Intramuscular tetanus neurotoxin reverses muscle atrophy: a randomized controlled trial in dogs with spinal cord injury.

BACKGROUND: Motor symptoms of spinal cord injury (SCI) considerably impair quality of life and are associated with a high risk of secondary diseases. So far, no pharmacological treatment is available for these symptoms. Therefore, we conducted a randomized, double-blinded, placebo-controlled study in dogs with spontaneous SCI due to disc herniation to test whether a reduction of spinal inhibitory activity by intramuscular injections of tetanus neurotoxin (TeNT) alleviates motor symptoms such as muscle atrophy or gait function. METHODS: To this end, 25 dogs were treated with injections of either TeNT or placebo into their paretic hindlimb muscles. Effects of TeNT on muscle thickness were assessed by ultrasound, while effects on gait function were measured using the modified functional scoring system in dogs. RESULTS: Four weeks after the TeNT injections, muscle thickness of the gluteus medius muscle (before median 1.56 cm [inter-quartile range {IQR} 1.34-1.71 cm] and after median 1.56 cm [IQR 1.37-1.85 cm], P-value 0.0133) as well as of the rectus femoris muscle (before median 0.76 cm [IQR 0.60-0.98 cm] and after median 0.93 cm [IQR 0.65-1.05 cm], P-value 0.0033) significantly increased in the TeNT group. However, there was no difference in gait function between the TeNT and placebo groups. The treatment was well tolerated by all dogs without any signs of generalized tetanus symptoms or any spreading of effects beyond the lumbar level of the injected hindlimbs. CONCLUSIONS: With regard to the beneficial effects on muscle thickness, intramuscular injections of TeNT represent the first pharmacological approach that focally reverses muscle atrophy in SCI. Moreover, the study data support the safety of this treatment when TeNT is used at low dose.

Therapeutic effects of Tetanus neurotoxin in spinal cord injury: a case series on four dogs.

STUDY DESIGN: Case series on four dogs. OBJECTIVES: To determine the alleviation of motor symptoms in spinal cord injury (SCI) by tetanus neurotoxin (TeNT). SETTING: Different Berlin veterinary clinics, Germany. METHODS: We report on the effect of intramuscular injections of low-dose TeNT into paretic hind limb muscles 2-157 weeks after SCI due to lumbar disc herniation in a clinical case series on four dogs. All dogs underwent unsuccessful or incomplete surgical decompression prior to TeNT treatment. TeNT was injected on a compassionate basis. Stance, gait ability and the diameter of the rectus femoris muscle were assessed as parameters. RESULTS: All four dogs improved their stance and three of these dogs improved in gait at 4 and 6 weeks after TeNT injections without evidence of side effects or spreading of TeNT effects. At the same time, the size of the rectus femoris muscle diameter increased considerably as compared with baseline (baseline: 100%; 4 weeks: 148.7% ± 10.9%; 6 weeks: 137.1% ± 7.9%). CONCLUSIONS: Facilitation of α-motor neurons by TeNT injections into paretic hind limb muscles of four dogs improved standing and/or gait abilities and partly reversed muscle atrophy after SCI. The absence of generalized or painful muscle spasms supports the safety of low-dose TeNT. Therefore, TeNT might evolve as a promising therapeutic option for muscle paresis of central origin, e.g. in individuals with SCI, stroke or multiple sclerosis.

Physical Fitness Training in Patients with Subacute Stroke (PHYS-STROKE): multicentre, randomised controlled, endpoint blinded trial.

OBJECTIVE: To determine the safety and efficacy of aerobic exercise on activities of daily living in the subacute phase after stroke. DESIGN: Multicentre, randomised controlled, endpoint blinded trial. SETTING: Seven inpatient rehabilitation sites in Germany (2013-17). PARTICIPANTS: 200 adults with subacute stroke (days 5-45 after stroke) with a median National Institutes of Health stroke scale (NIHSS, range 0-42 points, higher values indicating more severe strokes) score of 8 (interquartile range 5-12) were randomly assigned (1:1) to aerobic physical fitness training (n=105) or relaxation sessions (n=95, control group) in addition to standard care. INTERVENTION: Participants received either aerobic, bodyweight supported, treadmill based physical fitness training or relaxation sessions, each for 25 minutes, five times weekly for four weeks, in addition to standard rehabilitation therapy. Investigators and endpoint assessors were masked to treatment assignment. MAIN OUTCOME MEASURES: The primary outcomes were change in maximal walking speed (m/s) in the 10 m walking test and change in Barthel index scores (range 0-100 points, higher scores indicating less disability) three months after stroke compared with baseline. Safety outcomes were recurrent cardiovascular events, including stroke, hospital readmissions, and death within three months after stroke. Efficacy was tested with analysis of covariance for each primary outcome in the full analysis set. Multiple imputation was used to account for missing values. RESULTS: Compared with relaxation, aerobic physical fitness training did not result in a significantly higher mean change in maximal walking speed (adjusted treatment effect 0.1 m/s (95% confidence interval 0.0 to 0.2 m/s), P=0.23) or mean change in Barthel index score (0 (-5 to 5), P=0.99) at three months after stroke. A higher rate of serious adverse events was observed in the aerobic group compared with relaxation group (incidence rate ratio 1.81, 95% confidence interval 0.97 to 3.36). CONCLUSIONS: Among moderately to severely affected adults with subacute stroke, aerobic bodyweight supported, treadmill based physical fitness training was not superior to relaxation sessions for maximal walking speed and Barthel index score but did suggest higher rates of adverse events. These results do not appear to support the use of aerobic bodyweight supported fitness training in people with subacute stroke to improve activities of daily living or maximal walking speed and should be considered in future guidelines. TRIAL REGISTRATION: ClinicalTrials.gov NCT01953549.

Non-invasive brain stimulation to promote alertness and awareness in chronic patients with disorders of consciousness: Low-level, near-infrared laser stimulation vs. focused shock wave therapy.

PURPOSE: In order to promote alertness and awareness in patients with severe disorders of consciousness (DOC) frontal near infrared laser stimulation (N-LT) or transcranial focused shock wave therapy (F-SWT) might be an option. The study compared both techniques in severe chronic DOC patients. METHODS: Sixteen DOC patients were allocated to two groups (A and B). A three week baseline either followed a frontal N-LT (0,1 mJ/mm2, 10 min per session), five times a week over four weeks (group A), or a F-SWT (0,1 mJ/mm2, 4000 stimuli per session) three times a week over four weeks (group B). The primary variable was the revised Coma Recovery Scale (r-CRS, 0-23), blindly assessed. RESULTS: Both groups improved in the r-CRS over time, but revealed no differences between groups. One patient of group B had a focal seizure in the third therapy week. One patient with akinetic mutism improved most and three patients with global hypoxia did not improve at all. CONCLUSIONS: Both options might be an option to increase alertness and awareness of chronic DOC patients. An akinetic mutism seems to be a positive and severe cerebral hypoxia a negative predictor. Epileptic seizures are a potential unwanted side effect. More clinical studies are warranted.

Physical fitness training in Subacute Stroke (PHYS-STROKE)--study protocol for a randomised controlled trial.

BACKGROUND: Given the rising number of strokes worldwide, and the large number of individuals left with disabilities after stroke, novel strategies to reduce disability, increase functions in the motor and the cognitive domains, and improve quality of life are of major importance. Physical activity is a promising intervention to address these challenges but, as yet, there is no study demonstrating definite outcomes. Our objective is to assess whether additional treatment in the form of physical fitness-based training for patients early after stroke will provide benefits in terms of functional outcomes, in particular gait speed and the Barthel Index (co-primary outcome measures) reflecting activities of daily living (ADL). We will gather secondary functional outcomes as well as mechanistic parameters in an exploratory approach. METHODS/DESIGN: Our phase III randomised controlled trial will recruit 215 adults with moderate to severe limitations of walking and ADL 5 to 45 days after stroke onset. Participants will be stratified for the prognostic variables of "centre", "age", and "stroke severity", and randomly assigned to one of two groups. The interventional group receives physical fitness training delivered as supported or unsupported treadmill training (cardiovascular active aerobic training; five times per week, over 4 weeks; each session 50 minutes; total of 20 additional physical fitness training sessions) in addition to standard rehabilitation treatment. The control intervention consists of relaxation sessions (non-cardiovascular active; five times per week week, over 4 weeks; each session 50 minutes) in addition to standard rehabilitation treatment. Co-primary efficacy endpoints will be gait speed (in m/s, 10 m walk) and the Barthel Index (100 points total) at 3 months post-stroke, compared to baseline measurements. Secondary outcomes include standard measures of quality of life, sleep and mood, cognition, arm function, maximal oxygen uptake, and cardiovascular risk factors including blood pressure, pulse, waist-to-hip ratio, markers of inflammation, immunity and the insulin-glucose pathway, lipid profile, and others. DISCUSSION: The goal of this endpoint-blinded, phase III randomised controlled trial is to provide evidence to guide post-stroke physical fitness-based rehabilitation programmes, and to elucidate the mechanisms underlying this intervention. TRIAL REGISTRATION: Registered in ClinicalTrials.gov with the Identifier NCT01953549.

Effect on arm function and cost of robot-assisted group therapy in subacute patients with stroke and a moderately to severely affected arm: a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness and efficiency of robot-assisted arm group therapy (RAGT) versus individual arm therapy (IAT) to restore motor function in the moderately to severely affected patient after stroke. DESIGN: Single blind randomized controlled trial. SETTING: Two in-patient neurological rehabilitation centers. PARTICIPANTS: Fifty first time subacute patients with stroke and a non-functional hand. INTERVENTION: The patients practiced either 30 minutes of RAGT + 30 minutes of IAT (group A) or 2x30 minutes of IAT (group B), per workday for four weeks. The RAGT consisted of six workstations enabling repetitive practice of finger, wrist, forearm and shoulder movements. Patients practiced according to their impairment level on at least two workstations per session. The IAT followed the Motor Relearning Programme, enriched by elements of the impairment-oriented training. MAIN OUTCOME MEASURE: Changes of the Fugl Meyer Score (FM, 0-66) between baseline and after 4 weeks, incremental cost effectiveness. RESULTS: Patients were homogeneous at study onset. All patients improved their upper limb motor function over time, but there were no between group differences. The initial (terminal) FM scores were 14.6±9.4 (25.7±16.5) in group A and 16.5±9.8 (31.1±19.1) in group B. The treatment of a single patient with RAGT cost 4.15 €, compared to 10.00 € for a patient to receive IAT. CONCLUSION: RAGT in combination with IAT was equally effective as a double session of IAT regarding the restoration of upper limb motor functions in moderate to severely affected subacute patients with stroke. The treatment costs for RAGT were less.

A new orthosis for subluxed, flaccid shoulder after stroke facilitates gait symmetry: a preliminary study.

OBJECTIVE: The aims of this study were: (i) to evaluate the immediate effects on subluxation and gait pattern of a new shoulder orthosis, developed for treatment of painful shoulder syndrome in subacute stroke patients; and (ii) to evaluate patients' and therapists' opinions about its fit and benefits after 4 weeks. METHODS: A total of 40 subacute in-rehabilitation stroke patients with non-functional arm and painful shoulder were included in the study. Of these, 12 subjects underwent shoulder radiography and gait analysis with and without the orthosis to determine the immediate effects of the orthosis. All 40 patients wore the orthosis during the daytime for 4 weeks before completing a survey. Outcome measures were: repositioning of the humeral head, gait cycle parameters, and qualitative lower limb muscle activation patterns. Patients and therapists rated wearing comfort, odour nuisance, effect on pain and performing gait and mobility-related activities. RESULTS: When using the shoulder orthosis the humeral head was repositioned in 10 of 12 patients, patients walked more symmetrically due to a prolonged hemiparetic stance phase (p < 0.01), and the paretic quadriceps muscle activity was higher and more appropriately timed. The majority of patients and therapists rated the wearing comfort positive, the odour nuisance minimal, and that the orthosis helped with performing activities. However, less than half of patients and therapists reported improvement in pain. CONCLUSION: The well-tolerated shoulder orthosis improved gait quality and repositioned the subluxated humeral head, offered a good fit, and eased performing activities, but did not reduce pain. This preliminary study does not warrant any definite conclusions on the effectiveness of the orthosis; more studies are needed to compare its effect with other models.

Robot-assisted practice of gait and stair climbing in nonambulatory stroke patients.

A novel gait robot enabled nonambulatory patients the repetitive practice of gait and stair climbing. Thirty nonambulatory patients with subacute stroke were allocated to two groups. During 60 min sessions every workday for 4 weeks, the experimental group received 30 min of robot training and 30 min of physiotherapy and the control group received 60 min of physiotherapy. The primary variable was gait and stair climbing ability (Functional Ambulation Categories [FAC] score 0-5); secondary variables were gait velocity, Rivermead Mobility Index (RMI), and leg strength and tone blindly assessed at onset, intervention end, and follow-up. Both groups were comparable at onset and functionally improved over time. The improvements were significantly larger in the experimental group with respect to the FAC, RMI, velocity, and leg strength during the intervention. The FAC gains (mean +/- standard deviation) were 2.4 +/- 1.2 (experimental group) and 1.2 +/- 1.5 (control group), p = 0.01. At the end of the intervention, seven experimental group patients and one control group patient had reached an FAC score of 5, indicating an ability to climb up and down one flight of stairs. At follow-up, this superior gait ability persisted. In conclusion, the therapy on the novel gait robot resulted in a superior gait and stair climbing ability in nonambulatory patients with subacute stroke; a higher training intensity was the most likely explanation. A large randomized controlled trial should follow.

A randomized controlled trial of Cognitive Sensory Motor Training Therapy on the recovery of arm function in acute stroke patients.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of Cognitive Sensory Motor Training Therapy (Perfetti's method) vis-à-vis conventional occupational therapy in the recovery of arm function after acute stroke. DESIGN: Prospective randomized controlled trial. SETTING: Two rehabilitation centers in Bangkok, Thailand. SUBJECTS: Forty first-time acute stroke patients without severe cognitive or language impairment. INTERVENTION: All subjects were randomly divided into two groups; one was treated using Perfetti's method and the other using conventional occupational therapy. Each group underwent therapy for 30 minutes, five times a week for four weeks. MAIN MEASURES: The primary variable was arm function as assessed by the Action Research Arm Test; secondary variables were the extended Barthel Index and the box and block test score. RESULTS: The intention-to-treat analysis revealed no statistically significant differences between the two groups at the end of treatment for any variable. CONCLUSIONS: There was no evidence of a difference between Cognitive Sensory Motor Training Therapy of Perfetti's method and conventional occupational therapy with respect to the restoration of hand and arm function after a stroke.

Accurate quantification of tetanus neurotoxin-induced focal spasticity in mice using complex running wheels.

Tetanus neurotoxin (TeNT) enhances activity of motoneurons by blocking spinal inhibitory interneurons. Based on this pathomechanism, we propose that low-dosage intramuscular injections of TeNT could serve as a specific treatment for central paretic muscles. However in vivo TeNT research is restricted because of the fear of triggering widespread muscle spasms. In addition, no reliable test to measure the in vivo toxicity of low-dosage TeNT is available. We introduce a novel wheel running-based paradigm with mice to quantify functional effects and thus the toxicity of low-dosage TeNT in vivo. We accustomed three groups of wildtype mice (n=14) to using a complex running wheel with irregularly spaced crossbars. Each group received an injection with a different low-dosage of TeNT (0.15 ng, 0.1 ng or 0.05 ng TeNT) into both tibialis anterior muscles. The maximum running velocity and accumulative running time of the groups were recorded during the following weeks. Three days after TeNT injections, the mice exhibited an increase in muscle tone of the injected tibialis anterior muscles but no generalized symptoms. However, we found that normal running in the complex wheel set-up was disturbed such that the maximum running velocity and running time of the mice decreased with the size of the dose. This effect peaked on the fifth and sixth nights after injection and returned to baseline level again within the next two weeks. With this novel in vivo automated paradigm we can accurately and objectively quantify the duration and degree of TeNT-induced focal increase in muscle tone.

Botulinum toxin-induced focal paresis in mice is unaffected by muscle activity.

INTRODUCTION: To test the hypothesis that the efficacy of botulinum toxin depends on the activity of the neuromuscular junction, we developed an in vivo paradigm to determine the degree and duration of low-dose botulinum toxin-induced focal paresis in mice. METHODS: We combined an automated wheel-running paradigm with low-dose botulinum toxin injections into the calf muscles of wild-type mice. Half of the mice were injected either before the nightly running or before the daily resting period. RESULTS: After botulinum toxin injections, running distance and maximum velocity decreased dose-dependently. The degree and duration of decrease between the respective groups with regard to the time-points of injection were identical. CONCLUSIONS: This in vivo paradigm quantifies the degree of otherwise clinically inapparent botulinum toxin-induced focal calf muscle paresis. Increased muscle activity after low-dose injections does not influence the efficacy of botulinum toxin in normal muscles.

Rehabilitation after stroke.

BACKGROUND: Stroke is becoming more common in Germany as the population ages. Its long-term sequelae can be alleviated by early reperfusion in stroke units and by complication management and functional restoration in early-rehabilitation and rehabilitation centers. METHODS: Selective review of the literature. RESULTS: Successful rehabilitation depends on systematic treatment by an interdisciplinary team of experienced specialists. In the area of functional restoration, there has been major progress in our understanding of the physiology of learning, relearning, training, and neuroenhancement. There have also been advances in supportive pharmacotherapy and robot technology. CONCLUSION: Well-organized acute and intermediate rehabilitation after stroke can provide patients with the best functional results attainable on the basis of our current scientific understanding. Further experimental and clinical studies will be needed to expand our knowledge and improve the efficacy of rehabilitation.

Combined transcranial direct current stimulation and robot-assisted arm training in subacute stroke patients: an exploratory, randomized multicenter trial.

BACKGROUND: No rehabilitation intervention has effectively improved functional use of the arm and hand in patients with severe upper limb paresis after stroke. Pilot studies suggest the potential for transcranial direct current stimulation and bilateral robotic training to enhance gains. OBJECTIVE: In a double-blind, randomized trial the combination of these interventions was tested. METHODS: This study randomized 96 patients with an ischemic supratentorial lesion of 3 to 8 weeks' duration with severe impairment of motor control with a Fugl-Meyer score (FMS) for the upper limb <18 into 3 groups. For 6 weeks, group A received anodal stimulation of the lesioned hemisphere, group B received cathodal stimulation of the nonlesioned side for 20 minutes at 2.0 mA, and group C received sham stimulation. The electrodes were placed over the hand area and above the contralateral orbit. Contemporaneously, the subjects practiced 400 repetitions each of 2 different bilateral movements on a robotic assistive device. RESULTS: The groups were matched at onset. The FMS improved in all patients at 6 weeks (P < .001). No between-group differences were found; initial versus finish FMS scores were 7.8 ± 3.8 versus 19.1 ± 14.4 in group A, 7.9 ± 3.4 versus 18.8 ± 10.5 in group B, and 8.2 ± 4.4 versus 19.2 ± 15.0 in group C. No significant changes between groups were present at 3 months. CONCLUSIONS: Neither anodal nor cathodal transcranial direct current stimulation enhanced the effect of bilateral arm training in this exploratory trial of patients with cortical involvement and severe weakness. Unilateral hand training and upregulation of the nonlesioned hemisphere might also be tried in this population.

External lid loading for the temporary treatment of paresis of the M. orbicularis oculi: a case report.

This clinical note re-introduces external lid loading with the help of a lead weight for the temporary treatment of lagophthalmos. Although simple and effective, the technique is rarely used. Instead of wearing a monoculus, the patient uses an individually tailored lead weight (0.8-mm thickness, 1.0-2.0g) stuck on the lid to enable its closure. Spontaneous ptosis indicates a too-heavy weight. With the musculus (M.) levator palpebrae intact, lid lifting is possible. The effect is gravity dependent; therefore, the patient has to wear the monoculus at night. To minimize the risk for lead intoxication, the surface of the weight is varnished. In the case of persistent M. orbicularis oculi paresis, internal lid loading can follow. Since 1997, a total of 152 lagophthalmos cases have been treated. All patients could close the lid immediately. Almost half the patients had to readjust the weight several times per day because of hooded eyelids. Compliance was high, and partial or complete restoration of M. orbicularis oculi function occurred in 60% of cases. In some subjects, restoration of the M. orbicularis oculi was faster than for the M. orbicularis orbis. External lid loading for the temporary treatment of lagophthalmos is simple and effective. Compared with a monoculus, vision is unimpaired and the aesthetic is more appropriate for most patients. Faster restoration of the M. orbicularis oculi hints at a potentially facilitatory effect of the weight.

Improved gait after repetitive locomotor training in children with cerebral palsy.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of repetitive locomotor training with an electromechanical gait trainer in children with cerebral palsy. DESIGN: In this randomized controlled trial, 18 ambulatory children with diplegic or tetraplegic cerebral palsy were randomly assigned to an experimental group or a control group. The experimental group received 30 mins of repetitive locomotor training with an applied technology (Gait Trainer GT I) plus 10 mins of passive joint mobilization and stretching exercises. The control group received 40 mins of conventional physiotherapy. Each subject underwent a total of 10 treatment sessions over a 2-wk period. Performance on the 10-m walk test, 6-min walk test, WeeFIM scale, and gait analysis was evaluated by a blinded rater before and after treatment and at 1-mo follow-up. RESULTS: The experimental group showed significant posttreatment improvement on the 10-m walk test, 6-min walk test, hip kinematics, gait speed, and step length, all of which were maintained at the 1-mo follow-up assessment. No significant changes in performance parameters were observed in the control group. CONCLUSIONS: Repetitive locomotor training with an electromechanical gait trainer may improve gait velocity, endurance, spatiotemporal, and kinematic gait parameters in patients with cerebral palsy.

Adaptive locomotor training on an end-effector gait robot: evaluation of the ground reaction forces in different training conditions.

The main goal of robotic gait rehabilitation is the restoration of independent gait. To achieve this goal different and specific patterns have to be practiced intensively in order to stimulate the learning process of the central nervous system. The gait robot G-EO Systems was designed to allow the repetitive practice of floor walking, stair climbing and stair descending. A novel control strategy allows training in adaptive mode. The force interactions between the foot and the ground were analyzed on 8 healthy volunteers in three different conditions: real floor walking on a treadmill, floor walking on the gait robot in passive mode, floor walking on the gait robot in adaptive mode. The ground reaction forces were measured by a Computer Dyno Graphy (CDG) analysis system. The results show different intensities of the ground reaction force across all of the three conditions. The intensities of force interactions during the adaptive training mode are comparable to the real walking on the treadmill. Slight deviations still occur in regard to the timing pattern of the forces. The adaptive control strategy comes closer to the physiological swing phase than the passive mode and seems to be a promising option for the treatment of gait disorders. Clinical trials will validate the efficacy of this new option in locomotor therapy on the patients.

Innovative gait robot for the repetitive practice of floor walking and stair climbing up and down in stroke patients.

BACKGROUND: Stair climbing up and down is an essential part of everyday's mobility. To enable wheelchair-dependent patients the repetitive practice of this task, a novel gait robot, G-EO-Systems (EO, Lat: I walk), based on the end-effector principle, has been designed. The trajectories of the foot plates are freely programmable enabling not only the practice of simulated floor walking but also stair climbing up and down. The article intended to compare lower limb muscle activation patterns of hemiparetic subjects during real floor walking and stairs climbing up, and during the corresponding simulated conditions on the machine, and secondly to demonstrate gait improvement on single case after training on the machine. METHODS: The muscle activation pattern of seven lower limb muscles of six hemiparetic patients during free and simulated walking on the floor and stair climbing was measured via dynamic electromyography. A non-ambulatory, sub-acute stroke patient additionally trained on the G-EO-Systems every workday for five weeks. RESULTS: The muscle activation patterns were comparable during the real and simulated conditions, both on the floor and during stair climbing up. Minor differences, concerning the real and simulated floor walking conditions, were a delayed (prolonged) onset (duration) of the thigh muscle activation on the machine across all subjects. Concerning stair climbing conditions, the shank muscle activation was more phasic and timely correct in selected patients on the device. The severely affected subject regained walking and stair climbing ability. CONCLUSIONS: The G-EO-Systems is an interesting new option in gait rehabilitation after stroke. The lower limb muscle activation patterns were comparable, a training thus feasible, and the positive case report warrants further clinical studies.

Arm studio to intensify the upper limb rehabilitation after stroke: concept, acceptance, utilization and preliminary clinical results.

OBJECTIVES: To assess the acceptance, utilization and clinical results of an arm studio designed to intensify treatment of the severely to moderately affected arm after stroke. In line with a distal bilateral approach, the equipment comprised 4 workstations, 1 finger trainer, and 3 machines for bilateral training of selected distal and proximal movements. DESIGN: Open study. SUBJECTS: Of 119 treated patients after subacute stroke, 30 completed a questionnaire and 24 were assessed. METHODS: All patients completed 15 sessions, each of 30-45 min duration, on each of 2 workstations. Based on the patients' impairment level they were divided into 3 groups, as follows: group A, plegic; group B, proximal and distal movements but hand non-functional; and group C, able to grasp and release an object. Motor functions were assessed with the Fugl-Meyer Score (FM, 0-66) for groups A (n = 6) and B (n = 6), and the Action Arm Research Test (ARAT, 0-57) for group C (n = 12). RESULTS: No side-effects occurred. The patients regarded the training positively. The initial FM was 8.5 (standard deviation (SD) 3.3) and final FM 21.2 (SD 4.4) for group A, initial FM 25.3 (SD 6.9) and final FM 44.3 (SD 9.1) for group B, and initial ARAT 33.3 (SD 11.2) and final ARAT 43.5 (SD 10.7) for group C. CONCLUSION: The use of the arm studio to intensify upper limb rehabilitation after stroke is promising, and a controlled study is warranted.