Subjective Memory Complaints and Their Relationship with the Objective Cognitive Performance of Stroke Patients.

INTRODUCTION: Subjective memory complaints (SMCs) are common among patients with stroke, significantly affect long-term disability, and contribute to poor functional outcomes. We explored changes in the subjective memory complaints questionnaire (SMCQ) score of stroke patients, correlations among SMCs, objective cognitive performance (OCP), and functional status. We also explored whether participants could be divided into groups based on the presence or absence of SMCs and OCP impairment, which could be related to rehabilitation outcomes. METHODS: A total of 102 stroke patients were recruited from a single rehabilitation center. Their OCP was determined on admission. The Mini-Mental State Evaluation (MMSE), SMCQ, and modified Barthel Index (MBI) scores were obtained at admission and at discharge. These variables were compared and time and group interactions were explored. RESULTS: The SMCQ score did not show consistent patterns of change among individuals. The objective cognitive function and activities of daily living consistently improved after rehabilitation. The proposed cognitive impairment classification after stroke based on SMCs and objective cognitive decline was able to predict improvement attributable to rehabilitation. CONCLUSION: Changes in SMCQ scores of stroke patients were inconsistent and varied when compared to changes in MMSE and MBI scores, indicating that it is not a reliable metric on its own. SMCs have a clinical relationship with OCP and significant emotional and motivational effects. In clinical practice, it is important to understand and consider SMCs after stroke.

Post-stroke palatal tremor as a clinical predictor of dysphagia and its neuroanatomical correlates in patients with midbrain and pontine lesions.

The precise associations between dysphagia and palatal tremor (PT) remain unknown. We aimed to identify the association between PT and dysphagia among patients with midbrain/pontine stroke, compare the characteristics of dysphagia between patients with PT (PT + dysphagia) and without PT (PT- dysphagia), and verify neuroanatomical predictors of PT + dysphagia in this patient population. This retrospective observational study enrolled 40 patients (34 males, 6 females; mean age: 95% confidence interval [CI], 56.6 ± 14.6 years) with first-ever midbrain or pontine stroke exhibiting brain stem lesions admitted to the stroke unit of a single rehabilitation hospital between January 2010 and April 2020. Main outcome measures included dysphagia and aspiration rates and videofluoroscopic swallowing study findings. Lesion localization was stratified according to established vascular territories. Associations between PT and dysphagia and lesion location according to PT and dysphagia were analyzed. Dysphagia and aspiration rates were greater among patients with PT than among those without PT (95% CI, p = 0.030 and p = 0.017, respectively). The proportion of patients exhibiting oral stage impairment (95% CI, p = 0.007) was greater in the PT + dysphagia group than in the PT- dysphagia group. The posterolateral portion of the midbrain and pons (95% CI, p = 0.001 and p < 0.001, respectively) were the lesions more often involved in the PT + dysphagia group. Patients with PT following midbrain/pontine stroke more frequently present with dysphagia than those without PT. Thus, they should be carefully examined for PT and delayed dysphagia, including oral stage impairment, if initial brain images show posterolateral midbrain and pons lesions.

FOPR test: a virtual reality-based technique to assess field of perception and field of regard in hemispatial neglect.

BACKGROUND: We previously proposed a novel virtual reality-based method to assess human field of perception (FOP) and field of regard (FOR), termed the FOPR test. This study assessed the diagnostic validity of the FOPR test for hemispatial neglect (HSN). METHODS: We included 19 stroke patients with a lesion in the right hemisphere and with HSN (HSN+SS), 22 stroke patients with a lesion in the right hemisphere and without HSN (HSN-SS), and 22 healthy controls aged 19-65 years. The success rate (SR) and response time (RT) in the FOPR test for both FOP and FOR were assessed (FOP-SR, FOR-SR, FOP-RT, and FOR-RT, respectively). Using a Bland-Altman plot, agreements between the FOPR test and conventional tests were confirmed, and the FOPR test accuracy was verified using the support vector machine (SVM). Measured values were analysed using ANOVA and Kruskall-Wallis tests for group comparison. RESULTS: The Bland-Altman plot showed good agreement between FOPR test and conventional tests; individuals within 95% agreement limits were within the range of 94.8-100.0%. The SVM classification accuracy, using FOP and FOR variables from the left hemispace, ranged from 83.3 to 100.0% in a binary classification (HSN vs non-HSN). The FOPR test demonstrated differences in SR and RT for both FOP and FOR across the groups. CONCLUSION: The FOPR test was valid for the HSN diagnosis and provided quantitative and intuitive information regarding visuospatial function. Furthermore, it might enhance our understanding of visuospatial function including HSN by applying the time relative component and concepts of perception and exploration, FOP and FOR. TRIAL REGISTRATION: NCT03463122. Registered 13 March 2018, retrospectively registered.

Alterations in intermuscular coordination underlying isokinetic exercise after a stroke and their implications on neurorehabilitation.

BACKGROUND: Abnormal intermuscular coordination limits the motor capability of stroke-affected upper limbs. By evaluating the intermuscular coordination in the affected limb under various biomechanical task constraints, the impact of a stroke on motor control can be analyzed and intermuscular coordination-based rehabilitation strategies can be developed. In this study, we investigated upper limb intermuscular coordination after a stroke during isokinetic movements. METHODS: Sixteen chronic stroke survivors and eight neurologically intact individuals were recruited. End-point forces and electromyographic activities of the shoulder and elbow muscles were measured while the participants performed isokinetic upper limb movements in a three-dimensional space. Intermuscular coordination of the stroke survivors and the control participants was quantified in the form of muscle synergies. Then, we compared the number, composition, and activation coefficients of muscle synergies and the end-point force between the groups. The correlation between the alteration of muscle synergies and the level of motor impairment was investigated. RESULTS: Four and five muscle synergies in the stroke and control groups were observed, respectively. The composition of muscle synergies was comparable between the groups, except that the three heads of the deltoid muscle were co-activated and formed one synergy in the stroke group, whereas those muscles formed two synergies in the control group. When the number of muscle synergies between the groups matched, the comparable composition of muscle synergies was observed in both groups. Alternatively, the modulation of synergy activation coefficients was altered after a stroke. The severity of motor impairments was negatively correlated with the similarity of the post-stroke synergies with respect to the mean control synergies. CONCLUSIONS: Stroke-affected upper limbs seemed to modularize the activation of the shoulder and elbow muscles in a fairly similar way to that of neurologically intact individuals during isokinetic movements. Compared with free (i.e., unconstrained) movement, exercise under biomechanical constraints including the isokinetic constraint might promote the activation of muscle synergies independently in stroke survivors. We postulated the effect of biomechanical constraints on the intermuscular coordination and suggested a possible intermuscular coordination-based rehabilitation protocol that provides the biomechanical constraint appropriate to a trainee throughout the progress of rehabilitation.

Kinematic Assessment to Measure Change in Impairment during Active and Active-Assisted Type of Robotic Rehabilitation for Patients with Stroke.

Analysis of kinematic features related to clinical assessment scales may qualitatively improve the evaluation of upper extremity movements of stroke patients. We aimed to investigate kinematic features that could correlate the change in the Fugl-Meyer Assessment (FMA) score of stroke survivors through upper extremity robotic rehabilitation. We also analyzed whether changes in kinematic features by active and active-assisted robotic rehabilitation correlated differently with changes in FMA scores. Fifteen stroke patients participated in the upper extremity robotic rehabilitation program, and nine kinematic features were calculated from reach tasks for assessment. Simple and multiple linear regression analyses were used to characterize correlations. Features representing movement speed were associated with changes in FMA scores for the group that used an active rehabilitation robot. In contrast, in the group that used an active-assisted rehabilitation robot, features representing movement smoothness were associated with changes in the FMA score. These estimates can be an important basis for kinematic analysis to complement clinical scales.

Subjective Memory Complaints and Sensitivity of the Subjective Memory Complaint Questionnaire in Post-Stroke Dementia Patients.

INTRODUCTION: Subjective memory complaints (SMCs) among stroke patients are common. To date, reports on SMCs using the Subjective Memory Complaint Questionnaire (SMCQ) are limited. We provided descriptive information on SMCs using the SMCQ alongside objective neuropsychological function assessment in stroke patients and established the sensitivity of SMCQ for post-stroke dementia. METHODS: In total, 419 consecutive stroke patients who were admitted to a stroke unit for younger populations (age <65 years) at a rehabilitation hospital from June 1, 2014, to January 1, 2020, were reviewed. SMCs were measured using the SMCQ. Objective neuropsychological function was assessed using protocols of the Vascular Cognitive Impairment Harmonization Standards. RESULTS: SMCs were significantly correlated with objective neuropsychological functions including memory, executive function, language, and depression. SMCs were not significantly correlated with visuospatial function. The SMCQ exhibited comparable sensitivity to that of Mini-Mental Status Examination for evaluating post-stroke dementia. CONCLUSIONS: The SMCQ may be a valid measure of cognitive function among patients with stroke, is sensitive for post-stroke dementia, and may assume a complementary role for assessing patients with stroke.

A comparison of the effects and usability of two exoskeletal robots with and without robotic actuation for upper extremity rehabilitation among patients with stroke: a single-blinded randomised controlled pilot study.

BACKGROUND: Robotic rehabilitation of stroke survivors with upper extremity dysfunction may yield different outcomes depending on the robot type. Considering that excessive dependence on assistive force by robotic actuators may interfere with the patient's active learning and participation, we hypothesised that the use of an active-assistive robot with robotic actuators does not lead to a more meaningful difference with respect to upper extremity rehabilitation than the use of a passive robot without robotic actuators. Accordingly, we aimed to evaluate the differences in the clinical and kinematic outcomes between active-assistive and passive robotic rehabilitation among stroke survivors. METHODS: In this single-blinded randomised controlled pilot trial, we assigned 20 stroke survivors with upper extremity dysfunction (Medical Research Council scale score, 3 or 4) to the active-assistive robotic intervention (ACT) and passive robotic intervention (PSV) groups in a 1:1 ratio and administered 20 sessions of 30-min robotic intervention (5 days/week, 4 weeks). The primary (Wolf Motor Function Test [WMFT]-score and -time: measures activity), and secondary (Fugl-Meyer Assessment [FMA] and Stroke Impact Scale [SIS] scores: measure impairment and participation, respectively; kinematic outcomes) outcome measures were determined at baseline, after 2 and 4 weeks of the intervention, and 4 weeks after the end of the intervention. Furthermore, we evaluated the usability of the robots through interviews with patients, therapists, and physiatrists. RESULTS: In both the groups, the WMFT-score and -time improved over the course of the intervention. Time had a significant effect on the WMFT-score and -time, FMA-UE, FMA-prox, and SIS-strength; group × time interaction had a significant effect on SIS-function and SIS-social participation (all, p < 0.05). The PSV group showed better improvement in participation and smoothness than the ACT group. In contrast, the ACT group exhibited better improvement in mean speed. CONCLUSIONS: There were no differences between the two groups regarding the impairment and activity domains. However, the PSV robots were more beneficial than ACT robots regarding participation and smoothness. Considering the high cost and complexity of ACT robots, PSV robots might be more suitable for rehabilitation in stroke survivors capable of voluntary movement. Trial registration The trial was registered retrospectively on 14 March 2018 at ClinicalTrials.gov (NCT03465267).

Robot-assisted gait training for balance and lower extremity function in patients with infratentorial stroke: a single-blinded randomized controlled trial.

BACKGROUND: Balance impairments are common in patients with infratentorial stroke. Although robot-assisted gait training (RAGT) exerts positive effects on balance among patients with stroke, it remains unclear whether such training is superior to conventional physical therapy (CPT). Therefore, we aimed to investigate the effects of RAGT combined with CPT and compared them with the effects of CPT only on balance and lower extremity function among survivors of infratentorial stroke. METHODS: This study was a single-blinded, randomized controlled trial with a crossover design conducted at a single rehabilitation hospital. Patients (n = 19; 16 men, three women; mean age: 47.4 ± 11.6 years) with infratentorial stroke were randomly allocated to either group A (4 weeks of RAGT+CPT, followed by 4 weeks of CPT+CPT) or group B (4 weeks of CPT+CPT followed by 4 weeks of RAGT+CPT). Changes in dynamic and static balance as indicated by Berg Balance Scale scores were regarded as the primary outcome measure. Outcome measures were evaluated for each participant at baseline and after each 4-week intervention period. RESULTS: No significant differences in outcome-related variables were observed between group A and B at baseline. In addition, no significant time-by-group interactions were observed for any variables, indicating that intervention order had no effect on lower extremity function or balance. Significantly greater improvements in secondary functional outcomes such as lower extremity Fugl-Meyer assessment (FMA-LE) and scale for the assessment and rating of ataxia (SARA) were observed following the RAGT+CPT intervention than following the CPT+CPT intervention. CONCLUSION: RAGT produces clinically significant improvements in balance and lower extremity function in individuals with infratentorial stroke. Thus, RAGT may be useful for patients with balance impairments secondary to other pathologies. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02680691. Registered 09 February 2016; retrospectively registered.

Effects of virtual reality-based planar motion exercises on upper extremity function, range of motion, and health-related quality of life: a multicenter, single-blinded, randomized, controlled pilot study.

BACKGROUND: Virtual reality (VR)-based rehabilitation is considered a beneficial therapeutic option for stroke rehabilitation. This pilot study assessed the clinical feasibility of a newly developed VR-based planar motion exercise apparatus (Rapael Smart Board™ [SB]; Neofect Inc., Yong-in, Korea) for the upper extremities as an intervention and assessment tool. METHODS: This single-blinded, randomized, controlled trial included 26 stroke survivors. Patients were randomized to the intervention group (SB group) or control (CON) group. During one session, patients in the SB group completed 30 min of intervention using the SB and an additional 30 min of standard occupational therapy; however, those in the CON group completed the same amount of conventional occupational therapy. The primary outcome was the change in the Fugl-Meyer assessment (FMA) score, and the secondary outcomes were changes in the Wolf motor function test (WMFT) score, active range of motion (AROM) of the proximal upper extremities, modified Barthel index (MBI), and Stroke Impact Scale (SIS) score. A within-group analysis was performed using the Wilcoxon signed-rank test, and a between-group analysis was performed using a repeated measures analysis of covariance. Additionally, correlations between SB assessment data and clinical scale scores were analyzed by repeated measures correlation. Assessments were performed three times (baseline, immediately after intervention, and 1 month after intervention). RESULTS: All functional outcome measures (FMA, WMFT, and MBI) showed significant improvements (p < 0.05) in the SB and CON groups. AROM showed greater improvements in the SB group, especially regarding shoulder abduction and internal rotation. There was a significant effect of time × group interactions for the SIS overall score (p = 0.038). Some parameters of the SB assessment, such as the explored area ratio, mean reaching distance, and smoothness, were significantly associated with clinical upper limb functional measurements with moderate correlation coefficients. CONCLUSIONS: The SB was available for improving upper limb function and health-related quality of life and useful for assessing upper limb ability in stroke survivors. TRIAL REGISTRATION: The study was registered with the clinical research information service (CRIS) ( KCT0003783 , registered 15 April 2019; retrospectively registered).

Virtual Reality Rehabilitation With Functional Electrical Stimulation Improves Upper Extremity Function in Patients With Chronic Stroke: A Pilot Randomized Controlled Study.

OBJECTIVE: To compare virtual reality (VR) combined with functional electrical stimulation (FES) with cyclic FES for improving upper extremity function and health-related quality of life in patients with chronic stroke. DESIGN: A pilot, randomized, single-blind, controlled trial. SETTING: Stroke rehabilitation inpatient unit. PARTICIPANTS: Participants (N=48) with hemiplegia secondary to a unilateral stroke for >3 months and with a hemiplegic wrist extensor Medical Research Council scale score ranging from 1 to 3. INTERVENTIONS: FES was applied to the wrist extensors and finger extensors. A VR-based wearable rehabilitation device was used combined with FES and virtual activity-based training for the intervention group. The control group received cyclic FES only. Both groups completed 20 sessions over a 4-week period. MAIN OUTCOME MEASURES: Primary outcome measures were changes in Fugl-Meyer Assessment-Upper Extremity and Wolf Motor Function Test scores. Secondary outcome measures were changes in Box and Block Test, Jebsen-Taylor Hand Function Test, and Stroke Impact Scale scores. Assessments were performed at baseline (t0) and at 2 weeks (t1), 4 weeks (t4), and 8 weeks (t8). Between-group comparisons were evaluated using a repeated-measures analysis of variance. RESULTS: Forty-one participants were included in the analysis. Compared with FES alone, VR-FES produced a substantial increase in Fugl-Meyer Assessment-distal score (P=.011) and marginal improvement in Jebsen-Taylor Hand Function Test-gross score (P=.057). VR-FES produced greater, although nonsignificant, improvements in all other outcome measures, except in the Stroke Impact Scale-activities of daily living/instrumental activities of daily living score. CONCLUSIONS: FES with VR-based rehabilitation may be more effective than cyclic FES in improving distal upper extremity gross motor performance poststroke.

Examining impairment of adaptive compensation for stabilizing motor repetitions in stroke survivors.

The hand, one of the most versatile but mechanically redundant parts of the human body, suffers more and longer than other body parts after stroke. One of the rehabilitation paradigms, task-oriented rehabilitation, encourages motor repeatability, the ability to produce similar motor performance over repetitions through compensatory strategies while taking advantage of the motor system's redundancy. The previous studies showed that stroke survivors inconsistently performed a given motor task with limited motor solutions. We hypothesized that stroke survivors would exhibit deficits in motor repeatability and adaptive compensation compared to healthy controls in during repetitive force-pulse (RFP) production tasks using multiple fingers. Seventeen hemiparetic stroke survivors and seven healthy controls were asked to repeatedly press force sensors as fast as possible using the four fingers of each hand. The hierarchical variability decomposition model was employed to compute motor repeatability and adaptive compensation across finger-force impulses, respectively. Stroke survivors showed decreased repeatability and adaptive compensation of force impulses between individual fingers as compared to the control (p < 0.05). The stroke survivors also showed decreased pulse frequency and greater peak-to-peak time variance than the control (p < 0.05). Force-related variables, such as mean peak force and peak force interval variability, demonstrated no significant difference between groups. Our findings indicate that stroke-induced brain injury negatively affects their ability to exploit their redundant or abundant motor system in an RFP task.

Urological disturbance and its neuroanatomical correlate in patients with chronic brainstem stroke.

AIMS: Few studies have depicted urological disturbances among patients with chronic brainstem stroke, and little is known about the exact location of the micturition center or its role in humans. The aim of the present study was to retrospectively investigate urological disturbances and their neuroanatomical correlates among consecutively admitted patients with chronic brainstem stroke. METHODS: Urodynamic studies, brain images, and urological symptoms questionnaires were reviewed from consecutive patients suffering from brainstem stroke, who had been admitted to a stroke unit at a rehabilitation hospital between June 1, 2013 and January 31, 2015. For further comparison, consecutive data from urodynamic studies of patients with upper cervical spinal cord injury (admitted to a hospital between January 1, 2008 and January 31, 2015) were reviewed. RESULTS: Patients with chronic pontine stroke manifested more frequent detrusor underactivity, lower maximal detrusor pressure, and higher compliance than patients with upper cervical spinal cord injury. The most frequently involved lesions associated with detrusor underactivity were located around the central portion of the bilateral pons along the entire sagittal level. Urinary incontinence and symptoms associated with lower urinary tract dysfunction were reported in 10% and 95% of patients with brainstem stroke, respectively. No difference was found between genders or stroke subtypes in patients with brainstem stroke. CONCLUSIONS: The present study identified a relationship between chronic pontine stroke and detrusor underactivity. Thus, detrusor underactivity might be associated with lesions localized to central portions of the bilateral pons. The prevalence of lower urinary tract symptoms was also revealed to be high among patients with chronic brainstem stroke. Neurourol. Urodynam. 36:136-141, 2017. © 2015 Wiley Periodicals, Inc.

Cognitive-Motor Interference on Upper Extremity Motor Performance in a Robot-Assisted Planar Reaching Task Among Patients With Stroke.

OBJECTIVE: To explore motor performance on 2 different cognitive tasks during robotic rehabilitation in which motor performance was longitudinally assessed. DESIGN: Prospective study. SETTING: Rehabilitation hospital. PARTICIPANTS: Patients (N=22) with chronic stroke and upper extremity impairment. INTERVENTION: A total of 640 repetitions of robot-assisted planar reaching, 5 times a week for 4 weeks. MAIN OUTCOME MEASURES: Longitudinal robotic evaluations regarding motor performance included smoothness, mean velocity, path error, and reach error by the type of cognitive task. Dual-task effects (DTEs) of motor performance were computed to analyze the effect of the cognitive task on dual-task interference. RESULTS: Cognitive task type influenced smoothness (P=.006), the DTEs of smoothness (P=.002), and the DTEs of reach error (P=.052). Robotic rehabilitation improved smoothness (P=.007) and reach error (P=.078), while stroke severity affected smoothness (P=.01), reach error (P<.001), and path error (P=.01). Robotic rehabilitation or severity did not affect the DTEs of motor performance. CONCLUSIONS: The results provide evidence for the effect of cognitive-motor interference on upper extremity performance among participants with stroke using a robotic-guided rehabilitation system.

Effects of virtual reality-based rehabilitation on distal upper extremity function and health-related quality of life: a single-blinded, randomized controlled trial.

BACKGROUND: Virtual reality (VR)-based rehabilitation has been reported to have beneficial effects on upper extremity function in stroke survivors; however, there is limited information about its effects on distal upper extremity function and health-related quality of life (HRQoL). The purpose of the present study was to examine the effects of VR-based rehabilitation combined with standard occupational therapy on distal upper extremity function and HRQoL, and compare the findings to those of amount-matched conventional rehabilitation in stroke survivors. METHODS: The present study was a single-blinded, randomized controlled trial. The study included 46 stroke survivors who were randomized to a Smart Glove (SG) group or a conventional intervention (CON) group. In both groups, the interventions were targeted to the distal upper extremity and standard occupational therapy was administered. The primary outcome was the change in the Fugl-Meyer assessment (FM) scores, and the secondary outcomes were the changes in the Jebsen-Taylor hand function test (JTT), Purdue pegboard test, and Stroke Impact Scale (SIS) version 3.0 scores. The outcomes were assessed before the intervention, in the middle of the intervention, immediately after the intervention, and 1 month after the intervention. RESULTS: The improvements in the FM (FM-total, FM-prox, and FM-dist), JTT (JTT-total and JTT-gross), and SIS (composite and overall SIS, SIS-social participation, and SIS-mobility) scores were significantly greater in the SG group than in the CON group. CONCLUSIONS: VR-based rehabilitation combined with standard occupational therapy might be more effective than amount-matched conventional rehabilitation for improving distal upper extremity function and HRQoL. TRIAL REGISTRATION: This study is registered under the title "Effects of Novel Game Rehabilitation System on Upper Extremity Function of Patients With Stroke" and can be located in https://clinicaltrials.gov with the study identifier NCT02029651 .

Functional and physical abilities in the early continuum of cognitive decline.

BACKGROUND/AIMS: The early cognitive continuum has been emphasized recently. We sought to characterize the functional and physical aspects of the cognitive continuum in subjects with no cognitive impairment (NCI), subjective cognitive impairment (SCI), nonamnestic (NA-MCI), and amnestic mild cognitive impairment (A-MCI). Furthermore, we identified the potential diagnostic utility of specific functional tasks. METHODS: A total of 702 participants, aged ≥65 years and defined as NCI, SCI, NA-MCI, and A-MCI according to the original Petersen criteria, were included. They completed the Korean basic (K-ADL) and Instrumental Activities of Daily Living Scales (K-IADL) and the Performance-Oriented Mobility Assessment (POMA). RESULTS: Significant differences were observed between the different cognitive status groups in three items and total scores on the K-ADL, six items and total scores on the K-IADL and POMA. Controlling for confounding factors revealed that subjects from the A-MCI group performed poorly at bathing, shopping, handling money, and the sum of assorted functional items. CONCLUSION: These findings demonstrated the declining feature of functional and physical performance according to the cognitive continuum, with A-MCI being discriminative with respect to specific functional tasks as compared to milder cognitive statuses.

The role of tactile sensation in online and offline hierarchical control of multi-finger force synergy.

The hand, one of the most versatile but mechanically redundant parts of the human body, must overcome imperfect motor commands and inherent noise in both the sensory and motor systems in order to produce desired motor actions. For example, it is nearly impossible to produce a perfectly consistent note during a single violin stroke or to produce the exact same note over multiple strokes, which we denote online and offline control, respectively. To overcome these challenges, the central nervous system synergistically integrates multiple sensory modalities and coordinates multiple motor effectors. Among these sensory modalities, tactile sensation plays an important role in manual motor tasks by providing hand-object contact information. The purpose of this study was to investigate the role of tactile feedback in individual finger actions and multi-finger interactions during constant force production tasks. We developed analytical techniques for the linear decomposition of the overall variance in the motor system in both online and offline control. We removed tactile feedback from the fingers and demonstrated that tactile sensors played a critical role in the online control of synergistic interactions between fingers. In contrast, the same sensors did not contribute to offline control. We also demonstrated that when tactile feedback was removed from the fingers, the combined motor output of individual fingers did not change while individual finger behaviors did. This finding supports the idea of hierarchical control where individual fingers at the lower level work together to stabilize the performance of combined motor output at the higher level.

A task-specific interactive game-based virtual reality rehabilitation system for patients with stroke: a usability test and two clinical experiments.

BACKGROUND: Virtual reality (VR) is not commonly used in clinical rehabilitation, and commercial VR gaming systems may have mixed effects in patients with stroke. Therefore, we developed RehabMaster™, a task-specific interactive game-based VR system for post-stroke rehabilitation of the upper extremities, and assessed its usability and clinical efficacy. METHODS: A participatory design and usability tests were carried out for development of RehabMaster with representative user groups. Two clinical trials were then performed. The first was an observational study in which seven patients with chronic stroke received 30 minutes of RehabMaster intervention per day for two weeks. The second was a randomised controlled trial of 16 patients with acute or subacute stroke who received 10 sessions of conventional occupational therapy only (OT-only group) or conventional occupational therapy plus 20 minutes of RehabMaster intervention (RehabMaster + OT group). The Fugl-Meyer Assessment score (FMA), modified Barthel Index (MBI), adverse effects, and drop-out rate were recorded. RESULTS: The requirements of a VR system for stroke rehabilitation were established and incorporated into RehabMaster. The reported advantages from the usability tests were improved attention, the immersive flow experience, and individualised intervention. The first clinical trial showed that the RehabMaster intervention improved the FMA (P = .03) and MBI (P = .04) across evaluation times. The second trial revealed that the addition of RehabMaster intervention tended to enhance the improvement in the FMA (P = .07) but did not affect the improvement in the MBI. One patient with chronic stroke left the trial, and no adverse effects were reported. CONCLUSIONS: The RehabMaster is a feasible and safe VR system for enhancing upper extremity function in patients with stroke.

Resistive versus active assisted robotic training for the upper limb after a stroke: A randomized controlled study.

BACKGROUND: Selection of a suitable training modality according to the status of upper limb function can maximize the effects of robotic rehabilitation; therefore, it is necessary to identify the optimal training modality. OBJECTIVES: This study aimed to compare robotic rehabilitation approaches incorporating either resistance training (RET) or active-assisted training (AAT) using the same rehabilitation robot in people with stroke and moderate impairment. METHODS: In this randomized controlled trial, we randomly allocated 34 people with stroke who had moderate impairment to either the experimental group (RET, n = 18) or the control group (AAT, n = 16). Both groups performed robot-assisted therapy for 30 min, 5 days per week, for 4 weeks. The same rehabilitation robot provided resistance to the RET group and assistance to the AAT group. Body function and structure, activity, and participation outcomes were evaluated before, during, and after the intervention. RESULTS: RET led to greater improvements than AAT in terms of smoothness (p = 0.006). The Fugl-Meyer Assessment (FMA)-upper extremity (p < 0.001), FMA-proximal (p < 0.001), Action Research Arm Test-gross movement (p = 0.011), and kinematic variables of joint independence (p = 0.017) and displacement (p = 0.011) also improved at the end of intervention more in the RET group. CONCLUSIONS: Robotic RET was more effective than AAT in improving upper limb function, structure, and activity among participants with stroke who had moderate impairment.

Attitude Toward Virtual Rehabilitation and Active Video Games Among Therapists in Korea: A Nationwide Survey.

In this study, we conducted a survey targeting 191 physical therapists (PTs) and 159 occupational therapists (OTs) in South Korea to explore attitudes toward virtual rehabilitation. Utilizing the Korean version of the ADOPT VR by Glegg et al., OT exhibited significantly more experience with virtual reality (VR) and active video games (AVG) than PT. Therapists with VR/AVG experience scored significantly higher in most categories, and the scores in each category were significantly correlated with the Behavioral Intention category, reflecting the willingness to use VR/AVG. The biggest barriers identified were insufficient funds and setup assistance for the equipment. Differences in responses between the groups with and without VR/AVG experience were most prominent in terms of lack of interest and funding. Therapists' attitudes, perceptions, and intentions toward VR/AVG are crucial factors in the establishment and implementation of VR/AVG; thus, the results of this study provide valuable evidence for future policies related to VR/AVG in rehabilitation medicine.

Efficiency and usability of a modified pegboard incorporating computerized technology for upper limb rehabilitation in patients with stroke.

BACKGROUND: Traditionally, a pegboard has been commonly used as a useful training and assessment tool for patients with stroke. However, training using pegboards could be monotonous and may discourage motivation in patients with stroke, as it requires only repetitive movements without feedback. OBJECTIVES: We aimed to demonstrate the efficiency and usability of a novel rehabilitation instrument (Rapael Smart Pegboard; SP), which integrates computerized technology into a traditional pegboard. METHODS: This single-center study with a single-group pre-post design included 19 patients with hemiplegic stroke (11 outpatients and 8 inpatients). The patients received 20 SP training sessions (30 minutes per session, 5 days per week, over 4 weeks) according to their ability and status without any therapist intervention. The primary outcome was changes in the Fugl-Meyer assessment of upper extremity (FMA), and the secondary outcomes were changes in the Box and Block test and Jebsen-Taylor Hand Function test (JHFT). Additionally, usability assessment was performed. RESULTS: All outcome measurements except JHFT-gross score showed significant improvements with SP training. The significant improvements in these outcomes were consistently found in the outpatient group; however, the inpatient group failed to show improvement in the distal part of FMA, total JHFT score, and time. The usability test showed high satisfaction with 4.9 out of 5 points. CONCLUSIONS: The SP is an effective and feasible instrument for upper limb rehabilitation. Moreover, the SP can be used as a self-training tool without the assistance of a health care practitioner.