Abstract. BACKGROUND:Neurorehabilitation technologies such as robot therapy (RT) and transcranial Direct Current Stimulation (tDCS) can promote upper limb (UL) motor recovery after stroke. OBJECTIVE: To explore the effect of anodal tDCS with uni-lateral and three-dimensional RT for the impaired UL in people with sub-acute and chronic stroke. METHODS: A pilot randomised controlled trial was conducted. Stroke participants had 18 one-hour sessions of RT (Armeo ® Spring) over eight weeks during which they received 20 minutes of either real tDCS or sham tDCS during each session. The primary outcome measure was the Fugl-Meyer assessment (FMA) for UL impairments and secondary were: UL function, activities and stroke impact collected at baseline, post-intervention and three-month follow-up. RESULTS: 22 participants (12 sub-acute and 10 chronic) completed the trial. No significant difference was found in FMA between the real and sham tDCS groups at post-intervention and follow-up (p = 0.123). A significant 'time' x 'stage of stroke' was found for FMA (p = 0.016). A higher percentage improvement was noted in UL function, activities and stroke impact in people with sub-acute compared to chronic stroke. CONCLUSIONS: Adding tDCS did not result in an additional effect on UL impairment in stroke. RT may be of more benefit in the sub-acute than chronic phase.

h i g h l i g h t stDCS and rehabilitation had small non-significant effect on upper extremity impairments. Varied tDCS and rehabilitation programmes were identified in selected studies. Future research needs to further analyse tDCS and therapy interventions in stroke. a b s t r a c tObjective: To systematically review the methodology in particular treatment options and outcomes and the effect of multiple sessions of transcranial direct current stimulation (tDCS) with rehabilitation programmes for upper extremity recovery post stroke. Methods: A search was conducted for randomised controlled trials involving tDCS and rehabilitation for the upper extremity in stroke. Quality of included studies was analysed using the Modified Downs and Black form. The extent of, and effect of variation in treatment parameters such as anodal, cathodal and bi-hemispheric tDCS on upper extremity outcome measures of impairment and activity were analysed using meta-analysis. Results: Nine studies (371 participants with acute, sub-acute and chronic stroke) were included. Different methodologies of tDCS and upper extremity intervention, outcome measures and timing of assessments were identified. Real tDCS combined with rehabilitation had a small non-significant effect of +0.11 (p = 0.44) and +0.24 (p = 0.11) on upper extremity impairments and activities at post-intervention respectively. Conclusion: Various tDCS methods have been used in stroke rehabilitation. The evidence so far is not statistically significant, but is suggestive of, at best, a small beneficial effect on upper extremity impairment. Significance: Future research should focus on which patients and rehabilitation programmes are likely to respond to different tDCS regimes.

Background: Neurorehabilitation technologies used mainly in research such as robot therapy (RT) and transcranial direct current stimulation (tDCS) can promote upper limb motor recovery after stroke. Understanding the feasibility and efficacy of stroke rehabilitation technologies for upper limb impairments is crucial for effective implementation in practice. Small studies have explored views of RT by people with stroke; however experiences of people receiving tDCS in combination with RT have never been explored. Objective: To explore views and experiences of people with sub-acute and chronic stroke that had previously taken part in a randomised controlled trial involving tDCS and RT for their impaired upper limb. Methods: An interview study including a mixed method approach of open and closed questions. Face-to-face interviews were audio recorded. Open-ended question responses were transcribed and analyzed using thematic analysis; closed questions were analyzed using descriptive analysis. Results: Participants felt that RT was enjoyable (90%) and beneficial for their affected arm (100%). From the open question data, it was found that the intervention was effective for the impaired arm especially in the sub-acute stage. Main reported concerns were that tDCS caused painful, itching and burning sensations and RT was sometimes tiring and difficult. Participants recommended that future research should focus on designing a more comfortable method of tDCS and develop a robot that promotes hand movements. Conclusions: This study provides new knowledge about the benefits and barriers associated with these technologies are crucial to the future effective implementation of these tools in practice.

In our chronic sample, one in five patients showed good upper limb observed but low perceived function. Measuring both observed and perceived arm and hand function seems warranted together with considering a differential therapy approach for the distinct groups. Implications for rehabilitation A considerable group of patients in the chronic phase post-stroke have good motor function in their affected upper limb, but nevertheless perceive a restricted ability. In order to identify a mismatch in people with chronic stroke, both observed and perceived upper limb motor function should be assessed. Besides common measurement tools for observed function like the Fugl-Meyer Assessment, perceived function can be evaluated by means of the hand function section of the Stroke Impact Scale. For patients with good observed but low perceived function, an additional rehabilitation strategy should be considered, potentially including awareness of ability and a self-efficacy approach.

Objective: To determine the predictive markers for the occurrence of upper limb spasticity in the first 12 months after stroke. Data Sources: A systematic review was undertaken of the databases MEDLINE, EMBASE, CINAHL and PEDRO to 31st December 2017.Study Selection: Non-experimental or experimental studies that included a control group with spasticity who did not receive an experimental intervention which investigated at least one variable (explanatory variable) measured at baseline against the development (or not) of spasticity at a future time point within 12 months post-stroke were selected independently by two reviewers. Eleven papers met the selection criteria.Study Appraisal: Data were extracted into tabular format using predefined data fields by two reviewers. Study quality was evaluated using the modified Downs and Black tool. Data were analysed using a meta-analysis or narrative review. Results: Ten studies, including 858 participants were analysed. The predictive markers of upper limb spasticity at one month post-stroke were: motor 11.25 (odds ratio, OR); [95% CI:2.48, 51.04] and sensory impairments 4.91 (OR); [1.24,19.46]; haemorrhagic stroke 3.70 (OR); [1.05, 12.98] and age 0.01 (OR) [0.00, 69.89]. Only motor impairment was found as a significant predictor at six months post-stroke 30.68 (OR); [1.60, 587.06].Limitations: Low number of studies exploring biomechanical and neurophysiological in addition to clinical predictors of spasticity were included. Conclusion and implications of key findings:Using the results, the identified predictive markers have potential to better inform clinical decision-making and to plan specific rehabilitation interventions by physiotherapists for stroke survivors with upper limb spasticity.

BackgroundThe role of somatosensory feedback in motor performance has been warranted in the literature. Although sensorimotor deficits are common after stroke, current rehabilitation approaches primarily focus on restoring upper limb motor ability. Evidence for integrative sensorimotor rehabilitation approaches is scarce, as is knowledge about neural correlates of somatosensory impairments after stroke and the effect of rehabilitation on brain connectivity level. Therefore, we aim to investigate changes in sensorimotor function and brain connectivity following a sensorimotor therapy program compared to an attention-matched motor therapy program for the upper limb after stroke.MethodsAn assessor-blinded randomized controlled trial will be conducted. Sixty inpatient rehabilitation patients up to eight weeks after stroke will be included. Patients will be randomized to either an experimental group receiving sensorimotor therapy or a control group receiving attention-matched motor therapy for the upper limb, with both groups receiving conventional therapy. Thus, all patients will receive extra therapy, a total of 16 1-h sessions over four weeks. Patients will be assessed at baseline, after four weeks of training, and after four weeks of follow-up. Primary outcome measure is the Action Research Arm Test. Secondary outcome measures will consist of somatosensory, motor and cognitive assessments, and a standardized resting-state functional magnetic resonance imaging protocol.DiscussionThe integration of sensory and motor rehabilitation into one therapy model might provide the added value of this therapy to improve sensorimotor performance post stroke. Insight in the behavioral and brain connectivity changes post therapy will lead to a better understanding of working mechanisms of therapy and will provide new knowledge for patient-tailored therapy approaches.Trial registrationClinicalTrials.gov, NCT03236376. Registered on 8 August 2017.Electronic supplementary materialThe online version of this article (10.1186/s13063-018-2609-4) contains supplementary material, which is available to authorized users.

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Alterations in neural activity by means of EEG and MEG are demonstrated from the early post-stroke stage onwards, and related to sensorimotor upper limb impairment. Future work exploring cortical oscillatory signals in the acute stage could provide further insight about prediction of upper limb sensorimotor recovery.