Recovery of hand function through mental practice: A study protocol Cortico-spinal excitability and hand motor recovery in stroke: a longitudinal study Sensory Loss in Hospital-Admitted People With Stroke: Characteristics, Associated Factors, and Relationship With Function How Physically Active Are People with Stroke in Physiotherapy Sessions Aimed at Improving Motor Function? A Systematic Review Inter-individual Variability in the Capacity for Motor Recovery After Ischemic Stroke Best Conventional Therapy Versus Modular Impairment-Oriented Training for Arm Paresis After Stroke: A Single-Blind, Multicenter Randomized Controlled Trial Impairment–oriented training and adaptive motor cortex reorganisation after stroke: a fTMS study Effects of Computer-Aided Interlimb Force Coupling Training on Paretic Hand and Arm Motor Control following Chronic Stroke: A Randomized Controlled Trial Mental practice with motor imagery in stroke recovery: randomized controlled trial of efficacy Arm Motor Recovery Using a Virtual Reality Intervention in Chronic Stroke A pilot study of activity-based therapy in the arm motor recovery post stroke: a randomized controlled trial Factors Influencing Stroke Survivors' Quality of Life During Subacute Recovery Prognostic value of motor evoked potentials in motor function recovery of upper limb after stroke. Change of strength and rate of rise of tension relate to functional arm recovery after stroke. Comparing unilateral and bilateral upper limb training: The ULTRA-stroke program design
Background The study aims to assess the therapeutic benefits of motor imagery training in stroke patients with persistent motor weakness . There is evidence to suggest that mental rehearsal of movement can produce effects normally attributed to practising the actual movements . Imagining h and movements could stimulate the redistribution of brain activity , which accompanies recovery of h and function , thus result ing in a reduced motor deficit . Methods / Design A multi-centre r and omised controlled trial recruiting individuals between one and six months post-stroke ( n = 135 ) . Patients are assessed before and after a four-week evaluation period . In this trial , 45 patients daily mentally rehearse movements with their affected arm under close supervision . Their recovery is compared to 45 patients  who perform closely supervised non-motor mental rehearsal , and 45 patients  who are not engaged in a training program . Motor imagery training effectiveness is evaluated using outcome measures of motor function , psychological processes , and level of disability . Discussion The idea of enhancing motor recovery through the use of motor imagery rehabilitation techniques is important with potential implication s for clinical practice . The techniques evaluated as part of this r and omised controlled trial are informed by the current underst and ing in cognitive neuroscience and the trial is both of scientific and applied interest Objective To describe the relationship between changes of cortico-spinal excitability and motor recovery of the affected h and after stroke . Methods Eighteen hemiparetic stroke patients with a severe-to-mild upper limb motor impairment were r and omized .  Cortico-spinal excitability measures ( resting motor thresholds and motor evoked potentials )  obtained from a distal ( abductor pollicis brevis ) and proximal ( biceps brachii ) upper limb muscle were assessed for both hemispheres . Motor function of the affected h and was tested by the Wolf Motor Function and Action Research Arm tests . The evaluations were performed at baseline and weekly over 7 weeks of in-patient neurological rehabilitation . Results Severe h and dysfunction was associated with a strong suppression of ipsilesional cortico-spinal excitability and a shift of excitability towards the contralesional hemisphere . Mild h and impairment was associated with a shift of cortico-spinal excitability towards the ipsilesional hemisphere . Favorable motor recovery correlated with an increase of ipsilesional cortico-spinal excitability Objective : To characterize the nature of sensory impairments after stroke , identify associated factors , and assess the relationships between sensory impairment , disability , and recovery . Methods : Prospect i ve cross-sectional survey of 102 people with hemiparesis following their first stroke .  Tactile and proprioceptive sensation  in the affected arm and leg were measured using the Rivermead Assessment of Somatosensory Perception 2 - 4 weeks post-stroke . Demographics , stroke pathology , weakness , neglect , disability , and recovery were documented . Results : Tactile impairment was more common than proprioceptive ( P < .000 ) , impairment of discrimination was more common than detection ( P < .000 ) , and tactile sensation was more severely impaired in the leg than the arm ( P < .000 ) . No difference in proprioception between the arm and leg ( P = .703 ) or between proximal and distal joints ( P = .589 , P = .705 ) was found . The degree of weakness and the degree of stroke severity were significantly associated with sensory impairment ; demographics , stroke side and type , and neglect were not associated . All the sensory modalities were significantly related to independence , mobility , and recovery ( r = 0.287 [ P < .011 ] to r = 0.533 [ P < .000 ] ) . Conclusion : Sensory impairments of all modalities are common after stroke , although tactile impairment is more frequent than proprioceptive loss , especially in the leg . They are associated with the degree of weakness and the degree of stroke severity but not demographics , stroke pathology , or neglect , and they are related to mobility , independence in activities of daily living , and recovery Background . Targeted physical activity drives functional recovery after stroke . This review aim ed to determine the amount of time stroke survivors spend physically active during physiotherapy sessions . Summary of Review . A systematic search was conducted to identify published studies that investigated the use of time by people with stroke during physiotherapy sessions . Seven studies were included ; six observational and one r and omised controlled trial . People with stroke were found to be physically active for an average of 60 percent of their physiotherapy session duration . The most common activities practice d in a physiotherapy session were walking , sitting , and st and ing with a mean ( SD ) practice time of 8.7 ( 4.3 ) , 4.5 ( 4.0 ) , and 8.3 ( 2.6 ) minutes , respectively . Conclusion . People with stroke were found to spend less than two-thirds of their physiotherapy sessions duration engaged in physical activity . In light of dosage studies , practice time may be insufficient to drive optimal motor recovery Background . Motor recovery after stroke is predicted only moderately by clinical variables , implying that there is still a substantial amount of unexplained , biologically meaningful variability in recovery . Regression diagnostics can indicate whether this is associated simply with Gaussian error or instead with multiple sub population s that vary in their relationships to the clinical variables . Objective . To perform regression diagnostics on a linear model for recovery versus clinical predictors . Methods . Forty-one patients with ischemic stroke were studied . Impairment was assessed using the upper extremity Fugl-Meyer Motor Score . Motor recovery was defined as the change in the upper extremity Fugl-Meyer Motor Score from 24 to 72 hours after stroke to 3 or 6 months later . The clinical predictors in the model were age , gender , infa rct location ( subcortical vs cortical ) , diffusion weighted imaging infa rct volume , time to re assessment , and acute upper extremity Fugl-Meyer Motor Score . Regression diagnostics included a Kolmogorov-Smirnov test for Gaussian errors and a test for outliers using Studentized deleted residuals . Results . In the r and om sample , clinical variables explained only 47 % of the variance in recovery . Among the patients with the most severe initial impairment , there was a set of regression outliers who recovered very poorly . With the outliers removed , explained variance in recovery increased to 89 % , and recovery was well approximated by a proportional relationship with initial impairment ( recovery ≅ 0.70 × initial impairment ) . Conclusions . Clinical variables only moderately predict motor recovery . Regression diagnostics demonstrated the existence of a sub population of outliers with severe initial impairment who show little recovery . When these outliers were removed , clinical variables were good predictors of recovery among the remaining patients , showing a tight proportional relationship to initial impairment Background . The study investigated whether passive splinting or active motor training as either individualized best conventional therapy or as st and ardized impairment-oriented training ( IOT ) would be superior in promoting motor recovery in subacute stroke patients with mildly or severely paretic arms . Methods . A total of 148 anterior circulation ischemic stroke patients were r and omly assigned to 45 minutes of additional daily arm therapy over 3 to 4 weeks as either ( a ) passive therapy with inflatable splints or active arm motor therapy as either ( b ) individualized best conventional therapy ( CONV ) or ( c ) st and ardized IOT , that is Arm BASIS training for severe paresis or Arm Ability training for mild paresis . Main outcome measures included the following : Fugl-Meyer arm motor score ( severely paretic arms ) and the TEMPA time scores ( mildly affected arms ) . Pre — post ( immediate effects ) and pre—4 weeks follow-up analyses ( long-term effects ) were performed . Results . Overall improvements were documented ( mean baseline and change scores efficacy : Fugl-Meyer , arm motor scores , 24.4 , + 9.1 points ; TEMPA , 119 , −26.6 seconds ; P < .0001 ) , but with no differential effects between splint therapy and the combined active motor rehabilitation groups . Both efficacy and effectiveness analyses indicated , however , bigger immediate motor improvements after IOT as compared with best conventional therapy ( Fugl-Meyer , arm motor scores : IOT + 12.3 , CONV + 9.2 points ; TEMPA : IOT −31.1 seconds , CONV −20.5 seconds ; P = .0363 ) ; for mildly affected patients long-term effects could also be substantiated . Conclusions . Specificity of active training seemed more important for motor recovery than intensity ( therapy time ) . The comprehensive modular IOT approach promoted motor recovery in patients with either severe or mild arm paresis Abstract In a sample of 28 subacute anterior circulation ischemic stroke patients with severe arm paresis , reduced motor cortex excitability ( increased motor thresholds , reduced MEP amplitudes , reduced number of active points ) and a reduced conduction velocity in the corticospinal system were found in the affected hemisphere . At the same time motor cortex topology for the abductor pollicis brevis ( APB ) representation was comparable for the affected and non – affected hemisphere . Considerable arm motor recovery ( Fugl – Meyer test ) was observed when assessed four weeks later after a period of rehabilitation intervention . Motor cortex excitability and conduction velocity in the corticospinal system improved in the affected hemisphere . In addition , APB representation showed a medial shift in patients with such a representation at pre test ( n = 14 ) . Multiple stepwise regression indicated that of all transcranial magnetic stimulation ( TMS ) parameters only the medial shift of the motor cortex map predicted motor recovery . Assessing the effect of training time ( nonintensified vs. intensified therapy ) and type of arm training ( Bobath approach vs. Arm BASIS training ) with a r and omised controlled design revealed that the impairment – oriented Arm BASIS training improved motor control more than the control conditions . In addition , patients of the group receiving the Arm BASIS training with an APB representation at pre test showed a medial shift of the motor cortex map and improved conduction times . In conclusion , changes in motor cortex topology were likely to be relevant for motor recovery and might have been induced by the impairment – oriented training Objective We investigated the training effects of interlimb force coupling training on paretic upper extremity outcomes in patients with chronic stroke and analyzed the relationship between motor recovery of the paretic h and , arm and functional performances on paretic upper limb . Design A r and omized controlled trial with outcome assessment at baseline and after 4 weeks of intervention . Setting Taipei Veterans General Hospital , National Yang-Ming University . Participants Thirty-three subjects with chronic stroke were recruited and r and omly assigned to training ( n = 16 ) and control groups ( n = 17 ) . Interventions The computer-aided interlimb force coupling training task with visual feedback included different grip force generation methods on both h and s. Main Outcome Measures The Barthel Index ( BI ) , the upper extremity motor control Fugl-Meyer Assessment ( FMA-UE ) , the Motor Assessment Score ( MAS ) , and the Wolf Motor Function Test ( WMFT ) . All assessment s were executed by a blinded evaluator , and data management and statistical analysis were also conducted by a blinded research er . Results The training group demonstrated greater improvement on the FMA-UE ( p<.001 ) , WMFT ( p<.001 ) , MAS ( p = .004 ) and BI ( p = .037 ) than the control group after 4 weeks of intervention . In addition , a moderate correlation was found between the improvement of scores for h and scales of the FMA and other portions of the FMA UE ( r = .528 , p = .018 ) or MAS ( r = .596 , p = .015 ) in the training group . Conclusion Computer-aided interlimb force coupling training improves the motor recovery of a paretic h and , and facilitates motor control and enhances functional performance in the paretic upper extremity of people with chronic stroke . Trial Registration Clinical Trials.gov NCT02247674 This r and omized controlled trial evaluated the therapeutic benefit of mental practice with motor imagery in stroke patients with persistent upper limb motor weakness . There is evidence to suggest that mental rehearsal of movement can produce effects normally attributed to practising the actual movements . Imagining h and movements could stimulate restitution and redistribution of brain activity , which accompanies recovery of h and function , thus result ing in a reduced motor deficit . Current efficacy evidence for mental practice with motor imagery in stroke is insufficient due to method ological limitations . This r and omized controlled sequential cohort study included 121 stroke patients with a residual upper limb weakness within 6 months following stroke ( on average <3 months post-stroke ) . R and omization was performed using an automated statistical minimizing procedure . The primary outcome measure was a blinded rating on the Action Research Arm test . The study analysed the outcome of 39 patients involved in 4 weeks of mental rehearsal of upper limb movements during 45-min supervised sessions three times a week and structured independent sessions twice a week , compared to 31 patients who performed equally intensive non-motor mental rehearsal , and 32 patients receiving normal care without additional training . No differences between the treatment groups were found at baseline or outcome on the Action Research Arm Test ( ANCOVA statistical P = 0.77 , and effect size partial η2 = 0.005 ) or any of the secondary outcome measures . Results suggest that mental practice with motor imagery does not enhance motor recovery in patients early post-stroke . In light of the evidence , it remains to be seen whether mental practice with motor imagery is a valid rehabilitation technique in its own right Introduction . Despite interest in virtual environments ( VEs ) for poststroke arm motor rehabilitation , advantages over physical environment ( PE ) training have not been established . Objective . The authors compared kinematic and clinical outcomes of dose-matched upper-limb training between a 3D VE and a PE in chronic stroke . Methods : Participants ( n = 32 ) were r and omized to a 3D VE or PE for training . They pointed to 6 workspace targets ( 72 trials , 12 trials/target , r and omized ) for 12 sessions over 4 weeks with similar feedback on precision , movement speed , and trunk displacement . Primary ( kinematics , clinical arm motor impairment ) and secondary ( activity level , arm use ) outcomes were compared by time ( PRE , POST , and follow-up , RET ) , training environment , and impairment severity ( mild , moderate-to-severe ) using mixed-model analyses of variance ( ANOVAs ) . Results . Endpoint speed , overall performance on a reach-to-grasp task , and activity levels increased in both groups . Only participants in the VE group improved shoulder horizontal adduction at POST ( 9.5 ° ) and flexion at both POST ( 6.3 ° ) and RET ( 13 ° ) . Impairment level affected outcomes . After VE training , the mild group increased elbow extension ( RET , 25.5 ° ) . The moderate-to-severe group in VE increased arm use at POST ( 0.5 points ) and reaching ability at RET ( 2.2 points ) . The moderate-to-severe group training in PE  increased reaching ability earlier ( POST , 1.7 points ) and both elbow extension ( 10.7 ° ) and arm use ( 0.4 points ) at RET , but these changes were accompanied by increased compensatory trunk displacement ( RET , 30.2 mm ) . Conclusion . VE training led to more changes in the mild group and a motor recovery pattern in the moderate-to-severe group indicative of less compensation , possibly because of a better use of feedback Objective : To determine the efficacy of activity-based therapies using arm ergometer or robotic or group occupational therapy for motor recovery of the paretic arm in patients with an acute stroke ( ≤4 weeks ) admitted to an inpatient rehabilitation facility , and to obtain information to plan a large r and omized controlled trial . Design : Prospect i ve , r and omized controlled study . Setting : Stroke unit in a rehabilitation hospital . Subjects : Thirty patients with an acute stroke ( ≤4 weeks ) who had arm weakness ( Medical Research Council grade 2 or less at the shoulder joint ) . Intervention : Occupational therapy ( OT ) group ( control ) ( n = 10 ) , arm ergometer ( n = 10 ) or robotic ( n = 10 ) therapy group . All patients received st and ard , inpatient , post-stroke rehabilitation training for 3 hours a day , plus 12 additional 40-minute sessions of the activity-based therapy . Main measures : The primary outcome measures were discharge scores in the Fugl-Meyer Assessment Scale for upper limb impairment , Motor Status Scale , total Functional Independence Measure ( FIM ) and FIM-motor and FIM-cognition subscores . Results : The three groups ( OT group versus arm ergometer versus robotic ) were comparable on clinical demographic measures except the robotic group was significantly older and there were more  haemorrhagic  stroke patients in the arm ergometer group . After adjusting for age , stroke type and outcome measures at baseline , a similar degree of improvement in the discharge scores was found in all of the primary outcome measures . Conclusion : This study suggests that activity-based therapies using an arm ergometer or robot when used over shortened training periods have the same effect as OT group therapy in decreasing impairment and improving disability in the paretic arm of severely affected stroke patients in the subacute phase Background and Purpose — Health-related quality of life ( HRQOL ) is an important index of outcome after stroke and may facilitate a broader description of stroke recovery . This study examined the relationship of individual and clinical characteristics to HRQOL in stroke survivors with mild to moderate stroke during subacute recovery . Methods — Two hundred twenty-nine participants 3 to 9 months poststroke were enrolled in a national multisite clinical trial ( Extremity Constraint-Induced Therapy Evaluation ) . HRQOL was assessed using the  Stroke Impact Scale ( SIS ) , Version 3.0 . The Wolf Motor Function Test documented functional recovery of the hemiplegic upper extremity . Multiple analysis of variance and regression models examined the influence of demographic and clinical variables across SIS domains . Results — Age , gender , education level , stroke type , concordance ( paretic arm = dominant h and ) , upper extremity motor function ( Wolf Motor Function Test ) , and comorbidities were associated across SIS domains . Poorer HRQOL in the physical domain was associated with age , nonwhite race , more comorbidities , and reduced upper-extremity function . Stroke survivors with more comorbidities reported poorer HRQOL in the area of memory and thinking , and those with an ischemic stroke and concordance reported poorer communication . Conclusions — Although results may not generalize to lower functioning stroke survivors , individual characteristics of persons with mild to moderate stroke may be important to consider in developing comprehensive , targeted interventions design ed to maximize recovery and improve HRQOL OBJECTIVE To determine the prognostic value of clinical assessment and motor evoked potentials for upper limb strength and functional recovery after acute stroke , and to establish the possible use of motor evoked potentials in rehabilitation . DESIGN A prospect i ve study . SUBJECTS Fifty-two patients with hemiparesis were enrolled one month post-stroke ; 38 patients concluded the study at 12 months . METHODS Motor evoked potentials were recorded at baseline and after one month .  Upper limb muscular strength ( Medical Research Council Scale , MRC ) and functional tests ( Frenchay Arm Test , Barthel Index ) were used as dependent outcome variables 12 months later . Motor evoked potentials were classified as present or absent . Predictive values of motor evoked potentials and MRC were evaluated . RESULTS At 12 months , patients with baseline recordable motor evoked potentials showed a good functional recovery ( positive predictive value 94 % ) . The absence of motor evoked potentials did not exclude muscular strength recovery ( negative predictive value 95 % ) . Motor evoked potentials had a higher positive predictive value than MRC only in patients with MRC < 2 . CONCLUSION Motor evoked potentials could be a supportive tool to increase the prognostic accuracy of upper limb motor and functional outcome in hemiparetic patients , especially those with severe initial paresis ( MRC < 2 ) and /or with motor evoked potentials absent in the post-stroke acute phase OBJECTIVE To examine the relationship between individual strength parameters and functional motor ability over time during rehabilitation in stroke patients . DESIGN A multiple-baseline experiment with assessment at inclusion and after 3 and 6 weeks . SETTING Secondary -care rehabilitation center . PARTICIPANTS A convenience sample of 16 subacute stroke patients . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Maximal voluntary force and rate of rise of tension of h and grip , wrist extension , and elbow flexion and extension were recorded at all 3 times . At the same time , functional motor assessment s were evaluated by the  Action Research Arm Test ( ARAT ) , Box and Block test , and Rivermead Test . RESULTS We found no correlation between maximal voluntary force increases of various muscle contractions measurements . Neither the increase of grip strength nor that of wrist extension force correlated with improvement in ARAT score . Yet the improvement in the rate of rise of tension of h and grip ( Spearman rho=.91 ) and of wrist extension ( Spearman rho=.73 ) correlated with the improvement of the ARAT score and explained 77 % of the variance of the ARAT . CONCLUSIONS The change in the rate of rise of tension of the h and grip has a better predictive value for the functional recovery compared to the change in maximal voluntary force in patients with moderate arm and h and weakness after stroke . The rate of rise of tension of h and grip seems an adequate quantifiable parameter to detect small improvements during functional recovery Background About 80 % of all stroke survivors have an upper limb paresis immediately after stroke , only about a third of whom ( 30 to 40 % ) regain some dexterity within six months following conventional treatment programs . Of late , however , two recently developed interventions - constraint-induced movement therapy ( CIMT ) and bilateral arm training with rhythmic auditory cueing ( BATRAC ) - have shown promising results in the treatment of upper limb paresis in chronic stroke patients . The ULTRA-stroke ( acronym for Upper Limb TRaining After stroke ) program was conceived to assess the effectiveness of these interventions in subacute stroke patients and to examine how the observed changes in sensori-motor functioning relate to changes in stroke recovery mechanisms associated with peripheral stiffness , interlimb interactions , and cortical inter- and intrahemispheric networks . The present paper describes the design of this single-blinded r and omized clinical trial ( RCT ) , which has recently started and will take several years to complete . Methods / Design Sixty patients with a first ever stroke will be recruited . Patients will be stratified in terms of their remaining motor ability at the distal part of the arm ( i.e. , wrist and finger movements ) and r and omized over three intervention groups  receiving modified CIMT , modified BATRAC , or an equally intensive ( i.e. , dose-matched ) conventional treatment program for 6 weeks . Primary outcome variable is the score on the Action Research Arm test ( ARAT ) , which will be assessed before , directly after , and 6 weeks after the intervention . During those test sessions all patients will also undergo measurements aim ed at investigating the associated recovery mechanisms using haptic robots and magneto-encephalography ( MEG ) . Discussion ULTRA-stroke is a 3-year translational research program which aims ( 1 ) to assess the relative effectiveness of the three interventions , on a group level but also as a function of patient characteristics , and ( 2 ) to delineate the functional and neurophysiological changes that are induced by those interventions .The outcome on the ARAT together with information about changes in the associated mechanisms will provide a better underst and ing of how specific therapies influence neurobiological changes , and which post-stroke conditions lend themselves to specific treatments . Trial Registration The ULTRA-stroke program is registered at the Netherl and s Trial Register ( NTR , http://www.trialregister.nl , number NTR1665 )
Based on the available evidence , motor evoked potentials at rest were the only biomarker that predicted motor outcome in individuals with severe arm impairment following stroke .
To build an underst and ing of the neurobiology underpinning arm recovery in people with severe arm impairment due to stroke , we conducted a pooled individual data systematic review to : 1 ) characterize brain biomarkers ; 2 ) determine relationship(s ) between biomarkers and motor outcome ; and 3 ) establish relationship(s ) between biomarkers and motor recovery .