Movement-dependent stroke recovery: a systematic review and meta-analysis of TMS and fMRI evidence

Gamified Practice Improves Paretic Arm Motor Behavior in Individuals With Stroke

BACKGROUND

Stroke is a heterogeneous condition, making choice of treatment, and determination of how to structure rehabilitation outcomes difficult. Individualized goal-directed and repetitive physical practice is an important determinant of motor learning. Yet, many investigations of motor learning after stroke deliver task practice without consideration of individual capability of the learner.

OBJECTIVE

We developed a gamified arm rehabilitation task for people with stroke that is personalized to individual capacity for paretic arm movement, provides a high dose of practice, progresses through increasingly difficulty levels that are dependent on the performance of the individual, and is practiced in an engaging environment. The objectives of the current study were to determine if 10 days of gamified, object intercept training using the paretic arm would improve arm movement speed and clinical outcome measures of impairment or function.

METHODS

Individuals with chronic stroke and age-matched controls engaged in 10 days of gamified, skilled motor practice of a semi-immersive virtual reality-based intercept and release task. The paretic arm was assessed using the Fugl-Meyer Assessment (motor impairment) and Wolf Motor Function Test (motor function) before and after training.

RESULTS

Both groups showed faster arm movement speed with practice; individuals with stroke demonstrated reduced paretic arm motor impairment and increased function after the intervention. Age and sex (for both groups), and time post-stroke were not related to changes in movement speed.

CONCLUSIONS

Findings indicate that gamified motor training positively affects paretic arm motor behavior in individuals with mild to severe chronic stroke.

Effect of functional electrical stimulation-based mirror therapy using gesture recognition biofeedback on upper extremity function in patients with chronic stroke: A randomized controlled trial

BACKGROUND

Mirror therapy (MT) is an intervention used for upper extremity rehabilitation in stroke patients and has been studied in various fields. Recently, effective MT methods have been introduced in combination with neuromuscular electrical stimulation or with electromyography (EMG)-triggered biofeedback. The purpose of this study was to investigate the effects of functional electrical stimulation (FES)-based MT incorporating a motion recognition biofeedback device on upper extremity motor recovery to chronic stroke patients.

METHODS

Twenty-six chronic stroke patients with onset of more than 6 months were randomly assigned into experimental group (n = 13) and control group (n = 13). Both groups participated in conventional rehabilitation program, while the control group received conventional MT intervention and the experimental group received FES-based MT with motion recognition biofeedback device. All interventions were conducted for 30 min/d, 5 d/wk, for 4 weeks. Upper limb motor recovery, upper limb function, active-range of motion (ROM), and activities of daily living independence were measured before and after the intervention and compared between the 2 groups.

RESULTS

The Fugl-Meyer assessment (FMA), manual function test (MFT), K-MBI, and active-ROM (excluding deviation) were significantly improved in both groups (P < .05). Only the experimental group showed significant improvement in upper extremity recovery, ulnar and radial deviation (P < .05). There was a significant difference of change in Brunstrom's recovery level, FMA, MFT, and active-ROM in the experimental group compared to the control group (P < .05).

CONCLUSION

FES-based MT using gesture recognition biofeedback is an effective intervention method for improving upper extremity motor recovery and function, active-ROM in patients with chronic stroke. This study suggests that incorporating gesture-recognition biofeedback into FES-based MT can provide additional benefits to patients with chronic stroke.

An analysis of clinical outcomes and essential parameters for designing effective games for upper limb rehabilitation: A scoping review

Background and Aims

Upper limb disabilities are one of the most common disabilities among different groups of people who always need rehabilitation. One of the important methods in helping to carry out efficient rehabilitation processes and exercises is the use of games. The aim of this study is to identify the parameters necessary to design a successful rehabilitation game and the outcomes of using these games in upper limb disabilities rehabilitation.

Methods

This scoping review was conducted by searching the Web of Science, PubMed, and Scopus. The eligibility criteria were: any form of game-based upper limb rehabilitation, published in a peer-reviewed journal, published in English, and not include articles that did not focus upper limb disabilities rehabilitation games, review, meta-analysis, or conference papers. Analysis of collected data was done using descriptive statistics (frequency and percentage).

Results

The search strategy retrieved 537 relevant articles. Finally, after removing irrelevant and repetitive articles, 21 articles were included in this study. Among the six categories of diseases or complications of upper limb disabilities, games were mostly designed for stroke patients. Smart wearables, robots and telerehabilitation were three technologies that were used for rehabilitation along with games. Sports and shooters were the most used games for upper limb disability rehabilitation. Among 99 necessary parameters for designing and implementing a successful rehabilitation game in ten categories. "Increasing the patient's motivation to perform rehabilitation exercises", "Game difficulty levels", "Enjoying and the attractiveness of the game for patients", and "Providing positive or negative audiovisual feedback" were the most important parameters. "Improvement in musculoskeletal performance" and "Increasing users' enjoyment/joy of therapeutic exercises and their motivation to perform these exercises" were the most important positive outcomes, and "Mild discomfort such as nausea and dizziness when using games" was the only negative outcome.

Conclusions

The successful design of a game according to the parameters identified in the present study can lead to an increase in the positive outcomes of using games in the rehabilitation of disabilities. The study results indicate that upper limb therapeutic exercise augmented with virtual reality games may be highly effective in enhancing motor rehabilitation outcomes.

Effect of High-Frequency rTMS Combined with Bilateral Arm Training on Brain Functional Network in Patients with Chronic Stroke: An fNIRS study

OBJECTIVE

Neurological evidence for the combinational intervention coupling rTMS with motor training for stroke rehabilitation remains limited. This study aimed to investigate the effects of rTMS combined with bilateral arm training (BAT) on the brain functional reorganization in patients with chronic stroke via functional near-infrared spectroscopy (fNIRS).

METHODS

Fifteen stroke patients and fifteen age-matched healthy participants were enrolled and underwent single BAT session (s-BAT) and BAT immediately after 5-Hz rTMS over the ipsilesional M1 (rTMS-BAT), measured cerebral haemodynamics by fNIRS. Functional connectivity (FC), the clustering coefficient (C_coef), and local efficiency (E_loc) were applied to evaluate the functional response to the training paradigms.

RESULTS

The differences in FC responses to the two training paradigms were more pronounced in stroke patients than in healthy controls. In the resting state, stroke patients exhibited significantly lower FC than controls in both hemispheres. rTMS-BAT induced no significant difference in FC between groups. Compared to the resting state, rTMS-BAT induced significant decreases in C_coef and E_loc of the contralesional M1 and significant increases in E_loc of the ipsilesional M1 in stroke patients. Additionally, these above two network metrics of the ipsilesional motor area were significantly positively correlated with the motor function of stroke patients.

CONCLUSIONS

These results suggest that the rTMS-BAT paradigm had additional effects on task-dependent brain functional reorganization. The engagement of the ipsilesional motor area in the functional network was associated with the motor impairment severity of stroke patients. fNIRS-based assessments may provide information about the neural mechanisms underlying combination interventions for stroke rehabilitation.

The treatment of post-stroke dysarthria with a combination of different acupuncture types and language rehabilitation training: a systematic review and network meta-analysis

Background

This study used a network meta-analysis to evaluate the efficacy of various different acupuncture types and language rehabilitation training on post-stroke dysarthria (PSD), and examined the possible mechanisms involved. There are often clinical studies comparing the effects of different acupuncture methods on dysarthria after stroke. The efficacy of these methods can be ranked by network meta-analysis. This is necessary for clinical acupoints selection. The results of this study illustrated the comparison of the therapeutic effects of 6 different acupuncture types, which can provide some reference for clinical acupoints selection and research.

Methods

A comprehensive search for clinical studies related to the use of acupuncture to treat PSD was conducted in eight English and Chinese databases. Patients were divided into six groups based on the acupoints selected, namely, tongue, neck, scalp, body, combination, and traditional acupuncture. The recovery of neurological function in the patients was assessed based on the curative impact and the National Institutes of Health Stroke Scale (NIHSS) score. The quality of the included studies was evaluated using the Cochrane risk bias assessment tool and the STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) criteria. A network meta-analysis was performed using the network-meta package of Stata 15.1 software based on frequency. The heterogeneity test, consistency test, head-to-head mixed comparison, efficacy ranking, and publication bias study were all performed.

Results

A total of 47 studies were finally included. There was a total of 4,197 patients in the eligible studies. The model for network meta-analysis proved robust, with minimal heterogeneity and high consistency. Combined acupuncture combined with language rehabilitation training was the most effective in treating dysarthria symptoms, followed by tongue acupuncture (TA) and nape acupuncture (NA). In addition, the combined effect of acupuncture and language training was superior to that of acupuncture alone. In terms of recovery of nerve function, traditional acupuncture and body acupuncture were more effective. To facilitate the recovery of nerve function, increasing the frequency of acupoints is necessary.

Conclusions

Combined acupuncture may have the most beneficial healing effect on PSD, followed by acupuncture of the tongue and the nape of the neck. In terms of recovery of nerve function, traditional acupuncture and body acupuncture may have more effective.

Application of DTI and fMRI in moyamoya disease

Moyamoya disease (MMD) is a chronic and progressive cerebrovascular stenosis or occlusive disease that occurs near Willis blood vessels. Diffusion tensor imaging (DTI) and functional magnetic resonance imaging (fMRI) are used to detect the microstructure of white matter and the function of gray matter, respectively. The damage of these structures will lead to the change of cognitive level in patients with moyamoya disease. In this paper, the principles of DTI and fMRI, their applications and challenges in moyamoya disease are reviewed.

Genetic Algorithm for TMS Coil Position Optimization in Stroke Treatment

Transcranial magnetic stimulation (TMS), a non-invasive technique to stimulate human brain, has been widely used in stroke treatment for its capability of regulating synaptic plasticity and promoting cortical functional reconstruction. As shown in previous studies, the high electric field (E-field) intensity around the lesion helps in the recovery of brain function, thus the spatial location and angle of coil truly matter for the significant correlation with therapeutic effect of TMS. But, the error caused by coil placement in current clinical setting is still non-negligible and a more precise coil positioning method needs to be proposed. In this study, two kinds of real brain stroke models of ischemic stroke and hemorrhagic stroke were established by inserting relative lesions into three human head models. A coil position optimization algorithm, based on the genetic algorithm (GA), was developed to search the spatial location and rotation angle of the coil in four 4 × 4 cm search domains around the lesion. It maximized the average intensity of the E-field in the voxel of interest (VOI). In this way, maximum 17.48% higher E-field intensity than that of clinical TMS stimulation was obtained. Besides, our method also shows the potential to avoid unnecessary exposure to the non-target regions. The proposed algorithm was verified to provide an optimal position after nine iterations and displayed good robustness for coil location optimization between different stroke models. To conclude, the optimized spatial location and rotation angle of the coil for TMS stroke treatment could be obtained through our algorithm, reducing the intensity and duration of human electromagnetic exposure and presenting a significant therapeutic potential of TMS for stroke.

Low-Frequency rTMS over Contralesional M1 Increases Ipsilesional Cortical Excitability and Motor Function with Decreased Interhemispheric Asymmetry in Subacute Stroke: A Randomized Controlled Study

Objective

To determine the long-term effects of low-frequency repetitive transcranial magnetic stimulation (LF-rTMS) over the contralesional M1 preceding motor task practice on the interhemispheric asymmetry of the cortical excitability and the functional recovery in subacute stroke patients with mild to moderate arm paresis.

Methods

Twenty-four subacute stroke patients were randomly allocated to either the experimental or control group. The experimental group underwent rTMS over the contralesional M1 (1 Hz), immediately followed by 30 minutes of motor task practice (10 sessions within 2 weeks). The controls received sham rTMS and the same task practice. Following the 2-week intervention period, the task practice was continued twice weekly for another 10 weeks in both groups. Outcomes were evaluated at baseline (T0), at the end of the 2-week stimulation period (T1), and at 12-week follow-up (T2).

Results

The MEP (paretic hand) and interhemispheric asymmetry, Fugl-Meyer motor assessment, Action Research Arm Test, and box and block test scores improved more in the experimental group than controls at T1 (p < 0.05). The beneficial effects were largely maintained at T2.

Conclusion

LF-rTMS over the contralesional M1 preceding motor task practice was effective in enhancing the ipsilesional cortical excitability and upper limb function with reducing interhemispheric asymmetry in subacute stroke patients with mild to moderate arm paresis. Significance. Adding LF-rTMS prior to motor task practice may reduce interhemispheric asymmetry of cortical excitabilities and promote upper limb function recovery in subacute stroke with mild to moderate arm paresis.

Evidence for the Effectiveness of Feedback from Wearable Inertial Sensors during Work-Related Activities: A Scoping Review

Background: Wearable inertial sensor technology (WIST) systems provide feedback, aiming to modify aberrant postures and movements. The literature on the effects of feedback from WIST during work or work-related activities has not been previously summarised. This review examines the effectiveness of feedback on upper body kinematics during work or work-related activities, along with the wearability and a quantification of the kinematics of the related device. Methods: The Cinahl, Cochrane, Embase, Medline, Scopus, Sportdiscus and Google Scholar databases were searched, including reports from January 2005 to July 2021. The included studies were summarised descriptively and the evidence was assessed. Results: Fourteen included studies demonstrated a 'limited' level of evidence supporting posture and/or movement behaviour improvements using WIST feedback, with no improvements in pain. One study assessed wearability and another two investigated comfort. Studies used tri-axial accelerometers or IMU integration (n = 5 studies). Visual and/or vibrotactile feedback was mostly used. Most studies had a risk of bias, lacked detail for methodological reproducibility and displayed inconsistent reporting of sensor technology, with validation provided only in one study. Thus, we have proposed a minimum 'Technology and Design Checklist' for reporting. Conclusions: Our findings suggest that WIST may improve posture, though not pain; however, the quality of the studies limits the strength of this conclusion. Wearability evaluations are needed for the translation of WIST outcomes. Minimum reporting standards for WIST should be followed to ensure methodological reproducibility.

Effects of virtual reality intervention on neural plasticity in stroke rehabilitation: a systematic review

OBJECTIVE

To systematically review and examine the current literature regarding the effects of Virtual Reality (VR)-based rehabilitation on neural plasticity changes in stroke survivors.

DATA SOURCES

Six bioscience and engineering databases were searched, including Medline via Ebsco, Embase, PsycINFO, IEEE Explore, Cumulative Index of Nursing and Allied Health, and Scopus.

STUDY SELECTION

Studies reporting on the pre-post assessment of a VR intervention with neural plasticity measures published between 2000-2021 were included.

DATA EXTRACTION

Two independent reviewers conducted study selection, data extraction and quality assessment. Methodological quality of controlled trials was assessed using the Physiotherapy Evidence Database scale. Risk of bias of pre-post intervention and case studies was evaluated using the National Institutes of Health Quality Assessment Tool.

DATA SYNTHESIS

Twenty-seven studies (Total n=232) were included. Seven randomized controlled trials were rated as good quality while the two clinical controlled trials were moderate. Based on the risk of bias assessment, one pre-post study and one case study were graded as good quality, one pre-post study and one case study were poor, the other 14 studies were all at fair. After the VR intervention, main neurophysiological findings across studies include: (1) improved interhemispheric balance, (2) enhanced cortical connectivity, (3) increased cortical mapping of the affected limb muscles, (4) the improved neural plasticity measures were correlated to the enhanced behavior outcomes, (5) increased activation of regions in frontal cortex and (6) the mirror neuron system may be involved.

CONCLUSIONS

Virtual reality induced changes in neural plasticity for stroke survivors. Positive correlations between the neural plasticity changes and functional recovery elucidates the mechanisms of VR's therapeutic effects in stroke rehabilitation. This review prompts systematic understanding of the neurophysiological mechanisms of VR-based stroke rehabilitation and summarizes the emerging evidence for ongoing innovation of VR systems and application in stroke rehabilitation.

Zakaria H, M. Ragab W, Al Awaji NN, Y. Elzanaty M, R. Elserougy H. Therapeutic Efficacy of Transcutaneous Electrical Nerve Stimulation Acupoints on Motor and Neural Recovery of the Affected Upper Extremity in Chronic Stroke: A Sham-Controlled Randomized Clinical Trial

Inability to use the affected upper extremity (UE) in daily activities is a common complaint in stroke patients. The somatosensory system (central and peripheral) is essential for brain reorganization and plasticity. Neuromuscular electrical stimulation is considered an effective modality for improving UE function in stroke patients. The aim of the current study was to determine the therapeutic effects of transcutaneous electrical nerve stimulation (TENS) acupoints on cortical activity and the motor function of the affected UE in chronic stroke patients. Forty male and female patients diagnosed with stroke agreed to join the study. They were randomly assigned to group 1 (G1) and group 2 (G2). G1 received task-specific training (TST) and sham electrical stimulation while G2 received TST in addition to TENS acupoints. Session duration was 80 min. Both groups received 18 sessions for 6 successive weeks, 3 sessions per week. Evaluation was carried out before and after completion of the treatment program. Outcome measures used were the Fugl-Meyer Assessment of the upper extremity (FMA-UE) and the box and block test (BBT) as measures of the motor function of the affected UE. Brain activity of the motor area (C3) in the ipsilesional hemisphere was measured using a quantitative electroencephalogram (QEEG). The measured parameter was peak frequency. It was noted that the motor function of the affected UE improved significantly post-treatment in both groups, while no significant change was reported in the FMA-UE and BBT scores post-treatment in either G1 or G2. On the other hand, the activity of the motor area C3 improved significantly in G2 only, post-treatment, while G1 showed no significant improvement. There was also significant improvement in the activity of the motor area (C3) in G2 compared to G1 post-treatment. The results of the current study indicate that TST only or combined with TENS acupoints can be considered an effective method for improving motor function of the affected UE in chronic stroke patients, both being equally effective. However, TST combined with TENS acupoints proved better in improving brain plasticity in chronic stroke patients.

Task-related brain functional network reconfigurations relate to motor recovery in chronic subcortical stroke

Stroke leads to both regional brain functional disruptions and network reorganization. However, how brain functional networks reconfigure as task demand increases in stroke patients and whether such reorganization at baseline would facilitate post-stroke motor recovery are largely unknown. To address this gap, brain functional connectivity (FC) were examined at rest and motor tasks in eighteen chronic subcortical stroke patients and eleven age-matched healthy controls. Stroke patients underwent a 2-week intervention using a motor imagery-assisted brain computer interface-based (MI-BCI) training with or without transcranial direct current stimulation (tDCS). Motor recovery was determined by calculating the changes of the upper extremity component of the Fugl-Meyer Assessment (FMA) score between pre- and post-intervention divided by the pre-intervention FMA score. The results suggested that as task demand increased (i.e., from resting to passive unaffected hand gripping and to active affected hand gripping), patients showed greater FC disruptions in cognitive networks including the default and dorsal attention networks. Compared to controls, patients had lower task-related spatial similarity in the somatomotor-subcortical, default-somatomotor, salience/ventral attention-subcortical and subcortical-subcortical connections, suggesting greater inefficiency in motor execution. Importantly, higher baseline network-specific FC strength (e.g., dorsal attention and somatomotor) and more efficient brain network reconfigurations (e.g., somatomotor and subcortical) from rest to active affected hand gripping at baseline were related to better future motor recovery. Our findings underscore the importance of studying functional network reorganization during task-free and task conditions for motor recovery prediction in stroke.

Task-oriented circuit training combined with aerobic training improves motor performance and balance in people with Parkinson's Disease

Goal-based training such as task practice combined with aerobic training (AT) has been suggested to improve motor performance and neuroplasticity for people with Parkinson's Disease (PwPD); however, its effect on clinical outcomes is unclear. Therefore, the main aim was to investigate the effects of task-oriented circuit training combined with AT (TOCT-AT) on balance and gait in PwPD. The secondary aim was to investigate the effects of TOCT-AT on functional mobility, balance confidence, disease severity, and quality of life. Twenty-six PwPD were randomly assigned to either to the experimental group (n = 14) or the control group (n = 12). The control group received AT, while the experimental group received TOCT-AT three times a week for 8 weeks. The main outcomes were the Berg Balance Scale (BBS), Postural Stability Test (PST), Limits of Stability Test (LOS), Pull Test (PT), Six Minute Walk Test (6MWT), Timed Up and Go Test (TUG), Activities-specific Balance Confidence Scale (ABC), Unified Parkinson's Disease Rating Scale (UPDRS), and eight-item Parkinson's Disease Questionnaire (PDQ-8) were secondary outcomes. After intervention, between-group comparisons showed that the experimental group significantly improved more than the control group in all outcomes (p < 0.05). Additionally, both groups significantly improved in BBS, 6MWT, TUG, ABC, UPDRS-II, UPDRS-III, UPDRS total, and PDQ-8 (p < 0.05), while only the experimental group significantly improved in PST, LOS, and PT (p < 0.001). This study suggest that TOCT-AT could improve balance and gait performance, which could also be positively translated into functional mobility, balance confidence, disease severity, and quality of life in PwPD.

Clinical Neurorehabilitation: Using Principles of Neurological Diagnosis, Prognosis, and Neuroplasticity in Assessment and Treatment Planning

Neurorehabilitation aspires to restore a person to his or her fullest potential after incurring neurological dysfunction. In medical rehabilitation, diagnosis involves assessment of medical conditions and their effects on functioning. It is usually a team effort that involves an amalgam of diagnostic assessments by multiple disciplines, leading to a collection of rehabilitative treatment plans and goals. This article discusses a clinical neurological paradigm, using rigorous clinical assessment of neuropathological and clinical diagnosis, along with prognostication of natural history and recovery. In the context of the role of neuroplasticity in recovery, this paradigm can add significant value to rehabilitation team management and planning. It contributes to enhanced understanding of neurological impairments and syndromes as they relate to functional disability, aiding in targeting deficits and setting treatment goals. Rehabilitation strategies and goals should be informed by natural history and prognosis, and viewed in the framework of the stage of recovery. Prognostic formulations should suggest an emphasis on restorative versus compensatory strategies for functional problems. Treatment planning should be informed by evidence on how interventions modulate brain reorganization in promoting recovery. Strategies that promote adaptive neuroplasticity should be favored, especially with restorative efforts, and evidence supporting optimal techniques, timing, and dosing of rehabilitation should be considered in treatment planning.

From adults to pediatrics: A review noninvasive brain stimulation (NIBS) to facilitate recovery from brain injury

Stroke is a major problem worldwide that impacts over 100 million adults and children annually. Rehabilitation therapy is the current standard of care to restore functional impairments post-stroke, however its effects are limited and many patients suffer persisting functional impairments and life-long disability. Noninvasive Brain Stimulation (NIBS) has emerged as a potential rehabilitation treatment option in both adults and children with brain injury. In the last decade, Transcranial Magnetic Stimulation (TMS), Transcranial Direct Current Stimulation (tDCS) and Transcutaneous Auricular Vagus Nerve Stimulation (taVNS) have been investigated to improve motor recovery in adults post-stroke. These promising adult findings using NIBS, however, have yet to be widely translated to the area of pediatrics. The limited studies exploring NIBS in children have demonstrated safety, feasibility, and utility of stimulation-augmented rehabilitation. This chapter will describe the mechanism of NIBS therapy (cortical excitability, neuroplasticity) that underlies its use in stroke and motor function and how TMS, tDCS, and taVNS are applied in adult stroke treatment paradigms. We will then discuss the current state of NIBS in early pediatric brain injury and will provide insight regarding practical considerations and future applications of NIBS in pediatrics to make this promising treatment option a viable therapy in children.

The effect of transcranial direct current stimulation combined with functional task training on motor recovery in stroke patients

BACKGROUND

Motor deficits are common after stroke and are a major contributor to stroke-related disability and the potential for long-lasting neurobiological consequences of stroke remains unresolved. There are only a few treatments available for the improvement of motor function in stroke patients. However, the mechanisms underlying stroke recovery remain poorly understood, and effective neurorehabilitation interventions remain insufficiently proven for widespread implementation.

METHODS

Herein, we propose to enhance the effects of brain plasticity using a powerful noninvasive technique for brain modulation consisting of navigated transcranial magnetic stimulation (TMS) priming with transcranial direct current stimulation (tDCS) in combination with motor-training-like constraint-induced movement therapy (CIMT). Our hypothesis is that navigated low-frequency rTMS stimulus priming with precise location provided by neuronavigation on the healthy side of the brain and with anodal tDCS on the affected side combined with CIMT will induce a greater motor function improvement than that obtained with sham tDCS combined with CIMT alone. We predict that the application of this technique will result in a large reduction in cortical excitability and dis-inhibition in the affected hemisphere and lead to improvements in behavioral measures of hand function in stroke patients.

DISCUSSION

The proposed study, therefore, is important for several reasons. The results could potentially lead to improved stroke therapeutics, and the approach makes use of 2 potential pathways to modulate brain function.

TRIAL REGISTRATION

This study protocol was registered in Clinical Trials Registry (https://clinicaltrials.gov/ct2/show/NCT04646577).

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the Human Research Ethics Committee of the King Fahad Specialist Hospital Dammam. The results will be actively disseminated through peer-reviewed journals, conference presentations, social media, broadcast media, print media, the internet and various community/stakeholder engagement activities.

Development of anatomically accurate brain phantom for experimental validation of stimulation strengths during TMS

Transcranial magnetic stimulation (TMS) is a non-invasive technique for diagnosis and treatment of various neurological conditions. However, the lack of realistic physical models to test the safety and efficacy of stimulation from magnetic fields generated by the coils has hindered the development of new TMS treatment and diagnosis protocols for several neurological conditions. We have developed an anatomically and geometrically accurate brain and head phantom with an adjustable electrical conductivity matching the average conductivity of white matter and grey matter of the human brain and the cerebrospinal fluid. The process of producing the phantom starts with segmenting the MRI images of the brain and then creating shells from the segmented and reconstructed model ready for 3-D printing and serving as a mold for the conductive polymer. Furthermore, we present SEM images and conductivity measurements of the conductive polymer composite as well as confirmation of the anatomical accuracy of the phantom with computed tomography (CT) images. Finally, we show the results of induced voltage measurements obtained from TMS on the brain phantom.

Motor Imagery Hand Movement Direction Decoding Using Brain Computer Interface to Aid Stroke Recovery and Rehabilitation

Motor Imagery (MI)-based Brain Computer Interface (BCI) system is a potential technology for active neurorehabilitation of stroke patients by complementing the conventional passive rehabilitation methods. Research to date mainly focused on classifying left vs. right hand/foot MI of stroke patients. Though a very few studies have reported decoding imagined hand movement directions using electroencephalogram (EEG)-based BCI, the experiments were conducted on healthy subjects. Our work analyzes MI-based brain cortical activity from EEG signals and decodes the imagined hand movement directions in stroke patients. The decoded direction (left vs. right) of hand movement imagination is used to provide control commands to a motorized arm support on which patient's affected (paralyzed) arm is placed. This enables the patient to move his/her stroke-affected hand towards the intended (imagined) direction that aids neuroplasticity in the brain. The synchronization measure called Phase Locking Value (PLV), extracted from EEG, is the neuronal signature used to decode the directional movement of the MI task. Event-related desynchronization/synchronization (ERD/ERS) analysis on Mu and Beta frequency bands of EEG is done to select the time bin corresponding to the MI task. The dissimilarities between the two directions of MI tasks are identified by selecting the most significant channel pairs that provided maximum difference in PLV features. The training protocol has an initial calibration session followed by a feedback session with 50 trials of MI task in each session. The feedback session extracts PLV features corresponding to most significant channel pairs which are identified in the calibration session and is used to predict the direction of MI task in left/right direction. An average MI direction classification accuracy of 74.44% is obtained in performing the training protocol and 68.63% from the prediction protocol during feedback session on 16 stroke patients.

A Comparative Study on the Effect of Task Specific Training on Right Versus Left Chronic Stroke Patients

Functional impairment of the upper limb (UL) after stroke is a great problem. Finding methods that can improve UL function after stroke is a major concern to all medical service providers. This study was intended to compare the effect of upper limb task specific training (TST) on brain excitability of the affected hemisphere and motor function improvements in patients with left and right stroke. Forty male patients with mild impairment of UL functions were divided into two equal groups; G1 consisted of patients with left hemisphere affection (right side stroke) while G2 consisted of patients with right hemisphere affection (left side stroke). All patients received TST for the affected UL for one hour, three sessions per week for six consecutive weeks. Evaluation was performed twice, pre-, and post-treatment. Outcome measures used were Wolf Motor Function Test (WMFT) and Box and Block Test (BBT) as measures of UL motor function and Quantitative Electroencephalogram (QEEG) of motor and sensory areas of the affected hemisphere as a measure of brain reorganization post-stroke. Both groups showed improvement in motor function of the affected UL measured by WMFT and BBT with reported significant difference between them. G1 showed greater improvement in motor function of the affected UL post-treatment compared to G2. Additionally, there was a significant increase in peak frequency of motor and sensory areas with higher and significant excitability in G1 only. These findings imply that brain reorganization in the left hemisphere responded more to TST compared to the right hemisphere. Based on findings of the current study, we can recommend adding TST to the physical therapy program in stroke patients with left hemisphere lesions.

Individual head models for estimating the TMS-induced electric field in rat brain

In transcranial magnetic stimulation (TMS), the initial cortical activation due to stimulation is determined by the state of the brain and the magnitude, waveform, and direction of the induced electric field (E-field) in the cortex. The E-field distribution depends on the conductivity geometry of the head. The effects of deviations from a spherically symmetric conductivity profile have been studied in detail in humans. In small mammals, such as rats, these effects are more pronounced due to their less spherical head, proportionally much thicker neck region, and overall much smaller size compared to the TMS coils. In this study, we describe a simple method for building individual realistically shaped head models for rats from high-resolution X-ray tomography images. We computed the TMS-induced E-field with the boundary element method and assessed the effect of head-model simplifications on the estimated E-field. The deviations from spherical symmetry have large, non-trivial effects on the E-field distribution: for some coil orientations, the strongest stimulation is in the brainstem even when the coil is over the motor cortex. With modelling prior to an experiment, such problematic coil orientations can be avoided for more accurate targeting.

Systematic reviews evaluating the effectiveness of motor control exercises in patients with non-specific low back pain do not consider its principles - A review

BACKGROUND

Motor control exercise (MCEs), spinal stabilization or core stability exercises were developed with the aim of restoring the coordination, control, and capacity of the trunk muscles and systematic reviews (SR) evaluating their effectiveness has shown conflicting results. This we hypothesized was due to the non-consideration of principles of neuroplasticity. The objective of this review was to review the operating definitions used in these reviews for these exercises and evaluate if these reviews have considered and satisfied the principles of these exercises in persons with NSLBP, both acute and chronic.

METHODS

The available evidence to address the research question was sought in the reviews published in English between January 2006 and April 2019 using the population, intervention, comparison, and outcome format. Data were extracted against the following factors: satisfy the principles of specific inclusion criteria; interventions; experience-dependent plasticity; and measure any one of the concepts of motor control. The quality of the evidence obtained was graded using the National Institute for Health and Care Excellence protocol and the quality of SRs evaluated using the R-AMSTAR.

RESULTS

Eleven reviews on core stability/spinal stabilization exercises and four reviews on MCE were considered in this review. The results showed that most of the studies considered by the reviews did not adhere to the principles of these exercises.

CONCLUSION

There is wide heterogeneity in the understanding, administration, and progression of exercises. The exercises were implemented without considering the potential for neuroplasticity of the nervous system and the principles of motor learning.

Role of kinaesthetic motor imagery in mirror-induced visual illusion as intervention in post-stroke rehabilitation

Mirror-induced visual illusion obtained through mirror therapy is widely used to facilitate motor recovery after stroke. Activation of primary motor cortex (M1) ipsilateral to the moving limb has been reported during mirror-induced visual illusion. However, the mechanism through which the mirror illusion elicits motor execution processes without movements observed in the mirrored limb remains unclear. This study aims to review evidence based on brain imaging studies for testing the hypothesis that neural processes associated with kinaesthetic motor imagery are attributed to ipsilateral M1 activation. Four electronic databases were searched. Studies on functional brain imaging, investigating the instant effects of mirror-induced visual illusion among stroke survivors and healthy participants were included. Thirty-five studies engaging 78 stroke survivors and 396 healthy participants were reviewed. Results of functional brain scans (n = 20) indicated that half of the studies (n = 10, 50%) reported significant changes in the activation of ipsilateral M1, which mediates motor preparation and execution. Other common neural substrates included primary somatosensory cortex (45%, kinaesthesia), precuneus (40%, image generation and self-processing operations) and cerebellum (20%, motor control). Similar patterns of ipsilateral M1 activations were observed in the two groups. These neural substrates mediated the generation, maintenance, and manipulation of motor-related images, which were the key processes in kinaesthetic motor imagery. Relationships in terms of shared neural substrates and mental processes between mirror-induced visual illusion and kinaesthetic motor imagery generate new evidence on the role of the latter in mirror therapy. Future studies should investigate the imagery processes in illusion training for post-stroke patients.

Adipose tissue derived stromal vascular fraction as an adjuvant therapy in stroke rehabilitation: Case reports

INTRODUCTION

Stroke often causes residual hemiparesis, and upper extremity motor impairment is usually more disabling than lower extremity in those who are suffering from post-stroke hemiparesis. Cell therapy is one of the promising therapies to reduce post-stroke disability.

PATIENT CONCERNS

Three male participants were included in the study to investigate the feasibility and tolerability of autologous adipose tissue derived stromal vascular fraction.

DIAGNOSIS

All participants had hemiparesis after 1st-ever stroke longer than 6 months previously.

INTERVENTIONS

Under general anesthesia, liposuction of abdominal subcutaneous fat was performed. Stromal vascular fraction freshly isolated from the adipose tissue extract was injected into the muscles of paretic upper extremity. All participants received inpatient stroke rehabilitation consisted of physical and occupational therapy more than 3 hours a day for 2 months or more.

OUTCOMES

The whole procedure did not produce any significant adverse event in all participants. Adipose tissue extracts yielded sufficient stromal cells. One participant showed clinically important change in upper extremity Fugl-Meyer assessment after the injection and it lasted up to 6 months. Functional magnetic resonance imaging showed concomitant increase in ipsilesional cortical activity. The other 2 participants did not show remarkable changes.

LESSONS

Intramuscular injection of autologous adipose tissue derived stromal vascular fraction seems to be a safe and tolerable procedure in subjects with chronic stroke, and its utility in rehabilitation needs further investigation.

Immediate effect of voluntary-induced stepping response training on protective stepping in persons with chronic stroke: a randomized controlled trial

Purpose: To compare the immediate effects of voluntary-induced stepping response training (VSR) and DynSTABLE perturbation training (DST) on protective stepping in patients with stroke.Methods: A randomized controlled trial (registration number: TCTR20170827001) was conducted in 34 patients with chronic stroke who were randomly allocated to the VSR (n = 17) or DST (n = 17) group. The VSR group was instructed to lean forward to induce protective stepping, while the DST group experienced support surface translation. All participants received one session of training (3 set, 10 min for each set with 10-minute rest in between). Step length, step width, number of steps and center of mass (CoM) position during protective stepping were assessed using a computer-assisted rehabilitation environment (CAREN) system prior to and immediately after training. Two-way ANOVA was used to compare between groups and times.Results: Both types of training resulted in an increase in step width, but step length increased and there was a more positive COM position exhibited following DST (p < .05) than following VSR. Single-step incidence increased, whereas multiple-step incidence decreased significantly in both groups. Only participants in the VSR group generated protective stepping with the affected leg in a larger percentage of trials (27%) after training than before training.Conclusion: Both DST and VSR led to changes in protective stepping parameters after a single session of training. VSR may be a feasible alternative to equipment-based training but requires further study.Implication for RehabilitationVSR and DST trainings improved protective stepping in stroke.Step length and CoM control at foot touchdown increased after DST training.VSR training for 50 minutes led to increase affected stepping and reduce grasping.Step width, affected step length, and single step increased after both trainings.Without instrument, VSR increased steps execution and performance similar to DST.

Autologous Mesenchymal Stem Cells Improve Motor Recovery in Subacute Ischemic Stroke: a Randomized Clinical Trial

While preclinical stroke studies have shown that mesenchymal stem cells (MSCs) promote recovery, few randomized controlled trials (RCT) have assessed cell therapy in humans. In this RCT, we assessed the safety, feasibility, and efficacy of intravenous autologous bone marrow-derived MSCs in subacute stroke. ISIS-HERMES was a single-center, open-label RCT, with a 2-year follow-up. We enrolled patients aged 18-70 years less than 2 weeks following moderate-severe ischemic carotid stroke. Patients were randomized 2:1 to receive intravenous MSCs or not. Primary outcomes assessed feasibility and safety. Secondary outcomes assessed global and motor recovery. Passive wrist movement functional MRI (fMRI) activity in primary motor cortex (MI) was employed as a motor recovery biomarker. We compared "treated" and "control" groups using as-treated analyses. Of 31 enrolled patients, 16 patients received MSCs. Treatment feasibility was 80%, and there were 10 and 16 adverse events in treated patients, and 12 and 24 in controls at 6-month and 2-year follow-up, respectively. Using mixed modeling analyses, we observed no treatment effects on the Barthel Index, NIHSS, and modified-Rankin scores, but significant improvements in motor-NIHSS (p = 0.004), motor-Fugl-Meyer scores (p = 0.028), and task-related fMRI activity in MI-4a (p = 0.031) and MI-4p (p = 0.002). Intravenous autologous MSC treatment following stroke was safe and feasible. Motor performance and task-related MI activity results suggest that MSCs improve motor recovery through sensorimotor neuroplasticity. ClinicalTrials.gov Identifier NCT00875654.

Sensory retraining of the leg after stroke: systematic review and meta-analysis

OBJECTIVE

This systematic review aimed to investigate the effects of interventions intended for retraining leg somatosensory function on somatosensory impairment, and secondary outcomes of balance and gait, after stroke.

DATA SOURCES

Databases searched from inception to 16 January 2019 included Cochrane Library, PubMed, MEDLINE, CINAHL, EMBASE, PEDro, PsycINFO, and Scopus. Reference lists of relevant publications were also manually searched.

REVIEW METHODS

All types of quantitative studies incorporating interventions that intended to improve somatosensory function in the leg post stroke were retrieved. The Quality Assessment Tool for Quantitative Studies was used for quality appraisal. Standardised mean differences were calculated and meta-analyses were performed using preconstructed Microsoft Excel spreadsheets.

RESULTS

The search yielded 16 studies, comprising 430 participants, using a diverse range of interventions. In total, 10 of the included studies were rated weak in quality, 6 were rated moderate, and none was rated strong. Study quality was predominantly affected by high risk of selection bias, lack of blinding, and the use of somatosensory measures that have not been psychometrically evaluated. A significant heterogeneous positive summary effect size (SES) was found for somatosensory outcomes (SES: 0.52; 95% confidence interval (CI): 0.04 to 1.01; I2 = 74.48%), which included joint position sense, light touch, and two-point discrimination. There was also a significant heterogeneous positive SES for Berg Balance Scale scores (SES: 0.62; 95% CI: 0.10 to 1.14; I2 = 59.05%). Gait SES, mainly of gait velocity, was not significant.

CONCLUSION

This review suggests that interventions used for retraining leg somatosensory impairment after stroke significantly improved somatosensory function and balance but not gait.

A functional Magnetic Resonance Imaging study of patients with Polar Type II/III complex shoulder instability

The pathophysiology of Stanmore Classification Polar type II/III shoulder instability is not well understood. Functional Magnetic Resonance Imaging was used to measure brain activity in response to forward flexion and abduction in 16 patients with Polar Type II/III shoulder instability and 16 age-matched controls. When a cluster level correction was applied patients showed significantly greater brain activity than controls in primary motor cortex (BA4), supramarginal gyrus (BA40), inferior frontal gyrus (BA44), precentral gyrus (BA6) and middle frontal gyrus (BA6): the latter region is considered premotor cortex. Using voxel level correction within these five regions a unique activation was found in the primary motor cortex (BA4) at MNI coordinates -38 -26 56. Activation was greater in controls compared to patients in the parahippocampal gyrus (BA27) and perirhinal cortex (BA36). These findings show, for the first time, neural differences in patients with complex shoulder instability, and suggest that patients are in some sense working harder or differently to maintain shoulder stability, with brain activity similar to early stage motor sequence learning. It will help to understand the condition, design better therapies and improve treatment of this group; avoiding the common clinical misconception that their recurrent shoulder dislocations are a form of attention-seeking.

Aerobic exercise and consecutive task-specific training (AExaCTT) for upper limb recovery after stroke: A randomized controlled pilot study

OBJECTIVE

This study examined the feasibility of a parallel-group assessor-blinded randomized controlled trial investigating whether task-specific training preceded by aerobic exercise (AEX + TST) improves upper limb function more than task-specific training (TST) alone.

METHODS

People with upper limb motor dysfunction after stroke were allocated to TST or AEX + TST. Both groups were prescribed 60 hr of TST over 10 weeks (3 × 1-hr sessions with a therapist per week and 3 × 1 hr of home-based self-practice per week). The AEX + TST group performed 30 minutes of aerobic exercise immediately prior to the 1 hr of TST with the therapist. Recruitment, adherence, retention, participant acceptability, and adverse events were recorded. Clinical measures were performed prerandomization at baseline, on completion of the intervention, and at 1- and 6-month follow-up.

RESULTS

Fifty-nine persons after stroke were screened, 42 met the eligibility criteria, and 20 (11 male; mean [SD] age: 55.4 [16.0] years; time since stroke: 71.7 [91.2] months) were recruited over 17 months. The mean Wolf Motor Function Test Functional Ability Score at baseline was 27.4 (max = 75) and the mean Action Research Arm Test score was 11.2 (max = 57). Nine were randomized to AEX + TST and 11 to TST. There were no adverse events, but there was one drop out. Retention at 1- and 6-month follow-up was 80% and 85%, respectively. Attendance was 93% (6) for the AEX + TST group, and 89% (9) for the TST group. AEX + TST was perceived as acceptable (100%) and beneficial (87.5%). Exertional fatigue (visual analogue scale) prior to TST was worse in the AEX + TST group (3.5 [0.7] out of 10) than the TST group (1.7 [1.4] out of 10). The TST group performed 31% more repetitions per session than the AEX + TST group.

CONCLUSION

A subsequent Phase III study is feasible, but modifications to eligibility criteria, outcome measures, and intervention delivery are recommended.

Effects of task-oriented training on upper extremity functional performance in patients with sub-acute stroke: a randomized controlled trial

[Purpose] The present study aimed to determine the effects of a task-oriented training on paretic upper extremity functional performance in patients with subacute stroke. [Participants and Methods] Twenty-eight subacute stroke sufferers (mean age: 50.07, standard deviation 9.31 years; mean time since stroke 11.11, standard deviation 6.73 weeks) were randomly allocated to task-oriented training (n=14) or conventional exercise program (n=14) group. They were trained as a hospital-based, individualized training 1 hour a session, 5 sessions a week for 4 weeks. Wolf Motor Function Test (primary outcome), motor portion of Fugl-Meyer assessment upper extremity, and hand function domain of Stroke Impact Scale were assessed at baseline, after 2 and 4 weeks of training. [Results] All participants completed their training programs. At all post-training assessments, the task-oriented training group showed significantly more improvements in all outcomes than the conventional exercise program group. No serious adverse effects were observed during or after the training. [Conclusion] Task-oriented training produced statistically significant and clinically meaningful improvements of paretic upper extremity functional performance in patients with subacute stroke. These beneficial effects were observed after 2 weeks (10 hours) of training. Future investigation is warranted to confirm and expand these findings.

Evaluation of Changes in the Motor Network Following BCI Therapy Based on Graph Theory Analysis

Despite the established effectiveness of the brain-computer interface (BCI) therapy during stroke rehabilitation (Song et al., 2014a, 2015; Young et al., 2014a,b,c, 2015; Remsik et al., 2016), little is understood about the connections between motor network reorganization and functional motor improvements. The aim of this study was to investigate changes in the network reorganization of the motor cortex during BCI therapy. Graph theoretical approaches are used on resting-state functional magnetic resonance imaging (fMRI) data acquired from stroke patients to evaluate these changes. Correlations between changes in graph measurements and behavioral measurements were also examined. Right hemisphere chronic stroke patients (average time from stroke onset = 38.23 months, standard deviation (SD) = 46.27 months, n = 13, 6 males, 10 right-handed) with upper-extremity motor deficits received interventional rehabilitation therapy using a closed-loop neurofeedback BCI device. Eyes-closed resting-state fMRI (rs-fMRI) scans, along with T-1 weighted anatomical scans on 3.0T MRI scanners were collected from these patients at four test points. Immediate therapeutic effects were investigated by comparing pre and post-therapy results. Results displayed that th average clustering coefficient of the motor network increased significantly from pre to post-therapy. Furthermore, increased regional centrality of ipsilesional primary motor area (p = 0.02) and decreases in regional centrality of contralesional thalamus (p = 0.05), basal ganglia (p = 0.05 in betweenness centrality analysis and p = 0.03 for degree centrality), and dentate nucleus (p = 0.03) were observed (uncorrected). These findings suggest an overall trend toward significance in terms of involvement of these regions. Increased centrality of primary motor area may indicate increased efficiency within its interactive network as an effect of BCI therapy. Notably, changes in centrality of the bilateral cerebellum regions have strong correlations with both clinical variables [the Action Research Arm Test (ARAT), and the Nine-Hole Peg Test (9-HPT)]

Therapeutic effects of sensory input training on motor function rehabilitation after stroke

Motor dysfunction is a common and severe complication of stroke that affects the quality of life of these patients. Currently, motor function rehabilitation predominantly focuses on active movement training; nevertheless, the role of sensory input is usually overlooked. Sensory input is very important to motor function. Voluntary functional movement necessitates preparation, execution, and monitoring functions of the central nervous system, while the monitoring needs the participation of the sensory system. Sensory signals affect motor functions by inputting external environment information and intrinsic physiological status as well as by guiding initiation of the motor system. Recent studies focusing on sensory input-based rehabilitation training for post-stroke dyskinesia have demonstrated that sensory function has significant effects on voluntary functional movements. In conclusion, sensory input plays a crucial role in motor function rehabilitation, and the combined sensorimotor training modality is more effective than conventional motor-oriented approaches.

Designing robot-assisted neurorehabilitation strategies for people with both HIV and stroke

There is increasing evidence that HIV is an independent risk factor for stroke, resulting in an emerging population of people living with both HIV and stroke all over the world. However, neurorehabilitation strategies for the HIV-stroke population are distinctly lacking, which poses an enormous global health challenge. In order to address this gap, a better understanding of the HIV-stroke population is needed, as well as potential approaches to design effective neurorehabilitation strategies for this population. This review goes into the mechanisms, manifestations, and treatment options of neurologic injury in stroke and HIV, the additional challenges posed by the HIV-stroke population, and rehabilitation engineering approaches for both high and low resource areas. The aim of this review is to connect the underlying neurologic properties in both HIV and stroke to rehabilitation engineering. It reviews what is currently known about the association between HIV and stroke and gaps in current treatment strategies for the HIV-stroke population. We highlight relevant current areas of research that can help advance neurorehabilitation strategies specifically for the HIV-stroke population. We then explore how robot-assisted rehabilitation combined with community-based rehabilitation could be used as a potential approach to meet the challenges posed by the HIV-stroke population. We include some of our own work exploring a community-based robotic rehabilitation exercise system. The most relevant strategies will be ones that not only take into account the individual status of the patient but also the cultural and economic considerations of their respective environment.

The effects of silent visuomotor cueing on word retrieval in Broca's aphasies: A pilot study

About a quarter of stroke patients worldwide suffer serious language disorders such as aphasias. Most common symptoms of Broca's aphasia are word naming disorders which highly impact verbal communication and the quality of life of aphasic patients. In order to recover disturbances in word retrieval, several cueing methods (i.e. phonemic and semantic) have been established to improve lexical access establishing effective language rehabilitation techniques. Based on recent evidence from action-perception theories, which postulate that neural circuits for speech perception and articulation are tightly coupled, in the present work, we propose and investigate an alternative type of cueing using silent articulation-related visual stimuli. We hypothesize that providing patients with primes in the form of silent videos showing lip motions representative of correct pronunciation of target words, will result in faster word retrieval than when no such cue is provided. To test our prediction, we realize a longitudinal clinical virtual reality-based trial with four post-stroke Broca's patients and compare the interaction times between the two conditions over the eight weeks of the therapy. Our results suggest that silent visuomotor cues indeed facilitate word retrieval and verbal execution, and might be beneficial in lexical relearning in chronic Broca's patients.

Effects of a 12-month task-specific balance training on the balance status of stroke survivors with and without cognitive impairments in Selected Hospitals in Nnewi, Anambra State, Nigeria

BACKGROUND

Stroke results in varying levels of physical disabilities that may adversely impact balance with increased tendency to falls. This may intensify with cognitive impairments (CI), and impede functional recovery. Therefore, task-specific balance training (TSBT), which presents versatile task-specific training options that matches varied individual needs, was explored as a beneficial rehabilitation regime for stroke survivors with and without CI. It was hypothesized that there will be no significant difference in the balance control measures in stroke survivors with and without CI after a 12-month TSBT.

OBJECTIVE

To determine if TSBT will have comparable beneficial effects on the balance control status of sub-acute ischemic stroke survivors with CI and without CI.

METHODS

One hundred of 143 available sub-acute first ever ischemic stroke survivors were recruited using convenience sampling technique in a quasi-experimental study. They were later assigned into the cognitive impaired group (CIG) and non-cognitive impaired group (NCIG), respectively, based on the baseline presence or absence of CI, after screening with the mini-mental examination (MMSE) tool. With the help of four trained research assistants, TSBT was applied to each group, thrice times a week, 60 mins per session, for 12 months. Their balance was measured as Bergs Balance scores (BBS) at baseline, 4th, 8th, and 12th month intervals. Data were analyzed statistically using Kruskal Wallis test, and repeated measure ANOVA, at p < 0.05.

RESULTS

There was significant improvement across time points in the balance control of CIG with large effect size of 0.69 after 12 months of TSBT. There was also significant improvement across time points in the balance control of NCIG with large effect size of 0.544 after 12 months of TSBT. There was no significant difference between the improvement in CIG and NCIG after 8th and 12th months of TSBT.

CONCLUSIONS

Within the groups, a 12-month TSBT intervention significantly improved balance control, respectively, but with broader effects in the CIG than NCIG. Importantly, though between-group comparison at baseline revealed significantly impaired balance control in the CIG than NCIG, these differences were not significant at the 8th month and non-existent at the 12th month of TSBT intervention. These results underscore the robustness of TSBT to evenly address specific balance deficits of stroke survivors with and without CI within a long-term rehabilitation plan as was hypothesized.

A narrative review of gait training after stroke and a proposal for developing a novel gait training device that provides minimal assistance

BACKGROUND

Gait impairment is common in stroke survivors. Recovery of walking ability is one of the most pressing objectives in stroke rehabilitation.

OBJECTIVES

Of this report are to briefly review recent progress in gait training after stroke including the use of partial body weight-supported treadmill training (PBWSTT) and robot-assisted step training (RAST), and propose a minimal assistance strategy that may overcome some of limitations of current RAST.

METHODS

The literature review emphasizes a dilemma that recent randomized clinical trials did not support the use of RAST. The unsatisfactory results of current RAST clinical trials may be partially due to a lack of careful analysis of movement deficiencies and their relevance to gait training task specificity after stroke. Normal movement pattern is implied to be part of task specificity in the current RAST. Limitations of such task specificity are analyzed.

RESULTS

Based on the review, we redefine an alternative set of gait training task specificity that represents a minimal assistance strategy in terms of assisted body movements and amount of assistance. Specifically, assistances are applied only to hip flexion and ankle dorsiflexion of the affected lower limb during swing phase. Furthermore, we propose a conceptual design of a novel device that may overcome limitations of current RAST in gait training after stroke. The novel device uses a pulling cable, either manually operated by a therapist or automated by a servomotor, to provide assistive forces to help hip flexion and ankle dorsiflexion of the affected lower limb during gait training.

CONCLUSION

The proposed minimal assistance strategy may help to design better devices for gait or other motor training.

Evaluating the effects of delivering integrated kinesthetic and tactile cues to individuals with unilateral hemiparetic stroke during overground walking

BACKGROUND

Integration of kinesthetic and tactile cues for application to post-stroke gait rehabilitation is a novel concept which needs to be explored. The combined provision of haptic cues may result in collective improvement of gait parameters such as symmetry, balance and muscle activation patterns. Our proposed integrated cue system can offer a cost-effective and voluntary gait training experience for rehabilitation of subjects with unilateral hemiparetic stroke.

METHODS

Ten post-stroke ambulatory subjects participated in a 10 m walking trial while utilizing the haptic cues (either alone or integrated application), at their preferred and increased gait speeds. In the system a haptic cane device (HCD) provided kinesthetic perception and a vibrotactile feedback device (VFD) provided tactile cue on the paretic leg for gait modification. Balance, gait symmetry and muscle activity were analyzed to identify the benefits of utilizing the proposed system.

RESULTS

When using kinesthetic cues, either alone or integrated with a tactile cue, an increase in the percentage of non-paretic peak activity in the paretic muscles was observed at the preferred gait speed (vastus medialis obliquus: p <  0.001, partial eta squared (η2) = 0.954; semitendinosus p <  0.001, partial η2 = 0.793) and increased gait speeds (vastus medialis obliquus: p <  0.001, partial η2 = 0.881; semitendinosus p = 0.028, partial η2 = 0.399). While using HCD and VFD (individual and integrated applications), subjects could walk at their preferred and increased gait speeds without disrupting trunk balance in the mediolateral direction. The temporal stance symmetry ratio was improved when using tactile cues, either alone or integrated with a kinesthetic cue, at their preferred gait speed (p <  0.001, partial η2 = 0.702).

CONCLUSIONS

When combining haptic cues, the subjects walked at their preferred gait speed with increased temporal stance symmetry and paretic muscle activity affecting their balance. Similar improvements were observed at higher gait speeds. The efficacy of the proposed system is influenced by gait speed. Improvements were observed at a 20% increased gait speed, whereas, a plateau effect was observed at a 40% increased gait speed. These results imply that integration of haptic cues may benefit post-stroke gait rehabilitation by inducing simultaneous improvements in gait symmetry and muscle activity.

Current knowledge on selected rehabilitative methods used in post-stroke recovery

Understanding brain plasticity after stroke is important in developing rehabilitation strategies. Active movement therapies show considerable promise but their individual application is still not fully implemented. Among the analysed, available therapeutic modalities, some became widely used in therapeutic practice. Thus, we selected three relatively new methods, i.e. mirror therapy, motor imagery and constraint-induced movement therapy (CIMT). Mirror therapy was initially used in the treatment of phantom pain in patients with amputated limbs and later, in stroke patients. Motor imagery is widely used in sport to improve performance, which raises the possibility of applying it both as a rehabilitative method and in accessing the motor network independently of recovery. Whereas CIMT is based on the paradigm that impairment of arm function is exacerbated by learned non-use and that this, in turn, leads to loss of cortical representation in the upper limb.

Evidence for Training-Dependent Structural Neuroplasticity in Brain-Injured Patients: A Critical Review

Acquired brain injury (ABI) is associated with a range of cognitive and motor deficits, and poses a significant personal, societal, and economic burden. Rehabilitation programs are available that target motor skills or cognitive functioning. In this review, we summarize the existing evidence that training may enhance structural neuroplasticity in patients with ABI, as assessed using structural magnetic resonance imaging (MRI)-based techniques that probe microstructure or morphology. Twenty-five research articles met key inclusion criteria. Most trials measured relevant outcomes and had treatment benefits that would justify the risk of potential harm. The rehabilitation program included a variety of task-oriented movement exercises (such as facilitation therapy, postural control training), neurorehabilitation techniques (such as constraint-induced movement therapy) or computer-assisted training programs (eg, Cogmed program). The reviewed studies describe regional alterations in white matter architecture and/or gray matter volume with training. Only weak-to-moderate correlations were observed between improved behavioral function and structural changes. While structural MRI is a powerful tool for detection of longitudinal structural changes, specific measures about the underlying biological mechanisms are lacking. Continued work in this field may potentially see structural MRI metrics used as biomarkers to help guide treatment at the individual patient level.

Stroke

Stroke, or cerebrovascular accident, involves injury to the central nervous system as a result of a vascular cause, and is a leading cause of disability worldwide. People with stroke often experience sensory, cognitive, and motor sequelae that can lead to difficulty walking, controlling balance in standing and voluntary tasks, and reacting to prevent a fall following an unexpected postural perturbation. This chapter discusses the interrelationships between stroke-related impairments, problems with control of balance and gait, fall risk, fear of falling, and participation in daily physical activity. Rehabilitation can improve balance and walking function, and consequently independence and quality of life, for those with stroke. This chapter also describes effective interventions for improving balance and walking function poststroke, and identifies some areas for further research in poststroke rehabilitation.

AExaCTT - Aerobic Exercise and Consecutive Task-specific Training for the upper limb after stroke: Protocol for a randomised controlled pilot study

Motor function may be enhanced if aerobic exercise is paired with motor training. One potential mechanism is that aerobic exercise increases levels of brain-derived neurotrophic factor (BDNF), which is important in neuroplasticity and involved in motor learning and motor memory consolidation. This study will examine the feasibility of a parallel-group assessor-blinded randomised controlled trial investigating whether task-specific training preceded by aerobic exercise improves upper limb function more than task-specific training alone, and determine the effect size of changes in primary outcome measures. People with upper limb motor dysfunction after stroke will be allocated to either task-specific training or aerobic exercise and consecutive task-specific training. Both groups will perform 60 hours of task-specific training over 10 weeks, comprised of 3 × 1 hour sessions per week with a therapist and 3 × 1 hours of home-based self-practice per week. The combined intervention group will also perform 30 minutes of aerobic exercise (70-85%HRmax) immediately prior to the 1 hour of task-specific training with the therapist. Recruitment, adherence, retention, participant acceptability, and adverse events will be recorded. Clinical outcome measures will be performed pre-randomisation at baseline, at completion of the training program, and at 1 and 6 months follow-up. Primary clinical outcome measures will be the Action Research Arm Test (ARAT) and the Wolf Motor Function Test (WMFT). If aerobic exercise prior to task-specific training is acceptable, and a future phase 3 randomised controlled trial seems feasible, it should be pursued to determine the efficacy of this combined intervention for people after stroke.

Changes in transcranial magnetic stimulation outcome measures in response to upper-limb physical training in stroke: A systematic review of randomized controlled trials

BACKGROUND

Physical training is known to be an effective intervention to improve sensorimotor impairments after stroke. However, the link between brain plastic changes, assessed by transcranial magnetic stimulation (TMS), and sensorimotor recovery in response to physical training is still misunderstood. We systematically reviewed reports of randomized controlled trials (RCTs) involving the use of TMS over the primary motor cortex (M1) to probe brain plasticity after upper-limb physical training interventions in people with stroke.

METHODS

We searched 5 databases for articles published up to October 2016, with additional studies identified by hand-searching. RCTs had to investigate pre/post-intervention changes in at least one TMS outcome measure. Two independent raters assessed the eligibility of potential studies and reviewed the selected articles' quality by using 2 critical appraisal scales.

RESULTS

In total, 14 reports of RCTs (pooled participants=358; mean 26±12 per study) met the selection criteria. Overall, 11 studies detected plastic changes with TMS in the presence of clinical improvements after training, and these changes were more often detected in the affected hemisphere by using map area and motor evoked potential (MEP) latency outcome measures. Plastic changes mostly pointed to increased M1/corticospinal excitability and potential interhemispheric rebalancing of M1 excitability, despite sometimes controversial results among studies. Also, the strength of the review observations was affected by heterogeneous TMS methods and upper-limb interventions across studies as well as several sources of bias within the selected studies.

CONCLUSIONS

The current evidence encourages the use of TMS outcome measures, especially MEP latency and map area to investigate plastic changes in the brain after upper-limb physical training post-stroke. However, more studies involving rigorous and standardized TMS procedures are needed to validate these observations.

Comparing Cerebralcare Granule and aspirin for neurological dysfunction in acute stroke in real-life practice

BACKGROUND

Cerebralcare Granule (CG) is a polyherbal Chinese medicine that has been shown to have neuroprotective effects in experimental models of stroke. We compared the efficacy and safety of CG with aspirin in patients with acute stroke.

METHODS

For this open-label, controlled trial, we recruited patients with angiographically confirmed strokes and US National Institutes of Health Stroke Scale (NIHSS) scores of 4-22 within 2 weeks of symptom onset; recruitment was performed at 55 sites in China. Patients received CG or aspirin. The primary efficacy end-point was neurological function. Analyses were done by intention to treat. Patients were measured for NIHSS, Montreal Cognitive Assessment, and Mini-Mental State Examination scores and Barthel index at baseline and at 4, 8, and 12 weeks after treatment.

RESULTS

Between January 2013 and January 2014, we treated 1963 patients with CG and 1288 patients with aspirin. Baseline NIHSS, Mini-Mental State Examination, and Montreal Cognitive Assessment scores were comparable between the two groups. Patients in the CG group had a greater improvement than the aspirin group in terms of NIHSS (P < 0.01) and Barthel index at 4, 8, and 12 weeks. At 12 weeks, patients in the CG group had a greater improvement than the aspirin group in terms of Mini-Mental State Examination (P < 0.01) and Montreal Cognitive Assessment (P < 0.05). Adverse reactions were similar between the two groups.

CONCLUSIONS

This large-scale, controlled trial indicated that CG may be a useful treatment in the management of post-stroke patients.

Neural correlates of motor recovery after robot-assisted stroke rehabilitation: a case series study

Robot-assisted bilateral arm therapy (RBAT) has shown promising results in stroke rehabilitation; however, connectivity mapping of the sensorimotor networks after RBAT remains unclear. We used fMRI before and after RBAT and a dose-matched control intervention (DMCI) to explore the connectivity changes in 6 subacute stroke patients. Sensorimotor functions improved in the RBAT and DMCI groups after treatment. Enhanced activation changes were observed in bilateral primary motor cortex (M1) and bilateral supplementary motor area (SMA) after RBAT. Dynamic causal model analysis revealed that interhemispheric connections were enhanced in RBAT patients. These preliminary findings suggest that intracortical and intercortical coupling might underlie poststroke RBAT.