Upper Limb Motor Impairment After Stroke

Enhancing poststroke hand movement recovery: Efficacy of RehabSwift, a personalized brain-computer interface system

This study explores the efficacy of our novel and personalized brain-computer interface (BCI) therapy, in enhancing hand movement recovery among stroke survivors. Stroke often results in impaired motor function, posing significant challenges in daily activities and leading to considerable societal and economic burdens. Traditional physical and occupational therapies have shown limitations in facilitating satisfactory recovery for many patients. In response, our study investigates the potential of motor imagery-based BCIs (MI-BCIs) as an alternative intervention. In this study, MI-BCIs translate imagined hand movements into actions using a combination of scalp-recorded electrical brain activity and signal processing algorithms. Our prior research on MI-BCIs, which emphasizes the benefits of proprioceptive feedback over traditional visual feedback and the importance of customizing the delay between brain activation and passive hand movement, led to the development of RehabSwift therapy. In this study, we recruited 12 chronic-stage stroke survivors to assess the effectiveness of our solution. The primary outcome measure was the Fugl-Meyer upper extremity (FMA-UE) assessment, complemented by secondary measures including the action research arm test, reaction time, unilateral neglect, spasticity, grip and pinch strength, goal attainment scale, and FMA-UE sensation. Our findings indicate a remarkable improvement in hand movement and a clinically significant reduction in poststroke arm and hand impairment following 18 sessions of neurofeedback training. The effects persisted for at least 4 weeks posttreatment. These results underscore the potential of MI-BCIs, particularly our solution, as a prospective tool in stroke rehabilitation, offering a personalized and adaptable approach to neurofeedback training.

Effects of Limbs' Spasticity on Spinopelvic Alignment in Post-Stroke Patients: A Cross-Sectional Study

Objectives: This study aimed to determine the impacts of upper and lower limb (UL and LL) spasticity and impairment on spinal alignment in chronic post-stroke patients. Methods: A total of 45 consecutive chronic post-stroke patients, 18 women and 27 men, from 18 to 70 years old who presented post-stroke hemiparesis were recruited in this cross-sectional study. The clinical assessment included the Modified Ashworth Scale (UL-MAS and LL-MAS spasticity), Upper Limb Motricity Index (UL-MI), FAST-UL, and Five Times Sit-to-Stand Test (5T-STS); the Associated Reaction Rating Scale was used to measure associated reactions in the hemiparetic UL, the plumb line distance from the spinous process of C7 on the sagittal (PL-C7s) and frontal plane (Pl-C7f), the kyphosis apex (PL-AK), and the spinous process of L3 (PL-L3). Angular measures of spinal alignment were measured by a Bunnell scoliometer™ (angle of trunk rotation-ATR) and a gravity-dependent inclinometer (inclination at C7-T1 and T12-L1). Results: In chronic post-stroke patients, there was found to be an association between the 5T-STS and PL-C7f (β = 0.41, p = 0.05) and the angle of inclination at T12-L1 (β = 0.44, p = 0.01). The FAST-UL correlated with PL-C7f (β = -0.41, p = 0.05), while the UL-MI correlated with this last parameter (β = -0.36, p = 0.04) and the ATR (β = -0.31, p = 0.05). The UL-MAS showed correlation with the ATR (β = 0.38, p = 0.01). Conclusions: The results lead to the possibility that, in chronic post-stroke patients, spinal misalignment on the frontal and sagittal plane is associated both with strength impairment and UL spasticity. The improvement or restoration of spinopelvic parameters can take advantage of therapeutic interventions targeted at motor improvement and spasticity reduction of the hemiparetic side.

Stroke Survivors' Interaction With Hand Rehabilitation Devices: Observational Study

BACKGROUND

The hand is crucial for carrying out activities of daily living as well as social interaction. Functional use of the upper limb is affected in up to 55% to 75% of stroke survivors 3 to 6 months after stroke. Rehabilitation can help restore function, and several rehabilitation devices have been designed to improve hand function. However, access to these devices is compromised in people with more severe loss of function.

OBJECTIVE

In this study, we aimed to observe stroke survivors with poor hand function interacting with a range of commonly used hand rehabilitation devices.

METHODS

Participants were engaged in an 8-week rehabilitation intervention at a technology-enriched rehabilitation gym. The participants spent 50-60 minutes of the 2-hour session in the upper limb section at least twice a week. Each participant communicated their rehabilitation goals, and an Action Research Arm Test (ARAT) was used to measure and categorize hand function as poor (scores of 0-9), moderate (scores of 10-56), or good (score of 57). Participants were observed during their interactions with 3 hand-based rehabilitation devices that focused on hand rehabilitation: the GripAble, NeuroBall, and Semi-Circular Peg Board. Observations of device interactions were recorded for each session.

RESULTS

A total of 29 participants were included in this study, of whom 10 (34%) had poor hand function, 17 (59%) had moderate hand function, and 2 (7%) had good hand function. There were no differences in the age and years after stroke among participants with poor hand function and those with moderate (P=.06 and P=.09, respectively) and good (P=.37 and P=.99, respectively) hand function. Regarding the ability of the 10 participants with poor hand function to interact with the 3 hand-based rehabilitation devices, 2 (20%) participants with an ARAT score greater than 0 were able to interact with the devices, whereas the other 8 (80%) who had an ARAT score of 0 could not. Their inability to interact with these devices was clinically examined, and the reason was determined to be a result of either the presence of (1) muscle tone or stiffness or (2) muscle weakness.

CONCLUSIONS

Not all stroke survivors with impairments in their hands can make use of currently available rehabilitation technologies. Those with an ARAT score of 0 cannot actively interact with hand rehabilitation devices, as they cannot carry out the hand movement necessary for such interaction. The design of devices for hand rehabilitation should consider the accessibility needs of those with poor hand function.

Post-stroke hand gesture recognition via one-shot transfer learning using prototypical networks

BACKGROUND

In-home rehabilitation systems are a promising, potential alternative to conventional therapy for stroke survivors. Unfortunately, physiological differences between participants and sensor displacement in wearable sensors pose a significant challenge to classifier performance, particularly for people with stroke who may encounter difficulties repeatedly performing trials. This makes it challenging to create reliable in-home rehabilitation systems that can accurately classify gestures.

METHODS

Twenty individuals who suffered a stroke performed seven different gestures (mass flexion, mass extension, wrist volar flexion, wrist dorsiflexion, forearm pronation, forearm supination, and rest) related to activities of daily living. They performed these gestures while wearing EMG sensors on the forearm, as well as FMG sensors and an IMU on the wrist. We developed a model based on prototypical networks for one-shot transfer learning, K-Best feature selection, and increased window size to improve model accuracy. Our model was evaluated against conventional transfer learning with neural networks, as well as subject-dependent and subject-independent classifiers: neural networks, LGBM, LDA, and SVM.

RESULTS

Our proposed model achieved 82.2% hand-gesture classification accuracy, which was better (P<0.05) than one-shot transfer learning with neural networks (63.17%), neural networks (59.72%), LGBM (65.09%), LDA (63.35%), and SVM (54.5%). In addition, our model performed similarly to subject-dependent classifiers, slightly lower than SVM (83.84%) but higher than neural networks (81.62%), LGBM (80.79%), and LDA (74.89%). Using K-Best features improved the accuracy in 3 of the 6 classifiers used for evaluation, while not affecting the accuracy in the other classifiers. Increasing the window size improved the accuracy of all the classifiers by an average of 4.28%.

CONCLUSION

Our proposed model showed significant improvements in hand-gesture recognition accuracy in individuals who have had a stroke as compared with conventional transfer learning, neural networks and traditional machine learning approaches. In addition, K-Best feature selection and increased window size can further improve the accuracy. This approach could help to alleviate the impact of physiological differences and create a subject-independent model for stroke survivors that improves the classification accuracy of wearable sensors.

TRIAL REGISTRATION NUMBER

The study was registered in Chinese Clinical Trial Registry with registration number CHiCTR1800017568 in 2018/08/04.

Usability of mechanical assistive technologies for performing activities involving the upper extremities in individuals with impairments: a systematic review

PURPOSE

To conduct a systematic review on the impacts of using mechanical assistive devices on function, performance in activities and participation of persons with upper extremity impairments, and to synthesize the strengths and limitations of these devices.

METHOD

Three independent reviewers conducted systematic searches of articles published between 2003 and 2023 in Compendex, Inspec, Embase, PubMed/Medline, IEEE Xplore, and Web of Science, as well as manual searches on the RESNA website for conference papers over the same period. The methodological quality of articles was appraised using the QualSyst tool.

RESULTS

From the 34 retained studies, 28 mechanical devices were identified and classified into two categories: (1) mobile arm supports (MASs) designed to perform multiple activities, and (2) devices used to assist with a specific activity of daily living (ADL). Overall, MASs helped users to perform manual activities in elevation and/or against gravity. Specific ADL devices allowed users to perform unique activities requiring fine motor skills such as opening a medicine container. Some of these devices have advantages like portability, adaptability, low cost, and ease of use. Limitations most often reported included interference or mobility restraints.

CONCLUSION

This review synthesizes the impacts of mechanical devices on the three domains of the International Classification of Functioning, Disability and Health (ICF) for individuals with upper extremity impairments. Impacts regarding function and performance in activities were more often measured than participation. Future studies should include outcomes related to participation, as taking this aspect into account might favor successful continued use of assistive devices.

Combining muscle-computer interface guided training with bihemispheric tDCS improves upper limb function in patients with chronic stroke

Transcranial direct current stimulation (tDCS) may facilitate neuroplasticity but with a limited effect when administered while patients with stroke are at rest. Muscle-computer interface (MCI) training is a promising approach for training patients with stroke even if they cannot produce overt movements. However, using tDCS to enhance MCI training has not been investigated. We combined bihemispheric tDCS with MCI training of the paretic wrist and examined the effect of this intervention in patients with chronic stroke. A crossover, double-blind, randomized trial was conducted. Twenty-six patients with chronic stroke performed MCI wrist training for three consecutive days at home while receiving either real tDCS or sham tDCS in counterbalanced order and separated by at least 8 mo. The primary outcome measure was the Fugl-Meyer Assessment Upper Extremity Scale (FMA-UE) that was measured 1 wk before training, on the first training day, on the last training day, and 1 wk after training. There was neither a significant difference in the baseline FMA-UE score between groups nor between intervention periods. Patients improved 3.9 ± 0.6 points in FMA-UE score when receiving real tDCS, and 1.0 ± 0.7 points when receiving sham tDCS (P = 0.003). In addition, patients also showed continuous improvement in their motor control of the MCI tasks over the training days. Our study showed that the training paradigm could lead to functional improvement in patients with chronic stroke. We argue that appropriate MCI training in combination with bihemispheric tDCS could be a useful adjuvant for neurorehabilitation in patients with stroke.NEW & NOTEWORTHY Bihemispheric tDCS combined with a novel MCI training for motor control of wrist extensor can improve upper limb function especially a training-specific effect on the wrist movement in patients with chronic stroke. The training regimen can be personalized with adjustments made daily to accommodate the functional change throughout the intervention. This demonstrates that bihemispheric tDCS with MCI training could complement conventional poststroke neurorehabilitation.

Integration of music-based game approaches with wearable devices for hand neurorehabilitation: a narrative review

BACKGROUND

Restoring hand functionality is critical for fostering independence in individuals with neurological disorders. Various therapeutic approaches have emerged to address motor function restoration, with music-based therapies demonstrating notable advantages in enhancing neuroplasticity, an integral component of neurorehabilitation. Despite the positive effects observed, there remains a gap in the literature regarding implementing music treatments in neurorehabilitation, such as Neurologic Music Therapy (NMT), especially in conjunction with emerging fields like wearable devices and game-based therapies.

METHODS

A literature search was conducted in various databases, including PubMed, Scopus, IEEE Xplore, and ACM Digital Library. The search was performed using a literature search methodology based on keywords. Information collected from the studies pertained to the approach used in music therapy, the design of the video games, and the types of wearable devices utilized.

RESULTS

A total of 158 articles were found, including 39 from PubMed, 34 from IEEE Xplore, 48 from Scopus, 37 from ACM Digital Library, and 35 from other sources. Duplicate entries, of which there were 41, were eliminated. In the first screening phase, 152 papers were screened for title and abstract. Subsequently, 89 articles were removed if they contained at least one exclusion criterion. Sixteen studies were considered after 63 papers had their full texts verified.

CONCLUSIONS

The convergence of NMT with emerging fields, such as gamification and wearable devices designed for hand functionality, not only expands therapeutic horizons but also lays the groundwork for innovative, personalized approaches to neurorehabilitation. However, challenges persist in effectively incorporating NMT into rehabilitation programs, potentially hindering its effectiveness.

Task-Oriented Training by a Personalized Electromyography-Driven Soft Robotic Hand in Chronic Stroke: A Randomized Controlled Trial

BACKGROUND

Intensive task-oriented training has shown promise in enhancing distal motor function among patients with chronic stroke. A personalized electromyography (EMG)-driven soft robotic hand was developed to assist task-oriented object-manipulation training effectively. Objective. To compare the effectiveness of task-oriented training using the EMG-driven soft robotic hand.

METHODS

A single-blinded, randomized controlled trial was conducted with 34 chronic stroke survivors. The subjects were randomly assigned to the Hand Task (HT) group (n = 17) or the control (CON) group (n = 17). The HT group received 45 minutes of task-oriented training by manipulating small objects with the robotic hand for 20 sessions, while the CON group received 45 minutes of hand-functional exercises without objects using the same robot. Fugl-Meyer assessment (FMA-UE), Action Research Arm Test (ARAT), Modified Ashworth Score (MAS), Box and Block test (BBT), Maximum Grip Strength, and active range of motion (AROM) of fingers were assessed at baseline, after intervention, and 3 months follow-up. The muscle co-contraction index (CI) was analyzed to evaluate the session-by-session variation of upper limb EMG patterns.

RESULTS

The HT group showed more significant improvement in FMA-UE (wrist/hand, shoulder/elbow) compared to the CON group (P < .05). At 3-month follow-up, the HT group demonstrated significant improvements in FMA-UE, ARAT, BBT, MAS (finger), and AROMs (P < .05). The HT group exhibited a more significant decrease in muscle co-contractions compared to the CON group (P < .05).

CONCLUSIONS

EMG-driven task-oriented training with the personalized soft robotic hand was a practical approach to improving motor function and muscle coordination.

CLINICAL TRIAL REGISTRY NAME

Soft Robotic Hand System for Stroke Rehabilitation.

CLINICAL TRIAL REGISTRATION-URL

https://clinicaltrials.gov/.

UNIQUE IDENTIFIER

NCT03286309.

Motor Learning Following Stroke: Mechanisms of Learning and Techniques to Augment Neuroplasticity

Sensorimotor impairments are common after stroke requiring stroke survivors to relearn lost motor skills or acquire new ones in order to engage in daily activities. Thus, motor skill learning is a cornerstone of stroke rehabilitation. This article provides an overview of motor control and learning theories that inform stroke rehabilitation interventions, discusses principles of neuroplasticity, and provides a summary of practice conditions and techniques that can be used to augment motor learning and neuroplasticity in stroke rehabilitation.

Top-Down and Bottom-Up Mechanisms of Motor Recovery Poststroke

Stroke remains a leading cause of disability. Motor recovery requires the interaction of top-down and bottom-up mechanisms, which reinforce each other. Injury to the brain initiates a biphasic neuroimmune process, which opens a window for spontaneous recovery during which the brain is particularly sensitive to activity. Physical activity during this sensitive period can lead to rapid recovery by potentiating anti-inflammatory and neuroplastic processes. On the other hand, lack of physical activity can lead to early closure of the sensitive period and downstream changes in muscles, such as sarcopenia, muscle stiffness, and reduced cardiovascular capacity, and blood flow that impede recovery.

Upper-Limb Functional Recovery in Chronic Stroke Patients after COVID-19-Interrupted Rehabilitation: An Observational Study

Background/Objectives: Upper-limb function of chronic stroke patients declined when outpatient rehabilitation was interrupted and outings restricted, owing to the novel coronavirus infection (COVID-19) pandemic. We investigated whether these patients recovered upper-limb function post-resumption of outpatient rehabilitation. Methods: In this observational study, 43 chronic stroke hemiparesis patients with impaired upper extremity function were scored for limb function via the Fugl-Meyer assessment of the upper extremity (FMA-UE) and the Action Research Arm Test (ARAT) after a structured interview, evaluation, and intervention. Scores at 6 and 3 months pre- and 3 months post-rehabilitation interruption were examined retrospectively; scores immediately and at 3 and 6 months post-resumption of care were examined prospectively. The amount of change for each time period and an analysis of covariance were performed with time as a factor, changes in the FMA-UE and the ARAT scores as dependent variables, and statistical significance at 5%. Results: The time of evaluation significantly impacted the total score, as well as part C and part D of FMA-UE and total, pinch, and gross movement of the ARAT. Post-hoc tests showed that the magnitude of change in limb-function scores from immediately to 3 months post-resumption was significantly higher than the change from 3 months pre- to immediately post-interruption for the total score and part D of the FMA-UE, as well as grip and gross movement of the ARAT (p < 0.05). Conclusions: Upper-limb functional decline in chronic stroke patients, caused by the COVID-19 pandemic-related therapy interruption and outing restrictions, was resolved approximately 3 months post-resumption of rehabilitation therapy. Our data can serve as reference standards for planning and evaluating treatment for chronic stroke patients with inactivity-related impaired upper-limb function.

Dual-tDCS combined with sensorimotor training promotes upper limb function in subacute stroke patients: A randomized, double-blinded, sham-controlled study

BACKGROUND

Dual transcranial direct current stimulation (tDCS) over the bilateral primary somatosensory cortex (PSC) has potential benefits in stroke. In addition, compared with traditional rehabilitation training, sensorimotor training can significantly improve the sensorimotor function of patients. However, the efficacy of dual-tDCS combined with sensorimotor training in patients with subacute stroke is unknown.

OBJECTIVE

To assess whether dual-tDCS may enhance the efficacy of sensorimotor training on the upper limb functions in patients with subacute stroke. In addition, this study aims to explore the potential clinical mechanism of this combination therapy.

METHODS

We randomized 52 individuals with first-ever, unilateral subcortical stroke into the experimental group (n = 26) and the control group (n = 26). Patients in the experimental group received 20 min of dual-tDCS over the PSC and 40 min of sensorimotor training each session, while patients in the control group received sham dual-tDCS. The treatment cycle was a 1-h session of therapy each day, 5 days per week for 4 weeks. The Fugl-Meyer Assessment of Upper Extremity (FMA-UE) subscale, Action Research Arm Test (ARAT), Box and Block test (BBT), Erasmus MC revised Nottingham sensory assessment scale (Em-NSA), Neurometer sensory nerve quantitative detector (CPT), the Barthel index (BI), and Hospital Anxiety and Depression Scale (HADS) were used to assess upper limb function, activities of daily living (ADL), and mental health before and after the 4-week treatment period. In addition, functional near-infrared spectroscopy (fNIRS) was used to explore potential clinical brain mechanisms.

RESULTS

Both groups showed significant improvement in all clinical scales (All p < 0.05) after treatment. Compared with sham-tDCS plus sensorimotor training, active dual-tDCS coupled with sensorimotor training can significantly improve the FMA-UE, ARAT, Em-NSA-Stereognosis, and CPT-2K Hz. In addition, dual-tDCS combined with sensorimotor training can significantly activate the left pre-Motor and supplementary motor cortex (PM-SMC) and enhance the functional connection between the left somatosensory association cortex (SAC) and RPM-SMC. Furthermore, the difference of FMA-UE in the experimental group was positively correlated with the functional connectivity of RPM-SMC-LSAC (r = 0.815, p < 0.001).

CONCLUSION

Dual-tDCS over the PSC combined with sensorimotor training can improve upper limb sensory and motor dysfunction, enhance ADL, and alleviate depression and anxiety for subacute stroke patients. Our results indicated that RPM-SMC-LSAC may be potential therapeutic targets for dual-tDCS in upper limb rehabilitation on stroke.

Exploring the Prospects of Transcranial Electrical Stimulation (tES) as a Therapeutic Intervention for Post-Stroke Motor Recovery: A Narrative Review

INTRODUCTION

Stroke survivors often have motor impairments and related functional deficits. Transcranial Electrical Stimulation (tES) is a rapidly evolving field that offers a wide range of capabilities for modulating brain function, and it is safe and inexpensive. It has the potential for widespread use for post-stroke motor recovery. Transcranial Direct Current Stimulation (tDCS), Transcranial Alternating Current Stimulation (tACS), and Transcranial Random Noise Stimulation (tRNS) are three recognized tES techniques that have gained substantial attention in recent years but have different mechanisms of action. tDCS has been widely used in stroke motor rehabilitation, while applications of tACS and tRNS are very limited. The tDCS protocols could vary significantly, and outcomes are heterogeneous.

PURPOSE

the current review attempted to explore the mechanisms underlying commonly employed tES techniques and evaluate their prospective advantages and challenges for their applications in motor recovery after stroke.

CONCLUSION

tDCS could depolarize and hyperpolarize the potentials of cortical motor neurons, while tACS and tRNS could target specific brain rhythms and entrain neural networks. Despite the extensive use of tDCS, the complexity of neural networks calls for more sophisticated modifications like tACS and tRNS.

Effects of eccentric strength training on motor function in individuals with stroke: a scoping review

BACKGROUND

Preliminary evidence suggests that eccentric strength training (ECC) improves muscle strength and postural control in individuals with stroke; however, the evidence about the effects of ECC in people living with stroke has not been systematically analyzed.

OBJECTIVE

To determine the effects of ECC, compared to other exercise modalities (i.e., concentric training), on motor function in individuals with stroke.

METHODS

This scoping review was performed according to PRISMA extension for scoping reviews. Until March 2023, a comprehensive search of studies using ECC intervention to improve motor functions in individuals with stroke was performed. Study designs included were randomized and non-randomized controlled trials and quasi-experimental studies using MEDLINE, Web of Science, Rehabilitation & Sports Medicine, PEDro, and OTSeeker databases. Two independent reviewers selected articles based on title and abstract and extracted relevant information from the eligible studies. The results were qualitatively synthesized, and the critical appraisal was performed using the Rob 2.0 and Robins-I tools.

RESULTS

Ten studies, with 257 individuals, were analyzed. ECC revealed positive effects on muscle strength, muscular activity, balance, gait speed, and functionality, mainly compared with concentric training, physical therapy, and daily routine. No significant adverse events were reported during ECC. The critical appraisal of individual articles ranged from some to high concern.

CONCLUSION

ECC had a greater and positive effect on motor function in individuals with stroke than other exercise modalities. However, the limited number of studies, variability of outcomes, and the risk of bias produced a low certainty of evidence.

Efficacy of botulinum toxin A combined with extracorporeal shockwave therapy in post-stroke spasticity: a systematic review

Objectives

In recent years, there has been an increase in the number of randomized clinical trials of BTX-A combined with ESWT for the treatment of post-stroke spasticity. This has made it possible to observe the benefits of combination therapy in clinical practice. Therefore, this paper reviews the effectiveness of BTX-A in combination with ESWT for the treatment of post-stroke spasticity.

Methods

By October 2023, a systematic review was conducted in the databases PubMed, Cochrane, Embase, Medline, Web of Science, China National Knowledge Infrastructure, Wan Fang Database, China Biology Medicine disc and China Science and Technology Journal Database were systematically searched. We included randomized controlled trials that reported outcome metrics such as MAS, FMA, and MBI score. Studies were excluded if MAS was not reported. The quality of the included studies was assessed by the Cochrane Collaboration's tool for assessing risk of bias, and the AMSTAR quality rating scale was selected for self-assessment.

Results

A total of 70 articles were included in the initial search, and six were ultimately included. The results of the included studies showed that the combination therapy was effective in reducing MAS scores and improving FMA and MBI scores in patients with spasticity compared to the control group. Combination therapy has also been shown to improve joint mobility and reduce pain in spastic limbs.

Conclusion

Cumulative evidence from clinical randomized controlled trial studies suggests that the combination therapy is effective in reducing lower limb spasticity and improving mobility after stroke. However, more clinical trials are still needed to corroborate the evidence regarding the efficacy of BTX-A combined with shockwave therapy.

Systematic Review Registration

The system review can be searched in the PROSPERO database (CRD42023476654).

Efficacy of a Rehabilitation Program Using Mirror Therapy and Cognitive Therapeutic Exercise on Upper Limb Functionality in Patients with Acute Stroke

Applying evidence-based therapies in stroke rehabilitation plays a crucial role in this process, as they are supported by studies and results that demonstrate their effectiveness in improving functionality, such as mirror therapy (MT), cognitive therapeutic exercise (CTE), and task-oriented training. The aim of this study was to assess the effectiveness of MT and CTE combined with task-oriented training on the functionality, sensitivity, range, and pain of the affected upper limb in patients with acute stroke. A longitudinal multicenter study recruited a sample of 120 patients with acute stroke randomly and consecutively, meeting specific inclusion and exclusion criteria. They were randomly allocated into three groups: a control group only for task-oriented training (TOT) and two groups undergoing either MT or CTE, both combined with TOT. The overall functionality of the affected upper limb, specific functionality, sensitivity, range of motion, and pain were assessed using the Fugl-Meyer Assessment Upper Extremity (FMA-UE) scale validated for the Spanish population. An initial assessment was conducted before the intervention, a second assessment after completing the 20 sessions, and another three months later. ANCOVA analysis revealed statistically significant differences between the assessments and the experimental groups compared to the control group, indicating significant improvement in the overall functionality of the upper limb in these patients. However, no significant differences were observed between the two experimental groups. The conclusion drawn was that both therapeutic techniques are equally effective in treating functionality, sensitivity, range of motion, and pain in the upper limb following a stroke.

The efficacy of contralaterally controlled functional electrical stimulation compared to conventional neuromuscular electrical stimulation for recovery of limb function following a stroke: a systematic review and meta-analysis

Introduction

Limb paresis following a stroke is a common sequela that can impact patients' quality of life. Many rehabilitation strategies targeting the restoration of motor function exist. This systematic review and meta-analysis aim to evaluate the effects of contralaterally controlled functional electrical stimulation (CCFES) as a modality for limb rehabilitation. Unlike conventional neuromuscular electrical simulation (NMES), the contra-laterality in CCFES is achieved by two methods a bend angle sensor or an electromyographic bridge (EMGB) method, both of which targets signals from the unaffected limb.

Method

This review study was performed following the preferred reporting item for systematic review and meta-analysis (PRISMA) guidelines. Records that met the inclusion criteria were extracted from the following databases: Medline, Embase, and Cochrane Register of Controlled Trials (CENTRAL). Additional articles were also retrieved from clinicaltrials.gov and China/Asia on Demand (CAOD). Only randomized controlled studies (RCTs) were included.

Results

Sixteen RCTs met the inclusion criteria, and 14 of which were included in the quantitative analysis (meta-analysis). The results of the analysis show that when compared to conventional NMES, CCFES displayed a better improvement in the upper extremity Fugl-Meyer assessment (UEFMA) (SMD = 0.41, 95% CI: 0.21, 0.62, p-value <0.0001, I2 = 15%, GRADE: moderate), box and blocks test (BBT) (SMD = 0.48, 95% CI: 0.10, 0.86, p-value = 0.01, I2 = 0%, GRADE: very low), modified Barthel index (mBI) (SMD = 0.44, 95% CI: 0.16, 0.71, p-value = 0.002, I2 = 0%, GRADE: moderate), active range of motion (AROM) (SMD = 0.61, 95% CI: 0.29, 0.94, p-value = 0.0002, I2 = 23%, GRADE: moderate), and surface electromyography (sEMG) scores (SMD = 0.52, 95% CI: 0.14, 0.90, p-value = 0.008, I2 = 0%, GRADE: low). The results of the subgroup analysis for the type of sensor used in CCFES shows that an EMGB (SMD = 0.58, 95% CI: 0.33, 0.84, p-value <0.00001, I2 = 7%) is more effective than a bend angle sensor (SMD = 0.17, 95% CI: -0.12, 0.45, p-value = 0.25, I2 = 0%).

Conclusion

The results of this study provide strong evidence that shows CCFES being a better electrical stimulation modality compared to conventional NMES. This could be explained by the fact that CCFES is bilateral in nature which offers a platform for better neuroplasticity following a stroke. There is still a need for high-quality studies with a standardized approach comparing CCFES to other treatment modalities.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=342670, identifier CRD42022342670.

Electroacupuncture attenuates middle cerebral artery occlusion-induced learning and memory impairment by regulating microglial polarization in hippocampus

BACKGROUND

As a traditional medical therapy, electroacupuncture (EA) has been demonstrated to have beneficial effects on ischemic stroke-induced cognitive impairment. However, the underlying mechanism is largely unclear.

METHODS

Adult rats received occlusion of the middle cerebral artery and reperfusion (MCAO/R) to establish the ischemic stroke model. Morris water maze test was performed following EA stimulation at the GV20, PC6, and KI1 acupoints in rats to test the learning and memory ability. Western blot, immunofluorescent staining, and enzyme-linked immunosorbent assay were conducted to assess the cellular and molecular mechanisms.

RESULTS

EA stimulation attenuated neurological deficits. In the Morris water maze test, EA treatment ameliorated the MCAO/R-induced learning and memory impairment. Moreover, we observed that MCAO/R induced microglial activation and polarization in the ischemic hippocampus, whereas, EA treatment dampened microglial activation and inhibited M1 microglial polarization but enhanced M2 microglial polarization. EA treatment inhibited the increased expression of proinflammatory cytokines and enhanced the increased expression of anti-inflammatory cytokines. Finally, we found that EA treatment dampened microglial p38 mitogen-activated protein kinase (MAPK) phosphorylation.

CONCLUSION

Collectively, our data suggested that EA treatment ameliorated cognitive impairment induced by MCAO/R and the underlying mechanism may be p38-mediated microglia polarization and neuroinflammation.

Sleep and motor learning in stroke (SMiLES): a longitudinal study investigating sleep-dependent consolidation of motor sequence learning in the context of recovery after stroke

INTRODUCTION

There is growing evidence that sleep is disrupted after stroke, with worse sleep relating to poorer motor outcomes. It is also widely acknowledged that consolidation of motor learning, a critical component of poststroke recovery, is sleep-dependent. However, whether the relationship between disrupted sleep and poor outcomes after stroke is related to direct interference of sleep-dependent motor consolidation processes, is currently unknown. Therefore, the aim of the present study is to understand whether measures of motor consolidation mediate the relationship between sleep and clinical motor outcomes post stroke.

METHODS AND ANALYSIS

We will conduct a longitudinal observational study of up to 150 participants diagnosed with stroke affecting the upper limb. Participants will be recruited and assessed within 7 days of their stroke and followed up at approximately 1 and 6 months. The primary objective of the study is to determine whether sleep in the subacute phase of recovery explains the variability in upper limb motor outcomes after stroke (over and above predicted recovery potential from the Predict Recovery Potential algorithm) and whether this relationship is dependent on consolidation of motor learning. We will also test whether motor consolidation mediates the relationship between sleep and whole-body clinical motor outcomes, whether motor consolidation is associated with specific electrophysiological sleep signals and sleep alterations during subacute recovery.

ETHICS AND DISSEMINATION

This trial has received both Health Research Authority, Health and Care Research Wales and National Research Ethics Service approval (IRAS: 304135; REC: 22/LO/0353). The results of this trial will help to enhance our understanding of the role of sleep in recovery of motor function after stroke and will be disseminated via presentations at scientific conferences, peer-reviewed publication, public engagement events, stakeholder organisations and other forms of media where appropriate.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT05746260, registered on 27 February 2023.

Therapeutic robots for post-stroke rehabilitation

Stroke is a prevalent, severe, and disabling health-care issue on a global scale, inevitably leading to motor and cognitive deficits. It has become one of the most significant challenges in China, resulting in substantial social and economic burdens. In addition to the medication and surgical interventions during the acute phase, rehabilitation treatment plays a crucial role in stroke care. Robotic technology takes distinct advantages over traditional physical therapy, occupational therapy, and speech therapy, and is increasingly gaining popularity in post-stroke rehabilitation. The use of rehabilitation robots not only alleviates the workload of healthcare professionals but also enhances the prognosis for specific stroke patients. This review presents a concise overview of the application of therapeutic robots in post-stroke rehabilitation, with particular emphasis on the recovery of motor and cognitive function.

Neurophysiological underpinnings of an intensive protocol for upper limb motor recovery in subacute and chronic stroke patients

BACKGROUND

Upper limb (UL) motor impairment following stroke is a leading cause of functional limitations in activities of daily living. Robot-assisted therapy supports rehabilitation, but how its efficacy and the underlying neural mechanisms depend on the time after stroke is yet to be assessed.

AIM

We investigated the response to an intensive protocol of robot-assisted rehabilitation in sub-acute and chronic stroke patients, by analyzing the underlying changes in clinical scores, electroencephalography (EEG) and end-effector kinematics. We aimed at identifying neural correlates of the participants' upper limb motor function recovery, following an intensive 2-week rehabilitation protocol.

DESIGN

Prospective cohort study.

SETTING

Inpatients and outpatients from the Neurorehabilitation Unit of Pisa University Hospital, Italy.

POPULATION

Sub-acute and chronic stroke survivors.

METHODS

Thirty-one stroke survivors (14 sub-acute, 17 chronic) with mild-to-moderate UL paresis were enrolled. All participants underwent ten rehabilitative sessions of task-oriented exercises with a planar end-effector robotic device. All patients were evaluated with the Fugl-Meyer Assessment Scale and the Wolf Motor Function Test, at recruitment (T0), end-of-treatment (T1), and one-month follow-up (T2). Along with clinical scales, kinematic parameters and quantitative EEG were collected for each patient. Kinematics metrics were related to velocity, acceleration and smoothness of the movement. Relative power in four frequency bands was extracted from the EEG signals. The evolution over time of kinematic and EEG features was analyzed, in correlation with motor recovery.

RESULTS

Both groups displayed significant gains in motility after treatment. Sub-acute patients displayed more pronounced clinical improvements, significant changes in kinematic parameters, and a larger increase in Beta-band in the motor area of the affected hemisphere. In both groups these improvements were associated to a decrease in the Delta-band of both hemispheres. Improvements were retained at T2.

CONCLUSIONS

The intensive two-week rehabilitation protocol was effective in both chronic and sub-acute patients, and improvements in the two groups shared similar dynamics. However, stronger cortical and behavioral changes were observed in sub-acute patients suggesting different reorganizational patterns.

CLINICAL REHABILITATION IMPACT

This study paves the way to personalized approaches to UL motor rehabilitation after stroke, as highlighted by different neurophysiological modifications following recovery in subacute and chronic stroke patients.

Personalized robots for long-term telerehabilitation after stroke: a perspective on technological readiness and clinical translation

Stroke rehabilitation, which demands consistent, intensive, and adaptable intervention in the long term, faced significant challenges due to the COVID-19 pandemic. During this time, telerehabilitation emerged as a noteworthy complement to traditional rehabilitation services, offering the convenience of at-home care delivery and overcoming geographical and resource limitations. Self-help rehabilitation robots deliver repetitive and intensive physical assistance, thereby alleviating the labor burden. However, robots have rarely demonstrated long-term readiness for poststroke telerehabilitation services. The transition from research trials to general clinical services presents several challenges that may undermine the rehabilitative gains observed in these studies. This perspective discusses the technological readiness of personal use robots in the context of telerehabilitation and identifies the potential challenges for their clinical translation. The goal is to leverage technology to seamlessly integrate it into standard clinical workflows, ultimately enhancing the outcomes of stroke rehabilitation.

Upper limb assessment with inertial measurement units according to the international classification of functioning in stroke: a systematic review and correlation meta-analysis

OBJECTIVE

To investigate the usefulness of inertial measurement units (IMUs) in the assessment of motor function of the upper limb (UL) in accordance with the international classification of functioning (ICF).

DATA SOURCES

PubMed; Scopus; Embase; WoS and PEDro databases were searched from inception to 1 February 2022.

METHODS

The current systematic review follows PRISMA recommendations. Articles including IMU assessment of UL in stroke individuals have been included and divided into four ICF categories (b710, b735, b760, d445). We used correlation meta-analysis to pool the Fisher Z-score of each correlation between kinematics and clinical assessment.

RESULTS

A total of 35 articles, involving 475 patients, met the inclusion criteria. In the included studies, IMUs have been employed to assess the mobility of joint functions (n = 6), muscle tone functions (n = 4), control of voluntary movement functions (n = 15), and hand and arm use (n = 15). A significant correlation was found in overall meta-analysis based on 10 studies, involving 213 subjects: (r = 0.69) (95% CI: 0.69/0.98; p < 0.001) as in the d445 (r = 0.71) and b760 (r = 0.64) ICF domains, with no heterogeneity across the studies.

CONCLUSION

The literature supports the integration of IMUs and conventional clinical assessment in functional evaluation of the UL after a stroke. The use of a limited number of wearable sensors can provide additional kinematic features of UL in all investigated ICF domains, especially in the ADL tasks when a strong correlation with clinical evaluation was found.

Effects of Kinesiotaping on upper limb function and daily activities in subacute or chronic stroke survivors: A randomized control study

BACKGROUND

Impaired upper limb function in stroke survivors is characterized by muscle weakness, increased muscle tone, contracture, or impaired motor control.

OBJECTIVE

We aimed to evaluate the effectiveness of Kinesio-taping application for functional recovery on the affected arm and forearm during rehabilitation.

METHODS

Forty-one patients eligible for this study were randomly assigned to either the Kinesio-taping group (n = 21), receiving Kinesio-taping intervention and conventional therapy, or control group (n = 20), receiving sham Kinesio-taping intervention and conventional therapy. The whole intervention lasted for 3 weeks. Fugl-Meyer assessment of the upper extremity, Barthel Index, the Stroke Impact Scale, and modified Ashworth scale were measured at 3 time points: baseline, post-treatment (3rd week), and follow-up (6th week).

RESULTS

In the Kinesio-taping group, there were significant differences in the upper extremity (p = 0.003), wrist (p = 0.000) and hand (p = 0.000) parts of the Fugl-Meyer assessment of the upper extremity between the three assessment times. On the other hand, the Barthel Index showed significant differences in both groups after therapy.

CONCLUSION

Combining conventional rehabilitation with Kinesio-taping intervention may improve functional motor performance of both the proximal and distal parts of the affected upper extremity in stroke survivors, with potential benefits for activity of daily living.

Virtual reality after stroke: Identifying important characteristics when designing experiences to improve engagement in upper limb rehabilitation

Objective

Virtual reality (VR) has been used to improve upper limb function after stroke but there is little to guide product developers in building experiences that engage users in the sustained, repetitive training required. This research sought to understand the characteristics of VR scenarios best suited to engaging someone with a stroke during recovery to achieve therapeutic outcomes.

Methods

Five creative immersive VR scenarios were designed by an experienced VR content creator containing unique combinations of VR characteristics. The usefulness of the scenarios was reviewed by expert clinicians experienced in stroke rehabilitation. Following this review, seven stroke survivors participated in each experience and reported on their engagement and motivation. Outcome measures were the User Satisfaction Evaluation Questionnaire and the modified Intrinsic Motivation Inventory. Semi-structured interviews were conducted with five participants following their immersive VR experience and analysed thematically.

Results

Expert clinicians reported potential therapeutic value in the immersive VR scenarios by providing opportunities for repeated and graded practice of upper limb movements. Stroke survivors reported varied levels of enjoyment and engagement for each scenario. They recommended changes to the experiences, primarily relating to the tailoring of the scenarios to match varied upper limb capacities.

Conclusion

This study highlights the characteristics of immersive VR scenarios that are important in sustaining motivation and providing high-repetition task-specific movement experiences. Differences in the experience and preferences of stroke participants regarding the characteristics of immersive VR experiences indicate that a variety of experiences are necessary to engage and sustain participation in an immersive VR-related therapy programme.

Accelerometry in the Functional Assessment of Balance in People with Stroke: A Systematic Review

Balance disturbances in people with lived experience of stroke affect activities of daily living and social participation, so assessing them is essential to know the level of functional independence. Accelerometers are electronic devices that allow kinematic variables of balance to be recorded and are a tool of great interest in the assessment of functional balance. To determine the validity and reliability of, as well as the most performed protocols using accelerometers in the functional assessment of balance in people with experience of stroke, a systematic search of articles published in the electronic databases PubMed, Scopus, the Web of Science, the Cochrane Library, the PEDro and the Virtual Health Library from Spain was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. We used QUADAS-2 to assess the quality of the included studies. Eight studies met the inclusion criteria, two studied reliability and validity, two studied reliability and four studied the validity of accelerometers in the assessment of balance in people with stroke. All studies indicated the kind of accelerometer, localization on the body, tests and outcome variables. The results indicate that accelerometers show excellent reliability values in the assessment of balance in people who had a prior stroke and disparate results in terms of validity. Triaxial accelerometers were most used, and the 4th and 5th lumbar and 1st and 2nd sacral vertebrae were the body areas most used for their placement.

Utilization of Mirror Visual Feedback for Upper Limb Function in Poststroke Patients: A Systematic Review and Meta-Analysis

Mirror visual feedback (MVF), a noninvasive treatment method, is attracting attention as a possibility to promote the recovery of upper limb function in stroke patients. However, the cognitive effects of this therapy have received limited attention in the existing literature. To address this gap, we conducted a systematic review and meta-analysis to investigate the relationship between upper limb function and cognition in stroke patients and to evaluate the effect of MVF on improving upper limb function. A comprehensive search was performed on the Embase, MEDLINE, and PubMed databases to identify original articles and clinical studies published between 2013 and 2022. Qualitative analysis was performed using the Cochrane Risk of Bias tool, and in the quantitative analysis, a random-effects model was used as the effect model, and standard mean difference (SMD) was used as the effect measure. Eight studies that met the inclusion criteria were entered in the analysis. Data extraction included an assessment tool for upper extremity function. Results of the quantitative analysis demonstrate that MVF was effective in improving upper extremity function in stroke patients (SMD = 0.94, 95% CI 0.69 to 1.20). In conclusion, this systematic review and meta-analysis provides evidence supporting the effectiveness of MVF in improving upper limb function in stroke patients. However, further studies are needed to investigate the cognitive effects of MVF and elucidate the underlying mechanisms.

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.

A Multimodal Analysis to Explore Upper Limb Motor Recovery at 4 Weeks After Stroke: Insights From EEG and Kinematics Measures

Background. Stroke is a leading cause of death and disability worldwide and there is a very short period of increased synaptic plasticity, fundamental in motor recovery. Thus, it is crucial to acquire data to guide the rehabilitation treatment. Promising results have been achieved with kinematics and neurophysiological data, but currently, few studies integrate these different modalities. Objectives. We explored the correlations between standardized clinical scales, kinematic data, and EEG measures 4 weeks after stroke. Methods. 26 patients were considered. Among them, 20 patients also performed the EEG study, beyond the kinematic analysis, at 4 weeks. Results. We found correlations between the Fugl-Meyer Assessment-Upper Extremity, movement duration, smoothness measures, and velocity peaks. Moreover, EEG measures showed a tendency for the healthy hemisphere to vicariate the affected one in patients characterized by better clinical conditions. Conclusions. These results suggest the relevance of kinematic (in particular movement duration and smoothness) and EEG biomarkers to evaluate post-stroke recovery. We emphasize the importance of integrating clinical data with kinematic and EEG analyses from the early stroke stages, in order to guide rehabilitation strategies to best leverage the short period of increased synaptic plasticity.

Classification and Quantification of Physical Therapy Interventions across Multiple Neurological Disorders: An Italian Multicenter Network

Despite their relevance in neurorehabilitation, physical therapy (PT) goals and interventions are poorly described, compromising a proper understanding of PT effectiveness in everyday clinical practice. Thus, this paper aims to describe the prevalence of PT goals and interventions in people with neurological disorders, along with the participants' clinical features, setting characteristics of the clinical units involved, and PT impact on outcome measures. A multicenter longitudinal observational study involving hospitals and rehabilitation centers across Italy has been conducted. We recruited people with stroke (n = 119), multiple sclerosis (n = 48), and Parkinson's disease (n = 35) who underwent the PT sessions foreseen by the National Healthcare System. Clinical outcomes were administered before and after the intervention, and for each participant the physical therapists completed a semi-structured interview to report the goals and interventions of the PT sessions. Results showed that the most relevant PT goals were related to the ICF activities with "walking" showing the highest prevalence. The most used interventions aimed at improving walking performance, followed by those aimed at improving organ/body system functioning, while interventions targeting the cognitive-affective and educational aspects have been poorly considered. Considering PT effectiveness, 83 participants experienced a clinically significant improvement in the outcome measures assessing gait and balance functions.

An Exploration of the Effectiveness of Different Intensity Protocols of Modified Constraint-Induced Therapy in Stroke: A Systematic Review

Purpose

To examine the effectiveness of different modified Constraint-Inuced Therapy (mCIMT) protocol intensities on upper extremity motor function in adults with hemiplegia.

Methods

A search was conducted in PubMed, Scopus, EBSCO, and Cochrane Library for articles published between April 2010 and December 2021. Only randomized controlled trials (RCTs) were included. Studies were excluded if they used a sample of less than five, mCIMT in combination with other therapy, and/or if they were not written in English. Methodologic quality was assessed using the Cochrane collaboration risk of bias tool-2.

Results

Thirty-six RCTs with a total of 721 participants were included. Most researchers followed a moderate to low protocol intensity in terms of total treatment time and moderate to high intensity with regard to restriction time. Almost all of the upper limb motor function measures showed statistically significant improvements (p < .05) after mCIMT, irrespective of the protocol's intensity, but there was lack of high-quality studies. Statistically significant improvements did not always translate to clinical importance.

Conclusions

Low-intensity CIMT protocols may result in comparable improvements to more intensive ones but caution has to be taken when drawing conclusions due to high risk of bias studies.

A survey to assess perspectives of people with chronic stroke about customized safety harnesses for dance-based exergaming in home settings

BACKGROUND

Early dance-based exergaming (DBExG) trials in people with chronic stroke (PwCS) have shown promising results, but there remains a lack of knowledge if PwCS are interested in receiving such training in their homes and the applicability of a fall-protection safety harness in the home environment.

OBJECTIVE

To survey people with chronic stroke to understand the perspectives and preferences of various customized safety harnesses for home-based harness assisted dance-based exergaming rehabilitation.

METHODS

Participants were included in this survey study if they had a stroke, lived in the community, and understood English. Participants completed a study-specific safety harness survey via mail, in-person, or online. Descriptive statistics were used to characterize the sample and survey responses.

RESULTS

One hundred two survey responses were returned. The majority of participants voted for a door mountable harness (51%), side-release style buckle (58%), and preferred to receive a manual to explain how to use the harness (51%). Seventy-eight percent of the participants required permission to install or use a harness system in their homes. More than half of the participants preferred exhibiting independence by strapping the harness themselves (68%), along with choosing to live independently (the ability to live in one's own home and community safely, independently, comfortably, and able also perform their activities of daily living, regardless of physical ability level) (89%).

CONCLUSIONS

PwCS opted to use ShA-DBExG in their homes. The current survey serves as a guideline to develop, customize, and prescribe home-based ShA-DBExG rehabilitation.

Cognitive and Motor Therapy After Stroke Is Not Superior to Motor and Cognitive Therapy Alone to Improve Cognitive and Motor Outcomes: New Insights From a Meta-analysis

OBJECTIVE

To evaluate whether cognitive and motor therapy (CMT) is more effective than no therapy, motor therapy, or cognitive therapy on motor and/or cognitive outcomes after stroke. Additionally, this study evaluates whether effects are lasting and which CMT approach is most effective.

DATA SOURCES

AMED, EMBASE, MEDLINE/PubMed, and PsycINFO databases were searched in October 2022.

STUDY SELECTION

Twenty-six studies fulfilled the inclusion criteria: randomized controlled trials published in peer-reviewed journals since 2010 that investigated adults with stroke, delivered CMT, and included at least 1 motor, cognitive, or cognitive-motor outcome. Two CMT approaches exist: CMT dual-task ("classical" dual-task where the secondary cognitive task has a distinct goal) and CMT integrated (where cognitive components of the task are integrated into the motor task).

DATA EXTRACTION

Data on study design, participant characteristics, interventions, outcome measures (cognitive/motor/cognitive-motor), results and statistical analysis were extracted. Multilevel random effects meta-analysis was conducted.

DATA SYNTHESIS

CMT demonstrated positive effects compared with no therapy on motor outcomes (g=0.49; 95% confidence interval [CI], 0.10, 0.88) and cognitive-motor outcomes (g=0.29; 95% CI, 0.03, 0.54). CMT showed no significant effects compared with motor therapy on motor, cognitive, and cognitive-motor outcomes. A small positive effect of CMT compared with cognitive therapy on cognitive outcomes (g=0.18; 95% CI, 0.01, 0.36) was found. CMT demonstrated no follow-up effect compared with motor therapy (g=0.07; 95% CI, -0.04, 0.18). Comparison of CMT dual-task and integrated revealed no significant difference for motor (F1,141=0.80; P=.371) or cognitive outcomes (F1,72=0.61, P=.439).

CONCLUSIONS

CMT was not superior to monotherapies in improved outcomes after stroke. CMT approaches were equally effective, suggesting that training that enlists a cognitive load per se may benefit outcomes.

Delivering constraint-induced movement therapy in stroke rehabilitation requires informed stakeholders, sufficient resources and organisational buy-in: a mixed-methods systematic review

OBJECTIVE

To summarise and synthesise the qualitative literature relating to constraint-induced movement therapy (CIMT) among stroke survivors, carers, therapists and rehabilitation service managers.

DESIGN

Systematic review of qualitative studies. Quantitative studies using survey data were also included if they investigated perceptions and/or experiences related to CIMT.

DATA SOURCES

Cochrane Library, Medline, JBI, Emcare, Embase, PsycInfo, CINAHL, PEDro, OT Seeker and NICE from inception to January 2022.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data from the included studies and assessed comprehensiveness of reporting using established tools. Thematic synthesis was undertaken to synthesise findings for studies using focus groups and interviews. A summary of themes from quantitative studies using survey data was compiled to complement the qualitative synthesis.

RESULTS

Searches yielded 1,450 titles after removal of duplicates; 60 full-text articles were assessed for eligibility and 14 studies were included (1,570 total participants). Thematic synthesis identified nine descriptive themes from which four analytical themes were developed: CIMT is challenging but support at all levels helps; therapists need the know-how, resources and staffing; CIMT is different to other interventions, and there are positives and negatives to this; and functional outcomes do not always meet high expectations. Quantitative survey themes included: knowledge, skills and confidence in delivering CIMT programs; patient factors; and institutional factors.

CONCLUSIONS

This review identified several determinants of implementation related to CIMT. Rehabilitation therapists need to develop their knowledge and skills to deliver CIMT, engage with organisational leaders, and develop CIMT protocols to fit the local clinical context in order to sustainably deliver CIMT in stroke rehabilitation services. Stroke survivors and carers require improved education to increase their engagement and participation. After addressing these determinants, future research should evaluate population-level outcomes and policy-level implementation in establishing CIMT as global standard rehabilitation practice.

REGISTRATION

CRD42021237757.

The relationship between Rating of Everyday Arm-use in the Community and Home (REACH) scale affected arm-use assessment, activity and participation after stroke

BACKGROUND AND OBJECTIVES

While arm function has been traditionally used as a primary goal for upper extremity rehabilitation post-stroke, we propose a simple measure of arm use, which may translate into better activities and participation. The aim was to determine the relationship between arm use and measures of activity and participation.

METHODS

This was a cross-sectional study with evaluative components involving community-dwelling individuals with chronic stroke. The Rating of Everyday Arm-Use in the Community and Home (REACH) Scale was used to assess affected arm use, Barthel Index and activity domain of the Stroke Impact Scale (SIS) for activities, and participation domain of the SIS for participation. The participants were also asked if they resumed driving after the stroke.

RESULTS

Forty-nine individuals (mean age = 70.3 ± 11.5 years, male sex = 51%) living with the effects of a stroke for at least 3 months participated in this study. There was a positive relationship between affected arm use and activities (Barthel Index score - rs  = 0.464; SIS activities - rs  = 0.686), participation (rs  = 0.479), and driving (rs  = 0.581). The Barthel Index scores were higher for individuals with dominant arm hemiparesis (p = 0.003) or left hemisphere lesions (p = 0.005). There was also greater arm use in left hemisphere lesions (p = 0.018).

CONCLUSIONS

Affected arm use in individuals with chronic stroke is related to activities and participation. Given the importance of arm use in activities and participation after stroke, rehabilitation therapists may consider utilizing the REACH Scale, a simple and quick outcome measure, as a means to assess arm use and implement effective interventions for improving arm use.

Psychometric properties of the Chinese version of the Arm Activity Measure in people with chronic stroke

Introduction

The Arm Activity Measure was developed to assess active and passive functions of the upper limb in people with unilateral paresis, but a Chinese version is not available and its psychometric properties have not been specifically tested in people with stroke. This study aimed to translate and culturally adapt the Chinese version of the Arm Activity Measure (ArmA-C) and establish its psychometric properties in people with chronic stroke.

Methods

The psychometric properties of ArmA-C were determined in 100 people with chronic stroke.

Results

The ArmA-C had good test-retest reliability (intraclass correlation coefficients [ICC] = 0.87-0.93; quadratic weighted Kappa coefficients = 0.53-1.00). A floor effect was identified in section A of the ArmA-C. The content validity and internal consistency (Cronbach's alpha coefficients = 0.75-0.95) were good. The construct validity of the ArmA-C was supported by acceptable fit to the two-factor structure model and significant correlations with the Fugl-Meyer Assessment for Upper Extremity score, grip strength, the Wolf Motor Function Test score, the Trail Walking Test completion time, and the Oxford Participation and Activities Questionnaire scores.

Conclusions

The ArmA-C is reliable and valid for assessing active and passive functions in people with chronic stroke.

Impact of unilateral and bilateral impairments on bimanual force production following stroke

Large bilateral asymmetry and task deficits are typically observed during bimanual actions of stroke survivors. Do these abnormalities originate from unilateral impairments affecting their more-impaired limb, such as weakness and abnormal synergy, or from bilateral impairments such as incoordination of two limbs? To answer this question, 23 subjects including 10 chronic stroke survivors and 13 neurologically intact subjects participated in an experiment where they produced bimanual forces at different hand locations. The force magnitude and directional deviation of the more-impaired arm were measured for unilateral impairments and bimanual coordination across locations for bilateral impairments. Force asymmetry and task error were used to define task performance. Significant unilateral impairments were observed in subjects with stroke; the maximal force capacity of their more-impaired arm was significantly lower than that of their less-impaired arm, with a higher degree of force deviation. However, its force contribution during submaximal tasks was greater than its relative force capacity. Significant bilateral impairments were also observed, as stroke survivors modulated two forces to a larger degree across hand locations but in a less coordinated manner than control subjects did. But only unilateral, not bilateral, impairments explained a significant amount of between-subject variability in force asymmetry across subjects with stroke. Task error, in contrast, was correlated with neither unilateral nor bilateral impairments. Our results suggest that unilateral impairments of the more-impaired arm of stroke survivors mainly contribute to its reduced recruitment, but that the degree of its participation in bimanual task may be greater than their capacity as they attempt to achieve symmetry.NEW & NOTEWORTHY We studied how unilateral and bilateral impairments in stroke survivors affect their bimanual task performance. Unilateral impairments of the more-impaired limb, both weakness and loss of directional control, mainly contribute to bimanual asymmetry, but stroke survivors generally produce higher force with their more-impaired limb than their relative capacity. Bilateral force coordination was significantly impaired in stroke survivors, but its degree of impairment was not related to their unilateral impairments.

Exploring the Feasibility of Computer Vision for Detecting Post-Stroke Compensatory Movements

Compensatory movements are commonly observed post-stroke and can negatively affect long-term motor recovery. In this context, a system that monitors movement quality and provides feedback would be beneficial. In this study, we aimed to detect compensatory movements during seated reaching using a conventional tablet camera and an open-source markerless body pose tracking algorithm called MediaPipe [1]. We annotated compensatory movements of stroke patients per frame based on the comparison between the paretic and non-paretic arms. We trained a binary classification model using the XGBoost algorithm to detect compensatory movements, which showed an average accuracy of 0.92 (SD 0.07) in leave-one-trial-out cross-validation across four participants. Although we observed good model performance, we also encountered challenges such as missing landmarks and misalignment, when using MediaPipe Pose. This study highlights the feasibility of using near real-time compensatory movement detection with a simple camera system in stroke rehabilitation. More work is necessary to assess the generalizability of our approach across diverse groups of stroke survivors and fully implement near real-time compensatory movement detection on a mobile device.

Efficacy of Robot-Assisted Training on Rehabilitation of Upper Limb Function in Patients With Stroke: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically evaluate the effect of robot-assisted training (RAT) on upper limb function recovery in patients with stroke, providing the evidence-based medical basis for the clinical application of RAT.

DATA SOURCES

We searched online electronic databases up to June 2022, including PubMed, The Cochrane Library, Scopus, Web of Science, EMBASE, WanFang Data, CNKI, and VIP full-text databases.

STUDY SELECTION

Randomized controlled trials of the effect of RAT on upper extremity functional recovery in patients with stroke.

DATA EXTRACTION

The Cochrane Collaboration Tool for Assessing the Risk of Bias was used to assess study quality and risk of bias.

DATA SYNTHESIS

Fourteen randomized controlled trials involving 1275 patients were included for review. Compared with the control group, RAT significantly improved upper limb motor function and daily living ability. The overall differences were statistically significant, Fugl-Meyer Assessment for the Upper Extremity (FMA-UE; standard mean difference=0.69; 95% confidence interval, 0.34, 1.05; P=.0001), modified Barthel Index (standard mean difference=0.95; 95% confidence interval, 0.75, 1.15; P<.00001), whereas the differences in modified Ashworth Scale, FIM, and Wolf Motor Function Test scores were not statistically significant.

SUBGROUP ANALYSIS

Compared with the control group, the differences between FMA-UE and modified Barthel Index at 4 and 12 weeks of RAT, there were statistically significant, the differences of FMA-UE and modified Ashworth Scale in patients with stroke in the acute and chronic phases were statistically significant.

CONCLUSION

The present study showed that RAT can significantly enhance the upper limb motor function and activities of daily life in patients with stroke undergoing upper limb rehabilitation.

Uncertainty-aware automated assessment of the arm impedance with upper-limb exoskeletons

Providing high degree of personalization to a specific need of each patient is invaluable to improve the utility of robot-driven neurorehabilitation. For the desired customization of treatment strategies, precise and reliable estimation of the patient's state becomes important, as it can be used to continuously monitor the patient during training and to document the rehabilitation progress. Wearable robotics have emerged as a valuable tool for this quantitative assessment as the actuation and sensing are performed on the joint level. However, upper-limb exoskeletons introduce various sources of uncertainty, which primarily result from the complex interaction dynamics at the physical interface between the patient and the robotic device. These sources of uncertainty must be considered to ensure the correctness of estimation results when performing the clinical assessment of the patient state. In this work, we analyze these sources of uncertainty and quantify their influence on the estimation of the human arm impedance. We argue that this mitigates the risk of relying on overconfident estimates and promotes more precise computational approaches in robot-based neurorehabilitation.

Development and Validation of the Body Cognition Assessment System

Body awareness, which comprises the sense of body possession and action ownership, is essential for the adaptive movement of humans in response to external environments. However, existing body cognition assessments include many overt elements of cognitive functional activity, but no assessment captures the latent body cognition necessary for exercise and daily life activities. Therefore, this study aimed to devise a body cognition assessment system (BCAS) to examine the functional basis of body cognition in healthy participants and investigate its usefulness. The BCAS was used to assess body cognition on three occasions, and BCAS values were calculated from the results of the assessment. The intraclass correlation coefficient (ICC) was used to determine reproducibility. Neural activity in the brain during somatocognition assessment while conducting the BCAS was measured by electroencephalogram. Moreover, the functional basis for somatocognition with the BCAS was also investigated. The results demonstrated that the BCAS values varied across the three administrations (ICC (1.3) = 0.372), and changes in the state of neural activity in the brain were observed. The results suggest that assessment using the BCAS may be a new indicator of ever-changing body cognition.

The Translation of Mobile-Exoneuromusculoskeleton-Assisted Wrist-Hand Poststroke Telerehabilitation from Laboratory to Clinical Service

Rehabilitation robots are helpful in poststroke telerehabilitation; however, their feasibility and rehabilitation effectiveness in clinical settings have not been sufficiently investigated. A non-randomized controlled trial was conducted to investigate the feasibility of translating a telerehabilitation program assisted by a mobile wrist/hand exoneuromusculoskeleton (WH-ENMS) into routine clinical services and to compare the rehabilitative effects achieved in the hospital-service-based group (n = 12, clinic group) with the laboratory-research-based group (n = 12, lab group). Both groups showed significant improvements (p ≤ 0.05) in clinical assessments of behavioral motor functions and in muscular coordination and kinematic evaluations after the training and at the 3-month follow-up, with the lab group demonstrating better motor gains than the clinic group (p ≤ 0.05). The results indicated that the WH-ENMS-assisted tele-program was feasible and effective for upper limb rehabilitation when integrated into routine practice, and the quality of patient-operator interactions physically and remotely affected the rehabilitative outcomes.

Functional electrical stimulation therapy controlled by a P300-based brain-computer interface, as a therapeutic alternative for upper limb motor function recovery in chronic post-stroke patients. A non-randomized pilot study

Introduction

Up to 80% of post-stroke patients present upper-limb motor impairment (ULMI), causing functional limitations in daily activities and loss of independence. UMLI is seldom fully recovered after stroke when using conventional therapeutic approaches. Functional Electrical Stimulation Therapy (FEST) controlled by Brain-Computer Interface (BCI) is an alternative that may induce neuroplastic changes, even in chronic post-stroke patients. The purpose of this work was to evaluate the effects of a P300-based BCI-controlled FEST intervention, for ULMI recovery of chronic post-stroke patients.

Methods

A non-randomized pilot study was conducted, including 14 patients divided into 2 groups: BCI-FEST, and Conventional Therapy. Assessments of Upper limb functionality with Action Research Arm Test (ARAT), performance impairment with Fugl-Meyer assessment (FMA), Functional Independence Measure (FIM) and spasticity through Modified Ashworth Scale (MAS) were performed at baseline and after carrying out 20 therapy sessions, and the obtained scores compared using Chi square and Mann-Whitney U statistical tests (𝛼 = 0.05).

Results

After training, we found statistically significant differences between groups for FMA (p = 0.012), ARAT (p < 0.001), and FIM (p = 0.025) scales.

Discussion

It has been shown that FEST controlled by a P300-based BCI, may be more effective than conventional therapy to improve ULMI after stroke, regardless of chronicity.

Conclusion

The results of the proposed BCI-FEST intervention are promising, even for the most chronic post-stroke patients often relegated from novel interventions, whose expected recovery with conventional therapy is very low. It is necessary to carry out a randomized controlled trial in the future with a larger sample of patients.

Validity of the telematic Fugl Meyer assessment scale - upper extremity (TFMA-UE) Spanish version

Background

Telematic assistance has become indispensable in recent years. The increased prevalence of Acquired brain injury and the sequels it causes, requires long-lasting multidisciplinary treatments. Validated tools to assess the evolution of the disabilities and limitations of this pathology are essential to individualize and prescribe adapted treatments. The aim has been to create the telematic version of the Fugl Meyer Assessment-Upper Extremity Motor Function (TFMA-UE) Spanish scale and its adaptation to the remote assessment of neurologic patients.

Methods

An adapted scale was designed based on the Fugl Meyer Assessment scale-telematic version (FMA-TV): TFMA-UE. This scale is composed by 21 items which evaluate the upper extremity motor function. Physiotherapists trained in this tool, evaluate the results obtained from applying the two versions (on-site and telematic) to compare the results.

Results

TFMA-UE was administered to 30 patients with acquired brain injury. It was applied on site and through the web platform selected by the patients in two different days. Patients completed all the scale in an easily way without help. The exploratory and confirmatory factor analysis confirmed a factorial structure with a factor (76.08% of the variance). The Cronbach's internal consistency index obtained was 0.98 and the weight kappa index used to measure agreement between the two versions was 0.78 which represents substantial agreement.

Conclusion

The Telematic Fugl Meyer Assessment-Upper Extremity Motor Function (TFMA-UE) scale is a viable, useful and easy to apply tool that allows the upper extremity motor function assessment of Acquired Brain Injury patients.

Biomimetic Design of a Tendon-Driven Myoelectric Soft Hand Exoskeleton for Upper-Limb Rehabilitation

Degenerative diseases and injuries that compromise hand movement reduce individual autonomy and tend to cause financial and psychological problems to their family nucleus. To mitigate these limitations, over the past decade, hand exoskeletons have been designed to rehabilitate or enhance impaired hand movements. Although promising, these devices still have limitations, such as weight and cost. Moreover, the movements performed are not kinematically compatible with the joints, thereby reducing the achievements of the rehabilitation process. This article presents the biomimetic design of a soft hand exoskeleton actuated using artificial tendons designed to achieve low weight, volume, and cost, and to improve kinematic compatibility with the joints, comfort, and the sensitivity of the hand by allowing direct contact between the hand palm and objects. We employed two twisted string actuators and Bowden cables to move the artificial tendons and perform the grasping and opening of the hand. With this configuration, the heavy part of the system was reallocated to a test bench, allowing for a lightweight set of just 232 g attached to the arm. The system was triggered by the myoelectric signals of the biceps captured from the user's skin to encourage the active participation of the user in the process. The device was evaluated by five healthy subjects who were asked to simulate a paralyzed hand, and manipulate different types of objects and perform grip strength. The results showed that the system was able to identify the intention of movement of the user with an accuracy of 90%, and the orthosis was able to enhance the ability of handling objects with gripping force up to 1.86 kgf.

Feasibility of a serious game system including a tangible object for post stroke upper limb rehabilitation: a pilot randomized clinical study

Introduction

Serious games can be used to provide intensive rehabilitation through attractive exercises as part of post-stroke rehabilitation. However, currently available commercial and serious games systems primarily train shoulder and elbow movements. These games lack the grasping and displacement components that are essential to improve upper limb function. For this reason, we developed a tabletop device that encompassed a serious game with a tangible object to rehabilitate combined reaching and displacement movements: the Ergotact system.

Objectives

The aim of this pilot study was to assess the feasibility and the short-term effects of a training program using the Ergotact prototype in individuals with chronic stroke.

Methods

Participants were assigned to one of two groups: a serious game training group (Ergotact) or a control training group (Self).

Results

Twenty-eight individuals were included. Upper limb function increased after the Ergotact training program, although not statistically significantly, and the program did not induce pain or fatigue, demonstrating its safety.

Conclusion

The Ergotact system for upper limb rehabilitation was well accepted and induced participant satisfaction. It complies with current recommendations for people with stroke to autonomously perform intensive active exercises in a fun context, in addition to conventional rehabilitation sessions with therapists.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT03166020?term=NCT03166020&draw=2&rank=1, identifier NCT03166020.

Repetitive transcranial magnetic stimulation for stroke rehabilitation: insights into the molecular and cellular mechanisms of neuroinflammation

Stroke is a leading cause of mortality and disability worldwide, with most survivors reporting dysfunctions of motor, sensation, deglutition, cognition, emotion, and speech, etc. Repetitive transcranial magnetic stimulation (rTMS), one of noninvasive brain stimulation (NIBS) techniques, is able to modulate neural excitability of brain regions and has been utilized in neurological and psychiatric diseases. Moreover, a large number of studies have shown that the rTMS presents positive effects on function recovery of stroke patients. In this review, we would like to summarized the clinical benefits of rTMS for stroke rehabilitation, including improvements of motor impairment, dysphagia, depression, cognitive function, and central post-stroke pain. In addition, this review will also discuss the molecular and cellular mechanisms underlying rTMS-mediated stroke rehabilitation, especially immune regulatory mechanisms, such as regulation of immune cells and inflammatory cytokines. Moreover, the neuroimaging technique as an important tool in rTMS-mediated stroke rehabilitation has been discussed, to better understanding the mechanisms underlying the effects of rTMS. Finally, the current challenges and future prospects of rTMS-mediated stroke rehabilitation are also elucidated with the intention to accelerate its widespread clinical application.

The Effects of Shock Wave Therapy on Spasticity and Walking Ability in People with Stroke: A Comparative Study of Different Application Sites

BACKGROUND

This study was conducted to investigate the effects of extracorporeal shock wave therapy on the improvement of walking ability through a reduction in spasticity in stroke patients.

METHODS

Thirty-three patients diagnosed with ischemic stroke by a rehabilitation medicine specialist were randomly assigned to three groups. The patients were divided into experimental group 1 in which shock waves were applied to the muscle-tendon junction, experimental group 2 in which shock waves were applied to the middle of the muscle, and experimental group 3 in which shock waves were applied to both the muscle-tendon junction and the middle of the muscle. The MAS was used to evaluate spasticity in the subjects, and the Dartfish software was used to measure knee and ankle angles during heel-off when walking.

RESULTS

Based on the results of the study, a significant decrease in spasticity and increased joint angles were found in experimental groups 1 and 3 compared to experimental group 2, and the change in joint angle was significantly greater in experimental group 3 than in experimental groups 1 and 2.

CONCLUSIONS

These results indicate that treatment effect may vary depending on the application site of the shock wave, and to obtain the best treatment effect, the shock wave should be applied to both the muscle-tendon junction and the middle part of the muscle.

Lightweight Bioinspired Exoskeleton for Wrist Rehabilitation Powered by Twisted and Coiled Artificial Muscles

Stroke, cerebral palsy, and spinal cord injuries represent the most common leading causes of upper limb impairment. In recent years, rehabilitation robotics has progressed toward developing wearable technologies to promote the portability of assistive devices and to enable home rehabilitation of the upper extremities. However, current wearable technologies mainly rely on electric motors and rigid links or soft pneumatic actuators and are usually bulky and cumbersome. To overcome the limitations of existing technologies, in this paper, a first prototype of a lightweight, ungrounded, soft exoskeleton for wrist rehabilitation powered by soft and flexible carbon fibers-based twisted and coiled artificial muscles (TCAMs) is proposed. The device, which weighs only 0.135 kg, emulates the arrangement and working mechanism of skeletal muscles in the upper extremities and is able to perform wrist flexion/extension and ulnar/radial deviation. The range of motion and the force provided by the exoskeleton is designed through simple kinematic and dynamic theoretical models, while a thermal model is used to design a thermal insulation system for TCAMs during actuation. The device’s ability to perform passive and active-resisted wrist rehabilitation exercises and EMG-based actuation is also demonstrated.