Associated Mirror Therapy Enhances Motor Recovery of the Upper Extremity and Daily Function after Stroke: A Randomized Control Study

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

DESIGN

This was a prospective randomized controlled trial.

SETTING

A rehabilitation hospital.

PARTICIPANTS

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

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Application of immersive virtual reality mirror therapy for upper limb rehabilitation after stroke: a scoping review

Mirror therapy is a commonly used rehabilitation intervention in post stroke upper limb rehabilitation. Despite many potential technological developments, mirror therapy is routinely delivered through the use of a static mirror or mirror box. This review aims to synthesise evidence on the application of immersive virtual reality mirror therapy (IVRMT) in poststroke upper limb rehabilitation. A scoping review was performed on relevant English studies published between 2013 to 2023. Literature search was undertaken on APA PsycInfo, CINAHL, Cochrane Library, MEDLINE, PubMed and Web of Science between August 5 and 17, 2023. Additional studies were included from Google Scholar and reference lists of identified articles. A total of 224 records were identified, of which 8 full-text articles were selected for review. All included studies were published between 2019 and 2023, and from high- and upper-middle-income nations. All the studies were experimental (n = 8). The total sample size in the studies was 259, most of whom were stroke patients with upper limb weakness (n = 184). This review identified three major themes and two sub-themes based on the contents of the studies conducted on the application of IVRMT: IVRMT's technical application, feasibility and impact on clinical outcomes (motor recovery and adverse events). IVRMT was concluded to be a safe and feasible approach to post-stroke upper limb rehabilitation, offering enhanced engagement and motor recovery. However, more methodologically robust studies should be conducted to advance this area of practice, and to include a uniform IVRMT intervention protocol, dose, and use of outcome measure.

Motor imagery therapy improved upper limb motor function in stroke patients with hemiplegia by increasing functional connectivity of sensorimotor and cognitive networks

Background

Motor imagery therapy (MIT) showed positive effects on upper limbs motor function. However, the mechanism by which MIT improves upper limb motor function is not fully understood. Therefore, our purpose was to investigate the changes in functional connectivity (FC) within and outside the sensorimotor network (SMN) induced by MIT associated with improvement in upper limb motor function in stroke patients.

Methods

A total of 26 hemiplegic stroke patients were randomly divided into MIT (n = 13) and control (n = 13) groups. Fugl-Meyer Assessment Upper Extremity Scale (FMA-UL), Modified Barthel Index (MBI) and resting-state functional magnetic resonance imaging (rs-fMRI) were evaluated in the two groups before treatment and 4 weeks after treatment. The efficacy of MIT on motor function improvement in stroke patients with hemiplegia was evaluated by comparing the FMA-UL and MBI scores before and after treatment in the two groups. Furthermore, the FC within the SMN and between the SMN and the whole brain was measured and compared before and after different treatment methods in stroke patients. The correlation analysis between the improvement of upper limbs motor function and changes in FC within the SMN and between the SMN and the whole brain was examined.

Results

The FCs between ipsilesional primary motor cortex (M1.I) and contralateral supplementary motor area (SMA.C), M1.I and ipsilesional SMA (SMA.I), and SMA.C and contralateral dorsolateral premotor cortex (DLPM.C) significantly increased in the control group but decreased in the MIT group; while the FC between SMA.C and contralateral primary somatosensory cortex (S1.C) significantly increased in the control group but showed no significant difference in the MIT group. The FCs between M1.I and the ipsilesional hippocampal gyrus and ipsilesional middle frontal gyrus significantly decreased in the control group but increased in the MIT group; while the FC in the contralateral anterior cingulate cortex significantly increased in the MIT group but there was no significant difference in the control group. The results of the correlation analysis showed that the differences in abnormal intra-FCs within the SMN negatively correlated with the differences in FMA and MBI, and the difference in abnormal inter-FCs of the SMN positively correlated with the differences in FMA and MBI.

Conclusions

MIT can improve upper limb motor function and daily activities of stroke patients, and the improvement effect of conventional rehabilitation therapy (CRT) combined with MIT is significantly higher than that of CRT alone. CRT may improve the upper limb motor function of stroke patients with hemiplegia mainly through the functional reorganization between SMN, while MIT may mainly increase the interaction between SMN and other brain networks.

Electromyographic biofeedback therapy for improving limb function after stroke: A systematic review and meta-analysis

BACKGROUND

Upper and lower limb impairment is common after stroke. Electromyographic biofeedback therapy is a non-invasive treatment, and its effectiveness in functional rehabilitation of the limb after stroke still remains uncertain.

OBJECTIVE

The objective of this study was to evaluate whether electromyographic biofeedback can improve upper and lower limb dysfunction in stroke patients.

METHODS

PubMed, Embase, Cochrane Library, and Physiotherapy Evidence Database (PEDro) were searched from inception to 1st May 2022. Inclusion criteria were randomized controlled clinical trials of electromyographic biofeedback therapy interventions reporting changes in upper and lower limb function in post-stroke patients. Data were extracted by two independent reviewers and pooled in random-effects models using Review manager (RevMan) software.

RESULTS

Our analyses included 10 studies enrolling a total of 303 participants. Electromyographic biofeedback therapy can effectively improve limb function after stroke (standardized mean difference [SMD], 0.44; 95% confidence interval [CI], 0.12-0.77; P = 0.008) and in subgroup analyses, the effect sizes of short-term effect (SMD, 0.33; 95% CI, 0.02-0.64; P = 0.04) was significant, but the long-term was not (SMD, 0.61; 95% CI, -0.11-1.33; P = 0.10). In addition, Electromyographic biofeedback therapy can improve the active range of motion of shoulder (SMD, 1.49; 95% CI, 2.22; P<0.0001) and wrist joints (SMD, 0.77; 95% CI, 0.13-1.42; P = 0.02) after stroke.

CONCLUSION

In this meta-analysis, electromyographic biofeedback therapy intervention can improve upper and lower limb function in patients with stroke. Short-term (less than one month) improvement after electromyographic biofeedback therapy was supported, while evidence for long-term (more than one month) benefits was lacking. Range of motion in the glenohumeral and wrist joints were improved. Stronger evidence for individualized parameters, such as optimal treatment parameters and intervention period, is needed in the future.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/display_record.php?recordID=267596], identifier [CRD42022354363].

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

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

Effect of auricular acupuncture on neuroplasticity of stroke patients with motor dysfunction: A fNIRS study

Cerebral Stroke is an acute cerebrovascular disease, a disease of brain tissue damage caused by the sudden rupture or blockage of blood vessels in the brain that prevents blood flow to the brain. Acupuncture has become a popular treatment for stroke, with auricular acupuncture providing a new idea for stroke treatment. However, the neuromodulatory mechanism of auricular acupuncture in the brain is still unclear. The aim of this study was to investigate the effect of auricular acupuncture in the treatment of upper limb dysfunction and the activation of specific brain regions in stroke patients. Forty patients with stroke hemiplegia who met the nerf criteria were included in the experiment and randomly assigned into two groups (20 patients in each group): the auricular acupuncture group and the control group. Fugl-Meyer score (FMA) assessment of upper limb motor function, motor evoked potential (MEP) measurement, and functional near-infrared brain function imaging (fNIRS) data acquisition in the primary motor M1 area of the brain at rest were performed before and after treatment, respectively. It was found that: 1) after auricular acupuncture treatment, the patients in the auricular acupuncture group showed significantly greater peak MEP and significantly higher oxyhemoglobin content in the M1 region of the brain compared with the control group, with a significant activation effect (MEP: P-value = 0.032, t = -2.22; HbO2; f = 4.225, p = 0.046); 2) in the clinical efficacy assessment, the FMA score in the auricular acupuncture group after treatment (p = 0.0122, t = 2.769). The results suggest that auricular acupuncture has an ameliorative effect on upper limb motor deficits after stroke and that activation of the M1 region of the brain may be a key node in auricular acupuncture for treating upper limb dysfunction in stroke patients, a finding that emphasizes the potential for clinical application of auricular acupuncture therapy for stroke patients with potential mechanisms influencing the outcome.

Exploration on neurobiological mechanisms of the central–peripheral–central closed-loop rehabilitation

Central and peripheral interventions for brain injury rehabilitation have been widely employed. However, as patients’ requirements and expectations for stroke rehabilitation have gradually increased, the limitations of simple central intervention or peripheral intervention in the rehabilitation application of stroke patients’ function have gradually emerged. Studies have suggested that central intervention promotes the activation of functional brain regions and improves neural plasticity, whereas peripheral intervention enhances the positive feedback and input of sensory and motor control modes to the central nervous system, thereby promoting the remodeling of brain function. Based on the model of a central–peripheral–central (CPC) closed loop, the integration of center and peripheral interventions was effectively completed to form “closed-loop” information feedback, which could be applied to specific brain areas or function-related brain regions of patients. Notably, the closed loop can also be extended to central and peripheral immune systems as well as central and peripheral organs such as the brain–gut axis and lung–brain axis. In this review article, the model of CPC closed-loop rehabilitation and the potential neuroimmunological mechanisms of a closed-loop approach will be discussed. Further, we highlight critical questions about the neuroimmunological aspects of the closed-loop technique that merit future research attention.

Non-invasive brain stimulation associated mirror therapy for upper-limb rehabilitation after stroke: Systematic review and meta-analysis of randomized clinical trials

Background

Non-invasive brain stimulation (NIBS) techniques and mirror therapy (MT) are promising rehabilitation measures for stroke. While the combination of MT and NIBS has been employed for post-stroke upper limb motor functional rehabilitation, its effectiveness has not been examined.

Objective

This study aimed to evaluate the effectiveness of combined MT and NIBS in the recovery of upper limb motor function in stroke patients.

Methods

The search was carried out in PubMed, EMBASE, Cochrane Library, Web of Science, Science Direct, CNKI, WANFANG and VIP until December 2021. Randomized clinical trials (RCTs) comparing MT or NIBS alone with the combination of NIBS and MT in improving upper extremity motor recovery after stroke were selected. A meta-analysis was performed to calculate the mean differences (MD) or the standard mean differences (SMD) and 95% confidence intervals (CI) with random-effect models. Subgroup analyses were also conducted according to the types of control group, the types of NIBS, stimulation timing and phase poststroke.

Results

A total of 12 articles, including 17 studies with 628 patients, were reviewed in the meta-analysis. In comparison with MT or NIBS alone, the combined group significantly improved body structure and function (MD = 5.97; 95% CI: 5.01–6.93; P < 0.05), activity levels (SMD = 0.82; 95% CI 0.61–1.02; P < 0.05). For cortical excitability, the motor evoked potential cortical latency (SMD = −1.05; 95% CI:−1.57–−0.52; P < 0.05) and the central motor conduction time (SMD=-1.31 95% CI:−2.02-−0.61; P < 0.05) of the combined group were significantly shortened. A non-significant homogeneous summary effect size was found for MEP amplitude (SMD = 0.47; 95%CI = −0.29 to 1.23; P = 0.23). Subgroup analysis showed that there is an interaction between the stimulation sequence and the combined treatment effect.

Conclusion

In this meta-analysis of randomized clinical trials, in comparison to the control groups, MT combined with NIBS promoted the recovery of upper extremity motor function after stroke, which was reflected in the analysis of body structure and function, activity levels, and cortical excitability.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022304455.

Outcomes of Combined Visual and Auditive Stimulation on Functions of Hand and Grip Strengths in Patients with Hemiplegia

Background Stroke is a major ailment that results from hypoxia, ischemia, blockage, or hemorrhage. The recovery of hand functions is an essential goal in stroke patients' recovery.

Aim This study aimed to analyze the outcomes of rhythmic auditory stimulation (RAS) and mirror therapy on hand functions, as well as grip strength, in stroke patients.

Materials and Methods A quasiexperimental study has been used based on criteria of inclusion, 30 patients were enrolled. The participants were assigned to two groups, 15 patients each. Group A (control group) underwent traditional physiotherapy. Group B (experimental group) underwent RAS and mirror therapy. Both the groups received 20 minutes of treatment, 20 sessions in 1 month. The Action Research Arm Test (ARAT) and hand-held dynamometer were used to evaluate results. Paired t-test has been used to analyze the data with the SPSS software tool.

Results The paired t-test results showed that notable distinctions in ARAT mean pretest scores between two groups were not found. A notable change in ARAT results was present between the two groups with mean posttest score and difference in pretest to posttest. No notable distinctions in grip strength results were seen with mean pretest results. But a notable change was found in grip strength results among two groups with mean posttest scores.

Conclusion Combining RAS and mirror therapy programs has shown beneficial effects on hand functions, as well as grip strength of stroke patients and can be used as adjunct interventions along with conventional physiotherapy to encourage restoration of hand functions in hemiparetic patients.

Effects of Early Acupuncture Combined with Rehabilitation Training on Limb Function and Nerve Injury Rehabilitation in Elderly Patients with Stroke: Based on a Retrospective Cohort Study

Objective

A case-control study was conducted to explore the effect of acupuncture combined with rehabilitation training on limb function and nerve injury rehabilitation in elderly patients with stroke.

Methods

A total of 72 elderly patients with stroke treated from March 2019 to June 2021 in our hospital were enrolled as the object of study. The clinical data were collected and divided into two groups according to their different treatment methods. The patients cured with routine treatment combined with rehabilitation training were taken as the control group and the patients cured with acupuncture combined with rehabilitation training as the study group. The clinical efficacy was recorded, and the cognition and activities of daily living were evaluated by Terrell Cognitive Assessment scale, limb motor function score, and activities of daily living scale. The National Institutes of Health Stroke Scale (NIHSS) and Glasgow Coma Scale (GCS) were employed to compare the neurological function before and after treatment. Glasgow Outcome Scale (GOS) and Disability Rating Scale (DRS) were adopted to evaluate the functional prognosis. The simplified Fugl-Meyer assessment of motor recovery score was employed to evaluate the limb function of the patients. The Wolf Motor Function Test (WMFT) score was adopted to evaluate the functional rehabilitation effect of the patients. Enzyme-linked immunosorbent assay (ELISA) was adopted to determine the serum neurological function indexes such as nerve growth factor, Smur100B protein, and glial fibrillary acidic protein. The cerebral blood flow (CBF), peak time, average transit time, and cerebral blood volume were measured by CT perfusion imaging, and the incidence of side effects during treatment was recorded.

Results

Regarding the recovery of cognitive function and daily function after treatment, after treatment, the MoCA and ADL scores were increased, and the comparison indicated that the MoCA and ADL scores of the study group were remarkably higher compared to the control group (P < 0.05). With regard to the FMA-UE scores after treatment, the Fugl-Meyer scores were gradually increased, and the Fugl-Meyer scores in the study group were remarkably higher compared to the control group (P < 0.05) in the next two months. After 2 weeks, 4 weeks, 6 weeks, and 6 weeks of treatment, the WMFT scores gradually increased, and the WMFT score of the study group was remarkably higher compared to the control group. After treatment, the levels of nerve growth factor and S-100B protein were decreased, and the level of glial fibrillary acidic protein was increased. Comparison between the two groups, it indicated the improvement degree of each neurological function index in the study group was remarkably better (P < 0.05). With regard to cerebral hemodynamic indexes after treatment, 1 week after treatment, the CBF and average transit time of the observation group were remarkably higher compared to the control group, and the levels of cerebral blood volume and peak time were remarkably lower compared to the control group (P < 0.05). After 4 weeks of treatment, the cerebral hemodynamic indexes of the observation group did not change remarkably, and they were all lower than 1 week after the treatment. In the terms of side effects, 1 case of limb dysfunction, 1 case of swallowing dysfunction, 1 case of electrolyte disturbance, and none of infection in the study group, the incidence of adverse reactions was 8.33%. In the control group, there were 3 cases of limb dysfunction, 2 cases of swallowing dysfunction, 2 cases of electrolyte disturbance, and 3 cases of infection, and the incidence of adverse reactions was 27.78%. Compared between groups, the incidence of adverse reactions in the study group was lower (P < 0.05).

Conclusion

Early use of acupuncture combined with rehabilitation training has a remarkable therapeutic effect on elderly stroke patients. It can remarkably promote the recovery of the patient's condition, remarkably enhance their neurological function, cognitive function, motor function, and daily life function, and effectively strengthen the patient's prognosis score. It has important clinical application value to reduce the incidence of adverse reactions.

Emerging Limb Rehabilitation Therapy After Post-stroke Motor Recovery

Stroke, including hemorrhagic and ischemic stroke, refers to the blood supply disorder in the local brain tissue for various reasons (aneurysm, occlusion, etc.). It leads to regional brain circulation imbalance, neurological complications, limb motor dysfunction, aphasia, and depression. As the second-leading cause of death worldwide, stroke poses a significant threat to human life characterized by high mortality, disability, and recurrence. Therefore, the clinician has to care about the symptoms of stroke patients in the acute stage and formulate an effective postoperative rehabilitation plan to facilitate the recovery in patients. We summarize a novel application and update of the rehabilitation therapy in limb motor rehabilitation of stroke patients to provide a potential future stroke rehabilitation strategy.