Long-Dose Intensive Therapy Is Necessary for Strong, Clinically Significant, Upper Limb Functional Gains and Retained Gains in Severe/Moderate Chronic Stroke

Post Stroke Exercise Training: Intensity, Dosage, and Timing of Therapy

More intense, earlier exercise in rehabilitation results in improved motor outcomes following stroke. Timing and intensity of therapy delivery vary from study to study. For more intensive therapies, there are practical challenges in implementation. However, there are also opportunities for high intensity treatment through innovative approaches and new technologies. Timing of rehabilitation is important. As time post stroke increases, the dosage of therapy required to improve motor recovery outcomes increases. Very early rehabilitation may improve motor outcomes but should be delayed for at least 24 hours post stroke.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

REGISTRATION

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

Neurorehabilitation of the upper extremity - immersive virtual reality vs. electromechanically assisted training. A comparative study

Background

Severe paresis of the contralesional upper extremity is one of the most common and debilitating post-stroke impairments. The need for cost-effective high-intensity training is driving the development of new technologies, which can complement and extent conventional therapies. Apart from established methods using electromechanical devices, immersive virtual reality (iVR) systems hold promise to provide cost-efficient high-intensity arm training.

Objective

We investigated whether iVR-based arm training yields at least equivalent effects on upper extremity function as compared to an electromechanically assisted training in stroke patients with severe arm paresis.

Methods

52 stroke patients with severe arm paresis received a total of ten daily group therapy sessions over a period of three weeks, which consisted of 20 min of conventional therapy and 20 min of either electromechanically assisted (ARMEOSpring®) or iVR-based (CUREO®) arm training. Changes in upper extremity function was assessed using the Action Research Arm Test (ARAT) and user acceptance was measured with the User Experience Questionnaire (UEQ).

Results

iVR-based training was not inferior to electromechanically assisted training. We found that 84% of patients treated with iVR and 50% of patients treated with electromechanically assisted arm training showed a clinically relevant improvement of upper extremity function. This difference could neither be attributed to differences between the groups regarding age, gender, duration after stroke, affected body side or ARAT scores at baseline, nor to differences in the total amount of therapy provided.

Conclusion

The present study results show that iVR-based arm training seems to be a promising addition to conventional therapy. Potential mechanisms by which iVR unfolds its effects are discussed.

Stroke Recovery Is a Journey: Prediction and Potentials of Motor Recovery after a Stroke from a Practical Perspective

Stroke recovery is a journey. Stroke survivors can face many consequences that may last the rest of their lives. Assessment of initial impairments allows reasonable prediction of biological spontaneous recovery at 3 to 6 months for a majority of survivors. In real-world clinical practice, stroke survivors continue to improve their motor function beyond the spontaneous recovery period, but management plans for maximal recovery are not well understood. A model within the international classification of functioning (ICF) theoretical framework is proposed to systematically identify opportunities and potential barriers to maximize and realize the potentials of functional recovery from the acute to chronic stages and to maintain their function in the chronic stages. Health conditions of individuals, medical and neurological complications can be optimized under the care of specialized physicians. This permits stroke survivors to participate in various therapeutic interventions. Sufficient doses of appropriate interventions at the right time is critical for stroke motor rehabilitation. It is important to highlight that combining interventions is likely to yield better clinical outcomes. Caregivers, including family members, can assist and facilitate targeted therapeutic exercises for these individuals and can help stroke survivors comply with medical plans (medications, visits), and provide emotional support. With health optimization, comprehensive rehabilitation, support from family and caregivers and a commitment to a healthy lifestyle, many stroke survivors can overcome barriers and achieve potentials of maximum recovery and maintain their motor function in chronic stages. This ICF recovery model is likely to provide a guidance through the journey to best achieve stroke recovery potentials.

Movement Reminders to Encourage Arm Use During Daily Life in Stroke Patients

Stroke is a leading cause of long-term disability, such as loss of upper limb function. Active arm movement and frequent practice are essential to regain such function. Wearable sensors that trigger individualized movement reminders can promote awareness of the affected limb during periods of inactivity. This study investigated the immediate effect of vibrotactile reminders based on activity counts on affected arm use, the evolution of the effect throughout a 6-week intervention at home, and whether the time of the day influences the response to the reminder. Thirteen participants who experienced a unilateral ischemic stroke were included in the analysis. Activity counts were found to increase significantly after receiving a reminder. The immediate effect of receiving a reminder was maintained throughout the day as well as during the study duration of 6 weeks. In conclusion, wearable activity trackers with a feature to trigger individualized vibrotactile reminders could be a promising rehabilitation tool to increase arm activity of the affected side in stroke patients in their home environment.

Examining Usability, Acceptability, and Adoption of a Self-Directed, Technology-Based Intervention for Upper Limb Rehabilitation After Stroke: Cohort Study

BACKGROUND

Upper limb (UL) recovery after stroke is strongly dependent upon rehabilitation dose. Rehabilitation technologies present pragmatic solutions to dose enhancement, complementing therapeutic activity within conventional rehabilitation, connecting clinicians with patients remotely, and empowering patients to drive their own recovery. To date, rehabilitation technologies have been poorly adopted. Understanding the barriers to adoption may shape strategies to enhance technology use and therefore increase rehabilitation dose, thus optimizing recovery potential.

OBJECTIVE

We examined the usability, acceptability, and adoption of a self-directed, exercise-gaming technology within a heterogeneous stroke survivor cohort and investigated how stroke survivor characteristics, technology usability, and attitudes toward technology influenced adoption.

METHODS

A feasibility study of a novel exercise-gaming technology for self-directed UL rehabilitation in early subacute stroke survivors (N=30) was conducted in an inpatient, acute hospital setting. Demographic and clinical characteristics were recorded; participants' performance in using the system (usability) was assessed using a 4-point performance rating scale (adapted from the Barthel index), and adherence with the system was electronically logged throughout the trial. The technology acceptance model was used to formulate a survey examining the acceptability of the system. Spearman rank correlations were used to examine associations between participant characteristics, user performance (usability), end-point technology acceptance, and intervention adherence (adoption).

RESULTS

The technology was usable for 87% (n=26) of participants, and the overall technology acceptance rating was 68% (95% CI 56%-79%). Participants trained with the device for a median of 26 (IQR 16-31) minutes daily over an enrollment period of 8 (IQR 5-14) days. Technology adoption positively correlated with user performance (usability) (ρ=0.55; 95% CI 0.23-0.75; P=.007) and acceptability as well as domains of perceived usefulness (ρ=0.42; 95% CI 0.09-0.68; P=.03) and perceived ease of use (ρ=0.46; 95% CI 0.10-0.74; P=.02). Technology acceptance decreased with increased global stroke severity (ρ=-0.56; 95% CI -0.79 to -0.22; P=.007).

CONCLUSIONS

This technology was usable and acceptable for the majority of the cohort, who achieved an intervention dose with technology-facilitated, self-directed UL training that exceeded conventional care norms. Technology usability and acceptability were determinants of adoption and appear to be mediated by stroke severity. The results demonstrate the importance of selecting technologies for stroke survivors on the basis of individual needs and abilities, as well as optimizing the accessibility of technologies for the target user group. Facilitating changes in stroke survivors' beliefs and attitudes toward rehabilitation technologies may enhance adoption. Further work is needed to understand how technology can be optimized to benefit those with more severe stroke.

Prediction of rehabilitation induced motor recovery after stroke using a multi-dimensional and multi-modal approach

Background

Stroke is a debilitating disease affecting millions of people worldwide. Despite the survival rate has significantly increased over the years, many stroke survivors are left with severe impairments impacting their quality of life. Rehabilitation programs have proved to be successful in improving the recovery process. However, a reliable model of sensorimotor recovery and a clear identification of predictive markers of rehabilitation-induced recovery are still needed. This article introduces the cross-modality protocols designed to investigate the rehabilitation treatment's effect in a group of stroke survivors.

Methods/design

A total of 75 stroke patients, admitted at the IRCCS San Camillo rehabilitation Hospital in Venice (Italy), will be included in this study. Here, we describe the rehabilitation programs, clinical, neuropsychological, and physiological/imaging [including electroencephalography (EEG), transcranial magnetic stimulation (TMS), and magnetic resonance imaging (MRI) techniques] protocols set up for this study. Blood collection for the characterization of predictive biological biomarkers will also be taken. Measures derived from data acquired will be used as candidate predictors of motor recovery.

Discussion/summary

The integration of cutting-edge physiological and imaging techniques, with clinical and cognitive assessment, dose of rehabilitation and biological variables will provide a unique opportunity to define a predictive model of recovery in stroke patients. Taken together, the data acquired in this project will help to define a model of rehabilitation induced sensorimotor recovery, with the final aim of developing personalized treatments promoting the greatest chance of recovery of the compromised functions.

Long-term forecasting of a motor outcome following rehabilitation in chronic stroke via a hierarchical bayesian dynamic model

BACKGROUND

Given the heterogeneity of stroke, it is important to determine the best course of motor therapy for each patient, i.e., to personalize rehabilitation based on predictions of long-term outcomes. Here, we propose a hierarchical Bayesian dynamic (i.e., state-space) model (HBDM) to forecast long-term changes in a motor outcome due to rehabilitation in the chronic phase post-stroke.

METHODS

The model incorporates the effects of clinician-supervised training, self-training, and forgetting. In addition, to improve forecasting early in rehabilitation, when data are sparse or unavailable, we use the Bayesian hierarchical modeling technique to incorporate prior information from similar patients. We use HBDM to re-analyze the Motor Activity Log (MAL) data of participants with chronic stroke included in two clinical trials: (1) the DOSE trial, in which participants were assigned to a 0, 15, 30, or 60-h dose condition (data of 40 participants analyzed), and (2) the EXCITE trial, in which participants were assigned a 60-h dose, in either an immediate or a delayed condition (95 participants analyzed).

RESULTS

For both datasets, HBDM accounts well for individual dynamics in the MAL during and outside of training: mean RMSE = 0.28 for all 40 DOSE participants (participant-level RMSE 0.26 ± 0.19-95% CI) and mean RMSE = 0.325 for all 95 EXCITE participants (participant-level RMSE 0.32 ± 0.31), which are small compared to the 0-5 range of the MAL. Bayesian leave-one-out cross-validation shows that the model has better predictive accuracy than static regression models and simpler dynamic models that do not account for the effect of supervised training, self-training, or forgetting. We then showcase model's ability to forecast the MAL of "new" participants up to 8 months ahead. The mean RMSE at 6 months post-training was 1.36 using only the baseline MAL and then decreased to 0.91, 0.79, and 0.69 (respectively) with the MAL following the 1st, 2nd, and 3rd bouts of training. In addition, hierarchical modeling improves prediction for a patient early in training. Finally, we verify that this model, despite its simplicity, can reproduce previous findings of the DOSE trial on the efficiency, efficacy, and retention of motor therapy.

CONCLUSIONS

In future work, such forecasting models can be used to simulate different stages of recovery, dosages, and training schedules to optimize rehabilitation for each person. Trial registration This study contains a re-analysis of data from the DOSE clinical trial ID NCT01749358 and the EXCITE clinical trial ID NCT00057018.

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

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

Assessing the impact of a knowledge translation intervention on physical therapists' self-efficacy and implementation of motor learning practice

BACKGROUND

The application of motor learning (ML) principles and research in physical therapy can optimize patient outcomes. However, the translation of the accumulated knowledge in ML to clinical practice is limited. Knowledge translation interventions, which are designed to promote changes in clinical behaviors, have the potential to address this implementation gap. We developed, implemented, and evaluated a knowledge translation intervention for ML implementation that focuses on building clinical capacity among physical therapists for the systematic application of ML knowledge in clinical practice.

METHODS

A total of 111 physical therapists underwent the intervention, which consisted of the following: (1) an interactive didactic 20-hour course; (2) an illustrated conceptual model of ML elements; and (3) a structured clinical-thinking form. Participants completed the Physical Therapists' Perceptions of Motor Learning (PTP-ML) questionnaire pre and post intervention. The PTP-ML was used to assess ML-related self-efficacy and implementation. Participants also provided post-intervention feedback. A sub-sample (n = 25) provided follow-up feedback more than a year after the completion of the intervention. Pre-post and post-follow-up changes in the PTP-ML scores were calculated. The information gathered from the open-ended items of the post-intervention feedback was analyzed to identify emerging themes.

RESULTS

Comparing pre- and post-intervention scores, significant changes were found in the total questionnaire scores, self-efficacy subscale scores, reported implementation subscale scores (P < .0001), and general perceptions and work environment subscale score (P < .005). The mean changes in the total questionnaire and self-efficacy scores also significantly exceeded the Reliable Change Index. In the follow-up sample, these changes were maintained. Participants felt that the intervention helped them organize their knowledge in a structured manner and consciously link their practice elements to concepts in ML. Discussion of clinical cases was reported to be the most valuable educational method, and the illustrated conceptual model of ML elements was the least valued. Respondents also suggested support activities to maintain and enhance the learning experience, including on-site mentorship and hands-on experience.

CONCLUSIONS

Findings support the positive effect of an educational tool, most prominently on physical therapists' ML self-efficacy. The addition of practical modeling or ongoing educational support may enhance intervention effects.

A Comprehensive Review of Physical Therapy Interventions for Stroke Rehabilitation: Impairment-Based Approaches and Functional Goals

Stroke is the fourth leading cause of mortality and is estimated to be one of the major reasons for long-lasting disability worldwide. There are limited studies that describe the application of physical therapy interventions to prevent disabilities in stroke survivors and promote recovery after a stroke. In this review, we have described a wide range of interventions based on impairments, activity limitations, and goals in recovery during different stages of a stroke. This article mainly focuses on stroke rehabilitation tactics, including those for sensory function impairments, motor learning programs, hemianopia and unilateral neglect, flexibility and joint integrity, strength training, hypertonicity, postural control, and gait training. We conclude that, aside from medicine, stroke rehabilitation must address specific functional limitations to allow for group activities and superior use of a hemiparetic extremity. Medical doctors are often surprised by the variety of physiotherapeutic techniques available; they are unfamiliar with the approaches of researchers such as Bobath, Coulter, and Brunnstrom, among others, as well as the scientific reasoning behind these techniques.

Can specific virtual reality combined with conventional rehabilitation improve poststroke hand motor function? A randomized clinical trial

TRIAL OBJECTIVE

To verify whether conventional rehabilitation combined with specific virtual reality is more effective than conventional therapy alone in restoring hand motor function and muscle tone after stroke.

TRIAL DESIGN

This prospective single-blind randomized controlled trial compared conventional rehabilitation based on physiotherapy and occupational therapy (control group) with the combination of conventional rehabilitation and specific virtual reality technology (experimental group). Participants were allocated to these groups in a ratio of 1:1. The conventional rehabilitation therapists were blinded to the study, but neither the participants nor the therapist who applied the virtual reality-based therapy could be blinded to the intervention.

PARTICIPANTS

Forty-six patients (43 of whom completed the intervention period and follow-up evaluation) were recruited from the Neurology and Rehabilitation units of the Hospital General Universitario of Talavera de la Reina, Spain.

INTERVENTION

Each participant completed 15 treatment sessions lasting 150 min/session; the sessions took place five consecutive days/week over the course of three weeks. The experimental group received conventional upper-limb strength and motor training (100 min/session) combined with specific virtual reality technology devices (50 min/session); the control group received only conventional training (150 min/session).

RESULTS

As measured by the Ashworth Scale, a decrease in wrist muscle tone was observed in both groups (control and experimental), with a notably larger decrease in the experimental group (baseline mean/postintervention mean: 1.22/0.39; difference between baseline and follow-up: 0.78; 95% confidence interval: 0.38-1.18; effect size = 0.206). Fugl-Meyer Assessment scores were observed to increase in both groups, with a notably larger increase in the experimental group (total motor function: effect size = 0.300; mean: - 35.5; 95% confidence interval: - 38.9 to - 32.0; wrist: effect size = 0.290; mean: - 5.6; 95% confidence interval: - 6.4 to - 4.8; hand: effect size = 0.299; mean: - -8.9; 95% confidence interval: - 10.1 to - 7.6). On the Action Research Arm Test, the experimental group quadrupled its score after the combined intervention (effect size = 0.321; mean: - 32.8; 95% confidence interval: - 40.1 to - 25.5).

CONCLUSION

The outcomes of the study suggest that conventional rehabilitation combined with a specific virtual reality technology system can be more effective than conventional programs alone in improving hand motor function and voluntary movement and in normalizing muscle tone in subacute stroke patients. With combined treatment, hand and wrist functionality and motion increase; resistance to movement (spasticity) decreases and remains at a reduced level.

TRIALS REGISTRY

International Clinical Trials Registry Platform: ISRCTN27760662 (15/06/2020; retrospectively registered).

Assessment of Passive Upper Limb Stiffness and Its Function in Post-Stroke Individuals Wearing an Inertial Sensor during the Pendulum Test

This article proposes the evaluation of the passive movement of the affected elbow during the pendulum test in people with stroke and its correlation with the main clinical scales (Modified Ashworth Scale, Motor Activity Log, and Fulg Meyer). An inertial sensor was attached to the forearm of seven subjects, who then passively flexed and extended the elbow. Joint angles and variables that indicate viscoelastic properties, stiffness (K), damping (B), E1 amp, F1 amp, and relaxation indices were collected. The results show that the FM scale is significantly correlated with the natural frequency (p = 0.024). The MAL amount-of-use score correlates with the natural frequency (p = 0.024). The variables E1 amp, F1 amp, RI, and ERI are not correlated with the clinical scales, but they correlate with each other; the variable E1 amp correlates with F1 amp (p = 0.024) and RI (p = 0.024), while F1 amp correlates with ERI (p = 0.024). There was also a correlation between the natural frequency and K (r = 0.96, p = 0.003). Non-linear results were found for the properties of the elbow joint during the pendulum test, which may be due to the presence of neural and non-neural factors. These results may serve as a reference for future studies if alternative scales do not provide an accurate reflection.

Botulinum Toxin and Dynamic Splint Restore Grasping Function after Stroke: A Case Report

Evidence on the effectiveness of upper extremity rehabilitation post-stroke is inconclusive. We evaluated a tailored therapeutic program with dynamic splint and botulinum toxin injections for the treatment of upper extremity muscle spasticity. A case of a 43-year-old woman with chronic spastic hemiparesis after ischemic stroke with significant mobility impairment in the left upper extremity was described. A 16-week program consisted of three 50-min sessions daily and focused on grasping and releasing with and without the splint. The patient was evaluated before botulinum toxin injection and after 6, 12 and 16 weeks according to the International Classification of Functioning, Disability and Health, and included the following scales: Fugl-Meyer Upper Extremity Assessment (FMA-UE), Modified Ashworth Scale, Numerical Rating Scale (NRS), MyotonPro, Stroke Impact Scale, Box and Blocks. Photographic documentation made before and after the experiment was compared. Motor functions improved by 19.7% on FMA-UE, spasticity was reduced by one degree and pain at rest and during activity decreased by one score on NRS. A reduction in the oscillation frequency of the relaxed muscle and the stiffness of the examined muscles was observed. The patient regained grasping function. Health-related quality of life was systematically improving with a 35% increase at week 16 compared to the baseline. The combination treatment for spasticity based on botulinum toxin and SaeboFlex^® dynamic splint in a patient with chronic spastic hemiparesis reduces disability and improves quality of life. However, further research is needed to investigate the treatment results.

Rehabilitation Therapy Doses Are Low After Stroke and Predicted by Clinical Factors

BACKGROUND

Stroke is a leading cause of long-term disability. Greater rehabilitation therapy after stroke is known to improve functional outcomes. This study examined therapy doses during the first year of stroke recovery and identified factors that predict rehabilitation therapy dose.

METHODS

Adults with new radiologically confirmed stroke were enrolled 2 to 10 days after stroke onset at 28 acute care hospitals across the United States. Following an initial assessment during acute hospitalization, the number of physical therapy, occupational therapy, and speech therapy sessions were determined at visits occurring 3, 6, and 12 months following stroke. Negative binomial regression examined whether clinical and demographic factors were associated with therapy counts. False discovery rate was used to correct for multiple comparisons.

RESULTS

Of 763 patients enrolled during acute stroke admission, 510 were available for follow-up. Therapy counts were low overall, with most therapy delivered within the first 3 months; 35.0% of patients received no physical therapy; 48.8%, no occupational therapy, and 61.7%, no speech therapy. Discharge destination was significantly related to cumulative therapy; the percentage of patients discharged to an inpatient rehabilitation facility varied across sites, from 0% to 71%. Most demographic factors did not predict therapy dose, although Hispanic patients received a lower cumulative amount of physical therapy and occupational therapy. Acutely, the severity of clinical factors (grip strength and National Institutes of Health Stroke Scale score, as well as National Institutes of Health Stroke Scale subscores for aphasia and neglect) predicted higher subsequent therapy doses. Measures of impairment and function (Fugl-Meyer, modified Rankin Scale, and Stroke Impact Scale Activities of Daily Living) assessed 3 months after stroke also predicted subsequent cumulative therapy doses.

CONCLUSIONS

Rehabilitative therapy doses during the first year poststroke are low in the United States. This is the first US-wide study to demonstrate that behavioral deficits predict therapy dose, with patients having more severe deficits receiving higher doses. Findings suggest directions for identifying groups at risk of receiving disproportionately low rehabilitation doses.

Real-time auditory feedback may reduce abnormal movements in patients with chronic stroke

PURPOSE

The current pilot study assesses the use of real-time auditory feedback to help reduce abnormal movements during an active reaching task in patients with chronic stroke.

MATERIALS AND METHODS

20 patients with chronic stroke completed the study with full datasets (age: M = 53 SD = 14; sex: male = 75%; time since stroke in months: M = 34, SD = 33). Patients undertook 100 repetitions of an active reaching task while listening to self-selected music which automatically muted when abnormal movement was detected, determined by thresholds set by clinical therapists. A within-subject design with two conditions (with auditory feedback vs. without auditory feedback) presented in a randomised counterbalanced order was used. The dependent variable was the duration of abnormal movement as a proportion of trial duration.

RESULTS

A significant reduction in the duration of abnormal movement was observed when patients received auditory feedback, F(1,18) = 9.424, p = 0.007, with a large effect size (partial η2 = 0.344).

CONCLUSIONS

Patients with chronic stroke can make use of real-time auditory feedback to increase the proportion of time they spend in optimal movement patterns. The approach provides a motivating framework that encourages high dose with a key focus on quality of movement. Trial Registration: ISRCTN12969079 https://www.isrctn.com/ISRCTN12969079 ISRTCN trial registration REF: ISRCTN12969079IMPLICATIONS FOR REHABILITATIONMovement quality during upper limb rehabilitation should be targeted as part of a well-balanced rehabilitation programme.Auditory feedback is a useful tool to help patients with chronic stroke reduce compensatory movements.

A Unified Model for Stroke Recovery and Rehabilitation: Why Now?

ABSTRACT

The current model of stroke care delivery in the United States and in many parts of the world is fragmented, resulting in lack of continuity of care, inability to track recovery meaningfully across the continuum, and lack of access to the frequency, intensity, and duration of high-quality rehabilitation necessary to optimally harness recovery processes. The process of recovery itself has been overshadowed by a focus on length of stay and the movement of patients across levels of care. Here, we describe the rationale behind the recent efforts at the Johns Hopkins Sheikh Khalifa Stroke Institute to define and coordinate an intensive, strategic effort to develop effective stroke systems of care across the continuum through the development of a unified Sheikh Khalifa Stroke Institute model of recovery and rehabilitation.

Addressing the Operational Challenges for Outpatient Stroke Rehabilitation

ABSTRACT

The traditional model of rehabilitation services includes clear requirements for provision of services in the acute inpatient rehabilitation setting. However, there are fewer guidelines on the frequency and duration of rehabilitation services beyond the acute setting. Recent research has suggested that neurorehabilitation interventions that are provided frequently enough upon discharge from acute inpatient rehabilitation to facilitate repeated practice and feedback improve long-term stroke outcomes. However, it is challenging to provide high-frequency outpatient rehabilitation, as the logistics of scheduling and insurance limitations often do not allow it. The Sheikh Khalifa Stroke Institute at Johns Hopkins Medicine innovated a new model to provide the appropriate frequency of therapy for stroke rehabilitation in the outpatient setting. This article describes the restructured operational infrastructure for outpatient stroke rehabilitation to facilitate high-frequency transdisciplinary stroke rehabilitation in the real world, including the development of the outpatient postacute therapy programs and the identification of appropriate patients for each program, the development of scheduling matrices and treating teams to deliver the postacute therapy programs, the implementation of transdisciplinary neurorehabilitation, and the steps taken to empower patients to engage in rehabilitation at home and address barriers to accessing the programs. We assessed the effect of the operational restructuring on schedule utilization, no-show rates, and cancellation rates in the 3 mos before and after implementation of the program and show that it increased schedule utilization and reduced no-show rates and cancellation rates, suggesting that it may increase compliance with rehabilitation. It is possible to create the infrastructure needed to bridge the continuum of care for poststroke recovery and rehabilitation.

Therapies Targeting Stroke Recovery

Stroke recovery therapeutics include many classes of intervention and numerous treatment targets. Stroke is a very heterogeneous disease. As such, stroke recovery therapeutics benefit from a personalized medicine approach that considers intersubject differences, such as in infarct location or stroke severity, when assigning treatment. Prediction of treatment responders can be improved by incorporating biological measures, such as neural injury and neural function, as the bedside behavioral phenotype has an incomplete relationship with the biological events underlying stroke recovery. Another ramification of high variability between patients is the need to examine effects of restorative therapies in relation to dose, time poststroke, and stroke severity in clinical trials. For example, enrollment across a wide time interval poststroke or in a population with a very broad range of deficits means high variance across patients in the biological state of the brain. The doses of rehabilitation therapy being studied are often low; it takes substantial practice to acquire a skill in the healthy brain; this is more, not less, pronounced after a stroke. Recognition and treatment of poststroke depression represents a major unmet need. These points are considered in the context of a review of recent advances in stroke recovery therapeutics.

Robot-assisted therapy for upper limb paresis after stroke: Use of robotic algorithms in advanced practice

BACKGROUND

Rehabilitation of stroke-related upper limb paresis is a major public health issue.

OBJECTIVE

Robotic systems have been developed to facilitate neurorehabilitation by providing key elements required to stimulate brain plasticity and motor recovery, namely repetitive, intensive, adaptative training with feedback. Although the positive effect of robot-assisted therapy on motor impairments has been well demonstrated, the effect on functional capacity is less certain.

METHOD

This narrative review outlines the principles of robot-assisted therapy for the rehabilitation of post-stroke upper limb paresis.

RESULTS

A paradigm is proposed to promote not only recovery of impairment but also function.

CONCLUSION

Further studies that would integrate some principles of the paradigm described in this paper are needed.

Effects of robotic upper limb treatment after stroke on cognitive patterns: A systematic review

BACKGROUND

Robotic therapy (RT) has been internationally recognized for the motor rehabilitation of the upper limb. Although it seems that RT can stimulate and promote neuroplasticity, the effectiveness of robotics in restoring cognitive deficits has been considered only in a few recent studies.

OBJECTIVE

To verify whether, in the current state of the literature, cognitive measures are used as inclusion or exclusion criteria and/or outcomes measures in robotic upper limb rehabilitation in stroke patients.

METHODS

The systematic review was conducted according to PRISMA guidelines. Studies eligible were identified through PubMed/MEDLINE and Web of Science from inception to March 2021.

RESULTS

Eighty-one studies were considered in this systematic review. Seventy-three studies have at least a cognitive inclusion or exclusion criteria, while only seven studies assessed cognitive outcomes.

CONCLUSION

Despite the high presence of cognitive instruments used for inclusion/exclusion criteria their heterogeneity did not allow the identification of a guideline for the evaluation of patients in different stroke stages. Therefore, although the heterogeneity and the low percentage of studies that included cognitive outcomes, seemed that the latter were positively influenced by RT in post-stroke rehabilitation. Future larger RCTs are needed to outline which cognitive scales are most suitable and their cut-off, as well as what cognitive outcome measures to use in the various stages of post-stroke rehabilitation.

Neurotechnology’s Prospects for Bringing About Meaningful Reductions in Neurological Impairment

Here we report and comment on the magnitudes of post-stroke impairment reduction currently observed using new neurotechnologies. We argue that neurotechnology’s best use case is impairment reduction as this is neither the primary strength nor main goal of conventional rehabilitation, which is better at targeting the activity and participation levels of the ICF. The neurotechnologies discussed here can be divided into those that seek to be adjuncts for enhancing conventional rehabilitation, and those that seek to introduce a novel behavioral intervention altogether. Examples of the former include invasive and non-invasive brain stimulation. Examples of the latter include robotics and some forms of serious gaming. We argue that motor learning and training-related recovery are conceptually and mechanistically distinct. Based on our survey of recent results, we conclude that large reductions in impairment will need to begin with novel forms of high dose and high intensity behavioral intervention that are qualitatively different to conventional rehabilitation. Adjunct forms of neurotechnology, if they are going to be effective, will need to piggyback on these new behavioral interventions.

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

Introduction

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

Aim

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

Method

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

Results

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

Conclusions

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Targeting CNS Neural Mechanisms of Gait in Stroke Neurorehabilitation

The central nervous system (CNS) control of human gait is complex, including descending cortical control, affective ascending neural pathways, interhemispheric communication, whole brain networks of functional connectivity, and neural interactions between the brain and spinal cord. Many important studies were conducted in the past, which administered gait training using externally targeted methods such as treadmill, weight support, over-ground gait coordination training, functional electrical stimulation, bracing, and walking aids. Though the phenomenon of CNS activity-dependent plasticity has served as a basis for more recently developed gait training methods, neurorehabilitation gait training has yet to be precisely focused and quantified according to the CNS source of gait control. Therefore, we offer the following hypotheses to the field: Hypothesis 1. Gait neurorehabilitation after stroke will move forward in important ways if research studies include brain structural and functional characteristics as measures of response to treatment. Hypothesis 2. Individuals with persistent gait dyscoordination after stroke will achieve greater recovery in response to interventions that incorporate the current and emerging knowledge of CNS function by directly engaging CNS plasticity and pairing it with peripherally directed, plasticity-based motor learning interventions. These hypotheses are justified by the increase in the study of neural control of motor function, with emerging research beginning to elucidate neural factors that drive recovery. Some are developing new measures of brain function. A number of groups have developed and are sharing sophisticated, curated databases containing brain images and brain signal data, as well as other types of measures and signal processing methods for data analysis. It will be to the great advantage of stroke survivors if the results of the current state-of-the-art and emerging neural function research can be applied to the development of new gait training interventions.

The Predictive Role of Hand Section of Fugl–Meyer Assessment and Motor Activity Log in Action Research Arm Test in People With Stroke

Background:

Recent findings of clinical studies have demonstrated a significant positive relationship between Fugl–Meyer Assessment of upper extremity score and the action research arm test (ARAT) score in people with stroke. Although the motor activity log (MAL) can assess the self-perception of motor performance, which can affect the performance of the upper limb, the relationship between MAL score and ARAT score still remains unclear. The objective of this study is to quantify the independent contribution of MAL score and FMA-hand score on the ARAT score in people with stroke.

Methods

This is a cross-sectional study. There were a total of 87 subjects (50 males, 37 females; mean age = 61.12 ± 6.88 years, post-stroke duration=6.31 ± 2.84 years) included in this study. Self-perceived performance in using the paretic limb was measured by MAL, including subscale of the amount of usage (MAL-AOU) and quality of movement (MAL-QOM). Functional performance of the upper limb was measured by action research arm test (ARAT). Upper limb motor control of the hand was measured by hand section of Fugl–Meyer assessment (FMA-hand).

Results

The result showed that MAL-QOM (r = 0.648, p < 0.001), MAL-AOU (r = 0.606, p < 0.001), FMA-hand scores (r = 0.663, p < 0.001), and the use of a walking aid (r = −0.422, p < 0.001) were significantly correlated with the ARAT scores. A total 66.9% of the variance in the ARAT scores was predicted by the final regression model including MAL-QOM, MAL-AOU, FMA-hand scores, and walking aid. The FMA-hand score was the best predictor of ARAT scores, which can predict a 36.4% variance of ARAT scores in people with stroke, which controlled the effect of using a walking aid. After controlling for use of a walking aid and FMA-hand scores, the multiple linear regression modeling showed that MAL-QOM and MAL-AOU scores could also independently predict an additional 10.4% of the variance in ARAT scores.

Conclusion

In addition to the FMA-hand score, the MAL score was significantly correlated with the ARAT score. Improving self-perceived performance should be one goal of rehabilitation in people with stroke. Further work developing and testing techniques to do so is clearly warranted.

A focus group study of therapists' views on using a novel neuroanimation virtual reality game to deliver intensive upper-limb rehabilitation early after stroke

Background

Intensive training can significantly reduce upper-limb impairments after stroke but delivering interventions of sufficiently high intensity is extremely difficult in routine practice. The MindPod Dolphin® system is a novel neuroanimation experience which provides motivating and intensive virtual reality based training for the upper-limb. However several studies report that health professionals have reservations about using technology in rehabilitation. Therefore, this study sought to explore the views of therapists who had used this novel neuroanimation therapy (NAT) in a clinical centre to deliver intensive for the upper-limb of people after stroke in a phase 2 trial (SMARTS2).

Methods

Four therapists (three female, two physical and two occupational therapists) who delivered NAT participated in a focus group conducted by two independent researchers. The theoretical domains framework and COM-B behaviour change models informed the discussion schedule for the focus group. An inductive approach to content analysis was used. Recordings were transcribed, coded and thematically analysed. Generated key themes were cross-checked with participants.

Results

Whilst therapists had some initial concerns about using NAT, these were reduced by training, reference materials and face-to-face technical support. Therapists noted several significant benefits to using NAT including multi-system involvement, carry-over to functional tasks and high levels of patient engagement.

Conclusions

These findings illuminate key areas that clinicians, technology developers and researchers should consider when designing, developing and implementing NAT. Specifically, they highlight the importance of planning the implementation of rehabilitation technologies, ensuring technologies are robust and suggest a range of benefits that might be conferred to patients when using intensive NAT as part of rehabilitation for the upper-limb after stroke.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40945-022-00139-0.

Scientific basis and active ingredients of current therapeutic interventions for stroke rehabilitation

Background: Despite tremendous advances in the treatment and management of stroke, restoring motor and functional outcomes after stroke continues to be a major clinical challenge. Given the wide range of approaches used in motor rehabilitation, several commentaries have highlighted the lack of a clear scientific basis for different interventions as one critical factor that has led to suboptimal study outcomes. Objective: To understand the content of current therapeutic interventions in terms of their active ingredients. Methods: We conducted an analysis of randomized controlled trials in stroke rehabilitation over a 2-year period from 2019-2020. Results: There were three primary findings: (i) consistent with prior reports, most studies did not provide an explicit rationale for why the treatment would be expected to work, (ii) most therapeutic interventions mentioned multiple active ingredients and there was not a close correspondence between the active ingredients mentioned versus the active ingredients measured in the study, and (iii) multimodal approaches that involved more than one therapeutic approach tended to be combined in an ad-hoc fashion, indicating the lack of a targeted approach. Conclusion: These results highlight the need for strengthening cross-disciplinary connections between basic science and clinical studies, and the need for structured development and testing of therapeutic approaches to find more effective treatment interventions.

Neuromotor prosthetic to treat stroke-related paresis: N-of-1 trial

Background

Functional recovery of arm movement typically plateaus following a stroke, leaving chronic motor deficits. Brain-computer interfaces (BCI) may be a potential treatment for post-stroke deficits

Methods

In this n-of-1 trial (NCT03913286), a person with chronic subcortical stroke with upper-limb motor impairment used a powered elbow-wrist-hand orthosis that opened and closed the affected hand using cortical activity, recorded from a percutaneous BCI comprised of four microelectrode arrays implanted in the ipsilesional precentral gyrus, based on decoding of spiking patterns and high frequency field potentials generated by imagined hand movements. The system was evaluated in a home setting for 12 weeks

Results

Robust single unit activity, modulating with attempted or imagined movement, was present throughout the precentral gyrus. The participant acquired voluntary control over a hand-orthosis, achieving 10 points on the Action Research Arm Test using the BCI, compared to 0 without any device, and 5 using myoelectric control. Strength, spasticity, the Fugl-Meyer scores improved.

Conclusions

We demonstrate in a human being that ensembles of individual neurons in the cortex overlying a chronic supratentorial, subcortical stroke remain active and engaged in motor representation and planning and can be used to electrically bypass the stroke and promote limb function. The participant’s ability to rapidly acquire control over otherwise paralyzed hand opening, more than 18 months after a stroke, may justify development of a fully implanted movement restoration system to expand the utility of fully implantable BCI to a clinical population that numbers in the tens of millions worldwide.

Stroke is a restriction of blood flow to part of the brain and can lead to chronic issues with a person’s ability to control the limbs. The aim of this study was to see if a new type of device could restore movement in a person with arm weakness due to a stroke that occurred a year earlier. In our trial, a sensor was implanted into the surface of the brain, near the site of the stroke, and was connected to a computer that generated a command to open and close the hand with a motorized brace worn on the hand. This person was able to use their own brain activity to trigger the brace and pick up and move objects. This research could support the development of similar medical devices to restore movement in people who have had strokes.

Serruya et al. test in an N-of-1 trial whether a wearable, powered exoskeletal orthosis, driven by a percutaneous, implanted brain–computer interface can restore voluntary upper extremity function following chronic hemiparesis subsequent to a cerebral subcortical stroke. Using this approach, voluntary opening of the paralyzed hand is restored.

Virtuous and Vicious Cycles of Arm Use and Function Post-stroke

Large doses of movement practice have been shown to restore upper extremities' motor function in a significant subset of individuals post-stroke. However, such large doses are both difficult to implement in the clinic and highly inefficient. In addition, an important reduction in upper extremity function and use is commonly seen following rehabilitation-induced gains, resulting in "rehabilitation in vain". For those with mild to moderate sensorimotor impairment, the limited spontaneous use of the more affected limb during activities of daily living has been previously proposed to cause a decline of motor function, initiating a vicious cycle of recovery, in which non-use and poor performance reinforce each other. Here, we review computational, experimental, and clinical studies that support the view that if arm use is raised above an effective threshold, one enters a virtuous cycle in which arm use and function can reinforce each other via self-practice in the wild. If not, one enters a vicious cycle of declining arm use and function. In turn, and in line with best practice therapy recommendations, this virtuous/vicious cycle model advocates for a paradigm shift in neurorehabilitation whereby rehabilitation be embedded in activities of daily living such that self-practice with the aid of wearable technology that reminds and motivates can enhance paretic limb use of those who possess adequate residual sensorimotor capacity. Altogether, this model points to a user-centered approach to recovery post-stroke that is tailored to the participant's level of arm use and designed to motivate and engage in self-practice through progressive success in accomplishing meaningful activities in the wild.

Myoelectric Arm Orthosis in Motor Learning-Based Therapy for Chronic Deficits After Stroke and Traumatic Brain Injury

Background

Technologies that enhance motor learning-based therapy and are clinically deployable may improve outcome for those with neurological deficits. The MyoPro™ is a customized myoelectric upper extremity orthosis that utilizes volitionally generated weak electromyographic signals from paretic muscles to assist movement of an impaired arm. Our purpose was to evaluate MyoPro as a tool for motor learning-based therapy for individuals with chronic upper limb weakness.

Methods

This was a pilot study of thirteen individuals with chronic moderate/severe arm weakness due to either stroke (n = 7) or TBI (n = 6) who participated in a single group interventional study consisting of 2 phases. The in-clinic phase included 18 sessions (2x per week, 27hrs of face-to-face therapy) plus a home exercise program. The home phase included practice of the home exercise program. The study did not include a control group. Outcomes were collected at baseline and at weeks 3, 5, 7, 9, 12, 15, and 18. Statistics included mixed model regression analysis.

Results

Statistically significant and clinically meaningful improvements were observed on Fugl-Meyer (+7.5 points). Gains were seen at week 3, increased further through the in-clinic phase and were maintained during the home phase. Statistically significant changes in Modified Ashworth Scale, Range of Motion, and Chedoke Arm and Hand Activity Inventory were seen early during the in-clinic phase. Orthotic and Prosthetic User's Survey demonstrated satisfaction with the device throughout study participation. Both stroke and TBI participants responded to the intervention.

Conclusions

Use of MyoPro in motor learning-based therapy resulted in clinically significant gains with a relatively short duration of in-person treatment. Further studies are warranted.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier: NCT03215771.

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

Purpose:

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

Methods:

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

Results and conclusions:

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

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

Feasibility of High Repetition Upper Extremity Rehabilitation for Children with Unilateral Cerebral Palsy

AIMS

In pediatric upper extremity rehabilitation, feasible repetition rates are unknown. Our objectives were to examine repetition rates during rehabilitation and their impact on outcomes.

METHODS

Children with unilateral cerebral palsy due to perinatal stroke (n = 55, median 10 y 7 mo, 30 males) received Constraint-Induced Movement Therapy (CIMT) followed by Bimanual Therapy, each for 5 days. Repetitions were documented during one-on-one therapy (1.5 h/day). Outcomes included the Assisting Hand Assessment (AHA), Jebsen Taylor Test of Hand Function (JTTHF), and Box and Block Test (BBT). Means and standard deviations for motor outcomes and frequencies for repetition rates were calculated. Factors associated with repetition rates and outcome change were explored using standard linear regression.

RESULTS

Repetitions/hour averaged 365 ± 165 during CIMT and 285 ± 103 during Bimanual Therapy. Higher repetition rates were associated with higher baseline function by older age, a main effect of younger age, and improving motor skill (p < .05). Higher repetition rates corresponded with improvement of the AHA and BBT (p < .05, standardized ß = 0.392, 0.358).

CONCLUSIONS

Results suggest high repetition therapy is feasible in school-aged children with perinatal stroke, albeit with high individual variability. Multiple associations between repetition rates and baseline function and change point to the clinical importance of this measurable and potentially modifiable factor.

Video game rehabilitation for outpatient stroke (VIGoROUS): A multi-site randomized controlled trial of in-home, self-managed, upper-extremity therapy

BACKGROUND

Integrating behavioral intervention into motor rehabilitation is essential for improving paretic arm use in daily life. Demands on therapist time limit adoption of behavioral programs like Constraint-Induced Movement (CI) therapy, however. Self-managed motor practice could free therapist time for behavioral intervention, but there remains insufficient evidence of efficacy for a self-management approach.

METHODS

This completed, parallel, five-site, pragmatic, single-blind trial established the comparative effectiveness of using in-home gaming self-management as a vehicle to redirect valuable therapist time towards behavioral intervention. Community-dwelling adults with post-stroke (>6 months) mild/moderate upper extremity hemiparesis were randomized to receive one of 4 different interventions over a 3-week period: 5 h of behaviorally-focused intervention plus gaming self-management (Self-Gaming), the same with additional behaviorally-focused telerehabilitation (Tele-Gaming), 5 h of Traditional motor-focused rehabilitation, or 35 h of CI therapy. Primary outcomes assessed everyday arm use (Motor Activity Log Quality of Movement, MAL) and motor speed/function (Wolf Motor Function Test, WMFT) immediately before treatment, immediately after treatment, and 6 months later. Intent-to-treat analyses were implemented with linear mixed-effects models on data gathered from March 15, 2016 to November 21, 2019. ClinicalTrials.gov, NCT02631850.

RESULTS

Of 193 enrolled participants, 167 began treatment and were analyzed, 150 (90%) completed treatment, and 115 (69%) completed follow-up. Tele-Gaming and Self-Gaming produced clinically meaningful MAL gains that were 1·0 points (95% CI 0·8 to 1·3) and 0·8 points (95% CI 0·5 to 1·0) larger than Traditional care, respectively. Self-Gaming was less effective than CI therapy (-0·4 points, 95% CI -0·6 to -0·2), whereas Tele-Gaming was not (-0·2 points, 95% CI -0·4 to 0·1). Six-month retention of MAL gains across all groups was 57%. All had similar clinically-meaningful WMFT gains; six-month retention of WMFT gains was 92%.

INTERPRETATION

Self-managed motor-gaming with behavioral telehealth visits has outcomes similar to in-clinic CI therapy. It addresses most access barriers, requiring just one-fifth as much therapist time that is redirected towards behavioral interventions that enhance the paretic arm's involvement in daily life.

FUNDING

PCORI, NIH.

Motor learning in neurological rehabilitation

While most upper limb training interventions in neurological rehabilitation are based on established principles of motor learning and neural plasticity, recovery potential may be improved if the focus includes remediating an individual's specific motor impairment within the framework of a motor control theory. This paper reviews current theories of motor control and motor learning and describes how they can be incorporated into training programs to enhance sensorimotor recovery in patients with neurological lesions. An emphasis is placed on dynamical systems theory and the use of new technologies such as virtual, augmented and mixed reality applications for rehabilitation to facilitate learning.Implications for RehabilitationKinematic abundance allows the healthy nervous system to produce different combinations of joint rotations to perform a desired task.The structure of practice to improve the movement repertoire in rehabilitation should take into account the kinematic abundance of the system.Learning can be enhanced by varied practice with feedback about key movement elements.Virtual reality environments provide opportunities to manipulate the structure and schedule of practice and feedback.

The effect of time spent in rehabilitation on activity limitation and impairment after stroke

BACKGROUND

Stroke affects millions of people every year and is a leading cause of disability, resulting in significant financial cost and reduction in quality of life. Rehabilitation after stroke aims to reduce disability by facilitating recovery of impairment, activity, or participation. One aspect of stroke rehabilitation that may affect outcomes is the amount of time spent in rehabilitation, including minutes provided, frequency (i.e. days per week of rehabilitation), and duration (i.e. time period over which rehabilitation is provided). Effect of time spent in rehabilitation after stroke has been explored extensively in the literature, but findings are inconsistent. Previous systematic reviews with meta-analyses have included studies that differ not only in the amount provided, but also type of rehabilitation.

OBJECTIVES

To assess the effect of 1. more time spent in the same type of rehabilitation on activity measures in people with stroke; 2. difference in total rehabilitation time (in minutes) on recovery of activity in people with stroke; and 3. rehabilitation schedule on activity in terms of: a. average time (minutes) per week undergoing rehabilitation, b. frequency (number of sessions per week) of rehabilitation, and c. total duration of rehabilitation.

SEARCH METHODS

We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, eight other databases, and five trials registers to June 2021. We searched reference lists of identified studies, contacted key authors, and undertook reference searching using Web of Science Cited Reference Search.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of adults with stroke that compared different amounts of time spent, greater than zero, in rehabilitation (any non-pharmacological, non-surgical intervention aimed to improve activity after stroke). Studies varied only in the amount of time in rehabilitation between experimental and control conditions. Primary outcome was activities of daily living (ADLs); secondary outcomes were activity measures of upper and lower limbs, motor impairment measures of upper and lower limbs, and serious adverse events (SAE)/death.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies, extracted data, assessed methodological quality using the Cochrane RoB 2 tool, and assessed certainty of the evidence using GRADE. For continuous outcomes using different scales, we calculated pooled standardised mean difference (SMDs) and 95% confidence intervals (CIs). We expressed dichotomous outcomes as risk ratios (RR) with 95% CIs.

MAIN RESULTS

The quantitative synthesis of this review comprised 21 parallel RCTs, involving analysed data from 1412 participants.  Time in rehabilitation varied between studies. Minutes provided per week were 90 to 1288. Days per week of rehabilitation were three to seven. Duration of rehabilitation was two weeks to six months. Thirteen studies provided upper limb rehabilitation, five general rehabilitation, two mobilisation training, and one lower limb training. Sixteen studies examined participants in the first six months following stroke; the remaining five included participants more than six months poststroke. Comparison of stroke severity or level of impairment was limited due to variations in measurement. The risk of bias assessment suggests there were issues with the methodological quality of the included studies. There were 76 outcome-level risk of bias assessments: 15 low risk, 37 some concerns, and 24 high risk. When comparing groups that spent more time versus less time in rehabilitation immediately after intervention, we found no difference in rehabilitation for ADL outcomes (SMD 0.13, 95% CI -0.02 to 0.28; P = 0.09; I2 = 7%; 14 studies, 864 participants; very low-certainty evidence), activity measures of the upper limb (SMD 0.09, 95% CI -0.11 to 0.29; P = 0.36; I2 = 0%; 12 studies, 426 participants; very low-certainty evidence), and activity measures of the lower limb (SMD 0.25, 95% CI -0.03 to 0.53; P = 0.08; I2 = 48%; 5 studies, 425 participants; very low-certainty evidence). We found an effect in favour of more time in rehabilitation for motor impairment measures of the upper limb (SMD 0.32, 95% CI 0.06 to 0.58; P = 0.01; I2 = 10%; 9 studies, 287 participants; low-certainty evidence) and of the lower limb (SMD 0.71, 95% CI 0.15 to 1.28; P = 0.01; 1 study, 51 participants; very low-certainty evidence). There were no intervention-related SAEs. More time in rehabilitation did not affect the risk of SAEs/death (RR 1.20, 95% CI 0.51 to 2.85; P = 0.68; I2 = 0%; 2 studies, 379 participants; low-certainty evidence), but few studies measured these outcomes. Predefined subgroup analyses comparing studies with a larger difference of total time spent in rehabilitation between intervention groups to studies with a smaller difference found greater improvements for studies with a larger difference. This was statistically significant for ADL outcomes (P = 0.02) and activity measures of the upper limb (P = 0.04), but not for activity measures of the lower limb (P = 0.41) or motor impairment measures of the upper limb (P = 0.06).

AUTHORS' CONCLUSIONS

An increase in time spent in the same type of rehabilitation after stroke results in little to no difference in meaningful activities such as activities of daily living and activities of the upper and lower limb but a small benefit in measures of motor impairment (low- to very low-certainty evidence for all findings). If the increase in time spent in rehabilitation exceeds a threshold, this may lead to improved outcomes. There is currently insufficient evidence to recommend a minimum beneficial daily amount in clinical practice. The findings of this study are limited by a lack of studies with a significant contrast in amount of additional rehabilitation provided between control and intervention groups. Large, well-designed, high-quality RCTs that measure time spent in all rehabilitation activities (not just interventional) and provide a large contrast (minimum of 1000 minutes) in amount of rehabilitation between groups would provide further evidence for effect of time spent in rehabilitation.

Developing a Framework for Designing and Deploying Technology-Assisted Rehabilitation After Stroke: A Qualitative Study

OBJECTIVE

Many unmet rehabilitation needs of patients with stroke can be addressed effectively using technology. However, technological solutions have not yet been seamlessly incorporated into clinical care. The purpose of this pilot study was to examine how to bridge the gaps between the recovery process, technology, and clinical practice to impact stroke rehabilitation meaningfully.

DESIGN

Semistructured interviews were performed using a grounded theory approach with purposive sampling of 17 diverse expert providers in acute care, inpatient, and outpatient stroke rehabilitation settings. Common themes were identified from qualitative analyses of the transcribed conversations to develop a guiding framework from the emerging concepts.

RESULTS

Four core themes emerged that addressed major barriers in stroke rehabilitation and technology-assisted solutions to overcome these barriers: (1) accessibility to quality rehabilitation, (2) adaptability to patient differences, (3) accountability or compliance with rehabilitation, and (4) engagement with rehabilitation.

CONCLUSIONS

The results suggest a four-pronged framework, the A3E framework that stands for Accessibility, Adaptability, Accountability, and Engagement, to comprehensively address existing barriers in providing rehabilitation services. This framework can guide technology developers and clinicians in designing and deploying technology-assisted rehabilitation solutions for poststroke rehabilitation, particularly using telerehabilitation.

White matter integrity of contralesional and transcallosal tracts may predict response to upper limb task-specific training in chronic stroke

•

Increase in upper limb function post task specific training in chronic stroke.

•

Motor improvements were not accompanied by changes in white matter integrity.

•

Integrity in contralesional fibers predicted larger motor recovery in Responders.

•

Non-responders had more severe damage of transcallosal fibers than Responders.

Objective

To investigate white matter (WM) plasticity induced by intensive upper limb (UL) task specific training (TST) in chronic stroke.

Methods

Diffusion tensor imaging data and UL function measured by the Action Research Arm Test (ARAT) were collected in 30 individuals with chronic stroke prior to and after intensive TST. ANOVAs tested the effects of training on the entire sample and on the Responders [ΔARAT ≥ 5.8, N = 13] and Non-Responders [ΔARAT < 5.8, N = 17] groups. Baseline fractional anisotropy (FA) values were correlated with ARATpost TST controlling for baseline ARAT and age to identify voxels predictive of response to TST. Results.

While ARAT scores increased following training (p < 0.0001), FA changes within major WM tracts were not significant at p < 0.05. In the Responder group, larger baseline FA of both contralesional (CL) and transcallosal tracts predicted larger ARAT scores post-TST. Subcortical lesions and more severe damage to transcallosal tracts were more pronounced in the Non-Responder than in the Responder group.

Conclusions

The motor improvements post-TST in the Responder group may reflect the engagement of interhemispheric processes not available to the Non-Responder group. Future studies should clarify differences in the role of CL and transcallosal pathways as biomarkers of recovery in response to training for individuals with cortical and subcortical stroke. This knowledge may help to identify sources of heterogeneity in stroke recovery, which is necessary for the development of customized rehabilitation interventions.

Combined real-time fMRI and real time fNIRS brain computer interface (BCI): Training of volitional wrist extension after stroke, a case series pilot study

Objective

Pilot testing of real time functional magnetic resonance imaging (rt-fMRI) and real time functional near infrared spectroscopy (rt-fNIRS) as brain computer interface (BCI) neural feedback systems combined with motor learning for motor recovery in chronic severely impaired stroke survivors.

Approach

We enrolled a four-case series and administered three sequential rt-fMRI and ten rt-fNIRS neural feedback sessions interleaved with motor learning sessions. Measures were: Arm Motor Assessment Tool, functional domain (AMAT-F; 13 complex functional tasks), Fugl-Meyer arm coordination scale (FM); active wrist extension range of motion (ROM); volume of activation (fMRI); and fNIRS HbO concentration. Performance during neural feedback was assessed, in part, using percent successful brain modulations during rt-fNIRS.

Main results

Pre-/post-treatment mean clinically significant improvement in AMAT-F (.49 ± 0.22) and FM (10.0 ± 3.3); active wrist ROM improvement ranged from 20° to 50°. Baseline to follow-up change in brain signal was as follows: fMRI volume of activation was reduced in almost all ROIs for three subjects, and for one subject there was an increase or no change; fNIRS HbO was within normal range, except for one subject who increased beyond normal at post-treatment. During rt-fNIRS neural feedback training, there was successful brain signal modulation (42%–78%).

Significance

Severely impaired stroke survivors successfully engaged in spatially focused BCI systems, rt-fMRI and rt-fNIRS, to clinically significantly improve motor function. At the least, equivalency in motor recovery was demonstrated with prior long-duration motor learning studies (without neural feedback), indicating that no loss of motor improvement resulted from substituting neural feedback sessions for motor learning sessions. Given that the current neural feedback protocol did not prevent the motor improvements observed in other long duration studies, even in the presence of fewer sessions of motor learning in the current work, the results support further study of neural feedback and its potential for recovery of motor function in stroke survivors. In future work, expanding the sophistication of either or both rt-fMRI and rt-fNIRS could hold the potential for further reducing the number of hours of training needed and/or the degree of recovery.

ClinicalTrials.gov ID:NCT02856035.

Enhanced Spontaneous Motor Recovery After Stroke in Mice Treated With Cerebrolysin

BACKGROUND

Motor recovery after stroke in humans and in rodent models is time sensitive. Recovery in patients is a result of biological spontaneous recovery via endogenous repair mechanisms and is likely improved by enhancing the synaptic plasticity required for endogenous repair. Cerebrolysin is a polypeptide preparation known to enhance neuroplasticity and may improve recovery in patients. In mice, we tested the hypothesis that Cerebrolysin can act poststroke to enhance both spontaneous and training-associated motor recovery.

METHODS

Mice were trained to perform a skilled prehension task. We then induced a photothrombotic stroke in the caudal forelimb area, after which we retrained animals on the prehension task in the presence or absence of Cerebrolysin after a 2-day or 8-day delay. Mice received daily intraperitoneal Cerebrolysin or saline injections starting poststroke day 1 or poststroke day 7.

RESULTS

Prior studies showed that poststroke recovery of prehension can occur if animals receive rehabilitative training during an early sensitive period but is incomplete if rehabilitative training is delayed. In contrast, we show complete recovery of prehension, despite a delay in rehabilitative training, when mice receive daily Cerebrolysin administration starting on poststroke day 1 or on poststroke day 8. When Cerebrolysin is given on poststroke day 1, recovery occurred even in the absence of training. Stroke volumes were similar across groups.

CONCLUSIONS

Poststroke Cerebrolysin administration leads to recovery of motor function independent of rehabilitative training without a protective effect on stroke volume. This is one of the first demonstrations of training-independent motor recovery in rodent stroke models.

Neurorehabilitation From a Distance: Can Intelligent Technology Support Decentralized Access to Quality Therapy?

Current neurorehabilitation models primarily rely on extended hospital stays and regular therapy sessions requiring close physical interactions between rehabilitation professionals and patients. The current COVID-19 pandemic has challenged this model, as strict physical distancing rules and a shift in the allocation of hospital resources resulted in many neurological patients not receiving essential therapy. Accordingly, a recent survey revealed that the majority of European healthcare professionals involved in stroke care are concerned that this lack of care will have a noticeable negative impact on functional outcomes. COVID-19 highlights an urgent need to rethink conventional neurorehabilitation and develop alternative approaches to provide high-quality therapy while minimizing hospital stays and visits. Technology-based solutions, such as, robotics bear high potential to enable such a paradigm shift. While robot-assisted therapy is already established in clinics, the future challenge is to enable physically assisted therapy and assessments in a minimally supervized and decentralized manner, ideally at the patient’s home. Key enablers are new rehabilitation devices that are portable, scalable and equipped with clinical intelligence, remote monitoring and coaching capabilities. In this perspective article, we discuss clinical and technological requirements for the development and deployment of minimally supervized, robot-assisted neurorehabilitation technologies in patient’s homes. We elaborate on key principles to ensure feasibility and acceptance, and on how artificial intelligence can be leveraged for embedding clinical knowledge for safe use and personalized therapy adaptation. Such new models are likely to impact neurorehabilitation beyond COVID-19, by providing broad access to sustained, high-quality and high-dose therapy maximizing long-term functional outcomes.

Lost in Translation: Simple Steps in Experimental Design of Neurorehabilitation-Based Research Interventions to Promote Motor Recovery Post-Stroke

Stroke continues to be a leading cause of disability. Basic neurorehabilitation research is necessary to inform the neuropathophysiology of impaired motor control, and to develop targeted interventions with potential to remediate disability post-stroke. Despite knowledge gained from basic research studies, the effectiveness of research-based interventions for reducing motor impairment has been no greater than standard of practice interventions. In this perspective, we offer suggestions for overcoming translational barriers integral to experimental design, to augment traditional protocols, and re-route the rehabilitation trajectory toward recovery and away from compensation. First, we suggest that researchers consider modifying task practice schedules to focus on key aspects of movement quality, while minimizing the appearance of compensatory behaviors. Second, we suggest that researchers supplement primary outcome measures with secondary measures that capture emerging maladaptive compensations at other segments or joints. Third, we offer suggestions about how to maximize participant engagement, self-direction, and motivation, by embedding the task into a meaningful context, a strategy more likely to enable goal-action coupling, associated with improved neuro-motor control and learning. Finally, we remind the reader that motor impairment post-stroke is a multidimensional problem that involves central and peripheral sensorimotor systems, likely influenced by chronicity of stroke. Thus, stroke chronicity should be given special consideration for both participant recruitment and subsequent data analyses. We hope that future research endeavors will consider these suggestions in the design of the next generation of intervention studies in neurorehabilitation, to improve translation of research advances to improved participation and quality of life for stroke survivors.

Towards a Platform for Robot-Assisted Minimally-Supervised Therapy of Hand Function: Design and Pilot Usability Evaluation

Background

Robot-assisted therapy can increase therapy dose after stroke, which is often considered insufficient in clinical practice and after discharge, especially with respect to hand function. Thus far, there has been a focus on rather complex systems that require therapist supervision. To better exploit the potential of robot-assisted therapy, we propose a platform designed for minimal therapist supervision, and present the preliminary evaluation of its immediate usability, one of the main and frequently neglected challenges for real-world application. Such an approach could help increase therapy dose by allowing the training of multiple patients in parallel by a single therapist, as well as independent training in the clinic or at home.

Methods

We implemented design changes on a hand rehabilitation robot, considering aspects relevant to enabling minimally-supervised therapy, such as new physical/graphical user interfaces and two functional therapy exercises to train hand motor coordination, somatosensation and memory. Ten participants with chronic stroke assessed the usability of the platform and reported the perceived workload during a single therapy session with minimal supervision. The ability to independently use the platform was evaluated with a checklist.

Results

Participants were able to independently perform the therapy session after a short familiarization period, requiring assistance in only 13.46 (7.69–19.23)% of the tasks. They assigned good-to-excellent scores on the System Usability Scale to the user-interface and the exercises [85.00 (75.63–86.88) and 73.75 (63.13–83.75) out of 100, respectively]. Nine participants stated that they would use the platform frequently. Perceived workloads lay within desired workload bands. Object grasping with simultaneous control of forearm pronosupination and stiffness discrimination were identified as the most difficult tasks.

Discussion

Our findings demonstrate that a robot-assisted therapy device can be rendered safely and intuitively usable upon first exposure with minimal supervision through compliance with usability and perceived workload requirements. The preliminary usability evaluation identified usability challenges that should be solved to allow real-world minimally-supervised use. Such a platform could complement conventional therapy, allowing to provide increased dose with the available resources, and establish a continuum of care that progressively increases therapy lead of the patient from the clinic to the home.

Comparing a Novel Neuroanimation Experience to Conventional Therapy for High-Dose Intensive Upper-Limb Training in Subacute Stroke: The SMARTS2 Randomized Trial

BACKGROUND

Evidence from animal studies suggests that greater reductions in poststroke motor impairment can be attained with significantly higher doses and intensities of therapy focused on movement quality. These studies also indicate a dose-timing interaction, with more pronounced effects if high-intensity therapy is delivered in the acute/subacute, rather than chronic, poststroke period.

OBJECTIVE

To compare 2 approaches of delivering high-intensity, high-dose upper-limb therapy in patients with subacute stroke: a novel exploratory neuroanimation therapy (NAT) and modified conventional occupational therapy (COT).

METHODS

A total of 24 patients were randomized to NAT or COT and underwent 30 sessions of 60 minutes time-on-task in addition to standard care. The primary outcome was the Fugl-Meyer Upper Extremity motor score (FM-UE). Secondary outcomes included Action Research Arm Test (ARAT), grip strength, Stroke Impact Scale hand domain, and upper-limb kinematics. Outcomes were assessed at baseline, and days 3, 90, and 180 posttraining. Both groups were compared to a matched historical cohort (HC), which received only 30 minutes of upper-limb therapy per day.

RESULTS

There were no significant between-group differences in FM-UE change or any of the secondary outcomes at any timepoint. Both high-dose groups showed greater recovery on the ARAT (7.3 ± 2.9 points; P = .011) but not the FM-UE (1.4 ± 2.6 points; P = .564) when compared with the HC.

CONCLUSIONS

Neuroanimation may offer a new, enjoyable, efficient, and scalable way to deliver high-dose and intensive upper-limb therapy.

Arm-Hand Boost Therapy During Inpatient Stroke Rehabilitation: A Pilot Randomized Controlled Trial

Objective: It was the aim to assess feasibility, safety, and potential efficacy of a new intensive, focused arm-hand BOOST program and to investigate whether there is a difference between early vs. late delivery of the program in the sub-acute phase post stroke. Methods: In this pilot RCT, patients with stroke were randomized to the immediate group (IG): 4 weeks (4 w) BOOST +4 w CONTROL or the delayed group (DG): 4 w CONTROL +4 w BOOST, on top of their usual inpatient care program. The focused arm-hand BOOST program (1 h/day, 5x/week, 4 weeks) consisted of group exercises with focus on scapula-setting, core-stability, manipulation and complex ADL tasks. Additionally, 1 h per week the Armeo®Power (Hocoma AG, Switzerland) was used. The CONTROL intervention comprised a dose-matched program (24 one-hour sessions in 4 w) of lower limb strengthening exercises and general reconditioning. At baseline, after 4 and 8 weeks of training, the Fugl-Meyer assessment upper extremity (FMA-UE), action research arm test (ARAT), and stroke upper limb capacity scale (SULCS) were administered. Results: Eighteen participants (IG: n = 10, DG: n = 8) were included, with a median (IQR) time post stroke of 8.6 weeks (5-12). No adverse events were experienced. After 4 weeks of training, significant between-group differences were found for FMA-UE (p = 0.003) and SULCS (p = 0.033) and a trend for ARAT (p = 0.075) with median (IQR) change scores for the IG of 9 (7-16), 2 (1-3), and 12.5 (1-18), respectively, and for the DG of 0.5 (-3 to 3), 1 (0-1), and 1.5 (-1 to 9), respectively. In the IG, 80% of patients improved beyond the minimal clinical important difference of FMA-UE after 4 weeks, compared to none of the DG patients. Between 4 and 8 weeks of training, patients in the DG tend to show larger improvements when compared to the IG, however, between-group comparisons did not reach significance. Conclusions: Results of this pilot RCT showed that an intensive, specific arm-hand BOOST program, on top of usual care, is feasible and safe in the sub-acute phase post stroke and suggests positive, clinical meaningful effects on upper limb function, especially when delivered in the early sub-acute phase post stroke. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT04584177.

Intense Arm Rehabilitation Therapy Improves the Modified Rankin Scale Score: Association Between Gains in Impairment and Function

OBJECTIVE

To evaluate the effect of intensive rehabilitation on the modified Rankin Scale (mRS), a measure of activities limitation commonly used in acute stroke studies, and to define the specific changes in body structure/function (motor impairment) most related to mRS gains.

METHODS

Patients were enrolled >90 days poststroke. Each was evaluated before and 30 days after a 6-week course of daily rehabilitation targeting the arm. Activity gains, measured using the mRS, were examined and compared to body structure/function gains, measured using the Fugl-Meyer (FM) motor scale. Additional analyses examined whether activity gains were more strongly related to specific body structure/function gains.

RESULTS

At baseline (160 ± 48 days poststroke), patients (n = 77) had median mRS score of 3 (interquartile range, 2-3), decreasing to 2 [2-3] 30 days posttherapy (p < 0.0001). Similarly, the proportion of patients with mRS score ≤2 increased from 46.8% at baseline to 66.2% at 30 days posttherapy (p = 0.015). These findings were accounted for by the mRS score decreasing in 24 (31.2%) patients. Patients with a treatment-related mRS score improvement, compared to those without, had similar overall motor gains (change in total FM score, p = 0.63). In exploratory analysis, improvement in several specific motor impairments, such as finger flexion and wrist circumduction, was significantly associated with higher likelihood of mRS decrease.

CONCLUSIONS

Intensive arm motor therapy is associated with improved mRS in a substantial fraction (31.2%) of patients. Exploratory analysis suggests specific motor impairments that might underlie this finding and may be optimal targets for rehabilitation therapies that aim to reduce activities limitations.

CLINICAL TRIAL

Clinicaltrials.gov identifier: NCT02360488.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that for patients >90 days poststroke with persistent arm motor deficits, intensive arm motor therapy improved mRS in a substantial fraction (31.2%) of patients.

Robot enhanced stroke therapy optimizes rehabilitation (RESTORE): a pilot study

BACKGROUND

Robotic rehabilitation after stroke provides the potential to increase and carefully control dosage of therapy. Only a small number of studies, however, have examined robotic therapy in the first few weeks post-stroke. In this study we designed robotic upper extremity therapy tasks for the bilateral Kinarm Exoskeleton Lab and piloted them in individuals with subacute stroke. Pilot testing was focused mainly on the feasibility of implementing these new tasks, although we recorded a number of standardized outcome measures before and after training.

METHODS

Our team developed 9 robotic therapy tasks to incorporate feedback, intensity, challenge, and subject engagement as well as addressing both unimanual and bimanual arm activities. Subacute stroke participants were assigned to a robotic therapy (N = 9) or control group (N = 10) in a matched-group manner. The robotic therapy group completed 1-h of robotic therapy per day for 10 days in addition to standard therapy. The control group participated only in standard of care therapy. Clinical and robotic assessments were completed prior to and following the intervention. Clinical assessments included the Fugl-Meyer Assessment of Upper Extremity (FMA UE), Action Research Arm Test (ARAT) and Functional Independence Measure (FIM). Robotic assessments of upper limb sensorimotor function included a Visually Guided Reaching task and an Arm Position Matching task, among others. Paired sample t-tests were used to compare initial and final robotic therapy scores as well as pre- and post-clinical and robotic assessments.

RESULTS

Participants with subacute stroke (39.8 days post-stroke) completed the pilot study. Minimal adverse events occurred during the intervention and adding 1 h of robotic therapy was feasible. Clinical and robotic scores did not significantly differ between groups at baseline. Scores on the FMA UE, ARAT, FIM, and Visually Guided Reaching improved significantly in the robotic therapy group following completion of the robotic intervention. However, only FIM and Arm Position Match improved over the same time in the control group.

CONCLUSIONS

The Kinarm therapy tasks have the potential to improve outcomes in subacute stroke. Future studies are necessary to quantify the benefits of this robot-based therapy in a larger cohort.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04201613, Registered 17 December 2019-Retrospectively Registered, https://clinicaltrials.gov/ct2/show/NCT04201613 .