Neurorehabilitation and Neural Repair

BackgroundPediatric traumatic brain injury can lead to severe disability. Currently used standard clinical measures effectively capture secondary functional impairments, but do not measure neurologic impairment directly. ObjectiveEvaluate the feasibility of walking dynamic motor control (walk-DMC) assessments to more directly measure neurological impairment and recovery for individuals post-traumatic brain injury. MethodsThe trajectory of walk-DMC and standard clinical measures of balance, mobility, and function were assessed in a cohort of individuals post-traumatic brain injury. Measures were collected throughout participants inpatient rehabilitation stay and at short- and long-term follow-up assessments. ResultsFour pediatric participants with severe traumatic brain injury enrolled. All participants demonstrated substantial neurological impairment at enrollment. All clinical measures showed an initial deficit followed by recovery, with most returning to nondisabled ranges over the study period for all participants. In contrast, walk-DMC scores demonstrated an initial acute deficit and did not reach nondisabled ranges for two of the participants, indicating persistent neurologic impairment. ConclusionWalk-DMC shows promise in its ability to identify subtle ongoing neurologic impairment compared to traditionally used clinical assessments of balance, mobility, and function. Further work in a larger cohort of participants with traumatic brain injury will improve understanding of how walking dynamic motor control changes with injury severity and where such a measure can serve as a leading indicator of neurologic and functional recovery.

Background and AimUnilateral spatial neglect (UN) impairs patients ability to detect and respond to stimuli on the contralesional side, severely limiting functional recovery after right-hemispheric stroke. Neck muscle vibration (NMV) has been shown as a bottom-up, proprioceptive intervention to modulate spatial neglect. Although preliminary studies found promising effects, the isolated efficacy of NMV for neglect rehabilitation has not yet been tested in a randomized, blinded controlled trial. This study aimed to evaluate whether NMV alone improves neglect symptoms and activities of daily living. MethodsTwenty patients with right-hemispheric stroke and UN were randomly assigned to receive either active or placebo NMV over two weeks (5 sessions/week). Both groups received 20-minute daily vibration sessions. Standard neglect therapy was withheld in the active group but administered in the placebo group. Assessments included standard neglect diagnostics (e.g., Letter Cancellation, Bells Test), the Free Exploration Test (FET), and two ADL-based measures (NET, CBS), conducted before, immediately after, and (for the NMV group) one month post-treatment. ResultsThe active NMV group showed significant improvements in three of four standard neglect tests, exploration behavior (FET), and ADL performance, with effects remaining stable at one-month follow-up. The placebo group showed comparable gains in ADL outcomes but improved in one standard neglect test only. Between-group analyses revealed no statistically significant differences, suggesting similar efficacy of both interventions. ConclusionNMV alone yields clinically meaningful and lasting improvements in neglect symptoms and daily functioning, comparable to standard active exploration therapy. Its passive nature makes it a promising tool, especially for early rehabilitation.

ObjectivesSpatial neglect, a debilitating cognitive syndrome and predictor of poor functional outcome, affects attention and awareness after stroke. Early rehabilitation is essential but neglect itself may impede participation in therapy. In a proof-of-concept study nested within an RCT, we investigated whether the oft-reported immediate effects of prism adaptation training (PAT) might enable engagement if introduced at the start of an occupational therapy session. MethodsEarly after stroke we video-recorded in-patients carrying out a standardised activity in their first RCT occupational therapy session, before and after PAT (or a control therapy activity). Level of engagement was later scored by a video-rater, experienced in therapy, blind to arm allocation (intervention/control) and whether randomly presented videos were recorded pre-or post-therapy. The rater recorded engagement scores on a 100mm visual analogue scale. Treating therapists also reported, on a 3-point Likert scale, whether or not engagement changed. Results49 of the RCTs 53 patients were recruited (37 PAT, 12 control), 43 of whom consented to be video-recorded. Regression analysis did not suggest improvement in engagement following one session of PAT, using the blinded expert video scoring method: mean difference (95% CI) = -0.5 (-7.4 to 6.4) mm; p=0.89). Similarly, post-hoc re-rating of engagement scores (the video-rater viewed paired pre- and post-therapy recordings but remained blind to arm allocation) excluded any material difference in engagement following PAT: mean difference (95% CI) = 1.2 (-2.5 to 4.9) mm; p=.52). Impressions of level of engagement provided by the treating occupational therapists also suggested no change: OR (95% CI) = 1.3 (0.13 to 13); p=0.81). ConclusionsDespite the need to enable neglect patients to engage in the therapy they are offered, we are confident that a single session of PAT at the start of a therapy session does not enhance immediate engagement in occupational therapy early after stroke. Our study does not address the alternative definition of engagement as a longitudinal, rapport-building process which could meaningfully be explored.

Background and AimsSleep is important for consolidation of motor learning, but brain injury may affect sleep continuity and therefore rehabilitation outcomes. This study aims to assess the relationship between sleep quality and motor recovery in brain injury patients receiving inpatient rehabilitation. Methods59 patients with brain injury were recruited from two specialist inpatient rehabilitation units. Sleep quality was assessed (up to 3 times) objectively using actigraphy (7 nights) and subjectively using the Sleep Condition Indicator. Motor outcome assessments included: Action Research Arm test (upper limb function), Fugl Meyer assessment (motor impairment) and the Rivermead Mobility Index. The functional independence measure (FIM) was assessed at admission and discharge by the clinical team. 55 age and gender matched healthy controls completed one assessment. ResultsInpatients demonstrated lower self-reported sleep quality (p<0.001) and more fragmented sleep (p<0.001) than controls. For inpatients, sleep fragmentation explained significant additional variance in motor outcomes, over and above that explained by admission FIM score (p<0.017), such that more disrupted sleep was associated with poorer motor outcomes. Using stepwise linear regression, sleep fragmentation was the only variable found to explain variance in rate of change in FIM (R2adj = 0.12, p = 0.03), whereby more disrupted sleep was associated with slower recovery. ConclusionsInpatients with brain injury demonstrate impaired sleep quality, and this is associated with poorer motor outcomes and slower functional recovery. Further investigation is needed to determine how sleep quality can be improved and whether this affects outcome.

ObjectiveAsymmetric walking after stroke is common, detrimental, and difficult to treat, but current knowledge of underlying physiological mechanisms is limited. This study investigated electromyographic (EMG) features of temporal gait asymmetry (TGA). MethodsParticipants post-stroke with or without TGA and control adults (n=27, 8, and 9, respectively) performed self-paced overground gait trials. EMG, force plate, and motion capture data were collected. Lower limb muscle activity was compared across groups and sides (more/less affected). Correlation between burst timing variables and asymmetry ratios was examined. ResultsSignificant group by side interaction effects were found: fewer TGA group dorsiflexor bursts during swing (p=.0009), more affected plantarflexor stance activity ended early (p=.0006) and less affected dorsiflexor on/off time was delayed (p<.01) in persons with asymmetry compared to symmetric and normative controls. Less affected side EMG timing correlated most with swing time ratio (r=0.68-0.90, p<.001). ConclusionsTemporal patterns of muscular activation, particularly about the ankle around the stance-to-swing transition period, are associated with TGA. The results may reflect specific impairments or compensations that affect locomotor coordination. SignificanceNeuromuscular underpinnings of spatiotemporal asymmetry have not been previously characterized. These novel findings may inform targeted therapeutic strategies to improve gait quality after stroke.

BackgroundPeople with stroke often have asymmetric motor impairment. Investigating asymmetries in, and dynamic properties of, centre of pressure movement during quiet standing can inform how well balance is controlled. Research questionWhat are the test-retest reliabilities of novel measures of quiet standing balance control in people with chronic stroke? MethodsTwenty people with chronic stroke (>6 months post-stroke), who were able to stand for at least 30 seconds without support, were recruited. Participants completed two 30-second quiet standing trials in a standardized position. Novel measures of quiet standing balance control included: symmetry of variability in centre of pressure displacement and velocity, between-limb synchronization, and sample entropy. Root mean square of centre of pressure displacement and velocity in the antero-posterior and medio-lateral directions were also calculated. Intraclass correlation coefficients (ICCs) were used to determine test-retest reliability, and Bland-Altman plots were created to examine proportional biases. ResultsICC3,2 were between 0.79 and 0.95 for all variables, indicating good to excellent reliability (>0.75). However, ICC3,1 for symmetry indices and between-limb synchronization were <0.75. Bland-Altman plots revealed possible proportional biases for root mean square of medio-lateral centre of pressure displacement and velocity and between-limb synchronization, with larger between-trial differences for participants with worse values. SignificanceThese findings suggest that centre of pressure measures extracted from a single 30-second quiet standing trial may have sufficient reliability for some research studies in chronic stroke. However, for clinical applications, the average of at least two trials may be required.

Post-stroke gait dysfunction is biomechanically heterogeneous, yet biomechanically-informed classifications of functional walking remain underdeveloped. In particular, there is a lack of clinically accessible methods for classifying gait deficits that account for propulsion impairments--a historically laboratory-dependent gait parameter requiring measurement with force plate systems. This study examined whether propulsion impairment can be classified by combining a global measure of walking function (i.e., the 10-meter walk test speed) with specific measures of dynamic walking ability derived from individual items of the Functional Gait Assessment (FGA). Forty participants >6 months poststroke completed biomechanical evaluations quantifying propulsion during walking and clinical assessments including the FGA. Multivariable stepwise regression identified the FGA items most strongly associated with paretic propulsion. Models augmented with these FGA items explained 10-14% greater variance in propulsion peak and 2-5% greater variance in propulsion impulse compared with models using walking speed alone. Incorporating FGA items also yielded the highest overall accuracy (72.5%) and per-class performance in propulsion severity classification. These findings establish the co-assessment of walking speed and targeted FGA items as a clinically-feasible approach to biomechanically-informed classification of post-stroke gait dysfunction.

BackgroundMild traumatic brain injury (mTBI) affects millions worldwide, with cognitive impairment substantially impacting daily functioning. Despite this burden, evidence-based non-pharmaceutical interventions remain lacking in clinical practice. Emerging evidence suggests aerobic exercise may improve post-mTBI cognition; however, the methodological limitations, particularly inadequate control groups, prevent definitive conclusions. ObjectiveThis pilot randomized controlled trial examined the feasibility and preliminary efficacy of a 12-week virtual exercise intervention for community-dwelling adults aged 18-55 years with mTBI within one year of injury. MethodsThirty-seven participants were randomized to either symptom-guided aerobic exercise or active balance control; both delivered virtually three times weekly for 30 minutes over 12 weeks. Primary outcomes assessed feasibility metrics; secondary outcomes examined cognitive function. ResultsOf enrolled participants, 75% completed the intervention with 94.2% session adherence and zero adverse events, demonstrating excellent feasibility and safety. The aerobic group demonstrated greater improvements in executive function compared to balance controls, with large effect sizes for TMT B-A difference scores in both post-intervention comparisons (Hedges g = 1.20, 95% CI [0.00, 2.41]) and Group x Time interactions (Hedges g = 1.38, 95% CI [0.27, 2.49]). Additionally, the aerobic group reported fewer sleep disturbances post intervention (g = 1.65, 95% CI [0.22, 3.09]). ConclusionThese findings establish that virtual, supervised, symptom-guided exercise interventions are feasible and safe for mTBI populations, with preliminary evidence suggesting aerobic exercise specifically benefits cognitive flexibility and sleep quality following mTBI. A fully powered randomized controlled trial is warranted to confirm these effects

BackgroundEvidence from animal studies suggests that greater reductions in post-stroke motor impairment can be attained with significantly higher doses and intensities of therapy focused on movement quality. These studies also indicate a dose-timing interaction, with more pronounced effects if high-intensity therapy is delivered in the acute/subacute, rather than chronic, post-stroke period. ObjectiveTo compare two approaches of delivering high-intensity, high-dose upper limb therapy in patients with subacute stroke: a novel exploratory neuro-animation therapy (NAT), and modified conventional occupational therapy (COT). MethodsTwenty-four patients were randomized to NAT or COT and underwent 30 sessions of 60 minutes time-on-task in addition to standard care. The primary outcome was the Fugl-Meyer Upper Extremity motor score (FM-UE). Secondary outcomes included: Action Research Arm Test (ARAT), grip strength, Stroke Impact Scale (SIS) hand domain, and upper-limb kinematics. Outcomes were assessed at baseline, and days 3, 90, and 180 post-training. Both groups were compared to a matched historical cohort (HC), which received only 30 minutes of upper limb therapy per day. ResultsThere were no significant between-group differences in FM-UE change or any of the secondary outcomes at any timepoint. Both high-dose groups showed greater recovery on the ARAT (7.3 {+/-}2.9 pts, p=0.011), but not the FM-UE (1.4 {+/-}2.6 pts, p =0.564) when compared to the HC. ConclusionsTwo forms of high-dose intensive upper limb therapy produced greater activity but not impairment improvements compared with regular care. Neuroanimation may offer a new enjoyable, efficient and scalable way to deliver increased upper limb therapy. Clinicaltrials.gov registration NCT02292251

This systematic review and meta-analysis primarily aimed to investigate the differential effectiveness of motor dual-task training (MDT) and cognitive dual-task training (CDT) on gait performance, balance control, and motor function in stroke survivors, and explored other important moderating factors such as stroke chronicity and individual functional profiles to inform a precision-based, personalized approach. Twenty-one RCTs involving 786 stroke survivors were included. Dual-task training demonstrated a medium overall beneficial effect on both temporal and spatial gait performance (SMD=0.50, p=0.03; SMD=0.5, p=0.04) and balance control (SMD=0.71, p=0.02), whereas no statistically significant improvement was observed in lower-extremity motor function. Subgroup analysis revealed that dual-task training modality was a critical determinant of treatment response. MDT was significantly superior for gait performance on both gait speed and stride length (SMD=1.15, p=0.01; SMD=0.89, p<0.01), while CDT demonstrated a significant benefit for balance control (SMD=0.59, p<0.01). Those modality-specific effects were further supported by meta-regression analysis. Stroke survivors at high risk of falls showed greater balance improvements following dual-task training. Furthermore, improvements in balance control and motor function were observed in non-chronic stroke survivors ([&le;]6 months post-stroke) but not in chronic stroke survivors. These results offer crucial prescriptive insights, guiding clinicians to match the dual-task modality and timing of intervention to the individual patients functional profile. However, the high heterogeneity among studies and the lack of direct comparative trials between CDT and MDT limit the conclusive strength of these recommendations.

BackgroundStroke commonly results in permanent damage to central neural circuits. At a physiological level, this damage manifests as neuromotor impairments like reduced muscle strength, altered coordination, and delayed reaction time. At a functional level, this damage results in reduced gait speed, endurance, and balance ability, which leads to long-term disability and loss of independence. However, the interplay between these neuromotor impairments and functional disability is not well understood. An understanding of these relationships is critical to tailoring rehabilitation approaches for post-stroke recovery. MethodsWe measured upper extremity neuromotor capacities as well as mobility and balance measures in 20 chronic stroke survivors and 20 age- and sex-matched controls for this cross-sectional, case-control study. The upper extremity neuromotor capacities included grip strength and various reaction time measures (simple reaction time [SRT], reaction accuracy [All Accuracy], and All Accuracy/SRT) derived using the ReacStick--a novel instrumented ruler-drop test that provides greater ecological validity than computer-based measures. The mobility and balance measures included preferred gait speed, 6-minute walking distance, timed up-and-go test, and single leg balance ability. ANOVAs were used to make between-limb and between-group comparisons, and linear and logistic regression analyses were used to evaluate the neuromotor capacities as predictors of mobility and balance. ResultsAll neuromotor capacities except All Accuracy and all mobility and balance measures were negatively affected by stroke (all p<0.02). We observed that grip strength symmetry (the ratio of grip strength in the paretic limb to the nonparetic limb) was the primary predictor of all mobility measures (all p[&le;]0.014), and SRT symmetry and paretic All Accuracy/SRT were the primary predictors of balance (all p[&le;]0.002). ConclusionsThese results serve as foundational evidence for the relationship between neuromotor performance and functional ability following a stroke and may present an accessible clinical tool for safe measurement of post-stroke mobility and balance.

BackgroundIn recent years, the potential of non-invasive brain stimulation (NIBS) for therapeutic effects on cognitive functions has been explored for stroke and traumatic brain injury (TBI) populations. MethodsAll English articles from the following sources were searched from inception up to December 31, 2018: PubMed, Scopus, CINAHL, Embase, PsycINFO and CENTRAL. Randomized and prospective controlled trials, including cross-over studies, were included for analysis. Studies with at least five individuals post stroke or TBI, whereby at least five sessions of NIBS were provided and used standardized neuropsychological measurement of cognition, were included. ResultsA total of 17 studies met eligibility criteria which included 546 patients receiving either repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS). Sample sizes ranged 5-25 subjects per group. Seven studies used rTMS and ten studies used tDCS. Target symptoms included global cognition (n=8), memory (n=1), attention (n=1), and unilateral spatial neglect (USN) (n=7). Nine studies combined rehabilitation or additional therapy with NIBS. Six of ten studies showed significant improvement in attention, memory, working memory, and executive function. In the USN study, five of the seven studies had a significant improvement in the intervention group. ConclusionsThe effect of NIBS on executive functions including attention and memory post stroke or TBI yielded mixed results with variable stimulation parameters. A significant, consistent improvement was observed for USN post stroke or TBI. Future studies using advanced neurophysiological and neuroimaging tools to allow network-based approach to NIBS for cognitive symptoms post stroke or TBI are warranted.

ObjectiveTo investigate longitudinal changes in spatiotemporal gait parameters after maximal versus moderate speed locomotor training in chronic stroke, by comparing short-burst high-intensity interval training (HIIT) versus moderate-intensity aerobic training (MAT). Compared to MAT, short-burst HIIT was hypothesized to exhibit greater improvement in non-paretic step length. DesignSecondary analysis from the HIT-Stroke randomized controlled trial SettingThree rehabilitation research centers ParticipantsIndividuals with chronic stroke and residual walking limitations (N=55) InterventionsParticipants were randomized to short-burst HIIT (N=27) or MAT (N=28) for 45 minutes of walking practice, 3 times weekly, over 12 weeks. HIIT involved 30-second bursts of maximum walking speed, targeting >60% heart rate reserve (HRR). MAT involved continuous walking, targeting 40%-60% HRR. Main Outcome Measure(s)Mean spatiotemporal gait parameter changes between groups, averaging the 4-week, 8-week, and 12-week estimates minus baseline. The primary measure of interest was non-paretic step length, an indicator of paretic propulsion and biomechanical efficiency. ResultsNon-paretic step length increased significantly more in the HIIT group (+4.4 cm [95% CI, 1.9, 6.9]) compared to the MAT group (+0.1 [-2.5, 2.7]; HIIT vs. MAT p = .01). Both groups demonstrated significant increases in cadence, paretic step length, and bilateral single support time, and significant decreases in the coefficient of variation (CV) for stride velocity, stride time, and stride length. Symmetry measures did not significantly change in either group. ConclusionsGreater increases in non-paretic step length with short-burst HIIT suggest that maximal speed training may yield greater increases in paretic propulsion, a marker of biomechanical efficiency. Both moderate and maximal speed training (MAT and HIIT) appear to reduce spatiotemporal variability, possibly indicating improved gait stability.

ObjectiveTo examine speech rate and muscle function in athletes with and without sports related concussion (SRC). MethodsWe recruited 30 athletes aged 19-22 years-old who had sustained a SRC within the past 2 years and 30 pair-wise matched controls with no history of SRC from the student community at Michigan State University. Speech rate and muscle function were evaluated during diadochokinetic (DDK) tasks. Speech rate was measured via average time per syllable, average unvoiced time per syllable, and expert perceptual judgement. Speech muscle function was measured via surface electromyography over the obicularis oris, masseter, and segmental triangle. Group differences were assessed using MANOVA, bootstrapping and predictive ROC analyses. ResultsAthletes with SRC had slower speech rates during DDK tasks than controls as evidenced by longer average time per syllable (F(1, 52) = 11.072, p =.002, [95% CI : .01 to .04]), longer average unvoiced time per syllable (F(1, 52) = 16.031, p < .000, [95% CI : .01 to .029] and expert judgement of slowed rate (F(1, 22) = 9.782, p = .005, [95% CI : .163 to .807]). Rate measures were predictive of concussion history. Further, athletes with SRC required more speech muscle activation than controls to complete the DDK tasks (F(1, 3) = 17.12, p =.000, [95% CI: .003 to .006]). ConclusionWe found clear evidence of slowed speech and increased muscle activation during the completion of DDK tasks in athletes with SRC histories relative to controls. Speech rate and muscle assessment should be incorporated into clinical evaluation of concussion.

Background and PurposeWalking and balance impairments after stroke are a global health concern, causing significant morbidity and mortality. However, effective strategies for achieving meaningful recovery in the chronic stages are limited. Backward locomotor treadmill training (BLTT) is a novel walking rehabilitation protocol that is safe, feasible, and likely beneficial in stroke survivors; however, its efficacy has not been tested. This single-center, randomized, assessor-blind clinical trial aims to test the preliminary efficacy of BLTT compared to forward locomotor treadmill training (FLTT) on walking speed, symmetry, and postural stability. MethodsForty stroke survivors [BLTT (N=19), FLTT (N=21); mean age= 56.3 {+/-} 8.6 years; 53% Female; 30% Non-Hispanic Black] with mild-moderate walking impairment were enrolled. Participants underwent nine 30-minute BLTT or FLTT sessions over three weeks. The primary outcome was the mean change in the 10-meter walk test (10 MWT) at 24 hours post-training (24 hr POST). Secondary outcome measures were changes in spatiotemporal walking symmetry and postural stability during quiet standing at 24 hr POST. Retention was explored at Days 30- and 90 POST. ResultsWe report clinically meaningful ([&ge;] 0.16 m/s) improvements in overground walking speed at 24 hr POST, with retention up to Day 90 POST with BLTT and FLTT. However, contrary to our working hypothesis, no between-group differences in walking speed were observed. Nonetheless, we found that BLTT resulted in offline improvements in spatial symmetry and retention of subcomponents of the modified clinical test of sensory interaction on balance (mCTSIB), including the testing of proprio-vestibular integration up to Day 30 POST. ConclusionAmong chronic stroke patients with mild-moderate walking impairment, BLTT and FLTT both resulted in long-lasting and clinically meaningful improvement in walking speed. However, preliminary findings suggest that BLTT may better comprehensively target walking asymmetry and sensory systems processing and integration.

ObjectivesCoordination deficits in bilateral upper limbs make daily activities more difficult for stroke survivors. Previous studies showed worse kinematics during unilateral tasks compared to healthy individuals, but this was unclear for bimanual tasks. We aim to assess the potential of the towel folding task from the Wolf Motor Function Assessment as a measure of bimanual control by examining kinematic differences between stroke survivors and healthy individuals and correlating these differences with clinical parameters in the stroke group. MethodsThis was a cross-sectional design. Seventeen people with stroke and sixteen healthy individuals participated. Vicon motion capture obtained kinematics of bilateral upper limbs during the task, including movement time, initiation delay, velocity, trunk displacement, smoothness, and inter-/intra-limb coordination. Statistical analyses compared groups and correlated kinematic variables with clinical parameters. ResultsStroke survivors had longer movement times (P < .001, Cohens d = 1.396), slower initiation (P < .001, Cohens d = 0.797), lower max velocity (P = .026, Cohens d = -.815; P < .001, Cohens d = -2.156; and P = .005, Cohens d = -.736; respectively), greater trunk displacement (P < .001, Cohens d = 2.173 and P < .001, Cohens d = 1.727, respectively), less smoothness (P = .031, Cohens d = 0.883 and P < .001, Cohens d = .725, respectively), and altered inter-/intra-limb coordination. Regarding bilateral elbow-elbow coordination, stroke group exhibited decreased in-phase patterns (P < .001, partial {eta}{superscript 2} = .368) and increased anti-phase and non-hemiplegic elbow dominancy patterns (P = .001, partial {eta}{superscript 2} = .298 and P = .004, partial {eta}{superscript 2} = .244, respectively). Regarding bilateral shoulder-shoulder coordination, stroke group showed decreased hemiplegic shoulder leading patterns (P = .010, partial {eta}{superscript 2} = .196) and increased anti-phase and non-hemiplegic shoulder dominancy patterns (P = .001, partial {eta}{superscript 2} = .315 and P < .001, partial {eta}{superscript 2} = .463, respectively). For hemiplegic shoulder-elbow coordination, stroke group showed decreased anti-phase patterns (P < .001, partial {eta}{superscript 2} = .382) and increased elbow dominancy Patterns (P < .001, partial {eta}{superscript 2} = .324). Fugl-Meyer Assessment scores positively correlated with smoothness and hemiplegic shoulder-elbow coordination (r = -.500, P = .039 and r = .600, P = .010, respectively), while Action Research Arm Test scores negatively correlated with movement initiation delay (r = -.600, P = .010). ConclusionsThis study enhances understanding of the folding towel task and may provide metrics to quantify bilateral coordination task performance in stroke survivors.

The discrepancy between residual functional capacity and reduced use of the contralesional hand, frequently observed after a brain lesion, has been termed Learned Non-Use (LNU) and is thought to depend on the interaction of neuronal mechanisms during recovery and learning-dependent mechanisms such as negative reinforcement. Despite the generally accepted existence of the LNU phenomenon among clinicians and researchers, no unequivocal and transdisciplinary definition exists to date. Furthermore, although therapeutic approaches are implemented in clinical practice to explicitly target LNU, no standardized diagnostic routine is described in the current literature. Based on a structured group communication following the Delphi method among clinical and scientific experts in the field of LNU, knowledge from both, the work with patient populations and with animal models, was synthesized and integrated to reach consensus regarding a transdisciplinary definition of the LNU phenomenon. Furthermore, the mode and strategy of the diagnostic process, as well as the sources of information and outcome parameters relevant for the clinical decision making, were described with a wide range showing the current lack of a consistent universal diagnostic approach. Building on these results, the need for the development of a structured diagnostic procedure and its implementation into clinical practice is emphasized. Moreover, it exists a striking gap between the prevailing hypotheses regarding the mechanisms underlying the LNU phenomenon and the actual evidence. Therefore, basic research is needed to bridge between bedside and bench and eventually improve clinical decision making and further development of interventional strategies beyond the field of stroke rehabilitation.

QuestionIs sensorimotor upper limb (UL) therapy of more benefit for motor and somatosensory outcome than motor therapy? DesignRandomised assessor-blinded multi-centre controlled trial with block randomization stratified for neglect, severity of motor impairment, and type of stroke. Participants40 first-ever stroke patients with UL sensorimotor impairments admitted to the rehabilitation centre InterventionBoth groups received 16 hours of additional therapy over four weeks consisting of sensorimotor (N=22) or motor (N=18) UL therapy. Outcome measuresAction Research Arm test (ARAT) as primary outcome, and other motor and somatosensory measures were assessed at baseline, post-intervention and after four weeks follow-up. ResultsNo significant between-group differences were found for change scores in ARAT or any somatosensory measure between the three time points. For UL impairment (Fugl-Meyer assessment), a significant greater improvement was found for the motor group compared to the sensorimotor group from baseline to post-intervention (mean (SD) improvement 14.65 (2.19) versus 5.99 (2.06); p=0.01) and from baseline to follow-up (17.38 (2.37) versus 6.75 (2.29); p=0.003). ConclusionUL motor therapy may improve motor impairment more than UL sensorimotor therapy in patients with sensorimotor impairments in the early rehabilitation phase post stroke. For these patients, integrated sensorimotor therapy may not improve somatosensory function and may negatively influence motor recovery. Trial registrationThe trial is registered at clinicaltrials.gov NCT03236376.

Muscle tissue is prone to changes in composition and architecture following stroke. Changes in muscle tissue of the extremities are thought to increase passive muscle stiffness and joint impedance. These effects likely compound neuromuscular impairments exacerbating movement function. Unfortunately, conventional rehabilitation is devoid of quantitative measures yielding to subjective assessment of passive joint mobility and end feel. Shear wave ultrasound elastography is a conventional tool used by ultrasonographers that may be readily available for use in the rehabilitation setting as a quantitative measure, albeit at the muscle-tissue level, filling the gap. To support this postulation, we evaluated the criterion validity of shear wave ultrasound elastography of the biceps brachii by investigating the relationship to a laboratory-based criterion measure for quantifying elbow joint impedance in individuals with moderate to severe chronic stroke. Measurements were performed under passive conditions at seven positions spanning the arc of elbow joint extension in both arms of twelve individuals with hemiparetic stroke. Surface electromyography was utilized for threshold-based confirmation of muscle quiescence. A significant moderate relationship was identified near end range of elbow extension and all metrics were greater in the paretic arm. Data supports the progression toward clinical application of shear wave ultrasound elastography in evaluating altered muscle mechanical properties in stroke stipulating the confirmation of muscle quiescence. Considering the lack of bedside robotics in clinical practice, shear wave ultrasound elastography will likely augment the conventional method of manually testing joint mobility. Tissue-level measurement may also assist in identifying new therapeutic targets for patient-specific impairment-based interventions. New & NoteworthyMethods for quantifying passive (non-reflex mediated) joint mobility are absent in stroke rehabilitation. Rehabilitation specialists are left to subjective assessment of the impact on function. Here, we compare the application of shear wave ultrasound elastography for estimating mechanical properties of muscle with a robotic method (criterion measure) of measuring passive elbow extension joint impedance. Data support the clinical application of shear wave ultrasound elastography, especially with the absence of bedside robotics.

AIMExecutive functions (EF) are advanced cognitive processes that play an essential role in daily functioning and may be of increased importance in cerebral palsy (CP), given the complexity of primary and associated impairments. This study aims to synthesize existing evidence on the relation between EF and domains of the International Classification of Functioning, Disability and Health (ICF) in individuals with CP, and to quantify the magnitude of these associations through meta-analysis. METHODA systematic literature search was conducted in eight electronic databases up to 14 July 2025, examining associations between EF and ICF domains in CP. EF outcomes were classified into inhibitory control, working memory, cognitive flexibility, higher-order EF, and EF composite scores. Outcome measures were mapped onto ICF domains: Body Functions and Structures, Activity, Participation, and Contextual factors, using the CP Core Sets. Correlation coefficients were transformed to Fishers z and entered into three-level meta-analyses to estimate pooled effect sizes. Single moderator analyses examined CP subtype, EF domain, EF assessment type, and mean age. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. RESULTSFrom 4637 identified records, 38 studies were included, comprising a total sample of 1633 participants with CP. There was substantial heterogeneity in CP subtype, participant age, and EF conceptualization, while the ICF Contextual factors domain was underrepresented. A medium-to-large association was found between EF and functioning across all ICF domains combined (r=0.26, p<0.001). Domain-specific analyses showed a medium association of EF with Body Functions and Structures (r=0.21, p<0.01), a medium-to-large association with Activity (r=0.38, p<0.001) and Participation (r=0.26, p<0.01). CP subtype and mean age significantly moderated the overall EF-functioning association, with mixed CP and younger age associated with stronger effects. INTERPRETATIONEF are meaningfully associated with multiple domains of functioning in individuals with CP. These findings support the relevance of routine EF assessment and suggest that EF are an important cognitive correlate to consider when addressing broader aspects of daily functioning. WHAT THIS PAPER ADDSO_LIExecutive functions (EF) showed medium-to-large associations with all ICF domains in people with cerebral palsy (CP) C_LIO_LIThe strongest and most consistent associations were found between EF and ICF Activity C_LIO_LIOverall associations highlight the relevance of EF as a meaningful intervention target in CP C_LI