Posts Tagged Motor recovery

[Abstract] The Efficacy of Lower Extremity Mirror Therapy for Improving Balance, Gait, and Motor Function Poststroke: A Systematic Review and Meta-Analysis



Mirror therapy is less commonly used to target the lower extremity after stroke to improve outcomes but is simple to perform. This review and meta-analysis aimed to evaluate the efficacy of lower extremity mirror therapy in improving balance, gait, and motor function for individuals with stroke.


PubMed, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Physiotherapy Evidence Database, and PsychINFO were searched from inception to May 2018 for randomized controlled trials (RCTs) comparing lower extremity mirror therapy to a control intervention for people with stroke. Pooled effects were determined by separate meta-analyses of gait speed, mobility, balance, and motor recovery.


Seventeen RCTs involving 633 participants were included. Thirteen studies reported a significant between-group difference favoring mirror therapy in at least one lower extremity outcome. In a meta-analysis of 6 trials that reported change in gait speed, a large beneficial effect was observed following mirror therapy training (standardized mean differences [SMD] = 1.04 [95% confidence interval [CI] = .43, 1.66], I2 = 73%, and P < .001). Lower extremity mirror therapy also had a positive effect on mobility (5 studies, SMD = .46 [95% CI = .01, .90], I2 = 43%, and P = .05) and motor recovery (7 studies, SMD = .47 [95% CI = .21, .74], I2 = 0%, and P < .001). A significant pooled effect was not found for balance capacity.


Mirror therapy for the lower extremity has a large effect for gait speed improvement. This review also found a small positive effect of mirror therapy for mobility and lower extremity motor recovery after stroke.


via The Efficacy of Lower Extremity Mirror Therapy for Improving Balance, Gait, and Motor Function Poststroke: A Systematic Review and Meta-Analysis – Journal of Stroke and Cerebrovascular Diseases

, , , , , , ,

Leave a comment

[Abstract] Wearable Movement Sensors for Rehabilitation: A Focused Review of Technological and Clinical Advances – PM&R


Recent technologic advancements have enabled the creation of portable, low-cost, and unobtrusive sensors with tremendous potential to alter the clinical practice of rehabilitation. The application of wearable sensors to track movement has emerged as a promising paradigm to enhance the care provided to patients with neurologic or musculoskeletal conditions. These sensors enable quantification of motor behavior across disparate patient populations and emerging research shows their potential for identifying motor biomarkers, differentiating between restitution and compensation motor recovery mechanisms, remote monitoring, telerehabilitation, and robotics. Moreover, the big data recorded across these applications serve as a pathway to personalized and precision medicine. This article presents state-of-the-art and next-generation wearable movement sensors, ranging from inertial measurement units to soft sensors. An overview of clinical applications is presented across a wide spectrum of conditions that have potential to benefit from wearable sensors, including stroke, movement disorders, knee osteoarthritis, and running injuries. Complementary applications enabled by next-generation sensors that will enable point-of-care monitoring of neural activity and muscle dynamics during movement also are discussed.


via Wearable Movement Sensors for Rehabilitation: A Focused Review of Technological and Clinical Advances – PM&R

, , , , , , , , ,

Leave a comment

[Abstract + References] Transcranial Direct Current Stimulation for Poststroke Motor Recovery: Challenges and Opportunities – PM&R


There has been a renewed research interest in transcranial direct current stimulation (tDCS) as an adjunctive tool for poststroke motor recovery as it has a neuro-modulatory effect on the human cortex. However, there are barriers towards its successful application in motor recovery as several scientific issues remain unresolved, including device-related issues (ie, dose-response relationship, safety and tolerability concerns, interhemispheric imbalance model, and choice of montage) and clinical trial-related issues (ie, patient selection, timing of study, and choice of outcomes). This narrative review examines and discusses the existing challenges in using tDCS as a brain modulation tool in facilitating recovery after stroke. Potential solutions pertinent to using tDCS with the goal of harnessing the brains plasticity are proposed.


  1. Kreisel, S.H., Bazner, H., Hennerici, M.G. Pathophysiology of stroke rehabilitation: Temporal aspects of neuro-functional recovery. Cerebrovasc Dis2006;21:6–17.
  2. Nitsche, M.A., Paulus, W. Sustained excitability elevations induced by transcranial DC motor cortex stimulation in humans. Neurology2001;57:1899–1901.
  3. Fritsch, B., Reis, J., Martinowich, K. et al, Direct current stimulation promotes BDNF-dependent synaptic plasticity: Potential implications for motor learning. Neuron2010;66:198–204.
  4. Schlaug, G., Renga, V., Nair, D. Transcranial direct current stimulation in stroke recovery. Arch Neurol2008;65:1571–1576.
  5. Brunoni, A.R., Nitsche, M.A., Bolognini, N. et al, Clinical research with transcranial direct current stimulation (TDCS): Challenges and future directions. Brain Stimul2012;5:175–195.
  6. Fregni, F., Nitsche, M., Loo, C. et al, Regulatory considerations for the clinical and research use of transcranial direct current stimulation (TDCS): Review and recommendations from an expert panel.Clin Res Regul Aff2015;32:22–35.
  7. Feng, W.W., Bowden, M.G., Kautz, S. Review of transcranial direct current stimulation in poststroke recovery. Top Stroke Rehabil2013;20:68–77.
  8. Ferbert, A., Priori, A., Rothwell, J.C., Day, B.L., Colebatch, J.G., Marsden, C.D. Interhemispheric inhibition of the human motor cortex. J Physiol1992;453:525–546.
  9. Di Lazzaro, V., Oliviero, A., Profice, P. et al, Direct demonstration of interhemispheric inhibition of the human motor cortex produced by transcranial magnetic stimulation. Exp Brain Res1999;124:520–524.
  10. Stinear, C.M., Petoe, M.A., Byblow, W.D. Primary motor cortex excitability during recovery after stroke: Implications for neuromodulation. Brain Stimul2015;8:1183–1190.
  11. McDonnell, M.N., Stinear, C.M. TMS measures of motor cortex function after stroke: A meta-analysis. Brain Stimul2017;10:721–734.
  12. Wu, D., Qian, L., Zorowitz, R.D., Zhang, L., Qu, Y., Yuan, Y. Effects on decreasing upper-limb poststroke muscle tone using transcranial direct current stimulation: A randomized sham-controlled study. Arch Phys Med Rehabil2013;94:1–8.
  13. Waters, S., Wiestler, T., Diedrichsen, J. Cooperation not competition: Bihemispheric tdcs and fmri show role for ipsilateral hemisphere in motor learning. J Neurosci2017;37:7500–7512.
  14. Truong, D.Q., Huber, M., Xie, X. et al, Clinician accessible tools for gui computational models of transcranial electrical stimulation: Bonsai and spheres. Brain Stimul2014;7:521–524.
  15. Saturnino, G.B., Antunes, A., Thielscher, A. On the importance of electrode parameters for shaping electric field patterns generated by TDCS. NeuroImage2015;120:25–35.
  16. Vines, B.W., Cerruti, C., Schlaug, G. Dual-hemisphere TDCS facilitates greater improvements for healthy subjects’ non-dominant hand compared to uni-hemisphere stimulation. BMC Neurosci2008;9:103.
  17. Chi, R.P., Fregni, F., Snyder, A.W. Visual memory improved by non-invasive brain stimulation. Brain Res2010;1353:168–175.
  18. Chhatbar, P.Y., Ramakrishnan, V., Kautz, S., George, M.S., Adams, R.J., Feng, W. Transcranial direct current stimulation post-stroke upper extremity motor recovery studies exhibit a dose-response relationship. Brain Stimul2016;9:16–26.
  19. Nitsche, M.A., Paulus, W. Excitability changes induced in the human motor cortex by weak transcranial direct current stimulation. J Physiol2000;527:633–639.
  20. Bastani, A., Jaberzadeh, S. Differential modulation of corticospinal excitability by different current densities of anodal transcranial direct current stimulation. PLoS One2013;8:e72254.
  21. Bastani, A., Jaberzadeh, S. A-TDCS differential modulation of corticospinal excitability: The effects of electrode size. Brain Stimul2013;6:932–937.
  22. Liebetanz, D., Koch, R., Mayenfels, S., Konig, F., Paulus, W., Nitsche, M.A. Safety limits of cathodal transcranial direct current stimulation in rats. Clin Neurophysiol2009;120:1161–1167.
  23. Chhatbar, P.Y., George, M.S., Kautz, S.A., Feng, W. Quantitative reassessment of safety limits of tdcs for two animal studies. Brain Stimul2017;10:1011–1012.
  24. Chhatbar, P.Y., George, M.S., Kautz, S.A., Feng, W. Charge density, not current density, is a more comprehensive safety measure of transcranial direct current stimulation. Brain Behav Immun2017;66:414–415.
  25. Palm, U., Keeser, D., Schiller, C. et al, Skin lesions after treatment with transcranial direct current stimulation (TDCS). Brain Stimul2008;1:386–387.
  26. Frank, E., Wilfurth, S., Landgrebe, M., Eichhammer, P., Hajak, G., Langguth, B. Anodal skin lesions after treatment with transcranial direct current stimulation. Brain Stimul2010;3:58–59.
  27. Wang, J., Wei, Y., Wen, J., Li, X. Skin burn after single session of transcranial direct current stimulation (TDCS). Brain Stimul2015;8:165–166.
  28. Minhas, P., Datta, A., Bikson, M. Cutaneous perception during TDCS: Role of electrode shape and sponge salinity. Clin Neurophysiol2011;122:637–638.
  29. Chhatbar, P.Y., Chen, R., Deardorff, R. et al, Safety and tolerability of transcranial direct current stimulation to stroke patients—a phase I current escalation study. Brain Stimul2017;10:553–559.
  30. Kessler, S.K., Minhas, P., Woods, A.J., Rosen, A., Gorman, C., Bikson, M. Dosage considerations for transcranial direct current stimulation in children: A computational modeling study. PLoS One2013;8:e76112.
  31. Truong, D.Q., Magerowski, G., Blackburn, G.L., Bikson, M., Alonso-Alonso, M. Computational modeling of transcranial direct current stimulation (TDCS) in obesity: Impact of head fat and dose guidelines.Neuroimage Clin2013;2:759–766.
  32. Datta, A., Bikson, M., Fregni, F. Transcranial direct current stimulation in patients with skull defects and skull plates: High-resolution computational FEM study of factors altering cortical current flow.Neuroimage2010;52:1268–1278.
  33. Datta, A., Baker, J.M., Bikson, M., Fridriksson, J. Individualized model predicts brain current flow during transcranial direct-current stimulation treatment in responsive stroke patient. Brain Stimul2011;4:169–174.
  34. Suh, H.S., Lee, W.H., Kim, T.-S. Influence of anisotropic conductivity in the skull and white matter on transcranial direct current stimulation via an anatomically realistic finite element head model. Phys Med Biol2012;57:6961.
  35. Lee, W., Seo, H., Kim, S., Cho, M., Lee, S., Kim, T.-S. Influence of white matter anisotropy on the effects of transcranial direct current stimulation: A finite element study. in: C.K. Lim, J.C.H. Goh (Eds.)ICBME 2008-13th International Conference on Biomedical EngineeringSpringerHeidelberg2009:460–464.
  36. Metwally, M.K., Han, S.M., Kim, T.S. The effect of tissue anisotropy on the radial and tangential components of the electric field in transcranial direct current stimulation. Med Biol Eng Comput2015;53:1085–1101.
  37. Huang, Y., Liu, A.A., Lafon, B. et al, Measurements and models of electric fields in the in vivo human brain during transcranial electric stimulation. Elife2017;6:e18834.
  38. Opitz, A., Falchier, A., Yan, C.G. et al, Spatiotemporal structure of intracranial electric fields induced by transcranial electric stimulation in humans and nonhuman primates. Sci Rep2016;6:31236.
  39. Chhatbar, P.Y., Kautz, S.A., Takacs, I. et al, Evidence of transcranial direct current stimulation-generated electric fields at subthalamic level in human brain in vivo. Brain Stimul2018;11:727–733.
  40. Lindenberg, R., Renga, V., Zhu, L.L., Nair, D., Schlaug, G. Bihemispheric brain stimulation facilitates motor recovery in chronic stroke patients. Neurology2010;75:2176–2184.
  41. Levy, R.M., Harvey, R.L., Kissela, B.M. et al, Epidural electrical stimulation for stroke rehabilitation: Results of the prospective, multicenter, randomized, single-blinded Everest trial. Neurorehabil Neural Repair2016;30:107–119.
  42. Feng, W., Wang, J., Chhatbar, P.Y. et al, Corticospinal tract lesion load—a potential imaging biomarker for stroke motor outcomes. Ann Neurol2015;78:860–870.
  43. Dromerick, A.W., Edwardson, M.A., Edwards, D.F. et al, Critical periods after stroke study: Translating animal stroke recovery experiments into a clinical trial. Front Hum Neurosci2015;9:231.
  44. Jorgensen, H.S., Nakayama, H., Raaschou, H.O., Vive-Larsen, J., Stoier, M., Olsen, T.S. Outcome and time course of recovery in stroke. Part II: Time course of recovery. The Copenhagen Stroke Study.Arch Phys Med Rehabil1995;76:406–412.
  45. Cortes, J.C., Goldsmith, J., Harran, M.D. et al, A short and distinct time window for recovery of arm motor control early after stroke revealed with a global measure of trajectory kinematics. Neurorehabil Neural Repair2017;31:552–560.
  46. Bushnell, C., Bettger, J.P., Cockroft, K.M. et al, Chronic stroke outcome measures for motor function intervention trials: Expert panel recommendations. Circ Cardiovasc Qual Outcomes2015;8:S163–S169.
  47. Viana, R.T., Laurentino, G.E., Souza, R.J. et al, Effects of the addition of transcranial direct current stimulation to virtual reality therapy after stroke: A pilot randomized controlled trial.NeuroRehabilitation2014;34:437–446.
  48. Fusco, A., Assenza, F., Iosa, M. et al, The ineffective role of cathodal tdcs in enhancing the functional motor outcomes in early phase of stroke rehabilitation: An experimental trial. Biomed Res Int2014;2014:547290.
  49. Kim, D.Y., Lim, J.Y., Kang, E.K. et al, Effect of transcranial direct current stimulation on motor recovery in patients with subacute stroke. Am J Phys Med Rehabil2010;89:879–886.
  50. Boggio, P.S., Nunes, A., Rigonatti, S.P., Nitsche, M.A., Pascual-Leone, A., Fregni, F. Repeated sessions of noninvasive brain DC stimulation is associated with motor function improvement in stroke patients. Restor Neurol Neurosci2007;25:123–129.
  51. Bolognini, N., Vallar, G., Casati, C., Latif, L.A., El-Nazer, R., Williams, J. et al, Neurophysiological and behavioral effects of TDCS combined with constraint-induced movement therapy in poststroke patients. Neurorehabil Neural Repair2011;25:819–829.
  52. Hesse, S., Waldner, A., Mehrholz, J., Tomelleri, C., Pohl, M., Werner, C. Combined transcranial direct current stimulation and robot-assisted arm training in subacute stroke patients: An exploratory, randomized multicenter trial. Neurorehabil Neural Repair2011;25:838–846.
  53. Di Lazzaro, V., Dileone, M., Capone, F. et al, Immediate and late modulation of interhemipheric imbalance with bilateral transcranial direct current stimulation in acute stroke. Brain Stimul2014;7:841–848.
  54. Rossi, C., Sallustio, F., Di Legge, S., Stanzione, P., Koch, G. Transcranial direct current stimulation of the affected hemisphere does not accelerate recovery of acute stroke patients. Eur J Neurol2013;20:202–204.
  55. Nair, D.G., Renga, V., Lindenberg, R., Zhu, L., Schlaug, G. Optimizing recovery potential through simultaneous occupational therapy and non-invasive brain-stimulation using tdcs. Restor Neurol Neurosci2011;29:411–420.
  56. Ang, K.K., Guan, C., Phua, K.S. et al, Facilitating effects of transcranial direct current stimulation on motor imagery brain-computer interface with robotic feedback for stroke rehabilitation. Arch Phys Med Rehabil2015;96:S79–S87.
  57. Sattler, V., Acket, B., Raposo, N. et al, Anodal tdcs combined with radial nerve stimulation promotes hand motor recovery in the acute phase after ischemic stroke. Neurorehabil Neural Repair2015;29:743–754.
  58. Andrade, S.M., Batista, L.M., Nogueira, L.L. et al, Constraint-induced movement therapy combined with transcranial direct current stimulation over premotor cortex improves motor function in severe stroke: A pilot randomized controlled trial. Rehabil Res Pract2017;2017:6842549.
  59. Figlewski, K., Blicher, J.U., Mortensen, J., Severinsen, K.E., Nielsen, J.F., Andersen, H. Transcranial direct current stimulation potentiates improvements in functional ability in patients with chronic stroke receiving constraint-induced movement therapy. Stroke2017;48:229–232.
  60. Medeiros, L.F., de Souza, I.C.C., Vidor, L.P. et al, Neurobiological effects of transcranial direct current stimulation: A review. Front Psychiatry2012;3:110.


via Transcranial Direct Current Stimulation for Poststroke Motor Recovery: Challenges and Opportunities – PM&R

, , , ,

Leave a comment

[WEB SITE] Effects of Mirror Therapy on Walking Ability, Balance and Lower Limb Motor Recovery After Stroke

Leanne Loranger, PT, Manager Policy and Practice    August 2, 2018

Full Citation

Li Y, Wei Q, Gou W, He C. Effects of mirror therapy on walking ability, balance and lower limb recovery after stroke: A systematic review and meta-analysis of randomized controlled trials. Clinical Rehabilitation 2018; DOI: 10.1177/0269215518766642.1


“Stroke is the leading cause of death and disability in Canada.”2 Up to half of people with stroke-related hemiplegia cannot walk independently after rehabilitation;1 however, independent mobility is often a priority for people following stroke.

Mirror therapy involves the use of a mirror placed in the mid-sagittal plane to create the illusion that the affected limb is performing the movements that the unaffected limb is performing. It has been theorized that the visual feedback can help to prevent or reduce learned non-use of the affected limb. Mirror therapy first became common in the rehabilitation of stroke-related upper extremity dysfunction, but more recently has been used in the rehabilitation of lower limbs.

The authors conducted a systematic review and meta-analysis of randomized controlled trials of the use of mirror therapy in the rehabilitation of stroke-related lower-limb impairments.


  • Systematic search of MEDLINE, EMBASE, Web of Science, CENTRAL, Physiotherapy Evidence Database, CNKI, VIP, Wan Fang,, and Current Controlled Trials, conducted according to PRISMA guidelines.
  • Study Inclusion Criteria:
    • Randomized Controlled Trials
    • Patients > 18 years of age with stroke
    • More than five subjects in the study
    • Compared mirror to no intervention, a different intervention, or a control group with the same therapeutic intervention minus mirror therapy
    • Provided original data or sufficient information about at least one outcome to allow inclusion in Meta-analysis
    • Published in English or Chinese
  • The PEDro Scale was used to assess quality of included studies.
    • Scores ranged from five to eight points
    • Six studies were rated “good quality” while seven were rated “fair quality”
  • Meta-analysis was conducted using RevMan 5.3.
  • Subgroup analysis was conducted to establish the effectiveness of treatment depending on recovery stage (acute, subacute, or chronic) and nature of the treatment intervention (movement of unaffected limb only, or bilateral movement).
  • A total of 13 studies, representing 572 patients were included in the meta-analysis.
  • Timing of interventions ranged from six days to 16 months post-stroke.
  • Six studies involved bilateral movements, while in seven only the unaffected side was moved.
  • Frequency ranged from three to six days per week.
  • Duration of treatment ranged from two weeks to three months.


  • Significant improvement in walking speed compared with control group, measured by 10-meter walk test.
    • Both bilateral and unilateral movements led to improved walking speed.
  • No significant improvement in mobility, measured by Timed Up and Go or Functional Ambulatory Category.
  • Significant treatment effect for balance, measured by the Berg Balance Scale or Brunnel Balance Assessment.
  • Significant effect on lower limb motor recovery, measured by the Fugl-Meyer or Brunnstrom Scale.
  • No significant effect on spasticity of ankle muscles.
  • Significant improvement in PROM of ankle dorsiflexion.


The main finding of this systematic review and meta-analysis was that “patients with stroke who received mirror therapy had significant improvements in walking speed, balance, lower limb motor recovery and passive range of motion of ankle dorsiflexion.”1 However, although the findings were statistically significant, they “seemed to have little clinical significance.” For example, the average improvement in walking speed after mirror therapy treatment would not lead to a change in patient categorization from “house-hold ambulator” to “limited community ambulator.”


  • Considerable study heterogeneity regarding treatment frequency and duration may have impacted on the strength of the study findings.
  • Relatively small number of studies and total patients included.

Relevance to physiotherapy practice in Alberta

Mirror therapy shows some promise for lower limb rehabilitation of people who have experienced a stroke, leading to statistically significant changes in gait speed, balance, motor recovery and range of motion. However, current research findings show that effects may have limited clinically significance. More research is needed to determine the frequency, duration, timing and parameters of mirror therapy that may result in clinically significant effects, and the patient populations that derive greatest benefit from the intervention, if any.


The purpose of this summary is to highlight recently published research findings that are not openly accessible. Every effort is made to ensure accuracy and clarity of the summary. Readers are encouraged to review the published article in full for further information.


  1. Li Y, Wei Q, Gou W, He C. Effects of mirror therapy on walking ability, balance and lower limb recovery after stroke: A systematic review and meta-analysis of randomized controlled trials. Clinical Rehabilitation 2018; DOI: 10.1177/0269215518766642
  2. Physiotherapy Alberta – College + Association. Physiotherapy Works for Stroke. Available at Accessed July 13, 2018.

via Physiotherapy Alberta College + Association : The Movement Specialists: Research in Focus: Effects of Mirror Therapy on Walking Ability, Balance and Lower Limb Motor Recovery After Stroke

, , , , ,

Leave a comment

[WEB SITE] PaRRo Portable Arm Robot Designed for Rehab

Published on 


University of Michigan researchers have designed a low-cost, portable arm rehabilitation robot, which they suggest can be used at home and facilitate motor recovery in patients with cerebral palsy, stroke, or spinal cord injury.

The development of the rehab robot, named PaRRo, is described in a study published in the journal IEEE Transactions on Biomedical Engineering.

PaRRo was designed to provide task-specific training, according to the researchers, in a news story from Cerebral Palsy News Today.

It features an effector at the end of a robotic arm, which is engineered to be maneuvered by the patient. The effector is connected to a system of brakes that offer resistance to the arm’s movement, training muscle strength and improving arm resistance.

The amount of resistance can be controlled by each patient, meaning that the arm exercise intensities can be adapted to each patient’s motor skills.

However, the news story continues, the rehab robot is passive, which means it does not have any computer control, nor does it actively operate by taking over from the user.

In their research, the team performed simulations to calculate the robot’s resistive force and workspace. They then constructed a prototype based on these results, which was tested in a healthy male volunteer with no neurological or orthopedic impairments.

Nine surface electrodes were placed in different muscles and recorded the muscle activity via electromyography.

Both the force generated by the robot and the force produced by the user matched those predicted by the simulations when the device was moved across different directions.

Electromyography results also revealed the robot was capable of generating resistive forces adjustable to the subject’s motor abilities, the news story explains.

“These results indicate that PaRRo is a feasible low-cost approach to provide functional resistance training to the muscles of the upper-extremity,” according to the researchers, in the study.

“The proposed robotic device could provide a technological breakthrough that will make rehabilitation robots accessible for small outpatient rehabilitation centers and in-home therapy,” they add.

[Source: Cerebral Palsy News Today]


via PaRRo Portable Arm Robot Designed for Rehab – Rehab Managment

, , , , , ,

Leave a comment

[Abstract] Combining functional electrical stimulation and mirror therapy for upper limb motor recovery following stroke: a randomised trial

Introduction: There is a growing need to develop effective rehabilitation interventions for people presenting with stroke as healthcare services experience ever-increasing pressures on staff and resources. The primary objective of this research is to examine the effect that mirror therapy combined with functional electrical stimulation has on upper limb motor recovery and functional outcome for a sample of people admitted to an inpatient stroke unit.

Methods: A total of 50 participants were randomised to one of three treatment arms; Functional Electrical Stimulation, Mirror therapy or a combined intervention of Functional Electrical Stimulation with Mirror therapy. Socio-demographic and health information was collected at recruitment together with admission dates, medical diagnoses and baseline measures. Blinded assessments were undertaken at baseline and at discharge post-stroke by a registered physiotherapist and a clinical nurse specialist.

Results: The Action Research Arm Test and the Fugl–Meyer Upper Extremity assessment revealed statistically superior results for Functional Electrical Stimulation compared with Mirror therapy alone (p = 0.03). There were no other significant differences between the three groups.

Conclusion: The theory of combining interventions requires further investigation and warrants further research. Combining current interventions may have the potential to enhance stroke rehabilitation, improve functional outcomes and help reduce the overall burden of stroke.


via Combining functional electrical stimulation and mirror therapy for upper limb motor recovery following stroke: a randomised trial: European Journal of Physiotherapy: Vol 0, No 0

, , , , , , , , , , ,

Leave a comment

[ARTICLE] Effects of 8-week sensory electrical stimulation combined with motor training on EEG-EMG coherence and motor function in individuals with stroke – Full Text


The peripheral sensory system is critical to regulating motor plasticity and motor recovery. Peripheral electrical stimulation (ES) can generate constant and adequate sensory input to influence the excitability of the motor cortex. The aim of this proof of concept study was to assess whether ES prior to each hand function training session for eight weeks can better improve neuromuscular control and hand function in chronic stroke individuals and change electroencephalography-electromyography (EEG-EMG) coherence, as compared to the control (sham ES). We recruited twelve subjects and randomly assigned them into ES and control groups. Both groups received 20-minute hand function training twice a week, and the ES group received 40-minute ES on the median nerve of the affected side before each training session. The control group received sham ES. EEG, EMG and Fugl-Meyer Assessment (FMA) were collected at four different time points. The corticomuscular coherence (CMC) in the ES group at fourth weeks was significantly higher (p = 0.004) as compared to the control group. The notable increment of FMA at eight weeks and follow-up was found only in the ES group. The eight-week rehabilitation program that implemented peripheral ES sessions prior to function training has a potential to improve neuromuscular control and hand function in chronic stroke individuals.


Stroke is one of the leading contributing factors to the loss of functional abilities and independence in daily life in adults1. The most common and widely observed impairment following stroke is motor impairment, which can be regarded as a loss or limitation of function in muscle control or movement25. Most stroke survivors later regain the ability to walk independently, but only fewer than 50% of them will have fully recovered upper extremity functions6,7. From a review focusing on motor recovery after stroke, it has been indicated that the recovery of both arm and hand function among subacute and chronic stroke survivors is limited in current neural rehabilitation settings4; therefore, additional management with activating plasticity before or during performing motor training is necessary for better motor recovery.

The fundamental principle of stroke rehabilitation is inducing brain plasticity by sensory or proprioceptive input in order to facilitate motor functions8,9. It has been demonstrated that strong sensory input can induce plastic changes in the motor cortex via direct or indirect pathways1017. In this case, electrical stimulation (ES) that provides steady and adequate somatosensory input can be an ideal method of stimulating the motor cortex.

Recent studies using functional magnetic resonance imaging (fMRI) or transcranial magnetic stimulation (TMS) suggest that ES on peripheral nerves can increase motor-evoked potential (MEP)1820, increase the active voxel count in the corresponding motor cortex13, and increase blood-oxygen-level dependent (BOLD) signals in fMRI, suggesting peripheral ES induced higher excitability and activation level of cortical neurons21. Since the expansion of the motor cortical area or increase in the excitability of neural circuits is associated with learning new motor skills2226, clinicians should take advantage and assist patients with stroke on motor tasks training during this period of time. Celnik and colleagues27found that the hand function of chronic stroke subjects improved immediately after two-hour peripheral nerve stimulation combined with functional training, and the effect lasted for one day. Based on previous studies, the ES that increases corticomuscular excitability may turn out to be an ideal intervention added prior to traditional motor training to “activate” the neural circuit, so that patients may get the most out of the training. According to a recent study that applied single session peripheral ES on post-stroke individuals, the corticomuscular coherence (CMC), which is the synchronization level between EEG and EMG, increased significantly and was accompanied by improvement in the steadiness of force output28.

To our knowledge, however, there is no study investigating the long-term effect of ES combined with functional training on both motor performance and cortical excitability. We targeted the median nerve because its distribution covered the dorsal side of index, middle, and half of ring finger and the palmar side of the first three fingers and half of the ring finger. Besides, median nerve is in charge of the flexion of the first three fingers, which combined they accounts for most of the functional tasks of hand. Therefore, the purpose of this pilot study was to preliminarily evaluate the effect of eight-week ES-combined hand functional training among chronic stroke patients based on CMC and motor performance. We followed up for four weeks after the intervention ceased and examined the lasting effect. We hypothesized that those who received intervention with ES would have better hand function and higher CMC than those who received intervention with sham ES. We also hypothesized that the effect would last for at least four weeks during our follow-up.[…]


Continue —>  Effects of 8-week sensory electrical stimulation combined with motor training on EEG-EMG coherence and motor function in individuals with stroke

, , , , , , , ,

Leave a comment

[Abstract] A meta-analysis of the efficacy of anodal transcranial direct current stimulation for upper limb motor recovery in stroke survivors


Study Design

Systematic review and meta-analysis.


Prior reviews on the effects of anodal transcranial direct current stimulation (a-tDCS) have shown the effectiveness of a-tDCS on corticomotor excitability and motor function in healthy individuals but nonsignificant effect in subjects with stroke.


To summarize and evaluate the evidence for the efficacy of a-tDCS in the treatment of upper limb motor impairment after stroke.


A meta-analysis of randomized controlled trials that compared a-tDCS with placebo and change from baseline.


A pooled analysis showed a significant increase in scores in favor of a-tDCS (standard mean difference [SMD]=0.40, 95% confidence interval [CI]=0.10–0.70, p=0.010, compared with baseline). A similar effect was observed between a-tDCS and sham (SMD=0.49, 95% CI=0.18–0.81, p=0.005).


This meta-analysis of eight randomized placebo-controlled trials provides further evidence that a-tDCS may benefit motor function of the paretic upper limb in patients suffering from chronic stroke.

via A meta-analysis of the efficacy of anodal transcranial direct current stimulation for upper limb motor recovery in stroke survivors – Journal of Hand Therapy

, , , , , , , ,

Leave a comment

[ARTICLE] Brain-actuated functional electrical stimulation elicits lasting arm motor recovery after stroke – Full Text


Brain-computer interfaces (BCI) are used in stroke rehabilitation to translate brain signals into intended movements of the paralyzed limb. However, the efficacy and mechanisms of BCI-based therapies remain unclear. Here we show that BCI coupled to functional electrical stimulation (FES) elicits significant, clinically relevant, and lasting motor recovery in chronic stroke survivors more effectively than sham FES. Such recovery is associated to quantitative signatures of functional neuroplasticity. BCI patients exhibit a significant functional recovery after the intervention, which remains 6–12 months after the end of therapy. Electroencephalography analysis pinpoints significant differences in favor of the BCI group, mainly consisting in an increase in functional connectivity between motor areas in the affected hemisphere. This increase is significantly correlated with functional improvement. Results illustrate how a BCI–FES therapy can drive significant functional recovery and purposeful plasticity thanks to contingent activation of body natural efferent and afferent pathways.


Despite considerable efforts over the last decades, the quest for novel treatments for arm functional recovery after stroke remains a priority1. Synergistic efforts in neural engineering and restoration medicine are demonstrating how neuroprosthetic approaches can control devices and ultimately restore body function2,3,4,5,6,7. In particular, non-invasive brain-computer interfaces (BCI) are reaching their technological maturity8,9 and translate neural activity into meaningful outputs that might drive activity-dependent neuroplasticity and functional motor recovery10,11,12. BCI implies learning to modify the neuronal activity through progressive practice with contingent feedback and reward —sharing its neurobiological basis with rehabilitation13.

Most attempts to use non-invasive BCI systems for upper limb rehabilitation after stroke have coupled them with other interventions, although not all trials reported clinical benefits. The majority of these studies are case reports of patients who operated a BCI to control either rehabilitation robots14,15,16,17,18,19 or functional electrical stimulation (FES)20,21,22,23. A few works have described changes in functional magnetic resonance imaging (fMRI) that correlate with motor improvements17,18,22.

Recent controlled trials have shown the potential benefit of BCI-based therapies24,25,26,27. Pichiorri et al.26recruited 28 subacute patients and studied the efficacy of motor imagery with or without BCI support via visual feedback, reporting a significant and clinically relevant functional recovery for the BCI group. As a step forward in the design of multimodal interventions, BCI-aided robotic therapies yielded significantly greater motor gains than robotic therapies alone24,25,27. In the first study, involving 30 chronic patients24, only the BCI group exhibited a functional improvement. In the second study, involving 14 subacute and chronic patients, both groups improved, probably reflecting the larger variance in subacute patients’ recovery and a milder disability25. The last study27 showed that in a mixed population of 74 subacute and chronic patients, the percentage of patients who achieved minimally clinical important difference in upper limb functionality was higher in the BCI group. The effect in favor of the BCI group was only evident in the sub-population of chronic patients. Moreover, the conclusions of this study are limited due to differences between experimental and control groups prior to the intervention, such as number of patients and FMA-UE scores, which were always in favor of the BCI group.

In spite of promising results achieved so far, BCI-based stroke rehabilitation is still a young field where different works report variable clinical outcomes. Furthermore, the efficacy and mechanisms of BCI-based therapies remain largely unclear. We hypothesize that, for BCI to boost beneficial functional activity-dependent plasticity able to attain clinically important outcomes, the basic premise is contingency between suitable motor-related cortical activity and rich afferent feedback. Our approach is designed to deliver associated contingent feedback that is not only functionally meaningful (e.g., via virtual reality or passive movement of the paretic limb by a robot), but also tailored to reorganize the targeted neural circuits by providing rich sensory inputs via the natural afferent pathways28, so as to activate all spare components of the central nervous system involved in motor control. FES fulfills these two properties of feedback contingent on appropriate patterns of neural activity; it elicits functional movements and conveys proprioceptive and somatosensory information, in particular via massive recruitment of Golgi tendon organs and muscle spindle feedback circuits. Moreover, several studies suggest that FES has an impact on cortical excitability29,30.

To test our hypothesis, this study assessed whether BCI-actuated FES therapy targeting the extension of the affected hand (BCI–FES) could yield stronger and clinically relevant functional recovery than sham-FES therapy for chronic stroke patients with a moderate-to-severe disability, and whether signatures of functional neuroplasticity would be associated with motor improvement. Whenever the BCI decoded a hand-extension attempt, it activated FES of the extensor digitorum communis muscle that elicited a full extension of the wrist and fingers. Patients in the sham-FES group wore identical hardware and received identical instructions as BCI–FES patients, but FES was delivered randomly and not driven by neural activity.

As hypothesized, our results confirm that only the BCI group exhibit a significant functional recovery after the intervention, which is retained 6–12 months after the end of therapy. Besides the main clinical findings, we have also attempted to shed light on possible mechanisms underlying the proposed intervention. Specifically, electroencephalography (EEG) imaging pinpoint significant differences in favor of the BCI group, mainly an increase in functional connectivity between motor areas in the affected hemisphere. This increase is significantly correlated with functional improvement. Furthermore, analysis of the therapeutic sessions substantiates that contingency between motor-related brain activity and FES occurs only in the BCI group and contingency-based metrics correlate with the functional improvement and increase in functional connectivity, suggesting that our BCI intervention might have promoted activity-dependent plasticity.[…]

Continue —> Brain-actuated functional electrical stimulation elicits lasting arm motor recovery after stroke | Nature Communications

, , , , , , , , , , , ,

Leave a comment

[Abstract] Neurophysiological effects of constraint-induced movement therapy and motor function: A systematic review

There is a claim that improvements in motor function in people with stroke following constraint-induced movement therapy (CIMT) is due to compensation but not actually neurorestoration. However, few studies have demonstrated improvements in neurophysiological outcomes such as increased motor map size and activation of primary cortex, or their positive correlations with motor function, following CIMT. The aim of this study was to carry out a systematic review of CIMT trials using neurophysiological outcomes, and a meta-analysis of the relationship between the neurophysiological outcomes and motor function.

The PubMed, PEDro and CENTRAL databases, as well as the reference lists of the included studies, were searched. The included studies were randomised controlled trials comparing the effect of CIMT on neurophysiological outcomes compared with other rehabilitation techniques, conventional therapy, or another variant of CIMT. Methodological quality was assessed using the PEDro scale. The data extracted from the studies were sample size, eligibility criteria, dose of intervention and control, outcome measurements, and time since stroke.

A total of 10 articles (n=219) fulfilled the study inclusion criteria, all of which were used for narrative synthesis, and four studies were used in the meta-analysis. The methodological quality of the studies ranged from low to high. Strong, positive, and significant correlations were found between the neurophysiological and motor function outcomes in fixed effects (z=3.268, p=0.001; r=0.52, 95% confidence interval (CI) 0.227–0.994) and random-effects (z=2.106, p=0.035; r=0.54, 95% CI 0.0424–0.827) models.

Randomised controlled trials evaluating the effects of CIMT on neurophysiological outcomes are few in number. Additionally, these studies used diverse outcomes, which makes it difficult to draw any meaningful conclusion. However, there is a strong positive correlation between neurophysiological and motor function outcomes in these studies.


via Neurophysiological effects of constraint-induced movement therapy and motor function: A systematic review | International Journal of Therapy and Rehabilitation | Vol 25, No 4

, , , ,

Leave a comment

%d bloggers like this: