Motor recovery after stroke: a systematic review. Lancet Neurol. 2009;8:741-754. [PMID: 19608100 DOI: 10.1016/s1474-4422(09)70150-4]

Can kinematic parameters of 3D reach-to-target movements be used as a proxy for clinical outcome measures in chronic stroke rehabilitation? An exploratory study

BACKGROUND

Despite numerous trials investigating robot-assisted therapy (RT) effects on upper-extremity (UE) function after stroke, few have explored the relationship between three-dimensional (3D) reach-to-target kinematics and clinical outcomes. The objectives of this study were to 1) investigate the correlation between kinematic parameters of 3D reach-to-target movements and UE clinical outcome measures, and 2) examine the degree to which differences in kinematic parameters across individuals can account for differences in clinical outcomes in response to RT.

METHODS

Ten chronic stroke survivors participated in a pilot RT intervention (eighteen 1-h sessions) integrating cognitive skills training and a home-action program. Clinical outcome measures and kinematic parameters of 3D reach-to-target movements were collected pre- and post-intervention. The correlation between clinical outcomes and kinematic parameters was investigated both cross-sectionally and longitudinally (i.e., changes in response to the intervention). Changes in clinical outcomes and kinematic parameters were tested for significance in both group and subject-by-subject analyses. Potential associations between individual differences in kinematic parameters and differences in clinical outcomes were examined.

RESULTS

Moderate-to-strong correlation was found between clinical measures and specific kinematic parameters when examined cross-sectionally. Weaker correlation coefficients were found longitudinally. Group analyses revealed significant changes in clinical outcome measures in response to the intervention; no significant group changes were observed in kinematic parameters. Subject-by-subject analyses revealed changes with moderate-to-large effect size in the kinematics of 3D reach-to-target movements pre- vs. post-intervention. Changes in clinical outcomes and kinematic parameters varied widely across participants.

CONCLUSIONS

Large variability was observed across subjects in response to the intervention. The correlation between changes in kinematic parameters and clinical outcomes in response to the intervention was variable and not strong across parameters, suggesting no consistent change in UE motor strategies across participants. These results highlight the need to investigate the response to interventions at the individual level. This would enable the identification of clusters of individuals with common patterns of change in response to an intervention, providing an opportunity to use cluster-specific kinematic parameters as a proxy of clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02747433 . Registered on April 21st, 2016.

The effect of mirror therapy on lower extremity motor function and ambulation in post-stroke patients: A prospective, randomized-controlled study

Objectives

This study aims to evaluate the effects of mirror therapy (MT) on lower extremity motor function and ambulation in post-stroke patients.

Patients and methods

A total of 42 post-stroke patients (25 males, 17 females; mean age 58 years; range, 32 to 71 years) were included. All patients were randomly divided into two groups as the control group (n=21) receiving a conventional rehabilitation program for four weeks (60 to 120 min/day for five days a week) and as the MT group (n=21) receiving MT for 30 min in each session in addition to the conventional rehabilitation program. The Brunnstrom stages of stroke recovery, Functional Independence Measure (FIM), Berg Balance Scale (BBS) and Motricity Index (MI) scores, six-minute walking test (6MWT), Functional Ambulation Category (FAC), and the degree of ankle plantar flexion spasticity using the Modified Ashworth Scale (MAS) were evaluated at baseline (Day 0), at post-treatment (Week 4), and eight weeks after the end of treatment (Week 12).

Results

There were significant differences in all parameters between the groups, except for the degree of ankle plantar flexion spasticity, and in all time points between Week 0 and 4 and between Week 0 and 12 (p<0.05).

Conclusion

These results suggest that MT in addition to conventional rehabilitation program yields a greater improvement in the lower extremity motor function and ambulation, which sustains for a short period of time after the treatment.

Impact of virtual reality game therapy and task-specific neurodevelopmental treatment on motor recovery in survivors of stroke

Background/Aims

This study aimed to compare the impact of virtual reality game therapy and task-specific neurodevelopmental training on the motor recovery of upper limb and trunk control, as well as physical function, in people who have had a stroke.

Methods

This randomised, assessor-blinded clinical trial was conducted with 34 patients with post-stroke duration of 135 ± 23 days. Patients with first-onset cortical stroke aged 40–60 years, Mini-Mental State Examination score >20, ability to complete a nine-hole peg test within 120 seconds, ability to lift the affected arm at shoulder level and independent standing were included. Patients were excluded if they had unilateral neglect and musculoskeletal injuries of the affected limb in the past 2 months. Outcome measures used were the Fugl-Meyer Upper Extremity Scale, Action Research Arm Test, Trunk Impairment Scale and Stroke Impact Scale-16. The virtual reality game therapy group performed interactive table tennis, boxing and discus throwing games. The neurodevelopmental treatment group underwent task-specific movements of the upper limb in sitting and standing. All patients performed 45 minutes of treatment, 5 days a week for 4 weeks.

Results

Both groups showed improvements in all measures after training (P<0.05). There was a between-group difference of 3.47 points in Fugl-Meyer Upper Extremity Scale in favour of the virtual reality game therapy.

Conclusions

Both treatment regimens resulted in equal improvements in hand dexterity and trunk control after stroke. Virtual reality game therapy improved the upper limb motor recovery of stroke survivors to a greater extent than neurodevelopmental treatment.

Functional Electrical Stimulation Controlled by Motor Imagery Brain-Computer Interface for Rehabilitation

Sensorimotor rhythm (SMR)-based brain–computer interface (BCI) controlled Functional Electrical Stimulation (FES) has gained importance in recent years for the rehabilitation of motor deficits. However, there still remain many research questions to be addressed, such as unstructured Motor Imagery (MI) training procedures; a lack of methods to classify different MI tasks in a single hand, such as grasping and opening; and difficulty in decoding voluntary MI-evoked SMRs compared to FES-driven passive-movement-evoked SMRs. To address these issues, a study that is composed of two phases was conducted to develop and validate an SMR-based BCI-FES system with 2-class MI tasks in a single hand (Phase 1), and investigate the feasibility of the system with stroke and traumatic brain injury (TBI) patients (Phase 2). The results of Phase 1 showed that the accuracy of classifying 2-class MIs (approximately 71.25%) was significantly higher than the true chance level, while that of distinguishing voluntary and passive SMRs was not. In Phase 2, where the patients performed goal-oriented tasks in a semi-asynchronous mode, the effects of the FES existence type and adaptive learning on task performance were evaluated. The results showed that adaptive learning significantly increased the accuracy, and the accuracy after applying adaptive learning under the No-FES condition (61.9%) was significantly higher than the true chance level. The outcomes of the present research would provide insight into SMR-based BCI-controlled FES systems that can connect those with motor disabilities (e.g., stroke and TBI patients) to other people by greatly improving their quality of life. Recommendations for future work with a larger sample size and kinesthetic MI were also presented.

Influence of task-oriented circuit training on upper limb function among rural community-dwelling survivors of stroke

Background

Task-oriented circuit training using a Multi-Activities workstation emphasises goal-oriented tasks practiced in a circuit or series in order to learn a new skill. It can be used for upper limb rehabilitation among stroke patients in a community setting, but there is currently very little evidence available regarding its use in this patient group and setting. This study aimed to explore the influence of task-oriented circuit training using a Multi-Activities workstation on upper limb function among community-dwelling individuals with chronic stroke.

Methods

A pre-test–post-test study was conducted involving 17 community-dwelling individuals with chronic stroke who were attending a stroke rehabilitation centre. Six weeks of task-oriented circuit training was given using a Multi-Activities workstation aimed to improve strength, range of motion and dexterity. Streamlined Wolf Motor Function Test and Chedoke Arm and Hand Activity Inventory were used to measure outcomes. Wilcoxon signed-rank test was used for data analysis.

Results

A total of 12 sessions of task-oriented circuit training using Multi-Activities workstations did not result in any statistically significant differences in outcome measures.

Conclusions

Task-oriented circuit training using the Multi-Activities workstation did not improve upper limb function in community-dwelling individuals with chronic stroke.

Estimating the costs and benefits of stroke rehabilitation in South Africa

OBJECTIVE

This paper explores the economic value of rehabilitation to South Africa, using a costed example of cerebrovascular accident (CVA) (stroke) rehabilitation.

DESIGN

We report an economic modelling approach using a worked cost-effectiveness to validate the argument for the cost-saving benefits of stroke rehabilitation.

SETTING

South African health care, employing analysis of available secondary data from South African research and government reports.

PARTICIPANTS

In line with international trends in stroke epidemiology, we focused on people who were employed prior to having their stroke, with return-to-work as the desired rehabilitation outcome.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

We used information on stroke rehabilitation and secondary data derived from grey and published literature, to determine if early stroke rehabilitation represents value for money from the government perspective. For our worked example, we used return-to-work rates, intervention costs, and the cost of rehabilitation services to estimate cost-savings as a result of an individualized workplace intervention.

RESULTS

The cost of delivering the individualized intervention was estimated at R5633/patient. Combining survivor rates, return-to-work rate, and costs of the programme, a work intervention programme could result in a net saving of R133.1 million over 5 years (or about R26.6 per year (discount 3%).

CONCLUSION

The value of rehabilitation should not be considered in terms of cost-effectiveness alone, but also as an investment for the country. A staged, prioritized approach should be considered in future South African national health budget.

Neurostimulation and Reach-to-Grasp Function Recovery Following Acquired Brain Injury: Insight From Pre-clinical Rodent Models and Human Applications

Reach-to-grasp is an evolutionarily conserved motor function that is adversely impacted following stroke and traumatic brain injury (TBI). Non-invasive brain stimulation (NIBS) methods, such as transcranial magnetic stimulation and transcranial direct current stimulation, are promising tools that could enhance functional recovery of reach-to-grasp post-brain injury. Though the rodent literature provides a causal understanding of post-injury recovery mechanisms, it has had a limited impact on NIBS protocols in human research. The high degree of homology in reach-to-grasp circuitry between humans and rodents further implies that the application of NIBS to brain injury could be better informed by findings from pre-clinical rodent models and neurorehabilitation research. Here, we provide an overview of the advantages and limitations of using rodent models to advance our current understanding of human reach-to-grasp function, cortical circuitry, and reorganization. We propose that a cross-species comparison of reach-to-grasp recovery could provide a mechanistic framework for clinically efficacious NIBS treatments that could elicit better functional outcomes for patients.

Virtual reality training enhances gait poststroke: a systematic review and meta-analysis

Virtual reality (VR)-based interventions are gaining widespread attention for managing neurological disorders such as stroke. A metastatistical consensus regarding the intervention is strongly warranted. In this study, we attempt to address this gap in the literature and provide the current state of evidence for the effects of VR on gait performance. We conducted both between- and within-group meta-analyses to provide a state of evidence for VR. Moreover, we conducted a search adhering to PRISMA guidelines on nine databases. Out of 1866 records, 32 studies involving a total of 809 individuals were included in this review. Considering all included studies, significant enhancements in gait parameters were observed with VR-based interventions compared with conventional therapy. A between-group meta-analysis reported beneficial significant medium effects of VR training on cadence (Hedge's g = 0.55), stride length ((STrL; Hedge's g = 0.46), and gait speed (Hedge's g = 0.30). Similarly, a within-group meta-analysis further revealed positive medium effects of VR on cadence (Hedge's g = 0.76), STrL (Hedge's g = 0.61), and gait speed (Hedge's g = 0.69). Additional subgroup analyses revealed beneficial effects of joint application of VR and robot-assisted gait training on gait speed (Hedge's g = 0.50). Collectively, findings from this review provide evidence for the effectiveness of VR-based gait training for stroke survivors.

Drum Communication Program Intervention in Older Adults With Cognitive Impairment and Dementia at Nursing Home: Preliminary Evidence From Pilot Randomized Controlled Trial

Introduction: Inactivity and consequent deterioration of cognitive and physical function is a major concern among older adults with the limited walking ability and need a high level of care in nursing homes. We aimed to test whether a drumming communication program (DCP) that uses the rhythmic response function of the elderly with cognitive impairment, dementia, and other debilitating disorders would improve their cognitive and physical function. Methods: We conducted a Randomized Controlled Trial (RCT) to investigate the effects of the DCP in 46 nursing home residents who needed high levels of nursing care. The participants were randomly assigned to an intervention and control group. The intervention group attended 30 min of the DCP thrice a week for 3 months. Cognitive function was measured using the Mini-Mental State Examination-Japanese (MMSE-J) and Frontal Assessment Battery (FAB). Physical function was measured using grip strength and active upper limb range of motion with the dominant hand. Body composition was measured using bioelectrical impedance analysis (BIA). These measures were analyzed before and after the DCP intervention period, and data for the two groups were compared thereafter. Results: Initially, the participants had low scores on the MMSE-J, and 84.78% of them used wheelchairs. Following the DCP intervention, the MMSE-J and FAB scores of the DCP group improved significantly. In terms of motor function, the active range of motion of the wrist palmar and the shoulder flexion improved in the intervention group. Regarding body composition, the skeletal muscle mass index, total body protein, and the dominant hand muscle mass that was adding physical load decreased. Conclusions: The DCP provided the participants with an opportunity to engage in continued exercise for 3 months. The intervention group exhibited improved cognitive function and upper limb motion range, and changes in body composition. The results suggest that DCP can be used as an intervention method to promote exercise and improve various health and cognitive functions. Trial Registration: This trial was registered at the University Hospital Medical Information Network Clinical Trial Registry (UMIN000024714) on 4 November 2016. The URL is available at https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000028399.

Enhancement of Neurocognitive Assessments Using Smartphone Capabilities: Systematic Review

BACKGROUND

Comprehensive exams such as the Dean-Woodcock Neuropsychological Assessment System, the Global Deterioration Scale, and the Boston Diagnostic Aphasia Examination are the gold standard for doctors and clinicians in the preliminary assessment and monitoring of neurocognitive function in conditions such as neurodegenerative diseases and acquired brain injuries (ABIs). In recent years, there has been an increased focus on implementing these exams on mobile devices to benefit from their configurable built-in sensors, in addition to scoring, interpretation, and storage capabilities. As smartphones become more accepted in health care among both users and clinicians, the ability to use device information (eg, device position, screen interactions, and app usage) for subject monitoring also increases. Sensor-based assessments (eg, functional gait using a mobile device's accelerometer and/or gyroscope or collection of speech samples using recordings from the device's microphone) include the potential for enhanced information for diagnoses of neurological conditions; mapping the development of these conditions over time; and monitoring efficient, evidence-based rehabilitation programs.

OBJECTIVE

This paper provides an overview of neurocognitive conditions and relevant functions of interest, analysis of recent results using smartphone and/or tablet built-in sensor information for the assessment of these different neurocognitive conditions, and how human-device interactions and the assessment and monitoring of these neurocognitive functions can be enhanced for both the patient and health care provider.

METHODS

This survey presents a review of current mobile technological capabilities to enhance the assessment of various neurocognitive conditions, including both neurodegenerative diseases and ABIs. It explores how device features can be configured for assessments as well as the enhanced capability and data monitoring that will arise due to the addition of these features. It also recognizes the challenges that will be apparent with the transfer of these current assessments to mobile devices.

RESULTS

Built-in sensor information on mobile devices is found to provide information that can enhance neurocognitive assessment and monitoring across all functional categories. Configurations of positional sensors (eg, accelerometer, gyroscope, and GPS), media sensors (eg, microphone and camera), inherent sensors (eg, device timer), and participatory user-device interactions (eg, screen interactions, metadata input, app usage, and device lock and unlock) are all helpful for assessing these functions for the purposes of training, monitoring, diagnosis, or rehabilitation.

CONCLUSIONS

This survey discusses some of the many opportunities and challenges of implementing configured built-in sensors on mobile devices to enhance assessments and monitoring of neurocognitive functions as well as disease progression across neurodegenerative and acquired neurological conditions.

Hyperbaric oxygen and focused rehabilitation program: a feasibility study in improving upper limb motor function after stroke

Neuroplasticity and recovery after stroke can be enhanced by a rehabilitation program pertinent to upper limb motor function exercise and mental imagery (EMI) as well as hyperbaric oxygen therapy (HBOT). We assessed feasibility and safety of the combined approach utilizing both HBOT and EMI, and to derive preliminary estimates of its efficacy. In this randomized controlled trial, 27 patients with upper extremity hemiparesis at 3-48 months after stroke were randomized to receive either a complementary rehabilitation program of HBOT-EMI (intervention group), or EMI alone (control group). Feasibility and safety were assessed as total session attendance, duration of sessions, attrition rates, missing data, and intervention-related adverse events. Secondary clinical outcomes were assessed with both objective tools and self-reported measures at baseline, 8 weeks (end of treatment), and 12-weeks follow-up. Session attendance, duration, and attrition rate did not differ between the groups; there were no serious adverse events. Compared with baseline, there were significant sustained improvements of objective and subjective outcomes' measures in the intervention group, and a single improvement in an objective measure in the control group. Between-group outcome comparisons were not statistically significant. This study demonstrated that the combination HBOT-EMI was a safe and feasible approach in patients recovering from chronic stroke. There were also trends for improved motor function of the affected upper limb after the treatments. ClinicalTrials.gov registration no.: NCT02666469. Novelty HBOT combined with an upper limb exercise and mental imagery rehabilitation program is feasible and safe in chronic stroke patients. This combined approach showed trends for improved functional recovery.

Feasibility of ActivABLES to promote home-based exercise and physical activity of community-dwelling stroke survivors with support from caregivers: A mixed methods study

Background

Technical applications can promote home-based exercise and physical activity of community-dwelling stroke survivors. Caregivers are often able and willing to assist with home-based exercise and physical activity but lack the knowledge and resources to do so. ActivABLES was established to promote home-based exercise and physical activity among community-dwelling stroke survivors, with support from their caregivers. The aim of our study is to investigate the feasibility of ActivABLES in terms of acceptability, demand, implementation and practicality.

Methods

A convergent design of mixed methods research in which quantitative results were combined with personal experiences of a four-week use of ActivABLES by community-dwelling stroke survivors with support from their caregivers. Data collection before, during and after the four-week period included the Berg Balance Scale (BBS), Activities-Specific Balance Confidence Scale (ABC), Timed-Up-and-Go (TUG) and Five Times Sit to Stand Test (5xSST) and data from motion detectors. Semi-structured interviews were conducted with stroke survivors and caregivers after the four-week period. Descriptive statistics were used for quantitative data. Qualitative data was analysed with direct content analysis. Themes were identified related to the domains of feasibility: acceptability, demand, implementation and practicality. Data was integrated by examining any (dis)congruence in the quantitative and qualitative findings.

Results

Ten stroke survivors aged 55–79 years participated with their informal caregivers. Functional improvements were shown in BBS (+ 2.5), ABC (+ 0.9), TUG (− 4.2) and 5xSST (− 2.7). More physical activity was detected with motion detectors (stand up/sit down + 2, number of steps + 227, standing + 0.3 h, hours sitting/lying − 0.3 h). The qualitative interviews identified themes for each feasibility domain: (i) acceptability: appreciation, functional improvements, self-initiated activities and expressed potential for future stroke survivors; (2) demand: reported use, interest in further use and need for follow-up; (3) implementation: importance of feedback, variety of exercises and progression of exercises and (4) practicality: need for support and technical problems. The quantitative and qualitative findings converged well with each other and supported the feasibility of ActivABLES.

Conclusions

ActivABLES is feasible and can be a good asset for stroke survivors with slight or moderate disability to use in their homes. Further studies are needed with larger samples.

Patients' perspective and usability of innovation technology in a new rehabilitation pathway: An exploratory study in patients with multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) is an inflammatory neurodegenerative disease of the central nervous system, which causes sensori-motor and cognitive disabilities, as well as neuropsychiatric abnormalities. Technological innovations could offer a valuable way to improve neurorehabilitation outcomes. Aim of the study is to assess the feasibility and usability of new rehabilitation technologies as perceived by patients suffering from MS.

MATERIALS AND METHODS

MS inpatients attending the Robotic and Behavioral Neurorehabilitation Service of the IRCCS Centro Neurolesi Bonino Pulejo (Messina, Italy) from February 2017 to April 2019, were enrolled in this exploratory study. The patients were submitted to a personalized rehabilitation treatment using robotics (such as Lokomat, Geosystem, Ekso, Armeo) and virtual reality (i.e. BTS-Nirvana, CAREN, VRRS), following a dedicated innovative pathway.

RESULTS

All patients completed the study. Significant pre-post-treatment differences were found in the perception of patients' quality of life, regarding both physical and mental items (p<0,001), as well as in the achievement of the therapeutic goal. Finally, we observed that patients declared a high usability of the robotic devices, and that rehabilitation with the new devices was well tolerated.

CONCLUSIONS

our results support the idea that neurorehabilitation using innovation technologies can be useful for the commitment and motivation during the rehabilitation process, with possible positive effects on the functional and psychological outcomes of patients with MS.

Combined effects of backward treadmill training and botulinum toxin type A therapy on gait and balance in patients with chronic stroke: A pilot, single-blind, randomized controlled trial

BACKGROUND

Backward walking is recommended to improve the components of physiological gait in neurological disease. Botulinum toxin type A is an effective safe first line-treatment for post-stroke spasticity.

OBJECTIVE

To compare the effects of backward treadmill training (BTT) versus standard forward treadmill training (FTT) on motor impairment in patients with chronic stroke receiving botulinum toxin type A therapy.

METHODS

Eighteen chronic stroke patients were randomly assigned to receive BTT (n = 7) or FTT (n = 11) as adjunct to botulinum toxin type A therapy. A total of twelve 40-minute sessions (3 sessions/week for 4 weeks) of either BTT or FTT were conducted. A blinded assessor evaluated the patients before and after treatment. The primary outcome was the 10-meter Walking Test (10 MWT). Secondary outcomes were the modified Ashworth Scale, gait analysis, and stabilometric assessment.

RESULTS

Between-group comparison showed a significant change on the 10 MWT (P = 0.008) and on stabilometric assessment [length of centre of pressure CoP (P = 0.001) and sway area (P = 0.002) eyes open and length of CoP (P = 0.021) and sway area (P = 0.008) eyes closed] after treatment.

CONCLUSIONS

Greater improvement in gait and balance was noted after BTT than after FTT as an adjunct to botulinum toxin therapy in patients with chronic stroke.

Experience of enriched rehabilitation in the chronic phase of stroke

Purpose: In this study, we explored the experiences of patients who participated in an enriched task-specific therapy (ETT) program in the chronic phase after stroke.Method: Focus group interviews were conducted with twenty participants with a mean time since stroke of 30 months and mean age 61 years, who completed the ETT program including task-specific training and environmental enrichment. ETT was delivered 3.5-6 h per day, 5½ days per week for 3 weeks in a climate suitable for both indoor and outdoor activities. The training consisted of repetitive mass practice of gradually increasing difficulty. Directly after the intervention, qualitative interviews were conducted in six focus groups. The interviews were analysed with qualitative content analysis.Results: Three main categories describing the informants' experiences of the ETT program were identified. These categories were; 1. The program-different and hard - highlighting the participants view of the ETT as strenuous and different in nature; 2. My body and mind learn to know better - describing positive changes in participants' body function and functional ability as well as behavioural changes experienced throughout the ETT; and 3. The need and trust from others - emphasizing the perceived importance of trust in rehabilitation clinicians and the support of family and other participants. From these categories, a main theme emerged: It's hard but possible-but not alone!Conclusion: A therapy program including task-specific training and environmental enrichment may provide late-phase stroke survivors with perceived improvements in functional ability, knowledge insights, perceptions of rehabilitation needs and enriching emotional impacts.Implications for rehabilitationETT is feasible and may lead to perceived improvements in function and a change of mindset, even in the chronic phase after stroke.Trust in the competence of the rehabilitation staff is an important factor in compliance with the high-intensity training in the ETT program.Given the lack of stimulation and socialization among many individuals with chronic stroke, the social and physical environment are important components of the ETT program.

Pilot study on comparisons between the effectiveness of mobile video-guided and paper-based home exercise programs on improving exercise adherence, self-efficacy for exercise and functional outcomes of patients with stroke with 3-month follow-up: A single-blind randomized controlled trial

OBJECTIVE

To compare the effectiveness of mobile video-guided home exercise program and standard paper-based home exercise program.

METHODS

Eligible participants were randomly assigned to either experimental group with mobile video-guided home exercise program or control group with home exercise program in a standard pamphlet for three months. The primary outcome was exercise adherence. The secondary outcomes were self-efficacy for exercise by Self-Efficacy for Exercise (SEE) Scale; and functional outcomes including mobility level by Modified Functional Ambulatory Category (MFAC) and basic activities of daily living (ADL) by Modified Barthel Index (MBI). All outcomes were captured by phone interviews at 1 day, 1 month and 3 months after the participants were discharged from the hospitals.

RESULTS

A total of 56 participants were allocated to the experimental group ( n = 27 ) and control group ( n = 29 ) . There were a significant between-group differences in 3-months exercise adherence (experimental group: 75.6%; control group: 55.2%); significant between-group differences in 1-month SEE (experimental group: 58.4; control group: 43.3) and 3-month SEE (experimental group: 62.2; control group: 45.6). For functional outcomes, there were significant between-group differences in 3-month MFAC gain (experimental group: 1.7; control group: 1.0). There were no between-group differences in MBI gain.

CONCLUSION

The use of mobile video-guided home exercise program was superior to standard paper-based home exercise program in exercise adherence, SEE and mobility gain but not basic ADL gain for patients recovering from stroke.

Treadmill Exercise Improves Motor Function and Short-term Memory by Enhancing Synaptic Plasticity and Neurogenesis in Photothrombotic Stroke Mice

Purpose

Thrombotic stroke is a type of ischemic stroke characterized by motor dysfunction and memory impairments. In the present study, the effect of treadmill exercise on motor function and short-term memory was evaluated in relation with synaptic plasticity in the mice with photothrombotic stroke.

Methods

Photothrombotic stroke was induced by cortical photothrombotic vascular occlusion. The mice in the treadmill exercise groups performed running on a motorized treadmill for 28 days. Motor function was determined using rota-rod test and foot fault test. Step-through avoidance task was conducted to evaluate short-term memory. Immunohistochemistry for 5-bromo-2′-deoxyuridine and doublecortin was conducted to detect new cell generation. Postsynaptic density protein 95, synaptophysin, brain-derived neurotrophic factor (BDNF), and tyrosine kinase B receptor (TrkB) were determined using western blot. The number of dendritic spines was determined using Golgi stain.

Results

Treadmill exercise improved motor function and short-term memory in mice with the photothrombotic stroke. The infarct size was reduced and the number of dendritic spines and expression of postsynaptic density protein 95 and synaptophysin in the peri-infarct cortex and hippocampus were increased by treadmill exercise in photothrombotic stroke mice. Treadmill exercise enhanced neurogenesis through increasing the expression of the hippocampal BDNF and TrkB in photothrombotic stroke mice.

Conclusions

Treadmill exercise improved motor function and short-term memory through increasing synaptic plasticity and neurogenesis in photothrombotic stroke mice. Treadmill exercise can be used as an effective treatment strategy to improve brain function related to stroke.

Auditory rhythmical cueing to improve gait and physical activity in community-dwelling stroke survivors (ACTIVATE): study protocol for a pilot randomised controlled trial

Background

Mobility problems are present in 70–80% of stroke survivors and can result in impaired gait and reduced physical activity limiting independent living. Auditory rhythmic cueing (ARC) has been used to provide auditory feedback and shows promise in improving a variety of walking parameters following stroke. The aim of this pilot study is to assess the feasibility of conducting a multi-centre, observer blind, randomised controlled trial of auditory rhythmical cueing (ARC) intervention in home and community settings in North East England.

Methods

This pilot observer blind randomised controlled feasibility trial aims to recruit 60 participants over 15 months from community stroke services in the North East of England. Participants will be within 24 months of stroke onset causing new problems with mobility. Each participant will be randomised to the study intervention or control group. Intervention treatment participants will undertake 18 auditory rhythmical cueing (ARC) treatment sessions over 6 weeks (3 × 30 min per week, 6 supervised (physiotherapist/research associate)/12 self-managed) in a home/community setting. A metronome will be used to provide ARC during a series of balance and gait exercises, which will be gradually progressed. The control treatment participants will undertake the same duration balance and gait exercise training programme as the intervention group but without the ARC. Feasibility will be determined in terms of recruitment, retention, adverse events, adherence, collection of descriptive clinical and accelerometer motor performance data at baseline, 6 weeks and 10 weeks and description of participant, provider and clinical therapists’ experiences. As well as using questionnaires to collate participant views, qualitative interviews will be undertaken to further understand how the intervention is delivered in practice in a community setting and to identify aspects perceived important by participants.

Discussion

The ACTIVATE study will address an important gap in the evidence base by reporting whether it is feasible to deliver auditory rhythmical cueing in the home and community to improve gait and balance parameters following stroke. The feasibility of the study protocol will be established and results will inform the design of a future multi-centre randomised controlled trial.

Trial registration

Trial register: ISRCTN, Trial identifier: ISRCTN10874601: Date of registration: 12/03/2018.

The Effect of Priming on Outcomes of Task-Oriented Training for the Upper Extremity in Chronic Stroke: A Systematic Review and Meta-analysis

Background. Priming results in a type of implicit memory that prepares the brain for a more plastic response, thereby changing behavior. New evidence in neurorehabilitation points to the use of priming interventions to optimize functional gains of the upper extremity in poststroke individuals. Objective. To determine the effects of priming on task-oriented training on upper extremity outcomes (body function and activity) in chronic stroke. Methods. The PubMed, CINAHL, Web of Science, EMBASE, and PEDro databases were searched in October 2019. Outcome data were pooled into categories of measures considering the International Classification Functional (ICF) classifications of body function and activity. Means and standard deviations for each group were used to determine group effect sizes by calculating mean differences (MDs) and 95% confidence intervals via a fixed effects model. Heterogeneity among the included studies for each factor evaluated was measured using the I² statistic. Results. Thirty-six studies with 814 patients undergoing various types of task-oriented training were included in the analysis. Of these studies, 17 were associated with stimulation priming, 12 with sensory priming, 4 with movement priming, and 3 with action observation priming. Stimulation priming showed moderate-quality evidence of body function. Only the Wolf Motor Function Test (time) in the activity domain showed low-quality evidence. However, gains in motor function and in use of extremity members were measured by the Fugl-Meyer Assessment (UE-FMA). Regarding sensory priming, we found moderate-quality evidence and effect size for UE-FMA, corresponding to the body function domain (MD 4.77, 95% CI 3.25-6.29, Z = 6.15, P < .0001), and for the Action Research Arm Test, corresponding to the activity domain (MD 7.47, 95% CI 4.52-10.42, Z = 4.96, P < .0001). Despite the low-quality evidence, we found an effect size (MD 8.64, 95% CI 10.85-16.43, Z = 2.17, P = .003) in movement priming. Evidence for action observation priming was inconclusive. Conclusion. Combining priming and task-oriented training for the upper extremities of chronic stroke patients can be a promising intervention strategy. Studies that identify which priming techniques combined with task-oriented training for upper extremity function in chronic stroke yield effective outcomes in each ICF domain are needed and may be beneficial for the recovery of upper extremities poststroke.

Evaluating upper limb function after stroke using the free-living accelerometer data

Accelerometer devices are becoming efficient tools in clinical studies for automatically measuring the activities of daily living. Such data provides a time series describing activity level at every second and displays a subject’s activity pattern throughout a day. However, the analysis of such data is very challenging due to the large number of observations produced each second and the variability among subjects. The purpose of this study is to develop efficient statistical analysis techniques for predicting the recovery level of the upper limb function after stroke based on the free-living accelerometer data. We propose to use a Gaussian Mixture Model (GMM)-based method for clustering and extracting new features to capture the information contained in the raw data. A nonlinear mixed effects model with Gaussian Process prior for the random effects is developed as the predictive model for evaluating the recovery level of the upper limb function. Results of applying to the accelerometer data for patients after stroke are presented.

Interaction Between Recovery of Motor and Language Abilities After Stroke

OBJECTIVE

To analyze the nature of the interaction between motor and language recovery in patients with motor impairment and aphasia following left hemispheric stroke and to investigate prognostic factors of best recovery, that is, the significant recovery of both functions simultaneously.

DESIGN

Retrospective cohort study.

SETTING

Specialized inpatient rehabilitation facility.

PARTICIPANTS

Patients (N=435) with left hemispheric stroke in the postacute phase with motor impairment and aphasia.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURE

Patients who reached the minimal clinically important difference in the motor-FIM (M-FIM) were classified as motor responders, patients who reached a significant change in Aachen Aphasia Test were classified as language responders, and patients who reached a simultaneous and significant improvement in both functions were classified as motor and language responders.

RESULTS

Of the sample 45% were motor responders, 58% were language responders, and 35% were motor and language responders. Responder groups showed lower motor impairment and less severe aphasia at admission and greater improvement in both functions at discharge compared with nonresponder groups. Premorbid autonomy, dysphagia, apraxia, and number of rehabilitative sessions were also significantly different between groups. A logistic regression model identified M-FIM, repetition abilities, and number of sessions of speech and language therapy as independent predictors of best response (ie, motor and language responders).

CONCLUSIONS

This study provides evidence about a possible interaction between motor and language recovery after stroke. The improvement in one function was never associated with deterioration in the other. The results actually suggest a synergic effect between the amelioration of the 2 functions, with an overall increased efficiency when the 2 recovery pathways are combined.

Time for a Systems Biological Approach to Cognitive Aging?-A Critical Review

The underlying premise of current theories of cognitive decline with age tend to be primarily cognitive or biological explanations, with relatively few theories adequately integrating both aspects. Though literature has also emphasized the importance of several factors that contribute to cognitive aging including: (a) decline in sensory abilities; (b) the effect of motor speed on paper-pencil measures of cognitive speed; (c) the impact of level of education and physical activity; and (d) molecular biological changes that occur with age, these factors have seldom been implicated into any single theoretical model of cognitive aging. Indeed, such an integrated bio-cognitive model of aging has the potential to provide a more comprehensive understanding of attention, perception, learning, and memory across the lifespan. Thus, the aim of this review was to critically evaluate common theories of age-related cognitive decline and highlight the need for a more comprehensive systems neuroscience approach to cognitive aging.

Development of a flickering action video based steady state visual evoked potential triggered brain computer interface-functional electrical stimulation for a rehabilitative action observation game

BACKGROUND:

This study focused on developing an upper limb rehabilitation program. In this regard, a steady state visual evoked potential (SSVEP) triggered brain computer interface (BCI)-functional electrical stimulation (FES) based action observation game featuring a flickering action video was designed.

OBJECTIVE:

In particular, the synergetic effect of the game was investigated by combining the action observation paradigm with BCI based FES.

METHODS:

The BCI-FES system was contrasted under two conditions: with flickering action video and flickering noise video. In this regard, 11 right-handed subjects aged between 22–27 years were recruited. The differences in brain activation in response to the two conditions were examined.

RESULTS:

The results indicate that T3 and P3 channels exhibited greater Mu suppression in 8–13 Hz for the action video than the noise video. Furthermore, T4, C4, and P4 channels indicated augmented high beta (21–30 Hz) for the action in contrast to the noise video. Finally, T4 indicated suppressed low beta (14–20 Hz) for the action video in contrast to the noise video.

CONCLUSION:

The flickering action video based BCI-FES system induced a more synergetic effect on cortical activation than the flickering noise based system.

Immediate Effects of Ankle-Foot Orthosis Using Wire on Static Balance of Patients with Stroke with Foot Drop: A Cross-Over Study

The aim of this study was to investigate the immediate static balance effects of bare foot, UD-Flex ankle–foot orthosis (AFO), and AFO using wire (AOW) of patients with stroke with foot drop. Seventeen patients with stroke with foot drop (8 men and 9 women) were randomized to three conditions (bare foot, UD-Flex AFO, or AOW made with a flexible material). Static balance was assessed using the Zebris (Zebris GmbH, Isny, Germany) and BioRescue (RM Ingenierie, Rodez, France) pressure platform by a single examiner, who did not design the AOW. The order of testing with the equipment was random. The center of pressure path length (mm) measured using Zebris showed significant differences among the three conditions (bare foot, 484.47 ± 208.42; UD-Flex AFO, 414.59 ± 144.43; AOW, 318.29 ± 157.60) (p < 0.05). The bare-foot condition was not significantly different from the UD-Flex AFO condition (p > 0.05), but was significantly different from the AOW condition (p < 0.05). The surface area ellipse (mm²) measured using BioRescue showed significant differences among the three conditions (bare foot, 241.35 ± 153.76; UD-Flex AFO, 277.41 ± 381.83; AOW, 68.06 ± 48.98) (p < 0.05). The bare-foot condition was not significantly different from the UD-Flex AFO condition (p > 0.05), but the AOW condition was significantly different from the bare-foot (p < 0.05) and from the UD-Flex AFO conditions (p < 0.05). We suggest using the AOW made of flexible materials and wire instead of the UD-Flex AFO to improve immediate static balance of patients with stroke with foot drop after stroke. Further studies on the effects of dynamic balance and gait are required.

Multi-Exergames to Set Targets and Supplement the Intensified Conventional Balance Training in Patients With Stroke: A Randomized Pilot Trial

People who survive a stroke usually suffer movement disorders resulting in involuntary abnormal movements. Intensive and repetitive physiotherapy is often a key to functional restoration of movements. Rehabilitation centers have recently offered balance training supported by exergames in addition to conventional therapy. The primary objective was to investigate different types of balance training (multi-exergaming and conventional) in addition to a conventional 6-week physiotherapy program. Furthermore, we examined the choice of an appropriate exergame to target balance training. We designed a randomized pilot trial. Hospital inpatients with stroke aged 33–65 were recruited and randomized into 2 groups by drawing lots; a control group receiving 1 week of conventional balance training and an exergaming group 1 week of multiple-game exergaming, comprising single leg exercises, weight shifting, balancing and standing up. Center of pressure was monitored for the exergaming group and clinical data were collected (non-blinded assessment) using Four Square Step Test, Timed Up and Go, 10 m Walk Test, Romberg, Sharpened Romberg, Clinical Test for Sensory Interaction in Balance in both groups. Statistical tests were used to find significant (p < 0.05) differences and Cohen’s U3 for effect sizes. Recruited participants (20/30) met the inclusion criteria and were randomized; 10 per group. 1 participant of the exergaming group was excluded from center of pressure analysis. Both groups demonstrated substantively and statistically significant improvements of functional balance, in particular the exergaming group (FSST p = 0.009, U3 = 0.9 and 10 MWT p = 0.008, U3 = 0.9). However, significant differences between the groups were found in tests with eyes closed, Sharpened Romberg test (p = 0.05) and standing on the right leg (p = 0.035). The center of pressure area decreased up to 20% for the exergaming group. Both types of additional balance training demonstrated comparable outcomes, however, the multi-exergaming could target specific motor control disorders by the selection of exergames according to Gentile’s taxonomy. We may not prioritize exergaming due to the low statistical power of clinical outcomes. However, exergaming enables independent balance training, which is feasible without strenuous physiotherapy and may thus be crucial for future home or telerehabilitation services.

Clinical Trial Registration:www.clinicaltrials.gov/, identifier NCT03282968.

Three-dimensional modelling of wheelchair contrived with lower limb exoskeleton for right hemiplegic dysfunction

Hemiplegia is a type of paralysis that affects one side of the body due to stroke, characterizing severe weakness or rigid movement. Many people of different age groups are affected by this condition which cannot be completely cured but can be minimized through proper physiotherapy. A continuous and repeated exercise has to be given to the hemiplegic subjects to regain their motor function. To serve this purpose, a three-dimensional model of wheelchair contrived with lower limb exoskeleton is designed and motion analysis is done using SolidWorks. This virtual model of the object is created with the assistance of computer-aided design software. Professionals can be able to do the experiment on what-if scenarios with their three-dimensional designs, which helps to validate their devices and identify any snags with design quality. The pattern of behaviour of lower limb exoskeleton is predicted using SimMechanics in MATLAB.

Protocol for a multicenter observational prospective study of functional recovery from stroke beyond inpatient rehabilitation - The Interdisciplinary Platform for Rehabilitation Research and Innovative Care of Stroke Patients (IMPROVE)

Introduction

Stroke and its long-term consequences pose major challenges for the lives of those affected and healthcare systems. Neurological rehabilitation therefore primarily attempts to improve function in order to increase independence in activities of daily living, and to enable social participation. There is only scarce data on dynamics of functional recovery after patients discharge from inpatient neurological rehabilitation. Even less is known about the patient's perspective on long-term recovery from stroke. The Interdisciplinary Platform for Rehabilitation Research and Innovative Care of Stroke Patients (IMPROVE) aims to address this knowledge gap by providing new insights into the dynamics and extent of functional recovery from stroke beyond inpatient rehabilitation treatment.

Methods

We provide the protocol for an observational, longitudinal, multicenter study conducted in an Universitary Stroke Center in cooperation with five Neurological Rehabilitation Centers in Northern Germany. Patients who suffered from ischemic or hemorrhagic stroke will be enrolled by the end of inpatient rehabilitation and followed up to 1 year. In addition, a group of chronic stroke patients and a group of craniocerebral trauma patients will be enrolled as a comparison group. Data on stroke characteristics, vascular risk factors, co-morbidities, social support, and demographics will be recorded. Comprehensive clinical evaluation will be performed at baseline, three, six, and twelve months after enrollment. The assessments and scores used reflect the three components of the International Classification of Functioning, Disability and Health (ICF), some of them are tests regularly used in rehabilitation settings. Tests of motor function, cognition, and mood are included, as are tests of self-reported health-related quality of life. Primary outcome measure is a hand motor score, built by the sum of the hand items of the Fugl-Meyer Assessment as an objective measurement of hand function at 12 months after enrollment. Predictors of the primary outcome will be analyzed using linear regression analysis.

Perspective

The results of IMPROVE will inform about the long-term dynamics of functional stroke recovery after patients' discharge from inpatient rehabilitation and will provide insights into the association of clinical and demographic factors with recovery of function.

Trial registration

The protocol is registered at ClinicalTrials.gov (NCT04119479).

Is Resting-State EEG Longitudinally Associated With Recovery of Clinical Neurological Impairments Early Poststroke? A Prospective Cohort Study

Background. The time course of cortical activation and its relation with clinical measures may elucidate mechanisms underlying spontaneous neurobiological recovery after stroke. Objective. We aimed to investigate (1) the time course of cortical activation as revealed by EEG-based spectral characteristics during awake rest and (2) the development of these spectral characteristics in relation to global neurological and upper-limb motor recovery in the first 6 months poststroke. Methods. Resting-state EEG was measured serially in 41 patients after a first-ever ischemic stroke, within 3 and at 5, 12, and 26 weeks poststroke. We computed the brain symmetry index (BSI) and directional BSI (BSIdir) over different frequency bands (1-25 Hz, delta, theta) and delta/alpha ratio (DAR). The National Institutes of Health Stroke Scale (NIHSS) and Fugl-Meyer motor assessment of the upper extremity (FM-UE) were determined as clinical reflections of spontaneous neurobiological recovery. Longitudinal changes in spectral characteristics and within- and between-subject associations with NIHSS and FM-UE were analyzed with linear mixed models. Results. Spectral characteristics showed a gradual normalization over time, within and beyond 12 weeks poststroke. Significant within- and between-subject associations with NIHSS were found for DAR of the affected hemisphere (DAR_AH) and BSIdir_delta. BSIdir_delta also demonstrated significant within- and between-subject associations with FM-UE. Conclusions. Changes in spectral characteristics are not restricted to the time window of recovery of clinical neurological impairments. The present study suggests that decreasing DAR_AH and BSIdir_delta reflect improvement of global neurological impairments, whereas BSIdir_delta was also specifically associated with upper-limb motor recovery early poststroke.

Intracerebral implantation of human neural stem cells and motor recovery after stroke: multicentre prospective single-arm study (PISCES-2)

BACKGROUND

Human neural stem cell implantation may offer improved recovery from stroke. We investigated the feasibility of intracerebral implantation of the allogeneic human neural stem cell line CTX0E03 in the subacute-chronic recovery phase of stroke and potential measures of therapeutic response in a multicentre study.

METHODS

We undertook a prospective, multicentre, single-arm, open-label study in adults aged >40 years with significant upper limb motor deficits 2-13 months after ischaemic stroke. 20 million cells were implanted by stereotaxic injection to the putamen ipsilateral to the cerebral infarct. The primary outcome was improvement by 2 or more points on the Action Research Arm Test (ARAT) subtest 2 at 3 months after implantation.

FINDINGS

Twenty-three patients underwent cell implantation at eight UK hospitals a median of 7 months after stroke. One of 23 participants improved by the prespecified ARAT subtest level at 3 months, and three participants at 6 and 12 months. Improvement in ARAT was seen only in those with residual upper limb movement at baseline. Transient procedural adverse effects were seen, but no cell-related adverse events occurred up to 12 months of follow-up. Two deaths were unrelated to trial procedures.

INTERPRETATION

Administration of human neural stem cells by intracerebral implantation is feasible in a multicentre study. Improvements in upper limb function occurred at 3, 6 and 12 months, but not in those with absent upper limb movement at baseline, suggesting a possible target population for future controlled trials.

FUNDING

ReNeuron, Innovate UK (application no 32074-222145).

TRIAL REGISTRATION NUMBER

EudraCT Number: 2012-003482-18.

Immersive Virtual Reality Mirror Therapy for Upper Limb Recovery After Stroke: A Pilot Study

OBJECTIVE

This study was designed to examine the feasibility of immersive virtual reality mirror therapy for upper limb paresis after stroke using a head-mounted display and provide preliminary evidence of efficacy.

DESIGN

Ten outpatients with chronic stroke, upper limb hemiparesis, and a low predisposition for motion sickness completed a 12-session program of 30 mins each of immersive virtual reality mirror therapy. The virtual reality system provided the illusion of movement in the hemiparetic upper limb while suppressing the visual representation of the nonparetic side. Feasibility was assessed via patient compliance, adverse event tracking, the System Usability Scale, and the Simulator Sickness Questionnaire. Preliminary efficacy was evaluated using the Fugl-Meyer Upper Extremity and Action Research Arm Test.

RESULTS

Immersive virtual reality mirror therapy for patients with chronic stroke was safe, well-tolerated, and without adverse events, such as simulator sickness. Motor outcomes revealed a small improvement for the Fugl-Meyer Upper Extremity from 21.7 (SD = 8.68) to 22.8 (SD = 9.19) that did not achieve statistical significance (P = 0.084).

CONCLUSIONS

Four weeks of immersive virtual reality mirror therapy was well-tolerated by chronic stroke patients. Our findings support further clinical trials of immersive virtual reality technologies and visually enhanced mirror therapies for stroke survivors.

The effectiveness of a novel cable-driven gait trainer (Robowalk) combined with conventional physiotherapy compared to conventional physiotherapy alone following stroke: a randomised controlled trial

There is increasing interest in gait training devices to improve walking ability in people following stroke. This randomised controlled trial aimed to compare the effectiveness of the Robowalk, a novel cable-driven gait trainer combined with conventional physiotherapy to conventional physiotherapy alone in improving walking speed, endurance, balance, functional outcomes, and quality of life in people following stroke. Rehabilitation inpatients within 3 months following stroke (n = 40) were randomised to standard care with conventional physiotherapy ('control,' n = 20) and cable-driven gait trainer combined with conventional physiotherapy ('intervention,' n = 20). All participants received 1 hour of physiotherapy a day, 5 days a week. The control group received conventional physiotherapy only; the intervention group received a combination of 30 minutes of conventional physiotherapy and 30 minutes of cable-driven gait trainer consecutively. Outcome measures were 10-metre walk test (primary outcome), 6-minute walk test, timed up and go, step test, Functional Independence Measure, and EuroQol five-dimension scale. Evaluation timepoints were on admission (T0), discharge (T1), and 4 weeks post discharge (T2). There were no differences between groups at T0, T1, and T2 in all outcome measures although there was a trend towards a larger and more sustained improvement in 10-metre walk test in favour of the intervention group and in Functional Independence Measure motor and self-care in favour of the control group, both at T2. The combination of cable-driven gait trainer with conventional physiotherapy appears as effective as conventional physiotherapy alone in improving gait outcomes in people following a recent stroke. Further studies are required to confirm these findings and determine optimal dosing regimens and long-term outcomes.

Physical fitness training for stroke patients

BACKGROUND

Levels of physical activity and physical fitness are low after stroke. Interventions to increase physical fitness could reduce mortality and reduce disability through increased function.

OBJECTIVES

The primary objectives of this updated review were to determine whether fitness training after stroke reduces death, death or dependence, and disability. The secondary objectives were to determine the effects of training on adverse events, risk factors, physical fitness, mobility, physical function, health status and quality of life, mood, and cognitive function.

SEARCH METHODS

In July 2018 we searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, SPORTDiscus, PsycINFO, and four additional databases. We also searched ongoing trials registers and conference proceedings, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing either cardiorespiratory training or resistance training, or both (mixed training), with usual care, no intervention, or a non-exercise intervention in stroke survivors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed quality and risk of bias, and extracted data. We analysed data using random-effects meta-analyses and assessed the quality of the evidence using the GRADE approach. Diverse outcome measures limited the intended analyses.

MAIN RESULTS

We included 75 studies, involving 3017 mostly ambulatory participants, which comprised cardiorespiratory (32 studies, 1631 participants), resistance (20 studies, 779 participants), and mixed training interventions (23 studies, 1207 participants). Death was not influenced by any intervention; risk differences were all 0.00 (low-certainty evidence). There were few deaths overall (19/3017 at end of intervention and 19/1469 at end of follow-up). None of the studies assessed death or dependence as a composite outcome. Disability scores were improved at end of intervention by cardiorespiratory training (standardised mean difference (SMD) 0.52, 95% CI 0.19 to 0.84; 8 studies, 462 participants; P = 0.002; moderate-certainty evidence) and mixed training (SMD 0.23, 95% CI 0.03 to 0.42; 9 studies, 604 participants; P = 0.02; low-certainty evidence). There were too few data to assess the effects of resistance training on disability. Secondary outcomes showed multiple benefits for physical fitness (VO2 peak and strength), mobility (walking speed) and physical function (balance). These physical effects tended to be intervention-specific with the evidence mostly low or moderate certainty. Risk factor data were limited or showed no effects apart from cardiorespiratory fitness (VO2 peak), which increased after cardiorespiratory training (mean difference (MD) 3.40 mL/kg/min, 95% CI 2.98 to 3.83; 9 studies, 438 participants; moderate-certainty evidence). There was no evidence of any serious adverse events. Lack of data prevents conclusions about effects of training on mood, quality of life, and cognition. Lack of data also meant benefits at follow-up (i.e. after training had stopped) were unclear but some mobility benefits did persist. Risk of bias varied across studies but imbalanced amounts of exposure in control and intervention groups was a common issue affecting many comparisons.

AUTHORS' CONCLUSIONS

Few deaths overall suggest exercise is a safe intervention but means we cannot determine whether exercise reduces mortality or the chance of death or dependency. Cardiorespiratory training and, to a lesser extent mixed training, reduce disability during or after usual stroke care; this could be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programmes to improve fitness, balance and the speed and capacity of walking. The magnitude of VO2 peak increase after cardiorespiratory training has been suggested to reduce risk of stroke hospitalisation by ˜7%. Cognitive function is under-investigated despite being a key outcome of interest for patients. Further well-designed randomised trials are needed to determine the optimal exercise prescription, the range of benefits and any long-term benefits.

Concurrent Validity of a Novel Wireless Inertial Measurement System for Assessing Trunk Impairment in People with Stroke

Background: The Trunk Impairment Scale (TIS) is recommended for clinical research use to assess trunk impairment post-stroke. However, it is observer-dependent and neglects the quality of trunk movements. This study proposes an instrumented TIS (iTIS) using the Valedo system, comprising portable inertial sensors, as an objective measure of trunk impairment post-stroke. Objective: This study investigates the concurrent and discriminant ability of the iTIS in chronic stroke participants. Method: Forty participants (20 with chronic stroke, 20 healthy, age-matched) were assessed using the TIS and iTIS simultaneously. A Spearman rank correlation coefficient was used to examine concurrent validity. A ROC curve was used to determine whether the iTIS could distinguish between stroke participants with and without trunk impairment. Results: A moderate relationship was found between the observed iTIS parameters and the clinical scores, supporting the concurrent validity of the iTIS. The small sample size meant definitive conclusions could not be drawn about the parameter differences between stroke groups (participants scoring zero and one on the clinical TIS) and the parameter cut-off points. Conclusion: The iTIS can detect small changes in trunk ROM that cannot be observed clinically. The iTIS has important implications for objective assessments of trunk impairment in clinical practice.

Agency judgments in post-stroke patients with sensorimotor deficits

Sense of agency refers to the feeling of being in control of one's actions. Previous research has demonstrated that sense of agency is produced through the sensorimotor system, which is involved in comparing internal predictions with sensory feedback in motor control. Therefore, sensorimotor deficits might impair agency through a sensorimotor system malfunction. The present study examined this hypothesis by investigating post-stroke patients who had suffered a subcortical stroke that damaged regions associated with sensorimotor function. To examine agency judgments with respect to motor control, we adopted a self-other attribution task and applied it to post-stroke patients. Participants traced a horizontal straight line and received visual feedback through a cursor on a monitor. The cursor movement reflected either the participants' actual movement or the movement of an "other" that had been previously recorded. Participants judged whether the cursor movement reflected their own movement (self) or an other's movement while they engaged in four cycles of the horizontal tracing movement. After each trial, participants reported their self-other judgment on a nine-point scale. Post-stroke patients completed the experiment with their paretic as well as their non-paralyzed upper limbs. Compared to healthy controls, patients made significantly more self-attributions of others' movements. Interestingly, such misattributions were observed in the patients' performance using both paretic and non-paralyzed upper limbs. These results suggest that post-stroke patients with sensorimotor deficits form misattributions that cannot be explained solely by the sensorimotor system's role in motor control. We discuss these misattributions in post-stroke patients in terms of cue integration theory.

Neurochemical balance and inhibition at the subacute stage after stroke

Stroke is a leading cause of death and disability worldwide with many people left with impaired motor function. Evidence from experimental animal models of stroke indicates that reducing motor cortex inhibition may facilitate neural plasticity and motor recovery. This study compared primary motor cortex (M1) inhibition measures over the first 12 wk after stroke with a cohort of age-similar healthy controls. The excitation-inhibition ratio and gamma-aminobutyric acid (GABA) neurotransmission within M1 were assessed using magnetic resonance spectroscopy and threshold hunting paired-pulse transcranial magnetic stimulation respectively. Upper limb impairment and function were assessed with the Fugl-Meyer Upper Extremity Scale and Action Research Arm Test. Patients with a functional corticospinal pathway had motor-evoked potentials on the paretic side and exhibited better recovery from upper limb impairment and recovery of function than patients without a functional corticospinal pathway. Compared with age-similar controls, the neurochemical balance in terms of the excitation-inhibition ratio was greater within contralesional M1 in patients with a functional corticospinal pathway. There was evidence for elevated long-interval inhibition in both ipsilesional and contralesional M1 compared with controls. Short-interval inhibition measures differed between the first and second phases, with evidence for elevation of the former only in ipsilesional M1 and no evidence of disinhibition for the latter. Overall, findings from transcranial magnetic stimulation indicate an upregulation of GABA-mediated tonic inhibition in M1 early after stroke. Therapeutic approaches that aim to normalize inhibitory tone during the subacute period warrant further investigation.NEW & NOTEWORTHY Magnetic resonance spectroscopy indicated higher excitation-inhibition ratios within motor cortex during subacute recovery than age-similar healthy controls. Measures obtained from adaptive threshold hunting paired-pulse transcranial magnetic stimulation indicated greater tonic inhibition in patients compared with controls. Therapeutic approaches that aim to normalize motor cortex inhibition during the subacute stage of recovery should be explored.

Challenge Accepted? Individual Performance Gains for Motor Imagery Practice with Humanoid Robotic EEG Neurofeedback

Optimizing neurofeedback (NF) and brain–computer interface (BCI) implementations constitutes a challenge across many fields and has so far been addressed by, among others, advancing signal processing methods or predicting the user’s control ability from neurophysiological or psychological measures. In comparison, how context factors influence NF/BCI performance is largely unexplored. We here investigate whether a competitive multi-user condition leads to better NF/BCI performance than a single-user condition. We implemented a foot motor imagery (MI) NF with mobile electroencephalography (EEG). Twenty-five healthy, young participants steered a humanoid robot in a single-user condition and in a competitive multi-user race condition using a second humanoid robot and a pseudo competitor. NF was based on 8–30 Hz relative event-related desynchronization (ERD) over sensorimotor areas. There was no significant difference between the ERD during the competitive multi-user condition and the single-user condition but considerable inter-individual differences regarding which condition yielded a stronger ERD. Notably, the stronger condition could be predicted from the participants’ MI-induced ERD obtained before the NF blocks. Our findings may contribute to enhance the performance of NF/BCI implementations and highlight the necessity of individualizing context factors.

Post-Ischaemic Immunological Response in the Brain: Targeting Microglia in Ischaemic Stroke Therapy

Microglia, the major endogenous immune cells of the central nervous system, mediate critical degenerative and regenerative responses in ischaemic stroke. Microglia become "activated", proliferating, and undergoing changes in morphology, gene and protein expression over days and weeks post-ischaemia, with deleterious and beneficial effects. Pro-inflammatory microglia (commonly referred to as M1) exacerbate secondary neuronal injury through the release of reactive oxygen species, cytokines and proteases. In contrast, microglia may facilitate neuronal recovery via tissue and vascular remodelling, through the secretion of anti-inflammatory cytokines and growth factors (a profile often termed M2). This M1/M2 nomenclature does not fully account for the microglial heterogeneity in the ischaemic brain, with some simultaneous expression of both M1 and M2 markers at the single-cell level. Understanding and regulating microglial activation status, reducing detrimental and promoting repair behaviours, present the potential for therapeutic intervention, and open a longer window of opportunity than offered by acute neuroprotective strategies. Pharmacological modulation of microglial activation status to promote anti-inflammatory gene expression can increase neurogenesis and improve functional recovery post-stroke, based on promising preclinical data. Cell-based therapies, using preconditioned microglia, are of interest as a method of therapeutic modulation of the post-ischaemic inflammatory response. Currently, there are no clinically-approved pharmacological options targeting post-ischaemic inflammation. A major developmental challenge for clinical translation will be the selective suppression of the deleterious effects of microglial activity after stroke whilst retaining (or enhancing) the neurovascular repair and remodelling responses of microglia.

Walking speed changes in response to user-driven treadmill control after stroke

The objective of this study was to determine how individuals poststroke respond to user-driven treadmill (UDTM) controlin terms ofwalking speeds, peak anterior ground reaction forces (AGRF), peak posterior ground reaction forces (PGRF), and trailing limb angles (TLA). Twenty individuals with chronic stroke walked overground during a 10-meter walk test to determine their self-selected (SS) speeds before walking on a treadmill in its fixed-speed (FSTM) and UDTM control modes at their SS and fastest comfortable (Fast) speeds. Paired t-tests were used to compare the walking speeds, peak AGRF, peak PGRF, and TLA among test conditions (α = 0.05). Participants selected similar SS (p > 0.05) and faster Fast walking speeds (p < 0.05) with the UDTM control compared to the FSTM control. There were no changes in their peak AGRF or PGRF for either limb or speed between UDTM and FSTM conditions (p > 0.05). Individuals used greater paretic TLA at SS speeds with UDTM control (p < 0.05). There was no difference in the AGRF required at Fast speeds with FSTM and UDTM control even though participants selected faster speeds with UDTM control. In work with young, healthy adults, we found that the treadmill control condition did not affect the amount of forward propulsion needed. Therefore, it is likely that when walking with UDTM control, individuals poststroke adjust their posture to make better use of their forward propulsion. This means they can reach faster walking speeds without increasing their push-off forces. Future work should assess how to most effectively prescribe UDTM control for gait training programs.

Lithium treatment mitigates white matter injury after intracerebral hemorrhage through brain-derived neurotrophic factor signaling in mice

Intracerebral hemorrhage (ICH), a subtype of stroke with high morbidity and mortality, occurs mainly in the basal ganglia and causes white matter injury (WMI), resulting in severe motor dysfunction and poor prognosis in patients. The preservation of the white matter around the hematoma is crucial for motor function recovery, but there is currently no effective treatment for WMI following ICH. Lithium has been widely used for the treatment of bipolar disorder for decades. Although the protective effects of lithium on neurodegenerative diseases and cerebral trauma have been studied in recent years, whether it can be used to alleviate WMI after ICH remains to be researched. The results of this study revealed that ICH caused significant functional and pathological abnormalities in mice. After LiCl was administered to mice with ICH, behavioural performance and electrophysiological functions were improved and ICH-induced white matter pathological injury, including myelin sheath and axonal degeneration, was ameliorated. Furthermore, LiCl treatment decreased the death of mature oligodendrocytes (OLGs) in ICH mice, which may have been attributed to the enhanced expression of brain-derived neurotrophic factor (BDNF) regulated by the LiCl-induced inhibition of glycogen synthase kinase-3β (GSK-3β). The decreased death of OLGs was closely associated with decreased destruction of the myelin sheath and alleviated degradation of the axons. In summary, this study suggests that the protective effect of lithium on WMI after ICH might be related to an increased level of BDNF and that LiCl treatment may be a potential therapeutic method to palliate WMI after ICH.

Machine-learning prediction of self-care activity by grip strengths of both hands in poststroke hemiplegia

To investigate the relationships between grip strengths and self-care activities in stroke patients using a non-linear support vector machine (SVM).Overall, 177 inpatients with poststroke hemiparesis were enrolled. Their grip strengths were measured using the Jamar dynamometer on the first day of rehabilitation training. Self-care activities were assessed by therapists using Functional Independence Measure (FIM), including items for eating, grooming, dressing the upper body, dressing the lower body, and bathing at the time of discharge. When each FIM item score was ≥6 points, the subject was considered independent. One thousand bootstrap grip strength datasets for each independence and dependence in self-care activities were generated from the actual grip strength. Thereafter, we randomly assigned the total bootstrap datasets to 90% training and 10% testing datasets and inputted the bootstrap training data into a non-linear SVM. After training, we used the SVM algorithm to predict a testing dataset for cross-validation. This validation procedure was repeated 10 times.The SVM with grip strengths more accurately predicted independence or dependence in self-care activities than the chance level (mean ± standard deviation of accuracy rate: eating, 0.71 ± 0.04, P < .0001; grooming, 0.77 ± 0.03, P < .0001; upper-body dressing, 0.75 ± 0.03, P < .0001; lower-body dressing, 0.72 ± 0.05, P < .0001; bathing, 0.68 ± 0.03, P < .0001).Non-linear SVM based on grip strengths can prospectively predict self-care activities.

Updated Approach to Stroke Rehabilitation

This article summarizes stroke rehabilitation, with a particular focus on rehabilitation from acute diagnosis to chronic impairments of stroke. The emphasis is on both pharmacologic and nonpharmacologic intervention and interdisciplinary collaboration.

A randomized controlled study incorporating an electromechanical gait machine, the Hybrid Assistive Limb, in gait training of patients with severe limitations in walking in the subacute phase after stroke

Early onset, intensive and repetitive, gait training may improve outcome after stroke but for patients with severe limitations in walking, rehabilitation is a challenge. The Hybrid Assistive Limb (HAL) is a gait machine that captures voluntary actions and support gait motions. Previous studies of HAL indicate beneficial effects on walking, but these results need to be confirmed in blinded, randomized controlled studies. This study aimed to explore effects of incorporating gait training with HAL as part of an inpatient rehabilitation program after stroke. Thirty-two subacute stroke patients with severe limitations in walking were randomized to incorporated HAL training (4 days/week for 4 weeks) or conventional gait training only. Blinded assessments were carried out at baseline, after the intervention, and at 6 months post stroke. The primary outcome was walking independence according to the Functional Ambulation Categories. Secondary outcomes were the Fugl-Meyer Assessment, 2-Minute Walk Test, Berg Balance Scale, and the Barthel Index. No significant between-group differences were found regarding any primary or secondary outcomes. At 6 months, two thirds of all patients were independent in walking. Prediction of independent walking at 6 months was not influenced by treatment group, but by age (OR 0.848, CI 0.719-0.998, p = 0.048). This study found no difference between groups for any outcomes despite the extra resources required for the HAL training, but highlights the substantial improvements in walking seen when evidence-based rehabilitation is provided to patients, with severe limitations in walking in the subacute stage after stroke. In future studies potential subgroups of patients who will benefit the most from electromechanically-assisted gait training should be explored.

A 3D printing approach toward targeted intervention in telerehabilitation

Neuromuscular impairment requires adherence to a rehabilitation regimen for maximum recovery of motor function. Consumer-grade game controllers have emerged as a viable means to relay supervised physical therapy to patients' homes, thereby increasing their accessibility to healthcare. These controllers allow patients to perform exercise frequently and improve their rehabilitation outcomes. However, the non-universal design of game controllers targets healthy people and does not always accommodate people with disability. Consequently, many patients experience considerable difficulty assuming certain hand postures and performing the prescribed exercise correctly. Here, we explore the feasibility of improving rehabilitation outcomes through a 3D printing approach that enhances off-the-shelf game controllers in home therapy. Specifically, a custom attachment was 3D printed for a commercial haptic device that mediates fine motor rehabilitation. In an experimental study, 25 healthy subjects performed a navigation task, with the retrofit attachment and without it, while simulating disability of the upper limb. When using the attachment, subjects extended their wrist range of motion, yet maintained their level of compensation. The subjects also showed higher motivation to repeat the exercise with the enhanced device. The results bring forward evidence for the potential of this approach in transforming game controllers toward targeted interventions in home therapy.

[Exergames for patients with complex regional pain syndrome : A feasibility study]

BACKGROUND

Complex regional pain syndrome (CRPS) is a disease of the limbs composed of various disorders and defined by the cardinal symptom of pain. So-called exergames with a combination of physical activity and fun are increasingly being offered as part of treatment. Exergame therapy could also provide CRPS patients with repetitive training, reward and motivation.

METHOD

In this study 10 adult patients with CRPS of the hand (50% acute) received a 30 min therapy session using MindMotion™GO. MindMotion™GO is a software that enables control of the integrated games through visual feedback. Outcomes were the subjectively perceived workload (National Aeronautics and Space Administration-task load index, NASA-TLX), user-friendliness (system usability scale, SUS) and pain (numeric rating scale, NRS).

RESULTS

The CRPS patients rated the average workload as appropriate with a total score of 50.9 points (SD ± 18.13). The user-friendliness of the system was judged to be acceptable with an average total score of 89.5 ± 7.53 points. There were no significant changes in pain intensity after the exergames. The subgroup analysis (acute versus chronic) showed differences in the assessment of the individual dimensions of the workload.

CONCLUSION

In this study the use of exergames proved to be a suitable tool for rehabilitation of the hand in adult CRPS patients. Whether exergames represent an effective rehabilitation strategy should be examined by means of functional and activity-related target criteria in a representative sample in a randomized controlled study.

Cognitive Reserve as an Emerging Concept in Stroke Recovery

Stroke is a leading cause of death and disability. It is a complex and largely heterogeneous condition. Prognosis for variations in impairment and recovery following stroke continues to be challenging and inaccurate, highlighting the need to examine the influence of other currently unknown variables to better predict and understand interindividual differences in stroke impairment and recovery. The concept of "cognitive reserve," a feature of brain function said to moderate the relationship between brain pathology and clinical outcomes, might provide a partial explanation. This review discusses the potential significance of cognitive reserve in the context of stroke, with reference to reduced burden of disability poststroke, health promotion, intervention and secondary prevention of cognitive impairment, ease and challenges of translation into clinical practice, prognosis and prediction of recovery, and clinical decisions and trial stratification. Discussions from the review aim to encourage stroke clinicians and researchers to better consider the role of premorbid, lifestyle-related variables, such as cognitive reserve, in facilitating successful neurological outcomes and recovery following stroke.

Potential benefits of music playing in stroke upper limb motor rehabilitation

Music-based interventions have emerged as a promising tool in stroke motor rehabilitation as they integrate most of the principles of motor training and multimodal stimulation. This paper aims to review the use of music in the rehabilitation of upper extremity motor function after stroke. First, we review the evidence supporting current music-based interventions including Music-supported Therapy, Music glove, group music therapy, Rhythm- and music-based intervention, and Musical sonification. Next, we describe the mechanisms that may be responsible for the effectiveness of these interventions, focusing on motor learning aspects, how multimodal stimulation may boost motor performance, and emotional and motivational aspects related to music. Then, we discuss methodological concerns in music therapy research related to modifications of therapy protocols, evaluation of patients and study designs. Finally, we highlight clinical considerations for the implementation of music-based interventions in clinical settings.

Finding a new balance in life: a qualitative study on perceived long-term needs of people with acquired brain injury and partners

Objective: Although the long-term consequences of acquired brain injury are frequent and diverse, care and support over the longer term is an under-addressed issue. This study aims to identify the perceived needs of people with acquired brain injury and their partners.Methods: Interviews with four focus groups of people with brain injury (n = 17) and three partner groups (n = 19) were audio- and videotaped, transcribed verbatim and analyzed using inductive content analysis.Results: Needs were perceived on the intrapersonal, social, healthcare and societal levels, focusing on three themes: 1) Adaptation to changes, including awareness of consequences, acceptance, role changes and dealing with these; 2) Understanding from relatives/friends, professionals, institutions and society; 3) Timely, individualized care, involving information, transition to home, searching for support, peer support and support for partner/family.Discussion: The variety and complexity of needs show that people with brain injury and their partners need to find a new balance in order to live a fulfilling life despite the consequences of brain injury. The overarching need for continuity of care from the transition to home onwards provides important implications for supporting the process of learning how to live well with brain injury.