Functional rehabilitation of upper limb apraxia in poststroke patients: study protocol for a randomized controlled trial

Effect of Tai Chi Yunshou training on the balance and motor functions of stroke patients: a systematic review and meta-analysis of randomized controlled trials

Background

There is insufficient evidence on the effect of Tai Chi Yunshou on improving balance and motor function in stroke survivors. Therefore, this systematic review and meta-analysis aimed to evaluate the effect of Tai Chi Yunshou on improving balance and motor function in stroke patients through a comprehensive literature search.

Methods

English and Chinese databases were searched from inception to February 10, 2023, to collect randomized controlled trials (RCTs) investigating the effects of Tai Chi Yunshou on balance and motor function in stroke survivors. Two reviewers independently selected studies meeting eligibility criteria, extracted required data, and assessed the risk of bias using methods recommended by the Cochrane Reviewers' Handbook. Primary outcomes were balance function and motor function, while secondary outcomes included walking gait and activities of daily living. Review Manager software (version 5.4.1) was used for data analysis.

Results

Among the 1,400 identified records, 12 eligible randomized controlled trials were finally included, with a total of 966 subjects. The results of the meta-analysis showed that the balance function of the experimental group and the control group was assessed using the Berg Balance Scale (MD = 4.87, p < 0.001, I² = 90, 95% CI = 4.46-5.28). The motor function assessment of the experimental group and the control group used the Fugl-Meyer Motor Assessment (SMD = 1.11, p < 0.001, I² = 94, 95% CI = 0.94-1.28) and Simple Test of Extremity Function (MD = 10.28, p < 0.001, I² = 0, 95% CI = 7.89-12.68). Walking ability was measured using the Time-Up and Go Test (MD = -3.22, p < 0.001, I² = 83, 95% CI = -3.71--2.73). Activities of daily living were measured using the Modified Bathel Index (MD = 4.61, p < 0.001, I² = 81, 95% CI = 3.61-5.61).

Conclusion

Initial evidence seems to show that Tai Chi Yunshou training can improve the balance and motor function of stroke survivors and further improve walking ability and daily living ability, and the rehabilitation effect may be better than that of conventional rehabilitation training.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=376969, identifier [CRD42022376969].

Multicomponent Educational-Rehabilitation Approach in Rehabilitation of Patients After Stroke

Rehabilitation must be based on the individual needs and specific goals of the person and must be adapted to his abilities. According to the recommendation of the World Stroke Organization, the team involved in conducting rehabilitation should be multidisciplinary. One of the treatments that are applied within the multidisciplinary approach to a neurological patient is educational-rehabilitation treatment, which is multicomponent in nature. Before starting educational-rehabilitation treatment, an educational-rehabilitation clinical assessment is necessary, which aims to detect difficulties caused by impairment; identify potentials and constraints in these areas; determine the specifics, course, and forecasts of difficulties; formulate clear treatment recommendations; form a watch list that will be available to all team members in the process of diagnosis, treatment, education, and to evaluate the effectiveness of treatment; and continuously monitor the ability and adaptive behavior of the person. Educational-rehabilitation clinical treatment includes treatment of cognitive abilities, treatment of motor skills, relaxation, treatment of adaptive skills, as well as informing the person about the disease and counseling. This review focuses on some aspects of rehabilitation such as treatment of cognitive and motor disorders, treatment of adaptive skills, relaxation issues, and informing and counseling patients from the perspective of an educational rehabilitator with practical experiences in this area of rehabilitation.

Beyond motor recovery after stroke: The role of hand robotic rehabilitation plus virtual reality in improving cognitive function

Robot-assisted hand training adopting end-effector devices results in an additional reduction of motor impairment in comparison to usual care alone in different stages of stroke recovery. These devices often allow the patient to perform practical, attentive, and visual-spatial tasks in a semi-virtual reality (VR) setting. We aimed to investigate whether the hand end-effector robotic device Amadeo^TM could improve cognitive performance, beyond the motor deficit, as compared to the same amount of occupational treatment focused on the hand. Forty-eight patients (aged 54.3 ± 10.5 years, 62.5% female) affected by either ischemic or hemorrhagic stroke in the chronic phase were enrolled in the study. The experimental group (EG) underwent Amadeo^TM robotic training, while the control group (CG) performed occupational therapy involving the upper limb. Patients were assessed at the beginning and at the end of the rehabilitation protocol using a specific neuropsychological battery, as well as motor function tests. The EG showed greater improvements in different cognitive domains, including attentive abilities and executive functions, as well as in hand motor function, as compared to CG. Our study showed that task-oriented VR-based robotic rehabilitation enhanced not only motor function in the paretic arm but also global and specific cognitive abilities in post-stroke patients. We may argue that the hand robotic plus VR-based training may provide patients with an integration of cognitive and motor skill rehabilitation, thus amplifying the functional outcome achievement.

Motor sequence learning in patients with ideomotor apraxia: Effects of long-term training

Recent studies show that limb apraxia is a quite frequent, yet often underdiagnosed, higher motor impairment following stroke. Because it adversely affects every-day life and personal independence, successful rehabilitation of apraxia is essential for personal well-being. Nevertheless, evidence of long-term efficacy of training schemes and generalization to untrained actions is still scarce. One possible reason for the tendency of this neurological disorder to persist may be a deficit in planning, conceptualisation and storage of complex motor acts. This pilot study aims at investigating explicit motor learning in apractic stroke patients. In particular, we addressed the ability of apractic patients to learn and to retain new explicit sequential finger movements across 10 training sessions over a 3-week interval. Nine stroke patients with ideomotor apraxia in its chronic stage participated in a multi-session training regimen and were included in data analyses. Patients performed an explicit finger sequence learning task (MSLT - motor sequence learning task), which is a well-established paradigm to investigate motor learning and memory processes. Patients improved task performance in terms of speed and accuracy across sessions. Specifically, they showed a noticeable reduction in the mean time needed to perform a correct sequence and the number of erroneous sequences. We found also a trend for improved performance at the Goldenberg apraxia test protocol: "imitation of meaningless hand and finger gestures" relative to when assessed before the MSLT training. Patients with ideomotor apraxia demonstrated the ability to acquire and maintain a novel sequence of movements; and, this training was associated with hints towards improvement of apraxia symptoms.

[Compensatory and adaptive mechanisms in children with congenital multiple arthrogryposis in the absence of active flexion in the elbow joint]

Arthrogryposis is one of the most severe congenital orthopedic diseases, characterized by multiple joint contractures, hypoplasia or aplasia of the skeletal muscles of the extremities, as well as severe motor disorders. The use of compensatory strategies allows patients to improve the ability to self-care.

OBJECTIVE

To study the compensatory strategies in children with arthrogryposis with absent of active flexion in the elbow joint and estimate their dynamic after surgical treatment.

MATERIAL AND METHODS

We performed a clinical examination of 236 patients with arthrogryposis with deformities of the upper extremities due to arthrogryposis at the age of 10 months to 16 years. The examination was carried out before the operation, as well as at various times (from 1 month to 8 years) after. In 87 cases (67 patients), restoration of active elbow flexion was performed by transposition of latissimus dorsii or pectoralis major to the biceps position. The activity of the muscles involved that most commonly used in compensatory strategies (synergy of m. biceps brachii and m. deltoideus or m.biceps brachii and m. quadriceps femoris) in 10 patients (from 3 to 10 y.o.), was evaluated before and after (from 2 months to 2 years) surgery by surface electromyography.

RESULTS

It was found that children's compensatory strategies are formed at the age of 6 months to 1 y.o.6 months after surgery, the using of compensatory strategies becomes more rare, and 12-18 months after surgery, when the strength of the forearm muscles was 4 points, they were not used at all.

CONCLUSIONS

Compensatory strategies in children with the absence of active and preservation of passive flexion in the elbow joint are diverse. They depend on the amplitude of passive and active movements in the shoulder, the function of the hand and deformities of the lower extremities. These strategies in children with arthrogryposis are unstable and completely disappear when active movements in the elbow joint are restored in the functional range.

Effectiveness of a Functional Rehabilitation Program for Upper Limb Apraxia in Poststroke Patients: A Randomized Controlled Trial

OBJECTIVE

To analyze the effectiveness of a home-based restorative and compensatory upper limb apraxia (ULA) rehabilitation program.

DESIGN

Randomized controlled trial.

SETTING

Neurology Unit of San Cecilio Hospital and 2 private and specialized health care centers.

PARTICIPANTS

Community dwelling participants (N=38) between the ages of 25 and 95 years old (sex ratio, 1:1) with unilateral mild-to-moderate poststroke lesions (time of evolution since stroke, 12.03±8.98mo) and secondary ULA.

INTERVENTIONS

Participants were randomly assigned to an 8-week combined ULA functional rehabilitation group (n=19) 3 days per week for 30 minutes or to a traditional health care education protocol group (n=19) once a month for 8 weeks. Both interventions were conducted at home.

MAIN OUTCOME MEASURES

Sociodemographic and clinical data, Barthel Index (primary outcome), Lawton and Brody Scale, observation and scoring activities of daily living, the De Renzi tests for ideational and ideomotor apraxia and imitating gestures test, recognition of gestures, test for upper limb apraxia , and stroke-specific quality of life scale were assessed at 3 time points: baseline, posttreatment (8wk), and follow-up (8wk).

RESULTS

There were statistically significant differences among the groups regarding ideomotor apraxia, imitating gestures, global recognition of gestures, intransitive gestures, and comprehension of gesture production (P<.05) in favor of the experimental group. However, no statistically significant differences were found between the groups regarding functionality or quality of life (P>.05). Regarding the within-group effect, statistically significant differences were found in all neuropsychological outcomes at posttreatment and follow-up (P<.05).

CONCLUSION

A functional rehabilitation program was found to be superior to a traditional health care education program and resulted in improvements in neuropsychological functioning in ULA poststroke. Conventional education showed an insufficient effect on apraxia recovery. Further studies with larger sample sizes are needed to determine the effect of rehabilitation strategies on functionality and quality of life of poststroke ULA patients.

Prognostic Factors of Functional Outcome Assessed by Using the Modified Rankin Scale in Subacute Ischemic Stroke

Background

Most stroke survivors spent their lifetime with disability which not only affects the clients themselves and the family but also brings economic cost to the country. Therefore, this retrospective cohort study aimed to identify independent prognostic determinants associated with functional recovery in ischemic stroke within 6 months after onset.

Methods

Data from all first-onset ischemic stroke patients admitted to the acute stroke unit of the tertiary, university hospital were reviewed for 5 years consecutively. The functional outcome of the patients was recorded during 6-month follow-up by using the modified Rankin Scale (mRS). Baseline characteristics, motor assessment and all stroke-related variables were assessed during first week after stroke and 6-month follow-up. In order to derive clinical predictors, the backward stepwise multivariable risk regression analyses were used with the generalized linear model.

Results

The result revealed that in the 358 patients recruited into this study, 255 (71.2%) were in the functional recovery group (mRS score of 1 - 3) within 6 months after onset. The final model of multivariable risk regression analysis, with generalized linear model, demonstrated that the independent variables of functional recovery were leg score with a risk ratio (RR = 1.92, 95% confidence interval (CI): 1.14 - 3.21, P = 0.013), arm score (RR = 1.75, 95% CI: 1.02 - 3.01, P = 0.042) and age older than 75 years (RR = 1.36, 95% CI: 1.04 - 1.77, P = 0.025).

Conclusions

Achieving functional recovery during 6 months post stroke was related to age and motor improvement. With limited resources, continuity of rehabilitation training in the community system or allocation of caregiver training should be a part of discharge planning to promote recovery.

Effects of Real-Time (Sonification) and Rhythmic Auditory Stimuli on Recovering Arm Function Post Stroke: A Systematic Review and Meta-Analysis

Background: External auditory stimuli have been widely used for recovering arm function post-stroke. Rhythmic and real-time auditory stimuli have been reported to enhance motor recovery by facilitating perceptuomotor representation, cross-modal processing, and neural plasticity. However, a consensus as to their influence for recovering arm function post-stroke is still warranted because of high variability noted in research methods. Objective: A systematic review and meta-analysis was carried out to analyze the effects of rhythmic and real-time auditory stimuli on arm recovery post stroke. Method: Systematic identification of published literature was performed according to PRISMA guidelines, from inception until December 2017, on online databases: Web of science, PEDro, EBSCO, MEDLINE, Cochrane, EMBASE, and PROQUEST. Studies were critically appraised using PEDro scale. Results: Of 1,889 records, 23 studies which involved 585 (226 females/359 males) patients met our inclusion criteria. The meta-analysis revealed beneficial effects of training with both types of auditory inputs for Fugl-Meyer assessment (Hedge's g: 0.79), Stroke impact scale (0.95), elbow range of motion (0.37), and reduction in wolf motor function time test (-0.55). Upon further comparison, a beneficial effect of real-time auditory feedback was found over rhythmic auditory cueing for Fugl-meyer assessment (1.3 as compared to 0.6). Moreover, the findings suggest a training dosage of 30 min to 1 h for at least 3-5 sessions per week with either of the auditory stimuli. Conclusion: This review suggests the application of external auditory stimuli for recovering arm functioning post-stroke.

Prognostic Factors of Functional Recovery from Left Hemispheric Stroke

Although lateralization of the brain affects some specialized cortical functions, there are still limited data to address its influence on clinically important outcomes. This study aimed to reveal the prognostic variables that relate to functional recovery in stroke patients with a left-sided hemispheric lesion during 6 months of follow-up. Data from 167 left-sided and 183 right-sided hemispheric strokes were reviewed retrospectively. Outcomes in this study included walking capacity and functional recovery, assessed by the modified Rankin Scale (mRS). In order to obtain independent predictive variables, this study used the step-backward method of multivariable regression analysis of parameters. The final model demonstrated that motor function of the hemiparetic leg was the strongest independent predictor for both walking ability and functional recovery (risk ratio (RR) of 2.41, 95% CI: 1.61-3.60, and p < 0.001 and RR of 1.83, 95% CI: 1.03-3.26, and p = 0.04, resp.). Therefore, lateralization did not seem to be involved. Understanding predictable variables that are associated with recovery can guide the rehabilitation team in setting priority and appropriate treatment for stroke patients.