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

Differences in subacute motor recovery after intracerebral haemorrhage and ischaemic stroke: Analysis using the VISTA database cohort

BACKGROUND

Motor impairment is a significant contributor to disability after stroke, but recovery is often incomplete. Whether motor recovery differs between intracerebral haemorrhage (ICH), a subgroup of stroke with far worse outcomes, and ischaemic stroke is not clear.

METHODS

We performed a retrospective observational longitudinal cohort study using individual patient-level data from the Virtual International Stroke Trials Archive (VISTA) database (ICH n=892, ischaemic stroke n=6912). Differences in motor recovery to 90-days were examined between ICH and ischaemic stroke patients with mixed effect regression models adjusted for a priori determined confounders. Motor weakness was measured by NIHSS face, arm and leg sum with secondary analyses of total NIHSS, and NIHSS language score.

RESULTS

Recovery was observed in all NIHSS domains for both stroke types to 30-days (NIHSSmotorb=-2.78, 95%CI -2.89,-2.68; NIHSStotalb=-5.74, 95%CI -5.92,-5.56; NIHSSlanguageb=-0.28 95%CI -0.31,-0.24) and 90-days (NIHSSmotorb=-3.62, 95%CI -3.69,-3.54; NIHSStotalb=-7.17, 95%CI -7.30,-7.05; NIHSSlanguageb=-0.74, 95%CI -0.78,-0.71). Baseline impairment between groups was well matched with only motor impairment being slightly greater in ICH; NIHSSmotor mean(SD)=13.0 (5.3) vs 12.3 (5.4). To 30-days the extent of recovery was not different between stroke types but recovery to 90-days was greater in ICH for motor and statistically significant for total NIHSS score (b=-0.35, 95%CI -0.71,-0.002). Ischaemic stroke survivors recovered more in NIHSS language domain.

CONCLUSIONS

Timing and extent of recovery is different between stroke types. Motor recovery in ICH is greater and occurs later. Therefore, the assumption that most recovery occurs within 30-days and proportionality of recovery should be revisited in this population.

The Effect of Virtual Reality Therapy on Functional Recovery in Subacute Stroke Patients: A Randomized Controlled Trial

Virtual reality (VR) therapy can potentially enhance upper extremity recovery and motivation in stroke rehabilitation. The BTS Nirvana system, equipped with infrared sensors and real-time audiovisual feedback, enables objective performance recording and supports task-oriented, intensive exercises. This study evaluates the combined effect of VR therapy using BTS Nirvana and conventional rehabilitation on upper extremity functions in subacute stroke patients. This randomized, controlled, single-masked study included 22 subacute hemiplegic patients divided into a virtual reality group (n = 11) and a control group (n = 11). Both groups received conventional therapy for three weeks, with the VR group undergoing additional sessions using the BTS Nirvana system. Upper extremity functions were assessed using the Fugl-Meyer upper extremity scale, Brunnstrom stage, Functional Reach Test, Chedoke Arm and Hand Activity tests, and range of motion measurements. Both groups showed significant improvements (p < 0.05) in most outcomes, except for shoulder adduction (p = 0.222) and shoulder external rotation (p = 0.113). Intergroup analysis favored the VR group for upper extremity Brunnstrom stage (p = 0.030), shoulder external rotation (p = 0.029), and Chedoke arm test scores (p = 0.039). Time-group interaction analysis also highlighted superior improvements in the VR group for these measures (p < 0.05). The BTS Nirvana system is a safe and effective complement to conventional therapy, offering intensive and repetitive training for upper extremity rehabilitation in subacute stroke patients. Further research with larger sample sizes and extended treatment durations is needed to confirm these findings and refine treatment protocols.

The remapping of peripersonal space after stroke, spinal cord injury and amputation: A PRISMA systematic review

Peripersonal space (PPS) is the body-centered area where interactions occur and objects can be reached. Its boundaries are dynamic, modulated by ongoing sensorimotor experiences: limb immobilization shrinks PPS, whereas tool use expands it. However, consistent clinical information on PPS alterations remains limited due to methodological heterogeneity, varying types and severities of sensorimotor disorders, and diverse experimental paradigms. This review explores the causal mechanisms of PPS processing by integrating findings from brain-lesioned patients and individuals with body deafferentation, such as amputees and spinal cord injury (SCI) patients. By comparing the effects of brain lesions and sensorimotor deafferentation, it clarifies how PPS is encoded, maintained, and reorganized following central nervous system damage, bodily changes, and the use of assistive devices. A systematic search of Scopus, Web of Science, and PubMed identified 17 studies: 4 on stroke patients (N = 100), 6 on SCI patients (N = 104), and 7 on amputees (N = 65). Risk of bias was assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Despite the limited number of studies and methodological variability, findings consistently show that sensorimotor changes significantly affect PPS. Notably, a contraction of PPS around the affected limb was observed in stroke, SCI patients, and amputees. Assistive devices were able to restore PPS after training, or even immediately in the case of prosthesis use. A shared neurophysiological mechanism across these conditions may underlie PPS as an online construct, continuously updated to reflect the body's current state and its interaction with the environment.

Resting-state hemodynamic changes and effects on upper limb function after multi-channel transcranial direct current stimulation to the ipsilesional primary motor cortex and anterior intraparietal sulcus in stroke patients: an fNIRS pilot study

BACKGROUND

Stroke results in substantial long-term disability, necessitating effective recovery interventions. This study explored the effects of multi-channel transcranial direct current stimulation (tDCS) on hemodynamic responses and upper limb motor function in stroke patients, targeting the ipsilesional primary motor cortex (M1) and anterior intraparietal sulcus (aIPS).

METHODS

A double-blind, randomized, sham-controlled trial was conducted with 24 stroke patients (18 men; mean age, 57.3×14.2 years), who underwent 10 sessions of real or sham multi-channel tDCS combined with upper limb exercises. Functional near-infrared spectroscopy (fNIRS) measured resting-state cerebral hemodynamic responses for 5 min before and after each session. Motor function was evaluated using the Fugl-Meyer assessment for upper extremity (FMA-UE), box and block test (BBT), and other motor function tests before and after the interventions.

RESULTS

The real multi-channel tDCS group exhibited increases in regional accumulation of oxyhemoglobin (HbOAcc) and stronger seeded connectivity networks within the motor cortex poststimulation. In contrast, the sham group exhibited disassociation from these areas. The group × time interaction was significant for the Box and Block Test (BBT), indicating greater improvements in gross manual dexterity in the real-tDCS group compared to the sham group. While poststimulation changes in HbOAcc were examined in relation to FMA-UE scores, no strong linear relationship was observed in the real-tDCS group.

CONCLUSIONS

Multi-channel tDCS targeting the ipsilesional M1 and aIPS, combined with upper limb exercises, showed potential effects on cerebral hemodynamics and motor function in stroke patients. These findings suggest that multi-channel tDCS may have a role in motor rehabilitation, but further research is needed to validate its efficacy and clinical applicability.

CLINICALTRIALS

GOV: This study was registered at ClinicalTrials.gov (NCT05275114).

Hands-free Atalante exoskeleton in post-stroke gait and balance rehabilitation: a safety study

BACKGROUND

Stroke often results in gait dysfunction, impairing daily activities and quality of life. Overground robotic exoskeletons hold promise for post-stroke rehabilitation. This study primarily aimed to assess the safety of hands-free Atalante exoskeleton training in post-stroke subjects, with a secondary aim to assess gait and balance.

METHODS

Forty subjects (10.2 ± 12.1 months post-stroke) with gait dysfunction (Functional Ambulation Category [FAC] score ≤ 3) underwent five training sessions over three weeks with a hands-free exoskeleton (Atalante, Wandercraft, France). Safety, the primary outcome, was evaluated by the number and severity of adverse events (AEs), judged by an independent clinical evaluation committee (CEC). A usability test was performed during the fifth training session followed by the exoskeleton use questionnaire. Gait and balance were assessed pre/post-training via walking capacity score (FAC), gait speed by 10-meter walk test (10MWT), walked distance by 6-minute walk test (6MWT), and balance by Berg Balance Scale (BBS). Spasticity was assessed with the Modified Ashworth scale. Anxiety and depression were quantified using the Hospital Anxiety and Depression Scale. Safety outcomes were analyzed using the Wilson, Lee and Dubin methods for proportions, and occurrence rates were computed. Within-group differences were compared using Wilcoxon, McNemar, and Friedman tests, with significance set at P < 0.05.

RESULTS

Thirty-one subjects completed the training sessions, while nine discontinued. The study reported two serious adverse events (SAE) (vertigo, dysarthria) and six AEs, with the CEC concluding that no SAE was linked to the device/study procedure. The average AE rate per session was 2.5 ± 1.4%, including four events possibly linked to the device/study procedure (knee pain [n = 1], skin lacerations [n = 3]), classified as negligible or minor by the CEC. A high proportion (82.6%) successfully completed the usability test and reported satisfaction (90%) on the exoskeleton use questionnaire. For gait and balance, favorable changes were observed in FAC, 10MWT, 6MWT, and BBS scores Post-training (p < 0.05, respectively). Spasticity, anxiety, and depression remained unchanged.

CONCLUSIONS

This study indicates that the hands-free Atalante exoskeleton is safe, feasible, and well-tolerated for gait and balance rehabilitation in post-stroke subjects, warranting larger randomized controlled trials to assess its efficacy.

TRIAL REGISTRATION

Evaluation of the Use of the Atalante Exoskeleton in Patients Presenting an Hemiplegia Due to Cerebrovascular Accident (INSPIRE) trial was registered at ClinicalTrials.gov (NCT04694001, registered on 20201231).

Salivary chemokines and growth factors in patients with ischemic stroke

Stroke is a serious health problem that affects an increasing number of people. As a result of the blockage of blood flow, tissue necrosis occurs in areas of the brain supplied by the damaged vessel, and leads to the development of inflammation. Changes that occur in the brain allow molecules to enter the blood, and it has been suggested that some can also penetrate the saliva. This study is the first to assess the profile of 25 chemokines and growth factors in the saliva of stroke survivors compared to a control group. 22 stroke survivors and 22 individuals matched by age and gender were enrolled in the study. Salivary chemokines and growth factors were assessed using the multiplex ELISA method. In the unstimulated saliva of stroke patients, we demonstrated significantly higher levels of chemotactic factors (CTACK/CCL27, IL-8/CXCL8, MIG/CXCL9, MIF) and growth factors (basic FGF, G-CSF, HGF, LIF, VEGF) compared to controls. The levels of MCP-3/CCL7, eotaxin/CCL11, IP-10/CXCL10, IL-3/MCGF, and PDGF-BB were lower in the saliva of the study group. The concentration of basic FGF negatively correlated with cognitive function as measured by the Addenbrooke's Cognitive Examination (ACE) scale (p = 0.007 r = - 0.56), while salivary IL-3 and LIF levels positively correlated with scores on the Functional Independence Measure (FIM) scale (p = 0.019 r = 0.53; p  = 0.033 r = 0.47, respectively). Receiver Operating Characteristic (ROC) analysis showed that salivary basic FGF, HGF, IL-3 and LIF can distinguish ischemic stroke patients from the control group with high sensitivity and specificity. In conclusion, disruptions in chemokine and growth factor levels in saliva may suggest an inflammatory etiology of ischemic stroke. Salivary basic FGF, HGF, IL-3 and LIF could serve as potential biomarkers for stroke. Further research is needed to illuminate the differences in salivary inflammatory mediator profiles in stroke and to evaluate the diagnostic utility of chemokines and growth factors in clinical practice.

Differences in muscle activity and intermuscular coordination between dominant and non-dominant hands during chopstick manipulation

Introduction

To develop an efficient rehabilitation program for patients with stroke to acquire fine motor skills such as chopstick manipulation, it is necessary to examine the differences in fundamental muscle functions between the hands during motor tasks. The aim of this study was to clarify the differences in muscle activity and intermuscular coordination between dominant and non-dominant hands during chopstick manipulation.

Methods

Twenty-eight healthy adults performed the task of picking up different-sized objects using chopsticks with either their dominant or non-dominant hand. Surface electromyography of 11 intrinsic and extrinsic hand muscles was performed, and muscle activity and muscle activity waveforms during the task were calculated. Activity patterns and weighting for each pattern were extracted from the muscle activity waveforms using non-negative matrix factorization to represent muscle synergy. The muscle activity and weighting were compared between the dominant and non-dominant hands and among different-sized objects.

Results

The activities of most intrinsic and extrinsic muscles did not significantly differ between the dominant and non-dominant hands or among different-sized objects. Although activity patterns showed the coordination of intrinsic hand muscles in both the dominant and non-dominant hands, the combinations of the weighting differed between the dominant and non-dominant hands. The non-dominant hand had different muscle activation patterns of intrinsic and extrinsic hand muscles compared to the dominant hand. The activity patterns and weighting were mostly similar across different-sized objects.

Conclusion

The dominant hand showed coordination of the first and second lumbrical muscles, whereas the non-dominant hand showed no muscle activation patterns between the muscles. Therefore, it is important to emphasize the first and second lumbrical in the non-dominant hand during rehabilitation to improve the coordination between the muscles of the two hands during chopstick manipulation to effectively improve chopstick manipulation skills in the non-dominant hand.

Can motion capture improve task-based fMRI studies of motor function post-stroke? A systematic review

BACKGROUND

Variability in motor recovery after stroke represents a major challenge in its understanding and management. While functional MRI has been used to unravel interactions between stroke motor function and clinical outcome, fMRI alone cannot clarify any relation between brain activation and movement characteristics.

OBJECTIVES

We aimed to identify fMRI and kinematic coupling approaches and to evaluate their potential contribution to the understanding of motor function post-stroke.

METHOD

A systematic literature review was performed according to PRISMA guidelines on studies using fMRI and kinematics in post-stroke individuals. We assessed the internal, external, statistical, and technological validity of each study. Data extraction included study design and analysis procedures used to couple brain activity with movement characteristics.

RESULTS

Of the 404 studies found, 23 were included in the final review. The overall study quality was moderate (0.6/1). Thirteen studies used kinematic information either parallel to the fMRI results, or as a real-time input to external devices, for instance to provide feedback to the patient. Ten studies performed a statistical analysis between movement and brain activity by either using kinematics as variables during group or individual level regression or correlation. This permitted establishing links between movement characteristics and brain activity, unraveling cortico-kinematic relationships. For instance, increased activity in the ipsilesional Premotor Cortex was related to less smooth movements, whereas trunk compensation was expressed by increased activity in the contralesional Primary Motor Cortex.

CONCLUSION

Our review suggests that the coupling of fMRI and kinematics may provide valuable insight into cortico-kinematic relationships. The optimization and standardization of both data measurement and treatment procedures may help the field to move forward and to fully use the potential of multimodal cortico-kinematic integration to unravel the complexity of post-stroke motor function and recovery.

Comparing Interventions Used in Randomized Controlled Trials of Upper Extremity Motor Rehabilitation Post-stroke in High-Income Countries and Low-to-Middle-Income Countries

OBJECTIVE

To identify and compare interventions for upper extremity (UE) motor recovery poststroke in randomized controlled trials (RCTs) conducted in high-income countries (HICs) and low-to-middle-income countries (LMICs).

DATA SOURCE

Systematic searches were conducted for RCTs published in English in 5 databases (CINAHL, Embase, PubMed, Scopus, and Web of Science) up to April 2021, in line with PRISMA guidelines.

STUDY SELECTION

RCTs, including crossover design, were included if they were in English and evaluated an intervention for poststroke UE motor rehabilitation, in an adult population (≥18y) diagnosed with stroke.

DATA EXTRACTION

Data on country of origin and type of intervention in each RCT were extracted using a data extraction template in Covidence software. Study screenings and data extraction were performed by 2 independent reviewers.

DATA SYNTHESIS

A total of 1276 RCTs met the inclusion criteria, with 978 RCTs conducted in HICs and 298 in LMICs. A significantly larger proportion of RCTs evaluating robotics and task-specific training interventions were conducted in HICs, compared to LMICs (P<.009). In contrast, a higher proportion of RCTs conducted in LMICs examined acupuncture (P<.001) and repetitive transcranial magnetic stimulation (rTMS) (P=.001) when compared to HICs.

CONCLUSIONS

Poststroke rehabilitation in LMICs is conducted in a lower resource environment when compared to HICs. Some differences exist in the use of UE motor rehabilitation interventions between LMICs and HICs such as robotics, task-specific training, rTMS, and acupuncture; however, there was no significant difference between HICs and LMICs for most interventions.

Group versus individual delivery of upper limb intervention for adults post-stroke: A systematic review and meta-analysis

ObjectiveTo systematically review the evidence and examine the effectiveness of group-based UL intervention versus individual therapy, in decreasing impairment and improving UL function post-stroke.Data SourcesA comprehensive search of four key databases (CINAHL, Embase, Emcare, and MEDLINE) identified relevant studies published from inception through to November 2024.Review methodsTwo reviewers independently performed screening for inclusion according to selection criteria. Eligible studies provided dose-matched group and individual UL rehabilitation programs. Outcomes that measured UL impairment (Fugl-Meyer Upper Extremity Test) or function (Action Research Arm Test) were extracted for meta-analysis. Methodological quality was assessed using the PEDro scale.ResultsOf 3291 publications, eight studies were included (n = 348) (seven randomised controlled trials and one controlled trial) of poor to good quality. A random effects meta-analysis model was conducted. Statistical significance was determined using analysis of covariance. No significant effects were shown in the meta-analyses on the effect of group versus individual therapy on UL impairment (mean difference 0.87, 95% CI: -0.87 to 2.62, p = .327) or function (mean difference 1.53, 95% CI: -0.23 to 3.29, p = .089). Results were limited by small sample sizes and substantial heterogeneity, with wide variation in intervention type, dosage and setting.ConclusionMeta-analyses suggest group-based UL intervention may be as effective as intervention delivered one-to-one, post-stroke. Additional studies of large sample size and rigorous methodology are necessary to substantiate these findings. Future research should investigate which types of UL intervention are most effective when provided in group-based settings across the different stages of stroke recovery.

Brain-Controlled Hand Exoskeleton Based on Augmented Reality-Fused Stimulus Paradigm

Advancements in brain-machine interfaces (BMIs) have led to the development of novel rehabilitation training methods for people with impaired hand function. However, contemporary hand exoskeleton systems predominantly adopt passive control methods, leading to low system performance. In this work, an active brain-controlled hand exoskeleton system is proposed that uses a novel augmented reality-fused stimulus (AR-FS) paradigm as a human-machine interface, which enables users to actively control their fingers to move. Considering that the proposed AR-FS paradigm generates movement artifacts during hand movements, an enhanced decoding algorithm is designed to improve the decoding accuracy and robustness of the system. In online experiments, participants performed online control tasks using the proposed system, with an average task time cost of 16.27 s, an average output latency of 1.54 s, and an average correlation instantaneous rate (CIR) of 0.0321. The proposed system shows 35.37% better efficiency, 8.03% reduced system delay, and 35.28% better stability than the traditional system. This study not only provides an efficient rehabilitation solution for people with impaired hand function but also expands the application prospects of brain-control technology in areas such as human augmentation, patient monitoring, and remote robotic interaction. The video in Graphical Abstract Video demonstrates the user's process of operating the proposed brain-controlled hand exoskeleton system.

Stable Enhancement of Corticospinal Excitability by the Combination of Paired Associative Stimulation and Interlimb Cortical Network

Inter-individual variability is a common issue of noninvasive brain stimulation. This study aimed to augment neuroplasticity induced by paired associative stimulation (PAS) through leveraging interlimb neural interactions. Specifically, we assessed lower-limb corticospinal excitability when voluntary ipsilateral upper-limb muscle contraction (UMC) was integrated into lower-limb PAS in 19 able-bodied young adults. PAS targeted the right soleus muscle (i.e., a lower-limb muscle), pairing peripheral nerve stimulation (PNS) with transcranial magnetic stimulation (TMS) to modulate cortical excitability. Experiment 1 evaluated motor-evoked potentials (MEPs) and Hoffmann reflex (H-reflex) after PAS + UMC, PAS, and UMC interventions. Experiment 2 investigated the modulation of MEP and short-interval intracortical inhibition (SICI) following PAS + UMC and PAS interventions, with focused attention on PNS. During PAS + UMC intervention, participants performed right wrist flexion at 30% maximum voluntary contraction coinciding with stimulation. Results showed a significant increase in MEPs 30 min after PAS + UMC intervention, with enhanced increase under controlled attention. The H-reflex slightly increased 15 and 30 min after PAS + UMC intervention. SICI increased 30 min after PAS + UMC intervention, though the correlation between MEP and SICI observed in PAS intervention was absent in PAS + UMC intervention. Our findings suggest that combining lower-limb PAS with UMC can facilitate lower-limb corticospinal excitability more effectively than conventional PAS, despite the complex neural mechanism underlying PAS.

Mobility scale for acute stroke patients (MSAS): construct validity and reliability of the Italian scale

BACKGROUND

The Mobility Scale for Acute Stroke Patients (MSAS) was developed to discriminate between the lower levels of mobility in acute stroke patients in the first two weeks post-onset.

OBJECTIVE

The present study aims to develop and validate an Italian version of the MSAS.

METHODS

The English version of the MSAS was translated into Italian according to international guidelines. We recruited 58 patients admitted to a rehabilitation facility within 14 days of the stroke onset and administered the MSAS to test the internal consistency, concurrent validity, reliability, and responsiveness of the scale.

RESULTS

As for internal consistency, Cronbach's alpha showed values equal to 0.96, and the alpha deleted analysis indicated that all the items have reason to exist. Concurrent validity showed statistically significant data for all sub-scales. The Italian version of the MSAS showed significant and high inter-rater reliabilities (all ICCs ≥ 0.75). The MSAS also showed excellent test-retest reliabilities (all ICCs ≥ 0.90). The reactivity of the scale, evaluated through the Student's t-test for paired samples on a sub-sample of 32 patients, showed statistically significant improvements over time for all items and the total scale.

CONCLUSIONS

The results show that the scale is stable and reliable both in the evaluation after 24 h and between different operators. High internal consistency and a strong concurrent validity were found. The scale also proved able to detect the improvement obtained by patients following the rehabilitation treatments.

Intermittent theta burst stimulation vs. high-frequency repetitive transcranial magnetic stimulation for post-stroke dysfunction: a Bayesian model-based network meta-analysis of RCTs

OBJECTIVE

This research aims to comprehensively assess the efficacy of intermittent theta-burst stimulation (iTBS) vs. high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) in post-stroke dysfunction.

MATERIALS AND METHODS

Until January 2024, extensive electronic database searches were conducted (PubMed, Embase, Cochrane Library, Web of Science, etc.). Fugl-Meyer Assessment for Upper Extremities (FMA-UE) was used to assess upper limb (UL) dysfunction; post-stroke dysphagia (PSD) was identified by Standardized Swallowing Assessment (SSA), Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS), and Penetration/Aspiration Scale (PAS). Results were analyzed by network meta-analysis (NMA), and the mean difference (MD) and 95% confidence intervals (95% CI) were also reported. We conducted a descriptive analysis due to the inability to synthesize data on post-stroke cognitive impairment (PSCI).

RESULTS

19 studies were included for NMA analysis. For UL disorder, the efficacy of treatments was ranked as HF-rTMS [MD (95%CI):3.00 (1.69,4.31)], iTBS [MD (95%CI): 2.16 (0.84, 3.50)], and sham stimulation (reference). For PSD, the efficacy of treatment to reduce scores of FEDSS or SSA were iTBS [FEDSS, MD (95%CI): -0.80 (-1.13, -0.47); SSA, MD (95%CI): -3.37 (-4.36, -2.38)], HF-rTMS [FEDSS, MD (95%CI): -0.43 (-0.76, -0.10); SSA, MD (95%CI): -2.62 (-3.91, -1.35)], and sham stimulation(reference). Descriptive analysis of PSCI found that both iTBS and HF-rTMS were effective in improving PSCI.

CONCLUSIONS

HF-rTMS demonstrates superior efficacy in UL dysfunction, while iTBS is more effective in PSD. Clinicians should carefully evaluate the type and severity of post-stroke dysfunction in each patient to select the most appropriate treatment.

Mapping Trajectories of Gait Recovery in Clinical Stroke Rehabilitation

BackgroundHow gait changes during the early stages of stoke rehabilitation, and which patient characteristics are associated with these changes is still largely unknown.Objectivehe first objective was to describe the changes in gait during stroke rehabilitation. Secondly, we determined how various patient characteristics were associated with the rate of change of gait over time.MethodsParticipants were measured every 3 weeks during stroke rehabilitation. The assessment consisted of an inertial measurement unit (IMU) based 2-minute walk test (2MWT), 3 IMU-based balance tests, and standard clinical tests. In the 2MWT, participants were equipped with 3 IMUs, from which speed, variability, asymmetry, and smoothness were calculated. The changes in gait were examined from admission to discharge at an individual level. The effect of patient characteristics on the rate of change of the gait features over time was assessed with growth models.ResultsA total of 81 Trajectories from 72 participants were analyzed. On an individual basis, speed increased in 32 trajectories. Only a few trajectories exhibited significant changes in variability, asymmetry, and smoothness over the clinical rehabilitation period. The growth models revealed a significant increase in speed and decrease in variability and smoothness. Only the Berg Balance Scale and gait speed at onset were (negatively) associated with the rates of change of speed and smoothness, respectively.ConclusionWe found a substantial variability in the gait-feature outcomes and their progression in individuals after stroke during clinical rehabilitation. The patient characteristics studied had limited associations with the rate of change of gait features over time.

The Effects of Functional Electrical Stimulation of Hip Abductor and Tibialis Anterior Muscles on Standing and Gait Characteristics in Patients with Stroke

Background/Objectives: Functional electrical stimulation (FES) has been used to improve the quality of life of patients with stroke. Rehabilitation programs focus on standing and walking, which are vital to functional independence and keystone ingredients in functional competency. To examine the effects of simultaneous continuous ongoing FES of gluteus medius (GMed) and tibialis anterior (TA) muscles at isometric contraction during standing and walking in patients with stroke. Methods: Short- and long-term FES management programs of GMed and TA muscles during different conditions have been used in patients with stroke. FES was applied to hip abductors and dorsiflexor muscles of the affected limb during four different conditions: passive hip abduction and ankle dorsiflexion, respectively (condition 1), sit-to-stand (condition 2), 10 m walk test (condition 3), and walking on C-mill treadmill (condition 4). The Modified Ashworth Scale (MAS), Five Times sit-to-stand test (FTSST), 10-m walk test (10-MWT), and C-mill treadmill were used to assess spasticity in the hip adductor and calf muscles, sit-to-stand performance, and temporal-spatial characteristics, respectively. Results: Short- and long-term FES management programs significantly reduced spasticity in the hip adductor and calf muscles and improved sit-to-stand performance, gait speed, and gait temporal-spatial characteristics. Conclusions: Short- and long-term FES management programs of GMed and TA muscles can quickly and effectively improve the spasticity and ambulation of patients with stroke. Further research incorporating gait analysis with randomized controlled samples is needed.

Validation of the Malta Gait Scale: A Time-Efficient Tool for Poststroke Assessment

Over 80% of stroke survivors experience walking dysfunction, impacting quality of life. Rehabilitation is crucial for gait recovery, and accurate assessments facilitate tailored programs. While computerized gait analysis is the gold standard, it is costly and requires specialized training, making observational gait analysis (OGA) more common. However, OGA can also be time-consuming. This study validates the Malta Gait Scale (MGS), a concise, illustrated 7-item observational tool using video recordings for gait measurements. The aim is to provide an effective, time-efficient method for gait evaluations by comparing the MGS with the established Wisconsin Gait Scale (WGS) and Gait Assessment Intervention Tool (GAIT), which have 14 and 31 items, respectively. Forty-nine participants were included in a retrospective study to validate the MGS. We evaluated its reliability using weighted Cohen's kappa (κ) for intrarater and interrater reliability. Concurrent validity was assessed by comparing the MGS with the WGS and GAIT scales using Spearman's rho (ρ). The Wilcoxon test assessed the efficacy of the MGS in detecting rehabilitation-induced changes, differentiating healthy from stroke participants, and evaluating time efficiency. The MGS demonstrated almost perfect agreement, with interrater and intrarater κ values of 0.952 and 0.977, respectively. It showed high positive correlations with the WGS and GAIT, with ρ values of 0.898 and 0.877. MGS required an average administration time of 7 min and 29 s, significantly less than the WGS (27 min and 46 s) and GAIT (50 min and 6 s) (p < 0.001). Following rehabilitation, significant improvements were observed in patients using both the MGS and WGS scales (p = 0.018), and the MGS effectively distinguished between healthy individuals and stroke patients (p < 0.001). The MGS is a valid, reliable, and efficient tool for gait assessment in stroke survivors, supporting smartphone use and facilitating rapid measurements in clinical settings where time is critical.

The Role of Immersive Virtual Reality in Upper Limb Rehabilitation for Subacute Stroke: A Review

Background: Patients with stroke sequelae experience motor impairments that make it difficult to perform many activities of daily living, resulting in reduced social participation. Immersive virtual reality (VR) provides the necessary conditions for motor learning, such as repetitiveness, intensity, and task meaningfulness, and it could be a promising rehabilitation tool for upper limb recovery in individuals with stroke sequelae. Objective: The objectives of this study are to summarize the current scientific evidence on the use of immersive VR for upper limb rehabilitation in patients with subacute stroke and to identify clinical and instrumental criteria that may inform the development of a standardized VR treatment protocol. Materials and Methods: Bibliographic research on primary and secondary studies was conducted using the keywords "subacute stroke", "immersive virtual reality/head-mounted display (HMD)", and "upper extremity/arm/hand" in the following electronic databases: CINAHL, PubMed (MEDLINE), Embase, Web of Science, Cochrane Library, PEDro, and Google Scholar. Then, we performed the selection of studies and the assessment of the methodological quality of such studies using the PEDro scale. Finally, the qualitative synthesis of the data extracted from the selected studies was carried out. This systematic review was conducted according to the PRISMA 2020 guidelines. Results: After the selection process, five studies were included in this systematic review (two RCTs, two controlled clinical studies, one study protocol). Four studies reported significant improvements in some main outcomes after the VR intervention, including a significant increase in the Fugl-Meyer Upper Extremity total score, in favor of the virtual rehabilitation group. Conclusions: VR appears to be a promising rehabilitation tool for upper limb motor recovery. However, further research is needed to determine the intervention methods and long-term effects of VR on the stroke population.

Effects of transcranial direct current stimulation (tDCS) on motor function among people with stroke: evidence mapping

OBJECTIVE

To present, organize, and assess the methodological quality of the current research related to tDCS on motor function after a stroke and to identify gaps and clinical implications using an evidence mapping approach.

METHODS

Six electronic databases (PubMed, Embase, Cochrane Library, Web of Science, CINAHL, PEDro), gray literature, and reference lists of articles were searched from inception until October 2023. The Assessment of Multiple Systematic Reviews 2 (AMSTAR-2) checklist and PEDro scale were used to assess the methodology quality of systematic reviews (SRs) and randomized controlled trials (RCTs).

RESULTS

A total of 172 articles met the inclusion criteria from 5759 records, including 46 SRs and 126 RCTs. Related studies came from 29 countries around the world, and China has performed the most, with 12 SRs and 21 RCTs. More than half of SRs (65.22%) were evaluated with low or critically low quality, while 78.58% of RCTs have shown excellent or good quality. A total of 26 SRs and 93 RCTs have reported outcomes on upper limb motor function with kinds of tDCS, and 15 SRs and 44 RCTs have focused on lower extremity function. Studies with safety concerns have reported no or mild adverse events.

CONCLUSIONS

This study systematically identified gaps and indicated that tDCS is a kind of potential and safe intervention. Given potential concerns on the clinical application, more high-quality research with large sample size and kinds of objectives is needed in the future.

Long-term functional outcomes in patients with isolated cerebellar infarction: the KOSCO study

Background

There are relatively few reports on the long-term sequential functional recovery and prognosis in patients with cerebellar infarction. The aim of this study was to investigate the long-term recovery of multifaceted functional outcomes up to 36 months after onset and the functional prognosis of isolated cerebellar infarction.

Methods

This study was a retrospective analysis of the Korean Stroke Cohort for Functioning and Rehabilitation (KOSCO) data up to 36 months after onset. Isolated cerebellar infarction was defined as the presence of lesions in the cerebellum without lesions in other brain parenchyma. We assessed multifaceted functional domains, including motor (Fugl-Meyer Assessment, FMA), ambulatory (Functional Ambulation Category, FAC), cognitive (Korean Mini-Mental State Examination, K-MMSE), swallowing (American Speech-Language-Hearing Association National Outcome Measurement System Swallowing Scale, ASHA-NOMS), and language functions (Short version of the Korean Frenchay Aphasia Screening Test, Short K-FAST), using serial measurements. In addition, functional outcome was assessed with the Functional Independence Measure (FIM) up to 36 months after onset.

Results

Among 390 screened isolated cerebellar infarction patients, a total of 183 patients were included in this study. Cognitive (mean[SD] of K-MMSE 27.6 ± 3.6) and swallowing (ASHA-NOMS 6.8 ± 0.7) functions showed significant improvement up to 3 months (p < 0.05). Motor (FMA 98.8 ± 3.8) and language (ASHA-NOMS 6.9 ± 0.4) functions improved significantly up to 6 months (p < 0.05). Furthermore, ambulatory function (FAC 4.7 ± 0.9) and functional independency (FIM 122.2 ± 12.0) continued to improve up to 12 months (p < 0.05). Vascular territory involving superior cerebellar artery, older age, female sex, and greater initial severity were identified as negative independent prognostic factors predicting functional outcome measured by FIM at 12 months after stroke.

Conclusion

The plateau of recovery in multifaceted functional outcomes varied among patients with cerebellar infarction. Functional independence plateaued at 12 months and showed a relatively favorable prognosis up to 36 months after stroke.

Effects of brain-computer interface based training on post-stroke upper-limb rehabilitation: a meta-analysis

BACKGROUND

Previous research has used the brain-computer interface (BCI) to promote upper-limb motor rehabilitation. However, the results of these studies were variable, leaving efficacy unclear.

OBJECTIVES

This review aims to evaluate the effects of BCI-based training on post-stroke upper-limb rehabilitation and identify potential factors that may affect the outcome.

DESIGN

A meta-analysis including all available randomized-controlled clinical trials (RCTs) that reported the efficacy of BCI-based training on upper-limb motor rehabilitation after stroke.

DATA SOURCES AND METHODS

We searched PubMed, Cochrane Library, and Web of Science before September 15, 2024, for relevant studies. The primary efficacy outcome was the Fugl-Meyer Assessment-Upper extremity (FMA-UE). RevMan 5.4.1 with a random effect model was used for data synthesis and analysis. Mean difference (MD) and 95% confidence interval (95%CI) were calculated.

RESULTS

Twenty-one RCTs (n = 886 patients) were reviewed in the meta-analysis. Compared with control, BCI-based training exerted significant effects on FMA-UE (MD = 3.69, 95%CI 2.41-4.96, P < 0.00001, moderate-quality evidence), Wolf Motor Function Test (WMFT) (MD = 5.00, 95%CI 2.14-7.86, P = 0.0006, low-quality evidence), and Action Research Arm Test (ARAT) (MD = 2.04, 95%CI 0.25-3.82, P = 0.03, high-quality evidence). Additionally, BCI-based training was effective on FMA-UE for both subacute (MD = 4.24, 95%CI 1.81-6.67, P = 0.0006) and chronic patients (MD = 2.63, 95%CI 1.50-3.76, P < 0.00001). BCI combined with functional electrical stimulation (FES) (MD = 4.37, 95%CI 3.09-5.65, P < 0.00001), robots (MD = 2.87, 95%CI 0.69-5.04, P = 0.010), and visual feedback (MD = 4.46, 95%CI 0.24-8.68, P = 0.04) exhibited significant effects on FMA-UE. BCI combined with FES significantly improved FMA-UE for both subacute (MD = 5.31, 95%CI 2.58-8.03, P = 0.0001) and chronic patients (MD = 3.71, 95%CI 2.44-4.98, P < 0.00001), and BCI combined with robots was effective for chronic patients (MD = 1.60, 95%CI 0.15-3.05, P = 0.03). Better results may be achieved with daily training sessions ranging from 20 to 90 min, conducted 2-5 sessions per week for 3-4 weeks.

CONCLUSIONS

BCI-based training may be a reliable rehabilitation program to improve upper-limb motor impairment and function.

TRIAL REGISTRATION

PROSPERO registration ID: CRD42022383390.

People with aphasia show stable Cumulative Semantic Interference (CSI) when tested repeatedly in a web-based paradigm: A perspective for longitudinal assessment

Retrieving words quickly and correctly is an important language competence. Semantic contexts, such as prior naming of categorically related objects, can induce conceptual priming but also lexical-semantic interference, the latter likely due to enhanced competition during lexical selection. In the continuous naming (CN) paradigm, such semantic interference is evident in a linear increase in naming latency with each additional member of a category out of a seemingly random sequence of pictures being named (cumulative semantic interference/CSI effect). Extensively studied in neurotypical participants, CSI studies in people with aphasia (PWA) are rare, although some lesions regularly and persistently impair word retrieval. In the present study, 20 PWA with lesions in the extended left hemispheric language network and 20 matched controls underwent a CN paradigm, naming photographs of closely related objects from 24 categories (e.g., birds) with 5 members each. The experiment was conducted web-based (Stark et al., 2022) on three days (day 1, 2, and 8). The main results are: (i) Mild-moderate aphasia does not preclude web-based testing. (ii) The CSI effect in naming latencies (∼21 ms per ordinal position) did not differ significantly between groups but was more variable in the PWA; the effect was stable across days. (iii) Overall response times decreased between day 1 and day 2, but remained stable on day 8. (iv) In PWA, increased error-rates paralleled the latency-based CSI effect, suggesting stronger interference in this group. (v) Exploratory analyses suggest that lesions in a large area, including frontal, inferior parietal, pre- and post-central opercular cortices, are linked to a larger CSI effect. At a more lenient statistical threshold, lesions in occipital and supramarginal cortices were associated with increased overall naming latencies. These results offer an initial step toward identifying the neuronal underpinnings of semantic context effects in PWA. We conclude that web-based assessment is feasible in PWA and yields a stable CSI effect over repetitive testing. While not directly clinically applicable, the findings could serve as a foundation for exploring training-interventions targeting lexical activation, interference resolution, or word selection.

A novel TMS framework for assessing neurophysiological recovery at the subacute stage after stroke

OBJECTIVE

To use peri-threshold transcranial magnetic stimulation (TMS) intensities to elicit motor evoked potentials (MEPs) during the subacute stage after stroke and assess their association with upper limb motor recovery.

METHODS

Twenty-five MEP+ patients participated in three sessions at 1, 3, and 6 months post-stroke. Single-pulse TMS across a range of stimulation intensities was used to elicit MEPs in four muscles of the paretic and non-paretic upper limb. At each timepoint, threshold matrices were constructed based on MEP amplitude and persistence. A matrix element was suprathreshold if five out of ten stimulations elicited MEPs ≥ 50 μV. A subthreshold element produced MEPs below this criterion. Dexterity was assessed using the nine hole peg test.

RESULTS

There were fewer suprathreshold, and more subthreshold elements on the paretic compared to the non-paretic side. The number of suprathreshold elements on the paretic side increased between 1 and 6 months post-stroke. Neither sub- nor supra-threshold elements were associated with dexterity recovery.

CONCLUSION

The proportion of sub- and supra-threshold elements reflect neurophysiological recovery during the subacute stage after stroke. A threshold matrix framework can identify patients with stable versus dynamic neurophysiology post-stroke.

SIGNIFICANCE

A compositional analysis framework can quantify neurophysiological recovery after stroke.

Effects of intermittent theta burst stimulation on upper limb motor recovery in early stroke patients: an fNIRS study

Objective

To explore the recovery of upper limb motor function and the changes in cortical functional connectivity in patients with early subcortical small infarcts accompanied by severe upper limb motor dysfunction (PESSUM) after intermittent theta burst stimulation (iTBS) via functional near-infrared spectroscopy (fNIRS) and to explore the related mechanisms.

Methods

We enrolled 56 subcortical ischemic stroke patients with FMA-UE ≤28 and randomly assigned them to receive either genuine (TG, n = 29) or sham (CG, n = 23) iTBS plus standard rehabilitation over 8 days. fNIRS was used to monitor cerebral HbO, HbD, and HbT concentrations, and RSFC changes were analyzed. The FMA-UE and MBI scores were used to evaluate upper limb motor function and daily activities. Intergroup comparisons were conducted using independent samples t tests, whereas intragroup comparisons were performed using paired samples t tests or Mann-Whitney U tests. The trend of the RSFC changes was analyzed via repeated-measures Analysis of Variance (ANOVA).

Results

Both groups showed significant improvements in FMA-UE and MBI scores postintervention (p < 0.001). The TG had higher MBI scores than the CG (p = 0.005). fNIRS revealed accelerated cyclical changes in cortical activity in the TG.

Conclusion

iTBS significantly improved motor function and daily living ability in stroke patients, supporting a role for iTBS in promoting neural repair by accelerating cortical recovery cycles. This study provides evidence that iTBS is an effective rehabilitation strategy poststroke.

Clinical trial registration

https://www.chictr.org.cn/showproj.html?proj=169674, ChiCTR2200060955.

Feasibility of Smartphone-Based Exercise Training Integrated with Functional Electrical Stimulation After Stroke (SETS): A Preliminary Study

One emerging method in home stroke rehabilitation is digital technology. However, existing approaches typically target one domain (e.g., upper limb). Moreover, existing interventions do not cater to older adults with stroke (OAwS), especially those with high motor impairment, who require adjunct therapeutic agents to independently perform challenging exercises. We examined the feasibility of Smartphone-based Exercise Training after Stroke (SETS) with Functional Electrical Stimulation (FES). A total of 12 participants (67 ± 5 years) with stroke (onset > 6 months) exhibiting moderate-to-high motor impairment (Chedoke McMaster Leg ≤ 4/7) underwent 6 weeks of multicomponent (gait, functional strength, dynamic balance) training integrated with FES to paretic lower limb muscles. Primary measures included safety and adherence. Secondary measures included motivation, acceptability and attitude, usability, and clinical measures of gait and balance function like the 10-Meter Walk Test and Mini-BESTest. Participants reported no adverse events and moderate-to-high adherence (84.17 ± 11.24%) and improvement (up to 40%) in motivation, acceptability, and attitude and system usability. Participants also showed pre-post improvements in all measures of gait and balance function (p < 0.05). Integrating SETS and FES is feasible and yields short-term gains in gait and balance function among OAwS. Future studies could validate our findings by examining its efficacy with control groups to identify the differential effects of SETS and FES.

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.

Physical rehabilitation approaches for the recovery of function and mobility following stroke

BACKGROUND

Various approaches to physical rehabilitation to improve function and mobility are used after stroke. There is considerable controversy around the relative effectiveness of approaches, and little known about optimal delivery and dose. Some physiotherapists base their treatments on a single approach; others use components from several different approaches.

OBJECTIVES

Primary objective: To determine whether physical rehabilitation is effective for recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.

SECONDARY OBJECTIVE

To explore factors that may impact the effectiveness of physical rehabilitation approaches, including time after stroke, geographical location of study, intervention dose/duration, intervention provider, and treatment components. Stakeholder involvement: Key aims were to clarify the focus of the review, inform decisions about subgroup analyses, and co-produce statements relating to key implications.

SEARCH METHODS

For this update, we searched the Cochrane Stroke Trials Register (last searched November 2022), CENTRAL (2022, Issue 10), MEDLINE (1966 to November 2022), Embase (1980 to November 2022), AMED (1985 to November 2022), CINAHL (1982 to November 2022), and the Chinese Biomedical Literature Database (to November 2022).

SELECTION CRITERIA

Inclusion criteria: Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke.

EXCLUSION CRITERIA

RCTs of upper limb function or single treatment components.

PRIMARY OUTCOMES

measures of independence in activities of daily living (IADL) and motor function.

SECONDARY OUTCOMES

balance, gait velocity, and length of stay.

DATA COLLECTION AND ANALYSIS

Two independent authors selected studies according to pre-defined eligibility criteria, extracted data, and assessed the risk of bias in the included studies. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

In this review update, we included 267 studies (21,838 participants). Studies were conducted in 36 countries, with half (133/267) in China. Generally, studies were heterogeneous, and often poorly reported. We judged only 14 studies in meta-analyses as at low risk of bias for all domains and, on average, we considered 33% of studies in analyses of primary outcomes at high risk of bias. Is physical rehabilitation more effective than no (or minimal) physical rehabilitation? Compared to no physical rehabilitation, physical rehabilitation may improve IADL (standardised mean difference (SMD) 1.32, 95% confidence interval (CI) 1.08 to 1.56; 52 studies, 5403 participants; low-certainty evidence) and motor function (SMD 1.01, 95% CI 0.80 to 1.22; 50 studies, 5669 participants; low-certainty evidence). There was evidence of long-term benefits for these outcomes. Physical rehabilitation may improve balance (MD 4.54, 95% CI 1.36 to 7.72; 9 studies, 452 participants; low-certainty evidence) and likely improves gait velocity (SMD 0.23, 95% CI 0.05 to 0.42; 18 studies, 1131 participants; moderate-certainty evidence), but with no evidence of long-term benefits. Is physical rehabilitation more effective than attention control? The evidence is very uncertain about the effects of physical rehabilitation, as compared to attention control, on IADL (SMD 0.91, 95% CI 0.06 to 1.75; 2 studies, 106 participants), motor function (SMD 0.13, 95% CI -0.13 to 0.38; 5 studies, 237 participants), and balance (MD 6.61, 95% CI -0.45 to 13.66; 4 studies, 240 participants). Physical rehabilitation likely improves gait speed when compared to attention control (SMD 0.34, 95% CI 0.14 to 0.54; 7 studies, 405 participants; moderate-certainty evidence). Does additional physical rehabilitation improve outcomes? Additional physical rehabilitation may improve IADL (SMD 1.26, 95% CI 0.82 to 1.71; 21 studies, 1972 participants; low-certainty evidence) and motor function (SMD 0.69, 95% CI 0.46 to 0.92; 22 studies, 1965 participants; low-certainty evidence). Very few studies assessed these outcomes at long-term follow-up. Additional physical rehabilitation may improve balance (MD 5.74, 95% CI 3.78 to 7.71; 15 studies, 795 participants; low-certainty evidence) and gait velocity (SMD 0.59, 95% CI 0.26 to 0.91; 19 studies, 1004 participants; low-certainty evidence). Very few studies assessed these outcomes at long-term follow-up. Is any one approach to physical rehabilitation more effective than any other approach? Compared to other approaches, those that focus on functional task training may improve IADL (SMD 0.58, 95% CI 0.29 to 0.87; 22 studies, 1535 participants; low-certainty evidence) and motor function (SMD 0.72, 95% CI 0.21 to 1.22; 20 studies, 1671 participants; very low-certainty evidence) but the evidence in the latter is very uncertain. The benefit was sustained long-term. The evidence is very uncertain about the effect of functional task training on balance (MD 2.16, 95% CI -0.24 to 4.55) and gait velocity (SMD 0.28, 95% CI -0.01 to 0.56). Compared to other approaches, neurophysiological approaches may be less effective than other approaches in improving IADL (SMD -0.34, 95% CI -0.63 to -0.06; 14 studies, 737 participants; low-certainty evidence), and there may be no difference in improving motor function (SMD -0.60, 95% CI -1.32 to 0.12; 13 studies, 663 participants; low-certainty evidence), balance (MD -0.60, 95% CI -5.90 to 6.03; 9 studies, 292 participants; low-certainty evidence), and gait velocity (SMD -0.17, 95% CI -0.62 to 0.27; 16 studies, 630 participants; very low-certainty evidence), but the evidence is very uncertain about the effect on gait velocity. For all comparisons, the evidence is very uncertain about the effects of physical rehabilitation on adverse events and length of hospital stay.

AUTHORS' CONCLUSIONS

Physical rehabilitation, using a mix of different treatment components, likely improves recovery of function and mobility after stroke. Additional physical rehabilitation, delivered as an adjunct to 'usual' rehabilitation, may provide added benefits. Physical rehabilitation approaches that focus on functional task training may be useful. Neurophysiological approaches to physical rehabilitation may be no different from, or less effective than, other physical rehabilitation approaches. Certainty in this evidence is limited due to substantial heterogeneity, with mainly small studies and important differences between study populations and interventions. We feel it is unlikely that any studies published since November 2022 would alter our conclusions. Given the size of this review, future updates warrant consensus discussion amongst stakeholders to ensure the most relevant questions are explored for optimal decision-making.

Chronic Underrepresentation of Females and Women in Stroke Research Adversely Impacts Clinical Care

Unequal sex and gender sample sizes in rehabilitation studies have implications for the generalizability of the evidence and for the clinicians that utilize their recommendations. Physical therapists rely on evidence-based guidelines to tailor their assessments and interventions to optimize outcomes for patients. We currently know that females and women have worse stroke outcomes and prognoses than their counterparts, however, rehabilitation guidelines remain the same for all individuals. Notably, stroke prevention and acute care has recently shifted to include female- and women-oriented guidelines, however, rehabilitation guidelines have not yet caught up. This article summarizes the key differences that females and women with stroke experience, how they may impact recovery, and calls for researchers and rehabilitation professionals to consider sex and gender when working with patients who've had a stroke. Doing so will improve the lives for those with stroke and maximize treatment options and rehabilitation outcomes.

Computer-Based Gamified Tools for Facial Rehabilitation: A Scoping Review

Motor rehabilitation in patients with facial disorders, such as facial paralysis (FP), has faced challenges in maintaining the patients' engagement and motivation in the intensive and repetitive execution of the exercises. To assist in the facial rehabilitation process, gamified tools (GTs) have been proposed to promote stimulation and engagement in affected patients. This study provides a comprehensive review on the use of GTs to aid facial rehabilitation, with the aim of investigating the potential of such computer-based tools to motivate facial mime exercises. A systematic search conducted on May 22, 2024, across five databases (Scopus, Web of Science, IEEE Xplore, ACM Digital Library, and MEDLINE/PubMed) returned 1043 articles. The selection of studies resulted in 15 articles included for analysis, most of which were intended for patients recovering from FP. Bell's palsy, paralysis resulting from stroke, orofacial apraxia, and cerebral palsy were the patient disorders addressed in the articles. Facial mimic movements used for rehabilitation varied, the main actions considered in the studies were opening and closing the eyes, smiling, and raising the eyebrows. Studies focused on developing tools and conducting experiments with participants. Despite advances made by the selected studies, proposed computer-based tools for facial rehabilitation have not yet reached the necessary maturity for their use in clinical settings. Consequently, additional efforts are needed to perform new studies to mitigate the challenges presented in this research area. Therefore, this is a constantly evolving area of research and offers a huge window of opportunity for further research.

Corticomotor pathway function and recovery after stroke: a look back and a way forward

Stroke is a leading cause of adult disability that results in motor deficits and reduced independence. Regaining independence relies on motor recovery, particularly regaining function of the hand and arm. This review presents evidence from human studies that have used transcranial magnetic stimulation (TMS) to identify neurophysiological mechanisms underlying upper limb motor recovery early after stroke. TMS studies undertaken at the subacute stage after stroke have identified several neurophysiological factors that can drive motor impairment, including membrane excitability, the recruitment of corticomotor neurons, and glutamatergic and GABAergic neurotransmission. However, the inherent variability and subsequent poor reliability of measures derived from motor evoked potentials (MEPs) limit the use of TMS for prognosis at the individual patient level. Currently, prediction tools that provide the most accurate information about upper limb motor outcomes for individual patients early after stroke combine clinical measures with a simple neurophysiological biomarker based on MEP presence or absence, i.e. MEP status. Here, we propose a new compositional framework to examine MEPs across several upper limb muscles within a threshold matrix. The matrix can provide a more comprehensive view of corticomotor function and recovery after stroke by quantifying the evolution of subthreshold and suprathreshold MEPs through compositional analyses. Our contention is that subthreshold responses might be the most sensitive to reduced output of corticomotor neurons, desynchronized firing of the remaining neurons, and myelination processes that occur early after stroke. Quantifying subthreshold responses might provide new insights into post-stroke neurophysiology and improve the accuracy of prediction of upper limb motor outcomes.

Fusion of EEG and EMG signals for detecting pre-movement intention of sitting and standing in healthy individuals and patients with spinal cord injury

Introduction

Rehabilitation devices assist individuals with movement disorders by supporting daily activities and facilitating effective rehabilitation training. Accurate and early motor intention detection is vital for real-time device applications. However, traditional methods of motor intention detection often rely on single-mode signals, such as EEG or EMG alone, which can be limited by low signal quality and reduced stability. This study proposes a multimodal fusion method based on EEG-EMG functional connectivity to detect sitting and standing intentions before movement execution, enabling timely intervention and reducing latency in rehabilitation devices.

Methods

Eight healthy subjects and five spinal cord injury (SCI) patients performed cue-based sit-to-stand and stand-to-sit transition tasks while EEG and EMG data were recorded simultaneously. We constructed EEG-EMG functional connectivity networks using data epochs from the 1.5-s period prior to movement onset. Pairwise spatial filters were then designed to extract discriminative spatial network topologies. Each filter paired with a support vector machine classifier to classify future movements into one of three classes: sit-to-stand, stand-to-sit, or rest. The final prediction was determined using a majority voting scheme.

Results

Among the three functional connectivity methods investigated-coherence, Pearson correlation coefficient and mutual information (MI)-the MI-based EEG-EMG network showed the highest decoding performance (94.33%), outperforming both EEG (73.89%) and EMG (89.16%). The robustness of the fusion method was further validated through a fatigue training experiment with healthy subjects. The fusion method achieved 92.87% accuracy during the post-fatigue stage, with no significant difference compared to the pre-fatigue stage (p > 0.05). Additionally, the proposed method using pre-movement windows achieved accuracy comparable to trans-movement windows (p > 0.05 for both pre- and post-fatigue stages). For the SCI patients, the fusion method showed improved accuracy, achieving 87.54% compared to single- modality methods (EEG: 83.03%, EMG: 84.13%), suggesting that the fusion method could be promising for practical rehabilitation applications.

Conclusion

Our results demonstrated that the proposed multimodal fusion method significantly enhances the performance of detecting human motor intentions. By enabling early detection of sitting and standing intentions, this method holds the potential to offer more accurate and timely interventions within rehabilitation systems.

Upper-extremity motor recovery after stroke: A systematic review and meta-analysis of usual care in trials and observational studies

BACKGROUND

A better knowledge of upper-extremity (UE) recovery in patients with stroke receiving usual care (UC) is crucial for informing clinicians on expected recovery and serves as reference for future studies.

OBJECTIVES

This systematic review and meta-analysis aimed to assess rate and amount of recovery of UE with UC in the subacute phase of stroke and identify covariates of UE recovery.

METHODS

PRISMA-guidelines were used for search in PubMed, Cinahl and PEDro. Observational studies (OS) and UC groups of randomized control trials (RCT) of adults with subacute stroke and UE paresis were included, each reporting UE function at least at two time points. Placebo-, sham-controlled, dose-matched trials and trials with <10 participants were excluded.

RESULTS

From 1220 records, 54 papers (19 OS and 35 RCTs) involving 2774 subacute stroke patients were included. Fugl-Meyer Assessment of Upper Extremity (FMA-UE) and Action Research Arm Test (ARAT) were most frequently reported UE outcomes. Across RCTs, FMA-UE and ARAT improved 10 and 8 points, respectively, on average at 4-weeks from baseline. In OS, FMA-UE, improved 12 points at 12 weeks and 16 points at 24 weeks from baseline. Stroke severity, UE function, and lesion load of the cortico-spinal tract at baseline were associated with UE recovery.

CONCLUSIONS

UE function in subacute stroke showed improvements that exceeded the threshold for clinically important change across RCTs and OS. This review provides estimates of expected change in UC groups for sample size calculations and planning of future trials, thereby enhancing statistical power and comparability of findings.

The association between neighborhood social vulnerability and community-based rehabilitation after stroke

BACKGROUND

Timely rehabilitative care is vital for functional recovery after stroke. Social determinants may influence access to and use of post-stroke care but have been inadequately explored. The study examined the relationship between the Social Vulnerability Index (SVI) and community-based rehabilitation utilization.

METHODS

We included 6,843 adults (51.6% female; 75.1% White; mean age 70.1) discharged home after a stroke enrolled in the COMprehensive Post-Acute Stroke Services study, a pragmatic trial conducted in 40 North Carolina hospitals from 2016-2019. Rehabilitation utilization was sourced from administrative claims. Geocoded addresses were linked to 2018 Census tract SVI. Associations between SVI and 90-day rehabilitation use, adjusted for patient's clinical and socio-economic characteristics, were obtained from generalized estimating equations. We also examined the associations of SVI with therapy setting, types of therapy, intensity of visits, and time to first visit.

RESULTS

Thirty-five percent of patients had at least one physical (PT) or occupational therapy (OT) visit within 90 days, ranging from 32.4%-38.7% across SVI quintiles. In adjusted analysis, there was no dose-reponse relationship between higher summary SVI, nor most of its sub-domains, and 90-day rehabilitation use. Greater vulnerability in household composition and disability was modestly associated with -0.4% (95% CI -4.1% to 3.4%) to -4.3% (95% CI -0.8% to -7.7%) lower rehabilitation use across SVI quartiles. Greater summary and subdomain SVI was associated with higher odds of receiving therapy in the home versus outpatient clinic (OR = 1.88, 1.58 to 2.17 for Q5 vs Q1 summary SVI) and receiving both PT and OT versus a single-type therapy (1.72, 1.48 to 1.97 for Q5 vs. Q1 summary SVI). No differences were observed for therapy intensity or time to therapy.

CONCLUSION

Use of rehabilitation care was low, and largely similar across levels of SVI and most of its subdomains. Individuals residing in areas of high SVI were more likely to receive therapy in the home and to receive dual therapy, possibly reflecting greater need among these individuals. Future studies should evaluate potential mechanisms for these findings and further identify both patient and community factors that may inform strategies to improve rehabilitation use.

CLINICAL TRIAL NUMBER

https://www.

CLINICALTRIALS

gov/ NCT02588664 [registration date: 2015-10-23].

Effects of body weight-supported Tai Chi Yunshou training on upper limb motor function in stroke patients: A three-arm parallel randomized controlled trial

OBJECTIVES

To form a unique body weight support-Tai Chi Yunshou (BWS-TCY) training method, apply it to the treatment of upper limb dysfunction after stroke, and provide a new safe and effective treatment method for the clinic.

METHODS

A total of 93 subjects were recruited and randomly divided into conventional rehabilitation treatment (CRT) group, BWS-TCY group and traditional robot-assisted training (RAT) group in equal proportions. Subjects in the CRT group received 60 minutes of CRT daily. Subjects in the BWS-TCY group received 30 minutes of CRT and 30 minutes of BWS-TCY. Subjects in the RAT group received 30 minutes of CRT and 30 minutes of RAT. All interventions were conducted 5 days per week for 12 weeks. Outcome assessments included the Fugl-Meyer Upper Extremity Motor Function Assessment (FMA-UE), Wolf Motor Function Test (WMFT), absolute angular error (AAE), joint range of motion (JMA), modified Barthel Index (MBI), and stroke-related quality of life. Table (SS-QOL). Outcome measures were assessed at baseline, 4 weeks, 8 weeks, and 12 weeks later, and statistical analyzes were performed using two-way repeated measures analysis of variance.

RESULTS

After 12 weeks of intervention, significant improvements were observed in all evaluation indicators for the three groups of subjects compared to before the intervention. The upper limb motor function (FMA-UE and WMFT) and proprioception (AAE) showed time effects, time × group interaction effects, and group effects. When comparing the groups, the FMA-UE in the BWS-TCY group, as well as the WMFT and MBI, showed statistically significant differences compared to the CRT group (P<0.05), but not statistically significant compared to the RAT group (P>0.05). The AAE of the BWS-TCY group showed no statistical difference (P>0.05) when compared to the CRT group and RAT group. Furthermore, a time effect was observed on the rotation direction (P<0.05), and pairwise comparison between groups revealed that the BWS-TCY group performed better than both the CRT group and the RAT group. After 12 weeks of intervention, there were time effects and interaction effects between BWS-TCY and daily living activities (MBI) and quality of life (SS-QOL), but no group effect was observed. There was no statistical difference between the two groups in SS-QOL. However, there was a statistical difference (P<0.01) in MBI between the two groups.

CONCLUSIONS

The 12-week BWS-TCY intervention has been shown to effectively improve upper limb motor function.

TRIAL REGISTRATION

Retrospectively registered at chictr.org.cn on August 31, 2022 [ChiCTR2200063150] https://www.chictr.org.cn/showproj.html?proj=176229.

The role of muscle synergies and task constraints on upper limb motor impairment after stroke

This study explores the role of task constraints over muscle synergies expression in the context of upper limb motor impairment after stroke. We recruited nine chronic stroke survivors with upper limb impairments and fifteen healthy controls, who performed a series of tasks designed to evoke muscle synergies through various spatial explorations. These tasks included an isometric force task, a dynamic reaching task, the clinical Fugl-Meyer (FM) assessment, and a pinch task. Electromyographic data from 16 upper limb muscles were collected during each task, alongside intermuscular coherence (IMC) measurements during the pinch task to assess neuromuscular connectivity. The findings confirm that motor impairment is inversely related to the diversity of muscle synergies, with fewer synergies and more stereotypical synergy structures observed post-stroke. The study further reveals that the nature of motor tasks significantly affects the number of identifiable muscle synergies, with less constrained tasks revealing a broader array of synergies. These findings highlight the importance of carefully selecting motor tasks in the context of clinical research and assessments to understand a patient's motor impairment, thus aiding in developing tailored rehabilitation strategies.

Improved motor imagery skills after repetitive passive somatosensory stimulation: a parallel-group, pre-registered study

Introduction

Motor-imagery-based Brain-Machine Interface (MI-BMI) has been established as an effective treatment for post-stroke hemiplegia. However, the need for long-term intervention can represent a significant burden on patients. Here, we demonstrate that motor imagery (MI) instructions for BMI training, when supplemented with somatosensory stimulation in addition to conventional verbal instructions, can help enhance MI capabilities of healthy participants.

Methods

Sixteen participants performed MI during scalp EEG signal acquisition before and after somatosensory stimulation to assess MI-induced cortical excitability, as measured using the event-related desynchronization (ERD) of the sensorimotor rhythm (SMR). The non-dominant left hand was subjected to neuromuscular electrical stimulation above the sensory threshold but below the motor threshold (St-NMES), along with passive movement stimulation using an exoskeleton. Participants were randomly divided into an intervention group, which received somatosensory stimulation, and a control group, which remained at rest without stimulation.

Results

The intervention group exhibited a significant increase in SMR-ERD compared to the control group, indicating that somatosensory stimulation contributed to improving MI ability.

Discussion

This study demonstrates that somatosensory stimulation, combining electrical and mechanical stimuli, can improve MI capability and enhance the excitability of the sensorimotor cortex in healthy individuals.

A scoping review on the body awareness rehabilitation after stroke: are we aware of what we are unaware?

Body awareness (BA) is a complex multi-dimensional construct that refers to the subject's ability to consciously perceive and integrate sensory and proprioceptive information related to the position, movement, and balance of one's own body and body parts. Since it involves multiple brain regions and include different functional networks, it is very often affected by cerebrovascular damage such as stroke. Deficits in the ability to monitor our actions and predict their consequences or recognize our body parts and distinguish them from those of others may emerge after stroke. In this study, we decided to explore whether specific treatments targeting BA are discussed in current literature, and whether BA is considered as an outcome in neurorehabilitation processes for stroke patients. To achieve our goal, a scoping review on this often-underreported problem was performed. After analyzing the existing literature, emerged BA in stroke patients is rarely assessed or rehabilitated through specific stimulation or rehabilitation protocol. Additionally, treatment outcomes related to BA are often considered only from a "physical" perspective such as improvements in walking, balance, or the movement of specific body parts, rather than from a proprioceptive standpoint. Further research is needed to facilitate developing early and effective intervention strategies for the recovery of BA after stroke.

Assessing the fall risk with Stay Independent Questionnaire in people with stroke

Objectives

This study aimed to assess the psychometric properties of the Chinese version of the Stay Independent Questionnaire (C-SIQ) in evaluating individuals with stroke.

Design

The study adopted a cross-sectional design.

Setting

The research was conducted at a university-based neurorehabilitation center.

Participants

The study included a total of 100 individuals with stroke and 49 healthy older adults.

Methods

On Day 1, both individuals with stroke and healthy older adults underwent assessments using the C-SIQ. Additionally, individuals with stroke were evaluated using the Fugl-Meyer Assessment of Lower Extremity (FMA-LE), ankle dorsiflexion and plantarflexion strength, Berg Balance Scale (BBS), Timed-Up and Go Test (TUG), 10-meter walk test (10 mWT), Activities-specific Balance Confidence (ABC) Scale, Stroke Impact Scale (SIS), and Community Integration Measure (CIM). On Day 2 (7 days after Day 1), individuals with stroke were reassessed using the C-SIQ.

Results

Individuals with stroke exhibited a higher C-SIQ score (6.22 ± 2.98) compared to healthy older adults (1.59 ± 2.01). The C-SIQ demonstrated good test-retest reliability (intraclass correlation coefficient = 0.847) and internal consistency (Cronbach's alpha = 0.709). The Minimal Detectable Change in C-SIQ score was calculated as 3.05. Exploratory factor analysis revealed four factors with eigenvalues ≥1.0, explaining 57.17% of the total variance. The C-SIQ score exhibited significant correlations (ranging from -0.553 to 0.362) with completion times of the TUG and 10 mWT, FMA-LE, BBS, ABC, SIS, CIM score, paretic ankle dorsiflexion strength, and 6 mWT distance. A cut-off score of 2.5 was identified as the optimal threshold for discriminating fall risk between individuals with stroke and healthy controls.

Conclusion

The C-SIQ emerges as a reliable and valid tool for evaluating fall risk in individuals with stroke, showcasing strong correlations with key measures such as TUG times, 10 mWT, FMA-LE, BBS, ABC, SIS, CIM score, paretic ankle dorsiflexion strength, and 6 mWT distance. The C-SIQ demonstrated good test-retest reliability and internal consistency. Exploratory factor analysis revealed that this is a four factors assessment tool. The identified cut-off score of 2.5 effectively distinguishes fall risk between individuals with stroke and healthy controls.

Exploring the reasons behind the low focus on upper limb rehabilitation in the early stages after a stroke: A qualitative study

BACKGROUND

One aspect that is often impaired in people living with stroke is the motor function of the upper limb.

PURPOSE

To explore the reasons behind the low focus on upper limb rehabilitation after stroke and to understand the views of rehabilitation professionals (RPs) on the use of upper limb rehabilitation technologies for self-management of stroke.

STUDY DESIGN

A qualitative descriptive design that employs a one-on-one semistructured interview method.

METHODS

A total of nine RPs (physiotherapist n = 6 and occupational therapist n = 3) participated. Interviews were held in person or via teleconferencing, recorded, and transcribed verbatim. All transcribed data were analyzed using thematic analysis, with an inductive approach.

RESULTS

The average length of practice years of the RPs in this study was 24.7 ± 9.8, with 16.44 ± 9.19 experience in neurological rehabilitation. The views gathered from all nine (9/9) RPs point to a low focus on upper limb rehabilitation for people living with stroke. In an inpatient setting, this was attributed to the rehabilitation goals/ priorities (of people living with stroke, RPs, and/or hospital's rehabilitation/stroke units), inadequate resources, and the inability of the RPs to deal with the high incidence of stroke. After discharge, it was attributed to the cost of securing private rehabilitation and poor knowledge of technologies that can support self-rehabilitation. The cost, design, and inadequacy of evidence on the effectiveness of some available upper limb rehabilitation technologies were noted as reasons that could make it difficult for RPs to promote the use of rehabilitation technologies.

CONCLUSIONS

There is a low focus on upper limb rehabilitation after a stroke, particularly during the early stages, owing to the pursuit of early discharge which appears to attach higher priority to the lower limb in addition to inadequate resources and lack of capacity to deal with the high incidence of stroke.

Perceptions of Patients With Stroke Regarding an Immersive Virtual Reality-Based Exercise System for Upper Limb Rehabilitation: Questionnaire and Interview Study

BACKGROUND

With substantial resources allocated to develop virtual reality (VR)-based rehabilitation exercise programs for poststroke motor rehabilitation, it is important to understand how patients with stroke perceive these technology-driven approaches, as their perceptions can determine acceptance and adherence.

OBJECTIVE

This study aimed to examine the perceptions of patients with stroke regarding an immersive VR-based exercise system developed to deliver shoulder, elbow, forearm, wrist, and reaching exercises.

METHODS

A questionnaire was used to assess the perceptions of 21 inpatients who had experienced stroke (mean time from stroke onset: 37.2, SD 25.9 days; Brunnstrom stage of stroke recovery for the arm: 3-5) regarding the perceived usefulness of, ease of use of, attitude toward, intrinsic motivation for, and intention to use the exercise system. The measurement items were rated on a 7-point Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree), with higher values indicating more positive perceptions. Descriptive statistics were used to summarize the responses. Moreover, we conducted semistructured interviews that were audio recorded, transcribed, and subjected to content analysis to identify thematic patterns.

RESULTS

The questionnaire results revealed that the patients' perceptions of the exercise system were positive (mean ratings >6). The content analysis revealed 6 positive themes from 73 statements about the exercise system: ease of use, usefulness, enjoyment, motivation, accessibility, and game design. Conversely, 15 statements reflected negative perceptions, which were clustered into 3 themes: difficulty in handling VR devices, uncomfortable experiences when using VR devices, and monotony.

CONCLUSIONS

Integrating VR technology into poststroke functional exercises holds significant promise based on patient interests. However, patient preferences and adaptability must be considered to promote the technology's success. VR-guided exercises should be user-friendly, health-promoting, engaging, and well-designed. Furthermore, addressing challenges, such as bulkiness, motion sickness, discomfort, and exercise monotony, is crucial for the widespread adoption and diffusion of this technology.

Upper extremity function and disability recovery with vibration therapy after stroke: a systematic review and meta-analysis of RCTs

BACKGROUND

This study aimed to investigate the therapeutic effects of vibration therapy for improving upper extremity motor impairment, function, and disability recovery in people with stroke.

DESIGN

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. PubMed, EMBASE, the Cochrane Library Database, Physiotherapy Evidence Database (PEDro), China Knowledge Resource Integrated Database, and Google Scholar were searched from inception to May 31, 2024. Randomized controlled trials (RCTs) that evaluated the effects of vibration therapy on upper extremity motor impairment, function, and disability recovery post-stroke were analyzed.

SETTING AND PARTICIPANTS

Participants with a diagnosis of stroke with hemiplegia (or hemiparesis) were recruited.

METHODS

Methodological quality assessment was performed using the PEDro quality score. Upper extremity motor impairment, function, and disability were the primary outcomes. Upper extremity motor impairment was measured using the Fugl-Meyer Assessment scale and other methods. Upper extremity functions were evaluated using the Wolf Motor Function test or other tools assessing manipulative activities. Disability was assessed using the Functional Independence Measure, Barthel index, and other methods.

RESULTS

Overall, 30 RCTs including 1621 people with stroke were selected. Compared with the control, vibration therapy exerted significant effects on upper extremity motor impairment [standardized mean difference (SMD) = 1.19; p < 0.00001)], function (SMD = 0.62; p < 0.00001), and disability recovery (SMD = 1.01; p < 0.00001). The subgroup analysis revealed that focal vibration therapy (SMD = 2.14) had favorable effects on disability recovery compared with whole-body vibration therapy (SMD = 2.0). Interventions lasting 4-8 weeks showed significant improvements in motor impairment (SMD = 1.19), motor function (SMD = 0.57), and disability (SMD = 0.84); additionally, the effects of vibration therapy combined with conventional rehabilitation (SMD = 1.03) were superior to those of vibration therapy alone (SMD = 0.21).

CONCLUSIONS

Vibration therapy may be a reliable rehabilitation program to improve upper extremity motor functions and disabilities. Furthermore, vibration therapy should be performed at the earliest possibility after stroke for at least 4-8 weeks. Trial registration The protocol of this study was registered with PROSPERO (Registration number: CRD42022301119).

Mechanisms of Vagus Nerve Stimulation in Improving Motor Dysfunction After Stroke

Patients with stroke would have persistent functional deficits despite undergoing physiotherapy and rehabilitation training. Recently, vagus nerve stimulation (VNS), a newly emerging neuroregulatory technique, has been shown to improve motor dysfunction after stroke. Evidence from clinical and preclinical studies has proven the safety, feasibility, and efficacy of invasive and noninvasive VNS. It has been reported that the positive effect may be related to anti-inflammatory effects, mediating neuroplasticity, increasing blood-brain barrier integrity, promoting angiogenesis and reducing spreading depolarization. However, the underlying mechanism remains poorly understood. In this review, we have summarized the potential molecular mechanisms by which VNS promotes stroke prognosis. We believe that VNS combined with upper-extremity rehabilitation can improve impairment and function among moderately to severely impaired stroke survivors. The applications and further exploration are discussed to provide new insights into this novel therapeutic technique.

Evaluating inter- and intra-rater reliability in assessing upper limb compensatory movements post-stroke: creating a ground truth through video analysis?

BACKGROUND

Compensatory movements frequently emerge in the process of motor recovery after a stroke. Given their potential for unfavorable long-term effects, it is crucial to assess and document compensatory movements throughout rehabilitation. However, clinically applicable assessment tools are currently limited. Deep learning methods have shown promising potential for assessing movement quality and addressing this gap. A crucial prerequisite for developing an accurate measurement tool is ensuring reliability in assessing compensatory movements, which is essential for establishing a valid ground truth.

OBJECTIVE

The study aimed to assess inter- and intra-rater reliability of occupational and physical therapists' visual assessment of compensatory movements based on video analysis.

METHODS

Experienced therapists evaluated video-recorded performances of a standardized drinking task through an online labeling system. The standardized drinking task was performed by seven individuals with mild to moderate upper limb motor impairments after a stroke. The therapists rated compensatory movements in predetermined body segments and movement phases using a slider with a continuous scale ranging from 0 (no compensation) to 100 (maximum compensation). The collected data were analyzed using a generalized-linear mixed effects model with zero-inflated beta regression to estimate variance components. Intraclass correlation coefficients (ICC) were calculated to assess inter- and intra-rater reliability.

RESULTS

Twenty-two therapists participated in this study. Inter-rater reliability was good for the phases of reaching, drinking, and returning (ICC ≥ .0.75), and moderate for both phases of transporting. Intra-rater reliability was excellent for the drinking phase (ICC > 0.9) and moderate to good for the phases of reaching, transporting, and returning of our cohort. ICCs for smoothness and interjoint coordination were poor for both inter- and intra-rater reliability. The data analysis unveiled a wide range of credible intervals for the ICCs across all domains examined in this study.

CONCLUSIONS

While this study shows promising inter- and intra-rater reliability for the drinking phases within our sample, the wide credible intervals raise the possibility that these results may have occurred by chance. Consequently, we cannot recommend the establishment of a ground truth for the automatic assessment of compensatory movements during a drinking task based on therapists' ratings alone.

The Current State of the Literature on Dual-Task Performance Across Multiple Domains in Individuals With Chronic Poststroke Aphasia: A Scoping Review

BACKGROUND

Understanding the impact that poststroke aphasia has on dual-task performance across multiple domains of function may inform the development of effective interventions. The purpose of this scoping review is to identify (a) the main theoretical frameworks used to explain dual-task performance deficits in individuals with poststroke aphasia; (b) the domains of function measured and the assessments used; (c) interventions aimed to improve dual-task performance; and, finally, (d) gaps that exist in the current body of literature regarding dual-task in persons with aphasia.

METHOD

A search of Linguistics and Language Behavior Abstracts, PsycINFO, Communication & Mass Media Complete, PubMed, CINAHL Plus, ScienceDirect, and the Cochrane Library was undertaken to identify publications on the topic. Articles were included in the review if they (a) were written in English, (b) included individuals with chronic poststroke aphasia, (c) included measures of dual-task performance, and/or (d) consisted of a theoretical narrative with a focus on dual task in persons with aphasia.

RESULTS

Following the full-text screening, a total of 17 studies were in included for synthesis. Fourteen articles focused on dual-task experimental studies; one study consisted of a dual-task intervention; and two papers proposed a theory, framework, or schema to explain dual-task performance.

CONCLUSION

Gaps were identified in the literature, as well as differences in the methodology employed across studies, highlighting the need for consistency across experimental tasks and further examination across domains.

The efficacy of lower limb orthoses on quality of life, well-being, and participation following stroke: A systematic review

Stroke is the main cause of acquired adult disability globally, with motor impairment affecting 80% of people after stroke. To regain mobility, diminish falls, and improve quality of life (QoL), after a stroke, orthoses are recommended. Most studies, to date, have focused on the positive impact of ankle-foot orthoses on spatial-temporal, kinematic, and kinetic outcomes. The objective of this review is to assess the evidence of the effects of lower-extremity orthoses on perceptions of QoL, psychological well-being, and social participation after stroke. The following databases were used to search the literature: CINAHL, EMBASE, Scopus, and PubMed, between 1990 and 2022. Previous reviews and reference lists were also screened. Information on the trial design, sample characteristics, information of orthoses used, outcome measures, and results were extracted. Critical appraisal was conducted using SIGN guidelines. Ten articles were identified as meeting the inclusion criteria. The effect of orthoses on QoL was inconsistent: 4 articles reported a positive relationship, one found a negative relationship, and 3 did not find any relationship. Six of 7 articles reported a positive relationship between the use of orthoses and psychological well-being and participation, although the level of evidence was low. This literature review has identified a small number of articles addressing the research question. Furthermore, varied study designs, low levels of evidence seen, the variation in follow-up times, and the limited information about the fitting and appropriateness of the orthoses in the studies highlight that more research is needed.

Enhancing Heart Rate-Based Estimation of Energy Expenditure and Exercise Intensity in Patients Post Stroke

BACKGROUND

Indirect calorimetry is the gold standard field-testing technique for measuring energy expenditure and exercise intensity based on the volume of oxygen consumed (VO2, mL O2/min). Although heart rate is often used as a proxy for VO2, heart rate-based estimates of VO2 may be inaccurate after stroke due to changes in the heart rate-VO2 relationship. Our objective was to evaluate in people post stroke the accuracy of using heart rate to estimate relative walking VO2 (wVO2) and classify exercise intensity. Moreover, we sought to determine if estimation accuracy could be improved by including clinical variables related to patients' function and health in the estimation.

METHODS

Sixteen individuals post stroke completed treadmill walking exercises with concurrent indirect calorimetry and heart rate monitoring. Using 70% of the data, forward selection regression with repeated k-fold cross-validation was used to build wVO2 estimation equations that use heart rate alone and together with clinical variables available at the point-of-care (i.e., BMI, age, sex, and comfortable walking speed). The remaining 30% of the data were used to evaluate accuracy by comparing (1) the estimated and actual wVO2 measurements and (2) the exercise intensity classifications based on metabolic equivalents (METs) calculated using the estimated and actual wVO2 measurements.

RESULTS

Heart rate-based wVO2 estimates were inaccurate (MAE = 3.11 mL O2/kg/min) and unreliable (ICC = 0.68). Incorporating BMI, age, and sex in the estimation resulted in improvements in accuracy (MAE Δ: -36.01%, MAE = 1.99 mL O2/kg/min) and reliability (ICC Δ: +20, ICC = 0.88). Improved exercise intensity classifications were also observed, with higher accuracy (Δ: +29.85%, from 0.67 to 0.87), kappa (Δ: +108.33%, from 0.36 to 0.75), sensitivity (Δ: +30.43%, from 0.46 to 0.60), and specificity (Δ: +17.95%, from 0.78 to 0.92).

CONCLUSIONS

In people post stroke, heart rate-based wVO2 estimations are inaccurate but can be substantially improved by incorporating clinical variables readily available at the point of care.

Studying turn performance, trunk control, and mobility in acute stroke subjects: a cross-sectional study

Background

Stroke leads to various impairments like motor deficits, impaired trunk control and restricted mobility. However, rehabilitation professionals often underestimate the fundamental function of turning, which is essential for daily living activities like walking, cooking, or performing household chores. Impaired turning can be attributed to motor deficits post-stroke, resulting in restricted mobility and impaired trunk movement. Therefore, the present study aimed to determine the relationship between turn performance, trunk control, and mobility in stroke patients.

Materials and Methods

A total of 63 first-time supratentorial stroke (i.e., anterior circulation stroke) patients aged 18-90 years were recruited for the study. Turn performance was assessed by asking patients to walk for 10 feet comfortably, then take a 180° turn and return to the starting position. In addition, the duration and number of steps were recorded. Following this, the Trunk Impairment Scale (TIS) and Stroke Rehabilitation Assessment of Movement (STREAM) were used to assess trunk impairment and mobility, respectively. The group turn performance was analyzed using the Kruskal-Wallis test with a post hoc Mann-Whitney U test for between-group comparisons. The turn duration and turn steps were correlated with age, trunk control, and mobility using Spearman's rank correlation. A regression analysis was performed to determine the association of turn performance with age, trunk control, and mobility among stroke patients.

Results

Thirty stroke patients had turning difficulty, and 33 did not. Hence, they were categorized into the turning difficulty (TD) and non-turning difficulty (NTD) groups. When correlated with turn duration and the number of steps taken by the stroke patients while turning, the STREAM and TIS scores revealed a significant negative correlation (p < 0.001). The subjects' age showed a significant positive correlation with the turn duration and number of steps taken by stroke patients while turning (p < 0.001). A significant association was also found between turn performance and age and trunk control. However, there was no significant association between turn performance and mobility.

Conclusion

The observed associations highlight the complexity of turning ability and trunk control necessary to complete a turn safely. Additionally, with advancing age, turn performance and turning movement are compromised in stroke patients. This indicates that turning difficulty is more pronounced in older individuals with stroke.

We Will, We Will Shock You: Adaptive Versus Conventional Functional Electrical Stimulation in Individuals Post-Stroke

Functional electrical stimulation (FES) is often used in poststroke gait rehabilitation to address decreased walking speed, foot drop, and decreased forward propulsion. However, not all individuals experience clinically meaningful improvements in gait function with stimulation. Previous research has developed adaptive functional electrical stimulation (AFES) systems that adjust stimulation timing and amplitude at every stride to deliver optimal stimulation. The purpose of this work was to determine the effects of a novel AFES system on functional gait outcomes and compare them to the effects of the existing FES system. Twenty-four individuals with chronic poststroke hemiparesis completed 64-min walking trials on an adaptive and fixed-speed treadmill with no stimulation, stimulation from the existing FES system, and stimulation from the AFES system. There was no significant effect of stimulation condition on walking speed, peak dorsiflexion angle, or peak propulsive force. Walking speed was significantly faster and peak propulsive force was significantly larger on the adaptive treadmill (ATM) than the fixed-speed treadmill (both p < 0.0001). Dorsiflexor stimulation timing was similar between stimulation conditions, but plantarflexor stimulation timing was significantly improved with the AFES system compared to the FES system (p = 0.0059). Variability between and within subjects was substantial, and some subjects experienced clinically meaningful improvements in walking speed, peak dorsiflexion angle, and peak propulsive force. However, not all subjects experienced benefits, suggesting that further research to characterize which subjects exhibit the best instantaneous response to FES is needed to optimize poststroke gait rehabilitation using FES.