But you're missing the only goal in stroke:100% RECOVERY!
Rethinking stroke rehabilitation in the technological age
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Singapore is due to become a super-aged society by 2026, when more than 21% of the population would be aged 65 years or older.[1] This demographic shift coincides with a troubling trend: stroke is increasingly affecting younger and middle-aged (40–59 years) adults, challenging the traditional view of stroke as primarily a disease of advanced age.[2,3,4] From 2012 to 2022, the incidence of stroke rose by more than 50%.[4] Approximately 16% of all strokes now occur in individuals under the age of 50,[5] and nearly one in three of the 9702 individuals who suffer from stroke annually are under the age of 60.[4] Due to demographic shift and the increasing prevalence of vascular risk factors among younger age groups,[3,6] stroke occurring during the prime of life can disrupt careers and livelihood, derail personal aspirations and profoundly affect one’s sense of identity.[7] In Singapore, as in many other parts of the developed world, people in their middle age and early elderhood have become increasingly sophisticated in their personal and social life. Many are better educated and have grown up in a more prosperous, information-rich, performance-driven digital era than previous generations. For these adults, the loss of functional independence has more pronounced social and emotional consequences. The once-accepted endpoint of ‘independent walking’ or ‘basic activities of daily living’ may no longer be sufficient for meaningful reintegration into modern life.
Consequently, post-stroke disabilities have become one of the most urgent and complex neurorehabilitative challenges of our time. While advances in hyperacute and acute stroke care have dramatically improved outcomes — due to more rapid interventions, protocolisation of acute stroke units and greater public awareness — the rehabilitation framework must also evolve to keep pace. With lower post-stroke mortality and morbidity owing to early interventions such as endovascular thrombectomy, an emerging paradox has arisen. As more people survive strokes, many survivors are inflicted with potentially profound, disabling neurological deficits. For those with dense hemiplegia, the path to recovery is steep, particularly for dextrous hand movements, which are notoriously resistant to recovery. For these individuals, traditional rehabilitation methods are often limited in efficacy when the lack of volitional movement precludes effective limb use. This functional plateau underscores the urgent need to reimagine other ways of engaging the brain, including how the brain might be coaxed into relearning movement even when the communication link with the body has been interrupted.
CHANGING NEEDS OF STROKE SURVIVORS
Loss of quality of life persists years after stroke onset, and this is mainly attributed to deficits in mobility, self-care and usual activities, as well as neuropsychiatric sequelae.[8] Shifts in family dynamics, caregiver burnout and strain on healthcare systems result from long-term disability,[9] and stroke survivors must navigate a world that often fails to accommodate invisible disabilities. It is no longer sufficient to aim for survival; rehabilitation must aim for reintegration. Fatigue, cognitive impairment, anxiety and mood disorders — companion syndromes to physical deficits — constitute a critical ‘last-mile gap’, preventing return to work and social reintegration, and reducing overall quality of life,[8] despite patients having achieved a ‘good functional outcome’ on the traditional clinical outcome measures.[10]
With the changing needs in the digital era, stroke rehabilitation stands to benefit from modern technological advancements. While conventional methods remain foundational, they may no longer be sufficient for addressing the full spectrum of survivors’ needs.
STROKE REHABILITATION IN THE TECHNOLOGICAL AGE
In stroke, the brain may still be capable of generating motor instructions, but its ability to relay this to the end organs is impaired. It is here that new technology, such as robotic devices and brain–computer interfaces (BCIs), offers new potential for functional restoration.[11,12,13] A BCI is defined as a system that enables direct communication between the brain and an external device by translating brain activity into commands without the use of peripheral nerves or muscles.[13] It transfers a patient’s neural signals to an effector device such as a robotic limb, functional electrical stimulation of the patient’s paralysed muscles, or even non-anthropomorphic applications such as controlling a wheelchair, screen cursors, or virtual avatars (may be particularly useful for those with more profound deficits such as locked-in syndrome) [Figure 1].
The catastrophic impact of functional disruption is underscored by the observation that patients with haemorrhagic stroke — most frequently affecting deep structures such as the basal ganglia and thalamus, which relay key sensory and motor signals while sparing cortical neurons — have worse functional and return-to-work outcomes compared to those with ischaemic strokes.[10] A BCI offers a paradigm shift in how intentions can be leveraged to restore movement,[12] and importantly, this restoration is not merely biomechanical but represents a re-establishment of cognitive agency. This technology aims to sidestep the damaged circuitry by decoding motor intention directly from uninjured but disconnected cortical neurons through capturing their electrical signals, and then using them to drive external devices or stimulate somatosensory feedback loops.
Current evidence, though still early and preliminary, has been encouraging. Meta-analyses have demonstrated that BCI-guided therapy enhances motor function, most notably for upper limb rehabilitation,[12] beyond what conventional therapy alone has achieved. Brain–computer interfaces do not operate in isolation. They are part of a broader constellation of neurorehabilitative technologies, which include robotic-assisted therapy, virtual and augmented reality platforms, gamified therapy modules and non-invasive neuromodulation[11,14] [Figure 1]. Each offers a unique affordance: robotic frames provide precise, repetitive motion assistance; virtual reality and augmented reality offer immersive engagement and rich sensory feedback; and BCI closes the feedback loop between intention and action.
However, we must temper optimism with scientific rigour and practicality. Cost, accessibility and scalability must remain central to the conversation. This range of technology remains complex and expensive and requires a high degree of personalisation. The true efficacy of BCI systems has yet to be verified clinically, and their use remains largely confined to research settings. Calibration of BCI systems can be tedious, and performance varies significantly between individuals, with some inherently incapable of controlling a BCI, a phenomenon known as BCI ‘illiteracy’. It remains unclear whether this is due to poor signal because of patient-specific anatomical factors or disrupted motor intention networks. Clinical translation is also not merely a matter of demonstrating efficacy in controlled research settings. It requires integration into existing clinical workflows, financing structures and therapist training and adoption — larger-scale challenges in these areas cannot be solved by engineering alone. To take things further, some even envision fully implantable systems in the future that decode high-fidelity cortical signals to provide permanent motion assistance, should the native neurological system be beyond rehabilitation, akin to those already in development for spinal cord injury.[15]
While the ethical and regulatory dimensions of such progress must be carefully navigated, the possibilities are vast. It is time for clinicians, researchers and policymakers to consider the future potential of these technologies in reimagining functional restoration in stroke. The mind, after all, is a terrible resource to waste and perhaps our greatest untapped resource in the path of neurological recovery.
Acknowledgement
This article is co-authored by Lo YT and his mentor (Tan BYQ) as part of the SMJ Editorial Fellowship programme 2025.
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