Upper Limb Motor Impairment After Stroke

An Exploration of the Effectiveness of Different Intensity Protocols of Modified Constraint-Induced Therapy in Stroke: A Systematic Review

Purpose

To examine the effectiveness of different modified Constraint-Inuced Therapy (mCIMT) protocol intensities on upper extremity motor function in adults with hemiplegia.

Methods

A search was conducted in PubMed, Scopus, EBSCO, and Cochrane Library for articles published between April 2010 and December 2021. Only randomized controlled trials (RCTs) were included. Studies were excluded if they used a sample of less than five, mCIMT in combination with other therapy, and/or if they were not written in English. Methodologic quality was assessed using the Cochrane collaboration risk of bias tool-2.

Results

Thirty-six RCTs with a total of 721 participants were included. Most researchers followed a moderate to low protocol intensity in terms of total treatment time and moderate to high intensity with regard to restriction time. Almost all of the upper limb motor function measures showed statistically significant improvements (p < .05) after mCIMT, irrespective of the protocol's intensity, but there was lack of high-quality studies. Statistically significant improvements did not always translate to clinical importance.

Conclusions

Low-intensity CIMT protocols may result in comparable improvements to more intensive ones but caution has to be taken when drawing conclusions due to high risk of bias studies.

A survey to assess perspectives of people with chronic stroke about customized safety harnesses for dance-based exergaming in home settings

BACKGROUND

Early dance-based exergaming (DBExG) trials in people with chronic stroke (PwCS) have shown promising results, but there remains a lack of knowledge if PwCS are interested in receiving such training in their homes and the applicability of a fall-protection safety harness in the home environment.

OBJECTIVE

To survey people with chronic stroke to understand the perspectives and preferences of various customized safety harnesses for home-based harness assisted dance-based exergaming rehabilitation.

METHODS

Participants were included in this survey study if they had a stroke, lived in the community, and understood English. Participants completed a study-specific safety harness survey via mail, in-person, or online. Descriptive statistics were used to characterize the sample and survey responses.

RESULTS

One hundred two survey responses were returned. The majority of participants voted for a door mountable harness (51%), side-release style buckle (58%), and preferred to receive a manual to explain how to use the harness (51%). Seventy-eight percent of the participants required permission to install or use a harness system in their homes. More than half of the participants preferred exhibiting independence by strapping the harness themselves (68%), along with choosing to live independently (the ability to live in one's own home and community safely, independently, comfortably, and able also perform their activities of daily living, regardless of physical ability level) (89%).

CONCLUSIONS

PwCS opted to use ShA-DBExG in their homes. The current survey serves as a guideline to develop, customize, and prescribe home-based ShA-DBExG rehabilitation.

Cognitive and Motor Therapy After Stroke Is Not Superior to Motor and Cognitive Therapy Alone to Improve Cognitive and Motor Outcomes: New Insights From a Meta-analysis

OBJECTIVE

To evaluate whether cognitive and motor therapy (CMT) is more effective than no therapy, motor therapy, or cognitive therapy on motor and/or cognitive outcomes after stroke. Additionally, this study evaluates whether effects are lasting and which CMT approach is most effective.

DATA SOURCES

AMED, EMBASE, MEDLINE/PubMed, and PsycINFO databases were searched in October 2022.

STUDY SELECTION

Twenty-six studies fulfilled the inclusion criteria: randomized controlled trials published in peer-reviewed journals since 2010 that investigated adults with stroke, delivered CMT, and included at least 1 motor, cognitive, or cognitive-motor outcome. Two CMT approaches exist: CMT dual-task ("classical" dual-task where the secondary cognitive task has a distinct goal) and CMT integrated (where cognitive components of the task are integrated into the motor task).

DATA EXTRACTION

Data on study design, participant characteristics, interventions, outcome measures (cognitive/motor/cognitive-motor), results and statistical analysis were extracted. Multilevel random effects meta-analysis was conducted.

DATA SYNTHESIS

CMT demonstrated positive effects compared with no therapy on motor outcomes (g=0.49; 95% confidence interval [CI], 0.10, 0.88) and cognitive-motor outcomes (g=0.29; 95% CI, 0.03, 0.54). CMT showed no significant effects compared with motor therapy on motor, cognitive, and cognitive-motor outcomes. A small positive effect of CMT compared with cognitive therapy on cognitive outcomes (g=0.18; 95% CI, 0.01, 0.36) was found. CMT demonstrated no follow-up effect compared with motor therapy (g=0.07; 95% CI, -0.04, 0.18). Comparison of CMT dual-task and integrated revealed no significant difference for motor (F1,141=0.80; P=.371) or cognitive outcomes (F1,72=0.61, P=.439).

CONCLUSIONS

CMT was not superior to monotherapies in improved outcomes after stroke. CMT approaches were equally effective, suggesting that training that enlists a cognitive load per se may benefit outcomes.

Delivering constraint-induced movement therapy in stroke rehabilitation requires informed stakeholders, sufficient resources and organisational buy-in: a mixed-methods systematic review

OBJECTIVE

To summarise and synthesise the qualitative literature relating to constraint-induced movement therapy (CIMT) among stroke survivors, carers, therapists and rehabilitation service managers.

DESIGN

Systematic review of qualitative studies. Quantitative studies using survey data were also included if they investigated perceptions and/or experiences related to CIMT.

DATA SOURCES

Cochrane Library, Medline, JBI, Emcare, Embase, PsycInfo, CINAHL, PEDro, OT Seeker and NICE from inception to January 2022.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data from the included studies and assessed comprehensiveness of reporting using established tools. Thematic synthesis was undertaken to synthesise findings for studies using focus groups and interviews. A summary of themes from quantitative studies using survey data was compiled to complement the qualitative synthesis.

RESULTS

Searches yielded 1,450 titles after removal of duplicates; 60 full-text articles were assessed for eligibility and 14 studies were included (1,570 total participants). Thematic synthesis identified nine descriptive themes from which four analytical themes were developed: CIMT is challenging but support at all levels helps; therapists need the know-how, resources and staffing; CIMT is different to other interventions, and there are positives and negatives to this; and functional outcomes do not always meet high expectations. Quantitative survey themes included: knowledge, skills and confidence in delivering CIMT programs; patient factors; and institutional factors.

CONCLUSIONS

This review identified several determinants of implementation related to CIMT. Rehabilitation therapists need to develop their knowledge and skills to deliver CIMT, engage with organisational leaders, and develop CIMT protocols to fit the local clinical context in order to sustainably deliver CIMT in stroke rehabilitation services. Stroke survivors and carers require improved education to increase their engagement and participation. After addressing these determinants, future research should evaluate population-level outcomes and policy-level implementation in establishing CIMT as global standard rehabilitation practice.

REGISTRATION

CRD42021237757.

The relationship between Rating of Everyday Arm-use in the Community and Home (REACH) scale affected arm-use assessment, activity and participation after stroke

BACKGROUND AND OBJECTIVES

While arm function has been traditionally used as a primary goal for upper extremity rehabilitation post-stroke, we propose a simple measure of arm use, which may translate into better activities and participation. The aim was to determine the relationship between arm use and measures of activity and participation.

METHODS

This was a cross-sectional study with evaluative components involving community-dwelling individuals with chronic stroke. The Rating of Everyday Arm-Use in the Community and Home (REACH) Scale was used to assess affected arm use, Barthel Index and activity domain of the Stroke Impact Scale (SIS) for activities, and participation domain of the SIS for participation. The participants were also asked if they resumed driving after the stroke.

RESULTS

Forty-nine individuals (mean age = 70.3 ± 11.5 years, male sex = 51%) living with the effects of a stroke for at least 3 months participated in this study. There was a positive relationship between affected arm use and activities (Barthel Index score - rs  = 0.464; SIS activities - rs  = 0.686), participation (rs  = 0.479), and driving (rs  = 0.581). The Barthel Index scores were higher for individuals with dominant arm hemiparesis (p = 0.003) or left hemisphere lesions (p = 0.005). There was also greater arm use in left hemisphere lesions (p = 0.018).

CONCLUSIONS

Affected arm use in individuals with chronic stroke is related to activities and participation. Given the importance of arm use in activities and participation after stroke, rehabilitation therapists may consider utilizing the REACH Scale, a simple and quick outcome measure, as a means to assess arm use and implement effective interventions for improving arm use.

Psychometric properties of the Chinese version of the Arm Activity Measure in people with chronic stroke

Introduction

The Arm Activity Measure was developed to assess active and passive functions of the upper limb in people with unilateral paresis, but a Chinese version is not available and its psychometric properties have not been specifically tested in people with stroke. This study aimed to translate and culturally adapt the Chinese version of the Arm Activity Measure (ArmA-C) and establish its psychometric properties in people with chronic stroke.

Methods

The psychometric properties of ArmA-C were determined in 100 people with chronic stroke.

Results

The ArmA-C had good test-retest reliability (intraclass correlation coefficients [ICC] = 0.87-0.93; quadratic weighted Kappa coefficients = 0.53-1.00). A floor effect was identified in section A of the ArmA-C. The content validity and internal consistency (Cronbach's alpha coefficients = 0.75-0.95) were good. The construct validity of the ArmA-C was supported by acceptable fit to the two-factor structure model and significant correlations with the Fugl-Meyer Assessment for Upper Extremity score, grip strength, the Wolf Motor Function Test score, the Trail Walking Test completion time, and the Oxford Participation and Activities Questionnaire scores.

Conclusions

The ArmA-C is reliable and valid for assessing active and passive functions in people with chronic stroke.

Exploring the Feasibility of Computer Vision for Detecting Post-Stroke Compensatory Movements

Compensatory movements are commonly observed post-stroke and can negatively affect long-term motor recovery. In this context, a system that monitors movement quality and provides feedback would be beneficial. In this study, we aimed to detect compensatory movements during seated reaching using a conventional tablet camera and an open-source markerless body pose tracking algorithm called MediaPipe [1]. We annotated compensatory movements of stroke patients per frame based on the comparison between the paretic and non-paretic arms. We trained a binary classification model using the XGBoost algorithm to detect compensatory movements, which showed an average accuracy of 0.92 (SD 0.07) in leave-one-trial-out cross-validation across four participants. Although we observed good model performance, we also encountered challenges such as missing landmarks and misalignment, when using MediaPipe Pose. This study highlights the feasibility of using near real-time compensatory movement detection with a simple camera system in stroke rehabilitation. More work is necessary to assess the generalizability of our approach across diverse groups of stroke survivors and fully implement near real-time compensatory movement detection on a mobile device.

Impact of unilateral and bilateral impairments on bimanual force production following stroke

Large bilateral asymmetry and task deficits are typically observed during bimanual actions of stroke survivors. Do these abnormalities originate from unilateral impairments affecting their more-impaired limb, such as weakness and abnormal synergy, or from bilateral impairments such as incoordination of two limbs? To answer this question, 23 subjects including 10 chronic stroke survivors and 13 neurologically intact subjects participated in an experiment where they produced bimanual forces at different hand locations. The force magnitude and directional deviation of the more-impaired arm were measured for unilateral impairments and bimanual coordination across locations for bilateral impairments. Force asymmetry and task error were used to define task performance. Significant unilateral impairments were observed in subjects with stroke; the maximal force capacity of their more-impaired arm was significantly lower than that of their less-impaired arm, with a higher degree of force deviation. However, its force contribution during submaximal tasks was greater than its relative force capacity. Significant bilateral impairments were also observed, as stroke survivors modulated two forces to a larger degree across hand locations but in a less coordinated manner than control subjects did. But only unilateral, not bilateral, impairments explained a significant amount of between-subject variability in force asymmetry across subjects with stroke. Task error, in contrast, was correlated with neither unilateral nor bilateral impairments. Our results suggest that unilateral impairments of the more-impaired arm of stroke survivors mainly contribute to its reduced recruitment, but that the degree of its participation in bimanual task may be greater than their capacity as they attempt to achieve symmetry.NEW & NOTEWORTHY We studied how unilateral and bilateral impairments in stroke survivors affect their bimanual task performance. Unilateral impairments of the more-impaired limb, both weakness and loss of directional control, mainly contribute to bimanual asymmetry, but stroke survivors generally produce higher force with their more-impaired limb than their relative capacity. Bilateral force coordination was significantly impaired in stroke survivors, but its degree of impairment was not related to their unilateral impairments.

Efficacy of Robot-Assisted Training on Rehabilitation of Upper Limb Function in Patients With Stroke: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically evaluate the effect of robot-assisted training (RAT) on upper limb function recovery in patients with stroke, providing the evidence-based medical basis for the clinical application of RAT.

DATA SOURCES

We searched online electronic databases up to June 2022, including PubMed, The Cochrane Library, Scopus, Web of Science, EMBASE, WanFang Data, CNKI, and VIP full-text databases.

STUDY SELECTION

Randomized controlled trials of the effect of RAT on upper extremity functional recovery in patients with stroke.

DATA EXTRACTION

The Cochrane Collaboration Tool for Assessing the Risk of Bias was used to assess study quality and risk of bias.

DATA SYNTHESIS

Fourteen randomized controlled trials involving 1275 patients were included for review. Compared with the control group, RAT significantly improved upper limb motor function and daily living ability. The overall differences were statistically significant, Fugl-Meyer Assessment for the Upper Extremity (FMA-UE; standard mean difference=0.69; 95% confidence interval, 0.34, 1.05; P=.0001), modified Barthel Index (standard mean difference=0.95; 95% confidence interval, 0.75, 1.15; P<.00001), whereas the differences in modified Ashworth Scale, FIM, and Wolf Motor Function Test scores were not statistically significant.

SUBGROUP ANALYSIS

Compared with the control group, the differences between FMA-UE and modified Barthel Index at 4 and 12 weeks of RAT, there were statistically significant, the differences of FMA-UE and modified Ashworth Scale in patients with stroke in the acute and chronic phases were statistically significant.

CONCLUSION

The present study showed that RAT can significantly enhance the upper limb motor function and activities of daily life in patients with stroke undergoing upper limb rehabilitation.

Uncertainty-aware automated assessment of the arm impedance with upper-limb exoskeletons

Providing high degree of personalization to a specific need of each patient is invaluable to improve the utility of robot-driven neurorehabilitation. For the desired customization of treatment strategies, precise and reliable estimation of the patient's state becomes important, as it can be used to continuously monitor the patient during training and to document the rehabilitation progress. Wearable robotics have emerged as a valuable tool for this quantitative assessment as the actuation and sensing are performed on the joint level. However, upper-limb exoskeletons introduce various sources of uncertainty, which primarily result from the complex interaction dynamics at the physical interface between the patient and the robotic device. These sources of uncertainty must be considered to ensure the correctness of estimation results when performing the clinical assessment of the patient state. In this work, we analyze these sources of uncertainty and quantify their influence on the estimation of the human arm impedance. We argue that this mitigates the risk of relying on overconfident estimates and promotes more precise computational approaches in robot-based neurorehabilitation.

Development and Validation of the Body Cognition Assessment System

Body awareness, which comprises the sense of body possession and action ownership, is essential for the adaptive movement of humans in response to external environments. However, existing body cognition assessments include many overt elements of cognitive functional activity, but no assessment captures the latent body cognition necessary for exercise and daily life activities. Therefore, this study aimed to devise a body cognition assessment system (BCAS) to examine the functional basis of body cognition in healthy participants and investigate its usefulness. The BCAS was used to assess body cognition on three occasions, and BCAS values were calculated from the results of the assessment. The intraclass correlation coefficient (ICC) was used to determine reproducibility. Neural activity in the brain during somatocognition assessment while conducting the BCAS was measured by electroencephalogram. Moreover, the functional basis for somatocognition with the BCAS was also investigated. The results demonstrated that the BCAS values varied across the three administrations (ICC (1.3) = 0.372), and changes in the state of neural activity in the brain were observed. The results suggest that assessment using the BCAS may be a new indicator of ever-changing body cognition.

The Translation of Mobile-Exoneuromusculoskeleton-Assisted Wrist-Hand Poststroke Telerehabilitation from Laboratory to Clinical Service

Rehabilitation robots are helpful in poststroke telerehabilitation; however, their feasibility and rehabilitation effectiveness in clinical settings have not been sufficiently investigated. A non-randomized controlled trial was conducted to investigate the feasibility of translating a telerehabilitation program assisted by a mobile wrist/hand exoneuromusculoskeleton (WH-ENMS) into routine clinical services and to compare the rehabilitative effects achieved in the hospital-service-based group (n = 12, clinic group) with the laboratory-research-based group (n = 12, lab group). Both groups showed significant improvements (p ≤ 0.05) in clinical assessments of behavioral motor functions and in muscular coordination and kinematic evaluations after the training and at the 3-month follow-up, with the lab group demonstrating better motor gains than the clinic group (p ≤ 0.05). The results indicated that the WH-ENMS-assisted tele-program was feasible and effective for upper limb rehabilitation when integrated into routine practice, and the quality of patient-operator interactions physically and remotely affected the rehabilitative outcomes.

Functional electrical stimulation therapy controlled by a P300-based brain-computer interface, as a therapeutic alternative for upper limb motor function recovery in chronic post-stroke patients. A non-randomized pilot study

Introduction

Up to 80% of post-stroke patients present upper-limb motor impairment (ULMI), causing functional limitations in daily activities and loss of independence. UMLI is seldom fully recovered after stroke when using conventional therapeutic approaches. Functional Electrical Stimulation Therapy (FEST) controlled by Brain-Computer Interface (BCI) is an alternative that may induce neuroplastic changes, even in chronic post-stroke patients. The purpose of this work was to evaluate the effects of a P300-based BCI-controlled FEST intervention, for ULMI recovery of chronic post-stroke patients.

Methods

A non-randomized pilot study was conducted, including 14 patients divided into 2 groups: BCI-FEST, and Conventional Therapy. Assessments of Upper limb functionality with Action Research Arm Test (ARAT), performance impairment with Fugl-Meyer assessment (FMA), Functional Independence Measure (FIM) and spasticity through Modified Ashworth Scale (MAS) were performed at baseline and after carrying out 20 therapy sessions, and the obtained scores compared using Chi square and Mann-Whitney U statistical tests (𝛼 = 0.05).

Results

After training, we found statistically significant differences between groups for FMA (p = 0.012), ARAT (p < 0.001), and FIM (p = 0.025) scales.

Discussion

It has been shown that FEST controlled by a P300-based BCI, may be more effective than conventional therapy to improve ULMI after stroke, regardless of chronicity.

Conclusion

The results of the proposed BCI-FEST intervention are promising, even for the most chronic post-stroke patients often relegated from novel interventions, whose expected recovery with conventional therapy is very low. It is necessary to carry out a randomized controlled trial in the future with a larger sample of patients.

Validity of the telematic Fugl Meyer assessment scale - upper extremity (TFMA-UE) Spanish version

Background

Telematic assistance has become indispensable in recent years. The increased prevalence of Acquired brain injury and the sequels it causes, requires long-lasting multidisciplinary treatments. Validated tools to assess the evolution of the disabilities and limitations of this pathology are essential to individualize and prescribe adapted treatments. The aim has been to create the telematic version of the Fugl Meyer Assessment-Upper Extremity Motor Function (TFMA-UE) Spanish scale and its adaptation to the remote assessment of neurologic patients.

Methods

An adapted scale was designed based on the Fugl Meyer Assessment scale-telematic version (FMA-TV): TFMA-UE. This scale is composed by 21 items which evaluate the upper extremity motor function. Physiotherapists trained in this tool, evaluate the results obtained from applying the two versions (on-site and telematic) to compare the results.

Results

TFMA-UE was administered to 30 patients with acquired brain injury. It was applied on site and through the web platform selected by the patients in two different days. Patients completed all the scale in an easily way without help. The exploratory and confirmatory factor analysis confirmed a factorial structure with a factor (76.08% of the variance). The Cronbach's internal consistency index obtained was 0.98 and the weight kappa index used to measure agreement between the two versions was 0.78 which represents substantial agreement.

Conclusion

The Telematic Fugl Meyer Assessment-Upper Extremity Motor Function (TFMA-UE) scale is a viable, useful and easy to apply tool that allows the upper extremity motor function assessment of Acquired Brain Injury patients.

Biomimetic Design of a Tendon-Driven Myoelectric Soft Hand Exoskeleton for Upper-Limb Rehabilitation

Degenerative diseases and injuries that compromise hand movement reduce individual autonomy and tend to cause financial and psychological problems to their family nucleus. To mitigate these limitations, over the past decade, hand exoskeletons have been designed to rehabilitate or enhance impaired hand movements. Although promising, these devices still have limitations, such as weight and cost. Moreover, the movements performed are not kinematically compatible with the joints, thereby reducing the achievements of the rehabilitation process. This article presents the biomimetic design of a soft hand exoskeleton actuated using artificial tendons designed to achieve low weight, volume, and cost, and to improve kinematic compatibility with the joints, comfort, and the sensitivity of the hand by allowing direct contact between the hand palm and objects. We employed two twisted string actuators and Bowden cables to move the artificial tendons and perform the grasping and opening of the hand. With this configuration, the heavy part of the system was reallocated to a test bench, allowing for a lightweight set of just 232 g attached to the arm. The system was triggered by the myoelectric signals of the biceps captured from the user's skin to encourage the active participation of the user in the process. The device was evaluated by five healthy subjects who were asked to simulate a paralyzed hand, and manipulate different types of objects and perform grip strength. The results showed that the system was able to identify the intention of movement of the user with an accuracy of 90%, and the orthosis was able to enhance the ability of handling objects with gripping force up to 1.86 kgf.

Feasibility of a serious game system including a tangible object for post stroke upper limb rehabilitation: a pilot randomized clinical study

Introduction

Serious games can be used to provide intensive rehabilitation through attractive exercises as part of post-stroke rehabilitation. However, currently available commercial and serious games systems primarily train shoulder and elbow movements. These games lack the grasping and displacement components that are essential to improve upper limb function. For this reason, we developed a tabletop device that encompassed a serious game with a tangible object to rehabilitate combined reaching and displacement movements: the Ergotact system.

Objectives

The aim of this pilot study was to assess the feasibility and the short-term effects of a training program using the Ergotact prototype in individuals with chronic stroke.

Methods

Participants were assigned to one of two groups: a serious game training group (Ergotact) or a control training group (Self).

Results

Twenty-eight individuals were included. Upper limb function increased after the Ergotact training program, although not statistically significantly, and the program did not induce pain or fatigue, demonstrating its safety.

Conclusion

The Ergotact system for upper limb rehabilitation was well accepted and induced participant satisfaction. It complies with current recommendations for people with stroke to autonomously perform intensive active exercises in a fun context, in addition to conventional rehabilitation sessions with therapists.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT03166020?term=NCT03166020&draw=2&rank=1, identifier NCT03166020.

Repetitive transcranial magnetic stimulation for stroke rehabilitation: insights into the molecular and cellular mechanisms of neuroinflammation

Stroke is a leading cause of mortality and disability worldwide, with most survivors reporting dysfunctions of motor, sensation, deglutition, cognition, emotion, and speech, etc. Repetitive transcranial magnetic stimulation (rTMS), one of noninvasive brain stimulation (NIBS) techniques, is able to modulate neural excitability of brain regions and has been utilized in neurological and psychiatric diseases. Moreover, a large number of studies have shown that the rTMS presents positive effects on function recovery of stroke patients. In this review, we would like to summarized the clinical benefits of rTMS for stroke rehabilitation, including improvements of motor impairment, dysphagia, depression, cognitive function, and central post-stroke pain. In addition, this review will also discuss the molecular and cellular mechanisms underlying rTMS-mediated stroke rehabilitation, especially immune regulatory mechanisms, such as regulation of immune cells and inflammatory cytokines. Moreover, the neuroimaging technique as an important tool in rTMS-mediated stroke rehabilitation has been discussed, to better understanding the mechanisms underlying the effects of rTMS. Finally, the current challenges and future prospects of rTMS-mediated stroke rehabilitation are also elucidated with the intention to accelerate its widespread clinical application.

The Effects of Shock Wave Therapy on Spasticity and Walking Ability in People with Stroke: A Comparative Study of Different Application Sites

BACKGROUND

This study was conducted to investigate the effects of extracorporeal shock wave therapy on the improvement of walking ability through a reduction in spasticity in stroke patients.

METHODS

Thirty-three patients diagnosed with ischemic stroke by a rehabilitation medicine specialist were randomly assigned to three groups. The patients were divided into experimental group 1 in which shock waves were applied to the muscle-tendon junction, experimental group 2 in which shock waves were applied to the middle of the muscle, and experimental group 3 in which shock waves were applied to both the muscle-tendon junction and the middle of the muscle. The MAS was used to evaluate spasticity in the subjects, and the Dartfish software was used to measure knee and ankle angles during heel-off when walking.

RESULTS

Based on the results of the study, a significant decrease in spasticity and increased joint angles were found in experimental groups 1 and 3 compared to experimental group 2, and the change in joint angle was significantly greater in experimental group 3 than in experimental groups 1 and 2.

CONCLUSIONS

These results indicate that treatment effect may vary depending on the application site of the shock wave, and to obtain the best treatment effect, the shock wave should be applied to both the muscle-tendon junction and the middle part of the muscle.

Effect of Self-Directed Home Therapy Adherence Combined with TheraBracelet on Poststroke Hand Recovery: A Pilot Study

Hand impairment is a common consequence of stroke, resulting in long-term disability and reduced quality of life. Recovery may be augmented through self-directed therapy activities at home, complemented by the use of rehabilitation devices such as peripheral sensory stimulation. The objective of this study was to determine the effect of adherence to self-directed therapy and the use of TheraBracelet (subsensory random-frequency vibratory stimulation) on hand function for stroke survivors. In a double-blind, randomized controlled pilot trial, 12 chronic stroke survivors were assigned to a treatment or control group (n = 6/group). All participants were instructed to perform 200 repetitions of therapeutic hand tasks 5 days/week while wearing a wrist-worn device 8 hours/day for 4 weeks. The treatment group received TheraBracelet vibration from the device, while the control group received no vibration. Home task repetition adherence and device wear logs, as well as hand function assessment (Stroke Impact Scale Hand domain), were obtained weekly. Repetition adherence was comparable between groups but varied among participants. Participants wore the device to a greater extent than adhering to completing repetitions. A linear mixed model analysis showed a significant interaction between repetition and group (p = 0.01), with greater adherence resulting in greater hand function change for the treatment group (r = 0.94; R 2 = 0.88), but not for the control group. Secondary analysis revealed that repetition adherence was greater for those with lower motor capacity and greater self-efficacy at baseline. This pilot study suggests that adherence to self-directed therapy at home combined with subsensory stimulation may affect recovery outcomes in stroke survivors. This trial is registered with NCT04026399.

Mechanical Design and Feasibility of a Finger Exoskeleton to Support Finger Extension of Severely Affected Stroke Patients

In this paper we presented the mechanical design and evaluation of a low-profile and lightweight exoskeleton that supports the finger extension of stroke patients during daily activities without applying axial forces to the finger. The exoskeleton consists of a flexible structure that is secured to the index finger of the user while the thumb is fixed in an opposed position. Pulling on a cable will extend the flexed index finger joint such that objects can be grasped. The device can achieve a grasp size of at least 7 cm. Technical tests confirmed that the exoskeleton was able to counteract the passive flexion moments corresponding to the index finger of a severely affected stroke patient (with an MCP joint stiffness of k = 0.63Nm/rad), requiring a maximum cable activation force of 58.8N. A feasibility study with stroke patients (n=4) revealed that the body-powered operation of the exoskeleton with the contralateral hand caused a mean increase of 46° in the range of motion of the index finger MCP joint. The patients (n=2) who performed the Box & Block Test were able to grasp and transfer maximally 6 blocks in 60 sec. with exoskeleton, compared to 0 blocks without exoskeleton. Our results showed that the developed exoskeleton has the potential to partially restore hand function of stroke patients with impaired finger extension capabilities. An actuation strategy that does not involve the contralateral hand should be implemented during further development to make the exoskeleton suitable for bimanual daily activities.

Lightweight Bioinspired Exoskeleton for Wrist Rehabilitation Powered by Twisted and Coiled Artificial Muscles

Stroke, cerebral palsy, and spinal cord injuries represent the most common leading causes of upper limb impairment. In recent years, rehabilitation robotics has progressed toward developing wearable technologies to promote the portability of assistive devices and to enable home rehabilitation of the upper extremities. However, current wearable technologies mainly rely on electric motors and rigid links or soft pneumatic actuators and are usually bulky and cumbersome. To overcome the limitations of existing technologies, in this paper, a first prototype of a lightweight, ungrounded, soft exoskeleton for wrist rehabilitation powered by soft and flexible carbon fibers-based twisted and coiled artificial muscles (TCAMs) is proposed. The device, which weighs only 0.135 kg, emulates the arrangement and working mechanism of skeletal muscles in the upper extremities and is able to perform wrist flexion/extension and ulnar/radial deviation. The range of motion and the force provided by the exoskeleton is designed through simple kinematic and dynamic theoretical models, while a thermal model is used to design a thermal insulation system for TCAMs during actuation. The device’s ability to perform passive and active-resisted wrist rehabilitation exercises and EMG-based actuation is also demonstrated.

Upper Limb Function Recovery by Combined Repetitive Transcranial Magnetic Stimulation and Occupational Therapy in Patients with Chronic Stroke According to Paralysis Severity

Repetitive transcranial magnetic stimulation (rTMS) with intensive occupational therapy improves upper limb motor paralysis and activities of daily living after stroke; however, the degree of improvement according to paralysis severity remains unverified. Target activities of daily living using upper limb functions can be established by predicting the amount of change after treatment for each paralysis severity level to further aid practice planning. We estimated post-treatment score changes for each severity level of motor paralysis (no, poor, limited, notable, and full), stratified according to Action Research Arm Test (ARAT) scores before combined rTMS and intensive occupational therapy. Motor paralysis severity was the fixed factor for the analysis of covariance; the delta (post-pre) of the scores was the dependent variable. Ordinal logistic regression analysis was used to compare changes in ARAT subscores according to paralysis severity before treatment. We implemented a longitudinal, prospective, interventional, uncontrolled, and multicenter cohort design and analyzed a dataset of 907 patients with stroke hemiplegia. The largest treatment-related changes were observed in the Limited recovery group for upper limb motor paralysis and the Full recovery group for quality-of-life activities using the paralyzed upper limb. These results will help predict treatment effects and determine exercises and goal movements for occupational therapy after rTMS.

A Unified Model for Stroke Recovery and Rehabilitation: Why Now?

ABSTRACT

The current model of stroke care delivery in the United States and in many parts of the world is fragmented, resulting in lack of continuity of care, inability to track recovery meaningfully across the continuum, and lack of access to the frequency, intensity, and duration of high-quality rehabilitation necessary to optimally harness recovery processes. The process of recovery itself has been overshadowed by a focus on length of stay and the movement of patients across levels of care. Here, we describe the rationale behind the recent efforts at the Johns Hopkins Sheikh Khalifa Stroke Institute to define and coordinate an intensive, strategic effort to develop effective stroke systems of care across the continuum through the development of a unified Sheikh Khalifa Stroke Institute model of recovery and rehabilitation.

Usage of RePlay as a Take-Home System to Support High-Repetition Motor Rehabilitation After Neurological Injury

Stroke is a leading cause of chronic motor disability. While physical rehabilitation can promote functional recovery, several barriers prevent patients from receiving optimal rehabilitative care. Easy access to at-home rehabilitative tools could increase patients' ability to participate in rehabilitative exercises, which may lead to improved outcomes. Toward achieving this goal, we developed RePlay: a novel system that facilitates unsupervised rehabilitative exercises at home. RePlay leverages available consumer technology to provide a simple tool that allows users to perform common rehabilitative exercises in a gameplay environment. RePlay collects quantitative time series force and movement data from handheld devices, which provide therapists the ability to quantify gains and individualize rehabilitative regimens. RePlay was developed in C# using Visual Studio. In this feasibility study, we assessed whether participants with neurological injury are capable of using the RePlay system in both a supervised in-office setting and an unsupervised at-home setting, and we assessed their adherence to the unsupervised at-home rehabilitation assignment. All participants were assigned a set of 18 games and exercises to play each day. Participants produced on average 698 ± 36 discrete movements during the initial 1 hour in-office visit. A subset of participants who used the system at home produced 1593 ± 197 discrete movements per day. Participants demonstrated a high degree of engagement while using the system at home, typically completing nearly double the number of assigned exercises per day. These findings indicate that the open-source RePlay system may be a feasible tool to facilitate access to rehabilitative exercises and potentially improve overall patient outcomes.

Feasibility of an Enhanced Therapy Model of Care for Hospitalized Stroke Patients

INTRODUCTION

The aim of this study was to determine the safety and feasibility of an enhanced therapy model for hospitalized stroke patients.

METHODS

This was a quasi-experimental cohort study of acute stroke patients from a single hospital. In the intervention group, all hospitalized patients on the acute stroke service were seen by at least two therapy disciplines daily in addition to routine stroke care. The comparison group consisted of all patients admitted to the same stroke service 1 year before who received the standard of care. The primary endpoint was the number of completed therapy sessions. Exploratory endpoints compared the length of hospital stay, hospital readmission rates, and degree of disability measured by the 90-day modified Rankin Scale score.

RESULTS

A total of 1110 records were analyzed with 553 subjects in the intervention group and 557 in the control group. The intervention group received a significantly higher number of therapy sessions. There was no significant difference in length of hospital stay. However, 30-day readmission rates were lower, and the percentage of patients who achieved a good functional outcome on the modified Rankin Scale was higher during the intervention period.

CONCLUSION

Increasing exposure to intensive multidisciplinary therapy comparable with that of acute inpatient rehabilitation in the hospital setting is feasible and may reduce both readmission rates and disability.

Effect of Core Exercises on Motor Function Recovery in Stroke Survivors with Very Severe Motor Impairment

Paresis of the upper and lower limbs is a typical issue in stroke survivors. This study aims to determine whether core exercises help stroke survivors with very severe motor impairment recover their motor function. This study employed a within-subjects design. Eleven hemiparetic stroke patients with very severe motor impairment (FMA score < 35) and ages ranging from 24 to 52 years old were enrolled in this study. All participants engaged in supervised core exercise training twice a week for 12 weeks. The main outcome measures were Fugl-Meyer Assessment Lower Extremity (FMA-LE) and Fugl-Meyer Assessment Upper Extremity (FMA-UE), which were measured before training and at intervals of four weeks during training. Repeated measures ANOVA was used to analyze the effect of core exercises on motor function performance and lower extremity motor function and upper extremity motor function recovery. There were significant differences in the mean scores for motor function performance, lower extremity motor function, and upper extremity motor function throughout the four time points. A post-hoc pairwise comparison using the Bonferroni correction revealed that mean scores significantly increased and were statistically different between the initial assessment and follow-up assessments four, eight, and twelve weeks later. This study suggests that 12 weeks of core exercise training is effective for improving motor function recovery in patients with very severe motor impairment.

Ultrasound Assessment of Spastic Muscles in Ambulatory Chronic Stroke Survivors Reveals Function-Dependent Changes

OBJECTIVE

To correlate ultrasound characteristics of spastic muscles with clinical and functional measurements in chronic stroke survivors.

METHODS

Ultrasound assessment and clinical and functional assessments were performed in 28 ambulatory stroke survivors (12 females, mean age 57.8 ± 11.8 years, 76 ± 45 months after stroke).

RESULTS

Muscle thickness in the affected side was decreased compared with the contralateral side (p < 0.001). The decrease was more evident in the upper limb muscles. On the affected side, the modified Heckmatt scale score was lowest (closer to normal) in the rectus femoris (RF) muscle compared with other muscles (biceps brachii (BB), flexor carpi ulnaris (FCU) and medial gastrocnemius (MG)). Muscle thickness and echogenicity of spastic muscles did not correlate with spasticity, as measured with the modified Ashworth scale (MAS), Fugl-Meyer motor assessment scores, age, or time since stroke. There was a significant negative correlation between grip strength and percentage decrease in muscle thickness for the spastic FCU muscle (r = -0.49, p = 0.008). RF muscle thickness correlated with ambulatory function (Timed Up and Go test (r = 0.44, p = 0.021) and 6-metre walk test (r = 0.41, p = 0.032)). There was no significant correlation between echogenicity and functional assessments Conclusion: Ambulatory chronic stroke survivors had function-dependent changes in muscle thickness on the affected side. Muscle thickness and echogenicity of spastic muscles did not correlate with spasticity, Fugl-Meyer motor assessment scores, age, or time since stroke.

Characterization of the Structural and Mechanical Changes of the Biceps Brachii and Gastrocnemius Muscles in the Subacute and Chronic Stage after Stroke

The objective of this study was to characterize the changes of muscle tone, stiffness, and thickness of upper and lower limb muscles in stroke survivors. Forty patients with subacute or chronic stroke and 31 controls were included and measured using myotonometry (MyotonPRO), with multiple site assessments at muscle belly (MB) and musculotendinous (MT) locations of the biceps brachii and gastrocnemius muscles. Muscle thickness (ultrasonography) was obtained for each muscle. Upper and lower limb motor performance was evaluated with the Fugl−Meyer Assessment for Upper Extremity and the Functional Ambulance Category. Overall, muscle tone and stiffness were significantly higher at MT than at MB sites. Among stroke patients, differences between the paretic and nonparetic limb were found for the biceps brachii, with lower muscle tone, stiffness, and thickness of the paretic side (all, p < 0.05). There were weak to moderate correlations between mechanical (myotonometry) and structural (ultrasound) muscular changes, regardless of the post-stroke stage. This suggests that myotonometry and ultrasonography assess similar, although different, constructs and can be combined in the clinical setting. Their discriminative ability between the paretic and nonparetic sides and between participants with and without stroke differs depending on the muscle, the functional level, and the stroke stage.

Face-to-face assessment versus tele-assessment of chronic stroke patients: do the results meet the needs?

Aim: Baseline evaluation of stroke patients is valuable to manage the treatment plan. As in the case of stroke evaluation and rehabilitation, in every aspects of healthcare, tele-medicine is growing gradually. The aim of this descriptive study was to explore whether initial tele-assessment of chronic stroke patients is similar to face-to-face assessment in terms of clinical scales. Material and Method: Thirty-four chronic stroke patients (mean post-stroke duration 21.44±15.47 months; stroke etiology, 58.8% ischemic; hemiplegic side, 52.9% left; mean age 49.24±12.51; 22 males; 12 females) were included in this trial. Firstly, all the patients were evaluated online, and then at the same day they were evaluated face-to-face by the clinical scales including Chair Stand Test, Berg Balance Scale, Stroke specific Quality of Life scale, Motricity Index. Results: The findings of the present study revealed that there was no statistically significant difference between tele-assessment and face-to-face assessment for all the scales (p>0.05) except Chair Stand Test (mean time to stand: 9.41 secs vs 8.94 secs in tele-assessment and face-to-face respectively; p

Effectiveness of soft robotic glove versus repetitive transcranial magnetic stimulation in post-stroke patients with severe upper limb dysfunction: A randomised controlled trial

Purpose

To explore the difference in rehabilitation effect between soft robot gloves and repetitive transcranial magnetic stimulation (rTMS) in patients with severe upper limb motor dysfunction after a stroke.

Methods

A total of 69 post-stroke patients with severe upper limb dysfunction were randomly assigned to a repetitive transcranial magnetic group, a soft robotic glove group, and a conventional treatment group. The primary outcomes were the Fugl-Meyer Upper Extremity Assessment (FMA-UE) and the Modified Barthel Index (MBI). The secondary endpoints were the amplitude surface electromyogram of the extensor wrist muscle (sEMG) and the cerebral hemispheric resting motor threshold (RMT).

Results

The change of FMA-UE score in the soft robotic glove group was significantly better than that in the conventional treatment group (median difference: 2 points; 95% confidence interval [1, 3]; P < 0.05), but there was no significant difference compared with the repetitive transcranial magnetic stimulation group (median difference: 0 points; 95% confidence interval [-1, 2]; P [0.547] > 0.05). There was no significant difference in the change of MBI score between the soft robotic glove group and the conventional treatment and repetitive transcranial magnetic treatment groups [F = 2.458, P [0.093] > 0.05]. There was no significant difference in the change of sEMG score between the soft robotic glove group and the conventional treatment and repetitive transcranial magnetic treatment groups [H = 0.042, P [0.980] > 0.05]. Additionally, the change of RMT score in the soft robotic glove group was significantly inferior to that in the repetitive transcranial magnetic treatment group [difference: -1.09; 95% confidence interval [-2.048, 0.048]; P < 0.05], but there was no significant difference compared with the conventional treatment group [difference: 0.31 points; 95% confidence interval [-0.879, 0.358]; P [0.495] > 0.05].

Conclusion

For patients with severe dyskinesia after a stroke, soft robotic gloves are as effective as repetitive transcranial magnetic stimulation and may be a good choice for home rehabilitation. In addition, conventional treatment combined with repetitive transcranial magnetic stimulation (rTMS) or a soft robotic glove produced better rehabilitation outcomes than conventional treatment alone.

Considerations for ensuring safety during telerehabilitation of people with stroke. A protocol for a scoping review

INTRODUCTION

Exercise interventions have a positive impact on people with stroke. However, access to exercise interventions is variable, and there may be a delay in the start of rehabilitation. Telerehabilitation has enabled the delivery of exercise interventions replacing the traditional face-to-face approach. Aspects related to the safety of people with stroke should be considered to avoid adverse events during the delivery of exercise interventions remotely. However, such information is scattered in the literature, and the detail with which measures taken during the implementation of exercise interventions for people with stroke are reported is unknown.

OBJECTIVE

To summarise measures or aspects targeted at reducing the incidence of adverse events during the delivery of exercise interventions through telerehabilitation in patients after stroke.

MATERIALS AND METHODS

A scoping review will be conducted. A systematic search in MEDLINE-Ovid, Embase-Ovid CENTRAL, CINAHL Complete (EBSCOhost), and other resources will be carried out. We will include primary studies, published in full text in any language, involving people with stroke who undergo telerehabilitation where exercise is the main component. Two reviewers will independently select studies and extract data, and disagreements will be resolved by consensus or a third reviewer. The results will be reported in a narrative form, using tables and figures to support them.

DISCUSSION

To implement this strategy within rehabilitation services, one of the first aspects to be solved is to ensure the safety of people. The results of this scoping review could contribute an information base for clinicians and decision-makers when designing remotely delivered exercise intervention programs.

REGISTRATION NUMBER

INPLASY202290104.

A Cross-Sectional Study: Determining Factors of Functional Independence and Quality of Life of Patients One Month after Having Suffered a Stroke

(1) Background: loss of quality of life (QoL) and functional independence are two of the most common consequences of suffering a stroke. The main objective of this research is to study which factors are the greatest determinants of functional capacity and QoL a month after suffering a stroke so that they can be considered in early interventions. (2) Methods: a cross-sectional study was conducted which sample consisted of 81 people who had previously suffered a stroke. The study population was recruited at the time of discharge from the Neurology Service and Stroke Unit of the hospitals of Burgos and Córdoba, Spain, through a consecutive sampling. Data were collected one month after participants experienced a stroke, and the main study variables were quality of life, measured with the Stroke-Specific Quality of Life Measure (NEWSQOL), and functional independence, measured with the Functional Independence Measure-Functional Assessment Measure (FIM-FAM). (3) Results: the factors associated with a worse QoL and functional capacity one month after having suffered a stroke were living in a different dwelling than the usual flat or house (p < 0.05), a worse cognitive capacity (p < 0.001) and a worse functional capacity of the affected upper limb (p < 0.001). A higher age was related to a worse functional capacity one month after suffering a stroke (p = 0.048). (4) Conclusions: the type of dwelling, age, cognitive ability and functional capacity of the affected upper limb are determining aspects in functional independence and QoL during the first weeks after a stroke.

To engage or not engage: Early incentive motivation prevents symptoms of chronic post-stroke depression - A longitudinal study

BACKGROUND

Although post-stroke depression (PSD) is known to disrupt motor rehabilitation after stroke, PSD is often undertreated and its relationship with motor impairment remains poorly understood.

METHODS

In a longitudinal study design we investigated, which factors at the early post-acute stage may increase the risk for PSD symptoms. We were especially interested in whether interindividual differences in the motivational drive to engage in physically demanding tasks indicate PSD development in patients suffering from motor impairments. Accordingly, we used a monetary incentive grip force task where participants were asked to hold their grip force for high and low rewards at stake to maximize their monetary outcome. Individual grip force was normalized according to the maximal force prior to the experiment. Experimental data, depression, and motor impairment were assessed from 20 stroke patients (12 male; 7.7 ± 6.78 days post-stroke) with mild-to-moderate hand motor impairment and 24 age-matched healthy participants (12 male).

RESULTS

Both groups showed incentive motivation as indicated by stronger grip force for high versus low reward trials and the overall monetary outcome in the task. In stroke patients, severely impaired patients showed stronger incentive motivation, whereas early PSD symptoms were associated with reduced incentive motivation in the task. Larger lesions in corticostriatal tracts correlated with reduced incentive motivation. Importantly, chronic motivational deficits were preceded by initially reduced incentive motivation and larger corticostriatal lesions in the early stage post-stroke.

CONCLUSIONS

More severe motor impairment motivates reward-dependent motor engagement, whereas PSD and corticostriatal lesions potentially disturb incentive motivational behavior, thereby increasing the risk of chronic motivational PSD symptoms. Acute interventions should address motivational aspects of behavior to improve motor rehabilitation post-stroke.

[Modern view on upper limb physical rehabilitation after stroke. Literature review]

Stroke is the world's second leading cause of death and the first cause of disability among all diseases. The most common complication of a stroke is a violation of the motor function of the limbs, which significantly worsens the quality of life and the level of self-care and independence of patients. Restoring the function of the upper limb is one of the priority tasks of rehabilitation after a stroke. A large number of factors, such as the location and size of the primary brain lesion, the presence of complications in the form of spasticity, impaired skin and proprioceptive sensitivity, and comorbidities, determine the patient's rehabilitation potential and the prognosis of ongoing rehabilitation measures. Of particular note are the timing of the start of rehabilitation measures, the duration and regularity of the treatment methods. A number of authors propose scales for assessing the rehabilitation prognosis, as well as algorithms for compiling rehabilitation programs for restoring the function of the upper limb. A fairly large number of rehabilitation methods and their combinations have been proposed, including special methods of kinesitherapy, robotic mechanotherapy with biofeedback, the use of physiotherapeutic factors, manual and reflex effects, as well as ready-made programs that include sequential and combined use of various methods. Dozens of studies have been devoted to comparative analysis and evaluation of the effectiveness of these methods. The purpose of this work is to review current research on a given topic and draw up our own conclusion on the appropriateness of using and combining these methods at various stages of rehabilitation in stroke patients.

Body Schema as Assessed by Upper Limb Left/Right Judgment Tasks Is Altered in Stroke: Implications for Motor Imagery Training

BACKGROUND AND PURPOSE

Individuals with stroke often experience significant impairment of the upper limb. Rehabilitation interventions targeting the upper limb are typically associated with only small to moderate gains. The knowledge that body schema can be altered in other upper limb conditions has contributed to the development of tailored rehabilitation approaches. This study investigated whether individuals with stroke experienced alterations in body schema of the upper limb. If so, this knowledge may have implications for rehabilitation approaches such as motor imagery.

METHODS

An observational study performed online consisting of left/right judgment tasks assessed by response time and accuracy of: (i) left/right direction recognition; (ii) left/right shoulder laterality recognition; (iii) left/right hand laterality recognition; (iv) mental rotation of nonembodied objects. Comparisons were made between individuals with and without stroke. Secondary comparisons were made in the stroke population according to side of stroke and side of pain if experienced.

RESULTS

A total of 895 individuals (445 with stroke) participated. Individuals with stroke took longer for all tasks compared to those without stroke, and were less accurate in correctly identifying the laterality of shoulder (P < 0.001) and hand (P < 0.001) images, and the orientation of nonembodied objects (P < 0.001). Moreover, the differences observed in the hand and shoulder tasks were greater than what was observed for the control tasks of directional recognition and nonembodied mental rotation. No significant differences were found between left/right judgments of individuals with stroke according to stroke-affected side or side of pain.

DISCUSSION AND CONCLUSIONS

Left/right judgments of upper limb are frequently impaired after stroke, providing evidence of alterations in body schema. The knowledge that body schemas are altered in individuals with longstanding stroke may assist in the development of optimal, well-accepted motor imagery programs for the upper limb.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A394).

Factors influencing recovery of upper limb motor function during constraint-induced movement therapy for people with stroke

Objective

The aim of this study is to determine the personal and clinical factors that can predict recovery of motor function in people with stroke.

Methods

Characteristics of the study participants such as age, sex, time since stroke and type of stroke, motor function, shoulder pain, amount and quality of use of the affected limb in the real world, wrist and elbow spasticity, handedness, central post-stroke pain and dose of massed practice were recorded. The data obtained were analyzed using descriptive statistics and multiple regression.

Results

A total of 144 patients with stroke with mean age, 58.71 ± 19.90 years participated in the study. The result showed that, the whole model significantly explained the total variance by 88.4%, F(14, 144) = 32.870, R ² = 0. 0.781, p < 0.001. However, in the final model, only four independent variables in the order of degree of predictability, amount of use of the limb in the real world (Beta = 0.455, p = 0.003), intensity of practice during rehabilitation session (Beta = 0.321, p < 0.001), wrist spasticity (Beta = 0.148, p = 0.004) and side affected (Beta = 0.093, p = 0.033) significantly predicted recovery of motor function.

Conclusion

Encouraging the use of the limb in the real world may be more important than practice during rehabilitation session in the clinic or in the laboratory.

Baseline robot-measured kinematic metrics predict discharge rehabilitation outcomes in individuals with subacute stroke

Background: The literature on upper limb robot-assisted therapy showed that robot-measured metrics can simultaneously predict registered clinical outcomes. However, only a limited number of studies correlated pre-treatment kinematics with discharge motor recovery. Given the importance of predicting rehabilitation outcomes for optimizing physical therapy, a predictive model for motor recovery that incorporates multidirectional indicators of a patient's upper limb abilities is needed. Objective: The aim of this study was to develop a predictive model for rehabilitation outcome at discharge (i.e., muscle strength assessed by the Motricity Index of the affected upper limb) based on multidirectional 2D robot-measured kinematics. Methods: Re-analysis of data from 66 subjects with subacute stroke who underwent upper limb robot-assisted therapy with an end-effector robot was performed. Two least squares error multiple linear regression models for outcome prediction were developed and differ in terms of validation procedure: the Split Sample Validation (SSV) model and the Leave-One-Out Cross-Validation (LOOCV) model. In both models, the outputs were the discharge Motricity Index of the affected upper limb and its sub-items assessing elbow flexion and shoulder abduction, while the inputs were the admission robot-measured metrics. Results: The extracted robot-measured features explained the 54% and 71% of the variance in clinical scores at discharge in the SSV and LOOCV validation procedures respectively. Normalized errors ranged from 22% to 35% in the SSV models and from 20% to 24% in the LOOCV models. In all models, the movement path error of the trajectories characterized by elbow flexion and shoulder extension was the significant predictor, and all correlations were significant. Conclusion: This study highlights that motor patterns assessed with multidirectional 2D robot-measured metrics are able to predict clinical evalutation of upper limb muscle strength and may be useful for clinicians to assess, manage, and program a more specific and appropriate rehabilitation in subacute stroke patients.

The Mediating Effect of Age, Gender, and Post-Stroke Duration on the Association between Trunk and Upper Limb Recovery in Subacute Stroke Population: A Cross-Sectional Study with Mediation Analysis

BACKGROUND

The trunk acts as proximal support with which limbs execute smooth and purposeful movement. Furthermore, as upper extremity functions are an integral component of daily living activities, exploring the association between trunk and upper extremity recovery will guide therapists in developing appropriate rehabilitation goals and interventions. The objectives of this study were to (1) assess the association between trunk and upper extremity recovery in the subacute stroke population and (2) assess the effect of trunk control on upper extremity impairment and function with age, gender, and duration of stroke as mediators using mediation analysis in subacute stroke individuals.

METHODS

This cross-sectional study included 54 subacute stroke participants with a mean age of 58.37 ± 6.11 years. The trunk impairment scale (TIS) assessed the trunk's stability, mobility, and coordination. The level of upper extremity impairment was evaluated using the Fugl-Meyer Assessment scale (FMA). The quality and quantity of upper limb motor functions were measured using the Wolf motor function test (WMFT).

RESULTS

The TIS exhibited moderate positive correlations with the FMA-UE, WMFT-time scale (TS), and WMFT-functional ability scale (FAS) at p < 0.001. The mediation analysis reported a profound mediation effect of post-stroke duration on the association of trunk and upper limb recovery.

CONCLUSIONS

The study results substantiated that trunk control significantly correlates with upper limb impairment and the quality and quantity of its use in the subacute stroke population. Post-stroke duration proved to mediate the association between trunk and upper limb recovery. Therefore, the assessment and intervention of trunk and upper extremity motor control considering the post-stroke duration is vital and should be incorporated in stroke rehabilitation aiming at functional independence.

Supervised Myoelectrical Hand Gesture Recognition in Post-Acute Stroke Patients with Upper Limb Paresis on Affected and Non-Affected Sides

In clinical practice, acute post-stroke paresis of the extremities fundamentally complicates timely rehabilitation of motor functions; however, recently, residual and distorted musculoskeletal signals have been used to initiate feedback-driven solutions for establishing motor rehabilitation. Here, we investigate the possibilities of basic hand gesture recognition in acute stroke patients with hand paresis using a novel, acute stroke, four-component multidomain feature set (ASF-4) with feature vector weight additions (ASF-14NP, ASF-24P) and supervised learning algorithms trained only by surface electromyography (sEMG). A total of 19 (65.9 ± 12.4 years old; 12 men, seven women) acute stroke survivors (12.4 ± 6.3 days since onset) with hand paresis (Brunnstrom stage 4 ± 1/4 ± 1, SIAS 3 ± 1/3 ± 2, FMA-UE 40 ± 20) performed 10 repetitive hand movements reflecting basic activities of daily living (ADLs): rest, fist, pinch, wrist flexion, wrist extension, finger spread, and thumb up. Signals were recorded using an eight-channel, portable sEMG device with electrode placement on the forearms and thenar areas of both limbs (four sensors on each extremity). Using data preprocessing, semi-automatic segmentation, and a set of extracted feature vectors, support vector machine (SVM), linear discriminant analysis (LDA), and k-nearest neighbors (k-NN) classifiers for statistical comparison and validity (paired t-tests, p-value < 0.05), we were able to discriminate myoelectrical patterns for each gesture on both paretic and non-paretic sides. Despite any post-stroke conditions, the evaluated total accuracy rate by the 10-fold cross-validation using SVM among four-, five-, six-, and seven-gesture models were 96.62%, 94.20%, 94.45%, and 95.57% for non-paretic and 90.37%, 88.48%, 88.60%, and 89.75% for paretic limbs, respectively. LDA had competitive results using PCA whereas k-NN was a less efficient classifier in gesture prediction. Thus, we demonstrate partial efficacy of the combination of sEMG and supervised learning for upper-limb rehabilitation procedures for early acute stroke motor recovery and various treatment applications.

Study protocol of a randomized controlled trial for the synergizing effects of rTMS and Tui Na on upper limb motor function and cortical activity in ischemic stroke

Upper limb motor dysfunction after stroke is a serious threat to the living quality of patients and their families. Recovery of upper limb motor function after stroke largely relies on the activation and remodeling of neural circuits. rTMS (repetitive transcranial magnetic stimulation) has been proved to promote the reconstruction of neural synapses and neural circuits. However, there are still a large number of patients who cannot fully recover and leave behind varying degrees of dysfunction. Considering the systemic pathology after stroke, in addition to focal brain injury, stroke can also cause extensive dysfunction of peripheral organs. The rehabilitation strategy for stroke should combine the treatment of primary brain lesions with the intervention of secondary systemic damage. The aim of this trial is to verify the efficacy of rTMS synergize with Tui Na (Chinese Massage) on upper limb motor function after ischemic stroke, and to explore the mechanism of activation and remodeling of sensorimotor neural circuits with functional near-infrared spectroscopy. Ninety patients will be randomly assigned to either rTMS + Tui Na + conventional rehabilitation group (the experimental group) or rTMS + conventional rehabilitation group (the control group) in 1:1 ratio. Intervention is conducted five sessions a week, with a total of twenty sessions. The primary outcome is Fugl-Meyer Assessment, and the secondary outcomes include Muscle Strength, Modified Ashworth Assessment, Modified Barthel Index Assessment, motor evoked potentials and functional near-infrared spectroscopy. There are four time points for the evaluation, including baseline, 2 weeks and 4 weeks after the start of treatment, and 4 weeks after the end of treatment. This study is a randomized controlled trial. This study was approved by Institutional Ethics Committee of Shanghai Third Rehabilitation Hospital Affiliated to Shanghai University of Traditional Chinese Medicine (approval No. SH3RH-2021-EC-012) on December, 16th, 2021. The protocol was registered with Chinese Clinical Trial Registry (ChiCTR2200056266), on February 3th, 2022. Patient recruitment was initiated on February 10th, 2022, and the study will be continued until December 2023.

MyotonPRO is a Reliable and Repeatable Tool for Measuring Mechanical Properties of the Upper Limb Muscles in Patients with Chronic Stroke

Background/Aim Muscle mechanical properties can be measured using a variety of methods. The current study intended to examine the inter-session and inter-rater reliability of the MyotonPRO for assessing the mechanical properties of the upper limb muscles in chronic stroke patients.

Materials and Methods The research included 20 stroke patients (14 male and 6 female) ranging in age between 36 and 84 years (65.1±11.2 years). A MyotonPRO was used to assess the oscillation frequency, stiffness, and logarithmic decrement of the triceps brachii, biceps brachii, upper trapezius, and deltoid muscles. Two physiotherapists conducted the assessments to determine the tool's inter-rater reliability. A physiotherapist repeated the measurements 3 days after the first measurements for determining the inter-session reliability of the tool.

Results The ICCs of all assessed muscles ranged within 0.72–0.97. The coefficient of variation of all muscles varied within 3.2–11.0%, 3.4–9.7% for oscillation frequency, 3.9–7.4% for stiffness, and 3.2–11.0% for decrement. In the measured muscles, the standard error of assessment varied within 0.5–1.2 Hz for frequency, 9.2–21.2 N/m for stiffness, and 0.1–0.4 for decrement.

Conclusions The results indicate that MyotonPRO has a between good and excellent inter-section and inter-rater reliability for measuring the tone, stiffness, and elasticity of the triceps brachii, biceps brachii, upper trapezius, and deltoid muscles in chronic stroke patients. MyotonPRO can be used for the diagnostic and therapeutic intention in chronic stroke patients.

The Effect of Task-Oriented Activities Training on Upper-Limb Function, Daily Activities, and Quality of Life in Chronic Stroke Patients: A Randomized Controlled Trial

This randomized controlled study aimed to investigate the effects of 8-week task-oriented activities of daily living (T-ADL) training on upper limb functions, activities of daily living (ADL), and quality of life (QoL) in chronic stroke patients. The 33 patients were randomly assigned to the T-ADL training or conventional occupational therapy (OT) group. The respective interventions were provided for 45-min a day, five times a week for eight weeks. To compare the upper-limb function before and after the intervention, the manual function test (MFT), box and block test (BBT), and grasp power test were performed; to compare the level of ADL performance, the modified-Barthel index (MBI) was measured. To evaluate QoL, stroke-specific QoL was measured. There was a significant group-by-time interaction in the affected side MFT score and both sides of BBT scores, but no significant interaction was found in the unaffected side MFT score, ADL, and QoL. Both groups showed a significant main effect of time in their ADL and QoL after the intervention (p < 0.001). The results of this study indicate that the eight-week T-ADL training has a positive effect on upper limb functions and gross manual dexterity, and both T-ADL training and conventional OT are effective in improving ADL and QoL in chronic stroke patients.

Transcriptomic Profiling of Electroacupuncture Regulating the Molecular Network in Hippocampus of Rats with Cerebral Ischemia-Reperfusion Injury

Objective. To explore the mechanism of electroacupuncture stimulation of the hand-taiyin meridian in regulating the molecular network of rats with cerebral ischemia-reperfusion injury based on transcriptomics. Methods. Male SD rats were randomly divided into sham operation group, model group, and electroacupuncture (EA) group. Middle cerebral artery embolization/reperfusion injury (MCAO/R) was used to establish the model group and EA group. The sham operation group only performed sham operation without modeling and any intervention, and the model group was bound daily. The EA group received electroacupuncture to stimulate the acupoints of hand-taiyin meridian for 14 days. Then, neurological scores, pathomorphological observations, and Tunel staining were performed. Finally, the affected hippocampus of the rat was used for transcriptome sequencing and RT-PCR detection. Results. After electroacupuncture intervention in rats, neurological function scores were improved, and neuronal apoptosis was reduced. The results of transcriptomics showed that a total of 1097 differentially expressed genes were obtained, of which 422 were upregulated and 675 were downregulated. The bioinformatics analysis showed that those differentially expressed genes were related to axon development, neuron projection development, neuron projection morphogenesis, plasma membrane cell projection morphogenesis, cell part morphogenesis, notch signaling pathway, long-term potentiation, MAPK signaling pathway, Hedgehog signaling pathway, and so on. The results of RT-PCR showed that Caspase 9 mRNA increased and BDNF, Grin2a, and PlexinD1 mRNA decreased after electroacupuncture intervention $\left(P<0.05\right)$ . Conclusion. Electroacupuncture intervention on hand-taiyin meridian may reduce neurological function scores, inhibit neuron apoptosis, and enhance neuronal repair neuroreparation in MCAO/R rats, which may be related to the regulation of genes such as Caspase 9, BDNF, Grin2a, and PlexinD1.

Influence and significance of bilateral upper-extremity training on recovery of upper-extremity motor function for hemiplegic patients with mild-moderate cerebral apoplexy: a randomised controlled study

Background

The recovery of coordination ability of both hands is conductive to improving the activity of daily living for hemiplegic patients.

Objective

To explore the influence and significance of bilateral upper-extremity training on recovery of upper-extremity motor function for hemiplegic patients with mild-moderate cerebral apoplexy.

Methods

Patients were divided into control group and experimental group. The patients in the control group only exercised the upper limbs on the affected side, while the patients in the experimental group exercised the upper limbs on both sides. The Fugl Mayer Assessment Upper Extremity Scale (FMA-UE), Upper Extermities Functional Test (UEFT), modified Barthel index (MBI) and Brunnstrom scores were evaluated in the two groups before and after treatment.

Results

After four weeks, six weeks and eight weeks of treatment, scores of FMA-UE, UEFT, MBI and Brunnstrom for patients increased with the extension of training time, and FMA-UE, UEFT, MBI and Brunnstrom scores for patients of the two groups after four weeks six weeks and eight weeks of treatment showed a significant difference (P<0.05).

Conclusion

The improvement of upper-extremity motor function can be facilitated via relatively conventional training of bilateral upper-extremity training adopted by hemiplegic patients with mild-moderate cerebral apoplexy.

Nerve transfers in the forearm: potential use in spastic conditions

PURPOSE

Deformities of the spastic upper limb result frequently from the association of spasticity, muscle contracture and muscle imbalance between strong spastic muscles and weak non-spastic muscles. This study was designed to evaluate the feasibility of combining selective neurectomy of the usual spastic and strong muscles together with transfer of their motor nerves to the usual weak muscles, to improve wrist and fingers motion while decreasing spasticity.

METHODS

Twenty upper limbs from fresh frozen human cadavers were dissected. All motor branches of the radial and median nerve for the forearm muscles were identified. We attempted all possible end-to-end nerve transfers between the usually strong "donor" motor branches, namely FCR and PT, and the usually weak "recipient" motor branches (ERCL, ECRB, PIN, AIN).

RESULTS

 The PT had two nerve branches in 80%, thus allowing selective neurectomy. The proximal PT branch could be anastomosed end-to-end in 45% (AIN) to 85% (ECRL) of cases with the potential recipient branches. The distal PT branch could be anastomosed end to end to all potential recipient nerves. The FCR had a single branch in all cases. End-to-end anastomosis was possible in 90% for the ECRL and in 100% for all other recipient branches, but sacrificed all FCR innervation, ruling out hyperselective neurectomy.

CONCLUSION

 Selective neurectomies can be associated with distal nerve transfers at the forearm level in selected cases. The motor nerve to the PT is the best donor for nerve transfer combined with selective neurectomy, transferred to the ECRL, ECRB, PIN or AIN.

Development of a single device to quantify motor impairments of the elbow: proof of concept

Background

For patients with post-stroke upper limb impairments, the currently available clinical measurement instruments are inadequate for reliable quantification of multiple impairments, such as muscle weakness, abnormal synergy, changes in elastic joint properties and spasticity. Robotic devices to date have successfully achieved precise and accurate quantification but are often limited to the measurement of one or two impairments. Our primary aim is to develop a robotic device that can effectively quantify four main motor impairments of the elbow.

Methods

 The robotic device, Shoulder Elbow Perturbator, is a one-degree-of-freedom device that can simultaneously manipulate the elbow joint and support the (partial) weight of the human arm. Upper limb impairments of the elbow were quantified based on four experiments on the paretic arm in ten stroke patients (mean age 65 ± 10 yrs, 9 males, post-stroke) and the non-dominant arm in 20 healthy controls (mean age 65 ± 14 yrs, 6 males). The maximum strength of elbow flexor and elbow extensor muscles was measured isometrically at 90-degree elbow flexion. The maximal active extension angle of the elbow was measured under different arm weight support levels to assess abnormal synergy. Torque resistance was analyzed during a slow (6°/s) passive elbow rotation, where the elbow moved from the maximal flexion to maximal extension angle and back, to assess elastic joint properties. The torque profile was evaluated during fast (100°/s) passive extension rotation of the elbow to estimate spasticity.

Results

The ten chronic stroke patients successfully completed the measurement protocol. The results showed impairment values outside the 10^th and 90^th percentile reference intervals of healthy controls. Individual patient profiles were determined and illustrated in a radar figure, to support clinicians in developing targeted treatment plans.

Conclusion

The Shoulder Elbow Perturbator can effectively quantify the four most important impairments of the elbow in stroke patients and distinguish impairment scores of patients from healthy controls. These results are promising for objective and complete quantification of motor impairments of the elbow and monitoring patient prognosis. Our newly developed Shoulder Elbow Perturbator can therefore in the future be employed to evaluate treatment effects by comparing pre- and post-treatment assessments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-022-01050-2.

FarmDay: A Gamified Virtual Reality Neurorehabilitation Application for Upper Limb Based on Activities of Daily Living

Patients with upper limb disorders are limited in their activities of daily living and impose an important healthcare burden due to the repetitive rehabilitation they require. A way to reduce this burden is through home-based therapy using virtual reality solutions, since they are readily available, provide immersion, and enable accurate motion tracking, and custom applications can be developed for them. However, there is lack of guidelines for the design of effective VR rehabilitation applications in the literature, particularly for bimanual training. This work introduces a VR telerehabilitation system that uses off-the-shelf hardware, a real-time remote setup, and a bimanual training application that aims to improve upper extremity motor function. It is made of six activities and was evaluated by five physiotherapists specialised in (1) neuromotor disorders and (2) functional rehabilitation and (3) occupational therapy. A descriptive analysis of the results obtained from the System Usability Scale test of the application and a collection of qualitative assessments of each game have been carried out. The application obtained a mean score of 86.25 (±8.96 SD) in the System Usability Scale, and the experts concluded that it accurately reproduces activities of daily living movements except for wrist and finger movements. They also offer a set of design guidelines.