Upper-limb Motor Performance Research Articles

Effects of Repetitive Peripheral Sensory Stimulation in the Subacute and Chronic Phases After Stroke: Study Protocol for a Pilot Randomized Trial.

BackgroundRepetitive peripheral nerve sensory stimulation (RPSS) is a potential add-on intervention to motor training for rehabilitation of upper limb paresis after stroke. Benefits of RPSS were reported in subjects in the chronic phase after stroke, but there is limited information about the effects of this intervention within the 1st weeks or months. The primary goal of this study is to compare, in a head-to-head proof-of-principle study, the impact of a single session of suprasensory vs. subsensory RPSS on the upper limb motor performance and learning in subjects at different phases after stroke subacute and chronic phases and mild upper limb motor impairments after stroke. In addition, we examine the effects of RPSS on brain perfusion, functional imaging activation, and γ-aminobutyric acid (GABA) levels. Subjects with mild upper limb motor impairments will be tested with MRI and clinical assessment either at an early (7 days to 3 months post-stroke) or at a chronic (>6 months) stage after stroke.MethodsIn this multicenter, randomized, parallel-group, proof-of-principle clinical trial with blinded assessment of outcomes, we compare the effects of one session of suprasensory or subsensory RPSS in patients with ischemic or hemorrhagic stroke and upper limb paresis. Clinical assessment and MRI will be performed only once in each subject (either at an early or at a chronic stage). The primary outcome is the change in performance in the Jebsen–Taylor test. Secondary outcomes: hand strength, cerebral blood flow assessed with arterial spin labeling, changes in the blood oxygenation level-dependent (BOLD) effect in ipsilesional and contralesional primary motor cortex (M1) on the left and the right hemispheres assessed with functional MRI (fMRI) during a finger-tapping task performed with the paretic hand, and changes in GABA levels in ipsilesional and contralesional M1 evaluated with spectroscopy. The changes in outcomes will be compared in four groups: suprasensory, early; subsensory, early; suprasensory, chronic; and subsensory, chronic.DiscussionThe results of this study are relevant to inform future clinical trials to tailor RPSS to patients more likely to benefit from this intervention.Trial RegistrationNCT03956407.

A Tenodesis-Induced-Grip exoskeleton robot (TIGER) for assisting upper extremity functions in stroke patients: a randomized control study

Purpose This study was aimed toward developing a lightweight assisting tenodesis-induced-grip exoskeleton robot (TIGER) and to examine the performance of the TIGER in stroke patients with hemiplegia. Methods This was a single-blinded, randomized control trial with pre-treatment, immediate post-treatment, and 12-week follow-up assessments. Thirty-four stroke patients were recruited and randomized to either an experimental or control group, where each participant in both groups underwent 40 min of training. In addition to a 20-min bout of regular task-specific motor training, each participant in the experimental group received 20 min of TIGER training, and the controls received 20 min of traditional occupational therapy in each treatment session. Primary outcomes based on the Fugl-Meyer Motor Assessment of Upper Extremity (FMA-UE) were recorded. Results Thirty-two patients (94.1%) completed the study: 17 and 15 patients in the experimental and control groups, respectively. Significant beneficial effects were found on the total score (ANCOVA, p = 0.006), the wrist score (ANCOVA, p = 0.037), and the hand score (ANCOVA, p = 0.006) for the FMA-UE in the immediate post-treatment assessment of the participants receiving the TIGER training. Conclusion The TIGER has beneficial effects on remediating upper limb impairments in chronic stroke patients. Clinical trial registration: ClinicalTrials.gov; identifier NCT03713476 Implications for rehabilitation Based on use-dependent plasticity concepts, robot training with the more distal segments of the upper extremities has a beneficial effect in patients with chronic stroke. A novel lightweight assisting tenodesis-induced-grip exoskeleton robot (TIGER) system using a mechanism involving musculotendinous coordination of the wrist and hand was proposed in this study. Between-group differences in changes in the upper limb motor performance were observed in the experimental group as compared to patients in the control group. For patients with chronic stroke, receiving 20 min of TIGER training in conjunction with 20 min of task-specific motor training led to clinically important changes in motor control and functioning of the affected upper limb.

Upper limb dysfunction and activities in daily living in idiopathic normal pressure hydrocephalus

BackgroundIdiopathic normal pressure hydrocephalus (iNPH) is a neurodegenerative disease with a characteristic symptom triad of gait disturbance, cognitive decline, and incontinence. Recently, also dysfunctions in upper limbs have been described in iNPH and reported to improve after shunt surgery. We aim to describe the role of upper limb motor function in the clinical assessment of iNPH patients and its influence on activities of daily living (ADL).MethodsSeventy-five consecutive patients with probable iNPH were studied pre-operatively and at 3 and 12 months after shunt surgery. The pre-operative evaluation included lumbar drainage of cerebrospinal fluid (tap test). Motor functions were assessed in upper and lower limbs with Grooved Pegboard Test (GPT), Box & Block Test (BBT), Total Score of Gait (TSG), and balance test. ADL was assessed with Barthel’s index and cognition in accordance with the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD).ResultsPatients showed improvement in all motor tests and ADL at 3 months after shunt surgery. The improvement remained stable during the 12-month post-operative follow-up. The motor function tests correlated with each other and with ADL.ConclusionsA 3-month follow-up period after shunt surgery is adequate to show improvement in motor tasks, and a positive outcome will last for at least 12 months. A shunt-responsive dysfunction of upper limb motor performance plays a major role in ADL of iNPH patients. Therefore, we suggest an evaluation of upper limb motor performance to be included in routine evaluation of iNPH patients.

Impact of Sensory Deficits on Upper Limb Motor Performance in Individuals with Cerebral Palsy: A Systematic Review.

People living with cerebral palsy (CP) exhibit motor and sensory impairments that affect unimanual and bimanual functions. The importance of sensory functions for motor control is well known, but the association between motor and sensory functions remains unclear in people living with CP. The objective of this systematic review was to characterize the relationship between sensory deficits and upper limb motor function in individuals living with CP. Methods: Five databases were screened. The inclusion criteria were: (1) including people living with CP, (2) reporting measurements of upper limb motor and sensory functions. A qualitative analysis of the studies’ level of evidence was done. Results: Thirty-three articles were included. Twenty-five articles evaluated tactile functions, 10 proprioceptive functions and 7 visual functions; 31 of the articles reported on unimanual functions and 17 of them reported on bimanual functions. Tactile functions showed a moderate to high association; it was not possible to reach definitive conclusions for proprioceptive and visual functions. Conclusions: The heterogeneity of the results limits the ability to draw definitive conclusions. Further studies should aim to perform more comprehensive assessments of motor and sensory functions, to determine the relative contribution of various sensory modalities to simple and more complex motor functions.

Somatosensory discrimination impairment in children with hemiplegic cerebral palsy as measured by the sense_assess© kids.

To characterise somatosensory discrimination impairment of the upper-limb across domains of tactile discrimination, limb position sense and haptic object recognition using the sense_assess© kids and examine associations with upper-limb motor performance in children with hemiplegic cerebral palsy (CP). The sense_assess© kids was administered at one timepoint to 28 children, aged 6-15.5years (M=10.1, SD=2.4), with hemiplegic CP (right hemiplegia n=15) and Manual Ability Classification System Levels I (n=11) and II (n=17). Unimanual motor performance was quantified using the Box and Block Test. Tactile discrimination was impaired in 18, limb position sense in 20, and haptic object recognition was impaired in 21 of 28 children. Over 80% (23/28) of children had impaired somatosensory discrimination in one or more domains. Low to moderate correlations were observed between each measure of somatosensory discrimination and motor performance. Manual ability classification was associated with limb position sense and haptic object recognition. A moderate inverse correlation (r=-.57, p<.01) exists between the number of somatosensory domains impaired and motor performance. The frequency of somatosensory impairment in the upper limb of children in our sample was high and associated with manual ability, suggesting a need for routine assessment of somatosensation in this population.

Effects of attentional focus on upper extremity motor performance in post stroke patients: A randomized pilot study.

Introduction:To facilitate the command to the learner, therapist can use verbal cues for guidance: internal focus (own body) and external focus (consequence of movement in the environment).Objective:To examine the effects of different attentional focus on upper limb motor performance in post-stroke.Methods:Randomized controlled trial with 2 groups. Study realized at Integrated Clinic of the Faculty of Health Science at Trairi (Santa Cruz, Rio Grande do Norte, Brazil). Twelve participants allocated into 2 groups. Two motor tasks were used: task 1, reach-point; task 2, reach-grasp-fit, with the paretic extremity, using verbal commands directed by a trained therapist. In the first phase, Group 1 received commands with internal focus, while Group 2 was instructed with commands with external focus. After 1 week, the command type was changed between groups. The variables collected was movement time, velocity and number of peaks velocityResults:Both attentional focus promoted significant differences in movement time and velocity, however, only Internal Focus provided significant results in both tasks of the same variables.Discussion:The benefits of 1 attentional focus on the other are not fully confirmed. However, not receiving any kind of attention guidance compromises motor performance. The results support the hypothesis that the benefits of the External Focus are accentuated when preceded by the Internal Focus.Clinical Trial Registration:Research Ethics Committee of the Faculty of Helth Science at Trairi (Facisa - UFRN)- Number CAAE 2.625.609, approved on April 13, 2018; Brazilian Registry of Clinical Trials - RBR-4995cr approved on July 4, 2019 retrospectively registered (http://www.ensaiosclinicos.gov.br/rg/RBR-4995cr/).

Mapping grip force to motor networks

AimThere is ongoing debate about the role of cortical and subcortical brain areas in force modulation. In a whole-brain approach, we sought to investigate the anatomical basis of grip force whilst acknowledging interindividual differences in connectivity patterns. We tested if brain lesion mapping in patients with unilateral motor deficits can inform whole-brain structural connectivity analysis in healthy controls to uncover the networks underlying grip force. MethodsUsing magnetic resonance imaging (MRI) and whole-brain voxel-based morphometry in chronic stroke patients (n=55) and healthy controls (n=67), we identified the brain regions in both grey and white matter significantly associated with grip force strength. The resulting statistical parametric maps (SPMs) provided seed areas for whole-brain structural covariance analysis in a large-scale community dwelling cohort (n=977) that included beyond volume estimates, parameter maps sensitive to myelin, iron and tissue water content. ResultsThe SPMs showed symmetrical bilateral clusters of correlation between upper limb motor performance, basal ganglia, posterior insula and cortico-spinal tract. The covariance analysis with the seed areas derived from the SPMs demonstrated a widespread anatomical pattern of brain volume and tissue properties, including both cortical, subcortical nodes of motor networks and sensorimotor areas projections. ConclusionWe interpret our covariance findings as a biological signature of brain networks implicated in grip force. The data-driven definition of seed areas obtained from chronic stroke patients showed overlapping structural covariance patterns within cortico-subcortical motor networks across different tissue property estimates. This cumulative evidence lends face validity of our findings and their biological plausibility.

Fronto-parietal involvement in chronic stroke motor performance when corticospinal tract integrity is compromised

BackgroundPreserved integrity of the corticospinal tract (CST) is a marker of good upper-limb behavior and recovery following stroke. However, there is less understanding of neural mechanisms that might help facilitate upper-limb motor recovery in stroke survivors with extensive CST damage. ObjectiveThe purpose of this study was to investigate resting state functional connectivity in chronic stroke survivors with different levels of CST damage and to explore neural correlates of greater upper-limb motor performance in stroke survivors with compromised ipsilesional CST integrity. MethodsThirty chronic stroke survivors (24 males, aged 64.7 ± 10.8 years) participated in this study. Three experimental sessions were conducted to: 1) obtain anatomical (T1, T2) structural (diffusion) and functional (resting state) MRI sequences, 2) determine CST integrity with transcranial magnetic stimulation (TMS) and conduct assessments of upper-limb behavior, and 3) reconfirm CST integrity status. Participants were divided into groups according to the extent of CST damage. Those in the extensive CST damage group did not show TMS evoked responses and had significantly lower ipsilesional fractional anisotropy. ResultsOf the 30 chronic stroke survivors, 12 were categorized as having extensive CST damage. Stroke survivors with extensive CST damage had weaker functional connectivity in the ipsilesional sensorimotor network and greater functional connectivity in the ipsilesional fronto-parietal network compared to those with preserved CST integrity. For participants with extensive CST damage, improved motor performance was associated with greater functional connectivity of the ipsilesional fronto-parietal network and higher fractional anisotropy of the ipsilesional rostral superior longitudinal fasciculus. ConclusionsStroke survivors with extensive CST damage have greater resting state functional connectivity of an ipsilesional fronto-parietal network that appears to be a behaviorally relevant neural mechanism that improves upper-limb motor performance.

Fugl-Meyer Assessment Scores Are Related With Kinematic Measures in People with Chronic Hemiparesis after Stroke

Background: Stroke often results in motor impairment and limited functional capacity. This study aimed to verify the relationship between widely used clinical scales and instrumented measurements to evaluate poststroke individuals with mild, moderate, and severe motor impairment. Methods: This cross-sectional study included 34 participants with chronic hemiparesis after stroke. Fugl-Meyer Assessment and Modified Ashworth Scale were used to quantify upper and lower limb motor impairment and the resistance to passive movement (i.e., spasticity), respectively. Upper limb Motor performance (movement time and velocities) and movement quality (range of motion, smoothness and trunk displacement) were analyzed during a reaching forward task using an optoelectronic system (instrumented measurement). Lower limb motor performance (gait and functional mobility parameters) was assessed by using an inertial measurement unit system. Findings: Fugl-Meyer Assessment correlated with motor performance (upper and lower limbs) and with movement quality (upper limb). Modified Ashworth scale correlated with movement quality (upper limb). Cutoff values of 9.0 cm in trunk anterior displacement and .57 m/s in gait velocity were estimated to differentiate participants with mild/moderate and severe compromise according to the Fugl-Meyer Assessment. Conclusions: These results suggest that the Fugl-Meyer Assessment can be used to infer about motor performance and movement quality in chronic poststroke individuals with different levels of impairment.

Effects of Noisy Galvanic Vestibular Stimulation During a Bimanual Tracking Robotic Task.

BackgroundNoisy galvanic vestibular stimulation (nGVS) has been shown to improve motor performance in people with and without disabilities. Previous investigations on the use of nGVS to improve upper-limb motor performance have focused on unimanual fine motor movements, nevertheless, bimanual gross movements are also essential for conducting activities of daily living and can be affected as a result of cerebral dysfunction. Consequently, in this study we investigated the effects of nGVS on bimanual gross motor performance.MethodsTwelve healthy participants completed a visuomotor task in which they performed bimanual upper-limb movements using two robots. During the task, participants tracked a target that oscillated following a sinusoidal amplitude-modulated trajectory. In half of the trials, participants received subthreshold nGVS, in the other half, they received sham stimulation. Primary outcome measure: percent improvement in root mean square error (RMSE) between the target’s and cursors’ trajectories. Secondary outcome measures: percent improvement in lag between the cursors and target; and percent improvement in RMSE between the cursors’ trajectories. A post-test questionnaire was administered to evaluate the experience of participants.ResultsTracking error was not affected by nGVS: left −2.6(5.5)%, p = 0.128; right −0.9(6.2)%, p = 0.639; nor was bimanual coordination −1.5(9.6)%, p = 0.590. When comparing if one hand was affected more than the other, we did not find a statistically significant difference (−1.7(3.3)%, p = 0.098). Similar results were found for the lag. Questionnaire results indicated that the robotic devices did not limit participants’ movements, did not make participants feel unsafe, nor were they difficult to control. Furthermore, participants did not feel unsafe with the nGVS device, nor did they report any discomfort due to nGVS.ConclusionResults suggest that nGVS applied to people without disabilities do not affect bimanual gross motor performance. However, as this was the first study to investigate such effects, stimulation parameters were based on previous unimanual fine motor studies. Future studies should investigate optimal stimulation parameters for improving upper-limb gross motor performance. Overall, participants felt safe using the robotic devices and receiving the noisy electrical stimulation. As such, a similar setup could potentially be employed for subsequent studies investigating the relation between upper-limb performance and nGVS.

The effect of transcranial direct current stimulation on upper limb motor performance in Parkinson's disease: a systematic review.

Parkinson's disease (PD) reduces independence and quality of life through deterioration of upper limb motor function. Transcranial direct current stimulation (tDCS) may offer an alternative, adjunctive therapy for PD. However, the efficacy of tDCS for upper limb motor rehabilitation in PD is unknown. In this systematic review, evidence is compiled regarding the effects of tDCS on upper limb motor function in PD. Studies of tDCS applied to PD patients that assessed upper limb motor function, conducted between January 2000 and November 2018, were screened for inclusion via a systematic search of Medline, Cochrane, PsycINFO, EMBASE, CINAHL, and Web of Science. Ten out of 606 studies were included and their findings synthesized into five categories regarding the effects of tDCS on: (1) Unified Parkinson's Disease Rating Scale motor section (UPDRS III), (2) upper limb motor tasks, (3) manual dexterity, (4) reaction time, and (5) neurophysiology. When applied to the primary motor cortex, tDCS may improve UPDRS III and the speed and force of movement. Considerable variation was found in tDCS parameters and further study is needed to clarify the long-term effects of tDCS on both simple and complex motor tasks and to compile relevant neurophysiological evidence.

Effects of Local Ischemic Compression on Upper Limb Latent Myofascial Trigger Points: A Study of Subjective Pain and Linear Motor Performance.

Objective To analyse the effect of the manual ischemic compression (IC) on the upper limb motor performance (MP) in patients with LTrPs. Materials and Methods A quasiexperimental study was performed in twenty subjects allocated to either patients group with LTrPs (PG, n=10) or healthy group with no symptoms (HG, n=10). Subjective pain and linear MP (movement time and Fitts' Law) were assessed before and after a linear tapping task. Data were analysed with mixed factorial ANOVA for intergroup linear motor performance differences and dependent t-student test for intragroup pain differences. Results PG had a linear MP lower than the HG before treatment (p < 0.05). After IC, the PG showed a significant decrease of pain (4.07 ± 1.91 p < 0.001). Furthermore, the movement time (15.70 ± 2.05 p < 0.001) and the Fitts' Law coefficient (0.80 ± 0.53 p < 0.001) were significantly reduced. However, one IC session did not allow the PG to get the same MP than the HG (p < 0.05). Conclusion The results suggest the IC effectiveness on pain and MP impairment in subjects with LTrPs. However, the MP of these patients is only partially improved after the IC application.

Abstract WP189: Safety and Preliminary Efficacy of Cathodal Transcranial Direct Current Stimulation to Enhance Upper Limb Motor Function Early After Ischemic Stroke: a Double-blind, Randomized Clinical Trial

Introduction: Transcranial direct current stimulation (tDCS) has the potential to improve upper limb motor outcomes after stroke. Objective: To evaluate the safety and preliminary efficacy of active cathodal compared to sham tDCS of the primary motor cortex of the unaffected hemisphere (ctDCSM1 UH ), within 72 hours to 6 weeks post-ischemic stroke. Methods: In this randomized, double-blind study, 30 patients with unilateral hand paresis were assigned to either active or sham ctDCSM1 UH as add-on interventions to rehabilitation. The primary outcome was the frequency of adverse events. Secondary outcomes, compared before, immediately after treatment and three months later, included measures of upper limb motor performance and quality of life. Stroke volume was assessed before and after treatment. Results: Overall, tDCS was well tolerated and there were no serious adverse events. One subject in the active group reported paresthesias in the paretic arm during the first session of ctDCSM1 UH . Heart rate increased significantly after active and decreased significantly after sham ctDCSM1 UH but these changes were not clinically significant. Upper limb motor impairment and quality of life improved significantly more in the sham than in the active group at three months post-treatment according to intention-to-treat and per-protocol analyses. The between-group difference in motor impairment was not clinically relevant. There were no recurrent strokes and lesion volumes did not increase significantly in either group. Conclusions: Active ctDCSM1 UH was safe and well tolerated but the preliminary efficacy results do not support a beneficial role of this intervention within the first six weeks after stroke.

Abstract 114: Biomarkers for Patient Selection Improve Stroke Rehabilitation Trial Efficiency

There is high inter-individual variability in recovery after stroke, which reduces statistical power in rehabilitation trials. This could be addressed by using biomarkers for patient selection. Corticospinal tract function assessed with transcranial magnetic stimulation (TMS) is a candidate biomarker for trials aiming to improve upper-limb motor recovery. Patients in whom TMS can elicit motor evoked potentials (MEPs) have a functionally intact lateral corticospinal tract and better motor recovery. We used an existing data set to estimate the sample sizes required to detect rehabilitation benefits on upper-limb motor performance 90 days after stroke. Baseline clinical assessments were made and MEP status of the paretic upper-limb determined within 7 days post-stroke. Upper-limb Fugl-Meyer (UE-FM) and Action Research Arm Test (ARAT) scores were obtained 90 days after stroke. Analyses were carried out for the full sample, and repeated for the MEP+ subset. Population estimates of the UE-FM and ARAT scores 90 days post-stroke were used to calculate the sample sizes required to detect clinically meaningful treatment effects of 7 points on the UE-FM and ARAT scores. Baseline and 90-day assessments were completed by 207 patients (103 women, mean 70.6 SD 15.1 years). The full sample and MEP+ subset (n=177) had similar demographic and baseline clinical characteristics. The estimated required sample sizes to detect treatment effects for MEP+ patients were only 27-29% of those for the full sample of patients. The estimated percentage of patients who are MEP+ was 85.5% (95%CI 81.2%-89.9%). Biomarkers could be used to enrich samples for stroke rehabilitation trials. Selecting patients on the basis of MEP status reduces variance, thereby reducing required sample size by around 75% without significantly limiting the pool of participants. Using biomarkers for patient selection could markedly increase rehabilitation trial sensitivity and efficiency, with associated decreases in costs and time required for completion.

Motion Tracking for Quantitative and Qualitative Assessment of Upper Limb Movements Following Acromioclavicular Joint Ligament Reconstruction: A Pilot Study

Background: Technological tools as robotic devices and wearable sensors can provide accurate and repeatable measurements of physical variables (e.g., position, velocities, forces) which can be used for quantitative and qualitative assessment of movement analysis and upper limb motor performance. Objective: The study aims to propose a quantitative and qualitative assessment of upper limb motor performance by means of seven kinematic parameters recorded by a passive mechatronic device in patients who underwent a surgical procedure for ligament reconstruction following acromioclavicular joint dislocation. Method: Five patients (mean age: 40 ± 12 years) with acromioclavicular joint dislocation were enrolled. A passive end-effector mechatronic device characterized by 7 degrees of freedom and designed for the assessment of upper limb motor performance - especially for measuring the hand position in three-dimensional space - was used. The Constant-Murley score and seven kinematic parameters were used as clinical outcome measure and quantitative and qualitative assessment, respectively. Results: The preliminary results of this study show no significant differences between the impaired arm and unimpaired arm: the end-effector passive mechatronic device used in this study is able to provide an overall assessment of the upper limb motor performance following shoulder impairment. Conclusion: The motion tracker can be easily used as effective tool for quantitative and qualitative assessment of upper limb motor performance, even several years after the surgical operation.

Action observation for upper limb rehabilitation after stroke.

Action observation (AO) is a physical rehabilitation approach that facilitates the occurrence of neural plasticity through the activation of the mirror-neural system, promoting motor recovery in people with stroke. To assess whether action observation enhances motor function and upper limb motor performance and cortical activation in people with stroke. We searched the Cochrane Stroke Group Trials Register (last searched 4 September 2017), the Central Register of Controlled Trials (24 October 2017), MEDLINE (1946 to 24 October 2017), Embase (1974 to 24 October 2017) and five additional databases. We also searched trial registries and reference lists. Randomized controlled trials (RCTs) of AO, alone or associated with physical practice in adults after stroke. The primary outcome was upper limb motor function. Secondary outcomes included dependence on activities of daily living (ADL), motor performance, cortical activation, quality of life, and adverse effects. Two review authors independently selected trials according to the pre-defined inclusion criteria, extracted data, assessed risk of bias, and applied the GRADE approach to assess the quality of the evidence. The reviews authors contacted trial authors for clarification and missing information. We included 12 trials involving 478 individuals. A number of trials showed a high risk of bias and others an unclear risk of bias due to poor reporting. The quality of the evidence was 'low' for most of the outcomes and 'moderate' for hand function, according to the GRADE system. In most of the studies, AO was followed by some form of physical activity. the impact of AO on arm function showed a small significant effect (standardized mean difference (SMD) 0.36, 95% CI 0.13 to 0.60; 8 studies; 314 participants; low-quality evidence); and a large significant effect (mean difference (MD) 2.90, 95% CI 1.13 to 4.66; 3 studies; 132 participants; moderate-quality evidence) on hand function. there was a large significant effect for ADL outcome (SMD 0.86, 95% CI 0.11 to 1.61; 4 studies, 226 participants; low-quality evidence). We were unable to pool other secondary outcomes to extract the evidence. Only two studies reported adverse effects without significant adverse AO events. We found evidence that AO is beneficial in improving upper limb motor function and dependence in activities of daily living (ADL) in people with stroke, when compared with any control group; however, we considered the quality of the evidence to be low. We considered the effect of AO on hand function to be large, but it does not appear to be clinically relevant, although we considered the quality of the evidence as moderate. As such, our confidence in the effect estimate is limited because it will likely change with future research.

EEG predicts upper limb motor improvement after robotic rehabilitation in chronic stroke patients

Robotic rehabilitation is known to be at least as effective as conventional training for upper limb motor recovery after stroke; nevertheless, which patients could benefit from this treatment is unknown and finding markers that could predict rehabilitation outcome is a challenge. We aimed at understanding the neural mechanisms of motor function recovery after upper limb robotic rehabilitation in chronic stroke patients using neurophysiological markers obtained by electroencephalography recording (EEG). Fourteen chronic stroke patients (M/F: 11/3; 59.5 ± 13 yrs) with mild to moderate upper limb paresis were subjected to 10 sessions of upper limb rehabilitation with a planar mobile robotic device (MOTORE, Humanware). Fugl–Meyer Assessment Scale (FMAS) and Wolf Motor Function Test (WMFT) were administered before (t0), at the end (t1) and at 1 month follow-up (t2); at the same timing 64-channals EEG was recorded. We analyzed power spectrum density in different frequency bands of the affected and unaffected hemispheres with 64-ch EEG and their correlation with motor impairment as measured by clinical scales. Correlation analyses were performed to identify the indicators of good rehabilitative outcome. Clinical assessment indicated a significant functional improvement in upper limb motor function at the end of rehabilitation as assessed with FMAS and WMFT score that is maintained at follow-up. We found a positive correlation between global Alpha activity at t0 and WMFT score variation (t0–t1) and between global Beta activity at t0 and WMFT time variation (t0–t1) and a positive correlation between Beta activity at t0 in the unaffected hemisphere and FMAS variation (t0–t1 and t0–t2). Robotic rehabilitation improves upper limb motor performance in stroke patients even in the chronic phase. The amount of Alpha and Beta band power at t0 is suggestive of rehabilitation-related motor outcome. Our results suggest that EEG recording preliminarily to robotic rehabilitation could help identifying good responders to treatment thus optimizing results.

Reliability, validity and discriminant ability of the instrumental indices provided by a novel planar robotic device for upper limb rehabilitation

BackgroundIn the last few years, there has been an increasing interest in the use of robotic devices to objectively quantify motor performance of patients after brain damage. Although these robot-derived measures can potentially add meaningful information about the patient’s dexterity, as well as be used as outcome measurements after the rehabilitation treatment, they need to be validated before being used in clinical practice. The present work aims to evaluate the reliability, the validity and the discriminant ability of the metrics provided by a novel robotic device for upper limb rehabilitation.MethodsForty-eight patients with sub-acute stroke and 40 age-matched healthy subjects were involved in this study. Clinical evaluation included: Fugl-Meyer Assessment for the upper limb, Action Research Arm Test, and Barthel Index. Robotic evaluation of the upper limb performance consisted of 14 measures of motor ability quantifying the dexterity in performing planar reaching movements. Patients were evaluated twice, one day apart, to assess the reliability of the robotic metrics, using the Intraclass Correlation Coefficient. Validity was assessed by analyzing the correlation of the robotic metrics with the clinical scales, by means of the Spearman’s Correlation Coefficient. Finally, the ability of the robotic metrics to distinguish between patients with stroke and healthy subjects was investigated with t-tests and the Effect Size.ResultsReliability was found to be excellent for 12 measures and from moderate to good for the remaining 2. Most of the robotic indices were strongly correlated with the clinical scales, while a few showed a moderate correlation and only one was not correlated with the Barthel Index and weakly correlated with the remain two. Finally, all but one the provided metrics were able to discriminate between the two groups, with large effect sizes for most of them.ConclusionWe found that all the robotic indices except one provided by a novel robotic device for upper limb rehabilitation are reliable, sensitive and strongly correlated both with motor and disability clinical scales. Therefore, this device is suitable as evaluation tool for the upper limb motor performance of patients with sub-acute stroke in clinical practice.Trial registrationNCT02879279.

Upper limb muscle activation during sports video gaming of persons with spinal cord injury

Objective Video gaming as a therapeutic tool has largely been studied within the stroke population with some benefits reported in upper limb motor performance, balance, coordination, and cardiovascular status. To date, muscle activation of upper limb muscles in persons with spinal cord injuries (SCI) has not been studied during video game play. In this paper, we provide descriptive and comparative data for muscle activation and strength during gaming for players with tetraplegia and paraplegia, as well as, compare these results with data from traditional arm exercises (ie, biceps curl and shoulder press) with light weights which are commonly prescribed for a home program. Participants Fourteen individuals with chronic SCI (9 tetraplegia, 5 paraplegia). Design We measured upper limb muscle activation with surface electromyography (EMG) during Wii Sports video game play. Muscle activation was recorded from the playing arm during 4 selected games and normalized to a maximum voluntary contraction (MVC). Outcome measures Heart rate and upper limb motion were recorded simultaneously with EMG. Wilcoxon signed rank tests were used to analyze differences in muscle activation between participants with paraplegia versus tetraplegia and compare gaming with traditional arm exercises with light weights. A Friedman 2-way analysis of variance identified key muscle groups active during game play. Results Overall muscle activation across the games was not different between those with paraplegia and tetraplegia. Heart rate during video game play for tennis and boxing were on average 10 to 20 beats/minute above resting heart rate. The magnitude of EMG was relatively greater for traditional arm exercises with light weights compared with game play. Conclusion The selected Wii games were able to elicit upper extremity muscle activation and elevated heart rates for individuals with SCI that may be used to target therapeutic outcomes.

Mapping upper-limb motor performance after stroke - a novel method with utility for individualized motor training

BackgroundChronic upper limb motor impairment is a common outcome of stroke. Therapeutic training can reduce motor impairment. Recently, a growing interest in evaluating motor training provided by robotic assistive devices has emerged. Robot-assisted therapy is attractive because it provides a means of increasing practice intensity without increasing the workload of physical therapists. However, movements practised through robotic assistive devices are commonly pre-defined and fixed across individuals. More optimal training may result from individualizing the selection of the trained movements based on the individual’s impairment profile. This requires quantitative assessment of the degree of the motor impairment prior to training, in relevant movement tasks. However, standard clinical measures for profiling motor impairment after stroke are often subjective and lack precision. We have developed a novel robot-mediated method for systematic and fine-grained mapping (or profiling) of individual performance across a wide range of planar arm reaching movements. Here we describe and demonstrate this mapping method and its utilization for individualized training. We also present a novel principle for the individualized selection of training movements based on the performance maps.Methods and ResultsTo demonstrate the utility of our method we present examples of 2D performance maps produced from the kinetic and kinematics data of two individuals with stroke-related upper limb hemiparesis. The maps outline distinct regions of high motor impairment. The procedure of map-based selection of training movements and the change in motor performance following training is demonstrated for one participant.ConclusionsThe performance mapping method is feasible to produce (online or offline). The 2D maps are easy to interpret and to be utilized for selecting individual performance-based training. Different performance maps can be easily compared within and between individuals, which potentially has diagnostic utility.