Impact of the combination of virtual reality and noninvasive brain stimulation on the upper limb motor function of stroke patients: a systematic review and meta-analysis.

BACKGROUND: Stroke frequently results in upper limb motor dysfunction, with traditional therapies often failing to yield sufficient improvements. Emerging technologies such as virtual reality (VR) and noninvasive brain stimulation (NIBS) present promising new rehabilitation possibilities. OBJECTIVES: This study systematically reviews and meta-analyses the effectiveness of VR and NIBS in improving upper limb motor function in stroke patients. METHODS: Registered with PROSPERO (CRD42023494220) and adhering to the PRISMA guidelines, this study conducted a thorough search of databases including PubMed, MEDLINE, PEDro, REHABDATA, EMBASE, Web of Science, Cochrane, CNKI, Wanfang, and VIP from 2000 to December 1, 2023, to identify relevant studies. The inclusion criterion was stroke patients receiving combined VR and NIBS treatment, while exclusion criteria were studies with incomplete articles and data. The risk of bias was assessed using the Cochrane Collaboration tool. Statistical analysis was performed using Stata SE 15.0, employing either a fixed-effects model or a random-effects model based on the level of heterogeneity. RESULTS: A total of 11 studies involving 493 participants were included, showing a significant improvement in Fugl-Meyer Assessment Upper Extremity (FMA-UE) scores in the combined treatment group compared to the control group (SMD = 0.85, 95% CI [0.40, 1.31], p = 0.017). The Modified Ashworth Scale (MAS) scores significantly decreased (SMD = - 0.51, 95% CI [- 0.83, - 0.20], p = 0.032), the Modified Barthel Index (MBI) scores significantly increased (SMD = 0.97, 95% CI [0.76, 1.17], p = 0.004), and the Wolf Motor Function Test (WMFT) scores also significantly increased (SMD = 0.36, 95% CI [0.08, 0.64], p = 0.021). Subgroup analysis indicated that the duration of treatment influenced the outcomes in daily living activities. CONCLUSIONS: The combination of VR and NIBS demonstrates significant improvements in upper limb motor function in stroke patients. The duration of treatment plays a critical role in influencing the outcomes, particularly in activities of daily living. This systematic review has limitations, including language bias, unclear randomization descriptions, potential study omissions, and insufficient follow-up periods. Future studies should focus on exploring long-term effects and optimizing treatment duration to maximize the benefits of combined VR and NIBS therapy.

Social Determinants of Health and the Use of Community-Based Rehabilitation Following Stroke: Methodologic Considerations.

Social determinants are nonmedical factors frequently used to study disparities in health outcomes but have not been widely explored in regard to rehabilitation service utilization. In our National Institutes of Child Health and Human Development-funded study, Access to and Effectiveness of Community-Based Rehabilitation After Stroke, we reviewed several conceptual models and frameworks for the study of social determinants to inform our work. The overall objective of this special communication is to describe our approach to identifying, selecting, and using area-level measures of social determinants to explore the relationship between social determinants and rehabilitation use. We present our methods for developing a conceptual model and a methodologic framework for the selection of social determinant measures relevant to rehabilitation use, as well as an overview of publicly available data on social determinants. We then discuss the methodologic challenges encountered and future directions for this work.

Is There Room for Improvement? Stroke Rehabilitation Environments May Not Reflect Home Environments in Terms of Chair, Toilet, and Bed Heights.

The present study aims to describe the chair, bed, and toilet heights in rehabilitation hospitals and home environments to challenge rehabilitation clinicians to better prepare stroke survivors for discharge home. This study uses analysis of secondary outcomes from a multicentre, phase II randomized controlled trial (HOME Rehab trial) and additional observation of hospital environment. Data were collected from six rehabilitation hospitals and the homes of two hundred first-time stroke survivors who were aged >45 years. Chair, bed and toilet heights were measured; we measured 936 chairs and beds in hospital (17%) and home (83%) environments. Mean chair height at home was 47 cm (SD 6), which was 2 cm (95% CI, 0-4) lower than in the hospital ward and 5 cm (95% CI, 3-7) lower than in the hospital gym. Mean toilet height at home was 42 cm (SD 3), which was 3 cm (95% CI, 2-4) lower than in the hospital. Study findings suggest a disparity in heights between hospitals and home. Although clinicians may be aware of this disparity, they need to ensure that chair and bed heights within the hospital environment are progressively made lower to better prepare stroke survivors for discharge home.

Clinician and patient experiences with shared decision-making to promote daily arm use for individuals with chronic stroke: an exploratory qualitative study.

Purpose: To explore the attitudes and experiences of clinicians and individuals with chronic stroke on the use of shared decision-making (SDM) during upper extremity rehabilitation to improve daily arm use in the home environment. Specifically, we aimed to describe clinician and client perspectives regarding the facilitators and barriers to using SDM within the context of a self-directed upper extremity intervention for individuals living in the community with chronic stroke. Methods: Data were collected within the context of an interventional study examining the feasibility of the Use My Arm-Remote intervention. Focus group interviews were conducted with the clinicians (n = 3) providing the intervention and individual semi-structured interviews with the participants (n = 15) of the study. All interview data were collected after the end of the intervention period. Data were analyzed using thematic analysis. Results: The following themes were identified: (1) Equal partnership; (2) Enhancing clinician confidence; and (3) This is different. Facilitators and barriers were identified within each theme. Key facilitators for clinicians were competence with SDM and patient characteristics; while facilitators for patients were open and trusting relationships with clinicians and personalized experience. Key barriers to SDM for clinicians were lack of expertise in SDM and participant buy in; while patients identified a lack of foundational knowledge of stroke rehabilitation as a potential barrier. Conclusions: Key barriers were analyzed using the consolidated framework for advancing implementation science to interpret results and identify strategies for enhancing the implementation of SDM in a virtual setting. The CFIR-ERIC tool highlighted the need for targeted educational meetings and materials to address the training and educational needs of both clinicians and patients for future iterations of this intervention.

Blood flow modulation to improve motor and neurophysiological outcomes in individuals with stroke: a scoping review.

Ischemic Conditioning (IC) is a procedure involving brief periods of occlusion followed by reperfusion in stationary limbs. Blood Flow Restriction with Exercise (BFR-E) is a technique comprising blood flow restriction during aerobic or resistance exercise. Both IC and BFR-E are Blood Flow Modulation (BFM) strategies that have shown promise across various health domains and are clinically relevant for stroke rehabilitation. Despite their potential benefits, our knowledge on the application and efficacy of either intervention in stroke is limited. This scoping review aims to synthesize the existing literature on the impact of IC and BFR-E on motor and neurophysiological outcomes in individuals post-stroke. Evidence from five studies displayed enhancements in paretic leg strength, gait speed, and paretic leg fatiguability after IC. Additionally, BFR-E led to improvements in clinical performance, gait parameters, and serum lactate levels. While trends toward motor function improvement were observed post-intervention, statistically significant differences were limited. Neurophysiological changes showed inconclusive results. Our review suggests that IC and BFR-E are promising clinical approaches in stroke, however high-quality studies focusing on neurophysiological mechanisms are required to establish the efficacy and underlying mechanisms of both in stroke. Recommendations regarding future directions and clinical utility are provided.

Translating acceptability to sustained delivery: Clinician and manager perspectives on implementing modified constraint-induced movement therapy in an early-supported discharge rehabilitation service.

BACKGROUND: Modified constraint-induced movement therapy (mCIMT) improves upper limb (UL) function after stroke. Despite up to one-third of stroke survivors being eligible, clinical uptake remains poor. To address this, a multi-modal behaviour change intervention was implemented across a large seven-site early-supported discharge (ESD) rehabilitation service. This study investigated the acceptability of mCIMT implementation within this ESD service and identified adaptations required for sustained delivery. METHODS: This qualitative study was nested within a mixed-methods process evaluation of mCIMT implementation. Four focus groups (n = 24) comprising therapists (two groups), therapy assistants (one group), and allied health managers (one group) were conducted. Data were analysed using reflexive thematic analysis and mapped to the Theoretical Domains Framework (TDF). CONSUMER AND COMMUNITY INVOLVEMENT: Consumers were not directly involved in this study; however, lived experience research partners have helped shape the larger mixed-methods implementation study. FINDINGS: Four themes were generated and mapped to the TDF. Factors related to acceptability included interdisciplinary practice in sharing workloads (belief about capabilities), practice opportunities across a range of UL presentations (skills), clinician attitudes influencing patient engagement (optimism), time constraints (belief about consequences), and cognitive overload from multiple systems and processes (memory, attention, and decision-making processes). Factors facilitating sustained delivery included improving stroke survivor education (knowledge), sharing success stories across teams (reinforcement), manager facilitation (social/professional role and identity), and the perception that the ESD setting was optimal for mCIMT delivery (social influences). CONCLUSION: mCIMT was acceptable in the ESD service, with clinicians feeling a responsibility to provide it. Key adaptations for sustained delivery included ongoing training, resource adaptation, and enhanced patient and carer engagement. Successful implementation and sustained delivery of mCIMT in the ESD service could enhance UL function and reduce the burden of care for potentially hundreds of stroke survivors and their carers. PLAIN LANGUAGE SUMMARY: Modified constraint-induced movement therapy (mCIMT) helps improve arm movement after a stroke. However, many stroke survivors do not get this therapy. To fix this, we started a program in a large home-based rehabilitation service. This study looked at how well mCIMT could fit into this service. We also wanted to know what changes were needed to make sure it was regularly provided. We held four group discussions with therapists, therapy assistants, and health managers. A total of 24 people took part. From these discussions, we found several important points. Therapists needed to work together as a team. They also needed to practice mCIMT to get better at delivering it. Therapists having a positive attitude would encourage more stroke survivors to take part. For long-term success, stroke survivors need better education about mCIMT. Managers need to encourage therapists to provide mCIMT. The rehabilitation service should also share their success stories about this therapy to encourage therapists to deliver it and stroke survivors to ask for it. Therapists enjoyed delivering mCIMT in the rehabilitation service. It worked better than other therapies to improve a stroke survivor's arm function. Because of this, they also felt it was their duty to offer mCIMT. Having ongoing training and better resources would help keep mCIMT going. If mCIMT can be provided regularly in this service, it could lead to better arm function and less care needed for many stroke survivors and their carers.

Mobile Health (mHealth) Applications for Stroke Rehabilitation: A mini review.

Mobile Health (mHealth) applications are transforming stroke rehabilitation, through personalized care and datadriven insights. These applications employ AI-driven algorithms, tele-rehabilitation, wearable technologies, and gamification to enhance recovery process. The objective of this mini review is to explore the transformative role of Mobile Health (mHealth) applications in stroke rehabilitation, highlighting its capacity to transcend geographical barriers and establish extensive support networks connecting stroke survivors, caregivers, and healthcare professionals. Particularly in developing countries like Pakistan, where healthcare resources may be limited, mHealth offers a viable solution to bridge the gap in stroke care. By facilitating access to rehabilitation services, mHealth can significantly improve outcomes for stroke survivors in these regions. This integration of mobile technology with stroke rehabilitation not only promises personalized and more effective rehabilitation but also presents a unique blend of technology and compassion. This evolution in healthcare holds the potential to redefine stroke recovery, marking a significant milestone in the journey towards more inclusive, efficient, and compassionate care solutions.

IpsiHand Brain-Computer Interface Therapy Induces Broad Upper Extremity Motor Rehabilitation in Chronic Stroke.

BACKGROUND: Chronic hemiparetic stroke patients have very limited benefits from current therapies. Brain-computer interface (BCI) engaging the unaffected hemisphere has emerged as a promising novel therapeutic approach for chronic stroke rehabilitation. OBJECTIVES: This study investigated the effectiveness of contralesionally-controlled BCI therapy in chronic stroke patients with impaired upper extremity motor function. We further explored neurophysiological features of motor recovery driven by BCI. We hypothesized that BCI therapy would induce a broad motor recovery in the upper extremity, and there would be corresponding changes in baseline theta and gamma oscillations, which have been shown to be associated with motor recovery. METHODS: Twenty-six prospectively enrolled chronic hemiparetic stroke patients performed a therapeutic BCI task for 12 weeks. Motor function assessment data and resting state electroencephalogram signals were acquired before initiating BCI therapy and across BCI therapy sessions. The Upper Extremity Fugl-Meyer assessment served as a primary motor outcome assessment tool. Theta-gamma cross-frequency coupling (CFC) was computed and correlated with motor recovery. RESULTS: Chronic stroke patients achieved significant motor improvement in both proximal and distal upper extremity with BCI therapy. Motor function improvement was independent of Botox application. Theta-gamma CFC enhanced bilaterally over the C3/C4 motor electrodes and positively correlated with motor recovery across BCI therapy sessions. CONCLUSIONS: BCI therapy resulted in significant motor function improvement across the proximal and distal upper extremities of patients, which significantly correlated with theta-gamma CFC increases in the motor regions. This may represent rhythm-specific cortical oscillatory mechanism for BCI-driven rehabilitation in chronic stroke patients. TRIAL REGISTRATION: Advarra Study: https://classic.clinicaltrials.gov/ct2/show/NCT04338971 and Washington University Study: https://classic.clinicaltrials.gov/ct2/show/NCT03611855.

Effects of ankle joint degree of freedom of knee-ankle-foot orthoses on loading patterns and triceps surae muscle activity on the paretic side in individuals with subacute severe hemiplegia: a retrospective study.

BACKGROUND: Individuals with subacute severe hemiplegia often undergo alternate gait training to overcome challenges in achieving walking independence. However, the ankle joint setting in a knee-ankle-foot orthosis (KAFO) depends on trunk function or paralysis stage for alternate gait training with a KAFO. The optimal degree of ankle joint freedom in a KAFO and the specific ankle joint conditions for effective rehabilitation remain unclear. Therefore, this study aimed to investigate the effects of different degrees of freedom of the ankle joint on center-of-pressure (CoP) parameters and muscle activity on the paretic side using a KAFO and to investigate the recommended setting of ankle joint angle in a KAFO depending on physical function. METHODS: This study included 14 participants with subacute stroke (67.4 ± 13.3 years). The CoP parameters and muscle activity of the gastrocnemius lateralis (GCL) and soleus muscles were compared using a linear mixed model (LMM) under two ankle joint conditions in the KAFO: fixed at 0° and free ankle dorsiflexion. We confirmed the relationship between changes in CoP parameters or muscle activity under different conditions and physical functional characteristics such as the Fugl-Meyer Assessment of Lower Extremity Synergy Score (FMAs) and Trunk Impairment Scale (TIS) using LMM. RESULTS: Anterior-posterior displacement of CoP (AP_CoP) (p = 0.011) and muscle activity of the GCL (p = 0.043) increased in the free condition of ankle dorsiflexion compared with that in the fixed condition. The FMAs (p = 0.004) and TIS (p = 0.008) demonstrated a positive relationship with AP_CoP. A positive relationship was also found between TIS and the percentage of medial forefoot loading time in the CoP (p < 0.001). CONCLUSIONS: For individuals with severe subacute hemiplegia, the ankle dorsiflexion induction in the KAFO, which did not impede the forward tilt of the shank, promotes anterior movement in the CoP and muscle activity of the GCL. This study suggests that adjusting the dorsiflexion mobility of the ankle joint in the KAFO according to improvement in physical function promotes loading of the CoP to the medial forefoot.

Association of Age and Neurological Severity at Intensive Care Unit Admission With Driving Resumption Within 30 Days of Stroke: A Single-Center Historical Cohort Study.

Objectives Guidelines in several countries recommend against driving soon after a stroke; however, some patients resume driving within one month after onset. This study aimed to examine the relationship between neurological and social background factors at intensive care unit (ICU) admission and resumption of motor vehicle driving within 30 days of the first acute stroke/cerebral hemorrhage. Materials and methods Data were extracted from medical records of a single center linked to the National Cerebral and Cardiovascular Center Administration Office for Stroke Data Bank in Japan. The data included age, sex, Japan Coma Scale (JCS), National Institutes of Health Stroke Scale (NIHSS), employment status, family situation, and outcomes of driving resumption in patients with a valid driving license transported to the ICU within 24 hours of stroke onset. Time-to-event analysis was used to explore the associations between these factors and driving resumption, with data censored 30 days from onset. Results In total, 239 patients had complete medical records, of whom 66 resumed driving. A multivariate Cox proportional hazards analysis showed that fewer patients aged ≥65 years resumed driving than those aged <65 years (hazard ratio 0.46; 95% confidence interval: 0.25-0.84; p=0.009). Patients with NIHSS scores ≥5 and JCS scores ≥1 were also less likely to resume driving compared with those with scores <5 (0.22; 0.08-0.56; p=0.008) and 0 (0.13; 0.04-0.37; p<0.001), respectively. Conclusions Age, NIHSS score, and JCS score at ICU admission are independently associated with the likelihood of resuming driving within 30 days of stroke onset. These findings may aid with the provision of support and education to facilitate the efficient resumption of driving after an acute event.

Post-stroke lateropulsion in Australia and New Zealand: a survey investigating current knowledge, priorities and practice.

BACKGROUND: Post-stroke lateropulsion is prevalent and associated with poor rehabilitation outcomes, but evidence to guide rehabilitation of affected stroke survivors is limited. Current post-stroke lateropulsion rehabilitation practice across Australia and New Zealand has not been previously described. OBJECTIVES: This study aimed to describe lateropulsion rehabilitation practice in Australia and New Zealand, determine clinicians,' educators' and researchers' opinions about the need for educational resources to guide best-practice, and to identify current barriers to, and enablers of, optimal rehabilitation delivery. METHODS: This cross-sectional survey was distributed to stroke rehabilitation clinicians, educators and researchers across Australia and New Zealand using Qualtrics. Data were described using frequency distributions and Chi-squared tests. Responses to open-ended questions were summarized for reporting. RESULTS: The final analyses included 127 surveys. Most participants (93%) were physiotherapists. The importance of identifying and assessing post-stroke lateropulsion was noted by 97.6% of participants; however routine lateropulsion assessment was reported by only 60.6% of respondents. About 93.6% of participants indicated that lateropulsion should be targeted as a rehabilitation priority. Limitations in knowledge and skill among clinicians and insufficient evidence to guide rehabilitation were noted as barriers to best-practice rehabilitation delivery. Most respondents (95.2%) indicated that lateropulsion management should be included in stroke rehabilitation guidelines. CONCLUSIONS: A sample of clinicians, educators, and researchers involved in stroke rehabilitation across Australia and New Zealand have indicated that lateropulsion should be targeted as a rehabilitation priority. Knowledge and skill were identified as barriers to best-practice rehabilitation implementation, which could be improved by addressing lateropulsion in clinical practice guidelines.

Brain state-dependent repetitive transcranial magnetic stimulation for motor stroke rehabilitation: a proof of concept randomized controlled trial.

Background: In healthy subjects, repetitive transcranial magnetic stimulation (rTMS) targeting the primary motor cortex (M1) demonstrated plasticity effects contingent on electroencephalography (EEG)-derived excitability states, defined by the phase of the ongoing sensorimotor µ-oscillation. The therapeutic potential of brain state-dependent rTMS in the rehabilitation of upper limb motor impairment post-stroke remains unexplored. Objective: Proof-of-concept trial to assess the efficacy of rTMS, synchronized to the sensorimotor µ-oscillation, in improving motor impairment and reducing upper-limb spasticity in stroke patients. Methods: We conducted a parallel group, randomized double-blind controlled trial in 30 chronic stroke patients (clinical trial registration number: NCT05005780). The experimental intervention group received EEG-triggered rTMS of the ipsilesional M1 [1,200 pulses; 0.33 Hz; 100% of the resting motor threshold (RMT)], while the control group received low-frequency rTMS of the contralesional motor cortex (1,200 pulses; 1 Hz, 115% RMT), i.e., an established treatment protocol. Both groups received 12 rTMS sessions (20 min, 3× per week, 4 weeks) followed by 50 min of physiotherapy. The primary outcome measure was the change in upper-extremity Fugl-Meyer assessment (FMA-UE) scores between baseline, immediately post-treatment and 3 months' follow-up. Results: Both groups showed significant improvement in the primary outcome measure (FMA-UE) and the secondary outcome measures. This included the reduction in spasticity, measured objectively using the hand-held dynamometer, and enhanced motor function as measured by the Wolf Motor Function Test (WMFT). There were no significant differences between the groups in any of the outcome measures. Conclusion: The application of brain state-dependent rTMS for rehabilitation in chronic stroke patients is feasible. This pilot study demonstrated that the brain oscillation-synchronized rTMS protocol produced beneficial effects on motor impairment, motor function and spasticity that were comparable to those observed with an established therapeutic rTMS protocol. Clinical Trial Registration: ClinicalTrials.gov, identifier [NCT05005780].

Predicting improvement in biofeedback gait training using short-term spectral features from minimum foot clearance data.

Stroke rehabilitation interventions require multiple training sessions and repeated assessments to evaluate the improvements from training. Biofeedback-based treadmill training often involves 10 or more sessions to determine its effectiveness. The training and assessment process incurs time, labor, and cost to determine whether the training produces positive outcomes. Predicting the effectiveness of gait training based on baseline minimum foot clearance (MFC) data would be highly beneficial, potentially saving resources, costs, and patient time. This work proposes novel features using the Short-term Fourier Transform (STFT)-based magnitude spectrum of MFC data to predict the effectiveness of biofeedback training. This approach enables tracking non-stationary dynamics and capturing stride-to-stride MFC value fluctuations, providing a compact representation for efficient processing compared to time-domain analysis alone. The proposed STFT-based features outperform existing wavelet, histogram, and Poincaré-based features with a maximum accuracy of 95%, F1 score of 96%, sensitivity of 93.33% and specificity of 100%. The proposed features are also statistically significant (p < 0.001) compared to the descriptive statistical features extracted from the MFC series and the tone and entropy features extracted from the MFC percentage index series. The study found that short-term spectral components and the windowed mean value (DC value) possess predictive capabilities regarding the success of biofeedback training. The higher spectral amplitude and lower variance in the lower frequency zone indicate lower chances of improvement, while the lower spectral amplitude and higher variance indicate higher chances of improvement.

Exploring stroke survivors' and physiotherapists' perspectives of the potential for markerless motion capture technology in community rehabilitation.

INTRODUCTION: Many stroke survivors do not receive optimal levels of personalised therapy to support their recovery. Use of technology for stroke rehabilitation has increased in recent years to help minimise gaps in service provision. Markerless motion capture technology is currently being used for musculoskeletal and occupational health screening and could offer a means to provide personalised guidance to stroke survivors struggling to access rehabilitation. AIMS: This study considered context, stakeholders, and key uncertainties surrounding the use of markerless motion capture technology in community stroke rehabilitation from the perspectives of stroke survivors and physiotherapists with a view to adapting an existing intervention in a new context. METHODS: Three focus groups were conducted with eight stroke survivors and five therapists. Data were analysed using reflexive thematic analysis. RESULTS: Five themes were identified: limited access to community care; personal motivation; pandemic changed rehabilitation practice; perceptions of technology; and role of markerless technology for providing feedback. CONCLUSIONS: Participants identified problems associated with the access of community stroke rehabilitation, exacerbated by Covid-19 restrictions. Participants were positive about the potential for the use of markerless motion capture technology to support personalised, effective stroke rehabilitation in the future, providing it is developed to meet stroke survivor specific needs.

Perspectives of Decision Support System TeleRehab in the Management of Post-Stroke Telerehabilitation.

Stroke is the main cause of disability among adults. Decision-making in stroke rehabilitation is increasingly complex; therefore, the use of decision support systems by healthcare providers is becoming a necessity. However, there is a significant lack of software for the management of post-stroke telerehabilitation (TR). This paper presents the results of the developed software "TeleRehab" to support the decision-making of clinicians and healthcare providers in post-stroke TR. We designed a Python-based software with a graphical user interface to manage post-stroke TR. We searched Scopus, ScienceDirect, and PubMed databases to obtain research papers with results of clinical trials for post-stroke TR and to form the knowledge base of the software. The findings show that TeleRehab suggests recommendations for TR to provide practitioners with optimal and real-time support. We observed feasible outcomes of the software based on synthetic data of patients with balance problems, spatial neglect, and upper and lower extremities dysfunctions. Also, the software demonstrated excellent usability and acceptability scores among healthcare professionals.

Characterizing the Longitudinal Impact of Backward Locomotor Treadmill Training on Walking and Balance Outcomes in Chronic Stroke Survivors: A Randomized Single Center Clinical Trial.

Background and Purpose: Walking and balance impairments after stroke are a global health concern, causing significant morbidity and mortality. However, effective strategies for achieving meaningful recovery in the chronic stages are limited. Backward locomotor treadmill training (BLTT) is a novel walking rehabilitation protocol that is safe, feasible, and likely beneficial in stroke survivors; however, its efficacy has not been tested. This single-center, randomized, assessor-blind clinical trial aims to test the preliminary efficacy of BLTT compared to forward locomotor treadmill training (FLTT) on walking speed, symmetry, and postural stability. Methods: Forty stroke survivors [BLTT (N=19), FLTT (N=21); mean age= 56.3 ± 8.6 years; 53% Female; 30% Non-Hispanic Black] with mild-moderate walking impairment were enrolled. Participants underwent nine 30-minute BLTT or FLTT sessions over three weeks. The primary outcome was the mean change in the 10-meter walk test (10 MWT) at 24 hours post-training (24 hr POST). Secondary outcome measures were changes in spatiotemporal walking symmetry and postural stability during quiet standing at 24 hr POST. Retention was explored at Days 30- and 90 POST. Results: We report clinically meaningful (≥ 0.16 m/s) improvements in overground walking speed at 24 hr POST, with retention up to Day 90 POST with BLTT and FLTT. However, contrary to our working hypothesis, no between-group differences in walking speed were observed. Nonetheless, we found that BLTT resulted in offline improvements in spatial symmetry and retention of subcomponents of the modified clinical test of sensory interaction on balance (mCTSIB), including the testing of proprio-vestibular integration up to Day 30 POST. Conclusion: Among chronic stroke patients with mild-moderate walking impairment, BLTT and FLTT both resulted in long-lasting and clinically meaningful improvement in walking speed. However, preliminary findings suggest that BLTT may better comprehensively target walking asymmetry and sensory systems processing and integration.

The regional development and implementation of home-based stroke rehabilitation using participatory action research.

PURPOSE: This study aims to overcome the challenges experienced in the regional development and implementation of home-based stroke rehabilitation (HBSR) and to understand the change process needed. MATERIALS AND METHODS: Using participatory action research (PAR), participants and researchers collaboratively produced knowledge and took action to improve the offered HBSR. Different methods for data generation and analysis were used, depending on the aim of the PAR phase and the participants' stages of change. The Consolidated Framework for Implementation Research (CFIR) was used to select implementation strategies and to evaluate the implementation process. RESULTS: Developing and implementing HBSR resulted in multiple products that promoted the implementation of a regional stroke network and affiliated work arrangements. Work arrangements were embodied in a stroke care pathway, follow-up tool, and expertise requirements. Evaluating the PAR process identified participants being able to take the lead, being facilitated by others, and making progress visible, as implementation facilitators. Collaborating within a primary care project can be challenging but is considered essential and has a positive impact on multiple levels. Also, the implementation of HBSR calls for multiple implementation strategies reflecting multiple CFIR constructs. CONCLUSION: This study highlights the complexity and achievements of developing and implementing HBSR using PAR.

When developing home-based stroke rehabilitation, important topics concern: interprofessional collaboration, follow-up care, professional expertise, attention to the social network and "invisible consequences" of stroke, case management, and supporting self-management.When developing a regional stroke network, viewpoints and work arrangements should be documented, for example through a stroke care pathway, and a tool for follow-up care. This can overcome the challenges experienced regarding interprofessional collaboration while delivering home-based stroke rehabilitation.When implementing a complex intervention such as home-based stroke rehabilitation, participatory action research can be used to empower professionals and to facilitate the development of practical solutions to experienced implementation problems in the community.When developing home-based stroke rehabilitation and/or executing participatory action research, facilitation by a person with an overview of the project is important to guide the knowledge transformation process.

"I just kept asking and asking and there was nothing": re-thinking community resources & supports for young adult stroke survivors.

PURPOSE: Stroke is often regarded as a disease of the elderly. However, 10-15% of strokes occur in people aged 18 to 50, and rates continue to rise. Young stroke survivors face unique challenges due to their occupational, family and personal commitments, which current stroke rehabilitation services may not fully address. Our qualitative study aimed to identify gaps in patient care and resources for young stroke survivors. We used these findings to develop recommendations to inform clinical care, healthcare system design, and health policy. METHODS: Using Interpretive Description, we conducted semi-structured interviews with 19 stroke survivors aged 18-55 living in British Columbia, Canada, to explore their experiences during stroke recovery and assess current gaps in support and resources. We applied broad-based coding and thematic analysis to the transcripts. RESULTS: Key themes included: (1) the need for longitudinal medical follow-up and information provision, (2) the need for psychological/psychiatric care, (3) the need to adapt community supports and resources to young survivors, and (4) the need to centralize and integrate community stroke services and resources. CONCLUSION: Young stroke survivors experience unique challenges and lack appropriate services and resources. Many of our findings may be representative of remediable gaps that persist nationally and internationally.

Young Adult Stroke Survivors face unique challenges due to their occupational, family, and personal commitments, resulting in unmet needs during stroke recovery and rehabilitation.Policymakers, healthcare providers and community organizations need to re-think follow-up and information provision, psychological/psychiatric care, and community support and resources for young adult stroke survivors.Centralization and integration of different community stroke services and resources specific to young stroke survivors are key in stroke rehabilitation and recovery pathways.

Effects of high-definition tDCS targeting individual motor hotspot with EMG-driven robotic hand training on upper extremity motor function: a pilot randomized controlled trial.

BACKGROUND: Delivering HD-tDCS on individual motor hotspot with optimal electric fields could overcome challenges of stroke heterogeneity, potentially facilitating neural activation and improving motor function for stroke survivors. However, the intervention effect of this personalized HD-tDCS has not been explored on post-stroke motor recovery. In this study, we aim to evaluate whether targeting individual motor hotspot with HD-tDCS followed by EMG-driven robotic hand training could further facilitate the upper extremity motor function for chronic stroke survivors. METHODS: In this pilot randomized controlled trial, eighteen chronic stroke survivors were randomly allocated into two groups. The HDtDCS-group (n = 8) received personalized HD-tDCS using task-based fMRI to guide the stimulation on individual motor hotspot. The Sham-group (n = 10) received only sham stimulation. Both groups underwent 20 sessions of training, each session began with 20 min of HD-tDCS and was then followed by 60 min of robotic hand training. Clinical scales (Fugl-meyer Upper Extremity scale, FMAUE; Modified Ashworth Scale, MAS), and neuroimaging modalities (fMRI and EEG-EMG) were conducted before, after intervention, and at 6-month follow-up. Two-way repeated measures analysis of variance was used to compare the training effect between HDtDCS- and Sham-group. RESULTS: HDtDCS-group demonstrated significantly better motor improvement than the Sham-group in terms of greater changes of FMAUE scores (F = 6.5, P = 0.004) and MASf (F = 3.6, P = 0.038) immediately and 6 months after the 20-session intervention. The task-based fMRI activation significantly shifted to the ipsilesional motor area in the HDtDCS-group, and this activation pattern increasingly concentrated on the motor hotspot being stimulated 6 months after training within the HDtDCS-group, whereas the increased activation is not sustainable in the Sham-group. The neuroimaging results indicate that neural plastic changes of the HDtDCS-group were guided specifically and sustained as an add-on effect of the stimulation. CONCLUSIONS: Stimulating the individual motor hotspot before robotic hand training could further enhance brain activation in motor-related regions that promote better motor recovery for chronic stroke. TRIAL REGISTRATION: This study was retrospectively registered in ClinicalTrials.gov (ID NCT05638464).

Development and External Validation of a Motor Intention-Integrated Prediction Model for Upper Extremity Motor Recovery After Intention-Driven Robotic Hand Training for Chronic Stroke.

OBJECTIVE: To derive and validate a prediction model for minimal clinically important differences (MCIDs) in upper extremity (UE) motor function after intention-driven robotic hand training using residual voluntary electromyography (EMG) signals from affected UE. DESIGN: A prospective longitudinal multicenter cohort study. We collected preintervention candidate predictors: demographics, clinical characteristics, Fugl-Meyer assessment of UE (FMAUE), Action Research Arm Test scores, and motor intention of flexor digitorum and extensor digitorum (ED) measured by EMG during maximal voluntary contraction (MVC). For EMG measures, recognizing challenges for stroke survivors to move paralyzed hand, peak signals were extracted from 8 time windows during MVC-EMG (0.1-5s) to identify subjects' motor intention. Classification and regression tree algorithm was employed to predict survivors with MCID of FMAUE. Relationship between predictors and motor improvements was further investigated. SETTING: Nine rehabilitation centers. PARTICIPANTS: Chronic stroke survivors (N=131), including 87 for derivation sample, and 44 for validation sample. INTERVENTIONS: All participants underwent 20-session robotic hand training (40min/session, 3-5sessions/wk). MAIN OUTCOME MEASURES: Prediction efficacies of models were assessed by area under the receiver operating characteristic curve (AUC). The best effective model was final model and validated using AUC and overall accuracy. RESULTS: The best model comprised FMAUE (cutoff score, 46) and peak activity of ED from 1-second MVC-EMG (MVC-EMG 4.604 times higher than resting EMG), which demonstrated significantly higher prediction accuracy (AUC, 0.807) than other time windows or solely using clinical scores (AUC, 0.595). In external validation, this model displayed robust prediction (AUC, 0.916). Significant quadratic relationship was observed between ED-EMG and FMAUE increases. CONCLUSIONS: This study presents a prediction model for intention-driven robotic hand training in chronic stroke survivors. It highlights significance of capturing motor intention through 1-second EMG window as a predictor for MCID improvement in UE motor function after 20-session robotic training. Survivors in 2 conditions showed high percentage of clinical motor improvement: moderate-to-high motor intention and low-to-moderate function; as well as high intention and high function.