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

The Effect of Branched Chain Amino Acid Supplementation on Stroke-Related Sarcopenia

Background

Stroke-related sarcopenia is caused by various factors, such as brain damage, systemic catabolic state, skeletal muscle imbalance, and malnutrition. In the long-term care plan after stroke, appropriate rehabilitation strategies to achieve maximum functional improvement and prevent the development of sarcopenia are important. This study has investigated the effect of branched-chain amino acid (BCAA) supplementation on sarcopenia after stroke. We also evaluated the effect of BCAA on functional improvement during the intensive rehabilitation period.

Methods

Patients with subacute stroke with stroke-related disabilities were enrolled and given dietary supplement powder containing BCAAs for 1 month. These BCAAs were supplied through the nutrition team during feeding time. Patients whose age, sex, and stroke lesions were similar to those of the study group were enrolled in the control group through medical record review. Both groups received personalized intensive inpatient rehabilitation therapy in a single-unit rehabilitation center. All patients' target calories were calculated regularly by the nutritional support team in our institution. Sarcopenia status was evaluated using grip strength and the skeletal muscle index (SMI), which was assessed by dual-energy X-ray absorptiometry (DEXA). The functional status associated with stroke was evaluated every month, including activities of daily living, balance, gait, and swallowing.

Results

A total of 54 patients were enrolled, with 27 patients in each of the two groups. The study group showed significantly greater improvement in SMI after intervention than the control group. Both groups improved functionally over time, but the improvement in the study group was significantly greater than that in the control group. Univariate analysis revealed that patients with better functional status had a greater SMI with a combination of BCAA supplementation and intensive rehabilitation therapy.

Conclusion

Our results showed a positive effect of BCAA supplementation on sarcopenia after stroke. We also found that nutritional support helps functional improvement during neurological recovery. These results suggest that comprehensive rehabilitation intervention combined with BCAA supplementation could be a helpful option during the critical period of post-stroke neurological recovery.

Gait Training for Hemiplegic Stroke Patients: Employing an Automatic Neural Development Treatment Trainer with Real Time Detection

This paper presents a clinical rehabilitation protocol for stroke patients using a movable trainer, which can automatically execute a neurodevelopmental treatment (NDT) intervention based on key gait events. The trainer consists of gait detection and motor control systems. The gait detection system applied recurrent neural networks (RNNs) to recognize important gait events in real time to trigger the motor control system to repeat the NDT intervention. This paper proposes a modified intervention method that simultaneously improves the user’s gait symmetry and pelvic rotation. We recruited ten healthy subjects and had them wear a rehabilitation gaiter on one knee joint to mimic stroke gaits for verification of the effectiveness of the trainer. We used the RNN model and a modified intervention method to increase the trainer’s effectiveness in improving gait symmetry and pelvic rotation. We then invited ten stroke patients to participate in the experiments, and we found improvement in gait symmetry in 80% and 90% of the patients during and after the training, respectively. Similarly, pelvic rotation improved in 80% of the patients during and after the training. These findings confirmed that the movable NDT trainer could improve gait performance for the rehabilitation of stroke patients.

The effect of motor relearning on balance, mobility and performance of activities of daily living among post-stroke patients: Study protocol for a randomised controlled trial

BACKGROUND

Balance and gait impairments are the most common motor deficits due to stroke, limiting the patients' daily life activities and participation in society. Studies investigating effect of task-specific training using biomechanical balance and gait variables (i.e. kinetic and kinematic parameters) as well as posturography after stroke are scarce.

OBJECTIVES

The primary aim of this study is to assess the efficacy and long-term outcome of task-specific training based on motor relearning program (MRP) on balance, mobility and performance of activities of daily living among post-stroke patients.

METHODS

In this two-armed randomised controlled clinical trial, a total of 66 sub-acute stroke patients who meet the trial criteria will be recruited. The patients will randomly receive task-specific training based on MRP or a conventional physical therapy program (CPT). Twenty-four physiotherapy sessions will be conducted, divided into three training sessions per week, 1 h per session, for 8 weeks, followed by an analysis of changes in patient's balance, gait and performance of activates of daily living at three time periods; baseline, post-intervention and follow-up after 3-months, using clinical outcome measures and instrumental analysis of balance and gait.

DISCUSSION

The results of this study can guide to better understanding and provide an objective clinical basis for the use of task-specific training in stroke rehabilitation. Also, it intends to help bridge the current knowledge gap in rehabilitation and training recommendations to provide a therapeutic plan in post-stroke rehabilitation.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05076383). Registered on 13 October 2021 (Protocol version: v2.0).

Effects of Cognitive Exercise Therapy on Upper Extremity Sensorimotor Function and Activities of Daily Living in Patients with Chronic Stroke: A Randomized Controlled Trial

This study investigated the effects of cognitive exercise therapy on upper extremity sensorimotor function and daily activity in patients with chronic stroke and compared these effects to those of conventional occupational therapy. The 30 patients with chronic stroke (mean age: 63.6 ± 12.7 years; height: 162.8 ± 8.1 cm; weight: 60.6 ± 7.6 kg; body mass index: 22.8 ± 1.9 kg/m2) were divided into two treatment groups with 15 patients in each. The respective interventions were provided for 30 min per day, five times weekly for 4 weeks. Manual and sensory function tests were conducted to evaluate the sensorimotor function, while the Korean-Modified Barthel Index was used to assess daily activities. All outcome variables were assessed before and after the interventions. A significant interaction was observed in sensory function (p = 0.001) but not motor function or daily activities (p > 0.05). No significant main group effects were found for any outcome variables (p > 0.05). The experimental group showed significant improvements in motor function (p < 0.001), sensory function (p < 0.001), and daily life activities (p = 0.001) after cognitive exercise therapy, whereas the control group showed significant improvement only in daily life activities post-intervention (p = 0.012). These results demonstrated the positive effects of cognitive exercise therapy on upper extremity sensorimotor function and daily life activities and the lack of improvement in motor and sensory function following conventional occupational therapy in patients with chronic stroke. Thus, the combination of cognitive exercise and conventional occupational therapies may be an effective way to improve sensory function and upper extremity motor function in patients with chronic stroke.

Serious Games Strategies With Cable-Driven Robots for Bimanual Rehabilitation: A Randomized Controlled Trial With Post-Stroke Patients

Cable-driven robots can be an ideal fit for performing post-stroke rehabilitation due to their specific features. For example, they have small and lightweight moving parts and a relatively large workspace. They also allow safe human-robot interactions and can be easily adapted to different patients and training protocols. However, the existing cable-driven robots are mostly unilateral devices that can allow only the rehabilitation of the most affected limb. This leaves unaddressed the rehabilitation of bimanual activities, which are predominant within the common Activities of Daily Living (ADL). Serious games can be integrated with cable-driven robots to further enhance their features by providing an interactive experience and by generating a high level of engagement in patients, while they can turn monotonous and repetitive therapy exercises into entertainment tasks. Additionally, serious game interfaces can collect detailed quantitative treatment information such as exercise time, velocities, and force, which can be very useful to monitor a patient's progress and adjust the treatment protocols. Given the above-mentioned strong advantages of both cable driven robots, bimanual rehabilitation and serious games, this paper proposes and discusses a combination of them, in particular, for performing bilateral/bimanual rehabilitation tasks. The main design characteristics are analyzed for implementing the design of both the hardware and software components. The hardware design consists of a specifically developed cable-driven robot. The software design consists of a specifically developed serious game for performing bimanual rehabilitation exercises. The developed software also includes BiEval. This specific software allows to quantitatively measure and assess the rehabilitation therapy effects. An experimental validation is reported with 15 healthy subjects and a RCT (Randomized Controlled Trial) has been performed with 10 post-stroke patients at the Physiotherapy's Clinic of the Federal University of Uberlândia (Minas Gerais, Brazil). The RCT results demonstrate the engineering feasibility and effectiveness of the proposed cable-driven robot in combination with the proposed BiEval software as a valuable tool to augment the conventional physiotherapy protocols and for providing reliable measurements of the patient's rehabilitation performance and progress. The clinical trial was approved by the Research Ethics Committee of the UFU (Brazil) under the CAAE N° 00914818.5.0000.5152 on plataformabrasil@saude.gov.br.

Data-Driven Classification of Human Movements in Virtual Reality-Based Serious Games: Preclinical Rehabilitation Study in Citizen Science

BACKGROUND

Sustained engagement is essential for the success of telerehabilitation programs. However, patients' lack of motivation and adherence could undermine these goals. To overcome this challenge, physical exercises have often been gamified. Building on the advantages of serious games, we propose a citizen science-based approach in which patients perform scientific tasks by using interactive interfaces and help advance scientific causes of their choice. This approach capitalizes on human intellect and benevolence while promoting learning. To further enhance engagement, we propose performing citizen science activities in immersive media, such as virtual reality (VR).

OBJECTIVE

This study aims to present a novel methodology to facilitate the remote identification and classification of human movements for the automatic assessment of motor performance in telerehabilitation. The data-driven approach is presented in the context of a citizen science software dedicated to bimanual training in VR. Specifically, users interact with the interface and make contributions to an environmental citizen science project while moving both arms in concert.

METHODS

In all, 9 healthy individuals interacted with the citizen science software by using a commercial VR gaming device. The software included a calibration phase to evaluate the users' range of motion along the 3 anatomical planes of motion and to adapt the sensitivity of the software's response to their movements. During calibration, the time series of the users' movements were recorded by the sensors embedded in the device. We performed principal component analysis to identify salient features of movements and then applied a bagged trees ensemble classifier to classify the movements.

RESULTS

The classification achieved high performance, reaching 99.9% accuracy. Among the movements, elbow flexion was the most accurately classified movement (99.2%), and horizontal shoulder abduction to the right side of the body was the most misclassified movement (98.8%).

CONCLUSIONS

Coordinated bimanual movements in VR can be classified with high accuracy. Our findings lay the foundation for the development of motion analysis algorithms in VR-mediated telerehabilitation.

Can Individuals Poststroke Improve Their Performance in Reaction and Movement Times in a Nonimmersive Serious Game with Practice? A Cross-Sectional Study

Objective: To verify if individuals' poststroke and healthy controls would improve their performance in reaction and movement times practicing a serious game task using the upper limb movements. Materials and Methods: We evaluated 30 individuals poststroke and 30 healthy controls, matched for age and sex. We used the "Association Game for Rehabilitation" (AGaR) where participants played by matching a pair of images whose meanings were similar. Hand movements were captured by a Kinect system and poststroke participants used their nonparetic upper limb. Reaction time and movement times (time to select an image and movement time to the target) were measured. Data were analyzed using multiple analysis of variance. Results: Performance improved for both groups across all variables with better performance in movement times than reaction time only for poststroke individuals. Conclusions: Upper limb movements using nonimmersive serious games enhanced motor performance in reaction and movement times for healthy controls and individuals poststroke. ReBEC Trial Registration: RBR-4m4pk; Registeted on 08/24/2018.

Motion Analysis for Experimental Evaluation of an Event-Driven FES System

In this work, a system for controlling Functional Electrical Stimulation (FES) has been experimentally evaluated. The peculiarity of the system is to use an event-driven approach to modulate stimulation intensity, instead of the typical feature extraction of surface ElectroMyoGraphic (sEMG) signal. To validate our methodology, the system capability to control FES was tested on a population of 17 subjects, reproducing 6 different movements. Limbs trajectories were acquired using a gold standard motion tracking tool. The implemented segmentation algorithm has been detailed, together with the designed experimental protocol. A motion analysis was performed through a multi-parametric evaluation, including the extraction of features such as the trajectory area and the movement velocity. The obtained results show a median cross-correlation coefficient of 0.910 and a median delay of 800 ms, between each couple of voluntary and stimulated exercise, making our system comparable w.r.t. state-of-the-art works. Furthermore, a 97.39% successful rate on movement replication demonstrates the feasibility of the system for rehabilitation purposes.

Design of a 3D-Printed Hand Exoskeleton Based on Force-Myography Control for Assistance and Rehabilitation

Voluntary hand movements are usually impaired after a cerebral stroke, affecting millions of people per year worldwide. Recently, the use of hand exoskeletons for assistance and motor rehabilitation has become increasingly widespread. This study presents a novel hand exoskeleton, designed to be low cost, wearable, easily adaptable and suitable for home use. Most of the components of the exoskeleton are 3D printed, allowing for easy replication, customization and maintenance at a low cost. A strongly underactuated mechanical system allows one to synergically move the four fingers by means of a single actuator through a rigid transmission, while the thumb is kept in an adduction or abduction position. The exoskeleton’s ability to extend a typical hypertonic paretic hand of stroke patients was firstly tested using the SimScape Multibody simulation environment; this helped in the choice of a proper electric actuator. Force-myography was used instead of the standard electromyography to voluntarily control the exoskeleton with more simplicity. The user can activate the flexion/extension of the exoskeleton by a weak contraction of two antagonist muscles. A symmetrical master–slave motion strategy (i.e., the paretic hand motion is activated by the healthy hand) is also available for patients with severe muscle atrophy. An inexpensive microcontroller board was used to implement the electronic control of the exoskeleton and provide feedback to the user. The entire exoskeleton including batteries can be worn on the patient’s arm. The ability to provide a fluid and safe grip, like that of a healthy hand, was verified through kinematic analyses obtained by processing high-framerate videos. The trajectories described by the phalanges of the natural and the exoskeleton finger were compared by means of cross-correlation coefficients; a similarity of about 80% was found. The time required for both closing and opening of the hand exoskeleton was about 0.9 s. A rigid cylindric handlebar containing a load cell measured an average power grasp force of 94.61 N, enough to assist the user in performing most of the activities of daily living. The exoskeleton can be used as an aid and to promote motor function recovery during patient’s neurorehabilitation therapy.

Effect of Modulated TENS on Corticospinal Excitability in Healthy Subjects

Conventional transcutaneous electrical nerve stimulation (TENS) has been reported to effectively alleviate chronic pain, including phantom limb pain (PLP). Recently, literature has focused on modulated TENS patterns, such as pulse width modulation (PWM) and burst modulation (BM), as alternatives to conventional, non-modulated (NM) sensory neurostimulation to increase the efficiency of rehabilitation. However, there is still limited knowledge of how these modulated TENS patterns affect corticospinal (CS) and motor cortex activity. Therefore, our aim was to first investigate the effect of modulated TENS patterns on CS activity and corticomotor map in healthy subjects. Motor evoked potentials (MEP) elicited by transcranial magnetic stimulation (TMS) were recorded from three muscles before and after the application of TENS interventions. Four different TENS patterns (PWM, BM, NM 40 Hz, and NM 100 Hz) were applied. The results revealed significant facilitation of CS excitability following the PWM intervention. We also found an increase in the volume of the motor cortical map following the application of the PWM and NM (40 Hz). Although PLP alleviation has been reported to be associated with an enhancement of corticospinal excitability, the efficiency of the PWM intervention to induce pain alleviation should be validated in a future clinical study in amputees with PLP.

A New Framework to Interpret Individual Inter-Hemispheric Compensatory Communication after Stroke

Stroke constitutes the main cause of adult disability worldwide. Even after application of standard rehabilitation protocols, the majority of patients still show relevant motor impairment. Outcomes of standard rehabilitation protocols have led to mixed results, suggesting that relevant factors for brain re-organization after stroke have not been considered in explanatory models. Therefore, finding a comprehensive model to optimally define patient-dependent rehabilitation protocols represents a crucial topic in clinical neuroscience. In this context, we first report on the rehabilitation models conceived thus far in the attempt of predicting stroke rehabilitation outcomes. Then, we propose a new framework to interpret results in stroke literature in the light of the latest evidence regarding: (1) the role of the callosum in inter-hemispheric communication, (2) the role of prefrontal cortices in exerting a control function, and (3) diaschisis mechanisms. These new pieces of evidence on the role of callosum can help to understand which compensatory mechanism may take place following a stroke. Moreover, depending on the individual impairment, the prefrontal control network will play different roles according to the need of high-level motor control. We believe that our new model, which includes crucial overlooked factors, will enable clinicians to better define individualized motor rehabilitation protocols.

Does spatial perspective in virtual reality affect imitation accuracy in stroke patients?

Imitation is an important daily activity involved in social interactions, motor learning, and is commonly used for rehabilitation after stroke. Moreover, deficits in imitation of novel movements commonly occur after left hemisphere stroke (LCVA) in the syndrome of limb apraxia. In the current study, we used a novel virtual reality (VR) imitation paradigm to assess two factors that have remained underexplored in novel movement imitation: the imitation of complex, dynamic full-arm movements, and the effect of spatial perspective. VR holds promise as a tool for a number of clinical assessments and treatments, but has very rarely been studied in the context of imitation or diagnosis of apraxia. Thirty participants (18 with LCVA and 12 age- and education-matched controls) wore a VR headset and observed and imitated an instructor avatar demonstrating arm movements. Three spatial perspectives were examined within-subjects: first-person, third-person mirror, and third-person anatomical. Movements of the ipsilesional (left) arm were recorded and qualitatively coded for accuracy compared to the instructor avatar. Participants also completed embodiment questionnaires, a measure of limb apraxia (imitation of video-recorded meaningless movements), and three computerized background tasks that were hypothesized to evoke some of the same processing requirements of each of the three perspective conditions: a block-matching task, a block-mirroring task, and a mental rotation task. Imitation accuracy was highest in the first-person perspective, consistent with predictions, but did not differ between third-person mirror and anatomical. Surprisingly, patients and controls performed similarly on the imitation task for all spatial perspectives, with overall modest accuracy in both groups, and both patients and controls felt a moderate level of embodiment of their own avatar. Higher imitation accuracy related to quicker block-matching reaction times and higher mental rotation accuracy, regardless of perspective, but was unrelated to imitation of video-recorded meaningless movements. In sum, virtual reality provides advantages in terms of experimental manipulation and control but may present challenges in detecting clinical imitation deficits (limb apraxia).

Development and feasibility testing of action observation training videos in acute stroke survivors: Preliminary findings

Background: Action observation training (AOT) is used for lower limb (LL) stroke rehabilitation in subacute and chronic stages, but concise information regarding the types of activities to be used and the feasibility of administration in the acute stroke population is unknown. The aim of this study was to develop and validate videos of appropriate activities for LL AOT and test administrative feasibility in acute stroke.   Method: A video inventory of LL activities was created after a literature survey and expert scrutiny. Five stroke rehabilitation experts validated the videos per domains of relevance, comprehension, clarity, camera position and brightness. LL AOT was then tested on ten individuals with acute stroke for uncovering barriers for clinical use in a feasibility study. Participants watched the activities and attempted imitation of the same. Determination of administrative feasibility was undertaken via participant interviews.   Results: Suitable LL activities for stroke rehabilitation were identified. Content validation of videos led to improvements in selected activities and video quality. Expert scrutiny led to further video processing to include different perspectives of view and speeds of projected movements. Barriers identified included inability to imitate actions shown in videos and increased distractibility for some participants.    Conclusion: A video catalogue of LL activities was developed and validated. AOT was deemed safe and feasible for acute stroke rehabilitation and may be used in future research and clinical practice.

Greater Cognitive-Motor Interference in Individuals Post-Stroke During More Complex Motor Tasks

BACKGROUND AND PURPOSE

Dual-task (DT) walking assessments allow for the simultaneous evaluation of cognitive and motor performance. During DT walking, individuals may experience interference in one or both tasks, known as cognitive-motor interference (CMI). The primary purpose of this study was to compare CMI between individuals post-stroke and healthy persons group during single- and dual-motor and cognitive tasks, using 2 distinct walking tasks.

METHODS

Motor performance was quantified as the total time for the Timed Up and Go (TUG) and gait speed for the 90-second walk (90W). Cognitive performance was measured as the correct response rate (CRR) during serial 7 subtractions. Participants performed the motor and cognitive tasks in isolation for the single-task (ST) and simultaneously for DT conditions, TUG-DT and 90W-DT. A repeated-measures analysis of variance assessed group (poststroke and healthy) by condition (ST and DT) interactions for the TUG, 90W, and CRR.

RESULTS

There were significant main effects of group and condition for both the TUG and the 90W (P < 0.05). There was also an interaction effect for the TUG, with individuals post-stroke demonstrating a larger decrement in TUG-DT performance compared with healthy persons (P < 0.05). Furthermore, a significant interaction effect was observed for the CRR, in which healthy individuals exhibited a greater decrement in performance from the ST to the 90W-DT (P < 0.05).

DISCUSSION AND CONCLUSIONS

Individuals post-stroke were susceptible to greater motor interference during the more complex motor task, the TUG-DT. However, the only decrements observed in cognitive performance from the ST to DT occurred in healthy individuals during the 90W-DT.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A367).

A Novel and Clinically Feasible Instrument for Quantifying Upper Limb Muscle Tone and Motor Function via Indirect Measure Methods

Objective: Quantifying muscle tone is often based on a tester’s subjective judgment in clinical settings. There is, however, a lack of suitable tools that can be used to objectively assess muscle tone. This study thus introduces a reliable, clinically-feasible device, called the Arm Circumference Motor Evaluation System (ACMES), for quantifying the muscle tone of upper limbs without using mechanical torque transducers. Methods: While the ACMES conducts continuously passive arm circumduction motions, the voltage and current of the driving motor is transduced into torque values via a least square approximation. A torque sensor and springs with different spring constants were used for the validity and reliability test in the first part of this study. Fifteen healthy adults and two patients who had experienced a stroke participated in the second part, which was a clinical experiment used to examine the in-vivo test-retest reliability and to explore the inspection differences between healthy and patient participants. Results: The results showed that the ACMES has high validity (R²: ~0.99) and reliability (R²: 0.96~0.99). The reliability of the ACMES used on human subjects was acceptable (R²: 0.83~0.85). The various muscle tone patterns could be found among healthy and stroke subjects via the ACMES. Conclusion: Clinically, abnormal muscle tone, which seriously affects motion performance, will be found in many diagnoses, such as stroke or cerebral palsy. However, objectively and feasibly measuring abnormal tone in modern clinical settings is still a challenging task. Thus, the ACMES was developed and tested to verify its feasibility as a measurement system for detecting the mechanical torque associated with muscle tone.

[Recovery of social and everyday skills after a complex of functional spatially oriented rehabilitation in elderly patients with cerebral stroke]

OBJECTIVE

To analyze the effectiveness of social recovery (trip to the store by bus and making purchases) in elderly patients with stroke in the right middle cerebral artery undergoing a course of specialized trainings in a complex of functional spatially oriented rehabilitation.

MATERIAL AND METHODS

The study involved 44 patients with previous stroke (mean age 70.8±3.1 years) randomized into 2 equal groups: main group - basic standard of rehabilitation (exercises with instructor, mechanotherapeutic technique with cyclic simulators, massage of paretic limbs) and training of social adaptation in a complex of functional spatially oriented rehabilitation; control group - basic standard of rehabilitation alone. Duration of rehabilitation course was 14 days. To determine mean norm of timing of complex training of socially significant skill, we asked 23 volunteers without severe comorbidities to perform tasks of functional spatially oriented rehabilitation.

RESULTS

After complex rehabilitation program, we found significant dynamics of time necessary for the following actions: "take a bag and hang it over shoulder", "open the pockets of the bag with a zipper (2 pockets)", "take the jacket off the hanger and put it on", "take the products from the basket and put in the pocket". Moreover, the main group was characterized by significantly lower impairment of daily activity (Barthel score 66.3±4.5 vs. baseline 45.7±4.9, p<0.05), improvement of functional independence (FIM score 76.7±1.5 vs. baseline 65.2±3.1, p>0.05). These values turned out to be significantly better than in the control group.

CONCLUSION

These results indicate the effectiveness of functional spatially oriented rehabilitation in elderly patients with cerebral stroke. This approach increases personal independence in daily life and improves overall quality of life.

Mirror Therapy Rehabilitation in Stroke: A Scoping Review of Upper Limb Recovery and Brain Activities

BACKGROUND

Mirror therapy (MT) has been used as a treatment for various neurological disorders. Recent application of electroencephalogram (EEG) to the MT study allows researchers to gain insight into the changes in brain activity during the therapy.

OBJECTIVE

This scoping review is aimed at mapping existing evidence and identifying knowledge gaps about the effects of MT on upper limb recovery and its application for individuals with chronic stroke.

METHODS AND MATERIALS

A scoping review through a systematic literature search was conducted using PubMed, CINAHL, PsycINFO, and Scopus databases. Twenty articles published between 2010 and 2020 met the inclusion criteria. The efficacy of MT on upper limb recovery and brain activity during MT were discussed according to the International Classification of Functioning, Disability and Health (ICF).

RESULTS

A majority of the studies indicated positive effects of MT on upper limb recovery from the body structure/functional domain. All studies used EEG to indicate brain activation during MT.

CONCLUSION

MT is a promising intervention for improving upper limb function for individuals with chronic stroke. This review also highlights the need to incorporate EEG into the MT study to capture brain activity and understand the mechanism underlying the therapy.

Patient, carer, and staff perceptions of robotics in motor rehabilitation: a systematic review and qualitative meta-synthesis

BACKGROUND

In recent years, robotic rehabilitation devices have often been used for motor training. However, to date, no systematic reviews of qualitative studies exploring the end-user experiences of robotic devices in motor rehabilitation have been published. The aim of this study was to review end-users' (patients, carers and healthcare professionals) experiences with robotic devices in motor rehabilitation, by conducting a systematic review and thematic meta-synthesis of qualitative studies concerning the users' experiences with such robotic devices.

METHODS

Qualitative studies and mixed-methods studies with a qualitative element were eligible for inclusion. Nine electronic databases were searched from inception to August 2020, supplemented with internet searches and forward and backward citation tracking from the included studies and review articles. Data were synthesised thematically following the Thomas and Harden approach. The CASP Qualitative Checklist was used to assess the quality of the included studies of this review.

RESULTS

The search strategy identified a total of 13,556 citations and after removing duplicates and excluding citations based on title and abstract, and full text screening, 30 studies were included. All studies were considered of acceptable quality. We developed six analytical themes: logistic barriers; technological challenges; appeal and engagement; supportive interactions and relationships; benefits for physical, psychological, and social function(ing); and expanding and sustaining therapeutic options.

CONCLUSIONS

Despite experiencing technological and logistic challenges, participants found robotic devices acceptable, useful and beneficial (physically, psychologically, and socially), as well as fun and interesting. Having supportive relationships with significant others and positive therapeutic relationships with healthcare staff were considered the foundation for successful rehabilitation and recovery.

Implementation strategies and outcomes for occupational therapy in adult stroke rehabilitation: a scoping review

BACKGROUND

Stroke survivors often encounter occupational therapy practitioners in rehabilitation practice settings. Occupational therapy researchers have recently begun to examine the implementation strategies that promote the use of evidence-based occupational therapy practices in stroke rehabilitation; however, the heterogeneity in how occupational therapy research is reported has led to confusion about the types of implementation strategies used in occupational therapy and their association with implementation outcomes. This review presents these strategies and corresponding outcomes using uniform language and identifies the extent to which strategy selection has been guided by theories, models, and frameworks (TMFs).

METHODS

A scoping review protocol was developed to assess the breadth and depth of occupational therapy literature examining implementation strategies, outcomes, and TMFs in the stroke rehabilitation field. Five electronic databases and two peer-reviewed implementation science journals were searched to identify studies meeting the inclusion criteria. Two reviewers applied the inclusion parameters and consulted with a third reviewer to achieve consensus. The 73-item Expert Recommendations for Implementing Change (ERIC) implementation strategy taxonomy guided the synthesis of implementation strategies. The Implementation Outcomes Framework guided the analysis of measured outcomes.

RESULTS

The initial search yielded 1219 studies, and 26 were included in the final review. A total of 48 out of 73 discrete implementation strategies were described in the included studies. The most used implementation strategies were "distribute educational materials" (n = 11), "assess for readiness and identify barriers and facilitators" (n = 11), and "conduct educational outreach visits" (n = 10). "Adoption" was the most frequently measured implementation outcome, while "cost" was not measured in any included studies. Eleven studies reported findings supporting the effectiveness of their implementation strategy or strategies; eleven reported inconclusive findings, and four found that their strategies did not lead to improved implementation outcomes. In twelve studies, at least partially beneficial outcomes were reported, corresponding with researchers using TMFs to guide implementation strategies.

CONCLUSIONS

This scoping review synthesized implementation strategies and outcomes that have been examined in occupational therapy and stroke rehabilitation. With the growth of the stroke survivor population, the occupational therapy profession must identify effective strategies that promote the use of evidence-based practices in routine stroke care and describe those strategies, as well as associated outcomes, using uniform nomenclature. Doing so could advance the occupational therapy field's ability to draw conclusions about effective implementation strategies across diverse practice settings.

Effects of virtual reality in improving upper extremity function after stroke: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To investigate the effect of virtual reality on arm motor impairment, activity limitation, participation restriction, and quality of life in patients with stroke. To determine potential moderators that affect the efficacy of virtual reality.

DATA SOURCES

CINAHL, Medline, PubMed, EMBASE, Cochrane Library, Chinese National Knowledge Infrastructure, and Wanfang Data from inception to October 23, 2021.

REVIEW METHODS

Randomized controlled trials that investigated the effect of virtual reality on arm recovery in adult patients with stroke compared to conventional therapy or sham control were included. Physiotherapy Evidence Database Scale was used to assess the methodological quality of each study.

RESULTS

Forty studies with 2018 participants were identified. Quality of included studies was fair to high. Virtual reality exhibited better effects on overall arm function (g = 0.28, p < 0.001), motor impairment (g = 0.36, p < 0.001) and activity limitation (daily living) (g = 0.24, p < 0.001) compared with the control group. No significant improvement was observed in participation restriction and activity limitation (specific task). The result for quality of life was described qualitatively. Subgroup analyses demonstrated that immersive virtual reality produced a greater beneficial effect (g = 0.60, p < 0.001). Patients with moderate to severe arm paresis could make more progress after training (g = 0.71, p < 0.001).

CONCLUSION

Virtual reality is recommended for improving motor impairment and activities of daily living after stroke and is favorable to patients with moderate to severe paresis. An immersive design could produce greater improvement.

Limited Add-On Effects of Unilateral and Bilateral Transcranial Direct Current Stimulation on Visuo-Motor Grip Force Tracking Task Training Outcome in Chronic Stroke. A Randomized Controlled Trial

Background: This randomized controlled trial investigated if uni- and bihemispheric transcranial direct current stimulation (tDCS) of the motor cortex can enhance the effects of visuo-motor grip force tracking task training and transfer to clinical assessments of upper extremity motor function.

Methods: In a randomized, double-blind, sham-controlled trial, 40 chronic stroke patients underwent 5 days of visuo-motor grip force tracking task training of the paretic hand with either unilateral or bilateral (N = 15/group) or placebo tDCS (N = 10). Immediate and long-term (3 months) effects on training outcome and motor recovery (Upper Extremity Fugl-Meyer, UE-FM, Wolf Motor Function Test, and WMFT) were investigated.

Results: Trained task performance significantly improved independently of tDCS in a curvilinear fashion. In the anodal stimulation group UE-FM scores were higher than in the sham group at day 5 (adjusted mean difference: 2.6, 95%CI: 0.6–4.5, p = 0.010) and at 3 months follow up (adjusted mean difference: 2.8, 95%CI: 0.8–4.7, p = 0.006). Neither training alone, nor the combination of training and tDCS improved WMFT performance.

Conclusions: Visuo-motor grip force tracking task training can facilitate recovery of upper extremity function. Only minimal add-on effects of anodal but not dual tDCS were observed.

Clinical Trial Registration:https://clinicaltrials.gov/ct2/results?recrs=&cond=&term=NCT01969097&cntry=&state=&city=&dist=, identifier: NCT01969097, retrospectively registered on 25/10/2013.

Feasibility and Performance Validation of a Leap Motion Controller for Upper Limb Rehabilitation

The leap motion controller is a commercial low-cost marker-less optical sensor that can track the motion of a human hand by recording various parameters. Upper limb rehabilitation therapy is the treatment of people having upper limb impairments, whose recovery is achieved through continuous motion exercises. However, the repetitive nature of these exercises can be interpreted as boring or discouraging while patient motivation plays a key role in their recovery. Thus, serious games have been widely used in therapies for motivating patients and making the therapeutic process more enjoyable. This paper explores the feasibility, accuracy, and repeatability of a leap motion controller (LMC) to be applied in combination with a serious game for upper limb rehabilitation. Experimental feasibility tests are carried out by using an industrial robot that replicates the upper limb motions and is tracked by using an LMC. The results suggest a satisfactory performance in terms of tracking accuracy although some limitations are identified and discussed in terms of measurable workspace.

High-Intensity Interval Training Improves Physical Function, Prevents Muscle Loss, and Modulates Macrophage-Mediated Inflammation in Skeletal Muscle of Cerebral Ischemic Mice

Although skeletal muscle is the main effector organ largely accounting for disability after stroke, considerably less attention is paid to the secondary abnormalities of stroke-related skeletal muscle loss. It is necessary to explore the mechanism of muscle atrophy after stroke and further develop effective rehabilitation strategy. Here, we evaluated the effects of high-intensity interval (HIIT) versus moderate-intensity aerobic training (MOD) on physical function, muscle mass, and stroke-related gene expression profile of skeletal muscle. After the model of middle cerebral artery occlusion (MCAO) was successfully made, the blood lactate threshold corresponding speed (S_LT) and maximum speed (S_max) were measured. Different intensity training protocols (MOD < S_LT; S_LT < HIIT < S_max) were carried out for 3 weeks beginning at 7 days after MCAO in the MOD and HIIT groups, respectively. We found that both HIIT and MOD prevented stroke-related gastrocnemius muscle mass loss in MCAO mice. HIIT was more beneficial than MOD for improvements in muscle strength, motor coordination, walking competency, and cardiorespiratory fitness. Furthermore, HIIT was superior to MOD in terms of reducing lipid accumulation, levels of IL-1β and IL-6 in paretic gastrocnemius, and improving peripheral blood CD4+/CD8+ T cell ratio, level of IL-10. Additionally, RNA-seq analysis revealed that the differentially expressed genes among HIIT, MOD, and MCAO groups were highly associated with signaling pathways involved in inflammatory response, more specifically the I-kappaB kinase/NF-kappaB signaling. Following the outcome, we further investigated the infiltrating immune cells abundant in paretic muscles. The results showed that HIIT modulated macrophage activation by downregulating CD86+ (M1 type) macrophages and upregulating CD163+ (M2 type) macrophages via inhibiting the TLR4/MyD88/NFκB signaling pathway and exerting an anti-inflammatory effect in paretic skeletal muscle. It is expected that these data will provide novel insights into the mechanisms and potential targets underlying muscle wasting in stroke.

Concurrent impact of bilateral multiple joint functional electrical stimulation and treadmill walking on gait and spasticity in post-stroke survivors: a pilot study

Background: Stroke causes multi-joint gait deficits, so a major objective of post-stroke rehabilitation is to regain normal gait function. Design and Setting: A case series completed at a neuroscience institute. Aim: The aim of the study was to determine the concurrent impact of functional electrical stimulation (FES) during treadmill walking on gait speed, knee extensors spasticity and ankle plantar flexors spasticity in post-stroke survivors. Participants: Six post-stroke survivors with altered gait patterns and ankle plantar flexors spasticity (4 = male; age 56.8 ± 4.8 years; Body Mass Index (BMI) 26.2 ± 4.3; since onset of stroke: 30.8 ± 10.4 months; side of hemiplegia [L/R]: 3:3) were recruited. Intervention: Nine treatment sessions using FES bilaterally while walking on a treadmill. Main Outcome Measures: Primary outcome measures included the Modified Modified Ashworth Scale (MMAS), Timed Up and Go test (TUG), 10-m walking test, gait speed, and Functional ambulation category (FAC). Secondary outcome measures included the Step Length Test (SLT), and active range of motion (ROM) of the affected ankle and the knee. Measurements were taken at baseline (T0), at the end of last treatment (T1), and 1 month after the final treatment session (T2). Results: The TUG, 10-m walking test, gait speed, FAC, active ROM, and SLT all significantly improved following treatment (P< .05), while ankle plantar flexors spasticity (P = .135), and knee extensors spasticity (P = .368) did not show any significant decrease. Conclusions: A short duration of bilateral FES in conjugation with treadmill walking contributed to significant improvement in gait speed, functional mobility, functional ambulation, range of motion and step length in post-stroke survivors. In contrast, no significant decreases were identified in the spasticity of the ankle plantar flexors and knee extensors muscles.

Functional Recovery Caused by Human Adipose Tissue Mesenchymal Stem Cell-Derived Extracellular Vesicles Administered 24 h after Stroke in Rats

Ischemic stroke is a major cause of death and disability, intensely demanding innovative and accessible therapeutic strategies. Approaches presenting a prolonged period for therapeutic intervention and new treatment administration routes are promising tools for stroke treatment. Here, we evaluated the potential neuroprotective properties of nasally administered human adipose tissue mesenchymal stem cell (hAT-MSC)-derived extracellular vesicles (EVs) obtained from healthy individuals who underwent liposuction. After a single intranasal EV (200 µg/kg) administered 24 h after a focal permanent ischemic stroke in rats, a higher number of EVs, improvement of the blood-brain barrier, and re-stabilization of vascularization were observed in the recoverable peri-infarct zone, as well as a significant decrease in infarct volume. In addition, EV treatment recovered long-term motor (front paws symmetry) and behavioral impairment (short- and long-term memory and anxiety-like behavior) induced by ischemic stroke. In line with these findings, our work highlights hAT-MSC-derived EVs as a promising therapeutic strategy for stroke.

Hybrid dedicated and distributed coding in PMd/M1 provides separation and interaction of bilateral arm signals

Pronounced activity is observed in both hemispheres of the motor cortex during preparation and execution of unimanual movements. The organizational principles of bi-hemispheric signals and the functions they serve throughout motor planning remain unclear. Using an instructed-delay reaching task in monkeys, we identified two components in population responses spanning PMd and M1. A “dedicated” component, which segregated activity at the level of individual units, emerged in PMd during preparation. It was most prominent following movement when M1 became strongly engaged, and principally involved the contralateral hemisphere. In contrast to recent reports, these dedicated signals solely accounted for divergence of arm-specific neural subspaces. The other “distributed” component mixed signals for each arm within units, and the subspace containing it did not discriminate between arms at any stage. The statistics of the population response suggest two functional aspects of the cortical network: one that spans both hemispheres for supporting preparatory and ongoing processes, and another that is predominantly housed in the contralateral hemisphere and specifies unilateral output.

The motor cortex of the brain primarily controls the opposite side of the body, yet neural activity in this area is often observed during movements of either arm. To understand the functional significance of these signals we must first characterize how they are organized across the neural network. Are there patterns of activity that are unique to a single arm? Are there other patterns that reflect shared functions? Importantly, these features may change across time as motor plans are developed and executed. In this study, we analyzed the responses of individual neurons in the motor cortex and modeled their patterns of co-activity across the population to characterize the changes that distinguish left and right arm use. Across preparation and execution phases of the task, we found that signals became gradually more segregated. Despite many neurons modulating in association with either arm, those that were more dedicated to a single (typically contralateral) limb accounted for a disproportionately large amount of the variance. However, there were also weaker patterns of activity that did not distinguish between the two arms at any stage. These results reveal a heterogeneity in the motor cortex that highlights both independent and interactive components of reaching signals.

Observation of others' actions during limb immobilization prevents the subsequent decay of motor performance

There is rich clinical evidence that observing normally executed actions promotes the recovery of the corresponding action execution in patients with motor deficits. In this study, we assessed the ability of action observation to prevent the decay of healthy individuals' motor abilities following upper-limb immobilization. To this end, upper-limb kinematics was recorded in healthy participants while they performed three reach-to-grasp movements before immobilization and the same movements after 16 h of immobilization. The participants were subdivided into two groups; the experimental group observed, during the immobilization, the same reach-to-grasp movements they had performed before immobilization, whereas the control group observed natural scenarios. After bandage removal, motor impairment in performing reach-to-grasp movements was milder in the experimental group. These findings support the hypothesis that action observation, via the mirror mechanism, plays a protective role against the decline of motor performance induced by limb nonuse. From this perspective, action observation therapy is a promising tool for anticipating rehabilitation onset in clinical conditions involving limb nonuse, thus reducing the burden of further rehabilitation.

Portable, open-source solutions for estimating wrist position during reaching in people with stroke

Arm movement kinematics may provide a more sensitive way to assess neurorehabilitation outcomes than existing metrics. However, measuring arm kinematics in people with stroke can be challenging for traditional optical tracking systems due to non-ideal environments, expense, and difficulty performing required calibration. Here, we present two open-source methods, one using inertial measurement units (IMUs) and another using virtual reality (Vive) sensors, for accurate measurements of wrist position with respect to the shoulder during reaching movements in people with stroke. We assessed the accuracy of each method during a 3D reaching task. We also demonstrated each method's ability to track two metrics derived from kinematics-sweep area and smoothness-in people with chronic stroke. We computed correlation coefficients between the kinematics estimated by each method when appropriate. Compared to a traditional optical tracking system, both methods accurately tracked the wrist during reaching, with mean signed errors of 0.09 ± 1.81 cm and 0.48 ± 1.58 cm for the IMUs and Vive, respectively. Furthermore, both methods' estimated kinematics were highly correlated with each other (p < 0.01). By using relatively inexpensive wearable sensors, these methods may be useful for developing kinematic metrics to evaluate stroke rehabilitation outcomes in both laboratory and clinical environments.

Contralateral S1 function is involved in electroacupuncture treatment-mediated recovery after focal unilateral M1 infarction

Acupuncture at acupoints Baihui (GV20) and Dazhui (GV14) has been shown to promote functional recovery after stroke. However, the contribution of the contralateral primary sensory cortex (S1) to recovery remains unclear. In this study, unilateral local ischemic infarction of the primary motor cortex (M1) was induced by photothrombosis in a mouse model. Electroacupuncture (EA) was subsequently performed at acupoints GV20 and GV14 and neuronal activity and functional connectivity of contralateral S1 and M1 were detected using in vivo and in vitro electrophysiological recording techniques. Our results showed that blood perfusion and neuronal interaction between contralateral M1 and S1 is impaired after unilateral M1 infarction. Intrinsic neuronal excitability and activity were also disturbed, which was rescued by EA. Furthermore, the effectiveness of EA treatment was inhibited after virus-mediated neuronal ablation of the contralateral S1. We conclude that neuronal activity of the contralateral S1 is important for EA-mediated recovery after focal M1 infarction. Our study provides insight into how the S1–M1 circuit might be involved in the mechanism of EA treatment of unilateral cerebral infarction. The animal experiments were approved by the Committee for Care and Use of Research Animals of Guangzhou University of Chinese Medicine (approval No. 20200407009) April 7, 2020.

Use of the Leap Motion Controller® System in the Rehabilitation of the Upper Limb in Stroke. A Systematic Review

OBJECTIVES

Upper limb impairment is the most common motor impairment in stroke survivors. The use of new technologies in the field of rehabilitation aims to reduce the impact of functional problems. Our objective is to evaluate the effectiveness of using the Leap Motion Controller® virtual reality system in the treatment of upper limb functionality in people with stroke.

MATERIALS AND METHODS

PRISMA guidelines were used to carry out the systematic review. The literature search was restricted to articles written in English or Spanish published from 2012 to December 2020 in Pubmed, Web of Science, Scopus, PEDro and Science Direct. Of the 309 search results, 230 unique references were reviewed after duplicates were removed. The Downs and Black and CONSORT scales were applied to evaluate the methodological quality of the included papers and the degree of evidence and level of recommendation were determined through the Oxford Centre for Evidence-Based Medicine.

RESULTS

Six papers with a total of 144 participants were included in this review, with heterogeneity of the sample, assessment measures, protocols, number of sessions and diversity of games applied. The main results of the studies show favourable data after using the Leap Motion Controller® system in the improvement of upper limb functionality in people with stroke.

CONCLUSIONS

There is a growing trend in the use of the Leap Motion Controller® device as a tool in the treatment of the upper limb in people with stroke. Nevertheless, the limitations encountered suggest the need for future research protocols with greater scientific rigor.

Software Engineering Frameworks Used for Serious Games Development in Physical Rehabilitation: Systematic Review

Background

Serious games are a support in the rehabilitation process for treating people with physical disabilities. However, many of these serious games are not adapted to the patient’s needs because they are not developed with a software engineering framework with a set of activities, actions, and tasks that must be executed when creating a software product. Better serious games for rehabilitation will be developed if the patient and therapist requirements are identified, the development is planned, and system improvements and feedback are involved. The goal is that the serious game must offer a more attractive environment, while maintaining patient interest in the rehabilitation process.

Objective

This paper submits the results of a systematic review of serious games in physical rehabilitation identifying the benefits of using a software engineering framework.

Methods

A systematic research was conducted using PubMed, PEDro (Physiotherapy Evidence Database), IEEE Xplore, ScienceDirect, ACM Digital Library, Mary Ann Liebert, Taylor & Francis Online, Wiley Online Library, and Springer databases. The initial search resulted in 701 papers. After assessing the results according to the inclusion criteria, 83 papers were selected for this study.

Results

From the 83 papers reviewed, 8 used a software engineering framework for its development. Most of them focused their efforts on 1 or more aspects, such as data acquisition and processing, game levels, motivation, therapist supervision.

Conclusions

This systematic review proves that most of the serious games do not use a software engineering framework for their development. As a result, development systems overlook several aspects and do not have a standardized process, eventually omitting important implementation aspects, which impact the patient’s recovery time.

Relationship between the Corticospinal and Corticocerebellar Tracts and Their Role in Upper Extremity Motor Recovery in Stroke Patients

The corticospinal tract (CST) and corticocerebellar tract (CCT) are both involved in the upper extremity (UE) function after stroke. Understanding the relationship between the tracts and their functions can contribute to developing patient-specific rehabilitative strategies. Seventy ischemic stroke patients who underwent diffusion tensor imaging (DTI) two weeks after the stroke onset and motor function assessments two weeks and three months after the stroke onset were included in this study. To obtain the CST and CCT integrity, the functional anisotropy (FA) values of both tracts were extracted from the DTI data. Linear regression was used to identify the relationship and predictive accuracy. The CST FA data had predictive values, but CCT FA did not. There were interaction effects between the CST and CCT FA values (p = 0.011). The CCT was significantly associated with high CST FA but not low CST FA. When the CST or CCT FA were applied to patients depending on the CST status, the stratified model showed higher predictive accuracy (R² = 0.380) than that of the CST-only model (R² = 0.320). In this study, the conditional role of CCT depending on CST status was identified in terms of UE recovery in stroke patients. This result could provide useful information about individualized rehabilitative strategies in stroke patients.

Gait performance of adolescent mice assessed by the CatWalk XT depends on age, strain and sex and correlates with speed and body weight

The automatization of behavioral tests assessing motor activity in rodent models is important for providing robust and reproducible results and evaluating new therapeutics. The CatWalk system is an observer-independent, automated and computerized technique for the assessment of gait performance in rodents. This method has previously been used in adult rodent models of CNS-based movement disorders such as Parkinson's and Huntington's diseases. As motor and gait abnormalities in neuropsychiatric disorders are observed during infancy and adolescence, it became important to validate the CatWalk XT in the gait analysis of adolescent mice and unravel factors that may cause variations in gait performance. Three adolescent wild-type inbred mouse strains, C57BL/6N, DBA/2 and FVB/N, were tested using the CatWalk XT (Version 10.6) for suitable detection settings to characterize several gait parameters at P32 and P42. The same detection settings being suitable for C57BL/6N and DBA/2 mice allowed a direct comparison between the two strains. On the other hand, due to their increased body weight and size, FVB/N mice required different detection settings. The CatWalk XT reliably measured the temporal, spatial, and interlimb coordination parameters in the investigated strains during adolescence. Additionally, significant effects of sex, development, speed and body weight within each strain confirmed the sensitivity of motor and gait functions to these factors. The CatWalk gait analysis of rodents during adolescence, taking the effect of age, strain, sex, speed and body weight into consideration, will decrease intra-laboratory discrepancies and increase the face validity of rodent models of neuropsychiatric disorders.

Altered Modulation of the Movement-Related Beta Desynchronization with Force in Stroke - a Pilot Study

Conventional therapy improves motor recovery after stroke. However, 50% of stroke survivors still suffer from a significant level of long-term upper extremity impairment. Identifying a specific biomarker whose magnitude scales with the level of force could help in the development of more effective, novel, highly targeted rehabilitation therapies such as brain stimulation or neurofeedback. Four chronic stroke participants were enrolled in this pilot study to find such a neural marker using an Independent Component Analysis (ICA)-based source analysis approach, and investigate how it has been affected by the injury. Beta band desynchronization in the ipsilesional primary motor cortex was found to be most robustly scaling with force. This activity modulation with force was found to be significantly reduced, and to plateau at higher force than that of the contralesional (unaffected) side. A rehabilitation therapy that would target such a neuromarker could have the potential to strengthen the brain-to-muscle drive and improve motor learning and recovery.Clinical Relevance- This study identifies a neural marker that scales with motor output and shows how this modulation has been affected by stroke.

Evaluation of Central Fatigue in Post-stroke Rehabilitation: A Pilot Study

Central fatigue induced by excessive rehabilitation training would limit motor activity or even damage the post-stroke motor function recovery. However, the central fatigue progress during training is unclear and ignored in post-stroke rehabilitation. In this study, we tried to investigate the changes in central fatigue with fractal dimension (FD) of electromyography (EMG) at different peripheral fatigue levels based on the intracerebral haemorrhage (ICH) model. Ten Sprague-Dawley rats with ICH and EMG electrodes implantation were randomly distributed into two groups: the forced training (FOR) group with exhausted peripheral fatigue level (n=5) and fatigue-controlled (FAT) group (n=5) with peripheral fatigue constrained in moderate level. A higher central fatigue level was found in the FOR group (P<0.0001), and the central fatigue could be alleviated by peripheral fatigue-based modulation in the FAT group. The FAT group with less central fatigue achieved significantly better motor function recovery (P<0.0001), and it might be related to the recovery in the ability of motor unit recruitments.

Self-Rehabilitation for Post-Stroke Motor Function and Activity-A Systematic Review and Meta-Analysis

Background. Due to an increasing stroke incidence, a lack of resources to implement effective rehabilitation and a significant proportion of patients with remaining impairments after treatment, there is a rise in demand for effective and prolonged rehabilitation. Development of self-rehabilitation programs provides an opportunity to meet these increasing demands.Objective. The primary aim of this meta-analysis was to determine the effect of self-rehabilitation on motor outcomes, in comparison to conventional rehabilitation, among patients with stroke. The secondary aim was to assess the influence of trial location (continent), technology, time since stroke (acute/subacute vs chronic), dose (total training duration > vs ≤ 15 hours), and intervention design (self-rehabilitation in addition/substitution to conventional therapy) on effect of self-rehabilitation.Methods. Studies were selected if participants were adults with stroke; the intervention consisted of a self-rehabilitation program defined as a tailored program where for most of the time, the patient performed rehabilitation exercises independently; the control group received conventional therapy; outcomes included motor function and activity; and the study was a randomized controlled trial with a PEDro score ≥5.Results. Thirty-five trials were selected (2225 participants) and included in quantitative synthesis regarding motor outcomes. Trials had a median PEDro Score of 7 [6-8]. Self-rehabilitation programs were shown to be as effective as conventional therapy. Trial location, use of technology, stroke stage, and intervention design did not appear to have a significant influence on outcomes.Conclusion. This meta-analysis showed low to moderate evidence that self-rehabilitation and conventional therapy efficacy was equally valuable for post-stroke motor function and activity.

Timing is everything: Exercise therapy and remote ischemic conditioning for acute ischemic stroke patients

Physical exercise is a promising rehabilitative strategy for acute ischemic stroke. Preclinical trials suggest that exercise restores cerebral blood circulation and re-establishes the blood–brain barrier’s integrity with neurological function and motor skill improvement. Clinical trials demonstrated that exercise improves prognosis and decreases complications after ischemic events. Due to these encouraging findings, early exercise rehabilitation has been quickly adopted into stroke rehabilitation guidelines. Unfortunately, preclinical trials have failed to warn us of an adverse effect. Trials with very early exercise rehabilitation (within 24 h of ischemic attack) found an inferior prognosis at 3 months. It was not immediately clear as to why exercise was detrimental when performed very early while it was ameliorative just a few short days later. This review aimed to explore the potential mechanisms of harm seen in very early exercise administered to acute ischemic stroke patients. To begin, the mechanisms of exercise’s benefit were transposed onto the current understanding of acute ischemic stroke’s pathogenesis, specifically during the acute and subacute phases. Then, exercise rehabilitation’s mechanisms were compared to that of remote ischemic conditioning (RIC). This comparison may reveal how RIC may be providing clinical benefit during the acute phase of ischemic stroke when exercise proved to be harmful.

The effects of an object's height and weight on force calibration and kinematics when post-stroke and healthy individuals reach and grasp

Impairment in force regulation and motor control impedes the independence of individuals with stroke by limiting their ability to perform daily activities. There is, at present, incomplete information about how individuals with stroke regulate the application of force and control their movement when reaching, grasping, and lifting objects of different weights, located at different heights. In this study, we assess force regulation and kinematics when reaching, grasping, and lifting a cup of two different weights (empty and full), located at three different heights, in a total of 46 participants: 30 sub-acute stroke participants, and 16 healthy individuals. We found that the height of the reached target affects both force calibration and kinematics, while its weight affects only the force calibration when post-stroke and healthy individuals perform a reach-to-grasp task. There was no difference between the two groups in the mean and peak force values. The individuals with stroke had slower, jerkier, less efficient, and more variable movements compared to the control group. This difference was more pronounced with increasing stroke severity. With increasing stroke severity, post-stroke individuals demonstrated altered anticipation and preparation for lifting, which was evident for either cortical lesion side.

Using Probabilistic Movement Primitives in Analyzing Human Motion Differences Under Transcranial Current Stimulation

In medical tasks such as human motion analysis, computer-aided auxiliary systems have become the preferred choice for human experts for their high efficiency. However, conventional approaches are typically based on user-defined features such as movement onset times, peak velocities, motion vectors, or frequency domain analyses. Such approaches entail careful data post-processing or specific domain knowledge to achieve a meaningful feature extraction. Besides, they are prone to noise and the manual-defined features could hardly be re-used for other analyses. In this paper, we proposed probabilistic movement primitives (ProMPs), a widely-used approach in robot skill learning, to model human motions. The benefit of ProMPs is that the features are directly learned from the data and ProMPs can capture important features describing the trajectory shape, which can easily be extended to other tasks. Distinct from previous research, where classification tasks are mostly investigated, we applied ProMPs together with a variant of Kullback-Leibler (KL) divergence to quantify the effect of different transcranial current stimulation methods on human motions. We presented an initial result with 10 participants. The results validate ProMPs as a robust and effective feature extractor for human motions.

Transcranial direct current stimulation combined with robotic therapy for upper and lower limb function after stroke: a systematic review and meta-analysis of randomized control trials

BACKGROUND

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation method able to modulate neuronal activity after stroke. The aim of this systematic review was to determine if tDCS combined with robotic therapy (RT) improves limb function after stroke when compared to RT alone.

METHODS

A search for randomized controlled trials (RCTs) published prior to July 15, 2021 was performed. The main outcome was function assessed with the Fugl-Meyer motor assessment for upper extremities (FM/ue) and 10-m walking test (10MWT) for the lower limbs. As secondary outcomes, strength was assessed with the Motricity Index (MI) or Medical Research Council scale (MRC), spasticity with the modified Ashworth scale (MAS), functional independence with the Barthel Index (BI), and kinematic parameters.

RESULTS

Ten studies were included for analysis (n = 368 enrolled participants). The results showed a non-significant effect for tDCS combined with RT to improve upper limb function [standardized mean difference (SMD) = - 0.12; 95% confidence interval (CI): - 0.35-0.11)]. However, a positive effect of the combined therapy was observed in the lower limb function (SMD = 0.48; 95% CI: - 0.15-1.12). Significant results favouring tDCS combined with RT were not found in strength (SMD = - 0.15; 95% CI: - 0.4-0.1), spasticity [mean difference (MD) =  - 0.15; 95% CI: - 0.8-0.5)], functional independence (MD = 2.5; 95% CI: - 1.9-6.9) or velocity of movement (SMD = 0.06; 95% CI: - 0.3-0.5) with a "moderate" or "low" recommendation level according to the GRADE guidelines.

CONCLUSIONS

Current findings suggest that tDCS combined with RT does not improve upper limb function, strength, spasticity, functional independence or velocity of movement after stroke. However, tDCS may enhance the effects of RT alone for lower limb function. tDCS parameters and the stage or type of stroke injury could be crucial factors that determine the effectiveness of this therapy.

Comparative Assessment of Robotic versus Classical Physical Therapy Using Muscle Strength and Ranges of Motion Testing in Neurological Diseases

The use of robotic systems in physical rehabilitation protocols has become increasingly attractive and has been given more focus in the last decade as a result of the high prevalence of motor deficits in the population, which is linked to an overburdened healthcare system. In accordance with current trends, three robotic devices have been designed, called ParReEx Elbow, ParReEx Wrist, and ASPIRE, which were designed to improve upper-limb medical recovery (shoulder, elbow, forearm, and wrist). The three automated systems were tested in a hospital setting with 23 patients (12 men and 11 women) suffering from motor deficits caused by various neurological diseases such as stroke, Parkinson's disease, and amyotrophic lateral sclerosis (ALS). The patients were divided into three groups based on their pathology (vascular, extrapyramidal, and neuromuscular). Objective clinical measures, such as the Medical Research Council (MRC) scale, goniometry, and dynamometry, were used to compare pre- and post-rehabilitation assessments for both robotic-aided and manual physical rehabilitation therapy. The results of these tests showed that, with the exception of a few minor differences in muscular strength recovery, the robotic-assisted rehabilitation methods performed equally as well as the manual techniques, though only minor improvements were validated during short-term rehabilitation. The greatest achievements were obtained in the goniometric analysis where some rehabilitation amplitudes increased by over 40% in the vascular group, but the same analysis returned regressions in the neuromuscular group. The MRC scale analysis returned no significant differences, with most regressions occurring in the neuromuscular group. The dynamometric analysis mostly returned improvements, but the highest value evolution was 19.07%, which also in the vascular group. While the results were encouraging, more research is needed with a larger sample size and a longer study period in order to provide more information regarding the efficacy of both rehabilitation methods in neurological illnesses.

Effects of cognitive motor dual-task training on stroke patients: A RCT-based meta-analysis

Based on a randomized controlled trial (RCT), this meta-analysis aimed to comprehensively analyze the effects of cognitive motor dual-task training (CMDT) on stroke patients. The electronic databases PubMed, Embase, and the Cochrane Library were searched for papers on the influence of CMDT on stroke patients. Weighted mean difference (WMD) and 95% confidence interval (95% CI) were used as effect sizes. Cochran's Q and I² tests were performed for heterogeneity. Thirteen articles involving 326 patients were included in the study. The meta-analysis showed that CMDT significantly improved the walking balance of patients with stroke (P = 0.01). In addition, CMDT significantly improved the gait ability of patients with stroke (P < 0.0001). Furthermore, CMDT had a significant effect on the improvement of upper limb ability in patients with stroke (P < 0.00001). CMDT could significantly improve balance ability, gait, and upper limb function in patients with chronic stroke, which is worthy of clinical promotion.

Beyond motor recovery after stroke: The role of hand robotic rehabilitation plus virtual reality in improving cognitive function

Robot-assisted hand training adopting end-effector devices results in an additional reduction of motor impairment in comparison to usual care alone in different stages of stroke recovery. These devices often allow the patient to perform practical, attentive, and visual-spatial tasks in a semi-virtual reality (VR) setting. We aimed to investigate whether the hand end-effector robotic device Amadeo^TM could improve cognitive performance, beyond the motor deficit, as compared to the same amount of occupational treatment focused on the hand. Forty-eight patients (aged 54.3 ± 10.5 years, 62.5% female) affected by either ischemic or hemorrhagic stroke in the chronic phase were enrolled in the study. The experimental group (EG) underwent Amadeo^TM robotic training, while the control group (CG) performed occupational therapy involving the upper limb. Patients were assessed at the beginning and at the end of the rehabilitation protocol using a specific neuropsychological battery, as well as motor function tests. The EG showed greater improvements in different cognitive domains, including attentive abilities and executive functions, as well as in hand motor function, as compared to CG. Our study showed that task-oriented VR-based robotic rehabilitation enhanced not only motor function in the paretic arm but also global and specific cognitive abilities in post-stroke patients. We may argue that the hand robotic plus VR-based training may provide patients with an integration of cognitive and motor skill rehabilitation, thus amplifying the functional outcome achievement.

Effects of virtual reality exergame on psychophysiological and postural disorders in elderly patients

Balance impairment at advanced age is a serious medical problem that often has significant implications and affects the quality of the patient’s life. Among the underlying causes are overall slowness of motor response and vestibular syndrome. Virtual reality exergames, including reaction and balance training, hold promise for managing balance dysfunction. The aim of this study was to investigate the effects of a combination rehabilitation program containing elements of virtual reality exergame on the postural and psychophysiological parameters of elderly patients with small vascular disease The study was conducted in 24 patients with small vascular disease (median age: 66 years). All patients underwent a virtual reality rehabilitation program. Psychophysiological, postural and clinical evaluations were performed at baseline and after the program was completed. Balance function measured on the Berg scale improved significantly and was 53 [52; 55] after the training program vs 50 [45; 54] at baseline (p < 0.05). The strategy of balance control also changed: the Romberg ratio was 266 [199.5; 478.5] before rehabilitation and 221 [149.25; 404] after the program was completed (p < 0.05). The most pronounced changes in the measured psychophysiological parameters occurred in the simple audiomotor reaction, which improved from 210 [174.25; 245.5] at baseline to 180.5 [170.5; 208] after rehabilitation (p < 0.05). Thus, the combination balance and reaction virtual reality training is an effective rehabilitation method for advanced-age patients with balance impairment.

Classification of error-related potentials evoked during stroke rehabilitation training

Objective.Error-related potentials (ErrPs) are elicited in the human brain following an error's perception. Recently, ErrPs have been observed in a novel task situation, i.e. when stroke patients perform upper-limb rehabilitation exercises. These ErrPs can be used to developassist-as-needed(AAN) robotic stroke rehabilitation systems. However, to date, there is no reported research on assessing the feasibility of using the ErrPs to implement the AAN approach. Hence, in this study, we evaluated and compared the single-trial classification of novel ErrPs using various classical machine learning and deep learning approaches.Approach.Electroencephalogram data of 13 stroke patients recorded while performing an upper-limb physical rehabilitation exercise were used. Two classification approaches, one combining the xDAWN spatial filtering and support vector machines, and the other using a convolutional neural network-based double transfer learning, were utilized.Main results.Results showed that the ErrPs could be detected with a mean area under the receiver operating characteristics curve of 0.838, and a mean accuracy of 0.842, 0.257 above the chance level (p< 0.05), for a within-subject classification. The results indicated the feasibility of using ErrP signals in real-time AAN robot therapy with evidence from the conducted latency analysis, cross-subject classification, and three-class asynchronous classification.Significance.The findings presented support our proposed approach of using ErrPs as a measure to trigger and/or modulate as required the robotic assistance in a real-timehuman-in-the-looprobotic stroke rehabilitation system.

Stroke rehabilitation and recovery

Stroke is the UK's leading cause of disability. Stroke rehabilitation can maximise recovery and improve quality of life. This article discusses some post-stroke impairments, including hemiplegia, dysphagia, communication impairments and neglect, and how rehabilitation can address these. Developing techniques of adaptation or compensation is vital, since the extent of stroke recovery is dependent on successful neuroplasticity, with healthy neurons adapting to compensate for damaged ones.