Kinematic and Clinical Analyses of Upper-Extremity Movements After Constraint-Induced Movement Therapy in Patients With Stroke: A Randomized Controlled Trial

Transcranial direct current stimulation over the motor and premotor cortex with mirror therapy improves motor control, muscle function, and brain activity in chronic stroke: a double-blind randomized sham-controlled trial

BACKGROUND

Transcranial direct current stimulation (tDCS) is a popular approach to augment the effects of neurorehabilitation. Most studies stimulated the ipsilesional primary motor cortex (iM1); nonetheless, the success of iM1 stimulation was variable, suggesting that it may not be optimal for improving recovery. Ipsilesional premotor cortex (iPMC) may be an alternative candidate based on its likelihood of survival post-stroke and its contribution to functions. This study aimed to determine the effects of tDCS on the iPMC and iM1 with mirror therapy (MT) on motor control, muscle function, and brain activity in chronic stroke.

METHODS

Thirty-six participants were randomly distributed into (1) iPMC-tDCS with MT (PMC) (2), iM1-tDCS with MT (M1), and (3) sham tDCS with MT (sham). Motor control was assessed using kinematics. Muscle function was assessed using the modified Ashworth and the Medical Research Council Scales. The M1 and PMC activity was recorded using electroencephalography (EEG), and the event-related desynchronization and the laterality index (LI) were examined.

RESULTS

Significant within-group differences were identified in the kinematic outcomes. After interventions, the PMC group showed reduced paretic upper limb muscle spasticity and improved paretic limb control with greater movement smoothness and peak velocity. The M1 group showed reduced trunk compensation with fewer trunk displacement and flexion. However, the sham group relied more on trunk compensation, demonstrating increased trunk peak velocity and smoothness. Significant between-group differences were also found in paretic limb control and trunk displacement. Post-hoc analysis revealed that the PMC group improved paretic limb control, and the M1 group showed reduced trunk displacement more than the sham group. Significant within-and between-group differences were identified in EEG outcomes. The iM1 and contralesional PMC (cPMC) activity increased from pre-to-post intervention in the M1 group. In contrast, the iM1 activity decreased, and the LI declined from pre- to post-intervention in the sham group. Significant group differences were found in the iM1 activity, with the PMC and M1 having greater iM1 activation than the sham group.

CONCLUSIONS

Differential treatment benefits were identified between iPMC- and iM1-tDCS with MT. iPMC-tDCS with MT uniquely improved paretic upper limb control with reduced muscle spasticity while iM1-tDCS with MT mitigated trunk compensation during reaching. These findings suggest that both iPMC- and iM1-tDCS could augment the effects of stroke neurorehabilitation and may be considered in clinical applications.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04655209. Registered on 15th November 2020. https://clinicaltrials.gov/study/NCT04655209 .

The Effect of Constraint-Induced Movement Therapy on Arm Function and Activities of Daily Living in Post-stroke Patients: A Systematic Review and Meta-Analysis

This meta-analysis aimed to evaluate the effect of constraint-induced movement therapy (CIMT) on arm function and daily living compared with conventional rehabilitation in stroke patients with hemiplegia. We searched three international electronic databases-MEDLINE, Embase, and the Cochrane Library-for relevant studies. The risk of bias was evaluated using Cochrane's Risk of Bias version 1.0, and the certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations method. A total of 34 randomized controlled trials (RCTs) were included herein. Specifically, 21 RCTs regarding arm motor function, 13 on upper limb motor impairment, and 12 on activities of daily living (ADL) performance were analyzed. The results of the meta-analysis demonstrated that CIMT was significantly more effective than conventional therapy in improving arm motor function, reducing upper limb motor impairment, and enhancing ADL performance. CIMT should be implemented and tailored to the strength of the affected upper limb to improve upper limb function and ADL performance in post-stroke patients with hemiplegia.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Facial and upper-limb movement abnormalities in individuals with psychotic-like experiences: a motion analysis study

Slow movements and irregular muscle contraction have been reported separately in different studies targeting individuals with psychotic-like experiences (PLEs). To date, it remains unknown whether these two movement abnormalities, possibly associated with hypo- and hyper-dopaminergia, respectively, co-existed in one sample with PLEs and interrelated in the early stage of psychotic progression. Therefore, this study was to examine if facial and upper-limb slow movements and irregular muscle contraction co-existed in individuals with PLEs, interrelated, and were associated with PLEs. A total of 26 individuals with PLEs, who were identified using the 16-item Prodromal Questionnaire, and 26 age- and gender-matched healthy controls received the facial and upper-limb movement measurement. A motion capture system was used to record the movement procedure and thus calculate kinematic variables that represented severity of slow movements and irregular muscle contraction. Results showed that facial and upper-limb slow movements and facial irregular muscle contraction existed in individuals with PLEs. For the total sample, slower facial movements were associated with less regular facial muscle contraction; slower upper-limb movements were associated with less regular upper-limb muscle contraction. Slower and less regular facial and upper-limb movements were associated with more severe PLEs. Compensatory changes in dopaminergic neural pathways in response to elevated dopamine might explain connection between slow movements and irregular muscle contraction. Because of the ability to detect facial and upper-limb movement abnormalities objectively and sensitively, motion analysis has great applicability to sensorimotor studies for people in the psychosis continuum.

Effect of different constraint-induced movement therapy protocols on recovery of stroke survivors with upper extremity dysfunction: a systematic review and network meta-analysis

We aimed to assess and rank comparative efficacy of different constraint-induced movement therapy (CIMT) protocols on motor function of upper extremity and activities of daily living (ADL) in stroke survivors. A comprehensive search was conducted in PubMed, EMBASE, Web of Science and Cochrane Library to identify randomized controlled trials on CIMT. Included studies were evaluated using the revised Cochrane risk of bias tool. Then a random-effects network meta-analysis was performed within a frequentist framework using Stata v16.0. Of the 1150 studies retrieved, 44 studies with 1779 participants were included. In terms of motor recovery of upper extremity, CIMT combined with trunk restraint, in which the less affected arm was constrained at least 4 h but no more than 6 h per day, ranked as the most effective intervention for the improvement of the Fugl-Meyer Assessment-Upper Extremity and the Action Research Arm Test score. In terms of ADL improvement, constraining the less affected arm for at least 4 h but no more than 6 h per day in CIMT combined with trunk restraint, was found to significantly improve the Motor Activity Log of quality of movement scale and amount of use scale score. The protocol of CIMT combined with trunk restraint, in which the less affected arm was constrained at least 4 h but no more than 6 h per day, ranked the highest in this analysis and might be considered in practice.

Timing and Dose of Constraint-Induced Movement Therapy after Stroke: A Systematic Review and Meta-Regression

The aim of this study is to investigate the effects of constraint-induced movement therapy on stroke patients who had intact cognition and some voluntary finger extension and to identify optimal protocols to apply this therapy method. We searched PubMed, Cochrane Library, and Embase for randomized controlled trials conducted prior to January 2022. The outcomes included the Motor Activity Log, Fugl-Meyer Assessment, and Wolf Motor Function Test. The inverse variance method fixed-effect model as well as the DerSimonian and Laird estimator random-effects model were applied, and the mean difference was calculated with 95% confidence interval to measure continuous outcomes. Six randomized controlled trials involving a total of 169 patients with stroke were enrolled. Compared with conventional rehabilitation methods, there was no significant effect of constraint-induced movement therapy when evaluated by the Motor Activity Log, including the amount of use (random-effect, standardized mean difference 0.65; 95%, confidence interval: −0.23–1.52) and quality of movement (random-effect, standardized mean difference 0.60; 95% confidence interval: −0.19–1.39). However, among patients with chronic stroke symptoms, meta-regression analyses showed better performance with a constraint time of at least 6 h per day and 6 h training per week when assessing the amount of use (p = 0.0035) and quality of movement (p = 0.0031). Daily intervention time did not lead to a significant difference in functional upper limb performance. An efficient protocol of constraint-induced movement therapy designed as 6 h of training per week with 6 h constraint per day could bring significant stroke symptom improvement to patients with chronic stroke.

Early transcranial direct current stimulation with modified constraint-induced movement therapy for motor and functional upper limb recovery in hospitalized patients with stroke: A randomized, multicentre, double-blind, clinical trial

BACKGROUND

Constraint-induced movement therapy (CIMT) and transcranial direct current stimulation (tDCS) are used to reduce interhemispheric imbalance after stroke, which is why the combination of these therapies has been used for neurological recovery, but not in the acute phase.

OBJECTIVES

To evaluate the effectiveness of combining active or sham bihemispheric tDCS with modified CIMT (mCIMT) for the recovery of the Upper Limb (UL) in hospitalized patients with acute and subacute stroke.

METHODS

This randomized controlled, double-blind, placebo-controlled, parallel group clinical trial was executed between September 2018 to March 2021 recruited 70 patients. The patients were randomized to one of two groups to receive treatment for 7 consecutive days, which included 20 min of active or sham bihemispheric tDCS daily (anodal ipsilesional and cathodal contralesional), with an mCIMT protocol. The primary outcome was the difference in the evolution of motor and functional upper limb recovery with assessment on days 0, 5, 7, 10 and 90. The secondary outcomes were independence in activities of daily living (ADL) and quality of life.

RESULTS

The active group presented a statistically significant gap compared to the simulated group throughout the trend in the scores of the FMA (motor function and joint pain) and WMFT (functional ability and weight to box) (p < 0.05) and showed a minimal clinically important difference (FMA: difference between groups of 4.9 points [CI: 0.007- 9.799]; WMFT: difference between groups of 6.54 points [CI: 1.10-14.15]). In the secondary outcomes, there was a significant difference between the groups in ADL independence (Functional Independence Measure: difference of 8.63 [CI: 1.37-18.64]) and perceived recovery of quality of life evaluated at 90 days (p = 0.0176).

CONCLUSIONS

Combining mCIMT with bihemispheric tDCS in patients hospitalized with acute-subacute stroke allows us to maximize the motor and functional recovery of the paretic upper limb in the early stages and independence in ADL, maintaining the effects over time.

Feasibility and acceptability of novel functional electronic stimulated rehabilitation application for treatment in patients with cerebrovascular disorders: the FRAT study protocol

Background

The prognosis of patients with cerebrovascular disorders is poor owing to their high residual rate of hemiplegia. Delayed withdrawal from synkinesis is a major cause of prolonged hemiplegia; however, effective rehabilitation has not been established. This single-arm, open-label study aims to evaluate the influence of a low-frequency treatment device on canceling synkinesis in patients with incomplete paralysis and cerebrovascular disorders.

Methods

Eligible participants will include patients aged 20 years or older with incomplete paralysis, defined as upper limb Brunnstrom stage (BRS) of 2–4, who are within 1 month of onset of a cerebrovascular disorder. Qualified patients will be assigned to the novel rehabilitation treatment with IVES+ for 4 weeks. The primary endpoint of the study is the change from baseline in the upper-limb Fugl-Meyer Assessment (FMA) 2 weeks after the start of treatment. The secondary endpoints are changes in the amount of Functional Independence Measure, changes in the amount of upper-limb BRS, and changes in the amount of Barthel Index (BI) compared to the pre-intervention value at weeks 2 and 4; changes in the upper-limb FMA scores at 1, 3, and 4 weeks; changes in grip strength compared to the pre-intervention values at 1, 2, 3, and 4 weeks; and changes in upper-limb strength (manual muscle test) compared to the pre-intervention values at 1, 2, 3, and 4 weeks.

Discussion

This study will explore the usefulness of IVES+ for recovery from motor paralysis in patients with cerebrovascular disorders.

Trial registration

Japanese Clinical Registry, jRCTs052180226. Date of registration: February 1, 2022

Rhythmic auditory stimulation incorporated in training improved movements in individuals with psychotic-like experiences

Movement abnormalities, including movement slowing and irregular muscle contraction, exist in individuals with psychotic-like experiences (PLEs) and serve as vulnerable factors of developing psychotic diseases in the psychosis continuum. To date scarce studies have developed early intervention programs tackling these initial impairments, which may be caused by basal ganglia alterations, in the early stage of the psychosis course. Rhythmic auditory stimulation (RAS) is a technique of neurological music therapy and has been proved effective in inducing faster movements in patients with psychotic diseases. This pilot study examined if RAS incorporated in functional movement training reduced severity of movement slowing and irregular muscle contraction in individuals with PLEs. Seventeen individuals with PLEs were randomly allocated to receiving RAS or receiving no RAS and underwent daily 40-min movement training (picking up beans) for three weeks. This study used motion analysis to measure movement performance at pretest and posttest. Eighteen age- and gender-matched individuals without PLEs were also recruited to provide data of intact movements. Results showed that RAS may reduce severity of movement slowing and irregular muscle contraction in individuals with PLEs. This pilot study is one of the pioneering studies validating effectiveness of early intervention programs tackling movement abnormalities, which are initial impairments in the psychosis continuum, in individuals with PLEs.

Characterization of stroke-related upper limb motor impairments across various upper limb activities by use of kinematic core set measures

Background

Upper limb kinematic assessments provide quantifiable information on qualitative movement behavior and limitations after stroke. A comprehensive characterization of spatiotemporal kinematics of stroke subjects during upper limb daily living activities is lacking. Herein, kinematic expressions were investigated with respect to different movement types and impairment levels for the entire task as well as for motion subphases.

Method

Chronic stroke subjects with upper limb movement impairments and healthy subjects performed a set of daily living activities including gesture and grasp movements. Kinematic measures of trunk displacement, shoulder flexion/extension, shoulder abduction/adduction, elbow flexion/extension, forearm pronation/supination, wrist flexion/extension, movement time, hand peak velocity, number of velocity peaks (NVP), and spectral arc length (SPARC) were extracted for the whole movement as well as the subphases of reaching distally and proximally. The effects of the factors gesture versus grasp movements, and the impairment level on the kinematics of the whole task were tested. Similarities considering the metrics expressions and relations were investigated for the subphases of reaching proximally and distally between tasks and subgroups.

Results

Data of 26 stroke and 5 healthy subjects were included. Gesture and grasp movements were differently expressed across subjects. Gestures were performed with larger shoulder motions besides higher peak velocity. Grasp movements were expressed by larger trunk, forearm, and wrist motions. Trunk displacement, movement time, and NVP increased and shoulder flexion/extension decreased significantly with increased impairment level. Across tasks, phases of reaching distally were comparable in terms of trunk displacement, shoulder motions and peak velocity, while reaching proximally showed comparable expressions in trunk motions. Consistent metric relations during reaching distally were found between shoulder flexion/extension, elbow flexion/extension, peak velocity, and between movement time, NVP, and SPARC. Reaching proximally revealed reproducible correlations between forearm pronation/supination and wrist flexion/extension, movement time and NVP.

Conclusion

Spatiotemporal differences between gestures versus grasp movements and between different impairment levels were confirmed. The consistencies of metric expressions during movement subphases across tasks can be useful for linking kinematic assessment standards and daily living measures in future research and performing task and study comparisons.

Trial registration: ClinicalTrials.gov Identifier NCT03135093. Registered 26 April 2017, https://clinicaltrials.gov/ct2/show/NCT03135093.

An Instrumental Measure of Hand and Facial Movement Abnormalities in Patients With Schizophrenia

INTRODUCTION

Movement disorders have been suggested to be a cardinal component of schizophrenia. With increased research interests in this area, instrumental measures are needed. This study was to examine if the motion capture system was reliable in measuring hand and facial bradykinesia and dyskinesia and more sensitive to detecting movement differences between schizophrenia patients and healthy people than traditional rating scales.

METHODS

Sixteen schizophrenia patients and 20 control subjects were recruited. Hand and facial bradykinesia and dyskinesia were measured using the motion capture system and rated using the Extrapyramidal Symptom Rating Scale and the Abnormal Involuntary Movement Scale.

RESULTS

The system showed strong test-retest reliability and generated larger effect sizes of group differences than did the rating scales.

CONCLUSIONS

The results may support researchers and clinical practitioners to apply the system to sensitively measuring the hand and facial movement symptoms in schizophrenia patients, which contributes to gaining a deep understanding of movement issues in schizophrenia.

Responsiveness of kinematic and clinical measures of upper-limb motor function after stroke: A systematic review and meta-analysis

BACKGROUND

Kinematic analysis and clinical outcome measures with established responsiveness contribute to the quantified assessment of upper-limb function post-stroke, the selection of interventions and the differentiation of motor recovery patterns.

OBJECTIVE

This systematic review and meta-analysis aimed to report trends in use and compare the responsiveness of kinematic and clinical measures in studies measuring the effectiveness of constraint-induced movement, trunk restraint and bilateral arm therapies for upper-limb function after stroke.

METHODS

In this systematic review, randomised controlled trials implementing kinematic analysis and clinical outcome measures to evaluate the effects of therapies in post-stroke adults were eligible. We searched 8 electronic databases (MEDLINE, EMBASE, Web of Science, Scopus, CINAHL, CENTRAL, OTseeker and Pedro). Risk of bias was assessed according to the Cochrane Risk of Bias domains. A meta-analysis was conducted for repeated design measures of pre- and post-test data providing estimated standardised mean differences (SMDs).

RESULTS

We included reports of 12 studies (191 participants) reporting kinematic smoothness, movement duration and efficiency, trunk and shoulder range of motion, control strategy and velocity variables in conjunction with assessment by Motor Activity Log, Fugl-Meyer Assessment and Wolf Motor Function Test. Responsiveness was higher (i.e., non-overlap of 95% confidence intervals [CIs]) for Motor Activity Log score (SMD for amount of use 1.0, 95% CI 0.75-1.25, P<0.001; SMD for quality of movement 0.96, 95% CI 0.72-1.20, P<0.001) than movement efficiency, trunk and shoulder range of motion, control strategy and peak velocity.

CONCLUSION

These results are consistent with current literature supporting the use of combined kinematic and clinical measures for comprehensive and accurate evaluation of upper-limb function post-stroke. Future research should include other design trials and rehabilitation types to confirm these findings, focusing on subgroup analysis of type of rehabilitation intervention and functional levels.

The Effects of Unilateral Versus Bilateral Motor Training on Upper Limb Function in Adults with Chronic Stroke: A Systematic Review

OBJECTIVES

Rehabilitation goals for chronic stroke patients are largely focused around regaining functional ability and independence, with particular focus on upper limb motor function. Unilateral and Bilateral motor training may help achieve this. Our objective was to evaluate and compare the effects of unilateral and bilateral motor training on upper limb motor function in chronic stroke patients.

MATERIALS AND METHODS

A comprehensive literature search was conducted until June 2020 through several electronic databases (CENTRAL, Medline, CINAHL, EBSCO, AMED and PEDro) to identify relevant studies. Studies that used the Fugl Meyer Assessment (FMA) as a minimum, to assess upper limb motor function following unilateral versus bilateral training in chronic stroke patients, qualified for inclusion within the review. Randomised controlled trial (RCT), cohort study and cross-sectional study designs were considered. The Cochrane risk of bias tool was used to assess Randomised Controlled Trials (RCTs). The findings were qualitatively synthesised.

RESULTS

From a total of 838 studies identified, 7 RCTs were included in this review. All except one of the studies included reported an unclear risk of bias, with one low risk of bias reported. Overall, the studies reported that unilateral and bilateral training improved upper limb function in chronic stroke patients. Improvements between interventions were equivocal. Bilateral upper limb training however may be more efficacious for increasing upper limb strength and quality of movement, with unilateral training more beneficial for recovering functional ability for activities of daily living.

CONCLUSION

While the findings of the included studies support the use of unilateral and bilateral motor training post chronic stroke, the seven studies that were included methodologically all presented with limitations, hence strong conclusions cannot be drawn and further research is warranted.

Patterns of enhancement in paretic shoulder kinematics after stroke with musical cueing

Musical cueing has been widely utilised in post-stroke motor rehabilitation; however, the kinematic evidence on the effects of musical cueing is sparse. Further, the element-specific effects of musical cueing on upper-limb movements have rarely been investigated. This study aimed to kinematically quantify the effects of no auditory, rhythmic auditory, and melodic auditory cueing on shoulder abduction, holding, and adduction in patients who had experienced hemiparetic stroke. Kinematic data were obtained using inertial measurement units embedded in wearable bands. During the holding phase, melodic auditory cueing significantly increased the minimum Euler angle and decreased the range of motion compared with the other types of cueing. Further, the root mean square error in the angle measurements was significantly smaller and the duration of movement execution was significantly shorter during the holding phase when melodic auditory cueing was provided than when the other types of cueing were used. These findings indicated the important role of melodic auditory cueing for enhancing movement positioning, variability, and endurance. This study provides the first kinematic evidence on the effects of melodic auditory cueing on kinematic enhancement, thus suggesting the potential use of pitch-related elements in psychomotor rehabilitation.

iRebot: An Interactive Rehabilitation Robot with Gesture Control

Physical therapy efficacy relies on patient compliance and motivation. However, the monotony, intensity, and expense of most therapy routines do not promote engagement. Technology-based rehabilitation has the potential to provide engaging and cost-effective treatment, leading to better compliance and mobility outcomes. We present an interactive rehabilitation robot (iRebot) as an affordable, gesture-controlled vehicle that can provide a form of entertainment while conducting physical therapy. Healthy participants (n=11) executed a test maze with the iRebot for six repeated trials, three with each hand. Survey scores and quantitative metrics were evaluated to assess system usability and baseline motor performance, respectively. Wrist mobility across participants was evaluated, with an active range of motion of 39.7± 13° and 72.8± 18° for pitch and roll, respectively. In the course of conducting a single trial (time duration=87.2±67 sec), the participants performed on average 30 full wris t motion repetitions (e.g., flexion/extension). Participants rated the system's usability as excellent (survey score: 85 ± 13), and all participants indicated they would prefer iRebot over standard therapy. The iRebot demonstrated potential as an evidence-based rehabilitation tool based on excellent user ratings and the ability to monitor at- home compliance and motor performance.

Early non-invasive brain stimulation with modified constraint-induced movement therapy for motor and functional upper limb recovery in stroke patients: Study protocol

Introduction

Upper limb motor impairment after a stroke is an important sequela. Constraint-induced movement therapy is a rehabilitation approach that has strong evidence. The incorporation of transcranial direct-current stimulation has been proposed; however, there is a lack of studies that confirm its benefits. The principal aim is to compare the effectiveness of 7 days of active versus sham bi-hemispheric transcranial direct-current stimulation, combined with modified constraint-induced movement therapy, for motor and functional recovery of the hemiparetic upper limb in subacute stroke patients.

Method/design

Randomized, double blind, sham-controlled, parallel group clinical trial in two stroke units. Participants: adults over 18 years, at least 2 days post unihemispheric stroke event, with hemiparesis, and without severe pain, aphasia or cognitive impairment. Intervention: Patients will receive 7 days of continuous therapy and be assigned to one of the treatment groups: active bi-hemispheric transcranial direct-current stimulation or sham bi-hemispheric transcranial direct-current stimulation. Measurement: Evaluations will take place at days 0, 5, 7 and 10, and at 3rd months. The Fugl-Meyer Assessment – Upper Extremity, Wolf Motor Function Test, Functional Independence Measure and Stroke Impact Scale are considered.

Discussion

Modified constraint-induced movement therapy plus transcranial direct-current stimulation in subacute stroke patients with hemiparesis could maximize motor and functional recovery. Trial registration: ClinicalTrials.gov identifier NCT03452254.

A Gesture-Controlled Rehabilitation Robot to Improve Engagement and Quantify Movement Performance

Rehabilitation requires repetitive and coordinated movements for effective treatment, which are contingent on patient compliance and motivation. However, the monotony, intensity, and expense of most therapy routines do not promote engagement. Gesture-controlled rehabilitation has the potential to quantify performance and provide engaging, cost-effective treatment, leading to better compliance and mobility. We present the design and testing of a gesture-controlled rehabilitation robot (GC-Rebot) to assess its potential for monitoring user performance and providing entertainment while conducting physical therapy. Healthy participants (n = 11) completed a maze with GC-Rebot for six trials. User performance was evaluated through quantitative metrics of movement quality and quantity, and participants rated the system usability with a validated survey. For participants with self-reported video-game experience (n = 10), wrist active range of motion across trials (mean ± standard deviation) was 41.6 ± 13° and 76.8 ± 16° for pitch and roll, respectively. In the course of conducting a single trial with a time duration of 68.3 ± 19 s, these participants performed 27 ± 8 full wrist motion repetitions (i.e., flexion/extension), with a dose-rate of 24.2 ± 5 reps/min. These participants also rated system usability as excellent (score: 86.3 ± 12). Gesture-controlled therapy using the GC-Rebot demonstrated the potential to be an evidence-based rehabilitation tool based on excellent user ratings and the ability to monitor at-home compliance and performance.

Combined effects of Telehealth and Modified Constraint-Induced Movement Therapy for Individuals with Chronic Hemiparesis

Telehealth use allows improved access to services and results in potential cost savings. The purpose of this study was to examine the effectiveness of a combined modified Constrained Induced Movement Therapy (mCIMT) program using telehealth and in-person sessions, for participants with higher (Group 1) and lower (Group 2) functional ability of the hemiparetic upper extremity. Using a pre-experimental design with a 6-week intervention, 28 participants were assessed twice on use of upper extremity via subjective and objective measures. For the Motor Activity Log, the amount of use and quality of use were significant for Groups 1 and 2. Significant improvements were shown on the Wolf Motor Function Test (WMFT), the Fugl-Meyer UE, and the Functional Independence Measure (FIM) for both groups except for the strength subtest on the WMFT and the timed portion for Group 1. Percentages of attendance for telehealth and in-person sessions were also compared. Telehealth sessions had a higher attendance rate (84.5%) than in-person sessions (75.3%) (p=.004). The combined mCIMT program of telerehabilitation and in-person group sessions was effective in improving functional ability after a stroke.

Pragmatic Solutions for Stroke Recovery and Improved Quality of Life in Low- and Middle-Income Countries-A Systematic Review

Background: Given the limited healthcare resources in low and middle income countries (LMICs), effective rehabilitation strategies that can be realistically adopted in such settings are required. Objective: A systematic review of literature was conducted to identify pragmatic solutions and outcomes capable of enhancing stroke recovery and quality of life of stroke survivors for low- and middle- income countries. Methods: PubMed, HINARI, and Directory of Open Access Journals databases were searched for published Randomized Controlled Trials (RCTs) till November 2018. Only completed trials published in English with non-pharmacological interventions on adult stroke survivors were included in the review while published protocols, pilot studies and feasibility analysis of trials were excluded. Obtained data were synthesized thematically and descriptively analyzed. Results: One thousand nine hundred and ninety six studies were identified while 347 (65.22% high quality) RCTs were found to be eligible for the review. The most commonly assessed variables (and outcome measure utility) were activities of daily living [75.79% of the studies, with Barthel Index (37.02%)], motor function [66.57%; with Fugl Meyer scale (71.88%)], and gait [31.12%; with 6 min walk test (38.67%)]. Majority of the innovatively high technology interventions such as robot therapy (95.24%), virtual reality (94.44%), transcranial direct current stimulation (78.95%), transcranial magnetic stimulation (88.0%) and functional electrical stimulation (85.00%) were conducted in high income countries. Several traditional and low-cost interventions such as constraint-induced movement therapy (CIMT), resistant and aerobic exercises (R&AE), task oriented therapy (TOT), body weight supported treadmill training (BWSTT) were reported to significantly contribute to the recovery of motor function, activity, participation, and improvement of quality of life after stroke. Conclusion: Several pragmatic, in terms of affordability, accessibility and utility, stroke rehabilitation solutions, and outcome measures that can be used in resource-limited settings were found to be effective in facilitating and enhancing post-stroke recovery and quality of life.

Effects of robot therapy on upper body kinematics and arm function in persons post stroke: a pilot randomized controlled trial

BACKGROUND

Robot-based rehabilitation for persons post-stroke may improve arm function and daily-life activities as measured by clinical scales, but its effects on motor strategies during functional tasks are still poorly investigated. This study aimed at assessing the effects of robot-therapy versus arm-specific physiotherapy in persons post-stroke on motor strategies derived from upper body instrumented kinematic analysis, and on arm function measured by clinical scales.

METHODS

Forty persons in the sub-acute and chronic stage post-stroke were recruited. This sample included all those subjects, enrolled in a larger bi-center study, who underwent instrumented kinematic analysis and who were randomized in Center 2 into Robot (R_Group) and Control Group (C_Group). R_Group received robot-assisted training. C_Group received arm-specific treatment delivered by a physiotherapist. Pre- and post-training assessment included clinical scales and instrumented kinematic analysis of arm and trunk during a virtual untrained task simulating the transport of an object onto a shelf. Instrumented outcomes included shoulder/elbow coordination, elbow extension and trunk sagittal compensation. Clinical outcomes included Fugl-Meyer Motor Assessment of Upper Extremity (FM-UE), modified Ashworth Scale (MAS) and Functional Independence Measure (FIM).

RESULTS

R_Group showed larger post-training improvements of shoulder/elbow coordination (Cohen's d = - 0.81, p = 0.019), elbow extension (Cohen's d = - 0.71, p = 0.038), and trunk movement (Cohen's d = - 1.12, p = 0.002). Both groups showed comparable improvements in clinical scales, except proximal muscles MAS that decreased more in R_Group (Cohen's d = - 0.83, p = 0.018). Ancillary analyses on chronic subjects confirmed these results and revealed larger improvements after robot-therapy in the proximal portion of FM-UE (Cohen's d = 1.16, p = 0.019).

CONCLUSIONS

Robot-assisted rehabilitation was as effective as arm-specific physiotherapy in reducing arm impairment (FM-UE) in persons post-stroke, but it was more effective in improving motor control strategies adopted during an untrained task involving vertical movements not practiced during training. Specifically, robot therapy induced larger improvements of shoulder/elbow coordination and greater reduction of abnormal trunk sagittal movements. The beneficial effects of robot therapy seemed more pronounced in chronic subjects. Future studies on a larger sample should be performed to corroborate present findings.

TRIAL REGISTRATION

www.ClinicalTrials.gov NCT03530358. Registered 21 May 2018. Retrospectively registered.

Constraint-Induced Movement Therapy in multiple sclerosis: Safety and three-dimensional kinematic analysis of upper limb activity. A randomized single-blind pilot study

BACKGROUND

There are few evidences on safety of Constraint-Induced Movement Therapy (CIMT), as well as its effects in neurological conditions, including multiple sclerosis (MS).

OBJECTIVE

To evaluate safety and effectiveness of a 2-week CIMT protocol on upper limb activity of progressive MS patients through a three-dimensional (3D) kinematic analysis.

METHODS

In this randomized single-blind pilot study, we randomly allocated patients affected by progressive MS reporting a reduced use of one upper limb into two different groups: CIMT group (less affected limb blocked by a splint) and control group (undergoing bi-manual treatment). Primary outcome was CIMT safety. Furthermore, we assessed CIMT effects through clinical outcomes (hand grip strength, HGS, and 9 Hole Peg Test, 9HPT) and 3D kinematic analysis (normalized jerk, number of movement units, going phase duration, mean velocity, endpoint error). All evaluations were performed at baseline (T0) and after 2 weeks of treatment (T1) for both arms in both groups.

RESULTS

Ten MS patients, mean aged 51.0±7.7 years, were randomly allocated in the 2 groups. After treatment, no differences were found in the blocked arm. Furthermore, CIMT group showed significant improvements in clinical and kinematic parameters.

CONCLUSIONS

CIMT might be considered a safe and effective technique in MS patients.

Improvement of Upper Limb Motor Control and Function After Competitive and Noncompetitive Volleyball Exercises in Chronic Stroke Survivors: A Randomized Clinical Trial

OBJECTIVES

To investigate the effects of competitive and noncompetitive volleyball exercises on the functional performance and motor control of the upper limbs in chronic stroke survivors.

DESIGN

Randomized clinical trial.

SETTING

Outpatient rehabilitation center.

PARTICIPANTS

Chronic stroke survivors (N=48).

INTERVENTIONS

Participants were randomly assigned to competitive (n=16) or noncompetitive (n=16) volleyball exercise groups (60min/d volleyball exercise+30min/d traditional rehabilitation, 3d/wk for 7wk) and control group (n=16).

MAIN OUTCOME MEASURES

Reach and grasp motor control measures were evaluated through kinematic analysis. Functional outcomes were assessed via Motor Activity Log, Wolf Motor Function Test (WMFT), Box and Block Test, and Wrist Position Sense Test.

RESULTS

Significant improvement of functional performance was observed in both competitive (P<.0001) and noncompetitive volleyball exercise groups (P<.01), but not in the control group (P>.05), with the exception of WMFT score. Volleyball training, in general, resulted in more efficient spatiotemporal control of reach and grasp functions, as well as less dependence on feedback control as compared to the control group. Moreover, the competitive volleyball exercise group exhibited greater improvement in both functional performance and motor control levels.

CONCLUSIONS

Volleyball team exercises, especially in a competitive format, resulted in enhancing the efficacy of the preprogramming and execution of reach and grasp movements, as well as a shift from feedback to feedforward control of the affected upper limb in chronic stroke survivors. This may well be a potential underlying mechanism for improving functional performance.

Recovery of kinematic arm function in well-performing people with subacute stroke: a longitudinal cohort study

BACKGROUND

Most motor function improvements in people who have experienced strokes occur within the first 3 months. However, individuals showing complete or nearly complete arm function recovery, as assessed using clinical scales, still show certain movement kinematic deficits at 3 months, post-stroke. This study evaluated the changes in upper extremity kinematics, in individuals demonstrating minor clinical motor impairments, 3-12 months post-stroke, and also examined the association between kinematics and the subjects's self-perceived hand abilities during the chronic stage, 12 months post-stroke.

METHODS

Forty-two subjects recovering from strokes and having Fugl-Meyer upper extremity motor assessment scores ≥60 were included from the Stroke Arm Longitudinal Study at the University of Gothenburg (SALGOT). Kinematic analyses of a drinking task, performed 3, 6, and 12 months post-stroke, were compared with kinematic analyses performed in 35 healthy controls. The Stroke Impact Scale-Hand domain was evaluated at the 12-month follow-up.

RESULTS

There were no significant changes in kinematic performance between 3 and 12 months, post-stroke. The patients recovering from stroke showed lower peak elbow extension velocities, and increased shoulder abduction and trunk displacement during drinking than did healthy controls, at all time points. At 12 months, post-stroke, better self-perceived arm functions correlated with improved trunk displacements, movement times, movement units, and time to peak velocity percentages.

CONCLUSION

Kinematic movement deficits, observed at 3 months post-stroke, remained unchanged at 12 months. Movement kinematics were associated with the patient's self-perceived ability to use their more affected hand.

TRIAL REGISTRATION

ClinicalTrials: NCT01115348 .

Effects of object size and distance on reaching kinematics in patients with schizophrenia

BACKGROUND/OBJECTIVE

Patients with schizophrenia not only have psychiatric symptoms, but also have movement problems, which might also be associated with their reduced quality of life. Little is known about how to improve their movement performance for patients. Manipulating object size and distance is common in occupational therapy practice to evaluate and optimize reaching performance in patients with physical disabilities, but effects of the manipulation in patients with schizophrenia remain unclear. The purpose of this study was to examine whether object size and distance could change performance of reaching kinematics in patients with mild schizophrenia.

METHODS

Twenty-nine patients with mild schizophrenia and 15 age- and gender-matched healthy controls were required to reach for, as quickly as possible, a small or large object that was placed at a near or far distance. We measured movement time, peak velocity, path length ratio, percentage of time to peak velocity, and movement units to infer movement speed, forcefulness, spatial efficiency (directness), control strategies, and smoothness.

RESULTS

Patients' reaching movements were slower (p = .017) and less direct (p = .007) than those of controls. A larger object induced faster (p = .016), more preprogrammed (p = .018), and more forceful (p = .010) movements in patients. A farther object induced slower, more feedback dependent, but more forceful and more direct movements (all p < .001).

CONCLUSION

The results of kinematic deficiencies suggest the need of movement training for patients with mild schizophrenia. Occupational therapists may grade or adapt reaching activities by changing object size and distance to enhance movement performance in patients with schizophrenia.

Neurophysiological effects of constraint-induced movement therapy and motor function: A systematic review

Background/Aims:

There is a claim that improvements in motor function in people with stroke following constraint-induced movement therapy (CIMT) is due to compensation but not actually neurorestoration. However, few studies have demonstrated improvements in neurophysiological outcomes such as increased motor map size and activation of primary cortex, or their positive correlations with motor function, following CIMT. The aim of this study was to carry out a systematic review of CIMT trials using neurophysiological outcomes, and a meta-analysis of the relationship between the neurophysiological outcomes and motor function.

Methods:

The PubMed, PEDro and CENTRAL databases, as well as the reference lists of the included studies, were searched. The included studies were randomised controlled trials comparing the effect of CIMT on neurophysiological outcomes compared with other rehabilitation techniques, conventional therapy, or another variant of CIMT. Methodological quality was assessed using the PEDro scale. The data extracted from the studies were sample size, eligibility criteria, dose of intervention and control, outcome measurements, and time since stroke.

Findings:

A total of 10 articles (n=219) fulfilled the study inclusion criteria, all of which were used for narrative synthesis, and four studies were used in the meta-analysis. The methodological quality of the studies ranged from low to high. Strong, positive, and significant correlations were found between the neurophysiological and motor function outcomes in fixed effects (z=3.268, p=0.001; r=0.52, 95% confidence interval (CI) 0.227–0.994) and random-effects (z=2.106, p=0.035; r=0.54, 95% CI 0.0424–0.827) models.

Conclusions:

Randomised controlled trials evaluating the effects of CIMT on neurophysiological outcomes are few in number. Additionally, these studies used diverse outcomes, which makes it difficult to draw any meaningful conclusion. However, there is a strong positive correlation between neurophysiological and motor function outcomes in these studies.

Rehabilitation of Upper Limb in Children with Acquired Brain Injury: A Preliminary Comparative Study

Acquired brain injuries (ABIs) can lead to a wide range of impairments, including weakness or paralysis on one side of the body known as hemiplegia. In hemiplegic patients, the rehabilitation of the upper limb skills is crucial, because the recovery has an immediate impact on patient quality of life. For this reason, several treatments were developed to flank physical therapy (PT) and improve functional recovery of the upper limbs. Among them, Constraint-Induced Movement Therapy (CIMT) and robot-aided therapy have shown interesting potentialities in the rehabilitation of the hemiplegic upper limb. Nevertheless, there is a lack of quantitative evaluations of effectiveness in a standard clinical setting, especially in children, as well as a lack of direct comparative studies between these therapeutic techniques. In this study, a group of 18 children and adolescents with hemiplegia was enrolled and underwent intensive rehabilitation treatment including PT and CIMT or Armeo®Spring therapy. The effects of the treatments were assessed using clinical functional scales and upper limb kinematic analysis during horizontal and vertical motor tasks. Results showed CIMT to be the most effective in terms of improved functional scales, while PT seemed to be the most significant in terms of kinematic variations. Specifically, PT resulted to have positive influence on distal movements while CIMT conveyed more changes in the proximal kinematics. Armeo treatment delivered improvements mainly in the vertical motor task, showing trends of progresses of the movement efficiency and reduction of compensatory movements of the shoulder with respect to other treatments. Therefore, every treatment gave advantages in a specific and different upper limb district. Therefore, results of this preliminary study may be of help to define the best rehabilitation treatment for each patient, depending on the goal, and may thus support clinical decision.

Effects of somatosensory electrical stimulation on motor function and cortical oscillations

Background

Few patients recover full hand dexterity after an acquired brain injury such as stroke. Repetitive somatosensory electrical stimulation (SES) is a promising method to promote recovery of hand function. However, studies using SES have largely focused on gross motor function; it remains unclear if it can modulate distal hand functions such as finger individuation.

Objective

The specific goal of this study was to monitor the effects of SES on individuation as well as on cortical oscillations measured using EEG, with the additional goal of identifying neurophysiological biomarkers.

Methods

Eight participants with a history of acquired brain injury and distal upper limb motor impairments received a single two-hour session of SES using transcutaneous electrical nerve stimulation. Pre- and post-intervention assessments consisted of the Action Research Arm Test (ARAT), finger fractionation, pinch force, and the modified Ashworth scale (MAS), along with resting-state EEG monitoring.

Results

SES was associated with significant improvements in ARAT, MAS and finger fractionation. Moreover, SES was associated with a decrease in low frequency (0.9-4 Hz delta) ipsilesional parietomotor EEG power. Interestingly, changes in ipsilesional motor theta (4.8–7.9 Hz) and alpha (8.8–11.7 Hz) power were significantly correlated with finger fractionation improvements when using a multivariate model.

Conclusions

We show the positive effects of SES on finger individuation and identify cortical oscillations that may be important electrophysiological biomarkers of individual responsiveness to SES. These biomarkers can be potential targets when customizing SES parameters to individuals with hand dexterity deficits. Trial registration: NCT03176550; retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12984-017-0323-1) contains supplementary material, which is available to authorized users.

Motor compensation and its effects on neural reorganization after stroke

Stroke instigates a dynamic process of repair and remodelling of remaining neural circuits, and this process is shaped by behavioural experiences. The onset of motor disability simultaneously creates a powerful incentive to develop new, compensatory ways of performing daily activities. Compensatory movement strategies that are developed in response to motor impairments can be a dominant force in shaping post-stroke neural remodelling responses and can have mixed effects on functional outcome. The possibility of selectively harnessing the effects of compensatory behaviour on neural reorganization is still an insufficiently explored route for optimizing functional outcome after stroke.

Parameters and Measures in Assessment of Motor Learning in Neurorehabilitation; A Systematic Review of the Literature

Upper limb function, essential for daily life, is often impaired in individuals after stroke and cerebral palsy (CP). For an improved upper limb function, learning should occur, and therefore training with motor learning principles is included in many rehabilitation interventions. Despite accurate measurement being an important aspect for examination and optimization of treatment outcomes, there are no standard algorithms for outcome measures selection. Moreover, the ability of the chosen measures to identify learning is not well established. We aimed to review and categorize the parameters and measures utilized for identification of motor learning in stroke and CP populations. PubMed, Pedro, and Web of Science databases were systematically searched between January 2000 and March 2016 for studies assessing a form of motor learning following upper extremity training using motor control measures. Thirty-two studies in persons after stroke and 10 studies in CP of any methodological quality were included. Identified outcome measures were sorted into two categories, “parameters,” defined as identifying a form of learning, and “measures,” as tools measuring the parameter. Review's results were organized as a narrative synthesis focusing on the outcome measures. The included studies were heterogeneous in their study designs, parameters and measures. Parameters included adaptation (n = 6), anticipatory control (n = 2), after-effects (n = 3), de-adaptation (n = 4), performance (n = 24), acquisition (n = 8), retention (n = 8), and transfer (n = 14). Despite motor learning theory's emphasis on long-lasting changes and generalization, the majority of studies did not assess the retention and transfer parameters. Underlying measures included kinematic analyses in terms of speed, geometry or both (n = 39), dynamic metrics, measures of accuracy, consistency, and coordination. There is no exclusivity of measures to a specific parameter. Many factors affect task performance and the ability to measure it—necessitating the use of several metrics to examine different features of movement and learning. Motor learning measures' applicability to clinical setting can benefit from a treatment-focused approach, currently lacking. The complexity of motor learning results in various metrics, utilized to assess its occurrence, making it difficult to synthesize findings across studies. Further research is desirable for development of an outcome measures selection algorithm, while considering the quality of such measurements.

Constraint-induced movement therapy as a rehabilitation intervention for upper extremity in stroke patients: systematic review and meta-analysis

Constraint-induced movement therapy (CIMT) is a neurorehabilitation technique designed to improve upper extremity motor functions after stroke. This review aimed to investigate evidence of the effect of CIMT on upper extremity in stroke patients and to identify optimal methods to apply CIMT. Four databases (MEDLINE, EMBASE, CINHAL, and PEDro) and reference lists of relevant articles and reviews were searched. Randomized clinical trials that studied the effect of CIMT on upper extremity outcomes in stroke patients compared with other rehabilitative techniques, usual care, or no intervention were included. Methodological quality was assessed using the PEDro score. The following data were extracted for each trial: patients' characteristics, sample size, eligibility criteria, protocols of CIMT and control groups, outcome measurements, and the PEDro score. A total of 38 trials were identified according to the inclusion criteria. The trials included were heterogeneous in CIMT protocols, time since stroke, and duration and frequency of treatment. The pooled meta-analysis of 36 trials found a heterogeneous significant effect of CIMT on upper extremity. There was no significant effect of CIMT at different durations of follow-up. The majority of included articles did not fulfill powered sample size and quality criteria. The effect of CIMT changed in terms of sample size and quality features of the articles included. These meta-analysis findings indicate that evidence for the superiority of CIMT in comparison with other rehabilitative interventions is weak. Information on the optimal dose of CIMT and optimal time to start CIMT is still limited.

Sequencing bilateral robot-assisted arm therapy and constraint-induced therapy improves reach to press and trunk kinematics in patients with stroke

BACKGROUND

The combination of robot-assisted therapy (RT) and a modified form of constraint-induced therapy (mCIT) shows promise for improving motor function of patients with stroke. However, whether the changes of motor control strategies are concomitant with the improvements in motor function after combination of RT and mCIT (RT + mCIT) is unclear. This study investigated the effects of the sequential combination of RT + mCIT compared with RT alone on the strategies of motor control measured by kinematic analysis and on motor function and daily performance measured by clinical scales.

METHODS

The study enrolled 34 patients with chronic stroke. The data were derived from part of a single-blinded randomized controlled trial. Participants in the RT + mCIT and RT groups received 20 therapy sessions (90 to 105 min/day, 5 days for 4 weeks). Patients in the RT + mCIT group received 10 RT sessions for first 2 weeks and 10 mCIT sessions for the next 2 weeks. The Bi-Manu-Track was used in RT sessions to provide bilateral practice of wrist and forearm movements. The primary outcome was kinematic variables in a task of reaching to press a desk bell. Secondary outcomes included scores on the Wolf Motor Function Test, Functional Independence Measure, and Nottingham Extended Activities of Daily Living. All outcome measures were administered before and after intervention.

RESULTS

RT + mCIT and RT demonstrated different benefits on motor control strategies. RT + mCIT uniquely improved motor control strategies by reducing shoulder abduction, increasing elbow extension, and decreasing trunk compensatory movement during the reaching task. Motor function and quality of the affected limb was improved, and patients achieved greater independence in instrumental activities of daily living. Force generation at movement initiation was improved in the patients who received RT.

CONCLUSION

A combination of RT and mCIT could be an effective approach to improve stroke rehabilitation outcomes, achieving better motor control strategies, motor function, and functional independence of instrumental activities of daily living.

TRIAL REGISTRATION

ClinicalTrials.gov. NCT01727648.

To compare the effectiveness of constraint induced movement therapy versus motor relearning programme to improve motor function of hemiplegic upper extremity after stroke

Objective:

To compare the effectiveness of constraint induced movement therapy versus motor relearning programme to improve motor function of hemiplegic upper extremity after stroke.

Method:

A sample of 42 patients was recruited from the Physiotherapy Department of IPM&R and Neurology OPD of Civil Hospital Karachi through non probability purposive sampling technique. Twenty one patients were placed to each experimental and control groups. Experimental group was treated with Constraint Induced Movement Therapy (CIMT) and control group was treated with motor relearning programme (MRP) for three consecutive weeks. Pre and post treatment measurements were determined by upper arm section of Motor Assessment Scale (MAS) and Self Care item of Functional Independence Measure (FIM) Scale.

Results:

Intra group analysis showed statistically significant results (p-value<0.05) in all items of MAS in both groups. However, advanced hand activities item of MAS in MRP group showed insignificant result (p-value=0.059). Self-care items of FIM Scale also showed significant result (p-value< 0.05) in both groups except dressing upper body item (p-value=0.059) in CIMT group and grooming and dressing upper body items (p-value=0.059 & 0.063) in MRP group showed insignificant p-values.

Conclusion:

CIMT group showed more significant improvement in motor function and self-care performance of hemiplegic upper extremity as compared to MRP group in patients with sub-acute stroke assessed by the MAS and FIM scales. Thus CIMT is proved to be more statistically significant and clinically effective intervention in comparison to motor relearning programme among the patients aged between 35-60 years. Further studies are needed to evaluate CIMT effects in acute and chronic post stroke population.

Normative Data for an Instrumental Assessment of the Upper-Limb Functionality

Upper-limb movement analysis is important to monitor objectively rehabilitation interventions, contributing to improving the overall treatments outcomes. Simple, fast, easy-to-use, and applicable methods are required to allow routinely functional evaluation of patients with different pathologies and clinical conditions. This paper describes the Reaching and Hand-to-Mouth Evaluation Method, a fast procedure to assess the upper-limb motor control and functional ability, providing a set of normative data from 42 healthy subjects of different ages, evaluated for both the dominant and the nondominant limb motor performance. Sixteen of them were reevaluated after two weeks to perform test-retest reliability analysis. Data were clustered into three subgroups of different ages to test the method sensitivity to motor control differences. Experimental data show notable test-retest reliability in all tasks. Data from older and younger subjects show significant differences in the measures related to the ability for coordination thus showing the high sensitivity of the method to motor control differences. The presented method, provided with control data from healthy subjects, appears to be a suitable and reliable tool for the upper-limb functional assessment in the clinical environment.

Constraint-induced movement therapy for upper extremities in people with stroke

BACKGROUND

In people who have had a stroke, upper limb paresis affects many activities of daily life. Reducing disability is therefore a major aim of rehabilitative interventions. Despite preserving or recovering movement ability after stroke, sometimes people do not fully realise this ability in their everyday activities. Constraint-induced movement therapy (CIMT) is an approach to stroke rehabilitation that involves the forced use and massed practice of the affected arm by restraining the unaffected arm. This has been proposed as a useful tool for recovering abilities in everyday activities.

OBJECTIVES

To assess the efficacy of CIMT, modified CIMT (mCIMT), or forced use (FU) for arm management in people with hemiparesis after stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group trials register (last searched June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library Issue 1, 2015), MEDLINE (1966 to January 2015), EMBASE (1980 to January 2015), CINAHL (1982 to January 2015), and the Physiotherapy Evidence Database (PEDro; January 2015).

SELECTION CRITERIA

Randomised control trials (RCTs) and quasi-RCTs comparing CIMT, mCIMT or FU with other rehabilitative techniques, or none.

DATA COLLECTION AND ANALYSIS

One author identified trials from the results of the electronic searches according to the inclusion and exclusion criteria, three review authors independently assessed methodological quality and risk of bias, and extracted data. The primary outcome was disability.

MAIN RESULTS

We included 42 studies involving 1453 participants. The trials included participants who had some residual motor power of the paretic arm, the potential for further motor recovery and with limited pain or spasticity, but tended to use the limb little, if at all. The majority of studies were underpowered (median number of included participants was 29) and we cannot rule out small-trial bias. Eleven trials (344 participants) assessed disability immediately after the intervention, indicating a non-significant standard mean difference (SMD) 0.24 (95% confidence interval (CI) -0.05 to 0.52) favouring CIMT compared with conventional treatment. For the most frequently reported outcome, arm motor function (28 studies involving 858 participants), the SMD was 0.34 (95% CI 0.12 to 0.55) showing a significant effect (P value 0.004) in favour of CIMT. Three studies involving 125 participants explored disability after a few months of follow-up and found no significant difference, SMD -0.20 (95% CI -0.57 to 0.16) in favour of conventional treatment.

AUTHORS' CONCLUSIONS

CIMT is a multi-faceted intervention where restriction of the less affected limb is accompanied by increased exercise tailored to the person's capacity. We found that CIMT was associated with limited improvements in motor impairment and motor function, but that these benefits did not convincingly reduce disability. This differs from the result of our previous meta-analysis where there was a suggestion that CIMT might be superior to traditional rehabilitation. Information about the long-term effects of CIMT is scarce. Further trials studying the relationship between participant characteristics and improved outcomes are required.

Kinematic measures of Arm-trunk movements during unilateral and bilateral reaching predict clinically important change in perceived arm use in daily activities after intensive stroke rehabilitation

Background

Kinematic analysis has been used to objectively evaluate movement patterns, quality, and strategies during reaching tasks. However, no study has investigated whether kinematic variables during unilateral and bilateral reaching tasks predict a patient’s perceived arm use during activities of daily living (ADL) after an intensive intervention. Therefore, this study investigated whether kinematic measures during unilateral and bilateral reaching tasks before an intervention can predict clinically meaningful improvement in perceived arm use during ADL after intensive poststroke rehabilitation.

Methods

The study was a secondary analysis of 120 subjects with chronic stroke who received 90–120 min of intensive intervention every weekday for 3–4 weeks. Reaching kinematics during unilateral and bilateral tasks and the Motor Activity Log (MAL) were evaluated before and after the intervention.

Results

Kinematic variables explained 22 and 11 % of the variance in actual amount of use (AOU) and quality of movement (QOM), respectively, of MAL improvement during unilateral reaching tasks. Kinematic variables also explained 21 and 31 % of the variance in MAL-AOU and MAL-QOM, respectively, during bilateral reaching tasks. Selected kinematic variables, including endpoint variables, trunk involvement, and joint recruitment and interjoint coordination, were significant predictors for improvement in perceived arm use during ADL (P < 0.05).

Conclusions

Arm–trunk kinematics may be used to predict clinically meaningful improvement in perceived arm use during ADL after intensive rehabilitation. Involvement of interjoint coordination and trunk control variables as predictors in bilateral reaching models indicates that a high level of motor control (i.e., multijoint coordination) and trunk stability may be important in obtaining treatment gains in arm use, especially for bilateral daily activities, in intensive rehabilitation after stroke.

Kinematic analysis of unilateral and bilateral drinking task after brain and periphery injuries

In this study, we aim to understand how functional movement is affected by various physical and neurological injuries. Using a novel system known as the Bilateral Assessment System (BiAS), we tracked the wrist movement of subjects with stroke, cerebral palsy, transradial amputations, as well as healthy individuals in space and in time as they completed a drinking task. The BiAS allowed us to analyze the kinematics of the movement of subjects to describe how specific impairment types at varying levels of the nervous system affect upper limb movement. Using kinematics to provide an objective analysis, the results suggest that bilateral ability is not analogous to unilateral ability and the importance of bilateral training, in addition to unilateral training, in the rehabilitation of injured persons is highlighted. In addition, motor, sensory, and strength impairment and subsequent ADL functional ability is a function of impairment level and not just impairment type.

Constraint-induced movement therapy after stroke

Constraint-induced movement therapy (CIMT) was developed to overcome upper limb impairments after stroke and is the most investigated intervention for the rehabilitation of patients. Original CIMT includes constraining of the non-paretic arm and task-oriented training. Modified versions also apply constraining of the non-paretic arm, but not as intensive as original CIMT. Behavioural strategies are mostly absent for both modified and original CIMT. With forced use therapy, only constraining of the non-paretic arm is applied. The original and modified types of CIMT have beneficial effects on motor function, arm-hand activities, and self-reported arm-hand functioning in daily life, immediately after treatment and at long-term follow-up, whereas there is no evidence for the efficacy of constraint alone (as used in forced use therapy). The type of CIMT, timing, or intensity of practice do not seem to affect patient outcomes. Although the underlying mechanisms that drive modified and original CIMT are still poorly understood, findings from kinematic studies suggest that improvements are mainly based on adaptations through learning to optimise the use of intact end-effectors in patients with some voluntary motor control of wrist and finger extensors after stroke.

Concurrent and Predictive Validity of Arm Kinematics With and Without a Trunk Restraint During a Reaching Task in Individuals With Stroke

OBJECTIVE

To examine the concurrent and predictive validity of measurements of kinematic variables during reaching tasks with and without a trunk constraint in individuals with stroke.

DESIGN

Randomized controlled trials.

SETTINGS

Hospitals and a laboratory.

PARTICIPANTS

Individuals with stroke (N=95) enrolled in previous and ongoing clinical trials.

INTERVENTIONS

Upper limb training protocols were 90 to 120 minutes of intervention every weekday for 3 to 4 weeks.

MAIN OUTCOME MEASURES

Functional capacity was assessed using the Action Research Arm Test and motor impairment using the Fugl-Meyer Assessment for the Upper Extremity. Movement kinematics were measured during a reaching task with and without a trunk constraint. We derived 5 endpoint control variables and 3 joint recruitment variables for estimating concurrent and predictive validity.

RESULTS

The adjusted R(2) values for the constraint tasks ranged from .24 to .38 and for the unconstraint tasks from .29 to .40. Movement time was the most prominent kinematic variable for the Fugl-Meyer Assessment for the Upper Extremity before and after the intervention (P<.05). For the Action Research Arm Test, movement time and endpoint displacement were the most significant variables before and after the intervention, respectively (P<.05).

CONCLUSIONS

Measuring kinematic performance during an unconstrained task is appropriate and possibly sufficient to represent motor impairment and functional capacity of individuals with stroke. Movement time is the dominant variable associated with motor impairment and functional capacity, and endpoint displacement is unique in reflecting functional capacity of individuals with stroke.

Postural control during standing reach in children with Down syndrome

The purpose of the present study was to investigate the dynamic postural control of children with Down syndrome (DS). Specifically, we compared postural control and goal-directed reaching performance between children with DS and typically developing children during standing reach. Standing reach performance was analyzed in three main phases using the kinematic and kinetic data collected from a force plate and a motion capture system. Fourteen children with DS, age and gender matched with fourteen typically developing children, were recruited for this study. The results showed that the demand of the standing reach task affected both dynamic postural control and reaching performance in children with DS, especially in the condition of beyond arm's length reaching. More postural adjustment strategies were recruited when reaching distance was beyond arm's length. Children with DS tended to use inefficient and conservative strategies for postural stability and reaching. That is, children with DS perform standing reach with increased reaction and execution time and decreased amplitudes of center of pressure displacements. Standing reach resembled functional balance that is required in daily activities. It is suggested to be considered as a part of strength and balance training program with graded task difficulty.

The reliability of the ELEPAP clinical protocol for the 3D kinematic evaluation of upper limb function

Upper limb (UL) kinematic assessment protocols are becoming integrated into clinical practice due to their development over the last few years. We propose the ELEPAP UL protocol, a contemporary UL kinematic protocol that can be applied to different pathological conditions. This model is based on ISB modeling recommendations, uses functional joint definitions, and models three joints of the shoulder girdle. The specific aim of this study was to determine the within and between session reliability of the ELEPAP UL model. Ten healthy subjects (mean age: 13.6±4.3 years) performed four reach-to-grasp and five functional tasks, which included a novel throwing task to assess a wide spectrum of motor skills. Three trials of every task in two different sessions were analyzed. The reliability of angular waveforms was evaluated by measurement error (σ) and coefficient of multiple correlation (CMC). Spatiotemporal parameters were assessed by standard error of measurement (SEM). Generally joint kinematics presented low σw and σb errors (<100). A selection of angular waveforms errors was presented to inspect error fluctuation in different phases, which was found to be related to the demands of the different movements. CMCw and CMCb values (>0.60) were found, demonstrating good to excellent reliability especially in joints with larger ranges of motion. The throwing task proved equally reliable, enhancing the universal application of the protocol. Compared to the literature, this study demonstrated higher reliability of the thorax, scapula and wrist joints. This was attributed to the highly standardized procedure and the implementation of recent methodological advancements. In conclusion, ELEPAP protocol was proved a reliable tool to analyze UL kinematics.

[Intensity in the neurorehabilitation of spastic paresis]

Neurorestoration of motor command in spastic paresis requires a double action of stimulation and guidance of central nervous system plasticity. Beyond drug therapies, electrical stimulation and cell therapies, which may stimulate plasticity without precisely guiding it, two interventions seem capable of driving plasticity with a double stimulation and guidance component: the lesion itself (lesion-induced plasticity) and durable behavior modifications (behavior-induced plasticity). Modern literature makes it clear that the intensity of the neuronal and physical training is a primary condition to foster behavior-induced plasticity. When it comes to working on movement, intensity can be achieved by the combination of two key components, one is the difficulty of the trained movement, the other is the number of repetitions or the daily duration of the practice. A number of recent studies shed light on promising recovery prospects, particularly using the emergence of new technologies such as robot-assisted therapy and concepts such as guided self-rehabilitation contracts.

Functional electrical stimulation-facilitated proliferation and regeneration of neural precursor cells in the brains of rats with cerebral infarction

Previous studies have shown that proliferation of endogenous neural precursor cells cannot alone compensate for the damage to neurons and axons. From the perspective of neural plasticity, we observed the effects of functional electrical stimulation treatment on endogenous neural precursor cell proliferation and expression of basic fibroblast growth factor and epidermal growth factor in the rat brain on the infarct side. Functional electrical stimulation was performed in rat models of acute middle cerebral artery occlusion. Simultaneously, we set up a placebo stimulation group and a sham-operated group. Immunohistochemical staining showed that, at 7 and 14 days, compared with the placebo group, the numbers of nestin (a neural precursor cell marker)-positive cells in the subgranular zone and subventricular zone were increased in the functional electrical stimulation treatment group. Western blot assays and reverse-transcription PCR showed that total protein levels and gene expression of epidermal growth factor and basic fibroblast growth factor were also upregulated on the infarct side. Prehensile traction test results showed that, at 14 days, prehension function of rats in the functional electrical stimulation group was significantly better than in the placebo group. These results suggest that functional electrical stimulation can promote endogenous neural precursor cell proliferation in the brains of acute cerebral infarction rats, enhance expression of basic fibroblast growth factor and epidermal growth factor, and improve the motor function of rats.

Arm and trunk movement kinematics during seated reaching within and beyond arm's length in people with stroke: a validity study

BACKGROUND

Kinematic analysis is commonly used to objectively measure upper extremity movement performance after stroke. However, the concurrent validity and predictive validity of arm-trunk kinematics during reaching within and beyond arm's length have not been studied.

OBJECTIVE

The aim of this study was to estimate the concurrent validity of kinematic measures before and after treatment and the predictive validity for reaching within and beyond arm's length after stroke.

DESIGN

This was a secondary analysis study.

METHODS

Ninety-seven participants with stroke (mean age=55.9 years [SD=10.9]) received intensive treatment every weekday for 3 to 4 weeks. Kinematic reaching tasks and the Wolf Motor Function Test (WMFT) were used before and after treatment. The validity of the kinematic measures was estimated in relation to WMFT scores.

RESULTS

Of the 8 kinematic variables that were measured, index movement time before treatment (R2=.227-.362) and trunk movement time and trunk displacement after treatment (R2=.095-.346) had the strongest association with the WMFT at both reaching distances. Trunk movement time and trunk displacement before treatment explained 6.9% to 14.9% of the variance in the WMFT after treatment. Kinematic variables explained 6.9% to 49.3% and 9.4% to 38.7% of the variance in the WMFT during a task within arm's length and beyond arm's length, respectively.

LIMITATIONS

The study has limited generalizability.

CONCLUSIONS

Different kinematic variables may partially reflect motor function before and after treatment to a limited degree. Although the predictive validity was modest, trunk movement may be considered a prognostic determinant of motor function after treatment. A reaching task within arm's length may be a more suitable measure of kinematic performance for describing motor function than a reaching task beyond arm's length.

Is more better? Using metadata to explore dose-response relationships in stroke rehabilitation

BACKGROUND AND PURPOSE

Neurophysiological models of rehabilitation and recovery suggest that a large volume of specific practice is required to induce the neuroplastic changes that underlie behavioral recovery. The primary objective of this meta-analysis was to explore the relationship between time scheduled for therapy and improvement in motor therapy for adults after stroke by (1) comparing high doses to low doses and (2) using metaregression to quantify the dose-response relationship further.

METHODS

Databases were searched to find randomized controlled trials that were not dosage matched for total time scheduled for therapy. Regression models were used to predict improvement during therapy as a function of total time scheduled for therapy and years after stroke.

RESULTS

Overall, treatment groups receiving more therapy improved beyond control groups that received less (g=0.35; 95% confidence interval, 0.26-0.45). Furthermore, increased time scheduled for therapy was a significant predictor of increased improvement by itself and when controlling for linear and quadratic effects of time after stroke.

CONCLUSIONS

There is a positive relationship between the time scheduled for therapy and therapy outcomes. These data suggest that large doses of therapy lead to clinically meaningful improvements, controlling for time after stroke. Currently, trials report time scheduled for therapy as a measure of therapy dose. Preferable measures of dose would be active time in therapy or repetitions of an exercise.