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

Noninvasive brain stimulation combined with other therapies improves gait speed after stroke: a systematic review and meta-analysis

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are noninvasive brain stimulation (NIBS) techniques able to modulate cortical excitability.

OBJECTIVE

To determine the effects of NIBS combined with other therapies on gait speed after stroke.

METHODS

Electronic databases searched were PUBMED, EMBASE, COCHRANE, SCOPUS, SCIELO and PEDro. Eligibility criteria were randomized controlled trials that reported the effects of tDCS and rTMS combined with other therapies for improving gait speed, walking cadence, functional ambulation category (FAC) and motricity index (MI-LE) after stroke. Risk of bias was assessed by Cochrane risk of bias assessment tool. Mean differences (MD) and 95% confidence intervals were calculated. Quality of evidence was assessed by Grades of Researches, Assessment, Development and Evaluation approach.

RESULTS

Ten studies (226 subjects) were included in the meta-analysis. NIBS combined with other therapies was effective for improving gait speed (MD 0.09 m/s [95% CI, 0.05 to 0.13; I² 0%, p < 0.0001]). Gait speed improved in both acute/subacute (MD 0.08 m/s [95% CI, 0.02 to 0.14]) and chronic phases (MD 0.08 m/s [95% CI, 0.03 to 0.13]). Furthermore, inhibitory (MD 0.09 m/s [95% CI, 0.04 to 0.14]) and excitatory (MD 0.07 m/s [95% CI, 0.02 to 0.12]) protocols were effective to improve gait speed. NIBS was also effective to improve walking cadence but was unable to modify other outcomes (FAC and MI-LE).

CONCLUSIONS

This systematic review with meta-analysis synthesizes moderate-quality evidence that NIBS combined with other therapies are effective to improve gait speed after stroke. Systematic Review registration number: PROSPERO registration number CDR42015024237.

Brain-Machine Interface in Chronic Stroke: Randomized Trial Long-Term Follow-up

BACKGROUND

Brain-machine interfaces (BMIs) have been recently proposed as a new tool to induce functional recovery in stroke patients.

OBJECTIVE

Here we evaluated long-term effects of BMI training and physiotherapy in motor function of severely paralyzed chronic stroke patients 6 months after intervention.

METHODS

A total of 30 chronic stroke patients with severe hand paresis from our previous study were invited, and 28 underwent follow-up assessments. BMI training included voluntary desynchronization of ipsilesional EEG-sensorimotor rhythms triggering paretic upper-limb movements via robotic orthoses (experimental group, n = 16) or random orthoses movements (sham group, n = 12). Both groups received identical physiotherapy following BMI sessions and a home-based training program after intervention. Upper-limb motor assessment scores, electromyography (EMG), and functional magnetic resonance imaging (fMRI) were assessed before (Pre), immediately after (Post1), and 6 months after intervention (Post2).

RESULTS

The experimental group presented with upper-limb Fugl-Meyer assessment (cFMA) scores significantly higher in Post2 (13.44 ± 1.96) as compared with the Pre session (11.16 ± 1.73; P = .015) and no significant changes between Post1 and Post2 sessions. The Sham group showed no significant changes on cFMA scores. Ashworth scores and EMG activity in both groups increased from Post1 to Post2. Moreover, fMRI-BOLD laterality index showed no significant difference from Pre or Post1 to Post2 sessions.

CONCLUSIONS

BMI-based rehabilitation promotes long-lasting improvements in motor function of chronic stroke patients with severe paresis and represents a promising strategy in severe stroke neurorehabilitation.

Electromyogram-Related Neuromuscular Electrical Stimulation for Restoring Wrist and Hand Movement in Poststroke Hemiplegia: A Systematic Review and Meta-Analysis

Background. Clinical trials have demonstrated some benefits of electromyogram-triggered/controlled neuromuscular electrical stimulation (EMG-NMES) on motor recovery of upper limb (UL) function in patients with stroke. However, EMG-NMES use in clinical practice is limited due to a lack of evidence supporting its effectiveness. Objective. To perform a systematic review and meta-analysis to determine the effects of EMG-NMES on stroke UL recovery based on each of the International Classification of Functioning, Disability, and Health (ICF) domains. Methods. Database searches identified clinical trials comparing the effect of EMG-NMES versus no treatment or another treatment on stroke upper extremity motor recovery. A meta-analysis was done for outcomes at each ICF domain (Body Structure and Function, Activity and Participation) at posttest (short-term) and follow-up periods. Subgroup analyses were conducted based on stroke chronicity (acute/subacute, chronic phases). Sensitivity analysis was done by removing studies rated as poor or fair quality (PEDro score <6). Results. Twenty-six studies (782 patients) met the inclusion criteria. Fifty percent of them were considered to be of high quality. The meta-analysis showed that EMG-NMES has a robust short-term effect on improving UL motor impairment in the Body Structure and Function domain. No evidence was found in favor of EMG-NMES for the Activity and Participation domain. EMG-NMES had a stronger effect for each ICF domain in chronic (≥3 months) compared to acute/subacute phases. Conclusion. EMG-NMES is effective in the short term in improving UL impairment in individuals with chronic stroke.

Using Vision to Study Poststroke Recovery and Test Hypotheses About Neurorehabilitation

Approximately one-third of stroke patients suffer visual field impairment as a result of their strokes. However, studies using the visual pathway as a paradigm for studying poststroke recovery are limited. In this article, we propose that the visual pathway has many features that make it an excellent model system for studying poststroke neuroplasticity and assessing the efficacy of therapeutic interventions. First, the functional anatomy of the visual pathway is well characterized, which makes it well suited for functional neuroimaging studies of poststroke recovery. Second, there are multiple highly standardized and clinically available diagnostic tools and outcome measures that can be used to assess visual function in stroke patients. Finally, as a sensory modality, the assessment of vision is arguably less likely to be affected by confounding factors such as functional compensation and patient motivation. Given these advantages, and the general similarities between poststroke visual field recovery and recovery in other functional domains, future neurorehabilitation studies should consider using the visual pathway to better understand the physiology of neurorecovery and test potential therapeutics.

Targeted intraspinal injections to assess therapies in rodent models of neurological disorders

Despite decades of research, pharmacological therapies for spinal cord motor pathologies are limited. Alternatives using macromolecular, viral, or cell-based therapies show early promise. However, introducing these substances into the spinal cord, past the blood-brain barrier, without causing injury is challenging. We describe a technique for intraspinal injection targeting the lumbar ventral horn in rodents. This technique preserves motor performance and has a proven track record of translation into phase 1 and 2 clinical trials in amyotrophic lateral sclerosis (ALS) patients. The procedure, in brief, involves exposure of the thoracolumbar spine and dissection of paraspinous muscles over the target vertebrae. Following laminectomy, the spine is affixed to a stereotactic frame, permitting precise and reproducible injection throughout the lumbar spine. We have used this protocol to inject various stem cell types, primarily human spinal stem cells (HSSCs); however, the injection is adaptable to any candidate therapeutic cell, virus, or macromolecule product. In addition to a detailed procedure, we provide stereotactic coordinates that assist in targeting of the lumbar spine and instructional videos. The protocol takes ~2 h per animal.

Virtual reality gait training versus non-virtual reality gait training for improving participation in subacute stroke survivors: study protocol of the ViRTAS randomized controlled trial

Background

A stroke often results in gait impairments, activity limitations and restricted participation in daily life. Virtual reality (VR) has shown to be beneficial for improving gait ability after stroke. Previous studies regarding VR focused mainly on improvements in functional outcomes. As participation in daily life is an important goal for rehabilitation after stroke, it is of importance to investigate if VR gait training improves participation. The primary aim of this study is to examine the effect of VR gait training on participation in community-living people after stroke.

Methods/design

The ViRTAS study comprises a single-blinded, randomized controlled trial with two parallel groups. Fifty people between 2 weeks and 6 months after stroke, who experience constraints with walking in daily life, are randomly assigned to the virtual reality gait training (VRT) group or the non-virtual reality gait training (non-VRT) group. Both training interventions consist of 12 30-min sessions in an outpatient rehabilitation clinic during 6 weeks. Assessments are performed at baseline, post intervention and 3 months post intervention. The primary outcome is participation measured with the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P). Secondary outcomes are subjective physical functioning, functional mobility, walking ability, walking activity, fatigue, anxiety and depression, falls efficacy and quality of life.

Discussion

The results of the study provide insight into the effect of VR gait training on participation after stroke.

Trial registration

Netherlands National Trial Register, Identifier NTR6215. Registered on 3 February 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3165-7) contains supplementary material, which is available to authorized users.

The effectiveness of group exercise for improving activity and participation in adult stroke survivors: a systematic review

BACKGROUND

Following post stroke rehabilitation, group exercise interventions can be used to continue improving cardiovascular fitness, activity levels, balance, gait, movement efficiency, and strengthening. However, little is known of the effectiveness of group exercise for improving activity and participation in stroke survivors.

OBJECTIVES

This review aims to assess the effectiveness of group exercise for improving activity and participation in adult stroke survivors.

DATA SOURCES

Databases searched were MEDLINE, Web of Science (Core collection), CINAHL, and the Cochrane Library.

STUDY ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) of group exercise using validated outcome measures of activity and participation for post stroke rehabilitation. Two independent reviewers assessed all abstracts, extracted data, conducted a narrative synthesis and assessed the quality of all included articles. The Cochrane Risk of Bias Tool assessed methodological quality and included outcome measure quality was assessed.

RESULTS

14 RCTs were included (n=624 chronic stroke survivors collectively). Studies ranged between 12 and 243 stroke participants with an average of left:right hemisphere lesions of 32:39 and average age was 66.7 years. Although intervention and control groups improved, no significant difference between group differences were evident.

CONCLUSION

and implications of key findings: The review found improvements are short-term and less evident at long-term follow up with little improvements in participation after 6months. However, this review was limited to the standard of intervention reporting. Further research should consider consistency in measuring underpinning mechanisms of group exercise interventions, which may explain the lack of activity changes in long-term follow-up.

SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO

CRD42017078917.

Adherence to a Long-Term Physical Activity and Exercise Program After Stroke Applied in a Randomized Controlled Trial

BACKGROUND

Persistent physical activity is important to maintain motor function across all stages after stroke.

OBJECTIVE

The objective of this study was to investigate adherence to an 18-month physical activity and exercise program.

DESIGN

The design was a prospective, longitudinal study including participants who had had a stroke randomly allocated to the intervention arm of a randomized controlled trial.

METHODS

The intervention consisted of individualized monthly coaching by a physical therapist who motivated participants to adhere to 30 minutes of daily physical activity and 45 minutes of weekly exercise over an 18-month period. The primary outcome was the combination of participants' self-reported training diaries and adherence, as reported by the physical therapists. Mixed-effect models were used to analyze change in adherence over time. Intensity levels, measured by the Borg scale, were a secondary outcome.

RESULTS

In total, 186 informed, consenting participants who had had mild-to-moderate stroke were included 3 months after stroke onset. Mean age was 71.7 years (SD = 11.9). Thirty-four (18.3%) participants withdrew and 9 (4.8%) died during follow-up. Adherence to physical activity and exercise each month ranged from 51.2% to 73.1%, and from 63.5% to 79.7%, respectively. Adherence to physical activity increased by 2.6% per month (odds ratio = 1.026, 95% CI = 1.014-1.037). Most of the exercise was performed at moderate-to-high intensity levels, ranging from scores of 12 to 16 on the Borg scale, with an increase of 0.018 points each month (95% CI = 0.011-0.024).

LIMITATIONS

Limitations included missing information about adherence for participants with missing data and reasons for dropout.

CONCLUSIONS

Participants with mild and moderate impairments after stroke who received individualized regular coaching established and maintained moderate-to-good adherence to daily physical activity and weekly exercise over time.

Compensation or Recovery? Altered Kinetics and Neuromuscular Synergies Following High-Intensity Stepping Training Poststroke

BACKGROUND

High-intensity, variable stepping training can improve walking speed in individuals poststroke, although neuromuscular strategies used to achieve faster speeds are unclear. We evaluated changes in joint kinetics and neuromuscular coordination following such training; movement strategies consistent with intact individuals were considered evidence of recovery and abnormal strategies indicative of compensation.

METHODS

A total of 15 individuals with stroke (duration: 23 ± 30 months) received ≤40 sessions of high-intensity stepping in variable contexts (tasks and environments). Lower-extremity kinetics and electromyographic (EMG) activity were collected prior to (BSL) and following (POST) training at peak treadmill speeds and speeds matched to peak BSL (MATCH). Primary measures included positive (concentric) joint and total limb powers, measures of interlimb (paretic/nonparetic powers) and intralimb compensation (hip/ankle or knee/ankle powers), and muscle synergies calculated using nonnegative matrix factorization.

RESULTS

Gains in most positive paretic and nonparetic joint powers were observed at higher speeds at POST, with decreased interlimb compensation and limited changes in intralimb compensation. There were very few differences in kinetic measures between BSL to MATCH conditions. However, the number of neuromuscular synergies increased significantly following training at both POST and MATCH conditions, indicating gains from training rather than altered speeds. Despite these results, speed improvements were associated primarily with changes in nonparetic versus paretic powers.

CONCLUSION

Gains in locomotor function were accomplished by movement strategies consistent with both recovery and compensation. These and other data indicate that both strategies may be necessary to maximize walking function in patients poststroke.

Investigating the feasibility and acceptability of real-time visual feedback in reducing compensatory motions during self-administered stroke rehabilitation exercises: A pilot study with chronic stroke survivors

INTRODUCTION

Homework-based rehabilitation programs can help stroke survivors restore upper extremity function. However, compensatory motions can develop without therapist supervision, leading to sub-optimal recovery. We developed a visual feedback system using a live video feed or an avatar reflecting users' movements so users are aware of compensations. This pilot study aimed to evaluate validity (how well the avatar characterizes different types of compensations) and acceptability of the system.

METHODS

Ten participants with chronic stroke performed upper-extremity exercises under three feedback conditions: none, video, and avatar. Validity was evaluated by comparing agreement on compensations annotated using video and avatar images. A usability survey was administered to participants after the experiment to obtain information on acceptability.

RESULTS

There was substantial agreement between video and avatar images for shoulder elevation and hip extension (Cohen's κ: 0.6-0.8) and almost perfect agreement for trunk rotation and flexion (κ: 0.80-1). Acceptability was low due to lack of corrective prompts and occasional noise with the avatar display. Most participants suggested that an automatic compensation detection feature with visual and auditory cuing would improve the system.

CONCLUSION

The avatar characterized four types of compensations well. Future work will involve increasing sensitivity for shoulder elevation and implementing a method to detect compensations.

Cortico-Muscular Coherence Modulated by High-Definition Transcranial Direct Current Stimulation in People With Chronic Stroke

High-definition transcranial direct current stimulation (HD-tDCS) is a potential neuromodulation apparatus for stroke rehabilitation. However, its modulatory effects in stroke subjects is still not well understood. In this paper, the offline modulatory effects of HD-tDCS on the ipsilesional primary motor cortex were investigated by performing wrist isometric contraction tasks before and after HD-tDCS in eleven unilateral chronic stroke subjects using a synchronized HD-tDCS and electroencephalogram/electromyography measurement system. This paper is a randomized, single blinded, and sham-controlled crossover study. Each subject randomly received three HD-tDCS (anode, cathode, and sham) with at least one-week washout period. Online feedback-guided medium-level wrist isometric contraction tasks were conducted for the affected upper limbs before stimulation and 10, 30, and 50 min after the end of 10-min 1-mA HD-tDCS. The characteristics of corticomuscular coherence (CMC), cortical oscillation power spectral density, and power spectral entropy were analyzed during tasks and compared across all sessions and stimulation conditions. Anode HD-tDCS induced significant CMC changes in stroke subjects, while cathode and sham stimulation did not induce significant CMC changes. The largest neuromodulation effects were observed at 10 min immediately after anodal HD-tDCS.

Mirror therapy and treadmill training for patients with chronic stroke: a pilot randomized controlled trial

BACKGROUND

Previous lower-limb mirror therapy research has focused on non-weight bearing interventions.

OBJECTIVES

The primary aim of this study was to investigate the effect and feasibility of a combination of mirror therapy and treadmill training on post-stroke lower-limb recovery compared to a placebo intervention.

METHODS

All patients (N = 30) walked on a treadmill for 30 min per day, 3 days per week, for 4 weeks. The mirror therapy and treadmill training group (n = 15) walked on the treadmill while viewing a reflection of their non-paretic limb in a mirror positioned in their mid-sagittal plane. The placebo group (n = 15) received no mirror visual feedback due to an altered mirror position.

PRIMARY OUTCOME MEASURES

Ten Metre Walk Test (10MWT) and Six Minute Walk Test (6MWT).

SECONDARY OUTCOME MEASURES

Modified Ashworth Scale (MAS) and Fugl-Meyer Assessment-Lower Extremity (FMA-LE). Feasibility was appraised by examining participant compliance and any adverse events.

RESULTS

No significant between group differences were demonstrated for the 10MWT, 6MWT or FMA-LE at post-training or 3-month follow-up assessment. A significant between group difference on the MAS was demonstrated in the reduction of ankle dorsiflexion muscle tone (p = 0.006) and ankle plantarflexion muscle tone (p = 0.01) in the mirror therapy group compared to the placebo group at post-training assessment but not at 3-month follow-up.

CONCLUSION

Our study reveals that in our group of patients with chronic stroke, mirror therapy combined with treadmill training facilitated significant reductions in ankle muscle tone (p < 0.05) compared to a placebo intervention.

Combined action observation and motor imagery therapy: a novel method for post-stroke motor rehabilitation

Cerebral vascular accidents (strokes) are a leading cause of motor deficiency in millions of people worldwide. While a complex range of biological systems is affected following a stroke, in this paper we focus primarily on impairments of the motor system and the recovery of motor skills. We briefly review research that has assessed two types of mental practice, which are currently recommended in stroke rehabilitation. Namely, action observation (AO) therapy and motor imagery (MI) training. We highlight the strengths and limitations in both techniques, before making the case for combined action observation and motor imagery (AO + MI) therapy as a potentially more effective method. This is based on a growing body of multimodal brain imaging research showing advantages for combined AO + MI instructions over the two separate methods of AO and MI. Finally, we offer a series of suggestions and considerations for how combined AO + MI therapy could be employed in neurorehabilitation.

Community ambulation of stroke survivors at 6 months follow-up: an observational study on sociodemographic and sub-acute clinical indicators

BACKGROUND

Despite the importance of walking recovery in real life contexts, only 7% of stroke survivors at discharge from neuro-rehabilitation units recover independent walking in the community. However, studies on outcome indicators of walking ability restoration following stroke rarely regard the community ambulation.

AIM

The aim of the study is to investigate how sociodemographic and sub-acute clinical characteristics of stroke survivors at admission and at discharge may predict a good participation in community walking activity 6 months post-stroke.

DESIGN

Retrospective observational study.

SETTING

Inpatient neuro-rehabilitation centers.

POPULATION

Three-hundred-ten stroke survivors.

METHODS

A secondary analysis were performed on collected sociodemographic and clinical data of subjects after first-ever stroke within 72 hours of admission to acute care facilities (T1), at discharge (T2), and subsequently after 6-months post-stroke (T3). The regression analysis between every independent variable at T1 and T2 and Walking Handicap Scale-WHS (negative: 1-3; positive: 4-6) assessed at T3 were performed to identify the most important early predictors.

RESULTS

At T1, being younger, having a good ability to walk, early mobilization out of bed, not having TACI, and being female are significant positive indicators while, clinical complications are significantly negative for a WHS:4-6 at T3. No correlation was found between WHS and gender, etiology, the side of lesion, the presence of aphasia, and the presence of risk factors. The combination of risk factors indicates a negative WHS at T3.

CONCLUSIONS

The presence of risk factors and clinical complications delay significantly the walking ability restoration and return to social life. Such status consistently with the patient's compliance must not postpone the rehabilitation relatively, rehabilitation must be facilitated with targeted programs taking care particularly of people with negative indicators for recovery of community ambulation 6 months post-stroke.

CLINICAL REHABILITATION IMPACT

Early indicators are considerable in order to predict a targeted prognosis and better provide a tailored rehabilitation program.

Evaluating the Effectiveness and Safety of the Electroencephalogram-Based Brain-Machine Interface Rehabilitation System for Patients With Severe Hemiparetic Stroke: Protocol for a Randomized Controlled Trial (BEST-BRAIN Trial)

BACKGROUND

We developed a brain-machine interface (BMI) system for poststroke patients with severe hemiplegia to detect event-related desynchronization (ERD) on scalp electroencephalogram (EEG) and to operate a motor-driven hand orthosis combined with neuromuscular electrical stimulation. ERD arises when the excitability of the ipsi-lesional sensorimotor cortex increases.

OBJECTIVE

The aim of this study was to evaluate our hypothesis that motor training using this BMI system could improve severe hemiparesis that is resistant to improvement by conventional rehabilitation. We, therefore, planned and implemented a randomized controlled clinical trial (RCT) to evaluate the effectiveness and safety of intensive rehabilitation using the BMI system.

METHODS

We conducted a single blind, multicenter RCT and recruited chronic poststroke patients with severe hemiparesis more than 90 days after onset (N=40). Participants were randomly allocated to the BMI group (n=20) or the control group (n=20). Patients in the BMI group repeated 10-second motor attempts to operate EEG-BMI 40 min every day followed by 40 min of conventional occupational therapy. The interventions were repeated 10 times in 2 weeks. Control participants performed a simple motor imagery without servo-action of the orthosis, and electrostimulation was given for 10 seconds for 40 min, similar to the BMI intervention. Overall, 40 min of conventional occupational therapy was also given every day after the control intervention, which was also repeated 10 times in 2 weeks. Motor functions and electrophysiological phenotypes of the paretic hands were characterized before (baseline), immediately after (post), and 4 weeks after (follow-up) the intervention. Improvement in the upper extremity score of the Fugl-Meyer assessment between baseline and follow-up was the main outcome of this study.

RESULTS

Recruitment started in March 2017 and ended in July 2018. This trial is currently in the data correcting phase. This RCT is expected to be completed by October 31, 2018.

CONCLUSIONS

No widely accepted intervention has been established to improve finger function of chronic poststroke patients with severe hemiparesis. The results of this study will provide clinical data for regulatory approval and novel, important understanding of the role of sensory-motor feedback based on BMI to induce neural plasticity and motor recovery.

TRIAL REGISTRATION

UMIN Clinical Trials Registry UMIN000026372; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi? recptno=R000030299 (Archived by WebCite at http://www.webcitation.org/743zBJj3D).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/12339.

Correlations between cervical spinal cord magnetic resonance diffusion tensor and diffusion kurtosis imaging metrics and motor performance in patients with chronic ischemic brain lesions of the corticospinal tract

PURPOSE

To investigate modifications of Magnetic Resonance Diffusion Tensor Imaging (DTI) and Diffusion Kurtosis Imaging (DKI) metrics in lateral white matter (WM) bundles of the cervical spinal cord in patients with previous stroke in the vascular territory of the middle cerebral artery (MCA).

METHODS

Twenty consecutive patients with a previous ischemic stroke of the MCA territory and a varying degree of upper motor impairment were enrolled. DKI was centered at the C3C4 and C5C6 intervertebral level.

RESULTS

The fractional anisotropy (FA) values in C3C4 and C5C6 were found to be significantly lower in the lateral WM bundles contralateral to the ischemic lesion and thus, in the WM bundle including the affected corticospinal tract (CST) (p = 0.005 and p = 0.008, respectively), as well as mean kurtosis (MK) and axonal water fraction (AWF) values (p = 0.004 and p = 0.04. respectively). FA values correlated significantly with the Global Motor Index (GMI) both for C3C4 (ρ = 0.61, p = 0.004) and C5C6 (ρ = 0.69, p = 0.002). At C3C4, AWF correlated significantly with GMI (ρ = 0.54, p = 0.03). No correlations were found between lateral WM bundle volumes and GMI.

CONCLUSION

A reduction of anisotropy and microstructural complexity in the affected lateral WM bundle of the cervical spinal cord was observed in patients with previous ischemic stroke involving the CST. The correlations between these metrics and motor performance were statistically significant.

Stratification of stroke rehabilitation: Five-year profiles of functional outcomes

BACKGROUND

Stroke rehabilitation in inpatient setting requires high intensity of manpower and resources. Early stratification of patients with stroke could facilitate early discharge plan and reduce avoidable length of stay (LOS) in hospital. Stratification of patients with stroke in clinical setting is usually based on functional scores which are quite time-consuming and require a special training to complete the full score.

OBJECTIVE

The objective of the study was to explore whether Modified Functional Ambulation Category (MFAC) can serve as a stratification tool of patients with stroke in inpatient rehabilitation.

METHODS

This was a retrospective, descriptive study of the demographic, functional outcomes of patients with stroke in an inpatient rehabilitation center. A total of 2,722 patients completed a stroke rehabilitation program from 2011 to 2015 were recruited. The patients were divided into seven groups according to their admission MFAC. The between-group difference in LOS, functional outcomes at admission and discharge including Modified Rivermead Mobility Index (MRMI) and Modified Barthel Index (MBI) as well as MRMI gain, MRMI efficiency, MBI gain, and MBI efficiency were analyzed.

RESULTS

Subjects with admission categories of MFAC 2 and 3 had a highly significant ( p < 0 . 001 ) MRMI gain (6.2 and 6.6, respectively) and subjects with admission categories of MFAC 3 to 5 had highly significant ( P < 0 . 001 ) MRMI efficiency (0.34, 0.40, and 0.39, respectively). The subjects with admission categories of MFAC 2 to 5 had a highly significant ( p < 0 . 001 ) MBI gain (9.7, 10.2, 9.3, and 7.0, respectively) and the subjects with admission categories of MFAC 4 to 5 had a highly significant ( p < 0 . 001 ) MBI efficiency (0.70 and 0.72, respectively). The subjects with admission categories of MFAC 1 and 2 had a highly significant ( p < 0 . 001 ) LOS (27.7 and 26.6, respectively). MFAC profile was also established to represent the distribution of discharge MFAC of subjects according to their admission MFAC. The chance of subjects with admission categories of MFAC 1 and MFAC 2 progress to any kind of walker (MFAC > 2) is 12.7% and 58.2%, respectively. The chance of subjects with admission MFAC 3, MFAC 4 and MFAC 5 progress to independent walker (MFAC > 5) is 6.7%, 14.8%, and 50.3%, respectively. Both admission MFAC and admission MBI had strong correlations with discharge MFAC ( r = 0 . 84 , P < 0 . 0001 and r = 0 . 78 , P < 0 . 0001 , respectively), discharge MRMI ( r = 0 . 82 , P < 0 . 0001 and r = 0 . 78 , P < 0 . 0001 , respectively) and discharge MBI ( r = 0 . 78 , P < 0 . 0001 and r = 0 . 94 , P < 0 . 0001 , respectively).

CONCLUSION

This study showed that patients on admission with moderate disability in term of MFAC had the greatest mobility gain and basic activities of daily living (ADL) gain from inpatient stroke rehabilitation. Admission MFAC could be a stratification tool of patients with stroke in inpatient rehabilitation.

Value-Based Stroke Rehabilitation: Feasibility and Results of Patient-Reported Outcome Measures in the First Year After Stroke

PURPOSE

Structured application of patient-reported outcome measures (PROMs) is a key element in Value Based Healthcare. This study aimed to evaluate the feasibility of a broad set of PROMs reflecting similar patient reported health domains as proposed within the International Standard Set of Patient-Centered Outcome Measures After Stroke within the first year after stroke.

METHODS

The study included consecutive stroke patients admitted to inpatient or outpatient specialized rehabilitation. PROMs were administered upon admission, discharge (inpatients only), and at 3, 6, and 12 months. PROMs included: EuroQol 5 Dimensions (EQ-5D), Stroke Impact Scale (SIS), Stroke and Aphasia Quality of Life Scale (SAQOL-39NL), Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P), Hospital Anxiety and Depression Scale (HADS), and Fatigue Severity Scale (FSS). Feasibility was defined as participation, retention, and response rates. Paired t tests were conducted to analyze their changes over time.

RESULTS

Of 485 inpatients and 189 outpatients who were invited, 291 (60.0%) and 82 (43.3%) participated, of whom 45 (15.5%) and 7 (8.5%) dropped out before 12 months, respectively. Two hundred seven (71.1%) and 71 (86.6%) of the inpatients and outpatients returned the questionnaires on all or all but one time points, respectively. Between admission and 12 months statistically significant improvements of PROMs addressing general health and quality of life (EQ-5D), psychiatric functioning (HADS), motor functioning (SIS mobility), and social functioning (USER-P, SIS communication) were seen. The SIS memory scale, the SAQOL-39NL and the FSS did not show any changes.

CONCLUSIONS

Participation, retention, and response rates for a comprehensive set of PROMS for stroke in patients in rehabilitation were moderate to good, with clinical improvements seen until 1 year post stroke. The SAQOL-39NL and FSS did not demonstrate changes over time and cannot be recommended for repetitive measurements in this setting. By simplifying the set of questionnaires, participation and response rates may be further enhanced.

Rehabilitation via HOMe Based gaming exercise for the Upper-limb post Stroke (RHOMBUS): protocol of an intervention feasibility trial

INTRODUCTION

Effective interventions to promote upper-limb recovery poststroke are characterised by intensive and repetitive movements. However, the repetitive nature of practice may adversely impact on adherence. Therefore, the development of rehabilitation devices that can be used safely and easily at home, and are motivating, enjoyable and affordable is essential to the health and well-being of stroke survivors.The Neurofenix platform is a non-immersive virtual reality device for poststroke upper-limb rehabilitation. The platform uses a hand controller (a NeuroBall) or arm bands (NeuroBands) that facilitate upper-limb exercise via games displayed on a tablet. The Rehabilitation via HOMe Based gaming exercise for the Upper-limb post Stroke trial aims to determine the safety, feasibility and acceptability of the Neurofenix platform for home-based rehabilitation of the upper-limb poststroke.

METHODS AND ANALYSIS

Thirty people poststroke will be provided with a Neurofenix platform, consisting of a NeuroBall or NeuroBands (dependent on impairment level), seven specially designed games, a tablet and handbook to independently exercise their upper limb for 7 weeks. Training commences with a home visit from a research therapist to teach the participant how to safely use the device. Outcomes assessed at baseline and 8 weeks and 12 weeks are gross level of disability, pain, objectively measured arm function and impairment, self-reported arm function, passive range of movement, spasticity, fatigue, participation, quality of life (QOL) and health service use. A parallel process evaluation will assess feasibility, acceptability and safety of the intervention through assessment of fidelity to the intervention measured objectively through the Neurofenix platform, a postintervention questionnaire and semistructured interviews exploring participants' experiences of the intervention. The feasibility of conducting an economic evaluation will be determined by collecting data on QOL and resource use.

ETHICS AND DISSEMINATION

Ethics approval granted from Brunel University London (10249-MHR-Mar/2018-12322-2). Trial results will be submitted for publication in journals, presented at national and international conferences and distributed to people with stroke.

TRIAL REGISTRATION NUMBER

ISRCTN60291412; Pre-results.

Effects of gait training with auditory feedback on walking and balancing ability in adults after hemiplegic stroke: a preliminary, randomized, controlled study

The aim of this study was to identify a gait training type that better improves the walking and balancing abilities of adult patients with chronic hemiplegic stroke. Single-blinded, randomized, controlled, comparative preliminary study was carried out. Patients were recruited from the inpatient unit of a Rehabilitation Hospital. Thirty-one patients who had experienced hemiplegic stroke were randomly assigned to three groups: the heel group (gait training by active weight bearing on the paretic heel with auditory feedback), the forefoot group (gait training with auditory feedback from paretic metatarsals), and the control group (general gait intervention). All patients performed 30 min of comprehensive rehabilitation therapy followed by an additional 20 min of gait intervention with or without auditory feedback three times a week for 6 weeks. Significant improvements in walking and balancing variables were observed after gait training in all three groups (P<0.05). However, significantly larger gains were identified in the heel group than in the control group (center of loading path length, -29.4 vs. -11.4%, d=-1.0; center of loading path velocity, -35.8 vs. -19.6%, d=-1.4). In addition, significantly larger gains were observed in the forefoot group than in the control group (functional gait assessment, +42.6 vs. +20.1%, d=1.3; center of loading path length, -37.2 vs. -11.4%, d=-1.8; center of loading path velocity, -36.0 vs. -19.6%, d=-1.3). Auditory feedback during active weight bearing on paretic feet appears to more effectively improve the walking and balancing abilities of hemiplegic stroke patients than general gait training.

Technology-Assisted Ankle Rehabilitation Improves Balance and Gait Performance in Stroke Survivors: A Randomized Controlled Study With 1-Month Follow-Up

Many stroke survivors have limited ankle range of motion (ROM) caused by weak dorsiflexors and stiff plantarflexors. Passive ankle stretching exercises with physical therapists or a stretching board are usually recommended, but these treatments have some limitations (e.g., cost and availability of physical therapists). In this paper, we assessed the results of ankle stretching exercises delivered by a robotic ankle stretching system called motorized ankle stretcher (MAS) that we developed or by a stretching board on ankle ROM, balance control, and gait performance. The 16 stroke survivors were randomly assigned to an intervention group (IG) or a control group (CG) and participated in seven sessions of dorsiflexion stretching exercises for three-and-a-half consecutive weeks. Laboratory assessments included pre-assessment (baseline at the beginning of the first exercise session), post-assessment (at the end of the seventh exercise session), and retention assessment (one month after the seventh exercise session). All assessments included ankle ROM for the affected side, static/dynamic balance control with a sensory organization test (SOT), walking speed, walking cadence, and step length for the affected and unaffected sides. During seven sessions of ankle stretching exercises, the IG performed them using the MAS, and the CG used a stretching board. The IG significantly improved ankle ROM, SOT scores (i.e., static/dynamic balance control), walking speeds, walking cadences, and step lengths for the unaffected side after completing the seven exercise sessions of ankle stretching exercises and maintained the enhancements at the retention assessment. The CG did not significantly improve across the majority of outcome measures except for the SOT scores between the pre-assessment and retention assessment. Future work will investigate the ideal intensity, frequency, and duration of exercising with the MAS. Our research on technology-assisted ankle rehabilitation, which can ascertain the level of persistent improvement, long-term performance retention, and carry-over effects in stroke survivors, can be used to inform future designs.

Action observation for upper limb rehabilitation after stroke

BACKGROUND

Action observation (AO) is a physical rehabilitation approach that facilitates the occurrence of neural plasticity through the activation of the mirror-neural system, promoting motor recovery in people with stroke.

OBJECTIVES

To assess whether action observation enhances motor function and upper limb motor performance and cortical activation in people with stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched 4 September 2017), the Central Register of Controlled Trials (24 October 2017), MEDLINE (1946 to 24 October 2017), Embase (1974 to 24 October 2017) and five additional databases. We also searched trial registries and reference lists.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of AO, alone or associated with physical practice in adults after stroke. The primary outcome was upper limb motor function. Secondary outcomes included dependence on activities of daily living (ADL), motor performance, cortical activation, quality of life, and adverse effects.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We included 12 trials involving 478 individuals. A number of trials showed a high risk of bias and others an unclear risk of bias due to poor reporting. The quality of the evidence was 'low' for most of the outcomes and 'moderate' for hand function, according to the GRADE system. In most of the studies, AO was followed by some form of physical activity.

PRIMARY OUTCOME

the impact of AO on arm function showed a small significant effect (standardized mean difference (SMD) 0.36, 95% CI 0.13 to 0.60; 8 studies; 314 participants; low-quality evidence); and a large significant effect (mean difference (MD) 2.90, 95% CI 1.13 to 4.66; 3 studies; 132 participants; moderate-quality evidence) on hand function.

SECONDARY OUTCOMES

there was a large significant effect for ADL outcome (SMD 0.86, 95% CI 0.11 to 1.61; 4 studies, 226 participants; low-quality evidence). We were unable to pool other secondary outcomes to extract the evidence. Only two studies reported adverse effects without significant adverse AO events.

AUTHORS' CONCLUSIONS

We found evidence that AO is beneficial in improving upper limb motor function and dependence in activities of daily living (ADL) in people with stroke, when compared with any control group; however, we considered the quality of the evidence to be low. We considered the effect of AO on hand function to be large, but it does not appear to be clinically relevant, although we considered the quality of the evidence as moderate. As such, our confidence in the effect estimate is limited because it will likely change with future research.

Neuromuscular synergies in motor control in normal and poststroke individuals

Muscle synergies are proposed to function as motor primitives that are modulated by frontal brain areas to construct a large repertoire of movement. This paper reviews the history of the development of our current theoretical understanding of nervous system-based motor control mechanisms and more specifically the concept of muscle synergies. Computational models of muscle synergies, especially the nonnegative matrix factorization algorithm, are discussed with specific reference to the changes in synergy control post-central nervous system (CNS) lesions. An alternative approach for motor control is suggested, exploiting a combination of synergies control or flexible muscle control used for gross motor skills and for individualized finger movements. Rehabilitation approaches, either supporting or inhibiting the use of basic movement patterns, are discussed in the context of muscle synergies. Applications are discussed for the use of advanced technologies that can promote the recovery and functioning of the human CNS after stroke.

Effectiveness and Superiority of Rehabilitative Treatments in Enhancing Motor Recovery Within 6 Months Poststroke: A Systemic Review

OBJECTIVE

To investigate the effects of various rehabilitative interventions aimed at enhancing poststroke motor recovery by assessing their effectiveness when compared with no treatment or placebo and their superiority when compared with conventional training program (CTP).

DATA SOURCE

A literature search was based on 19 Cochrane reviews and 26 other reviews. We also updated the searches in PubMed up to September 30, 2017.

STUDY SELECTION

Randomized controlled trials associated with 18 experimented training programs (ETP) were included if they evaluated the effects of the programs on either upper extremity (UE) or lower extremity (LE) motor recovery among adults within 6 months poststroke; included ≥10 participants in each arm; and had an intervention duration of ≥10 consecutive weekdays.

DATA EXTRACTION

Four reviewers evaluated the eligibility and quality of literature. Methodological quality was assessed using the PEDro scale.

DATA SYNTHESIS

Among the 178 included studies, 129 including 7450 participants were analyzed in this meta-analysis. Six ETPs were significantly effective in enhancing UE motor recovery, with the standard mean differences (SMDs) and 95% confidence intervals outlined as follow: constraint-induced movement therapy (0.82, 0.45-1.19), electrostimulation (ES)-motor (0.42, 0.22-0.63), mirror therapy (0.71, 0.22-1.20), mixed approach (0.21, 0.01-0.41), robot-assisted training (0.51, 0.22-0.80), and task-oriented training (0.57, 0.16-0.99). Six ETPs were significantly effective in enhancing LE motor recovery: body-weight-supported treadmill training (0.27, 0.01-0.52), caregiver-mediated training (0.64, 0.20-1.08), ES-motor (0.55, 0.27-0.83), mixed approach (0.35, 0.15-0.54), mirror therapy (0.56, 0.13-1.00), and virtual reality (0.60, 0.15-1.05). However, compared with CTPs, almost none of the ETPs exhibited significant SMDs for superiority.

CONCLUSIONS

Certain experimented interventions were effective in enhancing poststroke motor recovery, but little evidence supported the superiority of experimented interventions over conventional rehabilitation.

Noninvasive Brain Stimulation to Enhance Functional Recovery After Stroke: Studies in Animal Models

Background. Stroke is the leading cause of adult disability, but treatment options remain limited, leaving most patients with incomplete recovery. Patient and animal studies have shown potential of noninvasive brain stimulation (NIBS) strategies to improve function after stroke. However, mechanisms underlying therapeutic effects of NIBS are unclear and there is no consensus on which NIBS protocols are most effective. Objective. Provide a review of articles that assessed effects and mechanisms of repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) in animal stroke models. Methods. Articles were searched in PubMed, including cross-references. Results. Nineteen eligible studies reporting effects of rTMS or tDCS after stroke in small rodents were identified. Seventeen of those described improved functional recovery or neuroprotection compared with untreated control or sham-stimulated groups. The effects of rTMS could be related to molecular mechanisms associated with ischemic tolerance, neuroprotection, anti-apoptosis, neurogenesis, angiogenesis, or neuroplasticity. Favorable outcome appeared most effectively when using high-frequency (>5 Hz) rTMS or intermittent theta burst stimulation of the ipsilesional hemisphere. tDCS effects were strongly dependent on stimulation polarity and onset time. Although these findings are promising, most studies did not meet Good Laboratory Practice assessment criteria. Conclusions. Despite limited data availability, animal stroke model studies demonstrate potential of NIBS to promote stroke recovery through different working mechanisms. Future studies in animal stroke models should adhere to Good Laboratory Practice guidelines and aim to further develop clinically applicable treatment protocols by identifying most favorable stimulation parameters, treatment onset, adjuvant therapies, and underlying modes of action.

Implementing biomarkers to predict motor recovery after stroke

BACKGROUND

There is growing interest in using biomarkers to predict motor recovery and outcomes after stroke. The PREP2 algorithm combines clinical assessment with biomarkers in an algorithm, to predict upper limb functional outcomes for individual patients. To date, PREP2 is the first algorithm to be tested in clinical practice, and other biomarker-based algorithms are likely to follow.

PURPOSE

This review considers how algorithms to predict motor recovery and outcomes after stroke might be implemented in clinical practice.

FINDINGS

There are two tasks: first the prediction information needs to be obtained, and then it needs to be used. The barriers and facilitators of implementation are likely to differ for these tasks. We identify specific elements of the Consolidated Framework for Implementation Research that are relevant to each of these two tasks, using the PREP2 algorithm as an example. These include the characteristics of the predictors and algorithm, the clinical setting and its staff, and the healthcare environment.

CONCLUSIONS

Active, theoretically underpinned implementation strategies are needed to ensure that biomarkers are successfully used in clinical practice for predicting motor outcomes after stroke, and should be considered in parallel with biomarker development.

Effects of transcutaneous electrical nerve stimulation alone or as additional therapy on chronic post-stroke spasticity: systematic review and meta-analysis of randomized controlled trials

Purpose: To evaluate the effects and to compare transcutaneous electrical nerve stimulation protocols, alone or as additional therapy in chronic post-stroke spasticity through a systematic review and meta-analysis of randomized clinical trials.Methods: Search was conducted in MEDLINE, Cochrane Library, EMBASE and Physiotherapy Evidence Database through November 2017 (CRD42015020146). Two independent reviewers performed articles selection, data extraction and methodological quality assessment using the Cochrane Collaboration's risk of bias tool. The main outcome was spasticity assessed with Modified Ashworth Scale or other valid scale. Meta-analysis was conducted using random effects method, and pooled-effect results are mean difference with 95% confidence interval.Results: Of 6506 articles identified, 10 studies with 360 subjects were included in the review. Transcutaneous electrical nerve stimulation alone or as additional therapy is superior to placebo TENS to reduce post-stroke spasticity assessed with Modified Ashworth Scale (-0.52 [-0.74 to -0.30] p < 0.0001, 6 studies), especially in lower limbs (-0.58 [-0.82 to -0.34] p < 0.0001, 5 studies), which is in accordance with the studies that used other scales. Low frequency TENS showed a slightly larger improvement than high-frequency, but without significant difference between subgroups. Most studies present low or unclear risk of bias.Conclusion: Transcutaneous electrical nerve stimulation can provide additional reduction in chronic post-stroke spasticity, mainly as additional therapy to physical interventions. Studies with better methodological quality and larger sample are needed to increase evidence power.Implications for RehabilitationTranscutaneous electrical nerve stimulation as additional treatment to physical interventions can lead to additional reduction in chronic post-stroke spasticity.High and low frequency transcutaneous electrical nerve stimulation showed similar results, with a smaller numerical superiority of low frequency TENS.More studies are needed to substantiate the best protocol of transcutaneous electrical nerve stimulation to the treatment of spasticity.

Effects of robot-(Morning Walk®) assisted gait training for patients after stroke: a randomized controlled trial

Objective:

To investigate the effects of Morning Walk®–assisted gait training for patients with stroke.

Design:

Prospective randomized controlled trial.

Setting:

Three hospital rehabilitation departments (two tertiary and one secondary).

Patients:

We enrolled 58 patients with hemiparesis following a first-time stroke within the preceding year and with Functional Ambulation Category scores ⩾2.

Intervention:

The patients were randomly assigned to one of two treatment groups: 30 minutes of training with Morning Walk®, a lower limb rehabilitation robot, plus 1 hour of conventional physiotherapy (Morning Walk® group; n = 28); or 1.5 hour of conventional physiotherapy (control group; n = 30). All received treatment five times per week for three weeks.

Main outcome measurements:

The primary outcomes were walking ability, assessed using the Functional Ambulation Category scale, and lower limb function, assessed using the Motricity Index-Lower. Secondary outcomes included the 10 Meter Walk Test, Modified Barthel Index, Rivermead Mobility Index, and Berg Balance Scale scores.

Results:

A total of 10 patients were lost to follow-up, leaving a cohort of 48 for the final analyses. After training, all outcome measures significantly improved in both groups. In Motricity Index-Lower of the affected limb, the Morning Walk® group (∆mean ± SD; 19.68 ± 14.06) showed greater improvement ( p = .034) than the control group (∆mean ± SD; 11.70 ± 10.65). And Berg Balance Scale scores improved more ( p = .047) in the Morning Walk® group (∆mean ± SD; 14.36 ± 9.01) than the control group (∆mean ± SD; 9.65 ± 8.14).

Conclusion:

Compared with conventional physiotherapy alone, our results suggest that voluntary strength and balance of stroke patients with hemiparesis might be improved with Morning Walk®–assisted gait training combined with conventional physiotherapy.

Functional differences in upper limb movement after early and chronic stroke based on kinematic motion indicators

AIMS

The main purpose of this study was to determine the changes in kinematic parameters of ischemic stroke affected upper limbs, during simple functional activity, to determine the most relevant changes.

METHODS

The OptiTrack system was used for motion capture. To determine upper extremity function in Activities of Daily Living (ADL) tasks. During particular phases, the following matrices were chosen: mean and peak speed, normalized movement unit, normalized jerk and phase movement time. The chosen matrices represent the speed and smoothness profile of end-point data. The the arm-trunk compensation was also taken into consideration. Twenty stroke patients, in early (G1 from 1 to 3 months after stroke) and chronic stage (G2 from 6 months to 1 year), were studied. The large and small cylinder forward and back transporting phases were evaluated.

RESULTS

The most significant differences between groups G1 and G2 were in mean and peak speed of the forward transport of the large and small cylinders for the paretic limb. Significant differences were also found for the smoothness (measured by movement unit, mean and peak speed and jerk) where the G2 group had a rougher motion. There were also differences in arm-trunk compensation in the frontal plane.

CONCLUSION

The variables used in the study showed applicability in assessing kinematic parameters in both the early and chronic period after stroke.

Effect of the combination of motor imagery and electrical stimulation on upper extremity motor function in patients with chronic stroke: preliminary results

Background

The combination of motor imagery (MI) and afferent input with electrical stimulation (ES) enhances the excitability of the corticospinal tract compared with motor imagery alone or electrical stimulation alone. However, its therapeutic effect is unknown in patients with hemiparetic stroke. We performed a preliminary examination of the therapeutic effects of MI + ES on upper extremity (UE) motor function in patients with chronic stroke.

Methods

A total of 10 patients with chronic stroke demonstrating severe hemiparesis participated. The imagined task was extension of the affected finger. Peripheral nerve electrical stimulation was applied to the radial nerve at the spiral groove. MI + ES intervention was conducted for 10 days. UE motor function as assessed with the Fugl-Meyer assessment UE motor score (FMA-UE), the amount of the affected UE use in daily life as assessed with a Motor Activity Log (MAL-AOU), and the degree of hypertonia in flexor muscles as assessed with the Modified Ashworth Scale (MAS) were evaluated before and after intervention. To assess the change in spinal neural circuits, reciprocal inhibition between forearm extensor and flexor muscles with the H reflex conditioning-test paradigm at interstimulus intervals (ISIs) of 0, 20, and 100 ms were measured before and after intervention.

Results

UE motor function, the amount of the affected UE use, and muscle hypertonia in flexor muscles were significantly improved after MI + ES intervention (FMA-UE: p < 0.01, MAL-AOU: p < 0.01, MAS: p = 0.02). Neurophysiologically, the intervention induced restoration of reciprocal inhibition from the forearm extensor to the flexor muscles (ISI at 0 ms: p = 0.03, ISI at 20 ms: p = 0.03, ISI at 100 ms: p = 0.01).

Conclusion

MI + ES intervention was effective for improving UE motor function in patients with severe paralysis.

Abnormal Metabolic Connectivity in Rats at the Acute Stage of Ischemic Stroke

Stroke at the acute stage is a major cause of disability in adults, and is associated with dysfunction of brain networks. However, the mechanisms underlying changes in brain connectivity in stroke are far from fully elucidated. In the present study, we investigated brain metabolism and metabolic connectivity in a rat ischemic stroke model of middle cerebral artery occlusion (MCAO) at the acute stage using 18F-fluorodeoxyglucose positron emission tomography. Voxel-wise analysis showed decreased metabolism mainly in the ipsilesional hemisphere, and increased metabolism mainly in the contralesional cerebellum. We used further metabolic connectivity analysis to explore the brain metabolic network in MCAO. Compared to sham controls, rats with MCAO showed most significantly reduced nodal and local efficiency in the ipsilesional striatum. In addition, the MCAO group showed decreased metabolic central connection of the ipsilesional striatum with the ipsilesional cerebellum, ipsilesional hippocampus, and bilateral hypothalamus. Taken together, the present study demonstrated abnormal metabolic connectivity in rats at the acute stage of ischemic stroke, which might provide insight into clinical research.

Neurorehabilitation therapy of patients with severe stroke based on functional electrical stimulation commanded by a brain computer interface

Introduction

Brain computer interface is an emerging technology to treat the sequelae of stroke. The purpose of this study was to explore the motor imagery related desynchronization of sensorimotor rhythms of stroke patients and to assess the efficacy of an upper limb neurorehabilitation therapy based on functional electrical stimulation controlled by a brain computer interface.

Methods

Eight severe chronic stroke patients were recruited. The study consisted of two stages: screening and therapy. During screening, the ability of patients to desynchronize the contralateral oscillatory sensorimotor rhythms by motor imagery of the most affected hand was assessed. In the second stage, a therapeutic intervention was performed. It involved 20 sessions where an electrical stimulator was activated when the patient's cerebral activity related to motor imagery was detected. The upper limb was assessed, before and after the intervention, by the Fugl-Meyer score (primary outcome). Spasticity, motor activity, range of movement and quality of life were also evaluated (secondary outcomes).

Results

Desynchronization was identified in all screened patients. Significant post-treatment improvement (p < 0.05) was detected in the primary outcome measure and in the majority of secondary outcome scores.

Conclusions

The results suggest that the proposed therapy could be beneficial in the neurorehabilitation of stroke individuals.

Intensive Multimodal Training to Improve Gait Resistance, Mobility, Balance and Cognitive Function in Persons With Multiple Sclerosis: A Pilot Randomized Controlled Trial

Introduction: Persons with multiple sclerosis (MS) have deficits in many aspects of physical and cognitive functioning that can impact on mobility and participation in daily life. The effect of a 4 week intensive multimodal treadmill training on functional mobility, balance, executive functions and participation in persons with MS with moderate to severe disability was investigated.

Methods: Thirty eight persons with MS admitted to a rehabilitation center participated in a two arm randomized 2:1 controlled trial. Participants in the experimental group received supervised intensive treadmill training including cognitive and motor dual tasks (DT-group, N = 26), 5 sessions per week and a control group received the same amount of supervised strength training (S-group, N = 12). The participants were assessed before and after the rehabilitation period with the 2 Minutes Walking Test (2MWT), speed and, static and dynamic balance measures, the Frontal Assessment Battery and the Short Form-12 questionnaire. The main hypothesis was related to the superiority of the treadmill intervention based on a greater proportion of people making a clinically relevant gain (15% increase on 2MWT) in gait resistance following treatment. ANCOVA (Analysis of covariance) models adjusting for baseline measurement of the respective outcome variable, as well as sex and age, were used to evaluate differences in efficacy for all variables. P was set at 0.05.

Results: Nineteen out of 26 persons in the DT-group made a clinically relevant gain and two out of 12 in the S-Group (P = 0.001). The DT-group improved more in gait resistance, speed and mobility (P < 0.01). Balance and executive functions instead improved moderately in both groups following training while perception of health remained similar in both groups.

Conclusion: A four week multimodal training on treadmill was highly effective in augmenting gait resistance and mobility in moderately to severely affected persons with MS.

Manual function of the unaffected upper extremity can affect functional outcome after stroke

Traditionally, motor deficits of ipsilesional side, generally considered as the unaffected side, have been investigated less and the influence of the impairment is unknown. To evaluate the association between the manual function test (MFT) of nonparetic limb and poststroke functional outcome. We conducted a retrospective analysis of 71 hemiplegic patients with stroke. MFT on both sides was routinely measured at admission and 1 month later after admission by an experienced occupational therapist. The parameters of functional outcome after stroke were measured with the total score of functional independence measure (FIM) and the self-care subscore of FIM. Age, initial cognitive function, and MFT of the affected hand and unaffected hand were each significant factors for independently predicting short-term functional outcome after stroke. Linear regression analysis showed that initial MFT score of unaffected side is a significant predictor for 1 month follow-up subscore FIM (P<0.0001) and total FIM score (P<0.0001). Our findings suggests that initial MFT score of the nonparetic side has a significant correlation with functional outcome. Therefore, it is important to conduct MFT on the nonparetic side as well as the paretic side. Furthermore, it is necessary to undergo rehabilitation therapy on the nonparetic side.

Effects of a 4-Week Self-Ankle Mobilization with Movement Intervention on Ankle Passive Range of Motion, Balance, Gait, and Activities of Daily Living in Patients with Chronic Stroke: A Randomized Controlled Study

GOAL

To compare the effects of a 4-week self-ankle mobilization with movement training program with those of self-ankle mobilization with movement with a 10° inclined board in patients with chronic stroke.

MATERIALS AND METHODS

A randomized controlled assessor-blind trial was conducted. The patients were randomized into 2 arms. Subjects were 28 chronic stroke patients with hemiplegia. Both arms attended standard rehabilitation therapy for 30 minutes per session. In addition, self-ankle mobilization with movement and self-ankle mobilization with movement with a 10° inclined board trainings were performed 3 times per week for 4 weeks. Ankle dorsiflexion passive range of motion, static balance ability, Berg balance scale, gait parameters (walking speed, cadence, and step length), and activities of daily living were used to assess changes in motor function after training.

FINDINGS

After 4 weeks of training, all dependent variables were significantly improved in both arms as compared with their baseline values. Furthermore, relative to the self-ankle mobilization with movement arm, the self-ankle mobilization with movement with a 10° inclined board arm demonstrated significantly improved ankle dorsiflexion passive range of motion, static balance ability, gait speed, cadence, and affected-side step length.

CONCLUSIONS

Our results support the hypothesis that self-ankle mobilization with movement with a 10° inclined board combined with standard rehabilitation was superior to self-ankle mobilization with movement combined with standard rehabilitation with respect to the improvement in motor function in the patients with chronic stroke.

Lateral visual occlusion does not change walking trajectories

Difficulties with walking are often reported following brain damage that causes a lateralized loss of awareness on one side. Whether lateralized loss of awareness has a direct causal impact on walking is unknown. A review of the literature on visually guided walking suggests several reasons why a lateralized loss of visual awareness might be expected to lead to difficulties walking. Here, we isolated and examined the effect of lateralized vision loss on walking behavior in real and virtual environments. Healthy young participants walked to a target placed within a real room, in a virtual corridor, or on a virtual ground plane. In the ground-plane condition, the scene either was empty or contained three obstacles. We reduced vision on one side by occluding one eye (Experiment 1 and 2) or removing one hemifield, defined relative to either the head or trunk (Experiment 2), through use of eye patching (Experiment 1) and a virtual-reality system (Experiment 2). Visual-field restrictions did not induce significant deviations in walking paths in any of the occlusion conditions or any of the environments. The results provide further insight into the visual information that guides walking in humans, and suggest that lateralized vision loss on its own is not the primary cause of walking difficulties.

New Treatment Approaches on the Horizon for Spastic Hemiparesis

This article presents 2 recent articles that propose novel interventions for treating spastic hemiparesis by changing biological infrastructure. In 18 patients with unilateral spastic arm paralysis due to chronic cerebral injury greater than 5 years' duration, Zheng et al transferred the C7 nerve from the nonparalyzed side to the side of the arm that was paralyzed. Over a follow-up period of 12 months, they found greater improvement in function and a reduction of spasticity compared to rehabilitation alone. Using functional magnetic resonance imaging, they also found evidence for physiological connectivity between the ipsilateral cerebral hemisphere and the paralyzed hand. In the second article, Raghavan et al examine the concept of stiffness, a common symptom in patients with spastic hemiparesis, as a physical change in the infrastructure of muscle. Raghavan's non-neural hyaluronan hypothesis postulates that an accumulation of hyaluronan within spastic muscles promotes the development of muscle stiffness in patients with an upper motor neuron syndrome (UMNS). In a case series of 20 patients with spastic hemiparesis, Raghavan et al report that upper limb intramuscular injections of hyaluronidase increased passive and active joint movement and reduced muscle stiffness. Interventions that change biological infrastructure in UMNS is a paradigm on the horizon that bears watching.

Effects of a 6-month self-rehabilitation programme in addition to botulinum toxin injections and conventional physiotherapy on limitations of patients with spastic hemiparesis following stroke (ADJU-TOX): protocol study for a randomised controlled, investigator blinded study

INTRODUCTION

Home-based self-rehabilitation programmes combined with botulinum toxin injections (BTIs) appear to be a relevant approach to increase the recommended intensive rehabilitation of patients with spasticity following a stroke. The literature highlights a lack of evidence of beneficial effects of this adjuvant therapy to reduce limitations of patients with stroke. The aim of this study is to assess the effects of a 6-month self-rehabilitation programme in adjunction to BTI, in comparison with BTI alone, to reduce limitations of patients with spasticity following a stroke.

METHODS AND ANALYSIS

220 chronic patients will participate to this multicentre, prospective, randomised, controlled, assessor blinded study. All patients will benefit from two successive BTI (3 months apart), and patients randomised in the self-rehabilitation group will perform in adjunction 6 months of self-rehabilitation at home. All patients continue their conventional physiotherapy. The main outcome is the primary treatment goal (PTG), which will be determined jointly by the patient and the medical doctor using Goal Attainment Scaling. Impairments and functions, quality of life, mood and fatigue will be assessed. Botulinum toxin will be injected into the relevant muscles according to the PTG. Patients in the self-rehab group will be taught the self-rehabilitation programme involving respectively 10 min of stretching, 10 min of strengthening and 10 min of task-oriented exercises, corresponding to their PTG. Compliance to the self-rehabilitation programme will be monitored.

ETHICS AND DISSEMINATION

Patients will sign written informed consent. Ethical approval was obtained from ethics committee. The results will be disseminated in a peer-reviewed journal and presented at international congresses. The results will also be disseminated to patients.

TRIAL REGISTRATION NUMBER

NCT02944929.

Effects of Temporary Functional Deafferentation in Chronic Stroke Patients: Who Profits More?

Temporary functional deafferentation (TFD) by an anesthetic cream on the stroke-affected forearm was shown to improve sensorimotor abilities of stroke patients. The present study investigated different predictors for sensorimotor improvements during TFD and indicated outcome differences between patients grouped in subcortical lesions only and lesions with any cortical involvement. Thirty-four chronic stroke patients were temporarily deafferented on the more affected forearm by an anesthetic cream. Somatosensory performance was assessed using von Frey Hair and grating orientation task; motor performance was assessed by a shape-sorter-drum task. Seven potential predictors were entered into three linear multiple regression models. Furthermore, effects of TFD on outcome variables for the two groups (cortical versus subcortical lesion) were compared. Sex and sensory deficit were significant predictors for changes in motor function while age accounted for changes in grating orienting task. Males, patients with a stronger sensory deficit, and older patients profited more. None of the potential predictors made significant contributions to changes in threshold for touch. Furthermore, there were no differences in sensorimotor improvement between lesion site groups. The effects of TFD together with the low predictability of the investigated parameters suggest that characteristics of patients alone are not suitable to exclude some patients from TFD.

Adoption of Stroke Rehabilitation Technologies by the User Community: Qualitative Study

Background

Using technology in stroke rehabilitation is attractive. Devices such as robots or smartphones can help deliver evidence-based levels of practice intensity and automated feedback without additional labor costs. Currently, however, few technologies have been adopted into everyday rehabilitation.

Objective

This project aimed to identify stakeholder (therapists, patients, and caregivers) priorities for stroke rehabilitation technologies and to generate user-centered solutions for enhancing everyday adoption.

Methods

We invited stakeholders (n=60), comprising stroke survivors (20/60, 33%), therapists (20/60, 33%), caregivers, and technology developers (including researchers; 20/60, 33%), to attend 2 facilitated workshops. Workshop 1 was preceded by a national survey of stroke survivors and therapists (n=177) to generate an initial list of priorities. The subsequent workshop focused on identifying practical solutions to enhance adoption.

Results

A total of 25 priorities were generated from the survey; these were reduced to 10 nonranked priorities through discussion, consensus activities, and voting at Workshop 1: access to technologies, ease of use, awareness of available technologies, technologies focused on function, supports self-management, user training, evidence of effectiveness, value for money, knowledgeable staff, and performance feedback. The second workshop provided recommendations for improving the adoption of technologies in stroke rehabilitation: an annual exhibition of commercially available and developing technologies, an online consumer-rating website of available technologies, and a user network to inspire and test new technologies.

Conclusions

The key outcomes from this series of stakeholder workshops provides a starting point for an integrated approach to promoting greater adoption of technologies in stroke rehabilitation. Bringing technology developers and users together to shape future and evaluate current technologies is critical to achieving evidence-based stroke rehabilitation.

Music meets robotics: a prospective randomized study on motivation during robot aided therapy

BACKGROUND

Robots have been successfully applied in motor training during neurorehabilitation. As music is known to improve motor function and motivation in neurorehabilitation training, we aimed at integrating music creation into robotic-assisted motor therapy. We developed a virtual game-like environment with music for the arm therapy robot ARMin, containing four different motion training conditions: a condition promoting creativity (C+) and one not promoting creativity (C-), each in a condition with (V+) and without (V-) a visual display (i.e., a monitor). The visual display was presenting the game workspace but not contributing to the creative process itself. In all four conditions the therapy robot haptically displayed the game workspace. Our aim was to asses the effects of creativity and visual display on motivation.

METHODS

In a prospective randomized single-center study, healthy participants were randomly assigned to play two of the four training conditions, either with (V+) or without visual display (V-). In the third round, the participants played a repetition of the preferred condition of the two first rounds, this time with a new V condition (i.e., with or without visual display). For each of the three rounds, motivation was measured with the Intrinsic Motivation Inventory (IMI) in the subscales interest/enjoyment, perceived choice, value/usefulness, and man-machine-relation. We recorded the actual training time, the time of free movement, and the velocity profile and administered a questionnaire to measure perceived training time and perceived effort. All measures were analysed using linear mixed models. Furthermore, we asked if the participants would like to receive the created music piece.

RESULTS

Sixteen healthy subjects (ten males, six females, mean age: 27.2 years, standard deviation: 4.1 years) with no known motor or cognitive deficit participated. Promotion of creativity (i.e., C+ instead of C-) significantly increased the IMI-item interest/enjoyment (p=0.001) and the IMI-item perceived choice (p=0.010). We found no significant effects in the IMI-items man-machine relation and value/usefulness. Conditions promoting creativity (with or without visual display) were preferred compared to the ones not promoting creativity. An interaction effect of promotion of creativity and omission of visual display was present for training time (p=0.013) and training intensity (p<0.001). No differences in relative perceived training time, perceived effort, and perceived value among the four training conditions were found.

CONCLUSIONS

Promoting creativity in a visuo-audio-haptic or audio-haptic environment increases motivation in robot-assisted therapy. We demonstrated the feasibility of performing an audio-haptic music creation task and recommend to try the system on patients with neuromuscular disorders.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02720341. Registered 25 March 2016, https://clinicaltrials.gov/ct2/show/NCT02720341.

Gait and balance one year after stroke; relationships with lesion side, subtypes of cognitive impairment and neuroimaging findings-a longitudinal, cohort study

OBJECTIVES

The aims of this study are to investigate impairments of balance and gait in various types of dementia and cognitive impairment, and neuroimaging correlates in patients one year after first-ever stroke or transient ischemic attack.

DESIGN

This is a longitudinal cohort study.

PARTICIPANTS

180 participants were included and a total of 156 participated in the assessments at the one-year follow-up.

MAIN OUTCOME MEASURES

Measurements of balance and gait comprised the Berg Balance Scale (BBS) and the 10meter walk test (10MWT). Dementia was diagnosed with the International Classification of Diseases 10th revision. Magnet Resonance Imaging assessed vascular and degenerative changes in the brain. Multivariate linear regressions were conducted regarding associations between the motoric test performances, white matter lesions, lesion of the stroke and cognition.

RESULTS

Cognitive impairment was significant associated with BBS (β=-7.28, P=0.005) and MWS (β=1.89, P=0.046) in the linear regression analyses. An association between 10MWT to living arrangements (β=1.58, P=0.049) and lesion side of the stroke (β=-1.50, P=0.037) was also observed. Pairwise associations with Mann-Whitney U test showed that participants with mixed pathology differed significantly from degenerative pathology (P=0.04, z=-2.1) with more impaired balance measured by BBS.

CONCLUSIONS

Impaired balance and gait are associated with cognitive impairment, and a lesion in the right hemisphere is related to impaired gait in this cohort of stroke survivors.