[Abstract] Effects of Robotic Therapy Associated With Noninvasive Brain Stimulation on Upper-Limb Rehabilitation After Stroke: Systematic Review and Meta-analysis of Randomized Clinical Trials

Abstract

Background

Robot-assisted therapy and noninvasive brain stimulation (NIBS) are promising strategies for stroke rehabilitation.

Objective

This systematic review and meta-analysis aims to evaluate the evidence of NIBS as an add-on intervention to robotic therapy in order to improve outcomes of upper-limb motor impairment or activity in individuals with stroke.

Methods

This study was performed according to the PRISMA Protocol and was previously registered on the PROSPERO Platform (CRD42017054563). Seven databases and gray literature were systematically searched by 2 reviewers, and 1176 registers were accessed. Eight randomized clinical trials with upper-limb body structure/function or activity limitation outcome measures were included. Subgroup analyses were performed according to phase poststroke, device characteristics (ie, arm support, joints involved, unimanual or bimanual training), NIBS paradigm, timing of stimulation, and number of sessions. The Grade-Pro Software was used to assess quality of the evidence.

Results

A nonsignificant homogeneous summary effect size was found both for body structure function domain (mean difference [MD] = 0.15; 95% CI = −3.10 to 3.40; P = 0.93; I² = 0%) and activity limitation domain (standard MD = 0.03; 95% CI = −0.28 to 0.33; P = 0.87; I² = 0%).

Conclusions

According to this systematic review and meta-analysis, at the moment, there are not enough data about the benefits of NIBS as an add-on intervention to robot-assisted therapy on upper-limb motor function or activity in individuals with stroke.

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[ARTICLE] Efficacy of repetitive transcranial magnetic stimulation for post-stroke depression: a systematic review and meta-analysis of randomized clinical trials – Full Text

ABSTRACT

We aimed to conduct a meta-analysis to evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) in patients with post-stroke depression (PSD). Six relevant electronic databases (PubMed, CENTRAL, Embase, Web of Science, CINAHL, and PsycINFO) were searched. Randomized controlled trials (RCTs) that compared rTMS with control condition for PSD were included. The mean change in depression symptom scores was defined as the primary efficacy outcome. Secondary outcomes included the remission rate of depression, stroke recovery, and cognitive function recovery. In total, 7 RCTs with 351 participants were included. At post-treatment, rTMS was significantly more effective than the control condition, with a standardized mean difference (SMD) of -1.15 (95%CI: -1.62 to -0.69; P<0.001, I²=71%) and remission with an odds ratio (OR) of 3.46 (95%CI: 1.68 to 7.12; P<0.001; I²=11%). As for stroke recovery, rTMS was also better than the control condition (SMD=-0.67, 95%CI: -1.02 to -0.32; P<0.001). However, no significant difference was found for cognitive function recovery between the two groups (SMD=4.07, 95%CI: -1.41 to 9.55; P=0.15). To explore the potential moderators for the primary outcome, a series of subgroup and sensitivity analyses were performed. The results implied that rTMS may be more effective in Asian samples than in North American samples (P=0.03). In conclusion, from the current evidence in this study, rTMS could be an effective treatment for patients with PSD. Further clinical studies with larger sample sizes and clearer subgroup definitions are needed to confirm these outcomes.

INTRODUCTION

Stroke is one of the major public health concerns in the world, because of its high morbidity, mortality, and disability rates and serious financial burden (¹). As one of the major obstacles in the process of stroke recovery, post-stroke depression (PSD) has attracted more and more attention (²). Studies have shown that PSD is associated with increased physical disabilities, impaired cognitive and social function, poor quality of life, and high risk of stroke recurrence and suicidality (³). Therefore, the treatment for PSD could benefit stroke functional recovery (⁴).

Several treatment options are now available for PSD, including medications, psychotherapy, and physiotherapy (^5 6–⁷). Antidepressants are widely used in various somatic diseases with depression (⁸), but there are many concerns focused on their safety. Due to the fact that many people who suffer from stroke are elderly or middle-aged with multiple risk factors of arteriosclerotic cardiovascular disease, antidepressants are usually cautiously prescribed for these people because of their common side effects such as blood pressure instability and QT interval prolongation (⁹,¹⁰). Some studies have demonstrated the efficacy of psychological therapy for PSD patients (¹¹). However, most people worldwide, especially in low-income countries, cannot access it.

Compared to medication, physiotherapy have been demonstrated to be safer for elderly people. Among the techniques, repetitive transcranial magnetic stimulation (rTMS) is one of the most important means for PSD patients (¹²). rTMS uses an electromagnetic coil applied to the scalp to produce a magnetic field. It causes cortical neurons in corresponding areas and neurons in distant areas to discharge, thereby regulating the function of the local cortex and related brain networks (¹³,¹⁴).

In the past decades, rTMS has been widely used in the treatment of psychiatric disorders, especially for major depressive disorder (MDD) (¹⁵). A number of studies have shown that rTMS is effective and safe for MDD patients (¹⁶). The possible mechanism could be a series of physiological effects induced by the focused magnetic field on specific brain regions, increasing the level of brain-derived neurotrophic factors (BDNF) and enhancing glucose metabolism in the cortex and other specific neural networks (¹⁷). However, whether rTMS is likewise effective for PSD patients remains unknown. Some studies have demonstrated promising results, but the conclusions are limited by the small sample size (^18 19–²⁰). Therefore, a well-designed meta-analysis to pool the comprehensive clinical evidence is needed to guide the application of rTMS in PSD patients.[…]

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[Abstract] Effectiveness of computer-based training on post-stroke cognitive rehabilitation: A systematic review and meta-analysis

ABSTRACT

A systematic review and meta-analysis based on randomized controlled trials (RCTs) from the last 10 years was conducted to identify the effect of computer-based training compared to routine methods on post-stroke cognitive rehabilitation and to provide recommendations for future research. A literature search was performed in the Cochrane Library, EMBASE, PubMed, EBSCO (CINAHL), and Web of Science that focused on studies comparing the effects of computerized cognitive training and routine methods in stroke survivors. After extraction of the study characteristics and methodological quality evaluation, a meta-analysis was conducted using the standard model based on the level of the overall cognitive domain. Ten out of 201 studies were included in the systematic review, with a total of 600 stroke survivors. The average age of the participants ranged from 42.1 to 66 years old, 305 participants used the computer-based training method, and males accounted for approximately 58.5%. All studies compared the baseline characteristics of participants at the onset of their studies, and no significant difference was shown. Six studies that reported the results for the overall cognitive domain were further analyzed by meta-analysis. The outcome of the meta-analysis showed that the effect size was 0.61 with a 95% confidence interval [−0.18, 0.35], and the P value (P = 0.54) indicated no significant difference between the control group and the computer-based cognitive training group. The results of the meta-analysis, based on a limited number of studies, did not show significant superiority of computer-based cognitive training compared to the traditional method in post-stroke patients. More high-quality studies focusing on different illness phases and various types of intervention software should be conducted to improve the meta-analysis and to explore the influence of computer-based cognitive training by subgroup analysis.

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[ARTICLE] The Effectiveness of Wearable Upper Limb Assistive Devices in Degenerative Neuromuscular Diseases: A Systematic Review and Meta-Analysis – Full Text

Abstract

Background: This systematic review summarizes the current evidence about the effectiveness of wearable assistive technologies for upper limbs support during activities of daily living for individuals with neuromuscular diseases.

Methods: Fourteen studies have been included in the meta-analysis, involving 184 participants. All included studies compared patients ability to perform functional tasks with and without assistive devices.

Results: An overall effect size of 1.06 (95% CI = 0.76-1.36, p < 0.00001) was obtained, demonstrating that upper limbs assistive devices significantly improve the performance in activities of daily living in people with neuromuscular diseases. A significant interaction between studies evaluating functional improvement with externally-assessed outcome measures or self-perceived outcome measures has been detected. In particular, the effect size of the sub-group considering self-perceived scales was 1.38 (95% CI = 1.08-1.68), while the effect size of the other group was 0.77 (95% CI = 0.41-1.11), meaning that patients’ perceived functional gain is often higher than the functional gain detectable through clinical scales.

Conclusion: Overall, the quality of the evidence ranged from low to moderate, due to low number of studies and participants, limitations in the selection of participants and in the blindness of outcome assessors, and risk of publication bias.

Significance: A large magnitude effect and a clear dose-response gradient were found, therefore, a strong recommendation, in favor of the use of assistive devices could be suggested.

 

1. Introduction

1.1. Background

Severe muscular weakness and chronic disability caused by neuromuscular diseases (e.g., muscular dystrophy, spinal muscular atrophy, spinal cord injuries or stroke) or neurodegenerative diseases (i.e., multiple sclerosis, amyotrophic lateral sclerosis) lead to the unavoidable loss of the possibility to perform even simple actions, such as walking, eating, and changing limbs posture. Patients suffer the consequences in terms of independence, quality of life, and self-esteem, given their need to continuously rely on assistance from their caregivers. This is particularly true for upper limbs, where independence is not primarily linked to essential tasks (e.g., eating, drinking, get dressed), but to simple actions not necessary for survival, but which increase the quality of life (e.g., pull up the glasses, scratch, use the mouse, etc.). To independently regain a lost motor function might be therefore a special experience towards a more independent daily life. Technological advancements might be a way to compensate patients’ muscular weakness through the use of Assistive Devices (ADs), which empower the user in the execution of daily life activities, and which are designed to maintain or to improve the functional capabilities of individuals with disabilities. ADs for lower limbs, such as wheelchairs and electric wheelchairs, have been successfully developed and diffused to deal with the deambulation issue. On the other side, the support of upper limbs related activities is more challenging. However, with the increased life expectancy, upper extremities functions became more and more important to be supported. Non-ambulant patients with neuromuscular disorders identified arm functions as their highest priority, indicating repositioning at night, bring hands to mouth, shift while seated, using the wheelchair joystick and the keyboard of a computer, and personal hygiene as priority functions to be regained (Janssen et al., 2014). The currently existing assistive devices to support upper limbs functions can be categorized in (i) end-effector devices, and (ii) exoskeletons. As for end-effector devices, they present a single interaction point between the user and the AD, usually located at forearm or hand level. The main disadvantage of robotic manipulator devices is the impossibility to control upper limb joints directly: the change in position of the interaction point results in unexpected movements of shoulder and elbow joints. As for exoskeletons, they are external structures worn by the patient, with joints and links placed in correspondence of human joints and bones. Patients usually prefer exoskeleton solutions, given that these devices not only help to execute the desired task, but they increase the perception of a self-executed movement. In a study conducted by Rupal et al. (2017) with 118 participants, 96.8% prefer to use an exoskeleton over other mobility aids, and 84.1% like the idea that exoskeletons should be made available in care homes (Rupal et al., 2017). In addition, from a survey conducted by the authors at Lignano Sabbiadoro (Italy) on June 2015, during the annual meeting of the UILDM Association (Italian Association of Muscular Dystrophy), 10 out of 15 interviewed patients affected by muscular dystrophy answered that they prefer exoskeleton solutions for possible upper limbs assistive devices. ADs driving technology can be either passive, working through pre-stored mechanical energy, or active, working with motors, and therefore able to exert greater forces or to control movements more precisely. However, even if a remarkable number of works have been published dealing with the development of innovative electromechanical technologies (e.g., Ragonesi et al., 2013; Jung et al., 2014; Dunning et al., 2015; Sin et al., 2015; Dalla Gasperina et al., 2018), scientific evidence for the benefits of these technologies is still lacking, which could justify costs and effort. When dealing with Assistive Devices, or in general with complex technologies, the demonstration of the effectiveness of their use is rather difficult to be demonstrated following the canonical research studies design [i.e., Randomized Control Trial (RCT) design], even if some effort in this direction is currently ongoing (Antonietti et al., 2019). This is due to several reasons, such as the difficulty to demonstrate the validity of the proposed approach independently from the users’ placebo effect (e.g., it is impossible to perform a blind session), the high cost of the technology and therefore the impossibility to recruit many volunteers contemporary, and the Ethical Committee procedures for non CE-marked devices. A recent systematic review on devices to assist and/or rehabilitate upper limbs made a quite large classification of different devices used, showing an intense research work towards the development of new technologies, which however are rarely methodologically properly tested, and therefore they have difficulties to effectively reach end-users (Onose et al., 2018). […]

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[Abstract] Safe and Sound: meta-analyzing the Mozart Effect on epilepsy

Highlights

• Our meta-analysis supports music therapy as a complementary intervention for epilepsy.
• Mozart music may improve seizures and EEG after both short- and long-term music treatment
• The therapeutic potential of music and the most effective protocols need further definition.

Abstract

Objective

The use of music-based neuro-stimulation for treating seizures and interictal epileptiform discharges (IED) (the so-called “Mozart effect”) remains a controversial issue. We have conducted an updated meta-analysis in order to systematically review literature evidence and provide further insights about the role of the Mozart effect in epilepsy.

Methods

Following the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA) guidelines, we searched three bibliographic databases from their date of inception to January 2020. Nine meta-analyses were performed according to both music stimulation protocols and outcome measures. We applied the Cochrane Q-test and the I²-index for heterogeneity evaluation, and either fixed-effect or random-effect models to compute mean differences and pool data.

Results

Of 147 abstracts, 12 studies were included and grouped according to stimulation protocols and outcome measures. The nine meta-analyses showed significant reductions in seizures and IED frequencies after long-term music treatment, and in IED frequency during and after a single music stimulus.

Conclusions

Music-based neurostimulation may improve the clinical outcome of individuals with epilepsy, by reducing the frequency of seizures and IED. Further and stronger evidence will allow defining its potential in the different forms of epilepsy, and the most effective stimulation protocols.

Significance

Music therapy should be considered as a complementary, non-invasive approach for treating epilepsy and epileptiform discharges.

via Safe and Sound: meta-analyzing the Mozart Effect on epilepsy – ScienceDirect

[Abstract] Pharmacological and Non-Pharmacological Interventions for Depression after Moderate-to-Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Abstract

The objective of this study was to systematically review the literature and perform a meta-analysis of randomized controlled trials (RCTs) on the effectiveness of pharmacological and non-pharmacological interventions for depression in patients with moderate-to-severe traumatic brain injury.

Databases searched were: Embase, PubMed, PsycInfo, Cochrane Central, Web of Science, and Google Scholar. Depression score on a self-report questionnaire was the outcome measure. Outcomes were collected at baseline and at the first follow-up moment. Data extraction was executed independently by two researchers. Thirteen RCTs were identified: five pharmacological and eight non-pharmacological. Although not all individual studies had significant results, the overall standardized mean difference (SMD) was −0.395, p ≤ 0.001, indicating that interventions improved the depression scores in patients with TBI.

The difference in effectiveness between pharmacological interventions and non-pharmacological interventions was not significant (ΔSMD: 0.203, p = 0.238). Further subdivision into methylphenidate, sertraline, psychological, and other interventions showed a significant difference in effectiveness between methylphenidate (ΔSMD: −0.700, p = 0.020) and psychological interventions (reference). This difference was not found if other depression outcomes in four of the included studies were analyzed. The SMD of low-quality studies did not differ significantly from moderate- and high-quality studies (ΔSMD: 0.321, p = 0.050).

Although RCTs targeting interventions for depression after TBI are scarce, both pharmacological and non-pharmacological interventions appear to be effective in treating depressive symptoms/depression after moderate-to-severe TBI. There is a need for high-quality RCTs in which the add-on effects of pharmacological and non-pharmacological interventions are investigated.

via Pharmacological and Non-Pharmacological Interventions for Depression after Moderate-to-Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis | Journal of Neurotrauma

 

 

[Abstract] Game-Based Virtual Reality Interventions to Improve Upper Limb Motor Function and Quality of Life After Stroke: Systematic Review and Meta-analysis

Abstract

Stroke is the main cause of disability in adulthood. Recent advances in virtual reality (VR) technologies have led to its increased use in the rehabilitation of stroke patients. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to determine the effectiveness of game-based reality on upper limb (UL) motor function and quality of life after stroke. In March 2018, a search of the following databases was performed: PubMed, PEDro, Web of Science, Scopus, The Cochrane Library, and Medline at EBSCO. The selection criteria were all RCTs published in English or Spanish during the past 10 years. The PEDro scale was used to evaluate the methodological quality of the studies. A total of 20 clinical trials were included in the systemic review, of which 15 contributed information to the meta-analysis. Favorable results were found for VR interventions on UL motor function (Fugl-Meyer Assessment for upper extremity, standardized mean difference [SMD] = 1.53, 95% CI [0.51–2.54]) and quality of life (functional independence measure, SMD = 0.77, 95% CI [0.05–1.49]). The results demonstrate the potential benefits of VR interventions on the recovery of UL motor function and on quality of life after stroke.

 

via Game-Based Virtual Reality Interventions to Improve Upper Limb Motor Function and Quality of Life After Stroke: Systematic Review and Meta-analysis | Games for Health Journal

[Abstract + References] The effects of ankle-foot orthoses on walking speed in patients with stroke: a systematic review and meta-analysis of randomized controlled trials

Abstract

Objective:

The aim of this study was to evaluate the effects of ankle-foot orthoses on speed walking in patients with stroke.

Data sources:

PubMed, Embase, Web of Science, Scopus, CENTRAL, PEDro, RehabData, RECAL, and ProQuest were searched from inception until 30 September 2019.

Review methods:

This study was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline statement. Risk of bias assessment was performed using the Cochrane Risk of Bias Tool. Begg’s test and Egger’s regression method were used to assess the publication bias. Trim and fill analysis was also used to adjust any potential publication bias. Sensitivity analysis was performed to evaluate the effect of individual studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

Results:

Overall, 14 studies were included with a total of 1186 participants. A small-to-moderate and non-significant improvement in favor of the ankle-foot orthosis versus without ankle-foot orthosis (standardized mean difference (SMD) = 0.41, 95% confidence interval = −0.15 to 0.96), similar effects of ankle-foot orthosis and functional electrical stimulation (SMD = 0.00, 95% confidence interval = −0.16 to 0.16), and a small and non-significant improvement in favor of ankle-foot orthosis versus another type of ankle-foot orthosis (SMD = 0.22, 95% confidence interval = −0.05 to 0.49) in walking speed were found. However, the quality of evidence for all comparisons was low or very low.

Conclusion:

Despite reported positive effects in some studies, there is no firm evidence of any benefit of ankle-foot orthoses on walking speed.

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Via https://journals.sagepub.com/doi/abs/10.1177/0269215519887784

[ARTICLE] The effects of ankle-foot orthoses on walking speed in patients with stroke: a systematic review and meta-analysis of randomized controlled trials – Full Text

Abstract

Objective:

The aim of this study was to evaluate the effects of ankle-foot orthoses on speed walking in patients with stroke.

Data sources:

PubMed, Embase, Web of Science, Scopus, CENTRAL, PEDro, RehabData, RECAL, and ProQuest were searched from inception until 30 September 2019.

Review methods:

This study was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline statement. Risk of bias assessment was performed using the Cochrane Risk of Bias Tool. Begg’s test and Egger’s regression method were used to assess the publication bias. Trim and fill analysis was also used to adjust any potential publication bias. Sensitivity analysis was performed to evaluate the effect of individual studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

Results:

Overall, 14 studies were included with a total of 1186 participants. A small-to-moderate and non-significant improvement in favor of the ankle-foot orthosis versus without ankle-foot orthosis (standardized mean difference (SMD) = 0.41, 95% confidence interval = −0.15 to 0.96), similar effects of ankle-foot orthosis and functional electrical stimulation (SMD = 0.00, 95% confidence interval = −0.16 to 0.16), and a small and non-significant improvement in favor of ankle-foot orthosis versus another type of ankle-foot orthosis (SMD = 0.22, 95% confidence interval = −0.05 to 0.49) in walking speed were found. However, the quality of evidence for all comparisons was low or very low.

Conclusion:

Despite reported positive effects in some studies, there is no firm evidence of any benefit of ankle-foot orthoses on walking speed.

Introduction

A total of 50% of patients with stroke suffer from diminished mobility due to hemiparesis.¹ Impaired walking is one of the major problems occurring for stroke patients;² although 70% of patients regain their ability for walking, they experience functional constraints due to spasticity, muscle weakness, and poor balance.³ Foot drop is among main causes of improper walking related to affected individuals. In response to this abnormality, clearance in swing phase and stability in stance phase are impaired, resulting in reduced walking speed and increased risk of falling.⁴

The use of ankle-foot orthosis and functional electrical stimulation as two major rehabilitation interventions is propounded to improve walking speed of individuals with stroke.⁵ An ankle-foot orthosis contributes to stabilization of the foot and ankle in stance phase, keeping the toes up while taking steps, and improving heel strike.^6,7 Ankle-foot orthoses are used in different models and designs such as articulated, non-articulated, rigid, and dynamic.⁸ Functional electrical stimulation refers to the usage of musculoskeletal electrical stimulation to activate the muscles while performing functional tasks,⁹ which has been established as an alternative to ankle-foot orthoses for patients with stroke.

To the best of our knowledge, a limited systematic review and meta-analysis has also been performed in 2013,¹⁰ aimed at investigating the effects of ankle-foot orthosis on balance and gait after stroke. In that review, different study designs were included with heterogeneous methodologies, and short-term effects were only assessed. Although the study was published in 2013, the authors only included the studies published until 2011. In recent years, two meta-analyses^11,12 have been carried out which aimed at comparing the therapeutic effects of ankle-foot orthoses and functional electrical stimulation on drop foot in central nervous system (CNS) diseases. In these reviews, stroke was considered along with other CNS diseases, and ankle-foot orthoses and functional electrical stimulation were found to have the same effects. Lack of publication bias assessment, quality of evidence evaluation, and combined different types of interventions resulted in inconclusive findings in these meta-analyses.

The primary objective of this up-to-date study is systematically reviewing the literature with regard to the effects of ankle-foot orthoses on walking speed of patients with stroke.[…]

 

Continue —->  The effects of ankle-foot orthoses on walking speed in patients with stroke: a systematic review and meta-analysis of randomized controlled trials – Saeed Shahabi, Hosein Shabaninejad, Mohammad Kamali, Maryam Jalali, Ahmad Ahmadi Teymourlouy,

[Abstract] Systematic Review and Meta-analysis of Home-Based Rehabilitation on Improving Physical Function Among Home-dwelling Patients with a Stroke

Abstract

Objective

To evaluate the effects of home-based rehabilitation on improving physical function in home-dwelling patients after a stroke.

Data sources

Various electronic databases, including PubMed, CINAL, Embase, the Cochrane Central Register of Controlled Trials, and two Chinese datasets (i.e., Chinese Electronic Periodical Services and China Knowledge Resource Integrated) were searched for studies published before March 20, 2019.

Study selection

Randomized controlled trials conducted to examine the effect of home-based rehabilitation on improving physical function in home-dwelling patients with a stroke and published in English or Chinese were included. In total, 49 articles in English (n=23) and Chinese (n=26) met the inclusion criteria.

Data extraction

Data related to patient characteristics, study characteristics, intervention details, and outcomes were extracted by two independent reviewers.

Data synthesis

A random-effects model with a sensitivity analysis showed that home-based rehabilitation exerted moderate improvements on physical function in home-dwelling patients with a stroke (g = 0.58, 95% confidence interval [CI] 0.45∼0.70). Moderator analyses revealed that those stroke patients of a younger age, of a male gender, with a first-ever stroke episode, in the acute stage, and receiving rehabilitation training from their caregiver showed greater improvements in physical function.

Conclusions

Home rehabilitation can improve functional outcome in stroke survivors and should be considered appropriate during discharge planning if continuation care is required.

via Systematic Review and Meta-analysis of Home-Based Rehabilitation on Improving Physical Function Among Home-dwelling Patients with a Stroke – Archives of Physical Medicine and Rehabilitation