Home-based constraint-induced movement therapy for patients with upper limb dysfunction after stroke (HOMECIMT): a cluster-randomised, controlled trial

Unlocking the restraint-Development of a behaviour change intervention to increase the provision of modified constraint-induced movement therapy in stroke rehabilitation

BACKGROUND

Strong evidence supports the provision of modified constraint-induced movement therapy (mCIMT) to improve upper limb function after stroke. A service audit identified that very few patients received mCIMT in a large subacute, early-supported discharge rehabilitation service. A behaviour change intervention was developed to increase the provision of mCIMT following an unsuccessful 'education only' attempt. This paper aims to systematically document the steps undertaken and to provide practical guidance to clinicians and rehabilitation services to implement this complex, yet effective, rehabilitation intervention.

METHODS

This clinician behaviour change intervention was developed over five stages and led by a working group of neurological experts (n = 3). Data collection methods included informal discussions with clinicians and an online survey (n = 35). The staged process included reflection on why the first attempt did not improve the provision of mCIMT (stage 1), mapping barriers and enablers to the Theoretical Domains Framework (TDF) and behaviour change wheel (BCW) to guide the behaviour change techniques (stages 2 and 3), developing a suitable mCIMT protocol (stage 4), and delivering the behaviour change intervention (stage 5).

RESULTS

Reflection among the working group identified the need for upskilling in mCIMT delivery and the use of a behaviour change framework to guide the implementation program. Key determinants of behaviour change operated within the TDF domains of knowledge, skills, environmental context and resources, social role and identity, and social influences. Following the development of a context-specific mCIMT protocol, the BCW guided the behaviour change intervention, which included education, training, persuasion, environmental restructuring, and modelling.

CONCLUSION

This paper provides an example of using the TDF and BCW to support the implementation of mCIMT in a large early-supported discharge service. It outlines the suite of behaviour change techniques used to influence clinician behaviour. The success of this behaviour change intervention will be explored in future research.

Home-based exercise program and Health education in patients with patellofemoral pain: a randomized controlled trial

BACKGROUND

Patellofemoral pain (PFP) is one of the most common disorders of the knee joint. Home-based exercise is an effective intervention to achieve self-management for chronic diseases. This study evaluated the effects of home-based exercise and health education in patients with PFP.

METHODS

Patients who had PFP were randomly allocated to an intervention group (IG) or control group (CG). Patients in the IG received a 6-week tailored home-based exercise program with health education via remote support, while patients in the CG group only received health education. Clinical outcomes were compared using the Anterior Knee Pain Scale (AKPS) to measure function and the Visual Analog Scale (VAS) to measure "worst pain" and "pain with daily activity". Muscle strength was measured according to the peak torque of the knee muscles using an isokinetic system.

RESULTS

Among a total of 112 participants screened for eligibility, 38 were randomized and analyzed, including 19 participants in the intervention group and 19 participants in the control group. There were no significant differences in baseline characteristics between the groups. At 6-week follow-up, the intervention group showed a greater worst pain reduction (between-group difference, -19.3 [95%CI, -23.2 to -15.5]; P < 0.01) and pain with daily activity (between-group difference, -22.9 [95%CI, -28.3 to -17.4]; P < 0.01) than the control group. Similarly, the intervention group had better improvements in AKPS (between-group difference, 9.0 [95%CI, 4.1 to 13.9]; P < 0.01) and knee extensor strength (between-group difference, 20.1 [95%CI, 14.5 to 25.8]; P < 0.01), compared to the control group. No adverse events were reported.

CONCLUSION

Home-based exercise and health education resulted in less pain, better function, and higher knee muscle strength compared with no exercise in patients with PFP. A large randomized controlled trial with long-term follow-up is required to confirm these findings.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2200056224 ( https://www.chictr.org.cn/showproj.aspx?proj=135506 ). Registered on February 1, 2022.

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.

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.

Adult experiences of constraint-induced movement therapy programmes: a qualitative study using the Theoretical Domains Framework and Capability, Opportunity, Motivation - Behaviour system

AIM

To explore the experiences of adults who completed a constraint-induced movement therapy (CIMT) programme, and the barriers and enablers to their participation.

METHODS

Qualitative design using semi-structured interviews. Stroke and brain injury survivors (n = 45) who had completed CIMT as part of their usual rehabilitation were interviewed 1 month post-CIMT. Interviews were audio-recorded, transcribed and imported into Nvivo for analysis. Inductive coding was used to identify initial themes. Themes were then deductively mapped to the Capability, Opportunity, Motivation - Behaviour system, a behaviour change model, to identify barriers and enablers to CIMT programme adherence and engagement.

RESULTS

Enablers influencing participation included being provided with education about the programme (Capability - psychological), seeing improvements in arm function (Motivation - reflective), being committed to the programme (Motivation - reflective) and having strong social support from staff, family and allied health students (Opportunity - social). The structured programme was a motivator and offered a way to fill the time, particularly during inpatient rehabilitation (Opportunity - physical). Barriers to participation included experiencing physical and mental fatigue (Capability - physical) and frustration early in the CIMT programme (Motivation - automatic), and finding exercises boring and repetitive (Motivation - automatic).

CONCLUSION

Therapist provision of educational supports for CIMT participants and their families is important to maximise CIMT programme uptake. During CIMT delivery, we recommend the provision of positive feedback and coaching in alignment with CIMT principles, and the inclusion of social supports such as group-based programmes to enhance participant adherence.

Effect of different constraint-induced movement therapy protocols on recovery of stroke survivors with upper extremity dysfunction: a systematic review and network meta-analysis

We aimed to assess and rank comparative efficacy of different constraint-induced movement therapy (CIMT) protocols on motor function of upper extremity and activities of daily living (ADL) in stroke survivors. A comprehensive search was conducted in PubMed, EMBASE, Web of Science and Cochrane Library to identify randomized controlled trials on CIMT. Included studies were evaluated using the revised Cochrane risk of bias tool. Then a random-effects network meta-analysis was performed within a frequentist framework using Stata v16.0. Of the 1150 studies retrieved, 44 studies with 1779 participants were included. In terms of motor recovery of upper extremity, CIMT combined with trunk restraint, in which the less affected arm was constrained at least 4 h but no more than 6 h per day, ranked as the most effective intervention for the improvement of the Fugl-Meyer Assessment-Upper Extremity and the Action Research Arm Test score. In terms of ADL improvement, constraining the less affected arm for at least 4 h but no more than 6 h per day in CIMT combined with trunk restraint, was found to significantly improve the Motor Activity Log of quality of movement scale and amount of use scale score. The protocol of CIMT combined with trunk restraint, in which the less affected arm was constrained at least 4 h but no more than 6 h per day, ranked the highest in this analysis and might be considered in practice.

Progress in the clinical application of constraint-induced therapy following stroke since 2014

Stroke is a group of cerebrovascular diseases with high prevalence and mortality rate. Stroke can induce many impairments, including motor and cognitive dysfunction, aphasia/dysarthria, dysphagia, and mood disorders, which may reduce the quality of life among the patients. Constraint-induced therapy has been proven to be an effective treatment method for stroke rehabilitation. It has been widely used in the recovery of limb motor dysfunction, aphasia, and other impairment like unilateral neglect after stroke. In recent years, constraint-induced therapy can also combine with telehealth and home rehabilitation. In addition, constraint-induced therapy produces significant neuroplastic changes in the central nervous system. Functional magnetic resonance imaging, diffusion tensor imaging, and other imaging/electrophysiology methods have been used to clarify the mechanism and neuroplasticity. However, constraint-induced therapy has some limitations. It can only be used under certain conditions, and the treatment time and effectiveness are controversial. Further research is needed to clarify the mechanism and effectiveness of CI therapy.

Modified constraint-induced movement therapy enhances cortical plasticity in a rat model of traumatic brain injury: a resting-state functional MRI study

Modified constraint-induced movement therapy (mCIMT) has shown beneficial effects on motor function improvement after brain injury, but the exact mechanism remains unclear. In this study, amplitude of low frequency fluctuation (ALFF) metrics measured by resting-state functional magnetic resonance imaging was obtained to investigate the efficacy and mechanism of mCIMT in a control cortical impact (CCI) rat model simulating traumatic brain injury. At 3 days after control cortical impact model establishment, we found that the mean ALFF (mALFF) signals were decreased in the left motor cortex, somatosensory cortex, insula cortex and the right motor cortex, and were increased in the right corpus callosum. After 3 weeks of an 8-hour daily mCIMT treatment, the mALFF values were significantly increased in the bilateral hemispheres compared with those at 3 days postoperatively. The mALFF signal values of left corpus callosum, left somatosensory cortex, right medial prefrontal cortex, right motor cortex, left postero dorsal hippocampus, left motor cortex, right corpus callosum, and right somatosensory cortex were increased in the mCIMT group compared with the control cortical impact group. Finally, we identified brain regions with significantly decreased mALFF values at 3 days postoperatively. Pearson correlation coefficients with the right forelimb sliding score indicated that the improvement in motor function of the affected upper limb was associated with an increase in mALFF values in these brain regions. Our findings suggest that functional cortical plasticity changes after brain injury, and that mCIMT is an effective method to improve affected upper limb motor function by promoting bilateral hemispheric cortical remodeling. mALFF values correlate with behavioral changes and can potentially be used as biomarkers to assess dynamic cortical plasticity after traumatic brain injury.

Effects of Coaching-Based Teleoccupational Guidance for Home-Based Stroke Survivors and Their Family Caregivers: A Pilot Randomised Controlled Trial

The aim of this pilot study was to investigate the feasibility and effectiveness of a 3-month coaching-based teleoccupational guidance (CTG) programme for home-based stroke survivors and their family caregivers. An assessor-blind pilot randomised controlled study was conducted. Twenty-five participant dyads (each dyad consisted of one home-based stroke patient and their caregivers) were randomised to a control group (RTG, n = 12) or an experimental group (CTG, n = 13). Participant dyads in the RTG group received routine teleoccupational guidance. Participant dyads in the CTG group received a six-step procedure: coaching-based teleoccupational guidance over 3 months via WeChat. Participant dyad compliance, the difficulty and suitability of outcome measures, and adverse effects were used to assess feasibility. The Reintegration to Normal Living Index, the Lawton Instructive Activities of Daily Life (Lawton IADL) scale, the Intrinsic Motivation Inventory, the Fugl-Meyer Assessment-Upper Extremity scale, the 6 min walking test, and the Stroke-Specific Quality of Life Scale were used to assess effectiveness outcomes of home-based stroke survivors; the Caregiver Benefit Finding Scale and the Zarit Caregiver Burden Interview were used to assess the effectiveness outcomes of family caregivers. Feasibility measures were assessed at the end of the pilot trial, and effectiveness measures were evaluated pre-intervention and post-intervention (after 3 months). The CTG programme significantly improved home-based stroke survivors' participation in daily life, IADL score, and intrinsic motivation, and increased caregivers' perceived benefit, and tended (not significantly) to reduce care burden. CTG has the potential to promote better integration of home-based stroke patients into their families and society, improve their quality of life and family well-being, and provide a reference for home rehabilitation of other clinical chronic diseases. CTG is a safe, effective, and promising intervention for home-based stroke populations and their caregivers and warrants further investigation in a larger randomised controlled trial.

Remote constraint induced therapy of the upper extremity (ReCITE): A feasibility study protocol

Background

Difficulty using the upper extremity in everyday activities is common after stroke. Constraint-induced movement therapy (CIMT) has been shown to be effective in both sub-acute and chronic phases of stroke recovery and is recommended in clinical practice guidelines for stroke internationally. Despite reports of equivalence of outcome when stroke rehabilitation interventions are delivered using telehealth, there has been limited evaluation of CIMT when using this mode of delivery. ReCITE will (a) evaluate the feasibility and acceptability of CIMT when delivered via telehealth to stroke survivors (TeleCIMT) and (b) explore therapists' experiences and use of an online support package inclusive of training, mentoring and resources to support TeleCIMT delivery in clinical practice.

Methods

A prospective single-group, single blinded, study design with embedded process evaluation will be conducted. The study will be conducted at three outpatient services in Sydney, Australia. A multi-faceted therapist support package, informed by the Capabilities, Opportunity, Motivation- Behaviour model (COM-B), will be used to support occupational therapists to implement TeleCIMT as part of routine care to stroke survivors. Each service will recruit 10 stroke survivor participants (n = 30) with mild to moderate upper extremity impairment. Upper extremity and quality of life outcomes of stroke survivor participants will be collected at baseline, post-intervention and at a 4 week follow-up appointment. Feasibility of TeleCIMT will be evaluated by assessing the number of stroke participants who complete 80% of intensive arm practice prescribed during their 3 week program (i.e., at least 24 h of intensive arm practice). Acceptability will be investigated through qualitative interviews and surveys with stroke survivors, supporter surveys and therapist focus groups. Qualitative interviews with therapists will provide additional data to explore their experiences and use of the online support package.

Discussion

The COVID-19 pandemic resulted in a rapid transition to delivering telehealth. The proposed study will investigate the feasibility and acceptability of delivering a complex intervention via telehealth to stroke survivors at home, and the support that therapists and patients require for delivery. The findings of the study will be used to inform whether a larger, randomized controlled trial is feasible.

Effectiveness of home-based upper limb rehabilitation in stroke survivors: A systematic review and meta-analysis

Background

Home-based training is an alternative option to provide intensive rehabilitation without costly supervised therapy. Though several studies support the effectiveness of home-based rehabilitation in improving hemiparetic upper limb function in stroke survivors, a collective evaluation of the evidence remains scarce.

Objectives

This study aims to determine the effects of home-based upper limb rehabilitation for hemiparetic upper limb recovery in stroke survivors.

Methods

The databases of the Cochrane Library, MEDLINE, CINAHL, and Web of Science were systematically searched from January 2000 to September 2020. Only randomized, controlled, and cross-over trials that evaluated the effects of home-based upper limb interventions were selected. The Pedro scale was used to assess the methodological quality of the studies. A meta-analysis of the upper limb function outcomes was performed by calculating the mean difference/standardized mean difference using a fixed/random effect model.

Results

An initial search yielded 1,049 articles. Twenty-six articles were included in the review. The pooled evidence of the meta-analysis showed that home-based upper limb intervention was more effective in improving upper limb function [SMD: 0.28, 95% CI (0.12, 0.44), I² = 0%, p < 0.001, fixed effect model] than conventional therapy. When comparing two types of home-based interventions, subgroup analysis revealed that home-based technology treatment—electrical stimulation—provided more significant improvement in upper limb function than treatment without the use of technology (SMD: 0.64, 95% CI (0.21, 1.07), I² = 0%, p = 0.003, random effect model).

Conclusion

The beneficial effects of home-based upper limb interventions were superior to conventional therapy in improving function and perceived use of the hemiparetic upper limb in daily activities. Among the home-based interventions, home-based electrical stimulation seemed to provide the most optimal benefits.

Community-Based Interventions After Acquired Brain Injury-A Systematic Review of Intervention Types and Their Effectiveness

OBJECTIVES

Comprehensive review of existing types and effectiveness of community-based interventions delivered to adults (mean age 18-65 years) with long-lasting (≥6 months) difficulties following acquired brain injury (ABI).

DESIGN

Systematic review of controlled intervention studies published until February 2021.

MAIN MEASURES

Systematic searches in databases (MEDLINE, PsycINFO, Database of Abstracts of Reviews of Effects [Cochrane Library], and Cochrane Central Register of Controlled Trials [Cochrane Library]) and inclusion of English peer-reviewed full-text articles; randomized or controlled community-based intervention studies; sample size of 20 or more participants; and 3 or more intervention sessions. Two reviewers independently extracted data for the synthesis and assessed the methodological quality. Data extraction included study characteristics, demographics of participants, content and dose of intervention, outcome measures, and findings.

RESULT

The search returned 7386 publications, of which 49 eligible studies were included, revealing a diverse range of community-based interventions and a myriad of outcome measures applied for assessing functional capacities, participation, and quality of life in the chronic phase of ABI. Intervention types encompassed 14 holistic, 23 physical, and 12 specific interventions. A large heterogeneity regarding intervention frequency and intensity was found. Meta-analyses performed on the holistic, physical, and specific interventions did not indicate any significant pooled effects but showed highly variable effects between individuals, both in persons with traumatic and nontraumatic brain injuries.

CONCLUSIONS

Because of lack of pooled effects within types of community-based interventions, specific evidence-based recommendations within holistic, physical, and specific interventions designed to mitigate long-lasting ABI problems cannot be made. This review highlights the need for future studies to address methodological issues concerning larger sample size, lack of clear description interventions and comparator, missing reports of effects in change scores, need for consistent use of recommended outcome measures, and investigating the wide variety in intervention responsiveness among participants with ABI. Systematic review registration: PROSPERO (CRD42019124949).

Home-based is as effective as centre-based rehabilitation for improving upper limb motor recovery and activity limitations after stroke: A systematic review with meta-analysis

OBJECTIVE

This systematic review aimed to examine the effects of home-based exercises in comparison with centre-based exercises for improving the paretic upper limb after stroke.

DATA SOURCES

AMED, MEDLINE, EMBASE CINAHL, Cochrane, PsycINFO, and PEDro databases.

REVIEW METHODS

Only randomized clinical trials were included. Participants in the reviewed studies were adults at any time after stroke. The experimental intervention was home-based exercises compared with centre-based exercises. Outcome data related to strength, motor recovery, dexterity, activity, and participation were extracted from the eligible trials and combined in meta-analyses. The quality of included trials was assessed by the PEDro scores. The quality of evidence was determined according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

Eight trials, involving 488 participants, were included. Most trials (63%) delivered semi-supervised interventions (amount of supervision 3-43%), and three trials provided full supervision. Random-effects meta-analyses provided moderate- to high-quality evidence that home- and centre-based exercises provide similar effects on motor recovery (MD 1.4 points; 95% CI -0.9 to 3.8), dexterity (MD -0.01 pegs/s; 95% CI -0.04 to 0.05), upper limb activity performance (SMD -0.04; 95% CI -0.25 to 0.18), and quality of movement (0.1 points; 95% CI -0.2 to 0.4). Effects on strength were also similar but the quality of the evidence was rated as low. No trials examined effects on participation.

CONCLUSION

Effects of home-based prescribed exercises on upper limb motor recovery, dexterity, and activity are likely to be similar to improvements obtained by centre-based exercises after stroke.

Effect of home-based interventions on basic activities of daily living for patients who had a stroke: a systematic review with meta-analysis

OBJECTIVES

To investigate the effectiveness of home-based interventions in improving the ability to do basic activities of daily living in patients who had a stroke.

METHODS

Randomised controlled trials were searched through MEDLINE, Embase and CINAHL from their inception to 31 December 2021. We included studies involving home-based intervention prescribed by professionals and implemented at patients' homes. The characteristics of these studies were collected. Risk of bias of individual study was assessed by Physiotherapy Evidence Database scale. Meta-analyses were performed where studies reported comparable interventions and outcomes.

RESULTS

In total, 49 studies were included in the systematic review and 16 studies had sufficient data for meta-analyses. The short-term effect of home-based intervention showed no significant difference when compared with institution-based intervention (standardised mean difference (SMD)=0.24, 95% CI -0.15 to 0.62, I²=0%). No significant difference was found between home-based intervention and usual care for long-term effect (SMD=0.02; 95% CI -0.17 to 0.22; I²=0%). Home-based rehabilitation combined with usual care showed a significant short-term effect on the ability to do basic daily activities, compared with usual care alone (SMD=0.55; 95% CI 0.22 to 0.87; p=0.001; I²=3%).

CONCLUSION

Home-based rehabilitation with usual care, which varied from no therapy to inpatient or outpatient therapy, may have a short-term effect on the ability to do basic activities of daily living for patients who had a stroke compared with usual care alone. However, the evidence quality is low because of the limited number of studies and participants included in the meta-analysis and the possible publication bias. Future research is needed to investigate the effectiveness of home-based rehabilitation in groups with stratification by stroke severity and time since stroke onset, with elaboration of details of the home-based and the control interventions. Moreover, more high-quality studies are required to prove the cost-effectiveness of newly developed strategies like caregiver-mediated rehabilitation and telerehabilitation.

THE PRIMARY SOURCE OF FUNDING

The Medical Research Fund of Guangdong Province (No: A2021041).

The Mechanism and Clinical Application of Constraint-Induced Movement Therapy in Stroke Rehabilitation

Constraint-induced movement therapy (CIMT) has been widely applied in stroke rehabilitation, and most relevant studies have shown that CIMT helps improve patients' motor function. In practice, however, principal issues include inconsistent immobilization durations and methods, while incidental issues include a narrow application scope and an emotional impact. Although many studies have explored the possible internal mechanisms of CIMT, a mainstream understanding has not been established.

Effectiveness of caregiver-mediated exercise interventions on activities of daily living, anxiety and depression post-stroke rehabilitation: A systematic review and meta-analysis

AIMS

This review aims to examine updated evidence to evaluate the effectiveness of caregiver-mediated exercise interventions on basic and extended activities of daily living (ADL), anxiety and depression of post-stroke rehabilitation individuals.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

Six electronic databases, including CINAHL, CENTRAL, Embase, PubMed, PsycINFO and Scopus, grey literature and trial registry were searched from inception until February 2021.

METHODS

Only randomized controlled trials written in English were included. Meta-analyses were conducted for basic and extended ADL, anxiety and depression outcomes using RevMan software. Overall quality of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation framework.

RESULTS

A total of 11 randomized controlled trials comprising 2120 participants were identified, with 10 trials meta-analysed. Meta-analyses indicated statistically significant effects favouring caregiver-mediated exercise interventions for basic ADL. Subgroup analyses revealed significant effects for exercise-only interventions mediated by caregivers for basic ADL. No significant effects were found for extended ADL, anxiety and depression for stroke survivors.

CONCLUSION

Caregiver-mediated exercise interventions appear to have beneficial impacts on basic ADL for stroke survivors, suggesting caregiver-mediated exercise interventions as a potentially feasible way to improve functional independence.

IMPACT

Caregiver-mediated intervention with exercises as a major component could be a promising approach to augment stroke rehabilitation. Future research should include high-quality studies with focus on specific intervention components or to explore caregiver outcomes.

Video game rehabilitation for outpatient stroke (VIGoROUS): A multi-site randomized controlled trial of in-home, self-managed, upper-extremity therapy

BACKGROUND

Integrating behavioral intervention into motor rehabilitation is essential for improving paretic arm use in daily life. Demands on therapist time limit adoption of behavioral programs like Constraint-Induced Movement (CI) therapy, however. Self-managed motor practice could free therapist time for behavioral intervention, but there remains insufficient evidence of efficacy for a self-management approach.

METHODS

This completed, parallel, five-site, pragmatic, single-blind trial established the comparative effectiveness of using in-home gaming self-management as a vehicle to redirect valuable therapist time towards behavioral intervention. Community-dwelling adults with post-stroke (>6 months) mild/moderate upper extremity hemiparesis were randomized to receive one of 4 different interventions over a 3-week period: 5 h of behaviorally-focused intervention plus gaming self-management (Self-Gaming), the same with additional behaviorally-focused telerehabilitation (Tele-Gaming), 5 h of Traditional motor-focused rehabilitation, or 35 h of CI therapy. Primary outcomes assessed everyday arm use (Motor Activity Log Quality of Movement, MAL) and motor speed/function (Wolf Motor Function Test, WMFT) immediately before treatment, immediately after treatment, and 6 months later. Intent-to-treat analyses were implemented with linear mixed-effects models on data gathered from March 15, 2016 to November 21, 2019. ClinicalTrials.gov, NCT02631850.

RESULTS

Of 193 enrolled participants, 167 began treatment and were analyzed, 150 (90%) completed treatment, and 115 (69%) completed follow-up. Tele-Gaming and Self-Gaming produced clinically meaningful MAL gains that were 1·0 points (95% CI 0·8 to 1·3) and 0·8 points (95% CI 0·5 to 1·0) larger than Traditional care, respectively. Self-Gaming was less effective than CI therapy (-0·4 points, 95% CI -0·6 to -0·2), whereas Tele-Gaming was not (-0·2 points, 95% CI -0·4 to 0·1). Six-month retention of MAL gains across all groups was 57%. All had similar clinically-meaningful WMFT gains; six-month retention of WMFT gains was 92%.

INTERPRETATION

Self-managed motor-gaming with behavioral telehealth visits has outcomes similar to in-clinic CI therapy. It addresses most access barriers, requiring just one-fifth as much therapist time that is redirected towards behavioral interventions that enhance the paretic arm's involvement in daily life.

FUNDING

PCORI, NIH.

Effects of cognitive motor dual-task training on stroke patients: A RCT-based meta-analysis

Based on a randomized controlled trial (RCT), this meta-analysis aimed to comprehensively analyze the effects of cognitive motor dual-task training (CMDT) on stroke patients. The electronic databases PubMed, Embase, and the Cochrane Library were searched for papers on the influence of CMDT on stroke patients. Weighted mean difference (WMD) and 95% confidence interval (95% CI) were used as effect sizes. Cochran's Q and I² tests were performed for heterogeneity. Thirteen articles involving 326 patients were included in the study. The meta-analysis showed that CMDT significantly improved the walking balance of patients with stroke (P = 0.01). In addition, CMDT significantly improved the gait ability of patients with stroke (P < 0.0001). Furthermore, CMDT had a significant effect on the improvement of upper limb ability in patients with stroke (P < 0.00001). CMDT could significantly improve balance ability, gait, and upper limb function in patients with chronic stroke, which is worthy of clinical promotion.

Tele-rehabilitation of upper-extremity hemiparesis after stroke: Proof-of-concept randomized controlled trial of in-home Constraint-Induced Movement therapy

BACKGROUND

Although Constraint-Induced Movement therapy (CIMT) has been deemed efficacious for adults with persistent, mild-to-moderate, post-stroke upper-extremity hemiparesis, CIMT is not available on a widespread clinical basis. Impediments include its cost and travel to multiple therapy appointments. To overcome these barriers, we developed an automated, tele-health form of CIMT.

OBJECTIVE

Determine whether in-home, tele-health CIMT has outcomes as good as in-clinic, face-to-face CIMT in adults ≥1-year post-stroke with mild-to-moderate upper-extremity hemiparesis.

METHODS

Twenty-four stroke patients with chronic upper-arm extremity hemiparesis were randomly assigned to tele-health CIMT (Tele-AutoCITE) or in-lab CIMT. All received 35 hours of treatment. In the tele-health group, an automated, upper-extremity workstation with built-in sensors and video cameras was set-up in participants' homes. Internet-based audio-visual and data links permitted supervision of treatment by a trainer in the lab.

RESULTS

Ten patients in each group completed treatment. All twenty, on average, showed very large improvements immediately afterwards in everyday use of the more-affected arm (mean change on Motor Activity Log Arm Use scale = 2.5 points, p < 0.001, d' = 3.1). After one-year, a large improvement from baseline was still present (mean change = 1.8, p < 0.001, d' = 2). Post-treatment outcomes in the tele-health group were not inferior to those in the in-lab group. Neither were participants' perceptions of satisfaction with and difficulty of the interventions. Although everyday arm use was similar in the two groups after one-year (mean difference = -0.1, 95% CI = -1.3-1.0), reductions in the precision of the estimates of this parameter due to drop-out over follow-up did not permit ruling out that the tele-health group had an inferior long-term outcome.

CONCLUSIONS

This proof-of-concept study suggests that Tele-AutoCITE produces immediate benefits that are equivalent to those after in-lab CIMT in stroke survivors with chronic upper-arm extremity hemiparesis. Cost savings possible with this tele-health approach remain to be evaluated.

Combination of Electroacupuncture and Constraint-Induced Movement Therapy Enhances Functional Recovery After Ischemic Stroke in Rats

Both electroacupuncture and constraint-induced movement therapy have been reported to produce therapeutic effects on the recovery of ischemic stroke. The combined use of these two therapies is not rare clinically, although its effectiveness is not yet clear. We aimed to evaluate the efficacy of the combination of electroacupuncture and constraint-induced movement therapy in ischemic stroke rats, and to explore the potential molecular mechanisms. Ischemic stroke rat models were established by middle cerebral artery occlusion. Then, the rats were assigned to receive one of the following interventions: sole electroacupuncture, sole constraint-induced movement therapy, the combination of both therapies, and no treatment. Functional recovery was assessed with the beam balance test and rotarod test. The infarct volume of the brain and the expression of the molecules Nogo-A, P75^NTR, NGF, BDNF, and VEGF in the brain tissue were investigated. The results demonstrated that the combination of the two therapies significantly improved neurological functional recovery in ischemic stroke rats compared to each therapy alone (P < 0.01). We also observed a significant decrease in infarct volume in rats receiving the combined treatment. Nogo-A and P75^NTR were downregulated and NGF, BDNF, and VEGF were upregulated in the combined treatment rats compared to the control rats. In conclusion, the combination of electroacupuncture and constraint-induced movement therapy enhanced functional recovery after ischemic stroke in rats, and it is a promising treatment strategy in the rehabilitation of stroke. The anti-Nogo-A effect of electroacupuncture may explain its good compatibility with CIMT in ischemic stroke rats.

Parents' Perspectives on a Computer Game-Assisted Rehabilitation Program for Manual Dexterity in Children With Cerebral Palsy: Qualitative Analysis of Expectations, Child Engagement, and Benefits

Background

Children with motor impairments affecting the upper extremity benefit from task-specific therapy, such as constraint-induced movement therapy. However, there is a need to improve engagement and compliance with task-specific exercise programs that target manual dexterity for children with cerebral palsy (CP). A computer game–based rehabilitation (GRP) platform was developed that combines fine manipulation and gross movement exercises with engaging game activities appropriate for young children with CP.

Objective

The objectives of this qualitative analysis were to compare parents’ perspectives and opinions about expectations, challenges, and benefits between 2 interventions.

Methods

A mixed methods, randomized controlled trial (RCT) was conducted to examine the feasibility and estimate the effect size of 2 exercise programs for rehabilitation of manual dexterity of children with CP using either GRP or conventional therapy. Parents of 26 of the children who completed the GRP program (n=33) and parents of 15 of the children who completed the conventional therapy program (n=27) participated in the interviews. A general conductive approach was used to analyze the data recorded during the parents’ interviews.

Results

Five themes captured the range of the parent’s experiences, viewpoints, and ideas: (1) parents’ expectations, (2) child’s engagement with therapy, (3) positive effects of the interventions, (4) challenges, and (5) improving the protocol.

Conclusions

Parents from both groups recognized that their expectations related to improving children’s object handling and manipulation skills including participation in activities of daily life were addressed during the 16-week therapy program. Parents perceived a change in the children’s level of independence in their daily tasks at home, school, and leisure activities.

Trial Registration

ClinicalTrials.gov NCT02728375; https://clinicaltrials.gov/ct2/show/NCT02728375

Axonal remodeling of the corticospinal tract during neurological recovery after stroke

Stroke remains the leading cause of long-term disability. Hemiparesis is one of the most common post-stroke motor deficits and is largely attributed to loss or disruption of the motor signals from the affected motor cortex. As the only direct descending motor pathway, the corticospinal tract (CST) is the primary pathway to innervate spinal motor neurons, and thus, forms the neuroanatomical basis to control the peripheral muscles for voluntary movements. Here, we review evidence from both experimental animals and stroke patients, regarding CST axonal damage, functional contribution of CST axonal integrity and remodeling to neurological recovery, and therapeutic approaches aimed to enhance CST axonal remodeling after stroke. The new insights gleaned from preclinical and clinical studies may encourage the development of more rational therapeutics with a strategy targeted to promote axonal rewiring for corticospinal innervation, which will significantly impact the current clinical needs of subacute and chronic stroke treatment.

Factors affecting the delivery of complex rehabilitation interventions in research with neurologically impaired adults: a systematic review

BACKGROUND

Rehabilitation research does not always improve patient outcomes because of difficulties implementing complex health interventions. Identifying barriers and facilitators to implementation fidelity is critical. Not reporting implementation issues wastes research resources and risks erroneously attributing effectiveness when interventions are not implemented as planned, particularly progressing from single to multicentre trials. The Consolidated Framework for Implementation Research (CFIR) and Conceptual Framework for Implementation Fidelity (CFIF) facilitate identification of barriers and facilitators. This review sought to identify barriers and facilitators (determinants) affecting implementation in trials of complex rehabilitation interventions for adults with long-term neurological conditions (LTNC) and describe implementation issues.

METHODS

Implementation, complex health interventions and LTNC search terms were developed. Studies of all designs were eligible. Searches involved 11 databases, trial registries and citations. After screening titles and abstracts, two reviewers independently shortlisted studies. A third resolved discrepancies. One reviewer extracted data in two stages; 1) descriptive study data, 2) units of text describing determinants. Data were synthesised by (1) mapping determinants to CFIF and CFIR and (2) thematic analysis.

RESULTS

Forty-three studies, from 7434 records, reported implementation determinants; 41 reported both barriers and facilitators. Most implied determinants but five used implementation theory to inform recording. More barriers than facilitators were mapped onto CFIF and CFIR constructs. "Patient needs and resources", "readiness for implementation", "knowledge and beliefs about the intervention", "facilitation strategies", "participant responsiveness" were the most frequently mapped constructs. Constructs relating to the quality of intervention delivery, organisational/contextual aspects and trial-related issues were rarely tapped. Thematic analysis revealed the most frequently reported determinants related to adherence, intervention perceptions and attrition.

CONCLUSIONS

This review has described the barriers and facilitators identified in studies implementing complex interventions for people with LTNCs. Early adoption of implementation frameworks by trialists can simplify identification and reporting of factors affecting delivery of new complex rehabilitation interventions. It is vital to learn from previous experiences to prevent unnecessary repetitions of implementation failure at both trial and service provision levels. Reported facilitators can provide strategies for overcoming implementation issues. Reporting gaps may be due to the lack of standardised reporting methods, researcher ignorance and historical reporting requirements.

SYSTEMIC REVIEW REGISTRATION

PROSPERO CRD42015020423.

Effectiveness of a self-rehabilitation program to improve upper-extremity function after stroke in developing countries: A randomized controlled trial

BACKGROUND

About two-thirds of stroke patients present long-term upper-limb impairment and limitations of activity, which constitutes a challenge in rehabilitation. This situation is particularly true in developing countries, where there is a need for inexpensive rehabilitation solutions.

OBJECTIVE

This study assessed the effectiveness of a self-rehabilitation program including uni- or bi-manual functional exercises for improving upper-limb function after stroke with respect to the context in Benin, West Africa.

METHODS

In this single-blind randomized controlled trial, chronic stroke individuals (>6 months post-stroke) performed a supervised home-based self-rehabilitation program for 8 weeks (intervention group); the control group did not receive any treatment. Participants were assessed before treatment (T0), at the end of treatment (T1) and 8 weeks after the end of treatment (T2). The primary outcome was the manual ability of the upper limb, assessed with ABILHAND-Stroke Benin. Secondary outcomes were grip force, motor impairment (Fugl-Meyer Assessment - Upper Extremity), gross manual ability (Box and Block test, Wolf Motor Function test) and quality of life (WHOQOL-26).

RESULTS

We included 28 individuals in the intervention group and 31 in the control group. Adherence to the program was 83%. After 8 weeks of self-rehabilitation, individuals in the intervention group showed significantly improved manual ability and grip force as compared with the control group (P<0.001), with effect size 0.75 and 0.24, respectively. In the intervention group, the difference in average scores was 10% between T0 and T1 and between T0 and T2. Subscores of physical and psychological quality of life were also significantly improved in the intervention group. The other variables remained unchanged.

CONCLUSIONS

A self-rehabilitation program was effective in improving manual ability, grip force and quality of life in individuals with stroke in Benin. More studies are needed to confirm these results in different contexts.

Competition Enhances the Effectiveness and Motivation of Attention Rehabilitation After Stroke. A Randomized Controlled Trial

Attention deficits are among the most common cognitive impairments observed after experiencing stroke. However, a very limited number of studies have investigated the effectiveness of interventions that specifically focus on the rehabilitation of attention deficits among subjects with impaired attention. Although several interventions have included the use of computerized programs to provide dynamic stimuli, real-time performance feedback, and motivating tasks, existing studies have not exploited the potential benefits of multi-user interactions. Group-based and competitive interventions have been reported to be more enjoyable and motivating, depending on individual traits, and may potentially be more demanding, which may increase their effectiveness. This study investigated the effectiveness and motivating abilities of an intervention specifically designed to address attention deficits. This intervention combined paper-and-pencil tasks and interactive, computerized, multi-touch exercises, which were administered, either non-competitively or competitively, to a group of 43 individuals with chronic stroke. The mediating effects of competitiveness were evaluated for both intervention effectiveness and motivation. Participants were randomly sorted into two groups and underwent 20 one-hour group-based sessions, during which they either worked individually or competed with peers, according to their group allocation. Participants were assessed before and after the intervention, using the Conners' Continuous Performance Test, the d2 Test of Attention, the Color Trail Test, the Digit Span Test, and the Spatial Span Test. The competitiveness and subjective experiences of the participants after the intervention were investigated with the Revised Competitiveness Index and the Intrinsic Motivation Inventory, respectively. The results showed that participants who competed demonstrated significantly greater improvements in all cognitive abilities, except for divided attention, and reported greater enjoyment than their non-competitive peers. Both groups reported comparable levels of perceived competence, pressure, and usefulness. Interestingly, the competitiveness of the participants did not alter either the effectiveness or the subjective experience of the intervention. These findings suggest that competition might enhance the effectiveness and enjoyment of rehabilitation interventions designed to address attention deficits in individuals post-stroke, regardless of their level of competitiveness and without having a negative effect on their perceived pressure and competence.

Assessing adherence to physical activity programs post-stroke at home: A systematic review of randomized controlled trials

BACKGROUND

Physical activity at home provides significant benefits post-stroke. Adherence assessments contribute to objective evaluation of treatment effectiveness across settings.

OBJECTIVES

The aims of this study were to (1) conduct a systematic review with focus on analyzing the reporting quality of RCTs that incorporate home physical activity interventions among people post-stroke, and utilize a physical activity adherence assessment and to: (2) identify, group, and critically appraise physical activity adherence assessments within the identified studies.

METHODS

A literature search for RCTs was conducted. Articles needed to (1) study adult, post-stroke participants, (2) include a physical activity intervention at home, (3) utilize a physical activity adherence assessment, (4) be published in English in a peer reviewed journal. Two independent reviewers assessed the reporting quality of each RCT for conformity to 39 Consolidated Standards of Reporting Trials (CONSORT) items, followed by an evaluation of adherence assessment methods.

RESULTS

Eleven studies met the inclusion criteria and none of them reported all CONSORT items. The median number of "fully reported" items was 7 out of 39. Ten of the 11 RCTs employed the adherence diary as an assessment method. The adherence parameters of frequency and duration were applied with greater frequency than intensity and accuracy. No evidence of an objective method of adherence assessment was found.

CONCLUSIONS

This systematic review revealed suboptimal reporting of RCTs of physical activity interventions. The use of a diary with the post-stroke population at home was common, despite the lack of an objective method of adherence assessment. Stricter compliance to CONSORT guidelines and complementary direct adherence measurement is advised to improve activity adherence research.

The impact of availability and identity of the caregiver on the post-stroke patient

Background

After having a stroke, most patients are helped by a caregiver with activities that they cannot perform by themselves. The caregiver presence and actions are an important variable that may affect rehabilitation in many ways. The aim of this review study was to evaluate the impact of caregiver presence (or absence) and identity (spouse, family, or foreign domestic worker) on therapeutic exercise performance, depression symptoms, patient–spouse relations and total functional outcomes of stroke patients. Assessing these effects may help health care professionals and families to prioritise/choose the caregiver for their patient/family member.

Methods

A narrative literature review was conducted, focusing on one-direction effects (caregiver on patient effects) on the topics of interest mentioned, in a post-stroke population. PubMed, CINAHL, PEDro, Trip database, and Google Scholar were searched, and included studies of most designs and research qualities. The search strategy had not been specified before commencing the review. Each study was analysed individually with the purpose of synthesising the available evidence to achieve a greater understanding of this topic.

Results

A total of 17 relevant papers were included: six randomised controlled trials, six observational studies, two systematic reviews, two survey-based studies, and one case series. Trials were consistent with the positive effect that caregivers have on therapeutic exercise performance. Studies have shown a positive effect of caregivers on the patient's depressive symptoms, but only at the chronic phase after stroke. A spouse caregiver seems to more positively affect the patient–spouse relations in the acute phase of rehabilitation, while foreign domestic workers can improve these relations at more chronic phases. The presence of a caregiver is shown to decrease functional outcomes within institutionalised rehabilitation centres, while it is necessary and positively affects functionality at more chronic phases within community settings.

Conclusions

The advantages and disadvantages of employing a caregiver depend in many cases on the rehabilitation phase. The caregiver might be beneficial or harmful to the patient's functional progress, depressive symptoms and marital relationship depending on the rehabilitation phase. More studies are needed to assess the caregiver effects on post-stroke patients' rehabilitation and quality of life.

Factors associated with depressive symptoms of carepartners of stroke survivors after discharge from rehabilitation therapy

Background: The long-term consequences of stroke affect both the carepartner (CP) and stroke survivor (SS). Understanding the effects of informal caregiving that may influence the ability of the family to carry over therapeutic activities in the home environment is critical for family-centered care.Objective: This study examined the relationship of CP and SS factors associated with CP depressive symptoms to gain insights into CP needs that may occur after formal rehabilitation therapy has ended for SS with upper extremity deficits.Methods: This correlational study used baseline data of 32 dyads of family CP and SS with upper extremity impairment who had completed rehabilitation therapy and were enrolled in a pilot study of a web-based CP-integrated rehabilitation program. Data using standard questionnaires for CP factors and SS memory and behavior problems and an objective assessment of SS upper extremity function were obtained. Data analysis included descriptive statistics and Pearson product moment correlations.Results: CPs were female (62.5%), White (61.29%), and spouses (68.75%). CPs reported mild-moderate depressive symptoms (M = 9.5 ± 8.3), and a majority had some degree of family conflict. Higher CP depressive symptoms were related to worse life changes (r = -0.41, p =.02), greater fatigue (r = 0.50, p =.004), less effective family functioning (r = 0.46, p =.01), less autonomy support to SS (r = -0.42, p =.02), and more SS memory and behavior problems (r = 0.45, p =.01). Only CP fatigue was related to SS upper extremity function.Conclusions: Negative impacts of caregiving were found in this group of relatively high physically functioning SS which may hinder CP from providing optimal support for SS. Addressing CP needs including education regarding depression, fatigue, SS memory, and behavior problems, and family functioning while SS is receiving rehabilitation therapy may be important considerations to help facilitate the CP to support the SS in carrying over therapeutic activities in the home environment.

Effect of 5-Minute Movies Shown via a Mobile Phone App on Risk Factors and Mortality After Stroke in a Low- to Middle-Income Country: Randomized Controlled Trial for the Stroke Caregiver Dyad Education Intervention (Movies4Stroke)

Background

Pakistan is the sixth most populous nation in the world and has an estimated 4 million stroke survivors. Most survivors are taken care of by community-based caregivers, and there are no inpatient rehabilitation facilities.

Objective

The objective of this study was to evaluate the effectiveness and safety of locally designed 5-min movies rolled out in order of relevance that are thematically delivered in a 3-month program to deliver poststroke education to stroke survivor and caregiver dyads returning to the community.

Methods

This study was a randomized controlled, outcome assessor–blinded, parallel group, single-center superiority trial in which participants (stroke survivor-caregiver dyads) with first-ever stroke (both ischemic and hemorrhagic) incidence were randomized within 48 hours of their stroke into either the video-based education intervention group or the control group. The video-based education intervention group had health education delivered through short videos that were shown to the participants and their caregivers at the time of admission, before discharge, and the first and third months of follow-up after discharge. The control group had standardized care including predischarge education and counseling according to defined protocols. All participants enrolled in the video education intervention and control groups were followed for 12 months after discharge for outcome assessment in the outpatient stroke clinics. The primary outcome measures were the proportion of participants achieving control of blood pressure, blood sugar, and blood cholesterol in the video intervention versus the control group. Several predefined secondary outcomes were included in this study, of which we report the mortality and functional disability in this paper. Analysis was by performed using the intention-to-treat principle.

Results

A total of 310 stroke survivors and their caregiver dyads (participant dyads) were recruited over a duration of 6 months. In total, 155 participant dyads were randomized into the intervention and control groups, each. The primary outcome of control of three major risk factors revealed that at 12 months, there was a greater percentage of participants with a systolic BP<125 mm Hg (18/54, 33% vs 11/52, 21%; P=.16), diastolic BP<85 mm Hg (44/54, 81% vs 37/52, 71%; P=.21), HbA_1c level<7% (36/55, 65% vs 30/40, 75%; P=.32), and low-density lipoprotein level<100 mg/dL (36/51, 70% vs 30/45, 67%; P=.68) in the intervention group than in the control group. The secondary outcome reported is the mortality among the stroke survivors because the number of stroke-related complications was higher in the control group than in the intervention group (13/155, 8.4% vs 2/155, 1.3%), and this difference was statistically significant (P<.001).

Conclusions

The Movies4Stroke trial failed to achieve its primary specified outcome. However, secondary outcomes that directly related to survival skills of stroke survivors demonstrated the effectiveness of the video-based intervention on improving stroke-related mortality and survival without disability.

Trial Registration

ClinicalTrials.gov NCT02202330; https://www.clinicaltrials.gov/ct2/show/NCT02202330

Hand strengthening exercises in chronic stroke patients: Dose-response evaluation using electromyography

STUDY DESIGN

Cross-sectional.

PURPOSE OF THE STUDY

This study evaluates finger flexion and extension strengthening exercises using elastic resistance in chronic stroke patients.

METHODS

Eighteen stroke patients (mean age: 56.8 ± 7.6 years) with hemiparesis performed 3 consecutive repetitions of finger flexion and extension, using 3 different elastic resistance levels (easy, moderate, and hard). Surface electromyography was recorded from the flexor digitorum superficialis (FDS) and extensor digitorum (ED) muscles and normalized to the maximal electromyography of the non-paretic arm.

RESULTS

Maximal grip strength was 39.2 (standard deviation: 12.5) and 7.8 kg (standard deviation: 9.4) in the nonparetic and paretic hand, respectively. For the paretic hand, muscle activity was higher during finger flexion exercise than during finger extension exercise for both ED (30% [95% confidence interval {CI}: 19-40] vs 15% [95% CI: 5-25] and FDS (37% [95% CI: 27-48] vs 24% [95% CI: 13-35]). For the musculature of both the FDS and ED, no dose-response association was observed for resistance and muscle activity during the flexion exercise (P > .05).

CONCLUSION

The finger flexion exercise showed higher muscle activity in both the flexor and extensor musculature of the forearm than the finger extension exercise. Furthermore, greater resistance did not result in higher muscle activity during the finger flexion exercise. The present results suggest that the finger flexion exercise should be the preferred strengthening exercise to achieve high levels of muscle activity in both flexor and extensor forearm muscles in chronic stroke patients. The finger extension exercise may be performed with emphasis on improving neuromuscular control.

LEVEL OF EVIDENCE

4b.

Systematic Review and Meta-Analysis of Home-Based Rehabilitation on Improving Physical Function Among Home-Dwelling Patients With a Stroke

OBJECTIVE

To evaluate the effects of home-based rehabilitation on improving physical function in home-dwelling patients after a stroke.

DATA SOURCES

Various electronic databases, including PubMed, Cumulative Index to Nursing and Allied Health, Embase, the Cochrane Central Register of Controlled Trials, and 2 Chinese data sets (ie, Chinese Electronic Periodical Services and China Knowledge Resource Integrated) were searched for studies published before March 20, 2019.

STUDY SELECTION

Randomized controlled trials conducted to examine the effect of home-based rehabilitation on improving physical function in home-dwelling patients with a stroke and published in English or Chinese were included. In total, 49 articles in English (n=23) and Chinese (n=26) met the inclusion criteria.

DATA EXTRACTION

Data related to patient characteristics, study characteristics, intervention details, and outcomes were extracted by 2 independent reviewers.

DATA SYNTHESIS

A random-effects model with a sensitivity analysis showed that home-based rehabilitation exerted moderate improvements on physical function in home-dwelling patients with a stroke (g=0.58; 95% CI, 0.45∼0.70). Moderator analyses revealed that those patients with stroke of a younger age, of male sex, with a first-ever stroke episode, in the acute stage, and receiving rehabilitation training from their caregiver showed greater improvements in physical function.

CONCLUSIONS

Home rehabilitation can improve functional outcome in survivors of stroke and should be considered appropriate during discharge planning if continuation care is required.

Virtual reality-based balance training system augmented with operant conditioning paradigm

Background

Stroke-related sensory and motor deficits often steal away the independent mobility and balance from stroke survivors. Often, this compels the stroke survivors to rely heavily on their non-paretic leg during weight shifting to execute activities of daily living (ADL), with reduced usage of the paretic leg. Increased reliance on non-paretic leg often leads to learned nonuse of the paretic leg. Therefore, it is necessary to measure the contribution of individual legs toward one’s overall balance. In turn, techniques can be developed to condition the usage of both the legs during one’s balance training, thereby encouraging the hemiplegic patients for increased use of their paretic leg. The aim of this study is to (1) develop a virtual reality (VR)-based balance training platform that can estimate the contribution of each leg during VR-based weight-shifting tasks in an individualized manner and (2) understand the implication of operant conditioning paradigm during balance training on the overall balance of hemiplegic stroke patients.

Result

Twenty-nine hemiplegic patients participated in a single session of VR-based balance training. The participants maneuvered virtual objects in the virtual environment using two Wii Balance Boards that measured displacement in the center of pressure (CoP) due to each leg when one performed weight-shifting tasks. For operant conditioning, the weight distribution across both the legs was conditioned (during normal trial) to reward participants for increased usage of the paretic leg during the weight-shifting task. The participants were offered multiple levels of normal trials with intermediate catch trial (with equal weight distribution between both legs) in an individualized manner. The effect of operant conditioning during the normal trials was measured in the following catch trials. The participants showed significantly improved performance in the final catch trial compared to their initial catch trial task. Also, the enhancement in CoP displacement of the paretic leg was significant in the final catch trial compared to the initial catch trial.

Conclusion

The developed system was able to encourage participants for improved usage of their paretic leg during weight-shifting tasks. Such an approach has the potential to address the issue of learned nonuse of the paretic leg in stroke patients.

Unilateral vs Bilateral Hybrid Approaches for Upper Limb Rehabilitation in Chronic Stroke: A Randomized Controlled Trial

OBJECTIVE

To investigate the effects of unilateral hybrid therapy (UHT) and bilateral hybrid therapy (BHT) compared with robot-assisted therapy (RT) alone in patients with chronic stroke.

DESIGN

A single-blind, randomized controlled trial.

SETTING

Four hospitals.

PARTICIPANTS

Outpatients with chronic stroke and mild to moderate motor impairment (N=44).

INTERVENTION

UHT combined unilateral RT (URT) and modified constraint-induced therapy. BHT combined bilateral RT (BRT) and bilateral arm training. The RT group received URT and BRT. The intervention frequency for the 3 groups was 90 min/d 3 d/wk for 6 weeks.

MAIN OUTCOME MEASURES

Fugl-Meyer Assessment (FMA, divided into the proximal and distal subscale) and Stroke Impact Scale (SIS) version 3.0 scores before, immediately after, and 3 months after treatment and Wolf Motor Function Test (WMFT) and Nottingham Extended Activities of Daily Living (NEADL) scale scores before and immediately after treatment.

RESULTS

The results favored BHT over UHT on the FMA total score and distal score at the posttest (P=.03 and .04) and follow-up (P=.01 and .047) assessment and BHT over RT on the follow-up FMA distal scores (P=.03). At the posttest assessment, the WMFT and SIS scores of the 3 groups improved significantly without between-group differences, and the RT group showed significantly greater improvement in the mobility domain of NEADL compared with the BHT group (P<.01).

CONCLUSIONS

BHT was more effective for improving upper extremity motor function, particularly distal motor function at follow-up, and individuals in the RT group demonstrated improved functional ambulation post intervention.

Stroke patients' and non-professional coaches' experiences with home-based constraint-induced movement therapy: a qualitative study

Objective:

To investigate the experiences of chronic stroke patients and non-professional coaches with home-based constraint-induced movement therapy (homeCIMT).

Design:

Qualitative study embedded within a cluster randomized controlled trial investigating the efficacy of homeCIMT to improve the use of the affected arm in daily activities.

Setting:

Patients’ home environment.

Participants:

13 stroke patients and 9 non-professional coaches’ alias family members who had completed the four-week homeCIMT programme in the context of the HOMECIMT trial.

Interventions:

Semi-structured interviews; qualitative data were analysed using the methodology of the hermeneutic phenomenological data analysis.

Results:

We identified six themes in the qualitative analysis describing the experiences of patients and non-professional coaches with homeCIMT: (1) homeCIMT can be integrated into everyday life with varying degrees of success; (2) training together may produce positive experiences as well as strain; (3) self-perceived improvements during and following homeCIMT; (4) using the affected arm in everyday life is challenging; (5) subjective evaluation of and experiences with homeCIMT-specific exercises; and (6) impact of professional therapists’ guidance and motivation during homeCIMT. Statements regarding theme five and six were only provided by patients, whereas the other themes contain both, the experiences of stroke patients and non-professional coaches.

Conclusion:

Patients’ and non-professional coaches’ narratives offer a detailed insight into the manifold experiences with the practical implementation of homeCIMT that may help improve implementing the homeCIMT programme and similar approaches involving increased training duration and intensity and/or involvement of family members.

To what extent does therapy of chronic stroke patients address participation? A content analysis of ambulatory physical and occupational therapy based on the International Classification of Functioning, Disability, and Health framework

Purpose: The study aim was to analyze whether ambulatory therapy of chronic stroke patients contains elements that specifically address "Activity and participation", and to what extent participation as a major goal in rehabilitation is realized in ambulatory care.Method: Qualitative and quantitative content analysis of standard therapy of 71 chronic stroke patients with upper limb impairment. 469 statements on therapy of 34 therapists were analyzed using data-driven and concept-driven coding based on the International Classification of Functioning, Disability and Health framework.Results: Almost half of therapy provided to stroke patients was related to "Upper extremity" (47.5%), as one out of seven identified main categories. Regarding International Classification of Functioning, Disability, and Health framework, 75.1% of therapeutic practices in ambulatory therapy covered "Body functions," but only 13.2% addressed "Activities and participation". Some statements contained specific therapeutic concepts (9.4%) or isolated notes (2.1%) and were not linkable to the International Classification of Functioning, Disability and Health framework.Conclusions: Ambulatory therapy of chronic stroke patients is related, in part, to participation. There is potential for an increase in participation by applying therapeutic approaches, which actively involve the patients in goal-setting and therapeutic exercises to specifically address activities and participation.Implications for rehabilitationTo realize participation as a major goal in the rehabilitation process ambulatory therapy of chronic stroke patients, one should focus on therapeutic approaches and exercises that specifically address activities and participation.Structured goal-setting, which actively involve patients, can be used to identify goals relevant to individual activities and participation.

"Remind-to-Move" for Promoting Upper Extremity Recovery Using Wearable Devices in Subacute Stroke: A Multi-Center Randomized Controlled Study

This paper examined the effects of "Remind-to-Move" (RTM) via vibration cueing using wearable devices to increase the use of the affected upper limb and integrate upper limb activities undertaken at home in patients with subacute stroke after inpatient discharge. In a multi-centered randomized controlled trial, 84 eligible patients from four general hospitals, who had a first stroke in the last six months, were randomly allocated to either an experimental, sham, or control group, stratified by arm function levels. Patients in the experimental group were treated by RTM, using wearable devices for three consecutive hours daily, over four weeks. The sham group used sham devices, and the control group received usual care alone. A masked assessor evaluated the patients at 0th, 4th, 8th, and 12th weeks using outcome measures included arm function tests, motor activity log, and movement recorded by the devices. Results showed that there was a significant group by time interaction, and the average movement amount and Action Research Arm Test score in the experimental group were significantly higher than in the sham group. This paper demonstrates that RTM via wearable devices used for the hemiplegic upper extremities could promote more arm recovery than the sham or control and, hence, produce an optimal functional improvement for subacute stroke patients.

Assessment of the Efficacy of ReoGo-J Robotic Training Against Other Rehabilitation Therapies for Upper-Limb Hemiplegia After Stroke: Protocol for a Randomized Controlled Trial

Background: Stroke patients experience chronic hemiparesis in their upper extremities leaving negative effects on quality of life. Robotic therapy is one method to recover arm function, but its research is still in its infancy. Research questions of this study is to investigate how to maximize the benefit of robotic therapy using ReoGo-J for arm hemiplegia in chronic stroke patients.

Methods: Design of this study is a multi-center parallel group trial following the prospective, randomized, open-label, blinded endpoint (PROBE) study model. Participants and setting will be 120 chronic stroke patients (over 6 months post-stroke) will be randomly allocated to three different rehabilitation protocols. In this study, the control group will receive 20 min of standard rehabilitation (conventional occupational therapy) and 40 min of self-training (i.e., sanding, placing and stretching). The robotic therapy group will receive 20 min of standard rehabilitation and 40 min of robotic therapy using ReoGo®-J device. The combined therapy group will receive 40 min of robotic therapy and 20 min of constraint-induced movement therapy (protocol to improve upper-limb use in ADL suggests). This study employs the Fugl-Meyer Assessment upper-limb score (primary outcome), other arm function measures and the Stroke Impact Scale score will be measured at baseline, 5 and 10 weeks of the treatment phase. In analysis of this study, we use the mixed effects model for repeated measures to compare changes in outcomes between groups at 5 and 10 Weeks. The registration number of this study is UMIN000022509.

Conclusions: This study is a feasible, multi-site randomized controlled trial to examine our hypothesis that combined training protocol could maximize the benefit of robotic therapy and best effective therapeutic strategy for patients with upper-limb hemiparesis.

Telehealth, Wearable Sensors, and the Internet: Will They Improve Stroke Outcomes Through Increased Intensity of Therapy, Motivation, and Adherence to Rehabilitation Programs?

BACKGROUND AND PURPOSE

Stroke, predominantly a condition of older age, is a major cause of acquired disability in the global population and puts an increasing burden on health care resources. Clear evidence for the importance of intensity of therapy in optimizing functional outcomes is found in animal models, supported by neuroimaging and behavioral research, and strengthened by recent meta-analyses from multiple clinical trials. However, providing intensive therapy using conventional treatment paradigms is expensive and sometimes not feasible because of social and environmental factors. This article addresses the need for cost-effective increased intensity of practice and suggests potential benefits of telehealth (TH) as an innovative model of care in physical therapy.

SUMMARY OF KEY POINTS

We provide an overview of TH and present evidence that a web-supported program, used in conjunction with constraint-induced therapy (CIT), can increase intensity and adherence to a rehabilitation regimen. The design and feasibility testing of this web-based program, "LifeCIT," is presented. We describe how wearable sensors can monitor activity and provide feedback to patients and therapists. The methodology for the development of a wearable device with embedded inertial and mechanomyographic sensors, algorithms to classify functional movement, and a graphical user interface to present meaningful data to patients to support a home exercise program is explained.

RECOMMENDATIONS FOR CLINICAL PRACTICE

We propose that wearable sensor technologies and TH programs have the potential to provide most-effective, intensive, home-based stroke rehabilitation.

Stroke rehabilitation. A call to action in Saudi Arabia

Stroke is a major cause of death and other complications worldwide. In Saudi Arabia, stroke has become an emerging health issue leading to disability and death. However, stroke care including rehabilitation services, in Saudi Arabia lags behind developed countries. Stroke rehabilitation is an essential recovery option after stroke and should start as early as possible to avoid potential complications. The growing evidence on stroke rehabilitation effectiveness in different health care settings and outcome measures used widely are reviewed in this call to action paper.

Video Game Rehabilitation for Outpatient Stroke (VIGoROUS): protocol for a multi-center comparative effectiveness trial of in-home gamified constraint-induced movement therapy for rehabilitation of chronic upper extremity hemiparesis

Background

Constraint-Induced Movement therapy (CI therapy) is shown to reduce disability, increase use of the more affected arm/hand, and promote brain plasticity for individuals with upper extremity hemiparesis post-stroke. Randomized controlled trials consistently demonstrate that CI therapy is superior to other rehabilitation paradigms, yet it is available to only a small minority of the estimated 1.2 million chronic stroke survivors with upper extremity disability. The current study aims to establish the comparative effectiveness of a novel, patient-centered approach to rehabilitation utilizing newly developed, inexpensive, and commercially available gaming technology to disseminate CI therapy to underserved individuals. Video game delivery of CI therapy will be compared against traditional clinic-based CI therapy and standard upper extremity rehabilitation. Additionally, individual factors that differentially influence response to one treatment versus another will be examined.

Methods

This protocol outlines a multi-site, randomized controlled trial with parallel group design. Two hundred twenty four adults with chronic hemiparesis post-stroke will be recruited at four sites. Participants are randomized to one of four study groups: (1) traditional clinic-based CI therapy, (2) therapist-as-consultant video game CI therapy, (3) therapist-as-consultant video game CI therapy with additional therapist contact via telerehabilitation/video consultation, and (4) standard upper extremity rehabilitation. After 6-month follow-up, individuals assigned to the standard upper extremity rehabilitation condition crossover to stand-alone video game CI therapy preceded by a therapist consultation. All interventions are delivered over a period of three weeks. Primary outcome measures include motor improvement as measured by the Wolf Motor Function Test (WMFT), quality of arm use for daily activities as measured by Motor Activity Log (MAL), and quality of life as measured by the Quality of Life in Neurological Disorders (NeuroQOL).

Discussion

This multi-site RCT is designed to determine comparative effectiveness of in-home technology-based delivery of CI therapy versus standard upper extremity rehabilitation and in-clinic CI therapy. The study design also enables evaluation of the effect of therapist contact time on treatment outcomes within a therapist-as-consultant model of gaming and technology-based rehabilitation.

Trial registration

Clinicaltrials.gov, NCT02631850.

Constraint-induced movement therapy as a rehabilitation intervention for upper extremity in stroke patients: systematic review and meta-analysis

Constraint-induced movement therapy (CIMT) is a neurorehabilitation technique designed to improve upper extremity motor functions after stroke. This review aimed to investigate evidence of the effect of CIMT on upper extremity in stroke patients and to identify optimal methods to apply CIMT. Four databases (MEDLINE, EMBASE, CINHAL, and PEDro) and reference lists of relevant articles and reviews were searched. Randomized clinical trials that studied the effect of CIMT on upper extremity outcomes in stroke patients compared with other rehabilitative techniques, usual care, or no intervention were included. Methodological quality was assessed using the PEDro score. The following data were extracted for each trial: patients' characteristics, sample size, eligibility criteria, protocols of CIMT and control groups, outcome measurements, and the PEDro score. A total of 38 trials were identified according to the inclusion criteria. The trials included were heterogeneous in CIMT protocols, time since stroke, and duration and frequency of treatment. The pooled meta-analysis of 36 trials found a heterogeneous significant effect of CIMT on upper extremity. There was no significant effect of CIMT at different durations of follow-up. The majority of included articles did not fulfill powered sample size and quality criteria. The effect of CIMT changed in terms of sample size and quality features of the articles included. These meta-analysis findings indicate that evidence for the superiority of CIMT in comparison with other rehabilitative interventions is weak. Information on the optimal dose of CIMT and optimal time to start CIMT is still limited.

Caregiver-mediated exercises for improving outcomes after stroke

BACKGROUND

Stroke is a major cause of long-term disability in adults. Several systematic reviews have shown that a higher intensity of training can lead to better functional outcomes after stroke. Currently, the resources in inpatient settings are not always sufficient and innovative methods are necessary to meet these recommendations without increasing healthcare costs. A resource efficient method to augment intensity of training could be to involve caregivers in exercise training. A caregiver-mediated exercise programme has the potential to improve outcomes in terms of body function, activities, and participation in people with stroke. In addition, caregivers are more actively involved in the rehabilitation process, which may increase feelings of empowerment with reduced levels of caregiver burden and could facilitate the transition from rehabilitation facility (in hospital, rehabilitation centre, or nursing home) to home setting. As a consequence, length of stay might be reduced and early supported discharge could be enhanced.

OBJECTIVES

To determine if caregiver-mediated exercises (CME) improve functional ability and health-related quality of life in people with stroke, and to determine the effect on caregiver burden.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (October 2015), CENTRAL (the Cochrane Library, 2015, Issue 10), MEDLINE (1946 to October 2015), Embase (1980 to December 2015), CINAHL (1982 to December 2015), SPORTDiscus (1985 to December 2015), three additional databases (two in October 2015, one in December 2015), and six additional trial registers (October 2015). We also screened reference lists of relevant publications and contacted authors in the field.

SELECTION CRITERIA

Randomised controlled trials comparing CME to usual care, no intervention, or another intervention as long as it was not caregiver-mediated, aimed at improving motor function in people who have had a stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials. One review author extracted data, and assessed quality and risk of bias, and a second review author cross-checked these data and assessed quality. We determined the quality of the evidence using GRADE. The small number of included studies limited the pre-planned analyses.

MAIN RESULTS

We included nine trials about CME, of which six trials with 333 patient-caregiver couples were included in the meta-analysis. The small number of studies, participants, and a variety of outcome measures rendered summarising and combining of data in meta-analysis difficult. In addition, in some studies, CME was the only intervention (CME-core), whereas in other studies, caregivers provided another, existing intervention, such as constraint-induced movement therapy. For trials in the latter category, it was difficult to separate the effects of CME from the effects of the other intervention.We found no significant effect of CME on basic ADL when pooling all trial data post intervention (4 studies; standardised mean difference (SMD) 0.21, 95% confidence interval (CI) -0.02 to 0.44; P = 0.07; moderate-quality evidence) or at follow-up (2 studies; mean difference (MD) 2.69, 95% CI -8.18 to 13.55; P = 0.63; low-quality evidence). In addition, we found no significant effects of CME on extended ADL at post intervention (two studies; SMD 0.07, 95% CI -0.21 to 0.35; P = 0.64; low-quality evidence) or at follow-up (2 studies; SMD 0.11, 95% CI -0.17 to 0.39; P = 0.45; low-quality evidence).Caregiver burden did not increase at the end of the intervention (2 studies; SMD -0.04, 95% CI -0.45 to 0.37; P = 0.86; moderate-quality evidence) or at follow-up (1 study; MD 0.60, 95% CI -0.71 to 1.91; P = 0.37; very low-quality evidence).At the end of intervention, CME significantly improved the secondary outcomes of standing balance (3 studies; SMD 0.53, 95% CI 0.19 to 0.87; P = 0.002; low-quality evidence) and quality of life (1 study; physical functioning: MD 12.40, 95% CI 1.67 to 23.13; P = 0.02; mobility: MD 18.20, 95% CI 7.54 to 28.86; P = 0.0008; general recovery: MD 15.10, 95% CI 8.44 to 21.76; P < 0.00001; very low-quality evidence). At follow-up, we found a significant effect in favour of CME for Six-Minute Walking Test distance (1 study; MD 109.50 m, 95% CI 17.12 to 201.88; P = 0.02; very low-quality evidence). We also found a significant effect in favour of the control group at the end of intervention, regarding performance time on the Wolf Motor Function test (2 studies; MD -1.72, 95% CI -2.23 to -1.21; P < 0.00001; low-quality evidence). We found no significant effects for the other secondary outcomes (i.e.

PATIENT

motor impairment, upper limb function, mood, fatigue, length of stay and adverse events; caregiver: mood and quality of life).In contrast to the primary analysis, sensitivity analysis of CME-core showed a significant effect of CME on basic ADL post intervention (2 studies; MD 9.45, 95% CI 2.11 to 16.78; P = 0.01; moderate-quality evidence).The methodological quality of the included trials and variability in interventions (e.g. content, timing, and duration), affected the validity and generalisability of these observed results.

AUTHORS' CONCLUSIONS

There is very low- to moderate-quality evidence that CME may be a valuable intervention to augment the pallet of therapeutic options for stroke rehabilitation. Included studies were small, heterogeneous, and some trials had an unclear or high risk of bias. Future high-quality research should determine whether CME interventions are (cost-)effective.

Behavioral self-management strategies for practice and exercise should be included in neurologic rehabilitation trials and care

PURPOSE OF REVIEW

Rehabilitation trials and postacute care to lessen impairments and disability after stroke, spinal cord injury, and traumatic brain injury almost never include training to promote long-term self-management of skills practice, strengthening and fitness. Without behavioral training to develop self-efficacy, clinical trials, and home-based therapy may fail to show robust results.

RECENT FINDINGS

Behavioral theories about self-management and self-efficacy for physical activity have been successfully incorporated into interventions for chronic diseases, but rarely for neurologic rehabilitation. The elements of behavioral training include education about the effects of practice and exercise that are relevant to the person, goal setting, identification of possible barriers, problem solving, feedback about performance, tailored instruction, decision making, and ongoing personal or social support. Mobile health and telerehabilitation technologies offer new ways to remotely enable such training by monitoring activity from wearable wireless sensors and instrumented exercise devices to allow real-world feedback, goal setting, and instruction.

SUMMARY

Motivation, sense of responsibility, and confidence to practice and exercise in the home can be trained to increase adherence to skills practice and exercise both during and after formal rehabilitation. To optimize motor learning and improve long-term outcomes, self-management training should be an explicit component of rehabilitation care and clinical trials.

[New aspects of neurorehabilitation: motor and language]

Advancements in medical care over the last decades have contributed to a continuous decline in immediate post-stroke mortality. The flipside of this development is that patients surviving the initial stroke are forced to live with sometimes extreme functional motor and/or language limitations for the remaining life span. The following overview presents evidence-based neurorehabilitative interventions to promote motor and language recovery in the acute and chronic post-stroke stages. Therapeutic approaches comprise intensive training, neuropharmacological drugs and non-invasive brain stimulation techniques, such as transcranial magnetic stimulation (TMS) or direct current stimulation (tDCS). Additionally, an outlook on promising future interventions for stroke neurorehabilitation is provided.

Effect of Virtual Reality-based Bilateral Upper Extremity Training on Upper Extremity Function after Stroke: A Randomized Controlled Clinical Trial

In the present study, we aimed to investigate the effect of virtual reality-based bilateral upper extremity training (VRBT) on paretic upper limb function and muscle strength in patients with stroke. Eighteen stroke survivors were assigned to either the VRBT group (n = 10) or the bilateral upper limb training group (BT, n = 8). Patients in the VRBT group performed bilateral upper extremity exercises in a virtual reality environment, whereas those in the BT group performed conventional bilateral upper extremity exercises. All training was conducted for 30 minutes day^-1 , 3 days a week, for a period of 6 weeks. Patients were assessed for upper extremity function and hand strength. Compared with the BT group, the VRBT group exhibited significant improvements in upper extremity function and muscle strength (p < 0.05) after the 6-week training programme. The Box and Block test results revealed that upper extremity function and elbow flexion in hand strength were significantly improved in terms of group, time and interaction effect of group by time. Furthermore, the VRBT group demonstrated significant improvements in upper extremity function, as measured by the Jebsen Hand Function Test and Grooved Pegboard test, and in the hand strength test, as measured by elbow extension, grip, palmar pinch, lateral pinch and tip pinch, in both time and the interaction effect of group by time. These results suggest that VRBT is a feasible and beneficial means of improving upper extremity function and muscle strength in individuals following stroke. Copyright © 2016 John Wiley & Sons, Ltd.

Somatosensory deficits after stroke: a scoping review

In the past years, there have been increasing research activities focusing on somatosensory symptoms following stroke. However, as compared to the large number of clinical and neuroimaging studies on motor symptoms, the number of studies tracing somatosensory symptoms after stroke and their recovery is rather small. It is an ongoing discussion, to which extent somatosensory deficits after stroke influence patient's long-term outcome in motor and sensory performance and functional independence in activities of daily living. Modern brain imaging techniques allow for studying the impact of stroke lesion localization and size on acute and persisting clinical impairment. Here, we review the literature on somatosensory symptoms after stroke. We summarize epidemiological information on frequency and characteristics of somatosensory symptoms affecting all parts of the body in the acute and chronic stage of stroke. We further give an overview of brain imaging studies of stroke affecting the somatosensory system. Finally, we identify open questions which need to be addressed in future research and summarize the implications for clinical practice.