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

Effect of vagus nerve stimulation paired with rehabilitation for upper limb function improvement after stroke: a systematic review and meta-analysis of randomized controlled trials

Vagus nerve stimulation (VNS) could potentially facilitate arm function recovery after stroke. The aim of this review was to evaluate the effect of VNS paired with rehabilitation on upper limb function recovery after stroke. We considered randomized controlled trials (RCTs) that used VNS paired with rehabilitation for the improvement of upper limb function after stroke and were published in English. Eligible RCTs were identified by searching electronic databases, including MEDLINE, Web of Science, Embase, CENTRAL and PEDro, from their inception until June 2021. Quality of included studies was assessed using PEDro score and Cochrane's risk of bias assessment. A meta-analysis was performed on the collected data. Five studies with a total of 178 participants met the inclusion criteria. Overall, the present meta-analysis revealed a significant effect of VNS on Fugl-Meyer Assessment for Upper Extremity (FMA-UE, MD = 3.59; 95% CI, 2.55-4.63; P < 0.01) when compared with the control group. However, no significant difference was observed in adverse events associated with device implantation between the invasive VNS and control groups (RR = 1.10; 95% CI, 0.92-1.32; P = 0.29). No adverse events associated with device use were reported in invasive VNS, and one was reported in transcutaneous VNS. This study revealed that VNS paired with rehabilitation can facilitate the recovery of upper limb function in patients with stroke on the basis of FMA-UE scores, but the long-term effects remain to be demonstrated.

Short-Term Outcome Assessment of Acute Ischemic Stroke After Intravenous Fibrinolytic Therapy: A Cross-Sectional Study

Background: The disease burden of acute ischemic stroke (AIS) is an important health issue in today’s patient care. Urgent intravenous thrombolytic (UIT) therapy is one of the most popular treatments in these cases. Objectives: This study aimed to evaluate the 1-month outcome of patients with AIS who received urgent intravenous fibrinolytic therapy. Methods: In a prospective cross-sectional study, we evaluated the 1-month outcome of cases with a confirmed diagnosis of AIS who had received UIT therapy at the emergency department. Demographic data, mortality and morbidity, hospital length of stay, admission functional disability by Modified Rankin Scale (MRS), National Institutes of Health Stroke Scale (NIHSS), and final disposition of patients were all evaluated and recorded via their medical records or structured telephone inquiries. We compared all variables between the 2 groups (i.e., survived and expired groups). Results: Among 490 cases we assessed, age had a mean ± SD of 69.41 ± 12.25 years, and most cases were males (74.3%). The 1-month mortality rate in our sample was 4.08% (20 cases). The mean ± SD of hospital length of stay was 6.84 ± 7.32 days, with no significant difference between the 2 groups (P = 0.869). Demographic data showed no significant differences between the 2 groups. NIHSS and MRS scores were significantly higher in the expired group than in the survived group (P = 0.005 and P = 0.001, respectively). Conclusions: NIHSS and MRS scores were significantly higher in the expired cases. The 1-month mortality rate in this study was 4.08%.

Cardiometabolic multimorbidity and activity limitation: a cross-sectional study of adults using the Canadian Longitudinal Study on Aging data

BACKGROUND

Cardiometabolic multimorbidity (CM) is the diagnosis of 2 or more cardiometabolic conditions. Multimorbidity and individual cardiometabolic conditions have been associated with activity limitation, a common form of disability, but few studies have investigated the association between CM and activity limitation.

OBJECTIVES

To estimate the prevalence of activity limitation among Canadians with CM and to quantify the association between CM and activity limitation.

METHODS

Using data from the Canadian Longitudinal Study on Aging, we conducted a cross-sectional analysis of activity limitation among Canadians aged 45-85 (n = 50,777; weighted n = 13,118,474). CM was defined as the diagnosis of 2 or more of diabetes/prediabetes, myocardial infarction, and stroke, and activity limitation was evaluated using the Older Americans Resources and Services scale. Descriptive statistics and logistic and multinomial logistic regression analyses were conducted to determine the association between CM and activity limitation.

RESULTS

The estimated prevalence of activity limitation among participants living with CM was 27.4% compared with 7.5% with no cardiometabolic conditions. Activity limitation increased in prevalence and severity with the number of cardiometabolic conditions. People with CM had increased odds of activity limitation compared with those without any cardiometabolic conditions (adjusted relative risk ratio = 3.99, 95% confidence interval [3.35-4.75]), and the odds increased with each additional condition. Stroke survivors had greater odds of activity limitation than those without a history of stroke and the same number of cardiometabolic conditions.

CONCLUSION

Activity limitation is common among Canadians living with CM. Odds of activity limitation increase with each additional cardiometabolic condition, especially for stroke survivors.

Brain Function and Upper Limb Deficit in Stroke With Motor Execution and Imagery: A Cross-Sectional Functional Magnetic Resonance Imaging Study

Background

Motor imagery training might be helpful in stroke rehabilitation. This study explored if a specific modulation of movement-related regions is related to motor imagery (MI) ability.

Methods

Twenty-three patients with subcortical stroke and 21 age-matched controls were recruited. They were subjectively screened using the Kinesthetic and Visual Imagery Questionnaire (KVIQ). They then underwent functional magnetic resonance imaging (fMRI) while performing three repetitions of different motor tasks (motor execution and MI). Two separate runs were acquired [motor execution tasks (ME and rest) and motor imagery (MI and rest)] in a block design. For the different tasks, analyses of cerebral activation and the correlation of motor/imagery task-related activity and KVIQ scores were performed.

Results

During unaffected hand (UH) active grasp movement, we observed decreased activations in the contralateral precentral gyrus (PreCG), contralateral postcentral gyrus (PoCG) [p &lt; 0.05, family wise error (FWE) corrected] and a positive correlation with the ability of FMA-UE (PreCG: r = 0.46, p = 0.028; PoCG: r = 0.44, p = 0.040). During active grasp of the affected hand (AH), decreased activation in the contralateral PoCG was observed (p &lt; 0.05, FWE corrected). MI of the UH induced significant activations of the contralateral superior frontal gyrus, opercular region of the inferior frontal gyrus, and ipsilateral ACC and deactivation in the ipsilateral supplementary motor area (p &lt; 0.05, AlphaSim correction). Ipsilateral anterior cingulate cortex (ACC) activity negatively correlated with MI ability (r = =–0.49, p = 0.022). Moreover, we found significant activation of the contralesional middle frontal gyrus (MFG) during MI of the AH.

Conclusion

Our results proved the dominant effects of MI dysfunction that exist in stroke during the processing of motor execution. In the motor execution task, the enhancement of the contralateral PreCG and PoCG contributed to reversing the motor dysfunction, while in the MI task, inhibition of the contralateral ACC can increase the impaired KVIQ ability. The bimodal balance recovery model can explain our results well. Recognizing neural mechanisms is critical to helping us formulate precise strategies when intervening with electrical or magnetic stimulation.

Calligraphy-based rehabilitation exercise for improving the upper limb function of stroke patients: protocol for an evaluator-blinded randomised controlled trial

INTRODUCTION

A common complication of stroke is upper limb dysfunction. Chinese calligraphy handwriting (CCH) is an aesthetical exercise developed from the traditional way of writing in China and holds potential to become a rehabilitation method to improve upper limb functions in patients with stroke. This study aims to design a randomised controlled trial to assess the effect of a customised CCH-based exercise for poststroke rehabilitation of upper limb dysfunction.

METHODS AND ANALYSIS

A single-blinded randomised controlled trial will be conducted on 60 stroke patients. The patients will be randomly allocated into three groups: (1) conventional occupational therapy (COT) group, (2) COT+CCH group, (3) COT+Graded Repetitive Arm Supplementary Program (GRASP) group. For the COT group, patients will receive COT treatment of 1 hour/day. For the COT+CCH group, patients will receive 30 mins COT treatment and 30 mins CCH training. For the COT+GRASP group, patients will receive 30 mins COT treatment and 30 mins GRASP training. All the interventions will be performed 5 days per week for a total of 3 weeks. The upper limb functions will be assessed before and after the interventions using a series of rating scales.

ETHICS AND DISSEMINATION

This study has been approved by the Research Ethics Committees of the Second Rehabilitation Hospital of Shanghai (study ID: 2020-32-01) and the Shanghai University of Sport (study ID: 102772021RT043). Results will be directly disseminated to the patients at the end of the study and to the public via publications in peer-reviewed journals and presentations in conferences.

TRIAL REGISTRATION NUMBER

ChiCTR 2100043036; Chinese Clinical Trials Registry.

Quantitative Assessment of Hand Function in Healthy Subjects and Post-Stroke Patients with the Action Research Arm Test

The Action Research Arm Test (ARAT) can provide subjective results due to the difficulty assessing abnormal patterns in stroke patients. The aim of this study was to identify joint impairments and compensatory grasping strategies in stroke patients with left (LH) and right (RH) hemiparesis. An experimental study was carried out with 12 patients six months after a stroke (three women and nine men, mean age: 65.2 ± 9.3 years), and 25 healthy subjects (14 women and 11 men, mean age: 40.2 ± 18.1 years. The subjects were evaluated during the performance of the ARAT using a data glove. Stroke patients with LH and RH showed significantly lower flexion angles in the MCP joints of the Index and Middle fingers than the Control group. However, RH patients showed larger flexion angles in the proximal interphalangeal (PIP) joints of the Index, Middle, Ring, and Little fingers. In contrast, LH patients showed larger flexion angles in the PIP joints of the Middle and Little fingers. Therefore, the results showed that RH and LH patients used compensatory strategies involving increased flexion at the PIP joints for decreased flexion in the MCP joints. The integration of a data glove during the performance of the ARAT allows the detection of finger joint impairments in stroke patients that are not visible from ARAT scores. Therefore, the results presented are of clinical relevance.

Effect of exercise from a very early stage after intracerebral hemorrhage on microglial and macrophage reactivity states in rats

OBJECTIVE

This study investigated the effects of exercise, starting very early after intracerebral hemorrhage (ICH), on microglia and macrophages in a rat model. Collagenase solution was injected into the left striatum to induce ICH.

METHODS

Rats were randomly assigned to receive placebo surgery without exercise (sham surgery), ICH without exercise (ICH), or ICH with very early exercise (ICH + VET). The ICH + VET group was subjected to treadmill running 6 h, 24 h, and days 2-6 after ICH. Motor function assessment was performed using the ladder test and rotarod test 3 h, 25 h, and 7 days after ICH. Postexercise brain tissue was collected on day 8 after surgery to investigate the lesion volume. Very early exercise temporarily worsened motor dysfunction. The protein expression levels of the macrophage and microglial markers CD80, CD163, and TMEM119 were analyzed 6 h, 24 h, and 8 days after ICH. Protein analysis of NeuN, GFAP, and PSD95 was also performed on day 8 after ICH.

RESULTS

There was no significant difference in lesion volume between the ICH and ICH + VET groups on day 8 after ICH. Exercise from very early stage prevented elevated CD163 protein expression.

CONCLUSION

Very early exercise may inhibit the activation of anti-inflammatory-associated macrophages/microglia.

Development of Supportive-Educative Range of Motion Exercise for Post-stroke Patients: A Pilot Study

The purpose of this pilot study was to assess of home care intervention on post-stroke related outcome of range of motion and muscle strength. Sample in 40 participants were divided into the intervention group and control group and included in this study according to the following criteria: post-stroke period of <12 months with hemiparesis, age of ≥18 years, and willingness to participate in the study. The intervention was carried out by nurses by providing education for 2 consecutive days and mentoring for 5 consecutive days, while the control group was given standard care and measured using a grip track, handheld dynamometer, and goniometer examination on June to September 2019. For the intervention group, paired t-test analysis confirmed a significant increase in the mean upper extremity muscle strength before (35.770 ± 46.063) and after (51.073 ± 50.866) the 7 day intervention ( p = .002), whereas the control group showed a value 36.570 ± 33.684 and then 31.400 ± 31.760 p = .256 and lower extremity strength before (3.627 ± 1.585) and after (4.365 ± 1.698) the 7-days intervention ( p = .000), whereas the control group showed a value 3.657 ± 1.671 and then 4.043 ± 1.849 p = .013. Almost all the items assessed from Range of Motion (ROM) in the upper and lower extremities showed a significant increase ( p < .05). Supportive-educative ROM exercise significantly contributed to an increase in the average muscle strength and ROM in post-stroke patients.

Efficacy of electromechanical-assisted gait training on clinical walking function and gait symmetry after brain injury of stroke: a randomized controlled trial

Electromechanical-assisted gait training may be an effective intervention to promote motor recovery after brain injury. However, many studies still have difficulties in clarifying the difference between electromechanical-assisted gait training and conventional gait training. To evaluate the effectiveness of electromechanical-assisted gait training compared to that of conventional gait training on clinical walking function and gait symmetry of stroke patients. We randomly assigned patients with stroke (n = 144) to a control group (physical therapist-assisted gait training) and an experimental group (electromechanical gait training). Both types of gait training were done for 30 min each day, 5 days a week for 4 weeks. The primary endpoint was the change in functional ambulatory category (FAC). Secondary endpoints were clinical walking functions and gait symmetries of swing time and step length. All outcomes were measured at baseline (pre-intervention) and at 4 weeks after the baseline (post-intervention). FAC showed significant improvement after the intervention, as did clinical walking functions, in both groups. The step-length asymmetry improved in the control group, but that in the experimental group and the swing-time asymmetry in both groups did not show significant improvement. In the subgroup analysis of stroke duration of 90 days, FAC and clinical walking functions showed more significant improvement in the subacute group than in the chronic group. However, gait symmetries did not show any significant changes in either the subacute or the chronic group. Electromechanically assisted gait training by EXOWALK was as effective as conventional gait training with a physiotherapist. Although clinical walking function in the subacute group improved more than in the chronic group, gait asymmetry did not improve for either group after gait training.

Trial registration: KCT0003411 Clinical Research Information Service (CRIS), Republic of Korea.

Precision medicine in stroke: towards personalized outcome predictions using artificial intelligence

Stroke ranks among the leading causes for morbidity and mortality worldwide. New and continuously improving treatment options such as thrombolysis and thrombectomy have revolutionized acute stroke treatment in recent years. Following modern rhythms, the next revolution might well be the strategic use of the steadily increasing amounts of patient-related data for generating models enabling individualized outcome predictions. Milestones have already been achieved in several health care domains, as big data and artificial intelligence have entered everyday life. The aim of this review is to synoptically illustrate and discuss how artificial intelligence approaches may help to compute single-patient predictions in stroke outcome research in the acute, subacute and chronic stage. We will present approaches considering demographic, clinical and electrophysiological data, as well as data originating from various imaging modalities and combinations thereof. We will outline their advantages, disadvantages, their potential pitfalls and the promises they hold with a special focus on a clinical audience. Throughout the review we will highlight methodological aspects of novel machine-learning approaches as they are particularly crucial to realize precision medicine. We will finally provide an outlook on how artificial intelligence approaches might contribute to enhancing favourable outcomes after stroke.

Efficacy and safety of electroacupuncture at auricular concha region in promoting of rehabilitation of ischemic stroke patients with upper limb motor dysfunction: A study protocol for a randomized pilot trial

INTRODUCTION

Ischemic stroke (IS) is the one of the most severe neurological disease, survivors may live with upper limb motor dysfunction (ULMD) resulting in heavy social and economic burden. Nowadays, there are few approaches to promote the rehabilitation of ULMD. Auricular acupuncture (electroacupuncture [EA]) has long been used in the treatment of neurological disorders in China. This treatment has become an attractive treatment option due to its low cost, portability, minimal side effects, and ease of use in clinical and operational environments. However, its efficacy and safety in consciousness recovery remain to be proved.

METHODS

A total of 80 IS patients with single upper limb motor function impairment will be recruited in the trial and randomized into EA or control groups. Patients in the control group will receive routine conventional treatment alone while patients in the EA group will receive EA treatment for 3 consecutive weeks based on routine conventional treatment. Baseline evaluation was carried out on day of enrollment, post-treatment evaluation was carried out 14 and 21 days after enrollment, and the 2 groups were follow-ups in 3 and 6 months after the end of the trial. The efficacy will be assessed with the changes in the upper limb Fugl-Meyer assessment, Wolf motor function test, action research arm test, active range of motion, and Barthel index. The safety of EA will be estimated by monitoring the incidence of adverse events and changes in vital signs during the study period. Analysis of feasibility will be descriptive and the change in outcome measures between groups will be analyzed using an independent sample t test.

DISCUSSION

This study tried to narrow the evidence gap on the efficacy of EA at the auricular on the recovery of ULMD in patients with IS. The results of this trial will provide strong evidence for the efficacy and safety of EA of auricular concha region stimulation for IS patients.Trial registration: This trial has been registered at the Chinese Clinical Trial Registry, numbered ChiCTR2100049678.

Validity study of a triaxial accelerometer for measuring energy expenditure in stroke inpatients of a physical medicine and rehabilitation center

PURPOSE

Establish the validity of a triaxial accelerometer (Dynaport®) for evaluating the energy expenditure of patients with stroke sequelae at a rehabilitation hospital.

METHODS

This is a cross-sectional study with 24 stroke inpatients of a rehabilitation hospital. The participants were assessed on energy expenditure by an ergospirometer system and the triaxial accelerometer simultaneously during a walk test. The data collected by both devices were compared by intraclass correlation coefficient (ICC) and Bland-Altman limits of agreement.

RESULTS

An almost perfect agreement (ICC = 0,94) in the energy expenditure measured by the accelerometer compared to the results of the ergospirometer system was found during the exercise test. The Bland-Altman analysis has shown suitable limits of agreement. Post hoc analyses with the maximum volume of oxygen and the total energy expenditure measured by the ergospirometer system evidenced significant correlation with the energy expenditure measurements by the accelerometer.

CONCLUSION

Our results evidence that the triaxial accelerometer Dynaport® and its built-in software are valid for estimating the energy expenditure of stroke sequelae during a walk exercise.

Task-Related Hemodynamic Changes Induced by High-Definition Transcranial Direct Current Stimulation in Chronic Stroke Patients: An Uncontrolled Pilot fNIRS Study

High-definition transcranial direct current stimulation (HD-tDCS) has recently been proposed as a tDCS approach that can be used on a specific cortical region without causing undesirable stimulation effects. In this uncontrolled pilot study, the cortical hemodynamic changes caused by HD-tDCS applied over the ipsilesional motor cortical area were investigated in 26 stroke patients. HD-tDCS using one anodal and four cathodal electrodes at 1 mA was administered for 20 min to C3 or C4 in four daily sessions. Cortical activation was measured as changes in oxyhemoglobin (oxyHb) concentration, as found using a functional near-infrared spectroscopy (fNIRS) system during the finger tapping task (FTT) with the affected hand before and after HD-tDCS. Motor-evoked potential and upper extremity functions were also measured before (T0) and after the intervention (T1). A group statistical parametric mapping analysis showed that the oxyHb concentration increased during the FTT in both the affected and unaffected hemispheres before HD-tDCS. After HD-tDCS, the oxyHb concentration increased only in the affected hemisphere. In a time series analysis, the mean and integral oxyHb concentration during the FTT showed a noticeable decrease in the channel closest to the hand motor hotspot (hMHS) in the affected hemisphere after HD-tDCS compared with before HD-tDCS, in accordance with an improvement in the function of the affected upper extremity. These results suggest that HD-tDCS might be helpful to rebalance interhemispheric cortical activity and to reduce the hemodynamic burden on the affected hemisphere during hand motor tasks. Noticeable changes in the area adjacent to the affected hMHS may imply that personalized HD-tDCS electrode placement is needed to match each patient's individual hMHS location.

Experiences of SENSory Relearning of the UPPer Limb (SENSUPP) after Stroke and Perceived Effects: A Qualitative Study

Recently, it was shown that sensory relearning of the upper limb (SENSUPP) is a promising intervention to improve sensorimotor function after stroke. There is limited knowledge, however, of how participants perceive the training. Here, we explored how persons with sensory impairments in the upper limb experienced the SENSUPP protocol (combined sensory- and motor training and home exercises for 5 weeks) and its effect. Fifteen persons (mean age 59 years; 10 men; >6 months post-stroke) were individually interviewed, and data were analyzed with qualitative content analysis. An overall theme ‘Sensory relearning was meaningful and led to improved ability to perform daily hand activities’ and two categories with six subcategories emerged. The outpatient training was perceived as meaningful, although the exercises were demanding and required concentration. Support from the therapist was helpful and training in small groups appreciated. The home training was challenging due to lack of support, time, and motivation. Small improvements in sensory function were perceived, whereas increased movement control and ability in performing daily hand activities were reported. In conclusion, the SENSUPP protocol is meaningful and beneficial in improving the functioning of the UL in chronic stroke. Improving compliance to the home training, regular follow-ups, and an exercise diary are recommended.

Electroacupuncture Alters BCI-Based Brain Network in Stroke Patients

Goal. Stroke patients are usually accompanied by motor dysfunction, which greatly affects daily life. Electroacupuncture is a kind of nondrug therapy that can effectively improve motor function. However, the effect of electroacupuncture is hard to be measured immediately in clinic. This paper is aimed to reveal the instant changes in brain activity of three groups of stroke patients before, during, and after the electroacupuncture treatment by the EEG analysis in the alpha band and beta band. Methods. Seven different functional connectivity indicators including Pearson correlation coefficient, spectral coherence, mutual information, phase locking value, phase lag index, partial directed coherence, and directed transfer function were used to build the BCI-based brain network in stroke patients. Results and Conclusion. The results showed that the brain activity based on the alpha band of EEG decreased after the electroacupuncture treatment, while in the beta band of EEG, the brain activity decreased only in the first two groups. Significance. This method could be used to evaluate the effect of electroacupuncture instantly and quantitatively. The study will hopefully provide some neurophysiological evidence of the relationship between changes in brain activity and the effects of electroacupuncture. The study of BCI-based brain network changes in the alpha and beta bands before, during, and after electroacupuncture in stroke patients of different periods is helpful in adjusting and selecting the electroacupuncture regimens for different patients. The trial was registered on the Chinese clinical trial registry (ChiCTR2000036959).

Whole Brain Hemodynamic Response Based on Synchrony Analysis of Brain Signals for Effective Application of HD-tDCS in Stroke Patients: An fNIRS Study

In this study, the effective application of high-definition transcranial direct current stimulation (HD-tDCS) based on the whole brain hemodynamic response in stroke patients was investigated using functional near-infrared spectroscopy (fNIRS). The intrahemispheric and interhemispheric synchronization and cortical activity based on the time during 1 mA HD-tDCS were examined in 26 chronic cerebrovascular disease patients. At the beginning of HD-tDCS, the synchronization and brain activity in the whole brain increased rapidly and decreased after 5 min. In the middle of tDCS, the synchronization began to increase again, and strong synchronic connections were formed around the desired stimulation area. After tDCS, strong cortical activation was observed in the stimulation area, indicating that the baseline of the oxyhemoglobin (HbO) signal increased in the desired stimulation area. Therefore, the results of this study indicate that HD-tDCS can be applied efficiently to enhance the effect of tDCS. This stimulation method with tDCS can be explored clinically for more neurorehabilitation of patients with degenerative brain diseases.

Structural Covariance of the Ipsilesional Primary Motor Cortex in Subcortical Stroke Patients with Motor Deficits

The analysis of structural covariance has emerged as a powerful tool to explore the morphometric correlations among broadly distributed brain regions. However, little is known about the interactions between the damaged primary motor cortex (M1) and other brain regions in stroke patients with motor deficits. This study is aimed at investigating the structural covariance pattern of the ipsilesional M1 in chronic subcortical stroke patients with motor deficits. High-resolution T1-weighted brain images were acquired from 58 chronic subcortical stroke patients with motor deficits (29 with left-sided lesions and 29 with right-sided lesions) and 50 healthy controls. Structural covariance patterns were identified by a seed-based structural covariance method based on gray matter (GM) volume. Group comparisons between stroke patients (left-sided or right-sided groups) and healthy controls were determined by a permutation test. The association between alterations in the regional GM volume and motor recovery after stroke was investigated by a multivariate regression approach. Structural covariance analysis revealed an extensive increase in the structural interactions between the ipsilesional M1 and other brain regions in stroke patients, involving not only motor-related brain regions but also non-motor-related brain regions. We also identified a slightly different pattern of structural covariance between the left-sided stroke group and the right-sided stroke group, thus indicating a lesion-side effect of cortical reorganization after stroke. Moreover, alterations in the GM volume of structural covariance brain regions were significantly correlated to the motor function scores in stroke patients. These findings indicated that the structural covariance patterns of the ipsilesional M1 in chronic subcortical stroke patients were induced by motor-related plasticity. Our findings may help us to better understand the neurobiological mechanisms of motor impairment and recovery in patients with subcortical stroke from different perspectives.

Telerehabilitation for lower extremity recovery poststroke: a systematic review and meta-analysis protocol

INTRODUCTION

Approximately 30% of individuals with stroke report unmet lower extremity recovery needs after formal hospital-based rehabilitation programmes have ended. Telerehabilitation can mitigate issues surrounding accessibility of rehabilitation services by providing ongoing support to promote recovery, however, no review exists that is specific to telerehabilitation for lower extremity recovery. This paper describes the protocol of a systematic review and meta-analysis that aims to describe and evaluate the effectiveness of lower extremity-focused telerehabilitation interventions on clinical outcomes poststroke.

METHODS AND ANALYSIS

A systematic review of relevant electronic databases (MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, Google Scholar, PEDro, PubMed and Cochrane Library) between inception and February 2022 will be undertaken to identify eligible interventional studies published in English that compared telerehabilitation focusing on lower extremity recovery to another intervention or usual care for individuals living in the community with stroke. Clinical outcomes examined will include those related to physical function and impairment, activities and participation that are typically assessed in clinical practice and research. Two reviewers will independently screen results, identify studies to be included for review, extract data and assess risk of bias. Meta-analyses will be performed if sufficient data exist. Sensitivity analyses will be performed by removing studies with low methodological quality, and subgroup analyses will be performed if data allow by stratifying papers based on salient demographic or stroke factors and comparing results. The reporting of the review will follow the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The quality of evidence regarding various outcomes for telerehabilitation for lower extremity recovery poststroke will be assessed according to the Grading of Recommendation, Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

No ethical approval or informed consent is needed for this systematic review. The findings of this review will be disseminated via peer-reviewed publications and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42021246886.

[Long-term consequences of stroke]

The treatment of stroke has significantly improved over the past two decades, resulting in reduced mortality and morbidity in high-income countries. However, strokes remain the third leading cause of mortality and disability worldwide. In addition to acute care and the prevention of risk factors, treatment of the various persisting disabilities that impact the daily activities and quality of life of patients also remain important. Motor and language deficits affect everyday life most obviously. Other deficits may involve complex movements, sensory, and cognitive functions. Patients also often suffer from anxiety, fatigue, and depression.Established ergotherapeutic, physiotherapeutic, and logopedic programs exist for motor and language deficits for in-patient treatment as well as in the ambulatory setting. The diagnosis and treatment of cognitive impairments and behavioral disorders, however, are largely confined to the early rehabilitation phase. Despite indications of a long-term impairment of quality of life due to cognitive deficits and behavioral disorders, previous study results speak against drug-based antidepressant therapy in in-patient rehabilitation. Individual patient-reported outcomes, supported by screening for cognitive deficits and consideration of individual risk factors and coping strategies, could further improve the treatment of stroke and its long-term burden.

Synergy-Based Motor Therapy Inducing Favorable Changes in Motor Function Components among Poststroke Subjects: A Single-Group Study

Background  Synergy is an outcome of multiple muscles acting in a synchronized pattern, controlled by the central nervous system. After brain insult, a set of deviated movement pattern emerges in the affected limb. The methods to train synchronization of muscles may diminish the deviated movement augmenting neuromotor control. The purpose of this investigation was to develop a synergy-based motor therapy (SBMT) protocol for the paretic upper limb in poststroke subjects. Further, the feasibility and effectiveness of the program was evaluated. .

Methods  The design was Pretest–posttest single-group assessor-blinded trial. Department of occupational therapy of a national institute for persons with physical disabilities was the study site. There were 40 study subjects (23 men, ranging from 40 to 60 years, 18 subjects with hemorrhagic cerebrovascular accident, and > 6 months after the accident) exhibiting motor paresis of half side of the body. SBMT is a stage-specific regime based on the linkage between the deviated and usual muscle action. SBMT items were selected considering the strength and magnitude of the deviated motor components. The movement linkages were utilized to dissociate strong coupled components; for instance, forearm pronation-supination with elbow 90-degree flexion. Fugl-Meyer Assessment (upper extremity) (FMA-UE), Wolf Motor Function Test (WMFT), and Barthel Index (BI) were applied to quantify the motor status, motor functional ability of the upper extremity, and self-care activities, respectively.

Results  All the enrolled subjects could perform their corresponding SBMT sessions. Posttreatment, FMA-UE improved significantly ( p  < 0.001) from mean of 26.30 (standard deviation [SD] 15.02) to 35.20 (SD 17.64). Similarly, the WMFT both time (in seconds) and quality also positively improved significantly ( p  < .001) from mean of 76.77 (SD 54.73) to 64.07 (SD 56.99) and 1.34 (SD 1.06) to 1.87 (SD 1.34), respectively. BI improved from 79.88 (SD 17.07) to 92.62 (SD 21.2) after the intervention ( p  < 0.001).

Conclusion  SBMT protocol was a feasible and effective intervention to facilitate motor function components in chronic hemiparetic subjects. The regime could be considered as a potential intervention for stroke rehabilitation. Further trials and use of sophisticated measures are recommended to authenticate the outcome of this investigation.

Clinical Trial Registration  Clinical Trial Registry of India as CTRI/2017/10/010162 on October 23, 2017 (retrospectively).

AI-enabled photonic smart garment for movement analysis

Smart textiles are novel solutions for remote healthcare monitoring which involve non-invasive sensors-integrated clothing. Polymer optical fiber (POF) sensors have attractive features for smart textile technology, and combined with Artificial Intelligence (AI) algorithms increase the potential of intelligent decision-making. This paper presents the development of a fully portable photonic smart garment with 30 multiplexed POF sensors combined with AI algorithms to evaluate the system ability on the activity classification of multiple subjects. Six daily activities are evaluated: standing, sitting, squatting, up-and-down arms, walking and running. A k-nearest neighbors classifier is employed and results from 10 trials of all volunteers presented an accuracy of 94.00 (0.14)%. To achieve an optimal amount of sensors, the principal component analysis is used for one volunteer and results showed an accuracy of 98.14 (0.31)% using 10 sensors, 1.82% lower than using 30 sensors. Cadence and breathing rate were estimated and compared to the data from an inertial measurement unit located on the garment back and the highest error was 2.22%. Shoulder flexion/extension was also evaluated. The proposed approach presented feasibility for activity recognition and movement-related parameters extraction, leading to a system fully optimized, including the number of sensors and wireless communication, for Healthcare 4.0.

Assessment of the Impact of the Tipstim® Device Application and the Study Position on Motor Coordination and Grip Strength of the Affected Upper Limb Post-Ischemic Stroke—A Randomized Parallel Crossover Trial

In the acute phase of stroke, most patients have reduced efficiency of the upper limb and in the chronic phase more than half of these patients still have a deficit in the mobility of the upper limb. The aim of this study was to investigate the effect of using the tipstim® device and the tested position of the body and affected upper limb on parameters of motor coordination and grip strength in patients after an ischemic stroke. A randomized, parallel crossover study was conducted in the Rehabilitation Department. The study included 29 people aged 68 ± 9.2 years, 5–7 weeks after ischemic stroke. Patients were randomly assigned to two parallel groups (A/B = 15 people and B/A = 14 people). In each of them, the patient received both experimental (A = tipstim®) and control (B = placebo effect) treatment in a specific order. The HandTutor was used to measure the parameters of motor coordination (maximum range of motion and frequency of motion). We also used an electronic dynamometer to measure the handgrip strength. The patients were examined in two positions: sitting (unstable) and lying with the trunk and affected upper limb stabilized. Results: The analysis showed smaller differences between the measurements in the A/B group than in the B/A group, both without stabilization and with stabilization (wrist Hz = p ˂ 0.001; fingers 2–5 Hz = p ˂ 0.001; handgrip strength = p ˂ 0.049 and p ˂ 0.003). When comparing the influence of the tested position on the results of motor coordination and the handgrip strength, statistically significant differences were found in the placebo group in a stable position (Hz wrist p = 0.007, MaxROM wrist = 0.038, HzF5 = 0.039, MaxROM F4 = 0.035, HzF3 = 0.035, MaxROM F3 = 0.010, HzF2 = 0.049). Conclusions: Repeated use of the tipstim® device did not improve the tested parameters. A significant improvement in the results of coordination of movements and grip strength is possible in a stable position, lying down.

The Effect of Task-Oriented Training on Upper-Limb Function, Visual Perception, and Activities of Daily Living in Acute Stroke Patients: A Pilot Study

This pilot study aimed to investigate the effects of task-oriented training on upper-limb functioning, visual perception, and activities of daily living (ADL) in acute stroke patients. Of 20 participants, 10 were randomly assigned in a 1:1 ratio to experimental and control groups. Task-oriented training and table-top activity training were implemented for 6 weeks. Change in upper-limb functioning was assessed with the Manual Function Test (MFT); visual perceptual skill and ADL performance were evaluated using the Motor-Free Visual Perception Test—Vertical (MVPT-V) and Korean Modified Barthel Index (K-MBI), respectively. There was a significant interaction in the MFT and MBI score between the group and time (p < 0.05), but the group effect was not significant (p > 0.05). The MFT and MBI score significantly increased in both groups after the intervention (p < 0.001), but the effect size was greater in the task-oriented training group than the table-top activity training group. No significant interaction with MVPT-V score was found between the group and time (p > 0.05), and no statistical group difference was found either (p > 0.05). Both groups showed significant improvement in their MVPT-V score after the intervention (p < 0.001). The pilot study findings demonstrate that both task-oriented training and table-top activity training are effective in recovering upper-limb function, visual perception, and ADL in acute stroke patients.

The Effects of the Biceps Brachii and Brachioradialis on Elbow Flexor Muscle Strength and Spasticity in Stroke Patients

Objective

Muscle weakness and spasticity are common consequences of stroke, leading to a decrease in physical activity. The effective implementation of precision rehabilitation requires detailed rehabilitation evaluation. We aimed to analyze the surface electromyography (sEMG) signal features of elbow flexor muscle (biceps brachii and brachioradialis) spasticity in maximum voluntary isometric contraction (MVIC) and fast passive extension (FPE) in stroke patients and to explore the main muscle groups that affect the active movement and spasticity of the elbow flexor muscles to provide an objective reference for optimizing stroke rehabilitation.

Methods

Fifteen patients with elbow flexor spasticity after stroke were enrolled in this study. sEMG signals of the paretic and nonparetic elbow flexor muscles (biceps and brachioradialis) were detected during MVIC and FPE, and root mean square (RMS) values were calculated. The RMS values (mean and peak) of the biceps and brachioradialis were compared between the paretic and nonparetic sides. Additionally, the correlation between the manual muscle test (MMT) score and the RMS values (mean and peak) of the paretic elbow flexors during MVIC was analyzed, and the correlation between the modified Ashworth scale (MAS) score and the RMS values (mean and peak) of the paretic elbow flexors during FPE was analyzed.

Results

During MVIC exercise, the RMS values (mean and peak) of the biceps and brachioradialis on the paretic side were significantly lower than those on the nonparetic side (p < 0.01), and the RMS values (mean and peak) of the bilateral biceps were significantly higher than those of the brachioradialis (p < 0.01). The MMT score was positively correlated with the mean and peak RMS values of the paretic biceps and brachioradialis (r = 0.89, r = 0.91, r = 0.82, r = 0.85; p < 0.001). During FPE exercise, the RMS values (mean and peak) of the biceps and brachioradialis on the paretic side were significantly higher than those on the nonparetic side (p < 0.01), and the RMS values (mean and peak) of the brachioradialis on the paretic side were significantly higher than those of the biceps (p < 0.01). TheMAS score was positively correlated with the mean RMS of the paretic biceps and brachioradialis (r = 0.62, p = 0.021; r = 0.74, p = 0.004), and the MAS score was positively correlated with the peak RMS of the paretic brachioradialis (r = 0.59, p = 0.029) but had no significant correlation with the peak RMS of the paretic biceps (r = 0.49, p > 0.05).

Conclusions

The results confirm that the biceps is a vital muscle in active elbow flexion and that the brachioradialis plays an important role in elbow flexor spasticity, suggesting that the biceps should be the focus of muscle strength training of the elbow flexors and that the role of the brachioradialis should not be ignored in the treatment of elbow flexor spasticity. This study also confirmed the application value of sEMG in the objective assessment of individual muscle strength and spasticity in stroke patients.

Robot-Assisted Therapy Combined with Trunk Restraint in Acute Stroke Patients: A Randomized Controlled Study

BACKGROUND

Reducing the compensatory mechanism by restraining unnecessary trunk movements may help enhance the effectiveness of robot-assisted therapy.

OBJECTIVE

This study aimed to investigate the effects of robot-assisted therapy in combination with trunk restraint on upper extremity function and on daily activities in patients with acute stroke (≤ 30days of onset).

METHODS

Thirty-six acute stroke patients were randomly assigned to an experimental (n=18) or control (n=18) group. The experimental group performed robot-assisted therapy combined with trunk restraint, while the control group performed only robot-assisted therapy. Both groups were treated for 30 min, 5 days a week, for a total of 3 weeks. The outcome measures included the Fugl-Meyer assessment upper extremity, wolf motor function test, motor activity log, upper extremity muscle strength, and modified Barthel index.

RESULTS

After the intervention, both groups showed significant improvements in Fugl-Meyer assessment upper extremity, wolf motor function test, motor activity log, elbow extensor muscle strength, and modified Barthel index (p < 0.05). Post-intervention, the experimental group exhibited greater changes in the Fugl-Meyer assessment upper extremity, motor activity log, and elbow extensor muscle strength (p < 0.05).

CONCLUSION

Our study suggests that robot-assisted therapy in combination with trunk restraint is more effective for improving upper extremity function than only robot-assisted therapy in acute stroke patients.

A Wearable System Composed of FBG-Based Soft Sensors for Trunk Compensatory Movements Detection in Post-Stroke Hemiplegic Patients

In this study, a novel wearable system for the identification of compensatory trunk movements (CTMs) in post-stroke hemiplegic patients is presented. The device is composed of seven soft sensing elements (SSEs) based on fiber Bragg grating (FBG) technology. Each SSE consists of a single FBG encapsulated into a flexible matrix to enhance the sensor’s robustness and improve its compliance with the human body. The FBG’s small size, light weight, multiplexing capability, and biocompatibility make the proposed wearable system suitable for multi-point measurements without any movement restriction. Firstly, its manufacturing process is presented, together with the SSEs’ mechanical characterization to strain. Results of the metrological characterization showed a linear response of each SSE in the operating range. Then, the feasibility assessment of the proposed system is described. In particular, the device’s capability of detecting CTMs was assessed on 10 healthy volunteers and eight hemiplegic patients while performing three tasks which are representative of typical everyday life actions. The wearable system showed good potential in detecting CTMs. This promising result may foster the use of the proposed device on post-stroke patients, aiming at assessing the proper course of the rehabilitation process both in clinical and domestic settings. Moreover, its use may aid in defining tailored strategies to improve post-stoke patients’ motor recovery and quality of life.

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.

Feasibility of deploying peer coaches to mentor frontline home health aides and promote mobility among individuals recovering from a stroke: pilot test of a randomized controlled trial

BACKGROUND

Each year, approximately 100,000 individuals receive home health services after a stroke. Evidence has shown the benefits of home-based stroke rehabilitation, but little is known about resource-efficient ways to enhance its effectiveness, nor has anyone explored the value of leveraging low-cost home health aides (HHAs) to reinforce repetitive task training, a key component of home-based rehabilitation. We developed and piloted a Stroke Homehealth Aide Recovery Program (SHARP) that deployed specially trained HHAs as "peer coaches" to mentor frontline aides and help individuals recovering from stroke increase their mobility through greater adherence to repetitive exercise regimens. We assessed the feasibility of SHARP and its readiness for a full-scale randomized controlled trial (RCT). Specifically, we examined (1) the practicability of recruitment and randomization procedures, (2) program acceptability, (3) intervention fidelity, and (4) the performance of outcome measures.

METHODS

This was a feasibility study including a pilot RCT. Target enrollment was 60 individuals receiving post-stroke home health services, who were randomized to SHARP + usual home care or usual care only. The protocol specified a 30-day intervention with four planned in-home coach visits, including one joint coach/physical therapist visit. The primary participant outcome was 60-day change in mobility, using the performance-based Timed Up and Go and 4-Meter Walk Gait Speed tests. Interviews with participants, coaches, physical therapists, and frontline aides provided acceptability data. Enrollment figures, visit tracking reports, and audio recordings provided intervention fidelity data. Mixed methods included thematic analysis of qualitative data and quantitative analysis of structured data to examine the intervention feasibility and performance of outcome measures.

RESULTS

Achieving the 60-participant enrollment target required modifying participant eligibility criteria to accommodate a decline in the receipt of HHA services among individuals receiving home care after a stroke. This modification entailed intervention redesign. Acceptability was high among coaches and participants but lower among therapists and frontline aides. Intervention fidelity was mixed: 87% of intervention participants received all four planned coach visits; however, no joint coach/therapist visits occurred. Sixty-day follow-up retention was 78%. However, baseline and follow-up performance-based primary outcome mobility assessments could be completed for only 55% of participants.

CONCLUSIONS

The trial was not feasible in its current form. Before progressing to a definitive trial, significant program redesign would be required to address issues affecting enrollment, coach/HHA/therapist coordination, and implementation of performance-based outcome measures.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04840407 . Retrospectively registered on 9 April 2021.

Motor Coordination and Grip Strength of the Dominant and Non-Dominant Affected Upper Limb Depending on the Body Position—An Observational Study of Patients after Ischemic Stroke

Stroke is one of the leading causes of human disability globally. Motor function deficits resulting from a stroke affect the entire body, but relatively often it is the upper limbs that remain ineffective, which is very limiting in everyday life activities. The finding in neurorehabilitation that trunk control contributes to upper limb function is relatively common but has not been confirmed in clinical trials. This observational prospective study aims to analyze the effect of the position of the trunk and the affected upper limb on the coordination and grip strength of the affected dominant and non-dominant hand and wrist in people after ischemic stroke. The research was carried out at the Department of Neurological Rehabilitation, on a group of 60 patients with acute ischemic stroke. A Hand Tutor device and a hand dynamometer were used for the main measurements of the motor coordination parameters (maximum range of motion, frequency of movement) and the grip strength of the dominant and non-dominant upper limb. The patients were examined in two positions: sitting without back support and lying on the back with stabilization of the upper limb. Higher and relevant results were observed in the non-dominant hand, in the supine position in terms of motor coordination parameters of the fingers (p = 0.019; p = 0.011) and wrist (p = 0.033), and grip strength (p = 0.017). Conclusions: The laying position and stabilization of the affected upper limb in the acute phase following ischemic stroke is more beneficial for the coordination of movements and grip strength of the non-dominant hand.

Robotic Device for Out-of-Clinic Post-Stroke Hand Rehabilitation

Due to the ageing population and an increasing number of stroke patients, we see the potential future of rehabilitation in telerehabilitation, which might alleviate the workload of physiotherapists and occupational therapists. In order to enable the use of telerehabilitation, devices aimed for home and independent use need to be developed. This paper describes the design of a robotic device for post-stroke wrist and finger rehabilitation and evaluates the movement it can perform. Six healthy subjects were tested in three experimental conditions: performing a coupled movement of wrist and fingers from flexion to extension without the device, with a passive device, and with an active device. The kinematics of the hand were captured using three Optotrak Certus motion capture systems and tracking 11 infrared active light-emitting diode (LED) markers. The results are presented in the form of base-line trajectories for all middle finger (MF) joints. In addition, the deviations of trajectories between conditions across all subjects were computed for the metacarpophalangeal (MCP) joint and fingertip of the MF and pinkie (PF) finger. Deviations from the base-line trajectory between measurement protocols and the root-mean-square deviation (RMSD) values indicate that the motion of the hand, imposed by the developed device, is comparable to the unconstrained motion of the healthy subjects, especially when moving into the extension, opening the hand.

Rhythm and Music-Based Interventions in Motor Rehabilitation: Current Evidence and Future Perspectives

Research in basic and clinical neuroscience of music conducted over the past decades has begun to uncover music’s high potential as a tool for rehabilitation. Advances in our understanding of how music engages parallel brain networks underpinning sensory and motor processes, arousal, reward, and affective regulation, have laid a sound neuroscientific foundation for the development of theory-driven music interventions that have been systematically tested in clinical settings. Of particular significance in the context of motor rehabilitation is the notion that musical rhythms can entrain movement patterns in patients with movement-related disorders, serving as a continuous time reference that can help regulate movement timing and pace. To date, a significant number of clinical and experimental studies have tested the application of rhythm- and music-based interventions to improve motor functions following central nervous injury and/or degeneration. The goal of this review is to appraise the current state of knowledge on the effectiveness of music and rhythm to modulate movement spatiotemporal patterns and restore motor function. By organizing and providing a critical appraisal of a large body of research, we hope to provide a revised framework for future research on the effectiveness of rhythm- and music-based interventions to restore and (re)train motor function.

Post-Stroke Treatment with Neuromuscular Functional Electrostimulation of Antagonistic Muscles and Kinesiotherapy Evaluated with Electromyography and Clinical Studies in a Two-Month Follow-Up

The aim of this study was to determine the sustained influence of personalized neuromuscular functional electrical stimulation (NMFES) combined with kinesiotherapy (mainly, proprioceptive neuromuscular facilitation (PNF)) on the activity of muscle motor units acting antagonistically at the wrist and the ankle in a large population of post-stroke patients. Clinical evaluations of spasticity (Ashworth scale), manual muscle testing (Lovett scale), and surface electromyography recordings at rest (rEMG) and during attempts of maximal muscle contraction (mcEMG) were performed three times in 120 post-stroke patients (T0: up to 7 days after the incidence; T1: after 21 days of treatment; T2: after 60 days of treatment). Patients (N = 120) were divided into two subgroups-60 patients received personalized NMFES and PNF treatment (NMFES+K), and the other 60 received only PNF (K). The NMFES+K therapy resulted in a decrease in spasticity and an increase in muscle strength of mainly flexor muscles, in comparison with the K group. A positive correlation between the increase of rEMG amplitudes and high Ashworth scale scores and a positive correlation between low amplitudes of mcEMG and low Lovett scale scores were found in the wrist flexors and calf muscles on the paretic side. Negative correlations were found between the rEMG and mcEMG amplitudes in the recordings. The five-grade alternate activity score of the antagonists' actions improved in the NMFES+K group. These improvements in the results of controlled NMFES treatment combined with PNF in patients having experienced an ischemic stroke, in comparison to the use of kinesiotherapy alone, might justify the application of conjoined rehabilitation procedures based on neurophysiological approaches. Considering the results of clinical and neurophysiological studies, we suppose that NMFES of the antagonistic muscle groups acting at the wrist and the ankle may evoke its positive effects in post-stroke patients by the modulation of the activity more in the spinal motor centers, including the level of Ia inhibitory neurons, than only at the muscular level.

Therapeutic Effects of a Newly Developed 3D Magnetic Finger Rehabilitation Device in Subacute Stroke Patients: A Pilot Study

We developed a magnetic-force-based three-dimensional (3D) rehabilitation device that can perform motor rehabilitation treatment for paralyzed fingers, regardless of upper extremity movement and position, and investigated the therapeutic effects of the device. An end-effector type rehabilitation device that can generate magnetic fields in three directions was developed using electromagnets and permanent magnetics. A double-blinded randomized controlled pilot study was conducted with a total of 12 patients. The intervention group had rehabilitation treatment using the developed magnetic finger rehabilitation device for 30 min a day for four weeks. The control group underwent exercise rehabilitation treatment. The control group received conventional occupational therapy on the upper limbs, including hands, from an occupational therapist, for the same amount of time. Adverse effects were monitored, and the patient’s sensory or proprioceptive deficits were examined before the intervention. No participants reported safety concerns while the intervention was conducted. The Wolf Motor Function Test (WMFT) scores were significantly improved in the intervention group (from 13.4 ± 3.6 to 20.9 ± 4.0 points) compared to the control group (from 13.1 ± 4.0 to 15.2 ± 3.8 points) (p = 0.016). The patients in the intervention group (from 88 ± 12 to 67 ± 13 s) showed greater improvement of WMFT times compared to the control group (from 89 ± 10 to 73 ± 11 s) (p = 0.042). The Manual Function Test and the upper limb score of the Fugl-Meyer Assessment were significantly improved in the intervention group compared with the control group (p = 0.038 and p = 0.042). The patients in the intervention group also showed significantly greater enhancement of the Korean version of the modified Barthel Index than the control group (p = 0.042). Rehabilitation treatment using the 3D magnetic-force-driven finger rehabilitation device helped improve finger motor function and activities of daily living in subacute stroke patients.

Early Wearing of Knee-Ankle-Foot Orthosis Improves Functional Prognosis in Patients after Stroke

OBJECTIVES

Knee-ankle-foot orthosis (KAFO) is sometimes used for gait training in stroke patients. The impact of the time of wearing KAFO on activities of daily living (ADL) recovery has not been clarified. This study aimed to examine the relationship between the days from onset to KAFO wearing and functional prognosis in patients after stroke.

MATERIALS AND METHODS

This retrospective, observational study was conducted with stroke patients who were prescribed a KAFO. Patients were divided into early and delayed groups according to the median days from onset to KAFO wearing. Baseline characteristics were evaluated at the initiation of KAFO wearing. The primary outcome was the Functional Independence Measure (FIM) gain, which was scored by the nurse at baseline and discharge.

RESULTS

112 participants (mean age 67.9 ± 14.0 years, 51.8% male) were included. The time period measure from day of onset to KAFO wearing for the early group was significantly shorter than the delayed group (35.8 ± 6.6 days vs. 73.5 ± 28.9 days). The early group had a higher FIM at discharge (84.9 ± 28.0% vs. 65.1 ± 29.0%, P < 0.001) and higher FIM gain (36.9 ± 19.8% vs. 26.8 ± 22.3, P = 0.013) than did the delayed group. Multiple regression analysis showed that the early group was associated with FIM gain (coefficient = 8.607, P = 0.032).

CONCLUSIONS

Early wearing of KAFO, irrespective of the difference in ADL at the time of KAFO wearing, may have a positive impact on the improvement of ADL in patients after stroke.

"Mine Works Better": Examining the Influence of Embodiment in Virtual Reality on the Sense of Agency During a Binary Motor Imagery Task With a Brain-Computer Interface

Motor imagery-based brain-computer interfaces (MI-BCI) have been proposed as a means for stroke rehabilitation, which combined with virtual reality allows for introducing game-based interactions into rehabilitation. However, the control of the MI-BCI may be difficult to obtain and users may face poor performance which frustrates them and potentially affects their motivation to use the technology. Decreases in motivation could be reduced by increasing the users' sense of agency over the system. The aim of this study was to understand whether embodiment (ownership) of a hand depicted in virtual reality can enhance the sense of agency to reduce frustration in an MI-BCI task. Twenty-two healthy participants participated in a within-subject study where their sense of agency was compared in two different embodiment experiences: 1) avatar hand (with body), or 2) abstract blocks. Both representations closed with a similar motion for spatial congruency and popped a balloon as a result. The hand/blocks were controlled through an online MI-BCI. Each condition consisted of 30 trials of MI-activation of the avatar hand/blocks. After each condition a questionnaire probed the participants' sense of agency, ownership, and frustration. Afterwards, a semi-structured interview was performed where the participants elaborated on their ratings. Both conditions supported similar levels of MI-BCI performance. A significant correlation between ownership and agency was observed (r = 0.47, p = 0.001). As intended, the avatar hand yielded much higher ownership than the blocks. When controlling for performance, ownership increased sense of agency. In conclusion, designers of BCI-based rehabilitation applications can draw on anthropomorphic avatars for the visual mapping of the trained limb to improve ownership. While not While not reducing frustration ownership can improve perceived agency given sufficient BCI performance. In future studies the findings should be validated in stroke patients since they may perceive agency and ownership differently than able-bodied users.

Safety, Feasibility, and Acceptability of a New Virtual Rehabilitation Platform: A Supervised Pilot Study

Purpose:

Stroke is the leading cause of disability in adults worldwide, with hemiparesis being the most prevalent consequence. The use of video games and movement sensors could contribute to improving patients’ chances of recovery. We performed a supervised pilot study to validate the safety, feasibility, and acceptability of a new virtual rehabilitation platform in patients with chronic post-stroke upper limb hemiparesis.

Methods:

The participants (n = 9) participated in 40 rehabilitation sessions, twice a week, for a period of 20 weeks. Their experiences with the platform were documented using a Likert-scale survey. Changes in motor function were evaluated using the Chedoke Arm and Hand Activity Inventory (CAHAI) and the Wolf Motor Function Test (WMFT).

Results and conclusions:

All participants expressed that they enjoyed the experience and felt comfortable using the platform. Preliminary results showed significant motor recovery (P = .0039) according to the WMFT scores. Patients with significant impairment showed no improvement in upper limb task-oriented motor function after therapy.

The new platform is safe and well-accepted by patients. The improvement in motor function observed in some of the participants should be attributed to the therapy since spontaneous functional recovery is not expected in chronic stroke patients.

A Co-creation Centre for Accessible Rehabilitation Technology

Background: The prevalence of disabling conditions is increasing globally. Rehabilitation improves function and quality of life across many conditions, particularly when applied intensively. The limited workforce, however, cannot deliver evidence-based intensive rehabilitation. By providing individuals with the tools for self- rehabilitation, technology helps bridge the gap between evidence and practise. Few people, however, can access rehabilitation technology. Barriers such as cost, training, education, portability and poor design stand in the way of equitable access. Our group of engineers and researchers have established a centre dedicated to developing accessible technology through close, frequent engagement with users and industry.

Methods: The centre employs a co-creation model, coupling engineering and science with user experience and industrial partnerships to develop accessible technology and associated processes. Due to the complexity and size of the challenge the initial focus is stroke. Recruited through a medical charity, participants, with a wide range of disabilities, use prototype and commercial technology during an 8-week rehabilitation programme with supervision from health professionals. The centre includes de-weighting systems, neurostimulation, virtual reality, treadmills, bespoke rehab games, communication apps, powered exercise equipment and gamified resistance equipment. Standard outcome measures (International Classification of Functioning, Disability and Health) are recorded before, during, immediately after, and 3 months after the intervention and used in combination with an interview to design the initial rehabilitation programme, which is reviewed fortnightly. Qualitative methods (surveys and interviews) are used to capture personal experiences of the programme and individual technology and an advisory group of stroke survivors help interpret outcomes to feed into the technology design process. Ethical approval has been granted for a pilot cohort study with stroke survivors, which is currently underway (01/09/2021–31/12/2021) investigating acceptability and feasibility, due to report findings in 2022.

Discussion: Through partnerships, research collaborations and a co-creation model a new centre dedicated to the development of accessible rehabilitation technology has been launched and currently undergoing acceptability and feasibility testing with stroke survivors. The centre, through its close engagement with users and industry, has the potential to transform the way rehabilitation technology is developed and help revolutionise the way rehabilitation is delivered.

Therapeutic Instrumental Music Training and Motor Imagery in Post-Stroke Upper-Extremity Rehabilitation: A Randomized-Controlled Pilot Study

Objective

To investigate the potential benefits of 3 therapeutic instrumental music performance (TIMP)-based interventions in rehabilitation of the affected upper-extremity (UE) for adults with chronic poststroke hemiparesis.

Design

Randomized-controlled pilot study.

Setting

University research facility.

Participants

Community-dwelling volunteers (N=30; 16 men, 14 women; age range, 33-76 years; mean age, 55.9 years) began and completed the protocol. All participants had sustained a unilateral stroke more than 6 months before enrollment (mean time poststroke, 66.9 months).

Intervention

Two baseline assessments, a minimum of 1 week apart; 9 intervention sessions (3 times/week for 3 weeks), in which rhythmically cued, functional arm movements were mapped onto musical instruments; and 1 post-test following the final intervention. Participants were block-randomized to 1 of 3 conditions: group 1 (45 minutes TIMP), group 2 (30 minutes TIMP, 15 minutes metronome-cued motor imagery [TIMP+cMI]), and group 3 (30 minutes TIMP, 15 minutes motor imagery without cues [TIMP+MI]). Assessors and investigators were blinded to group assignment.

Main Outcome Measures

Fugl-Meyer Upper-Extremity (FM-UE) and Wolf Motor Function Test- Functional Ability Scale (WMFT-FAS). Secondary measures were motor activity log (MAL)–amount of use scale and trunk impairment scale.

Results

All groups made statistically significant gains on the FM-UE (TIMP, P=.005, r=.63; TIMP+cMI, P=.007, r=.63; TIMP+MI, P=.007, r=.61) and the WMFT-FAS (TIMP, P=.024, r=.53; TIMP+cMI, P=.008, r=.60; TIMP+MI, P=.008, r=.63). Comparing between-group percent change differences, on the FM-UE, TIMP scored significantly higher than TIMP+cMI (P=.032, r=.57), but not TIMP+MI. There were no differences in improvement on WMFT-FAS across conditions. On the MAL, gains were significant for TIMP (P=.030, r=.54) and TIMP+MI (P=.007, r=.63).

Conclusion

TIMP-based techniques, with and without MI, led to significant improvements in paretic arm control on primary outcomes. Replacing a physical training segment with imagery-based training resulted in similar improvements; however, synchronizing internal and external cues during auditory-cMI may pose additional sensorimotor integration challenges.

Motor Imagery and Frontal Head Oxygenation: An fNIRS Study

Motor imagery (MI) is a manifestation of mental movements, but it cannot be identified visually. Therefore, to a large extent, MI assessment has not yet been established. The present study aimed to investigate whether frontal oxy-Hb changes and cardiac autonomic nervous system activity during MI are associated with the psychometric scale assessment of MI and clarify the utility of each index in MI assessment. Thirty-one healthy men and women were included in this study, and Pocket NIRS Duo was used to assess frontal oxygenated hemoglobin levels during walking MI. Simultaneously, heart rate and sympathetic index (low and high frequency (LF/HF) during MI were evaluated using Chiryou Meijin, a heart rate frequency analyser. In addition, a psychometric scale evaluation was carried out in MC and VAS, and its correlation with oxy-Hb levels, heart rate (HR), and LF/HF was investigated. HRs and LF/HF during MI were significantly increased compared with those at rest. However, oxy-Hb levels during MI were not increased. There was a significant correlation between right oxy-Hb levels and mental chronometry (MC) during MI (r = -0.3, p < 0.05). HR and LF/HF were not correlated with MC. VAS was not correlated with oxy-Hb levels, HR, or LF/HF. The results of this study confirm an association between MI performance and frontal oxy-Hb changes and that brain activity is not necessarily elevated during MI. HR were significantly increased but did not show any association with MC.

Reconstruction of paralyzed arm function in patients with hemiplegia through contralateral seventh cervical nerve cross transfer: a multicenter study and real-world practice guidance

BACKGROUND

A previous randomized controlled trial showed contralateral seventh cervical nerve (CC7) cross transfer to be safe and effective in restoring the arm function of spastic arm paralysis patients in a specified population. Guidance on indications, safety and expected long-term improvements of the surgery are needed for clinical practice.

METHODS

This is a retrospective, multicenter, propensity score-matched cohort study. All patients registered between 2013 and 2019 with unilateral spastic arm paralysis over 1 year who were registered at one of five centers in China and South Korea were included. Patients received CC7 cross transfer or rehabilitation treatment in each center. Primary outcome was the change in the upper-extremity Fugl-Meyer (UEFM) score from baseline to 2-year follow-up; larger increase indicated better functional improvements.

FINDINGS

The analysis included 425 eligible patients. After propensity score matching, 336 patients who were 1:1 matched into surgery and rehabilitation groups. Compared to previous trial, patient population was expanded on age (< 12 and > 45 years old), duration of disease (< 5 years) and severity of paralysis (severe disabled patients with UEFM < 20 points). In matched patients, the overall increases of UEFM score from preoperative evaluation to 2-year follow-up were 15.14 in the surgery group and 2.35 in the rehabilitation group (difference, 12.79; 95% CI: 12.02-13.56, p < 0.001). This increase was 16.58 at 3-year and 18.42 at 5-year follow-up compared with the surgery group baseline. Subgroup analysis revealed substantial increase on UEFM score in each subgroup of age, duration of disease, severity of paralysis and cause of injury. No severe complication or disabling sequela were reported in the surgery group.

INTERPRETATION

This study showed that CC7 cross transfer can provide effective, safe and stable functional improvements in long-term follow-up, and provided evidences for expanding the indications of the surgery to a wider population of patients with hemiplegia.

Long-term recovery of upper limb motor function and self-reported health: results from a multicenter observational study 1 year after discharge from rehabilitation

Background

Impaired motor functions after stroke are common and negatively affect patients' activities of daily living and quality of life. In particular, hand motor function is essential for daily activities, but often returns slowly and incompletely after stroke. However, few data are available on the long-term dynamics of motor recovery and self-reported health status after stroke. The Interdisciplinary Platform for Rehabilitation Research and Innovative Care of Stroke Patients (IMPROVE) project aims to address this knowledge gap by studying the clinical course of recovery after inpatient rehabilitation.

Methods

In this prospective observational longitudinal multicenter study, patients were included towards the end of inpatient rehabilitation after ischemic or hemorrhagic stroke. Follow-up examination was performed at three, six, and twelve months after enrollment. Motor function was assessed by the Upper Extremity Fugl-Meyer Assessment (FMA), grip and pinch strength, and the nine-hole peg test. In addition, Patient-Reported Outcomes Measurement Information System 10-Question Short Form (PROMIS-10) was included. Linear mixed effect models were fitted to analyze change over time. To study determinants of hand motor function, patients with impaired hand function at baseline were grouped into improvers and non-improvers according to hand motor function after twelve months.

Results

A total of 176 patients were included in the analysis. Improvement in all motor function scores and PROMIS-10 was shown up to 1 year after inpatient rehabilitation. FMA scores improved by an estimate of 5.0 (3.7–6.4) points per year. In addition, patient-reported outcome measures increased by 2.5 (1.4–3.6) and 2.4 (1.4–3.4) per year in the physical and mental domain of PROMIS-10. In the subgroup analysis non-improvers showed to be more often female (15% vs. 55%, p = 0.0155) and scored lower in the Montreal Cognitive Assessment (25 [23–27] vs. 22 [20.5–24], p = 0.0252).

Conclusions

Continuous improvement in motor function and self-reported health status is observed up to 1 year after inpatient stroke rehabilitation. Demographic and clinical parameters associated with these improvements need further investigation. These results may contribute to the further development of the post-inpatient phase of stroke rehabilitation.

Trial registration: The trial is registered at ClinicalTrials.gov (NCT04119479).

Review on Patient-Cooperative Control Strategies for Upper-Limb Rehabilitation Exoskeletons

Technology-supported rehabilitation therapy for neurological patients has gained increasing interest since the last decades. The literature agrees that the goal of robots should be to induce motor plasticity in subjects undergoing rehabilitation treatment by providing the patients with repetitive, intensive, and task-oriented treatment. As a key element, robot controllers should adapt to patients’ status and recovery stage. Thus, the design of effective training modalities and their hardware implementation play a crucial role in robot-assisted rehabilitation and strongly influence the treatment outcome. The objective of this paper is to provide a multi-disciplinary vision of patient-cooperative control strategies for upper-limb rehabilitation exoskeletons to help researchers bridge the gap between human motor control aspects, desired rehabilitation training modalities, and their hardware implementations. To this aim, we propose a three-level classification based on 1) “high-level” training modalities, 2) “low-level” control strategies, and 3) “hardware-level” implementation. Then, we provide examples of literature upper-limb exoskeletons to show how the three levels of implementation have been combined to obtain a given high-level behavior, which is specifically designed to promote motor relearning during the rehabilitation treatment. Finally, we emphasize the need for the development of compliant control strategies, based on the collaboration between the exoskeleton and the wearer, we report the key findings to promote the desired physical human-robot interaction for neurorehabilitation, and we provide insights and suggestions for future works.

A Real-Time Wearable Physiological Monitoring System for Home-Based Healthcare Applications

The acquisition of physiological data are essential to efficiently predict and treat cardiac patients before a heart attack occurs and effectively expedite motor recovery after a stroke. This goal can be achieved by using wearable wireless sensor network platforms for real-time healthcare monitoring. In this paper, we present a wireless physiological signal acquisition device and a smartphone-based software platform for real-time data processing and monitor and cloud server access for everyday ECG/EMG signal monitoring. The device is implemented in a compact size (diameter: 30 mm, thickness: 4.5 mm) where the biopotential is measured and wirelessly transmitted to a smartphone or a laptop for real-time monitoring, data recording and analysis. Adaptive digital filtering is applied to eliminate any interference noise that can occur during a regular at-home environment, while minimizing the data process time. The accuracy of ECG and EMG signal coverage is assessed using Bland–Altman analysis by comparing with a reference physiological signal acquisition instrument (RHS2116 Stim/Recording System, Intan). Signal coverage of R-R peak intervals showed almost identical outcome between this proposed work and the RHS2116, showing a mean difference in heart rate of 0.15 ± 4.65 bpm and a Wilcoxon’s p value of 0.133. A 24 h continuous recording session of ECG and EMG is conducted to demonstrate the robustness and stability of the device based on extended time wearability on a daily routine.

Electromechanical and Robotic Devices for Gait and Balance Rehabilitation of Children with Neurological Disability: A Systematic Review

In the last two decades, a growing interest has been focused on gait and balance robot-assisted rehabilitation in children with neurological disabilities. Robotic devices allow the implementation of intensive, task-specific training fostering functional recovery and neuroplasticity phenomena. However, limited attention has been paid to the protocols used in this research framework. This systematic review aims to provide an overview of the existing literature on robotic systems for the rehabilitation of gait and balance in children with neurological disabilities and their rehabilitation applications. The literature search was carried out independently and synchronously by three authors on the following databases: MEDLINE, Cochrane Library, PeDro, Institute of Electrical and Electronics Engineers, ScienceDirect, and Google Scholar. The data collected included three subsections referring to clinical, technical, and regulatory aspects. Thirty-one articles out of 81 found on the primary literature search were included in the systematic review. Most studies involved children with cerebral palsy. Only one-third of the studies were randomized controlled trials. Overall, 17 devices (nine end-effector systems and eight exoskeletons) were investigated, among which only 4 (24%) were bore the CE mark. Studies differ on rehabilitation protocols duration, intensity, and outcome measures. Future research should improve both rehabilitation protocols’ and devices’ descriptions.

Ipsilesional Motor Cortex Activation with High-force Unimanual Handgrip Contractions of the Less-affected Limb in Participants with Stroke

Stroke is a leading cause of severe disability that often presents with unilateral motor impairment. Conventional rehabilitation approaches focus on motor practice of the affected limb and aim to suppress brain activity in the contralesional hemisphere. Conversely, exercise of the less-affected limb promotes contralesional brain activity which is typically viewed as contraindicated in stroke recovery due to the interhemispheric inhibitory influence onto the ipsilesional hemisphere. Yet, high-force unimanual handgrip contractions are known to increase ipsilateral brain activation in control participants, and it remains to be determined if high-force contractions with the less-affected limb would promote ipsilateral brain activation in participants with stroke (i.e., the ipsilesional hemisphere). Therefore, this study aimed to determine how parametric increases in handgrip force during repeated contractions with the less-affected limb impacts brain activity bilaterally in participants with stroke and in a cohort of neurologically intact controls. Participants performed repeated submaximal contractions at 25%, 50%, and 75% of their maximum voluntary contraction during separate functional magnetic resonance imaging brain scans. Brain activation during the tasks was quantified as the present change from resting levels. In this study, higher force contractions were found to increase brain activation in the ipsilesional (stroke)/ipsilateral (controls) hemisphere in both groups (p = .002), but no between group differences were observed. These data suggest that high-force exercise with the less-affected limb may promote ipsilesional cortical plasticity to promote motor recovery of the affected-limb in participants with stroke.

Transcranial direct electrical stimulation for hand function in a stroke patient with severe upper limb paralysis due to lenticulostriate artery occlusion: a case report

BACKGROUND

Transcranial direct current stimulation, a therapeutic modality to modulate the excitability of injured and uninjured brain hemispheres in stroke patients, is expected to be effective in treating upper limb paralysis. We describe the use of transcranial direct current stimulation to improve the function and frequency of use of the paralyzed hand of a patient with lenticulostriate artery occlusion.

CASE PRESENTATION

A Japanese man in his fifties developed a left internal hindfoot perforator branch infarction owing to lenticulostriate artery occlusion, and presented with severe right upper and lower limb paralysis. Multiple interventions for the paralyzed hand, primarily robot therapy, did not noticeably change his hand function or frequency of use in daily life. Therefore, transcranial direct current stimulation was used in combination with upper limb functional exercises for 20 minutes a day, five times a week, for 6 weeks. Consequently, scores for the hand items of the Fugl-Meyer Assessment of the upper extremities improved, and pain and subluxation around the shoulder joint were reduced. Furthermore, the frequency of use and the quality of movement of the paralyzed hand were improved.

CONCLUSIONS

Upper limb functional training and transcranial direct current stimulation improved the function and frequency of use of the paralyzed hand in a stroke patient with severe upper limb paralysis, suggesting that this combined intervention could effectively improve hand function in patients with severe upper limb paralysis.

Post-stroke Rehabilitation of Severe Upper Limb Paresis in Germany - Toward Long-Term Treatment With Brain-Computer Interfaces

Severe upper limb paresis can represent an immense burden for stroke survivors. Given the rising prevalence of stroke, restoration of severe upper limb motor impairment remains a major challenge for rehabilitation medicine because effective treatment strategies are lacking. Commonly applied interventions in Germany, such as mirror therapy and impairment-oriented training, are limited in efficacy, demanding for new strategies to be found. By translating brain signals into control commands of external devices, brain-computer interfaces (BCIs) and brain-machine interfaces (BMIs) represent promising, neurotechnology-based alternatives for stroke patients with highly restricted arm and hand function. In this mini-review, we outline perspectives on how BCI-based therapy can be integrated into the different stages of neurorehabilitation in Germany to meet a long-term treatment approach: We found that it is most appropriate to start therapy with BCI-based neurofeedback immediately after early rehabilitation. BCI-driven functional electrical stimulation (FES) and BMI robotic therapy are well suited for subsequent post hospital curative treatment in the subacute stage. BCI-based hand exoskeleton training can be continued within outpatient occupational therapy to further improve hand function and address motivational issues in chronic stroke patients. Once the rehabilitation potential is exhausted, BCI technology can be used to drive assistive devices to compensate for impaired function. However, there are several challenges yet to overcome before such long-term treatment strategies can be implemented within broad clinical application: 1. developing reliable BCI systems with better usability; 2. conducting more research to improve BCI training paradigms and 3. establishing reliable methods to identify suitable patients.