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

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.

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.

Assessing Stroke-Related Sarcopenia in Chronic Stroke: Identification of Clinical Assessment Tools-A Pilot Study

Stroke-related sarcopenia has recently been defined as the muscle atrophy consequent to stroke and assessing it following the guidelines with simple clinical tools is crucial in chronic stroke survivors. The aim of this study was to determine the characteristics of patient-friendly instruments sarcopenia in a chronic stroke sample (SG) compared to non-stroke counterparts (CG). Each participant underwent a single assessment which consisted of: SARC-F questionnaire, assessment of muscle strength (hand grip and five-times sit-to-stand test, 5STS), the calf circumference (CC) of both legs, the short physical performance battery (SPPB), and the 10 m walk test. A total of 68 participants were included (SG, n = 34 and CG, n = 34). All variables showed statistical differences (p < 0.05) between the SG and the CG, except handgrip although it showed lower values for SG. The values of the 5STS (16.26 s) and the SPPB (7 points) were below to the cutoff values for the SG. The five-times sit-to-stand test, SPPB, and gait speed can lead clinicians to detect stroke-related sarcopenia. Maximum handgrip shows a trend of low values for men and women in the SG, however, CC did not detect sarcopenia in our sample.

Effects and safety of vagus nerve stimulation on upper limb function in patients with stroke: a systematic review and meta-analysis

Vagus nerve stimulation (VNS) is used to deliver electric current to stimulate the vagus nerve. The aim of this study is to carry out a systematic review and meta-analysis to determine its effects on motor function in patients with stroke. PubMED, Embase, Web of Science (WoS), and Scopus were searched. Data on time since stroke, and mean scores and standard deviation on outcomes such as level of impairment and motor function were extracted. The results showed that invasive (MD 2.66, 95% CI 1.19-4.13, P = 0.0004) and non-invasive (MD 24.16, 95% CI 23.56-24.75, P = 0.00001) VNS are superior at improving level of motor impairment than the control post intervention and at follow-up respectively. Similarly, VNS improved motor function post intervention (MD 0.28, 95% CI 0.15-0.41, P < 0.0001); and there was no significant difference in adverse events between invasive VNS and control (OR 2.15, 95% CI 0.97-4.74, P = 0.06), and between non-invasive VNS and control (OR 4.54, 95% CI 0.48-42.97, P = 0.19). VNS can be used to improve motor function in patients with stroke.

Electroencephalography-based parietofrontal connectivity modulated by electroacupuncture for predicting upper limb motor recovery in subacute stroke

BACKGROUND

Predicting motor recovery in stroke patients is essential for effective rehabilitation planning and goal setting. However, intervention-specific biomarkers for such predictions are limited. This study investigates the potential of electroacupuncture (EA) - induced brain network connectivity as a prognostic biomarker for upper limb motor recovery in stroke.

METHODS

A randomized crossover and prospective observational study was conducted involving 40 stroke patients within 30 days of onset. Patients underwent both EA and sham electroacupuncture (SEA) interventions. Simultaneously, resting electroencephalography signals were recorded to assess brain response. Patients' motor function was monitored for 3 months and categorized into Poor and proportional (Prop) recovery groups. The correlations between the targeted brain network of parietofrontal (PF) functional connectivity (FC) during the different courses of the 2 EA interventions and partial least squares regression models were constructed to predict upper limb motor recovery.

RESULTS

Before the EA intervention, only ipsilesional PF network FC in the beta band correlated with motor recovery (r = -0.37, P = .041). Post-EA intervention, significant correlations with motor recovery were found in the beta band of the contralesional PF network FC (r = -0.43, P = .018) and the delta and theta bands of the ipsilesional PF network FC (delta: r = -0.59, P = .0004; theta: r = -0.45, P = .0157). No significant correlations were observed for the SEA intervention (all P > .05). Specifically, the delta band ipsilesional PF network FC after EA stimulation significantly differed between Poor and Prop groups (t = 3.474, P = .002, Cohen's d = 1.287, Poor > Prop). Moreover, the partial least squares regression model fitted after EA stimulation exhibited high explanatory power (R2 = 0.613), predictive value (Q2 = 0.547), and the lowest root mean square error (RMSE = 0.192) for predicting upper limb proportional recovery compared to SEA.

CONCLUSION

EA-induced PF network FC holds potential as a robust prognostic biomarker for upper limb motor recovery, providing valuable insights for clinical decision-making.

Automated Quantifiable Assessments of Sensorimotor Function Using an Instrumented Fragile Object

Accurate assessment of hand dexterity plays a critical role in informing rehabilitation and care of upper-limb hemiparetic stroke patients. Common upper-limb assessments, such as the Box and Blocks Test and Nine Hole Peg Test, primarily evaluate gross motor function in terms of speed. These assessments neglect an individual's ability to finely regulate grip force, which is critical in activities of daily living, such as manipulating fragile objects. Here we present the Electronic Grip Gauge (EGG), an instrumented fragile object that assesses both gross and fine motor function. Embedded with a load cell, accelerometer, and Hall-effect sensor, the EGG measures grip force, acceleration, and relative position (via magnetic fields) in real time. The EGG can emit an audible "break" sound when the applied grip force exceeds a threshold. The number of breaks, transfer duration, and applied forces are automatically logged in real-time. Using the EGG, we evaluated sensorimotor function in implicit grasping and gentle grasping for the non-paretic and paretic hands of 3 hemiparetic stroke patients. For all participants, the paretic hand took longer to transfer the EGG during implicit grasping. For 2 of 3 participants, grip forces were significantly greater for the paretic hand during gentle grasping. Differences in implicit grasping forces were unique to each participant. This work constitutes an important step towards more widespread and quantitative measures of sensorimotor function, which may ultimately lead to improved personalized rehabilitation and better patient outcomes.

Impedance Control of a 2-DOF Spherical 5-Bar Exoskeleton for Physical Human-Robot Interaction During Rehabilitation and Assessment

This paper presents a novel impedance controller for THINGER (THumb INdividuating Grasp Exercise Robot), a 2-degree-of-freedom (DOF) spherical 5-bar exoskeleton designed to augment FINGER (Finger INdividuating Grasp Exercise Robot). Many rehabilitation and assessment tasks, for which THINGER is designed, are improved by rendering near-zero impedance during physical human-robot interaction (pHRI). To achieve this goal, the presented impedance controller includes several novel features. First, a reference trajectory is omitted, allowing free movements. Second, force-feedback gains are reduced near actuator limits and a saturation function limits the maximum commanded force; both allow more responsive (higher) force-feedback gains within the workspace and mitigate transient oscillations caused by external disturbances. Finally, manipulability-based directional force-feedback gains help improve rendered impedance isotropy. Validation experiments included free exploration of the workspace, following a prescribed circular thumb motion, and intentional exposure to external disturbances. The experimental results show that the presented impedance controller significantly reduces impedance to subject-initiated motion and accurately renders the desired isotropic low-impedance environment.

Hybrid Rehabilitation System with Motion Estimation Based on EMG Signals

Patients with upper limb paralysis undergo various types of rehabilitation to reconstruct upper limb functions necessary for their return to daily life and social activities. Therefore, it is necessary to develop an effective rehabilitation support system using robotic technologies. In this study, we propose an EMG-driven hybrid rehabilitation system based on the estimation of intended motion using a probabilistic neural network. In the proposed system, the developed robot and functional electrical stimulation are controlled by estimating the patient's intention, which enables the intuitive learning of the appropriate control abilities of joint motions and muscle contraction patterns. In the experiments, hybrid and visual feedback training were conducted for pointing movements of the wrist joint of the non-dominant hand. The results confirmed that the proposed method provides effective training and has great potential for use in rehabilitation.

Do kinematic measures, added to clinical measures, better predict upper extremity motor impairments at three months post-stroke?

OBJECTIVE

Predicting post-stroke recovery through prediction models is crucial for choosing appropriate treatment options. However, the existing models predominantly incorporate clinical measures although measurement of movement quality using kinematic measures is essential for distinguishing various types of recovery. Thus, this study aimed at determining if, by considering varied aspects of recovery, adding kinematic measurements over clinical measures would better predict upper extremity (UE) motor impairments at three months post-stroke.

MATERIALS AND METHODS

Eighty-nine stroke survivors (58.9 ± 11.8 years) were assessed for clinical predictors between 4 and 7 days, kinematic predictors within 1 month, and the impairment outcome of the Fugl Meyer Assessment of the UE (FM-UE) at three months post-stroke. Significant predictors (p<0.05) with a variation inflation factor (VIF) <10 were selected for model development. After performing further step-wise selection, three models incorporating clinical outcomes, kinematic measurements, and a combination of these two, respectively, were formulated.

RESULTS

The clinical model (R2 = 0.70) included shoulder abduction finger extension (SAFE) scores, the National Institutes of Health Stroke Scale (NIHSS), and the Montreal Cognitive Assessment (MoCA). The kinematic model (R2 = 0.34) included total displacement, total time, and reaction time. The combined model (R2 = 0.72) comprised of SAFE score and shoulder flexion. All the models had a minimal mean squared error on cross validation, which indicated a good validity.

CONCLUSION

The performance of clinical and combined prediction models for predicting three-month post-stroke UE motor recovery was nearly similar. However, in order to detect minimal changes over time and to understand all aspects of motor recovery, there is a need to add instrument-based kinematic measures.

Empirical Myoelectric Feature Extraction and Pattern Recognition in Hemiplegic Distal Movement Decoding

In myoelectrical pattern recognition (PR), the feature extraction methods for stroke-oriented applications are challenging and remain discordant due to a lack of hemiplegic data and limited knowledge of skeletomuscular function. Additionally, technical and clinical barriers create the need for robust, subject-independent feature generation while using supervised learning (SL). To the best of our knowledge, we are the first study to investigate the brute-force analysis of individual and combinational feature vectors for acute stroke gesture recognition using surface electromyography (EMG) of 19 patients. Moreover, post-brute-force singular vectors were concatenated via a Fibonacci-like spiral net ranking as a novel, broadly applicable concept for feature selection. This semi-brute-force navigated amalgamation in linkage (SNAiL) of EMG features revealed an explicit classification rate performance advantage of 10-17% compared to canonical feature sets, which can drastically extend PR capabilities in biosignal processing.

The Effect of Uni-Hemispheric Dual-Site Anodal tDCS on Brain Metabolic Changes in Stroke Patients: A Randomized Clinical Trial

Uni-hemispheric concurrent dual-site anodal transcranial direct current stimulation (UHCDS a-tDCS) of the primary motor cortex (M₁) and the dorsolateral prefrontal cortex (DLPFC) may enhance the efficacy of a-tDCS after stroke. However, the cellular and molecular mechanisms underlying its beneficial effects have not been defined. We aimed to investigate the effect of a-tDCS_M1-DLPFC on brain metabolite concentrations (N-acetyl aspartate (NAA), choline (Cho)) in stroke patients using magnetic resonance spectroscopy (MRS). In this double-blind, sham-controlled, randomized clinical trial (RCT), 18 patients with a first chronic stroke in the territory of the middle cerebral artery trunk were recruited. Patients were allocated to one of the following two groups: (1) Experimental 1, who received five consecutive sessions of a-tDCS_M1-DLPFC M₁ (active)-DLPFC (active). (2) Experimental 2, who received five consecutive sessions of a-tDCS_M1-DLPFC M1 (active)-DLPFC (sham). MRS assessments were performed before and 24 h after the last intervention. Results showed that after five sessions of a-tDCS_M1-DLPFC, there were no significant changes in NAA and Cho levels between groups (Cohen's d = 1.4, Cohen's d = 0.93). Thus, dual site a-tDCS_M1-DLPFC did not affect brain metabolites compared to single site a-tDCS M₁.

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.

Progressive Rehabilitation Based on EMG Gesture Classification and an MPC-Driven Exoskeleton

Stroke is a leading cause of disability and death worldwide, with a prevalence of 200 millions of cases worldwide. Motor disability is presented in 80% of patients. In this context, physical rehabilitation plays a fundamental role for gradually recovery of mobility. In this work, we designed a robotic hand exoskeleton to support rehabilitation of patients after a stroke episode. The system acquires electromyographic (EMG) signals in the forearm, and automatically estimates the movement intention for five gestures. Subsequently, we developed a predictive adaptive control of the exoskeleton to compensate for three different levels of muscle fatigue during the rehabilitation therapy exercises. The proposed system could be used to assist the rehabilitation therapy of the patients by providing a repetitive, intense, and adaptive assistance.

Perspectives of users for a future interactive wearable system for upper extremity rehabilitation following stroke: a qualitative study

BACKGROUND

Wearable sensor technology can facilitate diagnostics and monitoring of people with upper extremity (UE) paresis after stroke. The purpose of this study is to investigate the perspectives of clinicians, people living with stroke, and their caregivers on an interactive wearable system that detects UE movements and provides feedback.

METHODS

This qualitative study used semi-structured interviews relating to the perspectives of a future interactive wearable system including a wearable sensor to capture UE movement and a user interface to provide feedback as the means of data collection. Ten rehabilitation therapists, 9 people with stroke, and 2 caregivers participated in this study.

RESULTS

Four themes were identified (1) "Everyone is different" highlighted the need for addressing individual user's rehabilitation goal and personal preference; (2) "The wearable system should identify UE and trunk movements" emphasized that in addition to arm, hand, and finger movements, detecting compensatory trunk movements during UE movements is also of interest; (3) "Both quality and amount of movements are necessary to measure" described the parameters related to how well and how much the user is using their affected UE that participants envisioned the system to monitor; (4) "Functional activities should be practiced by the users" outlined UE movements and activities that are of priority in designing the system.

CONCLUSIONS

Narratives from clinicians, people with stroke, and their caregivers offer insight into the design of interactive wearable systems. Future studies examining the experience and acceptability of existing wearable systems from end-users are warranted to guide the adoption of this technology.

Compensatory movement detection by using near-infrared spectroscopy technology based on signal improvement method

Introduction

Compensatory movements usually occur in stroke survivors with hemiplegia, which is detrimental to recovery. This paper proposes a compensatory movement detection method based on near-infrared spectroscopy (NIRS) technology and verifies its feasibility using a machine learning algorithm. We present a differential-based signal improvement (DBSI) method to enhance NIRS signal quality and discuss its effect on improving detection performance.

Method

Ten healthy subjects and six stroke survivors performed three common rehabilitation training tasks while the activation of six trunk muscles was recorded using NIRS sensors. After data preprocessing, DBSI was applied to the NIRS signals, and two time-domain features (mean and variance) were extracted. An SVM algorithm was used to test the effect of the NIRS signal on compensatory behavior detection.

Results

Classification results show that NIRS signals have good performance in compensatory detection, with accuracy rates of 97.76% in healthy subjects and 97.95% in stroke survivors. After using the DBSI method, the accuracy improved to 98.52% and 99.47%, respectively.

Discussion

Compared with other compensatory motion detection methods, our proposed method based on NIRS technology has better classification performance. The study highlights the potential of NIRS technology for improving stroke rehabilitation and warrants further investigation.

Can vibrotactile stimulation and tDCS help inefficient BCI users?

Brain-computer interface (BCI) has helped people by allowing them to control a computer or machine through brain activity without actual body movement. Despite this advantage, BCI cannot be used widely because some people cannot achieve controllable performance. To solve this problem, researchers have proposed stimulation methods to modulate relevant brain activity to improve BCI performance. However, multiple studies have reported mixed results following stimulation, and the comparative study of different stimulation modalities has been overlooked. Accordingly, this study was designed to compare vibrotactile stimulation and transcranial direct current stimulation's (tDCS) effects on brain activity modulation and motor imagery BCI performance among inefficient BCI users. We recruited 44 subjects and divided them into sham, vibrotactile stimulation, and tDCS groups, and low performers were selected from each stimulation group. We found that the latter's BCI performance in the vibrotactile stimulation group increased significantly by 9.13% (p < 0.01), and while the tDCS group subjects' performance increased by 5.13%, it was not significant. In contrast, sham group subjects showed no increased performance. In addition to BCI performance, pre-stimulus alpha band power and the phase locking values (PLVs) averaged over sensory motor areas showed significant increases in low performers following stimulation in the vibrotactile stimulation and tDCS groups, while sham stimulation group subjects and high performers showed no significant stimulation effects across all groups. Our findings suggest that stimulation effects may differ depending upon BCI efficiency, and inefficient BCI users have greater plasticity than efficient BCI users.

A neuroergonomic approach to assessing motor performance in stroke patients using fNIRS and behavioral data

Stroke is characterized by high morbidity and disability, and proposing effective methods for assessing and designing rehabilitation products is an attractive topic in current research. In this study, a hand function rehabilitation aid was developed for stroke patients. Ten stroke patients and 20 healthy older people as a control group were recruited to perform a 600 s task after a 600 s resting by gripping a stick while clicking on a flashing light in an electronic insert in sequence according to a pattern. The functional near-infrared spectroscopy (fNIRS) and behavioral data were collected during their rehabilitation training. Brain function was analyzed using three indicators, namely brain area activation, functional connectivity and effective connectivity, while behavioral performance was analyzed using ten indicators, such as velocity and acceleration, and correlations were made between both. Followed by proposing a quantitative assessment method based on the fusion of multiple data sources. The results showed that the developed rehabilitation tool could effectively stimulate the patient's brain and help recover their cognitive and behavioral capacities. The scientific validity of the proposed assessment approach was further confirmed by contrasting the data results of the stroke group with those of the healthy elderly group. This study has integrated brain function and behavioral data, providing a practical quantitative evaluation method of product ergonomics and data-driven product design concepts for stroke patients.

Clinical utility of a decision-making aid for upper limb neurorehabilitation: applying the Hypertonicity Intervention Planning Model across cultures

BACKGROUND

The Hypertonicity Intervention Planning Model (HIPM) is a decision-making aid which guides clinical reasoning in individualizing upper limb (UL) neurorehabilitation.

AIM

To examine the HIPM's clinical utility across cultures, using therapists' perceptions of its usefulness and challenges when applied in clinical practice.

METHODS

Interpretive description methodology guided qualitative data collection and analysis because it produces clinically practical applications. Forty-four occupational therapists working in Australia or Singapore participated. Three group discussions were conducted using a modified nominal group technique.

RESULTS

Three themes were: (1) The HIPM guides systematic clinical decision-making for assessment, goal-setting, and intervention; (2) Utility was influenced by systemic or organizational supports and barriers including availability of time, resources, and funding; organizational readiness to change; multidisciplinary and transorganizational collaboration; (3) Therapists' skills and confidence to apply the HIPM, and openness to changing practice, influenced utility.

CONCLUSIONS

Therapists strongly support HIPM use for structuring and communicating clinical reasoning in UL neurorehabilitation. However, organizational support is key to optimizing clinical utility. Incorporating decision-making aids into documentation and referral processes may strengthen multidisciplinary and transorganizational teamwork, enhancing clinical use. Different training tiers to suit therapist experience levels, refresher courses, and supplementary resources may improve therapists' skills and confidence, thereby boosting utility.

Hand-Arm Bimanual Intensive Therapy Including Lower Extremities (HABIT-ILE) in adults with chronic stroke: protocol of a randomised controlled trial

INTRODUCTION

Stroke causes multiple deficits including motor, sensitive and cognitive impairments, affecting also individual's social participation and independence in activities of daily living (ADL) impacting their quality of life. It has been widely recommended to use goal-oriented interventions with a high amount of task-specific repetitions. These interventions are generally focused only on the upper or lower extremities separately, despite the impairments are observed at the whole-body level and ADL are both frequently bimanual and may require moving around. This highlights the need for interventions targeting both upper and lower extremities. This protocol presents the first adaptation of Hand-Arm Bimanual Intensive Therapy Including Lower Extremities (HABIT-ILE) for adults with acquired hemiparesis.

METHODS AND ANALYSIS

This randomised controlled trial will include 48 adults with chronic stroke, aged ≥40 years. This study will compare the effect of 50 hours of HABIT-ILE against usual motor activity and regular rehabilitation. HABIT-ILE will be provided in a 2-week, adult's day-camp setting, promoting functional tasks and structured activities. These tasks will continuously progress by increasing their difficulty. Assessed at baseline, 3 weeks after and at 3 months, the primary outcome will be the adults-assisting-hand-assessment stroke; secondary outcomes include behavioural assessments for hand strength and dexterity, a motor learning robotic medical device for quality of bimanual motor control, walking endurance, questionnaires of ADL, stroke impact on participation and self-determined patient-relevant goals, besides neuroimaging measures.

ETHICS AND DISSEMINATION

This study has full ethical approval from the Comité d'éthique Hospitalo-Facultaire/Université catholique de Louvain, Brussels (reference number: 2013/01MAR/069) and the local medical Ethical Committee of the CHU UCL Namur-site Godinne. Recommendations of the ethical board and the Belgian law of 7 May 2004, concerning human experiments will be followed. Participants will sign a written informed consent ahead of participation. Findings will be published in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04664673.

High-Tech Home-Based Rehabilitation after Stroke: A Systematic Review and Meta-Analysis

(1) Background: To improve existing rehabilitation technologies, we conducted a systematic review and meta-analysis to identify the effect size of home-based rehabilitation using robotic, virtual reality, and game devices on physical function for stroke survivors. (2) Methods: Embase, PubMed, Cochrane Library, ProQuest, and CINAHL were used to search the randomized controlled trials that applied technologies via home-based rehabilitation, such as virtual reality, robot-assisted devices, and games. The effect size (Hedges's g) of technology type and affected limb on physical function were calculated. (3) Results: Ten studies were included. The effect size of home-based rehabilitation in virtual reality had the greatest value (Hedges's g, 0.850; 95% CI, 0.314-1.385), followed by robot-assisted devices (Hedges's g, 0.120; 95% CI, 0.003-0.017) and games (Hedges's g, -0.162; 95% CI, -0.036 to -0.534). The effect size was larger in the upper limbs (Hedges's g, 0.287; 95% CI, 0.128-0.447) than in the lower limbs (Hedges's g, -0.113; 95% CI, -0.547 to 0.321). (4) Conclusions: Virtual reality home rehabilitation was highly effective for physical function compared to other rehabilitation technologies. Interventions that consisted of a pre-structured and tailored program applied to the upper limbs were effective for physical function and psychological outcomes.

Survey of Movement Reproduction in Immersive Virtual Rehabilitation

Virtual reality (VR) has emerged as a powerful tool for rehabilitation. Many effective VR applications have been developed to support motor rehabilitation of people affected by motor issues. Movement reproduction, which transfers users' movements from the physical world to the virtual environment, is commonly used in VR rehabilitation applications. Three major components are required for movement reproduction in VR: (1) movement input, (2) movement representation, and (3) movement modulation. Until now, movement reproduction in virtual rehabilitation has not yet been systematically studied. This article aims to provide a state-of-the-art review on this subject by focusing on existing literature on immersive motor rehabilitation using VR. In this review, we provided in-depth discussions on the rehabilitation goals and outcomes, technology issues behind virtual rehabilitation, and user experience regarding movement reproduction. Similarly, we present good practices and highlight challenges and opportunities that can form constructive suggestions for the design and development of fit-for-purpose VR rehabilitation applications and can help frame future research directions for this emerging area that combines VR and health.

Isolating Neurologic Deficits in Cervical Spondylotic Myelopathy: A Case-Controlled Study, Using the NIH Toolbox Motor Battery

Background and Objectives

Patients with cervical spondylotic myelopathy (CSM) have motor impairments, including weakness, imbalance, and loss of dexterity. The reliable assessment of these symptoms is critical for treatment decisions. This study aimed to determine, for the first time, the use of the NIH Toolbox motor battery (NIHTBm) in the objective assessment of motor deficits in patients with CSM.

Methods

Patients with symptoms and MRI evidence of CSM and age-matched healthy controls (HC), with no evidence of spinal disorder or surgery were included in this case-control study based on our inclusion and exclusion criteria. We performed motor tests, dexterity, gait speed, grip strength, and balance tests, using the NIHTBm in patients with CSM and HCs. Motor impairment rates were determined in patients with CSM based on the NIHTBm scores. We determined the association between NIHTBm scores and patient-reported outcome scores; patient-reported outcome measures (the modified Japanese Orthopedic Association [mJOA] and Nurick grade) to determine the association. One-way analysis of variance was used to analyze group differences and the Spearman rank correlation to determine the relationship between assessment scores.

Results

We enrolled 24 patients with CSM with a mean age (SD) of 57.96 (10.61) years and 24 age-matched HCs with a mean age (SD) of 53.17 (6.04) years in this study. Overall, we observed a significant decrease in the motor function T-scores mean (SD): dexterity 31.54 (14.82) vs 51.54 (9.72), grip strength 32.00 (17.47) vs 56.79 (8.46), balance 27.58 (16.65) vs 40.21 (6.35), and gait speed 0.64 (0.18) vs 0.99 (0.17) m/s, in patients with CSM compared with that in HCs. The lower extremity dysfunction scores on the NIHTBm, balance (ρ = -0.67) and gait speed (ρ = -0.62), were associated with higher Nurick grades. We observed a similar but weaker association with the Nurick grades and NIHTBm tests: dexterity (ρ = -0.49) and grip strength (ρ = -0.31) scores. The total motor mJOA showed a positive but weak association with NIHTBm scores, gait speed (ρ = 0.38), balance (ρ = 0.49), grip strength (ρ = 0.41), and dexterity (ρ = 0.45).

Discussion

Patients with CSM had significantly lower NIHTBm scores compared with HCs. The results from the NIHTBm are consistent with the clinical presentation of CSM showing patients have motor impairments in both upper and lower extremities. As a neurologic-specific scale, NIHTBm should be used in the evaluation and clinical management of patients with CSM.

Does frequent use of an exoskeletal upper limb robot improve motor function in stroke patients?

PURPOSE

To determine how differences in frequency of the single-joint hybrid assistive limb (HAL-SJ) use affect the improvement of upper limb motor function and activities of daily living (ADL) in stroke patients.

MATERIALS AND METHODS

Subacute stroke patients were divided into the high or low frequency of HAL-SJ use groups. The two groups were matched by propensity score, and the degree of changes 30 days after initiating HAL-SJ use was compared. A logistic regression analysis was performed to examine whether frequent use would increase the number of subjects experiencing the efficacy of more than the minimal clinically important difference (MCID) of Fugl-Meyer assessment (FMA).

RESULTS

Twenty-five stroke patients were matched by propensity score, and nine pairs were matched. The high-frequency group showed a significantly superior increase to total FMA shoulder, elbow, forearm, and Barthel index compared with the low-frequency group. Logistic regression analysis revealed no significant associations between frequent use and MCID.

CONCLUSIONS

The frequency of HAL-SJ use may affect the improvement of motor function and ADL ability of the upper limb with exception of the fingers and wrist. However, the frequency of intervention was not effective enough to further increase the number of subjects with clinically meaningful changes in upper limb motor function.IMPLICATIONS FOR REHABILITATIONThe current study aimed to clarify how differences in the frequency of single-joint hybrid assistive limb (HAL-SJ) use can affect the improvement of upper-limb motor functions and ADL in subacute stroke patients.Our results implied that the frequency of HAL-SJ use may influence the recovery of upper limb function.However, even if HAL-SJ is used frequently, it does not mean that more patients will achieve clinically meaningful recovery.

Effect of transcranial direct current stimulation in combination with robotic therapy in upper limb impairments in people with stroke: a systematic review

Background

Stroke is a devastating condition, which not only affects patients’ activity, but also is a primary reason for the psychosocial impact on them, their caregivers, and the healthcare system. Transcranial direct current stimulation (tDCS) modulates cortical activity, encouraging neuro-modulation and motor recovery in stroke rehabilitation. Robotic therapy (RT) provides repetitive, high-intensity, interactive, task-specific intervention and can measure changes while providing feedback to people with stroke.

Objectives

This study aimed to evaluate and summarize the scientific literature systematically to investigate the combined effect of tDCS and RT in patients with stroke.

Methods

Four databases (MEDLINE, Web of Science, ScienceDirect, & PEDro) were searched for clinical trials investigating the effect of RT and tDCS in stroke patients with upper limb impairment. PEDro scale was used for the quality assessment of included studies.

Results

The search yielded 208 articles. A total of 213 patients with stroke who had upper limb impairment were studied. In the majority of the trials, RT combined with tDCS lead to positive improvement in various measures of upper limb function and spasticity.

Conclusions

RT along with tDCS is an effective mode of rehabilitation, although no additional effects of tDCS plus RT in comparison with RT alone were reported. Large, robust studies are needed, so that health care providers and researchers can make better decisions about merging tDCS and RT in stroke rehabilitation settings in the future.

Acetylated α-tubulin alleviates injury to the dendritic spines after ischemic stroke in mice

BACKGROUND AND AIM

Functional recovery is associated with the preservation of dendritic spines in the penumbra area after stroke. Previous studies found that polymerized microtubules (MTs) serve a crucial role in regulating dendritic spine formation and plasticity. However, the mechanisms that are involved are poorly understood. This study is designed to understand whether the upregulation of acetylated α-tubulin (α-Ac-Tub, a marker for stable, and polymerized MTs) could alleviate injury to the dendritic spines in the penumbra area and motor dysfunction after ischemic stroke.

METHODS

Ischemic stroke was mimicked both in an in vivo and in vitro setup using middle cerebral artery occlusion and oxygen-glucose deprivation models. Thy1-YFP mice were utilized to observe the morphology of the dendritic spines in the penumbra area. MEC17 is the specific acetyltransferase of α-tubulin. Thy1 Cre^ERT2-eYFP and MEC17^fl/fl mice were mated to produce mice with decreased expression of α-Ac-Tub in dendritic spines of pyramidal neurons in the cerebral cortex. Moreover, AAV-PHP.B-DIO-MEC17 virus and tubastatin A (TBA) were injected into Thy1 Cre^ERT2-eYFP and Thy1-YFP mice to increase α-Ac-Tub expression. Single-pellet retrieval, irregular ladder walking, rotarod, and cylinder tests were performed to test the motor function after the ischemic stroke.

RESULTS

α-Ac-Tub was colocalized with postsynaptic density 95. Although knockout of MEC17 in the pyramidal neurons did not affect the density of the dendritic spines, it significantly aggravated the injury to them in the penumbra area and motor dysfunction after stroke. However, MEC17 upregulation in the pyramidal neurons and TBA treatment could maintain mature dendritic spine density and alleviate motor dysfunction after stroke.

CONCLUSION

Our study demonstrated that α-Ac-Tub plays a crucial role in the maintenance of the structure and functions of mature dendritic spines. Moreover, α-Ac-Tub protected the dendritic spines in the penumbra area and alleviated motor dysfunction after stroke.

Comparison of immersive and non-immersive virtual reality for upper extremity functional recovery in patients with stroke: a systematic review and network meta-analysis

OBJECTIVE

This systematic review aimed to compare the effects of immersive and non-immersive virtual reality on upper extremity function in stroke survivors by employing a network meta-analysis approach.

DATA SOURCES

MEDLINE, Embase, CINAHL Plus, APA PsycINFO, and Scopus were searched. Virtual reality was used for upper extremity rehabilitation; dose-matched conventional rehabilitation was used for comparison. Fugl-Meyer Assessment was used to assess upper extremity function. Searches were limited to English language randomized controlled trials.

METHODS

Two independent reviewers conducted study selection, data extraction, and quality assessment. Methodological quality was assessed using the Physiotherapy Evidence Database scale. A random-effects frequentist network meta-analysis was conducted by assuming a common random-effects standard deviation for all comparisons in the network.

RESULTS

Twenty randomized controlled trials with 813 participants were included, with each study evaluated as good quality. Immersive virtual reality systems were most effective at improving upper extremity function, followed by non-immersive virtual reality systems, then non-immersive gaming consoles of Microsoft Kinect and Nintendo Wii. Conventional rehabilitation was least effective. Immersive virtual reality was estimated to induce 1.39 (95% confidence interval (CI): 0.25, 2.53) and 1.38 (95% CI: 0.55, 2.20) standard mean differences of improvements in upper extremity function, compared to Nintendo Wii intervention and conventional rehabilitation, respectively.

CONCLUSION

This systematic review and network meta-analysis highlights the superior effects of immersive virtual reality to non-immersive virtual reality systems and gaming consoles on upper extremity motor recovery.

Striatal fibrinogen extravasation and vascular degeneration correlate with motor dysfunction in an aging mouse model of Alzheimer’s disease

Introduction: Alzheimer’s Disease (AD) patients exhibit signs of motor dysfunction, including gait, locomotion, and balance deficits. Changes in motor function often precede other symptoms of AD as well as correlate with increased severity and mortality. Despite the frequent occurrence of motor dysfunction in AD patients, little is known about the mechanisms by which this behavior is altered.

Methods and Results: In the present study, we investigated the relationship between cerebrovascular impairment and motor dysfunction in a mouse model of AD (Tg6799). We found an age-dependent increase of extravasated fibrinogen deposits in the cortex and striatum of AD mice. Interestingly, there was significantly decreased cerebrovascular density in the striatum of the 15-month-old as compared to 7-month-old AD mice. We also found significant demyelination and axonal damage in the striatum of aged AD mice. We analyzed striatum-related motor function and anxiety levels of AD mice at both ages and found that aged AD mice exhibited significant impairment of motor function but not in the younger AD mice.

Discussion: Our finding suggests an enticing correlation between extravasated fibrinogen, cerebrovascular damage of the striatum, and motor dysfunction in an AD mouse model, suggesting a possible mechanism underlying motor dysfunction in AD.

The Effect of Self-Care Nurturance Using the Theory of Modeling and Role-Modeling on Self-Efficacy in Stroke Patients: A Randomized Controlled Trial

The disability after a stroke results in reduced self-care capacity and lower levels of self-efficacy in survivors. Exploiting a holistic self-care plan to strengthen internal resources in clients can be thus deemed as an effective solution. This study aimed to determine the effect of self-care nurturance using the Theory of Modeling/Role-Modeling (TMRM) on self-efficacy in stroke clients. A randomized controlled trial was conducted at Qaem Hospital, Mashhad, Iran, in 2020. For this purpose, 70 clients were randomly assigned to 2 groups. Then, the experimental group received self-care nurturance based on the TMRM, all through 4 to 6 individual sessions of 30 to 45 minutes in the hospital, and subsequently 2 sessions of telephone counseling up to 8 weeks after the discharge. With reference to patient evaluation in terms of self-care resources, knowledge, and actions, the researcher also tried to strengthen such factors based on the individual needs of each client. The control group received routine care. The data were collected through completing a demographic/disease information form at the onset and the Stroke Self-Efficacy Questionnaire (SSEQ) before the intervention, 4 and 8 weeks after it. The results revealed that the self-efficacy mean scores of the experimental group, in the course of 3 measurement stages, had significantly improved, compared with that in the control group (P = .018). It was concluded that applying the TMRM could strengthen internal and external resources and self-care knowledge in stroke patients, develop their self-care actions, and improve their levels of self-efficacy.

Corticospinal and spinal adaptations following lower limb motor skill training: a meta-analysis with best evidence synthesis

Motor skill training alters the human nervous system; however, lower limb motor tasks have been less researched compared to upper limb tasks. This meta-analysis with best evidence synthesis aimed to determine the cortical and subcortical responses that occur following lower limb motor skill training, and whether these responses are accompanied by improvements in motor performance. Following a literature search that adhered to the PRISMA guidelines, data were extracted and analysed from six studies (n = 172) for the meta-analysis, and 11 studies (n = 257) were assessed for the best evidence synthesis. Pooled data indicated that lower limb motor skill training increased motor performance, with a standardised mean difference (SMD) of 1.09 being observed. However, lower limb motor skill training had no effect on corticospinal excitability (CSE), Hoffmann's reflex (H-reflex) or muscle compound action potential (M_MAX) amplitude. The best evidence synthesis found strong evidence for improved motor performance and reduced short-interval cortical inhibition (SICI) following lower limb motor skill training, with conflicting evidence towards the modulation of CSE. Taken together, this review highlights the need for further investigation on how motor skill training performed with the lower limb musculature can modulate corticospinal responses. This will also help us to better understand whether these neuronal measures are underpinning mechanisms that support an improvement in motor performance.

Bilateral Transfer of Performance between Real and Non-Immersive Virtual Environments in Post-Stroke Individuals: A Cross-Sectional Study

(1) Background: Post-stroke presents motor function deficits, and one interesting possibility for practicing skills is the concept of bilateral transfer. Additionally, there is evidence that the use of virtual reality is beneficial in improving upper limb function. We aimed to evaluate the transfer of motor performance of post-stroke and control groups in two different environments (real and virtual), as well as bilateral transfer, by changing the practice between paretic and non-paretic upper limbs. (2) Methods: We used a coincident timing task with a virtual (Kinect) or a real device (touch screen) in post-stroke and control groups; both groups practiced with bilateral transference. (3) Results: Were included 136 participants, 82 post-stroke and 54 controls. The control group presented better performance during most parts of the protocol; however, it was more evident when compared with the post-stroke paretic upper limb. We found bilateral transference mainly in Practice 2, with the paretic upper limb using the real interface method (touch screen), but only after Practice 1 with the virtual interface (Kinect), using the non-paretic upper limb. (4) Conclusions: The task with the greatest motor and cognitive demand (virtual-Kinect) provided transfer into the real interface, and bilateral transfer was observed in individuals post-stroke. However, this is more strongly observed when the virtual task was performed using the non-paretic upper limb first.

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.

Restoring Voluntary Bimanual Activities of Patients With Chronic Hemiparesis Through a Foot-Controlled Hand/Forearm Exoskeleton

A significant number of stroke patients are permanently left with a hemiparetic upper limb after the poststroke six-month golden recovery period, resulting in a drastic decline in their quality of life. This study develops a novel foot-controlled hand/forearm exoskeleton that enables patients with hemiparetic hands and forearms to restore their voluntary activities of daily living. Patients can accomplish dexterous hand/arm manipulation on their own with the assistance of a foot-controlled hand/forearm exoskeleton by utilizing foot movements on the unaffected side as command signals. The proposed foot-controlled exoskeleton was first tested on a stroke patient with a chronic hemiparetic upper limb. The testing results showed that the forearm exoskeleton can assist the patient in achieving approximately 107° of voluntary forearm rotation with a static control error less than 1.7°, whereas the hand exoskeleton can assist the patient in realizing at least six different voluntary hand gestures with a success rate of 100%. Further experiments involving more patients demonstrated that the foot-controlled hand/forearm exoskeleton can help patients in restoring some of the voluntary activities of daily living with their paretic upper limb, such as picking up food to eat and opening water bottles to drink, and etc. This research implies that the foot-controlled hand/forearm exoskeleton is a viable way to restore the upper limb activities of stroke patients with chronic hemiparesis.

Transcranial direct current stimulation (tDCS) effects on upper limb motor function in stroke: an overview review of the systematic reviews

BACKGROUND

Stroke is the prime cause of disability in the elderly population. Transcranial direct current stimulation (tDCS) is an emerging noninvasive brain stimulation in rehabilitating upper limb function post-stroke. However, mixed evidence exists in the literature and ambiguous conclusions regarding the effect of tDCS on upper limb function.

OBJECTIVE

This study aimed to assess the current evidence on the effect of (tDCS) on upper limb motor function and activities of daily living in patients after stroke by conducting an overview of systematic reviews.

METHODOLOGY

We performed electronic database searches and gray literature searches for the articles.

RESULTS

Two distinct literature searches gathered a total of 203 studies. Out of them, six systematic reviews and meta-analyses were included for methodological quality assessment and data extraction. All included studies were determined to be of good to high quality based on a methodological appraisal using the Assessment of Multiple Systematic Reviews checklist.

CONCLUSION

Identified evidence suggests that tDCS has superior effects to control interventions in improving functions of the upper limb and activities of daily living in patients who have had a stroke. Moreover, cathodal stimulation over the non-affected brain region was more effective than anodal and dual tDCS stimulation.

Synergic Effect of Robot-Assisted Rehabilitation and Antispasticity Therapy: A Narrative Review

BACKGROUND

Stroke and spinal cord injury are neurological disorders that cause disability and exert tremendous social and economic effects. Robot-assisted training (RAT), which may reduce spasticity, is widely applied in neurorehabilitation. The combined effects of RAT and antispasticity therapies, such as botulinum toxin A injection therapy, on functional recovery remain unclear. This review evaluated the effects of combined therapy on functional recovery and spasticity reduction.

MATERIALS AND METHODS

Studies evaluating the efficacy of RAT and antispasticity therapy in promoting functional recovery and reducing spasticity were systemically reviewed. Five randomized controlled trials (RCTs) were included. The modified Jadad scale was applied for quality assessment. Functional assessments, such as the Berg Balance Scale, were used to measure the primary outcome. Spasticity assessments, such as the modified Ashworth Scale, were used to measure the secondary outcome.

RESULTS

Combined therapy improves functional recovery in the lower limbs but does not reduce spasticity in the upper or lower limbs.

CONCLUSIONS

The evidence supports that combined therapy improves lower limb function but does not reduce spasticity. The considerable risk of bias among the included studies and the enrolled patients who did not receive interventions within the golden period of intervention are two major factors that should be considered when interpreting these results. Additional high-quality RCTs are required.

The Sonoelastography and Functional Outcome of Upper Extremity after Kinesiotaping on the Spastic Forearm in Patients with Subacute Stroke

Objectives

This study is aimed at exploring the feasibility of sonoelastography on muscle stiffness of spastic forearm and evaluating the improvement of functional performance in patients with poststroke spasticity (PSS) after receiving kinesiotaping (KT) and rehabilitation.

Methods

According to the spastic levels (using modified Ashworth scale (MAS)) of the affected upper extremity, 59 patients with stroke were allocated into two groups, group A (MAS 0-1): 31 patients (14 men and 17 women; mean age: 60 years) and group B (MAS 1+-2): 28 patients (22 men and 6 women; mean age: 51 years). The Brunnstrom motor recovery stage at the wrist/distal parts in groups A and B was stage 3/3.5 and stage 2.75/3. We evaluated the Brunnstrom stage, spastic levels by MAS and modified Tardieu scale (MTS), and Fugl-Meyer Assessment for upper extremity (FMA-UE). We also evaluated the muscle spasticity of flexor carpi radialis (FCR), flexor carpi ulnaris (FCU), and flexor digitorum superficialis (FDS) muscles using sonoelastography with shear wave velocity (SWV). We applied KT for 20 patients in group B, comparing the changes in sonoelastography and functional outcomes between KT and without KT interventions.

Results

Both the MAS and MTS scales were moderately correlated with the SWV in forearm muscles on hemiplegic side (r = 0.336-0.554) After KT intervention, the SWV in FCR decreased (p = 0.028). Muscle spasticity was reduced (p < 0.01), and distal part of the Brunnstrom stage and FMA-UE were increased (p = 0.045 and p = 0.001). In patients without KT intervention, only the MTS degree reduced (p = 0.026).

Conclusions

The SWV of sonoelastography could objectively assess the reduction of muscle stiffness of the affected forearms in patients with PSS after KT intervention. Advances in Knowledge. Sonoelastography could be a quantitative method to follow up for therapeutic effect of the spastic forearm.

The Efficacity of the NeuroAssist Robotic System for Motor Rehabilitation of the Upper Limb-Promising Results from a Pilot Study

The research aimed to evaluate the efficacy of the NeuroAssist, a parallel robotic system comprised of three robotic modules equipped with human-robot interaction capabilities, an internal sensor system for torque monitoring, and an external sensor system for real-time patient monitoring for the motor rehabilitation of the shoulder, elbow, and wrist. The study enrolled 10 consecutive patients with right upper limb paresis caused by stroke, traumatic spinal cord disease, or multiple sclerosis admitted to the Neurology I Department of Cluj-Napoca Emergency County Hospital. The patients were evaluated clinically and electrophysiologically before (T1) and after the intervention (T2). The intervention consisted of five consecutive daily sessions of 30-45 min each of 30 passive repetitive movements performed with the robot. There were significant differences (Wilcoxon signed-rank test) between baseline and end-point clinical parameters, specifically for the Barthel Index (53.00 ± 37.72 vs. 60.50 ± 36.39, p = 0.016) and Activities of Daily Living Index (4.70 ± 3.43 vs. 5.50 ± 3.80, p = 0.038). The goniometric parameters improved: shoulder flexion (70.00 ± 56.61 vs. 80.00 ± 63.59, p = 0.026); wrist flexion/extension (34.00 ± 28.75 vs. 42.50 ± 33.7, p = 0.042)/(30.00 ± 22.97 vs. 41.00 ± 30.62, p = 0.042); ulnar deviation (23.50 ± 19.44 vs. 33.50 ± 24.15, p = 0.027); and radial deviation (17.50 ± 18.14 vs. 27.00 ± 24.85, p = 0.027). There was a difference in muscle activation of the extensor digitorum communis muscle (1.00 ± 0.94 vs. 1.40 ± 1.17, p = 0.046). The optimized and dependable NeuroAssist Robotic System improved shoulder and wrist range of motion and functional scores, regardless of the cause of the motor deficit. However, further investigations are necessary to establish its definite role in motor recovery.

Factors associated with cognitive impairment at 3, 6, and 12 months after the first stroke among Lebanese survivors

INTRODUCTION

This study aimed to calculate the rate of post-stroke cognitive impairment (PSCI) by evaluating the cognitive domains among Lebanese stroke survivors at 3, 6, and 12 months post-stroke, and to identify the contributing factors including pre- and post-stroke related factors.

METHODS

A multicenter longitudinal prospective study was conducted in 10 hospitals from Beirut and Mount Lebanon for a 15-month period. Mini-Mental State Examination (MMSE), modified Rankin Scale (mRS), Short Form Health Survey (SF12), National Institutes of Health Stroke Scale (NIHSS), and Hospital Anxiety and Depression Scale (HADS) were used to assess cognitive function, disability degree, Quality of Life (QoL), stroke severity, and levels of anxiety and depression, respectively. Then, univariate and multivariable analyses were performed to identify the predictors of PSCI.

RESULTS

Low MMSE scores were found among survivors during the first 3 months post-stroke (74.8%) of whom 53.7% presented with an MMSE ≤ 17, followed by 46.7% in the 6 months, and 37.6% at 12 months post-stroke. Follow-up comparisons showed a significant increase of MMSE scores over time (p < .001), indicating a 37% improvement of the cognitive function over time. The most affected cognitive domain was the attention and concentration at the three time points. Independent factors that were positively associated with low MMSE scores were as follows: sedentary behavior ≥ 12 h/day (AOR = 3.062, p = .033), involvement of the left hemisphere (AOR = 2.710, p = .006), HADS ≥ 11 (AOR = 2.536, p = .049), and high NIHSS scores (AOR = 3, p = .009). Age was the main predictor in the three time periods (AOR ≈ 3, p < .05). Inversely, female gender (AOR = 0.09, p = .027), high educational level (AOR = 0.2, p < .02), employment post-stroke (AOR = 0.3, p = .023), high Physical Component Summary (PCS) of Quality of Life (QoL) (AOR = 0.8, p < .001), and the use of anti-diabetic treatment post-stroke (AOR = 0.17, p = .016) improved MMSE scores to > 23.

CONCLUSION

The risk of PSCI among Lebanese stroke survivors was high especially in the acute phase, depending on various determinants. Health care providers are invited to implement an emergency rehabilitation program for an appropriate successful management of the risk factors in order to reduce stroke burden and to improve overall cognitive performance.

Neural oscillations during acupuncture imagery partially parallel that of real needling

Introduction

Tasks involving mental practice, relying on the cognitive rehearsal of physical motors or other activities, have been reported to have similar patterns of brain activity to overt execution. In this study, we introduced a novel imagination task called, acupuncture imagery and aimed to investigate the neural oscillations during acupuncture imagery.

Methods

Healthy volunteers were guided to watch a video of real needling in the left and right KI3 (Taixi point). The subjects were then asked to perform tasks to keep their thoughts in three 1-min states alternately: resting state, needling imagery left KI3, and needling imagery right KI3. Another group experienced real needling in the right KI3. A 31-channel-electroencephalography was synchronously recorded for each subject. Microstate analyses were performed to depict the brain dynamics during these tasks.

Results

Compared to the resting state, both acupuncture needling imagination and real needling in KI3 could introduce significant changes in neural dynamic oscillations. Moreover, the parameters involving microstate A of needling imagery in the right KI3 showed similar changes as real needling in the right KI3.

Discussion

These results confirm that needling imagination and real needling have similar brain activation patterns. Needling imagery may change brain network activity and play a role in neural regulation. Further studies are needed to explore the effects of acupuncture imagery and the potential application of acupuncture imagery in disease recovery.

[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.

Functional Ability and Health Problems of Stroke Survivors: An Explorative Study

Background A stroke is an emergency medical condition that needs to be treated promptly. Patients who suffer from stroke frequently experience varying degrees of impairment, necessitating emergency hospital treatment and prolonged home care. It can lower the quality of life which leads to social isolation and makes it harder to function independently. The purpose of this research was to assess the health issues and functional capacity of individuals living with stroke. Methodology An exploratory study was conducted in the neurological outpatient department of tertiary care hospitals in Chennai. A total of 30 post-stroke participants were selected using a convenient sampling technique. Data were collected by structured interviews using the Post-Stroke Checklist and Barthel Index. The data were analyzed through descriptive and inferential statistics. Results The majority of the patients were (86.7%) men in the age group of 55-65 years. Regarding the health problems identified with the Post-Stroke Checklist, the activities of daily living (80%) were the most common, and spasticity (48%) and pain (34%) were the least common. However, 60% of the participants had new problems related to vision, 66% had problems with hearing, 76% had problems with getting around inside or outside, and 60% had a history of a recent fall. Further, 52% had problems with remembering and concentrating on things, 72% had problems sleeping, and 45% were worried about their relationship with their spouse after the stroke. The median Barthel Index score was 43.5. Conclusions More than half of all stroke survivors were dependent on others for everyday activities. We recommend that a well-designed and focused assessment is needed to identify the functional ability and stroke-related health problems among individuals by all healthcare professionals for the successful rehabilitation of stroke survivors.

Prediction of Factors Affecting Mobility in Patients with Stroke and Finding the Mediation Effect of Balance on Mobility: A Cross-Sectional Study

(1) Background: Regaining mobility after stroke is essential to facilitate patient independency in activities of daily living. Predicting post-stroke mobility is clinically important and plays a significant part in rehabilitation programs. The purpose of this study is to find the factors affecting mobility in patients with stroke and to analyze the mediation effect of balance on mobility. (2) Methods: This cross-sectional study included forty-one patients with stroke averaging an age of 57.2 ± 88.6. The Rivermead Mobility Index (RMI) was used for measuring the mobility, Timed Up and Go (TUG) to measure the walking speed, Berg Balance Scale (BBS) to assess the balance and a handheld dynamometer (HHD) was used for measuring the isometric strength of the ankle and knee. (3) Results: In regression analysis balance (β=0.58;&nbsp;p≤&nbsp;0.0001) and walking speed (β=-0.27;&nbsp;p=0.04) were the significant factors predicting mobility. (4) Conclusions: Balance and gait speed were the factors that influenced mobility in stroke patients, indicating the utility of measuring these aspects in order to provide appropriate rehabilitation programs.

Augmented reality for stroke rehabilitation during COVID-19

BACKGROUND

The lack of the rehabilitation professionals is a global issue and it is becoming more serious during COVID-19. An Augmented Reality Rehabilitation System (AR Rehab) was developed for virtual training delivery. The virtual training was integrated into the participants' usual care to reduce the human trainers' effort so that the manpower scarcity can be eased. This also resulted in the reduction of the contact rate in pandemics.

OBJECTIVE

To investigate the feasibility of the AR Rehab-based virtual training when integrated into the usual care in a real-world pandemic setting, by answering questions of whether the integrated trials can help fulfill the training goal and whether the trials can be delivered when resources are limited because of COVID-19.

METHODS

Chronic stroke participants were randomly assigned to either a centre-based group (AR-Centre) or a home-based group (AR-Home) for a trial consisting of 20 sessions delivered in a human-machine integrated intervention. The trial of the AR-Centre was human training intensive with 3/4 of each session delivered by human trainers (PTs/OTs/Assistants) and 1/4 delivered by the virtual trainer (AR Rehab). The trial of the AR-Home was virtual training intensive with 1/4 and 3/4 of each session delivered by human and virtual trainers, respectively. Functional assessments including Fugl-Meyer Assessment for Upper Extremity (FMA-UE) and Lower Extremity (FMA-LE), Functional Ambulation Category (FAC), Berg Balance Scale (BBS), Barthel Index (BI) of Activities of Daily Living (ADL), and Physical Component Summary (SF-12v2 PCS) and Mental Component Summary (SF-12v2 MCS) of the 12-Item Short Form Health Survey (SF-12v2), were conducted before and after the intervention. User experience (UX) using questionnaires were collected after the intervention. Time and human resources required to deliver the human and virtual training, respectively, and the proportion of participants with clinical significant improvement were also used as supplementary measures.

RESULTS

There were 129 patients from 10 rehabilitation centres enrolled in the integrated program with 39 of them were selected for investigation. Significant functional improvement in FMA-UE (AR-Centre: p = 0.0022, AR-Home: p = 0.0043), FMA-LE (AR-Centre: p = 0.0007, AR-Home: p = 0.0052), SF-12v2 PCS (AR-Centre: p = 0.027, AR-Home: p = 0.036) were observed in both groups. Significant improvement in balance ability (BBS: p = 0.0438), and mental components (SF-12v2 MCS: p = 0.017) were found in AR-Centre group, while activities of daily living (BI: p = 0.0007) was found in AR-Home group. Contact rate was reduced by 30.75-72.30% within AR-All, 0.00-60.00% within AR-Centre, and 75.00-90.00% within AR-Home.

CONCLUSION

The human-machine integrated mode was effective and efficient to reduce the human rehabilitation professionals' effort while fulfilling the training goals. It eased the scarcity of manpower and reduced the contact rate during the pandemics.

Effectiveness of contralaterally controlled functional electrical stimulation vs. neuromuscular electrical stimulation for recovery of lower extremity function in patients with subacute stroke: A randomized controlled trial

Objective

This study aimed to compare the efficacy of contralaterally controlled functional electrical stimulation (CCFES) vs. neuromuscular electrical stimulation (NMES) for motor recovery of the lower extremity in patients with subacute stroke.

Materials and methods

Seventy patients within 6 months post-stroke were randomly assigned to the CCFES group (n = 35) and the NMES group (n = 35). Both groups underwent routine rehabilitation plus 20-min electrical stimulation (CCFES or NMES) on ankle dorsiflexion muscles per day, 5 days a week, for 3 weeks. Ankle AROM (dorsiflexion), Fugl-Meyer assessment-lower extremity (FMA-LE), Barthel Index (BI), Functional Ambulation Category scale (FAC), 10-meter walking test, and surface electromyography (sEMG) were assessed at the baseline and at the end of the intervention.

Result

Ten patients did not complete the study (five in CCFES and five in NMES), so only 60 patients were analyzed in the end. After the 3-week intervention, FMA-LE, BI, Ankle AROM (dorsiflexion), and FAC increased in both groups (p < 0.05). Patients in the CCFES group showed significantly greater improvements only in the measurement of Fugl-Meyer assessment-lower extremity compared with the NMES group after treatment (p < 0.05). The improvement in sEMG response of tibialis anterior by CCFES was greater than NMES (p < 0.05).

Conclusion

Contralateral controlled functional electrical stimulation can effectively improve the motor function of the lower limbs better than conventional neuromuscular electrical stimulation in subacute patients after stroke, but the effect on improving the ability to walk, such as walking speed, was not good.

Clinical trial registration

http://www.chictr.org.cn/, identifier: ChiCTR2100045423.

A Systematic Review of Virtual Reality and Robot Therapy as Recent Rehabilitation Technologies Using EEG-Brain-Computer Interface Based on Movement-Related Cortical Potentials

To enhance the treatment of motor function impairment, patients' brain signals for self-control as an external tool may be an extraordinarily hopeful option. For the past 10 years, researchers and clinicians in the brain-computer interface (BCI) field have been using movement-related cortical potential (MRCP) as a control signal in neurorehabilitation applications to induce plasticity by monitoring the intention of action and feedback. Here, we reviewed the research on robot therapy (RT) and virtual reality (VR)-MRCP-based BCI rehabilitation technologies as recent advancements in human healthcare. A list of 18 full-text studies suitable for qualitative review out of 322 articles published between 2000 and 2022 was identified based on inclusion and exclusion criteria. We used PRISMA guidelines for the systematic review, while the PEDro scale was used for quality evaluation. Bibliometric analysis was conducted using the VOSviewer software to identify the relationship and trends of key items. In this review, 4 studies used VR-MRCP, while 14 used RT-MRCP-based BCI neurorehabilitation approaches. The total number of subjects in all identified studies was 107, whereby 4.375 ± 6.3627 were patient subjects and 6.5455 ± 3.0855 were healthy subjects. The type of electrodes, the epoch, classifiers, and the performance information that are being used in the RT- and VR-MRCP-based BCI rehabilitation application are provided in this review. Furthermore, this review also describes the challenges facing this field, solutions, and future directions of these smart human health rehabilitation technologies. By key items relationship and trends analysis, we found that motor control, rehabilitation, and upper limb are important key items in the MRCP-based BCI field. Despite the potential of these rehabilitation technologies, there is a great scarcity of literature related to RT and VR-MRCP-based BCI. However, the information on these rehabilitation methods can be beneficial in developing RT and VR-MRCP-based BCI rehabilitation devices to induce brain plasticity and restore motor impairment. Therefore, this review will provide the basis and references of the MRCP-based BCI used in rehabilitation applications for further clinical and research development.

Subjective and objective assessments are associated for physical function but not cognitive function in community-dwelling stroke survivors

PURPOSE

To investigate the relation between subjectively and objectively assessed cognitive and physical functioning among community-dwelling stroke survivors, and to examine the association of stroke severity with subjectively and objectively assessed cognitive and physical impairments.

MATERIALS AND METHODS

Secondary data analysis was conducted with 127 community-dwelling stroke survivors. For cognitive functioning, objective measures included the NIH Toolbox Cognition Battery and the Executive Function Performance Test; subjective measures included the Quality of Life in Neurological Disorders Applied Cognition. Objective and subjective physical functioning was measured by the NIH Toolbox 2-Minute Walk Test and the Patient-Reported Outcomes Measurement Information System Physical Function, respectively.

RESULTS

A positive correlation was observed between subjective and objective physical functioning, whereas the correlation between subjective and objective cognitive functioning was nonsignificant. Stroke severity was associated with objective cognitive impairment and objective and subjective physical impairment, but not subjective cognitive impairment.

CONCLUSIONS

The lack of association between objective and subjective cognitive functioning challenges the conventional assumption that perceived functioning reflects actual performance. We recommend using both objective and subjective measures to accurately identify cognitive and physical impairment following stroke.Implications for RehabilitationSubjective cognitive functioning is not associated with objective cognitive functioning, suggesting that solely relying on stroke patients' reports is inadequate and may inaccurately estimate patients' actual deficits.Both objective and subjective measures should be used to accurately identify cognitive and physical impairment following stroke.Practitioners should be cognizant of stroke patients' behavioral signs associated with underlying cognitive problems that warrant further evaluation.

Network Meta-Analysis of Non-Conventional Therapies for Improving Upper Limb Motor Impairment Poststroke

BACKGROUND

Network meta-analysis is a method that can estimate relative efficacy between treatments that may not have been compared directly within the literature. The purpose of this study is to present a network meta-analysis of non-conventional interventions to improve upper extremity motor impairment after stroke.

METHODS

A literature search was conducted in 5 databases from their inception until April 1, 2021. Terms were used to narrow down articles related to stroke, the upper extremity, and interventional therapies. Randomized controlled trials written in English were eligible if; 50% poststroke patients; ≥18 years old; applied an intervention for the upper extremity, and/or used the Fugl-Meyer upper extremity scale as an outcome measure; the intervention had ≥3 randomized controlled trials with comparisons against a conventional care group; conventional care groups were dose matched for therapy time. A Bayesian network meta-analysis approach was taken to estimate mean difference (MD) and 95% CI.

RESULTS

One hundred seventy-six randomized controlled trials containing 6781 participants examining 20 non-conventional interventions were identified for inclusion within the final model. Eight of the identified interventions proved significantly better than conventional care, with modified constraint induced movement therapy (MD, 6.7 [95% CI, 4.3-8.9]), high frequency repetitive transcranial magnetic stimulation (MD, 5.4 [95% CI, 1.9-8.9]), mental imagery (MD, 5.4 [95% CI, 1.8-8.9]), bilateral arm training (MD, 5.2 [95% CI, 2.2-8.1]), and intermittent theta-burst stimulation (MD, 5.1 [95% CI, 0.62-9.5]) occupying the top 5 spots according to the surface under the cumulative ranking curve.

CONCLUSIONS

Overall, it would seem that modified constraint induced movement therapy has the greatest probability of being the most effective intervention, with high-frequency repetitive transcranial magnetic stimulation, mental imagery, and bilateral arm training all having similar probabilities of occupying the next spot in the rankings. We think this analysis can provide a guide for where future resources and clinical trials should be directed, and where a clinician may begin when considering alternative therapeutic interventions.

Novel Platform for Quantitative Assessment of Functional Object Interactions After Stroke

Many persons with stroke exhibit upper extremity motor impairments. These impairments often lead to dysfunction and affect performance in activities of daily living, where successful manipulation of objects is essential. Hence, understanding how upper extremity motor deficits manifest in functional interactions with objects is critical for rehabilitation. However, quantifying skill in these tasks has been a challenge. Traditional rehabilitation assessments require highly trained clinicians, are time-consuming, and yield subjective scores. This paper introduces a custom-designed device, the "MAGIC Table", that can record real-time kinematics of persons with stroke during interaction with objects, specifically a 'cup of coffee'. The task and its quantitative assessments were derived from previous basic-science studies. Six participants after stroke and six able-bodied participants moved a 3D-printed cup with a rolling ball inside, representing sloshing coffee, with 3 levels of difficulty. Movements were captured via a high-resolution camera above the table. Conventional kinematic metrics (movement time and smoothness) and novel kinematic metrics accounting for object interaction (risk and predictability) evaluated performance. Expectedly, persons with stroke moved more slowly and less smoothly than able-bodied participants, in both simple reaches and during transport of the cup-and-ball system. However, the more sensitive metric was mutual information, which captured the predictability of interactions, essential in cup transport as shown in previous theoretical research. Predictability sensitively measured differences in performance with increasing levels of difficulty. It also showed the best intraclass consistency, promising sensitive differentiation between different levels of impairment. This first study highlights the feasibility of this new device and indicates that examining dynamic object interaction may provide valuable insights into upper extremity function after stroke useful for assessment and rehabilitation.

Longitudinal prediction of motor dysfunction after stroke: a disconnectome study

Motricity is the most commonly affected ability after a stroke. While many clinical studies attempt to predict motor symptoms at different chronic time points after a stroke, longitudinal acute-to-chronic studies remain scarce. Taking advantage of recent advances in mapping brain disconnections, we predict motor outcomes in 62 patients assessed longitudinally two weeks, three months, and one year after their stroke. Results indicate that brain disconnection patterns accurately predict motor impairments. However, disconnection patterns leading to impairment differ between the three-time points and between left and right motor impairments. These results were cross-validated using resampling techniques. In sum, we demonstrated that while some neuroplasticity mechanisms exist changing the structure-function relationship, disconnection patterns prevail when predicting motor impairment at different time points after stroke.

User-centered design and development of TWIN-Acta: A novel control suite of the TWIN lower limb exoskeleton for the rehabilitation of persons post-stroke

Introduction

Difficulties faced while walking are common symptoms after stroke, significantly reducing the quality of life. Walking recovery is therefore one of the main priorities of rehabilitation. Wearable powered exoskeletons have been developed to provide lower limb assistance and enable training for persons with gait impairments by using typical physiological movement patterns. Exoskeletons were originally designed for individuals without any walking capacities, such as subjects with complete spinal cord injuries. Recent systematic reviews suggested that lower limb exoskeletons could be valid tools to restore independent walking in subjects with residual motor function, such as persons post-stroke. To ensure that devices meet end-user needs, it is important to understand and incorporate their perspectives. However, only a limited number of studies have followed such an approach in the post-stroke population.

Methods

The aim of the study was to identify the end-users needs and to develop a user-centered-based control system for the TWIN lower limb exoskeleton to provide post-stroke rehabilitation. We thus describe the development and validation, by clinical experts, of TWIN-Acta: a novel control suite for TWIN, specifically designed for persons post-stroke. We detailed the conceived control strategy and developmental phases, and reported evaluation sessions performed on healthy clinical experts and people post-stroke to evaluate TWIN-Acta usability, acceptability, and barriers to usage. At each developmental stage, the clinical experts received a one-day training on the TWIN exoskeleton equipped with the TWIN-Acta control suite. Data on usability, acceptability, and limitations to system usage were collected through questionnaires and semi-structured interviews.

Results

The system received overall good usability and acceptability ratings and resulted in a well-conceived and safe approach. All experts gave excellent ratings regarding the possibility of modulating the assistance provided by the exoskeleton during the movement execution and concluded that the TWIN-Acta would be useful in gait rehabilitation for persons post-stroke. The main limit was the low level of system learnability, attributable to the short-time of usage. This issue can be minimized with prolonged training and must be taken into consideration when planning rehabilitation.

Discussion

This study showed the potential of the novel control suite TWIN-Acta for gait rehabilitation and efficacy studies are the next step in its evaluation process.

One-year recurrence of stroke and death in Lebanese survivors of first-ever stroke: Time-to-Event analysis

BACKGROUND

To date, despite the application of secondary prevention worldwide, first-ever stroke survivors remain at imminent risk of stroke recurrence and death in the short and long term. The present study aimed to assess the cumulative risk rates and identify baseline differences and stroke characteristics of Lebanese survivors.

METHODS

A prospective longitudinal study was conducted among survivors ≥18 years old who were followed-up for 15 months through a face-to-face interview. Kaplan-Meier method was used to calculate the cumulative rates of stroke mortality and recurrence. Cox-regression univariate and multivariable analyses were performed to identify the predictors of both outcomes.

RESULTS

Among 150 subjects (mean age 74 ± 12 years; 58.7% men vs. 44.3% women; 95.3% with ischemic stroke vs. 4.3% with intracerebral hemorrhage), high cumulative risk rates of stroke recurrence (25%) and death (21%) were highlighted, especially in the acute phase. Survival rates were lesser in patients with stroke recurrence compared to those without recurrence (Log rank test p < 0.001). Older age was the main predictor for both outcomes (p < 0.02). Large artery atherosclerosis was predominant in patients with stroke recurrence and death compared to small vessel occlusion (p < 0.02). Higher mental component summary scores of quality of life were inversely associated with stroke recurrence (p < 0.01). Lebanese survivors exhibited the highest percentages of depression and anxiety; elevated Hospital Anxiety and Depression Scale (HADS) scores were seen in those with stroke recurrence and those who died (≥80% with mean HADS scores ≥8). Lower Mini-Mental State Examination scores at the acute phase increased the risk of both outcomes by 10% (p < 0.03). Three out of 13 mortalities (23.1%) were presented with early epileptic seizures (p = 0.012). High educational level was the protective factor against stroke recurrence (p = 0.019). Administration of intravenous thrombolysis decreased the risk of both outcomes by 10% (p > 0.05).

CONCLUSION

Higher rates of stroke recurrence and death were observed in the first year following a stroke in Lebanon. Various factors were identified as significant determinants. Thus, health care providers and officials in Lebanon can use these findings to implement effective preventive strategies to best address the management of these factors to reduce the stroke burden and improve the short and long-term prognosis of stroke survivors.