brain oscillations, enabling stroke survivors to modulate their sensorimotor rhythms purposefully. A number of recent clinical studies indicate that repeated use of such BCIs might trigger neurological recovery and hence improvement in motor function. Here, we provide a first meta‐analysis evaluating the clinical effectiveness of BCI‐based post‐stroke motor rehabilitation. Trials were identified using MEDLINE, CENTRAL, PEDro and by inspection of references in several review articles. We selected randomized controlled trials that used BCIs for post‐stroke motor rehabilitation and provided motor impairment scores before and after the intervention. A random‐effects inverse variance method was used to calculate the summary effect size. We initially identified 524 articles and, after removing duplicates, we screened titles and abstracts of 473 articles. We found 26 articles corresponding to BCI clinical trials, of these, there were nine studies that involved a total of 235 post‐stroke survivors that fulfilled the inclusion criterion (randomized controlled trials that examined motor performance as an outcome measure) for the meta‐analysis. Motor improvements, mostly quantified by the upper limb Fugl‐Meyer Assessment (FMA‐UE), exceeded the minimal clinically important difference (MCID=5.25) in six BCI studies, while such improvement was reached only in three control groups. Overall, the BCI training was associated with a standardized mean difference of 0.79 (95% CI: 0.37 to 1.20) in FMA‐UE compared to control conditions, which is in the range of medium to large summary effect size. In addition, several studies indicated BCI‐induced functional and structural neuroplasticity at a subclinical level. This suggests that BCI technology could be an effective intervention for post‐stroke upper limb rehabilitation. However, more studies with larger sample size are required to increase the reliability of these results.

Immediate effect of mental practice with and without mirror therapy on muscle activation in hemiparetic stroke patients

Mental practice (MP) consists of the repeated mental rehearsal of a physical skill without movement, called motor imagery (MI). Studies show that MP and MI associated mirror therapy (MPMT) may improve muscle control of the upper limbs in hemiparesis. This study aimed to evaluate muscle activation during active flexion of the wrist (MA), MP, and MPMT in patients with history of stroke and hemiparesis. Individuals diagnosed with stroke showing sequelae of upper limb hemiparesis were enrolled. The flexor carpi ulnaris was analyzed using electromyography during tasks (MA, MP, MPMT) involving wrist flexion. Greater electromyographic activity was detected during MP and MPMT techniques compared to active movement (p = 0.02). There was no significant difference between MP and MPMT (p = 0.56). These results were found in both the affected limb and unaffected limb. Immediate effects on muscle activation are experienced during MP and MPMT, and muscle activity was similar with both therapies.

Motor Imagery-Based Rehabilitation: Potential Neural Correlates and Clinical Application for Functional Recovery of Motor Deficits after Stroke

Motor imagery (MI), defined as the mental implementation of an action in the absence of movement or muscle activation, is a rehabilitation technique that offers a means to replace or restore lost motor function in stroke patients when used in conjunction with conventional physiotherapy procedures. This article briefly reviews the concepts and neural correlates of MI in order to promote improved understanding, as well as to enhance the clinical utility of MI-based rehabilitation regimens. We specifically highlight the role of the cerebellum and basal ganglia, premotor, supplementary motor, and prefrontal areas, primary motor cortex, and parietal cortex. Additionally, we examine the recent literature related to MI and its potential as a therapeutic technique in both upper and lower limb stroke rehabilitation.

Increasing Lateralized Motor Activity in Younger and Older Adults using Real-time fMRI during Executed Movements

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Healthy adults performed movements while receiving neurofeedback from real-time fMRI.

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Two experiments were performed, one with younger and one with older adults.

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Neurofeedback (NF) represented the laterality of activation in the motor cortices.

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The NF groups produced more lateralized activity than the sham group.

Neurofeedback training involves presenting an individual with a representation of their brain activity and instructing them to alter the activity using the feedback. One potential application of neurofeedback is for patients to alter neural activity to improve function. For example, there is evidence that greater laterality of movement-related activity is associated with better motor outcomes after stroke; so using neurofeedback to increase laterality may provide a novel route for improving outcomes. However, we must demonstrate that individuals can control relevant neurofeedback signals. Here, we performed two proof-of-concept studies, one in younger (median age: 26 years) and one in older healthy volunteers (median age: 67.5 years). The purpose was to determine if participants could manipulate laterality of activity between the motor cortices using real-time fMRI neurofeedback while performing simple hand movements. The younger cohort trained using their left and right hand, the older group trained using their left hand only. In both studies participants in a neurofeedback group were able to achieve more lateralized activity than those in a sham group (younger adults: F(1,23) = 4.37, p < 0.05; older adults: F(1,15) = 9.08, p < 0.01). Moreover, the younger cohort was able to maintain the lateralized activity for right hand movements once neurofeedback was removed. The older cohort did not maintain lateralized activity upon feedback removal, with the limitation being that they did not train with their right hand. The results provide evidence that neurofeedback can be used with executed movements to promote lateralized brain activity and thus is amenable for testing as a therapeutic intervention for patients following stroke.

Neurorehabilitation: applied neuroplasticity

The prevalence of disability due to neurological conditions is escalating worldwide. Neurological disorders have significant disability-burden with long-term functional and psychosocial issues, requiring specialized rehabilitation services for comprehensive management, especially treatments tapping into brain recovery 'neuroplastic' processes. Neurorehabilitation is interdisciplinary and cross-sectorial, requiring coordinated effort of diverse sectors, professions, patients and community to manage complex condition-related disability. This review provides evidence for a range of neurorehabilitation interventions for four common neurological conditions: multiple sclerosis (MS), stroke, traumatic brain injury and Parkinson's disease using the Grade of Recommendation, Assessment, Development and Evaluation tool for quality of evidence. Although, existing best-evidence for many interventions is still sparse, the overall findings suggest 'strong' evidence for physical therapy and psychological intervention for improved patient outcomes; and. 'moderate' evidence for multidisciplinary rehabilitation for longer term gains at the levels of activity (disability) and participation in MS and stroke population. The effect of other rehabilitation interventions is inconclusive, due to a paucity of methodologically robust studies. More research is needed to improve evidence-base for many promising rehabilitation interventions.

Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery

Stroke is one of the leading causes for disability worldwide. Motor function deficits due to stroke affect the patients' mobility, their limitation in daily life activities, their participation in society and their odds of returning to professional activities. All of these factors contribute to a low overall quality of life. Rehabilitation training is the most effective way to reduce motor impairments in stroke patients. This multiple systematic review focuses both on standard treatment methods and on innovating rehabilitation techniques used to promote upper extremity motor function in stroke patients. A total number of 5712 publications on stroke rehabilitation was systematically reviewed for relevance and quality with regards to upper extremity motor outcome. This procedure yielded 270 publications corresponding to the inclusion criteria of the systematic review. Recent technology-based interventions in stroke rehabilitation including non-invasive brain stimulation, robot-assisted training, and virtual reality immersion are addressed. Finally, a decisional tree based on evidence from the literature and characteristics of stroke patients is proposed. At present, the stroke rehabilitation field faces the challenge to tailor evidence-based treatment strategies to the needs of the individual stroke patient. Interventions can be combined in order to achieve the maximal motor function recovery for each patient. Though the efficacy of some interventions may be under debate, motor skill learning, and some new technological approaches give promising outcome prognosis in stroke motor rehabilitation.

Effects of Adjuvant Mental Practice on Affected Upper Limb Function Following a Stroke: Results of Three-Dimensional Motion Analysis, Fugl-Meyer Assessment of the Upper Extremity and Motor Activity Logs

Objective

To investigate the effects of adjuvant mental practice (MP) on affected upper limb function following a stroke using three-dimensional (3D) motion analysis.

Methods

In this AB/BA crossover study, we studied 10 hemiplegic patients who had a stroke within the past 6 months. The patients were randomly allocated to two groups: one group received MP combined with conventional rehabilitation therapy for the first 3 weeks followed by conventional rehabilitation therapy alone for the final 3 weeks; the other group received the same therapy but in reverse order. The MP tasks included drinking from a cup and opening a door. MP was individually administered for 20 minutes, 3 days a week for 3 weeks. To assess the tasks, we used 3D motion analysis and three additional tests: the Fugl-Meyer Assessment of the upper extremity (FMA-UE) and the motor activity logs for amount of use (MAL-AOU) and quality of movement (MAL-QOM). Assessments were performed immediately before treatment (T0), 3 weeks into treatment (T1), and 6 weeks into treatment (T2).

Results

Based on the results of the 3D motion analysis and the FMA-UE index (p=0.106), the MAL-AOU scale (p=0.092), and MAL-QOM scale (p=0.273), adjuvant MP did not result in significant improvements.

Conclusion

Adjuvant MP had no significant effect on upper limb function following a stroke, according to 3D motion analysis and three clinical assessment tools (the FMA-UE index and the two MAL scales). The importance of this study is its use of objective 3D motion analysis to evaluate the effects of MP. Further studies will be needed to validate these findings.

Influence of mental practice on upper limb muscle activity and activities of daily living in chronic stroke patients

[Purpose] The aim of this study was to determine the effects of mental practice on muscle activity of the upper extremity and performance of daily activities in chronic stroke patients. [Subjects and Methods] In this research, mental practice was conducted by 2 chronic hemiplegic stroke patients. Mental practice was conducted 30 minutes a day, 5 times a week, for 2 weeks. Evaluation was conducted 4 times before and after intervention. Muscle activity was measured using a surface electromyogram test, and the Modified Barthel Index was used to measure changes in the ability to carry out daily activities. [Results] Both the muscle activity of the upper extremity and capability to perform daily activities showed improved outcomes after mental practice was conducted. [Conclusion] Through this research, mental practice was proven to be effective in improving the muscle activity of upper extremity and capability to perform daily activities in chronic hemiplegic stroke patients.

Relationship between functional connectivity and motor function assessment in stroke patients with hemiplegia: a resting-state functional MRI study

INTRODUCTION

Resting-state functional magnetic resonance imaging (fMRI) has been used to examine the brain mechanisms of stroke patients with hemiplegia, but the relationship between functional connectivity (FC) and treatment-induced motor function recovery has not yet been fully investigated. This study aimed to identify the brain FC changes in stroke patients and study the relationship between FC and motor function assessment using the resting-state fMRI.

METHODS

Seventeen stroke patients with hemiplegia and fifteen healthy control subjects (HCSs) were recruited in this study. We compared the FC between the ipsilesional primary motor cortex (M1) and the whole brain of the patients with the FC of the HCSs and studied the FC changes in the patients before and after conventional rehabilitation and motor imagery therapy. Additionally, correlations between the FC change and motor function of the patients were studied.

RESULTS

Compared to the HCSs, the FC in the patient group was significantly increased between the ipsilesional M1 and the ipsilesional inferior parietal cortex, frontal gyrus, supplementary motor area (SMA), and contralesional angular and decreased between the ipsilesional M1 and bilateral M1. After the treatment, the FC between the ipsilesional M1 and contralesional M1 increased while the FC between the ipsilesional M1 and ipsilesional SMA and paracentral lobule decreased. A statistically significant correlation was found between the FC change in the bilateral M1 and the Fugl-Meyer assessment (FMA) score change.

CONCLUSION

Our results revealed an abnormal motor network after stroke and suggested that the FC could serve as a biomarker of motor function recovery in stroke patients with hemiplegia.

Motor priming in neurorehabilitation

Priming is a type of implicit learning wherein a stimulus prompts a change in behavior. Priming has been long studied in the field of psychology. More recently, rehabilitation researchers have studied motor priming as a possible way to facilitate motor learning. For example, priming of the motor cortex is associated with changes in neuroplasticity that are associated with improvements in motor performance. Of the numerous motor priming paradigms under investigation, only a few are practical for the current clinical environment, and the optimal priming modalities for specific clinical presentations are not known. Accordingly, developing an understanding of the various types of motor priming paradigms and their underlying neural mechanisms is an important step for therapists in neurorehabilitation. Most importantly, an understanding of the methods and their underlying mechanisms is essential for optimizing rehabilitation outcomes. The future of neurorehabilitation is likely to include these priming methods, which are delivered prior to or in conjunction with primary neurorehabilitation therapies. In this Special Interest article, we discuss those priming paradigms that are supported by the greatest amount of evidence, including (i) stimulation-based priming, (ii) motor imagery and action observation, (iii) sensory priming, (iv) movement-based priming, and (v) pharmacological priming.Video Abstract available. (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A86) for more insights from the authors.

Emerging treatments for motor rehabilitation after stroke

Although numerous treatments are available to improve cerebral perfusion after acute stroke and prevent recurrent stroke, few rehabilitation treatments have been conclusively shown to improve neurologic recovery. The majority of stroke survivors with motor impairment do not recover to their functional baseline, and there remains a need for novel neurorehabilitation treatments to minimize long-term disability, maximize quality of life, and optimize psychosocial outcomes. In recent years, several novel therapies have emerged to restore motor function after stroke, and additional investigational treatments have also shown promise. Here, we familiarize the neurohospitalist with emerging treatments for poststroke motor rehabilitation. The rehabilitation treatments covered in this review will include selective serotonin reuptake inhibitor medications, constraint-induced movement therapy, noninvasive brain stimulation, mirror therapy, and motor imagery or mental practice.

Neural processes mediating the preparation and release of focal motor output are suppressed or absent during imagined movement

Movements that are executed or imagined activate a similar subset of cortical regions, but the extent to which this activity represents functionally equivalent neural processes is unclear. During preparation for an executed movement, presentation of a startling acoustic stimulus (SAS) evokes a premature release of the planned movement with the spatial and temporal features of the tasks essentially intact. If imagined movement incorporates the same preparatory processes as executed movement, then a SAS should release the planned movement during preparation. This hypothesis was tested using an instructed-delay cueing paradigm during which subjects were required to rapidly release a handheld weight while maintaining the posture of the arm or to perform first-person imagery of the same task while holding the weight. In a subset of trials, a SAS was presented at 1500, 500, or 200 ms prior to the release cue. Task-appropriate preparation during executed and imagined movements was confirmed by electroencephalographic recording of a contingent negative variation waveform. During preparation for executed movement, a SAS often resulted in premature release of the weight with the probability of release progressively increasing from 24 % at -1500 ms to 80 % at -200 ms. In contrast, the SAS rarely (<2 % of trials) triggered a release of the weight during imagined movement. However, the SAS frequently evoked the planned postural response (suppression of bicep brachii muscle activity) irrespective of the task or timing of stimulation (even during periods of postural hold without preparation). These findings provide evidence that neural processes mediating the preparation and release of the focal motor task (release of the weight) are markedly attenuated or absent during imagined movement and that postural and focal components of the task are prepared independently.

Interventions for improving upper limb function after stroke

BACKGROUND

Improving upper limb function is a core element of stroke rehabilitation needed to maximise patient outcomes and reduce disability. Evidence about effects of individual treatment techniques and modalities is synthesised within many reviews. For selection of effective rehabilitation treatment, the relative effectiveness of interventions must be known. However, a comprehensive overview of systematic reviews in this area is currently lacking.

OBJECTIVES

To carry out a Cochrane overview by synthesising systematic reviews of interventions provided to improve upper limb function after stroke.

METHODS

SEARCH METHODS

We comprehensively searched the Cochrane Database of Systematic Reviews; the Database of Reviews of Effects; and PROSPERO (an international prospective register of systematic reviews) (June 2013). We also contacted review authors in an effort to identify further relevant reviews.

SELECTION CRITERIA

We included Cochrane and non-Cochrane reviews of randomised controlled trials (RCTs) of patients with stroke comparing upper limb interventions with no treatment, usual care or alternative treatments. Our primary outcome of interest was upper limb function; secondary outcomes included motor impairment and performance of activities of daily living. When we identified overlapping reviews, we systematically identified the most up-to-date and comprehensive review and excluded reviews that overlapped with this.

DATA COLLECTION AND ANALYSIS

Two overview authors independently applied the selection criteria, excluding reviews that were superseded by more up-to-date reviews including the same (or similar) studies. Two overview authors independently assessed the methodological quality of reviews (using a modified version of the AMSTAR tool) and extracted data. Quality of evidence within each comparison in each review was determined using objective criteria (based on numbers of participants, risk of bias, heterogeneity and review quality) to apply GRADE (Grades of Recommendation, Assessment, Development and Evaluation) levels of evidence. We resolved disagreements through discussion. We systematically tabulated the effects of interventions and used quality of evidence to determine implications for clinical practice and to make recommendations for future research.

MAIN RESULTS

Our searches identified 1840 records, from which we included 40 completed reviews (19 Cochrane; 21 non-Cochrane), covering 18 individual interventions and dose and setting of interventions. The 40 reviews contain 503 studies (18,078 participants). We extracted pooled data from 31 reviews related to 127 comparisons. We judged the quality of evidence to be high for 1/127 comparisons (transcranial direct current stimulation (tDCS) demonstrating no benefit for outcomes of activities of daily living (ADLs)); moderate for 49/127 comparisons (covering seven individual interventions) and low or very low for 77/127 comparisons.Moderate-quality evidence showed a beneficial effect of constraint-induced movement therapy (CIMT), mental practice, mirror therapy, interventions for sensory impairment, virtual reality and a relatively high dose of repetitive task practice, suggesting that these may be effective interventions; moderate-quality evidence also indicated that unilateral arm training may be more effective than bilateral arm training. Information was insufficient to reveal the relative effectiveness of different interventions.Moderate-quality evidence from subgroup analyses comparing greater and lesser doses of mental practice, repetitive task training and virtual reality demonstrates a beneficial effect for the group given the greater dose, although not for the group given the smaller dose; however tests for subgroup differences do not suggest a statistically significant difference between these groups. Future research related to dose is essential.Specific recommendations for future research are derived from current evidence. These recommendations include but are not limited to adequately powered, high-quality RCTs to confirm the benefit of CIMT, mental practice, mirror therapy, virtual reality and a relatively high dose of repetitive task practice; high-quality RCTs to explore the effects of repetitive transcranial magnetic stimulation (rTMS), tDCS, hands-on therapy, music therapy, pharmacological interventions and interventions for sensory impairment; and up-to-date reviews related to biofeedback, Bobath therapy, electrical stimulation, reach-to-grasp exercise, repetitive task training, strength training and stretching and positioning.

AUTHORS' CONCLUSIONS

Large numbers of overlapping reviews related to interventions to improve upper limb function following stroke have been identified, and this overview serves to signpost clinicians and policy makers toward relevant systematic reviews to support clinical decisions, providing one accessible, comprehensive document, which should support clinicians and policy makers in clinical decision making for stroke rehabilitation.Currently, no high-quality evidence can be found for any interventions that are currently used as part of routine practice, and evidence is insufficient to enable comparison of the relative effectiveness of interventions. Effective collaboration is urgently needed to support large, robust RCTs of interventions currently used routinely within clinical practice. Evidence related to dose of interventions is particularly needed, as this information has widespread clinical and research implications.

What is the evidence for physical therapy poststroke? A systematic review and meta-analysis

BACKGROUND

Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT.

METHODS AND FINDINGS

Randomized controlled trials (RCTs) regarding PT in stroke rehabilitation were retrieved through a systematic search. Outcomes were classified according to the ICF. RCTs with a low risk of bias were quantitatively analyzed. Differences between phases poststroke were explored in subgroup analyses. A best evidence synthesis was performed for neurological treatment approaches. The search yielded 467 RCTs (N = 25373; median PEDro score 6 [IQR 5-7]), identifying 53 interventions. No adverse events were reported. Strong evidence was found for significant positive effects of 13 interventions related to gait, 11 interventions related to arm-hand activities, 1 intervention for ADL, and 3 interventions for physical fitness. Summary Effect Sizes (SESs) ranged from 0.17 (95%CI 0.03-0.70; I(2) = 0%) for therapeutic positioning of the paretic arm to 2.47 (95%CI 0.84-4.11; I(2) = 77%) for training of sitting balance. There is strong evidence that a higher dose of practice is better, with SESs ranging from 0.21 (95%CI 0.02-0.39; I(2) = 6%) for motor function of the paretic arm to 0.61 (95%CI 0.41-0.82; I(2) = 41%) for muscle strength of the paretic leg. Subgroup analyses yielded significant differences with respect to timing poststroke for 10 interventions. Neurological treatment approaches to training of body functions and activities showed equal or unfavorable effects when compared to other training interventions. Main limitations of the present review are not using individual patient data for meta-analyses and absence of correction for multiple testing.

CONCLUSIONS

There is strong evidence for PT interventions favoring intensive high repetitive task-oriented and task-specific training in all phases poststroke. Effects are mostly restricted to the actually trained functions and activities. Suggestions for prioritizing PT stroke research are given.

Towards the integration of mental practice in rehabilitation programs. A critical review

Many clinical studies have investigated the use of mental practice (MP) through motor imagery (MI) to enhance functional recovery of patients with diverse physical disabilities. Although beneficial effects have been generally reported for training motor functions in persons with chronic stroke (e.g., reaching, writing, walking), attempts to integrate MP within rehabilitation programs have been met with mitigated results. These findings have stirred further questioning about the value of MP in neurological rehabilitation. In fact, despite abundant systematic reviews, which customarily focused on the methodological merits of selected studies, several questions about factors underlying observed effects remain to be addressed. This review discusses these issues in an attempt to identify factors likely to hamper the integration of MP within rehabilitation programs. First, the rationale underlying the use of MP for training motor function is briefly reviewed. Second, three modes of MI delivery are proposed based on the analysis of the research protocols from 27 studies in persons with stroke and Parkinson's disease. Third, for each mode of MI delivery, a general description of MI training is provided. Fourth, the review discusses factors influencing MI training outcomes such as: the adherence to MI training, the amount of training and the interaction between physical and mental rehearsal; the use of relaxation, the selection of reliable, valid and sensitive outcome measures, the heterogeneity of the patient groups, the selection of patients and the mental rehearsal procedures. To conclude, the review proposes a framework for integrating MP in rehabilitation programs and suggests research targets for steering the implementation of MP in the early stages of the rehabilitation process. The challenge has now shifted towards the demonstration that MI training can enhance the effects of regular therapy in persons with subacute stroke during the period of spontaneous recovery.

A standardized motor imagery introduction program (MIIP) for neuro-rehabilitation: development and evaluation

Background: For patients with central nervous system (CNS) lesions and sensorimotor impairments a solid motor imagery (MI) introduction is crucial to understand and use MI to improve motor performance. The study's aim was to develop and evaluate a standardized MI group introduction program (MIIP) for patients after stroke, multiple sclerosis (MS), Parkinson's disease (PD), and traumatic brain injury (TBI).

Methods: Phase 1: Based on literature a MIIP was developed comprising MI theory (definition, type, mode, perspective, planning) and MI practice (performance, control). Phase 2: Development of a 27-item self-administered MIIP evaluation questionnaire, assessing MI knowledge self-evaluation of the ability to perform MI and patient satisfaction with the MIIP. Phase 3: Evaluation of MIIP and MI questionnaire by 2 independent MI experts based on predefined criteria and 2 patients using semi-structured interviews. Phase 4: Case series with a pre-post design to evaluate MIIP (3 × 30 min) using the MI questionnaire, Imaprax, Kinaesthetic and Visual Imagery Questionnaire, and Mental Chronometry. The paired t-test and the Wilcoxon signed-rank test were used to determine significant changes.

Results: Data of eleven patients were analysed (5 females; age 62.3 ± 14.1 years). Declarative MI knowledge improved significantly from 5.4 ± 2.2 to 8.8 ± 2.9 (p = 0.010). Patients demonstrated good satisfaction with MIIP (mean satisfaction score: 83.2 ± 11.4%). MI ability remained on a high level but showed no significant change, except a significant decrease in the Kinaesthetic and Visual Imagery Questionnaire score.

Conclusion: The presented MIIP seems to be valid and feasible for patients with CNS lesions and sensorimotor impairments resulting in improved MI knowledge. MIIP sessions can be held in groups of four or less. MI ability and Mental Chronometry remained unchanged after 3 training sessions.

Mental practice promotes motor anticipation: evidence from skilled music performance

Mental practice (MP) has been shown to improve movement accuracy and velocity, but it is not known whether MP can also optimize movement timing. We addressed this question by studying two groups of expert pianists who performed challenging music sequences after either MP or physical practice (PP). Performance and motion-capture data were collected along with responses to imagery questionnaires. The results showed that MP produced performance improvements, although to a lower degree than PP did. MP and PP induced changes in both movement velocity and movement timing, promoting the emergence of movement anticipatory patterns. Furthermore, motor imagery was associated with greater changes in movement velocity, while auditory imagery was associated with greater movement anticipation. Data from a control group that was not allowed to practice confirmed that the changes in accuracy and kinematics were not due to mere repetition of the sequence during testing. This study provides the first evidence of an anticipatory control following MP and extends the present knowledge on the effectiveness of MP to a task of unparalleled motor complexity. The practical implications of MP in the motor domain are discussed.

The effects of mental practice in neurological rehabilitation; a systematic review and meta-analysis

Objective: To investigate the beneficial and adverse effects of a mental practice intervention on activities, cognition, and emotion in patients after stroke, patients with Parkinson's disease or multiple sclerosis.

Methods: Electronic databases PubMed/Medline, PEDro, Science Direct, Cochrane Library, PsycINFO, Rehadat, Embase, and Picarta were searched until June 2012. Fourteen randomized controlled trials in stroke and two randomized controlled trials in Parkinson's disease were included, representing 491 patients (421 with stroke). No randomized controlled trials in multiple sclerosis were identified. The methodologic quality of the included trials was assessed with the Amsterdam-Maastricht-Consensus-List (AMCL). Information on study characteristics and outcomes was summarized and evidence for effects described. Data from individual studies in stroke with same outcome measures were pooled.

Results: The included 16 randomized controlled trials were heterogeneous and methodologic quality varied. Ten trials reported significant effects in favor of mental practice in patients with stroke (n = 9) and Parkinson's disease (n = 1). In six studies mental practice had similar effects as therapy as usual (n = 5 in stroke and n = 1 in Parkinson's disease). Of six performed meta-analyses with identical measures in stroke studies only two showed significant effects of mental practice: short-term improvement of arm-hand-ability (ARAT: SMD 0.62; 95% CI: 0.05 to 1.19) and improvement of performance of activities (NRS: SMD 0.9; 95% CI: 0.04 to 1.77). Five studies found effects on cognition (e.g., effects on attention, plan actions in unfamiliar surroundings) and four reported observed side-effects, both positive (e.g., might increase motivation and arousal and reduce depression) and negative (e.g., diminished concentration, irritation).

Conclusions: Mental practice might have positive effects on performance of activities in patients with neurological diseases, but this review reports less positive results than earlier published ones. Strengths and limitations of past studies are pointed out. Methodologic recommendations for future studies are given.

Noninvasive strategies to promote functional recovery after stroke

Stroke is a common and disabling global health-care problem, which is the third most common cause of death and one of the main causes of acquired adult disability in many countries. Rehabilitation interventions are a major component of patient care. In the last few years, brain stimulation, mirror therapy, action observation, or mental practice with motor imagery has emerged as interesting options as add-on interventions to standard physical therapies. The neural bases for poststroke recovery rely on the concept of plasticity, namely, the ability of central nervous system cells to modify their structure and function in response to external stimuli. In this review, we will discuss recent noninvasive strategies employed to enhance functional recovery in stroke patients and we will provide an overview of neural plastic events associated with rehabilitation in preclinical models of stroke.

Strategies to augment recovery after stroke

OPINION STATEMENT

The improvement of recovery after stroke remains one of the main priorities for patients with stroke. Acute de-occlusion of the artery should improve patient outcome and recovery. Recent data and meta-analysis confirmed the efficacy of IV thrombolysis when administered to selected patients less than 4.5 hours after the onset of ischemic stroke even in patients aged > 80 years. IV thrombolysis with rTPA is currently the only validated treatment for the acute phase of ischemic stroke. This has lead to a major public health effort to create stroke treatment units in developed countries. Mechanical thrombectomy is not yet validated despite major support from clinicians and the industry overall. Many other treatment options are currently being tested in various other therapeutic areas. Some data show clearly that some of these options are now close to clinical significance: specific and adapted rehabilitation procedures that will include a rationale in patients' care management, use of monoaminergic drugs like SSRIs with improvement of motor recovery through a specific action on cortical excitability, cortical stimulation or inhibition with magnetic or electric techniques with the aim of modifying functional inter cortical balance and connections, and clinical and bio markers of recovery that would help to ensure appropriate individual care of each patient. Finally, repair therapies with the aim of restoring the brain-damaged networks could be useful in patients with persistent severe deficits. Several classes are under study for brain repair, including the use of stem cells, growth factors, and small molecules, but these are still at a preclinical level of development.

Home-based therapy programmes for upper limb functional recovery following stroke

BACKGROUND

With an increased focus on home-based stroke services and the undertaking of programmes, targeted at upper limb recovery within clinical practice, a systematic review of home-based therapy programmes for individuals with upper limb impairment following stroke was required.

OBJECTIVES

To determine the effects of home-based therapy programmes for upper limb recovery in patients with upper limb impairment following stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group's Specialised Trials Register (May 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), MEDLINE (1950 to May 2011), EMBASE (1980 to May 2011), AMED (1985 to May 2011) and six additional databases. We also searched reference lists and trials registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in adults after stroke, where the intervention was a home-based therapy programme targeted at the upper limb, compared with placebo, or no intervention or usual care. PRIMARY OUTCOMES were performance in activities of daily living (ADL) and functional movement of the upper limb. SECONDARY OUTCOMES were performance in extended ADL and motor impairment of the arm.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts, extracted data and appraised trials. We undertook assessment of risk of bias in terms of method of randomisation and allocation concealment (selection bias), blinding of outcome assessment (detection bias), whether all the randomised patients were accounted for in the analysis (attrition bias) and the presence of selective outcome reporting.

MAIN RESULTS

We included four studies with 166 participants. No studies compared the effects of home-based upper limb therapy programmes with placebo or no intervention. Three studies compared the effects of home-based upper limb therapy programmes with usual care.

PRIMARY OUTCOMES

we found no statistically significant result for performance of ADL (mean difference (MD) 2.85; 95% confidence interval (CI) -1.43 to 7.14) or functional movement of the upper limb (MD 2.25; 95% CI -0.24 to 4.73)).

SECONDARY OUTCOMES

no statistically significant results for extended ADL (MD 0.83; 95% CI -0.51 to 2.17)) or upper limb motor impairment (MD 1.46; 95% CI -0.58 to 3.51). One study compared the effects of a home-based upper limb programme with the same upper limb programme based in hospital, measuring upper limb motor impairment only; we found no statistically significant difference between groups (MD 0.60; 95% CI -8.94 to 10.14).

AUTHORS' CONCLUSIONS

There is insufficient good quality evidence to make recommendations about the relative effect of home-based therapy programmes compared with placebo, no intervention or usual care.

Could motor imagery be effective in upper limb rehabilitation of individuals with spinal cord injury? A case study

STUDY DESIGN

A case study.

OBJECTIVE

The aim was to investigate whether motor imagery (MI) could be successfully incorporated into conventional therapy among individuals with spinal cord injury (SCI) to improve upper limb (UL) function.

SETTING

The Physical Medicine and Rehabilitation Unit at the Henry Gabrielle Hospital in Lyon, France.

METHODS

The participant was an individual with a complete C6 SCI. MI content was focused on functional UL movements, to improve hand transport to reach out and grasp with tenodesis. The participant was tested before and after 15 MI training sessions (45 min each, three times a week during 5 consecutive weeks). MI ability and program compliance were used as indicators of feasibility. The Minnesota and Box and Blocks tests, as well as movement time and hand trajectory during targeted movements were the dependent variables, evaluating motor performance before and after MI training.

RESULTS

The participant's ability to generate MI was checked and compliance with the rehabilitation program was confirmed. The time needed to complete the Minnesota test decreased by 1 min 25 s. The Box and Blocks score was improved by three units after MI program. Decreased movement time and enhanced hand trajectory smoothness were still observed 3 months later, despite a slight decrease in performance.

CONCLUSIONS

This study supports the feasibility for introducing MI in conventional therapy. Further studies should confirm the potential role of MI in motor recovery with a larger sample.

Multisensory stimulation in stroke rehabilitation

The brain has a large capacity for automatic simultaneous processing and integration of sensory information. Combining information from different sensory modalities facilitates our ability to detect, discriminate, and recognize sensory stimuli, and learning is often optimal in a multisensory environment. Currently used multisensory stimulation methods in stroke rehabilitation include motor imagery, action observation, training with a mirror or in a virtual environment, and various kinds of music therapy. Non-invasive brain stimulation has showed promising preliminary results in aphasia and neglect. Patient heterogeneity and the interaction of age, gender, genes, and environment are discussed. Randomized controlled longitudinal trials starting earlier post-stroke are needed. The advance in brain network science and neuroimaging enabling longitudinal studies of structural and functional networks are likely to have an important impact on patient selection for specific interventions in future stroke rehabilitation. It is proposed that we should pay more attention to age, gender, and laterality in clinical studies.

Plasticity of adult sensorimotor system in severe brain infarcts: challenges and opportunities

Functional reorganization forms the critical mechanism for the recovery of function after brain damage. These processes are driven by inherent changes within the central nervous system (CNS) triggered by the insult and further depend on the neural input the recovering system is processing. Therefore these processes interact with not only the interventions a patient receives, but also the activities and behaviors a patient engages in. In recent years, a wide range of research programs has addressed the association between functional reorganization and the spontaneous and treatment-induced recovery. The bulk of this work has focused on upper-limb and hand function, and today there are new treatments available that capitalize on the neuroplasticity of the brain. However, this is only true for patients with mild to moderated impairments; for those with very limited hand function, the basic understanding is much poorer and directly translates into limited treatment opportunities for these patients. The present paper aims to highlight the knowledge gap on severe stroke with a brief summary of the literature followed by a discussion of the challenges involved in the study and treatment of severe stroke and poor long-term outcome.