Effect of Virtual Reality-Based Training on Upper Limb Dysfunction during Post-Stroke Rehabilitation: A Meta-Analysis Combined with Meta-Regression.

Clinical Prediction Rule for Identifying the Stroke Patients who will Obtain Clinically Important Improvement of Upper Limb Motor Function by Robot-Assisted Upper Limb

INTRODUCTION. The prevalence of upper limb dysfunction and cognitive impairments are frequently observed following stroke, but are often considered as distinct entities, and there is little evidence regarding how they are related, as well as rehabilitation methods are aimed at monodomain restoration of any of these impairments. AIM. To analyze the data of recent years on the impact of rehabilitation interventions on cognitive and the upper limb (UL) motor functions in patients with stroke, and to establish how they are related. MATERIAL AND METHODS. The search was carried out in the Medline, Web of Science, PubMed and Scopus sources in accordance with the PRISMA principles and initially revealed 2,841 records. Of these, 35 articles were included in the study with publication 2011–2022. Keywords were used: stroke, movement, motor, upper limb, cognition, cognitive, cognitive-motor, motor-cognitive function. The relationship between cognitive impairments and the degree of restoration of the UL motor function under the influence of various rehabilitation interventions was assessed. RESULTS. Five studies were selected for meta-analysis with the inclusion of 180 stroke patients. It is shown that the improvement of cognitive tests (MoCA) is accompanied by an improvement in UL motor impairments (FMA, Jebsen-Taylor Hand Function Test), while hand dexterity (Box and blocks, NHPT, Minnesota manual dexterity test) remained without statistically significant changes during medical rehabilitation. CONCLUSION. The meta-analysis provides evidence of the relationship and mutual influence of cognitive functions on motor recovery and manual dexterity. However, the small sample size and heterogeneity of available studies are still limiting factors for obtaining unambiguous conclusions.

Background:Upper limb motor impairment is a common complication following stroke. Although few treatments are used to enhance motor function, still approximately 60% of survivors are left with upper limb motor impairment. Several studies have investigated vagus nerve stimulation (VNS) as a potential technique for upper limb function. However, the efficacy and safety of VNS on upper limb motor function after ischemic stroke have not been systematically evaluated. Therefore, a meta-analysis based on randomized controlled trial will be conducted to determine the efficacy and safety of VNS on upper limb motor function after ischemic stroke.Method:We searched PUBMED, MEDLINE, EMBASE, Cochrane Library, Web of Science, China National Knowledge Infrastructure Library (CNKI), and Wan Fang Database until April 1, 2021.Results:Six studies consisting of 234 patients were included in the analysis. Compared with control group, VNS improved upper limb function via Fugl-Meyer Assessment-Upper Extremity (mean difference = 3.26, 95% confidence interval [CI] [2.79, 3.74], P < .00001) and Functional Independence Measurement (mean difference = 6.59, 95%CI [5.77, 7.41], P < .00001), but showed no significant change on Wolf motor function test (standardized mean difference = 0.31, 95%CI [–0.15, 0.77], P = .19). The number of adverse events were not significantly different between the studied groups (risk ratio = 1.05, 95%CI [0.85, 1.31], P = .64).Conclusion:VNS resulted in improvement of motor function in patients after ischemic stroke, especially in the sub-chronic stage. Moreover, compared with implanted VNS, transcutaneous VNS exhibited greater efficacy in poststroke patients. Based on this meta-analysis, VNS could be a feasible and safe therapy for upper limb motor impairment.

BackgroundStroke is the leading cause of disability worldwide. Upper extremity paresis is the most common functional consequence, affecting more than half of all stroke survivors. Research has shown that an adequate therapy should begin in the sub-acute stage, but also that an enhanced intensity and frequency of therapy can positively affect patients’ recovery curve. Therefore, here we assessed whether an additional VR-based training can be beneficial for recovery of stroke patients, with particular emphasis on upper extremity functions.MethodsThe study was organized as prospective and single-blinded (analysis). Two groups of pairwise-matched subacute stroke patients with arm paresis were recruited at our rehabilitation clinic while controlling for gender, age, sidedness and modified Rankin scale (mRS). Both groups – conventional therapy (CT) and conventional therapy plus virtual reality (CT + VR) – received 30–45 min of conventional therapy on 3 to 4 days/week over 4 weeks; in addition to that, the CT + VR group received 3 times per week a specially designed VR-based training for upper extremity. Data acquisition was performed within 24 h before the baseline and after the training has ended. Main outcomes were patients’ performance on Fugl-Meyer test for upper extremity (FME), Box-and-Block test, hand dynamometry and Functional independence test (FIM).ResultsTwenty-two subjects aged 57–85 were pairwise-matched and assigned to the conventional therapy (CT) group (n = 11, 67.82 ± 8.69 years; three females) and the conventional therapy plus virtual reality (CT + VR) group (n = 11, 70.45 ± 6.79 years; three females). No difference in gender, age, sidedness, mRS and mini-mental status examination (MMSE) existed between the two groups. The CT + VR group showed significantly better improvements over time on FME (44.3 ± 7.8 to 58.7 ± 11.2 vs. 42.1 ± 6.2 to 49.5 ± 10.9; p = 0.009) and FIM (90.1 ± 18.0 to 118.1 ± 6.9 vs. 105.0 ± 12.4 to 110.6 ± 12.6; p < 0.001), compared to the CT group. Other tests revealed no significant differences.DiscussionAs hypothesized, an additional immersive VR-based training can be beneficial for stroke patients suffering from upper extremity deficiency. Nevertheless, the principle of specificity could be observed, with only trained functions being associated with improvements on FME and FIM. Future studies with larger sample of participants are required to confirm these findings.

Background: Traumatic brain injury (TBI) causes impairment in motor planning and may be impacted by damage to the brain networks and structures (cerebellum, basal ganglia, parietal cortex, and premotor cortex) which are responsible for the formation and execution of motor function. Objectives: The objective of this study was to determine the effect of action observation therapy (AOT) on upper extremity (UE) motor function among patients with TBI, assessed through the change in Fugl-Meyer Assessment UE (FMA-UE), Box and Block Test (BBT), and Functional Independence Measure (FIM) Scale. Materials and Methods: This experimental pre–post study included 26 samples recruited by convenient sampling method, diagnosed with TBI for ≤3 months. AOT was administered 60 min, 5 days a week for 6 weeks consecutively. An outcome measure of FMA, BBT, and FIM was assessed at baseline (T0), at the end of the 6 weeks (T1), and for follow-up at 3 months (T2). Results: After 6 weeks of AOT training, all the outcome measures showed significant progress statistically in the UE motor function (P = 0.01). Additionally, these findings were also showing significant improvements at 3-month follow-up. Conclusion: According to the results, it can be concluded that AOT is an effective therapy for enhancing UE motor function and overall recovery in TBI patients during the initial recovery phase.

BackgroundPost-stroke aphasia concurrent with upper limb (UL) motor dysfunction is very common and difficult to rehabilitate. Although mirror therapy (MT) has demonstrated efficacy in treating aphasia and UL motor dysfunction separately, it has not been utilized to address both conditions simultaneously. Our study introduces a novel Synchronous Mirror Therapy (SMT) system that integrates speech-language therapy with UL motor training to evaluate its clinical feasibility, preliminary efficacy, and potential cortical mechanisms.MethodFifteen patients and five therapists participated in this study. The patients had aphasia and UL motor dysfunction and underwent the SMT intervention ten times. They were evaluated through functional assessment scales (Aphasia Quotient of Western Aphasia Battery (WAB-AQ); Assessment of Fugl-Meyer Upper Limb scale (FMA-UL); Action Research Arm Test (ARAT)) and three questionnaires, and functional near-infrared (fNIRS) test. We analyzed the questionnaire results, functional changes before and after SMT, and differences between the SMT intervention and rest periods.ResultsNine patients underwent all SMT treatment sessions. Patients and therapists gave high ratings for SMT. Compared with before SMT interventions, significant improvements were observed in language function (WAB-AQ: p = 0.008) and UL motor function (FMA-UL: p = 0.007; ARAT: p = 0.016) after all SMT interventions, along with significant changes in three fNIRS channels (channel 9, p < 0.001; channel 20, p = 0.005; channel 30, p = 0.046) during the SMT intervention.ConclusionThe SMT intervention demonstrated feasibility and received positive feedback from both patients and therapists. The results indicate potential benefits of SMT in improving language and UL motor function for post-stroke patients. fNIRS findings suggest possible enhanced cortical activation during SMT, which may be associated with neural recovery processes. While encouraging, this still necessitates validation through larger sample sizes and rigorous randomized controlled designs.

Background: 80% of people with a stroke have impairment of the upper limb (UL). The hemiparetic arm is one of the most devastating consequences after stroke. Improving use of the affected UL is important however, because difficulty in using this UL in daily tasks has been related to lower quality of life.&#x0D; Design: A prospective randomized control trial type study.&#x0D; Setting: Malaysia Government and Private Hospitals and also in private Physiotherapy Centre’s.&#x0D; Population: A total of 25 subjects post stroke were randomly assigned to either in experimental group (n=13) and control group (n=12).&#x0D; Methods: Control group received 45 minutes of treatment session and therapy consisted of conventional therapy only with the affected upper extremity whereas experimental group also received 45 minutes of treatment session and therapy consisted of conventional therapy along with mirror therapy for three days/week. Outcome measures used were Fugl-meyer assessment and Functional independent measure.&#x0D; Results: Comparison of the changes in the Fugl-meyer assessment and Functional independent measure from baseline to six weeks between control and experimental group, revealed that significant improvement were in experimental group which was (p&lt;0.05).&#x0D; Conclusion: Combination of conventional and mirror therapy is an effective method on restoring upper limb motor function among hemiplegic patients.&#x0D; Bangladesh Journal of Medical Science Vol.19(2) 2020 p.208-213

To evaluate the effectiveness of virtual reality therapy (VRT) Armeo Spring® upper limb exoskeleton (Armeo), in early post-stroke rehabilitation with a focus on the elderly. Convalescence from a stroke is a complex process driven by a spontaneous recovery supported by multifactorial activation. Novel technology-based rehabilitation methods are being introduced to support brain plasticity. Using a randomised controlled study design, participants within 30 days after stroke with arm paresis were, in addition to a daily rehabilitation programme, assigned to an intervention group (45 minutes Armeo IG n = 25; mean age 66.5 years) performing VRT, or to a conventional physiotherapy (45 minutes) control group (Armeo CG, n = 25, mean age 68.1 years). Montreal Cognitive Assessment (MoCA), Functional Independence Measure (FIM) and Fugl Mayer Assessment Upper Extremity Scale (FMA-UE) were performed before and after the three-week therapy with 12 therapeutic sessions. Results of participants < 65 and ≥ 65 years old were compared. Paretic upper arm function improved significantly in both the IG and CG groups, the improvement in FMA-UE was significantly higher in the IG compared to the CG (p = 0.02), and patients ≥ 65 years old presented an equal magnitude of improvement in paretic arm function compared to younger patients. Early post-stroke rehabilitation strategies using, in addition to the daily rehabilitation programme, VRT with visual biofeedback is more effective on upper extremity motor performance than conventional physiotherapy, and the effectiveness does not diminish with patient age. This may be a promising addition to conventional physiotherapy in older stroke patients as well as in younger.

IntroductionUp to 80% of post-stroke patients present upper-limb motor impairment (ULMI), causing functional limitations in daily activities and loss of independence. UMLI is seldom fully recovered after stroke when using conventional therapeutic approaches. Functional Electrical Stimulation Therapy (FEST) controlled by Brain–Computer Interface (BCI) is an alternative that may induce neuroplastic changes, even in chronic post-stroke patients. The purpose of this work was to evaluate the effects of a P300-based BCI-controlled FEST intervention, for ULMI recovery of chronic post-stroke patients.MethodsA non-randomized pilot study was conducted, including 14 patients divided into 2 groups: BCI-FEST, and Conventional Therapy. Assessments of Upper limb functionality with Action Research Arm Test (ARAT), performance impairment with Fugl–Meyer assessment (FMA), Functional Independence Measure (FIM) and spasticity through Modified Ashworth Scale (MAS) were performed at baseline and after carrying out 20 therapy sessions, and the obtained scores compared using Chi square and Mann–Whitney U statistical tests (𝛼 = 0.05).ResultsAfter training, we found statistically significant differences between groups for FMA (p = 0.012), ARAT (p < 0.001), and FIM (p = 0.025) scales.DiscussionIt has been shown that FEST controlled by a P300-based BCI, may be more effective than conventional therapy to improve ULMI after stroke, regardless of chronicity.ConclusionThe results of the proposed BCI-FEST intervention are promising, even for the most chronic post-stroke patients often relegated from novel interventions, whose expected recovery with conventional therapy is very low. It is necessary to carry out a randomized controlled trial in the future with a larger sample of patients.

Upper limb (UL) dysfunction rehabilitation in stroke patients is complicated in the clinic. Action observation therapy's (AOT) impact on mirror neurons (MNs) has been observed and made applications in related brain disease treatment. Acupuncture mentioned in the present study mainly stimulates peripheral nerves for neuronal plasticity. However, the clinical effect of AOT impact on MNs and acupuncture irritate afferent nerve fibers in combination for UL motor impairment rehabilitation after stroke is still unclear. In the present study, we investigate the central and peripheral neural stimulation meanwhile for UL recovery with stroke patients. In this clinical study, 82 stroke patients recruited with impaired UL were randomly assigned to three groups. Twenty-four cases were in the AOT group, 28 cases were in the AOT combined acupuncture treatment group, and 30 cases were in the acupuncture treatment group. All volunteers were scored for limb function through the Fugl-Meyer Assessment of the Upper Extremity (FMA-UE), the Action Research Arm Test, and the modified Barthel Index (BI) before and after a systematic treatment according to the groups. Meanwhile, conventional physical therapy was also implemented for all cases. Before the specific intervention, the scores of FMA-UE, FMA-UE, and BI with all stroke patients have no significant statistical difference (P > 0.05). After the corresponding treatment, we assessed UL function again at 4 and 8 weeks. At 4 weeks, the patients with AOT showed a significant increase in BI scores compared to the acupuncture group (P < 0.05). At 8 weeks, the FMA-UE scores of the patients with AOT combined with acupuncture were significantly increased than acupuncture alone (P < 0.05). We also observed that the BI scores of the combination and the AOT group both were improved compared to the acupuncture group with significant statistical analysis (P < 0.05). Based on the MNs theory, we adopted AOT impact on MNs which would be a promising rehabilitation technique, especially combined with acupuncture treatment in UL recovery of stroke. Mirror therapy seems to be effective for central neuronal plasticity, but for action or AOT, there is still insufficient evidence to recommend its optimal strategy and neuromodulation mechanism. Here, research on the MNs-based AOT technique with acupuncture in UL dysfunction with stroke patients is recommended.TRIAL REGISTRATION: http://www.chictr.org.cn (identifier: ChiCTR2300077010).

Stroke is one of the leading causes of death and disability worldwide and poses a tremendous socioeconomic burden upon individuals, countries and healthcare systems. It causes debilitating symptoms and thus interferes with many aspects of the patient's life, including physical functioning, cognition, emotional status, activities of daily living, social reintegration and quality of life. Post-stroke patients frequently experience functional motor disabilities of the upper limb, which restrict autonomy and self-efficacy and cause limitations in engagement with activities and social participation, as well as difficulties in performing important occupations. It is therefore not surprising that motor impairment or loss of motor function of the upper limb is one of the most devastating sequelae of stroke. On these grounds, achieving optimal functioning of the upper limb after stroke remains a fundamental goal of stroke rehabilitation. Mirror therapy (MT) represents one of the several rehabilitation techniques used for restoring the upper limb's motor function after a stroke. However, conflicting results about the role of MT in the rehabilitation of the upper limb's motor deficits have been reported in the literature. Accordingly, the aim of this narrative review is to summarize existing evidence regarding the effects of MT on the upper limb's motor function in post-stroke patients and to further explore its role when applied in different phases of stroke.

New technologies have been developed to complement conventional interventions to better target the specific needs of people with stroke, and they have been shown to improve both function and performance. However, it is unknown whether the baseline levels of sensorimotor function and performance interrelate with the improvement in upper limb and daily performance. Thus, the aim of this study was to examine the relationship between baseline levels of sensorimotor function and daily performance and its impact on post-intervention improvement in people with stroke following a robotic intervention. A single-blind, non-randomized, controlled clinical trial was conducted. Participants in the experimental group (n = 9) received a robotic intervention in addition to conventional treatment. Sensorimotor function was measured with Semmes-Weinstein Monofilaments® and the Fugl-Meyer Assessment Upper Extremity Scale. Upper limb and daily performance were measured with the MAL and SIS-16 scales. The multivariate regression models showed that baseline levels of upper limb performance and motor function predicted >95% of the variance in upper limb performance (p < 0.001), while pre-intervention levels of daily performance explained >75% of the post-intervention variance (p < 0.05). These findings indicate that basal upper limb motor function is associated with improved performance following a combined intervention of conventional treatment and robotic intervention.

To evaluate the effectiveness of repetitive transcranial magnetic stimulation (rTMS) combined with repetitive peripheral magnetic stimulation (rPMS) on upper limb motor dysfunction after stroke. We systematically searched databases up to May 2024, including PubMed, Embase, Cochrane Library, Web of Science, CNKI, VIP, Wanfang, and CBM. Randomized controlled trials (RCTs) examining the application of rTMS combined rPMS on upper limb motor dysfunction after stroke were included based on predefined inclusion criteria. We used Cochrane Risk of Bias 2 tool to assess bias risk of the included RCTs. Meta-analysis was conducted using RevMan 5.4 and Stata 17.0 software. A total of 9 RCTs involving 483 participants were included in this study. Compared with the control groups that used either conventional therapy or rTMS alone, the experimental group that used rTMS combined rPMS showed significant improvements in stroke patients' upper limb motor function [MD = 3.65, 95% CI (2.75, 4.54), P < 0.05], ability of daily living [MD = 4.50, 95% CI (3.50, 5.50), P < 0.05], and spasticity [MD = -0.34, 95% CI (-0.48, -0.20), P < 0.05]. Meanwhile, in terms of neurophysiological indicators, significant differences were found both for motor evoked potential latency [MD = -1.77, 95% CI (-3.19, -0.35), P < 0.05] and motor evoked potential amplitude [MD = 0.25, 95% CI (0.01, 0.49), P < 0.05]. This study provides low-level evidence that the therapy of LF-rTMS or HF-rTMS combined with rPMS can improve the upper limb motor function and daily living ability of stroke patients. However, given that the low quality of the evidence for the evaluation results, further evidence from high-quality studies is needed to substantiate this conclusion. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024539195, PROSPERO Platform [CRD42024539195].

Brain lesion characteristics (timing, location, and extent) and the type of corticospinal tract (CST) wiring have been proposed as determinants of upper limb (UL) motor function in unilateral cerebral palsy (uCP), yet an investigation of the relative combined impact of these factors on both motor and sensory functions is still lacking. Here, we first investigated whether structural brain lesion characteristics could predict the underlying CST wiring and we explored the role of CST wiring and brain lesion characteristics to predict UL motor and sensory functions in uCP. Fifty-two participants with uCP (mean age (SD): 11 y and 3 m (3 y and 10 m)) underwent a single-pulse Transcranial Magnetic Stimulation session to determine CST wiring between the motor cortex and the more affected hand (n = 17 contralateral, n = 19 ipsilateral, and n = 16 bilateral) and an MRI to determine lesion timing (n = 34 periventricular (PV) lesion, n = 18 corticosubcortical (CSC) lesion), location, and extent. Lesion location and extent were evaluated with a semiquantitative scale. A standardized protocol included UL motor (grip strength, unimanual capacity, and bimanual performance) and sensory measures. A combination of lesion locations (damage to the PLIC and frontal lobe) significantly contributed to differentiate between the CST wiring groups, reclassifying the participants in their original group with 57% of accuracy. Motor and sensory functions were influenced by each of the investigated neurological factors. However, multiple regression analyses showed that motor function was predicted by the CST wiring (more preserved in individuals with contralateral CST (p < 0.01)), lesion extent, and damage to the basal ganglia and thalamus. Sensory function was predicted by the combination of a large and later lesion and an ipsilateral or bilateral CST wiring, which led to increased sensory deficits (p < 0.05). These novel insights contribute to a better understanding of the underlying pathophysiology of UL function and may be useful to delineate individualized treatment strategies.

Introduction: Cognitive and upper limb impairments are common following stroke. While transcutaneous electrical nerve stimulation, including transcutaneous vagus nerve stimulation (tVNS) and transcutaneous spinal cord stimulation (tSCS), are potential interventions to alleviate cognitive decline and promote motor recovery by activating neurotransmitter systems, current evidence remains inconclusive in people with stroke. Investigating the effects of tVNS and tSCS may clarify their therapeutic value and support the development of convenient and effective rehabilitation strategies in a clinical setting for people with stroke. Objective: This randomized controlled trial aimed to (1) investigate the effects of tVNS and tSCS and (2) compare their efficacy on improving cognitive function and upper limb motor function in people with stroke. Methods: Ninety people with chronic stroke were randomly allocated to receive 18 sessions of either tVNS, tSCS, or sham-stimulation concurrent with upper limb exercises for 45 minutes in each session, three sessions per week, for 6 weeks. Two main primary outcomes were the Montreal Cognitive Assessment (MoCA) and Fugl-Meyer Assessment for Upper Extremity (FMA-UE). Results: tVNS and tSCS groups demonstrated significantly greater improvement in the MoCA (mean difference: 1.18 and 0.88, respectively; p &lt;0.001), FMA-UE (mean difference: 1.68 and 1.05; p &lt;0.001 and p =0.007, respectively), and Rivermead Behavioural Memory Test (mean difference: 6.02 and 5.05, respectively; p &lt;0.001) than the sham group after the intervention. Also, tVNS induced a greater improvement in the Wolf Motor Function Test (mean difference: 1.50; p &lt;0.001), and tSCS induced a greater increase in the muscle strength of the elbow extensor (mean difference: 0.70; p &lt;0.001) compared to sham-stimulation. These improvements were maintained for 1 month, but tVNS group demonstrated significantly higher FMA-UE score than tSCS group (mean difference: 0.66; p =0.010) 1 month after the cessation of intervention. Conclusions: tVNS and tSCS are both superior to sham-stimulation in improving cognitive function and upper limb motor function after stroke when combined with upper limb exercises, but tVNS seems to have a more persistent effect on upper limb motor recovery compared to tSCS. These interventions offer a safe, cost-effective, and readily transferable therapeutic approach to clinical practice to manage post-stroke cognitive and motor impairment.