Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery

Artificial intelligence in stroke rehabilitation: From acute care to long-term recovery

Stroke is a leading cause of disability worldwide, driving the need for advanced rehabilitation strategies. The integration of Artificial Intelligence (AI) into stroke rehabilitation presents significant advancements across the continuum of care, from acute diagnosis to long-term recovery. This review explores AI's role in stroke rehabilitation, highlighting its impact on early diagnosis, motor recovery, and cognitive rehabilitation. AI-driven imaging techniques, such as deep learning applied to CT and MRI scans, improve early diagnosis and identify ischemic penumbra, enabling timely, personalized interventions. AI-assisted decision support systems optimize acute stroke treatment, including thrombolysis and endovascular therapy. In motor rehabilitation, AI-powered robotics and exoskeletons provide precise, adaptive assistance, while AI-augmented Virtual and Augmented Reality environments offer immersive, tailored recovery experiences. Brain-Computer Interfaces utilize AI for neurorehabilitation through neural signal processing, supporting motor recovery. Machine learning models predict functional recovery outcomes and dynamically adjust therapy intensities. Wearable technologies equipped with AI enable continuous monitoring and real-time feedback, facilitating home-based rehabilitation. AI-driven tele-rehabilitation platforms overcome geographic barriers by enabling remote assessment and intervention. The review also addresses the ethical, legal, and regulatory challenges associated with AI implementation, including data privacy and technical integration. Future research directions emphasize the transformative potential of AI in stroke rehabilitation, with case studies and clinical trials illustrating the practical benefits and efficacy of AI technologies in improving patient recovery.

Additional Effects of Facilitatory Cerebellar Repetitive Transcranial Magnetic Stimulation on Inhibitory Repetitive Transcranial Magnetic Stimulation over the Unaffected Contralesional Primary Motor Cortex for Motor Recovery in Subacute Ischemic Stroke Patients

Background/Objectives: Cerebellum might be one of the targets of repetitive transcranial magnetic stimulation (rTMS) for motor recovery in stroke patients. The aim of this study was to investigate the enhancing effects of rTMS over the cerebellum on inhibitory rTMS for motor recovery in patients with subacute ischemic stroke. Methods: Twenty-three patients with subacute ischemic stroke were recruited into this single-blind randomized, controlled study with a blinded observer. The Cr-Cbll group received Cr-Cbll rTMS consisting of continuous theta burst stimulation over the contralesional primary motor cortex (M1), a shoulder mobilization exercise, and high-frequency rTMS over the contralesional cerebellum. The Cr-sham group received sham rTMS over the cerebellum instead of high-frequency rTMS. All participants received ten daily sessions for 2 weeks. The Fugl-Meyer Assessment (FMA) was measured before, immediately after, and 2 months after the intervention. Results: A total of 20 participants (10 in the Cr-Cbll group and 10 in the Cr-sham group) who completed the two-week intervention were included in the intention-to-treat analysis. There was no significant difference in general and clinical characteristics between the two groups at baseline. Total and upper extremity scores of FMA showed a significant interaction between time and group (p < 0.05). Each improvement of upper extremity score of FMA immediately and 2 months after the intervention was significantly higher in the Cr-Cbll group than in the Cr-sham group (p < 0.05). Conclusions: These results demonstrated that rTMS over the cerebellum could have additional effects on inhibitory rTMS over contralesional M1 for improving upper extremity motor function in patients with subacute ischemic stroke.

Wrist Function Test and Its Use to Assess Treatment Efficacy in Ischemic Stroke Survivors-A Pilot Study

Stroke is a major health issue causing high mortality and disability rates. Around 80% of stroke survivors experience impaired upper limb function, which is typically evaluated clinically. Functional electrical stimulation (FES) may help in motor function recovery. This study aimed to create an objective test of wrist flexion and extension functions and to assess the use of such a test in evaluating the efficacy of conventional rehabilitation therapy, alone and in combination with FES, in patients with a paretic upper limb. Background/Objectives: A total of 55 subjects were involved: 15 healthy volunteers and 40 post-stroke patients. The patients were split into two groups: one receiving only conventional rehabilitation (control group) and another receiving both conventional and FES therapies (FES group). Methods: Inertial sensors measured wrist flexion and extension parameters before and after the study treatment. Results: Both groups showed improvement based on the ARAT and FMA-UE scales. Normative values were established in the healthy group, revealing interhemispheric asymmetry. The wrist motion amplitudes and phases in both patient groups differed significantly from the healthy group. Initially, the paretic side had a 40-degree reduction compared to healthy subjects, while the non-paretic side showed a 10-17-degree decrease. After treatment, the FES group demonstrated a 4-10-degree increase in the wrist motion amplitude on the paretic side. The phase parameters did not change significantly in either group. Conclusions: The developed wrist flexion-extension test was shown to be objective and sensitive. The FES treatment improved the movement amplitude, although it did not alter the temporal structure of motion in both patient groups.

Clinical Application Research on Stroke Situational Intelligent Rehabilitation Training System Based on Wearable Devices: A Randomized Controlled Trial

Background/Objectives: With the advancement of intelligent sensing technology, rehabilitation systems based on wearable devices have a positive impact on the functional recovery and quality of life of stroke patients. This study aims to evaluate the application value of a contextualized intelligent rehabilitation training system for stroke survivors, which is based on wearable devices, in the rehabilitation of motor function impairments following stroke. Methods: A randomized controlled trial design was employed, in which 100 stroke patients were randomly divided into a control group (n = 50, receiving standard physical therapy rehabilitation interventions) and an experimental group (n = 50). The experimental group additionally underwent motor function rehabilitation interventions and intelligent assessments through a wearable device-based contextual intelligent rehabilitation training system, with sessions conducted twice daily for 30 min each, five days a week, over a duration of eight weeks. Both groups of patients underwent clinical scale evaluations and data collection before and after the treatment, with primary outcome measures including motor ability (Fugl-Meyer Assessment, FMA), activities of daily living (Modified Barthel Index, MBI), and participation in rehabilitation therapy. The intervention effects of both groups were compared after eight weeks of rehabilitation. Results: Prior to the intervention, there were no significant differences in Fugl-Meyer Assessment (FMA) and Modified Barthel Index (MBI) scores between the experimental group and the control group (p > 0.05). After eight weeks of rehabilitation, the experimental group demonstrated significantly superior performance in motor function (FMA scores) and activities of daily living (MBI scores) compared to the control group (p < 0.01). Conclusions: The intelligent rehabilitation system significantly enhances motor function and activities of daily living in stroke survivors. Compared to traditional rehabilitation methods, it improves patient adherence to rehabilitation training and overall outcomes.

Combined effects and timing of robotic training and botulinum toxin on upper limb spasticity and motor function: a single‑blinded randomized controlled pilot study

BACKGROUND

This study aimed to evaluate the combined effects of robotic training (RT) and botulinum toxin (BTX) injections on motor function and spasticity in individuals with post-stroke upper limb spasticity (ULS). We also sought to investigate the optimal timing of RT and BTX administration.

METHODS

Forty-two participants with chronic stroke-induced ULS were initially enrolled and randomized into four groups: Group B4R4 (RT + BTX at 4 weeks [W4]), Group B0R0 (RT + BTX at baseline [W0]), Group B0R4 (BTX at W0, RT at W4), and Group B4R0 (RT at W0, BTX at W4). Clinical assessments and robotic kinematic evaluations were performed at W0, W4, and 8 weeks (W8). The primary outcome was the Fugl-Meyer assessment (FMA) score, and secondary outcomes included the modified Ashworth scale (MAS) of the elbow and kinematic parameters, such as spectral arc length, mean speed, hand path ratio, and movement deviation in various tasks. Changes in outcome measures over time were analyzed using a linear mixed-effects regression model or ordinal logistic regression.

RESULTS

Of the 42 participants, 40 completed the study. From W0 to W4, Group B0R0 exhibited the most favorable outcomes in terms of spasticity (MAS-elbow flexor and extensor) and kinematic variables, suggesting that the combined application of BTX and RT is superior to sole interventions in improving motor function and spasticity. From W0 to W8, Group B0R4 demonstrated the most substantial improvements in FMA scores and kinematic parameters, indicating that the combined use of BTX and RT, particularly when RT is initiated 1 month after BTX injection, results in superior functional outcomes compared to other intervention timings.

CONCLUSIONS

The combination of RT and BTX is more effective in enhancing motor function and reducing spasticity in individuals with ULS than either intervention alone or no intervention. Furthermore, the timing of RT relative to BTX injection plays a critical role in maximizing therapeutic benefits in individuals with stroke and ULS, given the distinct modes of action of each intervention.

TRIAL REGISTRATION

clinicaltrials.gov NCT02228863. The study was retrospectively registered on August 23, 2014.

Augmented Effect of Combined Robotic Assisted Gait Training and Proprioceptive Neuromuscular Facilitation-irradiation Technique on Muscle Activation and Ankle Kinematics in Hemiparetic Gait: A Preliminary Study

BackgroundProprioceptive neuromuscular facilitation (PNF) alone has limited effectiveness in restoring gait, while robotic-assisted gait training (RAGT) improves motor relearning through repetitive, task-specific movements. Combining PNF with robotic gait training (PRGT) may enhance locomotor recovery by promoting proprioceptive awareness and muscle activation alongside repetitive gait retraining in stroke patients.ObjectiveThis study compares the immediate effects of PRGT and RAGT on ankle dorsiflexion and muscle activity in chronic hemiparetic stroke patients and healthy controls.MethodsThirty participants, including 15 stroke patients and 15 healthy controls, were randomly assigned to PRGT or RAGT for a single 30-min session. Muscle activity (pectoralis major, external oblique, internal oblique/transverse abdominis, rectus femoris, tibialis anterior) was measured using electromyography, while ankle dorsiflexion angle was assessed using a dual-axis inclinometer.ResultsPRGT significantly increased muscle activations compared to RAGT in stroke patients (p < 0.05). Additionally, there was a significant difference in ankle dorsiflexion between RAGT and PRGT in both groups (p < 0.05).ConclusionPRGT demonstrated superior immediate effects on muscle activation and ankle movement, suggesting that combining PNF with robotic-assisted gait training is beneficial for chronic stroke rehabilitation.

Effect of visual biofeedback on fine motor function and activity daily of life in stroke patients: A pilot study

INTRODUCTION

Many stroke patients suffer from dysfunction in their upper limbs, which can lead to difficulties in performing activities of daily living (ADL) as well as social and work interactions. This is particularly true for patients whose dominant side has been affected. The aim of the current study was to explore how effective visual biofeedback could improve fine motor function in the hand and ADL for people suffering from a stroke.

METHODS

Ten individuals who had experienced a stroke with aged from 60 to 74 years old (mean: 64.3 years) were randomly divided into two groups. Patients in study group (n: 5) received 15 sessions of visual biofeedback therapy along with routine occupational therapy. Control group (n: 5) received only routine occupational therapy. Fine motor function was measured by Fugl Meyer Scale (FMS), box and block test (BBT), and Purdue pegboard test (PPBT). Also, ADL was measured by functional independence measure (FIM). These clinical outcomes were evaluated before, after, and 1.5 months following the interventions.

RESULTS

The results showed that the study group experienced a significant increase in fine motor function after receiving visual biofeedback, compared to the control group. The ADL also improved in both the study and control groups after the intervention, but there was no significant difference between the two groups during the intervention and follow-up stages for ADL.

CONCLUSION

It seems that combining biofeedback with routine occupational therapy could be a promising method to enhance fine motor function in individuals with stroke.

The Turkish Version of the Revised Nottingham Sensory Assessment: Validity and Reliability in Chronic Stroke Survivors

BACKGROUND

Evaluation of sensory functions in chronic stroke survivors is essential to plan and implement effective treatment and rehabilitation.

OBJECTIVE

To investigate the validity and reliability of the Turkish version of the Revised Nottingham Sensory Assessment (rNSA-T) in chronic stroke survivors.

METHODS

We applied the World Health Organization's translation protocols to develop the rNAS-T. We then tested its validity and reliability in 85 chronic stroke survivors using criterion validity and consistency for demographic variables, as well as test-retest and inter-rater reliability analyses.

RESULTS

The criterion validity of the rNSA-T was supported by significant correlation between participants' scores on the rNSA-T, the Katz Index of Independence in Activities of Daily Living (Katz-AD) ( r = 0.430-0.674, P < 0.05), and the Rivermead Motor Assessment (RMA) ( r = 0.528-0.773, P < 0.05). rNSA-T results remained consistent across variables of sex and side affected by stroke ( P > 0.05). The test-retest reliability of the rNSA-T was excellent in all subdimensions (ICC = 0.865-1.000), as was the inter-rater reliability (κ = 0.875-1.000).

CONCLUSION

The rNSA-T is a valid and reliable tool for evaluation of sensory functions in chronic stroke survivors.

Test-retest reliability and responsiveness of an adapted version of the ABILHAND questionnaire to assess performance in bimanual daily life activities in stroke patients in sub-Saharan Africa

The ABILHAND is a widely used questionnaire assessing bimanual daily life activities in adults with stroke. A recently modified version tailored for the sub-Saharan African population (ABILHAND-Stroke Benin) has been created. This study aimed to investigate its test-retest reliability and responsiveness. The study included 132 adults with stroke with a mean (SD) age = 54.6 (11.2) years and 40% women. The mean (SD) time since stroke was 15.2 (12) months for the subsample ( n  = 51) included in the reliability analysis and 1 (0.6) month for the subsample ( n  = 81) of the responsiveness analysis. Participants were assessed within a week interval with the ABILHAND-Stroke Benin questionnaire for the reliability analysis. As for the responsiveness analysis, they were additionally assessed with the ACTIVLIM-Stroke questionnaire, the Box and Block Test (BBT), and the Stroke Impairment Assessment Set, at baseline (T1), 2-month later (T2), and on average of 1.5 (0.5) years after stroke (T3). The ABILHAND-Stroke Benin questionnaire showed an excellent test-retest reliability (intraclass correlation coefficient = 0.98, P  < 0.001, minimal detectable change = 10.3%). Regarding the responsiveness analysis, participants showed a larger improvement during the acute phase (T1-T2) compared with the chronic phase (T2-T3). Changes with the ABILHAND-Stroke Benin questionnaire were significantly correlated with changes with the other outcome measures (correlations ranged from 0.36 to 0.70, P  < 0.05) except with the BBT less affected hand. The ABILHAND-Stroke Benin questionnaire demonstrates an excellent test-retest reliability and was responsive to changes in adults with stroke.

The Impact of Visualization on Stroke Rehabilitation in Adults: A Systematic Review of Randomized Controlled Trials on Guided and Motor Imagery

Background/Objectives: Guided imagery techniques, which include mentally picturing motions or activities to help motor recovery, are an important part of neuroplasticity-based motor therapy in stroke patients. Motor imagery (MI) is a kind of guided imagery in neurorehabilitation that focuses on mentally rehearsing certain motor actions in order to improve performance. This systematic review aims to evaluate the current evidence on guided imagery techniques and identify their therapeutic potential in stroke motor rehabilitation. Methods: Randomized controlled trials (RCTs) published in the English language were identified from an online search of PubMed, Web of Science, Embase, EBSCOhost, and Scopus databases without a specific search time frame. The inclusion criteria take into account guided imagery interventions and evaluate their impact on motor recovery through validated clinical, neurophysiological, or functional assessments. This review has been registered on Open OSF with the following number: DOI 10.17605/OSF.IO/3D7MF. Results: This review synthesized 41 RCTs on MI in stroke rehabilitation, with 996 participants in the intervention group and 757 in the control group (average age 50-70, 35% female). MI showed advantages for gait, balance, and upper limb function; however, the RoB 2 evaluation revealed 'some concerns' related to allocation concealment, blinding, and selective reporting issues. Integrating MI with gait training or action observation (AO) seems to improve motor recovery, especially in balance and walking. Technological methods like brain-computer interfaces (BCIs) and hybrid models that combine MI with circuit training hold potential for enhancing functional mobility and motor results. Conclusions: Guided imagery shows promise as a beneficial adjunct in stroke rehabilitation, with the potential to improve motor recovery across several domains such as gait, upper limb function, and balance.

Design and usability evaluation of an immersive virtual reality mirrored hand system for upper limb stroke rehabilitation

This study aimed to develop an immersive virtual reality (VR) mirrored-hand system with real-life activities designed for the upper limb rehabilitation of people with stroke and to evaluate its clinical usability and feasibility. This VR mirrored-hand system was developed using Blender and Unity software on a MacOS Apple Silicon platform. Fifteen individuals with stroke were recruited to evaluate the system's clinical usability and feasibility using the system usability scale (SUS), a self-designed user feedback questionnaire, and the virtual reality sickness questionnaire (VRSQ). The immersive VR mirrored-hand system, featuring 3D virtual environments simulating the real-life activities of cooking, driving, shopping, and housework, was successfully developed. Participants reported average scores of 56.67 (out of 100) on the SUS, 36.93 (out of 50) on the self-designed user feedback questionnaire, and 6.28 (out of 100) on the VRSQ. These scores suggest moderately acceptable levels of clinical usability and feasibility, with minimal incidence of motion sickness during the VR headset use. The VR mirrored-hand system, demonstrating moderately acceptable clinical usability and feasibility, shows promise for clinical application in post-stroke upper limb rehabilitation. Further research is warranted to explore its therapeutic effects on upper-limb motor function and daily activities in people with stroke.

Cervical spinal cord stimulation for treatment of upper limb paralysis: a narrative review

Recent advances in cervical spinal cord stimulation (SCS) have demonstrated improved efficacy as a therapeutic intervention for restoring hand functions in individuals with spinal cord injuries or stroke. Accumulating evidence consistently shows that cervical SCS yields significant improvements in grip force, proximal arm strength and muscle activation, with both immediate and sustained effects. This review synthesizes the evidence that electrical stimulations modulate the spinal and supraspinal organization of uninjured descending motor tracts, primarily the residual corticospinal tract, reticulospinal tract and propriospinal network of neurons, as well as increasing the sensitivity of spinal interneurons at the stimulated segments to these inputs. Additionally, we examine contemporary strategies aimed at achieving more precise patterned stimulations, including intraspinal microstimulation, ventral cord stimulation and closed-loop neuromodulation, and discuss the potential benefits of incorporating cervical SCS into a multimodal treatment paradigm.Level of evidence: V.

Dance harnesses humanity in exercise: perceptions of dance following an adapted dance program for people with chronic stroke

INTRODUCTION

Perceptions of exercise are important in ensuring physical activity is translated into daily life. If dance is perceived as enjoyable exercise, promoting it may increase exercise engagement in people with stroke.

OBJECTIVE

To examine perceptions of dance as exercise in people with chronic stroke after participating in an adapted dance program.

MATERIALS AND METHODS

Qualitative interpretive description approach utilizing semi-structured face to face interviews with 18 people post-stroke who completed a 10-week adapted dance program.

RESULTS

Three themes were identified: (1) Dance is Exercise; (2) Dance Moves Beyond Exercise; and (3) Dance Harnesses Humanity in Exercise.

DISCUSSION

According to participants in this study, dance offers elements of traditional physical rehabilitation (i.e. improved balance) and creates a humanistic space where more intangible elements (i.e. liberation, personal growth) are accessed organically. These findings illuminate dance as a holistic approach to rehabilitation, as it addresses both the physical and psychosocial impacts of stroke.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

Descriptive retrospective cross-sectional study of rehabilitation care for poststroke users in Québec during the COVID-19 pandemic

OBJECTIVES

During the COVID-19 pandemic, designated rehabilitation centres were established in the province of Québec, where strict sociosanitary measures such as isolation and mandatory personal protection equipment requirements were followed. This study aimed to describe the impact of the pandemic on rehabilitation care indicators for poststroke users with (COV+) and without (COV-) COVID-19 infection in designated rehabilitation centres compared with those admitted in the previous year (pre-COV).

METHOD

A retrospective analysis of 292 medical files was performed in 3 rehabilitation centres. Demographic characteristics were collected, as well as indicators routinely collected in acute care and rehabilitation such as length of stay (LOS), the Functional Independence Measure and a number of physical/occupational therapy (PT/OT) sessions. Non-parametric statistical tests were used to compare variables among the three groups.

RESULTS

COV+ users were older than COV- and pre-COV ones (p<0.01) and were more disabled on admission to a rehabilitation centre (p<0.01). They also exhibited longer LOS in acute care prior to rehabilitation (p<0.001) and were more often rehospitalised (p<0.002) during the course of their stay in the rehabilitation centre. Despite longer rehabilitation stays (p<0.001) and more PT/OT sessions, COV+ users remained more disabled at discharge (p<0.002). COV- users showed rehabilitation care indicators resembling the ones of pre-COV despite spending less time in rehabilitation.

CONCLUSIONS

Patients who had a stroke infected with COVID-19 exhibited greater vulnerability on admission to rehabilitation. They required more care and services during their rehabilitation period. However, this additional support did not enable them to achieve the same level of recovery as COV- and pre-COV users. This underscores the added impact of the disease on already impaired patients and highlights the specific needs of COV+ users undergoing rehabilitation.

Association between Undernutrition at Admission and Improvement in Balance Function Post-stroke

Introduction

The prognosis for activities of daily living (ADL) ability after stroke is negatively influenced by undernutrition and impaired balance. However, the association between undernutrition and balance improvement has not yet been elucidated. This study aimed to investigate the influence of undernutrition on balance function improvement in patients with stroke.

Methods

This retrospective observational study included patients with cerebral infarction aged ≥65 years. The study period was from May 2018 to May 2022. The patients were divided into undernutrition and intact nutrition groups according to the Global Leadership Initiative on Malnutrition criteria. The primary outcome was the change in the Berg Balance Scale (BBS) score (BBS score at discharge - BBS score at admission).

Results

This study included 304 patients (mean age, 79.2 ± 8.1 years; 173 men and 131 women). These patients were divided into the undernutrition (N = 114) and intact nutrition (N = 190) groups. The undernutrition group demonstrated lower BBS scores at admission (16.0 ± 17.1 vs. 28.3 ± 18.4, p < 0.001) and at discharge (24.2 ± 19.6 vs. 40.0 ± 16.9, p < 0.001) than the intact nutrition group. After adjusting for confounding factors, undernutrition was associated with a smaller change in the BBS score (coefficient = -2.988, 95% confidence interval = -5.481 to -0.495, p = 0.019).

Conclusions

Undernutrition negatively influences balance function recovery in post-stroke patients. A strategy aimed at improving nutritional status could have beneficial effects on patients' balance function.

Exploring New Tools in Upper Limb Rehabilitation After Stroke Using an Exoskeletal Aid: A Pilot Randomized Control Study

BACKGROUND/OBJECTIVES

Spasticity commonly occurs in individuals after experiencing a stroke, impairing their hand function and limiting activities of daily living (ADLs). In this paper, we introduce an exoskeletal aid, combined with a set of augmented reality (AR) games consisting of the Rehabotics rehabilitation solution, designed for individuals with upper limb spasticity following stroke.

METHODS

Our study, involving 60 post-stroke patients (mean ± SD age: 70.97  ±  4.89 years), demonstrates significant improvements in Ashworth Scale (AS) scores and Box and Block test (BBT) scores when the Rehabotics solution is employed.

RESULTS

The intervention group showed slightly greater improvement compared to the control group in terms of the AS (-0.23, with a confidence interval of -0.53 to 0.07) and BBT (1.67, with a confidence interval of 1.18 to 2.16). Additionally, the Rehabotics solution was particularly effective for patients with more severe deficits. Patients with an AS score of 3 showed more substantial improvements, with their AS scores increasing by -1.17 ± 0.39 and BBT scores increasing by -4.83 ± 0.72.

CONCLUSIONS

These findings underscore the potential of wearable hand robotics in enhancing stroke survivors' hand rehabilitation, emphasizing the need for further investigations into its broader applications.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effects of mirror therapy on upper limb motor function of patients with stroke: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

This study aimed to investigate and review the effects of mirror therapy on upper limb function, including improvements in shoulder, elbow, forearm, wrist, and hand function, as well as coordination between the upper extremities, in patients with stroke.

DATA SOURCES

Six databases, CINAHL Plus with Full Text, Cochrane Central Register of Controlled Trials, Embase, Medline Complete, PubMed, and Web of Science, were searched from database inception to 15 October 2024, as well as manual searching of Google Scholar, for relevant trials.

REVIEW METHODS

The methodological quality of the trials was assessed using version 2 of the Cochrane risk-of-bias tool with five domains. A random-effects model was applied to calculate the pooled mean difference of dichotomous variables using the 95% confidence interval. The variance in effect estimation in a forest plot for each trial was then quantified using I2.

RESULTS

Eighteen studies, representing 633 patients with stroke, were included in this study. Mirror therapy significantly improved upper limb motor function (mean difference [MD] = 1.79; 95% CI = 0.04-3.54; p = 0.04) and hand function (MD = 1.48; 95% CI = 0.17-2.78; p = 0.03) in patients with stroke. Subgroup analyses of overall upper limb function showed that mirror therapy was effective in improving function when delivered more than 5 times a week (MD = 2.75; 95% CI = 1.02-4.48) over a period of ≤ 4 weeks (MD = 3.26; 95% CI = 1.19-5.33). The results of the methodology assessment using RoB-2 on all the trials included in the analysis showed that 16 trials were considered to have some concerns.

CONCLUSION

Mirror therapy appears to be beneficial for improving upper limb motor function after stroke. More trials are needed to determine the effects of mirror therapy on shoulder/elbow/forearm, wrist, and hand function and coordination between upper extremities after stroke.

Effect of a Multicomponent Exercise Intervention on Recovery of Walking Ability in Stroke Survivors: A Systematic Review With Meta-analysis

OBJECTIVE

To evaluate whether multicomponent exercise (MCE) is more effective than single exercise in improving walking ability in patients with stroke.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

A systematic search of PubMed, Embase, Web of Science, Cochrane Library, and CINAHL from the establishment of each database to February 2024 was performed. A combination of medical subject headings and free-text terms relating to stroke and exercise were searched.

STUDY SELECTION

Randomized controlled trials treating stroke survivors with MCE were included. The control groups received conventional treatments such as conventional treatment or no intervention or sham training; the experimental groups received MCE. The outcome measures were walking endurance, gait speed, and balance ability.

DATA EXTRACTION

The data extraction form was completed by 2 independent reviewers. The risk of bias was assessed using the Cochrane Risk of Bias Tool for randomized controlled trials. Review manager 5.4 software was used for data analysis. Subgroup analysis and sensitivity analysis were used to supplement the results with higher heterogeneity. The preferred reporting project for systematic reviews and meta-analyses 2020 guidelines were followed.

DATA SYNTHESIS

Twelve studies were included. Meta-analyses found that compared with the control group, the MCE significantly affected gait speed (mean difference=0.11; 95% CI, 0.06-0.16; I2=0%), but the effect on balance ability was not statistically significant. Subgroup analysis showed that MCE (≥60min) was effective in improving walking endurance. These results suggest that MCE improves walking endurance and walking speed in patients with stroke.

CONCLUSIONS

MCE helps improve the gait speed of stroke survivors. Prolonging the MCE time may have a better effect on improving the walking endurance of patients with stroke.

Breaking Barriers in Stroke Therapy: Recent Advances and Ongoing Challenges

Acute ischemic stroke remains a significant global health challenge, prompting notable advancements in its management. Diagnostic innovations, including advanced imaging techniques and biomarker discovery, have greatly improved early detection and treatment precision. Mobile stroke units have expedited pre-hospital care, emphasizing the urgency of intervention under the principle "time is brain." These developments underscore the importance of timely and accurate diagnosis in improving outcomes. Therapeutic breakthroughs in thrombolytic therapy and mechanical thrombectomy have transformed acute stroke treatment. Refined thrombolytic protocols, new agents, and extended treatment windows have expanded therapeutic possibilities. Mechanical thrombectomy, bolstered by improved devices and techniques, has achieved higher recanalization rates and broader applicability, solidifying its role in endovascular interventions. Meanwhile, post-stroke care has embraced personalized, multidisciplinary rehabilitation approaches, with telemedicine breaking geographical barriers and enhancing recovery through patient-centered models. Despite these advancements, challenges persist, including disparities in access to advanced care and the underexplored management of minor strokes. Emerging technologies, such as artificial intelligence and machine learning, offer opportunities for better risk prediction and earlier interventions, though their long-term impacts require further study. This review highlights the transformative progress in stroke care while emphasizing the need for continued innovation, research, and equitable access to ensure better outcomes for all patients.

Psychological Interventions to Improve Upper Limb Motor Dysfunction Post-stroke: A Scoping Review

Cognitive strategies in post-stroke patients significantly influence upper limb motor function recovery. Integrating upper extremity and psychological interventions may enhance rehabilitation outcomes. This scoping review aimed to summarize studies evaluating the effectiveness of combining these approaches to improve upper extremity motor dysfunction in patients with post-stroke syndrome. Randomized controlled trials (RCTs) comparing combined upper extremity and psychological interventions versus upper extremity interventions alone were included. Studies published between November 25, 2024, and the study's conclusion were retrieved from PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Physiotherapy Evidence Database (PEDro), and Cumulative Index to Nursing and Allied Health Literature. Only English-language studies were reviewed. Three RCTs met the inclusion criteria. Two studies utilized cognitive orientation to daily occupational performance (CO-OP), while one employed cognitive-oriented strategy training augmented rehabilitation (COSTAR). The CO-OP studies demonstrated that combined psychological and physical interventions significantly improved motor function compared to physical interventions alone. However, the COSTAR-based study reported greater efficacy for upper extremity interventions alone. This review highlighted the mixed efficacy of combined interventions. While CO-OP showed potential benefits, the COSTAR findings suggest variability in the effectiveness of different cognitive strategies. Both approaches prioritized activity and goal setting rather than directly targeting motor recovery. Although the findings are inconclusive, this is the first review to explore the role of combined psychological and upper extremity interventions for post-stroke motor dysfunction, providing a foundation for further research.

IpsiHand Brain-Computer Interface Therapy Induces Broad Upper Extremity Motor Rehabilitation in Chronic Stroke

BACKGROUND

Chronic hemiparetic stroke patients have very limited benefits from current therapies. Brain-computer interface (BCI) engaging the unaffected hemisphere has emerged as a promising novel therapeutic approach for chronic stroke rehabilitation.

OBJECTIVES

This study investigated the effectiveness of contralesionally-controlled BCI therapy in chronic stroke patients with impaired upper extremity motor function. We further explored neurophysiological features of motor recovery driven by BCI. We hypothesized that BCI therapy would induce a broad motor recovery in the upper extremity, and there would be corresponding changes in baseline theta and gamma oscillations, which have been shown to be associated with motor recovery.

METHODS

Twenty-six prospectively enrolled chronic hemiparetic stroke patients performed a therapeutic BCI task for 12 weeks. Motor function assessment data and resting state electroencephalogram signals were acquired before initiating BCI therapy and across BCI therapy sessions. The Upper Extremity Fugl-Meyer assessment served as a primary motor outcome assessment tool. Theta-gamma cross-frequency coupling (CFC) was computed and correlated with motor recovery.

RESULTS

Chronic stroke patients achieved significant motor improvement in both proximal and distal upper extremity with BCI therapy. Motor function improvement was independent of Botox application. Theta-gamma CFC enhanced bilaterally over the C3/C4 motor electrodes and positively correlated with motor recovery across BCI therapy sessions.

CONCLUSIONS

BCI therapy resulted in significant motor function improvement across the proximal and distal upper extremities of patients, which significantly correlated with theta-gamma CFC increases in the motor regions. This may represent rhythm-specific cortical oscillatory mechanism for BCI-driven rehabilitation in chronic stroke patients.

TRIAL REGISTRATION

Advarra Study: https://classic.clinicaltrials.gov/ct2/show/NCT04338971 and Washington University Study: https://classic.clinicaltrials.gov/ct2/show/NCT03611855.

Specifications and functional impact of a self-triggered grasp neuroprosthesis developed to restore prehension in hemiparetic post-stroke subjects

BACKGROUND

Stroke is the leading cause of acquired motor deficiencies in adults. Restoring prehension abilities is challenging for individuals who have not recovered active hand opening capacities after their rehabilitation. Self-triggered functional electrical stimulation applied to finger extensor muscles to restore grasping abilities in daily life is called grasp neuroprosthesis (GNP) and remains poorly accessible to the post-stroke population. Thus, we developed a GNP prototype with self-triggering control modalities adapted to the characteristics of the post-stroke population and assessed its impact on abilities.

METHODS

Through two clinical research protocols, 22 stroke participants used the GNP and its control modalities (EMG activity of a pre-defined muscle, IMU motion detection, foot switches and voice commands) for 3 to 5 sessions over a week. The NeuroPrehens software interpreted user commands through input signals from electromyographic, inertial, foot switches or microphone sensors to trigger an external electrical stimulator using two bipolar channels with surface electrodes. Users tested a panel of 9 control modalities, subjectively evaluated in ease-of-use and reliability with scores out of 10 and selected a preferred one before training with the GNP to perform functional unimanual standardized prehension tasks in a seated position. The responsiveness and functional impact of the GNP were assessed through a posteriori analysis of video recordings of these tasks across the two blinded evaluation multi-crossover N-of-1 randomized controlled trials.

RESULTS

Non-paretic foot triggering, whether from EMG or IMU, received the highest scores in both ease-of-use (median scores out of 10: EMG 10, IMU 9) and reliability (EMG 9, IMU 9) and were found viable and appreciated by users, like voice control and head lateral inclination modalities. The assessment of the system's general responsiveness combined with the control modalities latencies revealed median (95% confidence interval) durations between user intent and FES triggering of 333 ms (211 to 561), 217 ms (167 to 355) and 467 ms (147 to 728) for the IMU, EMG and voice control types of modalities, respectively. The functional improvement with the use of the GNP was significant in the two prehension tasks evaluated, with a median (95% confidence interval) improvement of 3 (- 1 to 5) points out of 5.

CONCLUSIONS

The GNP prototype and its control modalities were well suited to the post-stroke population in terms of self-triggering, responsiveness and restoration of functional grasping abilities. A wearable version of this device is being developed to improve prehension abilities at home.

TRIAL REGISTRATION

Both studies are registered on clinicaltrials.gov: NCT03946488, registered May 10, 2019 and NCT04804384, registered March 18, 2021.

Proportional myoelectric control of a virtual bionic arm in participants with hemiparesis, muscle spasticity, and impaired range of motion

BACKGROUND

This research aims to improve the control of assistive devices for individuals with hemiparesis after stroke by providing intuitive and proportional motor control. Stroke is the leading cause of disability in the United States, with 80% of stroke-related disability coming in the form of hemiparesis, presented as weakness or paresis on half of the body. Current assistive exoskeletonscontrolled via electromyography do not allow for fine force regulation. Current control strategies provide only binary, all-or-nothing control based on a linear threshold of muscle activity.

METHODS

In this study, we demonstrate the ability of participants with hemiparesis to finely regulate their muscle activity to proportionally control the position of a virtual bionic arm. Ten stroke survivors and ten healthy, aged-matched controls completed a target-touching task with the virtual bionic arm. We compared the signal-to-noise ratio (SNR) of the recorded electromyography (EMG) signals used to train the control algorithms and the task performance using root mean square error, percent time in target, and maximum hold time within the target window. Additionally, we looked at the correlation between EMG SNR, task performance, and clinical spasticity scores.

RESULTS

All stroke survivors were able to achieve proportional EMG control despite limited or no physical movement (i.e., modified Ashworth scale of 3). EMG SNR was significantly lower for the paretic arm than the contralateral nonparetic arm and healthy control arms, but proportional EMG control was similar across conditions for hand grasp. In contrast, proportional EMG control for hand extension was significantly worse for paretic arms than healthy control arms. The participants' age, time since their stroke, clinical spasticity rate, and history of botulinum toxin injections had no impact on proportional EMG control.

CONCLUSIONS

It is possible to provide proportional EMG control of assistive devices from a stroke survivor's paretic arm. Importantly, information regulating fine force output is still present in muscle activity, even in extreme cases of spasticity where there is no visible movement. Future work should incorporate proportional EMG control into upper-limb exoskeletons to enhance the dexterity of stroke survivors.

Remote ischaemic conditioning for neurological disorders-a systematic review and narrative synthesis

INTRODUCTION

Remote ischaemic conditioning (RIC) refers to the use of controlled transient ischemic and reperfusion cycles, commonly of the upper or lower limb, to mitigate cellular damage from ischaemic injury. Preclinical studies demonstrate that RIC may have a neuroprotective effect and therefore could represent a novel therapeutic option in the management of neurological disorders. The aim of this review is to comprehensively describe the current clinical evidence of RIC in neurological disorders.

METHODS

A computerised search of EMBASE and OVID MEDLINE was conducted from 2002 to October 2023 for randomised controlled trials (RCTs) investigating RIC in neurological diseases.

RESULTS

A total of 46 different RCTs in 12 different neurological disorders (n = 7544) were included in the analysis. Conditions included acute ischaemic stroke, symptomatic intracranial stenosis and vascular cognitive impairment. The most commonly used RIC protocol parameters in the selected studies were as follows: cuff pressure at 200 mmHg (27 trials), 5-min cycle length (42 trials), 5 cycles of ischaemia and reperfusion (24 trials) and the application to the upper limb unilaterally (23 trials).

CONCLUSIONS

The comprehensive analysis of the included studies reveals promising results regarding the safety and therapeutic effect of RIC as an option for managing neurological diseases. Particularly, the strongest evidence supports its potential use in chronic stroke patients and vascular cognitive impairment. The neuroprotective effects of RIC, as demonstrated in preclinical studies, suggest that this therapeutic approach could extend its benefits to various other diseases affecting the nervous system. However, to establish the efficacy of RIC across different neurological disorders, further trials with larger sample sizes and more diverse patient populations are warranted. Upcoming trials are expected to provide valuable evidence that will not only confirm the efficacy of RIC in neurological disease management but also help identify the most optimal RIC regimen for specific conditions.

Life after stroke: changes in sensory health and the impact on participation

BACKGROUND

Research has demonstrated that adults post-stroke may experience sensory impairments across different sensory systems. There is a gap in research describing how sensory changes after stroke affect participation in health promoting activities.

OBJECTIVES

The purpose of this study is to understand how changes in sensory health after stroke affect participation in meaningful activities.

METHODS

We adopted a qualitative phenomenological design to conduct four focus groups with ten participants: two focus groups with a cohort of adults post-stroke (n=5) and two focus groups with a cohort of stroke rehabilitation therapists and stroke caregivers (n=5). Focus group transcripts were coded using open and focused coding with NVivo software to develop themes.

RESULTS

Participants reported changes in their visual, vestibular, proprioceptive, olfactory, gustatory, tactile, and auditory systems that affected their participation in meaningful activities. Participants also reported that they experienced insufficient resources and therapies addressing their sensory health after their stroke. Analyses yielded the following themes:(1) it's hidden and invisible;(2) sensory changes affect participation and can be overwhelming; and (3) it's easy to stay inside: sensory changes negatively affect social participation.

CONCLUSIONS

Adults post-stroke experience sensory changes that restrict their participation in meaningful activities including social activities; however, these changes were often missed. More research is needed to further explore the impact of changes in sensory health and understand needs regarding the development of assessment tools and intervention protocols to address the sensory health of adults post-stroke in the clinic, home, and community.

Quantitative electroencephalography to assess post-stroke functional disability: A systematic review and meta-analysis

OBJECTIVE

Quantitative electroencephalography (QEEG) is a non-invasive, reliable and easily accessible modality to assess neuronal activity. QEEG in acute stroke may predict short and long-term functional outcomes. The role of individual indices has not been studied in a meta-analysis. We aim to assess individual QEEG-derived indices to predict post-stroke disability.

METHODS

We included studies (sample size ≥ 10) with stroke patients who underwent EEG and a follow-up outcome assessment was available either in the form of modified Rankin scale (mRS) or National Institute of Stroke scale (NIHSS) or Fugl-Meyer scale (FMA). QEEG indices analysed were delta-alpha ratio (DAR), delta-theta-alpha-beta ratio (DTABR), brain symmetry index (BSI) and pairwise derived brain symmetry (pdBSI).

RESULTS

Nine studies (8 had only ischemic stroke, and one had both ischemic and haemorrhagic stroke), including 482 participants were included for meta-analysis. Higher DAR was associated with worse mRS (n=300, Pearson's r 0.26, 95 % CI 0.21-0.31). Higher DTABR was associated with worse mRS (n=337, r=0.32, 95 % CI 0.26-0.39). Higher DAR was associated with higher NIHSS (n=161, r=0.42, 95 % CI0.24-0.6). Higher DTABR was associated with higher NIHSS (n=158, r=0.49, 95 % CI 0.31-0.67).

CONCLUSIONS

QEEG-derived indices DAR and DTABR have the potential to assess post-stroke disability. Adding QEEG to the clinical and imaging biomarkers in the acute phase may help in better prediction of post-stroke recovery.

REGISTRY

PROSPERO 2022 CRD42022292281.

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

INTRODUCTION

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

MATERIALS AND METHOD

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

RESULTS

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

CONCLUSIONS

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

Site-specific skeletal muscle mass and functional prognosis in geriatric stroke patients

BACKGROUND

Evidence is scarce regarding prognostic value of site-specific muscle mass in geriatric stroke survivors. We aim to assess the association between four measures of muscle mass, namely the skeletal muscle mass index of the limbs (SMI), upper limb SMI (USMI), lower limb SMI (LSMI), and trunk muscle mass index (TMI), and the functional prognosis in stroke patients.

METHODS

This study conducted a retrospective cohort analysis involving post-acute stroke inpatients. Muscle mass data were obtained through bioelectrical impedance analysis and computed by dividing each muscle mass by the square of the height. The study outcomes included the Functional Independence Measure (FIM) motor at discharge and FIM-motor gain. Multiple regression analysis was conducted to assess the association between SMI, USMI, LSMI, and TMI with outcomes, while adjusting for confounding factors.

RESULTS

A total of 701 patients (mean age 72.8 years, 374 males) were analyzed. As a result, LSMI (β = 0.089, P = 0.003) and SMI (β = 0.083, P = 0.008) were significantly associated in the FIM-motor at discharge, with LSMI showing a stronger association. USMI (β = 0.019, P = 0.521) and TMI (β = 0.035, P = 0.231) showed no significant association. LSMI (β = 0.124, P = 0.003) and SMI (β = 0.116, P = 0.008) were significantly associated with FIM-motor gain; however, USMI (β = 0.027, P = 0.521) and TMI (β = 0.049, P = 0.231) showed no significant association with FIM-motor gain.

CONCLUSIONS

Differential associations were observed between site-specific muscle mass and functional prognosis in post-stroke patients. Among these, lower limb muscle mass was most strongly associated with activities of daily living (ADL) recovery.

Predictors of upper limb motor recovery in stroke survivors: a pre-post test study design

OBJECTIVES

The study aimed to assess the predictors of upper limb motor recovery in stroke survivors.

DESIGN

Pre-post test study design.

SETTING

Conducted in two centres (First Level Hospital and University Teaching Hospital in Lusaka).

PARTICIPANTS

Patients living with stroke accessing physiotherapy services at the two public hospitals. A total of 52 patients were recruited at the start of the study, 6 were lost to follow-up and 46 completed the study.

INTERVENTION

Conventional physiotherapy for 8 weeks (5 September 2022-28 October 2022).

PRIMARY OUTCOME

Motor function measured using a Fugl-Meyer assessment of the upper extremity.

RESULTS

Analysis was conducted on 46 participants. A significant difference was observed between the level of motor function at baseline and after 8 weeks of treatment (p=0.0183). At baseline, 50% of participants had mild motor function, which improved after 8 weeks, with 69.6% having mild motor function. Stroke patients with severe motor function impairment at baseline were associated with 0.01 times likelihood of having mild motor function impairment after 8 weeks of physiotherapy treatment (AOR 0.01; 95 % CI 0.00 to 0.16; p=0.002).

CONCLUSION

The motor function of stroke patients continues to improve over time. This study demonstrated that initial upper limb motor function impairment could be used as a predictor for upper limb motor function.

Individualized muscle architecture and contractile properties of ankle plantarflexors and dorsiflexors in post-stroke individuals

Objective

This study was to investigate alterations in contractile properties of the ankle plantar- and dorsiflexors in post-stroke individuals. The correlation between muscle architecture parameters and contractile properties was also evaluated.

Methods

Eight post-stroke individuals and eight age-matched healthy subjects participated in the study. Participants were instructed to perform maximal isometric contraction (MVC) of ankle plantar- and dorsiflexors at four ankle angles, and isokinetic concentric contraction at two angular velocities. B-mode ultrasound images of gastrocnemius medialis (GM) and tibialis anterior (TA) were collected simultaneously during the MVC and isokinetic measurements. Individualized torque-angle and torque-angular velocity relations were established by fitting the experimental data using a second-order polynomial and a rectangular hyperbola function, respectively. Muscle structure parameters, such as fascicle length, muscle thickness and pennation angle of the GM and TA muscles were quantified.

Results

Post-stroke subjects had significantly smaller ankle plantarflexor and dorsiflexor torques. The muscle structure parameters also showed a significant change in the stroke group, but no significant difference was observed in the TA muscle. A narrowed parabolic shape of the ankle PF torque-fiber length profile with a lower width span was also found in the stroke group.

Conclusion

This study showed that the contractile properties and architecture of ankle muscles in post-stroke individuals undergo considerable changes that may directly contribute to muscle weakness, decreased range of motion, and impaired motion function in individuals after stroke.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Exoskeleton-assisted upper limb rehabilitation after stroke: a randomized controlled trial

OBJECTIVES

The upper-limb exoskeleton training program which is repetetive and task-specific therapy can improve motor functions in patients with stroke. To compare the effect of an upper-limb exoskeleton training program with Bobath concept on upper limb motor functions in individuals with chronic stroke.

METHODS

Participants were randomly assigned to exoskeleton group (EG, n = 12) or to Bobath group (BG, n = 12). Interventions were matched in terms of session duration and total number of sessions and performed 2 times per week for 6-weeks. Primary outcome was Fugl-Meyer-Upper Extremity (FMA-UE). Secondary outcomes were Modified Ashworth Scale (elbow and wrist flexor muscles), Motor Activity Log-30 which is consist of two parts as an amount of use (AOU) and quality of movement (QOM), and The Nottingham Extended Activities of Daily Living (NEADL) index.

RESULTS

After 12-sessions of training, the mean (SD) FMA-UE score increased by 5.7 (2.9) in the EG, and 1.9 (1.5) points in the BG (p < .05). In total, 40% of participants (5/12) demonstrated a clinically meaningful improvement (≥5.25 points) in the FM-UE, while none of the participants reached MCID score in the bobath group. Changes in the AOU, QOM, and NEADL were significantly larger in the EG compared to BG (p < .05). 7/12 (58.33%) of participants for AOU and 5/12 (42%) of participants for QOM in the EG showed that clinically meaningful change. 5/12 of participants (42%) in the EG demonstrated ≥4.9-point increase in NEADL score.

DISCUSSION

High-intensity repetitive arm and hand exercises with an exoskeleton device was safe and feasible. Exoskeleton-assisted training demonstrated significant benefits in improving upper limb functions and quality of life in individuals after stroke.

Grade-4/5 motor activity log-Brazil for post-stroke individuals with a severely impaired upper limb: a validity, reliability and measurement error study

PURPOSE

This study examined the clinimetrics of the Brazilian-Portuguese translation of the Grade-4/5 Motor Activity Log (MAL 4/5), which assesses everyday use of the more affected upper-limb (UL) in stroke survivors with moderate/severe or severe motor impairment.

MATERIALS AND METHODS

The translated MAL 4/5 was administered to 47 stroke survivors with moderate/severe or severe UL motor impairment. Accelerometers were worn on participants' wrists for five days on average prior to the first assessment. Test-retest and inter-rater reliabilities were assessed using the intraclass correlation coefficient (ICC), internal consistency using Cronbach's α, and construct validity was tested with correlations with the accelerometry. The measurement error (SEM) and the minimal detectable change (MDC) were calculated.

RESULTS

MAL4/5-Brazil's test-retest reliability (AOU: ICC = 0.84; QOU: ICC = 0.90), inter-rater reliability (AOU: ICC = 0.83; QOU: ICC = 0.91), internal consistency (Cronbach's α = 0.91 and 0.95 for AOU and QOU scales, respectively), the SEM and MDC were 0.3 and 0.8 points for the AOU subscale and 0.2 and 0.5 points for the QOU subscale, respectively. The construct validity (AOU scale: r = 0.67; QOU scale: r = 0.76) was high.

CONCLUSION

Grade-4/5 Motor Activity Log-Brazil is a reliable and valid instrument for assessing the more-affected UL use of stroke patients with moderate/severe or severe UL motor impairments.

How the Somatosensory System Adapts to the Motor Change in Stroke: A Hemispheric Shift?

Previous studies found that post-stroke motor impairments are associated with damage to the lesioned corticospinal tract and a maladaptive increase in indirect contralesional motor pathways. How the somatosensory system adapts to the change in the use of motor pathways and the role of adaptive sensory feedback to the abnormal movement control of the paretic arm remains largely unknown. We hypothesize that following a unilateral stroke, there is an adaptive hemispheric shift of somatosensory processing toward the contralesional sensorimotor areas to provide sensory feedback support to the contralesional indirect motor pathways. This research could provide new insights related to somatosensory reorganization after stroke, which could enrich future hypothesis-driven therapeutic rehabilitation strategies from a sensory or sensory-motor perspective. Understanding how somatosensory information shifts may provide a target for a novel method to therapeutically prevent and mitigate the emergence and expression of upper limb motor impairments, following a stroke.

Investigating the synergistic neuromodulation effect of bilateral rTMS and VR brain-computer interfaces training in chronic stroke patients

Objective.Stroke is a major cause of adult disability worldwide, resulting in motor impairments. To regain motor function, patients undergo rehabilitation, typically involving repetitive movement training. For those who lack volitional movement, novel technology-based approaches have emerged that directly involve the central nervous system, through neuromodulation techniques such as transcranial magnetic stimulation (TMS), and closed-loop neurofeedback like brain-computer interfaces (BCIs). This, can be augmented through proprioceptive feedback delivered many times by embodied virtual reality (VR). Nonetheless, despite a growing body of research demonstrating the individual efficacy of each technique, there is limited information on their combined effects.Approach.In this study, we analyzed the Electroencephalographic (EEG) signals acquired from 10 patients with more than 4 months since stroke during a longitudinal intervention with repetitive TMS followed by VR-BCI training. From the EEG, the event related desynchronization (ERD) and individual alpha frequency (IAF) were extracted, evaluated over time and correlated with clinical outcome.Main results.Every patient's clinical outcome improved after treatment, and ERD magnitude increased during simultaneous rTMS and VR-BCI. Additionally, IAF values showed a significant correlation with clinical outcome, nonetheless, no relationship was found between differences in ERD pre- post- intervention with the clinical improvement.Significance.This study furnishes empirical evidence supporting the efficacy of the joint action of rTMS and VR-BCI in enhancing patient recovery. It also suggests a relationship between IAF and rehabilitation outcomes, that could potentially serve as a retrievable biomarker for stroke recovery.

Comparing the effects of Swiss-ball training and virtual reality training on balance, mobility, and cortical activation in individuals with chronic stroke: study protocol for a multi-center randomized controlled trial

BACKGROUND

Balance and mobility deficits are major concerns in stroke rehabilitation. Virtual reality (VR) training and Swiss-ball training are commonly used approaches to improve balance and mobility. However, no study has compared the efficacy of VR training, Swiss-ball training, and their combination in improving balance and mobility function or investigated cortical activation and connectivity in individuals with stroke.

METHODS

A prospective, single-blinded, parallel-armed, multi-center randomized controlled trial with factorial design will be conducted. Seventy-six participants aged 30-80 years with stroke will be recruited. Participants will be allocated to one of the four groups: (A) the VR training + Swiss-ball training + conventional physical therapy group; (B) the Swiss-ball training + conventional physical therapy group; (C) the VR training + conventional physical therapy group; or (D) the conventional physical therapy group. All participants will receive 50 min of training per day, 5 times per week, for a total of 4 weeks. The primary outcomes will be balance and mobility measures. Secondary outcomes will include the 10-min walk test, dynamic gait index, and cortical activation. Outcomes will be measured on three occasions: at baseline, after the training, and at the 4-week follow-up.

DISCUSSION

This trial will provide evidence to determine whether there are differences in clinical outcomes and cortical activation following two different types of exercise programs and their combination, and to elucidate the recovery mechanisms of balance and mobility function in individuals with stroke.

TRIAL REGISTRATION

Chinese Clinical Trial Registry reference: www.chictr.org.cn (No. ChiCTR2400082135). Registered on May 24, 2024.

Factors Influencing Decision-Making for Poststroke Paretic Upper Limb Treatment: A Survey of Japanese Physical and Occupational Therapists

This study investigated the treatment methods used by physical and occupational therapists for poststroke paretic upper limbs and the factors influencing their decision-making processes. For the treatment methods of poststroke paretic upper limbs, the respondents were asked to select the most clinically used treatment according to the severity of the patient's condition. For the factors influencing their decision-making processes, the respondents were asked to indicate each determinant using a 5-point Likert scale (1 = no influence at all to 5 = very strong influence). Six hundred thirty-eight therapists participated in this study. Exploratory factor analysis was used to assess the validity of the questionnaire. The findings indicated task-specific training (N = 333, 52%) as the most popular for mild cases, followed by repetitive facilitative exercise (n = 143, 22.3%) for moderate cases and electrical stimulation (n = 246, 38.4%) for severe cases. This study revealed that evidence about treatment (very strong: n = 171 (27.0%), and strong: n = 287 (45.0%)) and patient preferences (very strong: n = 203 (31.8%), and strong: n = 251 (39.3%)) affected decision-making significantly regarding treatment methods for the poststroke paretic upper limb.

Effects of eccentric strength training on motor function in individuals with stroke: a scoping review

BACKGROUND

Preliminary evidence suggests that eccentric strength training (ECC) improves muscle strength and postural control in individuals with stroke; however, the evidence about the effects of ECC in people living with stroke has not been systematically analyzed.

OBJECTIVE

To determine the effects of ECC, compared to other exercise modalities (i.e., concentric training), on motor function in individuals with stroke.

METHODS

This scoping review was performed according to PRISMA extension for scoping reviews. Until March 2023, a comprehensive search of studies using ECC intervention to improve motor functions in individuals with stroke was performed. Study designs included were randomized and non-randomized controlled trials and quasi-experimental studies using MEDLINE, Web of Science, Rehabilitation & Sports Medicine, PEDro, and OTSeeker databases. Two independent reviewers selected articles based on title and abstract and extracted relevant information from the eligible studies. The results were qualitatively synthesized, and the critical appraisal was performed using the Rob 2.0 and Robins-I tools.

RESULTS

Ten studies, with 257 individuals, were analyzed. ECC revealed positive effects on muscle strength, muscular activity, balance, gait speed, and functionality, mainly compared with concentric training, physical therapy, and daily routine. No significant adverse events were reported during ECC. The critical appraisal of individual articles ranged from some to high concern.

CONCLUSION

ECC had a greater and positive effect on motor function in individuals with stroke than other exercise modalities. However, the limited number of studies, variability of outcomes, and the risk of bias produced a low certainty of evidence.

Muscle synergies in upper limb stroke rehabilitation: a scoping review

INTRODUCTION

Upper limb impairment is a common consequence of stroke, significantly affecting the quality of life and independence of survivors. This scoping review assesses the emerging field of muscle synergy analysis in enhancing upper limb rehabilitation, focusing on the comparison of various methodologies and their outcomes. It aims to standardize these approaches to improve the effectiveness of rehabilitation interventions and drive future research in the domain.

EVIDENCE ACQUISITION

Studies included in this scoping review focused on the analysis of muscle synergies during longitudinal rehabilitation of stroke survivors' upper limbs. A systematic literature search was conducted using PubMed, Scopus, and Web of Science databases, until September 2023, and was guided by the PRISMA for scoping review framework.

EVIDENCE SYNTHESIS

Fourteen studies involving a total of 247 stroke patients were reviewed, featuring varied patient populations and rehabilitative interventions. Protocols differed among studies, with some utilizing robotic assistance and others relying on traditional therapy methods. Muscle synergy extraction was predominantly conducted using Non-Negative Matrix Factorization from electromyography data, focusing on key upper limb muscles essential for shoulder, elbow, and wrist rehabilitation. A notable observation across the studies was the heterogeneity in findings, particularly in the changes observed in the number, weightings, and temporal coefficients of muscle synergies. The studies indicated varied and complex relationships between muscle synergy variations and clinical outcomes. This diversity underscored the complexity involved in interpreting muscle coordination in the stroke population. The variability in results was also influenced by differing methodologies in muscle synergy analysis, highlighting a need for more standardized approaches to improve future research comparability and consistency.

CONCLUSIONS

The synthesis of evidence presented in this scoping review highlights the promising role of muscle synergy analysis as an indicator of motor control recovery in stroke rehabilitation. By offering a comprehensive overview of the current state of research and advocating for harmonized methodological practices in future longitudinal studies, this scoping review aspires to advance the field of upper limb rehabilitation, ensuring that post-stroke interventions are both scientifically grounded and optimally beneficial for patients.

Impact of Virtual Reality on Pain, ROM, Muscle Strength and Quality of Life among Breast Cancer Patients: An Integrative Review of Literature

BACKGROUND

Breast cancer is the most commonly diagnosed cancer among women globally, with significant impacts on physical, emotional, and functional well-being. Traditional rehabilitation methods may not fully address the multifaceted challenges faced by breast cancer survivors (BCSs), prompting exploration into innovative approaches such as Virtual Reality (VR) technology.

OBJECTIVE

The present review aims to assess the effectiveness of VR in alleviating pain, improving Range of Motion (ROM), enhancing muscle strength, and augmenting the overall quality of life in patients undergoing breast cancer rehabilitation.

METHODS

A comprehensive review of existing literature was conducted, focusing on studies investigating the use of VR in breast cancer rehabilitation. PubMed, Scopus, PEDro and Google scholar were searched for articles addressing VR interventions targeting pain management, ROM improvement, muscle strength enhancement, and quality of life enhancement in breast cancer patients.

RESULTS

Findings yielded total 12 articles matching the selection criteria. VR technology has shown promising results in addressing the multifaceted needs of breast cancer patients. VR also serves as a distraction tool, positively impacting psychological well-being and mitigating negative psychological symptoms associated with the disease.

CONCLUSION

VR represents a non-pharmacological approach to pain management and rehabilitation in breast cancer patients. Its ability to engage emotional, cognitive, and attention processes contributes to its effectiveness in enhancing overall quality of life. Further research is warranted to elucidate the long-term benefits and optimal utilization of VR technology in breast cancer rehabilitation programs.

Efficacy of a new video observational training method (intensive visual simulation) for motor recovery in the upper limb in subacute stroke: a feasibility and proof-of-concept study

OBJECTIVE

To demonstrate the feasibility and efficacy  of a new video-observation training method (intensive visual simulation) to improve upper limb function.

DESIGN

Small sample, randomized, evaluator-blind, monocentric study.

PATIENTS

Seventeen early subacute ischaemic stroke patients with complete hemiplegia were  randomly assigned to the therapeutic group (n = 8) or control group (CG, n = 9).

METHODS

Thirty sessions of intensive visual simulation combined with corrected visual feedback (therapeutic group) or uncorrected visual feedback (control group) were performed over 6 weeks on top of a standard rehabilitation programme.

MAIN OUTCOME MEASURE

400-point hand assessment test (400p-HA).

SECONDARY OUTCOME MEASURES

Box and Blocks (B&B), Purdue Pegboard test, Minnesota.

RESULTS

The 400p-HA test improved significantly from T0 to 6 months for both groups, with a significant difference between groups at 3 months (MW-UT p = 0.046) and 4 months (MW-UT p = 0.046) in favour of the therapeutic group. One-phase exponential modelling of 400p-HA showed a greater plateau for the therapeutic group (F test p = 0.0021). There was also faster recovery of the ability to perform the B&B tests for the therapeutic group (log-rank test p = 0.03).

CONCLUSION

This study demonstrated the feasibility and potential efficacy of an intensive visual simulation training programme to improve upper limb  function in subacute stroke patients. A larger study is needed to confirm these results.

High-frequency magnetic paired associated stimulation promotes motor function recovery in ischemic stroke patients: a study protocol for single-center, sham stimulation randomized controlled trials (H2MPAS)

BACKGROUND

Numerous studies have validated the clinical effectiveness of electromagnetic pairing-associated stimulation. Building upon this foundation, we have developed a novel approach involving high-frequency magnetic paired-associated stimulation, aiming to enhance clinical applicability and potentially improve efficacy. However, the clinical effectiveness of this approach remains unclear. Our objective is to demonstrate the therapeutic efficacy of this novel approach by employing high-frequency pairing to intervene in patients experiencing motor dysfunction following a stroke.

METHODS

This is a single-center, single-blind, sham stimulation controlled clinical trial involving patients with upper limb motor dysfunction post-stroke. The intervention utilizes paired magnetic stimulation, combining peripheral and central magnetic stimulation, in patients with Brunnstrom stage III-V stroke lasting from 3 months to 1 year. Evaluation of patients' upper limb motor function occurred before the intervention and after 3 weeks of intervention. Follow-up visits will be conducted after 5 weeks and 3 months of intervention. The primary outcome measure is the Action Research Arm Test, with secondary measures including the Fugl-Meyer Assessment-upper, Modified Barthel Index, modified Tardieu scale, functional near-infrared spectroscopy, and neuroelectrophysiology.

DISCUSSION

The high-frequency magnetic paired associative stimulation used in this study combined high-frequency magnetic stimulation with paired stimulation, potentially facilitating both cortical excitation through high-frequency stimulation and specific circuit enhancement through paired stimulation. As dual-coil magnetic stimulation equipment becomes increasingly popular, magnetic-magnetic paired associated stimulation may offer patients improved clinical outcomes at reduced costs.

TRIAL REGISTRATION

Chinese Clinical Trial Registry,ChiCTR2400083363. Registered on 23 April 2024.

Age-Related Differences in the Effectiveness of Rehabilitation to Improve Activities of Daily Living in Patients with Stroke: A Cross-Sectional Study

BACKGROUND

This study aimed to reveal differences in the effectiveness of rehabilitation in improving activities of daily living (ADL) in patients with acute stroke across age groups and propose age-appropriate rehabilitation strategies.

METHODS

This observational study analyzed nationwide administrative data of inpatients admitted to hospitals with acute stroke between April 1, 2018, and March 31, 2020. The data included the average length of daily rehabilitation sessions, weekly frequency of rehabilitation sessions, and initiation of rehabilitation within 3 days. The primary outcome was the improvement in the Barthel Index (BI) score from admission to discharge. We classified the patients based on age and analyzed improvements in ADL according to rehabilitation characteristics.

RESULTS

An increased daily rehabilitation dose was associated with improved ADL, except in patients aged <65 years (risk ratio [95% confidence interval] in the 65-74, 75-85, and ≥85 years age groups: 1.20 [1.14‒1.27], 1.21 [1.15‒1.27], and 1.43 [1.34‒1.53], respectively; all p<0.001 vs. <65 years: 1.05 [0.98‒1.12]; p=0.18). A rehabilitation frequency of seven sessions per week was associated with improved ADL in the 75-85 years and ≥85 years age groups (1.06 [1.02‒1.10] and 1.08 [1.03‒1.13], respectively; both p<0.001). The effects of initiating rehabilitation within 3 days on ADL post-admission did not differ across age groups.

CONCLUSION

Increasing the daily dose of rehabilitation was significantly associated with improved ADL in all age groups while increasing the frequency of rehabilitation per week improved ADL in older and very old patients.

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

OBJECTIVE

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

DESIGN

A single-blind pilot randomized controlled trial.

SETTING

Department of Rehabilitation Medicine of a medical center.

PARTICIPANTS

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

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Therapeutic effect of adjuvant therapy added to constraint-induced movement therapy in patients with subacute to chronic stroke: a systematic review and meta-analysis

PURPOSE

This review investigated the effectiveness of adjuvant therapy combined with constraint-induced movement therapy (CIMT) in improving the paretic upper limb functionality in adults with stroke sequelae during the subacute to chronic rehabilitation phase.

MATERIALS AND METHODS

In this systematic review and meta-analysis of randomized controlled trials (RCT), electronic databases, including PubMed, Web of Science, CINAHL, and MEDLINE, were searched. We included RCTs that investigated the outcomes of adjuvant therapy (i.e. other therapies) added to CIMT compared with CIMT alone. Key trial findings were qualitatively synthesized and analyzed. This meta-analysis examined variables, such as mean scores and standard deviations, using the following outcome measures: Fugl-Meyer Assessment (FMA) upper limb items, Action Research Arm Test (ARAT), Amount of Use (AOU) of Motor Activity Log (MAL), and Quality of Movement (QOM) of MAL.

RESULTS

Eighteen eligible RCTs were included in the analysis. Adding CIMT to adjunctive therapy significantly improved FMA compared with CIMT alone (mean difference [MD] 4.02, 95% confidence interval [CI] 2.60-5.44; I2 = 85%; 15 studies; 330 participants). Similarly, the ARAT and MAL-AOU scores improved significantly.

CONCLUSIONS

CIMT combined with several adjunctive therapies effectively improved upper limb function.

Association Between Frequency of Rehabilitation Therapy and Long-Term Mortality After Stroke: A Nationwide Cohort Study

BACKGROUND

Previous studies have demonstrated conflicting results regarding the effects of rehabilitation therapy on poststroke mortality. We aimed to investigate the association between rehabilitation therapy, including both inpatient and outpatient treatment, within the first 6 months after stroke and long-term all-cause mortality in patients with stroke using the Korean National Health Insurance System data.

METHODS

A total of 10 974 patients newly diagnosed with stroke using the International Classification of Diseases, Tenth Revision, codes (I60-I64) between 2003 and 2019 were enrolled and followed up for all-cause mortality until 2019. Follow-up for mortality began 6 months after the index event. Poststroke patients were categorized into 3 groups according to the frequency of rehabilitation therapy: no rehabilitation therapy, ≤40 sessions and >40 sessions. Cox proportional hazards models were used to assess the mortality risk according to rehabilitation therapy stratified by disability severity measured based on activities of daily living 6 months after stroke onset.

RESULTS

Within 6 months after stroke, 6738 patients (61.4%) did not receive rehabilitation therapy, whereas 2122 (19.3%) received ≤40 sessions and 2114 (19.3%) received >40 sessions of rehabilitation therapy. Higher frequency of rehabilitation therapy was associated with significantly lower poststroke mortality in comparison to no rehabilitation therapy (hazard ratio [HR], 0.88 [95% CI, 0.79-0.99]), especially among individuals with severe disability after stroke (mild to moderate: HR, 1.02 [95% CI, 0.77-1.35]; severe: HR, 0.74 [95% CI, 0.62-0.87]). In the context of stroke type, higher frequency of rehabilitation therapy was associated with reduced mortality rates compared with no rehabilitation therapy only in patients with hemorrhagic stroke (ischemic: HR, 1.04 [95% CI, 0.91-1.18]; hemorrhagic: HR, 0.60 [95% CI, 0.49-0.74]).

CONCLUSIONS

We found a positive association between rehabilitation therapy within 6 months after stroke onset and long-term mortality in patients with stroke. A higher frequency of rehabilitation therapy would be recommended for poststroke patients, especially those with hemorrhagic stroke and severe disability.

Spanish translation and cross-cultural adaptation of the Box and Block Test: a pilot study in adults with chronic acquired brain injury

Background The Box and Block Test (BBT) is a highly recommended outcome measure to assess unilateral gross motor activity of the upper limbs. The BBT has not previously been available in a version adapted to the Spanish context. Thus, this study aimed to cross-culturally adapt and translate the BBT's instructions and pilot test the Spanish version of BBT in adults with acquired brain injury (ABI). Methods The BBT was translated and cross-culturally adapted following standard procedures. An expert committee approved the final Spanish version of BBT and it was conceptually validated by four therapists with expertise in ABI. The tool was tested on 14 adults with ABI. Results The Spanish version of BBT included a new section of materials for the test and a record to count the number of blocks transferred from one compartment of the box to the other. Following the pilot study, a modification in terminology was implemented for referring to the dominant and non-dominant hands. Conclusions Our results suggest that the Spanish version of BBT is suitable for assessing manual dexterity in Spanish-speaking adults with ABI.

Stroke rehabilitation: from diagnosis to therapy

Stroke remains a significant global health burden, necessitating comprehensive and innovative approaches in rehabilitation to optimize recovery outcomes. This paper provides a thorough exploration of rehabilitation strategies in stroke management, focusing on diagnostic methods, acute management, and diverse modalities encompassing physical, occupational, speech, and cognitive therapies. Emphasizing the importance of early identification of rehabilitation needs and leveraging technological advancements, including neurostimulation techniques and assistive technologies, this manuscript highlights the challenges and opportunities in stroke rehabilitation. Additionally, it discusses future directions, such as personalized rehabilitation approaches, neuroplasticity concepts, and advancements in assistive technologies, which hold promise in reshaping the landscape of stroke rehabilitation. By delineating these multifaceted aspects, this manuscript aims to provide insights and directions for optimizing stroke rehabilitation practices and enhancing the quality of life for stroke survivors.