Task-related circuit training improves performance of locomotor tasks in chronic stroke: a randomized, controlled pilot trial. Bilateral and unilateral movement training on upper limb function in chronic stroke patients: A TMS study. Effects of constraint-induced therapy versus bilateral arm training on motor performance, daily functions, and quality of life in stroke survivors. Effectiveness of sensory and motor rehabilitation of the upper limb following the principles of neuroplasticity: patients stable poststroke. Intensive sensorimotor arm training mediated by therapist or robot improves hemiparesis in patients with chronic stroke. Response to upper-limb robotics and functional neuromuscular stimulation following stroke. Upper-limb robot-assisted therapy in rehabilitation of acute stroke patients: focused review and results of new randomized controlled trial. The effects of bilateral arm training on motor control and functional performance in chronic stroke: a randomized controlled study. Additional task-related practice improves mobility and upper limb function early after stroke: a randomised controlled trial. Reduced skilfulness of arm motor behaviour among motor stroke patients with good clinical recovery: does it indicate reduced automaticity? Can it be improved by unilateral or bilateral training? A kinematic motion analysis study. Robotic-assisted rehabilitation of the upper limb after acute stroke. A comparison of bilateral and unilateral upper-limb task training in early poststroke rehabilitation: a randomized controlled trial. Effectiveness of unilateral and symmetrical bilateral task training for arm during the subacute phase after stroke: a randomized controlled trial.
To evaluate the immediate and retention effects of a 4-week training program on the performance of locomotor-related tasks in chronic stroke.
                Randomized, controlled pilot study with 2-month follow-up.
                Rehabilitation center.
                A convenience sample consisting of 12 chronic stroke subjects was used. Subjects were randomly assigned to the experimental or the control group. Three subjects withdrew from the study.
                Both experimental and control groups participated in exercise classes three times a week for 4 weeks. The exercise class for the experimental group focused on strengthening the affected lower limb and practicing functional tasks involving the lower limbs, while the control group practiced upper-limb tasks.
                Lower-limb function was evaluated by measuring walking speed and endurance, peak vertical ground reaction force through the affected foot during sit-to-stand, and the step test.
                The experimental group demonstrated significant immediate and retained (2-month follow-up) improvement (p < or = .05) compared with the control group in walking speed and endurance, force production through the affected leg during sit-to-stand, and the number of repetitions of the step test.
                The pilot study provides evidence for the efficacy of a task-related circuit class at improving locomotor function in chronic stroke. The use of activity-dependent interventions has shown some success in promoting recovery of upper limb function in chronic stroke patients. This study compared the neurophysiological and behavioural changes associated with two such rehabilitation protocols: unilateral and bilateral movement training. Twelve chronic stroke patients were randomly assigned to the two training protocols involving six daily practice sessions. Each session consisted of 50 trials of a dowel placement task performed either with both impaired and unimpaired arm moving synchronously (bilateral training group) or with only the impaired arm moving (unilateral training). Kinematic measurements of upper limb movements were made in four unilateral test trials performed prior to and following each practice session. Functional assessments of the impaired upper limb and neurophysiological assessments, using transcranial magnetic stimulation (TMS), of the affected and non-affected cortical hemispheres were made prior to and following the intervention sessions. Individuals receiving bilateral training showed a reduction in movement time of the impaired limb and increased upper limb functional ability compared to individuals receiving unilateral training. In some patients changes to upper limb function were associated with changes to the cortical representation of a target muscle in the non-affected hemisphere. Overall, these findings suggest that a short-term bilateral training intervention may be effective in facilitating upper limb motor function in chronic stroke patients. This study investigated the relative effects of distributed constraint-induced therapy (CIT) and bilateral arm training (BAT) on motor performance, daily function, functional use of the affected arm, and quality of life in patients with hemiparetic stroke.
                A total of 60 patients were randomized to distributed CIT, BAT, or a control intervention of less specific but active therapy. Each group received intensive training for 2 hours/day, 5 days/week, for 3 weeks. Pretreatment and posttreatment measures included the Fugl-Meyer Assessment (FMA), Functional Independence Measure (FIM), Motor Activity Log (MAL), and Stroke Impact Scale (SIS). The proximal and distal scores of FMA were used to examine separate upper limb (UL) elements of movement.
                The distributed CIT and BAT groups showed better performance in the overall and the distal part score of the FMA than the control group. The BAT group exhibited greater gains in the proximal part score of the FMA than the distributed CIT and control groups. Enhanced performance was found for the distributed CIT group in the MAL, the subtest of locomotion in the FIM, and certain domains of the SIS (eg, ADL/IADL).
                BAT may uniquely improve proximal UL motor impairment. In contrast, distributed CIT may produce greater functional gains for the affected UL in subjects with mild to moderate chronic hemiparesis. Based on the principles of neuroplasticity, the purpose of this crossover study was to determine if improvement in upper extremity (UE) function and independence could be achieved in patients 6 months to 7 years poststroke following an outpatient rehabilitation program (supervised 1.5 hours per week for 8 weeks reinforced with home gloving unaffected side and attended, graded, repetitive sensory and motor training activities). Twenty-one subjects (right or left hemiparesis; able to walk 100 feet with or without a cane; partially opened and closed the hand; partially elevated the shoulder and elbow against gravity) were randomly assigned to Group A (sensory training 4 weeks, motor training 4 weeks) or Group B (motor training 4 weeks, sensory training 4 weeks). Greater than 20% (P < 0.01) improvement was measured in functional independence and UE function (fine motor, sensory discrimination, and musculoskeletal performance). Gains were hemispheric and training specific and maintained over 3 months. This study provides evidence documenting significant improvement in function in the late poststroke recovery period following 12 hours of supervised learning based sensory motor training. Investigators have demonstrated that a variety of intensive movement training protocols for persistent upper limb paralysis in patients with chronic stroke (6 months or more after stroke) improve motor outcome. This randomized controlled study determined in patients with upper limb motor impairment after chronic stroke whether movement therapy delivered by a robot or by a therapist using an intensive training protocol was superior. Robotic training (n = 11) and an intensive movement protocol (n = 10) improved the impairment measures of motor outcome significantly and comparably; there were no significant changes in disability measures. Motor gains were maintained at the 3-month evaluation after training. These data contribute to the growing awareness that persistent impairments in those with chronic stroke may not reflect exhausted capacity for improvement. These new protocols, rendered by either therapist or robot, can be standardized, tested, and replicated, and potentially will contribute to rational activity-based programs. Twelve moderately to severely involved chronic stroke survivors (>12 mo) were randomized to one of two treatments: robotics and motor learning (ROB-ML) or functional neuromuscular stimulation and motor learning (FNS-ML). Treatment was 5 h/d, 5 d/wk for 12 wk. ROB-ML group had 1.5 h per session devoted to robotics shoulder and elbow (S/E) training. FNS-ML had 1.5 h per session devoted to functional neuromuscular stimulation (surface electrodes) for wrist and hand (W/H) flexors/extensors. The primary outcome measure was the functional measure Arm Motor Ability Test (AMAT). Secondary measures were AMAT-S/E and AMAT-W/H, Fugl-Meyer (FM) upper-limb coordination, and the motor control measures of target accuracy (TA) and smoothness of movement (SM). ROB-ML produced significant gains in AMAT, AMAT-S/E, FM upper-limb coordination, TA, and SM. FNS-ML produced significant gains in AMAT-W/H and FM upper-limb coordination. The successful motor rehabilitation of stroke patients requires early intensive and task-specific therapy. A recent Cochrane Review, although based on a limited number of randomized controlled trials (RCTs), showed that early robotic training of the upper limb (i.e., during acute or subacute phase) can enhance motor learning and improve functional abilities more than chronic-phase training. In this article, a new subacute-phase RCT with the Neuro-Rehabilitation-roBot (NeReBot) is presented. While in our first study we used the NeReBot in addition to conventional therapy, in this new trial we used the same device in substitution of standard proximal upper-limb rehabilitation. With this protocol, robot patients achieved similar reductions in motor impairment and enhancements in paretic upper-limb function to those gained by patients in a control group. By analyzing these results and those of previous studies, we hypothesize a new robotic protocol for acute and subacute stroke patients based on both treatment modalities (in addition and in substitution). Most studies of bilateral arm training (BAT) did not employ a randomized controlled trial design and involved very limited functional training tasks.
                Compare the effects of BAT with control intervention (CI) on motor control and motor performance of the upper extremity and also functional gains in patients with chronic stroke.
                . This 2-group randomized controlled trial with pretreatment and posttreatment measures enrolled 33 stroke patients (mean age = 53.85 years) 6 to 67 months after onset of a first stroke. They received either a BAT program concentrating on both upper extremities moving simultaneously in functional tasks by symmetric patterns or CI (control treatment) for 2 hours on weekdays for 3 weeks. Outcome measures included kinematic analyses assessing motor control strategies for unilateral and bimanual reaching and clinical measures involving the Fugl-Meyer Assessment (FMA) of motor-impairment severity and the Functional Independence Measure (FIM) and the Motor Activity Log (MAL) evaluating functional ability.
                After treatment, the BAT group showed better temporal and spatial efficiency during unilateral and bilateral tasks and less online error correction only during the bilateral task than the control group. The BAT group showed a significantly greater improvement in the FMA than the control group but not in the FIM and MAL.
                Relative to CI, BAT improved the spatiotemporal control of the affected arm in both bilateral and unilateral tasks, decreased online corrections to perform bilateral tasks, and reduced motor impairment. These findings support the use of BAT to improve motor control and motor function of the affected upper limb in stroke patients. The purpose of this study was to investigate whether additional practice of either upper limb or mobility tasks improved functional outcome during inpatient stroke rehabilitation. This prospective, randomised, single blind clinical trial recruited 30 stroke subjects into either an Upper Limb or a Mobility Group. All subjects received their usual rehabilitation and an additional session of task-related practice using a circuit class format. Independent assessors, blinded to group allocation, tested all subjects. Outcome measures used were three items of the Jebsen Taylor Hand Function Test (JTHFT), two arm items of the Motor Assessment Scale (MAS), and three mobility measures, the Timed Up and Go Test (TUGT), Step Test, and Six Minute Walk Test (6MWT). Both groups improved significantly between pre- and post-tests on all of the mobility measures, however only the Upper Limb Group made a significant improvement on the JTHFT and MAS upper arm items. Following four weeks training, the Mobility Group had better locomotor ability than the Upper Limb Group (between-group differences in the 6MWT of 116.4 m, 95% CI 31.4 to 201.3 m, Step Test 2.6 repetitions, 95% CI -1.0 to 6.2 repetitions, and TUGT -7.6 sec, 95% CI -15.5 to 0.2 sec). The JTHFT dexterity scores in the Upper Limb Group were 6.5 sec (95% CI -7.4 to 20.4 sec) faster than the Mobility Group. Our findings support the use of additional task-related practice during inpatient stroke rehabilitation. The circuit class format was a practical and effective means to provide supervised additional practice that led to significant and meaningful functional gains. Functional cortical reorganisation had been demonstrated to accompany recovery from motor stroke. In agreement with a previous study, quantitative kinematic analysis of aimed movements in 14 almost completely recovered hemiparetic stroke patients and 14 healthy control subjects indicated a reduced skilfulness of both the more ballistic initial movement phase and the more feedback-guided late homing-in phase of aimed movements. By means of two dual motor tasks it was further investigated whether the reduced skilfulness of patients was due to an increased attentional demand and thus a reduced automaticity of motor control. Interference effects by dual tasks, however, were similar for patients and control subjects. Thus, the notion of reduced automaticity could not be supported empirically, and reduced skilfulness seemed rather related to residual pyramidal motor deficits. By means of a repetitive daily training for 1 week based on the Arm Ability Training approach, patients were able to reduce their performance deficits in both movement phases significantly. Whether patients practised with the affected arm or simultaneously with both the affected and non-affected arm only marginally modified outcome, unilateral training being slightly more efficacious. These findings demonstrate that even clinically minor residual motor deficits can be improved by a structured training for the affected arm. To investigate whether early therapy with a novel robotic device can reduce motor impairment and enhance functional recovery of poststroke patients with hemiparetic and hemiplegic upper limb.
                A single-blind randomized controlled trial, with an 8-month follow-up.
                Neurologic department and rehabilitation hospital.
                Thirty-five patients with acute (< or =1 wk of onset), unilateral, ischemic embolic, or thrombotic stroke.
                Patients of both groups received the same dose and length per day of standard poststroke multidisciplinary rehabilitation. Patients were randomly assigned to 2 groups. The experimental group (n=17) received additional early sensorimotor robotic training, 4 hours a week for 5 weeks; the control group (n=18) was exposed to the robotic device, 30 minutes a week, twice a week, but the exercises were performed with the unimpaired upper limb. Training by robot consisted of peripheral manipulation of the shoulder and elbow of the impaired limb, correlated with visual stimuli.
                The Fugl-Meyer Assessment (FMA) of upper-extremity function (shoulder/elbow and coordination and wrist/hand subsections) to measure each trained limb segment; the Medical Research Council (MRC) score to measure the strength of muscle force during 3 actions: shoulder abduction (MRC deltoid), elbow flexion (MRC biceps), and wrist flexion (MRC wrist flexors); the FIM instrument and its motor component; and the Trunk Control Test (TCT) and Modified Ashworth Scale (MAS).
                Compared with the patients in the control group, the experimental group showed significant gains in motor impairment and functional recovery of the upper limb after robot therapy, as measured by the MRC deltoid (P< or =.05) and biceps (P<.05) scores, the FMA for the proximal upper arm (P<.05), the FIM instrument (P<.05), and the FIM motor score (P<.01); these gains were also sustained at the 3- and 8-month follow-up. The FMA and MRC wrist flexor test findings did not differ statistically either at the end of training or at the follow-up sessions. We found no significant differences in MAS and TCT in either group in any of the evaluations. No adverse effects occurred and the robotic approach was very well accepted.
                Patients who received robotic therapy in addition to conventional therapy showed greater reductions in motor impairment and improvements in functional abilities. Robotic therapy may therefore effectively complement standard rehabilitation from the start, by providing therapeutic support for patients with poststroke plegic and paretic upper limb. To compare the effects of bilateral task training with unilateral task training on upper-limb outcomes in early poststroke rehabilitation.
                A single-blinded randomized controlled trial, with outcome assessments at baseline, postintervention (6 wk), and follow-up (18 wk).
                Inpatient acute and rehabilitation hospitals.
                Patients were randomized to receive bilateral training (n=56) or unilateral training (n=50) at 2 to 4 weeks poststroke onset.
                Supervised bilateral or unilateral training for 20 minutes on weekdays over 6 weeks using a standardized program.
                Upper-limb outcomes were assessed by Action Research Arm Test (ARAT), Rivermead Motor Assessment upper-limb scale, and Nine-Hole Peg Test (9HPT). Secondary measures included the Modified Barthel Index, Hospital Anxiety and Depression Scale, and Nottingham Health Profile. All assessment was conducted by a blinded assessor.
                No significant differences were found in short-term improvement (0-6 wk) on any measure (P>.05). For overall improvement (0-18 wk), the only significant between-group difference was a change in the 9HPT (95% confidence interval [CI], 0.0-0.1; P=.05) and ARAT pinch section (95% CI, 0.3-5.6; P=.03), which was lower for the bilateral training group. Baseline severity significantly influenced improvement in all upper-limb outcomes (P<.05), but this was irrespective of the treatment group.
                Bilateral training was no more effective than unilateral training, and in terms of overall improvement in dexterity, the bilateral training group improved significantly less. Intervention timing, task characteristics, dose, and intensity of training may have influenced the results and are therefore areas for future investigation. To evaluate the effect of an arm training programme combining repetition of unilateral and symmetrical bilateral tasks for people in the subacute phase after stroke.
                Randomized controlled trial.
                Inpatient functional rehabilitation unit.
                Forty-one people who had had a stroke, in the subacute phase, receiving conventional arm occupational and physical therapy, were randomized to an experimental group (n=20) and a control group (n=21).
                In addition to the usual arm therapy in the rehabilitation unit, the experimental group received an arm therapy programme (15-20 45-min sessions) based on repetition of unilateral and symmetrical bilateral tasks. The control group received additional usual arm therapy of a similar duration and frequency to the experimental treatment.
                The effect of the programme was judged on the basis of: (1) arm impairments (motor function, grip strength, gross and fine manual dexterity and motor co-ordination), (2) arm disabilities in tasks related to daily activities, and (3) functional independence in activities of daily living (ADL) and instrumental ADL (IADL).
                Although both experimental and control groups of participants improved similarly during the study period, the statistical analyses did not show any difference between the groups at the end of the treatment for the different dependent variables evaluated: (1) arm impairments: p = 0.43-0.79; (2) arm disabilities: p = 0.16-0.90; and (3) functional independence: p = 0.63 and 0.90.
                An arm training programme based on repetition of unilateral and symmetrical bilateral practice did not reduce impairment and disabilities nor improve functional outcomes in the subacute phase after stroke more than the usual therapy.
Repetitive task training resulted in modest improvement in lower limb function, but not upper limb function. Training may be sufficient to impact on daily living function. However, there is no evidence that improvements are sustained once training has ended. The review potentially investigates task specificity rather more than repetition. Further research should focus on the type and amount of training, and how to maintain functional gain.