Effect of activity-based mirror therapy on lower limb motor-recovery and gait in stroke: A randomised controlled trial.

Objective: To determine the effect of activity-based mirror therapy (MT) on motor recovery and gait in chronic poststroke hemiparetic subjects. Design: A randomised, controlled, assessor-blinded trial. Setting: Rehabilitation institute. Participants: Thirty-six chronic poststroke (15.89 ± 9.01 months) hemiparetic subjects (age: 46.44 ± 7.89 years, 30 men and functional ambulation classification of median level 3). Interventions: Activity-based MT comprised movements such as ball-rolling, rocker-board, and pedalling. The activities were provided on the less-affected side in front of the mirror while hiding the affected limb. The movement of the less-affected lower limb was projected as over the affected limb. Conventional motor therapy based on neurophysiological approaches was also provided to the experimental group. The control group received only conventional management. Main outcome measures: Brunnstrom recovery stages (BRS), Fugl-Meyer assessment lower extremity (FMA-LE), Rivermead visual gait assessment (RVGA), and 10-metre walk test (10-MWT). Results: Postintervention, the experimental group exhibited significant and favourable changes for FMA-LE (mean difference = 3.29, 95% CI = 1.23-5.35, p = .003) and RVGA (mean difference = 5.41, 95% CI = 1.12-9.71, p = .015) in comparison to the control group. No considerable changes were observed on 10-MWT. Conclusions: Activity-based MT facilitates motor recovery of the lower limb as well as reduces gait deviations among chronic poststroke hemiparetic subjects.

Mirror Illusion for Sensori-Motor Training in Stroke: A Randomized Controlled Trial.

BACKGROUND: Poststroke, sensory deficits are not uncommon. In spite of the close association between the sensory and motor recovery, the deficits are usually underemphasized. Mirror therapy (MT), a neural-based approach for the motor deficit has not been explored for the sensory impairment. The objective of the present study was to develop and determine the effect of a MT program for sensori-motor impairment among poststroke subjects. METHODS DESIGN: Randomized controlled trial. SETTING: Functional therapy laboratory of Rehabilitation Institute. PARTICIPANTS: Thirty-one chronic poststroke subjects (17 experimental and 14 controls), aged between 30 and 60years, with ≤ diminished light touch in the hand. OUTCOME MEASURE: Semmes Weinstein Monofilament (cutaneous threshold), 2-Point discrimination test (touch discrimination) and Fugl-Meyer Assessment (hand motor recovery). INTERVENTION: The experimental group received sensory stimulus such as tactile perception and motor tasks on the less-affected hand using mirror box. The control counterparts underwent only dose-matched conventional program. 30 sessions with a frequency of 5/week were imparted to the groups. RESULTS: Post intervention, there was a significant (P < .004) increase up to 30% positive touch-response for the hand quadrants among the experimental group in comparison to only 13.5% rise for the same among the controls. The cutaneous threshold of the less-affected palm also improved significantly among the experimental subjects in comparison to the controls (P = .04). CONCLUSION: MT may be considered as a promising regime for enhancing cutaneous sensibility in stroke. The mirror illusion induced by MT may be utilized for sensory and motor deficits as well as for the more-affected and less-affected hands.

Underlying neural mechanisms of mirror therapy: Implications for motor rehabilitation in stroke.

Mirror therapy (MT) is a valuable method for enhancing motor recovery in poststroke hemiparesis. The technique utilizes the mirror-illusion created by the movement of sound limb that is perceived as the paretic limb. MT is a simple and economical technique than can stimulate the brain noninvasively. The intervention unquestionably has neural foundation. But the underlying neural mechanisms inducing motor recovery are still unclear. In this review, the neural-modulation due to MT has been explored. Multiple areas of the brain such as the occipital lobe, dorsal frontal area and corpus callosum are involved during the simple MT regime. Bilateral premotor cortex, primary motor cortex, primary somatosensory cortex, and cerebellum also get reorganized to enhance the function of the damaged brain. The motor areas of the lesioned hemisphere receive visuo-motor processing information through the parieto-occipital lobe. The damaged motor cortex responds variably to the MT and may augment true motor recovery. Mirror neurons may also play a possible role in the cortico-stimulatory mechanisms occurring due to the MT.

Effect of motor training involving the less-affected side (MTLA) in post-stroke subjects: a pilot randomized controlled trial.

INTRODUCTION: Poststroke, less-severe motor impairment occurs on the ipsilesional side of body. The objective of the present study was to evaluate the effectiveness of the motor training involving the less-affected side (MTLA) in stroke. METHODS: This was a randomized, controlled, double-blinded pilot study conducted in the occupational therapy unit of a rehabilitation Institute. A convenience sample of 35 stroke subjects (mean poststroke duration, 28.76 weeks) was randomized into two groups (the experimental group: 17 and control group: 18). Thirty-two participants completed the entire study protocol. The experimental group and control group were provided MTLA and neurophysiological-based conventional therapy respectively. Both the groups received 24 treatment sessions (60 minutes each) over the period of two months. The Affected side was assessed using Brunnstrom recovery stage (BRS) and Fugl-Meyer assessment (FMA) whereas the less-affected side was evaluated by Minnesota manual dexterity test (MMDT), Purdue peg board test (PPBT) and Manual Muscle Testing (MMT). RESULTS: Postintervention, the less-affected side of experimental group demonstrated significant improvement for MMDT (P = 0.003), PPBT (P = 0.01) and MMT (P < 0.001 to 0.043) in comparison to the control group. Further, as compared to the control group, the experimental group exhibited positive significant change for the measure of affected side [BRS (P < 0.001) and FMA (P < 0.001 to 0.03)] at post assessment. CONCLUSION: MTLA enhanced the muscle strength, dexterity and coordination of the less-affected side as well as the motor recovery of the affected side in poststroke hemiparetic subjects.

Task-Based Mirror Therapy Augmenting Motor Recovery in Poststroke Hemiparesis: A Randomized Controlled Trial.

BACKGROUND: To establish the effect of the task-based mirror therapy (TBMT) on the upper limb recovery in stroke. METHODS: A pilot, randomized, controlled, assessor-blinded trial was conducted in a rehabilitation institute. A convenience sample of 33 poststroke (mean duration, 12.5 months) hemiparetic subjects was randomized into 2 groups (experimental, 17; control, 16). The subjects were allocated to receive either TBMT or standard motor rehabilitation-40 sessions (5/week) for a period of 8 weeks. The TBMT group received movements using various goal-directed tasks and a mirror box. The movements were performed by the less-affected side superimposed on the affected side. The main outcome measures were Brunnstrom recovery stage (BRS) and Fugl-Meyer assessment (FMA)-FMA of upper extremity (FMA-UE), including upper arm (FMA-UA) and wrist-hand (FMA-WH). RESULTS: The TBMT group exhibited highly significant improvement on mean scores of FMA-WH (P < .001) and FMA-UE (P < .001) at postassessment in comparison to the control group. Furthermore, there was a 12% increase in the number of subjects at BRS stage 5 (out of synergy movement) in the experimental group as compared to a 0% rise at the same stage in the control group. CONCLUSIONS: This pilot trial confirmed the role of TBMT in improving the wrist-hand motor recovery in poststroke hemiparesis. MT using tasks may be used as an adjunct in stroke rehabilitation.

Does motor training of the nonparetic side influences balance and function in chronic stroke? A pilot RCT.

BACKGROUND: Balance and functional abilities are controlled by both sides of the body. The role of nonparetic side has never been explored for such skills. OBJECTIVE: The objective of the present study was to examine the effect of a motor therapy program primarily involving the nonparetic side on balance and function in chronic stroke. METHOD: A randomized controlled, double blinded trial was conducted on 39 poststroke hemiparetic subjects (21, men; mean age, 42 years; mean poststroke duration, 13 months). They were randomly divided into the experimental group (n = 20) and control group (n = 19). The participants received either motor therapy focusing on the nonparetic side along with the conventional program or conventional program alone for 8 weeks (3 session/week, 60 minutes each). The balance ability was assessed using Berg Balance Scale (BBS) and Functional Reach Test (FRT) while the functional performance was measured by Barthel Index (BI). RESULT: After intervention, the experimental group exhibited significant (P < 0.05) change on BBS (5.65 versus 2.52) and BI (12.75 versus 2.16) scores in comparison to the control group. CONCLUSION: The motor therapy program incorporating the nonparetic side along with the affected side was found to be effective in enhancing balance and function in stroke.

Task-based and Magnified Mirror Therapy for Unilateral Spatial Neglect among post-stroke subjects: Study protocol for a randomized controlled trial.

BACKGROUND: Unilateral spatial neglect (USN) is a commonly occurring neurocognitive disability after a stroke. The neglect may affect the motor recovery of the upper and lower limbs and functional performances. Mirror therapy, a simple and economical approach has the potential to reduce the USN and related impairments. AIM: The primary objective of this study is to determine the effectiveness of task-based and magnified mirror therapy on the USN and on the motor recovery of the post-stroke subjects. The secondary objective is to investigate the effectiveness of the intervention on the function and disability of the subjects. METHODS: In this randomized controlled, assessor-blinded trial, 86 post-stroke subjects will be recruited from the neuro-rehabilitation laboratory of a rehabilitation institute, located in northern India. The participants,aged20 to 80 years, with 1 to 36 months of stroke onset, hemiparesis, and the USN, will be considered eligible for the study. In addition to the conventional rehabilitation, the experimental group(n = 43) will receive 40 sessions (8 weeks) of Task-based and MAGnified Mirror Therapy for Unilateral Spatial Neglect (T-MAGUSN). The control group (n = 43) will undergo a dose-matched conventional program only. The participants will be assessed at baseline, post-intervention and 4-week follow-up using primary (Line Bisection Test, Letter Cancellation Test, and Fugl-Myer Assessment) and secondary (Catherine Bergego Scale, Berg Balance Scale, Functional Ambulation Classification, Modified Rankin Scale) outcome measures. DISCUSSION: This proposed study will lead to the development of a novel rehabilitation protocol for the management of USN, aiming to enhance motor and functional recovery. The investigation will consider both the upper and lower limbs for the intervention, reducing the impact of cognitive disability in stroke. TRIAL REGISTRATION: Clinical Trial Registry of India (CTRI) as CTRI/2023/05/053184 (www.ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=74659).

Sensory deficits of the paretic and non-paretic upper limbs relate with the motor recovery of the poststroke subjects.

BACKGROUND: Post stroke, motor paresis has usually been considered to be a crucial factor responsible for the disability; other impairments such as somatosensory deficits may also play a role. OBJECTIVE: To determine the relation between the sensory deficits (paretic and non-paretic upper limbs) and the motor recovery of the paretic upper limb and to predict the potential of motor recovery based on the sensory deficits among stroke subjects. METHODS: The study was a cross-sectional study conducted in a rehabilitation institute. Ninety-five poststroke hemiparetic subjects having sensory impairment in any of the modalities were considered for this study. Sensory deficits were assessed on both the upper limbs (paretic and non-paretic) primarily using Erasmus MC modification of the revised version of Nottingham Sensory Assessment (Em-NSA) and Nottingham Sensory Assessment (Stereognosis) (NSA-S). The motor recovery was assessed using the Fugl-Meyer assessment (FMA). RESULTS: The measures of sensory deficits exhibited weak but significant correlation [the paretic (Em-NSA and NSA; r = .38 to .58; p < .001) and the non-paretic (Em-NSA and NSA; r = .24 to .38; p = .03 to .001)] with the motor recovery of the paretic upper limb as measured by FMA. The potential of favorable recovery of the paretic upper limb may be predicted using the cutoff scores of Em-NSA (30, 21, and 24) and NSA-S (5, 8, and 5) of the paretic side. CONCLUSION: In stroke, sensory deficits relate weakly with the recovery of the paretic upper limb and can predict recovery potential of the paretic upper limb.

Effect of task-based mirror therapy on motor recovery of the upper extremity in chronic stroke patients: a pilot study.

BACKGROUND AND AIMS: Mirror therapy (MT) is an alternative therapeutic intervention that uses the interaction of visuomotor-proprioception inputs to enhance movement performance of the impaired limb. Despite strong evidence for task-specific training in stroke, MT has been investigated using nontask movements. The aim of this pilot study was to assess the effectiveness of task-based MT on motor recovery of the upper extremity in chronic stroke patients. METHOD: In a pretest-posttest single-group design, a convenience sample of 13 chronic stroke patients at an occupational therapy department of a rehabilitation institute was assessed on a task-based MT intervention. Participants received a task-based MT program, performing various tasks by the less affected upper extremity and observing in the mirror box along with conventional management, 4 days per week for 4 weeks. Fugl-Meyer Assessment (FMA), which includes subsection upper extremity (FMA-UE) and subpart upper arm (FMA-UA) and hand (FMA-WH), was used as an outcome measure. RESULTS: Participants showed no significant improvement for FMA-UE and FMA-UA at postassessment. FMA-UE changed from 43% to 51%. Post FMA-UA score showed only 2% improvement. However, there was statistically significant improvement on mean scores of FMA-WH at postassessment (16.21 ± 3.06) as compared with the prescores (12.29 ± 3.1; P < .05). FMA-WH improved from 41% to 54%. CONCLUSIONS: The preliminary findings suggest that task-based MT is effective in improving wrist and hand motor recovery in chronic stroke patients. Further studies in the form of randomized trials are needed to validate its effectiveness.

Relation between the upper extremity synergistic movement components and its implication for motor recovery in poststroke hemiparesis.

BACKGROUND: Synergy is a functional linkage of muscles during voluntary motor action. In poststroke hemiparesis, synergistic movements get disorganized in the form of stereotyped behaviors. Furthermore, there is a linkage between the movement components of the synergies, which should be understood for focused motor rehabilitation. OBJECTIVE: To find the relationship between the synergistic motor behavior and recovery of the individual movement in chronic poststroke hemiparetic subjects. METHOD: A prospective, cross-sectional, observational study was conducted at an outpatient occupational therapy unit of a rehabilitation institute. A convenience sample of 30 chronic poststroke hemiparetic subjects (25 male and 5 female; 16 left sided and 14 right sided) was assessed using the Fugl-Meyer assessment (FMA) and Brunnstrom recovery stages of arm (BRS-A) and hand (BRS-H). RESULTS: The mean poststroke duration of the subjects was 40.9 months. There were significantly higher scores ( P < .001) for BRS-A (4.13 ± 1.07) and FMA upper arm (29.03 ± 4.31) as compared to BRS-H (2.47 ± 1.45) and FMA wrist and hand (11.50 ± 5.88), respectively. Very high correlation ( r = 0.9 to 1.0; P < .05) was found between the 2 components of FMA (wrist circumduction and spherical grasp). Moderate ( r = 0.5 to 0.69; P < .05) to high ( r = 0.7 to 0.89; P < .05) correlation was found between many components of FMA (flexor synergy, extensor synergy, movement combining synergies, movement out of synergy, upper arm, and wrist-hand components). CONCLUSION: Many upper extremity movement components of the paretic side were related to one another. The components may be used for motor rehabilitation in order of their strength of association. The concept of synergistic linkage may be applied for motor training of the upper limb at a particular stage of the recovery.

Meaningful task-specific training (MTST) for stroke rehabilitation: a randomized controlled trial.

BACKGROUND/OBJECTIVE: The upper extremity motor deficit is one of the functional challenges in post stroke patients. The objective of the present study was to evaluate the effectiveness of the meaningful task-specific training (MTST) on the upper extremity motor recovery during the subacute phase after a stroke. METHOD: This was a randomized, controlled, double-blinded trial in the neurology department of a university hospital and occupational therapy unit of a rehabilitation institute. A convenience sample of 103 people, 4 to 24 weeks (mean, 12.15 weeks) after the stroke, was randomized into 2 groups (MTST, 51; standard training group, 52). Subjects in the Brunnstrom stage of arm recovery of 2 to 5 were included in the study. Ninety-five participants completed the 8-week follow-up. INTERVENTIONS: Participants were assigned to receive either the MTST or dose-matched standard training program based on the Brunnstrom stage and Bobath neurodevelopmental technique, 4 to 5 days a week for 4 weeks. Fugl-Meyer assessment (FMA), Action Research Arm Test (ARAT), Graded Wolf Motor Function Test (GWMFT), and Motor Activity Log (MAL) were outcome measures RESULTS: The MTST group showed a positive improvement in the mean scores on the outcome measures at post and follow-up assessments in comparison to the control group. Further, statistically significant differences were observed in changes between the groups at post and follow-up assessment for FMA, ARAT, GWMFT, and MAL. CONCLUSION: The MTST produced statistically significant and clinically relevant improvements in the upper extremity motor recovery of the patients who had a subacute stroke.

Synergy-Based Motor Therapy Inducing Favorable Changes in Motor Function Components among Poststroke Subjects: A Single-Group Study.

Background Synergy is an outcome of multiple muscles acting in a synchronized pattern, controlled by the central nervous system. After brain insult, a set of deviated movement pattern emerges in the affected limb. The methods to train synchronization of muscles may diminish the deviated movement augmenting neuromotor control. The purpose of this investigation was to develop a synergy-based motor therapy (SBMT) protocol for the paretic upper limb in poststroke subjects. Further, the feasibility and effectiveness of the program was evaluated. . Methods The design was Pretest-posttest single-group assessor-blinded trial. Department of occupational therapy of a national institute for persons with physical disabilities was the study site. There were 40 study subjects (23 men, ranging from 40 to 60 years, 18 subjects with hemorrhagic cerebrovascular accident, and > 6 months after the accident) exhibiting motor paresis of half side of the body. SBMT is a stage-specific regime based on the linkage between the deviated and usual muscle action. SBMT items were selected considering the strength and magnitude of the deviated motor components. The movement linkages were utilized to dissociate strong coupled components; for instance, forearm pronation-supination with elbow 90-degree flexion. Fugl-Meyer Assessment (upper extremity) (FMA-UE), Wolf Motor Function Test (WMFT), and Barthel Index (BI) were applied to quantify the motor status, motor functional ability of the upper extremity, and self-care activities, respectively. Results All the enrolled subjects could perform their corresponding SBMT sessions. Posttreatment, FMA-UE improved significantly ( p < 0.001) from mean of 26.30 (standard deviation [SD] 15.02) to 35.20 (SD 17.64). Similarly, the WMFT both time (in seconds) and quality also positively improved significantly ( p < .001) from mean of 76.77 (SD 54.73) to 64.07 (SD 56.99) and 1.34 (SD 1.06) to 1.87 (SD 1.34), respectively. BI improved from 79.88 (SD 17.07) to 92.62 (SD 21.2) after the intervention ( p < 0.001). Conclusion SBMT protocol was a feasible and effective intervention to facilitate motor function components in chronic hemiparetic subjects. The regime could be considered as a potential intervention for stroke rehabilitation. Further trials and use of sophisticated measures are recommended to authenticate the outcome of this investigation. Clinical Trial Registration Clinical Trial Registry of India as CTRI/2017/10/010162 on October 23, 2017 (retrospectively).

Active Sensory Therapies Enhancing Upper Limb Recovery Among Poststroke Subjects: A Systematic Review.

Background: In stroke, sensory deficits may affect the motor recovery of the subjects. The evidence for the active sensory intervention to enhance motor recovery is sparsely available. Purpose: To systematically review the available evidence from the studies on active sensory therapies augmenting upper limb recovery among poststroke subjects. Methods: The following databases were searched for the desired articles: PubMed, the Cochrane Central Register of Trials (CENTRAL), DORIS, PEDro, and OTseeker. The primary search keywords were stroke, sensory, and motor. The articles published in English up to August 2021 were considered for the review. Only investigations that studied active sensory interventions to enhance motor recovery were considered for the review. The studies of robotic training, virtual reality, electrical stimulation, and acupuncture were excluded. Motor recovery and sensory recovery were considered as primary and secondary measures, respectively. Results: Out of 3528 screened studies, eight studies were found eligible for the present systematic review. Active sensory interventions in the form of sensory discrimination, mirror therapy, motor imagery, and specific somatosensory training were utilized in the selected studies. The interventions through mirror therapy and mental imaging have some promising roles in enhancing upper limb recovery. However, there is a lack of strong evidence for the effectiveness of the intervention enhancing motor improvement among the stroke subjects. Conclusion: A comprehensive active sensory protocol should be developed having components of cognitive, sensory, motor, and functional demand. There is a need to conduct good quality randomized trials to support the existing active sensory therapies.

Estimating the minimal clinically important difference of an upper extremity recovery measure in subacute stroke patients.

BACKGROUND: The minimal clinically important difference (MCID) estimates of some of the stroke-related measures are available; but MCID of the Fugl-Meyer assessment (FMA) measure is unknown, which limits the application and interpretation of change scores in poststroke patients with motor deficits. OBJECTIVE: To estimate the MCID of the FMA-UE (upper extremity) using the modified Rankin scale (mRS) and global rating of patient-perceived changes (GRPPC) in subacute poststroke patients. METHODS: The prospective, cohort study took place in the neurology department of a university hospital. Seventy-one subacute poststroke (mean duration, 8.42 weeks) patients were prospectively enrolled in a randomized clinical trial of the ongoing Meaningful Task Specific Training (MTST). FMA-UE, mRS, and GRPPC scores were obtained at pre- and 4 weeks postintervention. RESULTS: The MCID values of FMA-UE were 9 (80.39% sensitive and 70% specific) and 10 (97.62% sensitive and 89.66% specific) anchored to mRS and GRPPC, respectively. CONCLUSIONS: The estimated MCID score for the upper extremity motor recovery among patients with subacute stroke is 9 to 10 on the FMA-UE. Patients with subacute stroke who achieve a score of 9 to 10 on FMA-UE are more likely to experience or perceive a meaningful and clinically important improvement in their disability level than those who do not. The reference value can be used to develop goals and interpret progress in subacute poststroke patients.

Task-oriented circuit class training program with motor imagery for gait rehabilitation in poststroke patients: a randomized controlled trial.

BACKGROUND AND OBJECTIVE: The ability to walk is impaired in more than 80% of poststroke patients. The objective of the present study was to evaluate the effectiveness of the task-oriented circuit class training (TOCCT) with motor imagery (MI) on the gait during the subacute phase after a stroke. METHOD: This was a randomized, controlled, assessor-blinded trial in a neurology department of a university hospital. A convenience sample of 30 people, 4 to 12 weeks (mean, 6.3 weeks) after the stroke was randomized into 2 groups (the TOCCT with MI and standard training group) of 15 people each. Twenty-nine participants completed the 6-week follow-up. Participants were assigned to receive either the TOCCT with MI or dose-matched standard training program based on the Bobath's neurodevelopmental technique, 7 days a week for 2 weeks, as outpatients or inpatients. Outcome measures were the Functional Ambulation Classification (FAC), the Rivermead Visual Gait Assessment (RVGA), step length asymmetry, walking speed, and 6-minute walk test (6MWT). RESULTS: The TOCCT with MI group showed a positive improvement in the mean/median scores on most of the outcome measures at post and follow-up assessments in comparison to the control group. However, statistically significant differences were observed in changes between the groups at post and follow-up assessment for FAC, RVGA, walking speed, and 6MWT (ANOVA, P = .001 to .049; Mann-Whitney U test, P = .001). CONCLUSION: Among the patients who had a stroke within the previous 4 to 12 weeks, the TOCCT with MI produced statistically significant and clinically relevant improvements in the gait and the gait-related activities.

Rehabilitation of the Shoulder Subluxation Based on Ultrasonographic Findings among Post Stroke Subjects: A Case Series.

BACKGROUND: Up to three-fourths of the poststroke subjects may experience shoulder subluxation as a challenging complication. The existing rehabilitation management is based on the clinical assessment. Ultrasonographic evaluation demonstrates findings, which cannot be discerned by the usual methods. OBJECTIVES: To determine the effect of rehabilitation protocol based on the sonographic findings of the subluxed shoulder on reduction of the subluxation and upper limb motor recovery. MATERIALS AND METHODS: Setting: Department of Occupational therapy of a Rehabilitation Institute. Study Design: A prospective case series. Subjects: 08 Poststroke hemiparetic patients with subluxed shoulder. Outcome measure: Ultrasongraphy of the bilateral shoulder joints, Fingerbreadth palpation method, Visual analog scale (VAS), Fugl-Meyer assessment of upper extremity (FMA-UE). Intervention: As per the findings of the sonography, management in the form of shoulder support, physical agent modalities, motor therapy, and precautions and positioning was provided to the subjects for the period of 3 months. RESULTS: Post intervention, the participants showed 1 to 6 mm of reduction of acromion-greater tuberosity distance in addition to the reduction of atrophy and soft tissue or joint effusion. Furthermore, the participants also exhibited FMA-UE change ranging from 5 to 21. CONCLUSION: The ultrasonographic evaluation explores objective measurement and involvement of specific soft tissues among poststroke subject with the shoulder subluxation. The management based on the sonographic findings is an objective and valid approach.

Effect of NEuroplasticity-Principles-based SEnsory-Rehabilitation (NEPSER) on sensori-motor recovery in stroke: study protocol for a randomized controlled trial.

INTRODUCTION: Up to 2/3rd of the stroke subjects may experience impairment in any of the somatosensory modalities such as light touch, proprioception, and stereognosis. The sensory recovery is strongly associated with the level of motor recovery. Very negligible sensory-based interventions have been developed and found to be evident in enhancing the sensory deficit and associated motor recovery. The possible factor for the ineffectiveness of these sensory interventions could be lack of the neuroscientific basis in formulation of the program. Thus, the objective of the study is to determine the effectiveness of a neuralplasticity-principles-based sensory-rehabilitation protocol on motor and sensory recovery, and disability of the post-stroke hemiparetic subjects. METHODS: We propose to recruit 122 poststroke subjects in a randomized controlled, assessor blinded trial to be conducted in a rehabilitation-institute. The key eligibility criteria is age between 20 to 80 years, hemiparesis (right or left), ischemic or hemorrhagic stroke, 1 to 12 months poststroke, and impairment in any of the sensory modalities. The participants in the experimental group will receive NEuroplasticity-Principles-based SEnsory-Rehabilitation (NEPSER) protocol comprising active, repetitive, and meaningful training of the specific sensory modalities utilizing visuo-perceptual, cognitive, motor, and functional tasks will be imparted for 8 weeks, 5 sessions / week, each of 2 h. The control subjects will undergo only standard rehabilitation based on neurophysiological, biomechanical, and rehabilitative approaches. All the participants will be assessed for motor (Fugl-Meyer assessment, upper extremity section) and sensory recovery [Nottingham Sensory assessment (Erasmus MC modification of the revised version)] at baseline, 8-week, and 12-week follow-up. The Semmes weinstein monofilament, two-point discrimination test and modified rankin scale (disability) will be applied as secondary measures. A repeated-measures 2-way ANOVA will be used to estimate difference for the post intervention and follow-up scores between the groups. PERSPECTIVE: The proposed study will lead to development of a novel rehabilitation protocol that will not only enhance the sensory recovery but also the motor and functional recovery. This may reduce the impact of stroke disability and enhance the quality of life. TRIAL REGISTRATION: The trial has been registered under Clinical Trial Registry of India (CTRI) as CTRI/2019/09/021442 on 30th September 2019.

Interlimb coupling in poststroke rehabilitation: a pilot randomized controlled trial.

Background: The interlimb coupling, coordination between the limbs, gets hampered in post-stroke hemiparesis. Most of the poststroke motor regimes primarily focus on the more affected limb.Objectives: To develop an interlimb coupling protocol and assess its feasibility and effect on motor recovery, gait and disability among post-stroke subjects.Design: A pilot randomized controlled, doubled blinded trialSetting: A rehabilitation instituteMethods: 50 post-stroke (> 6 months) hemiparetic subjects (Brunnstrom recovery stage ≥ 3) were randomly divided into experimental (n=26) and control (n=24) groups. The 8-week experimental intervention (3 sessions of 1 hour each, per week) comprised activities demanding coordinated, alternate, and rhythmic use of the affected as well as the less-affected limbs. The outcome measures were feasibility of activities, Fugl-Meyer assessment (FMA), Rivermead visual gait assessment (RVGA), Functional ambulation category (FAC) and modified Rankin scale (mRS).Results: The experimental protocol was found to be feasible by the participants. Post intervention, the experimental group exhibited highly significant difference for FMA (mean difference = 7.12, 95% CI = 5.71 - 8.53, p < 0.001), RVGA reduction (mean difference = - 6.32, 95% CI = 7.51 - 5.13, p < 0.001), and median FAC enhancement (p < 0.001) in comparison to the controls. However, the median mRS level of experimental group did not change significantly (p = 0.056) when compared with the controls.Conclusions: The interlimb coupling training, a feasible program may enhance recovery of the upper and lower limbs and gait in stroke. Further definitive randomized trials are warranted to validate the present findings.