Action Research Arm Test Scores Research Articles

Development and External Validation of Motor-intention Integrated Prediction Model for Upper Extremity Motor Recovery After Intention-driven Robotic-hand Training for Chronic Stroke.

ObjectiveTo derive and validate a prediction model for minimal clinically important differences (MCID) in upper extremity (UE) motor function after intention-driven robotic-hand training using residual voluntary EMG signals from affected UE. DesignA prospective longitudinal multicenter cohort study. We collected pre-intervention candidate predictors: demographics, clinical characteristics, Fugl-Meyer assessment of UE (FMAUE), Action Research Arm Test scores, and motor-intention of flexor digitorum and extensor digitorum (ED) measured by EMG during maximal voluntary contraction (MVC). For EMG measures, recognizing challenges for stroke survivors to move paralyzed hand, peak signals were extracted from eight time-windows during MVC-EMG (0.1s-5s) to identify subjects’ motor-intention. Classification And Regression Tree algorithm was employed to predict survivors with MCID of FMAUE. Relationship between predictors and motor-improvements was further investigated. SettingNine rehabilitation centers. ParticipantsChronic stroke survivors (N=131), including 87 for Derivation-sample, and 44 for Validation-sample. InterventionsAll participants underwent 20-session robotic-hand training (40min/session, 3-5sessions/week). Main Outcome measuresPrediction efficacies of models were assessed by area under the receiver operating characteristic curve (AUC). The best effective model was final model and validated using AUC and overall accuracy. ResultsThe best model comprised FMAUE (cut-off score: 46) and peak activity of ED from one-second MVC-EMG (MVC-EMG 4.604 times higher than resting-EMG), which demonstrated significantly higher prediction accuracy (AUC: 0.807) than other time-windows or solely using clinical-scores (AUC: 0.595). In external validation, this model displayed robust prediction (AUC: 0.916). Significant quadratic relationship was observed between ED-EMG and FMAUE increases. ConclusionsThis study presents a prediction model for intention-driven robotic-hand training in chronic stroke survivors. It highlights significance of capturing motor-intention through 1-second EMG-window as a predictor for MCID improvement in UE motor-function after 20-session robotic-training. Survivors in two conditions showed high percentage of clinical motor-improvement: moderate-to-high motor-intention and low-to-moderate function; as well as high-intention and high-function.

Prediction of Upper Limb Motor Recovery by the PREP2 Algorithm in a Nonselected Population: External Validation and Influence of Cognitive Syndromes.

Early prediction of poststroke motor recovery is challenging in clinical settings. The Prediction recovery potential (PREP2) algorithm is the most accurate approach for prediction of Upper Limb function available to date but lacks external validation. (i) To externally validate the PREP2 algorithm in a prospective cohort, (ii) to study the characteristics of patients misclassified by the algorithm, and (iii) to compare the performance according to the presence of cognitive syndromes (aphasia, neglect, cognitive disorders). We enrolled 143 patients with stroke and upper extremity weakness persistent at Day 3. Evaluation to predict the recovery status according to the PREP2 algorithm included age, SAFE and NIHSS scores at Day 3 and transcranial magnetic stimulation to determine the presence of the motor-evoked potential before day seven. Actual recovery (excellent, good, limited, or poor) was defined based on the Action Research Arm test score at 3 months. Accuracy was computed by comparing the predictions of the PREP2 and the actual category of the patient. Additionally, to investigate misclassifications and the impact of cognitive syndromes, we recorded SAFE and NIHSS scores at Day 7, the Montreal Cognitive Assessment (MoCA) score, the presence of aphasia and neglect and Magnetic Resonance Imaging was used to evaluate the corticospinal tract lesion load. The PREP2 algorithm showed a very good predictive value with 78% accuracy [95% CI: 71.2%-86.1%], especially for the extreme categories of recovery (EXCELLENT 87.5% [95% CI: 78.9%-96.2%] and POOR 94.9% [95% CI: 87.9%-100%]), and only 46.5% [95% CI: 19.05%-73.25%] for the GOOD category and even worse than chance for the LIMITED category 0%. Pessimistic predictions (false-negative cases) had a drastic improvement in the SAFE score acutely compared to that of well-predicted patients with unfavorable recovery (P < 001). The predictive value of PREP2 decreased significantly when patients had cognitive disorders (MoCA score <24) versus not (69.4% [95% CI: 52.8%-86.1%] vs 93.1% [95% CI: 83.9%-100%], P = .01). Our study provides an external validation of the PREP2 algorithm in a prospective population and underlines the importance of taking into account cognitive syndromes in motor recovery prediction.

The association between dexterity and upper limb impairment during stroke recovery.

Stroke-induced upper limb disabilities can be characterized by both motor impairments and activity limitations, commonly assessed using Fugl-Meyer Motor Assessment for Upper Extremity (FMMA-UE) and Action Research Arm Test (ARAT), respectively. The relationship between the two assessments during recovery is largely unstudied. Expectedly they diverge over time when recovery of impairment (restitution) plateaus, but compensation-driven improvements still occur. The objective of this study is to evaluate the alignment between FMMA-UE and ARAT in defining upper limb functional recovery categories by ARAT scores. We aimed to establish cut-off scores for both measures from the acute/early subacute, subacute and chronic stages of stroke recovery. Secondary analysis of four prospective cohort studies (acute/early subacute: n = 133, subacute: n = 113, chronic: n = 92) stages post-stroke. Receiver operating characteristic curves calculated the area under the curve (AUC) to establish optimal FMMA-UE cut-offs based on predefined ARAT thresholds distinguishing five activity levels from no activity to full activity. Weighted kappa was used to determine agreement between the two assessments. We used minimally clinically important difference (MCID) and minimal detectable change (MDC95) for comparison. FMMA-UE and ARAT scores showed no relevant divergence across all recovery stages. Results indicated similar cut-off scores in all recovery stages with variability below MCID and MDC95 levels. Cut-off scores demonstrated robust AUC values from 0.77 to 0.86 at every recovery stage. Only in highly functional patients at the chronic stage, we found a reduced specificity of 0.55. At all other times sensitivity ranged between 0.68 and 0.99 and specificity between 0.71 and 0.99. Weighted kappa at the acute/early subacute, subacute and chronic stages was 0.76, 0.83, and 0.81, respectively. Our research shows a strong alignment between FMMA-UE and ARAT cut-off scores throughout stroke recovery, except among the subgroup of highly recovered patients at the chronic stage. Discrepancies in specificity potentially stem from fine motor deficits affecting dexterity outcomes that are not captured by FMMA-UE. Additionally, the high congruence of both measures suggests they are not suited to distinguish between restitution and compensation. Calling for more comprehensive assessment methods to better understand upper limb functionality in rehabilitation.

Efficacy of Motor Imagery in the Rehabilitation of Stroke Patients: A Scope Review

This review examines the efficacy of motor imagery (MI) as a supplementary rehabilitation technique for stroke patients. Nine randomized controlled trials (RCTs) were analyzed, highlighting MI's potential to enhance motor recovery, mobility, balance, and psychological well-being. Significant improvements in upper-limb function were observed with combined mental and physical practice, evidenced by notable gains in Fugl-Meyer Assessment (FMA) and Action Research Arm Test (ARAT) scores. MI-based exercise programs improved mobility and balance in elderly patients, reducing fall risk as measured by the Timed Up and Go (TUG) test and Berg Balance Scale (BBS). MI was also found to enhance self-efficacy and functional performance, with significant increases in Functional Independence Measure (FIM) and General Self-Efficacy Scale (GSES) scores. Neuroimaging studies revealed that MI activates cortical areas associated with motor control, supporting its role in promoting neural plasticity. Despite these promising results, the heterogeneity in participant characteristics, stroke severity, and MI protocols across studies poses challenges to standardization. Additionally, small sample sizes and reliance on self-report measures limit the generalizability of findings. Nevertheless, MI's low cost, minimal risk, and ease of integration into existing rehabilitation protocols make it a valuable adjunct to physical therapy. Standardized guidelines and personalized MI exercises tailored to individual needs are essential for maximizing benefits. Integrating MI into clinical practice can significantly enhance both physical and psychological recovery outcomes for stroke patients, offering a comprehensive approach to rehabilitation.

Stroke Survivors' Interaction With Hand Rehabilitation Devices: Observational Study.

The hand is crucial for carrying out activities of daily living as well as social interaction. Functional use of the upper limb is affected in up to 55% to 75% of stroke survivors 3 to 6 months after stroke. Rehabilitation can help restore function, and several rehabilitation devices have been designed to improve hand function. However, access to these devices is compromised in people with more severe loss of function. In this study, we aimed to observe stroke survivors with poor hand function interacting with a range of commonly used hand rehabilitation devices. Participants were engaged in an 8-week rehabilitation intervention at a technology-enriched rehabilitation gym. The participants spent 50-60 minutes of the 2-hour session in the upper limb section at least twice a week. Each participant communicated their rehabilitation goals, and an Action Research Arm Test (ARAT) was used to measure and categorize hand function as poor (scores of 0-9), moderate (scores of 10-56), or good (score of 57). Participants were observed during their interactions with 3 hand-based rehabilitation devices that focused on hand rehabilitation: the GripAble, NeuroBall, and Semi-Circular Peg Board. Observations of device interactions were recorded for each session. A total of 29 participants were included in this study, of whom 10 (34%) had poor hand function, 17 (59%) had moderate hand function, and 2 (7%) had good hand function. There were no differences in the age and years after stroke among participants with poor hand function and those with moderate (P=.06 and P=.09, respectively) and good (P=.37 and P=.99, respectively) hand function. Regarding the ability of the 10 participants with poor hand function to interact with the 3 hand-based rehabilitation devices, 2 (20%) participants with an ARAT score greater than 0 were able to interact with the devices, whereas the other 8 (80%) who had an ARAT score of 0 could not. Their inability to interact with these devices was clinically examined, and the reason was determined to be a result of either the presence of (1) muscle tone or stiffness or (2) muscle weakness. Not all stroke survivors with impairments in their hands can make use of currently available rehabilitation technologies. Those with an ARAT score of 0 cannot actively interact with hand rehabilitation devices, as they cannot carry out the hand movement necessary for such interaction. The design of devices for hand rehabilitation should consider the accessibility needs of those with poor hand function.

Effect of task-oriented training assisted by force feedback hand rehabilitation robot on finger grasping function in stroke patients with hemiplegia: a randomised controlled trial

BackgroundOver 80% of patients with stroke experience finger grasping dysfunction, affecting independence in activities of daily living and quality of life. In routine training, task-oriented training is usually used for functional hand training, which may improve finger grasping performance after stroke, while augmented therapy may lead to a better treatment outcome. As a new technology-supported training, the hand rehabilitation robot provides opportunities to improve the therapeutic effect by increasing the training intensity. However, most hand rehabilitation robots commonly applied in clinics are based on a passive training mode and lack the sensory feedback function of fingers, which is not conducive to patients completing more accurate grasping movements. A force feedback hand rehabilitation robot can compensate for these defects. However, its clinical efficacy in patients with stroke remains unknown. This study aimed to investigate the effectiveness and added value of a force feedback hand rehabilitation robot combined with task-oriented training in stroke patients with hemiplegia.MethodsIn this single-blinded randomised controlled trial, 44 stroke patients with hemiplegia were randomly divided into experimental (n = 22) and control (n = 22) groups. Both groups received 40 min/day of conventional upper limb rehabilitation training. The experimental group received 20 min/day of task-oriented training assisted by a force feedback rehabilitation robot, and the control group received 20 min/day of task-oriented training assisted by therapists. Training was provided for 4 weeks, 5 times/week. The Fugl-Meyer motor function assessment of the hand part (FMA-Hand), Action Research Arm Test (ARAT), grip strength, Modified Ashworth scale (MAS), range of motion (ROM), Brunnstrom recovery stages of the hand (BRS-H), and Barthel index (BI) were used to evaluate the effect of two groups before and after treatment.ResultsIntra-group comparison: In both groups, the FMA-Hand, ARAT, grip strength, AROM, BRS-H, and BI scores after 4 weeks of treatment were significantly higher than those before treatment (p < 0.05), whereas there was no significant difference in finger flexor MAS scores before and after treatment (p > 0.05). Inter-group comparison: After 4 weeks of treatment, the experimental group’s FMA-Hand total score, ARAT, grip strength, and AROM were significantly better than those of the control group (p < 0.05). However, there were no statistically significant differences in the scores of each sub-item of the FMA-Hand after Bonferroni correction (p > 0.007). In addition, there were no statistically significant differences in MAS, BRS-H, and BI scores (p > 0.05).ConclusionHand performance improved in patients with stroke after 4 weeks of task-oriented training. The use of a force feedback hand rehabilitation robot to support task-oriented training showed additional value over conventional task-oriented training in stroke patients with hand dysfunction.Clinical trial registration informationNCT05841108

Upper-Limb Functional Recovery in Chronic Stroke Patients after COVID-19-Interrupted Rehabilitation: An Observational Study.

Background/Objectives: Upper-limb function of chronic stroke patients declined when outpatient rehabilitation was interrupted and outings restricted, owing to the novel coronavirus infection (COVID-19) pandemic. We investigated whether these patients recovered upper-limb function post-resumption of outpatient rehabilitation. Methods: In this observational study, 43 chronic stroke hemiparesis patients with impaired upper extremity function were scored for limb function via the Fugl-Meyer assessment of the upper extremity (FMA-UE) and the Action Research Arm Test (ARAT) after a structured interview, evaluation, and intervention. Scores at 6 and 3 months pre- and 3 months post-rehabilitation interruption were examined retrospectively; scores immediately and at 3 and 6 months post-resumption of care were examined prospectively. The amount of change for each time period and an analysis of covariance were performed with time as a factor, changes in the FMA-UE and the ARAT scores as dependent variables, and statistical significance at 5%. Results: The time of evaluation significantly impacted the total score, as well as part C and part D of FMA-UE and total, pinch, and gross movement of the ARAT. Post-hoc tests showed that the magnitude of change in limb-function scores from immediately to 3 months post-resumption was significantly higher than the change from 3 months pre- to immediately post-interruption for the total score and part D of the FMA-UE, as well as grip and gross movement of the ARAT (p < 0.05). Conclusions: Upper-limb functional decline in chronic stroke patients, caused by the COVID-19 pandemic-related therapy interruption and outing restrictions, was resolved approximately 3 months post-resumption of rehabilitation therapy. Our data can serve as reference standards for planning and evaluating treatment for chronic stroke patients with inactivity-related impaired upper-limb function.

Impact of Hand Grip Strength on Functional Independence and Arm Motor Performance in Stroke Survivors

Background: Stroke remains a leading cause of disability worldwide, with a significant number of survivors experiencing impairments in upper limb function and hand grip strength, which are crucial for performing activities of daily living (ADLs). Understanding the relationship between hand grip strength, functional independence, and arm motor performance is essential for optimizing rehabilitation strategies. Objective: This study aimed to investigate the impact of hand grip strength on functional independence and arm motor performance in stroke survivors and to evaluate the effectiveness of Mirror Therapy in enhancing these outcomes. Methods: An analytical cross-sectional study was conducted at DHQ Teaching Hospital Sargodha, involving 22 stroke survivors, evenly split between genders. Participants were aged 45-65 years, clinically diagnosed with ischemic stroke in the subacute stage, and exhibited Modified Ashworth Scale scores of 1 to 1+ for hand flexors. The study employed randomized assignments to intervention groups, utilizing assessments such as the Action Research Arm Test (ARAT), Fugl-Meyer Assessment for Upper Extremity (FMA UE), Hand-Held Dynamometer (HHD), and Stroke Impact Scale (SIS) at baseline, 3 weeks, and 6 weeks. Statistical analysis was performed using Pearson’s coefficient of correlation with SPSS version 25. Results: Significant improvements were observed in upper limb strength and hand dexterity, particularly in the group undergoing Mirror Therapy. The correlation coefficients among ARAT, HHD, and SIS were .676**, .748**, and .704** respectively, indicating strong positive relationships between hand grip strength, functional ability, and quality of life. Mirror Therapy demonstrated notable enhancements in ARAT (p = .001), FMA UE (p &lt; .000), HHD (p = .000), and SIS scores (p = .000), reflecting increased functional ability, grip strength, and improved quality of life. Conclusion: The study confirmed the significant impact of hand grip strength on the functional independence and arm motor performance of stroke survivors, with Mirror Therapy providing substantial benefits. These findings advocate for the inclusion of grip strength-focused interventions and Mirror Therapy in stroke rehabilitation programs to improve survivors' functional outcomes and quality of life.

Accuracy and Reliability of Remote Categorization of Upper Limb Outcome After Stroke

Background There is an increasing need for motor assessments after stroke that can be performed quickly and remotely. The Fast Outcome Categorization of the Upper Limb after Stroke-4 (FOCUS-4) assessment remotely classifies upper limb outcome into 1 of 4 categories after stroke and was developed via retrospective analysis of Action Research Arm Test (ARAT) scores. Objective The aim of this study was to prospectively evaluate the accuracy and reliability of FOCUS-4 assessments for categorizing upper limb outcome after stroke when administered remotely during a videocall compared to an in-person ARAT. Methods Data were collected from 26 participants at 3 months post-stroke (3M), 27 participants at 6 months post-stroke (6M), and 56 participants at the chronic stage of stroke (>6M). Participants performed an in-person ARAT and a remote FOCUS-4 assessment administered during a videocall, and accuracy was evaluated by comparing the upper limb outcome categories. Participants at the chronic stage of stroke also performed a second remote FOCUS-4 assessment to assess between-day reliability. Results Overall accuracy of the remote FOCUS-4 assessment was 88% at 3M and 96% at 6M. Overall accuracy of the first and second remote FOCUS-4 assessments at the chronic stage was 75% and 79%, respectively. Reliability of the FOCUS-4 assessment at the chronic stage was 82%. The remote FOCUS-4 assessment was most accurate and reliable for participants with mild or severe upper limb functional impairment. Conclusions The remote FOCUS-4 assessment has potential to classify upper limb functional capacity or to screen possible participants for stroke trials, but external validation is required.

Combining Transcranial Direct Current Stimulation With Hand Robotic Rehabilitation in Chronic Stroke Patients: A Double-Blind Randomized Clinical Trial.

This study aimed to assess the impact of combining transcranial direct current stimulation with end-effector robot-assisted treatment on upper limb function, spasticity, and hand dexterity in chronic stroke patients. This was a prospective, double-blind randomized trial with 20 equally allocated stroke patients. The experimental group received dual transcranial direct current stimulation (anode over affected M1, cathode over contralateral M1) alongside robot-assisted treatment, while the control group received sham transcranial direct current stimulation with the same electrode placement + robot-assisted treatment. Each patient underwent 20 combined transcranial direct current stimulation and robot-assisted treatment sessions. The primary outcome measure was the Fugl-Meyer Upper Limb motor score, with secondary outcomes including AMADEO kinematic measures, Action Research Arm Test, and Functional Independence Measure. Assessments were conducted at baseline, after rehabilitation, and 3 mos later. Combining bilateral transcranial direct current stimulation with robot-assisted treatment did not yield additional improvements in Fugl-Meyer Upper Limb motor score, Functional Independence Measure, or Action Research Arm Test scores among stroke patients. However, the real transcranial direct current stimulation group showed enhanced finger flexion in the affected hand based on AMADEO kinematic measures. The addition of transcranial direct current stimulation to robot-assisted treatment did not result in significant overall functional improvements in chronic stroke patients. However, a benefit was observed in finger flexion of the affected hand.

Effects of scapulo-humeral training on ultrasonographic and clinical evaluations in stroke: a randomized controlled trial

ABSTRACT Background After stroke, the effects of focused scapulo-humeral training with simultaneous assessment of the changes in shoulder subluxation, related muscle thicknesses and upper limb performance have not been studied in the literature. Objectives This study aimed to investigate the effects of an 8-week scapulo-humeral training program in addition to conventional rehabilitation on upper extremity/trunk functions, shoulder pain, and sonographic measurements of the shoulder joint and periscapular muscles. Methods Thirty stroke individuals were randomly separated into two groups as Group I-scapulo-humeral training (5F/10 M) and Group II – control (5F/10 M). Conventional rehabilitation program was applied to both groups, and a scapulo-humeral training exercise protocol was added for the scapulo-humeral group. All the treatments were applied for 1 hour/day, 3 days/week, 8 weeks. Clinical evaluations were made using the Fugl Meyer Assessment-Upper Extremity(FMA-UE), Action Research Arm Test(ARAT), ABILHAND, Visual Analog Scale, and Trunk Impairment Scale(TIS). Ultrasound was used to measure serratus anterior/lower trapezius muscle thicknesses, and acromion-greater tubercule/acromio-humeral distances. Results FMA-UE, ARAT, ABILHAND and TIS scores increased in both groups, with greater increases in most parameters in the scapulo-humeral training group. Shoulder pain decreased only in the scapulo-humeral training group. Subacromial distances were decreased on the paretic side, and muscle thicknesses increased on both sides in the scapulo-humeral training group, and in the control group, only serratus anterior muscle thickness increased on the paretic side (p < 0.05 for all). Conclusions Additional scapulo-humeral exercises to conventional rehabilitation was seen to improve upper extremity/trunk performance and shoulder pain, and to increase scapula stabilizer muscle thicknesses in stroke individuals with mild-moderate upper extremity disability.

Brain–Computer Interface Using Functional Near-Infrared Spectroscopy for Post-Stroke Motor Rehabilitation: Case Series

Introduction. Non-invasive brain–computer interfaces (BCIs) enable feedback motor imagery [MI] training in neurological patients to support their motor rehabilitation. Nowadays, the use of BCIs based on functional near-infrared spectroscopy (fNIRS) for motor rehabilitation is yet to be investigated.&#x0D; Objective: To evaluate the potential fNIRS BCI use in hand MI training for comprehensive post-stroke rehabilitation.&#x0D; Materials and methods. This pilot study included clinically stable patients with mild-to-moderate post-stroke hand paresis. In addition to the standard rehabilitation, the patients underwent 10 nine-minute MI fNIRS BCI training sessions. To evaluate the quality of fNIRS BCI control, we assessed the percentage of time during which the classifier accurately detected patient's mental state. We scored the hand function using the Action Research Arm Test (ARAT) and the Fugl-Meyer Assessment (FMA).&#x0D; Results. The study included 5 patients at 1 day to 12 months of stroke. All the participants completed the study. All study participants achieved BCI control rates higher than random (41–68%). While three patients demonstrated the clinically significant improvements in their ARAT scores, one of them also showed an improvement in the FMA score. All the participants reported experiencing drowsiness during training.&#x0D; Conclusions. Post-stroke patients can operate the fNIRS BCI system under investigation. We suggest adjusting the feedback system, extending the duration of training, and incorporating functional electromyostimulation to enhance training effectiveness.

Post-stroke upper limb recovery is correlated with dynamic resting-state network connectivity.

Motor recovery is still limited for people with stroke especially those with greater functional impairments. In order to improve outcome, we need to understand more about the mechanisms underpinning recovery. Task-unbiased, blood flow-independent post-stroke neural activity can be acquired from resting brain electrophysiological recordings and offers substantial promise to investigate physiological mechanisms, but behaviourally relevant features of resting-state sensorimotor network dynamics have not yet been identified. Thirty-seven people with subcortical ischaemic stroke and unilateral hand paresis of any degree were longitudinally evaluated at 3 weeks (early subacute) and 12 weeks (late subacute) after stroke. Resting-state magnetoencephalography and clinical scores of motor function were recorded and compared with matched controls. Magnetoencephalography data were decomposed using a data-driven hidden Markov model into 10 time-varying resting-state networks. People with stroke showed statistically significantly improved Action Research Arm Test and Fugl-Meyer upper extremity scores between 3 weeks and 12 weeks after stroke (both P < 0.001). Hidden Markov model analysis revealed a primarily alpha-band ipsilesional resting-state sensorimotor network which had a significantly increased life-time (the average time elapsed between entering and exiting the network) and fractional occupancy (the occupied percentage among all networks) at 3 weeks after stroke when compared with controls. The life-time of the ipsilesional resting-state sensorimotor network positively correlated with concurrent motor scores in people with stroke who had not fully recovered. Specifically, this relationship was observed only in ipsilesional rather in contralesional sensorimotor network, default mode network or visual network. The ipsilesional sensorimotor network metrics were not significantly different from controls at 12 weeks after stroke. The increased recruitment of alpha-band ipsilesional resting-state sensorimotor network at subacute stroke served as functionally correlated biomarkers exclusively in people with stroke with not fully recovered hand paresis, plausibly reflecting functional motor recovery processes.

Neurorehabilitation of the upper extremity - immersive virtual reality vs. electromechanically assisted training. A comparative study.

Severe paresis of the contralesional upper extremity is one of the most common and debilitating post-stroke impairments. The need for cost-effective high-intensity training is driving the development of new technologies, which can complement and extent conventional therapies. Apart from established methods using electromechanical devices, immersive virtual reality (iVR) systems hold promise to provide cost-efficient high-intensity arm training. We investigated whether iVR-based arm training yields at least equivalent effects on upper extremity function as compared to an electromechanically assisted training in stroke patients with severe arm paresis. 52 stroke patients with severe arm paresis received a total of ten daily group therapy sessions over a period of three weeks, which consisted of 20 min of conventional therapy and 20 min of either electromechanically assisted (ARMEOSpring®) or iVR-based (CUREO®) arm training. Changes in upper extremity function was assessed using the Action Research Arm Test (ARAT) and user acceptance was measured with the User Experience Questionnaire (UEQ). iVR-based training was not inferior to electromechanically assisted training. We found that 84% of patients treated with iVR and 50% of patients treated with electromechanically assisted arm training showed a clinically relevant improvement of upper extremity function. This difference could neither be attributed to differences between the groups regarding age, gender, duration after stroke, affected body side or ARAT scores at baseline, nor to differences in the total amount of therapy provided. The present study results show that iVR-based arm training seems to be a promising addition to conventional therapy. Potential mechanisms by which iVR unfolds its effects are discussed.

External Validation of a Dynamic Prediction Model for Upper Limb Function After Stroke

ObjectiveTo externally validate the dynamic prediction model for prediction of upper limb (UL) function 6 months after stroke. The dynamic prediction model has been developed and cross-validated on data from 4 Dutch studies. DesignData from a prospective Danish cohort study were used to assess prediction accuracy. SettingA Danish neurorehabilitation hospital. ParticipantsIn this external validation study, follow-up data for 80 patients in the subacute phase after stroke (N=80), mean age 64 (SD11), 43% women, could be obtained. They were assessed at 2 weeks, 3 months, and 6 months after stroke with the Action Research Arm Test (ARAT), Fugl-Meyer Motor Assessment upper limb (FMA), and Shoulder Abduction (SA) Finger Extension (FE), (SAFE) test. InterventionNot applicable. Main Outcome MeasuresPrediction accuracy at 6 months was examined for 3 categories of ARAT (0-57 points): mild (48-57), moderate (23-47), and severe (0-22). Two individual predictions of ARAT scores at ±6 months post-stroke were computed based on, respectively, baseline (2 weeks) and 3 months ARAT, FE, SA values. The absolute individual differences between observed and predicted ARAT scores were summarized. ResultsThe prediction model performed best for patients with relatively good UL motor function, with an absolute error median (IQR) of 3 (2-9), and worst for patients with severe UL impairment, with a median (IQR) of 30 (3-39) at baseline. In general, prediction accuracy substantially improved when data obtained 3 months after stroke was included compared with baseline at 2 weeks after stroke. ConclusionWe found limited clinical usability due to the lack of prediction accuracy 2 weeks after stroke and for patients with severe UL impairments. The dynamic prediction model could probably be refined with data from biomarkers.

Intermittent theta burst stimulation combined with cognitive training improves cognitive dysfunction and physical dysfunction in patients with post-stroke cognitive impairment

ObjectivePost-stroke cognitive impairment (PSCI) is a common complication of stroke. Intermittent theta burst stimulation (iTBS) can inducing motor learning. We observed the effects of combination of iTBS with cognitive training on physical/cognitive dysfunctions in PSCI patients. MethodsPSCI patients treated with basic treatment & cognitive training (Control group)/iTBS & cognitive training (iTBS group) were enrolled, with Mini-mental State Examination (MMSE)/Montreal Cognitive Assessment (MoCA)/Frontal Assessment Battery (FAB)/barthel index (BI)/Upper Limb Fugl-Meyer Assessment (U-FMA)/Action Research Arm Test (ARAT) scores compared. Gait spatiotemporal parameters/dynamic parameters were analyzed by 3D gait analysis. Correlations between MMSE/MoCA scores and gait parameters in PSCI patients after iTBS & cognitive training were analyzed by Spearman analysis. ResultsIncreased MMSE/MoCA/FAB/BI/U-FMA/ARAT scores, step speed, step frequency, stride length, step width, step length on the affected side, percentage of swing phase on the affected side, hip joint flexion angle on the affected side, knee joint flexion angle on the affected side, and ankle plantar flexion angle on the affected side and reduced gait period on the affected side and percentage of stance phase on the affected side were found in patients of both groups after treatment, with the effects in the iTBS group more profound. ConclusioniTBS & cognitive training obviously improved the cognitive function scores/upper limb function scores/gait parameters in PSCI patients versus cognitive training treatment. After combination therapy, the MMSE/MoCA scores of PSCI patients were significantly correlated with gait parameters. This provided more data support for iTBS & cognitive training application in the rehabilitation treatment of PSCI patients.

Mixed methods usability evaluation of an assistive wearable robotic hand orthosis for people with spinal cord injury

BackgroundRobotic hand orthoses (RHO) aim to provide grasp assistance for people with sensorimotor hand impairment during daily tasks. Many of such devices have been shown to bring a functional benefit to the user. However, assessing functional benefit is not sufficient to evaluate the usability of such technologies for daily life application. A comprehensive and structured evaluation of device usability not only focusing on effectiveness but also efficiency and satisfaction is required, yet often falls short in existing literature. Mixed methods evaluations, i.e., assessing a combination of quantitative and qualitative measures, allow to obtain a more holistic picture of all relevant aspects of device usability. Considering these aspects already in early development stages allows to identify design issues and generate generalizable benchmarks for future developments.MethodsWe evaluated the short-term usability of the RELab tenoexo, a RHO for hand function assistance, in 15 users with tetraplegia after a spinal cord injury through a comprehensive mixed methods approach. We collected quantitative data using the Action Research Arm Test (ARAT), the System Usability Scale (SUS), and timed tasks such as the donning process. In addition, qualitative data were collected through semi-structured interviews and user observations, and analyzed with a thematic analysis to enhance the usability evaluation. All insights were attributed and discussed in relation to specifically defined usability attributes such as comfort, ease of use, functional benefit, and safety.ResultsThe RELab tenoexo provided an immediate functional benefit to the users, resulting in a mean improvement of the ARAT score by 5.8 points and peaking at 15 points improvement for one user (clinically important difference: 5.7 points). The mean SUS rating of 60.6 represents an adequate usability, however, indicating that especially the RHO donning (average task time = 295 s) was perceived as too long and cumbersome. The participants were generally very satisfied with the ergonomics (size, dimensions, fit) of the RHO. Enhancing the ease of use, specifically in donning, increasing the provided grasping force, as well as the availability of tailoring options and customization were identified as main improvement areas to promote RHO usability.ConclusionThe short-term usability of the RELab tenoexo was thoroughly evaluated with a mixed methods approach, which generated valuable data to improve the RHO in future iterations. In addition, learnings that might be transferable to the evaluation and design of other RHO were generated, which have the potential to increase the daily life applicability and acceptance of similar technologies.

Using "functional hand" protocol to improve hand function following a spinal cord injury: an explorative study.

A cervical spinal cord injury often affects hand control, causing ineffective grasping and handling functions, with a negative impact on patient's independence and quality of life. Literature recognises scientific evidence only for surgical or instrumental re-education approaches. The purpose of this study is to present the "functional hand" protocol, a physiotherapy tool that, to date, represents a good clinical practice but has no supporting literature. a longitudinal-single cohort study was conducted at Spinal Unit- Azienda Usl Piacenza. Patients with spinal cord injury at C5-C7 neurologic level, older than 18 years, with correct comprehension of Italian language were recruited. All patients were evaluated with Action Research Arm Test (ARAT) scale to state hand functionality; positive/negative history of Functional Hand protocol was deducted by physiotherapy discharge letters on first spinal unit hospitalisation. six patients were involved in the study; three of them had a positive history of protocol application. ARAT scores differences showed that patients who underwent functional hand protocol had a lower impairment, a better ability to produce cylindrical and cuboid sockets. Functional hand protocol reached a preliminary evidence as effective tool to improve hand recovery in tetraplegic patients; future studies should confirm these conclusions on larger samples, and verify protocol effectiveness in addition to other treatment strategies (functional electric stimulation/ transcranial direct current stimulation/robotic assisted therapy).

Task-specific training versus usual care to improve upper limb function after stroke: the "Task-AT Home" randomised controlled trial protocol.

Sixty percent of people have non-functional arms 6 months after stroke. More effective treatments are needed. Cochrane Reviews show low-quality evidence that task-specific training improves upper limb function. Our feasibility trial showed 56 h of task-specific training over 6 weeks resulted in an increase of a median 6 points on the Action Research Arm test (ARAT), demonstrating the need for more definitive evidence from a larger randomised controlled trial. Task-AT Home is a two-arm, assessor-blinded, multicentre randomised, controlled study, conducted in the home setting. The objective is to determine whether task-specific training is a more effective treatment than usual care, for improving upper limb function, amount of upper limb use, and health related quality of life at 6 weeks and 6 months after intervention commencement. Our primary hypothesis is that upper limb function will achieve a ≥ 5 point improvement on the ARAT in the task-specific training group compared to the usual care group, after 6 weeks of intervention. Participants living at home, with remaining upper limb deficit, are recruited at 3 months after stroke from sites in NSW and Victoria, Australia. Following baseline assessment, participants are randomised to 6 weeks of either task-specific or usual care intervention, stratified for upper limb function based on the ARAT score. The task-specific group receive 14 h of therapist-led task-specific training plus 42 h of guided self-practice. The primary outcome measure is the ARAT at 6 weeks. Secondary measures include the Motor Activity Log (MAL) at 6 weeks and the ARAT, MAL and EQ5D-5 L at 6 months. Assessments occur at baseline, after 6 weeks of intervention, and at 6 months after intervention commencement. Analysis will be intention to treat using a generalised linear mixed model to report estimated mean differences in scores between the two groups at each timepoint with 95% confidence interval and value of p. If the task-specific home-based training programme is more effective than usual care in improving arm function, implementation of the programme into clinical practice would potentially lead to improvements in upper limb function and quality of life for people with stroke. ANZCTR.org.au/ACTRN12617001631392p.aspx.

Continuous Theta-Burst Stimulation of the Contralesional Primary Motor Cortex for Promotion of Upper Limb Recovery After Stroke: A Randomized Controlled Trial.

Despite improvements in acute stroke therapies and rehabilitation strategies, many stroke patients are left with long-term upper limb motor impairment. We assessed whether an inhibitory repetitive transcranial magnetic stimulation treatment paradigm started within 3 weeks after stroke onset promotes upper limb motor recovery. We performed a single-center randomized, sham-controlled clinical trial. Patients with ischemic stroke or intracerebral hemorrhage and unilateral upper limb motor impairment were randomized to 10 daily sessions of active or sham continuous theta-burst stimulation (cTBS) of the contralesional primary motor cortex combined with standard upper limb therapy, started within 3 weeks after stroke onset. The primary outcome was the change in the Action Research Arm Test score from baseline (pretreatment) at 3 months after stroke. Secondary outcomes included the score on the modified Rankin Scale at 3 months and the length of stay at the rehabilitation center. Statistical analyses were performed using mixed models for repeated measures. We enrolled 60 patients between April 2017 and February 2021, of whom 29 were randomized to active cTBS and 31 to sham cTBS. One patient randomized to active cTBS withdrew consent before the intervention and was excluded from the analyses. The mean difference in the change in Action Research Arm Test score from baseline at 3 months poststroke was 9.6 points ([95% CI, 1.2-17.9]; P=0.0244) in favor of active cTBS. Active cTBS was associated with better scores on the modified Rankin Scale at 3 months (OR, 0.2 [95% CI, 0.1-0.8]; P=0.0225) and with an 18 days shorter length of stay at the rehabilitation center than sham cTBS ([95% CI, 0.0-36.4]; P=0.0494). There were no serious adverse events. Ten daily sessions of cTBS of the contralesional primary motor cortex combined with upper limb training, started within 3 weeks after stroke onset, promote recovery of the upper limb, reduce disability and dependence and leads to earlier discharge from the rehabilitation center. URL: https://trialsearch.who.int/; Unique identifier: NTR6133.