Background. Severe poststroke arm impairment is associated with greater activation of the nonlesioned hemisphere during movement of the affected arm. The circumstances under which this activation may be adaptive or maladaptive remain unclear.
Objective. To identify the functional relevance of key lesioned and nonlesioned hemisphere motor areas to reaching performance in patients with mild versus severe arm impairment.
Methods. A total of 20 participants with chronic stroke performed a reaching response time task with their affected arm. During the reaction time period, a transient magnetic stimulus was applied over the primary (M1) or dorsal premotor cortex (PMd) of either hemisphere, and the effect of the perturbation on movement time (MT) was calculated.
Results. For perturbation of the nonlesioned hemisphere, there was a significant interaction effect of Site of perturbation (PMd vs M1) by Group (mild vs severe; P < .001). Perturbation of PMd had a greater effect on MT in the severe versus the mild group. This effect was not observed with perturbation of M1. For perturbation of the lesioned hemisphere, there was a main effect of site of perturbation (P < .05), with perturbation of M1 having a greater effect on MT than PMd.
Conclusions. These results demonstrate that, in the context of reaching movements, the role of the nonlesioned hemisphere depends on both impairment severity and the specific site that is targeted. A deeper understanding of these individual-, task-, and site-specific factors is essential for advancing the potential usefulness of neuromodulation to enhance poststroke motor recovery.
Constraint-induced movement therapy (CI therapy) produces, on average, large and clinically meaningful improvements in the daily use of a more affected upper extremity in individuals with hemiparesis. However, individual responses vary widely.
The study objective was to investigate the extent to which individual characteristics before treatment predict improved use of the more affected arm following CI therapy.
This study was a retrospective analysis of 47 people who had chronic (> 6 months) mild to moderate upper extremity hemiparesis and were consecutively enrolled in 2 CI therapy randomized controlled trials.
An enhanced probabilistic neural network model predicted whether individuals showed a low, medium, or high response to CI therapy, as measured with the Motor Activity Log, on the basis of the following baseline assessments: Wolf Motor Function Test, Semmes-Weinstein Monofilament Test of touch threshold, Motor Activity Log, and Montreal Cognitive Assessment. Then, a neural dynamic classification algorithm was applied to improve prognostic accuracy using the most accurate combination obtained in the previous step.
Motor ability and tactile sense predicted improvement in arm use for daily activities following intensive upper extremity rehabilitation with an accuracy of nearly 100%. Complex patterns of interaction among these predictors were observed.
The fact that this study was a retrospective analysis with a moderate sample size was a limitation.
Advanced machine learning/classification algorithms produce more accurate personalized predictions of rehabilitation outcomes than commonly used general linear models.
For individuals with hand hemiparesis following a stroke, rehabilitation strategies are predominantly founded on the principles of neuroplasticity and automaticity  to regain optimal hand-related functional abilities and facilitate participation in everyday activities. Such an approach requires to engage these individuals into meaningful activity-specific exercises and to repeat those intensively on a daily basis. Adhering to these principles  remains challenging in clinical practice for rehabilitation professionals, especially given various time and productivity constraints. To overcome this challenge, the development of soft robotic gloves to facilitate hand rehabilitation have progressed substantially in the last decade. Moreover, these soft robotic gloves are foreseen as promising rehabilitation intervention to potentiate the effects of conventional rehabilitation interventions and are now about to transition into clinical practice, although their effects remain uncertain given the paucity of evidence. In this context, this review aims to map evidence on the effects of the different rehabilitation interventions using a soft robotic device for sensorimotor hand impairments and, whenever possible, the satisfaction related to their use.
Eligibility Criteria, Information Sources, And Search
This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . A review of the literature published in English and French from 2000 to October 2018 using a combination of search terms was conducted in Medline, EMBASE, and CINAHL. The search strategy included a combination of search terms related to three key domains: technology attributes (robotics, bionics, exoskeleton device, robot*, exoskelet*, motorized, motor-driven, motor assisted), anatomy of the hand (hand, hands, wrist*, finger*, prehension, dexterity), and rehabilitation domains (rehabilitation, exercise*, exercise therapy, physical therapy modalities, physical therapy speciality, physical therapists, occupational therapy, occupational therapist, therap*, physiothrap*). Search terms related to amputation, surgery, computer-assisted device, and teleoperation were excluded. From this initial search, 1870 articles were found and only 1206 articles remained after eliminating all duplicates. To narrow down the number of articles, a new domain was added (i.e., technology= glove, soft, wearable) and the search among the keywords, title, and abstracts was continued in EndNote. Thereafter, 181 articles remained and were imported into the web-based software platform Covidence where 9 additional duplicates were found.
SELECTION OF SOURCES OF EVIDENCE
The articles title, abstract and full text of 172 articles were screened by two rehabilitation professionals to identify the articles qualifying for a subsequent full review. To be considered for full review the article has to target 1) the effects or effectiveness of rehabilitation interventions using soft robotic gloves to optimize hand-related functional abilities and facilitate participation in everyday activities in people with sensorimotor disorders via randomized controlled trials (RCTs), non-randomized controlled trials (non-RCT), and other types of research designs (cohort studies, pre- and post-case interventions, case series, case-control studies and case reports) and 2) the users satisfaction and stakeholder views on the use of soft robotic gloves. For this review, in order to be considered a soft robotic glove, the technology had to generate assisted pinching or gripping movements soliciting multiple joints involving at least the thumb and the index finger and middle fingers. Interventions using a soft robotic glove could be performed in a hospital, rehabilitation center or at home with the direct or indirect supervision of a rehabilitation professional. The use of the soft robotic glove could also be combined with other technologies (e.g., virtual reality). Research protocols or manuscripts that did not include participants with sensorimotor impairment were excluded. All scientific manuscripts and conference abstracts focusing on upper limb exoskeleton including the elbow or shoulder joint were excluded.
Data Extraction And Charting Process
Studies that met the inclusion and exclusion criteria were read by a single rehabilitation professional and the following information were extracted on project-specific forms data extraction tables organized within an excel file: author-related information’s, journals and publication year, soft robotic glove attributes, study design, population and sample size, intervention, measurement instruments, results and interpretations, and user’s satisfaction. At the end, to establish if the use of a soft robotic glove yield to positive, neutral or negative effect, the p-value and effect size of each outcome measures from each article were determined.
Characteristics Of Sources Of Evidence
Ten articles included in this study originated from European or American countries; USA (5/10) [4-8], Italy (2/10) [9,10], United Kingdom (2/10) [11,12], and Netherlands (1/10) . The majority of these studies were published in 2017 (6/10) [6,8-12] or 2018 (3/10) [5,7,13]. Only one study was published in 2011 .
Study Designs And Populations
Both experimental (3/10) [8,10,12] and quasi-experimental studies (7/10) [4-7,9,11,13] were selected with mean sample sizes of 12,4 participants and ranging from 2 to 27. Most studies investigated individuals with hemiparesis following a stroke (9/10) [4-6,8-13] whereas one article investigated individuals with of a traumatic spinal cord injury .
Synthesis Of Findings
Soft robotic gloves
Eight different soft robotic gloves (i.e., HandSOME [4,6], FES Hand Glove , Gloreha Light Glove , Gloreha Professional , VAEDA , HandinMind [12,13] and two others without names) with different types of assistance (i.e., motor [7,8,9,10,12,13], elastic [4,6], and pneumatic [5,11]) were identified.
Four studies [4,5,11,13] used a transversal design to compare hand function with and without the use of a soft robotic device glove whereas three studies used an experimental design [8,10,12] and three used a quasi-experimental design [6,7,9] to compare hand sensorimotor integrity and functional abilities before and after an intervention with the soft robotic glove. No concomitant therapy was used in all of the studies. The intervention protocols of the experimental and quasi-experimental design studies varied in length from 4 to 8 weeks, in frequency from 3 to 6 times a week and training sessions duration from 40 to 90 minutes.
The outcome measures included: Ashworth Spasticity Index  or Ashworth modified scale , edema , Hand pain VAS , Barthel , Motricity index [9,10], Nine hole peg test (NHPT) [9,10], grip strength [4,6,8-10], active range of motion (AROM) , Velocity of movements , Box and blocks test , Fugl-Meyer Assessment of Upper Extremity (FMA-UE) [6,8], Fugl-Meyer Hand (FMH) , The Action Research Arm Test (ARAT) [6,8], The Motor Activity Log , time to execute tasks , Toronto Rehabilitation Institute Hand Function Test (TRI-HFT) , pinch strength [8,10,12], JTFHT , Activity of Daily Living (ADL) , Functional Independence Measure (FIM) , Wolf Motor Function Test (WMFT) , Chedoke McMaster Stroke Assessment Hand (CMSAH)  and the Quick-DASH . Then, each outcomes measure have been classified according to the International Classification of Functioning, Disability and Health (ICF)  (Figure. 1).
Effects and effectiveness
The results in terms of effects and effectiveness of the interventions are listed in the Figure 1. Mostly, the use of robotic gloves increased joint mobility and functional capacity of the upper limb in terms of performance rapidity. According to muscular strength, functional capacity of the upper limb assessed by questionnaire, and global functional capacity, the results are heterogeneous and do not allow conclusion on the effectiveness of intervention using this technology.
Usability, feasibility and satisfaction
Four studies also assessed the usability, feasibility or satisfaction of the users after trying the soft robotic glove [10-13] using the Usefulness-Satisfaction-and-Ease-of-Use questionnaire , observations [4,10], System Usability Scale [12,13], Intrinsic Motivation Inventory , cost analysis . Studies concluded that the use of soft robotic gloves is foreseen as being feasible and acceptable by participants and rehabilitation professionals [10-13] and as increasing engagement in rehabilitation program [11,13]. Most of the studies support the fact that the soft robotic gloves are easy to use [10, 1,13]. However, the robotic glove was found to be more useful when performing gross motor tasks when compared to fine motor tasks , the presence of a zipper on the glove made it difficult to put on , and the choice of material, especially its thickness, was found to interfere with hand and finger sensations . A preference for the rental of these devices has been demonstrated . The most important features highlighted in the studies included: easy to clean, comfortable, easy to put on and take off. Last, a decreased in rehabilitation cost linked to the use of a soft robotic device at home may be anticipated .
This systematic review of the literature confirms an increased interest over the last decade in the development and use of soft robotic gloves for rehabilitation of individuals with hand hemiparesis following a neurological event. Overall, the use of soft robotics devices in rehabilitation treatment is feasible, safe, and acceptable by patients while its effects and effectiveness appear promising. However, the strength of the currently available evidence remains limited and given the wide variety of soft robotic glove attributes, study designs and interventions, and outcomes measures alongside the small sample sizes tested, it is impossible to highlight which soft robotic glove or intervention protocol would be the most appropriate to obtain the best clinical results. Stronger evidence linked to the effects or effectiveness, in addition to comprehensive stakeholder perspectives (e.g., patients, rehabilitation professionals), especially on the usability, are needed to ensure a successful transition from the laboratory to clinical practice.
This systematic review maps currently available evidence on the use of soft robotic gloves as a rehabilitation intervention while considering effectiveness and usability. This technology is a promising solution to optimize sensorimotor capabilities, hand-related functional abilities and facilitate participation in everyday activities while overcoming some clinical constraints. Additional research in this area should be encouraged to strengthen current evidence.
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Supported by the Initiative for the Development of New Technologies and Innovative Practices in Rehabilitation and by the Université de Montréal (Direction des affaires internationales).
Background: Stroke is the leading cause of disability in adults, producing a major personal and economic impact on those affected. The scientific evidence regarding the use of Motor Imagery (MI) as a preparatory process for motor control reinforces the need to explore this method as a complement to physical therapy.
Objectives: The objectives of this systematic review were to determine the effectiveness of MI for functional recovery after stroke and to identify a possible intervention protocol, according to the level of existing scientific evidence.
Methods: A comprehensive literature search was performed using Medline, Cochrane Library and PEDro databases. Studies were limited to those published between 2007 and 2017, and restricted to English and/or Spanish language publications.
Results: Thirteen randomized clinical trials that met the inclusion criteria were included. The methodological quality of studies was determined using the Critical Review Form for Quantitative Studies, obtaining scores of 9-13 points out of 15. The level of evidence and strength of recommendations were assessed using the U.S. Preventive Services Task Force (USPSTF) assessment, obtaining levels IA and II-B1. Significant improvements were found in outcome measures evaluating upper limb functionality, balance and kinematic gait parameters.
Conclusions: The use of MI combined with conventional rehabilitation is an effective method for the recovery of functionality after stroke. Due to the great heterogeneity in the scientific literature available, new lines of research are necessary, in order to include well-designed studies of good methodological quality and to establish a consensus regarding the most appropriate protocols.
Stroke rehabilitation researchers test new electrical stimulation therapy for improving for hand function after stroke, as part of multi-site study headed by the MetroHealth System and Case Western Reserve University
East Hanover, NJ. November 26, 2019. Kessler Foundation is participating in a phase II multi-site study of an innovative treatment to improve hand function in stroke survivors. Olga Boukrina, PhD, research scientist in the Center for Stroke Rehabilitation Research, is the site’s principal investigator. The study is funded through a five-year $3.2 million grant from the National Institutes of Health awarded to the principal investigator, Jayme S. Knutson, PhD, director of Research and associate professor of Physical Medicine and Rehabilitation at the MetroHealth System and Case Western Reserve University.
This is the first multi-site clinical trial of contralaterally controlled functional electrical stimulation (CCFES), a new rehabilitation intervention for hand recovery following stroke developed by Knutson and colleagues. With CCFES, electrical stimulation is applied to the muscles of the weak hand through surface electrodes, causing the weak hand to open, a function that is often lost in stroke survivors. The patient controls the stimulation to their weak hand through a glove with sensors worn on their opposite, unaffected hand. Opening their unaffected hand delivers a proportional intensity of electrical stimulation that opens their weak hand, and enables them to practice using their hand in therapy. Researchers will enroll 129 patients who are 6 to 24 months post stroke who have upper extremity hemiparesis and limited hand movement.
The effectiveness of CCFES will be compared with two other treatments — cyclic neuromuscular electrical stimulation (CNMES), which has pre-set duration and intensity of stimulation and operates independent of patient control, and traditional task-based training without stimulation. Participants will be randomly assigned to one of the three treatment options for 12 weeks. The research teams will administer the treatments and conduct blinded outcome assessments. The durability of functional improvements will be evaluated at 6-month follow-up. Study sites include the MetroHealth System (Jayme Knutson, PhD), the Cleveland Clinic (Ela Plow, PT, PhD), Emory University (A.M. Barrett, MD), and Johns Hopkins University (Preeti Raghavan, MD).
“Because hand function is integral to so many activities of daily living, advances that improve function can have significant effect on the lives of stroke survivors,” said Dr. Boukrina. “This study will help determine the optimal method for restoring hand function. We anticipate that putting the patients in control of stimulating their weak hand with CCFES may activate neuroplastic changes that lead to greater and longer lasting functional gains.”
Background: Stroke often results in motor impairment and limited functional capacity. This study aimed to verify the relationship between widely used clinical scales and instrumented measurements to evaluate poststroke individuals with mild, moderate, and severe motor impairment.
Methods: This cross-sectional study included 34 participants with chronic hemiparesis after stroke. Fugl-Meyer Assessment and Modified Ashworth Scale were used to quantify upper and lower limb motor impairment and the resistance to passive movement (i.e., spasticity), respectively. Upper limb Motor performance (movement time and velocities) and movement quality (range of motion, smoothness and trunk displacement) were analyzed during a reaching forward task using an optoelectronic system (instrumented measurement). Lower limb motor performance (gait and functional mobility parameters) was assessed by using an inertial measurement unit system.
Findings: Fugl-Meyer Assessment correlated with motor performance (upper and lower limbs) and with movement quality (upper limb). Modified Ashworth scale correlated with movement quality (upper limb). Cutoff values of 9.0 cm in trunk anterior displacement and .57 m/s in gait velocity were estimated to differentiate participants with mild/moderate and severe compromise according to the Fugl-Meyer Assessment.
Conclusions: These results suggest that the Fugl-Meyer Assessment can be used to infer about motor performance and movement quality in chronic poststroke individuals with different levels of impairment.
People with hemiparesis after stroke appear to recover 70% to 80% of the difference between their baseline and the maximum upper extremity Fugl-Meyer (UEFM) score, a phenomenon called proportional recovery (PR). Two recent commentaries explained that PR should be expected because of mathematical coupling between the baseline and change score. Here we ask, If mathematical coupling encourages PR, why do a fraction of stroke patients (the “nonfitters”) not exhibit PR? At the neuroanatomical level of analysis, this question was answered by Byblow et al—nonfitters lack corticospinal tract (CST) integrity at baseline—but here we address the mathematical and behavioral causes. We first derive a new interpretation of the slope of PR: It is the average probability of scoring across remaining scale items at follow-up. PR therefore breaks when enough test items are discretely more difficult for a patient at follow-up, flattening the slope of recovery. For the UEFM, we show that nonfitters are most unlikely to recover the ability to score on the test items related to wrist/hand dexterity, shoulder flexion without bending the elbow, and finger-to-nose movement, supporting the finding that nonfitters lack CST integrity. However, we also show that a subset of nonfitters respond better to robotic movement training in the chronic phase of stroke. These persons are just able to move the arm out of the flexion synergy and pick up small blocks, both markers of CST integrity. Nonfitters therefore raise interesting questions about CST function and the basis for response to intensive movement training.
Purpose: Precise control of a car steering wheel requires adequate motor capability. Deficits in grip strength and force control after stroke could influence the ability steer a car. Our study aimed to determine the impact of stroke on car steering and identify the relative contribution of grip strength and grip force control to steering performance.
Methods: Twelve chronic stroke survivors and 12 controls performed three gripping tasks with each hand: maximum voluntary contraction, dynamic force tracking, and steering a car on a winding road in a simulated driving environment. We quantified grip strength, grip force variability, and deviation of the car from the center of the lane.
Results: The paretic hand exhibited reduced grip strength, increased grip force variability, and increased lane deviation compared with the non-dominant hand in controls. Grip force variability, but not grip strength, significantly predicted (R2 = 0.49, p < 0.05) lane deviation with the paretic hand.
Conclusion: Stroke impairs the steering ability of the paretic hand. Although grip strength and force control of the paretic hand are diminished after stroke, only grip force control predicts steering accuracy. Deficits in grip force control after stroke contribute to functional limitations in performing skilled tasks with the paretic hand.
Implications for rehabilitation
Driving is an important goal for independent mobility after stroke that requires motor capability to manipulate hand and foot controls.
Two prominent stroke-related motor impairments that may impact precise car steering are reduced grip strength and grip force control.
In individuals with mild-moderate impairments, deficits in grip force modulation rather than grip strength contribute to compromised steering performance with the paretic hand.
We recommend that driving rehabilitation should consider re-educating grip force modulation for successful driving outcomes post stroke.
Transcranial direct current stimulation (tDCS) is a treatment used in the rehabilitation of stroke patients aiming to improve functionality of the plegic upper extremity. Currently, tDCS is not routinely used in post stroke rehabilitation. The aim of this study was to establish the effects of bihemspheric tDCS combined with physical therapy (PT) and occupational therapy (OT) on upper extremity motor function.
Thirty-two stroke inpatients were randomised into 2 groups. All patients received 15 sessions of conventional upper extremity PT and OT over 3 weeks. The tDCS group (n = 16) also received 30 minutes of bihemispheric tDCS and the sham group (n = 16) 30 minutes of sham bihemispheric tDCS simultaneously to OT. Patients were evaluated before and after treatment using the Fugl Meyer upper extremity (FMUE), functional independence measure (FIM), and Brunnstrom stages of stroke recovery (BSSR) by a physiatrist blind to the treatment group
The improvement in FIM was higher in the tDCS group compared to the sham group (P = .001). There was a significant within group improvement in FMUE, FIM and BSSR in those receiving tDCS (P = .001). There was a significant improvement in FIM in the chronic (> 6months) stroke sufferers who received tDCS when compared to those who received sham tDCS and when compared to subacute stroke (3-6 months) sufferers who received tDCS/sham.
Upper extremity motor function in hemiplegic stroke patients improves when bihemispheric tDCS is used alongside conventional PT and OT. The improvement in functionality is greater in chronic stroke patients.
Stroke is the leading cause of functional disability in adults. Its neurovascular origin and injury location indicates the possible functional consequences. Virtual rehabilitation (VR) using patient’s motion control is a new technological tool for conventional rehabilitation, allowing patterns of movements in varied environments, involving the patient in therapy through the playful components offered by VR applications. The objective of this systematic review is to collect data regarding the influence promoted by VR in upper limb and hemiparetic gait. Full articles published between 2009 and 2015 in english were searched and selected in PubMed, Cochrane and Pedro databases. Eleven articles included (5 for VR and upper limbs; 4 for VR, gait and balance; and 2 for VR and neural mechanisms). The articles included demonstrate efficacy in VR treatment in hemiparetic patients in the variables analyzed.