Effect of a therapeutic intervention for the hemiplegic upper limb in the acute phase after stroke: a single-blind, randomized, controlled multicenter trial. Responses of the densely hemiplegic upper extremity to bilateral training. Facilitation of sensory and motor recovery by thermal intervention for the hemiplegic upper limb in acute stroke patients: a single-blind randomized clinical trial. Intensive sensorimotor arm training mediated by therapist or robot improves hemiparesis in patients with chronic stroke. A pilot study to investigate the effects of electrical stimulation on recovery of hand function and sensation in subacute stroke patients. Robotic-assisted rehabilitation of the upper limb after acute stroke. Exercises for paretic upper limb after stroke: a combined virtual-reality and telemedicine approach. A programme of static positional stretches does not reduce hemiplegic shoulder pain or maintain shoulder range of motion--a randomized controlled trial. Virtual reality in the rehabilitation of the arm after hemiplegic stroke: a randomized controlled pilot study.
Arm function recovery is notoriously poor in stroke patients. The effect of treatment modalities, particularly those directed at improving upper limb function, has been studied primarily in chronic stroke patients. The purpose of this study was to investigate the effect of a specific therapeutic intervention on arm function in the acute phase after stroke.
                In a single-blind, randomized, controlled multicenter trial, 100 consecutive patients were allocated to either an experimental group that received an additional treatment of sensorimotor stimulation or to a control group. The intervention was applied for 6 weeks. Patients were evaluated for level of impairment (Brunnström-Fugl-Meyer test) and disability (Action Research Arm test, Barthel Index) before, midway, and after the intervention period and at follow-up 6 and 12 months after stroke.
                Patients in the experimental group performed better on the Brunnström-Fugl-Meyer test than those in the control group throughout the study period, but differences were significant only at follow-up. Results on the Action Research Arm test and Barthel Index revealed no effect at the level of disability. The effect of the therapy was attributed to the repetitive stimulation of muscle activity. The treatment was most effective in patients with a severe motor deficit and hemianopia or hemi-inattention. No adverse effects due to the intervention were found.
                Adding a specific intervention during the acute phase after stroke improved motor recovery, which was apparent 1 year later. These results emphasize the potential beneficial effect of therapeutic interventions for the arm. Recovery of movement in the densely hemiplegic upper extremity remains a problem after stroke. This study aimed to determine whether movement recovery could be improved in the hemiplegic arm with bilateral isokinematic training.
                Within and between groups, planned comparisons investigated the effects of bilateral training on attempts at two movements by subjects with acute and chronic problems with one and two bilateral practice phases. Electromyographic (EMG) activity of middle deltoid and extensor carpi radialis longus in the hemiplegic arm was recorded during unilateral and bilateral isometric shoulder abduction and wrist extension.
                Small increases in muscle activity were demonstrated by both experimental and control subjects during most bilateral practices in both actions. However, these increases were not significantly different from the previous unilateral trial, and the bilateral effect failed to generalize to subsequent trials. Previous studies with less densely hemiplegic subjects had demonstrated generalization of improvements in movement patterns with bilateral training to unimanual actions of the densely hemiplegic arm.
                Extensive lesions may limit brain reorganization and recover of dense hemiplegia after stroke. Nonetheless, on the basis of findings from other studies in which functional improvements occurred in both acute and chronic severely stroke-affected subjects, outcome forecasting for the hemiplegic upper extremity should only eventuate after provision of practice under optimal learning conditions. Thermal stimulation (TS) is commonly used in orthopedic rehabilitation, but the role of TS in the facilitation of sensorimotor recovery in hemiplegic patients remains unknown. This study addressed the issue of TS intervention in the facilitation of functional outcomes.
                Forty-six stroke survivors were randomly assigned to standard rehabilitation treatment and standard treatment plus TS (30 minutes daily for 6 weeks). Twenty-nine patients completed the experiment. Six measures, including Brunnstrom stage, modified motor assessment scale, grasping strength, angles of wrist extension and flexion, sensation by monofilament, and muscle tone by modified Ashworth scale, were performed weekly to evaluate sensory and motor functional outcomes.
                The performance of Brunnstrom stage and wrist extension and sensation were improved significantly after TS intervention. Recovery rates of 6 measures after TS were significantly higher than those of the control, except for grasping. Similar muscle tones were found in both groups.
                TS on the paretic hand significantly enhances the recovery of several aspects of sensory and motor functions in hemiplegic stroke patients. Investigators have demonstrated that a variety of intensive movement training protocols for persistent upper limb paralysis in patients with chronic stroke (6 months or more after stroke) improve motor outcome. This randomized controlled study determined in patients with upper limb motor impairment after chronic stroke whether movement therapy delivered by a robot or by a therapist using an intensive training protocol was superior. Robotic training (n = 11) and an intensive movement protocol (n = 10) improved the impairment measures of motor outcome significantly and comparably; there were no significant changes in disability measures. Motor gains were maintained at the 3-month evaluation after training. These data contribute to the growing awareness that persistent impairments in those with chronic stroke may not reflect exhausted capacity for improvement. These new protocols, rendered by either therapist or robot, can be standardized, tested, and replicated, and potentially will contribute to rational activity-based programs. Objectives.  1) To compare the effect of cyclic neuromuscular electrical stimulation (NMES) of the forearm and elbow extensor muscles with passive stretching exercises on hand function and sensation following stroke. 2) To inform sample size for a larger randomized controlled trial (RCT). Materials and Methods.  Twenty-two subjects with hemiplegia resulting from a stroke during the previous 12 months were randomly allocated into stimulation (treatment) and exercise (control) groups. Stimulation was applied to the elbow, and forearm extensor muscle groups of the hemiplegic arm for 12 weeks. Subjects in the control group were taught passive stretching exercises for the same period. The primary outcome measure was the Action Research Arm test (ARAT). Sensation was tested using two-point discrimination. Statistical analysis applied nonparametric analysis of covariance (ancova). Results.  Statistically significant between-group differences in change in ARAT scores were shown between the two groups after 12 weeks of treatment (p = 0.003) and following 12 further weeks without intervention (p = 0.012). There were no significant differences in sensation. Conclusions.  1) A significant treatment effect of electrical stimulation over passive exercise has been demonstrated in a group of 22 subacute stroke patients, randomized into two equal groups and further work identified which may help to improve recovery of hand function and sensation following stroke. 2) A sample size of 24 subjects in each group has been estimated assuming a two-sided test significance level of 5% with 80% power, primary outcome variability SD = 6.75, a minimum difference of ten ARAT score units, and a 10% dropout rate. To investigate whether early therapy with a novel robotic device can reduce motor impairment and enhance functional recovery of poststroke patients with hemiparetic and hemiplegic upper limb.
                A single-blind randomized controlled trial, with an 8-month follow-up.
                Neurologic department and rehabilitation hospital.
                Thirty-five patients with acute (< or =1 wk of onset), unilateral, ischemic embolic, or thrombotic stroke.
                Patients of both groups received the same dose and length per day of standard poststroke multidisciplinary rehabilitation. Patients were randomly assigned to 2 groups. The experimental group (n=17) received additional early sensorimotor robotic training, 4 hours a week for 5 weeks; the control group (n=18) was exposed to the robotic device, 30 minutes a week, twice a week, but the exercises were performed with the unimpaired upper limb. Training by robot consisted of peripheral manipulation of the shoulder and elbow of the impaired limb, correlated with visual stimuli.
                The Fugl-Meyer Assessment (FMA) of upper-extremity function (shoulder/elbow and coordination and wrist/hand subsections) to measure each trained limb segment; the Medical Research Council (MRC) score to measure the strength of muscle force during 3 actions: shoulder abduction (MRC deltoid), elbow flexion (MRC biceps), and wrist flexion (MRC wrist flexors); the FIM instrument and its motor component; and the Trunk Control Test (TCT) and Modified Ashworth Scale (MAS).
                Compared with the patients in the control group, the experimental group showed significant gains in motor impairment and functional recovery of the upper limb after robot therapy, as measured by the MRC deltoid (P< or =.05) and biceps (P<.05) scores, the FMA for the proximal upper arm (P<.05), the FIM instrument (P<.05), and the FIM motor score (P<.01); these gains were also sustained at the 3- and 8-month follow-up. The FMA and MRC wrist flexor test findings did not differ statistically either at the end of training or at the follow-up sessions. We found no significant differences in MAS and TCT in either group in any of the evaluations. No adverse effects occurred and the robotic approach was very well accepted.
                Patients who received robotic therapy in addition to conventional therapy showed greater reductions in motor impairment and improvements in functional abilities. Robotic therapy may therefore effectively complement standard rehabilitation from the start, by providing therapeutic support for patients with poststroke plegic and paretic upper limb. Telerehabilitation enables a remotely controlled programme to be used to treat motor deficits in post-stroke patients. The effects of this telerehabilitation approach were compared with traditional motor rehabilitation methods.
                Randomized single-blind controlled trial.
                A total of 36 patients with mild arm motor impairments due to ischaemic stroke in the region of the middle cerebral artery.
                The experimental treatment was a virtual reality-based system delivered via the Internet, which provided motor tasks to the patients from a remote rehabilitation facility. The control group underwent traditional physical therapy for the upper limb. Both treatments were of 4 weeks duration. All patients were assessed one month prior to therapy, at the commencement and termination of therapies and one month post-therapy, with the Fugl-Meyer Upper Extremity, the ABILHAND and the Ashworth scales.
                Both rehabilitative therapies significantly improved all outcome scores after treatment, but only the Fugl-Meyer Upper Extremity scale showed differences in the comparison between groups.
                Both strategies were effective, but the experimental approach induced better outcomes in motor performance. These results may favour early discharge from hospital sustained by a telerehabilitation programme, with potential beneficial effects on the use of available resources. To evaluate the effectiveness of a programme of static positional stretches and positioning of the stroke-affected shoulder for maintaining shoulder external rotation and decreasing hemiplegic shoulder pain.
                Randomized controlled trial with pretest and posttest design.
                Inpatient rehabilitation unit.
                Thirty-two participants (17 treatment, 15 comparison) with a first time stroke who were admitted for rehabilitation. Interventions: Treatment participants completed a programme of static positional stretches of the stroke-affected shoulder twice daily and positioned the stroke-affected upper limb in an armrest support at all other times when seated.
                The main outcome measures were pain-free range of motion into external rotation, pain in the stroke-affected shoulder at rest and with movement, motor recovery and functional independence.
                All participants demonstrated a significant loss of external rotation (P = 0.005) with no significant group differences. All participants demonstrated a significant improvement in motor recovery (P < 0.01) and functional independence (P < 0.01) with no significant group differences. There were no significant effects for pain. The comparison group recorded a decrease in mean pain reported with movement from admission to discharge, and the treatment group recorded an increase.
                Participation in the management programme did not result in improved outcomes. The results of this study do not support the application of the programme of static positional stretches to maintain range of motion in the shoulder. The effect of increasing pain for the treatment group requires further investigation. To assess the feasibility of a trial to investigate the effectiveness of virtual reality-mediated therapy compared to conventional physiotherapy in the motor rehabilitation of the arm following stroke, and to provide data for a power analysis to determine numbers for a future main trial.
                Pilot randomized controlled trial.
                Clinical research facility.
                Eighteen people with a first stroke, 10 males and 8 females, 7 right and 2 left side most affected. Mean time since stroke 10.8 months.
                Participants were randomized to a virtual reality group or a conventional arm therapy group for nine sessions over three weeks.
                The upper limb Motricity Index and the Action Research Arm Test were completed at baseline, post intervention and six weeks follow-up.
                Outcome data were obtained from 95% of participants at the end of treatment and at follow-up: one participant withdrew. Compliance was high; only two people reported side-effects from virtual reality exposure. Both groups demonstrated small (7-8 points on upper limb Motricity Index and 4 points on the Action Research Arm Test), but non-significant, changes to their arm impairment and activity levels.
                A randomized controlled trial of virtual reality-mediated therapy comparable to conventional therapy would be feasible, with some suggested improvements in recruitment and outcome measures. Seventy-eight participants (39 per group) would be required for a main trial.
Overall, the review demonstrated that the limited evidence of benefit of stretching, passive exercises and mobilization, when applied to the hemiplegic upper limb following stroke, merits further research.