A Pilot Randomized Controlled Trial of Botulinum Toxin Treatment Combined with Robot-Assisted Therapy, Mirror Therapy, or Active Control Treatment in Patients with Spasticity Following Stroke.

Effects of the combined task-oriented trainings with botulinum toxin A (BoNT-A) injection on improving motor functions and reducing spasticity remains unclear. This study aims to investigate effects of 3 task-oriented trainings (robot-assisted therapy (RT), mirror therapy (MT), and active control treatment (AC)) in patients with stroke after BoNT-A injection. Thirty-seven patients with chronic spastic hemiplegic stroke were randomly assigned to receive RT, MT, or AC following BoNT-A injection over spastic upper extremity muscles. Each session of RT, MT, and AC was 75 min, 3 times weekly, for 8 weeks. Outcome measures were assessed at pretreatment, post-treatment, and 3-month follow-up, involving the Fugl-Meyer Assessment (FMA), Modified Ashworth Scale (MAS), Motor Activity Log (MAL), including amount of use (AOU) and quality of movement (QOM), and arm activity level. All 3 combined treatments improved FMA, MAS, and MAL. The AC induced a greater effect on QOM in MAL at the 3-month follow-up than RT or MT. All 3 combined trainings induced minimal effect on arm activity level. Our findings suggest that for patients with stroke who received BoNT-A injection over spastic UE muscles, the RT, MT, or AC UE training that followed was effective in improving motor functions, reducing spasticity, and enhancing daily function.

Comparative effects of EMG-driven robot-assisted therapy versus task-oriented training on motor and daily function in patients with stroke: a randomized cross-over trial.

BACKGROUND: Robot-assisted hand training has shown positive effects on promoting neuromuscular control. Since both robot-assisted therapy and task-oriented training are often used in post-stroke rehabilitation, we raised the question of whether two interventions engender differential effects in different domains. METHODS: The study was conducted using a randomized, two-period crossover design. Twenty-four chronic stroke survivors received a 12-session robot-assisted intervention followed by a 12-session task-oriented intervention or vice versa. A 1-month washout period between each intervention was implemented. Outcome measures were evaluated before the intervention, after the first 12-session intervention, and after the second 12-session intervention. Clinical assessments included Fugl-Meyer Assessment for Upper Extremity, Wolf Motor Function Test, Action Research Arm Test and Motor Activity Log. RESULTS: Our findings suggested that EMG-driven robot-assisted therapy was as effective as task-oriented training in terms of improving upper limbs functional performance in activity domain, and robot-assisted therapy was more effective in improving movement duration during functional tasks. Task-oriented training showed better improvement in body function domain and activity and participation domain, especially in improving spontaneous use of affected arm during daily activities. CONCLUSIONS: Both intervention protocol had their own advantages in different domains, and robot-assisted therapy may save manpower and be considered as an alternative intervention to task-oriented training. Combining the two approaches could yield results greater than either alone, which awaits further study. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03624153. Registered on 9th August 2018, https://clinicaltrials.gov/ct2/show/NCT03624153 .

Effects of virtual reality-based motor control training on inflammation, oxidative stress, neuroplasticity and upper limb motor function in patients with chronic stroke: a randomized controlled trial.

BACKGROUND: Immersive virtual reality (VR)-based motor control training (VRT) is an innovative approach to improve motor function in patients with stroke. Currently, outcome measures for immersive VRT mainly focus on motor function. However, serum biomarkers help detect precise and subtle physiological changes. Therefore, this study aimed to identify the effects of immersive VRT on inflammation, oxidative stress, neuroplasticity and upper limb motor function in stroke patients. METHODS: Thirty patients with chronic stroke were randomized to the VRT or conventional occupational therapy (COT) groups. Serum biomarkers including interleukin 6 (IL-6), intracellular adhesion molecule 1 (ICAM-1), heme oxygenase 1 (HO-1), 8-hydroxy-2-deoxyguanosine (8-OHdG), and brain-derived neurotrophic factor (BDNF) were assessed to reflect inflammation, oxidative stress and neuroplasticity. Clinical assessments including active range of motion of the upper limb and the Fugl-Meyer Assessment for upper extremity (FMA-UE) were also used. Two-way mixed analyses of variance (ANOVAs) were used to examine the effects of the intervention (VRT and COT) and time on serum biomarkers and upper limb motor function. RESULTS: We found significant time effects in serum IL-6 (p = 0.010), HO-1 (p = 0.002), 8-OHdG (p = 0.045), and all items/subscales of the clinical assessments (ps < 0.05), except FMA-UE-Coordination/Speed (p = 0.055). However, significant group effects existed only in items of the AROM-Elbow Extension (p = 0.007) and AROM-Forearm Pronation (p = 0.048). Moreover, significant interactions between time and group existed in item/subscales of FMA-UE-Shoulder/Elbow/Forearm (p = 0.004), FMA-UE-Total score (p = 0.008), and AROM-Shoulder Flexion (p = 0.001). CONCLUSION: This was the first study to combine the effectiveness of immersive VRT using serum biomarkers as outcome measures. Our study demonstrated promising results that support the further application of commercial and immersive VR technologies in patients with chronic stroke.

Timing-dependent effects of transcranial direct current stimulation with mirror therapy on daily function and motor control in chronic stroke: a randomized controlled pilot study.

BACKGROUND: The timing of transcranial direct current stimulation (tDCS) with neurorehabilitation interventions may affect its modulatory effects. Motor function has been reported to be modulated by the timing of tDCS; however, whether the timing of tDCS would also affect restoration of daily function and upper extremity motor control with neurorehabilitation in stroke patients remains largely unexplored. Mirror therapy (MT) is a potentially effective neurorehabilitation approach for improving paretic arm function in stroke patients. This study aimed to determine whether the timing of tDCS with MT would influence treatment effects on daily function, motor function and motor control in individuals with chronic stroke. METHODS: This study was a double-blinded randomized controlled trial. Twenty-eight individuals with chronic stroke received one of the following three interventions: (1) sequentially combined tDCS with MT (SEQ), (2) concurrently combined tDCS with MT (CON), and (3) sham tDCS with MT (SHAM). Participants received interventions for 90 min/day, 5 days/week for 4 weeks. Daily function was assessed using the Nottingham Extended Activities of Daily Living Scale. Upper extremity motor function was assessed using the Fugl-Meyer Assessment Scale. Upper extremity motor control was evaluated using movement kinematic assessments. RESULTS: There were significant differences in daily function between the three groups. The SEQ group had greater improvement in daily function than the CON and SHAM groups. Kinematic analyses showed that movement time of the paretic hand significantly reduced in the SEQ group after interventions. All three groups had significant improvement in motor function from pre-intervention to post-intervention. CONCLUSION: The timing of tDCS with MT may influence restoration of daily function and movement efficiency of the paretic hand in chronic stroke patients. Sequentially applying tDCS prior to MT seems to be advantageous for enhancing daily function and hand movement control, and may be considered as a potentially useful strategy in future clinical application. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02827864 . Registered on 29th June, 2016.

Alternative Motor Task-Based Pattern Training With a Digital Mirror Therapy System Enhances Sensorimotor Signal Rhythms Post-stroke.

Mirror therapy (MT) facilitates motor learning and induces cortical reorganization and motor recovery from stroke. We applied the new digital mirror therapy (DMT) system to compare the cortical activation under the three visual feedback conditions: (1) no mirror visual feedback (NoMVF), (2) bilateral synchronized task-based mirror visual feedback training (BMVF), and (3) reciprocal task-based mirror visual feedback training (RMVF). During DMT, EEG recordings, including time-dependent event-related desynchronization (ERD) signal amplitude in both mu and beta bands, were obtained from the standard C3 (ispilesional hemisphere, IH), C4 (contralesional hemisphere, CH), and Cz scalp sites (supplementary motor area, SMA). The entire ERD curve was separated into three time-phases: P0 (-2 to 0 s), P1 (0 to 2 s), and P2 (2 to 4 s). Four-way and subsequent repeated-measures analyses of variance were used to examine the effects of group (stroke vs. control group), test condition (NoMVF, BMVF, and RMVF), time-phase (P0, P1, and P2), and brain area (IH, CH, SMA) on the ERD areas (%) in mu and beta bands. For the mu band, generally, ERD areas (%) were larger in the control than in the stroke group. The ERD areas (%) were largest under the RMVF condition, followed by BMVF and NoMVF conditions. Similar results were found in the beta bands. The main effects of group, time-phase, and test condition on the ERD areas (%) were significant for the three brain areas, except the main effect of group in the SMA (Cz) and CH (C4) brain area. The ERD areas (%) were larger in the control than in the stroke group. The ERD area (%) was significantly larger during P1 than during P0 and P2 (ps < 0.02), and during P2 than during P0 (ps < 0.01). The ERD area (%) under the RMVF condition was significantly larger than that under the BMVF condition and NoMVF condition (ps < 0.05). The present study suggests that cortical activation particularly in the SMA (Cz) of the brain increases in the RMVF condition in both healthy subjects and stroke patients. This result supports the hypothesis that stroke patients may benefit from RMVF training.

Exploring Sensory Processing Dysfunction, Parenting Stress, and Problem Behaviors in Children With Autism Spectrum Disorder.

OBJECTIVE: We examined problem behavior in preschool- and school-age children with autism spectrum disorder and assessed whether sensory processing dysfunction (SPD) and parenting stress were differentially associated with problem behaviors in these groups of children. METHOD: Participants were 101 preschool- and 61 school-age children. An independent t test was used to examine group differences in problem behaviors. Pearson correlation analysis and multiple linear regression were conducted to identify associations among SPD, parenting stress, and problem behaviors. RESULTS: Preschool children had more social withdrawal than school-age children. Moderately negative correlations were found between SPD and problem behaviors among preschool children. Parenting stress was a factor associated with problem behaviors in both groups, whereas SPD was a factor specific to preschoolers. CONCLUSION: Understanding unique problem behaviors and the significant role of SPD and parenting stress in problem behaviors could help occupational therapy clinicians plan interventions accordingly.