Posts Tagged motor impairment

[ARTICLE] The effect of mirror therapy on lower extremity motor function and ambulation in post-stroke patients: A prospective, randomized-controlled study – Full Text


Objectives: This study aims to evaluate the effects of mirror therapy (MT) on lower extremity motor function and ambulation in post-stroke patients.

Patients and methods: A total of 42 post-stroke patients (25 males, 17 females; mean age 58 years; range, 32 to 71 years) were included. All patients were randomly divided into two groups as the control group (n=21) receiving a conventional rehabilitation program for four weeks (60 to 120 min/day for five days a week) and as the MT group (n=21) receiving MT for 30 min in each session in addition to the conventional rehabilitation program. The Brunnstrom stages of stroke recovery, Functional Independence Measure (FIM), Berg Balance Scale (BBS) and Motricity Index (MI) scores, six-minute walking test (6MWT), Functional Ambulation Category (FAC), and the degree of ankle plantar flexion spasticity using the Modified Ashworth Scale (MAS) were evaluated at baseline (Day 0), at post-treatment (Week 4), and eight weeks after the end of treatment (Week 12).

Results: There were significant differences in all parameters between the groups, except for the degree of ankle plantar flexion spasticity, and in all time points between Week 0 and 4 and between Week 0 and 12 (p<0.05).

Conclusion: These results suggest that MT in addition to conventional rehabilitation program yields a greater improvement in the lower extremity motor function and ambulation, which sustains for a short period of time after the treatment.



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[ARTICLE] Therapeutic Efficacy of Transcutaneous Electrical Nerve Stimulation Acupoints on Motor and Neural Recovery of the Affected Upper Extremity in Chronic Stroke: A Sham-Controlled Randomized Clinical Trial – Full Text


Inability to use the affected upper extremity (UE) in daily activities is a common complaint in stroke patients. The somatosensory system (central and peripheral) is essential for brain reorganization and plasticity. Neuromuscular electrical stimulation is considered an effective modality for improving UE function in stroke patients. The aim of the current study was to determine the therapeutic effects of transcutaneous electrical nerve stimulation (TENS) acupoints on cortical activity and the motor function of the affected UE in chronic stroke patients. Forty male and female patients diagnosed with stroke agreed to join the study. They were randomly assigned to group 1 (G1) and group 2 (G2). G1 received task-specific training (TST) and sham electrical stimulation while G2 received TST in addition to TENS acupoints. Session duration was 80 min. Both groups received 18 sessions for 6 successive weeks, 3 sessions per week. Evaluation was carried out before and after completion of the treatment program. Outcome measures used were the Fugl-Meyer Assessment of the upper extremity (FMA-UE) and the box and block test (BBT) as measures of the motor function of the affected UE. Brain activity of the motor area (C3) in the ipsilesional hemisphere was measured using a quantitative electroencephalogram (QEEG). The measured parameter was peak frequency. It was noted that the motor function of the affected UE improved significantly post-treatment in both groups, while no significant change was reported in the FMA-UE and BBT scores post-treatment in either G1 or G2. On the other hand, the activity of the motor area C3 improved significantly in G2 only, post-treatment, while G1 showed no significant improvement. There was also significant improvement in the activity of the motor area (C3) in G2 compared to G1 post-treatment. The results of the current study indicate that TST only or combined with TENS acupoints can be considered an effective method for improving motor function of the affected UE in chronic stroke patients, both being equally effective. However, TST combined with TENS acupoints proved better in improving brain plasticity in chronic stroke patients. 

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[WEB] Combining VNS and Rehab Suggests Benefits for Stroke Survivors, Per Lancet Study

Combining VNS and Rehab Suggests Benefits for Stroke Survivors, Per Lancet Study

Patients who received a novel treatment that combines vagus nerve stimulation (VNS) and rehabilitation showed improvement in upper body motor impairment compared to those who received a sham (inactive) form of stimulation and rehabilitation, according to results from a study published recently in The Lancet.

“This is incredibly exciting news for everyone involved in stroke rehabilitation and functional restoration and represents a unique intersection between neurosurgery and neurorehabilitation. These study results open up new possibilities for stroke patients, allowing them to reclaim more arm function even years after having a stroke.”  

— Charles Liu, MD, PhD, the lead neurosurgeon of the study and director of the USC Neurorestoration Center of Keck Medicine of USC

VNS Versus Sham Stimulation

In this international, multi-center clinical trial, 53 participants with moderate to severe arm weakness 9 months to 10 years post-stroke received rehabilitation paired with VNS via the Vivistim Paired Vagus Nerve Stimulation System from MicroTransponder Inc, who sponsored the study.

Fifty-five patients within the same parameters received a sham stimulation. The trial was randomized and triple blind.

Those receiving the nerve stimulation had a wire inserted into their neck that wrapped around the vagus nerve. The wire was then connected to a pulse generator device implanted in the chest. Those receiving the sham received placebo implants.

After the surgical procedure, all patients received 6 weeks of in-clinic intense physical therapy, which included tasks such as reaching and grasping, simulated eating and opening and closing containers. After the in-clinic period, patients continued treatment with a course of daily home therapy.

When the two patient groups were compared, those receiving the nerve stimulation scored higher on several standardized measures of upper arm functionality, a media release from Keck Medicine of USC explains.

VNS Trial Data

In a separate release, MicroTransponder Inc shares the following data from the clinical trial:

The multi-center, double-blinded, randomized controlled trial enrolled 108 subjects that were up to 10 years post-stroke with moderate to severe upper extremity impairment. 

Subjects in the study were randomized to either the Paired VNS group (intense physical therapy paired with active VNS) or Control group (intense physical therapy paired with sham VNS) and did 6 weeks of in-clinic therapy followed by 3 months of home-based therapy.

After in-clinic therapy, subjects in the Paired VNS group showed a 5.0 point improvement in the Upper Extremity Fugl-Meyer Assessment compared to 2.4 points in controls (p=0.001). The Wolf Motor Function Test score also improved after Paired VNS compared to controls (0.46 vs 0.16, p<0.0001). After 3 months of home-based therapy, the number of participants achieving a clinically meaningful response in upper limb impairment after Paired VNS was approximately twice that of controls.

The study showed that participants who received Paired VNS had clinically meaningful improvements in both motor impairment and function compared to controls. Improvements with Paired VNS were also observed in quality-of-life measures. There were no unexpected adverse events or serious adverse events associated with the Vivistim System. 

The VNS System

The Vivistim Paired VNS System is designed to stimulate the vagus nerve during task-specific rehabilitation. Stimulation of the vagus nerve triggers release of brain neuromodulators including acetylcholine and norepinephrine that strengthens motor circuits associated with movement, enabling the brain to effectively relearn the task, MicroTransponder Inc explains in its release.

“Not only were the results clinically meaningful, the fact that these patients were at least nine months post-stroke and in some instances years out, points to the possibility that meaningful improvements can be achieved even years after a stroke.

“For too long, stroke patients have faced limited options for recovery. This new treatment signifies a breakthrough that could be life-changing for many stroke patients and also represents an approach that will certainly be explored for many other functional restoration applications in the future.”

— Charles Liu, who also serves as chief of innovation and research and chair of neurosurgery and orthopedics at Rancho Los Amigos National Rehabilitation Center

[Source(s): MicroTransponder Inc, Keck Medicine of USC, PR Newswire, Newswise]


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[Abstract] Robot-Assisted Therapy for Upper Extremity Motor Impairment After Stroke: A Systematic Review and Meta-Analysis



The purpose of this study was to review the effects of robot-assisted therapy (RT) for improving poststroke upper extremity motor impairment.


The PubMed, Embase, Medline, and Web of Science databases were searched from inception to April 8, 2020. Randomized controlled trials that were conducted to evaluate the effects of RT on upper extremity motor impairment poststroke and that used Fugl-Meyer assessment for upper extremity scores as an outcome were included. Two authors independently screened articles, extracted data, and assessed the methodological quality of the included studies using the Physiotherapy Evidence Database (PEDro) scale. A random-effects meta-analysis was performed to pool the effect sizes across the studies.


Forty-one randomized controlled trials with 1916 stroke patients were included. Compared with dose-matched conventional rehabilitation, RT significantly improved the Fugl-Meyer assessment for upper extremity scores of the patients with stroke, with a small effect size (Hedges g = 0.25; 95% CI, 0.11-0.38; I2 = 45.9%). The subgroup analysis revealed that the effects of unilateral RT, but not that of bilateral RT, were superior to conventional rehabilitation (Hedges g = 0.32; 95% CI, 0.15-0.50; I2 = 55.9%). Regarding the type of robot devices, the effects of the end effector device (Hedges g = 0.22; 95% CI, 0.09–0.36; I2 = 35.4%), but not the exoskeleton device, were superior to conventional rehabilitation. Regarding the stroke stage, the between-group difference (ie, RT vs convention rehabilitation) was significant only for people with late subacute or chronic stroke (Hedges g = 0.33; 95% CI, 0.16-0.50; I2 = 34.2%).


RT might be superior to conventional rehabilitation in improving upper extremity motor impairment in people after stroke with notable upper extremity hemiplegia and limited potential for spontaneous recovery.


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[POSTER Abstract] Effects of Bilateral Transcutaneous Electrical Nerve Stimulation Combined With Task-Oriented Training on the Recovery of Upper Limb Motor Impairment in People With Chronic Stroke


Background: Transcutaneous electrical nerve stimulation(TENS) is an effective physiological intervention for people with stroke which aims at reducing muscle spasticity, enhancing muscle strength, and improving motor control and function. In view of the potentials to enhance greater cortical activation of the lesion side by eliciting spare neural pathways through bilateral intervention, this study examined whether the combined use of bilateral TENS (Bi-TENS) and task-oriented training (TOT) was superior to unilateral TENS(Uni-TENS)+TOT, placebo-TENS+TOT and no active treatment to improve the motor impairment of upper limb function in people with stroke.

Method: There were 120 subjects with stroke(44 females, mean age=61.52±6.73 years, post-stroke duration=6.04±3.12years) being randomly allocated into 4 groups, including the Bi-group (n=30), Uni-group (n=30), placebo group (n=30) and control group (n=30). Subjects in the Bi-group, Uni-group and placebo group got 60 minutes TENS and TOT simultaneously per time for 20 times(3 times per week for 7 weeks). In the Bi-group, TENS stimulated the radial and median nerves of the bilateral upper limbs. In the Uni-group, TENS and placebo-TENS stimulated the affected and unaffected side, respectively. In the placebo group, placebo-TENS were placed on bilateral sides. In the control group, subjects did not receive any active treatment. Level of motor impairment was assessed by the Fugl-Meyer Assessment of Upper Extremity (FMA-UE).

Result: The Bi-group had a significant greater improvement in FMA-UE than the Uni-group(mean change=2.02, p=0.005), placebo group (mean change=2.49, p=0.001) and control group(mean change=3.08, p<0.001) at post-intervention. The Bi-group(mean change=3.25, p<0.001) and Uni-group(mean change=1.23, p=0.015) showed a significant within-group improvement in FMA-UE since 10 sessions of treatment. No significant change was found in the placebo and control groups.

Conclusion: Bi-TENS is superior to Uni-TENS, placebo-TENS and no active treatment in augmenting the recovery of upper limb motor impairment in people with chronic stroke.


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[Abstract] Systematic review of guidelines to identify recommendations for upper limb robotic rehabilitation after stroke

INTRODUCTION: Upper limb motor impairment is one of the most frequent stroke consequences. Robot therapy may represent a valid option for upper limb stroke rehabilitation, but there are still gaps between research evidences and their use in clinical practice. The aim of this study was to determine the quality, scope, and consistency of guidelines clinical practice recommendations for upper limb robotic rehabilitation in stroke populations.

EVIDENCE ACQUISITION: We searched for guideline recommendations on stroke published between January 1st, 2010 and January 1st, 2020. Only the most recent guidelines for writing group were selected. Electronic databases (n=4), guideline repertories and professional rehabilitation networks (n=12) were searched. We systematically reviewed and assessed guidelines containing recommendation statements about upper limb robotic rehabilitation for adults with stroke. PROSPERO registration number: CRD42020173386.

EVIDENCE SYNTHESIS: Four independent reviewers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, and textual syntheses were used to appraise and compare recommendations. From 1324 papers screened, eight eligible guidelines were identified from six different regions/countries. Half of the included guidelines focused on stroke management, the other half on stroke rehabilitation. Rehabilitation assisted by robotic devices is generally recommended to improve upper limb motor function and strength. The exact characteristics of patients who could benefit from this treatment as well as the correct timing to use it are not known.

CONCLUSIONS: This systematic review has identified many opportunities to modernize and otherwise improve stroke patients’ upper limb robotic therapy. Rehabilitation assisted by robot or electromechanical devices for stroke needs to be improved in clinical practice guidelines in particular in terms of applicability.


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[ARTICLE] Kinematic parameters obtained with the ArmeoSpring for upper-limb assessment after stroke: a reliability and learning effect study for guiding parameter use – Full Text



After stroke, kinematic measures obtained with non-robotic and robotic devices are highly recommended to precisely quantify the sensorimotor impairments of the upper-extremity and select the most relevant therapeutic strategies. Although the ArmeoSpring exoskeleton has demonstrated its effectiveness in stroke motor rehabilitation, its interest as an assessment tool has not been sufficiently documented. The aim of this study was to investigate the psychometric properties of selected kinematic parameters obtained with the ArmeoSpring in post-stroke patients.


This study involved 30 post-stroke patients (mean age = 54.5 ± 16.4 years; time post-stroke = 14.7 ± 26.7 weeks; Upper-Extremity Fugl-Meyer Score (UE-FMS) = 40.7 ± 14.5/66) who participated in 3 assessment sessions, each consisting of 10 repetitions of the ‘horizontal catch’ exercise. Five kinematic parameters (task and movement time, hand path ratio, peak velocity, number of peak velocity) and a global Score were computed from raw ArmeoSpring’ data. Learning effect and retention were analyzed using a 2-way repeated-measures ANOVA, and reliability was investigated using the intra-class correlation coefficient (ICC) and minimal detectable change (MDC).


We observed significant inter- and intra-session learning effects for most parameters except peak velocity. The measures performed in sessions 2 and 3 were significantly different from those of session 1. No additional significant difference was observed after the first 6 trials of each session and successful retention was also highlighted for all the parameters. Relative reliability was moderate to excellent for all the parameters, and MDC values expressed in percentage ranged from 42.6 to 102.8%.


After a familiarization session, the ArmeoSpring can be used to reliably and sensitively assess motor impairment and intervention effects on motor learning processes after a stroke.


More than 40% of post-stroke patients display residual and permanent neurological upper extremity (UE) impairments [1]. It is essential to quantify these impairments in order to assess functional loss and develop more effective therapeutic interventions.

The effectiveness of motor rehabilitation is traditionally appraised using validated and standardized clinical scales [2], such as the upper extremity Fugl-Meyer subscale (UE-FMS) [3]. However, clinical scales are not always appropriate to assess motor strategies during movements, and they are not sensitive enough to capture the quality of sensorimotor performance or the effectiveness of therapeutic interventions [4]. They do not effectively distinguish between restitution and compensation [56]. Some authors therefore recommend using kinematic parameters provided by optokinetic, robotic or gravity-supporting devices to assess movements [5,6,7,8,9,10]. These parameters are thought to be more sensitive and provide more information on movement performance and quality in the context of health and disease, helping to fill the gap related to the use of clinical scales.

Many robotic and non-robotic devices have been developed for UE rehabilitation after neurological disorders such as stroke [1112], with the goal of increasing the intensity and control of therapies. The ArmeoSpring (developed by Hocoma, Inc) is a passive orthosis that assists the movements of patients’ joints, using a structure parallel to the mobilized UE. It also provides kinematic parameters that inform about movement speed, duration and trajectory [913], and thus could be used to assess movement efficacy and smoothness [714]. Based on clinical criteria for impairments and function, the effectiveness of the ArmeoSpring was demonstrated in the rehabilitation of patients with motor deficits related to cerebral palsy, multiple sclerosis and stroke [81516].

Given the increasing use of such devices as assessment tools, it is imperative to obtain better knowledge of the psychometric properties of the parameters provided [1718]. Indeed, these parameters must be sensitive enough to detect subclinical changes, and the variations observed must reflect a decrease in the motor deficit and not be due to a learning effect of the task. Some studies have addressed these questions [19,20,21,22]. Up to now, only one study has investigated the reliability of kinematic parameters provided by the ArmeoSpring [13]. Rudhe et al. demonstrated fair to good reliability of the movement workspace obtained with the ArmeoSpring in healthy participants and in patients with spinal cord injury [13]. Using mostly robotic devices, some authors have shown no or little learning effect [19,20,21] and advocated a single practice session to shorten the learning process. Other authors have demonstrated the existence of learning processes during mechanized training with the ArmeoSpring in post-stroke patients [23], and in children with cerebral palsy [16]. These latter studies used the vertical catch exercise, with only one or very few kinematic parameters used to assess motor learning and performance with the ArmeoSpring. Furthermore, motor learning is a fundamental process in rehabilitation and recovery post-stroke [6]. An increasing number of authors have suggested the use of kinematic parameters obtained with robotics to also assess motor learning and control in the contexts of health and disease. However, besides skill acquisition, motor learning also implies persistence of the changes brought about (i.e. retention) [24]. It is essential to at least demonstrate that the skills acquired are still present and measurable at a later time point. The majority of studies did not, however, address this question appropriately [24].

There is no consensus on the kinematic parameters to be used for UE assessment and little is known about their ability to identify learning during the post-stroke recovery phase. As far as we know, no study has investigated the extent of learning and its successful retention, together with the reliability of the parameters provided by the ArmeoSpring during the performance of a 2D-horizontal catch assessment exercise after a stroke. Thus, our main objective was to assess the learning effect and the reliability of the repeated measures of selected parameters obtained with the ArmeoSpring in post-stroke patients during their routine clinical care.



Thirty hemiparetic post-stroke patients were consecutively recruited during the course of their routine care in the Neurorehabilitation department of the Toulouse University Hospital. The routine care is standardized in accordance with the most recent guidelines for adult stroke rehabilitation and recovery [25] and with the French health authority [26]. Given the preliminary nature of this study for stroke, the sample size seemed appropriate and consistent with other studies [13]. All the patients included were naïve to the use of the ArmeoSpring and gave their written consents in accordance with the Declaration of Helsinki. The study was approved by the local hospital ethics committee in September 2016 (n°05-0916).

The inclusion criteria were: (i) a first ischemic or hemorrhagic stroke as diagnosed by a CT scan or MRI that occurred (ii) more than 3 weeks ago, (iii) an UE-FMS score between 10 and 44/66, and (iv) the presence of at least 10° voluntary movement at the shoulder and elbow. The exclusion criteria were: (i) the presence of apraxia, severe unilateral spatial neglect, (ii) UE pain limiting movement, and (iii) lack of stability of the trunk while seated or sitting position not recommended.

Study design

Each patient made 4 visits over 2 days with the same unique rater who was an advanced user of the ArmeoSpring. During the pre-inclusion visit, the patients were informed by the rater about the protocol details, and the inclusion/exclusion criteria meeting was verified. If included, each patient made 3 visits on 3 consecutive half-days. During the first visit, the patient was comfortably seated on the ArmeoSpring, which was adjusted to allow movements of the UE in a large tridimensional workspace required to perform the assessment exercises (Fig. 1). During the second and third visits, the patient was placed on the device in the same way and performed the same series of exercises as during the first visit.

Experimental setup. a Installation of the patient performing a training exercise of the impaired upper limb with the ArmeoSpring. b Screenshot of the 2D-horizontal catch assessment exercise used in this study


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[ARTICLE] Baseline Motor Impairment Predicts Transcranial Direct Current Stimulation Combined with Physical Therapy-Induced Improvement in Individuals with Chronic Stroke – Full Text


Transcranial direct current stimulation (tDCS) can enhance the effect of conventional therapies in post-stroke neurorehabilitation. The ability to predict an individual’s potential for tDCS-induced recovery may permit rehabilitation providers to make rational decisions about who will be a good candidate for tDCS therapy. We investigated the clinical and biological characteristics which might predict tDCS plus physical therapy effects on upper limb motor recovery in chronic stroke patients. A cohort of 80 chronic stroke individuals underwent ten to fifteen sessions of tDCS plus physical therapy. The sensorimotor function of the upper limb was assessed by means of the upper extremity section of the Fugl-Meyer scale (UE-FM), before and after treatment. A backward stepwise regression was used to assess the effect of age, sex, time since stroke, brain lesion side, and basal level of motor function on UE-FM improvement after treatment. Following the intervention, UE-FM significantly improved (), and the magnitude of the change was clinically important (mean 6.2 points, 95% CI: 5.2–7.4). The baseline level of UE-FM was the only significant predictor (, , ) of tDCS response. These findings may help to guide clinical decisions according to the profile of each patient. Future studies should investigate whether stroke severity affects the effectiveness of tDCS combined with physical therapy.

1. Introduction

Transcranial direct current stimulation (tDCS) is an emerging technique with the potential to enhance the effect of therapeutic approaches in post-stroke rehabilitation [12]. According to the interhemispheric competition model [34], anodal tDCS is applied to increase the excitability of the lesioned hemisphere. In contrast, cathodal tDCS is applied to decrease the excitability of the nonlesioned hemisphere. Lastly, bihemispheric tDCS involves anodal and cathodal tDCS applied simultaneously [5].

Regarding the effects of each tDCS method, it is suggested that bihemispheric tDCS has a more significant effect on chronic stroke [68]. Moreover, the positive effect of each tDCS approach on stroke motor recovery has been elucidated by previous studies [913]. Notably, recent systematic reviews reported the improvement of upper limb (UL) sensorimotor functions and improvement of activities of daily living following tDCS in post-stroke individuals [81014].

Despite its great potential, post-stroke subjects show different responses to tDCS. Furthermore, the variability of tDCS effectiveness limits its implementation as standard patient care [15]. A better understating of individual characteristics for predicting motor recovery in responding to treatment should be considered a crucial component for post-stroke rehabilitation.

Following a stroke, neural reorganization, due to spontaneous recovery or induced by therapeutic interventions, is influenced by clinical and biological factors [1618]. Some of these factors might help to predict therapy-mediated motor recovery [1821], i.e., stroke chronicity [2223], sex [2425], age [2326], prestroke hemispheric dominance [18], and time since stroke [17].

Initial motor impairment can also predict motor outcomes [27]. Post-stroke motor recovery is highly variable [15], and individuals could present mild to severe motor impairment [28]. Overall, the initial (i.e., baseline) motor impairment is a strong predictor of functional improvement; e.g., moderate motor impairment is associated with better recovery than severe impairment in post-stroke survivors [29].

Notably, previous studies employing tDCS combined with physical therapy included patients with different motor impairment levels and reported heterogeneous results [3032]. The variability of tDCS response could be related to different aspects related to the technique or the patient’s characteristics. Regarding the tDCS, the parameters of the technique, the ideal number of sessions, and the most appropriate stimulation site (lesioned hemisphere, nonlesioned hemisphere, or both hemispheres) should be considered. Concerning the post-stroke individuals, it is important to consider the motor impairment, the location and size of the lesion, and the previous condition of the subject. The most appropriate supporting therapy should also be considered. The heterogeneous results could be related to one or more of these factors (reviewed in Simonetta-Moreau [33]).

Considering predictive factors that might guide stroke recovery, recent studies suggest the development of algorithms or models to determine functional recovery following rehabilitation in either acute or chronic post-stroke individuals [534]. Although there is an increasing number of studies using tDCS in stroke rehabilitation and its relevance for clinical practice, it is unknown whether personal factors, e.g., age and sex, may predict the magnitude of the effect of tDCS on functional recovery [33]. Moreover, UL sensorimotor impairments (e.g., disrupted interjoint coordination, spasticity, and loss of dexterity) are common after stroke and persist in the chronic stage [3536]. These deficits may lead to decreased quality of life and social participation. Thus, this study was aimed at investigating if clinical and biological characteristics might predict the tDCS plus physical therapy effects on UL motor recovery in chronic stroke individuals. This knowledge might help to guide clinical decisions according to the clinical profile of each patient as well as to enhance clinical evidence-based practice for neurorehabilitation.[…]



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[Abstract] Localized muscle vibration in the treatment of motor impairment and spasticity in post-stroke patients: a systematic review

INTRODUCTION: During the last decades, many studies have been carried out to understand the possible positive effects of vibration therapy in post-stroke rehabilitation. In particular, the use of localized muscle vibration (LMV) seems to have promising results. The aim of this systematic review is to describe the use of LMV in post-stroke patients to improve motor recovery, reducing spasticity and disability in both upper and lower limb.

EVIDENCE ACQUISITION: A search was conducted on PubMed, Scopus, Pedro and REHABDATA electronic database. Only randomized controlled trials have been included, excluding no-localized vibratory treatments and other pathological conditions. Fourteen studies met the inclusion criteria and were included in this review.

EVIDENCE SYNTHESIS: Collectively, the studies involved 425 stroke patients. Most studies included chronic stroke patients (ten) and treated only the upper limb (eleven). There is evidence that LMV therapy is effective in reducing spasticity and improving motor recovery, especially when associated with conventional physical therapy.

CONCLUSIONS: LMV may be a feasible and safe tool to be integrated into traditional and conventional neurorehabilitation programs for post-stroke patients to reduce spasticity. Analysis of the available clinical trials do not allow us to indicate vibration therapy as effective in functional motor recovery, despite some studies showed encouraging results. Further studies, with larger size of homogeneous patients and with a shared methodology are needed to produce more reliable data especially on the lower limb.


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[REVIEW ARTICLE ] Robot-Assisted Therapy in Upper Extremity Hemiparesis: Overview of an Evidence-Based Approach – Full Text

Robot-mediated therapy is an innovative form of rehabilitation that enables highly repetitive, intensive, adaptive, and quantifiable physical training. It has been increasingly used to restore loss of motor function, mainly in stroke survivors suffering from an upper limb paresis. Multiple studies collated in a growing number of review articles showed the positive effects on motor impairment, less clearly on functional limitations. After describing the current status of robotic therapy after upper limb paresis due to stroke, this overview addresses basic principles related to robotic therapy applied to upper limb paresis. We demonstrate how this innovation is an evidence-based approach in that it meets both the improved clinical and more fundamental knowledge-base about regaining effective motor function after stroke and the need of more objective, flexible and controlled therapeutic paradigms.


Robot-mediated rehabilitation is an innovative exercise-based therapy using robotic devices that enable the implementation of highly repetitive, intensive, adaptive, and quantifiable physical training. Since the first clinical studies with the MIT-Manus robot (1), robotic applications have been increasingly used to restore loss of motor function, mainly in stroke survivors suffering from an upper limb paresis but also in cerebral palsy (2), multiple sclerosis (3), spinal cord injury (4), and other disease types. Thus, multiple studies suggested that robot-assisted training, integrated into a multidisciplinary program, resulted in an additional reduction of motor impairments in comparison to usual care alone in different stages of stroke recovery: namely, acute (57), subacute (18), and chronic phases after the stroke onset (911). Typically, patients engaged in the robotic therapy showed an impairment reduction of 5 points or more in the Fugl-Meyer assessment as compared to usual care. Of notice, rehabilitation studies conducted during the chronic stroke phase suggest that a 5-point differential represents the minimum clinically important difference (MCID), i.e., the magnitude of change that is necessary to produce real-world benefits for patients (12). These results were collated in multiple review articles and meta-analyses (1317). In contrast, the advantage of robotic training over usual care in terms of functional benefit is less clear, but there are recent results that suggest how best to organize training to achieve superior results in terms of both impairment and function (18). Indeed, the use of the robotic tool has allowed us the parse and study the ingredients that should form an efficacious and efficient rehabilitation program. The aim of this paper is to provide a general overview of the current state of robotic training in upper limb rehabilitation after stroke, to analyze the rationale behind its use, and to discuss our working model on how to more effectively employ robotics to promote motor recovery after stroke.

Upper Extremity Robotic Therapy: Current Status

Robotic systems used in the field of neurorehabilitation can be organized under two basic categories: exoskeleton and end-effector type robots. Exoskeleton robotic systems allow us to accurately determine the kinematic configuration of human joints, while end-effector type robots exert forces only in the most distal part of the affected limb. A growing number of commercial robotic devices have been developed employing either configuration. Examples of exoskeleton type include the Armeo®Spring, Armeo®Power, and Myomo® and of end-effector type include the InMotion™, Burt®, Kinarm™ and REAplan®. Both categories enable the implementation of intensive training and there are many other devices in different stages of development or commercialization (1920).

The last decade has seen an exponential growth in both the number of devices as well as clinical trials. The results coalesced in a set of systematic reviews, meta-analyses (1317) and guidelines such as those published by the American Heart Association and the Veterans Administration (AHA and VA) (21). There is a clear consensus that upper limb therapy using robotic devices over 30–60-min sessions, is safe despite the larger number of movement repetitions (14).

This technic is feasible and showed a high rate of eligibility; in the VA ROBOTICS (911) study, nearly two thirds of interviewed stroke survivors were enrolled in the study. As a comparison the EXCITE cohort of constraint-induced movement therapy enrolled only 6% of the screened patients participated (22). On that issue, it is relevant to notice the admission criteria of both chronic stroke studies. ROBOTICS enrolled subjects with Fugl-Meyer assessment (FMA) of 38 or lower (out of 66) while EXCITE typically enrolled subjects with an FMA of 42 or higher. Duret and colleagues demonstrated that the target population, based on motor impairments, seems to be broader in the robotic intervention which includes patients with severe motor impairments, a group that typically has not seen much benefit from usual care (23). Indeed, Duret found that more severely impaired patients benefited more from robot-assisted training and that co-factors such as age, aphasia, and neglect had no impact on the amount of repetitive movements performed and were not contraindicated. Furthermore, all patients enrolled in robotic training were satisfied with the intervention. This result is consistent with the literature (24).

The main outcome result is that robotic therapy led to significantly more improvement in impairment as compared to conventional usual care, but only slightly more on motor function of the limb segments targeted by the robotic device (16). For example, Bertani et al. (15) and Zhang et al. (17) found that robotic training was more effective in reducing motor impairment than conventional usual care therapy in patients with chronic stroke, and further meta-analyses suggested that using robotic therapy as an adjunct to conventional usual care treatment is more effective than robotic training alone (1317). Other examples of disproven beliefs: many rehabilitation professionals mistakenly expected significant increase of muscle hyperactivity and shoulder pain due to the intensive training. Most studies showed just the opposite, i.e., that intensive robotic training was associated with tone reduction as compared to the usual care groups (92526). These results are shattering the resistance to the widespread adoption of robotic therapy as a therapeutic modality post-stroke.

That said, not all is rosy. Superior changes in functional outcomes were more controversial until the very last years as most studies and reviews concluded that robotic therapy did not improve activities of daily living beyond traditional care. One first step was reached in 2015 with Mehrholz et al. (14), who found that robotic therapy can provide more functional benefits when compared to other interventions however with a quality of evidence low to very low. 2018 may have seen a decisive step in favor of robotic as the latest meta-analysis conducted by Mehrholz et al. (27) concluded that robot-assisted arm training may improve activities of daily living in the acute phase after stroke with a high quality of evidence However, the results must be interpreted with caution because of the high variability in trial designs as evidenced by the multicenter study (28) in which robotic rehabilitation using the Armeo®Spring, a non-motorized device, was compared to self-management with negative results on motor impairments and potential functional benefits in the robotic group.

The Robot Assisted Training for the Upper Limb after Stroke (RATULS) study (29) might clarify things and put everyone in agreement on the topic. Of notice, RATULS goes beyond the Veterans Administration ROBOTICS with chronic stroke or the French REM_AVC study with subacute stroke. RATULS included 770 stroke patients and covered all stroke phases, from acute to chronic, and it included a positive meaningful control in addition to usual care.[…]


Continue —-> Frontiers | Robot-Assisted Therapy in Upper Extremity Hemiparesis: Overview of an Evidence-Based Approach | Neurology

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