Effect of a Task-Oriented Rehabilitation Program on Upper Extremity Recovery Following Motor Stroke: The ICARE Randomized Clinical Trial

Association Between Real-World Actigraphy and Poststroke Motor Recovery

BACKGROUND

Stroke is a leading cause of long-term disability, but advances for rehabilitation have lagged those for acute treatment. Large biological studies (eg, omics) may offer mechanistic insights for recovery but require collecting detailed recovery phenotypes at scale, for example, in thousands of people with minimal burden for participants and researchers. This study investigates the concurrent validity between remotely collected wearable sensor data and in-clinic assessments of motor recovery poststroke.

METHODS

Utilizing a large, harmonized multisite dataset of adults at various stages of recovery poststroke, we analyzed cross-sectional (N=198; from 0 to >52 weeks) and longitudinal (N=98; from 0 to 26 weeks) changes in the use ratio, the Action Research Arm Test, and the Fugl-Meyer Assessment upper extremity subscale. The use ratio is the ratio of the time the paretic arm is active divided by the time the nonparetic arm is active.

RESULTS

Our findings indicate strong concurrent validity of the use ratio, the Action Research Arm Test, and the Fugl-Meyer Assessment upper extremity subscale both cross-sectionally (differences between people) and longitudinally (changes within a person), for example, r=0.87 (95% CI, 0.80-0.91) at 0 to 6 weeks, declining to r=0.58 (95% CI, 0.39-0.72) at ≥52 weeks for correlations between use ratio and Action Research Arm Test.

CONCLUSIONS

Although the use ratio strongly correlated with the Fugl-Meyer Assessment upper extremity subscale and Action Research Arm Test early after stroke, these correlations reduced with longer elapsed time poststroke. This decreasing correlation might be explained by the increasing influence that personal and environmental factors play as recovery progresses.

A randomized controlled trial of timing and dosage of upper extremity rehabilitation in virtual environments in persons with subacute stroke

Many people with stroke experience incomplete recoveries, leaving them with upper extremity (UE) deficits affecting their long-term independence. Interventions including virtual reality (VR) and robotics have been developed to foster neuroplasticity post stroke. Few of the many studies examining these interventions consider the impact of both timing and dosage. The primary aim of this randomized controlled trial was to investigate (1) dosage and (2) timing of UE VR/robotic training in the subacute period post stroke. 100 participants were consented 5-30 days after stroke. They were randomized to an Early (first month) or Delayed (second month) VR/robotic group (EVR/DVR), a dose matched usual care group (DMUC) or a usual care group (UC). Participants were evaluated using impairment, motor function, and quality of life measures immediately before, after, and 1 month after training, and 4 and 6 months post stroke. At 4 months post stroke the DVR group showed a higher rate of change from baseline on the Action Research Arm Test compared to the EVR group. This difference was not sustained; none of the training groups demonstrated significantly better scores on any outcome measure 6 months post stroke. Growth mixture modeling revealed three groups with patterns of recovery associated with early finger movement. At 6 months post stroke, the EuroQol was moderately correlated with impairment and activity.

Neurotechnology-Based, Intensive, Supplementary Upper-Extremity Training for Inpatients With Subacute Stroke: Feasibility Study

Background

Upper-extremity hemiparesis is a common and debilitating impairment after stroke, severely restricting stroke survivors' ability to participate in daily activities and function independently. Alarmingly, only a small percentage of stroke patients fully recover upper extremity function. Animal models indicate that high-dose upper extremity training during the early poststroke phase can significantly enhance motor recovery. However, translating such programs for human patients remains challenging due to resource limitations, patient compliance issues, and administrative constraints.

Objective

This study aimed to assess the feasibility and potential efficacy of an intensive, video game-based upper-extremity training protocol designed to improve movement quality during inpatient stroke rehabilitation. Additionally, it evaluated the resources required for this intervention. Specifically, the protocol provides high-intensity, high-dose training to facilitate motor recovery by engaging patients in targeted interactive exercises.

Methods

Twelve patients with upper-extremity hemiparesis completed a 4-week intensive training program comprising 40 sessions of 60 minutes; the training was conducted for 2 hours per day, 5 days per week. This was delivered in addition to standard care, which included 3 therapeutic sessions daily. Two video game-based platforms were used: one platform (tech 1) targeted proximal movements involving the shoulder and elbow, while the second platform (tech 2) emphasized distal movements of the wrist and fingers. Feasibility was assessed using the measure of time on task and measures of patients' motivation and engagement. Potential effectiveness was assessed using the Fugl-Meyer Assessment of the upper extremity (FMA-UE) scale, Action Research Arm Test (ARAT), and Stroke Impact Scale (SIS).

Results

Of the 12 patients, 8 completed the full protocol, 3 completed 34-38 sessions, and 1 completed 27 sessions. On average, patients actively engaged in exercises for 35 (SD 4) minutes per hour on the proximal platform (tech 1) and 37 (SD 2) minutes on the distal platform (tech 2). Patients reported high motivation and enjoyment throughout the sessions, with an Intrinsic Motivation Inventory enjoyment score of 6.49 (SD 0.66) out of 7. Pain levels were minimal, with a visual analogue scale (VAS) mean score of 2.00 (SD 2.32). Significant improvements were observed in motor function assessments: the mean improvement in FMA-UE score was 16.5 (SD 10.2) points, ARAT scores increased by 22.9 (SD 13.1) points, and the SIS Hand Function and Recovery score showed a mean delta of 1.23 (SD 0.80) points and a 23.33% (SD 21.5%) improvement, respectively.

Conclusions

These findings demonstrate that a high-dose, high-intensity, video game-based training protocol is feasible and can be successfully integrated into subacute stroke rehabilitation. Additionally, preliminary evidence suggests that this supplementary intervention may be effective in enhancing motor recovery. This approach holds promise for future stroke rehabilitation protocols by offering an engaging, high-dose, and high-intensity program during early recovery.

Downward adjustment of rehabilitation goals may facilitate post-stroke arm motor recovery

Objective: Patients starting with physical rehabilitation often hold unrealistically high expectations for their recovery. Because of a lower-than-expected rate of recovery, such unrealistic goals have been linked to adverse effects on mental health. Additionally, overtraining due to overly ambitious goals can lead to suboptimal recovery. We investigated the effectiveness of adjusting rehabilitation goals to a more realistic level as a strategy to select appropriate exercise intensity and achieve better recovery outcomes. Design: Patients with arm paralysis from recent stroke were recruited and went through 6-8 weeks of telerehabilitation and in-clinic rehabilitation programme conducted at 11 US sites (N = 124). Main Outcome Measures: Adjustment of recovery goal was assessed in two timepoints during the rehabilitation programme and arm motor function was assessed before and after the clinical trial. Results: Greater use of goal adjustment strategies predicted better recovery of arm motor function, independent from therapy compliance. This pattern was observed only when the choice of exercises is patient-regulated rather than directed by a physical therapist. Conclusion: Benefits from goal adjustment were more pronounced among patients who entered the programme with poorer motor functions, suggesting that goal adjustment is the most beneficial when goals of complete recovery are most unrealistic.

Rehabilitation using virtual gaming for Hospital and hOMe-Based training for the Upper limb in acute and subacute Stroke (RHOMBUS II): results of a feasibility randomised controlled trial

OBJECTIVE

To investigate the safety, feasibility and acceptability of the Neurofenix platform for upper-limb rehabilitation in acute and subacute stroke.

DESIGN

A feasibility randomised controlled trial with a parallel process evaluation.

SETTING

Acute Stroke Unit and participants' homes (London, UK).

PARTICIPANTS

24 adults (>18 years), acute and subacute poststroke, new unilateral weakness, scoring 9-25 on the Motricity Index (elbow and shoulder), with sufficient cognitive and communicative abilities to participate.

INTERVENTIONS

Participants randomised to the intervention or control group on a 2:1 ratio. The intervention group (n=16) received usual care plus the Neurofenix platform for 7 weeks. The control group (n=8) received usual care only.

OUTCOMES

Safety was assessed through adverse events (AEs), pain, spasticity and fatigue. Feasibility was assessed through training and support requirements and intervention fidelity. Acceptability was assessed through a satisfaction questionnaire. Impairment, activity and participation outcomes were also collected at baseline and 7 weeks to assess their suitability for use in a definitive trial.

RANDOMISATION

Computer-generated, allocation sequence concealed by opaque, sealed envelopes.

BLINDING

Participants and assessors were not blinded; statistician blinded for data processing and analysis.

RESULTS

192 stroke survivors were screened for eligibility, and 24 were recruited and randomised. Intervention group: n=16, mean age 66.5 years; median 9.5 days post stroke.

CONTROL GROUP

n=8, mean age 64.6 years; median 17.5 days post stroke. Three participants withdrew before the 7-week assessment, n=21 included in the analysis (intervention group n=15; control group n=6). No significant group differences in fatigue, spasticity, pain scores or total number of AEs. The median (IQR) time to train participants was 98 (64) min over 1-3 sessions. Participants trained with the platform for a median (range) of 11 (1-58) hours, equating to 94 min extra per week. The mean satisfaction score was 34.9 out of 40.

CONCLUSION

The Neurofenix platform is safe, feasible and well accepted as an adjunct to usual care in acute and subacute stroke rehabilitation. There was a wide range of engagement with the platform in a cohort of stroke survivors which was varied in age and level of impairment. Recruitment, training and support were manageable and completion of data was good, indicating that a future randomised controlled trial would be feasible.

TRIAL REGISTRATION NUMBER

ISRCTN11440079.

Gamified exercise for the distal upper extremity in people with post-stroke hemiparesis: feasibility study on subjective perspectives during daily continuous training

INTRODUCTION

Dose (number of repetitions) has been suggested as a key element in the effectiveness of rehabilitation exercises to promote motor recovery of the hemiparetic upper limb. However, rehabilitation exercises tend to be monotonous and require significant motivation to continue, making it difficult to increase the exercise dose. To address this issue, gamification technology has been implemented in exercises to promote self-engagement for people with hemiparesis in continuing monotonous repetitive movements. This study aimed to investigate how subjective perspectives, specifically enjoyability, motivation to continue, and expectancy of effectiveness, change through continuous daily exercise using a developed gamified exercise system.

MATERIALS AND METHOD

Ten people with stroke suffering upper limb dysfunction underwent daily gamified exercise for seven days. The gamified exercise consisted of an electromyography (EMG)-controlled operating system that enabled users to play virtual games using repetitive finger movements. The participants performed conventional self-exercise on the same day as the control exercise, and rated their subjective perspectives on both exercises on a numerical rating scale on each exercise day.

RESULTS

Ratings for enjoyability and motivation to continue consistently showed significantly higher scores for the gamified exercise than for conventional self-exercise on all exercise days. A similar trend was observed in the ratings for the expectancy of effectiveness. No changes over time were found in any of the ratings throughout the exercise period.

CONCLUSIONS

Exercise using the developed EMG-controlled gamified system may have the potential to maintain motivation and enjoyment in people with stroke to continue monotonous repetitive finger movements.

Gamified Practice Improves Paretic Arm Motor Behavior in Individuals With Stroke

BACKGROUND

Stroke is a heterogeneous condition, making choice of treatment, and determination of how to structure rehabilitation outcomes difficult. Individualized goal-directed and repetitive physical practice is an important determinant of motor learning. Yet, many investigations of motor learning after stroke deliver task practice without consideration of individual capability of the learner.

OBJECTIVE

We developed a gamified arm rehabilitation task for people with stroke that is personalized to individual capacity for paretic arm movement, provides a high dose of practice, progresses through increasingly difficulty levels that are dependent on the performance of the individual, and is practiced in an engaging environment. The objectives of the current study were to determine if 10 days of gamified, object intercept training using the paretic arm would improve arm movement speed and clinical outcome measures of impairment or function.

METHODS

Individuals with chronic stroke and age-matched controls engaged in 10 days of gamified, skilled motor practice of a semi-immersive virtual reality-based intercept and release task. The paretic arm was assessed using the Fugl-Meyer Assessment (motor impairment) and Wolf Motor Function Test (motor function) before and after training.

RESULTS

Both groups showed faster arm movement speed with practice; individuals with stroke demonstrated reduced paretic arm motor impairment and increased function after the intervention. Age and sex (for both groups), and time post-stroke were not related to changes in movement speed.

CONCLUSIONS

Findings indicate that gamified motor training positively affects paretic arm motor behavior in individuals with mild to severe chronic stroke.

A muscle synergies-based controller to drive a powered upper-limb exoskeleton in reaching tasks

This work introduces a real-time intention decoding algorithm grounded in muscle synergies (Syn-ID). The algorithm detects the electromyographic (EMG) onset and infers the direction of the movement during reaching tasks to control a powered shoulder-elbow exoskeleton. Features related to muscle synergies are used in a Gaussian Mixture Model and probability accumulation-based logic to infer the user's movement direction. The performance of the algorithm was verified by a feasibility study including eight healthy participants. The experiments comprised a transparent session, during which the exoskeleton did not provide any assistance, and an assistive session in which the Syn-ID strategy was employed. Participants were asked to reach eight targets equally spaced on a circumference of 25 cm radius (adjusted chance level: 18.1%). The results showed an average accuracy of 48.7% after 0.6 s from the EMG onset. Most of the confusion of the estimate was found along directions adjacent to the actual one (type 1 error: 33.4%). Effects of the assistance were observed in a statistically significant reduction in the activation of Posterior Deltoid and Triceps Brachii. The final positions of the movements during the assistive session were on average 1.42 cm far from the expected ones, both when the directions were estimated correctly and when type 1 errors occurred. Therefore, combining accurate estimates with type 1 errors, we computed a modified accuracy of 82.10±6.34%. Results were benchmarked with respect to a purely kinematics-based approach. The Syn-ID showed better performance in the first portion of the movement (0.14 s after EMG onset).

Application of Muscle Synergies for Gait Rehabilitation After Stroke: Implications for Future Research

BACKGROUND/OBJECTIVE

Muscle synergy analysis based on machine learning has significantly advanced our understanding of the mechanisms underlying the central nervous system motor control of gait and has identified abnormal gait synergies in stroke patients through various analytical approaches. However, discrepancies in experimental conditions and computational methods have limited the clinical application of these findings. This review seeks to integrate the results of existing studies on the features of muscle synergies in stroke-related gait abnormalities and provide clinical and research insights into gait rehabilitation.

METHODS

A systematic search of Web of Science, PubMed, and Scopus was conducted, yielding 10 full-text articles for inclusion.

RESULTS

By comprehensively reviewing the consistencies and differences in the study outcomes, we emphasize the need to segment the gait cycle into specific phases (e.g., weight acceptance, push-off, foot clearance, and leg deceleration) during the treatment process of gait rehabilitation and to develop rehabilitation protocols aimed at restoring normal synergy patterns in each gait phase and fractionating reduced synergies.

CONCLUSIONS

Future research should focus on validating these protocols to improve clinical outcomes and introducing indicators to assess abnormalities in the temporal features of muscle synergies.

Enhanced Muscle Activation Using Robotic Assistance Within the Electromechanical Delay: Implications for Rehabilitation?

Robotic rehabilitation has been shown to match the effects of conventional physical therapy on motor function for patients with neurological diseases. Rehabilitation robots have the potential to reduce therapists' workload in time-intensive training programs as well as perform actions that are not replicable by human therapists. We investigated the effects of one such modality that cannot be achieved by a human therapist: assistance and resistance within the electromechanical delay between muscle activation and muscle contraction during arm extension. We found increased muscle activation when providing robotic assistance within this electromechanical delay. Assistance provided within this delay moves the participant's arm quicker than their own muscle and increases the subsequent peak voluntary muscle activation compared to normal arm extension by 68.97 ± 80.05 % (SE = 0.021; p = 0.007 ). This is surprising since all previous literature shows that muscle activation either decreases or does not change when participants receive robotic assistance. As a consequence, traditional robotic rehabilitation incrementally reduces assistance as the patient improves to maintain levels of muscle activation which is suggested to be important for neuronal repair. The present result may enable therapists to no longer have to choose between providing assistance or increasing muscle activation. Instead, therapists may be able to provide assistance while also increasing muscle activation.

Neuroimaging biomarkers for predicting stroke outcomes: A systematic review

Background and Aims

Stroke is a prominent cause of long-term adult impairment globally and a significant global health issue. Only 14% of stroke survivors achieve full recovery, while 25% to 50% require varying degrees of support, and over half become dependent. The aftermath of a stroke brings profound changes to an individual's life, with early choices significantly impacting their quality of life. This review aims to establish the efficacy of neuroimaging data in predicting long-term outcomes and recovery rates following a stroke.

Methods

A scientific literature search was conducted using the Centre of Reviews and Dissemination (CRD) criteria and PRISMA guidelines for a combined meta-narrative and systematic quantitative review. The methodology involved a structured search in databases like PubMed and The Cochrane Library, following inclusion and exclusion criteria to identify relevant studies on neuroimaging biomarkers for stroke outcome prediction. Data collection utilized the Microsoft Edge Zotero plugin, with quality appraisal conducted via the CASP checklist. Studies published from 2010 to 2024, including observational, randomized control trials, case reports, and clinical trials. Non-English and incomplete studies were excluded, resulting in the identification of 11 pertinent articles. Data extraction emphasized study methodologies, stroke conditions, clinical parameters, and biomarkers, aiming to provide a thorough literature overview and evaluate the significance of neuroimaging biomarkers in predicting stroke recovery outcomes.

Results

The results of this systematic review indicate that integrating advanced neuroimaging methods with highly successful reperfusion therapies following a stroke facilitates the diagnosis of the condition and assists in improving neurological impairments resulting from stroke. These measures reduce the possibility of death and improve the treatment provided to stroke patients.

Conclusion

These findings highlight the crucial role of neuroimaging in advancing our understanding of post-stroke outcomes and improving patient care.

Task-oriented training for gait rehabilitation in people with multiple sclerosis: A systematic review

OBJECTIVES

This systematic review aims to examine the effects of task-oriented (TO) training on gait function in people with multiple sclerosis (MS) and to determine the most effective TO training protocol.

METHODS

We searched PubMed, Web of Science, Scopus, EMBASE, REHABDATA, and PEDro for studies that examined the effects of TO on gait ability (i.e., gait velocity, gait endurance, functional mobility) in people with MS from 1971 to October 2022. The quality of the selected studies was estimated using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Nine studies met the eligibility criteria. A total of 199 people with MS, 58.79% of whom were women, were included. Five studies revealed "good" quality, one revealed "fair", and three exhibited "poor" quality. Four studies administered TO training alone, and five combined TO training with conventional physiotherapy. The selected studies showed varied results for the influences of TO training on gait ability in people with MS.

CONCLUSIONS

The evidence for the impact of TO training on people with MS was limited. The optimal TO training protocol stills vague. Further studies with larger sample sizes are needed.

Effectiveness of Integrated Care for Diabetes Mellitus Type 2, Cardiovascular and Chronic Respiratory Diseases: A Systematic Review and Meta-Analysis

Introduction

In this paper, we use the Rainbow Model of Integrated Care (RMIC) framework to evaluate the effectiveness of integrated care in terms of enhancing the outcomes of chronic conditions such as diabetes mellitus type 2 (DMT2), cardiovascular diseases (CVD), chronic respiratory diseases (CRD), or their combinations.

Methods

The data extracted from randomized controlled trials (RCT) of integrated care interventions for DMT2, CVD, and CRD (follow-up ≥ 3 months) in 11 databases were analysed using random-effects meta-analysis.

Results

A total of 54 eligible studies covering 12,976 participants, with a mean follow-up of 54 weeks, were included. In moderate-quality evidence, integrated care interventions reduced mortality for CVD, adverse events for CVD and DMT2, and improved quality of life for CVD and DMT2, physical and mental functioning, self-management, and blood pressure control.

Conclusion

Integrated care can reduce all-cause mortality, adverse events, and improve quality of life, physical and mental functioning, self-management and blood pressure control in chronic disease patients. However, available evidence for some outcomes (e.g., all-cause hospital admissions) remains uncertain.

A single-center, assessor-blinded, randomized controlled clinical trial to test the safety and efficacy of a novel brain-computer interface controlled functional electrical stimulation (BCI-FES) intervention for gait rehabilitation in the chronic stroke population

BACKGROUND

In the United States, there are over seven million stroke survivors, with many facing gait impairments due to foot drop. This restricts their community ambulation and hinders functional independence, leading to several long-term health complications. Despite the best available physical therapy, gait function is incompletely recovered, and this occurs mainly during the acute phase post-stroke. Therapeutic options are limited currently. Novel therapies based on neurobiological principles have the potential to lead to long-term functional improvements. The Brain-Computer Interface (BCI) controlled Functional Electrical Stimulation (FES) system is one such strategy. It is based on Hebbian principles and has shown promise in early feasibility studies. The current study describes the BCI-FES clinical trial, which examines the safety and efficacy of this system, compared to conventional physical therapy (PT), to improve gait velocity for those with chronic gait impairment post-stroke. The trial also aims to find other secondary factors that may impact or accompany these improvements and establish the potential of Hebbian-based rehabilitation therapies.

METHODS

This Phase II clinical trial is a two-arm, randomized, controlled, longitudinal study with 66 stroke participants in the chronic (> 6 months) stage of gait impairment. The participants undergo either BCI-FES paired with PT or dose-matched PT sessions (three times weekly for four weeks). The primary outcome is gait velocity (10-meter walk test), and secondary outcomes include gait endurance, range of motion, strength, sensation, quality of life, and neurophysiological biomarkers. These measures are acquired longitudinally.

DISCUSSION

BCI-FES holds promise for gait velocity improvements in stroke patients. This clinical trial will evaluate the safety and efficacy of BCI-FES therapy when compared to dose-matched conventional therapy. The success of this trial will inform the potential utility of a Phase III efficacy trial.

TRIAL REGISTRATION

The trial was registered as "BCI-FES Therapy for Stroke Rehabilitation" on February 19, 2020, at clinicaltrials.gov with the identifier NCT04279067.

Freely available, online videos to support neurological physiotherapists and students in task-specific training skill acquisition: a scoping review

BACKGROUND

Videos to support learning of clinical skills are effective; however, little is known about the scope and educational quality of the content of freely available online videos demonstrating task-specific training (TST). This review aimed to determine the extent, characteristics of freely available online videos, and whether the content is suitable to guide skill acquisition of task-specific training for neurological physiotherapists and students.

METHODS

A scoping review was conducted. Google video and YouTube were searched in December 2022. Videos that met our eligibility criteria and were explicitly designed for (TST) skill acquisition were included in the report.

RESULTS

Ten videos met the inclusion criteria and were difficult to find amongst the range of videos available. Most were presented by physiotherapists or occupational therapists, originated from the USA, featured stroke as the condition of the person being treated, and involved a range of interventions (upper limb, constraint induced movement therapy, balance, bicycling). Most videos were created by universities or private practices and only two used people with a neurological condition as the participant. When the content of videos and their presentation (instruction and/or demonstration), was assessed against each key component of TST (practice structure, specificity, repetition, modification, progression, feedback), five of the videos were rated very suitable and five moderately suitable to guide skill acquisition. Most videos failed to demonstrate and provide instruction on each key component of TST and were missing at least one component, with feedback most frequently omitted.

CONCLUSIONS

There are many freely available online videos which could be described as demonstrating TST; very few are suitable to guide skill acquisition. The development of a standardised and validated assessment tool, that is easy to use and assesses the content of TST videos is required to support learners to critically evaluate the educational quality of video content. Guidelines based on sound teaching theory and practice are required to assist creators of online videos to provide suitable resources that meet the learning needs of neurological physiotherapists and students.

Telerehabilitation Following Stroke

Stroke remains a major cause of disability. Intensive rehabilitation therapy can improve outcomes, but most patients receive limited doses. Telehealth methods can overcome obstacles to delivering intensive therapy and thereby address this unmet need. A specific example is reviewed in detail, focused on a telerehabilitation system that targets upper extremity motor deficits after stroke. Strengths of this system include provision of daily therapy associated with very high patient compliance, safety and feasibility in the inpatient or home setting, comparable efficacy to dose-matched therapy provided in-clinic, and a holistic approach that includes assessment, education, prevention, and activity-based therapy.

Effects of taxane-induced peripheral neuropathy on hand dexterity impairment: evaluation of quantitative and subjective assessments

PURPOSE

Chemotherapy-induced peripheral neuropathy (CIPN) commonly involves hand dexterity impairment. However, the factors affecting hand dexterity impairment are unknown and there is currently no established treatment. The purpose of the current study was to clarify factors influencing hand dexterity impairment in taxane-induced peripheral neuropathy using subjective and objective assessments.

METHODS

We assessed patient characteristics, treatment-related factors, subjective symptoms of CIPN (Patient Neurotoxicity Questionnaire [PNQ]), psychological symptoms, and upper limb dysfunction (Quick Disabilities of the Arm, Shoulder and Hand [Quick DASH]). Quantitative assessments were pinch strength, sensory threshold, hand dexterity impairment, and grip force control. Multiple regression analysis was performed using hand dexterity impairment as the dependent variable and age and PNQ, Quick DASH, and control of grip force as independent variables.

RESULTS

Forty-three breast cancer patients were included in the analysis. Hand dexterity impairment in taxane-induced peripheral neuropathy patients was significantly correlated with age, grip force control, and PNQ sensory scores (p < 0.008). Multiple regression analysis demonstrated that PNQ sensory scores and grip force control were significantly associated with hand dexterity impairment (p < 0.01).

CONCLUSION

Subjective symptoms (numbness and pain) and grip force control contributed to impaired hand dexterity in taxane-induced peripheral neuropathy.

SECRETS: Subject-efficient clinical randomized controlled trials using synthetic intervention

Background

The parallel-group randomized controlled trial (RCT) is commonly used in Phase-3 clinical trials to establish treatment effectiveness but requires hundreds-to-thousands of subjects, making it difficult to implement, which leads to high Phase-3 trial failure rates. One approach to increasing power of a trial is to augment data collected from an RCT with external data from prospective studies or prior RCTs. However, this requires that external data be comparable to data from the study of interest, a condition that does not hold for new interventions or populations being studied. Another approach is to lower sample size requirements by using the cross-over design, which measures individual treatment effects (ITEs) to remove inter-subject variability; however, this design is only suitable for chronic conditions and interventions with effects that wash out rapidly.

Method

We propose a novel and practical framework called SECRETS (Subject-Efficient Clinical Randomized Controlled Trials using Synthetic Intervention) to increase power of any parallel-group RCT by simulating the cross-over design using only data collected from the study. SECRETS first estimates ITEs across all subjects recruited to the RCT by using a state-of-the-art counterfactual estimation algorithm called synthetic intervention (SI). Since SI induces dependencies among the ITEs, we introduce a novel hypothesis testing strategy to test for treatment effectiveness.

Results

We show that SECRETS can increase the power of an RCT while maintaining comparable significance levels; in particular, on three real-world clinical RCTs (Phase-3 trials), SECRETS increases power over the baseline method by 6 - 54 % (average: 21.5%, standard deviation: 15.8%), thereby reducing the number of subjects needed to obtain a typically desired statistical operating point of 80% power and 5% significance level by 25 - 76 % (10-3,957 fewer subjects per arm). Our analyses show that SECRETS increases power by consistently reducing the variance of the average treatment effect, thereby mimicking the effects of a cross-over design.

Conclusion

SECRETS increases subject efficiency of an RCT by simulating the cross-over design using only data collected from the RCT; therefore, it is a feasible solution for increasing the trial's power, especially under settings where satisfying sample size requirements is difficult.

The Utilization of Forced-Rate Cycling to Facilitate Motor Recovery Following Stroke: A Randomized Clinical Trial

BACKGROUND

The potential for aerobic exercise (AE) to enhance neuroplasticity post-stroke has been theorized but not systematically investigated. Our aim was to determine the effects of forced-rate AE (FE) paired with upper extremity (UE) repetitive task practice (FE + RTP) compared to time-matched UE RTP (RTP only) on motor recovery.

METHODS

A single center randomized clinical trial was conducted from April 2019 to December 2022. Sixty individuals ≥6 months post-stroke with UE hemiparesis were randomized to FE + RTP (N = 30) or RTP only (N = 30), completing 90-minute sessions, 3×/week for 8 weeks. The FE + RTP group underwent 45-minute of FE (5-minute warm-up, 35-minute main set, and 5-minute cool down) followed by 45-minute of UE RTP. The RTP only group completed 90-minute of RTP. Primary outcomes were the Fugl-Meyer Assessment (FMA) and Action Research Arm Test (ARAT). The 6-minute Walk Test (6MWT, secondary outcome) assessed walking capacity.

RESULTS

Sixty individuals enrolled and 56 completed the study. The RTP only group completed more RTP in terms of repetitions (411.8 ± 44.4 vs 222.8 ± 28.4, P < .001) and time (72.7 ± 6.7 vs 37.8 ± 2.4 minutes, P < .001) versus FE + RTP. There was no significant difference between groups on the FMA (FE + RTP, 36.2 ± 10.1-44.0 ± 11.8 and RTP only, 34.4 ± 11.0-41.2 ± 13.4, P = .43) or ARAT (FE + RTP, 32.5 ± 16.6-37.7 ± 17.9 and RTP only, 32.8 ± 18.6-36.4 ± 18.5, P = .88). The FE + RTP group demonstrated greater improvements on the 6MWT (274.9 ± 122.0-327.1 ± 141.2 m) versus RTP only (285.5 ± 160.3-316.9 ± 170.0, P = .003).

CONCLUSIONS

There was no significant difference between groups in the primary outcomes. The FE + RTP improved more on the 6MWT, a secondary outcome.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03819764.

Occupational Therapy Practice: Time From Stroke Onset to Outpatient Upper Limb Rehabilitation

Upper limb stroke rehabilitation has been understudied in usual occupational therapy. The study's purpose was to describe the timing and amount of usual occupational therapy in the stroke population for hospital-based outpatient upper limb rehabilitation. A multi-site study of timing and amount of occupational therapy was calculated for mild and moderate upper limb stroke impairments using the Fugl-Meyer Assessment-Upper Extremity (FMA-UE). Mild stroke participants (n = 58) had a mean of 164.25 days, and the moderate stroke participants (n = 64) had a mean of 106.75 days from the date of stroke onset to first treatment which was significantly different (p = .047). There were no significant differences in the amount of therapy between mild or moderate stroke patients. Mild stroke patients experience a longer delay in receiving outpatient occupational therapy compared with moderate impairments which may be attributed to the subtlety of the impairments that impact participation in daily activities.

Concurrent ankle-assisted movement, biofeedback, and proprioceptive stimulation reduces lower limb motor impairment and improves gait in persons with stroke

BACKGROUND

Persons with stroke live with residual sensorimotor impairments in their lower limbs (LL), which affects their gait.

PURPOSE

We investigated whether these residual impairments and resulting gait deficits can be reduced through concurrently applied assisted movement, biofeedback, and proprioceptive stimulation.

METHODS

A robotic device provided impairment-oriented training to the affected LL of 24 persons with stroke (PwS) with moderate-to-severe LL impairment. Participants were given 22-30 training sessions over 2-3 months. During training, the interventional device cyclically dorsiflexed and plantarflexed the ankle at 5 deg/s through ±15 deg for 30 min while the participant assisted with the imposed movement. Concurrently, participants received visual biofeedback of assistive joint torque or agonist EMG while mechanical vibration was applied to the currently lengthening (i.e. antagonist) tendon.

RESULTS

Sensorimotor impairment significantly decreased over the training period, which was sustained over 3 months, based on the Fugl-Meyer Assessment (FMA-LL) (p < .001), modified Ashworth scale in dorsiflexors (p < .05), and an ankle strength test (dorsiflexors and plantarflexors) (p < .05). Balance and gait also improved, based on the Tinetti Performance Oriented Mobility Assessment (POMA) (p < .05).

CONCLUSION

Impairment-oriented training using a robotic device capable of applying assisted movement, biofeedback, and proprioceptive stimulation significantly reduces LL impairment and improves gait in moderately-to-severely impaired PwS.

Effectiveness of Activity-Based Task-Oriented Training on Upper Extremity Recovery for Adults With Stroke: A Systematic Review

IMPORTANCE

Interventions for improving upper extremity (UE) recovery have become a priority in stroke rehabilitation because UE disability can undermine a person's capacity to perform daily activities after stroke. A better understanding of the use of activity-based task-oriented training (TOT) will inform the development of more effective UE interventions in stroke rehabilitation.

OBJECTIVE

To examine the effectiveness of activity-based TOT in improving the UE recovery of adults with stroke.

DATA SOURCES

CINAHL Plus, MEDLINE, and PubMed.

STUDY SELECTION AND DATA COLLECTION

Inclusion criteria included quantitative studies published between June 2012 and December 2022 that reported UE recovery as an outcome, including measurements of motor function, motor performance, and performance of activities of daily living (ADLs); a sample age ≥18 yr, with stroke in all phases; and interventions that incorporated real-world daily activities. We assessed articles for inclusion, quality, and risk of bias following Cochrane methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

FINDINGS

Sixteen studies (692 participants, Level 1-4 evidence) were included. Strong to moderate evidence supported the effectiveness of activity-based TOT in UE motor function, motor performance, and ADL performance for adults with stroke. Strong evidence supported the effectiveness of hospital-based TOT, and moderate evidence supported the effectiveness of home-based TOT.

CONCLUSIONS AND RELEVANCE

The results not only showed the value of activity-based TOT as an effective UE intervention in stroke rehabilitation but also supported the occupational therapy philosophy of using functional and meaningful activities in practice. Further research on home-based TOT is needed. Plain-Language Summary: This systematic review shows the effectiveness and value of using real-life activities in task-oriented training approaches for adult survivors of stroke. The authors found strong evidence for hospital-based task-oriented training interventions and moderate evidence for home-based interventions for improving upper extremity recovery. This review shows the value of upper extremity task-oriented training as an effective intervention in stroke rehabilitation. The review also supports the occupational therapy philosophy of using functional and meaningful activities in practice as well as the profession's use of evidence-based practice in stroke rehabilitation.

Effects of structured training on spinal posture and selective motor control in children with unilateral spastic cerebral palsy

BACKGROUND

Children with Unilateral Spastic Cerebral Palsy (USCP) have an asymmetrical postural pattern. Although functional limitations are less, deteriorations in spinal posture are observed.

RESEARCH QUESTION

What is the effect of structured training on spinal posture and selective motor control of upper extremity?

METHODS

Forty five children with USCP were included in the study. Participants were children ages 3-18 with GMFCS levels 1 and 2. Spinal posture and mobility was assessed by Spinal Mouse (SM) and the Spinal Alignment and Range of Motion Measure (SAROMM), and selective motor control of upper extremity was evaluated by the Selective Control of the Upper Extremity Scale (SCUES). Children were divided into two groups: structured training group (STG) (n = 22) and conventional physiotherapy group (CPG) (n = 23). Groups received treatment sessions lasting 45 min, 2 days a week for 8 weeks. Evaluations were made baseline and after treatment.

RESULTS

In sagittal plane, there was a significant decrease in the degree of thoracic kyphosis after treatment in the STG (p = 0.004). A significant difference was found in total spine angulation (p = 0.015) and mobility from flexion to extension in the STG group. There was a difference in total spine angulation (p = 0.014) in the CPG group, but no difference in spinal mobility. Post-training differences were found in thoracic angulation (p = 0.006) and lateral flexion mobility to the affected side in the STG in thoracic (p = 0.020), lumbar (p = 0.035) and total spine (p = 0.008) in the frontal plane. When SCUES-shoulder, elbow, wrist, total scores changes was significant in CPG (p < 0.001), SCUES-forearm (p = 0.002) and fingers (p = 0.007) changes was significant in STG.

SIGNIFICANCE

This study showed that although children with USCP are more mildly affected, there are adverse effects on their selective motor control and spinal posture. This study reveals the contribution of structured training in terms of selective movement, spinal smoothness and mobility in children.

Dose Response to Upper Extremity Stroke Rehabilitation Varies by Individual: Early Indicators of Treatment Response

BACKGROUND

Dose response has remained a priority area in motor rehabilitation research for decades, prompting several large randomized trials and meta-analyses. These between-subjects comparisons have revealed equivocal relationships between the duration of motor practice and rehabilitation response. Prior reliance on time-consuming clinical assessments made it infeasible to capture within-subjects dose response, as tracking the dose-response trajectory of an individual requires dozens of repeated administrations.

METHODS

This secondary observational cohort analysis of existing data from the gaming arms of the VIGoROUS multisite trial (Video Game Rehabilitation for Outpatient Stroke) describes the rehabilitation dose response of 80 participants with mild-moderate chronic stroke. The 3-dimensional joint position data were captured via the Kinect v2 optical sensor as participants completed a prescribed 15 hours of in-home unsupervised game-based motor practice. Kinematic dose response trajectories were fitted from hundreds to thousands of in-game repetitions for 4 separate upper extremity movements for each participant.

RESULTS

Of 75 participants with sufficient data for dose-response analysis, 85% showed improved motor capacity for at least 1 movement. Dose response was bimodal; 42% required <5 hours of motor practice before reaching a plateau in movement kinematics, whereas 55% required >10 and 34% required >30 hours. We could predict with 93% accuracy whether or not an individual would ultimately respond to game-based motor practice within 5 hours of gameplay.

CONCLUSIONS

Dose response varies considerably between individuals. About half of chronic stroke patients benefit from higher doses of motor practice than the current standard of care. Individualized dose-response data from motion capture rehabilitation gaming can guide clinical decision-making early on in treatment.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02631850.

Combined repetitive facilitative exercise under continuous neuromuscular electrical stimulation and task-oriented training for hemiplegic upper extremity during convalescent phase after stroke: before-and-after feasibility trial

Introduction

Whereas repetitive facilitative exercise (RFE) affects primarily recovery of motor impairment after stroke, task-oriented training (TOT) focuses on facilitating daily use of the affected upper extremity. However, feasibility of combined RFE and TOT has not been reported. We originated "task-oriented RFE," as a new combination therapy for patients with hemiplegic upper extremity after subacute stroke, to examine its feasibility in convalescent rehabilitation wards.

Methods

This is a before-and-after pilot study. Eight patients with hemiplegic upper extremity after subacute stroke received the task-oriented RFE program for 6 weeks at 80 min per day (20-60 min of TOT applied after 60-20 min of RFE under continuous neuromuscular electrical stimulation) in a convalescent rehabilitation ward. In the current program, we introduced the Aid for Decision-making in Occupation Choice (ADOC) iPad application as a goal-setting method for determining tasks. Feasibility was assessed with adherence to the protocol, adverse events in response to the intervention, and preliminary efficacy. Motor functions, amount of use and quality of movement in the hemiparetic upper extremity, and satisfaction of the patients were evaluated with Fugl-Meyer Assessment (FMA), the Action Research Arm Test (ARAT), the motor activity log (MAL) for the amount of use (AOU) and quality of movement (QOM) of the paralyzed hand, and ADOC.

Results

All participants accomplished the program, which was implemented as originally planned; neither nonattendance nor an adverse event occurred during the study. Favorable outcomes were obtained with all measures; mean changes in FMA, ARAT in the dominant hand, MAL-AOU, and MAL-QOM were greater than minimal clinically important differences. Mean changes in ADOC were greater than the minimal detectable change.

Discussion

The task-oriented RFE program was safe, well-tolerated, beneficial, and feasible within 80 min a day of occupational therapy, which means also within the procedural constraints of the Japanese health insurance system during the convalescent phase. Future studies are warranted to examine whether combined RFE and TOT enhances the efficacies of each program alone.

'Smart reminder': A feasibility pilot study on the effects of a wearable device treatment on the hemiplegic upper limb in persons with stroke

INTRODUCTION

Emerging literature suggests that wearable devices offer a promising option for self-directed home-based upper limb training for persons with stroke. However, little research is available to explore integrating smartphone applications with wearable devices to provide upper limb telerehabilitation to stroke survivors at home. This study examined the feasibility and potential therapeutic effects of a wearable device integrated with a smartphone-based telerehabilitation system to provide upper limb rehabilitation to stroke survivors at home.

METHODS

Twelve stroke survivors from community support groups participated in a treatment consisting of 4-week telerehabilitation using a wearable device and 4-week conventional therapy successively in a single-blind, randomised crossover study. A 3-week washout period was administered between the two 4-week treatments. The primary outcome measures were the Fugl Meyer Assessment, the Action Research Arm Test, and the active range of motion (ROM) of the upper limb. Secondary outcome measures included the Motor Activity Log and exercise adherence.

RESULTS

Results showed that the active ROM of participants' hemiplegic shoulder improved more significantly after 4 weeks of telerehabilitation with the wearable device than with conventional therapy. No significant differences were found in other outcome measures.

CONCLUSIONS

A 4-week telerehabilitation programme using a wearable device improves the hemiplegic upper limb in community-dwelling stroke survivors and may be feasible as an effective intervention for self-directed upper limb rehabilitation at home.

Investigating Activity Recognition for Hemiparetic Stroke Patients Using Wearable Sensors: A Deep Learning Approach with Data Augmentation

Measuring the daily use of an affected limb after hospital discharge is crucial for hemiparetic stroke rehabilitation. Classifying movements using non-intrusive wearable sensors provides context for arm use and is essential for the development of a home rehabilitation system. However, the movement classification of stroke patients poses unique challenges, including variability and sparsity. To address these challenges, we collected movement data from 15 hemiparetic stroke patients (Stroke group) and 29 non-disabled individuals (ND group). The participants performed two different tasks, the range of motion (14 movements) task and the activities of daily living (56 movements) task, wearing five inertial measurement units in a home setting. We trained a 1D convolutional neural network and evaluated its performance for different training groups: ND-only, Stroke-only, and ND and Stroke jointly. We further compared the model performance with data augmentation from axis rotation and investigated how the performance varied based on the asymmetry of movements. The joint training of ND + Stroke yielded an increased F1-score by a margin of 31.6% and 10.6% compared to ND-only training and Stroke-only training, respectively. Data augmentation further enhanced F1-scores across all conditions by an average of 11.3%. Finally, asymmetric movements decreased the F1-score by 25.9% compared to symmetric movements in the Stroke group, indicating the importance of asymmetry in movement classification.

ENHANCE proof-of-concept three-arm randomized trial: effects of reaching training of the hemiparetic upper limb restricted to the spasticity-free elbow range

Post-stroke motor recovery processes remain unknown. Timescales and patterns of upper-limb (UL) recovery suggest a major impact of biological factors, with modest contributions from rehabilitation. We assessed a novel impairment-based training motivated by motor control theory where reaching occurs within the spasticity-free elbow range. Patients with subacute stroke (≤ 6 month; n = 46) and elbow flexor spasticity were randomly allocated to a 10-day UL training protocol, either personalized by restricting reaching to the spasticity-free elbow range defined by the tonic stretch reflex threshold (TSRT) or non-personalized (non-restricted) and with/without anodal transcranial direct current stimulation. Outcomes assessed before, after, and 1 month post-intervention were elbow flexor TSRT angle and reach-to-grasp arm kinematics (primary) and stretch reflex velocity sensitivity, clinical impairment, and activity (secondary). Results were analyzed for 3 groups as well as those of the effects of impairment-based training. Clinical measures improved in both groups. Spasticity-free range training resulted in faster and smoother reaches, smaller (i.e., better) arm-plane path length, and closer-to-normal shoulder/elbow movement patterns. Non-personalized training improved clinical scores without improving arm kinematics, suggesting that clinical measures do not account for movement quality. Impairment-based training within a spasticity-free elbow range is promising since it may improve clinical scores together with arm movement quality.Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique Identifier: NCT02725853; Initial registration date: 01/04/2016.

Autonomy support encourages use of more-affected arm post-stroke

BACKGROUND

Autonomy support, which involves providing individuals the ability to control their own behavior, is associated with improved motor control and learning in various populations in clinical and non-clinical settings. This study aimed to investigate whether autonomy support combined with an information technology (IT) device facilitated success in using the more-affected arm during training in individuals with stroke. Consequently, we examined whether increased success influenced the use of the more-affected arm in mild to moderate subacute to chronic stroke survivors.

METHODS

Twenty-six participants with stroke were assigned to the autonomy support or control groups. Over a 5-week period, training and test sessions were conducted using the Individualized Motivation Enhancement System (IMES), a device developed specifically for this study. In the autonomy support group, participants were able to adjust the task difficulty parameter, which controlled the time limit for reaching targets. The control group did not receive this option. The evaluation of the more-affected arm's use, performance, and impairment was conducted through clinical tests and the IMES. These data were then analyzed using mixed-effect models.

RESULTS

In the IMES test, both groups showed a significant improvement in performance (p < 0.0001) after the training period, without any significant intergroup differences (p > 0.05). However only the autonomy support group demonstrated a significant increase in the use of the more-affected arm following the training (p < 0.001). Additionally, during the training period, the autonomy support group showed a significant increase in successful experiences with using the more-affected arm (p < 0.0001), while the control group did not exhibit the same level of improvement (p > 0.05). Also, in the autonomy support group, the increase in the use of the more-affected arm was associated with the increase in the successful experience significantly (p = 0.007).

CONCLUSIONS

Combining autonomy support with an IT device is a practical approach for enhancing performance and promoting the use of the more-affected upper extremity post-stroke. Autonomy support facilitates the successful use of the more-affected arm, thereby increasing awareness of the training goal of maximizing its use.

TRIAL REGISTRATION

The study was registered retrospectively with the Clinical Research Information Service (KCT0008117; January 13, 2023; https://cris.nih.go.kr/cris/search/detailSearch.do/23875 ).

The Critical Period After Stroke Study (CPASS) Upper Extremity Treatment Protocol

Objective

To present the development of a novel upper extremity (UE) treatment and assess how it was delivered in the Critical Periods After Stroke Study (CPASS), a phase II randomized controlled trial (RCT).

Design

Secondary analysis of data from the RCT.

Setting

Inpatient and outpatient settings the first year after stroke.

Participants

Of the 72 participants enrolled in CPASS (N=72), 53 were in the study groups eligible to receive the treatment initiated at ≤30 days (acute), 2-3 months (subacute), or ≥6 months (chronic) poststroke. Individuals were 65.1±10.5 years of age, 55% were women, and had mild to moderate UE motor capacity (Action Research Arm Test=17.2±14.3) at baseline.

Intervention

The additional 20 hours of treatment began using the Activity Card Sort (ACS), a standardized assessment of activities and participation after stroke, to identify UE treatment goals selected by the participants that were meaningful to them. Treatment activities were broken down into smaller components from a standardized protocol and process that operationalized the treatments essential elements.

Main Outcome Measures

Feasibility of performing the treatment in a variety of clinical settings in an RCT and contextual factors that influenced adherence.

Results

A total of 49/53 participants fully adhered to the CPASS treatment. The duration and location of the treatment sessions and the UE activities practiced during therapy are presented for the total sample (n=49) and per study group as an assessment of feasibility and the contextual factors that influenced adherence.

Conclusions

The CPASS treatment and therapy goals were explicitly based on the meaningful activities identified by the participants using the ACS as a treatment planning tool. This approach provided flexibility to customize UE motor therapy without sacrificing standardization or quantification of the data regardless of the location and UE impairments of participants within the first year poststroke.

Sensitivity to Change and Responsiveness of the Upper Extremity Fugl-Meyer Assessment in Individuals With Moderate to Severe Acute Stroke

BACKGROUND

The Fugl-Meyer Assessment-Upper Extremity (FMA-UE) is a widely used outcome measure for quantifying motor impairment in stroke recovery. Meaningful change (responsiveness) in the acute to subacute phase of stroke recovery has not been determined.

OBJECTIVE

Determine responsiveness and sensitivity to change of the FMA-UE from 1-week to 6-weeks (subacute) after stroke in individuals with moderate to severe arm impairment who received standard clinical care.

METHODS

A total of 51 participants with resulting moderate and severe UE hemiparesis after stroke had FMA-UE assessment at baseline (within 2 weeks of stroke) and 6-weeks later. Sensitivity to change was assessed using Glass's delta, standardized response means (SRM), standard error of measure (SEM), and minimal detectable change (MDC). Responsiveness was assessed with the minimal clinically important difference (MCID), estimated using receiver operating characteristic curve analysis with patient-reported global rating of change scales (GROC) and a provider-reported modified Rankin Scale (mRS) as anchors.

RESULTS

The MCID estimates were 13, 12, and 9 anchored to the GROC Arm Weakness, GROC Recovery, and mRS. Glass's delta and the SRM revealed large effect sizes, indicating high sensitivity to change, (∆ = 1.24, 95% CI [0.64, 1.82], SRM = 1.10). Results for the SEM and MDC were 2.46 and 6.82, respectively.

CONCLUSION

The estimated MCID for the FMA-UE for individuals with moderate to severe motor impairment from 1 to 6-weeks after stroke is 13. These estimates will provide clinical context for FMA-UE change scores by helping to identify the change in upper-extremity motor impairment that is both beyond measurement error and clinically meaningful.

Task-specific training versus usual care to improve upper limb function after stroke: the "Task-AT Home" randomised controlled trial protocol

Background

Sixty percent of people have non-functional arms 6 months after stroke. More effective treatments are needed. Cochrane Reviews show low-quality evidence that task-specific training improves upper limb function. Our feasibility trial showed 56 h of task-specific training over 6 weeks resulted in an increase of a median 6 points on the Action Research Arm test (ARAT), demonstrating the need for more definitive evidence from a larger randomised controlled trial. Task-AT Home is a two-arm, assessor-blinded, multicentre randomised, controlled study, conducted in the home setting.

Aim

The objective is to determine whether task-specific training is a more effective treatment than usual care, for improving upper limb function, amount of upper limb use, and health related quality of life at 6 weeks and 6 months after intervention commencement. Our primary hypothesis is that upper limb function will achieve a ≥ 5 point improvement on the ARAT in the task-specific training group compared to the usual care group, after 6 weeks of intervention.

Methods

Participants living at home, with remaining upper limb deficit, are recruited at 3 months after stroke from sites in NSW and Victoria, Australia. Following baseline assessment, participants are randomised to 6 weeks of either task-specific or usual care intervention, stratified for upper limb function based on the ARAT score. The task-specific group receive 14 h of therapist-led task-specific training plus 42 h of guided self-practice. The primary outcome measure is the ARAT at 6 weeks. Secondary measures include the Motor Activity Log (MAL) at 6 weeks and the ARAT, MAL and EQ5D-5 L at 6 months. Assessments occur at baseline, after 6 weeks of intervention, and at 6 months after intervention commencement. Analysis will be intention to treat using a generalised linear mixed model to report estimated mean differences in scores between the two groups at each timepoint with 95% confidence interval and value of p.

Discussion

If the task-specific home-based training programme is more effective than usual care in improving arm function, implementation of the programme into clinical practice would potentially lead to improvements in upper limb function and quality of life for people with stroke.

Clinical Trial Registration

ANZCTR.org.au/ACTRN12617001631392p.aspx.

Combining high dose therapy, bilateral motor priming, and vagus nerve stimulation to treat the hemiparetic upper limb in chronic stroke survivors: a perspective on enhancing recovery

Stroke is a leading cause of disability worldwide and upper limb hemiparesis is the most common post-stroke disability. Recent studies suggest that clinically significant motor recovery is possible in chronic stroke survivors with severe impairment of the upper limb. Three promising strategies that have been investigated are (1) high dose rehabilitation therapy (2) bilateral motor priming and (3) vagus nerve stimulation. We propose that the future of effective and efficient upper limb rehabilitation will likely require a combination of these approaches.

Machine learning in predicting outcomes for stroke patients following rehabilitation treatment: A systematic review

OBJECTIVE

This review aimed to summarize the use of machine learning for predicting the potential benefits of stroke rehabilitation treatments, to evaluate the risk of bias of predictive models, and to provide recommendations for future models.

MATERIALS AND METHODS

This systematic review was conducted in accordance with the PRISMA statement and the CHARMS checklist. The PubMed, Embase, Cochrane Library, Scopus, and CNKI databases were searched up to April 08, 2023. The PROBAST tool was used to assess the risk of bias of the included models.

RESULTS

Ten studies within 32 models met our inclusion criteria. The optimal AUC value of the included models ranged from 0.63 to 0.91, and the optimal R2 value ranged from 0.64 to 0.91. All of the included models were rated as having a high or unclear risk of bias, and most of them were downgraded due to inappropriate data sources or analysis processes.

DISCUSSION AND CONCLUSION

There remains much room for improvement in future modeling studies, such as high-quality data sources and model analysis. Reliable predictive models should be developed to improve the efficacy of rehabilitation treatment by clinicians.

Predicting models for arm impairment: External validation of the Scandinavian models and identification of new predictors in post-acute stroke settings

BACKGROUND

Post-stroke arm impairment at rehabilitation admission as predictor of discharge arm impairment was consistently reported as extremely useful. Several models for acute prediction exist (e.g. the Scandinavian), though lacking external validation and larger time-window admission assessments.

OBJECTIVES

(1) use the 33 Fugl-Meyer Assessment-Upper Extremity (FMA-UE) individual items to predict total FMA-UE score at discharge of patients with ischemic stroke admitted to rehabilitation within 90 days post-injury, (2) use eight individual items (seven from the Scandinavian study plus the top predictor item from objective 1) to predict mild impairment (FMA-UE≥48) at discharge and (3) adjust the top three models from objective 2 with known confounders.

METHODS

This was an observational study including 287 patients (from eight settings) admitted to rehabilitation (2009-2020). We applied regression models to candidate predictors, reporting adjusted R2, odds ratios and ROC-AUC using 10-fold cross-validation.

RESULTS

We achieved good predictive power for the eight item-level models (AUC: 0.70-0.82) and for the three adjusted models (AUC: 0.85-0.88). We identified finger mass flexion as new item-level top predictor (AUC:0.88) and time to admission (OR = 0.9(0.9;1.0)) as only common significant confounder.

CONCLUSION

Scandinavian item-level predictors are valid in a different context, finger mass flexion outperformed known predictors, days-to-admission predict discharge mild arm impairment.

Post-stroke cardiovascular management: Current concepts, integrated care and future developments

After an ischaemic stroke patients often have cardiovascular complications known as stroke-heart syndrome. The cardiovascular management after stroke has a significant impact on life expectancy as well as the quality of life. The development and implementation of management pathways to improve outcomes for patients with stroke-heart syndrome requires a multidisciplinary involvement from health care professionals from primary, secondary and tertiary prevention levels. A holistic, integrated care approach could follow the ABC pathway: A) Appropriate antithrombotic therapy in all stroke/TIA patients in the acute phase as well as recommendations for the longer term treatment regimen are required to avoid recurrent stroke. B) For better functional and psychological status the assessment of post-stroke cognitive and physical impairment, depression, and anxiety as part of routine post-stroke work-up in every patient is necessary. C) Cardiovascular risk factors and comorbidities management further includes cardiovascular work-up, adapted drug therapy, but often also lifestyle changes that are central to the success of integrated care for stroke-heart syndrome. Greater patient and family/caregiver involvement in planning actions and the input and feedback on optimizing stroke care pathways is needed. Achieving integrated care is challenging and highly context dependent on different healthcare levels. A tailored approach will utilize a variety of enabling factors. In this narrative review, we summarize the current evidence and outline potential factors that will contribute to the successful implementation of integrated cardiovascular care for stroke-heart syndrome management.

Stroke Rehabilitation and Motor Recovery

OBJECTIVE

Up to 50% of the nearly 800,000 patients who experience a new or recurrent stroke each year in the United States fail to achieve full independence afterward. More effective approaches to enhance motor recovery following stroke are needed. This article reviews the rehabilitative principles and strategies that can be used to maximize post-stroke recovery.

LATEST DEVELOPMENTS

Evidence dictates that mobilization should not begin prior to 24 hours following stroke, but detailed guidelines beyond this are lacking. Specific classes of potentially detrimental medications should be avoided in the early days poststroke. Patients with stroke who are unable to return home should be referred for evaluation to an inpatient rehabilitation facility. Research suggests that a substantial increase in both the dose and intensity of upper and lower extremity exercise is beneficial. A clinical trial supports vagus nerve stimulation as an adjunct to occupational therapy for motor recovery in the upper extremity. The data remain somewhat mixed as to whether robotics, transcranial magnetic stimulation, functional electrical stimulation, and transcranial direct current stimulation are better than dose-matched traditional exercise. No current drug therapy has been proven to augment exercise poststroke to enhance motor recovery.

ESSENTIAL POINTS

Neurologists will collaborate with rehabilitation professionals for several months following a patient's stroke. Many questions still remain about the ideal exercise regimen to maximize motor recovery in patients poststroke. The next several years will likely bring a host of new research studies exploring the latest strategies to enhance motor recovery using poststroke exercise.

Telerehabilitation Initiated Early in Post-Stroke Recovery: A Feasibility Study

BACKGROUND

Enhanced neural plasticity early after stroke suggests the potential to improve outcomes with intensive rehabilitation therapy. Most patients do not get such therapy, however, due to limited access, changing rehabilitation therapy settings, low therapy doses, and poor compliance.

OBJECTIVE

To examine the feasibility, safety, and potential efficacy of an established telerehabilitation (TR) program after stroke initiated during admission to an inpatient rehabilitation facility (IRF) and completed in the patient's home.

METHODS

Participants with hemiparetic stroke admitted to an IRF received daily TR targeting arm motor function in addition to usual care. Treatment consisted of 36, 70-minute sessions (half supervised by a licensed therapist via videoconference), over a 6-week period, that included functional games, exercise videos, education, and daily assessments.

RESULTS

Sixteen participants of 19 allocated completed the intervention (age 61.3 ± 9.4 years; 6 female; baseline Upper Extremity Fugl-Meyer [UEFM] score 35.9 ± 6.4 points, mean ± SD; NIHSS score 4 (3.75, 5.25), median, IQR; intervention commenced 28.3 ± 13.0 days post-stroke). Compliance was 100%, retention 84%, and patient satisfaction 93%; 2 patients developed COVID-19 and continued TR. Post-intervention UEFM improvement was 18.1 ± 10.9 points (P < .0001); Box and Blocks, 22.4 ± 9.8 blocks (P = .0001). Digital motor assessments, acquired daily in the home, were concordant with these gains. The dose of rehabilitation therapy received as usual care during this 6-week interval was 33.9 ± 20.3 hours; adding TR more than doubled this to 73.6 ± 21.8 hours (P < .0001). Patients enrolled in Philadelphia could be treated remotely by therapists in Los Angeles.

CONCLUSIONS

These results support feasibility, safety, and potential efficacy of providing intense TR therapy early after stroke.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov; NCT04657770.

Training for walking through an opening improves collision avoidance behavior in subacute patients with stroke: a randomized controlled trial

PURPOSE

Paretic side collisions frequently occur in stroke patients, especially while walking through narrow spaces. We determined whether training for walking through an opening (T-WTO) while entering from the paretic side would improve collision avoidance behavior and prevent falls after 6 months.

MATERIALS AND METHODS

Thirty-eight adults with moderate-to-mild hemiparetic gait after stroke who were hospitalized in a rehabilitation setting were randomly allocated to the T-WTO (n = 20) or regular rehabilitation (R-Control; n = 18) program. Both groups received five sessions of 40 min per week, for three weeks total. T-WTO included walking through openings of various widths while rotating with the paretic side in front, and R-Control involved normal walking without body rotation. Obstacle avoidance ability, 10-m walking test, timed Up and Go test, Berg Balance Scale, Activities-specific Balance Confidence, the perceptual judgment of passability, and fall incidence were assessed.

RESULTS

Collision rate and time to passage of the opening in obstacle avoidance task significantly improved in the T-WTO group compared with those in the R-Control group. Contrast, T-WTO did not lead to significant improvements in other outcomes.

CONCLUSIONS

T-WTO improved efficiency and safety in managing subacute stroke patients. Such training could improve patient outcomes/safety because of the paretic body side during walking.

CLINICAL TRIAL REGISTRATION NO.

R000038375 UMIN000033926.

Virtual reality in post-stroke neurorehabilitation - a systematic review and meta-analysis

BACKGROUND

Stroke is a neurological disorder and one of the leading causes of disability worldwide. The patient may lose the ability to adequately move the extremities, perceive sensations, or ambulate independently. Recent experimental studies have reported the beneficial influence of virtual reality training strategies on improving overall functional abilities for stroke survivors.

METHODS

Conducted a systematic review of the literature using the following keywords to retrieve the data: stroke, virtual reality, motor deficits, neurorehabilitation, cognitive impairments, and sensory deficits. A random-effect meta-analysis was performed for seven scales - one cognitive (MMSE) and six motor (Fugl-Meyer, Berg Balance Scale, Time up and go, Wolf motor function, 10 m walk, Brunnstrom score).

OBJECTIVE

To organize and compare all the available data regarding the effectiveness of virtual reality for stroke rehabilitation.

RESULTS

This literature reviewed 150 studies and included 46 for qualitative and 27 for quantitative analysis. There was no statistically significant difference between groups in MMSE score (MD = 0.24, 95%CI = ((-0.42) -(0.9)), p = .47, I² = 0%) and Fugl-Meyer score (MD = (-0.38), 95%CI = ((-12.88)-(12.11)), p = .95, I² = 98%) . The statistical significance was not reached in any of the other outcomes.

CONCLUSIONS

This review supports that stroke rehabilitation programs incorporating virtual reality are associated with improved functional outcomes, but there is no statistically significant difference compared to standard therapy.

Identification of inverse kinematic parameters in redundant systems: Towards quantification of inter-joint coordination in the human upper extremity

Understanding and quantifying inter-joint coordination is valuable in several domains such as neurorehabilitation, robot-assisted therapy, robotic prosthetic arms, and control of supernumerary arms. Inter-joint coordination is often understood as a consistent spatiotemporal relation among kinematically redundant joints performing functional and goal-oriented movements. However, most approaches in the literature to investigate inter-joint coordination are limited to analysis of the end-point trajectory or correlation analysis of the joint rotations without considering the underlying task; e.g., creating a desirable hand movement toward a goal as in reaching motions. This work goes beyond this limitation by taking a model-based approach to quantifying inter-joint coordination. More specifically, we use the weighted pseudo-inverse of the Jacobian matrix and its associated null-space to explain the human kinematics in reaching tasks. We propose a novel algorithm to estimate such Inverse Kinematics weights from observed kinematic data. These estimated weights serve as a quantification for spatial inter-joint coordination; i.e., how costly a redundant joint is in its contribution to creating an end-effector velocity. We apply our estimation algorithm to datasets obtained from two different experiments. In the first experiment, the estimated Inverse Kinematics weights pinpoint how individuals change their Inverse Kinematics strategy when exposed to the viscous field wearing an exoskeleton. The second experiment shows how the resulting Inverse Kinematics weights can quantify a robotic prosthetic arm's contribution (or the level of assistance).

Using exergame-based exercise to prevent and postpone the loss of muscle mass, muscle strength, cognition, and functional performance among elders in rural long-term care facilities: A protocol for a randomized controlled trial

Objective

Elderly individuals in long-term care facilities (LTCFs) have a higher prevalence of sarcopenia than those in the community. Exercise is the gold standard for preventing and treating sarcopenia. Regarding exercise, multicomponent exercises, including progressive resistance training (PRT), are beneficial. However, developing routine, structured exercise programs for the elderly in LTCFs is difficult because of a shortage of healthcare providers, particularly in rural regions. Exergame-based exercises can increase a player's motivation and reduce staff time for an intervention. Nintendo Switch RingFit Adventure (RFA) is a novel exergame that combines resistance, aerobic, and balance exercises. In this study, we aim to investigate the clinical effectiveness of RFA on muscle and functional performance parameters among the elderly in LTCFs.

Methods

The EXPPLORE (using EXergame to Prevent and Postpone the LOss of muscle mass, muscle strength, and functional performance in Rural Elders) trial is a single-center randomized controlled trial involving elderly individuals (≥60 years) living in LTCFs in rural southern Taiwan. The participants will be equally randomized to the intervention group (exergame-based exercise plus standard care) or the control group (standard care alone). Both groups will receive standard care except that the intervention group will receive exergame-based exercises at the time previously scheduled for sedentary activities in the LTCFs. The exergame-based exercise will be performed using RFA in the sitting position with a specialized design, including arm fit skills and knee assist mode. Each session of the exercise lasts 30 mins and will be performed two times per week for 12 weeks. The primary outcomes will be the osteoporotic fracture index, appendicular skeletal muscle mass index, dominant handgrip strength, and gait speed. Meanwhile, the secondary outcomes will be the dexterity and agility, muscle strength and thickness, range of motion of the joints of the dominant upper extremity, Kihon checklist, Medical Outcomes Study 36-Item Short-Form Health Survey, and Brain Health Test.

Discussion

This trial will provide valuable knowledge on whether exergames using RFA can counteract physical decline and improve quality of life and cognition among the elderly in LTCFs.

Clinical trial registration

[www.ClinicalTrials.gov], identifier [NCT05360667].

Assessment of human expertise and movement kinematics in first-person shooter games

In contrast to traditional professional sports, there are few standardized metrics in professional esports (competitive multiplayer video games) for assessing a player's skill and ability. We assessed the performance of professional-level players in Aim LabTM, a first-person shooter training and assessment game, with two target-shooting tasks. These tasks differed primarily in target size: the task with large targets provided an incentive to be fast but imprecise and the task with large targets provided an incentive to be precise but slow. Each player's motor acuity was measured by characterizing the speed-accuracy trade-off in shot behavior: shot time (elapsed time for a player to shoot at a target) and shot spatial error (distance from center of a target). We also characterized the fine-grained kinematics of players' mouse movements. Our findings demonstrate that: 1) movement kinematics depended on task demands; 2) individual differences in motor acuity were significantly correlated with kinematics; and 3) performance, combined across the two target sizes, was poorly characterized by Fitts Law. Our approach to measuring motor acuity has widespread applications not only in esports assessment and training, but also in basic (motor psychophysics) and clinical (gamified rehabilitation) research.

Integrating hand exoskeletons into goal-oriented clinic and home stroke and spinal cord injury rehabilitation

Introduction

Robotic exoskeletons are emerging as rehabilitation and assistive technologies that simultaneously restore function and enable independence for people with disabilities.

Aim

We investigated the feasibility and orthotic and restorative effects of an exoskeleton-supported goal-directed rehabilitation program for people with hand impairments after stroke or Spinal Cord Injury (SCI).

Method

A single-arm case-series feasibility study was conducted using a wearable untethered hand exoskeleton during goal-directed therapy programs with in-clinic and at-home components. Therapists trained stroke and SCI patients to use a hand exoskeleton during rehabilitation exercises, activities of daily living and patient-selected goals. Each patient received a 1-hour in-clinic training session on five consecutive days, then took the exoskeleton home for two consecutive days to perform therapist-recommended tasks. Goal Attainment Scaling (GAS) and the Box and Block Test (BBT) were administered at baseline, after in-clinic therapy and after home use, with and again without wearing the exoskeleton. The System Usability Scale (SUS), Motor Activity Log, and Fugl-Meyer Assessment were also administered to assess the intervention’s acceptability, adherence, usability and effectiveness.

Results

Four stroke patients (Chedoke McMaster Stage of Hand 2–4) and one SCI patient (ASIA C8 Motor Stage 1) 23 ± 19 months post-injury wore the hand exoskeleton to perform 280 ± 23 exercise repetitions in the clinic and additional goal-oriented tasks at home. The patients performed their own goals and the dexterity task with higher performance following the 7-days therapy program in comparison to baseline for both exoskeleton-assisted (ΔGAS: 18 ± 10, ΔBBT: 1 ± 5) and unassisted (ΔGAS: 14 ± 14, ΔBBT: 3 ± 4) assessments. Therapists and patients provided ‘good’ SUS ratings of 78 ± 6 and no harmful events were reported.

Conclusions

The exoskeleton-supported stroke and SCI therapy program with in-clinic and at-home training components was feasible.

Revisiting dose and intensity of training: Opportunities to enhance recovery following stroke

PURPOSE

Stroke is a global leading cause of adult disability with survivors often enduring persistent impairments and loss of function. Both intensity and dosage of training appear to be important factors to help restore behavior. However, current practice fails to achieve sufficient intensity and dose of training to promote meaningful recovery. The purpose of this review is to propose therapeutic solutions that can help achieve a higher dose and/or intensity of therapy. Raising awareness of these intensive, high-dose, treatment strategies might encourage clinicians to re-evaluate current practice and optimize delivery of stroke rehabilitation for maximal recovery.

METHODS

Literature that tested and evaluated solutions to increase dose or intensity of training was reviewed. For each therapeutic strategy, we outline evidence of clinical benefit, supporting neurophysiological data (where available) and discuss feasibility of clinical implementation.

RESULTS

Possible therapeutic solutions included constraint induced movement therapy, robotics, circuit therapy, bursts of training, gaming technologies, goal-oriented instructions, and cardiovascular exercise.

CONCLUSION

Our view is that clinicians should evaluate current practice to determine how intensive high-dose training can be implemented to promote greater recovery after stroke.

Reaching a Tipping Point for Neurorehabilitation Research: Obstacles and Opportunities in Trial Design, Description, and Pooled Analysis

The record-breaking pace of COVID-19 vaccine development and implementation depended heavily on collaboration among academic, government, and commercial stakeholders, especially through data-sharing and robust multicenter trials. Collaborative efforts have not been as fruitful in fields such as neurorehabilitation, where non-pharmacological interventions play a much larger role. Barriers to translating scientific advancements into clinical practice in neurorehabilitation include pervasively small study sizes, exacerbated by limited funding for non-pharmacological multicenter clinical trials; difficulty standardizing—and adequately describing—non-pharmacological interventions; and a lack of incentives for individual patient-level data-sharing. These barriers prevent reliable meta-analysis of non-pharmacological clinical studies in neurorehabilitation. This point-of-view will highlight these challenges as well as suggest practical steps that may be taken to improve the neurorehabilitation pipeline between evidence and implementation.

Barriers to Enrollment in Post-Stroke Brain Stimulation in a Racially and Ethnically Diverse Population

BACKGROUND AND PURPOSE

Brain stimulation is an adjuvant strategy to promote rehabilitation after stroke. Here, we evaluated the influence of inclusion/exclusion criteria on enrollment in a transcranial direct current stimulation (tDCS) trial in the context of a racially/ethnically diverse acute stroke service at University of Texas Southwestern (UTSW).

METHODS

3124 (59.7 ± 14.5 years) racially/ethnically diverse (38.4% non-Hispanic white, (W), Hispanic (H) 22%, African American (AA) 33.5%, Asian (A) 2.3%) patients were screened in the acute stroke service at UTSW. Demographics, stroke characteristics, and reasons for exclusion were recorded prospectively.

RESULTS

2327 (74.5%) patients had a verified stroke. Only 44 of them (1.9%) were eligible. Causes for exclusion included in order of importance: (1) magnitude of upper extremity (UE) motor impairment, (2) prior strokes (s), (3) hemorrhagic stroke, (4) psychiatric condition or inability to follow instructions, and (5) old age, of these (2) and (4) were more common in AA patients but not in other minorities. 31 of the 44 eligible individuals were enrolled (W 1.68%, H 1.37%, AA .77%, A 3.774%). 90.5% of verified stroke patients did not exhibit contraindications for stimulation.

CONCLUSIONS

3 main conclusions emerged: (a) The main limitations for inclusion in brain stimulation trials of motor recovery were magnitude of UE motor impairments and stroke lesion characteristics, (b) most stroke patients could be stimulated with tDCS without safety concerns and (c) carefully tailored inclusion criteria could increase diversity in enrollment.Clinical Trial Registration-URL: http://clinicaltrials.gov. Unique identifier: NCT01007136.

Reporting Quality in Abstracts of Randomized Controlled Trials Published in High-Impact Occupational Therapy Journals

IMPORTANCE

Adequate reporting in the abstracts of randomized controlled trials (RCTs) is essential to enable occupational therapy practitioners to critically appraise the validity of findings.

OBJECTIVE

To evaluate the reporting quality and characteristics of RCT abstracts published between 2008 and 2018 in the occupational therapy journals with the five highest impact factors in 2018.

DESIGN

A descriptive cross-sectional study.

DATA SOURCES

The American Journal of Occupational Therapy (AJOT), Australian Occupational Therapy Journal (AOTJ), Canadian Journal of Occupational Therapy (CJOT), Scandinavian Journal of Occupational Therapy (SJOT), and Physical and Occupational Therapy in Pediatrics (POTP) were identified using a Web of Science search.

STUDY SELECTION AND DATA COLLECTION

We searched Scopus for abstracts in the five included journals. We used a 17-point scale based on the CONSORT for Abstracts (CONSORT-A) checklist to assess reporting quality. We also identified characteristics of the abstracts.

FINDINGS

Seventy-eight RCT abstracts were assessed and showed moderate to low adherence to the CONSORT-A checklist (Mdn = 8, interquartile range = 7-9). Abstracts of articles with authors from a higher number of institutions, European first authors, and >200 words had higher CONSORT-A scores. The most underreported CONSORT-A items were trial design, blinding, numbers analyzed, outcome (results), harms, trial registration, and funding.

CONCLUSIONS AND RELEVANCE

Between 2008 and 2018, the reporting quality in RCT abstracts from the five highest impact occupational therapy journals was moderate to low. Inadequate reporting in RCT abstracts raises the risk that occupational therapy practitioners will make ineffective clinical decisions based on misinterpretation of findings. What This Article Adds: Reporting quality in RCT abstracts in occupational therapy journals is moderate to low. Journal editors should require authors of RCTs to use the CONSORT-A checklist to promote optimal reporting and transparency in abstracts.

Impact of Gravity Compensation on Upper Extremity Movements in Harmony Exoskeleton

Robots have been used to offset the limb weight through gravity compensation in upper body rehabilitation to delineate the effects of loss of strength and loss of dexterity, which are two common forms of post-stroke impairments. In this paper, we explored the impact of this anti-gravity support on the quality of movement during reaching and coordinated arm movements in a pilot study with two participants with chronic stroke. The subjects donned the Harmony exoskeleton which supported proper shoulder coordination in addition to providing gravity compensation. Participants had previously taken part in seven one-hour sessions with the Harmony exoskeleton, performing six sets of passive-stretching and active exercises. Pre- and post-training sessions included assessments of two separate tasks, planar reaching and a set of six coordinated arm movements, in two conditions, outside of and supported by the exoskeleton. The movements were recorded using an optical motion capture system and analyzed using spectral arc length (SPARC) and straight line deviation to quantify movement smoothness and quality. We observed that gravity compensation resulted in an increased smoothness for the subject with high level of impairment whereas compensation resulted in a reduction in smoothness for the subject with low level of impairment in the reaching task. Both participants demonstrated better coordination of the shoulder-arm joint with gravity compensation. This result motivates further studies into the role of gravity compensation during coordinated movement training and rehabilitation interventions.