Precision grip in congenital and acquired hemiparesis: similarities in impairments and implications for neurorehabilitation

Effects of virtual reality-based robot therapy combined with task-oriented therapy on upper limb function and cerebral cortex activation in patients with stroke

BACKGROUND

This study aimed to investigate the effects of virtual reality (VR)-based robot therapy combined with task-oriented therapy on cerebral cortex activation and upper limb function in patients with stroke.

METHODS

This study included 46 patients with hemiplegia within 1 year of stroke onset. Patients were divided into an experimental group (n = 23) and a control group (n = 23) using a computer randomization program. The experimental group received VR-based robot and task-oriented therapies, whereas the control group received only task-oriented therapy. All participants received interventions for 40 minutes per session, 5 times a week, for 8 weeks. For the pre- and post-evaluation of all participants, the Fugl-Meyer Assessment for the upper extremity, manual function test, motor activity log, and Jebsen-Taylor Hand Function Test were used to evaluate changes in upper limb function and motor-evoked potential amplitudes were measured to compare cerebral cortex activation.

RESULTS

In comparison to the control group, experimental group demonstrated an improvement in the function of the upper limb (P < .01) and activation of the cerebral cortex (P < .01).

CONCLUSION

The combined intervention of VR-based robot and task-oriented therapies is valuable for improving upper limb function and cerebral cortex activation in patients with stroke.

Use of computational modeling to examine fingertip force production in children with hemiplegic cerebral palsy

Most children with hemiplegic cerebral palsy (HCP), one of the most prevalent subtypes of cerebral palsy, struggle with grasping and manipulating objects. This impairment may arise from a diminished capacity to properly direct forces created with the finger pad due to aberrant force application. Children with HCP were asked to create maximal force with the index finger pad in the palmar (normal) direction with both the paretic and non-paretic hands. The resulting forces and finger postures were then applied to a computational musculoskeletal model of the hand to estimate the corresponding muscle activation patterns. Subjects tended to create greater shear force relative to normal force with the paretic hand (p < 0.05). The resultant force was directed 33.6°±10.8° away from the instructed palmar direction in the paretic hand, but only 8.0°±7.3° in the non-paretic hand. Additionally, participants created greater palmar force with the non-paretic hand than with the paretic hand (p < 0.05). These differences in force production are likely due to differences in muscle activation pattern, as our computational models showed differences in which muscles are active and their relative activations when recreating the measured force vectors for the two hands (p < 0.01). The models predicted reduced activation in the extrinsic and greater reductions in activation in the intrinsic finger muscles, potentially due to reduced voluntary activation or muscle atrophy. As the large shear forces could lead to objects slipping from grasp, muscle activation patterns may provide an important target for therapeutic treatment in children with HCP.

Exergames as a rehabilitation tool to enhance the upper limbs functionality and performance in chronic stroke survivors: a preliminary study

Introduction

Post-stroke hemiplegia commonly occurs in stroke survivors, negatively impacting the quality of life. Despite the benefits of initial specific post-acute treatments at the hospitals, motor functions, and physical mobility need to be constantly stimulated to avoid regression and subsequent hospitalizations for further rehabilitation treatments.

Method

This preliminary study proposes using gamified tasks in a virtual environment to stimulate and maintain upper limb mobility through a single RGB-D camera-based vision system (using Microsoft Azure Kinect DK). This solution is suitable for easy deployment and use in home environments. A cohort of 10 post-stroke subjects attended a 2-week gaming protocol consisting of Lateral Weightlifting (LWL) and Frontal Weightlifting (FWL) gamified tasks and gait as the instrumental evaluation task.

Results and discussion

Despite its short duration, there were statistically significant results (p < 0.05) between the baseline (T0) and the end of the protocol (TF) for Berg Balance Scale and Time Up-and-Go (9.8 and -12.3%, respectively). LWL and FWL showed significant results for unilateral executions: rate in FWL had an overall improvement of 38.5% (p < 0.001) and 34.9% (p < 0.01) for the paretic and non-paretic arm, respectively; similarly, rate in LWL improved by 19.9% (p < 0.05) for the paretic arm and 29.9% (p < 0.01) for non-paretic arm. Instead, bilateral executions had significant results for rate and speed: considering FWL, there was an improvement in rate with p < 0.01 (31.7% for paretic arm and 37.4% for non-paretic arm), whereas speed improved by 31.2% (p < 0.05) and 41.7% (p < 0.001) for the paretic and non-paretic arm, respectively; likewise, LWL showed improvement in rate with p < 0.001 (29.0% for paretic arm and 27.8% for non-paretic arm) and in speed with 23.6% (p < 0.05) and 23.5% (p < 0.01) for the paretic and non-paretic arms, respectively. No significant results were recorded for gait task, although an overall good improvement was detected for arm swing asymmetry (-22.6%). Hence, this study suggests the potential benefits of continuous stimulation of upper limb function through gamified exercises and performance monitoring over medium-long periods in the home environment, thus facilitating the patient's general mobility in daily activities.

The Effects of Proprioceptive Neuromuscular Facilitation Pattern Kinesio Taping on Arm Swing, Balance, and Gait Parameters among Chronic Stroke Patients: A Randomized Controlled Trial

(1) Background: This study aimed to investigate the effects of proprioceptive neuromuscular facilitation pattern kinesio taping on arm swing, balance, and gait parameters among chronic stroke patients. (2) Methods: Twenty-eight participants were randomized into proprioceptive neuromuscular facilitation pattern kinesio taping during gait training (n = 14) and gait training (n = 14) groups. The proprioceptive neuromuscular facilitation pattern kinesio taping during gait training group employed proprioceptive neuromuscular facilitation pattern kinesio taping during 15 min treadmill-based gait training five times a week for four weeks, while the gait training group underwent the same gait training without proprioceptive neuromuscular facilitation pattern kinesio taping. Arm swing angle was measured using the Image J program, static balance was assessed with an AMTI force plate, dynamic balance was evaluated through the Timed Up and Go test, and gait parameters were recorded using the GAITRite system and the Dynamic Gait Index. (3) Results: After 4 weeks of training, the proprioceptive neuromuscular facilitation pattern kinesio taping during gait training group exhibited significant improvements in all variables compared to the baseline (p < 0.05), whereas the gait training group did not show statistically significant differences in any variables (p > 0.05). (4) Conclusions: This study demonstrates the effectiveness of proprioceptive neuromuscular facilitation pattern kinesio taping during gait training in enhancing arm swing angle, balance, and gait parameters.

Effectiveness and safety of virtual reality rehabilitation after stroke: an overview of systematic reviews

Background

Virtual reality (VR) is an innovative neurorehabilitation modality that has been variously examined in systematic reviews. We assessed VR effectiveness and safety after cerebral stroke.

Methods

In this overview of systematic reviews, we searched eleven databases (Cochrane Database of Systematic Reviews, EMBASE, MEDLINE, SCOPUS, ISI Web of Science, CINAHL, PsycINFO, Pedro, Otseeker, Healthevidence.org, Epistemonikos) and grey literature from inception to January 17, 2023. Studies eligible for inclusion were systematic reviews published in English that included adult patients with a clinical diagnosis of stroke (acute to chronic phase) undergoing any kind of immersive, semi-immersive or non-immersive VR intervention with or without conventional therapy versus conventional therapy alone. The primary outcome was motor upper limb function and activity. The secondary outcomes were gait and balance, cognitive and mental function, limitation of activities, participation, and adverse events. We calculated the degree of overlap between reviews based on the corrected covered area (CCA). Methodological quality was assessed using the A MeaSurement Tool to Assess systematic Reviews (AMSTAR 2) and the Certainty of Evidence (CoE) using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. Discordances between results were examined using a conceptual framework based on the Jadad algorithm. This overview is registered with PROSPERO, CRD42022329263.

Findings

Of the 58 reviews included (n = 345 unique primary studies), 42 (72.4%) had conducted meta-analysis. More than half of the reviews (58.6%) were published between 2020 and 2022 and many (77.6%) were judged critically low in quality by AMSTAR 2. Most reported the Fugl Meyer Assessment scale (FMA-UE) to measure upper limb function and activity. For the primary outcome, there was a moderate overlap of primary studies (CCA 9.0%) with discordant findings. Focusing on upper limb function (FMA-UE), VR with or without conventional therapy seems to be more effective than conventional therapy alone, with low to moderate CoE and probable to definite clinical relevance. For secondary outcomes there was uncertainty about the superiority or no difference between groups due to substantial heterogeneity of measurement scales (eg, methodological choices). A few reviews (n = 6) reported the occurrence of mild adverse events.

Interpretation

Current evidence suggests that multiple meta-analyses agreed on the superiority of VR with or without conventional therapy over conventional therapy on FME-UE for upper limb. Clinicians may consider embedding VR technologies into their practice as appropriate with patient's goals, abilities, and preferences. However, caution is needed given the poor methodological quality of reviews.

Funding

Italian Ministry of Health.

Obesity induces extracellular vesicle release from the endothelium as a contributor to brain damage after cerebral ischemia in rats

OBJECTIVES

Cerebral ischemia is the most common cause of disability, the second most common cause of dementia, and the fourth most common cause of death in the developed world [Sveinsson OA, Kjartansson O, Valdimarsson EM. Heilablóðþurrð/heiladrep: Faraldsfræði, orsakir og einkenni [Cerebral ischemia/infarction - epidemiology, causes and symptoms]. Laeknabladid. 2014 May;100(5):271-9. Icelandic. doi:10.17992/lbl.2014.05.543]. Obesity has been associated with worse outcomes after ischemia in rats, triggering proinflammatory cytokine production related to the brain microvasculature. The way obesity triggers these effects remains mostly unknown. Therefore, the aim of this study was to elucidate the cellular mechanisms of damage triggered by obesity in the context of cerebral ischemia.

METHODS

We used a rat model of obesity induced by a 20% high fructose diet (HFD) and evaluated peripheral alterations in plasma (lipid and cytokine profiles). Then, we performed cerebral ischemia surgery using two-vessel occlusion (2VO) and analyzed neurological/motor performance and glial activation. Next, we treated endothelial cell line cultures with glutamate in vitro to simulate an excitotoxic environment, and we added 20% plasma from obese rats. Subsequently, we isolated EVs released from endothelial cells and treated primary cultures of astrocytes with them.

RESULTS

Rats fed a HFD had an increased BMI with dyslipidemia and high levels of proinflammatory cytokines. Glia from the obese rats exhibited altered morphology, suggesting hyperreactivity related to neurological and motor deficits. Plasma from obese rats induced activation of endothelial cells, increasing proinflammatory signals and releasing more EVs. Similarly, these EVs caused an increase in NF-κB and astrocyte cytotoxicity. Together, the results suggest that obesity activates proinflammatory signals in endothelial cells, resulting in the release of EVs that simultaneously contribute to astrocyte activation.

Object-centered sensorimotor bias of torque control in the chronic stage following stroke

When lifting objects whose center of mass (CoM) are not centered below the handle one must compensate for arising external torques already at lift-off to avoid object tilt. Previous studies showed that finger force scaling during object lifting may be impaired at both hands following stroke. However, torque control in object manipulation has not yet been studied in patients with stroke. In this pilot study, thirteen patients with chronic stage left hemispheric stroke (SL), nine patients with right hemispheric stroke (SR) and hand-matched controls had to grasp and lift an object with the fingertips of their ipsilesional hand at a handle while preventing object tilt. Object CoM and therewith the external torque was varied by either relocating a covert weight or the handle. The compensatory torque at lift-off (Tcom) is the sum of the torque resulting from (1) grip force being produced at different vertical finger positions (∆CoP × GF) and (2) different vertical load forces on both sides of the handle (∆Fy × w/2). When having to rely on sensorimotor memories, ∆CoP × GF was elevated when the object CoM was on the ipsilesional-, but decreased when CoM was on the contralesional side in SL, whereas ∆Fy × w/2 was biased in the opposite direction, resulting in normal Tcom. SR patients applied a smaller ∆CoP × GF when the CoM was on the contralesional side. Torques were not altered when geometric cues were available. Our findings provide evidence for an object-centered spatial bias of manual sensorimotor torque control with the ipsilesional hand following stroke reminiscent of premotor neglect. Both intact finger force-to-position coordination and visuomotor control may compensate for the spatial sensorimotor bias in most stroke patients. Future studies will have to confirm the found bias and evaluate the association with premotor neglect.

The Interactions Between Primary Somatosensory and Motor Cortex during Human Grasping Behaviors

Afferent inputs to the primary somatosensory cortex (S1) are differentially processed during precision and power grip in humans. However, it remains unclear how S1 interacts with the primary motor cortex (M1) during these two grasping behaviors. To address this question, we measured short-latency afferent inhibition (SAI), reflecting S1-M1 interactions via thalamo-cortical pathways, using paired-pulse transcranial magnetic stimulation (TMS) during precision and power grip. The TMS coil over the hand representation of M1 was oriented in the posterior-anterior (PA) and anterior-posterior (AP) direction to activate distinct sets of corticospinal neurons. We found that SAI increased during precision compared with power grip when AP, but not PA, currents were applied. Notably, SAI tested in the AP direction were similar during two-digit than five-digit precision grip. The M1 receives movement information from S1 through direct cortico-cortical pathways, so intra-hemispheric S1-M1 interactions using dual-site TMS were also evaluated. Stimulation of S1 attenuated M1 excitability (S1-M1 inhibition) during precision and power grip, while the S1-M1 inhibition ratio remained similar across tasks. Taken together,our findings suggest that distinct neural mechanisms for S1-M1 interactions mediate precision and power grip, presumably by modulating neural activity along thalamo-cortical pathways.

Efficacy and safety of manual acupuncture for the treatment of upper limb motor dysfunction after stroke: Protocol for a systematic review and meta-analysis

Introduction

The incidence of stroke sequelae among patients is as high as 70%–80%. Flexor spasm is the most common stroke sequela, presenting a heavy burden to the patients and their families. This study will evaluate the results of randomized controlled trials to determine the efficacy and safety of hand manipulation acupuncture for the treatment of upper limb motor dysfunction after stroke.

Methods

Eight databases, including China National Knowledge Infrastructure, Chinese Scientific Journal Database, Cochrane Central Register of Controlled Trials, Embase, MEDLINE, PubMed, Wanfang Database, and Web of Science, will be searched using English and Chinese search strategies. In addition, manual retrieval of research papers, conference papers, ongoing experiments, and internal reports, among others, will supplement electronic retrieval. All eligible studies published on or before January 15, 2021 will be selected. To enhance the effectiveness of the study, only clinical randomized controlled trials related to the use of manual acupuncture for the treatment of upper limb motor dysfunction after stroke will be included.

Analysis

The Fugl-Meyer upper extremity assessment will be the primary outcome measure, whereas the Wolf Motor Function Test, Modified Ashworth Scale, arm movement survey test table, and upper extremity freehand muscle strength assessment scores will be the secondary outcomes. Side effects and adverse events will be included as safety evaluations. To ensure the quality of the systematic evaluation, study selection, data extraction, and quality assessment will be independently performed by two authors, and a third author will resolve any disagreement.

Ethics and dissemination

This systematic review will evaluate the efficacy and safety of manual acupuncture for the treatment of upper limb motor dysfunction after stroke. Since all included data will be obtained from published articles, it does not require ethical approval and will be published in a peer-reviewed journal.

INPLASY registration number: INPLASY202110071.

Impairment and Compensation in Dexterous Upper-Limb Function After Stroke. From the Direct Consequences of Pyramidal Tract Lesions to Behavioral Involvement of Both Upper-Limbs in Daily Activities

Impairments in dexterous upper limb function are a significant cause of disability following stroke. While the physiological basis of movement deficits consequent to a lesion in the pyramidal tract is well demonstrated, specific mechanisms contributing to optimal recovery are less apparent. Various upper limb interventions (motor learning methods, neurostimulation techniques, robotics, virtual reality, and serious games) are associated with improvements in motor performance, but many patients continue to experience significant limitations with object handling in everyday activities. Exactly how we go about consolidating adaptive motor behaviors through the rehabilitation process thus remains a considerable challenge. An important part of this problem is the ability to successfully distinguish the extent to which a given gesture is determined by the neuromotor impairment and that which is determined by a compensatory mechanism. This question is particularly complicated in tasks involving manual dexterity where prehensile movements are contingent upon the task (individual digit movement, grasping, and manipulation…) and its objective (placing, two step actions…), as well as personal factors (motivation, acquired skills, and life habits…) and contextual cues related to the environment (presence of tools or assistive devices…). Presently, there remains a lack of integrative studies which differentiate processes related to structural changes associated with the neurological lesion and those related to behavioral change in response to situational constraints. In this text, we shall question the link between impairments, motor strategies and individual performance in object handling tasks. This scoping review will be based on clinical studies, and discussed in relation to more general findings about hand and upper limb function (manipulation of objects, tool use in daily life activity). We shall discuss how further quantitative studies on human manipulation in ecological contexts may provide greater insight into compensatory motor behavior in patients with a neurological impairment of dexterous upper-limb function.

Inter-rater reliability of physiotherapists using the Action Research Arm Test in chronic stroke

OBJECTIVES

The purpose of this study is to establish whether physiotherapists' ratings are consistent, when using the Action Research Arm Test (ARAT) to score a chronic stroke patient.

METHODS

This was part of a large project establishing the reliability in chronic stroke. This study used a correlational design comparing the association between physiotherapist scores of the same patient, to establish the ARAT's inter-rater reliability. The COSMIN checklist was followed to enhance the methodology of the study.

RESULTS

Twenty physiotherapists (8 female and 12 male) aged between 25 and 53 years were selected. There were no participant dropouts or withdrawals. The sample size was normally distributed. The physiotherapists appeared representative of the UK physiotherapy population, with the exception of gender. The distribution of scores showed a normal distribution with standard deviation of score of 1.9. The Kendall's W test showed 0.711 of agreement between the raters. The scores achieved statistical significance showing consistency between physiotherapists' scores with chronic stroke. Limitations of the study were the use of a small single center convenience sample that may reduce the generalizability of the findings.

CONCLUSIONS

The ARAT is consistent when scored by physiotherapists in a chronic stroke population. The inter-rater reliability range was (0.70 to 0.90) which is categorized as good.

Bilateral Tactile Feedback-Enabled Training for Stroke Survivors Using Microsoft KinectTM

Rehabilitation and mobility training of post-stroke patients is crucial for their functional recovery. While traditional methods can still help patients, new rehabilitation and mobility training methods are necessary to facilitate better recovery at lower costs. In this work, our objective was to design and develop a rehabilitation training system targeting the functional recovery of post-stroke users with high efficiency. To accomplish this goal, we applied a bilateral training method, which proved to be effective in enhancing motor recovery using tactile feedback for the training. One participant with hemiparesis underwent six weeks of training. Two protocols, “contralateral arm matching” and “both arms moving together”, were carried out by the participant. Each of the protocols consisted of “shoulder abduction” and “shoulder flexion” at angles close to 30 and 60 degrees. The participant carried out 15 repetitions at each angle for each task. For example, in the “contralateral arm matching” protocol, the unaffected arm of the participant was set to an angle close to 30 degrees. He was then requested to keep the unaffected arm at the specified angle while trying to match the position with the affected arm. Whenever the two arms matched, a vibration was given on both brachialis muscles. For the “both arms moving together” protocol, the two arms were first set approximately to an angle of either 30 or 60 degrees. The participant was asked to return both arms to a relaxed position before moving both arms back to the remembered specified angle. The arm that was slower in moving to the specified angle received a vibration. We performed clinical assessments before, midway through, and after the training period using a Fugl-Meyer assessment (FMA), a Wolf motor function test (WMFT), and a proprioceptive assessment. For the assessments, two ipsilateral and contralateral arm matching tasks, each consisting of three movements (shoulder abduction, shoulder flexion, and elbow flexion), were used. Movements were performed at two angles, 30 and 60 degrees. For both tasks, the same procedure was used. For example, in the case of the ipsilateral arm matching task, an experimenter positioned the affected arm of the participant at 30 degrees of shoulder abduction. The participant was requested to keep the arm in that position for ~5 s before returning to a relaxed initial position. Then, after another ~5-s delay, the participant moved the affected arm back to the remembered position. An experimenter measured this shoulder abduction angle manually using a goniometer. The same procedure was repeated for the 60 degree angle and for the other two movements. We applied a low-cost Kinect to extract the participant’s body joint position data. Tactile feedback was given based on the arm position detected by the Kinect sensor. By using a Kinect sensor, we demonstrated the feasibility of the system for the training of a post-stroke user. The proposed system can further be employed for self-training of patients at home. The results of the FMA, WMFT, and goniometer angle measurements showed improvements in several tasks, suggesting a positive effect of the training system and its feasibility for further application for stroke survivors’ rehabilitation.

Effects of Hand Configuration on the Grasping, Holding, and Placement of an Instrumented Object in Patients With Hemiparesis

Objective: Limitations with manual dexterity are an important problem for patients suffering from hemiparesis post stroke. Sensorimotor deficits, compensatory strategies and the use of alternative grasping configurations may influence the efficiency of prehensile motor behavior. The aim of the present study is to examine how different grasp configurations affect patient ability to regulate both grip forces and object orientation when lifting, holding and placing an object.

Methods: Twelve stroke patients with mild to moderate hemiparesis were recruited. Each was required to lift, hold and replace an instrumented object. Four different grasp configurations were tested on both the hemiparetic and less affected arms. Load cells from each of the 6 faces of the instrumented object and an integrated inertial measurement unit were used to extract data regarding the timing of unloading/loading phases, regulation of grip forces, and object orientation throughout the task.

Results: Grip forces were greatest when using a palmar-digital grasp and lowest when using a top grasp. The time delay between peak acceleration and maximum grip force was also greatest for palmar-digital grasp and lowest for the top grasp. Use of the hemiparetic arm was associated with increased duration of the unloading phase and greater difficulty with maintaining the vertical orientation of the object at the transitions to object lifting and object placement. The occurrence of touch and push errors at the onset of grasp varied according to both grasp configuration and use of the hemiparetic arm.

Conclusion: Stroke patients exhibit impairments in the scale and temporal precision of grip force adjustments and reduced ability to maintain object orientation with various grasp configurations using the hemiparetic arm. Nonetheless, the timing and magnitude of grip force adjustments may be facilitated using a top grasp configuration. Conversely, whole hand prehension strategies compound difficulties with grip force scaling and inhibit the synchrony of grasp onset and object release.

Dexterity and Finger Sense: A Possible Dissociation in Children With Cerebral Palsy

Both hand and finger sensory perception and motor abilities are essential for the development of skilled gestures and efficient bimanual coordination. While finger dexterity and finger sensory perception can be impaired in children with cerebral palsy (CP), the relationship between these two functions in this population is not clearly established. The common assumption that CP children with better sensory function also demonstrate better motor outcomes has been recently challenged. To study these questions further, we assessed both finger dexterity and finger gnosia, the ability to perceive one’s own fingers by touch, in groups of 11 children with unilateral (i.e., hemiplegic CP) and 11 children with bilateral spastic CP (i.e., diplegic CP) and compared them with typical children. In our sample, children with hemiplegia exhibited finger dexterity deficit in both hands and finger gnosia deficit only in their paretic hand. In contrast, children with diplegia exhibited finger gnosia deficits in both hands and finger dexterity deficit only in their dominant hand. Thus, our results indicated that children with spastic hemiplegia and diplegia present different sensory and motor profiles and suggest that these two subgroups of CP should be considered separately in future experimental and clinical research. We discuss the implications of our results for rehabilitation.

Hand Robotic Therapy in Children with Hemiparesis: A Pilot Study

OBJECTIVE

The aim of this study was to understand the impact of training with a hand robotic device on hand paresis and function in a population of children with hemiparesis.

METHODS

Twelve children with hemiparesis (mean age, 9 [SD, 3.64] years) completed participation in this prospective, experimental, pilot study. Participants underwent clinical assessments at baseline and again 6 weeks later with instructions to not initiate new therapies. After these assessments, participants received 6 weeks of training with a hand robotic device, consisting of 1-hour sessions, 3 times weekly. Assessments were repeated on completion of training.

RESULTS

Results showed significant improvements after training on the Assisting Hand Assessment (mean difference, 2.0 Assisting Hand Assessment units; P = 0.011) and on the upper-extremity component of the Fugl-Meyer scale (raw score mean difference, 4.334; P = 0.001). No significant improvements between pretest and posttest were noted on the Jebsen-Taylor Test of Hand Function, the Quality of Upper Extremity Skills Test, or the Pediatric Evaluation of Disability Inventory after intervention. Total active mobility of digits and grip strength also failed to demonstrate significant changes after training.

INTERPRETATION

Participants tolerated training with the hand robotic device, and significant improvements in bimanual hand use, as well as impairment-based scales, were noted. Improvements were carried over into bimanual skills during play.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Understand key components of neuroplasticity; (2) Discuss the benefits of robotic therapy in the recovery of hand function in pediatric patients with hemiplegia; and (3) Appropriately incorporate robotic therapy into the treatment plan of pediatric patients with hemiplegia.

LEVEL

Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery

Stroke is one of the leading causes for disability worldwide. Motor function deficits due to stroke affect the patients' mobility, their limitation in daily life activities, their participation in society and their odds of returning to professional activities. All of these factors contribute to a low overall quality of life. Rehabilitation training is the most effective way to reduce motor impairments in stroke patients. This multiple systematic review focuses both on standard treatment methods and on innovating rehabilitation techniques used to promote upper extremity motor function in stroke patients. A total number of 5712 publications on stroke rehabilitation was systematically reviewed for relevance and quality with regards to upper extremity motor outcome. This procedure yielded 270 publications corresponding to the inclusion criteria of the systematic review. Recent technology-based interventions in stroke rehabilitation including non-invasive brain stimulation, robot-assisted training, and virtual reality immersion are addressed. Finally, a decisional tree based on evidence from the literature and characteristics of stroke patients is proposed. At present, the stroke rehabilitation field faces the challenge to tailor evidence-based treatment strategies to the needs of the individual stroke patient. Interventions can be combined in order to achieve the maximal motor function recovery for each patient. Though the efficacy of some interventions may be under debate, motor skill learning, and some new technological approaches give promising outcome prognosis in stroke motor rehabilitation.