Efficacy of brain-computer interface training with motor imagery-contingent feedback in improving upper limb function and neuroplasticity among persons with chronic stroke: a double-blinded, parallel-group, randomized controlled trial

Where is the protocol located so survivors can find it and deliver it to their 'professionals'? Top down has been proven numerous times not to work, so survivors have to take charge of their own recovery!

Efficacy of brain-computer interface training with motor imagery-contingent feedback in improving upper limb function and neuroplasticity among persons with chronic stroke: a double-blinded, parallel-group, randomized controlled trial

• Myeong Sun Kim,
• Hyunju Park,
• Ilho Kwon,
• Kwang-Ok An,
• Hayeon Kim,
• Gyulee Park,
• Wooseok Hyung,
• Chang-Hwan Im &
• Joon-Ho Shin 

Journal of NeuroEngineering and Rehabilitation volume 22, Article number: 1 (2025) Cite this article

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Abstract

Background

Brain-computer interface (BCI) technology can enhance neural plasticity and motor recovery in persons with stroke. However, the effects of BCI training with motor imagery (MI)-contingent feedback versus MI-independent feedback remain unclear. This study aimed to investigate whether the contingent connection between MI-induced brain activity and feedback influences functional and neural plasticity outcomes. We hypothesized that BCI training, with MI-contingent feedback, would result in greater improvements in upper limb function and neural plasticity compared to BCI training, with MI-independent feedback.

Methods

This randomized controlled trial included persons with chronic stroke who underwent BCI training involving functional electrical stimulation feedback on the affected wrist extensor. Primary outcomes included the Medical Research Council (MRC) scale score for muscle strength in the wrist extensor (MRC-WE) and active range of motion in wrist extension (AROM-WE). Resting-state electroencephalogram recordings were used to assess neural plasticity.

Results

Compared to the MI-independent feedback BCI group, the MI-contingent feedback BCI group showed significantly greater improvements in MRC-WE scores (mean difference = 0.52, 95% CI = 0.03–1.00, p = 0.036) and demonstrated increased AROM-WE at 4 weeks post-intervention (p = 0.019). Enhanced functional connectivity in the affected hemisphere was observed in the MI-contingent feedback BCI group, correlating with MRC-WE and Fugl-Meyer assessment-distal scores. Improvements were also observed in the unaffected hemisphere’s functional connectivity.

Conclusions

BCI training with MI-contingent feedback is more effective than MI-independent feedback in improving AROM-WE, MRC, and neural plasticity in individuals with chronic stroke. BCI technology could be a valuable addition to conventional rehabilitation for stroke survivors, enhancing recovery outcomes.

Trial registration

CRIS (KCT0009013).

Background

Upper limb impairments, which are common after stroke, have a significant impact on stroke survivors’ lives. Recent advancements in technologies, such as virtual rehabilitation, rehabilitation robots, and non-invasive brain stimulation, have enabled their use as adjunct or stand-alone therapies for upper-limb rehabilitation [1]. More recently, a brain-computer interface (BCI) system, that captures central nervous system (CNS) activity and translates it into artificial signals, has been used to substitute, restore, or enhance CNS output [2]. BCI allows direct communication between the human brain and external devices, enabling control of external devices, such as computer or robotic devices, bypassing conventional motor pathways. In upper-limb rehabilitation among persons with stroke, BCIs interpret the patient’s intention to move, aiding muscle stimulation or external device control. Through repetitive learning, BCIs can facilitate neural plasticity and fundamental motor recovery [3]. Several studies have demonstrated the beneficial effects of BCI training on motor function and neuroplasticity during stroke rehabilitation [4, 5].

A BCI system continuously monitors brain signals and provides feedback or stimulation to the user based on brain signals across various processes such as data acquisition, signal processing, feedback, adaptive training, and progress monitoring [4,5,6]. In the context of motor rehabilitation, reward feedback is provided only when the user imagines the desired movement, allowing the user to learn how to control the movement more effectively. The patient’s intention-driven feedback gradually creates a closed loop from intention to motor execution throughout BCI training, becoming an integral part of motor learning. Therefore, a contingency between the neural correlates of motor intention and consequent feedback should be established in BCIs to reorganize the targeted neural circuit, fundamentally leading to functional improvement.

Previous studies have demonstrated the favorable effects of this close connection between intention and feedback; however, there are inconsistencies in BCI systems and results of previous studies comparing motor imagery (MI)-contingent feedback (real-BCI) and BCI operated by MI-independent feedback (sham-BCI). Frolov et al. [7] employed a BCI-controlled hand exoskeleton and demonstrated within-group improvements after real-BCI without directly comparing real-BCI and sham-BCI. Ramos-Murguialday et al. [8] compared real and sham-BCI using BCI-driven finger orthosis and demonstrated significant improvement in motor function, particularly in terms of the upper limb Fugl-Meyer assessment (FMA) scores in the real-BCI group compared to those in the sham-BCI group. In addition, the improvements were associated with changes in the affected hand’s fMRI laterality index and electromyographic activity. Biasiucci et al. [9] compared real and sham-BCI using functional electrical stimulation (FES) feedback and demonstrated significant differences in the improvement of FMA, muscle strength of the wrist extensor, and functional connectivity in the affected hemisphere in the real-BCI group compared with that in the sham-BCI group.

recoveriX-PRO^® (g.tec Medical Engineering GmbH, Austria) is a ready-to-use BCI system and comprises different features to strengthen closed-loops. First, it detects motor intention in different ways. recoveriX-PRO compares brain activity between hemispheres during mental rehearsal of affected or unaffected (right or left) hand movements. This approach differs from previous methods that obtained signals from MI of the affected hand versus rest. Second, calibration is conducted in every session before the BCI intervention, reflecting the variability of electrode position and electroencephalogram (EEG) electrode impedance. Third, FES is provided during calibration, aiming to align more closely with motor intentions during BCI training, as EEG signals are influenced by sensory feedback during actual BCI-FES training. Lastly, recoveriX-PRO provides visual feedback through animated upper extremities of an avatar in virtual reality and proprioceptive feedback by generating movement via FES. In contrast to traditional BCIs, our study used a virtual reality-based game task. We believe that virtual reality enhances motor performance by boosting motivation and active engagement, which facilitate BCI participation [10]. We hypothesized that close contingent connection between MI-induced brain activity and consequent sensory feedback is essential in BCI systems for functional improvement and neural plasticity and that this contingency should be confirmed for individual BCI systems, considering their unique characteristics. Therefore, this study aimed to compare the effects of the BCI system operated by MI-contingent feedback BCI group, versus the effects of BCI operated by MI-independent feedback BCI group on distal upper limb function and brain activity in persons with chronic stroke with weak wrist extensor strength.

Effects of robot therapy on upper body kinematics and arm function in persons post stroke: a pilot randomized controlled trial

Where is the protocol located so survivors can bring it to their stroke medical 'professionals' attention? Top down dissemination of research is a complete fucking failure; bottom up is the way to go!

Effects of robot therapy on upper body kinematics and arm function in persons post stroke: a pilot randomized controlled trial

Ilaria Carpinella 1 , 

Tiziana Lencioni 1* , 

Thomas Bowman 1 , 

Rita Bertoni 1 , 

Andrea Turolla 2 , 

Maurizio Ferrarin 1 and 

Johanna Jonsdottir 1 

Abstract 

Background: 

Robot-based rehabilitation for persons post-stroke may improve arm function and daily-life activities as measured by clinical scales, but its effects on motor strategies during functional tasks are still poorly investigated. This study aimed at assessing the effects of robot-therapy versus arm-specific physiotherapy in persons post-stroke on motor strategies derived from upper body instrumented kinematic analysis, and on arm function measured by clinical scales. 

Methods: 

Forty persons in the sub-acute and chronic stage post-stroke were recruited. This sample included all those subjects, enrolled in a larger bi-center study, who underwent instrumented kinematic analysis and who were randomized in Center 2 into Robot (R_Group) and Control Group (C_Group). R_Group received robot-assisted training. C_ Group received arm-specific treatment delivered by a physiotherapist. Pre- and post-training assessment included clinical scales and instrumented kinematic analysis of arm and trunk during a virtual untrained task simulating the transport of an object onto a shelf. Instrumented outcomes included shoulder/elbow coordination, elbow extension and trunk sagittal compensation. Clinical outcomes included Fugl-Meyer Motor Assessment of Upper Extremity (FM-UE), modified Ashworth Scale (MAS) and Functional Independence Measure (FIM). 

Results: 

R_Group showed larger post-training improvements of shoulder/elbow coordination (Cohen’sd= - 0.81, p = 0.019), elbow extension (Cohen’sd= - 0.71, p = 0.038), and trunk movement (Cohen’sd= - 1.12, p = 0.002). Both groups showed comparable improvements in clinical scales, except proximal muscles MAS that decreased more in R_Group (Cohen’sd= - 0.83, p = 0.018). Ancillary analyses on chronic subjects confirmed these results and revealed larger improvements after robot-therapy in the proximal portion of FM-UE (Cohen’s d = 1.16, p = 0.019). 

Conclusions: 

Robot-assisted rehabilitation was as effective as arm-specific physiotherapy in reducing(NOT RECOVERY!) arm impairment (FM-UE) in persons post-stroke, but it was more effective(If not 100% recovery, IT IS NOT EFFECTIVE!) in improving motor control strategies adopted during an untrained task involving vertical movements not practiced during training. Specifically, robot therapy induced larger improvements of shoulder/elbow coordination and greater reduction of abnormal trunk sagittal movements. The beneficial effects of robot therapy seemed more pronounced in chronic subjects. Future studies on a larger sample should be performed to corroborate present findings. Trial registration: www.ClinicalTrials.gov NCT03530358. Registered 21 May 2018. Retrospectively registered. Keywords: Stroke, Robot therapy, Upper limb, Trunk, Kinematic analysis, Motor strategies 

Effectiveness of unilateral lower-limb exoskeleton robot on balance and gait recovery and neuroplasticity in patients with subacute stroke: a randomized controlled trial

 Where is the protocol located so survivors can bring it to their stroke medical 'professionals' attention? Top down dissemination of research is a complete fucking failure; bottom up is the way to go!

Effectiveness of unilateral lower-limb exoskeleton robot on balance and gait recovery and neuroplasticity in patients with subacute stroke: a randomized controlled trial

• Congcong Huo,
• Guangjian Shao,
• Tiandi Chen,
• Wenhao Li,
• Jue Wang,
• Hui Xie,
• Yan Wang,
• Zengyong Li,
• Pengyuan Zheng,
• Liguo Li &
• Luya Li 

Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 213 (2024) Cite this article

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Abstract

Background

Impaired balance and gait in stroke survivors are associated with decreased functional independence. This study aimed to evaluate the effectiveness of unilateral lower-limb exoskeleton robot-assisted overground gait training compared with conventional treatment and to explore the relationship between neuroplastic changes and motor function recovery in subacute stroke patients.

Methods

In this randomized, single-blind clinical trial, 40 patients with subacute stroke were recruited and randomly assigned to either a robot-assisted training (RT) group or a conventional training (CT) group. All outcome measures were assessed at the enrollment baseline (T0), 2nd week (T1) and 4th week (T2) of the treatment. The primary outcome was the between-group difference in the change in the Berg balance scale (BBS) score from baseline to T2. The secondary measures included longitudinal changes in the Fugl-Meyer assessment of the lower limb (FMA-LE), modified Barthel index (mBI), functional ambulation category (FAC), and locomotion assessment with gait analysis. In addition, the cortical activation pattern related to robot-assisted training was measured before and after intervention via functional near-infrared spectroscopy.

Results

A total of 30 patients with complete data were included in this study. Clinical outcomes improved after 4 weeks of training in both groups, with significantly better BBS (F = 6.341, p = 0.018, partial η2 = 0.185), FMA-LE (F = 5.979, p = 0.021, partial η2 = 0.176), FAC (F = 7.692, p = 0.010, partial η2 = 0.216), and mBI scores (F = 7.255, p = 0.042, partial η2 = 0.140) in the RT group than in the CT group. Both groups showed significant improvement in gait speed and stride cadence on the locomotion assessment. Only the RT group presented a significantly increased stride length (F = 4.913, p = 0.015, partial η2 = 0.267), support phase (F = 5.335, p = 0.011, partial η2 = 0.283), and toe-off angle (F = 3.829, p = 0.035, partial η2 = 0.228) on the affected side after the intervention. The RT group also showed increased neural activity response over the ipsilesional motor area and bilateral prefrontal cortex during robot-assisted weight-shift and gait training following 4 weeks of treatment.

Conclusions

Overground gait training with a unilateral exoskeleton robot showed improvements in balance and gait functions, resulting in better gait patterns and increased gait stability for stroke patients. The increased cortical response related to the ipsilesional motor areas and their related functional network is crucial in the rehabilitation of lower limb gait in post-stroke patients.

Introduction

Stroke is commonly associated with motor dysfunction of the lower extremities, manifested as decreased muscle strength, impaired balance, and abnormal gait. Despite professional rehabilitation attempts, 20–30% of patients still experience difficulties or loss of the ability to walk [1]. Three months after stroke, 85% of patients still have great potential to improve their walking ability, which is strongly correlated with quality of life of stroke survivors [2]. Consequently, improving walking ability is the primary focus of lower-limb rehabilitation for stroke patients.

Specific, repetitive, and high-intensity motor training is a key element in inducing functional neuroplasticity related to stroke motor rehabilitation within the 6-month post-stroke window [3, 4]. Thus, implementing gait training for stroke patients at an early stage is critical for the restoration of lower-limb function. However, traditional physical therapies are limited in providing long-term, high-quality gait training due to decreased muscle strength in early stroke patients. Robotic exoskeleton training is a promising way to deliver repetitive walking training assisted by mechanical legs, promoting the walking, balance, and daily living abilities of stroke patients [5, 6]. Achieving positive effects in gait training necessitates repetitive natural walking on the ground along with accurate proprioception and external sensory feedback [7]. Wearable robots possess the advantage of portability, enabling treatments to be performed in real-world scenarios, which have been widely applied to improve walking efficiency and enhance mobility in stroke patients [8,9,10,11]. Currently, robots for overground gait training mainly target chronic stroke survivors, with limited application in the subacute patients due to early muscle weakness. Based on the early-stage gait rehabilitation needs, the unilateral lower-limb exoskeleton robot is designed to support overground walking in real environments with active engagement of stroke patients with hemiplegia. However, there is scant evidence to support the effectiveness of overground gait training with a unilateral lower-limb exoskeleton robot for stroke patients in the literature.

Furthermore, restoring motor ability poststroke relies on brain functional reorganization. Assessment of cortical activation related to a specific task is essential for a better understanding of neural motor control. Currently, limited information is available on the cerebral mechanisms underlying locomotor recovery after stroke due to technical limitations in assessing cerebral activation during movement, particularly walking tasks. Recently, functional near-infrared spectroscopy (fNIRS) has gained attraction as a novel neuroimaging technology in stroke rehabilitation. Its low cost, portability, noninvasiveness, and motion tolerance make it a suitable for studying gait disturbances induced by stroke [12, 13]. Research has shown a bilateral increase in oxygenated hemoglobin (

[oxy-Hb]) in the sensorimotor cortex (SMC) and supplementary motor area (SMA) in stroke patients during gait training [14]. Additionally, increased activation in the SMC, SMA, and premotor cortex (PMC) was detected in healthy participants during exoskeleton robot walking in contrast to treadmill walking or stepping [15]. However, the effects of long-term robot-assisted overground gait training on neuroplastic reorganization have not been adequately studied in subacute patients.

This study aimed to compare the effectiveness of robot-assisted overground gait training and conventional training for the lower-limb rehabilitation of stroke patients with hemiplegia. Wearable gait analyzers(Where and what are these so our stroke medical 'professionals' can get an objective damage diagnosis of our gait problems, so they can prescribe EXACT PROTOCOLS to fix those problems?) combined with clinical assessment scales, including the Berg balance scale (BBS), Fugl Meyer assessment for lower extremity (FMA-LE), functional ambulation category (FAC), and modified Barthel index (mBI), were used to evaluate the motor function of the patients before and after 4 weeks of training. It was hypothesized that compared with conventional training (CT), robot-assisted training (RT) would have superior effects on both clinical outcomes and gait balance. Additionally, fNIRS was employed to monitor the cortical activation response of the patients during robot-assisted training. It was expected that the activation of ipsilesional motor-related cortices would increase following motor recovery of the lower limb. The results of this study will be used to explore the relationship between neuroplasticity and lower-limb motor recovery, thereby providing a theoretical basis for the clinical application of robot-assisted lower-limb rehabilitation.

More at link.

Home-based guidance training system with interactive visual feedback using kinect on stroke survivors with moderate to severe motor impairment

 

I see nothing here that suggests that protocols were written and placed in a public database that survivors can find and access so this can be presented to their stroke medical 'professionals' to implement. Top down research dissemination does not work, bottom up will work because survivors will demand it be delivered to them.

Home-based guidance training system with interactive visual feedback using kinect on stroke survivors with moderate to severe motor impairment

• Hsuan-Yu Lu,
• Xiaoyi Wang,
• Chengpeng Hu,
• Cathy Choi-Yin Lau &
• Raymond Kai-Yu Tong 

Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 189 (2024) Cite this article

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Abstract

The home-based training approach benefits stroke survivors by providing them with an increased amount of training time and greater feasibility in terms of their training schedule, particularly for those with severe motor impairment. Computer-guided training systems provide visual feedback with correct movement patterns during home-based training. This study aimed to investigate the improvement in motor performance among stroke survivors with moderate to severe motor impairment after 800 min of training using a home-based guidance training system with interactive visual feedback. Twelve patients with moderate to severe stroke underwent home-based training, totaling 800 min (20–40 min per session, with a frequency of 3 sessions per week). The home-based guidance training system uses Kinect to reconstruct the 3D human body skeletal model and provides real-time motor feedback during training. The training exercises consisted of six core exercises and eleven optional exercises, including joint exercises, balance control, and coordination. Pre-training and post-training assessments were conducted using the Fugl-Meyer Assessment-Upper Limb (FMA-UE), Fugl-Meyer Assessment-Lower Limb (FMA-LE), Functional Ambulation Categories (FAC), Berg Balance Scale (BBS), Barthel Index (BI), Modified Ashworth Scale (MAS), as well as kinematic data of joint angles and center of mass (COM). The results indicated that motor training led to the attainment of the upper limit of functional range of motion (FROM) in hip abduction, shoulder flexion, and shoulder abduction. However, there was no improvement in the active range of motion (AROM) in the upper extremity (U/E) and lower extremity (L/E) joints, reaching the level of the older healthy population. Significant improvements were observed in both left/right and superior/inferior displacements, as well as body sway in the mediolateral axis of the COM, after 800 min of training. In conclusion, the home-based guidance system using Kinect aids in improving joint kinematics performance at the level of FROM and balance control, accompanied by increased mediolateral body sway of the COM for stroke survivors with moderate to severe stroke. Additionally, spasticity was reduced in both the upper and lower extremities after 800 min of home-based training.

Introduction

Existing home-based training systems use games as the primary trend to enhance the level of motivation [1,2,3,4,5]. In addition, the training efficiency, in terms of repetitions, may be lower when utilizing the home-based training system without feedback [6]. If the fun environment is enriched and the correct movement is guided by visual feedback during training exercises, this approach would be a feasible training approach. Cloud computing technology has advanced recently, cloud-based networks can easily connect the training from home to the center, and therapists can adjust the training protocol remotely and access the training data. Two markerless systems for motion tracking 3D depth sensor technique and RGB camera system. 3D depth-sensing cameras, employing technologies such as stereo vision, time of flight, or structured light, are now capable of identifying 3D body segments. Notable examples include Kinect [7,8,9,10,11], ZED [12, 13], Intel RealSense [14]. Another type of system using markerless’s AI-driven motion capture technology with RGB cameras (e.g., Theia3D) [15] to construct the 3D skeletal models for tracking joint movements and balance control. In this work, we raise the following questions: Is it possible to have an interactive guidance system for home-based users during training, and what is the effectiveness of motor recovery after 800 min of home-based training using computer-guided visual feedback?

The home-based training approach [16,17,18] provides training for chronic stroke and benefits stroke survivors with an increased amount of training time and more feasibility in the training schedule, especially in patients with severe levels. The depth sensor-based training systems (i.e., UINCARE Home + (UINCARE Corp., South Korea) [19, 20], MindMotion^® GO (Switzerland) [21], EvolvRehab (Spain) [22], LongGood TeleRehabilitation System (Taiwan) [23]) provide the visual feedback with specific symbols or targets to guide the user in achieving the tasks. However, these training approaches display virtual objects in a video game or demonstration videos without providing feedback on the user’s real-time motions. In this study, we developed a home-based guidance training system for stroke survivors, enabling to provide the RGB-depth sensor to capture 25 artificial anatomical landmarks to reconstruct the body skeleton and real-time visual feedback on users' body segment movements and joint angles during training.

The purpose of this study was to investigate the improvement in motor performance for stroke survivors with moderate to severe motor impairment after 800 min of training using the home-based guidance training system with interactive visual feedback. With the technology of depth sensors, home-based training with computer-guided motion guidance in real-time may help users improve motor performance with minimal therapist assistance, which can greatly enhance the flexibility to facilitate their training time schedule.

Bottom-up versus Top-down designed rehabilitation sessions in chronic stroke survivors: a pilot randomized controlled trial

 Nothing here tells me what protocols are used in bottom-up vs. top-down. So totally useless in survivors telling their stroke medical 'professionals' how to treat them. USELESS!

Bottom-up versus Top-down designed rehabilitation sessions in chronic stroke survivors: a pilot randomized controlled trial

Mahnaz Hejazi-Shirmard

,

Ghorban Taghizadeh

,

Mehdi Rassafiani

,

Moslem Cheraghifard

,

Mahin Yousefi

,

Seyed Hossein Hosseini

, show all

Received 29 Aug 2023, Accepted 14 Jul 2024, Published online: 30 Jul 2024

• Cite this article
• https://doi.org/10.1080/09638288.2024.2384622
• CrossMark

 

Abstract

Purpose

The present study aimed to compare the effectiveness of Top-down and Bottom-up approaches on levels of the International Classification of Functioning, Disability and Health Framework (ICF), including impairments, activities, and participation.

Materials and methods

Thirty-nine chronic stroke survivors were recruited for this single-blinded randomized clinical trial. Participants were assigned to Top-down, Bottom-up interventions, or control group, and received a 6-week intervention. They were assessed before/after treatments and at follow-up (6 weeks later). Impairments were measured through kinematic analysis, Trail Making Tests (TMT), and Fugl-Meyer Assessment (FMA). Activity and participation were evaluated via Box and Block Test, Motor Activity Log (MAL), and Canadian Occupational Performance Measure (COPM), respectively.

Results

We found significant improvements in impairment (FMA) and participation (COPM) in all groups, however, COPM scores improved beyond the MCID only in the Top-down, and FMA scores exceeded the MCID in Top-down and Bottom-up groups. Use of the upper limb in daily activities (MAL) enhanced in the Top-down group, although was not clinically significant.

Conclusion

In most of the outcome measures, no significant difference was observed between groups. It seems that Top-down, Bottom-up, and traditional interventions have relatively comparable effectiveness in chronic stroke survivors.

Trial Registration

IRCT20150721023277N2

IMPLICATIONS FOR REHABILITATION

• Sensory-motor, cognitive, and psychological impairments are the most common consequences of stroke that lead to activity limitations and participation restrictions in stroke survivors.

• There are various rehabilitation approaches for stroke survivors.

• Some rehabilitation approaches address underlying impairments (Bottom-up), while others focus on enhancing individuals’ ability to participate in meaningful roles (Top-down).

• Top-down, Bottom-up, and traditional interventions seem to have relatively comparable effectiveness in chronic stroke survivors, and occupational therapists should use their clinical reasoning to select the most appropriate approach for each client.

The effect of balance and gait training on specific balance abilities of survivors with stroke: a systematic review and network meta-analysis

If  virtual reality gait training was the best, where is the protocol located so all 10 million yearly stroke survivors can easily find it?  Top-down does not work, it's easy to prove hospitals and doctors do not read and implement stroke research.

The effect of balance and gait training on specific balance abilities of survivors with stroke: a systematic review and network meta-analysis

Meng Zhang¹ Zhide Liang² Yali Li¹ Jun Meng³ Xu Jiang¹ Bichan Xu¹ Haojie Li^3* Tao Liu^4*

• ¹Postgraduate Department, Xi’an Physical Education University, Xi’an, China
• ²School of Physical Education, Qingdao University, Qingdao, China
• ³School of Physical Education, Gunagxi Minzu Normal University, Chongzuo, China
• ⁴School of Exercise and Health Sciences, Xi’an Physical Education University, Xi’an, China

Background: Stroke, which is a common clinical cerebrovascular disease, causes approximately 83% of survivors to suffer from balance impairments. Balance and gait training (BGT) is widely used to restore balance in patients with stroke. However, its wide variety presents clinicians with a dilemma when selecting interventions. This study aimed to compare and rank BGT interventions by quantifying information based on randomized controlled trials (RCTs).

Methods: We conducted a network meta-analysis (NMA) of non-gait-trained controls and head-to-head RCTs and compared the effects of 12 BGT interventions. A total of nine literature databases, including Medline, Embase, Cochrane Library, Web of Science, Scopus, SPORTDiscus, ClinicalTrials.gov, CNKI, and Chinese biomedical literature databases, were searched from their database inception to August 2023. Two authors independently selected studies and extracted data. The difference in outcomes, which were expressed as standardized mean differences and confidence intervals (CIs) of 95%, were explored in this meta-analysis.

Results: A total of 66 studies with 1,933 participants were included. Effect size estimates showed that not all BGT interventions were more effective than controls, with treadmill training as the least effective for balance test batteries (SMD = −0.41, 95% CI [−1.09, 0.27]) and proactive balance (SMD = −0.50, 95% CI [−1.14, 0.14]). Body-weight-supported treadmill training with external stimulation was most effective for proactive balance and dynamic steady-state balance (SMD = 1.57, 95% CI [−0.03, 3.16]); SMD = 1.18, 95% CI [0.67, 1.68]. Virtual reality gait training (SMD = 1.37, 95% CI [0.62, 2.11]) had the best effect on improving balance test batteries, while dual-task BGT (SMD = 1.64, 95% CI [0.50, 2.78]) had the best effect on static steady-state balance. After analyses for possible impact covariates, the findings through the outcomes did not change substantially. Confidence in the evidence was generally low or very low.

Conclusion: This NMA suggested that virtual reality gait training was the most effective BGT modality for improving balance test batteries. Body-weight support treadmill training with external stimulation was the most effective for improving active and dynamic balance. In addition, dual-task BGT was the best choice for improving static balance. However, balance is a multidimensional concept, and patients’ different needs should be considered when selecting BGT.

Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022316057, ID: CRD42022316057.

Use of Rehab Therapy Poststroke Low in the United States

Since there is nothing out there with 100% recovery protocols even those that get rehab don't get recovered. With a publicly available database of rehab protocols survivors could take them to their therapists to get them recovered.  The top down approach of doctors and therapists deciding on what therapy to provide is wrong. Survivors want to control rehab since they know what they want to recover.

Use of Rehab Therapy Poststroke Low in the United States

Use of rehabilitative therapy within a year of stroke is low. Among 510 patients with acute stroke, 35.0% received no physical therapy, 48.8% received no occupational therapy, and 61.7% received no speech therapy. Severity of clinical factors, and not demographic factors, predicted rehab dosage.

Ipsilateral Motor Pathways and Transcallosal Inhibition During Lower Limb Movement After Stroke

I have absolutely no clue what this says so there is no way I can tell my doctor and therapists what is needed to be done to get me recovered. The top-down approach to stroke rehab is a complete failure, only 10% almost fully recover. Bottom up, where survivors specify the protocols they want used to recover would work much much better.  They would be invested in their recovery, right now with guidelines they are just a bystander.

Ipsilateral Motor Pathways and Transcallosal Inhibition During Lower Limb Movement After Stroke

Brice T. Cleland PhD, Sangeetha Madhavan, PT, PhD

First Published March 11, 2021 Research Article 

https://doi.org/10.1177/1545968321999049

Article information

 

Abstract

Background

Stroke rehabilitation may be improved with a better understanding of the contribution of ipsilateral motor pathways to the paretic limb and alterations in transcallosal inhibition. Few studies have evaluated these factors during dynamic, bilateral lower limb movements, and it is unclear whether they relate to functional outcomes.

Objective

Determine if lower limb ipsilateral excitability and transcallosal inhibition after stroke depend on target limb, task, or number of limbs involved, and whether these factors are related to clinical measures.

Methods

In 29 individuals with stroke, ipsilateral and contralateral responses to transcranial magnetic stimulation were measured in the paretic and nonparetic tibialis anterior during dynamic (unilateral or bilateral ankle dorsiflexion/plantarflexion) and isometric (unilateral dorsiflexion) conditions. Relative ipsilateral excitability and transcallosal inhibition were assessed. Fugl-Meyer, ankle movement accuracy, and walking characteristics were assessed.

Results

Relative ipsilateral excitability was greater during dynamic than isometric conditions in the paretic limb (P ≤ .02) and greater in the paretic than the nonparetic limb during dynamic conditions (P ≤ .004). Transcallosal inhibition was greater in the ipsilesional than contralesional hemisphere (P = .002) and during dynamic than isometric conditions (P = .03). Greater ipsilesional transcallosal inhibition was correlated with better ankle movement accuracy (R² = 0.18, P = .04). Greater contralateral excitability to the nonparetic limb was correlated with improved walking symmetry (R² = 0.19, P = .03).

Conclusions

Ipsilateral pathways have increased excitability to the paretic limb, particularly during dynamic tasks. Transcallosal inhibition is greater in the ipsilesional than contralesional hemisphere and during dynamic than isometric tasks. Ipsilateral pathways and transcallosal inhibition may influence walking asymmetry and ankle movement accuracy.

Keywords lower extremity, neural pathways, neuroplasticity, stroke

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