- •The post-stroke spasticity of upper limb can cause significant functional impairment.
- •This study for spasticity was a nationwide multicenter study in South Korea.
- •The median time to develop upper limb spasticity after stroke onset was 34 days.
- •The 13% of post-stroke spasticity cases developed after 90 days from onset.
Posts Tagged Stroke
[Abstract] When does spasticity in the upper limb develop after a first stroke? A nationwide observational study on 861 stroke patients
This study investigated the time taken for upper extremity spasticity to develop and its regional difference after first-ever stroke onset in a nationwide multicenter study in South Korea. The retrospective observational study included 861 individuals with post-stroke spasticity in the upper limbs. Spasticity in the upper extremity joints was defined as a modified Ashworth Scale score ≥1. The median time to develop upper limb spasticity after stroke onset was 34 days. 12% of post-stroke spasticity cases developed between 2 months and 3 months and 13% developed after 3 months from onset. At the time of diagnosis of spasticity, most patients showed only a slight increase in muscle tone, which was observed most frequently in the elbow, followed by the wrist, and fingers. Younger stroke survivors were more spastic, and the severity of spasticity increased with time. Approximately half of the patients with post-stroke spasticity developed spasticity during the first month. However, post-stroke spasticity can develop more than 3 months after stroke onset. Therefore, it is important to assess spasticity, even in the chronic state.
[ARTICLE] Elements virtual rehabilitation improves motor, cognitive, and functional outcomes in adult stroke: evidence from a randomized controlled pilot study – Full Text
Virtual reality technologies show potential as effective rehabilitation tools following neuro-trauma. In particular, the Elements system, involving customized surface computing and tangible interfaces, produces strong treatment effects for upper-limb and cognitive function following traumatic brain injury. The present study evaluated the efficacy of Elements as a virtual rehabilitation approach for stroke survivors.
Twenty-one adults (42–94 years old) with sub-acute stroke were randomized to four weeks of Elements virtual rehabilitation (three weekly 30–40 min sessions) combined with treatment as usual (conventional occupational and physiotherapy) or to treatment as usual alone. Upper-limb skill (Box and Blocks Test), cognition (Montreal Cognitive Assessment and selected CogState subtests), and everyday participation (Neurobehavioral Functioning Inventory) were examined before and after inpatient training, and one-month later.
Effect sizes for the experimental group (d = 1.05–2.51) were larger compared with controls (d = 0.11–0.86), with Elements training showing statistically greater improvements in motor function of the most affected hand (p = 0.008), and general intellectual status and executive function (p ≤ 0.001). Proportional recovery was two- to three-fold greater than control participants, with superior transfer to everyday motor, cognitive, and communication behaviors. All gains were maintained at follow-up.
A course of Elements virtual rehabilitation using goal-directed and exploratory upper-limb movement tasks facilitates both motor and cognitive recovery after stroke. The magnitude of training effects, maintenance of gains at follow-up, and generalization to daily activities provide compelling preliminary evidence of the power of virtual rehabilitation when applied in a targeted and principled manner.
this pilot study was not registered.
Stroke is one of the most common forms of acquired brain injury (ABI), with around 60,000 new and recurrent strokes occurring every year in Australia alone . The clinical outcome of stroke is variable but often includes persistent upper-limb motor deficits, including weakness, discoordination, and reduced speed and mobility , and cognitive impairments in information processing and executive function [3, 4]. Not surprisingly, stroke is a leading cause of disability worldwide, and the burden of stroke across all levels of the International Classification of Functioning (ICF) – body structures/function, activity, and participation – underlines the importance of interventions that can impact multiple domains of functioning [5, 6].
Recovery of functional performance following stroke remains a significant challenge for rehabilitation specialists [7, 8], but may be enhanced by innovation in the use of new technologies like virtual reality [9, 10, 11, 12]. A critical goal is to find compelling ways of engaging individuals in their therapy by creating meaningful, stimulating and intensive forms of training . The term, virtual rehabilitation (VR), is used to describe a form of training wherein patients interact with virtual or augmented environments, presented with the aid of technology [14, 15]. The technologies can be either commercial systems (e.g. Nintendo Wii, Xbox Kinect) or those customised specifically for rehabilitation. VR offers a number of advantages over traditional therapies, including the ability to engage individuals in the simulated practice of functional tasks at higher doses [16, 17], automated assessment of performance over time, flexibility in the scaling of task constraints, and a variety of reward structures to help maintain compliance .
While evaluation research is still in its infancy, recent systematic reviews and meta-analyses show that VR can enhance upper-limb motor outcomes in stroke [10, 11, 19], yielding treatment effects of medium-to-large magnitude [10, 11], and complementing conventional approaches to rehabilitation. VR has been shown to engender high levels of engagement in stroke patients undergoing physical therapy [20, 21] and training of even moderate intensity can afford functional benefits at the activity/skill level [9, 19]. In the specific case of upper-limb VR, however, there is little available evidence that these benefits transfer to participation . Furthermore, most available data is on patients in chronic stages of recovery, with less on acute stroke . Notwithstanding this, use of VR has begun to emerge in clinical practice, recommended in Australian and international stroke guidelines as a viable adjunct in therapy to improve motor and functional outcomes [22, 23, 24].
Until recently, most VR systems have been designed to improve motor functions, with cognitive outcomes often a secondary consideration in evaluation studies [9, 10, 11]. Notwithstanding this, treatments that target both motor and cognitive functions are indicated for stroke, given evidence that cognitive and motor systems overlap at a structural and functional level [25, 26], and work synergistically in a “perception-action cycle”  in stroke patients undergoing rehabilitation . Recent studies provide preliminary evidence of improved attention and memory in stroke patients following motor-oriented VR [29, 30, 31, 32], amounting to a small-to-medium effect on cognition . When designed to address aspects of cognitive control and planning, VR has the potential to enhance dual-task control, resulting in better generalization of trained skills to daily functioning .
While evaluation research is still in its infancy, several recent customized systems (like Elements, the system evaluated here) have been deliberately designed to exploit factors known to enhance training intensity and motor learning. Informed by neuroscience and learning theory [for a recent review see 12], the Elements VR system was designed to enhance neuro-plastic recovery processes via: (1) an enriched therapeutic environment affording a natural form of user interaction via tangible computing and surface displays , which engage both the cognitive attention of participants and their motivation to explore training tasks; (2) concurrent augmented feedback (AF) on performance  offering participants additional information on the outcome of their actions to assist in re-building a sense of body position in space (aka body schema) and ability to predict/plan future actions; and (3) scaling of task challenges to the current level of motor and cognitive function , ensuring dynamic scaffolding of participants’ information processing and response capabilities. The Elements system, described in detail below and in earlier publications [37, 38], consists of a large (42 in.) tabletop surface display, tangible user interfaces, and software for presenting both goal-directed and exploratory virtual environments. Previous evaluations of the system in patients with traumatic brain injury showed improvements in both motor and cognitive performance, with transfer to activities of daily living [37, 39]. However, the impact of Elements in other forms of ABI, such as stroke, has not been evaluated.
The broad aim of current study was to evaluate the efficacy of the Elements VR interactive tabletop system for rehabilitation of motor and cognitive functions in sub-acute stroke, compared with treatment as usual (TAU). We were particularly interested in motor and cognitive outcomes, their relationship, and the transfer and maintenance of treatment effects. Training-related changes at the activity/skill level on standardized measures of motor and cognitive performance were investigated, together with functional changes. By offering an engaging, principled and customized form of interaction, we predicted that the Elements system would effect (i) greater changes on both motor and cognitive outcomes than with TAU alone; (ii) sustained benefits, as assessed over a short follow-up period, and (iii) transfer to everyday functional performance (i.e. participation).[…]
Continue —> Elements virtual rehabilitation improves motor, cognitive, and functional outcomes in adult stroke: evidence from a randomized controlled pilot study | Journal of NeuroEngineering and Rehabilitation | Full Text
Examples of the Elements (a) goal-directed Bases task with visual augmented feedback, and (b) exploratory Squiggles task
Motus Nova is expanding its list of partner hospitals and clinics using its FDA-approved robotic stroke therapy system. It also plans to introduce its system to the consumer market for home use in Q3 2019.
Twenty-five hospitals in the Atlanta area within Emory Healthcare, the Grady Health System, and the Wellstar Health System are now using the Motus Nova rehabilitation therapy system, which is designed to use Artificial Intelligence (AI) to accelerate recovery from neurological injuries such as strokes.
The system features a Hand Mentor and Foot Mentor, which are sleeve-like robots that fit over a stroke survivor’s impaired hand or foot. Equipped with an active-assist air muscle and a suite of sensors and accelerometers, they provide clinically appropriate assistance and resistance while individual’s perform the needed therapeutic exercises.
A touchscreen console provides goal-directed biofeedback through interactive games—which Motus Nova calls “theratainment”—that make the tedious process of neuro rehab engaging and fun.
“It’s a system that has proven to be a valuable partner to stroke therapy professionals, where it complements skilled clinical care by augmenting the repetitive rehabilitation requirements of stroke recovery and freeing the clinician to do more nuanced care and assessment,” says Nick Housley, director of clinical research for Atlanta-based Motus Nova, in a media release.
“And while we continue to fill orders for the system to support therapy in the clinic and hospital, we also are looking to use our system to fill the gap patients often experience in receiving the needed therapy once they go home.”
Clinical studies show that neuroplasticity begins after approximately many 10’s to 100’s of hours of active guided rehab. The healing process can take months or years, and sometimes the individuals might never fully recover. Yet the typical regimen for stroke survivors is only two to three hours of outpatient therapy per week for a period of three to four months.
“These constraints were instituted by the Centers for Medicare & Medicaid Services (CMS) in determining Medicare reimbursement without a full understanding of the appropriate dosing required for stroke recovery, and many private insurers have adopted the policy, as well,” states David Wu, Motus Nova’s CEO.
Motus Nova plans to offer a more practical model, the release continues.
“By making the system available for home use at a reasonable weekly rate as long as the patient needs it, the individual can perform therapy anytime,” Wu adds. “A higher dosage of therapy can be achieved without the inconvenience of scheduling appointments with therapists or traveling to and from a clinic, and without the high cost of going to an outpatient center every time the individual wants to do therapy.”
While the system gathers data about individual performance, AI tailors the regimen to maximize user gains, discover new approaches, minimize side effects and help the stroke survivor realize his or her full potential more quickly.
“By optimizing factors such as frequency, intensity, difficulty, encouragement, and motivation, the AI system builds a personalized medicine plan uniquely tailored to each individual user of the system,” Housley comments.
“Our system is durable, too, proven in clinical trials to deliver an engaging physical therapy experience over thousands of repetitions. We look forward to making it available on a much wider scale in the coming months.”
[Source(s): Motus Nova, PR Newswire]
[THESIS] Participation in everyday life after stroke : development and evaluation of f@ce – a team-based, person-centred rehabilitation intervention supported by information and communication technology
AIM: The general aim of this thesis was to generate knowledge about how Information and Communication technology (ICT) could be used in the rehabilitation process after stroke in order to develop and evaluate the feasibility of F@ce- a person-centred, team-based intervention, supported by ICT, to enable performance of daily activities and participation in everyday life for people after stroke.
METHODS: Studies I and II were qualitative grounded theory studies that were performed to generate knowledge on people after stroke and health care professionals working with rehabilitation after stroke, regarding the experiences of using ICT. The third study was a secondary analysis of a previously performed randomised controlled trial, evaluating a client-centred activities of daily living (CADL) intervention, to analyse factors of importance for a positive outcome in participation after stroke. The knowledge generated in studies I-III combined with previous research was used to develop F@ce, a team-based, person-centred intervention for rehabilitation after stroke, that was supported by ICT. Study IV was an evaluation of the feasibility of using F@ce, and the study design, in terms of the recruitment process, outcome measures used, fidelity, adherence, acceptability and potential harms.
RESULTS: People after stroke in study I described their drive to integrate ICT in their everyday lives after stroke. They used their mobile phones to feel safe, to stay connected to friends and family, and to improve physical and cognitive functions. They also used their computer for social networks, to manage daily occupations such as paying bills, online shopping and searching for information. The healthcare professionals in study II did not use ICT to any greater extent outside their office, however, they had a vision that ICT could be used as a platform for sharing information and collaboration within the rehabilitation process. The results from study III showed that within the control group (receiving usual ADL interventions) those with mild stroke and home-based rehabilitation had a better outcome in perceived participation compared to the intervention group, however, in the intervention group the difference between stroke severity and context of rehabilitation were not significant. This would indicate that the CADL intervention were specifically useful for those with moderate to severe stroke and those receiving rehabilitation at an in-patient unit. The feasibility testing of the newly developed F@ce intervention in study IV showed that it was feasible to use, and that the fidelity, adherence and acceptability of the intervention were good. The participants had positive outcomes in performance (n=4) and satisfaction with the performance (n=6) of daily activities according to Canadian Occupational Performance measure (COPM) and several participants had clinically significant improvements in different domains in the Stroke Impact Scale (SIS).
CONCLUSION: The studies within this thesis enabled the development and evaluation of a new rehabilitation intervention, F@ce, using ICT which is relevant in this time, with the rapid digitalization in the society, healthcare and rehabilitation. The knowledge from the previously developed CADL study, along with the experiences of people after stroke and healthcare professionals’ use of ICT, and the modelling of F@ce together with stakeholders created a strong foundation for the new intervention. Using a team-based, person-centred intervention with the support of ICT seemed to enable people to perform daily activities and thus increase their participation in everyday life.
List of papers:
I.Martha Gustavsson, Charlotte Ytterberg, Mille Nabsen Marwaa, Kerstin Tham & Susanne Guidetti. Experiences of using information and communication technology within the first year after stroke – a grounded theory study. Disability and Rehabilitation. 2016 (40) 561-568
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THERE IS LIFE – AND HOPE – AFTER STROKE. WITH TIME, NEW ROUTINES WILL BECOME SECOND NATURE. REHABILITATION CAN BUILD YOUR STRENGTH, CAPABILITY AND CONFIDENCE. IT CAN HELP YOU CONTINUE YOUR DAILY ACTIVITIES DESPITE THE EFFECTS OF YOUR STROKE.
If you are the caregiver, family member or friend of a stroke survivor, your role is vital. You should know the prevention plan and help your loved one to comply with the plan. With a committed health care team and a rehabilitation plan specific to their needs, most stroke survivors can prevent another stroke and thrive.
We hope this guide will help you and your loved ones understand the effects of stroke and how to maximize your rehabilitation and recovery.
Published on May 8, 2019
NEOFECT has redesigned its Smart Board for Home in reply to feedback from patients recovering from stroke and other musculoskeletal conditions and neurological disorders.
The new Smart Board for Home NextGen includes a smaller surface to help patients use it at home more easily, a redesigned handle to better stabilize the user’s hand and arm, and updated gamified software.
The board size has been reduced from 42 inches to 32 inches so it can fit on most tables. To accommodate the weakened grip of many stroke patients, the redesigned handle includes more straps to better stabilize the user’s arm, ensure appropriate measurement for the post-game metrics, and provide a more secure, comfortable experience, according to the company in a media release.
“We took patient feedback and completely revamped the Smart Board for Home NextGen,” says Scott Kim, co-founder and CEO of San Francisco-based NEOFECT USA.
“This new model still has all the fun, measurable qualities patients can use at home, but now we’ve reduced even more barriers so that people of all abilities can gain back function in their hands and upper arms.”
Patients play games on the Smart Board for Home NextGen by placing their forearm in a cradle and moving their arm across the board. All movements are virtually mimicked on a Bluetooth-connected screen in real time. The gamified software also features an updated AI-powered algorithm to curate a more customized experience for each patient.
The Smart Board for Home NextGen games mimic real-world motions to rehabilitate users’ upper arms and shoulders, including new games like “Air Hawk” and “Tennis.”
Additionally, NEOFECT is developing a dual-player game for patients to use at home, which will be available in summer 2019.
[Source(s): NEOFECT, Business Wire]
Health and wellness at Chatham-Kent Health Alliance soon won’t be confined to the hospital walls with new virtual reality technology available to some patients and staff.
The hospital organization recently awarded staff members several innovation grants, two of which incorporate devices which put the user into different locations or scenarios.
Jarrod Prieur, the clinical manager for rehabilitation, pitched a $10,000 project meant to help stroke patients recover.
The virtual reality equipment will put these patients at places like a grocery store. When they move their arms to reach for a carton of milk, for example, they will see an arm capturing those same movements.
“It’s designed specifically for activities of daily living and with input from occupational therapists (and) physiotherapists, and part of why we haven’t been able to access some of this equipment in the past has been it’s expensive,” said Prieur.
Other scenarios will likely include preparing meals, caring for pets, folding laundry and gardening.
As someone who previously worked as an occupational therapist, Prieur said this is something he’s wanted to see at the hospital for over five years.
He said patients always ask how their rehabilitation is meant to be applied to their life once they return home and these types of programs give them actual practice with some of those tasks.
The Health Alliance currently uses peg boards – wooden boards with different-shaped holes which require patients to put pegs through the correct holes. Prieur said the different shapes of the pegs means the patient gets to practice different grips required in day-to-day life.
The hospital also has other boards which have features like a handle to turn on a hose, a faucet for a tap and electrical sockets.
“The reason we moved in this direction with the virtual reality is because that’s where the evidence is with stroke rehabilitation right now,” said Prieur. “I would say half of the research being done in stroke rehabilitation is how we use technology to further these patients’ journeys.”
About 150 to 200 people come through rehab at the hospital due to a stroke each year, according to Prieur, and they would be the primary users of this equipment. There will only be one virtual reality unit, but all of those patients should be able to use it, he said.
Some patients on the complex continuing care floor, including those with dementia, will be able to work with the equipment as well, he said.
Officials at the hospital said they have a request for proposals process they need to go through with this project, but they hope to have it available by April.
The hospital also gave out a $1,000 grant to occupational health, safety and wellness manager Alexis MacPherson for three virtual reality headsets.
These are meant for staff to be put in the mindset of someone with a mental illness to gain empathy for patients or to help with staff wellness through meditation and mindfulness programs.
“It’s like a simulation of what it’s like to have depression, go through an anxiety attack, have dementia and the thought processes that go on there,” said MacPherson, adding it also lets someone experience living with a visual impairment.
MacPherson said the programs and the hospital are considerate about any potential negative effects going through a schizophrenic simulation, as an example, could have on a user.
“Even at the beginning of some of the videos it says if you have these kinds of issues, it might be triggering to go through some of these processes,” she said. “Also, wearing these can kind of cause motion sickness for some people.”
Staff will go through education and training before using these devices.
Another side to these headsets will give staff the opportunity to go through a meditation, practise yoga or visit places like the Grand Canyon.
“There is high percentage of health care workers that are experiencing burnout and so we hope that this is a tool that they can use to help build their resiliency and decrease their stress,” said Lisa Northcott, vice president and chief nursing executive.
The headsets will be used to go along with monthly wellness themes the hospital is planning to start promoting. When they are not being used for those events, staff will be able to sign them out.
[Abstract + References] Effect of Transcutaneous Electrical Nerve Stimulation on Spasticity in Adults With Stroke: A Systematic Review and Meta-analysis
(1) To determine the effect of transcutaneous electrical nerve stimulation (TENS) on poststroke spasticity. (2) To determine the effect of different parameters (intensity, frequency, duration) of TENS on spasticity reduction in adults with stroke. (3) To determine the influence of time since stroke on the effectiveness of TENS on spasticity.
PubMed, PEDro, CINAHL, Web of Science, CENTRAL, and EMBASE databases were searched from inception to March 2017.
Randomized controlled trial (RCT), quasi-RCT, and non-RCT were included if (1) they evaluated the effects of TENS for the management of spasticity in participants with acute or subacute or chronic stroke using clinical and neurophysiological tools; and (2) TENS was delivered either alone or as an adjunct to other treatments.
Two authors independently screened and extracted data from 15 of the 829 studies retrieved through the search using a pilot tested pro forma. Disagreements were resolved through discussion with other authors. Quality of studies was assessed using Cochrane risk of bias criteria.
Meta-analysis was performed using a random-effects model that showed (1) TENS along with other physical therapy treatments was more effective in reducing spasticity in the lower limbs compared to placebo TENS (SMD −0.64; 95% confidence interval [95% CI], −0.98 to −0.31; P=.0001; I2=17%); and (2) TENS, when administered along with other physical therapy treatments, was effective in reducing spasticity when compared to other physical therapy interventions alone (SMD −0.83; 95% CI, −1.51 to −0.15; P=.02; I2=27%). There were limited studies to evaluate the effectiveness of TENS for upper limb spasticity.
There is strong evidence that TENS as an adjunct is effective in reducing lower limb spasticity when applied for more than 30 minutes over nerve or muscle belly in chronic stroke survivors (review protocol registered at PROSPERO: CRD42015020151)
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[Abstract] Brain-machine interface of upper limb recovery in stroke patients rehabilitation: A systematic review
Technologies such as brain-computer interfaces are able to guide mental practice, in particular motor imagery performance, to promote recovery in stroke patients, as a combined approach to conventional therapy.
The aim of this systematic review was to provide a status report regarding advances in brain-computer interface, focusing in particular in upper limb motor recovery.
The databases PubMed, Scopus, and PEDro were systematically searched for articles published between January 2010 and December 2017. The selected studies were randomized controlled trials involving brain-computer interface interventions in stroke patients, with upper limb assessment as primary outcome measures. Reviewers independently extracted data and assessed the methodological quality of the trials, using the PEDro methodologic rating scale.
From 309 titles, we included nine studies with high quality (PEDro ≥ 6). We found that the most common interface used was non-invasive electroencephalography, and the main neurofeedback, in stroke rehabilitation, was usually visual abstract or a combination with the control of an orthosis/robotic limb. Moreover, the Fugl-Meyer Assessment Scale was a major outcome measure in eight out of nine studies. In addition, the benefits of functional electric stimulation associated to an interface were found in three studies.
Neurofeedback training with brain-computer interface systems seem to promote clinical and neurophysiologic changes in stroke patients, in particular those with long-term efficacy.
[ARTICLE] Whole-Body Vibration in Horizontal Direction for Stroke Rehabilitation: A Randomized Controlled Trial – Full Text
As most of the existing whole-body vibration (WBV) training programs provide vertical or rotatory vibration, studies on the effects of horizontal vibration have rarely been reported. The present study was conducted to investigate the effect of WBV in the horizontal direction on balance and gait ability in chronic stroke survivors.
This study was designed as a randomized controlled trial. Twenty-one stroke survivors were randomly allocated into 2 groups (whole-body vibration group [n=9] and control group [n=12]). In the WBV group, WBV training in the horizontal direction was conducted for 6 weeks, and a conventional rehabilitation for 30 min, 3 days per week for a 6-week period, was conducted in both the WBV and control groups. Outcome variables included the static balance and gait ability measured before training and after 6 weeks.
On comparing the outcome variables before and after training in the WBV group, significant differences were observed in the cadence and single support time of gait ability. However, there were no significant differences in other variables, including velocity, step length, stride length, and double support time. In addition, after training, no significant differences in all variables were observed between the 2 groups.
The results of this study suggest that WBV training in the horizontal direction has few positive effects on balance and gait function in chronic stroke survivors. However, further investigation is needed to confirm this.
Stroke survivors suffer from central nervous system damage, with sensory and motor system damage, which leads to consequences such as decreased control of muscle tone, delay in muscle contraction, and absence of selective movement [1,2]. In addition, stroke survivors have unstable balance and poor gait ability, which naturally limits their activities of daily living and participation in the community, while losing independence [2,3]. Consequently, the first priority for stroke survivors is recovery of independent activities, and for this, the recovery of balance in a standing posture and gait abilities is essential.
For functional recovery of stroke survivors, various methods have been suggested , and whole-body vibration (WBV) is a relatively novel form of exercise intervention that could improve functional recovery . WBV involves the use of a vibrating platform in a static position or while performing dynamic movements. In previous studies, it was suggested that WBV training could improve physical functions. Castrogiovanni et al.  reported that a multi-component training, including aerobic activity and other types of training (resistance and/or strength exercises), is the best kind of exercise for improving bone mass and bone metabolism in elderly people and especially in osteopenic and osteoporotic women. With regard to whole-body vibration training, studies have suggested that it could be a valid method. Pichler et al.  reported that mechanical stimulation such as treadmill and vibration stimulation training inhibits the activity of RANKL in osteoporosis. In addition, Musumeci et al.  suggested that, in certain diseases such as osteoporosis, mechanical stimulation including treadmill and vibration platform training could be a possible therapeutic treatment. Based on their results, they proposed the hypothesis that physical activity could also be used as a therapeutic treatment for cartilage diseases such as osteoarthritis. Van Nes et al.  introduced WBV as a means of somatic sensory stimulation for functional recovery of stroke survivors. They also reported that somatosensory stimulation through WBV can significantly improve muscle performance, balance, and daily activities. Balance, defined as the ability to maintain the center of pressure (COP) on the support surface in given circumstances, can be held through adjusted harmony of visual, vestibular, and somatic sensory system , and vibration stimulation is reported to cause small changes in the skeletal muscle length of the human body and affect the motor neurons to facilitate activation of the spinal reflexes through short spindle-motor neuron connections .
Balance is a major component required for controlling or maintaining the COP in mobility and locomotion in which the support surface changes . The information on changes of the support surface along with the biomechanic information needed for movement control is passed on to the central nervous system by muscle spindles, Golgi tendon organs, and joint receptors in the proprioception sense; thus, they have a very important role in controlling balance [13,14]. In addition, Muller and Redfern  performed a comparative analysis of the latency of beginning muscle activity by measuring electromyogram (EMG) activation degree of muscle strength of the lower extremities caused by movement of the COP while the support surface moved back and forth. Consequently, the latency of activation of the tibialis anterior muscle was rapid on the support surface moving forward and that of the soleus muscle was rapid when moving backward. Given these reports, for recovery of balance ability, the horizontal vibration in all directions might be needed more than the vertical or rotatory vibration provided by the original WBV training. Additionally, our bodies maintain standing posture using ankle strategy, hip strategy, or both . The ankle strategy, which is the postural control strategy that starts first in postural sway, enables immediate recovery of standing balance through ankle joint muscle contraction . Horizontal vibration, therefore, may significantly activate not only stimulation of somatosensory, but also ankle strategy or hip strategy.
However, since most of the existing WBV training programs provide only vertical or rotatory vibrations, studies on effects of horizontal vibrations have been rarely reported. Accordingly, the present study examined the effects of horizontal WBV in an antero-posterior or medio-lateral direction on balance and gait abilities of stroke survivors.[…]