Responsiveness of the Reaching Performance Scale for Stroke

OBJECTIVE

The objective of the study was to estimate the internal and external responsiveness of the Reaching Performance Scale for Stroke (RPSS) in individuals with stroke.

DESIGN

Retrospective analysis of data from 4 randomized controlled trials.

SETTING

Recruitment locations spanning rehabilitation centers and hospitals in Canada, Italy, Argentina, Peru, and Thailand.

PARTICIPANTS

Data from 567 participants (acute to chronic stroke; N=567) were available.

INTERVENTIONS

All 4 studies involved training using virtual reality for upper limb rehabilitation.

MAIN OUTCOME MEASURES

RPSS and upper extremity Fugl-Meyer Assessment (FMA-UE) scores. Responsiveness was quantified for all data and across different stages of stroke. Internal responsiveness of the RPSS was quantified as effect-sizes calculated using post and preintervention change data. External responsiveness was quantified using orthogonal regressions between FMA-UE and RPSS scores. The area under the Receiver Operating Characteristic curve (AUC) was quantified based on the ability of RPSS scores to detect change above FMA-UE minimal clinically important different values across different stages of stroke.

RESULTS

The RPSS had high internal responsiveness overall and across the acute or subacute and chronic stages of stroke. For external responsiveness, orthogonal regression analyses indicated that change in FMA-UE scores had positive moderate correlations with both RPSS Close and Far Target scores for all data and across the acute or subacute and chronic stages of stroke (0.6

CONCLUSIONS

In addition to being reliable and valid, the RPSS is also responsive. Along with the FMA-UE, using RPSS scores can help present a more comprehensive picture of motor compensations to characterize poststroke upper limb motor improvement.

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Key Words

• Movement quality
• cerebrovascular accident
• compensation
• outcomes
• reaching
• restitution or true recovery
• upper limb

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MESH Headings

• Humans
• Disability Evaluation
• Recovery of Function
• Retrospective Studies
• Stroke
• Stroke Rehabilitation
• Upper Extremity
• Randomized Controlled Trials as Topic

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Grants Collapse

Affiliation(s)

Sandeep K Subramanian Departments of Physical Therapy, Physician Assistant Studies and Rehabilitation Medicine, University of Texas Health San Antonio, San Antonio, TX
Gita Margolese School of Physical and Occupational Therapy, McGill University, Montreal, Canada; Centre for Interdisciplinary Research in Rehabilitation, Montreal, Canada
Andrea Turolla Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; Laboratory of Rehabilitation Technologies, Hospital San Camillo IRCCS, Venice, Italy
Gustavo Saposnik Stroke Outcomes and Decision Neuroscience Unit, Unity Health Toronto, University of Toronto, Toronto, Canada
Mindy F Levin School of Physical and Occupational Therapy, McGill University, Montreal, Canada; Centre for Interdisciplinary Research in Rehabilitation, Montreal, Canada.

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Effect of skill proficiency on motor imagery ability between amateur dancers and non-dancers

Evidence has shown that athletes with high motor skill proficiency possess higher motor imagery ability than those with low motor skill proficiency. However, less is known whether this superiority in motor imagery ability emerges over amateur athletes. To address the issue, the present study aimed to investigate the individual differences in motor imagery ability between amateur dancers and non-dancers. Forty participants completed a novel dance movement reproduction task and measures of the vividness of visual imagery questionnaire (VVIQ) and the vividness of motor imagery questionnaire (VMIQ). The results showed that, relative to non-dancers, amateur dancers had higher ability of motor imagery to reproduce the lower-limb and upper-limb dance movements during the dance movement reproduction task. Besides, amateur dancers displayed higher abilities of the visual motor imagery and the kinesthetic imagery, but comparable visual imagery ability as the non-dancers. These findings suggest that the mental representation of motors but not the visual is affected by the motor skill levels, due to the motor imagery practice in sports amateurs.

Motor Imagery-Based Brain-Computer Interface Combined with Multimodal Feedback to Promote Upper Limb Motor Function after Stroke: A Preliminary Study

Background

Recently, the brain-computer interface (BCI) has seen rapid development, which may promote the recovery of motor function in chronic stroke patients.

Methods

Twelve stroke patients with severe upper limb and hand motor impairment were enrolled and randomly assigned into two groups: motor imagery (MI)-based BCI training with multimodal feedback (BCI group, n = 7) and classical motor imagery training (control group, n = 5). Motor function and electrophysiology were evaluated before and after the intervention. The Fugl-Meyer assessment-upper extremity (FMA-UE) is the primary outcome measure. Secondary outcome measures include an increase in wrist active extension or surface electromyography (the amplitude and cocontraction of extensor carpi radialis during movement), the action research arm test (ARAT), the motor status scale (MSS), and Barthel index (BI). Time-frequency analysis and power spectral analysis were used to reflect the electroencephalogram (EEG) change before and after the intervention.

Results

Compared with the baseline, the FMA-UE score increased significantly in the BCI group (p = 0.006). MSS scores improved significantly in both groups, while ARAT did not improve significantly. In addition, before the intervention, all patients could not actively extend their wrists or just had muscle contractions. After the intervention, four patients regained the ability to extend their paretic wrists (two in each group). The amplitude and area under the curve of extensor carpi radialis improved to some extent, but there was no statistical significance between the groups.

Conclusion

MI-based BCI combined with sensory and visual feedback might improve severe upper limb and hand impairment in chronic stroke patients, showing the potential for application in rehabilitation medicine.

Investigating the dose-response relationship between motor imagery and motor recovery of upper-limb impairment and function in chronic stroke: A scoping review

The recovery of upper-limb impairment and dysfunction post-stroke is often incomplete owing to the limited time in therapy focused on upper-limb recovery and the severity of the impairment. In these cases, motor imagery (MI) may be used as a precursor to physical therapies to initiate rehabilitation early on when it would be otherwise impossible to engage in therapy, as well as to increase the dose of therapy when MI is used in adjunct to physical therapy. While previous reviews have shown MI to be effective as a therapeutic option, disparity in findings exists, with some studies suggesting MI is not an effective treatment for post-stroke impairment and dysfunction. One factor contributing to these findings is inconsistency in the dose of MI applied. To explore the relationship between MI dose and recovery, a scoping review of MI literature as a treatment for adult survivors of stroke with chronic upper-limb motor deficit was performed. Embase, Medline and CINHAL databases were searched for articles related to MI and stroke. Following a two-phase review process, 21 papers were included, and data related to treatment dose and measures of impairment and function were extracted. Effect sizes were calculated to investigate the effect of dosage on motor recovery. Findings showed a high degree of variability in dosage regimens across studies, with no clear pattern for the effect of dose on outcome. The present review highlights the gaps in MI literature, including variables that contribute to the dose-response relationship, that future studies should consider when implementing MI.

Reaching performance scale for stroke - Test-retest reliability, measurement error, concurrent and discriminant validity

INTRODUCTION

Post-stroke upper limb motor improvement can be better quantified by describing movement patterns characterizing movement quality and use of compensations. Movement patterns can be described using both kinematic and clinical outcomes. One clinical outcome that assesses movement quality and compensations used for reaching a Close (18 points) and Far target (18 points) is the Reaching Performance Scale for Stroke (RPSS).

OBJECTIVE

To estimate the pilot test-retest reliability and validity (concurrent, discriminant) of the RPSS in individuals with chronic stroke.

DESIGN

Retrospective data analysis.

SETTING

Research laboratory.

PARTICIPANTS

Seventy-two individuals with upper limb hemiparesis ≥6 months prior to participation.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURE

RPSS Close and Far Target scores. Intraclass correlation coefficients (ICCs) helped assess pilot test-retest reliability on a subset of 14 participants. Concurrent validity was assessed for individual RPSS items with corresponding kinematic outcomes (trunk displacement, shoulder flexion, shoulder horizontal adduction, elbow extension, trajectory straightness) using Pearson correlations. We also ran multiple regression analyses with the RPSS total scores and used kinematic outcomes as the criterion standard. Logistic regression analyses estimated discriminant validity. We divided participants into two groups based on the Fugl-Meyer Assessment (FMA) scores (mild: ≥50/66; moderate-to-severe: ≤49/66).

RESULTS

Test-retest reliability was excellent for Close (ICC = 0.98, 95% confidence interval [CI] 0.94-0.99) and Far targets (ICC = 0.98, 95% CI 0.95-0.99). Individual RPSS items for both targets were mildly to moderately correlated with corresponding kinematic values. A combination of trajectory straightness, elbow extension, and trunk displacement explained the majority of the variance in RPSS scores (47%) for both targets. The RPSS scores discriminated between individuals with mild and moderate-to-severe motor impairment for both Close (ExpB = 3.33, P < .001; 95% CI 1.70-6.52) and Far targets (ExpB = 2.59, P < .001, 95% CI 1.65-4.07). Cutoff points for transition between groups were 15.5 (Close target) and 14 (Far target).

CONCLUSION

The RPSS is a valid clinical measure with excellent pilot results of test-retest reliability for assessing movement patterns and compensations used for reaching.

Study Paradigms and Principles Investigated in Motor Learning Research After Stroke: A Scoping Review

Objectives

To (1) characterize study paradigms used to investigate motor learning (ML) poststroke and (2) summarize the effects of different ML principles in promoting skill acquisition and retention. Our secondary objective is to evaluate the clinical utility of ML principles on stroke rehabilitation.

Data Sources

Medline, Excerpta Medica Database, Allied and Complementary Medicine, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched from inception on October 24, 2018 and repeated on June 23, 2020. Scopus was searched on January 24, 2019 and July 22, 2020 to identify additional studies.

Study Selection

Our search included keywords and concepts to represent stroke and "motor learning. An iterative process was used to generate study selection criteria. Three authors independently completed title, abstract, and full-text screening.

Data Extraction

Three reviewers independently completed data extraction.

Data Synthesis

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension guidelines for scoping reviews were used to guide our synthesis. Thirty-nine studies were included. Study designs were heterogeneous, including variability in tasks practiced, acquisition parameters, and retention intervals. ML principles investigated included practice complexity, feedback, motor imagery, mental practice, action observation, implicit and explicit information, aerobic exercise, and neurostimulation. An additional 2 patient-related factors that influence ML were included: stroke characteristics and sleep. Practice complexity, feedback, and mental practice/action observation most consistently promoted ML, while provision of explicit information and more severe strokes were detrimental to ML. Other factors (ie, sleep, practice structure, aerobic exercise, neurostimulation) had a less clear influence on learning.

Conclusions

Improved consistency of reporting in ML studies is needed to improve study comparability and facilitate meta-analyses to better understand the influence of ML principles on learning poststroke. Knowledge of ML principles and patient-related factors that influence ML, with clinical judgment can guide neurologic rehabilitation delivery to improve patient motor outcomes.

Motor imagery for gait rehabilitation after stroke

BACKGROUND

Motor imagery (MI) is defined as a mentally rehearsed task in which movement is imagined but is not performed. The approach includes repetitive imagined body movements or rehearsing imagined acts to improve motor performance.

OBJECTIVES

To assess the treatment effects of MI for enhancing ability to walk among people following stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group registry, CENTRAL, MEDLINE, Embase and seven other databases. We also searched trial registries and reference lists. The last searches were conducted on 24 February 2020.

SELECTION CRITERIA

Randomized controlled trials (RCTs) using MI alone or associated with action observation or physical practice to improve gait in individuals after stroke. The critical outcome was the ability to walk, assessed using either a continuous variable (walking speed) or a dichotomous variable (dependence on personal assistance). Important outcomes included walking endurance, motor function, functional mobility, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials according to pre-defined inclusion criteria, extracted the data, assessed the risk of bias, and applied the GRADE approach to evaluate the certainty of the evidence. The review authors contacted the study authors for clarification and missing data.

MAIN RESULTS

We included 21 studies, involving a total of 762 participants. Participants were in the acute, subacute, or chronic stages of stroke, and had a mean age ranging from 50 to 78 years. All participants presented at least some gait deficit. All studies compared MI training versus other therapies. Most of the included studies used MI associated with physical practice in the experimental groups. The treatment time for the experimental groups ranged from two to eight weeks. There was a high risk of bias for at least one assessed domain in 20 of the 21 included studies. Regarding our critical outcome, there was very low-certainty evidence that MI was more beneficial for improving gait (walking speed) compared to other therapies at the end of the treatment (pooled standardized mean difference (SMD) 0.44; 95% confidence interval (CI) 0.06 to 0.81; P = 0.02; six studies; 191 participants; I² = 38%). We did not include the outcome of dependence on personal assistance in the meta-analysis, because only one study provided information regarding the number of participants that became dependent or independent after interventions. For our important outcomes, there was very low-certainty evidence that MI was no more beneficial than other interventions for improving motor function (pooled mean difference (MD) 2.24, 95% CI -1.20 to 5.69; P = 0.20; three studies; 130 participants; I² = 87%) and functional mobility at the end of the treatment (pooled SMD 0.55, 95% CI -0.45 to 1.56; P = 0.09; four studies; 116 participants; I² = 64.2%). No adverse events were observed in those studies that reported this outcome (seven studies). We were unable to pool data regarding walking endurance and all other outcomes at follow-up.

AUTHORS' CONCLUSIONS

We found very low-certainty evidence regarding the short-term benefits of MI on walking speed in individuals who have had a stroke, compared to other therapies. Evidence was insufficient to estimate the effect of MI on the dependence on personal assistance and walking endurance. Compared with other therapies, the evidence indicates that MI does not improve motor function and functional mobility after stroke (very low-certainty evidence). Evidence was also insufficient to estimate the effect of MI on gait, motor function, and functional mobility after stroke compared to placebo or no intervention. Motor Imagery and other therapies used for gait rehabilitation after stroke do not appear to cause significant adverse events.

Modulation of motor cortex inhibition during motor imagery

Motor imagery (MI) is similar to overt movement, engaging common neural substrates and facilitating the corticomotor pathway; however, it does not result in excitatory descending motor output. Transcranial magnetic stimulation (TMS) can be used to assess inhibitory networks in the primary motor cortex via measures of 1-ms short-interval intracortical inhibition (SICI), long-interval intracortical inhibition (LICI), and late cortical disinhibition (LCD). These measures are thought to reflect extrasynaptic GABA_A tonic inhibition, postsynaptic GABA_B inhibition, and presynaptic GABA_B disinhibition, respectively. The behavior of 1-ms SICI, LICI, and LCD during MI has not yet been explored. This study aimed to investigate how 1-ms SICI, LICI, and LCD are modulated during MI and voluntary relaxation (VR) of a target muscle. Twenty-five healthy young adults participated. TMS was used to assess nonconditioned motor evoked potential (MEP) amplitude, 1-ms SICI, 100- (LICI₁₀₀) and 150-ms LICI, and LCD in the right abductor pollicis brevis (APB) and right abductor digiti minimi during rest, MI, and VR of the hand. Compared with rest, MEP amplitudes were facilitated in APB during MI. SICI was not affected by task or muscle. LICI₁₀₀ decreased in both muscles during VR but not MI, whereas LCD was recruited in both muscles during both tasks. This indicates that VR modulates postsynaptic GABA_B inhibition, whereas both tasks modulate presynaptic GABA_B inhibition in a non-muscle-specific way. This study highlights further neurophysiological parallels between actual and imagined movement, which may extend to voluntary relaxation.NEW & NOTEWORTHY This is the first study to investigate how 1-ms short-interval intracortical inhibition, long-interval intracortical inhibition, and late cortical disinhibition are modulated during motor imagery and voluntary muscle relaxation. We present novel findings of decreased 100-ms long-interval intracortical inhibition during voluntary muscle relaxation and increased late cortical disinhibition during both motor imagery and voluntary muscle relaxation.

Cognitive-linguistic effort in multidisciplinary stroke rehabilitation: Decreasing vs. increasing cues for word retrieval

Approximately 24% of stroke survivors experience co-occurring aphasia and hemiparesis. These individuals typically attend back-to-back therapy sessions. However, sequentially scheduled therapy may trigger physical and mental fatigue and have an adverse impact on treatment outcomes. The current study tested a hypothesis that exerting less effort during a therapy session would reduce overall fatigue and enhance functional recovery. Two stroke survivors chronically challenged by non-fluent aphasia and right hemiparesis sequentially completed verbal naming and upper-limb tasks on their home computers. The level of cognitive-linguistic effort in speech/language practice was manipulated by presenting verbal naming tasks in two conditions: Decreasing cues (i.e., most-to-least support for word retrieval), and Increasing cues (i.e., least-to-most support). The participants completed the same upper-limb exercises throughout the study periods. Both individuals showed a statistically significant advantage of decreasing cues over increasing cues in word retrieval during the practice period, but not at the end of the practice period or thereafter. The participant with moderate aphasia and hemiparesis achieved clinically meaningful gains in upper-limb functions following the decreasing cues condition, but not after the increasing cues condition. Preliminary findings from the current study suggest a positive impact of decreasing cues in the context of multidisciplinary stroke rehabilitation.

The improvement effect of limited mental practice in individuals with poststroke hemiparesis: the influence of mental imagery and mental concentration

[Purpose] This study examined whether limited mental practice improves the motor performance of poststroke individuals with hemiparesis. [Subjects] Twenty-three participants with poststroke hemiparesis (40–82 years of age) participated in this study. [Methods] The subjects were divided into four groups with respect to a dart-throwing task: the no-practice, physical practice only, mental practice only, and mental and physical practice groups. The groups were compared in terms of gains in motor performance, mental imagery vividness, and level of concentration during mental practice. [Results] No statistically significant difference was found for gains in motor performance among groups, and there was no correlation between imagery vividness and motor performance gains. However, a correlation was found between gains in motor performance and mental concentration during mental practice. [Conclusion] The results suggested that limited mental practice for individuals with poststroke hemiparesis may not improve motor performance. However, a higher degree of concentration during mental practice may improve motor performance.

Specific Brain Lesions Impair Explicit Motor Imagery Ability: A Systematic Review of the Evidence

OBJECTIVE

To determine which neurologic disorders/lesions impair or restrict motor imagery (MI) ability.

DATA SOURCES

CINAHL, Cochrane, Embase, MEDLINE, Web of Science, PsychINFO, Physiotherapy Evidence Database, and Grey Literature were searched between May 8 and May 14, 2014. Keywords and Medical Subject Headings from 2 concepts (MI and lesion) were exploded to include related search terms (eg, mental practice/mental imagery, neurologic damage/lesion).

STUDY SELECTION

Two independent reviewers assessed the 3861 studies that resulted from the database search. The studies were assessed for relevancy using the following inclusion criteria: use of explicit kinesthetic MI; neurologic lesion location identified; and use of an MI ability assessment tool.

DATA EXTRACTION

Twenty-three studies encompassing 196 participants were included. The 23 studies used 8 different methods for assessing MI ability. MI assessment scores were then normalized to facilitate comparison across studies.

DATA SYNTHESIS

Lesion locations comprised many brain areas, including cortical (eg, parietal and frontal lobes), subcortical (eg, basal ganglia, thalamus), and cerebellum. Lesion etiology primarily was comprised of stroke and Parkinson disease. Several participants presented with lesions resulting from other pathologies. Subjects with parietal lobe damage were most impaired on their ability to perform MI. Subjects with frontal lobe and basal ganglia damage also consistently showed impairment in MI ability.

CONCLUSIONS

Subjects with damage to specific brain structures, including the parietal and frontal lobes, showed impaired MI ability. As such, MI-based neurorehabilitation may not be efficacious in all patient populations. Therefore, decisions related to the use of MI in neurorehabilitation should, in part, be based on the patient's underlying pathophysiology.

Effect of Motor Imagery on the F-Wave Parameters in Hemiparetic Stroke Survivors

Objective

To assess the effect of motor imagery, as a rehabilitation method in stroke, on F-wave parameters that undergo changes during upper motor neuron involvement.

Methods

Twenty-one fully conscious hemiparetic stroke survivors with a completely plegic hand (power 0/5) and a minimum interval of 72 hours since stroke were recruited into this study. The mean F-wave latency, amplitude, and persistence in the median and ulnar nerves were measured in both the affected and non-affected sides at rest and in the paretic hand during a mental task. Comparison was made between data from the affected hand and the non-affected hand as well as between data from the affected hand at baseline and during motor imagery.

Results

Patients had significantly different F-wave persistence between the affected and non-affected sides (paired t-test, p<0.001). Motor imagery could improve F-wave persistence in both the investigated nerves (paired t-test, p=0.01 for ulnar nerve and p<0.001 for median nerve) and F-response amplitude in the median nerve (paired t-test, p=0.01) of the affected limb.

Conclusion

The amplitude and persistence of F-wave were improved during motor imagery, representing F-wave facilitation. This result suggests that motor imagery can restore motor neuron excitability, which is depressed after stroke.

Utilization of motor imagery in upper limb rehabilitation: a systematic scoping review

Objective:

To determine how motor imagery is being delivered in upper limb rehabilitation to guide practice and research.

Data source:

MEDLINE, PubMed, CINAHL, EMBASE, PsychINFO databases were searched from 1987 to November 2014

Study selection:

English, adults, any clinical population or diagnosis, intervention for upper limb with an outcome measure used. All types of studies were included. Two authors independently selected studies for review using consensus.

Data extraction:

Seven motor imagery elements were extracted using a model implemented in sport research: PETTLEP model (Physical, Environment, Task, Timing, Learning, Emotion, and Perspective).

Results:

The search yielded 1107 articles with 1059 excluded leaving 48 articles for full review. A total of 38 articles involved individuals with stroke, five articles involved individuals with complex regional pain syndrome, and five articles for other conditions. Motor imagery elements most commonly described were physical, environment, task, and perspective. Elements less commonly described were timing, learning, and emotional aspects. There were significant differences between study populations (e.g. stroke and complex regional pain syndrome) and within populations on how motor imagery was delivered.

Conclusion:

Many of the imagery elements reviewed are not being considered or reported on in the selected studies. How motor imagery is being delivered within and between populations is inconsistent, which may lead to difficulties in determining key elements of effectiveness.

Interventions for improving sit-to-stand ability following stroke

BACKGROUND

Standing up from a seated position is one of the most frequently performed functional tasks, is an essential pre-requisite to walking and is important for independent living and preventing falls. Following stroke, patients can experience a number of problems relating to the ability to sit-to-stand independently.

OBJECTIVES

To review the evidence of effectiveness of interventions aimed at improving sit-to-stand ability after stroke. The primary objectives were to determine (1) the effect of interventions that alter the starting posture (including chair height, foot position, hand rests) on ability to sit-to-stand independently; and (2) the effect of rehabilitation interventions (such as repetitive practice and exercise programmes) on ability to sit-to-stand independently. The secondary objectives were to determine the effects of interventions aimed at improving ability to sit-to-stand on: (1) time taken to sit-to-stand; (2) symmetry of weight distribution during sit-to-stand; (3) peak vertical ground reaction forces during sit-to-stand; (4) lateral movement of centre of pressure during sit-to-stand; and (5) incidence of falls.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (June 2013), CENTRAL (2013, Issue 5), MEDLINE (1950 to June 2013), EMBASE (1980 to June 2013), CINAHL (1982 to June 2013), AMED (1985 to June 2013) and six additional databases. We also searched reference lists and trials registers and contacted experts.

SELECTION CRITERIA

Randomised trials in adults after stroke where: the intervention aimed to affect the ability to sit-to-stand by altering the posture of the patient, or the design of the chair; stated that the aim of the intervention was to improve the ability to sit-to-stand; or the intervention involved exercises that included repeated practice of the movement of sit-to-stand (task-specific practice of rising to stand).The primary outcome of interest was the ability to sit-to-stand independently. Secondary outcomes included time taken to sit-to-stand, measures of lateral symmetry during sit-to-stand, incidence of falls and general functional ability scores.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts, extracted data and appraised trials. We undertook an assessment of methodological quality for random sequence generation, allocation concealment, blinding of outcome assessors and method of dealing with missing data.

MAIN RESULTS

Thirteen studies (603 participants) met the inclusion criteria for this review, and data from 11 of these studies were included within meta-analyses. Twelve of the 13 included studies investigated rehabilitation interventions; one (nine participants) investigated the effect of altered starting posture for sit-to-stand. We judged only four studies to be at low risk of bias for all methodological parameters assessed. The majority of randomised controlled trials included participants who were already able to sit-to-stand or walk independently.Only one study (48 participants), which we judged to be at high risk of bias, reported our primary outcome of interest, ability to sit-to-stand independently, and found that training increased the odds of achieving independent sit-to-stand compared with control (odds ratio (OR) 4.86, 95% confidence interval (CI) 1.43 to 16.50, very low quality evidence).Interventions or training for sit-to-stand improved the time taken to sit-to-stand and the lateral symmetry (weight distribution between the legs) during sit-to-stand (standardised mean difference (SMD) -0.34; 95% CI -0.62 to -0.06, seven studies, 335 participants; and SMD 0.85; 95% CI 0.38 to 1.33, five studies, 105 participants respectively, both moderate quality evidence). These improvements are maintained at long-term follow-up.Few trials assessing the effect of sit-to-stand training on peak vertical ground reaction force (one study, 54 participants) and functional ability (two studies, 196 participants) were identified, providing very low and low quality evidence respectively.The effect of sit-to-stand training on number of falls was imprecise, demonstrating no benefit or harm (OR 0.75, 95% CI 0.46 to 1.22, five studies, 319 participants, low quality evidence). We judged the majority of studies that assessed falls to be at high risk of bias.

AUTHORS' CONCLUSIONS

This review has found insufficient evidence relating to our primary outcome of ability to sit-to-stand independently to reach any generalisable conclusions. This review has found moderate quality evidence that interventions to improve sit-to-stand may have a beneficial effect on time taken to sit-to-stand and lateral symmetry during sit-to-stand, in the population of people with stroke who were already able to sit-to-stand independently. There was insufficient evidence to reach conclusions relating to the effect of interventions to improve sit-to-stand on peak vertical ground reaction force, functional ability and falls. This review adds to a growing body of evidence that repetitive task-specific training is beneficial for outcomes in people receiving rehabilitation following stroke.

Cortical lateralization in stroke patients measured by event‑related potentials during motor imagery

Stroke is a leading cause of impairment and disability worldwide, and motor imagery (MI) has been used in stroke rehabilitation. Electroencephalography (EEG) has been used to study MI. However, the characteristic features of EEG during MI in stroke patients have not been established. The purpose of this study was to investigate the difference in event‑related potentials (ERPs) during MI between healthy controls and stroke patients. This study included nine stroke patients and nine healthy age‑matched controls, who performed tasks involving MI, passive movement without MI and passive movement with MI. One hundred and twenty‑eight channel ERPs were recorded to capture cerebral activation. Electrodes E44 and E120 (corresponding to the inferior precentral area) were selected to analyze the lateralization effects of ERPs. Lateralization was calculated as the ratio of the potential at 500 ms at electrode E120 to that at electrode E44. In the controls, the different ERPs exhibited differential direction between the 0‑300 and the 300‑700 ms interval. ERPs were evoked by passive movement with MI and MI alone, but not passive movement without MI. In addition, a lateralization effect in control patients as shown by the observation that the lateralization ratio in passive movement with MI and MI alone was significantly different from that in passive movement without MI (P<0.05). The amplitudes of the different ERPs were significantly smaller in stroke patients compared with those in the controls (P<0.05). The lateralization ratio in the stroke patients was opposite and significantly different from that of the controls (P<0.05). The results suggested that the MI‑induced lateralization effect in ERPs may be used as a measure for evaluating the MI impairment and recovery in stroke patients.

Towards the integration of mental practice in rehabilitation programs. A critical review

Many clinical studies have investigated the use of mental practice (MP) through motor imagery (MI) to enhance functional recovery of patients with diverse physical disabilities. Although beneficial effects have been generally reported for training motor functions in persons with chronic stroke (e.g., reaching, writing, walking), attempts to integrate MP within rehabilitation programs have been met with mitigated results. These findings have stirred further questioning about the value of MP in neurological rehabilitation. In fact, despite abundant systematic reviews, which customarily focused on the methodological merits of selected studies, several questions about factors underlying observed effects remain to be addressed. This review discusses these issues in an attempt to identify factors likely to hamper the integration of MP within rehabilitation programs. First, the rationale underlying the use of MP for training motor function is briefly reviewed. Second, three modes of MI delivery are proposed based on the analysis of the research protocols from 27 studies in persons with stroke and Parkinson's disease. Third, for each mode of MI delivery, a general description of MI training is provided. Fourth, the review discusses factors influencing MI training outcomes such as: the adherence to MI training, the amount of training and the interaction between physical and mental rehearsal; the use of relaxation, the selection of reliable, valid and sensitive outcome measures, the heterogeneity of the patient groups, the selection of patients and the mental rehearsal procedures. To conclude, the review proposes a framework for integrating MP in rehabilitation programs and suggests research targets for steering the implementation of MP in the early stages of the rehabilitation process. The challenge has now shifted towards the demonstration that MI training can enhance the effects of regular therapy in persons with subacute stroke during the period of spontaneous recovery.

Equal prefrontal cortex activation between males and females in a motor tasks and different visual imagery perspectives: a functional near-infrared spectroscopy (fNIRS) study

The purpose of this study was to compare the prefrontal cortex (PFC) blood flow variation and time on in males and females while performing a motor task and imagery perspectives. Eighteen right handed subjects (11 males and 7 females) were volunteers to this study. All subjects went through three randomly conditions, a motor task condition (MT) in which they had to do a simple finger tap. The other conditions included practicing imagery in first and third views. During all the conditions, the fNIRS device was attached to the subject forehead to obtain the blood flow; the total time in each task which was measured with a chronometer. No difference had been found in any condition for both sexes in the PFC and time, nor for all subjects integrated in the PFC. Therefore, we conclu-de that both imageries can be used to mentally train a motor task, and probably both sexes can be benefited.

The effects of mental practice in neurological rehabilitation; a systematic review and meta-analysis

Objective: To investigate the beneficial and adverse effects of a mental practice intervention on activities, cognition, and emotion in patients after stroke, patients with Parkinson's disease or multiple sclerosis.

Methods: Electronic databases PubMed/Medline, PEDro, Science Direct, Cochrane Library, PsycINFO, Rehadat, Embase, and Picarta were searched until June 2012. Fourteen randomized controlled trials in stroke and two randomized controlled trials in Parkinson's disease were included, representing 491 patients (421 with stroke). No randomized controlled trials in multiple sclerosis were identified. The methodologic quality of the included trials was assessed with the Amsterdam-Maastricht-Consensus-List (AMCL). Information on study characteristics and outcomes was summarized and evidence for effects described. Data from individual studies in stroke with same outcome measures were pooled.

Results: The included 16 randomized controlled trials were heterogeneous and methodologic quality varied. Ten trials reported significant effects in favor of mental practice in patients with stroke (n = 9) and Parkinson's disease (n = 1). In six studies mental practice had similar effects as therapy as usual (n = 5 in stroke and n = 1 in Parkinson's disease). Of six performed meta-analyses with identical measures in stroke studies only two showed significant effects of mental practice: short-term improvement of arm-hand-ability (ARAT: SMD 0.62; 95% CI: 0.05 to 1.19) and improvement of performance of activities (NRS: SMD 0.9; 95% CI: 0.04 to 1.77). Five studies found effects on cognition (e.g., effects on attention, plan actions in unfamiliar surroundings) and four reported observed side-effects, both positive (e.g., might increase motivation and arousal and reduce depression) and negative (e.g., diminished concentration, irritation).

Conclusions: Mental practice might have positive effects on performance of activities in patients with neurological diseases, but this review reports less positive results than earlier published ones. Strengths and limitations of past studies are pointed out. Methodologic recommendations for future studies are given.

Effectiveness of motor imagery or mental practice in functional recovery after stroke: a systematic review

INTRODUCTION

In recent decades, many stroke rehabilitation methods have been developed. Mental practice (MP) is a dynamic state in which the subject evokes an imaginary representation of a motor action or skill in order to learn or perfect that action. Although functional imaging has shown that MP produces similar cortical activation patterns to those of movement, the clinical effectiveness of such methods in rehabilitation and functional recovery has yet to be demonstrated.

DEVELOPMENT

Systematic search of all clinical studies published in the main scientific databases between December 2011 and October 2012 concerning mental practice in stroke rehabilitation. We selected 23 clinical trials testing different MP protocols in patients with hemiparesis.

CONCLUSIONS

MP is effective when used in conjunction with conventional physical therapy for functional rehabilitation of both upper and lower limbs, as well as for the recovery of daily activities and skills. Owing to the heterogeneity of the studies with regard to the intervention protocol, specific imagery technique, time spent practicing, patient characteristics, etc., more studies are needed in order to determine the optimal treatment protocol and patient profile.