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Robot-Assisted Therapy (RT) is an innovative approach to neurological rehabilitation that uses intensive, repetitive, interactive, and individualized practice. This systematic review aimed to investigate the effectiveness of RT on the body function and structure of people with upper limb impairments (PROSPERO registration: CRD42017054982). A search strategy conducted on seven databases identified randomized controlled studies. Methodological quality was assessed using the PEDro scale. When possible, the data were pooled, the strength of evidence was assessed using the GRADE system, and the effect sizes were assessed using Cohen coefficient. Subgroup analyses investigated the impact on the estimated effects of the following parameters: methodological quality; portion of the assessed upper limb; duration of stroke; and intervention dose and duration. Thirty-eight studies involving 1174 participants were included. Pooled estimates revealed small effects of RT on motor control and medium effects on strength compared with other intervention (OI) at a short-term follow-up. Standardized differences in means were as follows: 0.3 (95% CI 0.1 to 0.4) and 0.5 (95% CI 0.2 to 0.8). Effects at other time points and on other investigated outcomes related to body function and structure were not found (p>0.05). The strength of the current evidence was usually low quality. Subgroup analyses suggested that the methodological quality, and duration and dose of RT may influence the estimated effects. In conclusion, RT has small effects on motor control and medium effects on strength in people with limited upper limb function. Poor methodological quality, and lower treatment dose and duration may impact negatively the estimated effects. [ABSTRACT FROM AUTHOR]

Background: Upper limb paresis is one of the most frequent and persistent impairments following stroke. Only 12-34% of stroke patients achieve full recovery of upper limb functioning, which seems to be required to habitually use the affected arm in daily tasks. Although the recovery of upper limb functioning is most pronounced during the first 4 weeks post stroke, there are few studies investigating the effect of rehabilitation during this critical time window. The purpose of this trial is to determine the effect of electrical somatosensory stimulation (ESS) initiated in the acute stroke phase on the recovery of upper limb functioning in a nonselected sample of stroke patients.Methods/design: A sample of 102 patients with upper limb paresis of varying degrees of severity is assigned to either the intervention or the control group using stratified random sampling. The intervention group receives ESS plus usual rehabilitation and the control group receives sham ESS plus usual rehabilitation. The intervention is applied as 1 h of ESS/sham ESS daily, followed by motor training of the affected upper limb. The ESS/sham ESS treatment is initiated within 7 days from stroke onset and it is delivered during hospitalization, but no longer than 4 weeks post stroke. The primary outcome is hand dexterity assessed by the Box and Block Test; secondary outcomes are the Fugl-Meyer Assessment, hand grip strength, pinch strength, perceptual threshold of touch, degree of pain, and modified Rankin Scale score. Outcome measurements are conducted at baseline, post intervention and at 6-month follow-up.Discussion: Because of the wide inclusion criteria, we believe that the results can be generalized to the larger population of patients with a first-ever stroke who present with an upper limb paresis of varying severity. On the other hand, the sample size (n = 102) may preclude subgroup analyses in such a heterogeneous sample. The sham ESS treatment totals a mere 2% of the active ESS treatment delivered to the intervention group per ESS session, and we consider that this dose is too small to induce a treatment effect.Trial Registration: ClinicalTrials.gov, NCT02250365 . Registered on 18 September 2014. [ABSTRACT FROM AUTHOR]

Sound inverse dynamics modeling is lacking in aquatic locomotion research because of the difficulty in measuring hydrodynamic forces in dynamic conditions. Here we report the successful implementation and validation of an innovative methodology crossing new computational fluid dynamics and inverse dynamics techniques to quantify upper limb joint forces and moments while moving in water. Upper limb kinematics of seven male swimmers sculling while ballasted with 4 kg was recorded through underwater motion capture. Together with body scans, segment inertial properties, and hydrodynamic resistances computed from a unique dynamic mesh algorithm capable to handle large body deformations, these data were fed into an inverse dynamics model to solve for joint kinetics. Simulation validity was assessed by comparing the impulse produced by the arms, calculated by integrating vertical forces over a stroke period, to the net theoretical impulse of buoyancy and ballast forces. A resulting gap of 1.2±3.5% provided confidence in the results. Upper limb joint load was within 5% of swimmer׳s body weight, which tends to supports the use of low-load aquatic exercises to reduce joint stress. We expect this significant methodological improvement to pave the way towards deeper insights into the mechanics of aquatic movement and the establishment of practice guidelines in rehabilitation, fitness or swimming performance. [ABSTRACT FROM AUTHOR]

The main purpose of this study was to determine the clinical, electrophysiological and thermal effects of radial extracorporeal shock wave (rESW) stimulation on upper limb muscles affected by spasticity in patients with chronic stroke. Patients included in the study were randomly assigned into the following two groups: 30 patients stimulated with active rESW (A); and 30 patients stimulated with placebo rESW (B). All patients were analyzed using the Modified Ashworth Scale (MAS) to test the spasticity levels of the elbow (E), radio carpal (RC) and fingers (FF) joints; surface electromyography (sEMG) was performed for the resting bioelectrical activity registration of the flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU) muscles; and infrared thermal imaging (IRT) was used to assess the temperature distributions of the carpal flexor muscles (CFM). All assessments were performed at baseline (t0), immediately after rESW (t1) as well as 1 and 24 h following its finalization (t2 and t3). Patients treated with active rESW showed a statistically significant reduction in the MAS score for the RC joint at t1 and for the FF joints at t1, t2 and t3 (p < 0.05). A significant decrease in sEMG activity was observed in the FCR and FCU muscles at t1, t2 and t3 (p < 0.05); significant increases in the mean and maximum values of the IRT detection was observed using inter-group comparisons in t2 and t3 (p < 0.05). No significant alterations were observed in patients after placebo rESW stimulation (p > 0.05). Applications of rESW demonstrating positive effects at reducing the level of spastic hypertonia of the upper limb muscles in patients with chronic stroke. ESW treatments should be considered as a potential anti-spastic effect to regulate vasculature. [ABSTRACT FROM AUTHOR]

Objective: The nature of changes in brain activation related to good recovery of arm function after stroke is still unclear. While the notion that this is a reflection of neuronal plasticity has gained much support, confounding by compensatory strategies cannot be ruled out. We address this issue by comparing brain activity in recovered patients 6 months after stroke with healthy controls. Methods: We included 20 patients with upper limb paresis due to ischemic stroke and 15 controls. We measured brain activation during a finger flexion-extension task with functional MRI, and the relationship between brain activation and hand function. Patients exhibited various levels of recovery, but all were able to perform the task. Results: Comparison between patients and controls with voxel-wise whole-brain analysis failed to reveal significant differences in brain activation. Equally, a region of interest analysis constrained to the motor network to optimize statistical power, failed to yield any differences. Finally, no significant relationship between brain activation and hand function was found in patients. Patients and controls performed scanner task equally well. Conclusion: Brain activation and behavioral performance during finger flexion-extensions in (moderately) well recovered patients seems normal. The absence of significant differences in brain activity even in patients with a residual impairment may suggest that infarcts do not necessarily induce reorganization of motor function. While brain activity could be abnormal with higher task demands, this may also introduce performance confounds. It is thus still uncertain to what extent capacity for true neuronal repair after stroke exists. [ABSTRACT FROM AUTHOR]

In patients with unilateral upper limb paralysis from strokes and other brain lesions, strategies for functional recovery may eventually include brain-machine interfaces (BMIs) using control signals from residual sensorimotor systems in the damaged hemisphere. When voluntary movements of the contralateral limb are not possible due to brain pathology, initial training of such a BMI may require use of the unaffected ipsilateral limb. We conducted an offline investigation of the feasibility of decoding ipsilateral upper limb movements from electrocorticographic (ECoG) recordings in three patients with different lesions of sensorimotor systems associated with upper limb control. We found that the first principal component (PC) of unconstrained, naturalistic reaching movements of the upper limb could be decoded from ipsilateral ECoG using a linear model. ECoG signal features yielding the best decoding accuracy were different across subjects. Performance saturated with very few input features. Decoding performances of 0.77, 0.73, and 0.66 (median Pearson's r between the predicted and actual first PC of movement using nine signal features) were achieved in the three subjects. The performance achieved here with small numbers of electrodes and computationally simple decoding algorithms suggests that it may be possible to control a BMI using ECoG recorded from damaged sensorimotor brain systems. [ABSTRACT FROM AUTHOR]

INTRODUCTION: The physical disability and the level of dependence for daily activities that follow a stroke requires validated and standardized instruments to measure objectively the functional status and the impact of interventions on prognosis. The Motor Activity Log (MAL-30) and Action Research Arm (ARA) scales possess these characteristics, currently being the most used in evaluation of the upper extremity. OBJECTIVE: TO analyze the psychometric properties and utility of MAL-30 and ARA as tools to assess the function of the paretic upper limb after stroke for the clinical practice and research. METHODS: We performed an observational, longitudinal design with clinimetric performance analysis, with a sample of 80 patients. Two measurements were made, at baseline (time 1) clinical and socio-demographic profile, MAL-30 and ARA was applied. One month later (time 2), MAL-30, ARA and Stroke Impact Scale (SIS 3.0) were applied. RESULTS: MAL-30 and ARA have adequate internal consistency and temporal stability. In addition, an appropriate construct validity by correlating significantly and in the expected direction between the two instruments and items of SIS 3.0, spasticity, pain, age, educational level and employment status. CONCLUSIONS: The evidence indicates that both MAL-30 and ARA have psychometric properties that make them ideal tools for assessing functional recovery in the paretic arm. However, it is necessary to consider some characteristics of each instrument before defining its clinical use and research properties. [ABSTRACT FROM AUTHOR]

Background. Stroke commonly affects upper extremity motor abilities, yet there has been very limited success in developing effective rehabilitation interventions to remediate motor impairments, particularly for the upper extremity. Objective. To determine if task-oriented practice administered soon after stroke is more effective than usual care in improving poststroke upper extremity motor recovery and to explore the optimal amount of practice. Methods. A systematic review of the literature was performed from 1950 to November 2012, to identify randomized controlled trials of task-oriented practice compared to usual care, or to different amounts of task-oriented practice to improve motor impairment and activity. Studies were excluded if specific types of interventions were used as comparators or if they were of poor methodological quality. Results. Six studies met the review criteria. Three of the six studies demonstrated a statistically significant effect of task-oriented practice. Study results could not be pooled because of a lack of homogeneity in populations and intervention. Conclusions. The results demonstrate that an increase in the amount of task-oriented practice after stroke may result in less upper extremity impairment; further research on both effect and required dosage is needed as results are inconsistent. [ABSTRACT FROM AUTHOR]

Introduction: This study aims to evaluate the upper extremity vessels of hemiplegic patients by Doppler Ultrasonography (DU) and to determine pulsatility-resistive index (PI-RI) values and factors related to these values. Materials and Method: The study evaluated 50 hemiplegic patients and 36 healthy controls with no complaints in their upper extremities. In both groups, a radiologist measured the brachial artery PI and RI values with DU and checked the veins for thrombosis in the upper extremities. Results: The mean age of the patients was 61.98±12.46 years, and the mean age of the controls was 60.88±8.57 years. The intra and inter group comparisons of both upper extremities of the groups showed no statistically significant differences and no thromboses were detected in the venous structures. In the patient group, the PI and RI values of the affected side were not statistically correlated with Brunnstrom or Ashworth scores, subluxation or limited motion in the shoulder, or the presence of clinical complex regional pain syndrome (CRPS) in the hand. In both the patient and control groups, PI and RI values and age were correlated. Conclusion: The findings of this study showed that in hemiplegic patients, arterial PI and RI values in the upper extremities were affected by age. [ABSTRACT FROM AUTHOR]

Abstract: Objective: This study determined the variability and regularity of force production in impaired upper extremities of chronic stroke survivors. Two hypotheses included: (1) stroke will increase the variability and regularity of force output in comparison to age-matched controls and (2) degree of motor impairments will be positively correlated with the variability and regularity of force output. Methods: Nine chronic stroke and nine age-matched controls performed unimanual isometric wrist and finger extension movements for 20s to three different target force levels. Force output was indexed by magnitude, accuracy, variability, and regularity. Stroke motor impairment levels were determined by Fugl-Meyer upper extremity assessment. Results: The stroke group demonstrated increased variability and regularity of the force output. Further, motor impairments scaled with increase in variability and regularity of force output. Conclusions: The variability and regularity of force differentiated isometric contractions performed by chronic stroke survivors from age-matched controls. Moreover, in clinical settings an objective assessment of force control on variability and regularity appears to be most meaningful at 25% of MVC. Significance: Increased variability contributes to reduced steadiness in force output. Increased regularity characterizes the adaptability losses in motor capabilities following stroke. This knowledge may facilitate planning and evaluating rehabilitation protocols. [ABSTRACT FROM AUTHOR]

Background: Proprioceptive sense plays a significant role in the generation and correction of skilled movements and, consequently, in most activities of daily living. We developed a new proprioception assessment protocol that enables the quantification of elbow position sense without using the opposite arm, involving active movement of the evaluated limb or relying on working memory. The aims of this descriptive study were to validate this assessment protocol by quantifying the elbow position sense of healthy adults, before using it in individuals who sustained a stroke, and to investigate its test-retest reliability.Methods: Elbow joint position sense was quantified using a robotic device and a virtual reality system. Two assessments were performed, by the same evaluator, with a one-week interval. While the participant's arms and hands were occluded from vision, the exoskeleton passively moved the dominant arm from an initial to a target position. Then, a virtual arm representation was projected on a screen placed over the participant's arm. This virtual representation and the real arm were not perfectly superimposed, however. Participants had to indicate verbally the relative position of their arm (more flexed or more extended; two-alternative forced choice paradigm) compared to the virtual representation. Each participant completed a total of 136 trials, distributed in three phases. The angular differences between the participant's arm and the virtual representation ranged from 1° to 27° and changed pseudo-randomly across trials. No feedback about results was provided to the participants during the task. A discrimination threshold was statistically extracted from a sigmoid curve fit representing the relationship between the angular difference and the percentage of successful trials. Test-retest reliability was evaluated with 3 different complementary approaches, i.e. a Bland-Altman analysis, an intraclass correlation coefficient (ICC) and a standard error of measurement (SEm).Results: Thirty participants (24.6 years old; 17 males, 25 right-handed) completed both assessments. The mean discrimination thresholds were 7.0 ± 2.4 (mean ± standard deviation) and 5.9 ± 2.1 degrees for the first and the second assessment session, respectively. This small difference between assessments was significant (- 1.1 ± 2.2 degrees), however. The assessment protocol was characterized by a fair to good test-retest reliability (ICC = 0.47).Conclusion: This study demonstrated the potential of this assessment protocol to objectively quantify elbow position sense in healthy individuals. Futures studies will validate this protocol in older adults and in individuals who sustained a stroke. [ABSTRACT FROM AUTHOR]

Background: Robotic devices for neurorehabilitation of movement impairments in persons with stroke have been studied extensively. However, the vast majority of these devices only allow practice of stereotyped components of simulated functional tasks in the clinic. Previously we developed SpringWear, a wearable, spring operated, upper extremity exoskeleton capable of assisting movements during real-life functional activities, potentially in the home. SpringWear assists shoulder flexion, elbow extension and forearm supination/pronation. The assistance profiles were designed to approximate the torque required to move the joint passively through its range. These three assisted DOF are combined with two passive shoulder DOF, allowing complex multi-joint movement patterns.Methods: We performed a cross-sectional study to assess changes in movement patterns when assisted by SpringWear. Thirteen persons with chronic stroke performed range of motion (ROM) and functional tasks, including pick and place tasks with various objects. Sensors on the device measured rotation at all 5 DOF and a kinematic model calculated position of the wrist relative to the shoulder. Within subject t-tests were used to determine changes with assistance from SpringWear.Results: Maximum shoulder flexion, elbow extension and forearm pronation/supination angles increased significantly during both ROM and functional tasks (p < 0.002). Elbow flexion/extension ROM also increased significantly (p < 0.001). When the subjects volitionally held up the arm against gravity, extension at the index finger proximal interphalangeal joint increased significantly (p = 0.033) when assisted by SpringWear. The forward reach workspace increased 19% (p = 0.002). Nine subjects could not complete the functional tasks unassisted and only one showed improvement on task completion with SpringWear.Conclusions: SpringWear increased the usable workspace during reaching movements, but there was no consistent improvement in the ability to complete functional tasks. Assistance levels at the shoulder were increased only until the shoulder could be voluntarily held at 90 degrees of flexion. A higher level of assistance may have yielded better results. Also combining SpringWear with HandSOME, an exoskeleton for assisting hand opening, may yield the most dramatic improvements in functional task performance. These low-cost devices can potentially reduce effort and improve performance during task practice, increasing adherence to home training programs for rehabilitation. [ABSTRACT FROM AUTHOR]

Background Following a cerebrovascular accident (CVA or stroke), many patients experience learned non-use of the paretic arm (LNU UL ). One part of LNU is explained by the fact that the patient moves his trunk forward instead of extending his arm to reach a given object, even though he is capable of extending his arm. This is because using the trunk for this task demands less energy and concentration than using the paretic arm. This phenomenon is known to be detrimental to neuroplasticity and recovery. Objective The aim of this study is to quantify this part of learned non-use of the paretic upper limb during a hand-reaching task using 3D movement analysis. Methods Thirty-four post-supratentorial stroke participants were asked to reach a cone placed in front of them at 80% of their arm length. The reaching movement was repeated 5 times with the paretic hand, and then 5 times with the less-impaired hand. This sequence was first performed with the trunk free, then with the trunk restrained. Learned non-use of the upper limb (LNU UL ) was obtained from the difference of the amount of trunk compensation between the free trunk condition and the restrained trunk condition. Results LNU UL was significantly higher for the paretic hand, with individual values ranging from 1 to 43%, and one half of the patients with a LNU UL higher than 15%. Discussion/conclusion This quantification of LNU UL can be used to objectively pinpoint patients who have maladaptive trunk compensation and need specific trunk rehabilitation. It can be also used for monitoring the rehabilitation progress. This quantification of LNU UL may guide upper limb rehabilitation towards more optimal motor recovery avoiding maladaptive trunk compensation and its consequences on neuroplasticity. Considering LNU U could advance both theoretical and practical knowledge about the recovery of arm use after a CVA. [ABSTRACT FROM AUTHOR]