Search

Background: Mirror movement therapy may reduce lower limb motor impairment after stroke. The dose is unknown., Objective: identify the maximum tolerable dose a day (MTD) of lower limb mirror movement therapy DESIGN: 3 + 3 cohort rule-based, dose escalation/de-escalation study. After undertaking baseline measures participants performed mirror movement therapy for 14 consecutive days. Participants then undertook outcome measures. Cohort One trained for 15 minutes daily. Subsequent cohorts exercised at a dose set according to pre-set rules and the modified Fibonacci sequence. The study stopped when the difference between set doses for consecutive cohorts was 10% or less., Setting: Participants' homes (intervention) and a movement analysis laboratory (measures)., Participants: Adults discharged from statutory stroke rehabilitation services., Intervention: Mirror movement therapy ankle exercises., Outcome Measures: Motricity Index (primary) and bilateral time symmetry from movement onset to peak activation of Tibialis Anterior muscles during standardised sit-to-stand (secondary)., Results: Five cohorts of three participants were included (n = 15). Mean (SD) age and time after stroke were 61 (9) years and 35 (42) months respectively. Set daily doses for the five cohorts were: 15, 30, 50, 40 then 35 minutes. The set dose for a subsequent cohort (six) would have been 38 minutes thus the difference from cohort five would have been three minutes i.e., 9% different. Therefore, the study stopped CONCLUSION: The identified MTD of lower limb mirror therapy was 35 minutes daily when frequency was set at seven days a week and duration as two weeks., Clinical Trial Registration Number: NCT04339803 (ClinicalTrials.gov) CONTRIBUTION OF THE PAPER: This early phase study found that the maximum tolerable dose per day (MTD) of mirror movement therapy ankle exercises was 35 minutes when frequency was set at seven days a week and duration as two weeks. The optimal therapeutic dose will therefore be somewhere in the range of 15 (starting dose) to 35 minutes per day. Further dose articulation studies are required to identify the optimal therapeutic dose before use of findings in clinical practice. This study is the first step in that research process., Competing Interests: Conflict of interest statement Valerie M. Pomeroy is an Associate Editor and was not involved in the peer review of this paper., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Virtual reality-augmented therapist-delivered exercise-based training has promise for enhancing upper limb motor recovery after stroke. However, the neurophysiological mechanisms are unclear., Objective: To find if neurophysiological changes are correlated with or accompany a reduction in motor impairment in response to virtual reality-aided exercise-based training., Data Sources: Databases searched from inception to August 2020: MEDLINE, AMED, EMBASE, PUBMED, COCHRANE, CINHAL, PROQUEST and OPEN GREY., Eligibility Criteria: Studies that investigated virtual reality-augmented exercise-based training for the upper limb in adults with stroke, and, measured motor impairment and neurophysiological outcomes. Studies that combined VR with another technology were excluded., Data Extraction and Synthesis: Using pre-prepared proformas, three reviewers independently: identified eligible studies, assessed potential risk-of-bias, and extracted data. A critical narrative synthesis was conducted. A meta-analysis was not possible because of heterogeneity in participants, interventions and outcome measures., Results: Of 1387 records identified, four studies were eligible and included in the review. Overall, included studies were assessed as having high potential risk-of-bias. The VR equipment, and control interventions varied between studies. Two studies measured motor impairment with the Fugl-Meyer Assessment but there was no commonality in the use of neurophysiological measures. One study found improvement in neurophysiological measures only. The other three studies found a reduction in motor impairment and changes in neurophysiological outcomes, but did not calculate correlation coefficients., Conclusion: There is insufficient evidence to identify the neurophysiological changes that are correlated with, or accompany, reduction in upper limb motor impairment in response to virtual reality-augmented exercise-based training after stroke. Systematic Review Registration Number PROSPERO 2017 CRD42017071312., (Copyright © 2021 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)

Objectives: To co-design lower limb mirror therapy (MT) equipment and setup by working directly with stroke survivors and physiotherapists., Design: Co-design approach through focus groups., Participants: Twenty-six participants. Sixteen stroke survivors and ten physiotherapists., Data Collection and Analysis: Data were collected in an iterative process through two sets of focus groups. Firstly, prototype one of the MT equipment was presented to the participants. They were encouraged to use and comment on it. Then, the key requirements for ankle exercise with MT were presented, and participants discussed whether the prototype one was able to deliver these requirements. These findings informed iterations to the device, and a second prototype was produced and discussed in the second set of focus groups. The final prototype was then produced based on the participants' feedback. All focus groups were audio-recorded, followed by verbatim transcriptions and thematic analysis., Results: Main characteristics required of the lower limb MT device were found to be: the ability to produce MT ankle exercise from an upright sitting posture, an adjustable angle between 5 to 15 degree from the midline to allow clear lower limb reflection during seated exercise, and a lightweight device to enable easy use for stroke survivors., Conclusion: This work produced an iteratively co-design lower limb MT to be used with stroke survivors., (Copyright © 2021 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)

Background: Stroke survivors do not have routine access to objective feedback on their movement performance., Objective: To devise visual representation of objective measures of movement performance that are understandable by and meaningful to stroke survivors., Design: Co-production through interviews and generative discussion., Participants: Eight people, mean age 65 years, who were at least one year after stroke with low, medium or high functional ability. All provided informed consent., Data Collection: Participants performed standardised upper and lower limb functional tasks. Their movement was measured using the Vicon motion analysis system and surface electromyography. Participants returned six months later when they were shown anonymised visual representations of the movement tasks. Nobody saw their own data. Visual representations were provided of people with low, medium and high functional ability. A generative discussion elicited participants' views on how the measures should be presented visually to maximise understandability and meaningfulness., Findings: Participants' understanding of the visual presentation of movement analysis was enhanced with the addition of everyday symbols such as a stick-figure and a brief explanation from a physiotherapist/researcher. Meaningfulness was seen in terms of motivation to participate in and ownership of their rehabilitation., Implications: These findings justify further development of objective measures of movement performance for use in routine clinical practice., (Copyright © 2019 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)

Objectives: Restoration of walking is a priority for stroke survivors and key target for physical therapies. Upright pedalling (UP) can provide functional walking-like activity using a variety of muscle synergies; it is unclear which synergies might be most useful for recovery of walking. Objectives here were as follows: to examine whether neuromuscular measures derived during UP might identify targets for walking rehabilitation after stroke and to determine test-retest repeatability and concurrent validity of the measures., Design: This was a prospective correlational study., Setting: The study was carried out in a movement science laboratory., Participants: The participants were 18 adults with stroke (StrS) and 10 healthy older adults (HOA)., Intervention/measurement: StrS and HOA took part in two identical measurement sessions. During UP, surface electromyography and kinematic data were recorded and then processed to derive three measures: reciprocal activity of quadriceps and hamstrings; percentage muscle activity "on" according to crank angle; and smoothness of movement., Results: HOA and StrS demonstrated differences in reciprocal muscle activity (p = .044) and quadriceps activity according to crank angle (p = .034) but pedalled similarly smoothly (p = .367). For muscle activation according to crank angle in StrS, intraclass correlation coefficients (95% confidence interval) showing acceptable repeatability were 0.46 [0.32, 0.58] affected quadriceps; 0.43 [0.28, 0.56] affected hamstrings; and 0.67 [0.56, 0.75] unaffected quadriceps., Conclusion: Muscle activation according to crank angle is a promising measure of lower limb impairment during functional activity after stroke; subsequent investigation should determine magnitude of variance between testing sessions. Reciprocal activity of quadriceps and hamstrings muscles and quadriceps activity according to crank angle are both potential targets for physical therapies to improve motor recovery. Further investigations are warranted., (© 2019 John Wiley & Sons, Ltd.)

Background: Recovery of the sit-to-stand (StS) movement early after stroke could be improved by targeting physical therapy at the underlying movement deficits in those people likely to respond., Aim: To compare the movement characteristics of successful and failed StS movements in people early after stroke and identify which characteristics change in people recovering their ability to perform this movement independently following rehabilitation., Methods: Muscle activity and kinematic (including center of mass, CoM) data were recorded from 91 participants (mean 35 days after stroke) performing the StS movement before (baseline), immediately after (outcome), and 3 months after (follow-up) rehabilitation. Three subgroups (never-able [n = 19], always-able [n = 51], and able-after-baseline [n = 21]) were compared at baseline with the able-after-baseline subgroup compared before and after rehabilitation., Results: The subgroups differed at baseline for quadriceps onset time ( P = .009) and forward body position when quadriceps peaked ( P = .038). Following rehabilitation, the able-after-baseline subgroup increased their forward position ( P < .001), decreased the time difference between bilateral quadriceps peaks ( P < .001) and between quadriceps and hamstrings peaks on the nonhemiplegic side ( P = .007). An improved performance in the always-able subgroup was associated with a number of baseline factors, including forward positioning ( P = .002) and time difference between peak activity of bilateral quadriceps ( P = .001)., Conclusions: This neuromechanical study of StS before and after rehabilitation in a sample of people early after stroke identified the importance of temporal coupling between forward trunk movement and quadriceps and hamstrings' activity. These findings advance the science of stroke rehabilitation by providing evidence-based therapy targets to promote recovery of the StS movement.

Background and Objectives: Reach-to-grasp is an essential everyday activity that is often impaired after stroke. The objectives of this review are: (1) identify differences in the kinematic characteristics of reach-to-grasp between individuals with and without stroke, and (2) determine the influence of object location on kinematics., Data Sources: MEDLINE, AMED, and Embase databases., Eligibility Criteria: Studies investigating individuals with stroke and neurologically intact control participants completing reach-to-grasp (paretic upper limb) of an object assessed via kinematic assessment (motion analysis)., Review Methods: Following Cochrane Collaboration guidelines a meta-analysis comparing kinematic characteristics of reach-to-grasp between individuals with and without stroke. Potential risk of bias was assessed using the Down's and Black Tool. Data were synthesised by calculating the standardised mean difference (SMD) in kinematic characteristics between adults with and without stroke., Results: Twenty-nine studies met the review criteria, mainly of observational design; 460 individuals with stroke and 324 control participants. Kinematic differences in reach-to-grasp were identified in the central and ipsilateral workspace for example, individuals with stroke exhibited significantly lower peak velocity SMD -1.48 (95% CI -1.94, -1.02), and greater trunk displacement SMD 1.55 (95% CI 0.85, 2.25) than control participants. Included studies were assessed as demonstrating unclear or high potential risk-of-bias., Conclusions: Differences in kinematic characteristics between individuals with and without stroke were identified which may be different reaching in the ipsilateral and central workspace. Suggesting, that object location may influence some kinematic characteristics and not others which may be pertinent when re-training reach-to-grasp., Prospero: CRD42014009479., (Copyright © 2017 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)

Objective: To assess the feasibility and acceptability of training stroke service staff to provide supported communication for people with moderate-severe aphasia in the acute phase; assess the suitability of outcome measures; collect data to inform sample size and Health Economic evaluation in a definitive trial., Design: Phase II cluster-controlled, observer-blinded feasibility study., Settings: In-patient stroke rehabilitation units in the UK matched for bed numbers and staffing were assigned to control and intervention conditions., Participants: 70 stroke rehabilitation staff from all professional groups, excluding doctors, were recruited. 20 patients with moderate-severe aphasia were recruited., Intervention: Supported communication for aphasia training, adapted to the stroke unit context versus usual care. Training was supplemented by a staff learning log, refresher sessions and provision of communication resources., Main Outcome Measures: Feasibility of recruitment and acceptability of the intervention and of measures required to assess outcomes and Health Economic evaluation in a definitive trial. Staff outcomes: Measure of Support in Conversation; patient outcomes: Stroke and Aphasia Quality of Life Scale; Communicative Access Measure for Stroke; Therapy Outcome Measures for aphasia; EQ-5D-3L was used to assess health outcomes., Results: Feasibility of staff recruitment was demonstrated. Training in the intervention was carried out with 28 staff and was found to be acceptable in qualitative reports. 20 patients consented to take part, 6 withdrew. 18 underwent all measures at baseline; 16 at discharge; and 14 at 6-month follow-up. Of 175 patients screened 71% were deemed to be ineligible, either lacking capacity or too unwell to participate. Poor completion rates impacted on assessment of patient outcomes. We were able to collect sufficient data at baseline, discharge and follow-up for economic evaluation., Conclusions: The feasibility study informed components of the intervention and implementation in day-to-day practice. Modifications to the design are needed before a definitive cluster-randomised trial can be undertaken., Trial Registration Number: ISRCTN37002304; Results., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objectives: Recovery of independent ambulation after stroke is a major goal. However, which rehabilitation regimen best benefits each individual is unknown and decisions are currently made on a subjective basis. Predictors of response to specific therapies would guide the type of therapy most appropriate for each patient. Although lesion topography is a strong predictor of upper limb response, walking involves more distributed functions. Earlier studies that assessed the cortico-spinal tract (CST) were negative, suggesting other structures may be important., Experimental Design: The relationship between lesion topography and response of walking speed to standard rehabilitation was assessed in 50 adult-onset patients using both volumetric measurement of CST lesion load and voxel-based lesion-symptom mapping (VLSM) to assess non-CST structures. Two functional mobility scales, the functional ambulation category (FAC) and the modified rivermead mobility index (MRMI) were also administered. Performance measures were obtained both at entry into the study (3-42 days post-stroke) and at the end of a 6-week course of therapy. Baseline score, age, time since stroke onset and white matter hyperintensities score were included as nuisance covariates in regression models., Principal Observations: CST damage independently predicted response to therapy for FAC and MRMI, but not for walk speed. However, using VLSM the latter was predicted by damage to the putamen, insula, external capsule and neighbouring white matter., Conclusions: Walk speed response to rehabilitation was affected by damage involving the putamen and neighbouring structures but not the CST, while the latter had modest but significant impact on everyday functions of general mobility and gait. Hum Brain Mapp 37:689-703, 2016. © 2015 Wiley Periodicals, Inc., (© 2015 The Authors Human Brain Mapping Published by Wiley Periodicals, Inc.)

Background: Bilateral training (BT) of the upper limb (UL) might enhance recovery of arm function after stroke. To better understand the therapeutic potential of BT, this study aimed to determine the correlation between arm motor behavior and brain structure/function as a result of bilateral arm training poststroke., Methods: A systematic review of quantitative studies of BT evaluating both UL motor behavior and neuroplasticity was conducted. Eleven electronic databases were searched. Two reviewers independently selected studies, extracted data and assessed methodological quality, using the Effective Public Health Practice Project (EPHPP) tool., Results: Eight studies comprising 164 participants met the inclusion criteria. Only two studies rated "strong" on the EPHPP tool. Considerable heterogeneity of participants, BT modes, comparator interventions and measures contraindicated pooled outcome analysis. Modes of BT included: in-phase and anti-phase; functional movements involving objects; and movements only. Movements were mechanically coupled, free, auditory-cued, or self-paced. The Fugl-Meyer Assessment (UL section) was used in six of eight studies, however, different subsections were used by different studies. Neural correlates were measured using fMRI and TMS in three and five studies, respectively, using a wide variety of variables. Associations between changes in UL function and neural plasticity were inconsistent and only two studies reported a statistical correlation following BT., Conclusions: No clear pattern of association between UL motor and neural response to BT was apparent from this review, indicating that the neural correlates of motor behavior response to BT after stroke remain unknown. To understand the full therapeutic potential of BT and its different modes, further investigation is required.

Rationale: Functional strength training in addition to conventional physical therapy could enhance upper limb recovery early after stroke more than movement performance therapy plus conventional physical therapy., Aims: To determine (a) the relative clinical efficacy of conventional physical therapy combined with functional strength training and conventional physical therapy combined with movement performance therapy for upper limb recovery; (b) the neural correlates of response to conventional physical therapy combined with functional strength training and conventional physical therapy combined with movement performance therapy; (c) whether any one or combination of baseline measures predict motor improvement in response to conventional physical therapy combined with functional strength training or conventional physical therapy combined with movement performance therapy., Design: Randomized, controlled, observer-blind trial., Study: The sample will consist of 288 participants with upper limb paresis resulting from a stroke that occurred within the previous 60 days. All will be allocated to conventional physical therapy combined with functional strength training or conventional physical therapy combined with movement performance therapy. Functional strength training and movement performance therapy will be undertaken for up to 1·5 h/day, five-days/week for six-weeks., Outcomes and Analysis: Measurements will be undertaken before randomization, six-weeks thereafter, and six-months after stroke. Primary efficacy outcome will be the Action Research Arm Test. Explanatory measurements will include voxel-wise estimates of brain activity during hand movement, brain white matter integrity (fractional anisotropy), and brain-muscle connectivity (e.g. latency of motor evoked potentials). The primary clinical efficacy analysis will compare treatment groups using a multilevel normal linear model adjusting for stratification variables and for which therapist administered the treatment. Effect of conventional physical therapy combined with functional strength training versus conventional physical therapy combined with movement performance therapy will be summarized using the adjusted mean difference and 95% confidence interval. To identify the neural correlates of improvement in both groups, we will investigate associations between change from baseline in clinical outcomes and each explanatory measure. To identify baseline measurements that independently predict motor improvement, we will develop a multiple regression model., (© 2013 The Authors. International Journal of Stroke published by John Wiley & Sons Ltd on behalf of World Stroke Organization.)

Rationale: Functional Strength Training may enhance motor function of people who are more than six months post stroke., Aims: to evaluate the clinical efficacy of enhancing upper and lower limb motor function with FST to explore participants' views (expectations and experiences) of FST, and to determine what cost-effectiveness data to collect in a subsequent Phase III trial., Design: Randomized, observer-blind trial with embedded qualitative investigation of participants' views of FST (n = 6, purposive sampling)., Study: Participants (n = 58), six months to five years after stroke with difficulty using their paretic upper (UL) and lower limbs (LL) for everyday functional activity. All will be randomized to either FST-UL or FST-LL delivered in their own homes for four days each week for six weeks. FST involves repetitive progressive resisted exercise during goal directed functional activities. The therapist's main input is to provide verbal prompting and feedback., Outcomes: Measures will be undertaken before randomization (baseline), after the six-week intervention (outcome) and six weeks thereafter (follow-up). Primary outcomes for clinical efficacy will be the Functional Ambulation Categories (FAC) and the Action Research Arm Test (ARAT). Clinical efficacy analysis will use the proportional odds model for FAC and a Mann-Whitney test for ARAT. Participants' views of FST will be explored at baseline and outcome through audiotaped, semi-structured, narrative approach, interviews. The analytic process for interviews will sort transcribed data thematically and seek categories to inform conceptualization (theory-building). A purpose-designed cost questionnaire will identify what cost resource items are likely to be affected by FST., (© 2012 The Authors. International Journal of Stroke © 2012 World Stroke Organization.)

Background and Purpose: In recovered subcortical stroke, the pattern of motor network activation during motor execution can appear normal or not, depending on the task. Whether this applies to other aspects of motor function is unknown. We used functional MRI to assess motor imagery (MI), a promising new approach to improve motor function after stroke, and contrasted it to motor execution., Methods: Twenty well-recovered patients with hemiparetic subcortical stroke (14 males; mean age, 66.5 years) and 17 aged-matched control subjects were studied. Extensive behavioral screening excluded 8 patients and 4 control subjects due to impaired MI abilities. Subjects performed MI and motor execution of a paced finger-thumb opposition sequence using a functional MRI paradigm that monitored compliance. Activation within the primary motor cortex (BA4a and 4p), dorsal premotor, and supplementary motor areas was examined., Results: The pattern of activation during affected-hand motor execution was not different from control subjects. Affected-hand MI activation was also largely similar to control subjects, including involvement of BA4, but with important differences: (1) unlike control subjects and the nonaffected hand, activation in BA4a and dorsal premotor was not lower during MI as compared with motor execution; (2) the hemispheric balance of BA4p activation was significantly less lateralized than control subjects; and (3) ipsilesional BA4p activation positively correlated with motor performance., Conclusions: In well-recovered subcortical stroke, the motor system, including ipsilesional BA4, is activated during MI despite the lesion. It, however, remains disorganized in proportion to residual motor impairment. Thus, components of movement upstream from execution appear differentially affected after stroke and could be targeted by rehabilitation in more severely affected patients.

Objective: Repetitive transcranial magnetic stimulation (rTMS) of the lesioned hemisphere might enhance motor recovery after stroke, but the appropriate dose (parameters of rTMS) remains uncertain. The present review collates evidence of the effect of rTMS on corticospinal pathway excitability and motor function in healthy adults and in people after stroke., Methods: The authors searched MEDLINE and EMBASE (1996 to April 2007), their own collection of peer-reviewed articles, and the reference lists of included studies. They included healthy adults or people with stroke who received rTMS to the primary motor cortex to facilitate or inhibit contralateral corticospinal excitability or movement control., Findings: Of the 625 references identified, 37 studies were included with 455 healthy adults (34 studies) and 69 people with stroke (3 studies). For healthy adults, the effects of rTMS on corticospinal pathway excitability varied within each frequency, for example, 1 Hz rTMS was found to facilitate, inhibit, and have no effect on amplitude of motor-evoked potentials (MEPs). After stroke there was a trend for recovery of MEPs (ie, presence of MEPs) after 10 daily sessions of 3 Hz rTMS (one study). Motor function in healthy adults might be adversely affected by 1 Hz rTMS (two studies), whereas combined frequency rTMS was found to have no effect (one study)., Interpretation: There is as yet insufficient published evidence to guide the dose of rTMS to the lesioned hemisphere after stroke to improve recovery of a paretic limb. Moreover, it is apparent that there is variability in response to rTMS in healthy adults. Dose-finding studies in groups of well-characterized stroke patients are needed.

Objective: To explore the efficacy of repetitive transcranial magnetic stimulation (rTMS) and voluntary muscle contraction (VMC) to improve corticospinal transmission, muscle function, and purposeful movement early after stroke., Methods: Factorial 2 x 2 randomized single-blind trial., Subjects: n = 27, mean age 75 years, mean 27 days after middle cerebral artery infarct (24 subjects completed outcome measures)., Procedure: after baseline measurement (day 1), subjects were randomized to 1 of 4 groups. Treatment was given for the next 8 working days, and outcome was measured on day 10., Interventions: (a) Real-rTMS + RealVMC, (b) Real-rTMS + PlaceboVMC, (c) Placebo-rTMS + RealVMC, and (d) Placebo-rTMS + PlaceboVMC. Real-rTMS consisted of 200 1-Hz stimuli at 120% motor threshold in 5 blocks of 40 separated by 3 minutes delivered to the lesioned hemisphere. Placebo-rTMS used a dummy coil. In RealVMC, the paretic elbow was repeatedly flexed/extended for 5 minutes. In PlaceboVMC, subjects viewed pairs of drawings of upper limbs and reported their likeness., Outcomes: frequency of motor-evoked potentials in biceps and triceps, muscle function (torque about elbow), and purposeful movement (Action Research Arm Test)., Analysis: group mean changes (outcome - baseline) were compared., Results: In the Real-rTMS + RealVMC group, motor-evoked potential frequency increased 14% for biceps and 20% for triceps, whereas in the Placebo-rTMS + PlaceboVMC group, it decreased 12% for biceps and 6% for triceps. For other groups, there were changes of intermediate values. No meaningful differences were found for secondary outcomes., Conclusions: A positive trend for motor-evoked potential frequency was found for Real-rTMS + RealVMC, whereas a negative trend for motor-evoked potential frequency was found for Placebo-rTMS + PlaceboVMC.

Recovery of upper limb movement control after stroke might be enhanced by repetitive goal-directed functional activities. Providing such activity is challenging in the presence of severe paresis. A possible new approach is based on the discovery of mirror neurons in the monkey cortical area F5, which are active both in observing and executing a movement. Indirect evidence for a comparable human "mirror neurone system" is provided by functional imaging. The primary motor cortex, the premotor cortex, other brain areas, and muscles appropriate for the action being observed are probably activated in healthy volunteers observing another's movement. These findings raise the hypothesis that observation of another's movement might train the movement execution system of stroke patients who have severe paresis to bring them to the point at which they could actively participate in rehabilitation consisting of goal-directed activities. The point of providing an observation therapy would be to facilitate the voluntary production of movement; therefore, the condition of interest would be observation with intent to imitate. However, there is as yet insufficient evidence to enable the testing of this hypothesis in stroke patients. Studies in normal subjects are needed to determine which brain sites are activated in response to observation with intent to imitate. Studies in stroke subjects are needed to determine how activation is affected after damage to different brain areas. The information from such studies should aid identification of those stroke patients who might be most likely to benefit from observation to imitate and therefore guide phase I clinical studies.

Background: Somatosensory stimulation of the lower extremity could improve motor recovery and walking post-stroke. This pilot study investigated the feasibility of a subsequent randomized controlled trial (RCT) to determine whether task-specific gait training is more effective following either (a) intensive hands-on somatosensory stimulation or (b) wearing textured insoles. Objectives: Determine recruitment and attrition rates, adherence to intervention, acceptability and viability of interventions and outcome measures, and estimate variance of outcome data to inform sample size for a subsequent RCT. Methods: Design: randomized, single-blinded, mixed-methods pilot study. Setting: In-patient rehabilitation ward and community. Participants: n = 34, 18+years, 42–112 days following anterior or posterior circulation stroke, able to follow simple commands, able to walk independently pre-stroke, and providing informed consent. Intervention: Twenty 30-min sessions of task-specific gait training (TSGT) (delivered over 6 weeks) in addition to either: (a) 30–60 min mobilization and tactile stimulation (MTS); or (b) unlimited textured insole (TI) wearing. Outcomes: Ankle range of movement (electrogoniometer), touch-pressure sensory thresholds (Semmes Weinstein Monofilaments), motor impairment (Lower Extremity Motricity Index), walking ability and speed (Functional Ambulation Category, 5-m walk test, pressure insoles) and function (modified Rivermead Mobility Index), measured before randomization, post-intervention, and 1-month thereafter (follow-up). Adherence to allocated intervention and actual dose delivered (fidelity) were documented in case report forms and daily diaries. Focus groups further explored acceptability of interventions and study experience. Analysis: Recruitment, attrition, and dose adherence rates were calculated as percentages of possible totals. Thematic analysis of daily diaries and focus group data was undertaken. Standard deviations of outcome measures were calculated and used to inform a sample size calculation. Results: Recruitment, attrition, and adherence rates were 48.57, 5.88, and 96.88%, respectively. Focus groups, daily-diaries and case report forms indicated acceptability of interventions and outcome measures to participants. The 5-m walk was selected as primary outcome measure for a future trial [mean (SD) at end of intervention: 16.86 (11.24) MTS group and 21.56 (13.57) TI group]; sample size calculation indicated 60 participants are required per group. Conclusion: Recruitment, attrition and adherence rates and acceptability of interventions and outcomes justify a subsequent powered RCT of MTS+TSGT compared with TI+TSGT. [ABSTRACT FROM AUTHOR]

AbstractPurposeMethodsResultsConclusionsClinical Trial Registration\nIMPLICATIONS FOR REHABILITATIONMotor evoked potential (MEP) characteristics are potential biomarkers of whether rehabilitation interventions drive motor recovery after stroke. The test-retest reliability of Transcranial Magnetic Stimulation (TMS) measurements in sub-acute stroke remains unclear. This study aims to determine the test-retest reliability of upper limb MEP measures elicited by non-neuronavigated transcranial magnetic stimulation in sub-acute-stroke.In two identical data collection sessions, 1–3 days apart, TMS measures assessed: motor threshold (MT), amplitude, latency (MEP-L), silent period (SP), recruitment curve slope in the biceps brachii (BB), extensor carpi radialis (ECR), and abductor pollicis brevis (APB) muscles of paretic and non-paretic upper limbs. Test-retest reliability was calculated using the intra-class correlation coefficient (ICC) and 95% confidence intervals (CI). Acceptable reliability was set at a lower 95% CI of 0.70 or above. The limits of agreement (LOA) and smallest detectable change (SDC) were calculated.30 participants with sub-acute stroke were included (av 36 days post stroke) reliability was variable between poor to good for the different MEP characteristics. The SDC values differed across muscles and MEP characteristics in both paretic and less paretic limbs.The present findings indicate there is limited evidence for acceptable test-retest reliability of non-navigated TMS outcomes when using the appropriate 95% CI for ICC, SDC and LOA values.Current Controlled Trials: ISCRT 19090862, http://www.controlled-trials.comThis study identified that Non-navigated Transcranial Magnetic Stimulation (TMS) demonstrates low reliability of TMS measures in upper limb with variation between muscles and measures in sub-acute strokeWhen using non-navigated TMS to explore corticospinal pathway excitability the individual target muscle and TMS measure should be taken into considerationNon-navigated TMS may be more useful in exploring group differences rather than individual differences in corticospinal pathway excitabilityNon-navigated TMS could provide a means of measuring recovery in clinical practice and could inform the development of more effective interventions but this needs further development before it can be used as a clinical recovery biomarker [ABSTRACT FROM AUTHOR]

Background: Better upper limb recovery after stroke could be achieved through tailoring rehabilitation interventions directly at movement deficits. Aim: To identify potential; targets for therapy by synthesizing findings of differences in kinematics and muscle activity between stroke survivors and healthy adults performing reach-to-target tasks. Methods: A systematic review with identification of studies, data extraction, and potential risk of bias was completed independently by two reviewers. Online databases were searched from their inception to November 2017 to find studies of reach-to-target in people-with-stroke and healthy adults. Potential risk-of-bias was assessed using the Down's and Black Tool. Synthesis was undertaken via: (a) meta-analysis of kinematic characteristics utilizing the standardized mean difference (SMD) [95% confidence intervals]; and (b), narrative synthesis of muscle activation. Results: Forty-six studies met the review criteria but 14 had insufficient data for extraction. Consequently, 32 studies were included in the meta-analysis. Potential risk-of-bias was low for one study, unclear for 30, and high for one. Reach-to-target was investigated with 618 people-with-stroke and 429 healthy adults. The meta-analysis found, in all areas of workspace, that people-with-stroke had: greater movement times (seconds) e.g., SMD 2.57 [0.89, 4.25]; lower peak velocity (millimeters/second) e.g., SMD −1.76 [−2.29, −1.24]; greater trunk displacement (millimeters) e.g. SMD 1.42 [0.90, 1.93]; a more curved reach-path-ratio e.g., SMD 0.77 [0.32, 1.22] and reduced movement smoothness e.g., SMD 0.92 [0.32, 1.52]. In the ipsilateral and contralateral workspace, people-with-stroke exhibited: larger errors in target accuracy e.g., SMD 0.70 [0.39, 1.01]. In contralateral workspace, stroke survivors had: reduced elbow extension and shoulder flexion (degrees) e.g., elbow extension SMD −1.10 [−1.62, −0.58] and reduced shoulder flexion SMD −1.91 [−1.96, −0.42]. Narrative synthesis of muscle activation found that people-with-stroke, compared with healthy adults, exhibited: delayed muscle activation; reduced coherence between muscle pairs; and use of a greater percentage of muscle power. Conclusions: This first-ever meta-analysis of the kinematic differences between people with stroke and healthy adults performing reach-to-target found statistically significant differences for 21 of the 26 comparisons. The differences identified and values provided are potential foci for tailored rehabilitation interventions to improve upper limb recovery after stroke. [ABSTRACT FROM AUTHOR]

Background: Variation in physiological deficits underlying upper limb paresis after stroke could influence how people recover and to which physical therapy they best respond. Objectives: To determine whether functional strength training (FST) improves upper limb recovery more than movement performance therapy (MPT). To identify: (a) neural correlates of response and (b) whether pre-intervention neural characteristics predict response. Design: Explanatory investigations within a randomised, controlled, observer-blind, and multicentre trial. Randomisation was computer-generated and concealed by an independent facility until baseline measures were completed. Primary time point was outcome, after the 6-week intervention phase. Follow-up was at 6 months after stroke. Participants: With some voluntary muscle contraction in the paretic upper limb, not full dexterity, when recruited up to 60 days after an anterior cerebral circulation territory stroke. Interventions: Conventional physical therapy (CPT) plus either MPT or FST for up to 90 min-a-day, 5 days-a-week for 6 weeks. FST was "hands-off" progressive resistive exercise cemented into functional task training. MPT was "hands-on" sensory/facilitation techniques for smooth and accurate movement. Outcomes: The primary efficacy measure was the Action Research Arm Test (ARAT). Neural measures: fractional anisotropy (FA) corpus callosum midline; asymmetry of corticospinal tracts FA; and resting motor threshold (RMT) of motor-evoked potentials. Analysis: Covariance models tested ARAT change from baseline. At outcome: correlation coefficients assessed relationship between change in ARAT and neural measures; an interaction term assessed whether baseline neural characteristics predicted response. Results: 288 Participants had: mean age of 72.2 (SD 12.5) years and mean ARAT 25.5 (18.2). For 240 participants with ARAT at baseline and outcome the mean change was 9.70 (11.72) for FST + CPT and 7.90 (9.18) for MPT + CPT, which did not differ statistically (p = 0.298). Correlations between ARAT change scores and baseline neural values were between 0.199, p = 0.320 for MPT + CPT RMT (n = 27) and -0.147, p = 0.385 for asymmetry of corticospinal tracts FA (n = 37). Interaction effects between neural values and ARAT change between baseline and outcome were not statistically significant. Conclusions: There was no significant difference in upper limb improvement between FST and MPT. Baseline neural measures did not correlate with upper limb recovery or predict therapy response. Trial registration: Current Controlled Trials: ISRCT 19090862, http://www.controlled- trials.com [ABSTRACT FROM AUTHOR]

Background. Physical therapy doses may need to be higher than provided in current clinical practice, especially for patients with severe paresis. The authors aimed to find the most effective and feasible dose of Mobilisation and Tactile Stimulation (MTS), which includes joint and soft-tissue mobilization and passive or active-assisted movement to enhance voluntary muscle contraction. Methods. This 2-center, randomized, controlled, observer-blinded feasibility trial compared conventional rehabilitation but no extra therapy (group 1) with conventional therapy plus 1 of 3 daily doses of MTS, up to 30 (group 2), 60 (group 3), or 120 (group 4) minutes for 14 days. The 76 participants had substantial paresis (Motricity Index [MI] < 61) a mean of 30 days (standard deviation [SD] = 20 days) after anterior circulation stroke. MTS was delivered using a standardized schedule of techniques (eg, sensory input, active-assisted movement). The primary outcome was the Motricity Index (MI) and secondary outcome was the Action Research Arm Test (ARAT) tested on day 16. Adverse events were monitored daily. Results. No difference was found in the change in control group MI compared with each of the 3 intervention groups (P = .593) or in the ARAT. Mean actual daily treatment time for all MTS groups was less than expected. The attrition rate was 1.3%. No adverse events related to overuse occurred. Conclusion. The authors were not able to deliver a maximum dose of 120 minutes of daily therapy each day. The mean daily dose of MTS feasible for subsequent evaluation is between 37 and 66 minutes. [ABSTRACT FROM PUBLISHER]

After stroke, physiotherapy can promote brain reorganization and motor recovery. Combining muscle strength and functional training (functional strength training, FST) may be beneficial. The aim of the authors was to compare FST with conventional physiotherapy (CPT) while controlling for the potential confounder of therapy intensity in a multicenter, randomized controlled observer-blind trial. The mean age of the participants was 68.3 (standard deviation [SD] = 12.03) years at a mean of 34 (SD = 20) days after stroke, with mean peak paretic knee extension torque (torque) of 22 (SD = 25) Nm. The estimated sample size was 102 to detect a between-group difference of 0.2 m/s in walking speed. After baseline measures, participants were allocated randomly to CPT or CPT + CPT or CPT + FST for 6 weeks. Additional experimental therapy was provided for up to 1 hour a day, 4 times each week. Outcomes were measured 6 weeks after baseline and at follow-up 12 weeks thereafter. Measures included walking speed, knee extensor torque, and functional mobility (Rivermead). At outcome, both extraintensity groups showed greater increases in walking speed than the CPT group, but this reached significance only for the CPT + CPT group (P = .031). The CPT + CPT group also had a greater number of participants who walked at 0.8 m/s or above. No significant differences were observed for torque about the knee or for the Rivermead score. At follow-up, no significant differences were observed. These phase I results justify a subsequent trial of CPT + CPT versus CPT + FST. [ABSTRACT FROM AUTHOR]

Background. Motor imagery may enhance motor recovery after stroke. Objectives. To estimate the proportion of patients able to perform motor imagery, the feasibility of delivery of motor imagery training (MIT), and the effects of MIT on motor recovery in an exploratory study.Methods.An immediate pretreatment and posttreatment single-group design was used to study 10 patients after subcortical stroke with neuromuscular weakness in the upper limb. MIT that included upper limb activities reflecting everyday tasks was provided for 10 consecutive working days. Measures included assessment of chaotic motor imagery, patient report of tolerability of MIT, Motricity Index (MI), Nine Hole Peg Test (9HPT), and quality of movement (MAL-QOM). MIT dose was changed in response to patient feedback. Graphed motor function scores were inspected visually for clinically important changes.Results. Four of the 10 patients were unable to perform motor imagery. Patient opinion was positive about the content and shaped daily dose of MIT given in two 20-minute periods separated by a 10-minute rest. Clinically important changes in motor scores were found. Four patients increased MI score (range 8-16), 3 patients increased 9HPT score (range 0.02-0.04 pegs/second), and 4 patients increased MAL-QOM score (range 0.63-1.29). Conclusions. MIT was received positively by patients, but 40% were unable to perform imagery and interindividual variations were found on motor function. [ABSTRACT FROM AUTHOR]

There are many randomized controlled trials relating to stroke rehabilitation being carried out in China, which are often published in Chinese-language journals. A recent update to our Cochrane systematic review of physical rehabilitation to improve function and mobility after stroke included 96 trials; over half (51) were conducted in China; 37 of these included studies were published in Chinese. Analyses within this Cochrane review support the conclusion that physical rehabilitation, using a mix of components from different approaches, is effective for the recovery of function and mobility after stroke. The inclusion of the Chinese studies had a substantial impact on the volume of evidence and, consequently, the conclusions. In this paper, we explore whether it is appropriate to draw implications for clinical practice throughout the world from evidence relating to a complex rehabilitation intervention delivered within one particular geographical healthcare setting. We explore the unique challenges associated with incorporating the body of evidence from China, particularly the Chinese-language publications, and identify the ongoing debate about the quality of Chinese research publications. We conclude that the growing body of evidence from China has important implications for future systematic reviews and evidence-based stroke care, but analysis and interpretation raise challenges, and improved reporting is critical. [ABSTRACT FROM AUTHOR]

This study investigated the feasibility of the uncontrolled manifold approach (UCM) to analyse gait data variability in relation to the control of the centre of mass (COM) in adults with and without neuropathology. The proposed method was applied to six able-bodied subjects to characterise mechanisms of normal postural control during stance phase. This approach was repeated on an early stroke patient, who attended the laboratory three times at three monthly intervals, to characterise the variability of COM movement during walking with and without an orthosis. Both able-bodied subjects and the stroke participant controlled COM movement during stance but utilized a different combination of lower limb joint kinematics to ensure that the COM trajectory was not compromised. Interestingly, the stroke subject, despite a higher variability in joint kinematics, was able to maintain a stable COM position throughout stance phase. The stabilisation of the COM decreased when the patient walked unaided without the prescribed orthosis but increased over the six months of study. The UCM analysis demonstrated how a stroke patient used a range of lower limb motion pattern to stabilise the COM trajectory. It is suggested that this analysis can be used to track changes in these movement patterns in response to rehabilitation. As such we propose that this approach could have clinical utility to evaluate and prescribe rehabilitation in stroke patients. [ABSTRACT FROM AUTHOR]