Constraint-induced movement therapy after stroke

Effectiveness of modified constraint-induced movement therapy on upper limb function of stroke survivors in inpatient hospital settings: a systematic review and meta-analysis

PURPOSE

To synthesise evidence on the effectiveness of modified constraint-induced movement therapy on upper limb function in stroke survivors within inpatient hospital settings.

METHODS

A systematic review was pre-registered in PROSPERO (CRD42023421715b) and searched six databases (EMBASE, AMED, MEDLINE, CINAHL, Cochrane Library, OTseeker) up to November 2024.

Articles included adults with stroke undergoing modified constraint-induced movement therapy in inpatient hospital settings. Article quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. Homogenous data was synthesised in a meta-analysis and assessed using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Remaining data was synthesised descriptively.

RESULTS

Ten randomised controlled trials (364 participants) were included. Four (191 participants) were analysed in a meta-analysis, showing modified constraint-induced movement therapy improved upper limb function (standardised mean difference (SMD) 0.94, 95% confidence interval (CI) 0.40 to 1.48), based on low-quality evidence. Five articles included follow-up, with two (90 participants) reporting sustained improvements. Five articles assessed activities of daily living, with two (136 participants) reporting positive effects.

CONCLUSION

Modified constraint-induced movement therapy improves upper limb function in the acute and sub-acute stages of stroke recovery within inpatient hospital settings. Sustainability of improvements and the impact on activities of daily living remains uncertain.

High-Dose, High-Intensity Stroke Rehabilitation: Why Aren't We Giving It?

Current doses and intensities of post-stroke rehabilitation therapy provided as “usual care” are paltry compared to the magnitudes needed to drive large behaviorally-relevant reductions in neurologic impairments. There is convergent evidence indicating that high dose, high intensity rehabilitation is effective for improving outcomes after stroke with large effect sizes compared to usual care. Here we highlight some of this evidence (focusing on studies of upper extremity motor rehabilitation) and then ask the simple question— why are we not delivering high doses and intensities of rehabilitation in clinical practice? We contend that reasons for lack of implementation of high dose, high intensity rehabilitation have to do with questionable conceptual, ideological, and economic assumptions. In addition, there are practical challenges, which we argue can be overcome with technology. Current practice (we refer primarily to the context of US healthcare) in stroke rehabilitation is itself built on very little evidence, indeed considerably less than the cumulative evidence indicating that high dose, high intensity rehabilitation would be more effective. Our hope is that this Perspective will help persuade multiple stake holders (neurologists, physiatrists, therapists, researchers, patients, policy makers, and insurance companies) to advocate for higher doses and intensities of rehabilitation. There is certainly more research to be done on new ways to deliver high-dose, high-intensity neurorehabilitation, as well as zeroing in on its best timing and dosing, and how to best combine it with drugs and physiological stimulation. In the meantime, our view is that a large body of convergent evidence already justifies seeking to incorporate higher doses and intensities of therapy into current clinical practice as the new standard of care.

MGH Laboratory for Translational Neurorecovery: @LTNeurorecovery (X), @ltneuro (Instagram)

MGH Center for Neurotechnology and Neurorecovery: @MGH_CNTR (X)

Exploring seamless home rehabilitation: a tool to enhance hand function through integration with ADL

OBJECTIVE

Hand impairments greatly impact the execution of daily activities. Home rehabilitation is essential to improve functional tasks and prevent function decline, but also tends to be a lengthy process where patients lose motivation over time. In our approach, we want to bypass the need for intrinsic motivation and offer hand-function exercises that are seamlessly integrated into activities of daily living. We do this by integrating exercises with tools that are used during daily routines. In this paper, we present the design of an interactive toothbrush that integrates wrist exercises with the routine of brushing teeth: TumbleTooth.

MATERIALS AND METHODS

To assess how well the tool allows for seamless integration of the exercise and the daily activity, we performed usability tests, semi-structured interviews, and a dual task on cognitive workload. The evaluation involved two groups of ten healthy participants and two stroke survivors. For the healthy participants the tests were conducted in a lab setting, for the stroke survivors at their homes.

RESULTS

Both the quantitative and qualitative data suggest a high seamlessness indication of our rehabilitation tool. Users show minimal cognitive workload while using it and appreciate the ease of use of the system.

DISCUSSION AND CONCLUSION

Our work presents design features that must be considered when designing seamless home rehabilitation devices.

A clinical trial evaluating feasibility and acceptability of a brain-computer interface for telerehabilitation in patients with stroke

BACKGROUND

We have created a groundbreaking telerehabilitation system known as Tele BCI-FES. This innovative system merges brain-computer interface (BCI) and functional electrical stimulation (FES) technologies to rehabilitate upper limb function following a stroke. Our system pioneers the concept of allowing patients to undergo BCI therapy from the comfort of their homes, while ensuring supervised therapy and real-time adjustment capabilities. In this paper, we introduce our single-arm clinical trial, which evaluates the feasibility and acceptance of this proposed system as a telerehabilitation solution for upper extremity recovery in stroke survivors.

METHOD

The study involved eight chronic patients with stroke and their caregivers who were recruited to attend nine home-based Tele BCI-FES sessions (three sessions per week) while receiving remote support from the research team. The primary outcomes of this study were recruitment and retention rates, as well as participants perception on the adoption of technology. The secondary outcomes involved assessing improvements in upper extremity function using the Fugl-Meyer Assessment for Upper Extremity (FMA_UE) and the Leeds Arm Spasticity Impact Scale.

RESULTS

Seven chronic patients with stroke completed the home-based Tele BCI-FES sessions, with high retention (87.5%) and recruitment rates (86.7%). Although participants provided mixed feedback on setup ease, they found the system progressively easier to use, and the setup process became more efficient with continued sessions. Participants suggested modifications to enhance user experience. Following the intervention, a significant increase in FMA_UE scores was observed, with an average improvement of 3.83 points (p = 0.032). The observed improvement of 3.83 points in the FMA-UE score approaches the reported Minimal clinically important difference of 4.25 points for patients with chronic stroke.

CONCLUSION

This study serves as a proof of concept, showcasing the feasibility and acceptability of the proposed Tele BCI-FES system for rehabilitating the upper extremities of stroke survivors. While some participants demonstrated significant improvements in FMA-UE scores, these findings are not generalizable, as they were derived from a small-scale feasibility study. The results should be interpreted cautiously within the study's specific context. Additionally, the intervention was not compared to other therapeutic approaches, limiting conclusions regarding its relative effectiveness. To further validate the efficacy of the proposed Tele BCI-FES system, it is essential to conduct additional research with larger sample sizes and extended rehabilitation sessions. Moreover, future studies should include comparisons with other therapeutic approaches to better evaluate the relative effectiveness of this intervention. Trial registration This clinical study is registered at clinicaltrials.gov https://clinicaltrials.gov/study/NCT05215522 under the study identifier (NCT05215522) and registered with the ISRCTN registry https://doi.org/10.1186/ISRCTN42991002 (ISRCTN42991002).

Effectiveness of task-oriented circuit training on the motor performance of ischaemic stroke patients: a study protocol for randomised clinical trial

Stroke is one of the most common causes of disability and death worldwide. With the rapidly growing stroke survivor population, it is crucial to identify an effective method for their healthcare. Recovery from stroke is followed by physiotherapy to promote rehabilitation. Task-oriented circuit training is designed to improve stroke patients' overall functioning during rehabilitation. This research aims to assess the effectiveness of task-oriented circuit training compared with conventional physiotherapy. The investigators have planned an 8-week parallel, two-arm, prospective, randomised clinical study. Participants will be enrolled from eight branches of the centre for the rehabilitation of the paralysed (CRP). We have planned to recruit 506 stroke survivors via a 1:1 random assignment procedure for 24 months. As a main objective, the Action Arm Research Test and the Timed Up and Go will be used to test upper and lower limb motor function. The secondary objectives will include daily living and balance activities, which will be evaluated using the Barthel Index and the Berg Balance Scale. The post-test and follow-up data will be collected after 8 and 12 weeks. The final analysis will include dropouts and treatment side effects. This study has been granted ethical approval by the Ethics Review Committee of the CRP (CRP-R&E-0401-357)). All activities and interventions will be carried out following the Helsinki Declaration of 2020. The findings will be published in peer-reviewed journals and disseminated at international conferences. Trial registration number: CTRI/2023/09/057907 (21 September 2023) (Prospectively registered).

Repetitive transcranial magnetic stimulation and constraint-induced movement therapy combined in the treatment of post-stroke movement disorders: a narrative review

Stroke is a significant cardiovascular and cerebrovascular condition and is among the primary causes of prolonged neurological impairment globally. Approximately 55%-75% of stroke survivors will experience some form of long-term sensorimotor impairment. Post-stroke, the upper limb typically exhibits restricted mobility, complicating daily chores for 70% of patients and impairing normal limb utilization. Repetitive Transcranial Magnetic Stimulation (rTMS), a prominent non-invasive neuromodulation technique designed to enhance functional recovery post-stroke, has garnered significant attention in clinical studies. Likewise, constraint-induced movement therapy (CIMT) has been extensively employed in therapeutic settings to promote neuroplasticity. However, there remain several issues with it in practical application. Recently, considerable focus has been directed toward a novel treatment known as rTMS in conjunction with obligatory motor therapy. This can circumvent the issues associated with conventional treatments and optimize the advantages of both. This article discusses the present status of clinical research with rTMS and CIMT.

Relationships and representations of brain structures, connectivity, dynamics and functions

The review explores the complex interplay between brain structures and their associated functions, presenting a diversity of hierarchical models that enhances our understanding of these relationships. Central to this approach are structure-function flow diagrams, which offer a visual representation of how specific neuroanatomical structures are linked to their functional roles. These diagrams are instrumental in mapping the intricate connections between different brain regions, providing a clearer understanding of how functions emerge from the underlying neural architecture. The study details innovative attempts to develop new functional hierarchies that integrate structural and functional data. These efforts leverage recent advancements in neuroimaging techniques such as fMRI, EEG, MEG, and PET, as well as computational models that simulate neural dynamics. By combining these approaches, the study seeks to create a more refined and dynamic hierarchy that can accommodate the brain's complexity, including its capacity for plasticity and adaptation. A significant focus is placed on the overlap of structures and functions within the brain. The manuscript acknowledges that many brain regions are multifunctional, contributing to different cognitive and behavioral processes depending on the context. This overlap highlights the need for a flexible, non-linear hierarchy that can capture the brain's intricate functional landscape. Moreover, the study examines the interdependence of these functions, emphasizing how the loss or impairment of one function can impact others. Another crucial aspect discussed is the brain's ability to compensate for functional deficits following neurological diseases or injuries. The investigation explores how the brain reorganizes itself, often through the recruitment of alternative neural pathways or the enhancement of existing ones, to maintain functionality despite structural damage. This compensatory mechanism underscores the brain's remarkable plasticity, demonstrating its ability to adapt and reconfigure itself in response to injury, thereby ensuring the continuation of essential functions. In conclusion, the study presents a system of brain functions that integrates structural, functional, and dynamic perspectives. It offers a robust framework for understanding how the brain's complex network of structures supports a wide range of cognitive and behavioral functions, with significant implications for both basic neuroscience and clinical applications.

Constraint-Induced Movement Therapy Promotes Contralesional Red Nucleus Plasticity and Increases Bilateral Motor Cortex-to-Red Nucleus Projections After a Large-Area Stroke

For decades, scientists have explored the patterns of neural network remodeling that occur after a stroke. Several studies have shown that both motor cortexes (MCs) undergo crucial remodeling after cerebral ischemia. However, the mechanism by which corticofugal fibers are remodeled is not well understood. Therefore, this study was aimed at investigating the changes in the bilateral red nucleus (RN) and MC-RN projections during recovery from a large-area stroke in a rat stroke model with or without constraint-induced movement therapy (CIMT). A large-area middle cerebral artery occlusion (MCAO) model was established in rats using the Longa method. CIMT was initiated 7 days after MCAO and continued for 1, 2, or 3 weeks. Rats in the control group underwent spontaneous recovery. Locomotor impairment was evaluated using the CatWalk automated gait analysis system, and overall neurological function was evaluated with the modified neurological severity score. Bilateral MC-RN projections were visualized by labeling fiber tracts with an anterograde tracer. Postsynaptic density 95 (PSD95), growth-associated protein 43 (GAP43), and synaptophysin expression levels in the RN were detected using western blotting and immunohistochemistry. The results showed that CIMT promoted motor recovery after a stroke, increased levels of GAP43 and PSD95 in the contralesional but not ipsilesional RN, and increased projections from the MC to the bilateral RN. Thus, CIMT promotes neuroplasticity after a large-area stroke by stimulating axon outgrowth, improving postsynaptic membrane function in the contralesional RN, and increasing bilateral projections of the MC-RN. These results provide evidence for the therapeutic efficacy of CIMT in restoring motor function and help with understanding RN plasticity after a large-area 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.

Harnessing Mirror Neurons: Improving Balance and Quality of Life After a Stroke

BACKGROUND

Action observation engages brain motor networks, and action imitation helps neurological and musculoskeletal problem patients improve motor learning and functional recovery. In this study, we focused on identifying the impact of action observation training (AOT) on balance and quality of life (QOL) in hemiparetic stroke patients.

METHOD

 A quasi-experimental study in Bengaluru (from December 2021 to July 2022) involved 60 hemiparetic patients randomly divided into two groups. Group A received 30 minutes of AOT alongside standard physiotherapy, while Group B received conventional therapy. Sessions focused on balance exercises, and outcomes were assessed using the Berg Balance Scale (BBS) and the Stroke-Specific Quality of Life (ss-QOL) scale. Statistical analyses, including paired and independent t-tests, highlighted significant differences, ensuring methodological rigor and ethical compliance.

RESULTS

 The findings show a significant difference in the pretest BBS scores between the experimental and control groups (p = 0.010), with the experimental group having a lower baseline. However, there was no significant difference in posttest BBS scores (p = 0.431). Both groups showed significant improvements in their BBS and ss-QOL scores (p < 0.05). The experimental group showed a larger improvement in BBS (p = 0.001), while ss-QOL improvements were not statistically significant (p = 0.732).

CONCLUSION

The study concluded that the experimental and control groups demonstrated significant improvements in balance and QOL after the intervention, with the experimental group showing significantly larger improvements in balance, compared to control group.

A Randomized Control Trial of a Virtually Delivered Program for Increasing Upper Limb Activity After Stroke

BackgroundUpper limb activity following stroke is low, which may limit recovery. We investigated whether a virtually-delivered upper limb program, that included a wearable device with reach-to-grasp feedback, would increase upper limb activity after stroke.MethodsThis was a parallel-group, assessor-blinded, randomized control trial conducted at 6 sites across 5 provinces of the CanStroke Recovery Trials Platform between 2020 to 2022. Participants (n = 73) were community-living, less than 1 year post stroke, and had residual arm movement and upper limb use limitations. Participants were randomized via a central web-based randomization service to receive a virtually delivered program (Virtual Arm Boot Camp [V-ABC], n = 36) or waitlist control (n = 37) receiving usual care. V-ABC consisted of a home exercise program, feedback from a wrist-worn device to monitor reach-to-grasp counts, and 6 virtual sessions with a trained therapist over 3 weeks. The primary outcome was the average daily reach-to-grasp counts over 3 days at 4 weeks post baseline assessment. Secondary outcomes included upper limb function, self-reported use, and quality of life. Within-subject changes between pre, post treatment, and 2 months follow up for all participants were also examined as a tertiary analysis.ResultsThe V-ABC group demonstrated greater average daily reach-to-grasp counts (primary outcome) at 4 weeks compared to control (mean difference = 368, 95% confidence interval = 6-730, P = .046).ConclusionsThis study provided evidence that a virtually delivered upper limb program that consists of exercise, feedback from a wearable device, and therapist support can increase real-world upper limb activity following stroke.Clinical Trial Registration:NCT04232163.

Factors associated with upper extremity use after stroke: a scoping review of accelerometry studies

BACKGROUND

A discrepancy between the level of impairment at the upper extremity (UE) and its use in activities of daily life is frequently observed in individuals who have experienced a stroke. Wrist-worn accelerometers allow an objective and valid measure of UE use in everyday life. Accelerometer studies have shown that a wide range of factors beyond UE impairment can influence UE use. This scoping review aims to identify factors associated with UE use and to investigate the influence of different types of accelerometry metrics on these associations.

METHOD

A search using CINHAL, Embase, MEDLINE, Compendex, and Web of Science Core Collection databases was performed. Studies that assessed the association between UE use quantified with accelerometers and factors related to the person or their environment in individuals with stroke were included. Data related to study design, participants characteristics, accelerometry methodology (absolute vs. relative UE use metrics), and associations with personal and environmental factors were extracted.

RESULTS

Fifty-four studies were included. Multiple studies consistently reported associations between relative UE use and stroke severity, UE motor impairment, unimanual capacity, bimanual capacity, and mobility. In contrast, there were inconsistent associations with factors such as neglect and concordance between dominance and side of paresis and a consistent lack of association between relative UE use and time since stroke, sex, and age. Metrics of absolute paretic UE use yielded different results regarding their association with personal and environmental factors, as they were more influenced by factors related to physical activity and less associated with factors related to UE capacity.

CONCLUSION

Healthcare providers should recognize the complexity of the relationship between UE use and impairment and consider additional factors when selecting assessments during rehabilitation to identify patients at risk of underutilizing their paretic arm in daily life. Future research in this domain should preconize relative UE use metrics or multi-sensors method to control for the effect of physical activity.

Flexibility, Resistance, Aerobic, Movement Execution (FRAME) training program to improve gait capacity in adults with Hereditary Spastic Paraplegia: protocol for a single-cohort feasibility trial

Background

Hereditary Spastic Paraplegia (HSP) is a heterogeneous group of inherited neurological disorders characterized by progressive weakness and spasticity in the lower limbs, significantly affecting gait capacity (endurance and speed). Although specific interventions have been already investigated, there is currently a lack of comprehensive, structured neurorehabilitation programs to improve gait capacity in adults with HSP. Thus, this protocol aims to explore the feasibility and effectiveness of a composite training targeting flexibility, muscle strength, motor control, balance, and aerobic capacity.

Methods

20 adults diagnosed with HSP will participate in 10 to 16 therapist-guided sessions (intervention), lasting 60 to 120 minutes each, occurring once or twice weekly based on individual preferences. Depending on the number and frequency of sessions, the intervention period may vary in between five to 10 weeks. Upon completion, participants will receive a transfer package (manual, video tutorials) to stimulate long-term exercise at home. Assessments will take place before intervention (T0), at the end of the intervention (T1), and 12 weeks post-T1 (T2). Primary outcomes will focus on feasibility (recruitment, retention, adherence, absence of adverse events, and patient's satisfaction). Secondary outcomes will evaluate improvements in gait capacity and specific contributing factors such as reduced spasticity, increased muscle strength, and improved balance.

Relevance

The significance of this protocol is to provide valuable insights for clinicians regarding the feasibility and potential efficacy of a comprehensive, clinical-oriented program to improve gait capacity in adults with HSP, and inform future translational research studies in the field.

Clinical trial registration

ClinicalTrials.gov, identifier NCT06742697.

Electroencephalogram features reflect effort corresponding to graded finger extension: implications for hemiparetic stroke

Brain-computer interfaces (BCIs) offer disabled individuals the means to interact with devices by decoding the electroencephalogram (EEG). However, decoding intent in fine motor tasks can be challenging, especially in stroke survivors with cortical lesions. Here, we attempt to decode graded finger extension from the EEG in stroke patients with left-hand paresis and healthy controls. Participants extended their fingers to one of four levels: low, medium, high, or 'no-go' (none), while hand, muscle (electromyography: EMG), and brain (EEG) activity were monitored. Event-related desynchronization (ERD) was measured as the change in 8-30 Hz EEG power during movement. Classifiers were trained on EEG features, EMG power, or both (EEG+EMG) to decode finger extension, and accuracy assessed via four-fold cross-validation for each hand of each participant. Mean accuracy exceeded chance (25%) for controls (n = 11) at 62% for EMG, 60% for EEG, and 71% for EEG+EMG on the left hand; and 67%, 60%, and 74%, respectively, on the right hand. Accuracies were similar on the unimpaired right hand for the stroke group (n = 3): 61%, 68%, and 78%, respectively. But on the paretic left hand, EMG only discriminated no-go from movement above chance (41%); in contrast, EEG gave 65% accuracy (68% for EEG+EMG), comparable to the non-paretic hand. The median ERD was significant (p < 0.01) over the cortical hand area in both groups and increased with each level of finger extension. But while the ERD favored the hemisphere contralateral to the active hand as expected, it was ipsilateral for the left hand of stroke due to the lesion in the right hemisphere, which may explain its discriminative ability. Hence, the ERD captures effort in finger extension regardless of success or failure at the task; and harnessing residual EMG improves the correlation. This marker could be leveraged in rehabilitative protocols that focus on fine motor control.

Effects of home-based virtual reality upper extremity rehabilitation in persons with chronic stroke: a randomized controlled trial

BACKGROUND

Upper extremity rehabilitation in persons with stroke should be dose-dependent and task-oriented. Virtual reality (VR) has the potential to be used safely and effectively in home-based rehabilitation. This study aimed to investigate the effects of home-based virtual reality upper extremity rehabilitation in persons with chronic stroke.

METHODS

This was a single-blind, randomized, controlled trial conducted at two centers. The subjects were 14 outpatients with chronic stroke more than 6 months after the onset of the stroke. The participants were randomly divided into two groups. The intervention group (n = 7) performed a home rehabilitation program for the paretic hand (30 min/day, five days/week) using a VR device (RAPAEL Smart Glove™; NEOFECT Co., Yung-in, Korea) for four weeks. The control group (n = 7) participated in a conventional home rehabilitation program at the same frequency. All participants received outpatient occupational therapy once a week during the study period. The outcome measures included the Fugl-Meyer Assessment of upper extremity motor function (FMA-UE), Motor Activity Log-14 (MAL), Jebsen-Taylor Hand Function Test (JTT), and Box and Block Test (BBT) scores.

RESULTS

All 14 participants completed the study. Compared to the control group, the intervention group showed more significant improvements in FMA-UE (p = 0.027), MAL (p = 0.014), JTT (p = 0.002), and BBT (p = 0.014). No adverse events were observed during or after the intervention.

CONCLUSION

Compared to a conventional home program, combining a task-oriented virtual reality home program and outpatient occupational therapy might lead to greater improvements in upper extremity function and the frequency of use of the paretic hand.

TRIAL REGISTRATION

This study was registered in the University Hospital Medical Information Network (UMIN) Clinical Trial Registry in Japan (Unique Identifier: UMIN000038469) on November 1, 2019; https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000043836 .

Investigating the acceptability of modified constraint-induced movement therapy among stroke survivors and carers: a qualitative study

PURPOSE

To investigate the acceptability of modified constraint-induced movement therapy (mCIMT) among stroke survivors and carers within an early-supported discharge (ESD) service, and to inform further adaptations of the program to enhance acceptability.

METHODS

Qualitative study within a mixed methods process evaluation of mCIMT implementation. Semi-structured interviews were analysed using reflexive thematic analysis and mapped to the Capability, Opportunity, Motivation- Behaviour (COM-B) model.

RESULTS

Fifteen stroke survivors and ten carers participated. Five themes were generated and mapped to the COM-B. Participants attributed functional improvements to the program whilst also encountering several challenges with returning home after stroke (Capability- physical); the importance of education (Capability- psychological); the benefits afforded by the structured nature of the program (Opportunity- physical); the challenges for carers to support mCIMT programs whilst navigating new relationship roles (Opportunity- social); the desire to improve (Motivation- automatic); and the influence each of the mCIMT program's components had in facilitating long term upper limb use (Motivation- reflective).

CONCLUSION

mCIMT was an acceptable intervention for stroke survivors and carers within the ESD service, offering considerable benefits compared to other therapies. The findings suggest that multifaceted education strategies could increase stroke survivor preparedness. Extending the mCIMT program duration may maximise functional improvements.

Translating acceptability to sustained delivery: Clinician and manager perspectives on implementing modified constraint-induced movement therapy in an early-supported discharge rehabilitation service

BACKGROUND

Modified constraint-induced movement therapy (mCIMT) improves upper limb (UL) function after stroke. Despite up to one-third of stroke survivors being eligible, clinical uptake remains poor. To address this, a multi-modal behaviour change intervention was implemented across a large seven-site early-supported discharge (ESD) rehabilitation service. This study investigated the acceptability of mCIMT implementation within this ESD service and identified adaptations required for sustained delivery.

METHODS

This qualitative study was nested within a mixed-methods process evaluation of mCIMT implementation. Four focus groups (n = 24) comprising therapists (two groups), therapy assistants (one group), and allied health managers (one group) were conducted. Data were analysed using reflexive thematic analysis and mapped to the Theoretical Domains Framework (TDF).

CONSUMER AND COMMUNITY INVOLVEMENT

Consumers were not directly involved in this study; however, lived experience research partners have helped shape the larger mixed-methods implementation study.

FINDINGS

Four themes were generated and mapped to the TDF. Factors related to acceptability included interdisciplinary practice in sharing workloads (belief about capabilities), practice opportunities across a range of UL presentations (skills), clinician attitudes influencing patient engagement (optimism), time constraints (belief about consequences), and cognitive overload from multiple systems and processes (memory, attention, and decision-making processes). Factors facilitating sustained delivery included improving stroke survivor education (knowledge), sharing success stories across teams (reinforcement), manager facilitation (social/professional role and identity), and the perception that the ESD setting was optimal for mCIMT delivery (social influences).

CONCLUSION

mCIMT was acceptable in the ESD service, with clinicians feeling a responsibility to provide it. Key adaptations for sustained delivery included ongoing training, resource adaptation, and enhanced patient and carer engagement. Successful implementation and sustained delivery of mCIMT in the ESD service could enhance UL function and reduce the burden of care for potentially hundreds of stroke survivors and their carers.

PLAIN LANGUAGE SUMMARY

Modified constraint-induced movement therapy (mCIMT) helps improve arm movement after a stroke. However, many stroke survivors do not get this therapy. To fix this, we started a program in a large home-based rehabilitation service. This study looked at how well mCIMT could fit into this service. We also wanted to know what changes were needed to make sure it was regularly provided. We held four group discussions with therapists, therapy assistants, and health managers. A total of 24 people took part. From these discussions, we found several important points. Therapists needed to work together as a team. They also needed to practice mCIMT to get better at delivering it. Therapists having a positive attitude would encourage more stroke survivors to take part. For long-term success, stroke survivors need better education about mCIMT. Managers need to encourage therapists to provide mCIMT. The rehabilitation service should also share their success stories about this therapy to encourage therapists to deliver it and stroke survivors to ask for it. Therapists enjoyed delivering mCIMT in the rehabilitation service. It worked better than other therapies to improve a stroke survivor's arm function. Because of this, they also felt it was their duty to offer mCIMT. Having ongoing training and better resources would help keep mCIMT going. If mCIMT can be provided regularly in this service, it could lead to better arm function and less care needed for many stroke survivors and their carers.

Using mechanistic knowledge to appraise contemporary approaches to the rehabilitation of upper limb function following stroke

It is a paradox of neurological rehabilitation that, in an era in which preclinical models have produced significant advances in our mechanistic understanding of neural plasticity, there is inadequate support for many therapies recommended for use in clinical practice. When the goal is to estimate the probability that a specific form of therapy will have a positive clinical effect, the integration of mechanistic knowledge (concerning 'the structure or way of working of the parts in a natural system') may improve the quality of inference. This is illustrated by analysis of three contemporary approaches to the rehabilitation of lateralized dysfunction affecting people living with stroke: constraint-induced movement therapy; mental practice; and mirror therapy. Damage to 'cross-road' regions of the structural (white matter) brain connectome generates deficits that span multiple domains (motor, language, attention and verbal/spatial memory). The structural integrity of these regions determines not only the initial functional status, but also the response to therapy. As structural disconnection constrains the recovery of functional capability, 'disconnectome' modelling provides a basis for personalized prognosis and precision rehabilitation. It is now feasible to refer a lesion delineated using a standard clinical scan to a (dis)connectivity atlas derived from the brains of other stroke survivors. As the individual disconnection pattern thus obtained suggests the functional domains most likely be compromised, a therapeutic regimen can be tailored accordingly. Stroke is a complex disorder that burdens individuals with distinct constellations of brain damage. Mechanistic knowledge is indispensable when seeking to ameliorate the behavioural impairments to which such damage gives rise.

Insights into the dependence of post-stroke motor recovery on the initial corticospinal tract connectivity from a computational model

There is a consensus that motor recovery post-stroke primarily depends on the degree of the initial connectivity of the ipsilesional corticospinal tract (CST). Indeed, if the residual CST connectivity is sufficient to convey motor commands, the neuromotor system continues to use the CST predominantly, and motor function recovers up to 80%. In contrast, if the residual CST connectivity is insufficient, hand/arm dexterity barely recovers, even as the phases of stroke progress. Instead, the functional upregulation of the reticulospinal tract (RST) often occurs. In this study, we construct a computational model that reproduces the dependence of post-stroke motor recovery on the initial CST connectivity. The model emulates biologically plausible evolutions of primary motor descending tracts, based on activity-dependent or use-dependent plasticity and the preferential use of more strongly connected neural circuits. The model replicates several elements of the empirical evidence presented by the Fugl-Meyer Assessment (FMA) subscores, which evaluate the capabilities for out-of-synergy and in-synergy movements. These capabilities presumably change differently depending on the degree of the initial CST connectivity post-stroke, providing insights into the interactive dynamics of the primary descending motor tracts. We discuss findings derived from the proposed model in relation to the well-known proportional recovery rule. This modeling study aims to present a way to differentiate individuals who can achieve 70 to 80% recovery in the chronic phase from those who cannot by examining the interactive evolution of out-of-synergy and in-synergy movement capabilities during the subacute phase, as assessed by the FMA.

Effects of a Distributed Form of Constraint-Induced Movement Therapy for Clinical Application: The Keys Treatment Protocol

BACKGROUND/AIM

Currently, there are limited evidence-based protocols for improving upper extremity (UE) motor function after stroke. The Keys protocol, a distributed form of constraint-induced movement therapy (CIMT), delivers CIMT components in fewer hours per day over an extended period, fitting outpatient rehabilitation schedules and third-party payor models. This pilot study aimed to assess the effectiveness of the Keys protocol in enhancing UE capacity and performance poststroke.

METHODS

Ten adults with chronic stroke (>6 months) participated in an 8-week intervention. The protocol included 22 supervised training sessions (1.5 h each): 4 days/week for 4 weeks, 2 days/week for weeks 5-6, and 1 day/week for weeks 7-8. Participants wore a restraint mitt on the less-affected UE during waking hours and used an adapted transfer package. Outcome measures included the Motor Activity Log (MAL), Wolf Motor Function Test (WMFT), Stroke Impact Scale (SIS), and Zung Depression Scale, assessed pre-treatment, mid-treatment (4 weeks), and posttreatment.

RESULTS

Significant improvements were observed in SIS Strength, ADLs/IADLs, Mobility, and Hand Function domains, exceeding MCID thresholds. Memory and Communication domains improved significantly at the 3-month follow-up. WMFT performance times improved, with fewer incomplete tasks. MAL scores for Amount of Use and Quality of Movement increased across all time points. Depressive symptoms significantly decreased posttreatment.

CONCLUSIONS

The Keys protocol effectively improves UE use, motor function, mood, and quality of life, with the greatest gains observed mid-intervention. These findings support its feasibility and potential for outpatient stroke rehabilitation (ClinicalTrials.gov Registration: NCT05311384).

Exploring Therapists' Experiences of an Educational Website to Support Telehealth Delivery of Constraint-Induced Movement Therapy

Purpose: Constraint-induced movement therapy (CIMT) is an evidence-based intervention for arm recovery after acquired brain injury. Clinician knowledge, time and confidence in delivering CIMT are established barriers to the routine use of CIMT in practice. CIMT delivery via telehealth is one option to help overcome these barriers. This study aimed to understand clinician experiences of using an educational website and if the education and online resources contributed to their self-reported use of constraint-induced movement therapy via telehealth (TeleCIMT) in practice. Materials and Methods: Data were collected from a purposive sample of therapists registered to use the TeleCIMT website and website analytics. An online survey explored participants' experience with CIMT delivery (both face to face and via telehealth), their perceptions of the website, and barriers and enablers to TeleCIMT implementation using the Capability, Opportunity, Motivation-Behaviour model. Website analytics were used to evaluate website traffic and resource use. Data were analysed using descriptive statistics (quantitative data) and content analysis (qualitative data). Results: Forty therapists responded to the survey; 72.5% (n = 29) of the respondents were occupational therapists, and 37.5% (n = 15) had delivered TeleCIMT. Most of the participants agreed that the website was easy to navigate (n = 26, 90%) and felt that they had the knowledge (n = 28, 96.6%) and skills (n = 24, 82.7%) to deliver TeleCIMT. The enablers to TeleCIMT included motivation to implement learnings from the website, confidence in delivering the programme, and the convenience of remote delivery. The perceived barriers to TeleCIMT use included limited access to technology and the availability of a client supporter to enable engagement in TeleCIMT. The resources used most frequently by the respondents were the participant preparation pack and participant programme pack. Shorter video learning modules (<11 min in duration) had greater engagement than longer video learning modules. Conclusions: Whilst online education and resources may enhance clinician knowledge of constraint-induced movement therapy and telehealth delivery, other barriers such as lack of technology access, may need to be addressed through additional learning and implementation strategies to support the routine use of TeleCIMT in practice.

Prediction of clinical efficacy of acupuncture intervention on upper limb dysfunction after ischemic stroke based on machine learning: a study driven by DSA diagnostic reports data

Objective

To develop a machine learning-based model for predicting the clinical efficacy of acupuncture intervention in patients with upper limb dysfunction following ischemic stroke, and to assess its potential role in guiding clinical practice.

Methods

Data from 1,375 ischemic stroke patients with upper limb dysfunction were collected from two hospitals, including medical records and Digital Subtraction Angiography (DSA) reports. All patients received standardized acupuncture treatment. After screening, 616 datasets were selected for analysis. A prediction model was developed using the AutoGluon framework, with three outcome measures as endpoints: the National Institutes of Health Stroke Scale (NIHSS), Fugl-Meyer Assessment for Upper Extremity (FMA-UE), and the Modified Barthel Index (MBI).

Results

The prediction model demonstrated high accuracy for the three endpoints, with prediction accuracies of 84.3% for NIHSS, 77.8% for FMA-UE, and 88.1% for MBI. Feature importance analysis identified the M1 segment of the Middle Cerebral Artery (MCA), the origin of the Internal Carotid Artery (ICA), and the C1 segment of the ICA as the most critical factors influencing the model's predictions. Notably, the MBI emerged as the most sensitive outcome measure for evaluating patient response to acupuncture treatment. Additionally, secondary analysis revealed that the number of sites with cerebral vascular stenosis (specifically 1 and 3 sites) had a significant impact on the final model's predictions.

Conclusion

This study highlights the M1 segment, the origin of the ICA, and the C1 segment as key stenotic sites affecting acupuncture treatment efficacy in stroke patients with upper limb dysfunction. The MBI was found to be the most responsive outcome measure for evaluating treatment sensitivity in this cohort.

Cortical drive may facilitate enhanced use of the paretic leg induced by random constraint force to the non-paretic leg during walking in chronic stroke

The goal of this study was to determine the effects of applying random vs. constant constraint force to the non-paretic leg during walking on enhanced use of the paretic leg in individuals post-stroke, and examine the underlying brain mechanisms. Twelve individuals with chronic stroke were tested under two conditions while walking on a treadmill: random vs. constant magnitude of constraint force applied to the non-paretic leg during swing phase of gait using a custom designed robotic system. Leg kinematics, muscle activity of the paretic leg, and electroencephalography (EEG) were recorded during treadmill walking. Paretic step length and muscle activity of the paretic ankle plantarflexors significantly increased after walking with random and constant constraint forces. Cortico-cortical connectivity between motor cortices and cortico-muscular connectivity from the lesioned motor cortex to the paretic ankle plantarflexors significantly increased for the random force condition but not for the constant force condition. In addition, individuals post-stroke with greater baseline gait variability showed greater improvements in the paretic step length after walking with random force condition but not with the constant force condition. In conclusion, application of random constraint force to the non-paretic leg may enhance the use of the paretic leg during walking by facilitating cortical drive from the lesioned motor cortex to the paretic ankle plantarflexors. Results from this study may be used for the development of constraint induced locomotor intervention approaches aimed at improving locomotor function in individuals after stroke.

Portable robots for upper-limb rehabilitation after stroke: a systematic review and meta-analysis

BACKGROUND

Robot-assisted upper-limb rehabilitation has been studied for many years, with many randomised controlled trials (RCTs) investigating the effects of robotic-assisted training on affected limbs. The current trend directs towards end-effector devices. However, most studies have focused on the effectiveness of rehabilitation devices, but studies on device sizes are relatively few.

GOAL

Systematically review the effect of a portable rehabilitation robot (PRR) on the rehabilitation effectiveness of paralysed upper limbs compared with non-robotic therapy.

METHODS

A meta-analysis was conducted on literature that included the Fugl-Meyer Assessment (FMA) obtained from the PubMed and Web of Science (WoS) electronic databases until June 2023.

RESULTS

A total of 9 studies, which included RCTs, were completed and a meta-analysis was conducted on 8 of them. The analysis involved 295 patients. The influence on upper-limb function before and after treatment in a clinical environment is analysed by comparing the experimental group using the portable upper-limb rehabilitation robot with the control group using conventional therapy. The result shows that portable robots prove to be effective (FMA: SMD = 0.696, 95% = 0.099 to.293, p < 0.05).

DISCUSSION

Both robot-assisted and conventional rehabilitation effects are comparable. In some studies, PRR performs better than conventional rehabilitation, but conventional treatments are still irreplaceable. Smaller size with better portability has its advantages, and portable upper-limb rehabilitation robots are feasible in clinical rehabilitation.

CONCLUSION

Although portable upper-limb rehabilitation robots are clinically beneficial, few studies have focused on portability. Further research should focus on modular design so that rehabilitation robots can be decomposed, which benefits remote rehabilitation and household applications.

The feasibility of the adapted H-GRASP program for perceived and actual daily-life upper limb activity in the chronic phase post-stroke

PURPOSE

Assessing feasibility and initial impact of the Home-Graded Repetitive Arm Supplementary Program combined with in-home accelerometer-based feedback (AH-GRASP) on perceived and actual daily-life upper limb (UL) activity in stroke survivors during the chronic phase with good UL motor function but low perceived daily-life activity.

MATERIAL AND METHODS

A 4-week intervention program (4 contact hours, 48 h self-practice) encompassing task-oriented training, behavioral techniques, phone-based support, monitoring, and weekly feedback sessions using wrist-worn accelerometery was implemented using a pre-post double baseline repeated measures design. Feasibility, clinical assessments, patient-reported outcomes, and accelerometer data were investigated.

RESULTS

Of the 34 individuals approached, nineteen were included (recruitment rate 56%). Two dropped out, one due to increased UL pain (retention rate 89%). Seven (41%) achieved the prescribed exercise target (120 min/day, six days/week). Positive patient experiences and improvements in UL capacity, self-efficacy, and contribution of the affected UL to overall activity (p < 0.05, small to large effect sizes) were observed. Additionally, seven participants (41%) surpassed the minimal clinically important difference in perceived UL activity.

CONCLUSIONS

A home-based UL exercise program with accelerometer-based feedback holds promise for enhancing perceived and actual daily-life UL activity for our subgroup of chronic stroke survivors.

Neural Interface-Based Motor Neuroprosthesis in Poststroke Upper Limb Neurorehabilitation: An Individual Patient Data Meta-analysis

OBJECTIVE

To determine the efficacy of neural interface-based neurorehabilitation, including brain-computer interface, through conventional and individual patient data (IPD) meta-analysis and to assess clinical parameters associated with positive response to neural interface-based neurorehabilitation.

DATA SOURCES

PubMed, EMBASE, and Cochrane Library databases up to February 2022 were reviewed.

STUDY SELECTION

Studies using neural interface-controlled physical effectors (functional electrical stimulation and/or powered exoskeletons) and reported Fugl-Meyer Assessment-upper-extremity (FMA-UE) scores were identified. This meta-analysis was prospectively registered on PROSPERO (#CRD42022312428). PRISMA guidelines were followed.

DATA EXTRACTION

Changes in FMA-UE scores were pooled to estimate the mean effect size. Subgroup analyses were performed on clinical parameters and neural interface parameters with both study-level variables and IPD.

DATA SYNTHESIS

Forty-six studies containing 617 patients were included. Twenty-nine studies involving 214 patients reported IPD. FMA-UE scores increased by a mean of 5.23 (95% confidence interval [CI]: 3.85-6.61). Systems that used motor attempt resulted in greater FMA-UE gain than motor imagery, as did training lasting >4 vs ≤4 weeks. On IPD analysis, the mean time-to-improvement above minimal clinically important difference (MCID) was 12 weeks (95% CI: 7 to not reached). At 6 months, 58% improved above MCID (95% CI: 41%-70%). Patients with severe impairment (P=.042) and age >50 years (P=.0022) correlated with the failure to improve above the MCID on univariate log-rank tests. However, these factors were only borderline significant on multivariate Cox analysis (hazard ratio [HR] 0.15, P=.08 and HR 0.47, P=.06, respectively).

CONCLUSION

Neural interface-based motor rehabilitation resulted in significant, although modest, reductions in poststroke impairment and should be considered for wider applications in stroke neurorehabilitation.

Effects of adding interactive videogames to conventional rehabilitation program on radiological progression and upper extremity motor function in patients with hemiplegic stroke: a preliminary study

OBJECTIVES

To investigate the effects of adding interactive videogames to conventional rehabilitation programmes on radiological progression and upper extremity functional status.

PATIENTS AND METHODS

A total of 18 patients with hemiplegic stroke were randomized into two groups as conventional rehabilitation (control) group (n = 9), and the conventional rehabilitation + interactive videogames (intervention) group (n = 9). Each group received a 4-week program (5 days/week). Radiological progression (diffuse tensor imaging), and upper extremity functional status (upper extremity motor functioning part of the Fugl Meyer Assessment, self-care part of the Functional Independence Measure (FIM), and Motor Activity Log) were assessed at baseline and 4-week later.

RESULTS

While no changes were detected in radiological status in the intervention group (p > 0.05), some regions on the affected side were improved significantly in the control group (p < 0.05). Total upper extremity motor functioning part of the Fugl Meyer Assessment scores and the self-care part of the FIM scores significantly improved in both groups (p < 0.05). No differences were detected in the amount of changes between groups (p > 0.05).

CONCLUSION

According to our results, adding videogames to a conventional rehabilitation program does not seem enhancing the radiological progression or the functional status of the upper extremities.

Combined robot-assisted therapy virtual reality for upper limb rehabilitation in stroke survivors: a systematic review of randomized controlled trials

BACKGROUND

Upper limb impairments are among the most common consequences following a stroke. Recently, robot-assisted therapy (RT) and virtual reality (VR) have been used to improve upper limb function in stroke survivors.

OBJECTIVES

This review aims to investigate the effects of combined RT and VR on upper limb function in stroke survivors and to provide recommendations for researchers and clinicians in the medical field.

METHODS

We searched PubMed, SCOPUS, REHABDATA, PEDro, EMBASE, and Web of Science from inception to March 28, 2024. Randomized controlled trials (RCTs) involving stroke survivors that compared combined RT and VR interventions with either passive (i.e., sham, rest) or active (i.e., traditional therapy, VR, RT) interventions and assessed outcomes related to upper limb function (e.g., strength, muscle tone, or overall function) were included. The Cochrane Collaboration tool was used to evaluate the methodological quality of the included studies.

RESULTS

Six studies were included in this review. In total, 201 patients with stroke (mean age 57.84 years) were involved in this review. Four studies were considered 'high quality', while two were considered as 'moderate quality' on the Cochrane Collaboration tool. The findings showed inconsistent results for the effects of combined RT and VR interventions on upper limb function poststroke.

CONCLUSION

In conclusion, there are potential effects of combined RT and VR interventions on improving upper limb function, but further research is needed to confirm these findings, understand the underlying mechanisms, and assess the consistency and generalizability of the results.

Post-rehabilitation programme to support upper limb recovery in community-dwelling stroke survivors: a mixed methods cluster-feasibility controlled trial

BACKGROUND

Less than 50% of stroke survivors regain their pre-stroke level of upper limb function, compounded with a lack of long-term rehabilitation options available. The Graded Repetitive Arm Supplementary Programme (GRASP) is an evidence-based upper limb programme delivered as a standalone programme to stroke survivors. To improve access to such a programme, there is the potential to combine it with a high-utility community-based exercise programme, such as the post-rehabilitation enablement programme (PREP). We aimed to establish if this was feasible to deliver alongside the experience of stroke survivors and therapists, identify any refinements the intervention and the acceptability of the intervention and trial procedures.

METHODS

A cluster feasibility-controlled trial was conducted using both quantitative and qualitative outcome measures with stroke survivors who were discharged from NHS care. Participants completed PREP for 6 weeks (control), with the intervention group also completing GRASP. The GRASP intervention was refined in between five iterative testing cycles. Focus groups with participants explored the acceptability and feasibility. Individual interviews with intervention therapists explored how feasible it was to embed the intervention into practice, and determine the feasibility of a future larger, mixed methods, randomised controlled trial. Clinical endpoints for upper limb and overall function were explored through the Rating of Everyday Arm use in the Community and Home, 10-metre walk test (10MWT) and quality of life via the Shortened Edinburgh Warwick questionnaire. No further suggestions for intervention design were noted after cycle 4.

RESULTS

Recruitment (n=72) and retention levels (84.7%) were high with 61 participants (mean age of 66 years and 49 weeks post-stroke) completing the study. Participants and therapists reported positive acceptability of the intervention with goal setting and family support noted as beneficial. The home exercise programme was noted as challenging. Participants within both groups demonstrated improvements in clinical measures, with the intervention group demonstrating a greater improvement within the Rating of Everyday Arm-use in the Community and Home and the 10MWT.

CONCLUSION

This study successfully recruited and retained stroke survivors into an upper limb community-based programme. It poses a feasible delivery mechanism to combine evidence-based upper limb approaches with established physical activity programmes in a future large scale and fully powered study.

TRIAL REGISTRATION NUMBER

NCT05090163.

Deep brain stimulation versus vagus nerve stimulation for the motor function of poststroke hemiplegia: study protocol for a multicentre randomised controlled trial

INTRODUCTION

Deep brain stimulation (DBS) and vagus nerve stimulation (VNS) can improve motor function in patients with poststroke hemiplegia. No comparison study exists.

METHODS AND ANALYSIS

This is a randomised, double-blind, controlled clinical trial involving 64 patients who had their first stroke at least 6 months ago and are experiencing poststroke limb dysfunction. These patients must receive necessary support at home and consent to participate. The aim is to evaluate the effectiveness and safety of DBS and VNS therapies. Patients are excluded if they have implantable devices that are sensitive to electrical currents, severe abnormalities in their lower limbs or are unable to comply with the trial procedures. The study has two parallel, distinct treatment arms: the Stimulation Group and the Sham Group. Initially, the Stimulation Group will undergo immediate electrical stimulation postsurgery, while the Sham Group will receive non-stimulation 1 month later. After 3 months, these groups will swap treatments, with the Stimulation Group discontinuing stimulation and the Sham Group initiating stimulation. Six months later, both groups will resume active stimulation. Our primary outcomes will meticulously assess motor function improvements, using the Fugl-Meyer Assessment, and safety, monitored by tracking adverse reaction rates. Furthermore, we will gain a comprehensive view of patient outcomes by evaluating secondary measures, including clinical improvement (National Institutes of Health Stroke Scale), surgical complications/side effects, quality of life (36-item Short Form Questionnaire) and mental health status (Hamilton Anxiety Rating Scale/Hamilton Depression Rating Scale). To ensure a thorough understanding of the long-term effects, we will conduct follow-ups at 9 and 12 months postsurgery, with additional long-term assessments at 15 and 18 months. These follow-ups will assess the sustained performance and durability of the treatment effects. The statistical analysis will uncover the optimal treatment strategy for poststroke hemiplegia, providing valuable insights for clinicians and patients alike.

ETHICS AND DISSEMINATION

This study was reviewed and approved by the Ethical Committee of Chinese PLA General Hospital (S2022-789-01). The findings will be submitted for publication in peer-reviewed journals with online accessibility, ensuring adherence to the conventional scientific publishing process while clarifying how the research outcomes will be disseminated and accessed.

TRIAL REGISTRATION NUMBER

NCT06121947.

Positive effects of lower extremity constraint-induced movement therapy on balance, leg strength and dual-task ability in stroke patients: a longitudinal cohort study

OBJECTIVE

To investigate whether high-intensity lower extremity constraint-induced movement therapy can improve balance, leg strength, and dual-task ability.

DESIGN

A longitudinal cohort study in a real-world outpatient clinic.

PATIENTS

147 community-dwelling participants in the subacute and chronic poststroke phases.

METHODS

Participants received lower extremity constraint-induced movement therapy for 6 hours/day during 2 consecutive weeks, including balance, strength, and functional training. The Berg Balance Scale (BBS), Single-Leg-Stance (SLS) bilaterally, one Repetition Maximum (1RM) in a leg press, symmetry of leg strength (Diff-1RM), Timed Up and Go (TUG), and the TUG Manual test were assessed before, after, and 3 months after lower extremity constraint-induced movement therapy.

RESULTS

Compared with preintervention data, statistically significant improvements after lower extremity constraint-induced movement therapy (p < 0.001) were demonstrated for balance with an absolute value in BBS at 1.9 points (effect size 0.38) and SLS at 2.4 s (effect size 0.24), and for leg strength at 10.2 kg (effect size 0.54) for the affected leg. Diff 1RM decreased significantly at 5.8 kg (effect size 0.39) and improvements on dual-task ability at 2.7 s were significant (effect size 0.14). The effects persisted at the 3-month follow-up.

CONCLUSIONS

High-intensity lower extremity constraint-induced movement therapy may be a feasible treatment option for middle-aged stroke patients to affect balance, leg strength, and dual-task ability positively in an out-patient clinical setting.

Research trends and hotspots of post-stroke upper limb dysfunction: a bibliometric and visualization analysis

Background

The global prevalence of stroke has been increasing. Motor dysfunction is observed in approximately 55 to 75% of stroke patients, with upper limb impairment affecting around 85% of them. Following upper limb dysfunction, the body's recovery time is not only slower compared to the lower limbs, but the restoration of its fine motor skills is significantly more challenging, greatly impacting the daily lives of patients. Consequently, there is an increasing urgency for study on the upper limb function in stroke.

Methods

A search was conducted in the Web of Science Core Collection: Science Citation Index Expanded (SCI-Expanded) database for material published from January 1, 2004 to December 31, 2023. We included all relevant literature reports and conducted an analysis of annual publications, countries/regions, institutions, journals, co-cited references, and keywords using the software packages CiteSpace, VOSviewer, and Bibliometrix R. Next, we succinctly outlined the research trends and hotspots in post-stroke upper limb dysfunction.

Results

This analysis comprised 1,938 articles from 1,897 institutions, 354 journals, and 53 countries or regions. A yearly rise in the production of publications was noted. The United States is the foremost nation on the issue. Northwestern University has the most amounts of papers compared to all other institutions. The journal Neurorehabilitation and Neural Repair is a highly significant publication in this field, with Catherine E. Lang serving as the principal author. The majority of the most-cited references focus on subjects such as the reliability and validity of assessment instruments, RCT of therapies, systematic reviews, and meta-analyses. The intervention measures primarily comprise three types of high-frequency phrases that are related, as determined by keyword analysis: intelligent rehabilitation, physical factor therapy, and occupational therapy. Current areas of focus in research include randomized clinical trials, neurorehabilitation, and robot-assisted therapy.

Conclusion

Current research has shown a growing interest in studying upper limb function assessment, occupational therapy, physical therapy, robot-assisted therapy, virtual reality, brain-computer interface, telerehabilitation, cortical reorganisation, and neural plasticity. These topics have become popular and are expected to be the focus of future research.

Predictive value of early serum ACSL4 and ASITN/SIR grade for motor function recovery in patients with post-ischemic stroke lower limb neurological sequelae after modified constraint-induced movement therapy

BACKGROUND

Ischemic stroke accounts for over 85 % of all stroke types. Acyl-CoA synthetase long chain family member 4 (ACSL4) is considered to promote myocardial and cerebral ischaemia/ reperfusion. However, up to now, no study focused on the role of ACSL4 in patients with post-stroke lower limb neurological sequelae.

OBJECTIVE

The present study aimed to investigate the predictive value of ACSL4 and collateral circulation for lower limb neurological sequelae of ischemic stroke patients after modified constraint-induced movement therapy (mCIMT).

METHODS

This is a prospective cohort study which included 99 ischemic stroke patients with lower limb neurological sequelae who were admitted to our hospital during January 2021 to December 2022. All patients received mCIMT after the admission. Collateral circulation was evaluated by digital subtraction angiography (DSA) and graded by the American Society of Interventional and Therapeutic Neuroradiology/ Society of Interventional Radiology (ASITN/SIR) grading system. Enzyme linked immunosorbent assay (ELISA) was used to detect serum ACSL4. Basic characteristics were collected and lower limb motor function was measured by Fugl-Meyer score (FMS), modified Ashworth score (MAS) and Brunnstrom stage, as well as timed up and go (TUG) test, ten-Meter walk test (10MWT), and six-minute walk test (6MWT) before and after treatment.

RESULTS

Serum ACSL4 and percentage of patients with ASITN/SIR 0-1 decreased significantly after treatment compared with the values before treatment. Patients with higher baseline serum ACSL4 values at admission showed significantly lower FMS scores, higher TUG and 10MWT, as well as lower 6MWT. Patients with ASITN/SIR grade 0-1 at admission only showed significantly higher TUG and 10MWT, as well as lower 6MWT. Receiver operating characteristic (ROC) curves showed ACSL4 and ASITN/SIR grade could be used to predict the prognosis. Logistic regression found only national institutes of health stroke scores (NIHSS) was the independent risk factor for post-treatment motor impairment after mCIMT.

CONCLUSION

Higher levels of ACSL4 and ASITN/SIR 0-1 are associated with poor recovery of motor functions of patients with post-stroke sequelae after mCIMT.

Effectiveness of Intermittent Theta Burst Stimulation to Enhance Upper Extremity Recovery After Stroke: A Pilot Study

OBJECTIVES

To first investigate the effectiveness of modified constraint-ınduced movement therapy (mCIMT) in low-functioning patients with stroke (PwS). Second, we aimed to investigate the efficiency of intermittent theta-burst stimulation (iTBS), applied on intermittent days, in addition to the mCIMT in PwS.

DESIGN

A randomized, sham-controlled, single-blinded study.

SETTING

Outpatient clinic.

PARTICIPANTS

Fifteen PwS (age [mean±SD]: 66.3±9.2 years; 53% female) who were in the first 1 to 12 months after the incident were included in the study.

INTERVENTIONS

PwS were divided into 3 groups: (1) mCIMT alone; (2) mCIMT + sham iTBS; (3) mCIMT + iTBS. Each group received 15 sessions of mCIMT (1 hour/session, 3 sessions/week). iTBS was applied with 600 pulses on impaired M1 before mCIMT.

MAIN OUTCOME MEASURES

Upper extremity (UE) impairment was assessed with the Fugl-Meyer Test (FMT-UE), whereas the motor function was evaluated with the Wolf-Motor Function Test (WMFT). Motor Activity Log-28 (MAL-28) was used to evaluate the amount of use and how well (How Well Scale) the impaired UE movements.

RESULTS

With-in-group analysis revealed that all groups had statistically significant improvements based on the FMT-UE and MAL-28 (p<.05). However, the performance time and arm strength variables of WMFT were only increased in the mCIMT + iTBS group (p<.05). The only between-group difference was observed in the intracortical facilitation in favor of the mCIMT + iTBS group (p<.05). The effect size of iTBS was f=0.18.

CONCLUSIONS

Our findings suggest that mCIMT with and without the application of iTBS has increased the UE motor function in low-functioning PwS. iTBS applied on intermittent days may have additional benefits as an adjunct therapy for facilitating cortical excitability, increasing the speed and strength of the impaired UE as well as decreasing disability.

Impact of whole-body vibration training on ankle joint proprioception and balance in stroke patients: a prospective cohort study

BACKGROUND

Although whole-body vibration (WBV) training is acknowledged for its benefits in enhancing motor functions across several neurological disorders, its precise influence on ankle joint proprioception and balance in stroke patients is still not well understood. This research seeks to assess the impact of WBV training on ankle joint proprioception and balance in stroke patients, thereby filling this important research void.

METHODS

In this prospective cohort study, thirty-five stroke patients were randomly assigned to either the WBV group (n = 17) or a control group (n = 18) using a random number table method. The control group received daily general rehabilitation for four weeks, while the WBV group received an additional 30 min of WBV training each day with the Trunsan S110 Vibration Training System. Blinded outcome assessments were conducted at baseline and post-treatment, utilizing the Berg balance scale (BBS), Functional reach test (FRT), Romberg test length (RTL) and area (RTA), and completion rates of ankle joint dorsiflexion-plantar flexion (DP) and inversion-eversion (IE) tests. Follow-up assessments were performed after four weeks of intervention, focusing on RTL, RTA, DP, and IE as primary outcomes.

RESULTS

Analysis of intra-group changes from baseline to post-treatment revealed significant improvements across the BBS, FRT, RTL, RTA, and DP and IE assessments (p < 0.001). Notably, the WBV group showed significant enhancements compared to the control group in DP and IE (p < 0.001 and p < 0.05, respectively), with mean values increasing from 13.556 to 16.765 (23.7%) and from 5.944 to 8.118 (36.6%), respectively. However, WBV did not provide additional benefits over the control treatment for balance recovery parameters such as BBS, FRT, RTL, and RTA (p > 0.05).

CONCLUSIONS

This study demonstrates that WBV therapy is equally effective as conventional methods in enhancing proprioception and balance in stroke patients, but it does not provide additional benefits for balance recovery. WBV significantly improves proprioceptive functions, particularly in DP and IE parameters. However, it does not surpass traditional rehabilitation methods in terms of balance recovery. These findings indicate that WBV should be incorporated into stroke rehabilitation primarily to enhance proprioception rather than to optimize balance recovery.

TRIAL REGISTRATION

This study was retrospectively registered in the ISRCTN Registry on 29/07/2024 ( https://www.isrctn.com/ , ISRCTN64602845).

Increasing the delivery of upper limb constraint-induced movement therapy programs for stroke and brain injury survivors: evaluation of the ACTIveARM project

PURPOSE

To increase the number of constraint-induced movement therapy (CIMT) programs provided by rehabilitation services.

METHODS

A before-and-after implementation study involving nine rehabilitation services. The implementation package to help change practice included file audit-feedback cycles, 2-day workshops, poster reminders, a community-of-practice and drop-in support. File audits were conducted at baseline, every three months for 1.5 years, and once after support ceased to evaluate maintenance of change. CIMT participant outcomes were collected to evaluate CIMT effectiveness and maintenance (Action Research Arm Test and Motor Activity Log). Staff focus groups explored factors influencing CIMT delivery.

RESULTS

CIMT adoption improved from baseline where only 2% of eligible people were offered and/or received CIMT (n = 408 files) to more than 50% over 1.5 years post-implementation (n = 792 files, 52% to 73% offered CIMT, 27%-46% received CIMT). Changes were maintained at 6-month follow-up (n = 172 files, 56% offered CIMT, 40% received CIMT). CIMT participants (n = 74) demonstrated clinically significant improvements in arm function and occupational performance. Factors influencing adoption included interdisciplinary collaboration, patient support needs, intervention adaptations, a need for continued training, and clinician support.

CONCLUSIONS

The implementation package helped therapists overcome an evidence-practice gap and deliver CIMT more routinely.

Home-Based Balance Training on Balance and Mobility in Persons With Multiple Sclerosis: A Systematic Review and Meta-analysis

OBJECTIVES

To (1) examine the effects of home-based balance training on balance and mobility outcomes; (2) evaluate comparable effects between home- and center-based balance training; (3) determine the effects of different levels of supervision on treatment effects; and (4) investigate dose-response relationships of home-based balance training on balance and mobility performance in persons with multiple sclerosis (MS).

DATA SOURCES

Literature searches were conducted in MEDLINE, EMBASE, PsycINFO, SPORTSDiscus, and CINAHL in April 2023. Other literature sources included website and citation searches.

STUDY SELECTION

The study included randomized controlled trials of home-based balance training that included balance and mobility outcomes in persons with MS.

DATA EXTRACTION

Data extracted from each study included (1) number of participants; (2) dropout rate; (3) sex; (4) MS phenotype; (5) age; (6) Expanded Disability Status Scale (range); (7) exercise dose; (8) level of supervision; (9) type of intervention; (10) exercise progression; (11) type of control; and (12) outcomes measures. For the meta-analysis, mean and SD of the balance and mobility outcomes in both the intervention and control groups were used. The methodological quality of included studies was evaluated by Tool for the Assessment of Study Quality and Reporting in Exercise.

DATA SYNTHESIS

Eleven studies were identified in this systematic review and meta-analysis. Each balance and mobility outcome was standardized using Hedges' g.

CONCLUSIONS

This meta-analysis revealed comparable results between home- and center-based balance training in terms of balance and mobility improvement. There was also no evidence for the superiority of home-based balance training over no training except for static steady-state balance. This study revealed that training sessions (>36 sessions) and total exercise time (>1100min) were significant moderators for overall balance improvements. Results also indicated that, when designing future interventions, at least an indirect level of supervision (eg, weekly or biweekly phone/video calls) is warranted to maintain adherence.

Development of a behaviour change intervention to increase the delivery of upper limb constraint-induced movement therapy programs to people with stroke and traumatic brain injury

PURPOSE

Constraint-induced movement therapy (CIMT) is a recommended intervention for arm recovery after acquired brain injury but is underutilised in practice. The purpose of this study is to describe the development of a behaviour change intervention targeted at therapists, to increase delivery of CIMT.

METHODS

A theoretically-informed approach for designing behaviour change interventions was used including identification of which behaviours needed to change (Step 1), barriers and enablers that needed to be addressed (Step 2), and intervention components to target those barriers and enablers (Step 3). Data collection methods included file audits and therapist interviews. Quantitative data (file audits) were analysed using descriptive statistics. Qualitative data analysis (interviews) was informed by the Theoretical Domains Framework (TDF) and Behaviour Change Wheel.

RESULTS

Fifty two occupational therapists, physiotherapists and allied health assistants participated in focus groups (n = 7) or individual interviews (n = 6). Key barriers (n = 20) and enablers (n = 10) were identified across 11 domains of the TDF and perceived to influence CIMT implementation. The subsequent behaviour change intervention included training workshops, nominated team champions, community of practice meetings, three-monthly file audit feedback cycles, poster reminders and drop-in support during CIMT.

CONCLUSION

This study describes the development of a behaviour change intervention to increase CIMT delivery by clinicians.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, Trial ID: ACTRN12617001147370.

Clinician and patient experiences with shared decision-making to promote daily arm use for individuals with chronic stroke: an exploratory qualitative study

Purpose

To explore the attitudes and experiences of clinicians and individuals with chronic stroke on the use of shared decision-making (SDM) during upper extremity rehabilitation to improve daily arm use in the home environment. Specifically, we aimed to describe clinician and client perspectives regarding the facilitators and barriers to using SDM within the context of a self-directed upper extremity intervention for individuals living in the community with chronic stroke.

Methods

Data were collected within the context of an interventional study examining the feasibility of the Use My Arm-Remote intervention. Focus group interviews were conducted with the clinicians (n = 3) providing the intervention and individual semi-structured interviews with the participants (n = 15) of the study. All interview data were collected after the end of the intervention period. Data were analyzed using thematic analysis.

Results

The following themes were identified: (1) Equal partnership; (2) Enhancing clinician confidence; and (3) This is different. Facilitators and barriers were identified within each theme. Key facilitators for clinicians were competence with SDM and patient characteristics; while facilitators for patients were open and trusting relationships with clinicians and personalized experience. Key barriers to SDM for clinicians were lack of expertise in SDM and participant buy in; while patients identified a lack of foundational knowledge of stroke rehabilitation as a potential barrier.

Conclusions

Key barriers were analyzed using the consolidated framework for advancing implementation science to interpret results and identify strategies for enhancing the implementation of SDM in a virtual setting. The CFIR-ERIC tool highlighted the need for targeted educational meetings and materials to address the training and educational needs of both clinicians and patients for future iterations of this intervention.

Exceptional improvement in chronic stroke through Guided Self-rehabilitation Contract: a case report study

A 44-year-old woman suffered a carotid dissection causing a deep and superficial right middle cerebral artery stroke in October 2013, despite undergoing thrombolysis and thrombectomy. Sixteen months later, massive left upper extremity impairment persisted. She then agreed to embark upon a guided self-rehabilitation contract (GSC). This GSC is a moral contract where the physician or therapist identifies specific muscles, particularly hypo-extensible and disabling that act as antagonists to functional activities. The physician or therapist then teaches and prescribes quantified daily high-load self-stretch postures for these muscles, alternating with repeated maximal amplitude movement exercises against their resistance. In turn, the patient commits to practicing the prescribed program and to delivering a diary of the stretch postures and alternating movement exercises performed each day. Over 4 years of GSC, the patient practiced upon prescription against a total of seven upper limb antagonists to common functional movements: shoulder extensors, shoulder internal rotators, elbow flexors, elbow pronators, wrist and finger flexors, and interossei muscles. She manually filled up her diary 99% of the days. Each day, she practiced an average of 20 min of high-load static self-stretch per muscle, alternating with about 50 maximal active efforts against the resistance of each targeted muscle's resistance. Overall, her mean static self-stretch time was 81 ± 2 (mean ± SEM) min/day, and her mean number of active maximal efforts was 285 ± 78/day, for a total daily self-rehabilitation time of over 2 h a day. Five years after her stroke, she had recovered all left upper extremity use in daily activities and resumed her previous job as a nurse's aide. She now spontaneously uses her left hand in most tasks. Functional MRI (March 2020) demonstrated bilateral primary motor and motor supplementary area activation upon left-hand exercise. Prolonged static self-stretch increased muscle extensibility (muscle plasticity) while maximal amplitude, alternating movement training reduced co-contraction in these muscles (neural plasticity). The Modified Frenchay Scale assessment was video-recorded by the clinician at each visit, allowing qualitative and quantitative evaluation of the functional capacities. The two videos of the first and last clinic visits have been uploaded and are available.

Segmentary exclusion syndrome in hand traumatology - definition, rehabilitation and orthosis

BACKGROUND

Segmentary exclusion syndrome is a motor behavioral disorder consisting in non-use or underuse of a limb or limb segment following local inflammation, most often of traumatic origin, primarily affecting the fingers and hand. It can be associated with somatosensory disorder, limitation of range of motion, and pain.

PURPOSE OF THE STUDY

The objective of this article is to further describe segmentary exclusion syndrome, and to present practical rehabilitation techniques and strategies focused on prevention, assessment and treatment.

The effect of transcranial direct current stimulation on balance, gait function and quality of life in patients with stroke

Transcranial direct current stimulation (tDCS) has been used in various neurological diseases due to its positive effects on cortical excitability. The aim of our study is to examine the effects of tDCS in stroke and 28 patients with stroke were randomly divided into two groups as intervention and control groups. Balance was evaluated with the Timed Up and Go Test and Berg Balance Scale. Walking functions were evaluated using the 10-meter Walk Test and the 6 Minutes Walk Test, lower extremity function was evaluated by Fugl Meyer Lower Extremity Scale, quality of life by Stroke-Specific Quality of Life Scale (SS-QOL). A task-oriented physiotherapy and rehabilitation program was applied to both groups. In addition to the task-oriented program, anodal tDCS was applied in the intervention group and carried out with a current of 2 mA, 5 days a week, 20 min, for a total of 4 weeks. In the control group, after the flow was opened for 30 s and the patient felt a tingling sensation, it was turned off without the patient noticing. As a result, significant improvement was obtained in all parameters in both groups (p < 0.05). At the difference values of both groups, only SS-QOL mobility subgroup was significant and other parameters were not significant. Considering all these results, it can be seen that tDAS applied in addition to the task-oriented training program in individuals with stroke makes a positive contribution to the patients' balance, walking function and quality of life. We think that tDAS may be a feasible and safe additional approach in this patient group.

Alternating Hot-Cold Water Immersion Facilitates Motor Function Recovery in the Paretic Upper Limb After Stroke: A Pilot Randomized Controlled Trial

OBJECTIVE

To assess the effectiveness of alternating hot-cold water immersion (AHCWI) in patients with acute stroke.

DESIGN

A single-blind pilot randomized controlled trial.

SETTING

Department of Rehabilitation Medicine of a medical center.

PARTICIPANTS

Early stroke survivors (N=24) with moderate-to-severe arm paresis.

INTERVENTIONS

In addition to conventional rehabilitation, eligible patients were randomly assigned to an AHCWI group (n=12, for AHCWI) or a control group (n=12, for upper limb [UL] cycling exercises) 5 times per week for 6 weeks.

MAIN OUTCOME MEASURES

The Fugl-Meyer Assessment motor-UL (FMA-UL) score, Motricity Index-UL (MI-UL) score, modified Motor Assessment Scale (MMAS; including its UL sections, MMAS-UL) score, Berg Balance Scale score, Barthel Index (BI), and modified Ashworth Scale score were assessed by the same uninvolved physical therapist at baseline and after 4 and 6 weeks of intervention.

RESULTS

Compared with the control group, the AHCWI group performed better, with significant group effects (P<.05), and exhibited significant improvements in FMA-UL, MI-UL, and MMAS-UL scores at 4 and 6 weeks (P<.05). Although the remaining outcomes were not significantly different, they favored the AHCWI group. Notably, a significant difference was observed in the BI at 4 weeks (P=.032). Significant changes in the muscle tone or adverse effects were not observed in either group after the intervention.

CONCLUSIONS

AHCWI with stroke rehabilitation is feasible and may facilitate motor function recovery of the paretic UL after a stroke.

Activity-dependent transcriptional programs in memory regulate motor recovery after stroke

Stroke causes death of brain tissue leading to long-term deficits. Behavioral evidence from neurorehabilitative therapies suggest learning-induced neuroplasticity can lead to beneficial outcomes. However, molecular and cellular mechanisms that link learning and stroke recovery are unknown. We show that in a mouse model of stroke, which exhibits enhanced recovery of function due to genetic perturbations of learning and memory genes, animals display activity-dependent transcriptional programs that are normally active during formation or storage of new memories. The expression of neuronal activity-dependent genes are predictive of recovery and occupy a molecular latent space unique to motor recovery. With motor recovery, networks of activity-dependent genes are co-expressed with their transcription factor targets forming gene regulatory networks that support activity-dependent transcription, that are normally diminished after stroke. Neuronal activity-dependent changes at the circuit level are influenced by interactions with microglia. At the molecular level, we show that enrichment of activity-dependent programs in neurons lead to transcriptional changes in microglia where they differentially interact to support intercellular signaling pathways for axon guidance, growth and synaptogenesis. Together, these studies identify activity-dependent transcriptional programs as a fundamental mechanism for neural repair post-stroke.

Cortical response characteristics of passive, active, and resistance movements: a multi-channel fNRIS study

Objective

This study aimed to explore the impact of exercise training modes on sensory and motor-related cortex excitability using functional near-infrared spectroscopy technology (fNIRS) and reveal specific cortical effects.

Materials and methods

Twenty participants with no known health conditions took part in a study involving passive, active, and resistance tasks facilitated by an upper-limb robot, using a block design. The participants wore functional near-infrared spectroscopy (fNIRS) devices throughout the experiment to monitor changes in cortical blood oxygen levels during the tasks. The fNIRS optode coverage primarily targeted key areas of the brain cortex, including the primary motor cortex (M1), primary somatosensory cortex (S1), supplementary motor area (SMA), and premotor cortex (PMC) on both hemispheres. The study evaluated cortical activation areas, intensity, and lateralization values.

Results

Passive movement primarily activates M1 and part of S1, while active movement mainly activates contralateral M1 and S1. Resistance training activates brain regions in both hemispheres, including contralateral M1, S1, SMA, and PMC, as well as ipsilateral M1, S1, SMA, and PMC. Resistance movement also activates the ipsilateral sensorimotor cortex (S1, SMA, PMC) more than active or passive movement. Active movement has higher contralateral activation in M1 compared to passive movement. Resistance and active movements increase brain activity more than passive movement. Different movements activate various cortical areas equally on both sides, but lateralization differs. The correlation between lateralization of brain regions is significant in the right cortex but not in the left cortex during three movement patterns.

Conclusion

All types of exercise boost motor cortex excitability, but resistance exercise activates both sides of the motor cortex more extensively. The PMC is crucial for intense workouts. The right cortex shows better coordination during motor tasks than the left. fNIRS findings can help determine the length of treatment sessions.

Hybrid Brain-Computer Interface Controlled Soft Robotic Glove for Stroke Rehabilitation

Soft robotic glove controlled by a brain-computer interface (BCI) have demonstrated effectiveness in hand rehabilitation for stroke patients. Current systems rely on static visual representations for patients to perform motor imagination (MI) tasks, resulting in lower BCI performance. Therefore, this study innovatively used MI and high-frequency steady-state visual evoked potential (SSVEP) to construct a friendly and natural hybrid BCI paradigm. Specifically, the stimulation interface sequentially presented decomposed action pictures of the left and right hands gripping a ball, with the pictures flashing at specific stimulation frequencies (left: 34 Hz, right: 35 Hz). Integrating soft robotic glove as feedback, we established a comprehensive "peripheral - central - peripheral" hand rehabilitation system to facilitate the hand rehabilitation of patients. Filter bank common spatial pattern (FBCSP) and filter bank canonical correlation analysis (FBCCA) algorithms were used to identify MI and SSVEP signals, respectively. Additionally, we proposed a novel fusion algorithm to decide the final output of the system. The feasibility of the proposed system was validated through online experiments involving 12 healthy subjects and 9 stroke patients, achieving accuracy rates of 95.83 ± 6.83% and 63.33 ± 10.38, respectively. The accuracy of MI and SSVEP in 12 healthy subjects reached 81.67 ± 15.63% and 95.14 ± 7.47%, both lower than the accuracy after fusion, these results confirmed the effectiveness of the proposed algorithm. The accuracy rate was more than 50% in both healthy subjects and patients, confirming the effectiveness of the proposed system.

Global research hotspots and trends in constraint-induced movement therapy in rehabilitation over the past 30 years: a bibliometric and visualization study

Background

Stroke is a cerebrovascular disease with high prevalence and mortality, and upper limb hemiparesis is a major factor limiting functional recovery in stroke patients. Improvement of motor function in stroke patients through various forms of constraint-induced movement therapy (CITM) has been recognized as safe and effective in recent years. This research field lacks a comprehensive systematic and clear vein combing analysis, analyzing the literature research of CIMT in the field of rehabilitation in the past three decades, summarizing the research hotspots and cutting-edge trends in this field, in an effort to offer ideas and references for subsequent researchers.

Methods

Relevant literature on CIMT in rehabilitation was collected from 1996 to 2024 within the Web of Science database's core dataset by using CiteSpace6.1, VOSviewer1.6.18, R-bibliometrix4.6.1, Pajek5.16, Scimago Graphica 1.0.26 software for visualization and analysis.

Results

There were 970 papers in all United States was ranked first with 401 papers. Alabama Univ was ranked first for institutions with 53 papers. Neurorehabilitation and Neural Repair was ranked first for journals with 78 papers, and Taub E was ranked first for author publications with 64 papers. Research keywords were CIMT, stroke rehabilitation, upper extremity function, lower extremity gait balance, randomized controlled trials, physical therapy techniques (transcranial magnetic stimulation and sensory amplitude electrical stimulation), primary motor cortex plasticity, lateral dominance (spatial behaviors), cerebral vascular accidents, activities of daily living, hand function, disability, functional restoration, bimanual training, aphasia, acquired invalidity, type A Botulinum toxin and joystick riding toys.

Conclusion

The current state of research shows that CIMT still has a vast potential for development in the field of rehabilitation research. The research hotspots are the clinical efficacy of CIMT combined with other therapies (botulinum toxin type A, transcranial direct current stimulation, virtual reality, mirror therapy, robotic-assisted) to enhance the functionality of upper limb hemiparesis in stroke patients, the mechanism of CIMT to improve the plasticity of the motor cortex through electrophysiological and imaging methods, and improvement of lower limb gait balance function in stroke patients and aphasia applications, the optimal intervention time and dose, and exploration of CIMT in new settings such as robot-assisted, telemedicine, and home rehabilitation.

Priming constraint-induced movement therapy with intermittent theta burst stimulation to enhance upper extremity recovery in patients with stroke: protocol for a randomized controlled study

BACKGROUND

The treatments based on motor control and motor learning principles have gained popularity in the last 20 years, as well as non-invasive brain stimulations that enhance neuroplastic changes after stroke. However, the effect of intermittent theta burst stimulation (iTBS) in addition to evidence-based, intensive neurorehabilitation approaches such as modified constraint-induced movement therapy (mCIMT) is yet to be investigated.

AIM

We aim to establish a protocol for a randomized controlled study investigating the efficiency of mCIMT primed with iTBS after stroke.

METHODS

In this randomized controlled, single-blind study, patients with stroke (N = 17) will be divided into 3 groups: (a) mCIMT + real iTBS, (b) mCIMT + sham iTBS, and (c) mCIMT alone. 600-pulse iTBS will be delivered to the primary motor cortex on the ipsilesional hemisphere, and then, patients will receive mCIMT for 1 h/session, 3 sessions/week for 5 weeks. Upper extremity recovery will be assessed with Fugl-Meyer Test-Upper Extremity and Wolf Motor Function Test. Electrophysiological assessments, such as Motor-Evoked Potentials, Resting Motor Threshold, Short-Intracortical Inhibition, and Intracortical Facilitation, will also be included.

CONCLUSIONS

In this study, a protocol of an ongoing intervention study investigating the effectiveness of iTBS on ipsilesional M1 prior to the mCIMT in patients with stroke is proposed. This will be the first study to research priming mCIMT with iTBS and it may have the potential to reveal the true effect of the iTBS when it is added to the high-quality neurorehabilitation approaches.

TRIAL REGISTRATION

Trial registration number: NCT05308667.

Pharmacological and stem cell therapy of stroke in animal models: Do they accurately reflect the response of humans?

Cerebrovascular diseases are the second leading cause of death worldwide. Despite significant research investment, the only available therapeutic options are mechanical thrombectomy and tissue plasminogen activator thrombolysis. None of the more than a thousand drugs tested on animal models have proven successful in human clinical trials. Several factors contribute to this poor translation of data from stroke-related animal models to human stroke patients. Firstly, our understanding of the molecular and cellular processes involved in recovering from an ischemic stroke is severely limited. Secondly, although the risk of stroke is particularly high among older patients with comorbidities, most drugs are tested on young, healthy animals in controlled laboratory conditions. Furthermore, in animal models, the tracking of post-stroke recovery typically spans only 3 to 28 days, with occasional extensions to 60 days, whereas human stroke recovery is a more extended and complex process. Thirdly, young animal models often exhibit a considerably higher rate of spontaneous recovery compared to humans following a stroke. Fourth, only a very limited number of animals are utilized for each condition, including control groups. Another contributing factor to the much smaller beneficial effects in humans is that positive outcomes from numerous animal studies are more readily accepted than results reported in human trials that do not show a clear benefit to the patient. Useful recommendations for conducting experiments in animal models, with increased chances of translatability to humans, have been issued by both the STEPS investigative team and the STAIR committee. However, largely, due to economic factors, these recommendations are largely ignored. Furthermore, one might attribute the overall failures in predicting and subsequently developing effective acute stroke therapies beyond thrombolysis to potential design deficiencies in clinical trials.

Effectiveness of virtual reality-supported exercise therapy in improving upper extremity function and activities of daily living among patients after stroke: a systematic review of randomized control trials

BACKGROUND

This systematic review describes the effectiveness of virtual reality (VR)-supported exercise therapy on upper limb motor function and activities of daily living after stroke.

METHODS

Studies published through January 24, 2022, were identified using CINAHL, Cochrane Library, Embase, Medline, and Web of Science. Randomized control trials comparing VR treatment with conventional therapy (CT) for upper extremity rehabilitation after stroke were included. Methodological quality was assessed using the Cochrane risk-of-bias tool.

RESULTS

Of 9 included studies, 5 concluded that the VR group outperformed control participants, 1 indicated the superiority of VR-supported exercises alone over CT, and 3 found VR comparable to CT in promoting upper limb motor function. Five studies analyzed independence in daily living, with 4 reporting no significant difference between VR and CT groups. No strong evidence indicated long-term benefits of VR-assisted exercise. All included studies demonstrated low risk of bias concerning random sequence generation, allocation concealment, outcome assessment blinding, incomplete outcome data, and selective reporting bias. However, a high risk of bias was observed regarding participant blinding due to the nature of the intervention.

CONCLUSION

Most studies suggested that VR, used alongside CT, can improve motor function following stroke. However, the evidence was insufficient to conclude that VR outperforms conventional approaches.