Abstract-We systematically reviewed and analyzed the literature to find randomized controlled trials (RCTs) that employed robotic devices in upper-limb rehabilitation of people with stroke. Out of 574 studies, 12 matching the selection criteria were found. The Fugl-Meyer, Functional Independence Measure, Motor Power Scale, and Motor Status Scale outcome measures from the selected RCTs were pooled together, and the corresponding effect sizes were estimated. We found that when the duration/intensity of conventional therapy (CT) is matched with that of the robot-assisted therapy (RT), no difference exists between the intensive CT and RT groups in terms of motor recovery, activities of daily living, strength, and motor control. However, depending on the stage of recovery, extra sessions of RT in addition to regular CT are more beneficial than regular CT alone in motor recovery of the hemiparetic shoulder and elbow of patients with stroke; gains are similar to those that have been observed in intensive CT.

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To characterize muscle synergy organization underlying multidirectional control of stance posture, electromyographic activity was recorded from 11 lower limb and trunk muscles of 7 healthy subjects while they were subjected to horizontal surface translations in 12 different, randomly presented directions. The latency and amplitude of muscle responses were quantified for each perturbation direction. Tuning curves for each muscle were examined to relate the amplitude of the muscle response to the direction of surface translation. The latencies of responses for the shank and thigh muscles were constant, regardless of perturbation direction. In contrast, the latencies for another thigh [tensor fascia latae (TFL)] and two trunk muscles [rectus abdominis (RAB) and erector spinae (ESP)] were either early or late, depending on the perturbation direction. These three muscles with direction-specific latencies may play different roles in postural control as prime movers or as stabilizers for different translation directions, depending on the timing of recruitment. Most muscle tuning curves were within one quadrant, having one direction of maximal activity, generally in response to diagonal surface translations. Two trunk muscles (RAB and ESP) and two lower limb muscles (semimembranosus and peroneus longus) had bipolar tuning curves, with two different directions of maximal activity, suggesting that these muscle can play different roles as part of different synergies, depending on translation direction. Muscle tuning curves tended to group into one of three regions in response to 12 different directions of perturbations. Two muscles [rectus femoris (RFM) and TFL] were maximally active in response to lateral surface translations. The remaining muscles clustered into one of two diagonal regions. The diagonal regions corresponded to the two primary directions of active horizontal force vector responses. Two muscles (RFM and adductor longus) were maximally active orthogonal to their predicted direction of maximal activity based on anatomic orientation. Some of the muscles in each of the synergic regions were not anatomic synergists, suggesting a complex central organization for recruitment of muscles. The results suggest that neither a simple reflex mechanism nor a fixed muscle synergy organization is adequate to explain the muscle activation patterns observed in this postural control task. Our results are consistent with a centrally mediated pattern of muscle latencies combined with peripheral influence on muscle magnitude. We suggest that a flexible continuum of muscle synergies that are modifiable in a task-dependent manner be used for equilibrium control in stance.

The sixth update of the Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Reintegration following Stroke. Part one: Rehabilitation and Recovery Following Stroke is a comprehensive set of evidence-based guidelines addressing issues surrounding impairments, activity limitations, and participation restrictions following stroke. Rehabilitation is a critical component of recovery, essential for helping patients to regain lost skills, relearn tasks, and regain independence. Following a stroke, many people typically require rehabilitation for persisting deficits related to hemiparesis, upper-limb dysfunction, pain, impaired balance, swallowing, and vision, neglect, and limitations with mobility, activities of daily living, and communication. This module addresses interventions related to these issues as well as the structure in which they are provided, since rehabilitation can be provided on an inpatient, outpatient, or community basis. These guidelines also recognize that rehabilitation needs of people with stroke may change over time and therefore intermittent reassessment is important. Recommendations are appropriate for use by all healthcare providers and system planners who organize and provide care to patients following stroke across a broad range of settings. Unlike the previous set of recommendations, in which pediatric stroke was included, this set of recommendations includes primarily adult rehabilitation, recognizing many of these therapies may be applicable in children. Recommendations related to community reintegration, which were previously included within this rehabilitation module, can now be found in the companion module, Rehabilitation, Recovery, and Community Participation following Stroke. Part Two: Transitions and Community Participation Following Stroke.

The performance of a maximal graded exercise test triggers only modest neuroplastic changes in patients with chronic stroke. However, a single bout of high-intensity interval training performed immediately after motor practice improves skill retention, which could potentially accelerate motor recovery in these individuals.

A virtual reality (VR)-based locomotor training system has been developed for gait rehabilitation post-stroke. The system consists of a self-paced treadmill mounted onto a 6-degrees-of-freedom motion platform. Virtual environments (VEs) that are synchronized with the speed of the treadmill and the motions of the platform are rear-projected onto a screen in front of the walking subject. A feasibility study was conducted to test the capability of two stroke patients and one healthy control to be trained with the system. Three VE scenarios (corridor walking, street crossing, and park stroll) were woven into a gait-training program that provided three levels of complexity (walking speed, slopes, collision avoidances), progression criteria (number of successful trials) and knowledge of results. Results show that, with practice, patients can effectively increase their gait speed as demanded by the task and adapt their gait with respect to the change in physical terrain. However, successful completion of tasks requiring adaptation to increasing demands related to speed and physical terrains does not necessarily predict the patient's ability to anticipate and avoid collision with obstacles during walking. This feasibility study demonstrates that persons with stroke are able to adapt to this novel VR system and be immersed in the VEs for gait training.

The effect of stance width on postural responses to 12 different directions of surface translations was examined. Postural responses were characterized by recording 11 lower limb and trunk muscles, body kinematics, and forces exerted under each foot of 7 healthy subjects while they were subjected to horizontal surface translations in 12 different, randomly presented directions. A quasi-static approach of force analysis was done, examining force integrals in three different epochs (background, passive, and active periods). The latency and amplitude of muscle responses were quantified for each direction, and muscle tuning curves were used to determine the spatial activation patterns for each muscle. The results demonstrate that the horizontal force constraint exerted at the ground was lessened in the wide, compared with narrow, stance for humans, a similar finding to that reported by Macpherson for cats. Despite more trunk displacement in narrow stance, there were no significant changes in body center of mass (CoM) displacement due to large changes in center of pressure (CoP), especially in response to lateral translations. Electromyographic (EMG) magnitude decreased for all directions in wide stance, particularly for the more proximal muscles, whereas latencies remained the same from narrow to wide stance. Equilibrium control in narrow stance was more of an active postural strategy that included regulating the loading/unloading of the limbs and the direction of horizontal force vectors. In wide stance, equilibrium control relied more on an increase in passive stiffness resulting from changes in limb geometry. The selective latency modulation of the proximal muscles with translation direction suggests that the trunk was being actively controlled in all directions. The similar EMG latencies for both narrow and wide stance, with modulation of only the muscle activation magnitude as stance width changed, suggest that the same postural synergy was only slightly modified for a change in stance width. Nevertheless, the magnitude of the trunk displacement, as well as of CoP displacement, was modified based on the degree of passive stiffness in the musculoskeletal system, which increased with stance width. The change from a more passive to an active horizontal force constraint, to larger EMG magnitudes especially in the trunk muscles and larger trunk and CoP excursions in narrow stance are consistent with a more effortful response for equilibrium control in narrow stance to perturbations in all directions.

Tango-dancing and walking programs are compared in nondemented seniors at risk for falls. Fallers (N = 30) age 62–91 were randomly assigned to a 10-wk (40 hr, 2 hr 2×/wk) tango class or walk group. The Activities-specific Balance Confidence (ABC) scale, sit-to-stand scores, and normal and fast walk were measured pre-, post-, and 1 month postintervention. Two-way repeated-measures ANOVAs indicated a significant main effect (p < .01) for time on all measures. Group and interaction effects for ABC led to improvement only in tango because of high baseline mean for the walk group. Clinical improvements measured using Established Populations for Epidemiologic Studies of the Elderly scoring were greater for the tango group. From these preliminary results it is suggested that although both interventions are effective activities for increasing strength and walk speed, tango might result in greater improvements than walking in balance skills and in walking speed in the 10-wk intervention. The study needs to be repeated with a greater sample size to determine the effectiveness of walking on fear of falling.