Posts Tagged Stroke

[ARTICLE] Home-based transcranial direct current stimulation plus tracking training therapy in people with stroke: an open-label feasibility study – Full Text



Transcranial direct current stimulation (tDCS) is an effective neuromodulation adjunct to repetitive motor training in promoting motor recovery post-stroke. Finger tracking training is motor training whereby people with stroke use the impaired index finger to trace waveform-shaped lines on a monitor. Our aims were to assess the feasibility and safety of a telerehabilitation program consisting of tDCS and finger tracking training through questionnaires on ease of use, adverse symptoms, and quantitative assessments of motor function and cognition. We believe this telerehabilitation program will be safe and feasible, and may reduce patient and clinic costs.


Six participants with hemiplegia post-stroke [mean (SD) age was 61 (10) years; 3 women; mean (SD) time post-stroke was 5.5 (6.5) years] received five 20-min tDCS sessions and finger tracking training provided through telecommunication. Safety measurements included the Digit Span Forward Test for memory, a survey of symptoms, and the Box and Block test for motor function. We assessed feasibility by adherence to treatment and by a questionnaire on ease of equipment use. We reported descriptive statistics on all outcome measures.


Participants completed all treatment sessions with no adverse events. Also, 83.33% of participants found the set-up easy, and all were comfortable with the devices. There was 100% adherence to the sessions and all recommended telerehabilitation.


tDCS with finger tracking training delivered through telerehabilitation was safe, feasible, and has the potential to be a cost-effective home-based therapy for post-stroke motor rehabilitation.


Post-stroke motor function deficits stem not only from neurons killed by the stroke, but also from down-regulated excitability in surviving neurons remote from the infarct [1]. This down-regulation results from deafferentation [2], exaggerated interhemispheric inhibition [3], and learned non-use [4]. Current evidence suggests that post-stroke motor rehabilitation therapies should encourage upregulating neurons and should target neuroplasticity through intensive repetitive motor practice [56]. Previously, our group has examined the feasibility and efficacy of a custom finger tracking training program as a way of providing people with stroke with an engaging repetitive motor practice [789]. In this program, the impaired index finger is attached to an electro-goniometer, and participants repeatedly move the finger up and down to follow a target line that is drawn on the display screen. In successive runs, the shape, frequency and amplitude of target line is varied, which forces the participant to focus on the tracking task. In one study, we demonstrated a 23% improvement in hand function (as measured by the Box and Block test; minimal detectable change is 18% [10]) after participants with stroke completed the tracking training program [9]. While our study did not evaluate changes in activity in daily life (ADL) or quality of life (because efficacy of the treatment was not the study objective), the Box and Block test is moderately correlated (r = 0.52) to activities in daily life and quality of life (r = 0.59) [11]. In addition, using fMRI, we showed that training resulted in an activation transition from ipsilateral to contralateral cortical activation in the supplementary motor area, primary motor and sensory areas, and the premotor cortex [9].

Recently, others have shown that anodal transcranial direct current stimulation (tDCS) can boost the beneficial effects of motor rehabilitation, with the boost lasting for at least 3 months post-training [12]. Also, bihemispheric tDCS stimulation (anodal stimulation to excite the ipsilateral side and cathodal stimulation to downregulate the contralateral side) in combination with physical or occupational therapy has been shown to provide a significant improvement in motor function (as measured by Fugl-Meyer and Wolf Motor Function) compared to a sham group [13]. Further, a recent meta-analysis of randomized-controlled trials comparing different forms of tDCS shows that cathodal tDCS is a promising treatment option to improve ADL capacity in people with stroke [14]. Compared to transcutaneous magnetic stimulation (TMS), tDCS devices are inexpensive and easier to operate. Improvement in upper limb motor function can appear after only five tDCS sessions [15], and there are no reports of serious adverse events when tDCS has been used in human trials for periods of less than 40 min at amplitudes of less than 4 mA [16].

Moreover, tDCS stimulation task also seems beneficial for other impairments commonly seen in people post-stroke. Stimulation with tDCS applied for 20 sessions of 30 min over a 4-week period has been shown to decrease depression and improve quality of life in people after a stroke [1718]. Four tDCS sessions for 10 min applied over the primary and sensory cortex in eight patients with sensory impairments more than 10 months post-stroke enhanced tactile discriminative performance [19]. Breathing exercises with tDCS stimulation seems to be more effective than without stimulation in patient with chronic stroke [20], and tDCS has shown promise in treating central post-stroke pain [21]. Finally, preliminary research on the effect of tDCS combined with training on resting-state functional connectivity shows promise to better understand the mechanisms behind inter-subject variability regarding tDCS stimulation [22].

Motor functional outcomes in stroke have declined at discharge from inpatient rehabilitation facilities [2324], likely a result of the pressures to reduce the length of stay at inpatient rehabilitation facilities as part of a changing and increasingly complex health care climate [2526]. Researchers, clinicians, and administrators continue to search for solutions to facilitate and post-stroke rehabilitation after discharge. Specifically, there has been considerable interest in low-cost stroke therapies than can be administered in the home with only a modest level of supervision by clinical professionals.

Home telerehabilitation is a strategy in which rehabilitation in the patient’s home is guided remotely by the therapist using telecommunication technology. If patients can safely apply tDCS to themselves at home, combining telerehabilitation with tDCS would be an easy way to boost therapy without costly therapeutic face-to-face supervision. For people with multiple sclerosis, the study of Charvet et al. (2017) provided tDCS combined with cognitive training, delivered through home telerehabilitation, and demonstrated greater improvement on cognitive measures compared to those who received just the cognitive training [27]. The authors demonstrated the feasibility of remotely supervised, at-home tDCS and established a protocol for safe and reliable delivery of tDCS for clinical studies [28]. Some evidence shows that telerehabilitation approaches are comparable to conventional rehabilitation in improving activities of daily living and motor function for stroke survivors [2930], and that telemedicine for stroke is cost-effective [3132]. A study in 99 people with stroke receiving training using telerehabilitation (either with home exercise program or robot assisted therapy with home program) demonstrated significant improvements in quality of life and depression [33].

A recent search of the literature suggests that to date, no studies combine tDCS with repetitive tracking training in a home telerehabilitation setting to determine whether the combination leads to improved motor rehabilitation in people with stroke. Therefore, the aim of this pilot project was to explore the safety, usability and feasibility of the combined system. For the tDCS treatment, we used a bihemispheric montage with cathodal tDCS stimulation to suppress the unaffected hemisphere in order to promote stroke recovery [34353637]. For the repetitive tracking training therapy, we used a finger tracking task that targets dexterity because 70% of people post-stroke are unable to use their hand with full effectiveness after stroke [38]. Safety was assessed by noting any decline of 2 points or more in the cognitive testing that persists over more than 3 days. We expect day to day variations of 1 digit. Motor decline is defined by a decline of 6 blocks on the Box and Block test due to muscle weakness. This is based on the minimal detectable change (5.5 blocks/min) [10]. The standard error of measurement is at least 2 blocks for the paretic and stronger side. We expect possible variations in muscle tone that could influence the scoring of the test. Usability was assessed through a questionnaire and by observing whether the participant, under remote supervision, could don the apparatus and complete the therapy sessions. Our intent was to set the stage for a future clinical trial to determine the efficacy of this approach.



Participants were recruited from a database of people with chronic stroke who had volunteered for previous post-stroke motor therapy research studies at the University of Minnesota. Inclusion criteria were: at least 6 months post-stroke; at least 10 degrees of active flexion and extension motion at the index finger; awareness of tactile sensation on the scalp; and a score of greater than or equal to 24 (normal cognition) on the Mini-Mental State Examination (MMSE) to be cognitively able to understand instructions to don and use the devices [39]. We excluded those who had a seizure within past 2 years, carried implanted medical devices incompatible with tDCS, were pregnant, had non-dental metal in the head or were not able to understand instructions on how to don and use the devices. The study was approved by the University of Minnesota IRB and all enrolled participants consented to be in the study.


tDCS was applied using the StarStim Home Research Kit (NeuroElectrics, Barcelona, Spain). The StarStim system consists of a Neoprene head cap with marked positions for electrode placement, a wireless cap-mounted stimulator and a laptop control computer. Saline-soaked, 5 cm diameter sponge electrodes were used. For electrode placement, we followed a bihemispheric montage [14] involving cathodal stimulation on the unaffected hemisphere with the anode positioned at C3 and the cathode at C4 for participants with left hemisphere stroke, and vice versa for participants with right hemisphere stroke. Stimulation protocols were set by the investigator on a web-based application that communicated with the tDCS control computer. A remote access application (TeamViewer) was also installed on the control computer, as was a video conferencing application (Skype).

The repetitive finger tracking training system was a copy of what we used in our previous stroke studies [789]. The apparatus included an angle sensor mounted to a lightweight brace and aligned with the metacarpophalangeal (MCP) joint of the index finger, a sensor signal conditioning circuit, and a target tracking application loaded on a table computer. Figure 1 shows a participant using the apparatus during a treatment session.

Fig. 1

Fig. 1Participant with right hemiparesis receiving transcranial direct current magnetic stimulation (tDCS) in their home simultaneous while performing the finger movement tracking task on the tracking computer (left). The tDCS computer (right) shows the supervising investigator, located off-site, who communicated with the participant through the video conferencing application, controlled the tDCS stimulator through web-based software, and controlled the tracking protocols. (Permission was obtained from the participant for the publication of this picture)



Continue —>  Home-based transcranial direct current stimulation plus tracking training therapy in people with stroke: an open-label feasibility study | Journal of NeuroEngineering and Rehabilitation | Full Text

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[Abstract] Repetitive Peripheral Sensory Stimulation and Upper Limb Performance in Stroke: A Systematic Review and Meta-analysis

Background. Enhancement of sensory input in the form of repetitive peripheral sensory stimulation (RPSS) can enhance excitability of the motor cortex and upper limb performance.

Objective. To perform a systematic review and meta-analysis of effects of RPSS compared with control stimulation on improvement of motor outcomes in the upper limb of subjects with stroke.

Methods. We searched studies published between 1948 and December 2017 and selected 5 studies that provided individual data and applied a specific paradigm of stimulation (trains of 1-ms pulses at 10 Hz, delivered at 1 Hz). Continuous data were analyzed with means and standard deviations of differences in performance before and after active or control interventions. Adverse events were also assessed.

Results. There was a statistically significant beneficial effect of RPSS on motor performance (standard mean difference between active and control RPSS, 0.67; 95% CI, 0.09-1.24; I2 = 65%). Only 1 study included subjects in the subacute phase after stroke. Subgroup analysis of studies that only included subjects in the chronic phase showed a significant effect (1.04; 95% CI, 0.66-1.42) with no heterogeneity. Significant results were obtained for outcomes of body structure and function as well as for outcomes of activity limitation according to the International Classification of Function, Disability and Health, when only studies that included subjects in the chronic phase were analyzed. No serious adverse events were reported.

Conclusions. RPSS is a safe intervention with potential to become an adjuvant tool for upper extremity paresis rehabilitation in subjects with stroke in the chronic phase.

via Repetitive Peripheral Sensory Stimulation and Upper Limb Performance in Stroke: A Systematic Review and Meta-analysis – Adriana Bastos Conforto, Sarah Monteiro dos Anjos, Wanderley Marques Bernardo, Arnaldo Alves da Silva, Juliana Conti, André G. Machado, Leonardo G. Cohen, 2018

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[VIDEO] Smart FES Treatment for Foot Drop – YouTube

Smart Functional Electrical Stimulation System.

Treatment for foot drop patient.

It can be used when an upper motor neuron injury has caused a foot injury.

  • – Multiple sclerosis (MS)
  • – Stroke (CVA)
  • – Incomplete spinal cord injury (SCI)
  • – Cerebral palsy (CP)
  • – Traumatic brain injury (TBI)

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[Study] Effects of Exoskeleton Robotic Training Device on Upper Extremity in Brain The Effects of Exoskeleton Robotic Training Device


The purpose of this study is to examine the effects of the EMG-driven exoskeleton hand robotic training device on upper extremity motor and physiological function, daily functions, quality of life and self-efficacy in brain injury patients.

Full Title of Study: “The Effects of the EMG-driven Exoskeleton Hand Robotic Training Device on Upper Extremity Motor and Physiological Function, Daily Functions, Quality of Life and Self-efficacy in Brain Injury Patients”

Study Type

  • Study Type: Interventional
  • Study Design
    • Allocation: Randomized
    • Intervention Model: Crossover Assignment
    • Primary Purpose: Treatment
    • Masking: Single (Outcomes Assessor)
  • Study Primary Completion Date: November 1, 2018

Detailed Description

In the Robot-assisted group, participants receive training including passive movement, active movement, and game practices.

Let’s see the operation of the robot system by video. First, the passive movement. Patients could perform a movement of full hand, or thumb/second/middle finger together.

Second, the active movement. There were three types of active movement, including full hand grasp/ release/ or grasp and release together.

The researcher chose two out of three of the movements. Third, the game mode. There were several games to practice the active movement, including only distal part/ or distal plus proximal part together.

In the Conventional group, participants receive conventional occupational therapy.

The intervention was conducted 1.5 hour a day, 3 days a week for consecutive 4 weeks.


more —>  Effects of Exoskeleton Robotic Training Device on Upper Extremity in Brain…

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[BLOG POST] How to Treat Spasticity After Stroke – Saebo

How to Treat Spasticity After Stroke-blog

After a stroke, 17 to 38 percent of people experience spasticity. After a spinal cord injury, 40 to 78 percent of people experience it. Individuals with mild spasticity might have muscle tightness and stiffness, and those with severe spasticity can experience painful, uncontrollable spasms in their extremities. A charley horse is nothing in comparison.

What is Spasticity?

Spasticity is a neuromuscular condition usually caused by damage to the portion of the brain or spinal cord that controls voluntary movement. This damage causes a change in the balance of signals between the nervous system and the muscles. It is usually found in individuals affected by stroke, spinal cord injury, cerebral palsy, traumatic brain injury, and multiple sclerosis.

If left untreated, spasticity can lead to adverse effects such as overactive reflexes, pressure sores, chronic constipation, urinary tract infections, and contracture. Contracture causes the muscles in the hand and wrist to tighten and shrink, which can in turn lead to deformity of the joints and posture.

How is Spasticity Treated?

Fortunately, there are many treatments available to help individuals manage and recover from spasticity. In order to achieve the best results, most people will use a variety of treatments. Your healthcare provider will help determine the right combination of treatments for you. Treatments can vary based on the severity and cause of your spasticity. Below are some of the common treatments for spasticity.

Oral Medications

age, medicine, healthcare and people concept - close up of senior man hands with pills and water glass at home

One way to relax muscles affected by spasticity is taking oral medications that block the neurotransmitters causing the muscles to tighten. These medications are commonly known as muscle relaxers. Baclofen is often prescribed as it acts on the central nervous system, reducing spasms and allowing for greater range of motion. Tizanidine is another common medication for treating spasticity that blocks nerve impulses.

There are drawbacks to using oral medications to treat spasticity. One is that there is no way to target specific muscles. Muscle relaxers will relax all of your muscles regardless of whether they are affected by spasticity or not. Some of these medications also have side effects like drowsiness. The biggest thing to keep in mind is that none of these medications are a cure for spasticity. They work best when combined with stretching and strengthening exercises.


Medical vials for injection with a syringe isolated on white background.

Rather than taking oral medications that affect every muscle, having injected medications allows the affected muscles to be targeted specifically. The most common injected medication is one you’re probably familiar with: botulinum toxin or Botox. Botox injection is not just a cosmetic procedure to reverse the signs of aging; it is a neurotoxin that blocks the chemical that tells your muscles to start contracting.

By injecting botox into the affected muscles, the risk of spasms and spasticity is reduced. Lessening the spasticity in a patient’s muscles can allow them to participate in physical therapy and complete exercises that will help them recover. Botox can have some side effects, though, such as soreness, rash, trouble swallowing, and weak muscles.

Stretching Exercises

physiotherapy -therapist excercising with patient working on arm stretching

If you are suffering from spasticity, doing stretching exercises is the simplest and most important step you can take to manage it and recover. These exercises are often used in conjunction with other treatments like medication and orthoses, especially if your spasticity is severe and you cannot complete the exercises without additional interventions. For those with mild to moderate spasticity, you may be able to complete stretching exercises unassisted.

When starting an exercise routine, your therapist will teach you passive range-of-motion (PROM) exercises. PROM exercises are called as such because the muscles are moved by an outside force, which can be your own unaffected hand, a machine, or another person. These exercises are effective at treating spasticity as they help prevent stiffness in your joints, work to stretch muscles, and help increase and maintain range of motion. While your therapist will instruct you on which stretches to do and how often, in general, you should move your affected limb through its full range of motion at least three times per day.

Anti-Spasticity Orthoses

Spasticity can be reduced by using special orthotics designed to relieve pressure on the joints, reduce muscle spasms, and provide a prolonged muscle stretch. While static splints were previously used to keep the arm and wrist in a neutral position, studies have shown that static splinting is not effective against spasticity or preventing contracture and may actually cause joint deformity. Instead, dynamic splints like the SaeboStretch allow the fingers to move through flexion caused by involuntary reflexes (like the affected hand curling when you yawn or sneeze) and increased tone and gradually return to the desired resting position, reducing pain and helping to stretch out muscles.

Functional Orthoses

The SaeboGlove is another option for patients with mild spasticity. The SaeboGlove’s mechanical devices incorporate extra features that support specific joints and muscles, decreasing the impact of gravity and making it easier to move stiff or sore joints. Spasticity is less likely when patients rely on these artificial tension systems, which can be adjusted as they regain more strength and mobility. For patients with more severe spasticity, the SaeboFlex provides additional support.


Traumatology orthopedic surgery hospital emergency operating room prepared for arthroscopy operation photo of nurse scrubbing doctor putting hands insterile plastic gloves.

In severe cases of spasticity where the tendon has shortened permanently, surgery may be necessary. Surgery is usually saved as a last resort and only considered if the other available treatments have failed and the spasticity is causing significant pain or limiting the patient’s independence and mobility. The most frequently performed surgeries for spasticity are orthopedic procedures. The tendons can be released or lengthened to remove tension, and the muscles can be denervated.

Releasing the Tension

Spasticity can negatively affect your life in many ways by causing chronic and excruciating muscle pain. Luckily, for many people, spasticity is a treatable condition, even if their spasticity is severe. Effective medications, stretches, and specialized devices are a few of the common methods to relieve pain. By working with your doctor, you can find the treatment options that are right for you.

via How to Treat Spasticity After Stroke | Saebo

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[Abstract] Addition of botulinum toxin type A to casting may improve wrist extension in people with chronic stroke and spasticity: a pilot double-blind randomized trial


Aims: Does the addition of botulinum toxin type A increase the effect of casting for improving wrist extension after stroke in people with upper limb spasticity?

Methods: Randomized trial with concealed allocation, assessor blinding and intention-to-treat analysis which was part of a larger trial included 18 adults with upper limb spasticity two years after stroke (89%) or stroke-like conditions (11%). The experimental group (n=7) received botulinum toxin type A injections to upper limb muscles for spasticity management followed by two weeks of wrist casting into maximum extension. The control group (n=11) received two weeks of casting only. Range of motion (goniometry) measured at baseline and after two weeks of casting.

Results: Passive wrist extension for the experimental group improved over two weeks from 22 degrees (SD 16) to 54 degrees (SD 16), while the control group improved from 21 degrees (SD 29) to 43 degrees (SD 26). The experimental group increased passive wrist extension 13 degrees (95% CI 4 to 31) more than the control group which was not statistically significant.

Conclusion: Joint range of motion improved over a two-week period for both groups. Botulinum toxin type A injection followed-by casting produced a mean, clinically greater range of motion than casting alone, therefore, a fully-powered trial is warranted.

via Addition of botulinum toxin type A to casting may improve wrist extension in people with chronic stroke and spasticity: a pilot double-blind randomized trial

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[Abstract] How is sexuality after stroke experienced by stroke survivors and partners of stroke survivors? A systematic review of qualitative studies

To synthesise how post-stroke sexuality is experienced by stroke survivors and partners of stroke survivors.

MEDLINE, PubMed, SCOPUS, CINAHL and PsycINFO were searched from inception to May 2018 using a combination of relevant Medical Subject Headings and Free Text Terms. Only papers published in English reporting original qualitative research were included. Methodological quality was assessed using the Critical Appraisal Skills Programme Qualitative Research Checklist. All text presented as ‘results’ or ‘findings’ in the included studies was extracted and subjected to a thematic analysis and synthesis which was discussed and agreed by the research team.

The initial search yielded 136 unique papers with a further 8 papers identified through reference checking. Following full-text review, 43 papers were included in the final synthesis. Two analytical themes were identified: sexuality is silenced and sexuality is muted and sometimes changed, but not forgotten. These themes were made up of six descriptive themes: struggle to communicate within relationships, health professionals don’t talk about sexuality, sexuality and disability is a taboo topic, changes to pre-stroke relationships, changed relationship with the stroke survivor’s own body and resuming sexual intimacy – adaptation and loss.

Stroke has a profound impact on how sexuality is experienced by both stroke survivors and partners of stroke survivors. Despite this, post-stroke sexuality is rarely discussed openly. Stroke survivors and partners value sexuality and may benefit from strategies to support adjustment to post-stroke sexuality.

via How is sexuality after stroke experienced by stroke survivors and partners of stroke survivors? A systematic review of qualitative studies – Margaret McGrath, Sandra Lever, Annie McCluskey, Emma Power, 2018

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[Abstract] Eye Movements Interfere With Limb Motor Control in Stroke Survivors

Background. Humans use voluntary eye movements to actively gather visual information during many activities of daily living, such as driving, walking, and preparing meals. Most stroke survivors have difficulties performing these functional motor tasks, and we recently demonstrated that stroke survivors who require many saccades (rapid eye movements) to plan reaching movements exhibit poor motor performance. However, the nature of this relationship remains unclear.

Objective. Here we investigate if saccades interfere with speed and smoothness of reaching movements in stroke survivors, and if excessive saccades are associated with difficulties performing functional tasks.

Methods. We used a robotic device and eye tracking to examine reaching and saccades in stroke survivors and age-matched controls who performed the Trail Making Test, a visuomotor task that uses organized patterns of saccades to plan reaching movements. We also used the Stroke Impact Scale to examine difficulties performing functional tasks.

Results. Compared with controls, stroke survivors made many saccades during ongoing reaching movements, and most of these saccades closely preceded transient decreases in reaching speed. We also found that the number of saccades that stroke survivors made during ongoing reaching movements was strongly associated with slower reaching speed, decreased reaching smoothness, and greater difficulty performing functional tasks.

Conclusions. Our findings indicate that poststroke interference between eye and limb movements may contribute to difficulties performing functional tasks. This suggests that interventions aimed at treating impaired organization of eye movements may improve functional recovery after stroke.


via Eye Movements Interfere With Limb Motor Control in Stroke Survivors – Tarkeshwar Singh, Christopher M. Perry, Stacy L. Fritz, Julius Fridriksson, Troy M. Herter, 2018

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[Abstract] Motor Impairment–Related Alterations in Biceps and Triceps Brachii Fascicle Lengths in Chronic Hemiparetic Stroke

Poststroke deficits in upper extremity function occur during activities of daily living due to motor impairments of the paretic arm, including weakness and abnormal synergies, both of which result in altered use of the paretic arm. Over time, chronic disuse and a resultant flexed elbow posture may result in secondary changes in the musculoskeletal system that may limit use of the arm and impact functional mobility. This study utilized extended field-of-view ultrasound to measure fascicle lengths of the biceps (long head) and triceps (distal portion of the lateral head) brachii in order to investigate secondary alterations in muscles of the paretic elbow. Data were collected from both arms in 11 individuals with chronic hemiparetic stroke, with moderate to severe impairment as classified by the Fugl-Meyer assessment score. Across all participants, significantly shorter fascicles were observed in both biceps and triceps brachii (P < .0005) in the paretic limb under passive conditions. The shortening in paretic fascicle length relative to the nonparetic arm measured under passive conditions remained observable during active muscle contraction for the biceps but not for the triceps brachii. Finally, average fascicle length differences between arms were significantly correlated to impairment level, with more severely impaired participants showing greater shortening of paretic biceps fascicle length relative to changes seen in the triceps across all elbow positions (r = −0.82, P = .002). Characterization of this secondary adaptation is necessary to facilitate development of interventions designed to reduce or prevent the shortening from occurring in the acute stages of recovery poststroke.


via Motor Impairment–Related Alterations in Biceps and Triceps Brachii Fascicle Lengths in Chronic Hemiparetic Stroke – Christa M. Nelson, Wendy M. Murray, Julius P. A. Dewald, 2018

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[Abstract] The effects of robot-assisted gait training using virtual reality and auditory stimulation on balance and gait abilities in persons with stroke

via The effects of robot-assisted gait training using virtual reality and auditory stimulation on balance and gait abilities in persons with stroke – IOS Press

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