Measurement of Upper-Extremity Function Early After Stroke: Properties of the Action Research Arm Test

Modification of the toronto rehabilitation institute-hand function test for integration into robot-assisted therapy: technical validation and usability

BACKGROUND

Effective rehabilitation of the upper extremity function is vital for individuals recovering from stroke or cervical spinal cord injury, as it can enable them to regain independence in daily tasks. While robotic therapy provides precise and consistent motor training, it often lacks the integration of real-world objects that stimulate sensorimotor experiences. The Toronto Rehabilitation Institute-Hand Function Test (TRI-HFT) utilizes 19 everyday items to assess hand function. This study aims to modify the 3D-printed TRI-HFT objects to ensure their compatibility with robotic manipulation, thereby enhancing the functional relevance of robot-assisted rehabilitation, and to evaluate the usability of the new robotic system to ensure its safety and technical performance.

RESULTS

We successfully redesigned the 3D-TRI-HFT objects to enable manipulation by a robotic arm equipped with a gripper. The modified 3D-printed objects closely matched the original specifications, with most weight and size deviations within acceptable limits. Performance tests demonstrated reliable robotic manipulation, achieving a 100% success rate in 50 pick-and-place trials for each object without any breakage or slippage. Usability assessments further supported the system's performance, indicating that participants found the system engaging, useful, and comfortable.

CONCLUSIONS

The modified 3D-printed TRI-HFT objects allow seamless integration into robotic therapy, facilitating the use of real-world objects in rehabilitation exercises. These modifications enhance functional engagement without compromising user interaction with the objects, demonstrating the feasibility of combining traditional rehabilitation tools with robotic systems, potentially leading to improved outcomes in upper extremity rehabilitation. Future research may focus on adapting these designs for compatibility with a broader range of robotic equipment, reducing the cost of the objects as 3D printing technology advances, and evaluating the system's performance among individuals with stroke and SCI.

Association Between Real-World Actigraphy and Poststroke Motor Recovery

BACKGROUND

Stroke is a leading cause of long-term disability, but advances for rehabilitation have lagged those for acute treatment. Large biological studies (eg, omics) may offer mechanistic insights for recovery but require collecting detailed recovery phenotypes at scale, for example, in thousands of people with minimal burden for participants and researchers. This study investigates the concurrent validity between remotely collected wearable sensor data and in-clinic assessments of motor recovery poststroke.

METHODS

Utilizing a large, harmonized multisite dataset of adults at various stages of recovery poststroke, we analyzed cross-sectional (N=198; from 0 to >52 weeks) and longitudinal (N=98; from 0 to 26 weeks) changes in the use ratio, the Action Research Arm Test, and the Fugl-Meyer Assessment upper extremity subscale. The use ratio is the ratio of the time the paretic arm is active divided by the time the nonparetic arm is active.

RESULTS

Our findings indicate strong concurrent validity of the use ratio, the Action Research Arm Test, and the Fugl-Meyer Assessment upper extremity subscale both cross-sectionally (differences between people) and longitudinally (changes within a person), for example, r=0.87 (95% CI, 0.80-0.91) at 0 to 6 weeks, declining to r=0.58 (95% CI, 0.39-0.72) at ≥52 weeks for correlations between use ratio and Action Research Arm Test.

CONCLUSIONS

Although the use ratio strongly correlated with the Fugl-Meyer Assessment upper extremity subscale and Action Research Arm Test early after stroke, these correlations reduced with longer elapsed time poststroke. This decreasing correlation might be explained by the increasing influence that personal and environmental factors play as recovery progresses.

Closed-loop rehabilitation of upper-limb dyskinesia after stroke: from natural motion to neuronal microfluidics

This review proposes an innovative closed-loop rehabilitation strategy that integrates multiple subdomains of stroke science to address the global challenge of upper-limb dyskinesia post-stroke. Despite advancements in neural remodeling and rehabilitation research, the compartmentalization of subdomains has limited the effectiveness of current rehabilitation strategies. Our approach unites key areas-including the post-stroke brain, upper-limb rehabilitation robotics, motion sensing, metrics, neural microfluidics, and neuroelectronics-into a cohesive framework designed to enhance upper-limb motion rehabilitation outcomes. By leveraging cutting-edge technologies such as lightweight rehabilitation robotics, advanced motion sensing, and neural microfluidic models, this strategy enables real-time monitoring, adaptive interventions, and personalized rehabilitation plans. Furthermore, we explore the potential of closed-loop systems to drive neural plasticity and functional recovery, offering a transformative perspective on stroke rehabilitation. Finally, we discuss future directions, emphasizing the integration of emerging technologies and interdisciplinary collaboration to advance the field. This review highlights the promise of closed-loop strategies in achieving unprecedented integration of subdomains and improving post-stroke upper-limb rehabilitation outcomes.

Can motion capture improve task-based fMRI studies of motor function post-stroke? A systematic review

BACKGROUND

Variability in motor recovery after stroke represents a major challenge in its understanding and management. While functional MRI has been used to unravel interactions between stroke motor function and clinical outcome, fMRI alone cannot clarify any relation between brain activation and movement characteristics.

OBJECTIVES

We aimed to identify fMRI and kinematic coupling approaches and to evaluate their potential contribution to the understanding of motor function post-stroke.

METHOD

A systematic literature review was performed according to PRISMA guidelines on studies using fMRI and kinematics in post-stroke individuals. We assessed the internal, external, statistical, and technological validity of each study. Data extraction included study design and analysis procedures used to couple brain activity with movement characteristics.

RESULTS

Of the 404 studies found, 23 were included in the final review. The overall study quality was moderate (0.6/1). Thirteen studies used kinematic information either parallel to the fMRI results, or as a real-time input to external devices, for instance to provide feedback to the patient. Ten studies performed a statistical analysis between movement and brain activity by either using kinematics as variables during group or individual level regression or correlation. This permitted establishing links between movement characteristics and brain activity, unraveling cortico-kinematic relationships. For instance, increased activity in the ipsilesional Premotor Cortex was related to less smooth movements, whereas trunk compensation was expressed by increased activity in the contralesional Primary Motor Cortex.

CONCLUSION

Our review suggests that the coupling of fMRI and kinematics may provide valuable insight into cortico-kinematic relationships. The optimization and standardization of both data measurement and treatment procedures may help the field to move forward and to fully use the potential of multimodal cortico-kinematic integration to unravel the complexity of post-stroke motor function and recovery.

Barriers and Facilitators of Implementing Arabic-Validated Standardised Outcome Measures for Chronic Stroke Rehabilitation Among Physical Therapists

BACKGROUND

Implementing standardised outcome measures (SOMs) in stroke rehabilitation practices enhances patient care, communication, and overall clinical effectiveness. However, the implementation of Arabic-validated SOMs in stroke rehabilitation practices among Arabic-speaking patients has not been fully explored.

AIMS

To examine the use, facilitators, and barriers of implementing Arabic-validated SOMs for chronic stroke rehabilitation among physical therapists.

METHODS

A cross-sectional survey was conducted among 262 physical therapists managing patients with chronic stroke. The survey evaluated the use, facilitators, and barriers to implementing Arabic-validated SOMs. Descriptive statistics summarised demographic and professional characteristics, while multivariate logistic regression identified independent predictors of SOM use, with adjusted odds ratios and 95% confidence intervals calculated.

RESULTS

The use of Arabic-validated SOMs in chronic stroke rehabilitation was reported by 54% of therapists within the first week of physical therapy services and 64% at discharge. The Berg Balance Scale and the Timed Up and Go test were the two most commonly employed scales. Facilitators for implementing SOMs included facilitating adherence to clinical practice guidelines, providing valuable patient insights, and supporting balanced assessments. Barriers included time constraints, financial limitations, and time demands on both patients and therapists. Familiarity with clinical practice guidelines was significantly associated with increased use of Arabic-validated SOMs.

CONCLUSIONS

Implementing Arabic-validated SOMs is essential to ensure culturally appropriate and linguistically accurate evaluations that support evidence-based decision-making and enhance patient management in stroke rehabilitation among Arabic-speaking patients. Enhancing familiarity with clinical practice guidelines and addressing barriers such as time constraints and financial challenges can further promote the implementation of Arabic-validated SOMs into routine practice, ultimately improving patient outcomes.

Construct validity and responsiveness of clinical upper limb measures and sensor-based arm use within the first year after stroke: a longitudinal cohort study

BACKGROUND

Construct validity and responsiveness of upper limb outcome measures are essential to interpret motor recovery poststroke. Evaluating the associations between clinical upper limb measures and sensor-based arm use (AU) fosters a coherent understanding of motor recovery. Defining sensor-based AU metrics for intentional upper limb movements could be crucial in mitigating bias from walking-related activities. Here, we investigate the measurement properties of a comprehensive set of clinical measures and sensor-based AU metrics when gait and non-functional upper limb movements are excluded.

METHODS

In this prospective, longitudinal cohort study, individuals with motor impairment were measured at days 3 ± 2 (D3), 10 ± 2 (D10), 28 ± 4 (D28), 90 ± 7 (D90), and 365 ± 14 (D365) after their first stroke. Using clinical measures, upper limb motor function (Fugl-Meyer Assessment), capacity (Action Research Arm Test, Box & Block Test), and perceived performance (14-item Motor Activity Log) were assessed. Additionally, individuals wore five movement sensors (trunk, wrists, and ankles) for three days. Thirteen AU metrics were computed based on functional movements during non-walking periods. Construct validity across clinical measures and AU metrics was determined by Spearman's rank correlations for each time point. Criterion responsiveness was examined by correlating patient-reported Global Rating of Perceived Change (GRPC) scores and observed change in upper limb measures and AU metrics. Optimal cut-off values for minimal important change (MIC) were estimated by ROC curve analysis.

RESULTS

Ninety-three individuals participated. At D3 and D10, correlations between clinical measures and AU metrics showed variability (range rs: 0.44-0.90). All following time points showed moderate-to-high positive correlations between clinical measures and affected AU metrics (range rs: 0.57-0.88). Unilateral nonaffected AU duration was negatively correlated with clinical measures (range rs: -0.48 to -0.77). Responsiveness across outcomes was highest between D10-D28 within moderate to strong relations between GRPC and clinical measures (rs: range 0.60-0.73), whereas relations were weaker for AU metrics (range rs: 0.28-0.43) Eight MIC values were estimated for clinical measures and nine for AU metrics, showing moderate to good accuracy (66-87%).

CONCLUSIONS

We present reference data on the construct validity and responsiveness of clinical upper limb measures and specified sensor-based AU metrics within the first year after stroke. The MIC values can be used as a benchmark for clinical stroke rehabilitation.

TRIAL REGISTRATION

This trial was registered on clinicaltrials.gov; registration number NCT03522519.

Rehabilitation using virtual gaming for Hospital and hOMe-Based training for the Upper limb in acute and subacute Stroke (RHOMBUS II): results of a feasibility randomised controlled trial

OBJECTIVE

To investigate the safety, feasibility and acceptability of the Neurofenix platform for upper-limb rehabilitation in acute and subacute stroke.

DESIGN

A feasibility randomised controlled trial with a parallel process evaluation.

SETTING

Acute Stroke Unit and participants' homes (London, UK).

PARTICIPANTS

24 adults (>18 years), acute and subacute poststroke, new unilateral weakness, scoring 9-25 on the Motricity Index (elbow and shoulder), with sufficient cognitive and communicative abilities to participate.

INTERVENTIONS

Participants randomised to the intervention or control group on a 2:1 ratio. The intervention group (n=16) received usual care plus the Neurofenix platform for 7 weeks. The control group (n=8) received usual care only.

OUTCOMES

Safety was assessed through adverse events (AEs), pain, spasticity and fatigue. Feasibility was assessed through training and support requirements and intervention fidelity. Acceptability was assessed through a satisfaction questionnaire. Impairment, activity and participation outcomes were also collected at baseline and 7 weeks to assess their suitability for use in a definitive trial.

RANDOMISATION

Computer-generated, allocation sequence concealed by opaque, sealed envelopes.

BLINDING

Participants and assessors were not blinded; statistician blinded for data processing and analysis.

RESULTS

192 stroke survivors were screened for eligibility, and 24 were recruited and randomised. Intervention group: n=16, mean age 66.5 years; median 9.5 days post stroke.

CONTROL GROUP

n=8, mean age 64.6 years; median 17.5 days post stroke. Three participants withdrew before the 7-week assessment, n=21 included in the analysis (intervention group n=15; control group n=6). No significant group differences in fatigue, spasticity, pain scores or total number of AEs. The median (IQR) time to train participants was 98 (64) min over 1-3 sessions. Participants trained with the platform for a median (range) of 11 (1-58) hours, equating to 94 min extra per week. The mean satisfaction score was 34.9 out of 40.

CONCLUSION

The Neurofenix platform is safe, feasible and well accepted as an adjunct to usual care in acute and subacute stroke rehabilitation. There was a wide range of engagement with the platform in a cohort of stroke survivors which was varied in age and level of impairment. Recruitment, training and support were manageable and completion of data was good, indicating that a future randomised controlled trial would be feasible.

TRIAL REGISTRATION NUMBER

ISRCTN11440079.

The association between dexterity and upper limb impairment during stroke recovery

Introduction

Stroke-induced upper limb disabilities can be characterized by both motor impairments and activity limitations, commonly assessed using Fugl-Meyer Motor Assessment for Upper Extremity (FMMA-UE) and Action Research Arm Test (ARAT), respectively. The relationship between the two assessments during recovery is largely unstudied. Expectedly they diverge over time when recovery of impairment (restitution) plateaus, but compensation-driven improvements still occur. The objective of this study is to evaluate the alignment between FMMA-UE and ARAT in defining upper limb functional recovery categories by ARAT scores. We aimed to establish cut-off scores for both measures from the acute/early subacute, subacute and chronic stages of stroke recovery.

Methods

Secondary analysis of four prospective cohort studies (acute/early subacute: n = 133, subacute: n = 113, chronic: n = 92) stages post-stroke. Receiver operating characteristic curves calculated the area under the curve (AUC) to establish optimal FMMA-UE cut-offs based on predefined ARAT thresholds distinguishing five activity levels from no activity to full activity. Weighted kappa was used to determine agreement between the two assessments. We used minimally clinically important difference (MCID) and minimal detectable change (MDC95) for comparison.

Results

FMMA-UE and ARAT scores showed no relevant divergence across all recovery stages. Results indicated similar cut-off scores in all recovery stages with variability below MCID and MDC95 levels. Cut-off scores demonstrated robust AUC values from 0.77 to 0.86 at every recovery stage. Only in highly functional patients at the chronic stage, we found a reduced specificity of 0.55. At all other times sensitivity ranged between 0.68 and 0.99 and specificity between 0.71 and 0.99. Weighted kappa at the acute/early subacute, subacute and chronic stages was 0.76, 0.83, and 0.81, respectively.

Discussion

Our research shows a strong alignment between FMMA-UE and ARAT cut-off scores throughout stroke recovery, except among the subgroup of highly recovered patients at the chronic stage. Discrepancies in specificity potentially stem from fine motor deficits affecting dexterity outcomes that are not captured by FMMA-UE. Additionally, the high congruence of both measures suggests they are not suited to distinguish between restitution and compensation. Calling for more comprehensive assessment methods to better understand upper limb functionality in rehabilitation.

Efficacy of personalized rTMS to enhance upper limb function in subacute stroke patients: a protocol for a multi-center, randomized controlled study

Background

Repetitive transcranial magnetic stimulation (rTMS) is widely used therapy to enhance motor deficit in stroke patients. To date, rTMS protocols used in stroke patients are relatively unified. However, as the pathophysiology of stroke is diverse and individual functional deficits are distinctive, more precise application of rTMS is warranted. Therefore, the objective of this study was to determine the effects of personalized protocols of rTMS therapy based on the functional reserve of each stroke patient in subacute phase.

Methods

This study will recruit 120 patients with stroke in subacute phase suffering from the upper extremity motor impairment, from five different hospitals in Korea. The participants will be allocated into three different study conditions based on the functional reserve of each participant, measured by the results of TMS-induced motor evoked potentials (MEPs), and brain MRI with diffusion tensor imaging (DTI) evaluations. The participants of the intervention-group in the three study conditions will receive different protocols of rTMS intervention, a total of 10 sessions for 2 weeks: high-frequency rTMS on ipsilesional primary motor cortex (M1), high-frequency rTMS on ipsilesional ventral premotor cortex, and high-frequency rTMS on contralesional M1. The participants of the control-group in all three study conditions will receive the same rTMS protocol: low-frequency rTMS on contralesional M1. For outcome measures, the following assessments will be performed at baseline (T0), during-intervention (T1), post-intervention (T2), and follow-up (T3) periods: Fugl-Meyer Assessment (FMA), Box-and-block test, Action Research Arm Test, Jebsen-Taylor hand function test, hand grip strength, Functional Ambulatory Category, fractional anisotropy measured by the DTI, and brain network connectivity obtained from MRI. The primary outcome will be the difference of upper limb function, as measured by FMA from T0 to T2. The secondary outcomes will be the differences of other assessments.

Discussion

This study will determine the effects of applying different protocols of rTMS therapy based on the functional reserve of each patient. In addition, this methodology may prove to be more efficient than conventional rTMS protocols. Therefore, effective personalized application of rTMS to stroke patients can be achieved based on their severity, predicted mechanism of motor recovery, or functional reserves.

Clinical trial registration

https://clinicaltrials.gov/, identifier NCT06270238.

Effect of Graded Motor Imagery Combined With Repetitive Transcranial Magnetic Stimulation on Upper Extremity Motor Function in Stroke Patients: A Randomized Controlled Trial

OBJECTIVE

To investigate the efficacy of graded motor imagery therapy (GMI) and repetitive transcranial magnetic stimulation (rTMS) on upper extremity function alone and in combination in patients with stroke.

DESIGN

This was a prospective randomized controlled trial.

SETTING

A rehabilitation hospital.

PARTICIPANTS

Participants (N=56) were randomized into GMI (n=19), rTMS (n=18), or combined groups (n=19).

INTERVENTIONS

There were 2 interventions: (1) 20 minutes of 1 Hz rTMS. (2) 30 minutes of GMI. In addition to this, all participants receive conventional rehabilitation including 120 minutes of physical therapy and occupational therapy daily. All treatments were administered once a day, 5 days a week, for 4 weeks. The Fugl-Meyer assessment of upper extremity (FMA-UE), Action Research Arm Test (ARAT), modified Barthel Index (MBI), motor activity log (MAL), and motor evoked potential (MEP) were assessed in a blinded manner at baseline and 4 weeks after treatment, respectively.

MAIN OUTCOME MEASURES

The primary endpoint was the improvement from baseline in FMA-UE for stroke patients at 4 weeks.

RESULTS

After 4 weeks of treatment, the FMA-UE scores in the GMI, rTMS, and combined groups were higher than those at baseline assessment, with statistically significant differences among the 3 groups (P=.009). The efficacy of the combined group was significantly better than that of the GMI and rTMS groups (P=.015, P=.043, respectively). In the motor activity log-amount of use (MAL-AOU) score, the efficacy of the combined group was better than that of the rTMS group (P=.035).

CONCLUSIONS

Both GMI and rTMS were effective in improving upper extremity function in patients with stroke, but the combination of the 2 techniques was more effective. However, GMI was better than rTMS in improving the interest of stroke patients in active training.

The Utilization of Forced-Rate Cycling to Facilitate Motor Recovery Following Stroke: A Randomized Clinical Trial

BACKGROUND

The potential for aerobic exercise (AE) to enhance neuroplasticity post-stroke has been theorized but not systematically investigated. Our aim was to determine the effects of forced-rate AE (FE) paired with upper extremity (UE) repetitive task practice (FE + RTP) compared to time-matched UE RTP (RTP only) on motor recovery.

METHODS

A single center randomized clinical trial was conducted from April 2019 to December 2022. Sixty individuals ≥6 months post-stroke with UE hemiparesis were randomized to FE + RTP (N = 30) or RTP only (N = 30), completing 90-minute sessions, 3×/week for 8 weeks. The FE + RTP group underwent 45-minute of FE (5-minute warm-up, 35-minute main set, and 5-minute cool down) followed by 45-minute of UE RTP. The RTP only group completed 90-minute of RTP. Primary outcomes were the Fugl-Meyer Assessment (FMA) and Action Research Arm Test (ARAT). The 6-minute Walk Test (6MWT, secondary outcome) assessed walking capacity.

RESULTS

Sixty individuals enrolled and 56 completed the study. The RTP only group completed more RTP in terms of repetitions (411.8 ± 44.4 vs 222.8 ± 28.4, P < .001) and time (72.7 ± 6.7 vs 37.8 ± 2.4 minutes, P < .001) versus FE + RTP. There was no significant difference between groups on the FMA (FE + RTP, 36.2 ± 10.1-44.0 ± 11.8 and RTP only, 34.4 ± 11.0-41.2 ± 13.4, P = .43) or ARAT (FE + RTP, 32.5 ± 16.6-37.7 ± 17.9 and RTP only, 32.8 ± 18.6-36.4 ± 18.5, P = .88). The FE + RTP group demonstrated greater improvements on the 6MWT (274.9 ± 122.0-327.1 ± 141.2 m) versus RTP only (285.5 ± 160.3-316.9 ± 170.0, P = .003).

CONCLUSIONS

There was no significant difference between groups in the primary outcomes. The FE + RTP improved more on the 6MWT, a secondary outcome.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03819764.

Correlation between kinetic and kinematic measures, clinical tests and subjective self-evaluation questionnaires of the affected upper limb in people after stroke

Introduction

Assessment of stroke recovery should include multiple sources of information in order to obtain a complete understanding of the individual's rehabilitation progress. Self-evaluation questionnaires' scores do not always correspond to the scores of commonly used clinical evaluation tools. The purpose of this study was to assess the relationship between self-evaluation questionnaires, clinical tests, and kinematic and kinetic analyses of the affected upper limb after stroke, and to determine the correlation between these measures and self-reported general function 2-4 years after the stroke.

Methods

Twenty-six subjects recovering from stroke were included in the study. Spearman's correlation coefficient was used to measure the correlation between Stroke Impact Scale (SIS), Motor activity Log (MAL), Fugl-Meyer Assessment (FMA) and Action Reach Arm Test (ARAT) scores, and kinematic and kinetic analyses. A logistic regression was used to assess the extent to which these measures may predict the participants' functional self-reported status 2-4 years post stroke.

Results

Sections regarding hand function, hand force and general ADL of the self-evaluation questionnaires correlated with kinematic variables. However, only questionnaires that focus on hand function correlated with clinical tests. Mean and maximal hand velocity had the strongest correlations with self-evaluation questionnaires and with the clinical tests, more than other kinematic variables. Self-evaluation questionnaires and clinical tests were found to be correlated with hand kinetic metrics force-to-time ratio and number of force peaks. SIS hand force domain, mean velocity and maximal velocity predicted self-reported general function 2-4 years after the stroke.

Conclusion

Self-evaluation questionnaires should be considered for wider use in the clinical evaluation of a patient's stroke recovery, since they add important information on the individual's functional status, which is not reflected in the clinical tests.

An evaluation of 3D printable elastics for post stroke dynamic hand bracing: a pilot study

The rise of 3D printing allows unprecedented customization of rehabilitation devices, and with an ever-expanding library of 3D printable (3DP) materials, the spectrum of attenable rehabilitation devices is likewise expanding. The current pilot study explores feasibility of using 3DP elastic materials to create dynamic hand orthoses for stroke survivors. A dynamic orthosis featuring a replaceable finger component was fabricated using 3DP elastic materials. Duplicates of the finger component were printed using different materials ranging from low stiffness (low elastic modulus) to relatively high stiffness (high elastic modulus). Five stroke survivors with predominantly moderate hand impairment were recruited to evaluate usability and impact of orthoses on upper extremity function and biomechanics. No significant differences in usability were found between 3D-printed orthoses and a commercial orthosis. Increases in stiffness of the 3DP material reduced pincer force (p = .0041) and the BBT score (p = .043). In comparison, the commercial orthosis did not reduce pincer force but may reduce BBT score to a degree that is clinically significant (p = .0002). While preliminary, these findings suggest that a dynamic orthosis is a feasible clinical application of 3DP elastic materials, and future study is warranted.

An Intensive Exercise Program Using a Technology-Enriched Rehabilitation Gym for the Recovery of Function in People With Chronic Stroke: Usability Study

BACKGROUND

Rehabilitation improves poststroke recovery with greater effect for many when applied intensively within enriched environments. The failure of health care providers to achieve minimum recommendations for rehabilitation motivated the development of a technology-enriched rehabilitation gym (TERG) that enables individuals under supervision to perform high-intensity self-managed exercises safely in an enriched environment.

OBJECTIVE

This study aimed to assess the feasibility of the TERG approach and gather preliminary evidence of its effect for future research.

METHODS

This feasibility study recruited people well enough to exercise but living with motor impairment following a stroke at least 12 months previously. Following assessment, an 8-week exercise program using a TERG (eg, virtual reality treadmills, power-assisted equipment, balance trainers, and upper limb training systems) was structured in partnership with participants. The feasibility was assessed through recruitment, retention, and adherence rates along with participant interviews. Effect sizes were calculated from the mean change in standard outcome measures.

RESULTS

In total, 70 individuals registered interest, the first 50 were invited for assessment, 39 attended, and 31 were eligible and consented. Following a pilot study (n=5), 26 individuals (mean age 60.4, SD 13.3 years; mean 39.0, SD 29.2 months post stroke; n=17 males; n=10 with aphasia) were recruited to a feasibility study, which 25 individuals completed. Participants attended an average of 18.7 (SD 6.2) sessions with an 82% attendance rate. Reasons for nonattendance related to personal life, illness, weather, care, and transport. In total, 19 adverse events were reported: muscle or joint pain, fatigue, dizziness, and viral illness, all resolved within a week. Participants found the TERG program to be a positive experience with the equipment highly usable albeit with some need for individual tailoring to accommodate body shape and impairment. The inclusion of performance feedback and gamification was well received. Mean improvements in outcome measures were recorded across all domains with low to medium effect sizes.

CONCLUSIONS

This study assessed the feasibility of a holistic technology-based solution to the gap between stroke rehabilitation recommendations and provision. The results clearly demonstrate a rehabilitation program delivered through a TERG is feasible in terms of recruitment, retention, adherence, and user acceptability and may lead to considerable improvement in function, even in a chronic stroke population.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-doi.org/10.3389/fresc.2021.820929.

Can specific virtual reality combined with conventional rehabilitation improve poststroke hand motor function? A randomized clinical trial

TRIAL OBJECTIVE

To verify whether conventional rehabilitation combined with specific virtual reality is more effective than conventional therapy alone in restoring hand motor function and muscle tone after stroke.

TRIAL DESIGN

This prospective single-blind randomized controlled trial compared conventional rehabilitation based on physiotherapy and occupational therapy (control group) with the combination of conventional rehabilitation and specific virtual reality technology (experimental group). Participants were allocated to these groups in a ratio of 1:1. The conventional rehabilitation therapists were blinded to the study, but neither the participants nor the therapist who applied the virtual reality-based therapy could be blinded to the intervention.

PARTICIPANTS

Forty-six patients (43 of whom completed the intervention period and follow-up evaluation) were recruited from the Neurology and Rehabilitation units of the Hospital General Universitario of Talavera de la Reina, Spain.

INTERVENTION

Each participant completed 15 treatment sessions lasting 150 min/session; the sessions took place five consecutive days/week over the course of three weeks. The experimental group received conventional upper-limb strength and motor training (100 min/session) combined with specific virtual reality technology devices (50 min/session); the control group received only conventional training (150 min/session).

RESULTS

As measured by the Ashworth Scale, a decrease in wrist muscle tone was observed in both groups (control and experimental), with a notably larger decrease in the experimental group (baseline mean/postintervention mean: 1.22/0.39; difference between baseline and follow-up: 0.78; 95% confidence interval: 0.38-1.18; effect size = 0.206). Fugl-Meyer Assessment scores were observed to increase in both groups, with a notably larger increase in the experimental group (total motor function: effect size = 0.300; mean: - 35.5; 95% confidence interval: - 38.9 to - 32.0; wrist: effect size = 0.290; mean: - 5.6; 95% confidence interval: - 6.4 to - 4.8; hand: effect size = 0.299; mean: - -8.9; 95% confidence interval: - 10.1 to - 7.6). On the Action Research Arm Test, the experimental group quadrupled its score after the combined intervention (effect size = 0.321; mean: - 32.8; 95% confidence interval: - 40.1 to - 25.5).

CONCLUSION

The outcomes of the study suggest that conventional rehabilitation combined with a specific virtual reality technology system can be more effective than conventional programs alone in improving hand motor function and voluntary movement and in normalizing muscle tone in subacute stroke patients. With combined treatment, hand and wrist functionality and motion increase; resistance to movement (spasticity) decreases and remains at a reduced level.

TRIALS REGISTRY

International Clinical Trials Registry Platform: ISRCTN27760662 (15/06/2020; retrospectively registered).

Measurement of Functional Use in Upper Extremity Prosthetic Devices Using Wearable Sensors and Machine Learning

Trials for therapies after an upper limb amputation (ULA) require a focus on the real-world use of the upper limb prosthesis. In this paper, we extend a novel method for identifying upper extremity functional and nonfunctional use to a new patient population: upper limb amputees. We videotaped five amputees and 10 controls performing a series of minimally structured activities while wearing sensors on both wrists that measured linear acceleration and angular velocity. The video data was annotated to provide ground truth for annotating the sensor data. Two different analysis methods were used: one that used fixed-size data chunks to create features to train a Random Forest classifier and one that used variable-size data chunks. For the amputees, the fixed-size data chunk method yielded good results, with 82.7% median accuracy (range of 79.3-85.8) on the 10-fold cross-validation intra-subject test and 69.8% in the leave-one-out inter-subject test (range of 61.4-72.8). The variable-size data method did not improve classifier accuracy compared to the fixed-size method. Our method shows promise for inexpensive and objective quantification of functional upper extremity (UE) use in amputees and furthers the case for use of this method in assessing the impact of UE rehabilitative treatments.

Telerehabilitation Initiated Early in Post-Stroke Recovery: A Feasibility Study

BACKGROUND

Enhanced neural plasticity early after stroke suggests the potential to improve outcomes with intensive rehabilitation therapy. Most patients do not get such therapy, however, due to limited access, changing rehabilitation therapy settings, low therapy doses, and poor compliance.

OBJECTIVE

To examine the feasibility, safety, and potential efficacy of an established telerehabilitation (TR) program after stroke initiated during admission to an inpatient rehabilitation facility (IRF) and completed in the patient's home.

METHODS

Participants with hemiparetic stroke admitted to an IRF received daily TR targeting arm motor function in addition to usual care. Treatment consisted of 36, 70-minute sessions (half supervised by a licensed therapist via videoconference), over a 6-week period, that included functional games, exercise videos, education, and daily assessments.

RESULTS

Sixteen participants of 19 allocated completed the intervention (age 61.3 ± 9.4 years; 6 female; baseline Upper Extremity Fugl-Meyer [UEFM] score 35.9 ± 6.4 points, mean ± SD; NIHSS score 4 (3.75, 5.25), median, IQR; intervention commenced 28.3 ± 13.0 days post-stroke). Compliance was 100%, retention 84%, and patient satisfaction 93%; 2 patients developed COVID-19 and continued TR. Post-intervention UEFM improvement was 18.1 ± 10.9 points (P < .0001); Box and Blocks, 22.4 ± 9.8 blocks (P = .0001). Digital motor assessments, acquired daily in the home, were concordant with these gains. The dose of rehabilitation therapy received as usual care during this 6-week interval was 33.9 ± 20.3 hours; adding TR more than doubled this to 73.6 ± 21.8 hours (P < .0001). Patients enrolled in Philadelphia could be treated remotely by therapists in Los Angeles.

CONCLUSIONS

These results support feasibility, safety, and potential efficacy of providing intense TR therapy early after stroke.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov; NCT04657770.

Non-invasive brain stimulation for limb motor function and daily living activity improvement in acute stroke: A meta-analysis

OBJECTIVE

To evaluate the effect of non-invasive brain stimulation (NIBS) in improving limb motor dysfunction and daily living activity during at the phase of acute stroke.

MATERIALS AND METHODS

Randomized controlled trials about the effect of NIBS on hemiparesis in acute stroke were retrieved from databases of China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), Wanfang Data, CBM, PubMed, Embase, Cochrane Library, and Web of Science from inception until January 3rd 2022. The quality of the trials was assessed, and the data were extracted according to the Cochrane Handbook for Systematic Reviews of Interventions. A statistical analysis was carried out using Review Manager 5.3 and STATA 14. The effect size was evaluated by using the weighed mean difference (WMD) and a 95% confidence interval (CI). The stability and sensitivity of the results and sources of heterogeneity were also analyzed.

RESULTS

12 studies involving 639 patients were included. Our meta-analysis showed that NIBS could improve the Fugl-Meyer Assessment (weighed mean difference = 3.96, 95% confidence interval = 3.45 to 4.48) and Barthel Index (weighed mean difference = 12.29, 95% confidence interval = 4.93 to 19.66), while reducing the National Institutes of Health Stroke Scale (weighed mean difference = -2.37, 95% confidence interval = -3.43 to -1.31).

CONCLUSION

NIBS is effective in improving paretic limb motor function and activities of daily living in patients during at the phase of acute stroke.

Improvement in the Capacity for Activity Versus Improvement in Performance of Activity in Daily Life During Outpatient Rehabilitation

We addressed questions about the potential discrepancy between improvements in activity capacity and improvements in activity performance in daily life. We asked whether this discrepancy is: Common in routine, outpatient care, or an artifact of intervention studies? Unique to upper limb (UL) rehabilitation, or is it seen in walking rehabilitation too? Only seen in persons with stroke, or a broader neurorehabilitation problem?

Interaction of network and rehabilitation therapy parameters in defining recovery after stroke in a Bilateral Neural Network

BACKGROUND

Restoring movement after hemiparesis caused by stroke is an ongoing challenge in the field of rehabilitation. With several therapies in use, there is no definitive prescription that optimally maps parameters of rehabilitation with patient condition. Recovery gets further complicated once patients enter chronic phase. In this paper, we propose a rehabilitation framework based on computational modeling, capable of mapping patient characteristics to parameters of rehabilitation therapy.

METHOD

To build such a system, we used a simple convolutional neural network capable of performing bilateral reaching movements in 3D space using stereovision. The network was designed to have bilateral symmetry to reflect the bilaterality of the cerebral hemispheres with the two halves joined by cross-connections. This network was then modified according to 3 chosen patient characteristics-lesion size, stage of recovery (acute or chronic) and structural integrity of cross-connections (analogous to Corpus Callosum). Similarly, 3 parameters were used to define rehabilitation paradigms-movement complexity (Exploratory vs Stereotypic), hand selection mode (move only affected arm, CIMT vs move both arms, BMT), and extent of plasticity (local vs global). For each stroke condition, performance under each setting of the rehabilitation parameters was measured and results were analyzed to find the corresponding optimal rehabilitation protocol.

RESULTS

Upon analysis, we found that regardless of patient characteristics network showed better recovery when high complexity movements were used and no significant difference was found between the two hand selection modes. Contrary to these two parameters, optimal extent of plasticity was influenced by patient characteristics. For acute stroke, global plasticity is preferred only for larger lesions. However, for chronic, plasticity varies with structural integrity of cross-connections. Under high integrity, chronic prefers global plasticity regardless of lesion size, but with low integrity local plasticity is preferred.

CONCLUSION

Clinically translating the results obtained, optimal recovery may be observed when paretic arm explores the available workspace irrespective of the hand selection mode adopted. However, the extent of plasticity to be used depends on characteristics of the patient mainly stage of stroke and structural integrity. By using systems as developed in this study and modifying rehabilitation paradigms accordingly it is expected post-stroke recovery can be maximized.

The Predictive Role of Hand Section of Fugl–Meyer Assessment and Motor Activity Log in Action Research Arm Test in People With Stroke

Background:

Recent findings of clinical studies have demonstrated a significant positive relationship between Fugl–Meyer Assessment of upper extremity score and the action research arm test (ARAT) score in people with stroke. Although the motor activity log (MAL) can assess the self-perception of motor performance, which can affect the performance of the upper limb, the relationship between MAL score and ARAT score still remains unclear. The objective of this study is to quantify the independent contribution of MAL score and FMA-hand score on the ARAT score in people with stroke.

Methods

This is a cross-sectional study. There were a total of 87 subjects (50 males, 37 females; mean age = 61.12 ± 6.88 years, post-stroke duration=6.31 ± 2.84 years) included in this study. Self-perceived performance in using the paretic limb was measured by MAL, including subscale of the amount of usage (MAL-AOU) and quality of movement (MAL-QOM). Functional performance of the upper limb was measured by action research arm test (ARAT). Upper limb motor control of the hand was measured by hand section of Fugl–Meyer assessment (FMA-hand).

Results

The result showed that MAL-QOM (r = 0.648, p < 0.001), MAL-AOU (r = 0.606, p < 0.001), FMA-hand scores (r = 0.663, p < 0.001), and the use of a walking aid (r = −0.422, p < 0.001) were significantly correlated with the ARAT scores. A total 66.9% of the variance in the ARAT scores was predicted by the final regression model including MAL-QOM, MAL-AOU, FMA-hand scores, and walking aid. The FMA-hand score was the best predictor of ARAT scores, which can predict a 36.4% variance of ARAT scores in people with stroke, which controlled the effect of using a walking aid. After controlling for use of a walking aid and FMA-hand scores, the multiple linear regression modeling showed that MAL-QOM and MAL-AOU scores could also independently predict an additional 10.4% of the variance in ARAT scores.

Conclusion

In addition to the FMA-hand score, the MAL score was significantly correlated with the ARAT score. Improving self-perceived performance should be one goal of rehabilitation in people with stroke. Further work developing and testing techniques to do so is clearly warranted.

BCI-FES With Multimodal Feedback for Motor Recovery Poststroke

An increasing number of research teams are investigating the efficacy of brain-computer interface (BCI)-mediated interventions for promoting motor recovery following stroke. A growing body of evidence suggests that of the various BCI designs, most effective are those that deliver functional electrical stimulation (FES) of upper extremity (UE) muscles contingent on movement intent. More specifically, BCI-FES interventions utilize algorithms that isolate motor signals-user-generated intent-to-move neural activity recorded from cerebral cortical motor areas-to drive electrical stimulation of individual muscles or muscle synergies. BCI-FES interventions aim to recover sensorimotor function of an impaired extremity by facilitating and/or inducing long-term motor learning-related neuroplastic changes in appropriate control circuitry. We developed a non-invasive, electroencephalogram (EEG)-based BCI-FES system that delivers closed-loop neural activity-triggered electrical stimulation of targeted distal muscles while providing the user with multimodal sensory feedback. This BCI-FES system consists of three components: (1) EEG acquisition and signal processing to extract real-time volitional and task-dependent neural command signals from cerebral cortical motor areas, (2) FES of muscles of the impaired hand contingent on the motor cortical neural command signals, and (3) multimodal sensory feedback associated with performance of the behavioral task, including visual information, linked activation of somatosensory afferents through intact sensorimotor circuits, and electro-tactile stimulation of the tongue. In this report, we describe device parameters and intervention protocols of our BCI-FES system which, combined with standard physical rehabilitation approaches, has proven efficacious in treating UE motor impairment in stroke survivors, regardless of level of impairment and chronicity.

Quantitative Assessment of Hand Function in Healthy Subjects and Post-Stroke Patients with the Action Research Arm Test

The Action Research Arm Test (ARAT) can provide subjective results due to the difficulty assessing abnormal patterns in stroke patients. The aim of this study was to identify joint impairments and compensatory grasping strategies in stroke patients with left (LH) and right (RH) hemiparesis. An experimental study was carried out with 12 patients six months after a stroke (three women and nine men, mean age: 65.2 ± 9.3 years), and 25 healthy subjects (14 women and 11 men, mean age: 40.2 ± 18.1 years. The subjects were evaluated during the performance of the ARAT using a data glove. Stroke patients with LH and RH showed significantly lower flexion angles in the MCP joints of the Index and Middle fingers than the Control group. However, RH patients showed larger flexion angles in the proximal interphalangeal (PIP) joints of the Index, Middle, Ring, and Little fingers. In contrast, LH patients showed larger flexion angles in the PIP joints of the Middle and Little fingers. Therefore, the results showed that RH and LH patients used compensatory strategies involving increased flexion at the PIP joints for decreased flexion in the MCP joints. The integration of a data glove during the performance of the ARAT allows the detection of finger joint impairments in stroke patients that are not visible from ARAT scores. Therefore, the results presented are of clinical relevance.

A low-dimensional representation of arm movements and hand grip forces in post-stroke individuals

Characterizing post-stroke impairments in the sensorimotor control of arm and hand is essential to better understand altered mechanisms of movement generation. Herein, we used a decomposition algorithm to characterize impairments in end-effector velocity and hand grip force data collected from an instrumented functional task in 83 healthy control and 27 chronic post-stroke individuals with mild-to-moderate impairments. According to kinematic and kinetic raw data, post-stroke individuals showed reduced functional performance during all task phases. After applying the decomposition algorithm, we observed that the behavioural data from healthy controls relies on a low-dimensional representation and demonstrated that this representation is mostly preserved post-stroke. Further, it emerged that reduced functional performance post-stroke correlates to an abnormal variance distribution of the behavioural representation, except when reducing hand grip forces. This suggests that the behavioural repertoire in these post-stroke individuals is mostly preserved, thereby pointing towards therapeutic strategies that optimize movement quality and the reduction of grip forces to improve performance of daily life activities post-stroke.

Evaluation of a shortened version of the Action Research Arm Test (ARAT) for upper extremity function after stroke: The Mini-ARAT

OBJECTIVES

(i) to create a shortened version of the Action Research Arm Test scale, (ii) to investigate its psychometric properties compared to the original scale and (iii) to externally validate it within an independent cohort.

DESIGN

Prospective longitudinal cohort study.

SETTINGS

Two University Hospitals (France, Switzerland).

PARTICIPANTS

47 patients with poststroke motor deficits of the upper limb coming from two different sites were included and divided into two cohorts (n = 22 for the construction cohort; n = 25 for the validation cohort).

MAIN MEASURES

We used the first cohort to build the Mini-ARAT by shortening the Action Research Arm Test scale on the basis of ceiling/floor effects and collinearity of the subscales. We studied its reliability, validity, and responsiveness and performed an external validation with the second cohort.

RESULTS

The Mini-ARAT consisted of 2 subscales from the original Action Research Arm Test scale (Grip and Pinch). Internal consistency (α = 87) and inter-rater reliability (0.99, 95% CI: 0.98-0.99, p < 0.01) were good and similar to those of the Action Research Arm Test scale. The Minimal Clinically Important Difference of the Mini-ARAT was 9 points. The predictive validity in the construction and validation cohorts showed good correlation between the Mini-ARAT at baseline and the Fugl Meyer at 3 months (rho, 95% CI: 0.77, 0.49-0.90, p < 0.01, and 0.58, 0.19-0.96, p < 0.01).

CONCLUSION

The Mini-ARAT is a time-effective tool able to capture the dynamics of motor deficits with high reliability and consistency, providing excellent information about residual motor functions, which is critically important for clinical and research purposes.

The effect of first-person perspective action observation training on upper extremity function and activity of daily living of chronic stroke patients

The purpose of this study was to investigate the effects of First-Person Perspective Action Observation training and Third-Person Perspective Action Observation training on upper extremity function and activities of daily living of patients with stroke-induced hemiplegia. This was a single-blind randomized study of 20 stroke patients (more than 6 months after the incident stroke) with upper extremity disabilities. The subjects who satisfied the inclusion and exclusion criteria were randomly divided into two groups: First-Person Perspective Action Observation training group and Third-Person Perspective Action Observation training group. The measurements were performed using Action Research Arm Test (ARAT) and Korean Modified Barthel Index (K-MBI) and Motor Activity Log (MAL). The results of this study showed statistically significant differences (p < .05) in the upper extremity function and activity of daily living after the intervention in all two groups. Upon comparison of the amount of change between the experimental group and the control group, there was significant difference in upper extremity function and activity of daily living (p < .05). Action Observation training was found to have an effect on the upper extremity function and activity of daily living on chronic stroke patients. First-Person Perspective Action Observation training was more effective in improving upper limb function and activity of daily living than the Third-Person Perspective Action Observation training.

Intermittent Theta Burst Stimulation Increases Natural Oscillatory Frequency in Ipsilesional Motor Cortex Post-Stroke: A Transcranial Magnetic Stimulation and Electroencephalography Study

Objective

Intermittent theta burst stimulation (iTBS) has been widely used as a neural modulation approach in stroke rehabilitation. Concurrent use of transcranial magnetic stimulation and electroencephalography (TMS-EEG) offers a chance to directly measure cortical reactivity and oscillatory dynamics and allows for investigating neural effects induced by iTBS in all stroke survivors including individuals without recordable MEPs. Here, we used TMS-EEG to investigate aftereffects of iTBS following stroke.

Methods

We studied 22 stroke survivors (age: 65.2 ± 11.4 years; chronicity: 4.1 ± 3.5 months) with upper limb motor deficits. Upper-extremity component of Fugl-Meyer motor function assessment and action research arm test were used to measure motor function of stroke survivors. Stroke survivors were randomly divided into two groups receiving either Active or Sham iTBS applied over the ipsilesional primary motor cortex. TMS-EEG recordings were performed at baseline and immediately after Active or Sham iTBS. Time and time-frequency domain analyses were performed for quantifying TMS-evoked EEG responses.

Results

At baseline, natural frequency was slower in the ipsilesional compared with the contralesional hemisphere (P = 0.006). Baseline natural frequency in the ipsilesional hemisphere was positively correlated with upper limb motor function following stroke (P = 0.007). After iTBS, natural frequency in the ipsilesional hemisphere was significantly increased (P < 0.001).

Conclusions

This is the first study to investigate the acute neural adaptations after iTBS in stroke survivors using TMS-EEG. Our results revealed that natural frequency is altered following stroke which is related to motor impairments. iTBS increases natural frequency in the ipsilesional motor cortex in stroke survivors. Our findings implicate that iTBS holds the potential to normalize natural frequency in stroke survivors, which can be utilized in stroke rehabilitation.

Quantifying Quality of Reaching Movements Longitudinally Post-Stroke: A Systematic Review

Background

Disambiguation of behavioral restitution from compensation is important to better understand recovery of upper limb motor control post-stroke and subsequently design better interventions. Measuring quality of movement (QoM) during standardized performance assays and functional tasks using kinematic and kinetic metrics potentially allows for this disambiguation.

Objectives

To identify longitudinal studies that used kinematic and/or kinetic metrics to investigate post-stroke recovery of reaching and assess whether these studies distinguish behavioral restitution from compensation.

Methods

A systematic literature search was conducted using the databases PubMed, Embase, Scopus, and Wiley/Cochrane Library up to July 1st, 2020. Studies were identified if they performed longitudinal kinematic and/or kinetic measurements during reaching, starting within the first 6 months post-stroke.

Results

Thirty-two longitudinal studies were identified, which reported a total of forty-six different kinematic metrics. Although the majority investigated improvements in kinetics or kinematics to quantify recovery of QoM, none of these studies explicitly addressed the distinction between behavioral restitution and compensation. One study obtained kinematic metrics for both performance assays and a functional task.

Conclusions

Despite the growing number of kinematic and kinetic studies on post-stroke recovery, longitudinal studies that explicitly seek to delineate between behavioral restitution and compensation are still lacking in the literature. To rectify this situation, future studies should measure kinematics and/or kinetics during performance assays to isolate restitution and during a standardized functional task to determine the contributions of restitution and compensation.

Corticocortical paired associative stimulation for treating motor dysfunction after stroke: study protocol for a randomised sham-controlled double-blind clinical trial

INTRODUCTION

Stroke survivors can have a high disability rate with low quality of daily life, resulting in a heavy burden on family and society. Transcranial magnetic stimulation has been widely applied to brain injury repair, neurological disease treatment, cognition and emotion regulation and so on. However, there is still much to be desired in the theories of using these neuromodulation techniques to treat stroke-caused hemiplegia. It is generally recognised that synaptic plasticity is an important basis for functional repair after brain injury. This study protocol aims to examine the corticocortical paired associative stimulation (ccPAS) for inducing synaptic plasticity to rescue the paralysed after stroke.

METHODS AND ANALYSIS

The current study is designed as a 14-week double-blind randomised sham-controlled clinical trial, composed of 2-week intervention and 12-week follow-up. For the study, 42 patients who had a stroke aged 40-70 will be recruited, who are randomly assigned either to the ccPAS intervention group, or to the control group at a 1:1 ratio, hence an equal number each. In the intervention group, ccPAS is practised in conjunction with the conventional rehabilitation treatment, and in the control group, the conventional rehabilitation treatment is administered with sham stimulation. A total of 10 interventions will be made, 5 times a week for 2 weeks. The same assessors are supposed to evaluate the participants' motor function at four time points of the baseline (before 10 interventions), treatment ending (after 10 interventions), and two intervals of follow-up (1 and 3 months later, respectively). The Fugl-Meyer Assessment Upper Extremity is used for the primary outcomes. The secondary outcomes include changes in the assessment of Action Research Arm Test (ARAT), Modified Barthel Index (MBI), electroencephalogram (EEG) and functional MRI data. The adverse events are to be recorded throughout the study.

ETHICS AND DISSEMINATION

This study was approved by the Medical Ethics Committee of Yueyang Hospital. All ethical work was performed in accordance with the Helsinki declaration. Written informed consent was obtained from all individual participants included in the study. Study findings will be disseminated in the printed media.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry: ChiCTR2000036685.

Reducing the number of test items of the Action Research Arm Test post stroke: A decision tree analysis

Objective - The present study aimed to create a shorter version of the Action Research Arm Test (ARAT) without compromising its measurement properties. Design - Secondary analysis of stroke recovery cohorts that used the ARAT to measure upper-limb impairment. Setting - Rehabilitation centers. Participants - Patients with stroke from five different stroke recovery cohorts. Interventions - Not applicable. Main Outcome Measures - A decision tree version of the ARAT (ARAT-DT) was developed using Chi-squared Automated Interaction Detection (CHAID). In an independent validation subset, criterion validity, agreement of ARAT-DT with original ARAT scores and score categories, and construct validity with the Fugl-Meyer upper extremity (FM-UE) score were determined. Results - In total, 3738 ARAT measurements were available involving 1,425 subjects. CHAID analysis in the development subset (n=2803) revealed an optimized decision tree with a maximum of four consecutive items. In the validation dataset (n=935), the ARAT-DT differed by a mean of 0.19 points (0.3% of the total scale) from the original ARAT scores (limits of agreement: -5.67 to 6.05). The ARAT-DT demonstrated excellent criterion validity with the original ARAT scores (ICC=0.99 and ρ=0.99) and scoring categories (κ_w=0.97). The ARAT-DT showed very good construct validity with the FM-UE motor scale (ρ=0.92). Conclusion - A decision tree version of the ARAT was developed, reducing the maximum number of items necessary for ARAT administration from 19 to 4. The scores produced by the decision tree had excellent criterion validity with original ARAT scores.

Estimating upper-extremity function from kinematics in stroke patients following goal-oriented computer-based training

INTRODUCTION

After a stroke, a wide range of deficits can occur with varying onset latencies. As a result, assessing impairment and recovery are enormous challenges in neurorehabilitation. Although several clinical scales are generally accepted, they are time-consuming, show high inter-rater variability, have low ecological validity, and are vulnerable to biases introduced by compensatory movements and action modifications. Alternative methods need to be developed for efficient and objective assessment. In this study, we explore the potential of computer-based body tracking systems and classification tools to estimate the motor impairment of the more affected arm in stroke patients.

METHODS

We present a method for estimating clinical scores from movement parameters that are extracted from kinematic data recorded during unsupervised computer-based rehabilitation sessions. We identify a number of kinematic descriptors that characterise the patients' hemiparesis (e.g., movement smoothness, work area), we implement a double-noise model and perform a multivariate regression using clinical data from 98 stroke patients who completed a total of 191 sessions with RGS.

RESULTS

Our results reveal a new digital biomarker of arm function, the Total Goal-Directed Movement (TGDM), which relates to the patients work area during the execution of goal-oriented reaching movements. The model's performance to estimate FM-UE scores reaches an accuracy of [Formula: see text]: 0.38 with an error ([Formula: see text]: 12.8). Next, we evaluate its reliability ([Formula: see text] for test-retest), longitudinal external validity ([Formula: see text] true positive rate), sensitivity, and generalisation to other tasks that involve planar reaching movements ([Formula: see text]: 0.39). The model achieves comparable accuracy also for the Chedoke Arm and Hand Activity Inventory ([Formula: see text]: 0.40) and Barthel Index ([Formula: see text]: 0.35).

CONCLUSIONS

Our results highlight the clinical value of kinematic data collected during unsupervised goal-oriented motor training with the RGS combined with data science techniques, and provide new insight into factors underlying recovery and its biomarkers.

Home-Based Therapy After Stroke Using the Hand Spring Operated Movement Enhancer (HandSOME II)

We have developed a passive and lightweight wearable hand exoskeleton (HandSOME II) that improves range of motion and functional task practice in laboratory testing. For this longitudinal study, we recruited 15 individuals with chronic stroke and asked them to use the device at home for 1.5 h per weekday for 8 weeks. Subjects visited the clinic once per week to report progress and troubleshoot problems. Subjects were then given the HandSOME II for the next 3 months, and asked to continue to use it, but without any scheduled contact with the project team. Clinical evaluations and biomechanical testing was performed before and after the 8 week intervention and at the 3 month followup. EEG measures were taken before and after the 8 weeks of training to examine any recovery associated brain reorganization. Ten subjects completed the study. After 8 weeks of training, functional ability (Action Research Arm Test), flexor tone (Modified Ashworth Test), and real world use of the impaired limb (Motor Activity Log) improved significantly (p < 0.05). Gains in real world use were retained at the 3-month followup (p = 0.005). At both post-training and followup time points, biomechanical testing found significant gains in finger ROM and hand displacement in a reaching task (p < 0.05). Baseline functional connectivity correlated with gains in motor function, while changes in EEG functional connectivity paralleled changes in motor recovery. HandSOME II is a low-cost, home-based intervention that elicits brain plasticity and can improve functional motor outcomes in the chronic stroke population.

The Effects of Intermittent Theta Burst Stimulation on Functional Brain Network Following Stroke: An Electroencephalography Study

Objective: Intermittent theta burst stimulation (iTBS) is a special form of repetitive transcranial magnetic stimulation (rTMS), which effectively increases cortical excitability and has been widely used as a neural modulation approach in stroke rehabilitation. As effects of iTBS are typically investigated by motor evoked potentials, how iTBS influences functional brain network following stroke remains unclear. Resting-state electroencephalography (EEG) has been suggested to be a sensitive measure for evaluating effects of rTMS on brain functional activity and network. Here, we used resting-state EEG to investigate the effects of iTBS on functional brain network in stroke survivors. Methods: We studied thirty stroke survivors (age: 63.1 ± 12.1 years; chronicity: 4.0 ± 3.8 months; UE FMA: 26.6 ± 19.4/66) with upper limb motor dysfunction. Stroke survivors were randomly divided into two groups receiving either Active or Sham iTBS over the ipsilesional primary motor cortex. Resting-state EEG was recorded at baseline and immediately after iTBS to assess the effects of iTBS on functional brain network. Results: Delta and theta bands interhemispheric functional connectivity were significantly increased after Active iTBS (P = 0.038 and 0.011, respectively), but were not significantly changed after Sham iTBS (P = 0.327 and 0.342, respectively). Delta and beta bands global efficiency were also significantly increased after Active iTBS (P = 0.013 and 0.0003, respectively), but not after Sham iTBS (P = 0.586 and 0.954, respectively). Conclusion: This is the first study that used EEG to investigate the acute neuroplastic changes after iTBS following stroke. Our findings for the first time provide evidence that iTBS modulates brain network functioning in stroke survivors. Acute increase in interhemispheric functional connectivity and global efficiency after iTBS suggest that iTBS has the potential to normalize brain network functioning following stroke, which can be utilized in stroke rehabilitation.

Intensive rehabilitation programme for patients with subacute stroke in an inpatient rehabilitation facility: describing a protocol of a prospective cohort study

INTRODUCTION

Rehabilitation is recognised as a cornerstone of multidisciplinary stroke care. Intensity of therapy is related to functional recovery although there is high variability on the amount of time and techniques applied in therapy sessions. There is a need to better describe stroke rehabilitation protocols to develop a better understanding of current practice increasing the internal validity and generalisation of clinical trial results. The aim of this study is to describe an intensive rehabilitation programme for patients with stroke in an inpatient rehabilitation facility, measuring the amount and type of therapies (physical, occupational and speech therapy) provided and reporting functional outcomes.

METHODS AND ANALYSIS

This will be a prospective observational cohort study of patients with subacute stroke admitted to our inpatient rehabilitation facility during 2 years. A therapy recording tool was developed in order to describe the rehabilitation interventions performed in our unit. This tool was designed using the Delphi method, literature search and collaboration with senior clinicians. Therapists will record the time spent on different activities available in our unit during specific therapy sessions. Afterwards, the total time spent in each activity, and the total rehabilitation time for all activities, will be averaged for all patients. Outcome variables were divided into three different domains: body structure and function outcomes, activity outcomes and participation outcomes and will be assessed at baseline (admission at the rehabilitation unit), at discharge from the rehabilitation unit and at 3 and 6 months after stroke.

ETHICS AND DISSEMINATION

This study was approved by the Medical Research Committee at Hospital del Mar Research Institute (Project ID: 34/C/2017). The results of this study will be presented at national and international congress and submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04191109.

Brain-Computer Interface Training With Functional Electrical Stimulation: Facilitating Changes in Interhemispheric Functional Connectivity and Motor Outcomes Post-stroke

While most survivors of stroke experience some spontaneous recovery and receive treatment in the subacute setting, they are often left with persistent impairments in upper limb sensorimotor function which impact autonomy in daily life. Brain-Computer Interface (BCI) technology has shown promise as a form of rehabilitation that can facilitate motor recovery after stroke, however, we have a limited understanding of the changes in functional connectivity and behavioral outcomes associated with its use. Here, we investigate the effects of EEG-based BCI intervention with functional electrical stimulation (FES) on resting-state functional connectivity (rsFC) and motor outcomes in stroke recovery. 23 patients post-stroke with upper limb motor impairment completed BCI intervention with FES. Resting-state functional magnetic resonance imaging (rs-fMRI) scans and behavioral data were collected prior to intervention, post- and 1-month post-intervention. Changes in rsFC within the motor network and behavioral measures were investigated to identify brain-behavior correlations. At the group-level, there were significant increases in interhemispheric and network rsFC in the motor network after BCI intervention, and patients significantly improved on the Action Research Arm Test (ARAT) and SIS domains. Notably, changes in interhemispheric rsFC from pre- to both post- and 1 month post-intervention correlated with behavioral improvements across several motor-related domains. These findings suggest that BCI intervention with FES can facilitate interhemispheric connectivity changes and upper limb motor recovery in patients after stroke.

Pilot Test of Dosage Effects in HEXORR II for Robotic Hand Movement Therapy in Individuals With Chronic Stroke

Impaired use of the hand in functional tasks remains difficult to overcome in many individuals after a stroke. This often leads to compensation strategies using the less-affected limb, which allows for independence in some aspects of daily activities. However, recovery of hand function remains an important therapeutic goal of many individuals, and is often resistant to conventional therapies. In prior work, we developed HEXORR I, a robotic device that allows practice of finger and thumb movements with robotic assistance. In this study, we describe modifications to the device, now called HEXORR II, and a clinical trial in individuals with chronic stroke. Fifteen individuals with a diagnosis of chronic stroke were randomized to 12 or 24 sessions of robotic therapy. The sessions involved playing several video games using thumb and finger movement. The robot applied assistance to extension movement that was adapted based on task performance. Clinical and motion capture evaluations were performed before and after training and again at a 6-month followup. Fourteen individuals completed the protocol. Fugl-Meyer scores improved significantly at the 6 month time point compared to baseline, indicating reductions in upper extremity impairment. Flexor hypertonia (Modified Ashworth Scale) also decreased significantly due to the intervention. Motion capture found increased finger range of motion and extension ability after the intervention that continued to improve during the followup period. However, there was no change in a functional measure (Action Research Arm Test). At the followup, the high dose group had significant gains in hand displacement during a forward reach task. There were no other significant differences between groups. Future work with HEXORR II should focus on integrating it with functional task practice and incorporating grip and squeezing tasks.

Trial Registration:ClinicalTrials.gov, NCT04536987. Registered 3 September 2020 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/record/NCT04536987.

Critical Period After Stroke Study (CPASS): A phase II clinical trial testing an optimal time for motor recovery after stroke in humans

Restoration of postinjury brain function is a signal neuroscience challenge. Animal models of stroke recovery demonstrate time-limited windows of heightened motor recovery, similar to developmental neuroplasticity. However, no equivalent windows have been demonstrated in humans. We report a randomized controlled trial applying essential elements of animal motor training paradigms to humans, to determine the existence of an analogous sensitive period in adults. We found a similar sensitive or optimal period 60 to 90 d after stroke, with lesser effects ≤30 d and no effect 6 mo or later after stroke. These findings prospectively demonstrated the existence of a sensitive period in adult humans. We urge the provision of more intensive motor rehabilitation within 60 to 90 d after stroke onset.

Restoration of human brain function after injury is a signal challenge for translational neuroscience. Rodent stroke recovery studies identify an optimal or sensitive period for intensive motor training after stroke: near-full recovery is attained if task-specific motor training occurs during this sensitive window. We extended these findings to adult humans with stroke in a randomized controlled trial applying the essential elements of rodent motor training paradigms to humans. Stroke patients were adaptively randomized to begin 20 extra hours of self-selected, task-specific motor therapy at ≤30 d (acute), 2 to 3 mo (subacute), or ≥6 mo (chronic) after stroke, compared with controls receiving standard motor rehabilitation. Upper extremity (UE) impairment assessed by the Action Research Arm Test (ARAT) was measured at up to five time points. The primary outcome measure was ARAT recovery over 1 y after stroke. By 1 y we found significantly increased UE motor function in the subacute group compared with controls (ARAT difference = +6.87 ± 2.63, P = 0.009). The acute group compared with controls showed smaller but significant improvement (ARAT difference = +5.25 ± 2.59 points, P = 0.043). The chronic group showed no significant improvement compared with controls (ARAT = +2.41 ± 2.25, P = 0.29). Thus task-specific motor intervention was most effective within the first 2 to 3 mo after stroke. The similarity to rodent model treatment outcomes suggests that other rodent findings may be translatable to human brain recovery. These results provide empirical evidence of a sensitive period for motor recovery in humans.

BEAGLE-A Kinematic Sensory System for Objective Hand Function Assessment in Technology-Mediated Rehabilitation

We present a hand functions assessment system (BEAGLE) for kinematic tracking of hand and finger movements, envisioned as a technology-mediated rehabilitation tool. The system is custom-designed for fast and easy placement on an impaired hand (spastic or flaccid), featuring inertial sensors integrated into simple finger caps and a hand strap. An algorithm for a range of motion (ROM) estimation was implemented to provide an objective assessment of hand functions. The efficacy and feasibility of the BEAGLE system were examined in a pilot clinical study performed with ten stroke survivors in the subacute phase. Participants received therapy within two consecutive intensity-matched rehabilitation cycles. The first consisted of conventional therapy, while the second involved a combination of conventional therapy and advanced functional electrical stimulation. Assessments were performed before and after each phase. These included BEAGLE estimates of active voluntary ROM for wrist and various digits, as well as two referent clinical measures for hand functions assessment, Fugl-Meyer and Action Research Arm Test. The results indicate that the ROM assessments can detect change with sensitivity comparable to the standardized clinical scales. Statistically significant changes between the beginning and the end of the second cycle existed in all observed measures, whereas none of these measurements showed a statistically significant improvement in the first therapy cycle. The noted usability metrics indicate that the BEAGLE could be integrated into the rehabilitation workflow in a clinical environment.

Accuracy of an Algorithm in Predicting Upper Limb Functional Capacity in a United States Population

OBJECTIVE

To determine the accuracy of an algorithm, using clinical measures only, on a sample of persons with first-ever stroke in the United States (US). It was hypothesized that algorithm accuracy would fall in a range of 70%-80%.

DESIGN

Secondary analysis of prospective, observational, longitudinal cohort; 2 assessments were done: (1) within 48 hours to 1 week poststroke and (2) at 12 weeks poststroke.

SETTING

Recruited from a large acute care hospital and followed over the first 6 months after stroke.

PARTICIPANTS

Adults with first-ever stroke (N=49) with paresis of the upper limb (UL) at ≤48 hours who could follow 2-step commands and were expected to return to independent living at 6 months.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

The overall accuracy of the algorithm with clinical measures was quantified by comparing predicted (expected) and actual (observed) categories using a correct classification rate.

RESULTS

The overall accuracy (61%) and weighted κ (62%) were significant. Sensitivity was high for the Excellent (95%) and Poor (81%) algorithm categories. Specificity was high for the Good (82%), Limited (98%), and Poor (95%) categories. Positive predictive value (PPV) was high for Poor (82%) and negative predictive value (NPV) was high for all categories. No differences in participant characteristics were found between those with accurate or inaccurate predictions.

CONCLUSIONS

The results of the present study found that use of an algorithm with clinical measures only is better than chance alone (chance=25% for each of the 4 categories) at predicting a category of UL capacity at 3 months post troke. The moderate to high values of sensitivity, specificity, PPV, and NPV demonstrates some clinical utility of the algorithm within health care settings in the US.

Why Are Stroke Rehabilitation Trial Recruitment Rates in Single Digits?

Background: Recruitment of patients in early subacute rehabilitation trials (<30 days post-stroke) presents unique challenges compared to conventional stroke trials recruiting individuals >6 months post-stroke. Preclinical studies suggest treatments be initiated sooner after stroke, thus requiring stroke rehabilitation trials be conducted within days post-stroke. How do specific inclusion and exclusion criteria affect trial recruitment rates for early stroke rehabilitation trials?

Objectives: Provide estimates of trial recruitment based on screening and enrollment data from a phase II early stroke rehabilitation trial.

Methods: CPASS, a phase II intervention trial screened ischemic stroke patients in acute care (18-months, N = 395) and inpatient rehabilitation (22-months, N = 673). Patients were stratified by upper extremity (UE) impairment into mild (NIHSS motor arm = 0, 1); moderate (NIHSS = 2, 3); severe (NIHSS = 4) and numbers of patients disqualified due to CPASS exclusion criteria determined. We also examined if a motor-specific evaluation (Action Research Arm Test, ARAT) increases the pool of eligible patients disqualified by the NIHSS motor arm item.

Results: CPASS recruitment in acute care (5.3%) and inpatient rehabilitation (5%) was comparable to prior trials. In acute care, a short stay (7–17-days), prior stroke (13.5% in moderately; 13.2% in severely impaired) disqualified the majority. In inpatient rehabilitation, the majority (40.8%) were excluded for “too mild” impairment. The next majority were disqualified for reaching inpatient rehabilitation “too late” to participate in an early stroke trial (15% in moderately; 24% in severely impaired). Mean ARAT in the “too mild” showed significant impairment and potential to benefit from participation in select UE rehabilitation trials.

Conclusions: Screening of ischemic stroke patients while they are still in acute care is crucial to successful recruitment for early stroke rehabilitation trials. A significant proportion of eligible patients are lost to “short length of stay” in acute care, and arrive to inpatient rehabilitation “too late” for an early rehabilitation trial. Additional screening of mildly impaired patients using a motor function specific scale will benefit the trial recruitment and generalizability.

Trial Registration Number:http://www.clinicaltrials.gov Identifier: NCT02235974.

Brain-Computer Interface Coupled to a Robotic Hand Orthosis for Stroke Patients' Neurorehabilitation: A Crossover Feasibility Study

Brain-Computer Interfaces (BCI) coupled to robotic assistive devices have shown promise for the rehabilitation of stroke patients. However, little has been reported that compares the clinical and physiological effects of a BCI intervention for upper limb stroke rehabilitation with those of conventional therapy. This study assesses the feasibility of an intervention with a BCI based on electroencephalography (EEG) coupled to a robotic hand orthosis for upper limb stroke rehabilitation and compares its outcomes to conventional therapy. Seven subacute and three chronic stroke patients (M = 59.9 ± 12.8) with severe upper limb impairment were recruited in a crossover feasibility study to receive 1 month of BCI therapy and 1 month of conventional therapy in random order. The outcome measures were comprised of: Fugl-Meyer Assessment of the Upper Extremity (FMA-UE), Action Research Arm Test (ARAT), motor evoked potentials elicited by transcranial magnetic stimulation (TMS), hand dynamometry, and EEG. Additionally, BCI performance and user experience were measured. All measurements were acquired before and after each intervention. FMA-UE and ARAT after BCI (23.1 ± 16; 8.4 ± 10) and after conventional therapy (21.9 ± 15; 8.7 ± 11) were significantly higher (p < 0.017) compared to baseline (17.5 ± 15; 4.3 ± 6) but were similar between therapies (p > 0.017). Via TMS, corticospinal tract integrity could be assessed in the affected hemisphere of three patients at baseline, in five after BCI, and four after conventional therapy. While no significant difference (p > 0.05) was found in patients’ affected hand strength, it was higher after the BCI therapy. EEG cortical activations were significantly higher over motor and non-motor regions after both therapies (p < 0.017). System performance increased across BCI sessions, from 54 (50, 70%) to 72% (56, 83%). Patients reported moderate mental workloads and excellent usability with the BCI. Outcome measurements implied that a BCI intervention using a robotic hand orthosis as feedback has the potential to elicit neuroplasticity-related mechanisms, similar to those observed during conventional therapy, even in a group of severely impaired stroke patients. Therefore, the proposed BCI system could be a suitable therapy option and will be further assessed in clinical trials.

Prognosis of stroke upper limb recovery with physiological variables using regression tree ensembles

Objective.This study assesses upper limb recovery prognosis after stroke with solely physiological information, which can provide an objective estimation of recovery.Approach.Clinical recovery was forecasted using EEG-derived Event-Related Desynchronization/Synchronization and coherence, in addition to Transcranial Magnetic Stimulation elicited motor-evoked potentials and upper limb grip and pinch strength. A Regression Tree Ensemble predicted clinical recovery of a stroke database (n= 10) measured after a two-month intervention with the Fugl-Meyer Assessment for the Upper Extremity (FMA-UE) and the Action Research Arm Test (ARAT).Main results.There were no significant differences between predicted and actual outcomes with FMA-UE (p= 0.29) and ARAT (p= 0.5). Median prediction error for FMA-UE and ARAT were of 0.3 (IQR = 6.2) and 3.4 (IQR = 9.4) points, respectively. Predictions with the most pronounced errors were due to an underestimation of high upper limb recovery. The best features for FMA-UE prediction included mostly beta activity over the sensorimotor cortex. Best ARAT prediction features were cortical beta activity, corticospinal tract integrity of the unaffected hemisphere, and upper limb strength.Significance.Results highlighted the importance of measuring cortical activity related to motor control processes, the unaffected hemisphere's integrity, and upper limb strength for prognosis. It was also implied that stroke upper limb recovery prediction is feasible using solely physiological variables with a Regression Tree Ensemble, which can also be used to analyze physiological relationships with recovery.

Inflated Estimates of Proportional Recovery From Stroke: The Dangers of Mathematical Coupling and Compression to Ceiling

The proportional recovery rule states that most survivors recover a fixed proportion (≈70%) of lost function after stroke. A strong (negative) correlation between the initial score and subsequent change (outcome minus initial; ie, recovery) is interpreted as empirical support for the proportional recovery rule. However, this rule has recently been critiqued, with a central observation being that the correlation of initial scores with change over time is confounded in the situations in which it is typically assessed. This critique has prompted reassessments of patients' behavioral trajectory following stroke in 2 prominent papers. The first of these, by van der Vliet et al presented an impressive modeling of upper limb deficits following stroke, which avoided the confounded correlation of initial scores with change. The second by Kundert et al reassessed the value of the proportional recovery rule, as classically formulated as the correlation between initial scores and change. They argued that while effective prediction of recovery trajectories of individual patients is not supported by the available evidence, group-level inferences about the existence of proportional recovery are reliable. In this article, we respond to the van der Vliet and Kundert papers by distilling the essence of the argument for why the classic assessment of proportional recovery is confounded. In this respect, we reemphasize the role of mathematical coupling and compression to ceiling in the confounded nature of the correlation of initial scores with change. We further argue that this confound will be present for both individual-level and group-level inference. We then focus on the difficulties that can arise from ceiling effects, even when initial scores are not being correlated with change/recovery. We conclude by emphasizing the need for new techniques to analyze recovery after stroke that are not confounded in the ways highlighted here.

Translational Value of Skilled Reaching Assessment in Clinical and Preclinical Studies on Motor Recovery After Stroke

Background

Assessment of skilled reaching enables extensive analysis of upper limb function in clinical and preclinical studies on poststroke outcome. However, translational research if often limited by lack of correspondence between tests of human and rodent motor function.

Objectives

To determine (1) the translational value of skilled reaching performance for preclinical research by comparing the behavioral recovery profiles of skilled reaching characteristics between humans and rats recovering from stroke and (2) the relationship between skilled reaching performance and commonly used clinical outcome measures after stroke.

Methods

Twelve patients with ischemic or hemorrhagic stroke and 17 rats with photothrombotic stroke underwent an equivalent skilled reaching test at different time points, representing early to late subacute stages poststroke. Success scores and a movement element rating scale were used to measure the skilled reaching performance. The Fugl-Meyer Upper Extremity (FM-UE) assessment and the Action Research Arm Test (ARAT) were used as clinical outcome measures.

Results

Both species had muscle flaccidity at the early subacute stage after stroke and showed motor recovery following a proximal-distal principle toward the early subacute stage, albeit for rats within a shorter time course. Human skilled reaching scores and FM-UE and ARAT scores in the first 3 months poststroke were significantly correlated (P < .05).

Conclusions

Our study demonstrates that poststroke changes in skilled reaching performance are highly similar between rats and humans and correspond with standard clinical outcome measures. Skilled reaching testing therefore offers an effective and highly translational means for assessment of motor recovery in experimental and clinical stroke settings.

Comparing a Novel Neuroanimation Experience to Conventional Therapy for High-Dose Intensive Upper-Limb Training in Subacute Stroke: The SMARTS2 Randomized Trial

BACKGROUND

Evidence from animal studies suggests that greater reductions in poststroke motor impairment can be attained with significantly higher doses and intensities of therapy focused on movement quality. These studies also indicate a dose-timing interaction, with more pronounced effects if high-intensity therapy is delivered in the acute/subacute, rather than chronic, poststroke period.

OBJECTIVE

To compare 2 approaches of delivering high-intensity, high-dose upper-limb therapy in patients with subacute stroke: a novel exploratory neuroanimation therapy (NAT) and modified conventional occupational therapy (COT).

METHODS

A total of 24 patients were randomized to NAT or COT and underwent 30 sessions of 60 minutes time-on-task in addition to standard care. The primary outcome was the Fugl-Meyer Upper Extremity motor score (FM-UE). Secondary outcomes included Action Research Arm Test (ARAT), grip strength, Stroke Impact Scale hand domain, and upper-limb kinematics. Outcomes were assessed at baseline, and days 3, 90, and 180 posttraining. Both groups were compared to a matched historical cohort (HC), which received only 30 minutes of upper-limb therapy per day.

RESULTS

There were no significant between-group differences in FM-UE change or any of the secondary outcomes at any timepoint. Both high-dose groups showed greater recovery on the ARAT (7.3 ± 2.9 points; P = .011) but not the FM-UE (1.4 ± 2.6 points; P = .564) when compared with the HC.

CONCLUSIONS

Neuroanimation may offer a new, enjoyable, efficient, and scalable way to deliver high-dose and intensive upper-limb therapy.

Responsiveness of kinematic and clinical measures of upper-limb motor function after stroke: A systematic review and meta-analysis

BACKGROUND

Kinematic analysis and clinical outcome measures with established responsiveness contribute to the quantified assessment of upper-limb function post-stroke, the selection of interventions and the differentiation of motor recovery patterns.

OBJECTIVE

This systematic review and meta-analysis aimed to report trends in use and compare the responsiveness of kinematic and clinical measures in studies measuring the effectiveness of constraint-induced movement, trunk restraint and bilateral arm therapies for upper-limb function after stroke.

METHODS

In this systematic review, randomised controlled trials implementing kinematic analysis and clinical outcome measures to evaluate the effects of therapies in post-stroke adults were eligible. We searched 8 electronic databases (MEDLINE, EMBASE, Web of Science, Scopus, CINAHL, CENTRAL, OTseeker and Pedro). Risk of bias was assessed according to the Cochrane Risk of Bias domains. A meta-analysis was conducted for repeated design measures of pre- and post-test data providing estimated standardised mean differences (SMDs).

RESULTS

We included reports of 12 studies (191 participants) reporting kinematic smoothness, movement duration and efficiency, trunk and shoulder range of motion, control strategy and velocity variables in conjunction with assessment by Motor Activity Log, Fugl-Meyer Assessment and Wolf Motor Function Test. Responsiveness was higher (i.e., non-overlap of 95% confidence intervals [CIs]) for Motor Activity Log score (SMD for amount of use 1.0, 95% CI 0.75-1.25, P<0.001; SMD for quality of movement 0.96, 95% CI 0.72-1.20, P<0.001) than movement efficiency, trunk and shoulder range of motion, control strategy and peak velocity.

CONCLUSION

These results are consistent with current literature supporting the use of combined kinematic and clinical measures for comprehensive and accurate evaluation of upper-limb function post-stroke. Future research should include other design trials and rehabilitation types to confirm these findings, focusing on subgroup analysis of type of rehabilitation intervention and functional levels.

Psychometric properties of measures of upper limb activity performance in adults with and without spasticity undergoing neurorehabilitation-A systematic review

INTRODUCTION

This systematic review appraises the measurement quality of tools which assess activity and/or participation in adults with upper limb spasticity arising from neurological impairment, including methodological quality of the psychometric studies. Differences in the measurement quality of the tools for adults with a neurological impairment, but without upper limb spasticity, is also presented.

METHODS

29 measurement tools identified in a published review were appraised in this systematic review. For each identified tool, we searched 3 databases (Medline, Embase, CINAHL) to identify psychometric studies completed with neurorehabilitation samples. Methodological quality of instrument evaluations was assessed with use of the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN) checklist. Synthesis of ratings allowed an overall rating of the psychometric evidence for each measurement tool to be calculated.

RESULTS

149 articles describing the development or evaluation of psychometric properties of 22 activity and/or participation measurement tools were included. Evidence specific to tool use for adults with spasticity was identified within only 15 of the 149 articles and provided evidence for 9 measurement tools only. Overall, COSMIN appraisal highlighted a lack of evidence of measurement quality. Synthesis of ratings demonstrated all measures had psychometric weaknesses or gaps in evidence (particularly for use of tools with adults with spasticity).

CONCLUSIONS

The systematic search, appraisal and synthesis revealed that currently there is insufficient measurement quality evidence to recommend one tool over another. Notwithstanding this conclusion, newer tools specifically designed for use with people with neurological conditions who have upper limb spasticity, have emergent measurement properties that warrant further research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014013190.

Can the ARAT Be Used to Measure Arm Function in People With Cerebellar Ataxia?

OBJECTIVE

For people with ataxia, there are validated outcome measures to address body function and structure (BFS) impairments and participation; however, no outcome measure exists for upper extremity (UE) activity level in this population. The purpose of this study was to determine whether the action research arm test (ARAT), a measure of UE activity validated for other neurological conditions, might be a useful outcome measure for capturing UE activity limitations in ataxia.

METHODS

A total of 22 participants with ataxia were evaluated to assess construct validity of the ARAT; 19 of the participants were included in the interrater reliability assessment. Participants received a neurologic examination and completed a battery of outcome measures, including the ARAT. ARAT performance was video recorded and scored by 4 additional raters.

RESULTS

For construct validity, Spearman rho showed a significant moderate relationship between the ARAT and BSF outcome measures. A small, nonsignificant relationship was noted for the ARAT and the participation measure. For interrater reliability, Spearman rho showed a large, significant relationship among all raters for the ARAT (range = .87-.94). High reliability was demonstrated using the intraclass correlation coefficient ([2,1] = .97).

CONCLUSION

The ARAT is moderately correlated with ataxia BFS outcome measures, but not with participation scores. The ARAT is a measure of UE activity, which is different from BFS and participation outcome measures. The ARAT was identified to have strong interrater reliability among raters with varying amounts of experience administering the ARAT. Thus, for the ataxic population, the ARAT may be useful for assessing UE activity limitations.

IMPACT

Ataxia can negatively affect reaching tasks; therefore, it is important to assess UE activity level in people with ataxia. Until this study, no outcome measure had been identified for this purpose.

LAY SUMMARY

People with ataxia may have difficulty with daily tasks that require reaching. The ARAT is an outcome measure that clinicians can use to assess UE activity limitations to help design a treatment program.

Improving Accelerometry-Based Measurement of Functional Use of the Upper Extremity After Stroke: Machine Learning Versus Counts Threshold Method

BACKGROUND

Wrist-worn accelerometry provides objective monitoring of upper-extremity functional use, such as reaching tasks, but also detects nonfunctional movements, leading to ambiguity in monitoring results.

OBJECTIVE

Compare machine learning algorithms with standard methods (counts ratio) to improve accuracy in detecting functional activity.

METHODS

Healthy controls and individuals with stroke performed unstructured tasks in a simulated community environment (Test duration = 26 ± 8 minutes) while accelerometry and video were synchronously recorded. Human annotators scored each frame of the video as being functional or nonfunctional activity, providing ground truth. Several machine learning algorithms were developed to separate functional from nonfunctional activity in the accelerometer data. We also calculated the counts ratio, which uses a thresholding scheme to calculate the duration of activity in the paretic limb normalized by the less-affected limb.

RESULTS

The counts ratio was not significantly correlated with ground truth and had large errors (r = 0.48; P = .16; average error = 52.7%) because of high levels of nonfunctional movement in the paretic limb. Counts did not increase with increased functional movement. The best-performing intrasubject machine learning algorithm had an accuracy of 92.6% in the paretic limb of stroke patients, and the correlation with ground truth was r = 0.99 (P < .001; average error = 3.9%). The best intersubject model had an accuracy of 74.2% and a correlation of r =0.81 (P = .005; average error = 5.2%) with ground truth.

CONCLUSIONS

In our sample, the counts ratio did not accurately reflect functional activity. Machine learning algorithms were more accurate, and future work should focus on the development of a clinical tool.

Gains Across WHO Dimensions of Function After Robot-Based Therapy in Stroke Subjects

BACKGROUND

Studies examining the effects of therapeutic interventions after stroke often focus on changes in loss of body function/structure (impairment). However, improvements in activities limitations and participation restriction are often higher patient priorities, and the relationship that these measures have with loss of body function/structure is unclear.

OBJECTIVE

This study measured gains across WHO International Classification of Function (ICF) dimensions and examined their interrelationships.

METHODS

Subjects were recruited 11 to 26 weeks after hemiparetic stroke. Over a 3-week period, subjects received 12 sessions of intensive robot-based therapy targeting the distal arm. Each subject was assessed at baseline and at 1 month after end of therapy.

RESULTS

At baseline, subjects (n = 40) were 134.7 ± 32.4 (mean ± SD) days poststroke and had moderate-severe arm motor deficits (arm motor Fugl-Meyer score of 35.6 ± 14.4) that were stable. Subjects averaged 2579 thumb movements and 1298 wrist movements per treatment session. After robot therapy, there was significant improvement in measures of body function/structure (Fugl-Meyer score) and activity limitations (Action Research Arm Test, Barthel Index, and Stroke Impact Scale-Hand), but not participation restriction (Stroke Specific Quality of Life Scale). Furthermore, while the degree of improvement in loss of body function/structure was correlated with improvement in activity limitations, neither improvement in loss of body function/structure nor improvement in activity limitations was correlated with change in participation restriction.

CONCLUSIONS

After a 3-week course of robotic therapy, there was improvement in body function/structure and activity limitations but no reduction in participation restriction.