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Objective: The aim of this systematic review is to identify currently available tele-assessments for motor impairments of the upper extremity in adults after a stroke and to assess their psychometric properties and clinical utility., Data Sources: We searched for studies describing the psychometric properties of tele-assessments for the motor function of the upper extremity. A systematic search was conducted in the Cumulative Index to Nursing and Allied Health Literature, Medline via OVID, Embase, The Cochrane Library, Scopus, Web of Science and Institute of Electrical and Electronics Engineers Xplore from inception until 30 April 2024., Review Methods: The quality assessment for the included studies and the rating of the psychometric properties were performed using the COSMIN Risk of Bias Checklist for systematic reviews of patient-reported outcome measures., Results: A total of 12 studies (N = 3912) describing 11 tele-assessments met the predefined inclusion criteria. The included assessments were heterogeneous in terms of quality and psychometric properties and risk of bias. None of the tele-assessments currently meets the criteria of clinical utility to be recommended for clinical practice without restriction., Conclusion: The quality and clinical utility of tele-assessments varied widely, suggesting a cautious consideration for immediate clinical practice application. There is potential for tele-assessments in clinical practice, but the clinical benefits need to be improved by simplifying the complexity of tele-assessments., Registration Number: CRD42022335035., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To propose a consensus-based definition and framework for motor rehabilitation after stroke., Methods: An expert European working group reviewed the literature, attaining internal consensus after external feedback., Findings: Motor rehabilitation is defined as a process that engages people with stroke to benefit their motor function, activity capacity and performance in daily life. It is necessary for people with residual motor disability whose goal is to enhance their functioning, independence and participation. Motor rehabilitation operates through learning- and use-dependent mechanisms. The trajectory of motor recovery varies across patients and stages of recovery. Early behavioral restitution of motor function depends on spontaneous biological mechanisms. Further improvements in activities of daily living are achieved by compensations. Motor rehabilitation is guided by regular assessment of motor function and activity using consensus-based measures, including patient-reported outcomes. Results are discussed with the patient and their carers to set personal goals. During motor rehabilitation patients learn to optimize and adapt their motor, sensory and cognitive functioning through appropriately dosed repetitive, goal-oriented, progressive, task- and context-specific training. Motor rehabilitation supports people with stroke to maximize health, well-being and quality of life. The framework describes the International Classification of Functioning, Disability and Health in the context of stroke, describes neurobiological mechanisms of behavioral restitution and compensation, and summarizes recommendations for clinical assessment, prediction tools, and motor interventions with strong recommendations from clinical practice guidelines (2016-2022)., Conclusions: This definition and framework may guide clinical educators, inform clinicians on current recommendations and guidelines, and identify gaps in the evidence base., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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

The restoration of gait and mobility after stroke is an important and challenging therapy goal due to the complexity of the potentially impaired functions. As a result, precise and clinically feasible assessment methods are required for personalized gait rehabilitation after stroke. The aim of this study is to investigate the reliability and validity of a sensor-based gait analysis system in stroke survivors with different severities of gait deficits. For this purpose, 28 chronic stroke survivors (9 women, ages: 62.04 ± 11.68 years) with mild to moderate walking impairments performed a set of ambulatory assessments (3× 10MWT, 1× 6MWT per session) twice while being equipped with a sensor suit. The derived gait reports provided information about speed, step length, step width, swing and stance phases, as well as joint angles of the hip, knee, and ankle, which we analyzed for test-retest reliability and hypothesis testing. Further, test-retest reliability resulted in a mean ICC of 0.78 (range: 0.46-0.88) for walking 10 m and a mean ICC of 0.90 (range: 0.63-0.99) for walking 6 min. Additionally, all gait parameters showed moderate-to-strong correlations with clinical scales reflecting lower limb function. These results support the applicability of this sensor-based gait analysis system for individuals with stroke-related walking impairments.

The proportional recovery rule (PRR) posits that most stroke survivors can expect to reduce a fixed proportion of their motor impairment. As a statistical model, the PRR explicitly relates change scores to baseline values - an approach that arises in many scientific domains but has the potential to introduce artifacts and flawed conclusions. We describe approaches that can assess associations between baseline and changes from baseline while avoiding artifacts due either to mathematical coupling or to regression to the mean. We also describe methods that can compare different biological models of recovery. Across several real datasets in stroke recovery, we find evidence for non-artifactual associations between baseline and change, and support for the PRR compared to alternative models. We also introduce a statistical perspective that can be used to assess future models. We conclude that the PRR remains a biologically relevant model of stroke recovery., Competing Interests: JG, TK, AG, RK, AL, CS, WB, GK, JK No competing interests declared, (© 2022, Goldsmith et al.)

Objective: The 'Early Prediction of Functional Outcome after Stroke' (EPOS) model was developed to predict the presence of at least some upper limb capacity (Action Research Am Test [ARAT] ≥10/57) at 6 months based on assessments on days 2, 5 and 9 after stroke. External validation of the model is the next step towards clinical implementation. The objective here is to externally validate the EPOS model for upper limb outcome 3 months poststroke in Switzerland and extend the model using an ARAT cut-off at 32 points., Methods: Data from two prospective longitudinal cohort studies including first-ever stroke patients admitted to a Swiss stroke center were analyzed. The presence of finger extension and shoulder abduction was measured on days 1 and 8 poststroke in Cohort 1, and on days 3 and 9 in Cohort 2. Upper limb capacity was measured 3 months poststroke. Discrimination (area under the curve; AUC) and calibration obtained with the model were determined., Results: In Cohort 1 (N = 39, median age 74 years), the AUC on day 1 was 0.78 (95%CI 0.61, 0.95) and 0.96 (95%CI 0.90, 1.00) on day 8, using the model of day 5. In Cohort 2 (N = 85, median age 69 years), the AUC was 0.96 (95%CI 0.93, 0.99) on day 3 and 0.89 (95% CI 0.80, 0.98) on day 9. Applying a 32-point ARAT cut-off resulted in an AUC ranging from 0.82 (95%CI 0.68, 0.95; Cohort 1, day 1) to 0.95 (95%CI 0.87, 1.00; Cohort 1, day 8)., Conclusions: The EPOS model was successfully validated in first-ever stroke patients with mild-to-moderate neurological impairments, who were independent before their stroke. Now, its impact on clinical practice should be investigated in this population. Testing the model's performance in severe (recurrent) strokes and stratification of patients using the ARAT 32-point cut-off is required to enhance the model's generalizability and potential clinical impact., Competing Interests: ARL received a grant from Boehringer Ingelheim International GmbH (contract number 43084008; https://www.boehringer-ingelheim.ch/) and P & K Pühringer Foundation (no URL available). This did not alter our adherence to PLOS ONE policies on sharing data and materials. JMV, JPOH and JP declared that no competing interests exist.

Introduction: Many stroke survivors require continuous outpatient rehabilitation therapy to maintain or improve their neurological functioning, independ-ence, and quality of life. In Switzerland and many other countries, the shutdown to contain SARS-CoV-2 infections led to mobility restrictions and a decrease in therapy delivery. This study investigated the impact of the COVID-19 shutdown on stroke survivors' access to therapy, physical activity, functioning and mood., Methods: A prospective observational cohort study in stroke subjects. At 4 time-points (before, during, after the shutdown, and at 3-month follow-up), the amount of therapy, physical activities, motor func-tion, anxiety, and depression were assessed., Results: Thirty-six community-dwelling stroke subjects (median 70 years of age, 10 months post--stroke) were enrolled. Therapy reductions related to the shutdown were reported in 72% of subjects. This decrease was associated with significantly extended sedentary time and minimal deterioration in physical activity during the shutdown. Both parameters improved between reopening and 3-month follow-up. Depressive symptoms increased slightly during the observation period. Patients more frequently report-ed on self-directed training during shutdown., Conclusion: The COVID-19 shutdown had measurable immediate, but no persistent, effects on post--stroke outcomes, except for depression. Importantly, a 2-month reduction in therapy may trigger improvements when therapy is fully re-initiated thereafter.

Background: Learning and learning-related neuroplasticity in motor cortex are potential mechanisms mediating recovery of movement abilities after stroke. These mechanisms depend on dopaminergic projections from midbrain that may encode reward information. Likewise, therapist experience confirms the role of feedback/reward for training efficacy after stroke., Objective: To test the hypothesis that rehabilitative training can be enhanced by adding performance feedback and monetary rewards., Methods: This multicentric, assessor-blinded, randomized controlled trial used the ArmeoSenso virtual reality rehabilitation system to train 37 first-ever subacute stroke patients in arm-reaching to moving targets. The rewarded group (n = 19) trained with performance feedback (gameplay) and contingent monetary reward. The control group (n = 18) used the same system without monetary reward and with graphically minimized performance feedback. Primary outcome was the change in the two-dimensional reaching space until the end of the intervention period. Secondary clinical assessments were performed at baseline, after 3 weeks of training (15 1-hour sessions), and at 3 month follow-up. Duration and intensity of the interventions as well as concomitant therapy were comparable between groups., Results: The two-dimensional reaching space showed an overall improvement but no difference between groups. The rewarded group, however, showed significantly greater improvements from baseline in secondary outcomes assessing arm activity (Box and Block Test at post-training: 6.03±2.95, P = .046 and 3 months: 9.66±3.11, P = .003; Wolf Motor Function Test [Score] at 3 months: .63±.22, P = .007) and arm impairment (Fugl-Meyer Upper Extremity at 3 months: 8.22±3.11, P = .011)., Conclusions: Although neutral in its primary outcome, the trial signals a potential facilitating effect of reward on training-mediated improvement of arm paresis., Trial Registration: ClinicalTrials.gov (ID: NCT02257125).

Background: A previously shown 'mismatch' group of patients with good observed upper limb (UL) motor function but low perceived UL activity at six months post stroke tends to use the affected UL less in daily life than would be expected based on clinical tests, and this mismatch may also be present at 12 months. We aimed to confirm this group in another cohort, to investigate the evolution of this group from six to 12 months, and to determine factors on admission to inpatient rehabilitation and at 6 months that can discriminate between mismatch and good match groups at 12 months., Methods: Persons after stroke were recruited on rehabilitation admission and re-assessed at six and 12 months. Observed UL function was measured with the upper extremity subscale of the Fugl-Meyer Assessment (FMA-UE) and perceived UL activity by the hand subscale of the Stroke Impact Scale 3.0 (SIS-Hand). We defined mismatch as good observed UL function (FMA-UE > 50/66) but low perceived activity (SIS-Hand≤75/100). Potential discriminators at admission and 6 months (demographic characteristics, stroke characteristics, UL somatosensory function, cognitive deficits, mental function and activity) were statistically compared for match and mismatch groups at 12 months., Results: We included 60 participants (female: 42%) with mean (SD) age of 65 (12) years. We confirmed a mismatch group of 11 (18%) patients at 6 months, which increased to 14 (23%) patients at 12 months. In the mismatch group compared to the good match group at 12 months, patients had a higher stroke severity and more somatosensory impairments on admission and at 6 months., Conclusions: We confirmed a group of patients with good observed UL function but low perceived activity both at six and at 12 months post stroke. Assessment of stroke severity and somatosensory impairments on admission into rehabilitation could determine mismatch at 12 months and might warrant intervention. However, large differences in clinical outcomes between patients in the mismatch group indicate the importance of tailoring training to the individual needs., (© 2021. The Author(s).)

We investigated actual daily life upper limb (UL) activity in relation to observed UL motor function and perceived UL activity in chronic stroke in order to better understand and improve UL activity in daily life. In 60 patients, we collected (1) observed UL motor function (Fugl-Meyer Assessment (FMA-UE)), (2) perceived UL activity (hand subscale of the Stroke Impact Scale (SIS-Hand)), and (3) daily life UL activity (bilateral wrist-worn accelerometers for 72 h) data. Data were compared between two groups of interest, namely (1) good observed (FMA-UE >50) function and good perceived (SIS-Hand >75) activity (good match, n = 16) and (2) good observed function but low perceived (SIS-Hand ≤75) activity (mismatch, n = 15) with Mann-Whitney U analysis. The mismatch group only differed from the good match group in perceived UL activity (median (Q1-Q3) = 50 (30-70) versus 93 (85-100); p < 0.001). Despite similar observed UL motor function and other clinical characteristics, the affected UL in the mismatch group was less active in daily life compared to the good match group ( p = 0.013), and the contribution of the affected UL compared to the unaffected UL for each second of activity (magnitude ratio) was lower ( p = 0.022). We conclude that people with chronic stroke with low perceived UL activity indeed tend to use their affected UL less in daily life despite good observed UL motor function.

Background: Evidence from animal studies suggests that greater reductions in poststroke motor impairment can be attained with significantly higher doses and intensities of therapy focused on movement quality. These studies also indicate a dose-timing interaction, with more pronounced effects if high-intensity therapy is delivered in the acute/subacute, rather than chronic, poststroke period., Objective: To compare 2 approaches of delivering high-intensity, high-dose upper-limb therapy in patients with subacute stroke: a novel exploratory neuroanimation therapy (NAT) and modified conventional occupational therapy (COT)., Methods: A total of 24 patients were randomized to NAT or COT and underwent 30 sessions of 60 minutes time-on-task in addition to standard care. The primary outcome was the Fugl-Meyer Upper Extremity motor score (FM-UE). Secondary outcomes included Action Research Arm Test (ARAT), grip strength, Stroke Impact Scale hand domain, and upper-limb kinematics. Outcomes were assessed at baseline, and days 3, 90, and 180 posttraining. Both groups were compared to a matched historical cohort (HC), which received only 30 minutes of upper-limb therapy per day., Results: There were no significant between-group differences in FM-UE change or any of the secondary outcomes at any timepoint. Both high-dose groups showed greater recovery on the ARAT (7.3 ± 2.9 points; P = .011) but not the FM-UE (1.4 ± 2.6 points; P = .564) when compared with the HC., Conclusions: Neuroanimation may offer a new, enjoyable, efficient, and scalable way to deliver high-dose and intensive upper-limb therapy.

Precise and objective assessments of upper limb movement quality after strokes in functional task conditions are an important prerequisite to improve understanding of the pathophysiology of movement deficits and to prove the effectiveness of interventions. Herein, a wearable inertial sensing system was used to capture movements from the fingers to the trunk in 10 chronic stroke subjects when performing reach-to-grasp activities with the affected and non-affected upper limb. It was investigated whether the factors, tested arm, object weight, and target height, affect the expressions of range of motion in trunk compensation and flexion-extension of the elbow, wrist, and finger during object displacement. The relationship between these metrics and clinically measured impairment was explored. Nine subjects were included in the analysis, as one had to be excluded due to defective data. The tested arm and target height showed strong effects on all metrics, while an increased object weight showed effects on trunk compensation. High inter- and intrasubject variability was found in all metrics without clear relationships to clinical measures. Relating all metrics to each other resulted in significant negative correlations between trunk compensation and elbow flexion-extension in the affected arm. The findings support the clinical usability of sensor-based motion analysis.

Background: Gait and balance impairments are common in neurological diseases, including stroke, and negatively affect patients' quality of life. Improving balance and gait are among the main goals of rehabilitation. Rehabilitation is mainly performed in clinics, which lack context specificity; therefore, training in the patient's home environment is preferable. In the last decade, developed rehabilitation technologies such as virtual reality and augmented reality (AR) have enabled gait and balance training outside clinics. Here, we propose a new method for gait rehabilitation in persons who have had a stroke in which mobile AR technology and a sensor-based motion capture system are combined to provide fine-grained feedback on gait performance in real time., Objective: The aims of this study were (1) to investigate manipulation of the gait pattern of persons who have had a stroke based on virtual augmentation during overground walking compared to walking without AR performance feedback and (2) to investigate the usability of the AR system., Methods: We developed the ARISE (Augmented Reality for gait Impairments after StrokE) system, in which we combined a development version of HoloLens 2 smart glasses (Microsoft Corporation) with a sensor-based motion capture system. One patient with chronic minor gait impairment poststroke completed clinical gait assessments and an AR parkour course with patient-centered performance gait feedback. The movement kinematics during gait as well as the usability and safety of the system were evaluated., Results: The patient changed his gait pattern during AR parkour compared to the pattern observed during the clinical gait assessments. He recognized the virtual objects and ranked the usability of the ARISE system as excellent. In addition, the patient stated that the system would complement his standard gait therapy. Except for the symptom of exhilaration, no adverse events occurred., Conclusions: This project provided the first evidence of gait adaptation during overground walking based on real-time feedback through visual and auditory augmentation. The system has potential to provide gait and balance rehabilitation outside the clinic. This initial investigation of AR rehabilitation may aid the development and investigation of new gait and balance therapies., (©Jeremia Philipp Oskar Held, Kevin Yu, Connor Pyles, Janne Marieke Veerbeek, Felix Bork, Sandro-Michael Heining, Nassir Navab, Andreas Rüdiger Luft. Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 26.05.2020.)

Upper limb functions are severely affected in 23% of the chronic stroke patients, compromising their life quality. To re-enable hand use, providing a degree of functionality and motivating against learned non-use, we propose a robotic supernumerary limb, the SoftHand X (SHX), consisting of a robotic hand, a gravity support system, and different sensors to detect the patient's intent for controlling the robotic hand. In this paper, this novel compensational approach is introduced and experimentally evaluated in stroke patients, assessing its efficacy, usability and safety. Ten patients were asked to perform tasks of a modified Action Research Arm Test with the SHX, by using three input methods. The mARAT scores rated the potentiality of the system. Usability was evaluated with the System Usability Scale, while spasticity before and after use was measured by the modified Ashworth Scale (mAS). Nine patients, not able to perform any tasks without external support, completed the whole experimental procedure using the proposed system with a median score greater than 12/30. Among the three input methods tested, the usability of one was rated as "good" while the other two were rated as "ok". Seven patients exhibited a reduction of the mAS. All nine patients stated that they would use the system frequently. Results obtained suggest that the SHX has the potential to partially compensate severely impaired hand function in stroke patients.

In 2008, it was proposed that the magnitude of recovery from nonsevere upper limb motor impairment over the first 3 to 6 months after stroke, measured with the Fugl-Meyer Assessment (FMA), is approximately 0.7 times the initial impairment ("proportional recovery"). In contrast to patients with nonsevere hemiparesis, about 30% of patients with an initial severe paresis do not show such recovery ("nonrecoverers"). Hence it was suggested that the proportional recovery rule (PRR) was a manifestation of a spontaneous mechanism that is present in all patients with mild-to-moderate paresis but only in some with severe paresis. Since the introduction of the PRR, it has subsequently been applied to other motor and nonmotor impairments. This more general investigation of the PRR has led to inconsistencies in its formulation and application, making it difficult to draw conclusions across studies and precipitating some cogent criticism. Here, we conduct a detailed comparison of the different studies reporting proportional recovery and, where appropriate, critique statistical methodology. On balance, we conclude that existing data in aggregate are largely consistent with the PRR as a population-level model for upper limb motor recovery; recent reports of its demise are exaggerated, as these excessively focus on the less conclusive issue of individual subject-level predictions. Moving forward, we suggest that methodological caution and new analytical approaches will be needed to confirm (or refute) a systematic character to spontaneous recovery from motor and other poststroke impairments, which can be captured by a mathematical rule either at the population or at the subject level.

Background . After stroke, recovery of movement in proximal and distal upper extremity (UE) muscles appears to follow different time courses, suggesting differences in their neural substrates. Objective . We sought to determine if presence or absence of motor evoked potentials (MEPs) differentially influences recovery of volitional contraction and strength in an arm muscle versus an intrinsic hand muscle. We also related MEP status to recovery of proximal and distal interjoint coordination and movement fractionation, as measured by the Fugl-Meyer Assessment (FMA). Methods . In 45 subjects in the year following ischemic stroke, we tracked the relationship between corticospinal tract (CST) integrity and behavioral recovery in the biceps (BIC) and first dorsal interosseous (FDI) muscle. We used transcranial magnetic stimulation to probe CST integrity, indicated by MEPs, in BIC and FDI. We used electromyography, dynamometry, and UE FMA subscores to assess muscle-specific contraction, strength, and inter-joint coordination, respectively. Results . Presence of MEPs resulted in higher likelihood of muscle contraction, greater strength, and higher FMA scores. Without MEPs, BICs could more often volitionally contract, were less weak, and had steeper strength recovery curves than FDIs; in contrast, FMA recovery curves plateaued below normal levels for both the arm and hand. Conclusions . There are shared and separate substrates for paretic UE recovery. CST integrity is necessary for interjoint coordination in both segments and for overall recovery. In its absence, alternative pathways may assist recovery of volitional contraction and strength, particularly in BIC. These findings suggest that more targeted approaches might be needed to optimize UE recovery.

The accurate assessment of upper limb motion impairment induced by stroke - which represents one of the primary causes of disability world-wide - is the first step to successfully monitor and guide patients' recovery. As of today, the majority of the procedures relies on clinical scales, which are mostly based on ordinal scaling, operator-dependent, and subject to floor and ceiling effects. In this work, we intend to overcome these limitations by proposing a novel approach to analytically evaluate the level of pathological movement coupling, based on the quantification of movement complexity. To this goal, we consider the variations of functional Principal Components applied to the reconstruction of joint angle trajectories of the upper limb during daily living task execution, and compared these variations between two conditions, i.e. the affected and non-affected arm. A Dissimilarity Index, which codifies the severity of the upper limb motor impairment with respect to the movement complexity of the non-affected arm, is then proposed. This methodology was validated as a proof of concept upon a set of four chronic stroke subjects with mild to moderate arm and hand impairments. As a first step, we evaluated whether the derived outcomes differentiate between the two conditions upon the whole data-set. Secondly, we exploited this concept to discern between different subjects and impairment levels. Results show that: i) differences in terms of movement variability between the affected and nonaffected upper limb are detectable and ii) different impairment profiles can be characterized for single subjects using the proposed approach. Although provisional, these results are very promising and suggest this approach as a basis ingredient for the definition of a novel, operator-independent, sensitive, intuitive and widely applicable scale for the evaluation of upper limb motion impairment.

Objective: Patients with chronic stroke have been shown to have failure to release interhemispheric inhibition (IHI) from the intact to the damaged hemisphere before movement execution (premovement IHI). This inhibitory imbalance was found to correlate with poor motor performance in the chronic stage after stroke and has since become a target for therapeutic interventions. The logic of this approach, however, implies that abnormal premovement IHI is causal to poor behavioral outcome and should therefore be present early after stroke when motor impairment is at its worst. To test this idea, in a longitudinal study, we investigated interhemispheric interactions by tracking patients' premovement IHI for one year following stroke., Methods: We assessed premovement IHI and motor behavior five times over a 1-year period after ischemic stroke in 22 patients and 11 healthy participants., Results: We found that premovement IHI was normal during the acute/subacute period and only became abnormal at the chronic stage; specifically, release of IHI in movement preparation worsened as motor behavior improved. In addition, premovement IHI did not correlate with behavioral measures cross-sectionally, whereas the longitudinal emergence of abnormal premovement IHI from the acute to the chronic stage was inversely correlated with recovery of finger individuation., Interpretation: These results suggest that interhemispheric imbalance is not a cause of poor motor recovery, but instead might be the consequence of underlying recovery processes. These findings call into question the rehabilitation strategy of attempting to rebalance interhemispheric interactions in order to improve motor recovery after stroke. Ann Neurol 2019;85:502-513., (© 2019 American Neurological Association.)

Background and Purpose- Assessing upper limb movements poststroke is crucial to monitor and understand sensorimotor recovery. Kinematic assessments are expected to enable a sensitive quantification of movement quality and distinguish between restitution and compensation. The nature and practice of these assessments are highly variable and used without knowledge of their clinimetric properties. This presents a challenge when interpreting and comparing results. The purpose of this review was to summarize the state of the art regarding kinematic upper limb assessments poststroke with respect to the assessment task, measurement system, and performance metrics with their clinimetric properties. Subsequently, we aimed to provide evidence-based recommendations for future applications of upper limb kinematics in stroke recovery research. Methods- A systematic search was conducted in PubMed, Embase, CINAHL, and IEEE Xplore. Studies investigating clinimetric properties of applied metrics were assessed for risk of bias using the Consensus-Based Standards for the Selection of Health Measurement Instruments checklist. The quality of evidence for metrics was determined according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Results- A total of 225 studies (N=6197) using 151 different kinematic metrics were identified and allocated to 5 task and 3 measurement system groups. Thirty studies investigated clinimetrics of 62 metrics: reliability (n=8), measurement error (n=5), convergent validity (n=22), and responsiveness (n=2). The metrics task/movement time, number of movement onsets, number of movement ends, path length ratio, peak velocity, number of velocity peaks, trunk displacement, and shoulder flexion/extension received a sufficient evaluation for one clinimetric property. Conclusions- Studies on kinematic assessments of upper limb sensorimotor function are poorly standardized and rarely investigate clinimetrics in an unbiased manner. Based on the available evidence, recommendations on the assessment task, measurement system, and performance metrics were made with the goal to increase standardization. Further high-quality studies evaluating clinimetric properties are needed to validate kinematic assessments, with the long-term goal to elucidate upper limb sensorimotor recovery poststroke. Clinical Trial Registration- URL: https://www.crd.york.ac.uk/prospero/ . Unique identifier: CRD42017064279.

Background: New technologies, such as telerehabilitation and gaming devices offer the possibility for patients to train at home. This opens the challenge of safety for the patient as he/she is called to exercise neither with a therapist on the patients' side nor with a therapist linked remotely to supervise the sessions., Aim: To study the safety, usability and patient acceptance of an autonomous telerehabilitation system for balance and gait (the REWIRE platform) in the patients home., Design: Cohort study., Setting: Community, in the stroke patients' home., Population: Fifteen participants with first-ever stroke, with a mild to moderate residual deficit of the lower extremities., Methods: Autonomous rehabilitation based on virtual rehabilitation was provided at the participants' home for twelve weeks. The primary outcome was compliance (the ratio between days of actual and scheduled training), analyzed with the two-tailed Wilcoxon Mann-Whitney test. Furthermore safety is defined by adverse events. The secondary endpoint was the acceptance of the system measured with the Technology Acceptance Model (TAM). Additionally, the cumulative duration of weekly training was analyzed., Results: During the study there were no adverse events related to the therapy. Patients performed on average 71% (range 39 to 92%) of the scheduled sessions. The TAM Questionnaire showed excellent values for stroke patients after the training. The average training duration per week was 99±53min., Conclusions: Autonomous telerehabilitation for balance and gait training with the REWIRE-system is safe, feasible and can help to intensive rehabilitative therapy at home., Clinical Rehabilitation Impact: Telerehabilitation enables safe training in home environment and supports of the standard rehabilitation therapy.

Background: Fifty percent of all stroke survivors remain with functional impairments of their upper limb. While there is a need to improve the effectiveness of rehabilitative training, so far no new training approach has proven to be clearly superior to conventional therapy. As training with rewarding feedback has been shown to improve motor learning in humans, it is hypothesized that rehabilitative arm training could be enhanced by rewarding feedback. In this paper, we propose a trial protocol investigating rewards in the form of performance feedback and monetary gains as ways to improve effectiveness of rehabilitative training., Methods: This multicentric, assessor-blinded, randomized controlled trial uses the ArmeoSenso virtual reality rehabilitation system to train 74 first-ever stroke patients (< 100 days post stroke) to lift their impaired upper limb against gravity and to improve the workspace of the paretic arm. Three sensors are attached to forearm, upper arm, and trunk to track arm movements in three-dimensional space while controlling for trunk compensation. Whole-arm movements serve as input for a therapy game. The reward group (n = 37) will train with performance feedback and contingent monetary reward. The control group (n = 37) uses the same system but without monetary reward and with reduced performance feedback. Primary outcome is the change in the hand workspace in the transversal plane. Standard clinical assessments are used as secondary outcome measures., Discussion: This randomized controlled trial will be the first to directly evaluate the effect of rewarding feedback, including monetary rewards, on the recovery process of the upper limb following stroke. This could pave the way for novel types of interventions with significantly improved treatment benefits, e.g., for conditions that impair reward processing (stroke, Parkinson's disease)., Trial Registration: ClinicalTrials.gov, ID: NCT02257125 . Registered on 30 September 2014.

Impaired hand function after stroke is a major cause of long-term disability. We developed a novel paradigm that quantifies two critical aspects of hand function, strength, and independent control of fingers (individuation), and also removes any obligatory dependence between them. Hand recovery was tracked in 54 patients with hemiparesis over the first year after stroke. Most recovery of strength and individuation occurred within the first 3 mo. A novel time-invariant recovery function was identified: recovery of strength and individuation were tightly correlated up to a strength level of ~60% of estimated premorbid strength; beyond this threshold, strength improvement was not accompanied by further improvement in individuation. Any additional improvement in individuation was attributable instead to a second process that superimposed on the recovery function. We conclude that two separate systems are responsible for poststroke hand recovery: one contributes almost all of strength and some individuation; the other contributes additional individuation. NEW & NOTEWORTHY We tracked recovery of the hand over a 1-yr period after stroke in a large cohort of patients, using a novel paradigm that enabled independent measurement of finger strength and control. Most recovery of strength and control occurs in the first 3 mo after stroke. We found that two separable systems are responsible for motor recovery of hand: one contributes strength and some dexterity, whereas a second contributes additional dexterity., (Copyright © 2017 the American Physiological Society.)

Background: Studies demonstrate that most arm motor recovery occurs within three months after stroke, when measured with standard clinical scales. Improvements on these measures, however, reflect a combination of recovery in motor control, increases in strength, and acquisition of compensatory strategies., Objective: To isolate and characterize the time course of recovery of arm motor control over the first year poststroke., Methods: Longitudinal study of 18 participants with acute ischemic stroke. Motor control was evaluated using a global kinematic measure derived from a 2-dimensional reaching task designed to minimize the need for antigravity strength and prevent compensation. Arm impairment was evaluated with the Fugl-Meyer Assessment of the upper extremity (FMA-UE), activity limitation with the Action Research Arm Test (ARAT), and strength with biceps dynamometry. Assessments were conducted at: 1.5, 5, 14, 27, and 54 weeks poststroke., Results: Motor control in the paretic arm improved up to week 5, with no further improvement beyond this time point. In contrast, improvements in the FMA-UE, ARAT, and biceps dynamometry continued beyond 5 weeks, with a similar magnitude of improvement between weeks 5 and 54 as the one observed between weeks 1.5 and 5., Conclusions: Recovery after stroke plateaued much earlier for arm motor control, isolated with a global kinematic measure, compared to motor function assessed with clinical scales. This dissociation between the time courses of kinematic and clinical measures of recovery may be due to the contribution of strength improvement to the latter. Novel interventions, focused on the first month poststroke, will be required to exploit the narrower window of spontaneous recovery for motor control.

Wearable sensor technology has enabled unobtrusive monitoring of arm movements of stroke survivors in the home environment. However, the most widely established method, based on activity counts, provides quantitative rather than qualitative information on arm without functional insights, and is sensitive to passive arm movements during ambulatory activities. We propose a method to quantify functionally relevant arm use in stroke survivors relying on a single wrist-worn inertial measurement unit. Orientation of the forearm during movements is measured in order identify gross arm movements. The method is validated in 10 subacute/chronic stroke survivors wearing inertial sensors at 5 anatomical locations for 48 h. Measurements are compared to conventional activity counts and to a test for gross manual dexterity. Duration of gross arm movements of the paretic arm correlated significantly better with the Box and Block Test ([Formula: see text]) than conventional activity counts when walking phases were included ([Formula: see text]), and similar results were found when comparing ratios of paretic and non-paretic arms for gross movements and activity counts. The proposed gross arm movement metric is robust against passive arm movements during ambulatory activities and requires only a single-sensor module placed at the paretic wrist for the assessment of functionally relevant arm use.

Background: The effect of rehabilitative training after stroke is dose-dependent. Out-patient rehabilitation training is often limited by transport logistics, financial resources and a lack of motivation/compliance. We studied the feasibility of an unsupervised arm therapy for self-directed rehabilitation therapy in patients' homes., Methods: An open-label, single group study involving eleven patients with hemiparesis due to stroke (27 ± 31.5 months post-stroke) was conducted. The patients trained with an inertial measurement unit (IMU)-based virtual reality system (ArmeoSenso) in their homes for six weeks. The self-selected dose of training with ArmeoSenso was the principal outcome measure whereas the Fugl-Meyer Assessment of the upper extremity (FMA-UE), the Wolf Motor Function Test (WMFT) and IMU-derived kinematic metrics were used to assess arm function, training intensity and trunk movement. Repeated measures one-way ANOVAs were used to assess differences in training duration and clinical scores over time., Results: All subjects were able to use the system independently in their homes and no safety issues were reported. Patients trained on 26.5 ± 11.5 days out of 42 days for a duration of 137 ± 120 min per week. The weekly training duration did not change over the course of six weeks (p = 0.146). The arm function of these patients improved significantly by 4.1 points (p = 0.003) in the FMA-UE. Changes in the WMFT were not significant (p = 0.552). ArmeoSenso based metrics showed an improvement in arm function, a high number of reaching movements (387 per session), and minimal compensatory movements of the trunk while training., Conclusions: Self-directed home therapy with an IMU-based home therapy system is safe and can provide a high dose of rehabilitative therapy. The assessments integrated into the system allow daily therapy monitoring, difficulty adaptation and detection of maladaptive motor patterns such as trunk movements during reaching., Trial Registration: Unique identifier: NCT02098135 .

In the last praxis edition (9/2016) the article with the title “Neues in der Akutdiagnostik” reported about the relevant factors for the extension of thrombolytic procedures despite the usual inclusion criteria of thrombolysis. The rapid clinical and imaging identification of patients who benefit from endovascular therapy based on the “target mismatch” is an other key factor in the race against time. In addition the advantages of new mechanical devices allow to remove a thrombus quickly, completely and especially with better outcome. The recently published randomized controlled studies MR-CLEAN, EXTEND-IA, ESCAPE, SWIFT-PRIME and REVASCAT showed significant benefits of intra-arterial thrombolysis in patients with large artery occlusions. The following article discusses the state-of-the-art of the basic therapy and the major pathways of acute therapy.

Background: Stroke survivors often suffer from mobility deficits. Current clinical evaluation methods, including questionnaires and motor function tests, cannot provide an objective measure of the patients' mobility in daily life. Physical activity performance in daily-life can be assessed using unobtrusive monitoring, for example with a single sensor module fixed on the trunk. Existing approaches based on inertial sensors have limited performance, particularly in detecting transitions between different activities and postures, due to the inherent inter-patient variability of kinematic patterns. To overcome these limitations, one possibility is to use additional information from a barometric pressure (BP) sensor., Methods: Our study aims at integrating BP and inertial sensor data into an activity classifier in order to improve the activity (sitting, standing, walking, lying) recognition and the corresponding body elevation (during climbing stairs or when taking an elevator). Taking into account the trunk elevation changes during postural transitions (sit-to-stand, stand-to-sit), we devised an event-driven activity classifier based on fuzzy-logic. Data were acquired from 12 stroke patients with impaired mobility, using a trunk-worn inertial and BP sensor. Events, including walking and lying periods and potential postural transitions, were first extracted. These events were then fed into a double-stage hierarchical Fuzzy Inference System (H-FIS). The first stage processed the events to infer activities and the second stage improved activity recognition by applying behavioral constraints. Finally, the body elevation was estimated using a pattern-enhancing algorithm applied on BP. The patients were videotaped for reference. The performance of the algorithm was estimated using the Correct Classification Rate (CCR) and F-score. The BP-based classification approach was benchmarked against a previously-published fuzzy-logic classifier (FIS-IMU) and a conventional epoch-based classifier (EPOCH)., Results: The algorithm performance for posture/activity detection, in terms of CCR was 90.4 %, with 3.3 % and 5.6 % improvements against FIS-IMU and EPOCH, respectively. The proposed classifier essentially benefits from a better recognition of standing activity (70.3 % versus 61.5 % [FIS-IMU] and 42.5 % [EPOCH]) with 98.2 % CCR for body elevation estimation., Conclusion: The monitoring and recognition of daily activities in mobility-impaired stoke patients can be significantly improved using a trunk-fixed sensor that integrates BP, inertial sensors, and an event-based activity classifier.

Background: Recovering useful hand function after stroke is a major scientific challenge for patients with limited motor recovery. We hypothesized that sequential training beginning with proximal bilateral followed by unilateral task oriented training is superior to time-matched unilateral training alone. Proximal bilateral training could optimally prepare the motor system to respond to the more challenging task-oriented training., Participants: Twenty-six participants with moderate severity hemiparesis Intervention: PARTICIPANTS received either 6-weeks of bilateral proximal training followed sequentially by 6-weeks unilateral task-oriented training (COMBO) or 12-weeks of unilateral task-oriented training alone (SAEBO). A subset of 8 COMB0 and 9 SAEBO participants underwent three functional magnetic resonance imaging (fMRI) scans of hand and elbow movement every 6 weeks., Main Outcome Measures: Fugl-Meyer Upper extremity scale, Modified Wolf Motor Function Test, University of Maryland Arm Questionnaire for Stroke, Motor cortex activation (fMRI)., Results: The COMBO group demonstrated significantly greater gains between baseline and 12-weeks over all outcome measures (p = .018 based on a MANOVA test) and specifically in the Modified Wolf Motor Function test (time). Both groups demonstrated within-group gains on the Fugl-Meyer Upper Extremity test (impairment) and University of Maryland Arm Questionnaire for Stroke (functional use). fMRI subset analyses showed motor cortex (primary and premotor) activation during hand movement was significantly increased by sequential combination training but not by task-oriented training alone., Conclusions: Sequentially combining a proximal bilateral before a unilateral task-oriented training may be an effective way to facilitate gains in arm and hand function in those with moderate to severe paresis post-stroke compared to unilateral task oriented training alone.

Background: Arm hemiparesis secondary to stroke is common and disabling. We aimed to assess whether robotic training of an affected arm with ARMin--an exoskeleton robot that allows task-specific training in three dimensions-reduces motor impairment more effectively than does conventional therapy., Methods: In a prospective, multicentre, parallel-group randomised trial, we enrolled patients who had had motor impairment for more than 6 months and moderate-to-severe arm paresis after a cerebrovascular accident who met our eligibility criteria from four centres in Switzerland. Eligible patients were randomly assigned (1:1) to receive robotic or conventional therapy using a centre-stratified randomisation procedure. For both groups, therapy was given for at least 45 min three times a week for 8 weeks (total 24 sessions). The primary outcome was change in score on the arm (upper extremity) section of the Fugl-Meyer assessment (FMA-UE). Assessors tested patients immediately before therapy, after 4 weeks of therapy, at the end of therapy, and 16 weeks and 34 weeks after start of therapy. Assessors were masked to treatment allocation, but patients, therapists, and data analysts were unmasked. Analyses were by modified intention to treat. This study is registered with ClinicalTrials.gov, number NCT00719433., Findings: Between May 4, 2009, and Sept 3, 2012, 143 individuals were tested for eligibility, of whom 77 were eligible and agreed to participate. 38 patients assigned to robotic therapy and 35 assigned to conventional therapy were included in analyses. Patients assigned to robotic therapy had significantly greater improvements in motor function in the affected arm over the course of the study as measured by FMA-UE than did those assigned to conventional therapy (F=4.1, p=0.041; mean difference in score 0.78 points, 95% CI 0.03-1.53). No serious adverse events related to the study occurred., Interpretation: Neurorehabilitation therapy including task-oriented training with an exoskeleton robot can enhance improvement of motor function in a chronically impaired paretic arm after stroke more effectively than conventional therapy. However, the absolute difference between effects of robotic and conventional therapy in our study was small and of weak significance, which leaves the clinical relevance in question., Funding: Swiss National Science Foundation and Bangerter-Rhyner Stiftung., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Therapies for effective neurorehabiltiation are in part based on brain mechanism commonly described as neuroplasticity. These therapeutic approaches emphasize the re-learning of functionality that was lost due to the injury through reorganization of neural circuits in the remaining intact tissue. Important elements of these therapies are intensive and repetitive training, motivation and potentially interactive devices (therapy "robots") and supportive therapies such as brain stimulation or plasticity inducing medications. Because neuroplasticity-based interventions are complex and multifactorial optimized treatment protocols have to be developed before large clinical trials can provide the evidence of efficacy., (Copyright © 2013 S. Karger AG, Basel.)

Background and Objective: Ambulatory subjects after stroke may benefit from gait-oriented cardiovascular fitness training, but trials to date have not primarily assessed older persons., Methods: Thirty-eight subjects (age >60 years) with residual hemiparetic gait were enrolled >6 months after stroke. Participants were randomized to receive 3 months (3×/week) progressive graded, high-intensity aerobic treadmill exercise (TAEX) or conventional care physiotherapy. Primary outcome measures were peak exercise capacity (Vo(2peak)) and sustained walking capacity in 6-minute walks (6MW). Secondary measures were gait velocity in 10-m walks, Berg Balance Scale, functional leg strength (5 chair-rise), self-rated mobility (Rivermead Mobility Index), and quality of life (SF-12)., Results: Thirty-six participants completed the study (18 TAEX, 18 controls). TAEX but not conventional care improved Vo(2peak) (difference 6.4 mL/kg/min, P < .001) and 6MW (53 m, P < .001). Likewise, maximum walking speed (0.13 m/s, P = .01), balance (P < .05), and the mental subscore of the SF-12 (P < .01) improved more after TAEX. Gains in Vo(2peak) correlated with the degree at which training intensity could be progressed in the individual participant (P < .01). Better walking was related to progression in treadmill velocity and training duration (P < .001). Vo(2peak) and 6MW performances were still higher 1 year after the end of training when compared with the baseline, although endurance walking (6MW) at 1 year was lower than immediately after training (P < .01)., Conclusion: This trial demonstrates that TAEX effectively improves cardiovascular fitness and gait in persons with chronic stroke.

Background and Purpose: This randomized controlled trial tests the efficacy of bilateral arm training with rhythmic auditory cueing (BATRAC) versus dose-matched therapeutic exercises (DMTEs) on upper-extremity (UE) function in stroke survivors and uses functional magnetic resonance imaging (fMRI) to examine effects on cortical reorganization., Methods: A total of 111 adults with chronic UE paresis were randomized to 6 weeks (3×/week) of BATRAC or DMTE. Primary end points of UE assessments of Fugl-Meyer UE Test (FM) and modified Wolf Motor Function Test Time (WT) were performed 6 weeks prior to and at baseline, after training, and 4 months later. Pretraining and posttraining, fMRI for UE movement was evaluated in 17 BATRAC and 21 DMTE participants., Results: The improvements in UE function (BATRAC: FM Δ = 1.1 + 0.5, P = .03; WT Δ = -2.6 + 0.8, P < .00; DMTE: FM Δ = 1.9 + 0.4, P < .00; WT Δ = -1.6 + 0.7; P = .04) were comparable between groups and retained after 4 months. Satisfaction was higher after BATRAC than DMTE (P = .003). BATRAC led to significantly higher increase in activation in ipsilesional precentral, anterior cingulate and postcentral gyri, and supplementary motor area and contralesional superior frontal gyrus (P < .05). Activation change in the latter was correlated with improvement in the WMFT (P = .01)., Conclusions: BATRAC is not superior to DMTE, but both rehabilitation programs durably improve motor function for individuals with chronic UE hemiparesis and with varied deficit severity. Adaptations in brain activation are greater after BATRAC than DMTE, suggesting that given similar benefits to motor function, these therapies operate through different mechanisms.

Objective: Stroke survivors with motor deficits often have pyramidal tract atrophy caused by degeneration of corticospinal fibers. The authors hypothesized that the degree of atrophy correlates with severity of motor impairment in patients with chronic stroke and predicts the response to rehabilitation training., Methods: They performed a post hoc analysis of 42 hemiparetic patients (>6 months) who had been randomized to either 6 weeks of bilateral arm training with rhythmic auditory cueing (BATRAC) or dose-matched therapeutic exercise (DMTE). Arm function was measured using the Fugl-Meyer (FM) and modified Wolf Motor Function Test (WMFT). Structural MRI and diffusion tensor imaging (DTI) on the pontine level measured corticospinal tract (CST) atrophy by planimetric measurement of the mesencephalon (mesencephalic atrophy ratio) and fractional anisotropy (FA), respectively. Voxel-based lesion symptom mapping (VLSM) was used to determine the lesions associated with highest degrees of atrophy. The predictive value of CST atrophy for impairment and training response was analyzed., Results: CST atrophy predicted baseline motor arm function measured by the FM and WMFT. The authors found only a trend for the correlation with FA. No measure of atrophy predicted response to either BATRAC or DMTE. CST atrophy was higher with larger lesions and those that affected the CST. VLSM identified internal capsule lesions as being associated with highest CST atrophy., Conclusion: Larger lesions, internal capsule lesions, and those overlapping the pyramidal tract are associated with greater CST atrophy. CST atrophy explains in part the variability of baseline deficits but does not seem to predict the response to BATRAC or unilateral arm training on upper-extremity function.

The investigation and characterization of sensori-motor learning and execution represents a key objective for the design of optimal rehabilitation therapies following stroke. By supplying new tools to investigate sensorimotor learning and objectively assess recovery, robot assisted techniques have opened new lines of research in neurorehabilitation aiming to complement current clinical strategies. Human studies, however, are limited by the complex logistics, heterogeneous patient populations and large dropout rates. Rat models may provide a substitute to explore the mechanisms underlying these processes in humans with larger and more homogeneous populations. This paper describes the development and evaluation of a three-degrees-of-freedom robotic manipulandum to train and assess precision forelimb movement in rats before and after stroke. The mechanical design is presented based on the requirements of interaction with rat kinematics and kinetics. The characterization of the robot exhibits a compact, low friction device, with a sufficient bandwidth suitable for motor training studies with rodents. The manipulandum was integrated with an existing training environment for rodent experiments and a first study is currently underway., (© 2011 IEEE)

Background: Aerobic treadmill exercise (T-EX) therapy has been shown to benefit walking and cardiorespiratory fitness in stroke survivors with chronic gait impairment even long after their stroke. The response, however, varies between individuals., Objective: The purpose of this post hoc analysis of 2 randomized controlled T-EX trials was to identify predictors for therapy response., Methods: In all, 52 participants received T-EX for 3 (Germany) or 6 (United States) months. Improvements in overground walking velocity (10 m/6-min walk) and fitness (peak VO(2)) were indicators of therapy response. Lesion location and volume were measured on T1-weighted magnetic resonance scans., Results: T-EX significantly improved gait and fitness, with gains in 10-m walk tests ranging between +113% and -25% and peak VO(2) between -12% and 88%. Baseline walking impairments or fitness deficits were not predictive of therapy response; 10-m walk velocity improved more in those with subcortical rather than cortical lesions and in patients with smaller lesions. Improvements in 6-minute walk velocity were greater in those with more recent strokes and left-sided lesions. No variable other than training intensity, which was different between trials, predicted fitness gains., Conclusions: Despite proving overall effectiveness, the response to T-EX varies markedly between individuals. Whereas intensity of aerobic training seems to be an important predictor of gains in cardiovascular fitness, lesion size and location as well as interval between stroke onset and therapy delivery likely affect therapy response. These findings may be used to guide the timing of training and identify subgroups of patients for whom training modalities could be optimized.

Stroke commonly leads to reduced mobility, which leads to deconditioning and a worsening of vascular risk factors, such as diabetes. The worsened risk profile leads to further strokes and disability--a vicious cycle for the stroke survivor. Exercise (walking) therapy may break this cycle by providing adequate stimuli for improving gait through plastic adaptation in the brain and through increasing fitness. Randomized, controlled data demonstrate the efficacy for gains in fitness and walking speed, the latter being related to lasting changes in activation patterns of the brainstem and cerebellum. Diabetes and muscle inflammation can also be improved by aerobic exercise training. The scope of this review summarizes these data and identifies unresolved issues related to optimization, intensity and maintenance of therapy effects. Exercise should be an integral part of every rehabilitation program.

Background and Purpose: Stroke often impairs gait thereby reducing mobility and fitness and promoting chronic disability. Gait is a complex sensorimotor function controlled by integrated cortical, subcortical, and spinal networks. The mechanisms of gait recovery after stroke are not well understood. This study examines the hypothesis that progressive task-repetitive treadmill exercise (T-EX) improves fitness and gait function in subjects with chronic hemiparetic stroke by inducing adaptations in the brain (plasticity)., Methods: A randomized controlled trial determined the effects of 6-month T-EX (n=37) versus comparable duration stretching (CON, n=34) on walking, aerobic fitness and in a subset (n=15/17) on brain activation measured by functional MRI., Results: T-EX significantly improved treadmill-walking velocity by 51% and cardiovascular fitness by 18% (11% and -3% for CON, respectively; P<0.05). T-EX but not CON affected brain activation during paretic, but not during nonparetic limb movement, showing 72% increased activation in posterior cerebellar lobe and 18% in midbrain (P<0.005). Exercise-mediated improvements in walking velocity correlated with increased activation in cerebellum and midbrain., Conclusions: T-EX improves walking, fitness and recruits cerebellum-midbrain circuits, likely reflecting neural network plasticity. This neural recruitment is associated with better walking. These findings demonstrate the effectiveness of T-EX rehabilitation in promoting gait recovery of stroke survivors with long-term mobility impairment and provide evidence of neuroplastic mechanisms that could lead to further refinements in these paradigms to improve functional outcomes.

A plateau in recovery within the first few months of rehabilitative therapy was assumed to be the norm in stroke survivors. Recent studies in our laboratory examined the effect of 6 months of treadmill exercise training in chronically disabled stroke survivors. Treadmill exercise improves fitness and walking ability in patients when initiated 6 months or more following their index stroke. Functional imaging studies show that such exercise also induces subcortical reorganization in these patients. Future investigations will explore the relationship between these functional and structural effects and characterize the therapeutic mechanisms of post-stroke rehabilitation. Nonetheless, treadmill exercise appears to have motor, cardiac, and daily functional benefits in stroke survivors.

Assumptions that motor recovery plateaus within months after stroke are being challenged by advances in novel motor-learning-based rehabilitation therapies. The use of lower-limb treadmill (TM) exercise has been effective in improving hemiparetic gait function. In this review, we provide a rationale for treadmill exercise as stimulus for locomotor relearning after stroke. Recent studies using neuroimaging and neurophysiological measures demonstrate central nervous system (CNS) influences on lower-limb motor control and gait. As with studies of upper limbs, evidence shows that rapid transient CNS plasticity can be elicited in the lower limb. Such effects observed after short-term paretic leg exercises suggest potential mechanisms for motor learning with TM exercise. Initial intervention studies provide evidence that long-term TM exercise can mediate CNS plasticity, which is associated with improved gait function. Critical needs are to determine the optimal timing and intensities of TM therapy to maximize plasticity and learning effects.

Context: Reorganization in central motor networks occurs during early recovery from hemiparetic stroke. In chronic stroke survivors, specific rehabilitation therapy can improve upper extremity function., Objective: To test the hypothesis that in patients who have chronic motor impairment following stroke, specific rehabilitation therapy that improves arm function is associated with reorganization of cortical networks., Design, Setting, and Patients: A randomized controlled clinical trial conducted in a US ambulatory rehabilitation program with 21 patients (median [IQR], 50.3 [34.8-77.3] months after unilateral stroke). Data were collected between 2001 and 2004., Interventions: Patients were randomly assigned to bilateral arm training with rhythmic auditory cueing (BATRAC) (n = 9) or standardized dose-matched therapeutic exercises (DMTE) (n = 12). Both were conducted for 1 hour, 3 times a week, for 6 weeks., Main Outcome Measures: Within 2 weeks before and after the intervention, brain activation during elbow movement assessed by functional magnetic resonance imaging (fMRI) and functional outcome assessed using arm function scores., Results: Patients in the BATRAC group but not in the DMTE group increased hemispheric activation during paretic arm movement (P = .03). Changes in activation were observed in the contralesional cerebrum and ipsilesional cerebellum (P = .009). BATRAC was associated with significant increases in activation in precentral (P<.001) and postcentral gyri (P = .03) and the cerebellum (P<.001), although 3 BATRAC patients showed no fMRI changes. Considering all patients, there were no differences in functional outcome between groups. When only BATRAC patients with fMRI response were included (n = 6), BATRAC improved arm function more than DMTE did (P = .02)., Conclusions: These preliminary findings suggest that BATRAC induces reorganization in contralesional motor networks and provide biological plausibility for repetitive bilateral training as a potential therapy for upper extremity rehabilitation in hemiparetic stroke.

Introduction: Stroke-induced upper limb disabilities can be characterized by both motor impairments and activity limitations, commonly assessed using Fugl-Meyer Motor Assessment for Upper Extremity (FMMA-UE) and Action Research Arm Test (ARAT), respectively. The relationship between the two assessments during recovery is largely unstudied. Expectedly they diverge over time when recovery of impairment (restitution) plateaus, but compensationdriven improvements still occur. The objective of this study is to evaluate the alignment between FMMA-UE and ARAT in defining upper limb functional recovery categories by ARAT scores. We aimed to establish cut-off scores for both measures from the acute/early subacute, subacute and chronic stages of stroke recovery. Methods: Secondary analysis of four prospective cohort studies (acute/early subacute: n = 133, subacute: n = 113, chronic: n = 92) stages post-stroke. Receiver operating characteristic curves calculated the area under the curve (AUC) to establish optimal FMMA-UE cut-offs based on predefined ARAT thresholds distinguishing five activity levels from no activity to full activity. Weighted kappa was used to determine agreement between the two assessments. We used minimally clinically important difference (MCID) and minimal detectable change (MDC95) for comparison. Results: FMMA-UE and ARAT scores showed no relevant divergence across all recovery stages. Results indicated similar cut-off scores in all recovery stages with variability below MCID and MDC95 levels. Cut-off scores demonstrated robust AUC values from 0.77 to 0.86 at every recovery stage. Only in highly functional patients at the chronic stage, we found a reduced specificity of 0.55. At all other times sensitivity ranged between 0.68 and 0.99 and specificity between 0.71 and 0.99. Weighted kappa at the acute/early subacute, subacute and chronic stages was 0.76, 0.83, and 0.81, respectively. Discussion: Our research shows a strong alignment between FMMA-UE and ARAT cut-off scores throughout stroke recovery, except among the subgroup of highly recovered patients at the chronic stage. Discrepancies in specificity potentially stem from fine motor deficits affecting dexterity outcomes that are not captured by FMMA-UE. Additionally, the high congruence of both measures suggests they are not suited to distinguish between restitution and compensation. Calling for more comprehensive assessment methods to better understand upper limb functionality in rehabilitation. [ABSTRACT FROM AUTHOR]

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