[Abstract] Effects of Circuit Class Training Versus Individual, Task Specific Training on Upper Extremity Function in Chronic Stroke Patients

Abstract

Background: Stroke is a leading contributor to disability globally, emphasizing the need for effective rehabilitation techniques. Circuit class training (CCT) and individual, task-specific training (ITST) have emerged as potential approaches for enhancing upper extremity function in stroke survivors. Comparative analyses of their efficacy, especially among chronic stroke patients, are scant.

Objective: This study aimed to evaluate and compare the impacts of CCT and ITST on upper extremity spasticity, motor function, and quality of life in individuals with chronic stroke.

Methods: In a randomized controlled trial, 36 chronic stroke patients were allocated to either CCT or ITST groups. Participants were aged 45-70 years, had experienced a single stroke episode, and were at least 6 months post-stroke, with specific inclusion criteria regarding spasticity and motor function levels. The interventions were delivered for 1.5 hours daily, five days a week, over eight weeks. Outcomes were measured using the Modified Ashworth Scale (MAS) for spasticity, Functional Independence Measure for Upper Extremity (FMA-UE) for motor function, and Stroke-Specific Quality of Life (SS-QOL) scale for quality of life, analyzed using SPSS version 25.

Results: Post-intervention, both CCT and ITST participants exhibited significant improvements in their outcomes. MAS scores showed a reduction in spasticity, with average improvements not significantly differing between the groups. FMA-UE scores increased by an average of 10 points in both groups, indicating enhanced motor function without a significant difference between the groups (p > 0.05). SS-QOL scores improved by an average of 20 points in each group, reflecting better quality of life, with no significant intergroup difference observed.

Conclusion: The study concludes that CCT and ITST are equally effective in ameliorating upper extremity spasticity, motor function, and quality of life among chronic stroke patients. The selection between CCT and ITST can thus be personalized based on patient preferences, available resources, and logistical considerations, maintaining rehabilitation efficacy.

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[ARTICLE] Brain oscillations in reflecting motor status and recovery induced by action observation-driven robotic hand intervention in chronic stroke – Full Text

Hand rehabilitation in chronic stroke remains challenging, and finding markers that could reflect motor function would help to understand and evaluate the therapy and recovery. The present study explored whether brain oscillations in different electroencephalogram (EEG) bands could indicate the motor status and recovery induced by action observation-driven brain–computer interface (AO-BCI) robotic therapy in chronic stroke. The neurophysiological data of 16 chronic stroke patients who received 20-session BCI hand training is the basis of the study presented here. Resting-state EEG was recorded during the observation of non-biological movements, while task-stage EEG was recorded during the observation of biological movements in training. The motor performance was evaluated using the Action Research Arm Test (ARAT) and upper extremity Fugl–Meyer Assessment (FMA), and significant improvements (p < 0.05) on both scales were found in patients after the intervention. Averaged EEG band power in the affected hemisphere presented negative correlations with scales pre-training; however, no significant correlations (p > 0.01) were found both in the pre-training and post-training stages. After comparing the variation of oscillations over training, we found patients with good and poor recovery presented different trends in delta, low-beta, and high-beta variations, and only patients with good recovery presented significant changes in EEG band power after training (delta band, p < 0.01). Importantly, motor improvements in ARAT correlate significantly with task EEG power changes (low-beta, c.c = 0.71, p = 0.005; high-beta, c.c = 0.71, p = 0.004) and task/rest EEG power ratio changes (delta, c.c = −0.738, p = 0.003; low-beta, c.c = 0.67, p = 0.009; high-beta, c.c = 0.839, p = 0.000). These results suggest that, in chronic stroke, EEG band power may not be a good indicator of motor status. However, ipsilesional oscillation changes in the delta and beta bands provide potential biomarkers related to the therapeutic-induced improvement of motor function in effective BCI intervention, which may be useful in understanding the brain plasticity changes and contribute to evaluating therapy and recovery in chronic-stage motor rehabilitation.

1 Introduction

Stroke has been the leading cause of acquired disability in adults globally for decades (Mendis, 2013). Although the mortality rate declined with improved healthcare, approximately 80% of stroke victims still experience motor impairment, and more than 30% of patients suffer despite intensive rehabilitation (Lai et al., 2002; Young and Forster, 2007). It is worse for the chronic group with severe motor impairments in the upper limbs. On the one hand, effective interventions like constraint-induced movement therapy (CIMT) may not be applicable to those patients without enough residual active movement (Thrasher et al., 2008). On the other hand, motor recovery in chronic stroke is more challenging due to the decreasing plasticity of spontaneous recovery (Cassidy and Cramer, 2017). Since the upper limbs, especially the hands, play a significant role in daily activity, exploring novel rehabilitation therapies for hand motor recovery in this group is essential (Neumann, 2016). Robot-assisted therapy (RAT) and motor imagery (MI) have been introduced to enhance motor recovery for stroke patients through passive motion or mental practice. However, although these interventions benefit training without requiring patients’ residual ability, rehabilitation effectiveness is still limited by a lack of active engagement (Kwakkel et al., 2008; Ietswaart et al., 2011). Recent advances in brain–computer interface (BCI) technology offer a novel method that could extract the motor intention of patients executing MI to support active rehabilitation training. Related studies have shown promising results that MI-actuated BCI improves motor ability more than pure MI or sham BCI (Ramos-Murguialday et al., 2013; Ang et al., 2014; Pichiorri et al., 2015). However, this intervention still faces limitations in practical use (Mulder, 2007; Baniqued et al., 2021). First, BCI may not be easy for everyone due to the “BCI illiteracy” phenomenon or the limited training schedule in clinical environments (Blankertz et al., 2009; Horowitz et al., 2021). In addition, most stroke subjects show more difficulty executing MI tasks than healthy subjects because of brain impairment in motor-related areas (Mulder, 2007). Worse situations occur in severe patients because they can hardly perform effective MI or fall into fatigue quickly under effortful attempts. Recent studies found that action observation (AO) could also activate sensorimotor features, as in MI and motor execution tasks (Friesen et al., 2017; Hardwick et al., 2017). In addition, repeated AO could induce plasticity changes by activating the mirror neuron system (MNS) (Rizzolatti and Sinigaglia, 2010; Agosta et al., 2017). These inspired studies combined AO in the BCI system, where stronger event-related desynchronization (ERD) responses are found than in pure MI-BCI (Kondo et al., 2015; Ono et al., 2018; Nagai and Tanaka, 2019). However, most of these studies focused on healthy subjects, while related endeavors in the clinical rehabilitation of stroke subjects are still insufficient.

Another major concern in exploring novel interventions in chronic stroke is better evaluating the motor deficits and understanding the therapeutic-induced improvement during rehabilitation neurologically. On the one hand, the recovery in post-stroke motor rehabilitation is usually heterogeneous. Except for individual factors such as age, time since stroke, and related complications, a variety of neuro-clinical factors, such as the degree of brain lesion and neural status, would also affect the patient’s recovery (Riley et al., 2011; Chang et al., 2013; Feng et al., 2015; Kim and Winstein, 2017). On the other hand, chronic stroke recovery is more challenging with the decreasing plasticity of spontaneous recovery and depends more on intervention-induced plasticity (Cassidy and Cramer, 2017). The routinely used assessment of motor recovery is on clinical scales, which are semi-objective and limited in monitoring the underlying neural factors. Hence, recent studies have focused on finding neural biomarkers that could serve as an additional physiological approach to probe brain status and reflect the extent of post-stroke functional recovery (Kim and Winstein, 2017). Potential biomarkers have been found in physiological measuring tools such as Functional magnetic resonance imaging (fMRI) and magnetoencephalograms (MEG) (Várkuti et al., 2013; Kim and Winstein, 2017).

Compared with these tools, electroencephalography (EEG) offers another economical and widely available choice, making it a more practical approach in clinical environments for rehabilitation (Gerloff et al., 2006; Ang and Guan, 2016). In addition, the EEG is easy to implement in EEG-based BCI interventions. However, most related investigations of EEG markers focused on acute or subacute-stage patients, and studies concerned with chronic patients are still lacking (Foreman and Claassen, 2012; Assenza et al., 2017; Trujillo et al., 2017; Bentes et al., 2018). Notably, EEG oscillations in different bands themselves play roles in reflecting the physiological and pathological status of the neural systems. For example, the increasing low-frequency power (delta and theta bands) and decreasing high-frequency power (alpha and beta bands) are believed to reflect the severity of acute neurological deficits (Rabiller et al., 2015; Assenza et al., 2017). Apart from reflecting the motor status, the EEG features may also promote an understanding of varied recovery resulting from additional factors during rehabilitation. For instance, a previous study found that patients under different interventions have different EEG indicators (Mane et al., 2019). We infer that patients with varying degrees of recovery may also differ in EEG features after experiencing different neural processes in training. Overall, how these EEG oscillations would act in chronic stroke and whether related EEG features could reflect therapeutic-induced improvement in effective interventions remains to be determined.

To fill this gap, the present study aimed to explore whether brain oscillations in different EEG bands can reflect the motor status and recovery induced by novel BCI therapy in chronic stroke. Specifically, an AO-BCI robotic hand training intervention was studied in a clinical environment, and the motor scales were assessed before and after the training. The correlations between EEG band power and motor scales both before and after the intervention were analyzed to study their feasibility in reflecting motor status by EEG band power in chronic stroke patients. In addition, we presented the difference in EEG variation during an intervention on patients with and without effective recovery [whether the minimal clinically important difference (MCID) was reached] (van der Lee et al., 2001; Wagner et al., 2008). Moreover, we examined which EEG rhythm variations correlate with motor function improvement and their potential as markers in reflecting therapeutic-induced neuroplasticity changes and guiding rehabilitation intervention in chronic stroke patients. […]

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Figure 1. (A) Experimental setup of the BCI training and the analysis of offline data in biomarker analysis. (B) The timeline of recording resting state EEG while observation of non-biological movements. (C) The timing for BCI training while observation of biological movements.

[Abstract + References] Virtual Reality-Based Rehabilitation for Patients with Stroke: Preliminary Results on User Experience – Conference paper

Abstract

Stroke is one of the major causes of disability worldwide, and most stroke survivors require rehabilitation to recover motor and cognitive functions. Virtual Reality (VR) has emerged as a promising means to administer rehabilitative interventions due to its potential to provide high engagement and motivation, with positive effects on treatment compliance. In this context, we present the Virtual Supermarket (VSS), i.e., an immersive ecological VR application to retrain upper limb movements and cognitive functions in patients with stroke. The exercise foresees identifying, reaching, and grabbing grocery items on supermarket shelves and paying for them. Currently, we are conducting a study assessing the user experience of patients with sub-acute and chronic stroke undergoing rehabilitation with the VSS over a period of 4 weeks, 3 times a week. Up to now, 9 patients have experienced the supermarket and have answered questionnaires about perceived ease of use, involvement, and cyber-sickness after the first rehabilitation session. The VSS was evaluated satisfactorily, and no side effects emerged. Although preliminary, these outcomes are encouraging, and we expect the positive results to be maintained at the end of the rehabilitation period too. Further studies will be needed to investigate better clinical improvements that the VSS may lead to.

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[Abstract] A Bidirectional Fabric-Based Soft Robotic Glove for Hand Function Assistance in Patients with Chronic Stroke – Full Text PDF

Abstract and Figures

Background Chronic stroke patients usually experience reduced hand functions, impeding their ability to perform activities of daily living (ADLs) independently. Additionally, improvements in hand functions by physical therapy beyond six months after the initial onset of stroke are much slower than in the earlier months. As such, chronic stroke patients could benefit from an assistive device to enhance their hand functions, allowing them to perform ADLs independently daily. In recent years, soft robotics has provided a novel approach to assistive devices for motor impaired individuals, offering more compliant and lightweight alternatives to traditional robotic devices. The scope of this study is to demonstrate the viability of a fabric-based soft robotic (SR) glove with bidirectional actuators in assisting chronic stroke study participants with hand impairments in performing ADLs.

Methods Force and torque measurement tests were conducted to characterize the SR Glove, and hand functional tasks were given to eight chronic stroke patients to assess the efficacy of the SR Glove as an assistive device. The tasks involved object manipulation tasks that simulate ADLs, and the series of tasks was done by the participants once without assistance for baseline data, and once while using the SR Glove. A usability questionnaire was also given to each participant after the tasks were done to gain insight into how the SR Glove impacts their confidence and reliance on support while performing ADLs.

Results The SR Glove improved the participants’ manipulation of objects in ADL tasks. Difference in mean scores between the unassisted and assisted conditions was significant across all participants. Additionally, the usability questionnaire showed the participants felt more confident and less reliant on support while using the SR Glove to perform ADLs than without the SR Glove.

Conclusions The results from this study demonstrated that the SR Glove is a viable option to assist hand function in chronic stroke patients who suffer from hand motor impairments.

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[Abstract] Functional improvement in chronic stroke patients when following a supervised home-based computerized cognitive training

ABSTRACT

Background

Computerized Cognitive Training (CCT) is an effective treatment for cognitive impairment in the post-acute stage of stroke. However, it is still not clear if it is suitable for chronic stage.

Objectives

To explore if patients with cognitive deficit following stroke may benefit from CCT.

Methods

Thirty patients post-stroke between 24 and 62 years old were randomized into two groups (A and B) to receive two different types of CCT. All patients were tested with a neuropsychological battery and functional questionnaires, before and after each CCT and also 6 months after the end of the study. In phase I, Group A received a customized CCT and Group B received a non-customized CCT, over 6 weeks. Three months after, each group received the other intervention (phase II).

Results

After phase I, between-group analyses revealed that Group A showed a relative decrease in subjective complaints. In contrast, Group B showed improvement in performance-based measures. After phase II, the decrease in subjective complaints continued in Group A, and both groups showed improvement in performance-based measures.

Conclusions

Patients with chronic stroke improved cognitive functioning after performing supervised home-based multi-domain computerized cognitive training.

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[Abstract] Effects of a combined group physical activity program in people with chronic stroke: A randomized, cross-over trial in a low-income setting

Abstract

Background: The prevalence of physical inactivity after stroke is high and exercise training improves many outcomes. However, access to community training protocols is limited, especially low-income settings.

Objective: To investigate the feasibility and efficacy of a new intervention: Circuit walking, balance, cycling and strength training (CBCS) on activity of daily living (ADL) limitations, motor performance, and social participation restrictions in people after stroke.

Methods: Forty-six community-dwelling individuals with chronic stroke who were no longer in conventional rehabilitation were randomized into an immediate CBCS group (IG; initially received CBCS training for 12 weeks in phase 1), and a delayed CBCS group (DG) that first participated in sociocultural activities for 12 weeks. In phase 2, participants crossed over so that the DG underwent CBCS and the IG performed sociocultural activities. The primary outcome was ADL limitations measured with the ACTIVLIM-Stroke scale. Secondary outcomes included motor performance (balance: Berg Balance Scale [BBS], global impairment: Stroke Impairment Assessment Set [SIAS] and mobility: 6-minute and 10-metre walk tests [6MWT and 10mWT] and psychosocial health [depression and participation]). Additional outcomes included feasibility (retention, adherence) and safety.

Results: ADL capacity significantly improved pre to post CBCS training (ACTIVLIM-stroke, +3,4 logits, p < 0.001; ES 0.87), balance (BBS, +21 points, p < 0.001; ES 0.9), impairments (SIAS, +11 points, p < 0.001; effect size [ES] 0.9), and mobility (+145 m for 6MWT and +0.37 m/s for 10mWT; p < 0.001; ES 0.7 and 0.5 respectively). Similar improvements in psychosocial health occurred in both groups. Adherence and retention rates were 95% and 100%, respectively.

Conclusion: CBCS was feasible, safe and improved functional independence and motor abilities in individuals in the chronic stage of stroke. Participation in CBCS improved depression and social participation similarly to participation in sociocultural activities. The benefits persisted for at least 3 months after intervention completion.

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[ARTICLE] EEG-Based Brain Network Analysis of Chronic Stroke Patients After BCI Rehabilitation Training – Full Text

Traditional rehabilitation strategies become difficult in the chronic phase stage of stroke prognosis. Brain–computer interface (BCI) combined with external devices may improve motor function in chronic stroke patients, but it lacks comprehensive assessments of neurological changes regarding functional rehabilitation. This study aimed to comprehensively and quantitatively investigate the changes in brain activity induced by BCI–FES training in patients with chronic stroke. We analyzed the EEG of two groups of patients with chronic stroke, one group received functional electrical stimulation (FES) rehabilitation training (FES group) and the other group received BCI combined with FES training (BCI–FES group). We constructed functional networks in both groups of patients based on direct directed transfer function (dDTF) and assessed the changes in brain activity using graph theory analysis. The results of this study can be summarized as follows: (i) after rehabilitation training, the Fugl–Meyer assessment scale (FMA) score was significantly improved in the BCI–FES group (p < 0.05), and there was no significant difference in the FES group. (ii) Both the global and local graph theory measures of the brain network of patients with chronic stroke in the BCI–FES group were improved after rehabilitation training. (iii) The node strength in the contralesional hemisphere and central region of patients in the BCI–FES group was significantly higher than that in the FES group after the intervention (p < 0.05), and a significant increase in the node strength of C4 in the contralesional sensorimotor cortex region could be observed in the BCI–FES group (p < 0.05). These results suggest that BCI–FES rehabilitation training can induce clinically significant improvements in motor function of patients with chronic stroke. It can improve the functional integration and functional separation of brain networks and boost compensatory activity in the contralesional hemisphere to a certain extent. The findings of our study may provide new insights into understanding the plastic changes of brain activity in patients with chronic stroke induced by BCI–FES rehabilitation training.

Introduction

Stroke is a cerebrovascular disease with high morbidity, disability, and mortality (Sheorajpanday et al., 2011; Larivière et al., 2018). Patients are likely to suffer various degrees of functional impairment after the onset of stroke, among which motor dysfunction is one of the most significant disabling manifestations after stroke (Krueger et al., 2015). Motor dysfunction seriously affects the quality of life of patients with stroke and their families, and therefore stroke rehabilitation is essential. Currently, resources for stroke rehabilitation are focused on the prognosis of patients with stroke in the acute and subacute phases (Teasell et al., 2012). For patients with stroke in the chronic phase, which is more than 6 months after stroke (Bernhardt et al., 2017), a standardized outpatient regimen of exercise fails to effectively promote the recovery of motor function. One possible contributing factor is the neuromuscular adaptation to a standardized outpatient regimen of exercise in patients with chronic stroke (Teasell et al., 2014). When neuromuscular adaptation occurs, finding a treatment regimen that differs from that during rehabilitation can be beneficial in overcoming the adaptive state (Page et al., 2004). Several recent studies have shown that alternative or new treatment options, such as brain–computer interface (BCI) combined with external devices or other neuromodulation paradigms, can be effective in chronic stroke rehabilitation (Broetz et al., 2010; Ramos-Murguialday et al., 2013; Mukaino et al., 2014; Naros and Gharabaghi, 2017; Mohanty et al., 2018; Miao et al., 2020).

Brain–computer interface can directly measure brain activity and convert it into control signals of computers or external devices. The BCI used to overcome stroke-related motor paralysis can be broadly divided into two categories: assistive BCI and rehabilitative BCI (Soekadar et al., 2015). The assistive BCI is designed to continuously or permanently control the robotic device to assist in daily life activities. The rehabilitative BCI is meant to establish connections between the brain and the periphery (Pichiorri and Mattia, 2020) and induce neuroplasticity to facilitate motor recovery (Soekadar et al., 2011). BCI focuses on brain activity and can recognize and enhance motor-related brain activity (Hallett, 2007). Due to this ability to modify brain activity, BCI is considered a form of endogenous neuromodulation that can induce plastic remodeling of brain activity (Pichiorri and Mattia, 2020). By altering the brain activity, BCI can induce recovery of function. There are two common strategies for the application of the BCI technique in motor function rehabilitation of patients with chronic stroke. The first strategy is to drive external devices, such as robotic devices or functional electrical stimulation (FES), to assist in the execution of limb movements. This strategy can close the sensorimotor loop disrupted by the stroke event and re-establish connections between the central nervous system and the periphery (Pichiorri and Mattia, 2020). Several studies have shown that patients with chronic stroke who receive BCI-assisted robotic therapy can achieve greater motor gains compared to robotic therapy alone (Ramos-Murguialday et al., 2013; Keng et al., 2014; Frolov et al., 2017). Representative among these studies is a randomized controlled study conducted by Ramos-Murguialday et al. (2013) in 32 patients with chronic stroke. Their results showed that BCI-driven arm orthosis improved upper limb motor function more significantly in patients with chronic stroke than in a control group where movements of the arm orthoses occurred randomly. Similar results have been reported in studies of the BCI combined with the Haptic Knob (HK) robot (Keng et al., 2014) and the BCI-controlled exoskeleton (Frolov et al., 2017) for the rehabilitation of patients with chronic stroke. In addition, some studies have compared the differences in motor function of patients before and after intervention, and the results have shown that BCI-driven robotic devices play a beneficial role in the rehabilitation of patients with chronic stroke (Shindo et al., 2011; Takashi et al., 2014; Sun et al., 2017; Lu et al., 2020). Similar effective effects were also found in studies on the rehabilitation of patients with chronic stroke based on BCI-driven FES (Tabernig et al., 2018). A recent study by Biasiucci et al. (2018) showed that BCI-driven FES was more effective in inducing significant and durable motor recovery in patients with chronic stroke than sham FES. They pointed out that BCI combined with FES can promote significant functional recovery and purposeful plasticity.[…]

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FIGURE 1. The schematic of the BCI–FES system.

[Abstract] Association of Hand Stiffness with Balance Impairment in Chronic Stroke Patients

Abstract

Objective: To determine the association of hand stiffness with balance impairment in chronic stroke patients.

Methodology: A cross sectional study was conducted on eighteen chronic stroke patients with age range between 40 to 70 years. Patients were taken from Riphah Rehab Center and Govt. Kot Khawaja Saeed Teaching Hospital KEMU Lahore. The balance of patients was assessed by using Berg Balance Scale (BBS) and Timed Up and Go Test (TUG) while motor function of the hand was assessed by using Fugl Meyer Assessment-Upper Extremity (FMA-UE).

Results: The analysis of data done by using SPSS version25. The mean value of age of the patients was 54.9 + 9.09 years. FMA-UE tool was used to assess motor activity of hand. Postural balance was measured by using BBS and TUG. The results showed a positive correlation of FMA-UE with BBS (r_s = 0.704, p =<0 .001) and a negative correlation with TUG (r_s = -.705, p = .001).

Conclusion: This study concluded that there is association of hand stiffness with balance impairment in chronic stroke patients

[Abstract] Effects of exergaming on functional outcomes in people with chronic stroke: A systematic review and meta-analysis – Review

Abstract

Aims: The aim of this review is to synthesize and evaluate effectiveness of exergaming on balance, lower limb functional mobility and functional independence in individuals with chronic stroke.

Design: The present review is a systematic review and meta-analysis. The review is written in accordance with the guidelines from the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) DATA SOURCE: Searches were conducted across seven databases (PubMed, EMBASE, Web of Science, CINAHL, CENTRAL, Scopus and PEDro) and in grey literature from inception until January 2021.

Review methods: Only randomized controlled trials (RCTs) written in English were included. All eligible studies were assessed for risk of bias by two reviewers independently. Meta-analyses were performed using RevMan 5.4.1 software. Narrative syntheses were adopted whenever meta-analysis was inappropriate. The overall quality of evidence from included studies was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework.

Results: 4511 records were retrieved, with 32 RCTs eligible for inclusion and 27 RCTs included in meta-analysis. Meta-analyses reported statistically significant small effect sizes favouring exergaming on balance (pooled standardized mean difference [SMD] = 0.25, 95% confidence interval [CI, 0.08-0.41], p = .004), lower limb functional mobility (pooled SMD = 0.29, 95% CI [0.08-0.50], p = .007) and functional independence (pooled SMD = 0.41, 95% CI [0.09-0.73], p = .01). Most of the included studies failed to provide adequate description of the measures taken to prevent bias.

Conclusion: Exergaming has favourable effects on improving balance, lower limb functional mobility and functional independence among individuals with chronic stroke, making it a suitable adjunct to conventional physiotherapy.

Impact: People with chronic stroke have difficulty achieving the required rehab intensity. Exergaming can help individuals with chronic stroke to undertake further rehabilitation exercises at home. It can be a suitable adjunct to conventional physiotherapy.

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[ARTICLE] Motor-cognitive intervention concepts can improve gait in chronic stroke, but their effect on cognitive functions is unclear: A systematic review with meta-analyses – Full Text

Highlights

• Motor-cognitive intervention concepts should be classified as sequential or simultaneous and as competing or incorporated.

• Motor-cognitive trainings are superior to single physical training in improving gait speed and walking endurance in chronic stroke.

• Of different motor-cognitive intervention concepts, simultaneous-incorporated exergames seem to be the most promising type for improving gait speed and potentially other functions.

• Whether motor-cognitive trainings can improve cognitive functions in chronic stroke remains unclear, thus future studies are warranted.

Abstract

Motor-cognitive intervention concepts are promising to counteract residual gait and cognitive impairments in chronic stroke. There is, however, considerable variation in motor-cognitive intervention types, which may lead to different effects. This systematic review strived to summarize and compare the effects of different motor-cognitive intervention concepts on gait and cognitive functions in chronic stroke. The systematic search identified twenty-nine articles, which were allocated to three types of motor-cognitive training concepts; SEQUENTIAL, SIMULTANEOUS-ADDITIONAL, and SIMULTANEOUS-INCORPORATED. Random-effects meta-analyses revealed that motor-cognitive interventions may be better than non-combined training approaches for improving gait function in chronic stroke (e.g. gait speed: g = 0.43, 95 % CI [0.22, 0.64], p < 0.0001). SIMULTANEOUS-INCORPORATED motor-cognitive training seems the most promising concept. As very few articles measured both, spatiotemporal gait parameters and cognitive outcomes, future studies are warranted to investigate the effects of motor-cognitive intervention concepts on gait control and cognitive functions in chronic stroke.

1. Introduction

Stroke is a major cause for long-term disability worldwide (Benjamin et al., 2019; Feigin et al., 2017). While only a fourth of stroke survivors fully regain pre-stroke levels of participation and functioning in daily life (Lai et al., 2002; Mayo et al., 2002), approximately half of them stay moderately to severely impaired (FragileSuisse, 2021). Moreover, four-fifths of stroke survivors have been reported to not feeling completely recovered from the incident within four years (Gadidi et al., 2011). Accordingly, stroke survivors are often disappointed with professional services because they feel rehabilitation programs end too abruptly and are not specific enough to substantially improve the perceived quality of life (Robison et al., 2009).

Stroke survivors may face a broad range of impairments affecting their motor and cognitive abilities (Jorgensen et al., 2010; Maaijwee et al., 2014; Sun et al., 2014; Tang et al., 2018). A majority of stroke survivors suffer from hemiparesis, a one-sided weakness of one or both extremities, which results in loss of motor function (Langhorne et al., 2009; Sheffler and Chae, 2015). Hemiparetic gait is characterized by asymmetries and changes in spatiotemporal parameters, resulting in reduced gait speed and increased energy costs for walking (Balaban and Tok, 2014; Patterson et al., 2010; Sheffler and Chae, 2015). Furthermore, cognitive impairments may persist after the sub-acute phase of stroke, including deficits in attention, executive functions, visuo-spatial skills, and processing speed (Cumming et al., 2013; Tang et al., 2018). Formulating their top ten research priorities, stroke patients first named the need to improve cognition, followed by the need to address long-term consequences; the need to improve balance and gait is the seventh priority on this list (Pollock et al., 2012). In contrast to the priorities mentioned from the patients’ perspective, hardly any RCTs have focused on cognitive functions in stroke survivors, and effective treatments for memory and executive functions, for example, are largely lacking (Cumming et al., 2013).

Moreover, the first and seventh patients’ priority are closely related as many daily life activities simultaneously challenge walking and cognitive abilities. While healthy individuals cope well with simultaneous performance of motor and cognitive activities, people suffering from a neurological condition such as stroke struggle with it (Cockburn, 1998). Stroke has been linked to Motoric Cognitive Risk syndrome, where cognitive and gait impairments are intertwined (Allali et al., 2016), as post-stroke cognitive and gait impairments share structural and functional roots (Hamacher et al., 2015; Ursin et al., 2019; Verstraeten et al., 2016). Consequently, it can be hypothesised that interventions that focus on both motor and cognitive aspects within the same treatment are beneficial in chronic stroke. A promising approach are motor-cognitive training intervention concepts. These concepts are designed such that they require sequential or simultaneous performance of both motor and cognitive tasks (Herold et al., 2018; Levin et al., 2017). According to the “guided plasticity facilitation” model (Bamidis et al., 2014; Fissler et al., 2013), motor-cognitive intervention concepts should especially trigger neuroplasticity, a main goal of stroke rehabilitation (Maier et al., 2019; Pin-Barre and Laurin, 2015).

Various reviews and intervention studies have reported beneficial effects of motor-cognitive interventions on single- and dual-task walking, balance, and cognition in healthy or cognitively impaired older adults and neurological patients (N. E. Fritz et al., 2015; Lauenroth et al., 2016; Law et al., 2014; Levin et al., 2017; Raichlen et al., 2020; Zhu et al., 2016). In subacute stroke patients with vascular cognitive impairments, a motor-cognitive intervention has been found to improve various cognitive functions (Bo et al., 2019). Furthermore, studies with chronic stroke patients have found promising effects of motor-cognitive interventions on mobility, balance, gait speed and walking endurance as well as for reducing fall risk (An et al., 2014; Lee et al., 2017; Pang et al., 2018).

However, the effects of different motor-cognitive intervention concepts on gait and cognitive functions in chronic stroke have never been investigated systematically. Currently it is unclear whether motor-cognitive intervention concepts are more effective than single motor- and/or cognitive-training interventions. Furthermore, the variation in motor-cognitive interventions is considerable depending on the applied concept (Herold et al., 2018); as a result, different motor-cognitive intervention concepts could yield different results in chronic stroke. For this reason, this systematic review assesses how different types of motor-cognitive training intervention concepts affect gait and cognitive functions in chronic stroke. Our aim is to identify, summarize and contrast randomized controlled trials (RCTs), which evaluate motor-cognitive intervention concepts compared to single training interventions in chronic stroke regarding gait and cognitive functions.[…]

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