Poststroke depression: risk factors and potential effects on functional recovery

Cognitive and emotional impairment in stroke survivors: insights from a multi-center study on inpatient rehabilitation therapy

BACKGROUND

Individuals recovering from stroke often experience cognitive and emotional impairments, but rehab programs tend to focus on motor skills. The aim of this investigation is to systematically assess the change of magnitude of cognitive and emotional function subsequent to a conventional rehabilitative protocol administered to stroke survivors within a defined locale in China.

METHODS

This is a multicenter study; a total of 1884 stroke survivors who received in-hospital rehabilitation therapy were assessed on admission (T0) and discharge (T1). The tool of InterRAI was used to assess cognitive, emotional, and behavioral abnormality.

RESULTS

The patients aged >60 years, with a history of hypertension, and long stroke onset duration were more exposed to functional impairment (all p < 0.05). Both cognitive and emotional sections were significantly improved at T1 compared to T0 (p < 0.001). Initially, 64.97% and 46.55% of patients had cognitive or emotional impairment at T0, respectively; this percentage was 58.55% and 37.15% at T1.

CONCLUSION

Many stroke survivors have ongoing cognitive and emotional problems that require attention. It is essential to focus on rehabilitating these areas during the hospital stay, especially for older patients, those with a longer recovery, and those with hypertension history.

Immediate Neurophysiological effect of electrical stimulation via dry needling on H-reflex in post stroke spasticity

BACKGROUND

Many non-pharmacological interventions have been proposed for spasticity modulation in spastic stroke subjects.

OBJECTIVE

To investigate the immediate effect of dry needling (DN), electrical stimulation (ES), and dry needling with intramuscular electrical stimulation (DN+IMES) on H-reflex in post-stroke spasticity.

METHODS

Spastic subjects with stroke (N = 90) (55-85 years) were evaluated after 1 month of stroke onset using Modified Ashworth Scale (MAS) score ≥1. Subjects were randomly allocated to receive one session of DN - Soleus (N = 30), ES - posterior lateral side of the leg with 100 Hz and 250 μs pulse width (N = 30), or DN+IMES - Soleus (N = 30). MAS, H-reflex, maximum latency, H-amplitude, M-amplitude and H/M ratio, were recorded before and after one session of intervention. Relationships for each variable within group or the difference among groups were calculated by effect size.

RESULTS

Significant decrease in H/M ratio in Gastrocnemius and Soleus at post-treatment within DN group (P = .024 and P = .029, respectively), large effect size (d = 0.07 and 0.62, respectively); and DN+IMES group (P = .042 and P = .001, respectively), large effect size (d = 0.69 and 0.71, respectively). No significant differences in all variables at pre-treatment and post-treatment was recorded among ES, DN, and DN+IMES groups. Significant decrease in MAS was recorded at post-treatment compared to pre-treatment within ES group (P = .002), DN group (P = .0001), and DN+IMES group (P = .0001), but not significant (P > .05) among three groups at pre-treatment (P = .194) and post-treatment (P = .485).

CONCLUSIONS

Single session of DN, ES, and the DN+IMES can significantly modulate post-stroke spasticity by possible bottom-up regulation mechanisms.

Neuroinflammation and Post-Stroke Depression: Focus on the Microglia and Astrocytes

Post-stroke depression (PSD), a frequent and disabling complication of stroke, has a strong impact on almost thirty percent of stroke survivors. The pathogenesis of PSD is not completely clear so far. Neuroinflammation following stroke is one of underlying mechanisms that involves in the pathophysiology of PSD and plays an important function in the development of depression and is regarded as a sign of depression. During the neuroinflammation after ischemic stroke onset, both astrocytes and microglia undergo a series of morphological and functional changes and play pro-inflammatory or anti-inflammatory effect in the pathological process of stroke. Importantly, astrocytes and microglia exert dual roles in the pathological process of PSD due to the phenotypic transformation. We summarize the latest evidence of neuroinflammation involving in PSD in this review, focus on the phenotypic transformation of microglia and astrocytes following ischemic stroke and reveal the dual roles of both microglia and astrocytes in the PSD via modulating the neuroinflammation.

Association between thyroid hormone levels in the acute stage of stroke and risk of poststroke depression: A meta-analysis

BACKGROUND

Thyroid hormones have been indicated to be associated with depression, but their relationship with poststroke depression (PSD) remains controversial. Therefore, we performed a meta-analysis to explore the correlation between thyroid hormone levels in acute stroke and PSD.

METHODS

We searched databases for eligible studies. Standard mean differences (SMD) and 95% confidence intervals (CI) were applied to evaluate the association among levels of thyroid hormones, including thyroid-stimulating hormone (TSH), free triiodothyronine (FT3), and free thyroxine (FT4), in acute stroke patients and the risk of PSD.

RESULTS

A total of 13 studies were included in the analysis. Compared to non-PSD patients, PSD patients had remarkably lower serum TSH and FT3 levels (TSH: SMD = -0.59, 95%CI = -1.04 to -.15, p = .009; FT3: SMD = -0.40, 95%CI = -.51 to -.30, p = .000) and higher serum FT4 levels (SMD = 0.33, 95%CI = .07-.59, p = .013). Subgroup analysis showed that there may be a more statistically significant association between FT3 and the risk of PSD compared to TSH and FT4.

CONCLUSIONS

Our results suggested that patients with lower serum TSH and FT3 levels as well as higher serum FT4 levels in the acute stage of stroke may be more susceptible to PSD.

Screening, prevention, and management of patients with poststroke depression in a tertiary hospital in China: a best practice implementation project

INTRODUCTION

Poststroke depression (PSD) is common but insufficiently addressed by health professionals, and management is not always evidence-based.

OBJECTIVES

This evidence implementation project aimed to improve adherence to evidence-based practice for screening, prevention, and management of patients with PSD in the neurology ward of the Fifth Affiliated Hospital of Zunyi Medical University, China.

METHODS

This project was based on the JBI methodological approach and was conducted in three phases, from January to June 2021: a baseline audit, implementation of strategies, and a follow-up audit. We utilized the JBI Practical Application of Clinical Evidence System software and the Getting Research into Practice tools. Fourteen nurses, 162 stroke patients, and their caregivers participated in this study.

RESULTS

The results of the baseline audit showed that compliance with evidence-based practice was poor, with 3/6 criteria showing 0% adherence and the other three audit criteria showing 5.7, 10.3, and 49.4% adherence, respectively. Through feedback to nurses regarding the baseline audit results, the project team identified five barriers and adopted a battery of strategies to overcome these barriers. The follow-up audit revealed significantly enhanced outcomes across all the best practice criteria, and the compliance of each criterion reached at least 80%.

CONCLUSION

The implementation program designed to screen, prevent, and manage PSD in a tertiary hospital in China improved nurses' knowledge and compliance with evidence-based management of PSD. Further testing of this program in more hospitals is needed.

Astrocytes in Post-Stroke Depression: Roles in Inflammation, Neurotransmission, and Neurotrophin Signaling

Post-stroke depression (PSD) is a frequent and disabling complication of stroke that affects up to one-third of stroke survivors. The pathophysiology of PSD involves multiple mechanisms, including neurochemical, neuroinflammatory, neurotrophic, and neuroplastic changes. Astrocytes are a type of glial cell that is plentiful and adaptable in the central nervous system. They play key roles in various mechanisms by modulating neurotransmission, inflammation, neurogenesis, and synaptic plasticity. This review summarizes the latest evidence of astrocyte involvement in PSD from human and animal studies, focusing on the alterations of astrocyte markers and functions in relation to monoamine neurotransmitters, inflammatory cytokines, brain-derived neurotrophic factor, and glutamate excitotoxicity. We also discuss the potential therapeutic implications of targeting astrocytes for PSD prevention and treatment. Astrocytes could be new candidates for antidepressant medications and other interventions that aim to restore astrocyte homeostasis and function in PSD. Astrocytes could be new candidates for antidepressant medications and other interventions that aim to restore astrocyte homeostasis and function in PSD.

Associations among depression, demographic variables, and language impairments in chronic post-stroke aphasia

INTRODUCTION

Depression may influence treatment participation and outcomes of people with post-stroke aphasia, yet its prevalence and associated characteristics in aphasia are poorly understood. Using retrospective data from an overarching experimental study, we examined depressive symptoms and their relationship to demographic and language characteristics in people with chronic aphasia. As a secondary objective, we compared prevalence of depressive symptoms among the overarching study's included and excluded participants.

METHODS

We examined retrospective data from 121 individuals with chronic aphasia including depression scale scores, demographic information (sex, age, time post onset of stroke, education, race/ethnicity, and Veteran status), and scores on assessments of general and modality-specific language impairments.

RESULTS

Approximately 50% of participants reported symptoms indicative of depressive disorders: 23% indicative of major depression and 27% indicative of mild depression. Sex (males) and comparatively younger age emerged as statistically significant variables associated with depressive symptoms; naming ability was minimally associated with depressive symptoms. Time post onset of stroke, education level, race/ethnicity, Veteran status, and aphasia severity were not significantly associated with depressive symptoms. Depression-scale scores were significantly higher for individuals excluded from the overarching study compared to those who were included.

CONCLUSIONS

The rate of depressive disorders in this sample was higher than rates of depression reported in the general stroke literature. Participant sex, age, and naming ability emerged as factors associated with depressive symptoms, though these links appear complex, especially given variable reports from prior research. Importantly, depressive symptoms do not appear to diminish over time for individuals with chronic aphasia. Given these results and the relatively limited documentation of depression in aphasia literature, depression remains a pressing concern for aphasia research and routine clinical care.

Time-Varying Risk Factors Associated With the Progress of Functional Recovery and Psychological Distress in First-Ever Stroke Patients

ABSTRACT

BACKGROUND: Evaluation of stroke recovery outcome is crucial and a major goal of clinical practice. A recovery trajectory model serves as a prognostic tool that enables development of effective intervention and long-term management to improve poststroke recovery outcomes. This study explored time-varying risk factors associated with the progression of functional recovery and psychological distress poststroke. METHODS: Participants were patients with first-ever stroke who underwent assessment for activities of daily living, psychological distress, and social support at the onset (within 72 hours) and at 1, 3, and 6 months. A generalized estimation equation was used to account for the correlation between the repeated measurements. RESULTS: Of the 101 patients, 60.4% were men, and the mean (SD) age was 63.06 (13.12) years. Over time, the physical functions of patients after stroke significantly increased, and anxiety and depression significantly decreased. Approximately 50% of patients achieved full functional recovery after 6 months. The time-varying risk factors for National Institutes of Health Stroke Scale scores and depression levels affected the trajectory of functional recovery during follow-up. Factors associated with patient anxiety levels were National Institutes of Health Stroke Scale scores and depression levels. Factors associated with patient depression levels included education, anxiety, and social support levels. CONCLUSION: This study demonstrates the progression of time-varying risk factors for functional recovery and psychological distress in patients with first-ever stroke. We recommend that nurses work with patients and their families in the early poststroke stages to identify comprehensive goals based on individual needs and related factors at different stages and that they educate patients on what is required for them to regain independence.

Implication of problematic substance use in poststroke depression: an hospital-based study

The prevalence of clinically defined problematic substance use among stroke patients is overlooked and its association with post-stroke depression (PSD) is unknown. Our aims were to: (1) estimate the proportion of stroke patients with a problematic substance use as defined by clinical screening scales; (2) determine the proportion of PSD at three months of follow-up; (3) explore if the baseline severity in substance use and its evolution are independent predictors of PSD. A cohort of first-ever non-severe stroke adult patients was screened at baseline and three months post-stroke using recommended cut-off scores of standardized scales for tobacco, alcohol and cannabis abuse. PSD was defined using the Center of Epidemiological Studies Depression scale score. Out of the 244 eligible patients, 74 (30.3%) presented a problematic substance use, including 21 (8.6%) polydrug abusers. Among these patients, the prevalence of PSD was 50.8%, including 29.5% of severe depression. The severity of tobacco dependence at baseline was found to double the risk (OR 1.59, 95% CI 1.05–2.43) of presenting a PSD, independently of previously reported risk factors. We found no significant evidence for an effect of the evolution in substance use at follow-up. Addictive disorders are part of the critical unmet needs that should be addressed in the management of PSD.

Depression after stroke

Stroke treatment has dramatically improved in recent decades. However, although new treatments have reduced its mortality and the severity of its physical and cognitive sequelae, many people still have incapacitating disabilities following a stroke. Depression is the most common psychiatric disorder following stroke; it is important to recognise and treat as it limits motor and cognitive rehabilitation. Antidepressant medication is an effective treatment and can improve adherence to clinically recommended physical and cognitive tasks, thereby enhancing functional remodelling of neuronal pathways and improving rehabilitation outcomes.

Relationships between stroke, depression, generalized anxiety disorder and physical disability: some evidence from the Canadian Community Health Survey-Mental Health

The objective of this study is to evaluate associations between stroke, depression, anxiety and physical disability. The sample of 19,159 participants aged ≥30 was obtained from the 2012 Canadian Community Health Survey-Mental Health. Depression or anxiety was defined as major depressive disorder (MDD) or generalized anxiety disorder (GAD) within the past 12 months. The history of anxiety was defined as GAD at any time point during the respondent's lifetime. Physical disability was assessed by the past 14-day disability in daily-living activities. For statistical analysis, two logistic regression models (crude and adjusted models) were presented. The results showed that subjects with stroke had greater likelihoods of MDD-GAD comorbidity and GAD only compared those without stroke. People with GAD only had higher likelihood of physical disability than those with neither of the two conditions. Among participants with stroke, lifetime GAD was associated with a greater likelihood of MDD. In conclusion, individuals with stroke may be vulnerable to comorbid depression-anxiety as well as anxiety only. Additionally, subjects with anxiety were more likely to have physical disability. The history of anxiety increased the risk for developing post-stroke depression.

Admission Heart Rate Variability Is Associated With Poststroke Depression in Patients With Acute Mild-Moderate Ischemic Stroke

BACKGROUND

Stroke has been shown to cause cardiac autonomic dysfunction. Depression is common complication after acute ischemic stroke (AIS). The purpose of this study was to investigate whether decreased heart rate variability (HRV) was related to poststroke depression (PSD) in patients with mild-moderate AIS.

METHODS

In this study, we assessed autonomic function of ischemic stroke patients within 72 h from symptom onset by fractal dimension (FD). 503 patients (mean age 65.93 ± 10.19) with mild-moderate AIS underwent FD test after admission. Depressive symptoms were assessed using 17-item Hamilton Depression Rating Scale (HDRS) at baseline (within 7 days) and 3 months. Depression were defined if HDRS >6 points. According to the data of FD, we investigated association with early-onset PSD status and 3-month PSD.

RESULTS

59.24% (293/503) of patients had early-onset PSD status at baseline, and 38.66% (184/476) of patients had PSD at 3 months. ROC curve analysis shown that the optimal cut point of FD for early-onset PSD status and 3-month PSD were FD ≤ 1.27 and FD ≤ 1.19, respectively. In fully adjusted models, higher NIHSS [adjusted odd ratios (OR), 1.15; 95% confidence interval (CI), 1.05-1.27; P=0.005], younger age (adjusted OR, 1.18; 95% CI, 1.01-1.13; P=0.046), and FD ≤ 1.27 (adjusted OR, 3.31; 95% CI, 2.23-4.92; P<0.001) were associated with increased risk of early-onset PSD status. Higher NIHSS (adjusted OR, 1.21; 95% CI, 1.09-1.43; P<0.001) and FD ≤ 1.19 (adjusted OR, 2.68; 95% CI, 1.79-4.03; P=0.000) were associated with increased risk of 3-month PSD.

CONCLUSIONS

PSD is common after mild-moderate AIS and is highly correlated with decreased HRV, FD could serve as an objective tool to help in prediction of PSD.

Determinant of Quality of Life in Patients with Chronic Cerebral Infarct

This study investigated how physical and cognitive function and psychological factors affected the health-related quality of life (HRQoL, hereafter HQ) of stroke patients in South Korea. The study enrolled 32 right-handed subjects with chronic cerebral infarction with disability and preserved cognitive function (Mini-Mental State Examination ≥ 20). Physical disability was assessed using the modified Rankin Scale (mRS) and Korean modified Barthel Index (KMBI). Quality of life was measured using the World Health Organization Quality of Life-Abbreviated form (WHOQOL-BREF, hereafter WB) and the 36-Item Short-form Health Survey (SF-36) in face-to-face interviews. Psychological distress was investigated using the Beck Depression Inventory Scale-II. The associations of each domain of WB and SF-36 were investigated using Pearson correlation analyses. Physical disability was negatively correlated with HQ in the SF-36. The physical function and bodily pain scales of the SF-36 were negatively correlated with physical disability. The general health domain of the SF-36 was negatively correlated with psychological scores. Emotional status was associated with physical health, social relationships, and general health in HQ. In summary, the severity of physical disability was associated with the patient's general and physical health and body pain. These findings suggest the importance of psychological, cognitive, and physiological interventions for improving the quality of life of patients after cerebral infarction.

Predictors of Remission of Early-Onset Poststroke Depression and the Interaction Between Depression and Cognition During Follow-Up

Objectives: This study aimed to examine the rate of remission in individuals experiencing early-onset poststroke depression (PSD) in China and to identify predictors of remission during a 3-month follow-up. This study also explored the interaction between cognitive impairment and depression. Methods: A total of 820 patients with PSD from a massive multicenter prospective cohort project in China (PRIOD) were included in the present study. Depressive symptoms were measured with the Hamilton Depression Rating Scale (17 Items, HDRS-17) at 2 weeks and the endpoint of the 3-month follow-up. The cut-off score of HDRS-17 (< 8) was used to define remission of depression at the endpoint. The Mini-Mental State Exam (MMSE) was used to evaluate the cognitive impairment of the patients (at the 2-week follow-up and 3-month endpoint). The National Institutes of Health Stroke Scale (NIHSS) was used to measure the severity of stroke. Results: (1) Six hundred and forty-two patients completed the 3-month follow-up, and 332 (51.7%) patients remitted by the end of the study. Univariate analyses indicated that there was a higher proportion of patients who had hypertension, frontal lobe lesion, basal ganglia lesion, poor outcome at 2 weeks, high scores on the NIHSS at 2 weeks, major life events within 3 months, and major medical diseases within 3 months in the nonremission group. In stepwise multiple logistic regression analyses, remission was significantly predicted by lower NIHSS scores at 2 weeks (p = 0.001, OR = 1.086, 95% CI 1.035-1.139), fewer major life events (p = 0.036, OR = 5.195, 95% CI 1.111-27.283), fewer major medical comorbidities (p = 0.015, OR = 2.434, 95% CI 1.190-4.979), and fewer frontal lobe lesions (p = 0.042, OR = 1.717, 95% CI 1.019-2.891). (2) After controlling for confounding variables, repeated measures analysis of variance revealed a significant interaction between time (2 weeks vs. 3 months) and group (remitters vs. nonremitters) on MMSE scores [F (1, 532) = 20.2, p < 0.001]. Conclusions: Early-onset PSD patients with milder neurological impairment, fewer major life events, fewer major medical comorbidities and no frontal lobe lesion at baseline were more likely to achieve remission 3 months after stroke. Only remitters of PSD improved significantly in cognitive impairment after stroke. The PRIOD trial is registered at http://www.isrctn.com/, number ISRCTN62169508.

Does the severity of depressive symptoms after stroke affect long-term survival? An 18-year follow-up

Objective

We tested whether the severity of depressive symptoms in acute stroke and 4 years later are predictors of long-time survival.

Method

We evaluated the severity of stroke in 82 patients with acute stroke by the Barthel index, the Scandinavian Stroke Scale and the Orgogozo scale, and we also quantified the severity of depressive symptoms by the Beck and the Hamilton scales in the first week of stroke, in 1995. We re-evaluated the scales 4 years after stroke in 41 out of 48 survivors. We checked the survival status of the initial cohort 18 years after stroke. In the assessment Kaplan-Meier graphs were constructed and the outcomes between groups were compared with log-rank tests.

Results

Clinically important depressive symptoms (≥10 on the Beck scale) was present in 16 patients (19,5%) with acute stroke one week after admission. Case fatality was 41% at 4 years and 84% at 18 years after stroke. Those patients who survived at 4 years were significantly younger (p<0,05). Depressive symptoms in acute stage were not independent predictor of the length of survival. More severe strokes were associated with more severe depressive symptoms 4 years after stroke. In the survival subgroup of patients, those who had more severe depression (≥10 on the Beck scale) at 4 years, had shorter post-stroke survival than those with milder or no depression (Mann-Whitney test, p = 0.022; log-rank-test, p = 0.047). In multivariate analyses, adjusted for age, sex, stroke severity and the severity of depressive symptoms, age, sex and stroke severity remained the significant predictors of the length of survival.

Conclusions

The severity of depressive symptoms either in the acute phase or 4 years after stroke is not an independent predictor of the length of survival in an 18-year follow-up.

Poststroke Depression Biomarkers: A Narrative Review

Poststroke depression (PSD) is the most prevalent psychiatric disorder after stroke, which is independently correlated with negative clinical outcome. The identification of specific biomarkers could help to increase the sensitivity of PSD diagnosis and elucidate its pathophysiological mechanisms. The aim of current study was to review and summarize literature exploring potential biomarkers for PSD diagnosis. The PubMed database was searched for papers published in English from October 1977 to December 2017, 90 of which met inclusion criteria for clinical studies related to PSD biomarkers. PSD biomarkers were subdivided into neuroimaging, molecular, and neurophysiological. Some of them could be recommended to support PSD diagnosing. According to the data, lesions affecting the frontal-subcortical circles of mood regulation (prefrontal cortex, basal nuclei, and thalamus) predominantly in the left hemisphere can be considered as neuroimaging markers and predictors for PSD for at least 1 year after stroke. Additional pontine and lobar cerebral microbleeds in acute stroke patients, as well as severe microvascular lesions of the brain, increase the likelihood of PSD. The following molecular candidates can help to differentiate PSD patients from non-depressed stroke subjects: decreased serum BDNF concentrations; increased early markers of inflammation (high-sensitivity C-reactive protein, ferritin, neopterin, and glutamate), serum pro-inflammatory cytokines (TNF-α, IL-1β, IL-6, IL-18, IFN-γ), as well as pro-inflammatory/anti-inflammatory ratios (TNF-α/IL-10, IL-1β/IL-10, IL-6/IL-10, IL-18/IL-10, IFN-γ/IL-10); lowered complement expression; decreased serum vitamin D levels; hypercortisolemia and blunted cortisol awakening response; S/S 5-HTTLPR, STin2 9/12, and 12/12 genotypes of the serotonin transporter gene SLC6A4, 5-HTR2a 1438 A/A, and BDNF met/met genotypes; higher SLC6A4 promoter and BDNF promoter methylation status. Neurophysiological markers of PSD, that reflect a violation of perception and cognitive processing, are the elongation of the latency of N200, P300, and N400, as well as the decrease in the P300 and N400 amplitude of the event-related potentials. The selected panel of biomarkers may be useful for paraclinical underpinning of PSD diagnosis, clarifying various aspects of its multifactorial pathogenesis, optimizing therapeutic interventions, and assessing treatment effectiveness.

Is two better than one? Muscle vibration plus robotic rehabilitation to improve upper limb spasticity and function: A pilot randomized controlled trial

Even though robotic rehabilitation is very useful to improve motor function, there is no conclusive evidence on its role in reducing post-stroke spasticity. Focal muscle vibration (MV) is instead very useful to reduce segmental spasticity, with a consequent positive effect on motor function. Therefore, it could be possible to strengthen the effects of robotic rehabilitation by coupling MV. To this end, we designed a pilot randomized controlled trial (Clinical Trial NCT03110718) that included twenty patients suffering from unilateral post-stroke upper limb spasticity. Patients underwent 40 daily sessions of Armeo-Power training (1 hour/session, 5 sessions/week, for 8 weeks) with or without spastic antagonist MV. They were randomized into two groups of 10 individuals, which received (group-A) or not (group-B) MV. The intensity of MV, represented by the peak acceleration (a-peak), was calculated by the formula (2πf)2A, where f is the frequency of MV and A is the amplitude. Modified Ashworth Scale (MAS), short intracortical inhibition (SICI), and Hmax/Mmax ratio (HMR) were the primary outcomes measured before and after (immediately and 4 weeks later) the end of the treatment. In all patients of group-A, we observed a greater reduction of MAS (p = 0.007, d = 0.6) and HMR (p<0.001, d = 0.7), and a more evident increase of SICI (p<0.001, d = 0.7) up to 4 weeks after the end of the treatment, as compared to group-B. Likewise, group-A showed a greater function outcome of upper limb (Functional Independence Measure p = 0.1, d = 0.7; Fugl-Meyer Assessment of the Upper Extremity p = 0.007, d = 0.4) up to 4 weeks after the end of the treatment. A significant correlation was found between the degree of MAS reduction and SICI increase in the agonist spastic muscles (p = 0.004). Our data show that this combined rehabilitative approach could be a promising option in improving upper limb spasticity and motor function. We could hypothesize that the greater rehabilitative outcome improvement may depend on a reshape of corticospinal plasticity induced by a sort of associative plasticity between Armeo-Power and MV.