A Randomized Controlled Trial of Augmented Reality with and Without Robotic Priming in Stroke Rehabilitation.

Mirror therapy (MT) and augmented reality (AR) are gaining popularity in stroke rehabilitation. MT uses mirror visual feedback to promote bilateral brain coupling and increase primary motor cortex excitability. AR offers an interactive context of practice for promoting motor and cognitive recovery. MT and AR may complement each other for hybrid interventions in stroke rehabilitation. This study investigated the benefits of MT-primed AR (MT + AR) versus AR group, relative to conventional therapy (CT) for individuals with stroke. The study randomly assigned 45 stroke survivors to the MT + AR group, the AR, or the CT group, and 44 of them completed the experiment and were included in the analysis. Each treatment session was 90min, 3 times a week, for 6 weeks. All assessments were administered before, immediately after treatment, and at 3 months. Primary outcome measures were the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) and the Berg Balance Scale (BBS). Secondary outcome measures were the revised Nottingham Sensory Assessment (rNSA), Chedoke Arm and Hand Activity Inventory (CAHAI), Motor Activity Log (MAL), and Stroke Impact Scale Version 3.0 (SIS). Adverse events were monitored before and after each session. After 6 weeks of treatment, the three groups demonstrated significant improvements in the FMA-UE, BBS, CAHAI, MAL, and SIS. In the between-group comparisons, MT + AR and AR groups demonstrated significant advantages in the BBS, proprioception scale of rNSA and SIS, compared with the CT group. Only the MT + AR group, not the AR group, showed significantly better improvements in the FMA-UE and tactile scale of rNSA than the CT group. The MT + AR and AR alone showed differential benefits in the FMA-UE, tactile scale of rNSA, and SIS; the MT + AR rendered significantly better benefits. There were no significant differences among the three groups in the stereognosis scale of rNSA and MAL. No adverse effects were observed. MT + AR and AR both effectively enhanced sensorimotor functions, balance and postural control, task performance, and life quality in patients with stroke with moderate-to-severe motor impairments. The results showed that MT + AR and AR were more beneficial for improving stroke survivors' balance, functional mobility, proprioception recovery, and quality of life than the CT group. Furthermore, the MT + AR revealed better outcomes in the upper limb motor function and tactile sensory recovery. Between the MT + AR and AR comparisons, the MT + AR was more beneficial for improving upper limb motor function, tactile sensory recovery, and quality of life. Trial registration NCT05993091.

Purpose: To develop a Singapore version of the Chedoke Arm and Hand Activity Inventory (CAHAI) and to estimate the construct validity and inter-rater reliability.Materials and methods: The Translation and Cross-Cultural Adaptation of Objectively Assessed Outcome measure procedure was used to systematically adapt the CAHAI. We recruited 56 adults admitted to an inpatient stroke facility to evaluate the psychometric properties of the Singapore version of the CAHAI. The Singapore version of the CAHAI, Fugl-Meyer Assessment of Upper Extremity (FMA-UE), and the Action Research Arm Test (ARAT) were administered to all participants. We used Spearman’s rank correlation coefficients to estimate convergent and discriminative validity, and reliability was estimated using the intra-class correlation coefficient and standard error of measurement.Results: Implementation of the Translation and Cross-Cultural Adaptation of Objectively Assessed Outcome measure procedure resulted in the modification to two test items. The Singapore version of the CAHAI demonstrated convergent validity with the FMA-UE (rs = 0.87; 95% CI: 0.76, 0.92) and ARAT (rs = 0.80; 95% CI: 0.63, 0.9). Discriminative validity between the Singapore version of the CAHAI and FMA-UE pain subscale was rs= 0.42 (95% CI: 0.22, 0.59). Reliability of the Singapore version of the CAHAI was 0.97 (95% CI: 0.94, 0.99) and standard error of measurement of 4.80 points (95% CI: 4.23, 5.55).Conclusion: The Singapore version of the CAHAI demonstrated good validity and reliability, similar to the properties of the original CAHAI.Implications for rehabilitationThe Singapore version of the Chedoke Arm and Hand Activity Inventory demonstrates evidence of construct validity and inter-rater reliability.The Singapore version of the Chedoke Arm and Hand Activity Inventory can be used by clinicians and researchers to evaluate function in the affected upper extremity for persons with stroke in Singapore.

Stroke rehabilitation in clinic- and home-based settings may yield differential effects on motor and functional outcomes. To investigate the effects of mirror therapy preceding augmented-reality therapy in the clinic and home setting. Single-blinded, randomized crossover study. Rehabilitation clinics and home environment of participants. Thirty-one stroke survivors. Participants were randomized to receive clinic-based practice first or home-based practice first. The intervention involved mirror therapy-primed augmented-reality practice. Participants received nine treatment sessions, with a 3-wk washout period between two phases. Outcome measures included the Fugl-Meyer Assessment Scale of Upper Extremity (FMA-UE), Berg Balance Scale (BBS), Chedoke Arm and Hand Activity Inventory, Motor Activity Log (MAL), and Stroke Impact Scale (SIS). Clinic-based practice significantly improved the FMA-UE (p = .04), BBS (p = .01), and SIS Mobility domain scores (p = .05). Home-based practice showed a trend for better performance on the MAL. Clinic-based practice revealed retention of treatment gains at the 3-mo follow-up assessment on the FMA-UE (p = .01) and the Activities of Daily Living-Instrumental Activities of Daily Living (p = .01), Mobility (p = .02), and Hand Function (p = .03) domains of the SIS. Clinic-based practice improved motor and balance deficits, whereas home-based practice may enhance functional arm use. Practice setting is relevant for consideration in stroke rehabilitation. Plain-Language Summary: Research supports the benefits of using augmented reality in stroke rehabilitation. Stroke rehabilitation that includes mirror therapy has also shown promising benefits. This study investigated the effects of using mirror therapy before augmented-reality therapy to improve motor and balance after a stroke. Stroke survivors participated in sessions in either a clinic- or a home-based setting. The results showed that the clinic-based sessions led to more improvements in motor and balance, whereas the home-based sessions improved patients' use of the affected arm in real-life situations. The findings suggest the need to take into consideration the occupational therapy practice setting as part of stroke rehabilitation. Clinic- and home-based practice may complement each other to optimize the effects of stroke rehabilitation.

Background: Access to stroke rehabilitation in low-resource South African areas is limited. Telerehabilitation (TR) offers a promising solution, particularly for upper limb recovery post-stroke.Aim: To assess the feasibility of a task-oriented TR home programme for mild to moderate upper limb impairment post-stroke in a South African context.Setting: Bishop Lavis, South Africa, a low-income area.Methods: A single-site parallel randomised feasibility study was conducted. Feasibility outcomes included: process, resource, management and scientific outcomes. Outcome measures included satisfaction survey, log sheets, Fugl-Meyer Assessment-Upper Extremity (FMA-UE), Chedoke Arm and Hand Activity Inventory (CAHAI), Visual Analogue Scale (VAS) and BORG Rating of Perceived Exertion (RPE) scale. Participants completed an 8-week home programme (H-Graded Repetitive Arm Supplementary Program [GRASP]). The experimental group received weekly TR, while the control group received face-to-face care.Results: A total of 12 participants were recruited, with 10 completing the programme. The experimental group reported 96.9% perceived benefit, 60.0% exercise and task adherence and had 41 telephonic sessions in total. The control group reported 76.9% perceived benefit, no exercise adherence, 20.0% task adherence and attended 13 face-to-face sessions in total (67.5% non-attendance). Post-intervention, FMA-UE improved significantly (control: p = 0.0003; experimental: p = 0.0013) with a mean difference of 6.0 (95% confidence interval [CI]: -6.2 to 18.2). The CAHAI showed borderline significance (control: p = 0.0556; experimental: p = 0.0601) with a mean difference of -1.0 (95% CI: -3.2 to 1.2).Conclusion: The feasibility study achieved success in retention rates, safety and perceived benefit for the experimental group, with treatment equivalence in the CAHAI scores. Recruitment rate and exercise and task adherence were below criteria. Perceived benefit in the control group fell short. Treatment equivalence for FMA-UE scores exceeded the set margin.Contribution: Persons with upper limb impairments post-stroke in low-resource contexts may benefit from a repetitive task-oriented TR home programme.

Objective Technologically adapted mirror therapy shows promising results in improving motor function for stroke survivors. The treatment effects of a newly developed multi-mode stroke rehabilitation system offering multiple training modes in digital mirror therapy remain unknown. This study aimed to examine the effects of unilateral mirror visual feedback (MVF) with unimanual training (UM-UT), unilateral MVF with bimanual training (UM-BT), and bilateral MVF with bimanual training (BM-BT) on clinical outcomes in stroke survivors, compared to classical mirror therapy (CMT). Methods Thirty-five participants were randomly assigned to one of four groups receiving fifteen 60-minute training sessions for 3–4 weeks. The Fugl-Meyer Assessment for Upper Extremity (FMA-UE), Chedoke Arm and Hand Activity Inventory (CAHAI), Revised Nottingham Sensory Assessment (rNSA), Motor Activity Log (MAL), and EQ-5D-5L were administered at pre- and post-intervention and at 1-month follow-up. Results After intervention and follow-up, significant within-group treatment efficacies were found on most primary outcomes of the FMA-UE and CAHAI scores in all four groups. Significant within-group improvements in the secondary outcomes were found on the MAL and EQ-5D-5L index in the UM-BT group, and the rNSA tactile sensation and MAL quality of movement subscales in the BM-BT group. No significant between-group treatment efficacies were found. Conclusions UM-UT, UM-BT, BM-BT, and CMT led to similar clinical effects on the FMA-UE and can be considered effective alternative interventions for post-stroke upper-limb motor rehabilitation. UM-BT and BM-BT showed within-group improvements in functional performance in the patients’ affected upper limbs in real-life activities.

The Chedoke Arm and Hand Activity Inventory (CAHAI) is an outcome measure that assesses upper limb ability after stroke. To explore the clinical utility of the CAHAI when used by occupational therapists in stroke rehabilitation. A qualitative study consisting of two focus groups was conducted with occupational therapists (Group A: n = 8; Group B: n = 5). Data were analysed inductively to identify themes. A range of perspectives on the clinical utility of the CAHAI were described. Themes that emerged were "instructions ambiguous and scoring unclear," "how we use it," "whole task versus motor components," "knowing when to use it," "detecting other impairments," and "changing the way clients do tasks." The clinical application of the CAHAI may be influenced by occupational therapy values, differences in training procedures, and organisational barriers. Training and strategies to address these issues may be beneficial.

Test-Retest Reliability, Validity, and Sensitivity of the Chedoke Arm and Hand Activity Inventory: A New Measure of Upper-Limb Function for Survivors of Stroke

The Chedoke Arm and Hand Activity Inventory (CAHAI) is an assessment of upper limb function designed for use in the stroke population. The CAHAI has strong reliability and validity in this population; however, it is unknown whether this measure can be used with other clinical populations such as acquired brain injury (ABI). The purpose of this study was to estimate the inter-rater reliability of the CAHAI when used with persons with ABI. The research design was an observational parameter estimation study. The administration of the CAHAI was videotaped for 6 persons with ABI. To estimate inter-rater reliability each video was assessed independently by 6 clinicians yielding a total of 36 assessments. A Latin square design was used to balance the order raters evaluated the videos. Shrout and Fleiss Type 2,1 intra class correlation coefficients (ICC) and standard error of measurement (SEM) were calculated to estimate inter-rater reliability of the CAHAI. Inter-rater reliability was high ICC = 0.96 (95% CL: 0.88, 0.99) and the SEM was 3.35 (95% CL: 2.63, 4.63) CAHAI points. These results suggest that the CAHAI, although designed for use in the stroke population, can be used reliably in the ABI population.

More than 70% of individuals who have a stroke experience upper limb deficits that impact daily activities. Increased amount of upper limb therapy has positive effects; however, practical and inexpensive methods of therapy are needed to deliver this increase in therapy. This was a multi-site single blind randomized controlled trial to determine the effectiveness of a 4-week self-administered graded repetitive upper limb supplementary program (GRASP) on arm recovery in stroke. 103 inpatients with stroke were randomized to the experimental group (GRASP group, n=53) or the control group (education protocol, n=50). The primary outcome measure was the Chedoke Arm and Hand Activity Inventory (CAHAI), a measure of upper limb function in activities of daily living. Secondary measures were used to evaluate grip strength and paretic upper limb use outside of therapy time. Intention-to-treat analysis was performed. Group differences were tested using analysis of covariance. At the end of the 4-week intervention (approximately 7 weeks poststroke), the GRASP group showed greater improvement in upper limb function (CAHAI) compared to the control group (mean difference 6.2; 95% CI: 3.4 to 9.0; P<0.001). The GRASP group maintained this significant gain at 5 months poststroke. Significant differences were also found in favor of the GRASP protocol for grip strength and paretic upper limb use. No serious adverse effects were experienced. A self-administered homework exercise program provides a cost-, time-, and treatment-effective delivery model for improving upper limb recovery in subacute stroke.

Aims The purpose of this study was to compare three upper limb ability assessments – the Action Research Arm Test (ARAT), Arm Motor Ability Test (AMAT), and Chedoke Arm and Hand Activity Inventory (CAHAI) – in acute stroke occupational therapy practice during a 6-month period, to identify whether any or all were appropriate for use in acute stroke care. Methods Medical records of clients with stroke admitted to an acute stroke unit were reviewed retrospectively. Inclusion criteria were: (a) admission between March and August 2006, (b) new diagnosis of stroke, (c) upper limb involvement, and (d) assessed by an occupational therapist with ARAT, AMAT or CAHAI. Included records were reviewed and the following noted: diagnosis, upper limb weakness, gender, age, assessment score, when assessed, time to administer, test items completed, and qualitative notations. Findings Thirty three records satisfied the inclusion criteria. A range of stroke subtypes were assessed. The mean ARAT score was 21.4/45, CAHAI was 66.5/91 and AMAT was 3.0/5. The median number of days post-stroke when assessed was 9 days. Conclusions Overall, ARAT, CAHAI and AMAT were useful for assessment of upper limb ability. The results cannot specifically identify which assessment is most suited to the acute stroke setting. The findings do support the inclusion of ARAT, CAHAI and AMAT in standard clinical care.

Aims: The purpose of this study was to compare three upper limb ability assessments - the Action Research Arm Test (ARAT), Arm Motor Ability Test (AMAT), and Chedoke Arm and Hand Activity Inventory (CAHAI) - in acute stroke occupational therapy practice during a 6-month period, to identify whether any or all were appropriate for use in acute stroke care. Methods: Medical records of clients with stroke admitted to an acute stroke unit were reviewed retrospectively. Inclusion criteria were: (a) admission between March and August 2006, (b) new diagnosis of stroke, (c) upper limb involvement, and (d) assessed by an occupational therapist with ARAT, AMAT or CAHAI. Included records were reviewed and the following noted: diagnosis, upper limb weakness, gender, age, assessment score, when assessed, time to administer, test items completed, and qualitative notations. Findings: Thirty three records satisfied the inclusion criteria. A range of stroke subtypes were assessed. The mean ARAT score was 21.4/45, CAHAI was 66.5/91 and AMAT was 3.0/5. The median number of days post-stroke when assessed was 9 days. Conclusions: Overall, ARAT, CAHAI and AMAT were useful for assessment of upper limb ability. The results cannot specifically identify which assessment is most suited to the acute stroke setting. The findings do support the inclusion of ARAT, CAHAI and AMAT in standard clinical care.

BackgroundStroke is a leading cause of long-term disability among stroke survivors. Despite the availability of numerous stroke rehabilitative therapies, such as mirror therapy, bilateral arm training, and robot-assisted therapy, the recovery of motor function after stroke remains incomplete. Bilateral arm function is a key component in stroke patients to perform activities of daily living and to reflect their functional autonomy.ObjectiveThis clinimetric study investigated and compared the construct validity and responsiveness of 2 bimanual activity outcome measures, the Chedoke Arm and Hand Activity Inventory (CAHAI) and the ABILHAND Questionnaire, in individuals receiving stroke rehabilitation.MethodsThe present study is a secondary analysis following the framework of the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN). Individuals with chronic stroke (N = 113) were recruited from outpatient rehabilitation settings. Participants received 18 to 20 sessions of robot-assisted therapy, mirror therapy, combined therapy, or conventional rehabilitation for 4 to 6 weeks. The CAHAI, ABILHAND Questionnaire, and a comparison instrument, the Motor Activity Log (MAL), were administered twice at a 4- to 6-week interval to all participants. ABILHAND scores, in logits, were converted from raw ordinal scores into a linear measure.ResultsThere was medium to large correlation of the CAHAI and the MAL (ρ = 0.60–0.62, p &amp;lt; 0.01) as well as the ABILHAND Questionnaire and the MAL (ρ = 0.44–0.51, p &amp;lt; 0.01). Change scores from the initial measurement to the post-intervention measurement demonstrated small to medium correlation of the CAHAI and the MAL (ρ = 0.27–0.31, p &amp;lt; 0.01) and medium to large correlation of the ABILHAND Questionnaire and the MAL (ρ = 0.37–0.41, p &amp;lt; 0.01). Overall, 7 of 8 hypotheses were supported. The hypothesis testing regarding the construct validity and responsiveness of the CAHAI and ABILHAND Questionnaire was confirmed.ConclusionThe CAHAI and ABILHAND Questionnaire are both responsive and suitable to detect changes in bilateral arm functional daily activities in individuals with chronic stroke. Patient-reported outcome measures are recommended to use along with therapist-rated outcome measures for upper limb capacity evaluation in stroke rehabilitation. Further study with a prospective study design to capture specific clinical features of participants and the use of body-worn sensors, such as the arm accelerometer, is suggested.

This study examined the treatment effects between unilateral hybrid therapy (UHT; unilateral robot-assisted therapy [RT] + modified constraint-induced movement therapy) and bilateral hybrid therapy (BHT; bilateral RT + bilateral arm training) compared with RT. Thirty patients with chronic stroke were randomized to UHT, BHT, or RT groups. Preliminary efficacy was assessed using the Fugl-Meyer Assessment (FMA), the Chedoke Arm and Hand Activity Inventory (CAHAI), and the goal attainment scaling (GAS). Possible adverse effects of abnormal muscle tone, pain, and fatigue were recorded. All groups showed large improvements in motor recovery and individual goals. Significant between-group differences were found on GAS favoring the hybrid groups but not on FMA and CAHAI. No adverse effects were reported. Hybrid therapies are safe and applicable interventions for chronic stroke and favorable for improving individual functional goals. Treatment effects on motor recovery and functional activity might be similar among the three groups.

BackgroundBrain/neural hand exoskeletons (B/NHEs) can restore motor function after severe stroke, enabling bimanual tasks critical for various activities of daily living. Yet, reliable clinical tests for assessing bimanual function compatible with B/NHEs are lacking. Here, we introduce the Berlin Bimanual Test for Stroke (BeBiT-S), a 10-task assessment focused on everyday bimanual activities, and evaluate its psychometric properties as well as compatibility with assistive technologies such as B/NHEs.MethodsBeBiT-S tasks were selected based on their relevance to daily activities, representation of various grasp types, and compatibility with current (neuro-)prosthetic devices. A scoring system was developed to assess key aspects of bimanual function—including reaching, grasping, stabilizing, manipulating, and lifting—based on video recordings of task performance. The BeBiT-S was administered without support of assistive technology (unassisted condition) to 24 stroke survivors (mean age = 56.5 years; 9 female) with upper-limb hemiparesis. We evaluated interrater reliability through the intraclass correlation coefficient (ICC) and construct validity through correlations with the Chedoke Arm and Hand Activity Inventory (CAHAI), and Stroke Impact Scale (SIS). A subgroup of 15 stroke survivors (mean age 50.3 years, 5 female) completed a second session supported by a B/NHE (B/NHE-assisted condition) to assess the BeBiT-S’ sensitivity to change related to B/NHE-application.ResultsThe BeBiT-S demonstrated high interrater reliability in both the unassisted (ICC = 0.985, P < .001) and B/NHE-assisted (ICC = 0.862, P < .001) conditions. Unassisted BeBiT-S scores correlated with the CAHAI-8 (r(22) = 0.95, P < .001) and the SIS subscales “strength” (r(20) = 0.53, P = .012) and “hand function” (r(20) = 0.50, P = .018), indicating construct validity. BeBiT-S scores improved significantly with B/NHE assistance (Mdn = 60, P < .05), compared to when no assistance was provided (Mdn = 38, P < .05), demonstrating the test’s sensitivity to change following the application of a B/NHE.ConclusionsThe findings support that the BeBiT-S is a reliable and valid tool for evaluating bimanual task performance in stroke survivors and is compatible with the use of assistive technology such as B/NHEs.Trial registration NCT04440709, submitted June 18th, 2020.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12984-025-01822-6.

Backgrounds: To date, several therapies are shown to be effective in patients with chronic stroke such as constraint-induced therapy (CIT), bilateral arm training (BAT) and robot-assisted therapy (RT). CIT provides unilateral functional trainings by using a glove to restrict non-affected hand. Bilateral functional training can be offered through BAT by conducting symmetrical tasks with both hands simultaneously. RT provides high intensity, high repetitive and high accuracy motor training. Besides, task-oriented training is recommended after RT to transfer the gains of motor ability from RT to daily life performance. The differential effects between unilateral and bilateral practice modes had been demonstrated. As hybrid therapy is a promising therapy reported to promote additional effects, the combination of unilateral RT with CIT and bilateral RT with BAT may possibly transfer the learned motor control strategies provided by RT to daily life. Objectives: This study aimed to investigate the differential effects between unilateral hybrid therapy (UHT) and bilateral hybrid therapy (BHT). RT group (RTG) was set as control group to examine the additional effects of both hybrid therapies. Methods: Participants were randomly assigned to UHT, BHT or RTG groups. In the UHT group, unilateral RT and CIT were conducted. In the BHT group, participants received bilateral RT and BAT. Participants in the RTG group received only RT. Each participant was provided an intervention of 90minutes/day, 3 days/week for 6 weeks (a total of 18 sessions). Outcomes measures included clinical assessments, kinematic analyses and accelerometric measures. Clinical assessments including Fugl-Meyer Assessment (FMA), Modified Ashworth Scale (MAS), Medical Research Council (MRC), Motor Activity Log (MAL), Functional Independence Measure (FIM), Chedoke Arm and Hand Activity Inventory (CAHAI) and Stroke Impact Scale (SIS). Results: Total of seven participants were recruited to this study. One participant was allocated to the UHT group; three participants were distributed to the BHT group; three participants were allocated to the RTG group. Finally, six participants completed this study and analyzed. In relative change of FMA-UE total score, one participant in the RTG group reached the minimal clinically important change (MCID). From the prospective of relative change of FMA-UE proximal subscale score, one participant in the BHT group and one participant in the RTG group nearly reached the MCID of the FMA-UE proximal subscale. In relative change of FMA-UE distal subscale score, one participant in the RTG group reached the MCID of FMA-UE distal subscale and one participant nearly reached the MCID of FMA-UE distal subscale. Based on the line chart of FMA-UE score, the RTG group revealed more positive within-group trend than other groups. From the aspect of MAL score, the hybrid group (the UHT and the BHT group) showed relatively greater positive within-group trend than the RTG group in MAL changing scores. Likewise, the hybrid group revealed more positive trend than the RTG group in the FIM changing score. In kinematic analyses, endpoint control variables including index MT and index PV of the UHT group showed more advantageous trend than the BHT group in unilateral beyond reaching task; while, trunk NTD and trunk NMU in trunk control variables of the BHT group revealed more positive tendency than the UHT group. In the accelerometric measures, the ratio of vector magnitude and caloric consumption of the BHT group revealed greater positive trend than other groups. Conclusion: This study supports the potential positive effects of unilateral hybrid therapy and bilateral hybrid therapy on motor functions, activities of daily life (ADL) functions and motor control strategies in patients with chronic stroke. Based on the results of this study, the UHT group might benefit in temporal efficiency of unilateral task; the BHT group might receive progress in enhancing trunk control. Furthermore, the hybrid therapy might have better positive effects than RT in ADL functions.