Chapter 10 Upper Extremity Interventions PDF

EBRSR
[Evidence-Based Review of Stroke Rehabilitation]
10
Upper Extremity Interventions
Andreea Cotoi MSc, Alice Iliescu BSc, Norine Foley MSc, Magdalena Mirkowski MSc MScOT, Jocelyn
Harris PhD OT, Sean Dukelow MD, Jayme Knutson PhD, John Chae MD, Tom Miller MD, Andrea Lee BSc
(cand.), Scott Janssen MSc, Robert Teasell MD
Last Updated: March 2018
Abstract
Upper extremity complications are common following stroke and may be seriously debilitating.
Regaining mobility in the upper extremities is often more difficult than in lower extremities, which can
seriously impact the progress of rehabilitation. A large body of research exists around upper extremity
complications but debate continues regarding the timing of treatment and adequate prognostic factors.
This review provides current information regarding upper extremity interventions. Topics include
robotic devices for movement therapy, virtual reality technology, spasticity treatment,
EMG/biofeedback, electrical stimulation, brain stimulation, drugs and medical interventions, alternative
and complementary medicine, hyperbaric oxygen therapy, and hand edema treatment.
Neurodevelopmental upper extremity therapy techniques are reviewed along with other therapy
options including repetitive/task-specific training, sensorimotor interventions, splinting, and constraint-
induced movement therapy.
10. Upper Extremity Interventions pg. 1 of 208
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Key Points
• Attempts to regain function in the affected upper extremity should be limited to those
individuals already showing signs of some recovery.
• Neurodevelopmental techniques are not superior or inferior compared with other therapeutic
approaches in treatment of the hemiparetic upper extremity.
• Motor relearning programs may be superior to the Bobath method, while Brunnstrom hand
manipulation treatment may be superior to motor relearning programs for patients post stroke.
• Bilateral arm training on its own or in combination with other therapies is likely not more
effective for improving upper limb motor function than unilateral arm training or other
conventional therapies.
• Arm training is likely more effective than leg training for improving arm function after stroke.
• Additional upper limb therapy does not appear to be superior to conventional therapy for
improving upper limb motor function or functional independence.
• Strength training likely helps improve grip strength, motor function, and shoulder range of
motion following stroke.
• Due to the variation of the treatment protocols, it is unclear whether repetitive task-specific
training in combination with additional treatments improves upper extremity function.
• Trunk restraint may improve some aspects of upper limb motor function but not others (i.e.
elbow extension, reaching trajectory, trunk displacement).
• Transcutaneous electrical nerve stimulation, vibration therapy, mesh glove, and thermal
stimulation may improve upper limb motor function.
• Peripheral nerve stimulation and electroacupuncture may not improve upper limb motor
function.
• Mental practice may improve upper limb motor function after stroke, while motor imagery likely
does not.
• Splinting, taping, and orthoses likely do not improve upper limb motor function.
• Constraint-induced movement therapy (CIMT) may be ineffective in the acute stage of stroke,
but likely effective in the chronic phase for improving upper extremity motor function.
• Modified constraint-induced movement therapy (mCIMT) may improve adaption to preserved

function, but not neurological impairment in the early stage of stroke. However, mCIMT may
improve upper limb motor function in the chronic phase.
• Mirror therapy is likely effective for improving upper limb motor function.
• Feedback may improve upper limb motor function post stroke.

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• Evidence for the use of action observation is conflicting, although the combination of action
observation with brain-computer interface-based functional electrical stimulation may be
effective for upper limb motor rehabilitation.
• Music therapy may improve upper limb motor function but not muscle strength.
• Home-based rehabilitation interventions are likely not effective for improving upper limb motor
funtion
• Additional research is needed to evaluate the effectiveness of additional exercise therapy for
upper limb motor function.
• There is conflicting evidence as to whether the use of robotic devices is effective for improving
• Virtual reality therapy may not improve upper limb motor function in chronic stroke patients.
• Computer-brain-interface technology is likely not effective for improving upper limb motor
function although more research is required to come to a more definitive result.
• Hand splints alone likely do not reduce spasticity or prevent contracture.
• Stretching programs may improve upper limb spasticity.
• Botulinum toxin likely decreases spasticity, but likely does not improve upper limb motor
function.
• Botulinum toxin in combination with electrical stimulation or modified constraint induced

movement therapy likely improves muscle tone in the upper extremity.
• More research is needed to determine whether nerve block treatment decreases spasticity in
the upper extremity.
• Physical therapy may not decrease spasticity, or pain, or contracture, or improve upper
extremity motor function.
• Neuromuscular electrical stimulation (NMES) may not reduce wrist or elbow spasticity.
• Extracorporeal shockwave therapy likely improves upper limb spasticity.
• Further research is needed to determine the benefits of tolperisone on upper limb muscle tone.
• EMG/biofeedback therapy is likely not effective for improving upper limb motor function or
spasticity.
• Both functional electrical stimulation (FES) and neuromuscular electrical stimulation (NMES)
may help improve impaired upper extremity motor function during all phases of stroke (i.e. from
acute to chronic).
• FES may be more beneficial at improving impaired motor function when delivered early (<6
months) than late (>6months).

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• There is no significant difference in the benefits observed following different NMES delivery
modalities (i.e. cyclic, EMG-triggered, and passive).
• Motor Cortex Stimulation via implanted electrodes may not improve upper limb function in
patients post-stroke. More studies are needed to conclude on the effectiveness of vagus nerve
stimulation for upper limb motor function.
• It is unclear whether low-frequency (1 Hz) Repetitive Transcranial Magnetic Stimulation (RTMS)

is effective, while high-frequency (5 Hz) and Dual RTMS Repetitive Transcranial Magnetic
Stimulation is likely effective for improving upper limb motor function.
• Intermittent Theta Burst Stimulation (iTBS) may improve upper limb motor function in the
acute/subacute phase as well as during the chronic phase post stroke. While iTBS may not be
effective for improving dexterity in the acute/subacute phase, it is likely effective during the
chronic phase.
• Continuous Theta Burst Stimulation (cTBS) may not be effective for improving upper limb motor
function or dexterity after stroke.
• Anodal Transcranial Direct Current Stimulation (tDCS) is likely not effective for improving upper
limb motor function, spasticity, and grip strength, with uncertainty regarding its effectiveness
for dexterity.
• The effectiveness of Cathodal Transcranial Direct Current Stimulation (tDCS) remains uncertain
for upper limb motor function, dexterity, and activities of daily living.
• Dual Transcranial Direct Current Stimulation is likely effective for dexterity.
• Stimulants may help improve impaired upper limb function; however, the effects may not be
observed in the long term.
• More research is needed to determine the effects of Levodopa on impaired upper limb motor
function.
• Stimulants may help improve impaired upper limb function; however, the effects may not be
• Antidepressants may help improve impaired upper extremity motor function following a stroke.
• Further research is needed to determine if steroid injections are beneficial at reducing upper
limb pain and improving range of motion following a stroke.
• Further research is needed to determine the effects of d-cycloserine on post-stroke upper

• Evidence for the use of the ozonated autohemotherapy for improving post-stroke upper limb
motor function is currently limited.
• Cerebrolysin may improve upper limb motor function, dexterity, and measures of
independence/daily living.

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• NeuroAid may not improve upper limb motor function and phosphodiesterase-5 inhibitor may
not improve dexterity, grip strength, or level of independence/daily living.
• Evidence for the use of Atorvastatin for improving outcomes after stroke is limited.
• Acupuncture likely does not improve upper limb motor function or level of independence.
• Limited evidence indicates a potential benefit of meridian acupuncture on upper limb motor
function, performance of activities of daily living, and pain post-stroke.
• Limited evidence regarding the use of Traditional Chinese Herbal Medicine suggests potential
benefits of improved functional independence after stroke.
• Massage Therapy likely does not improve functional independence, spasticity, hand dexterity, or
quality of life after stroke.
• Intermittent pneumatic compression does not appear to reduce hand edema or improve upper
limb strength post stroke.
Dr. Robert Teasell

Parkwood Institute, 550 Wellington Road, London, Ontario, Canada, N6C 0A7
Phone: 519.685.4000 ● Web: www.ebrsr.com ● Email: Robert.Teasell@sjhc.london.on.ca

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Table of Contents
Abstract .............................................................................................................................................1
Key Points..........................................................................................................................................2
Table of Contents ...............................................................................................................................6
Introduction ......................................................................................................................................8
10.1 Consensus Panel Treatment and Recommendations .................................................................9
10.2 Upper Extremity Interventions ............................................................................................... 10
10.2.1 Neurodevelopmental Techniques ............................................................................................. 10
10.2.2 Bilateral Arm Training ................................................................................................................ 13
10.2.3 Arm and Leg Training................................................................................................................. 18
10.2.4 Additional/Enhanced Therapy ................................................................................................... 19
10.2.5 Strength Training ....................................................................................................................... 22
10.2.6 Repetitive/Task- Specific Training Techniques .......................................................................... 23
10.2.7 Trunk Restraint .......................................................................................................................... 27
10.2.8 Sensorimotor Training and Somatosensory Stimulation .......................................................... 29
10.2.9 Mental Practice/ Motor Imagery............................................................................................... 37
10.2.10 Splinting ................................................................................................................................... 41
10.2.11 Constraint-Induced Movement Therapy (CIMT) ..................................................................... 42
10.2.12 Mirror Therapy ........................................................................................................................ 54
10.2.13 Feedback Therapy ................................................................................................................... 58
10.2.14 Action Observation .................................................................................................................. 61
10.2.15 Music Therapy ......................................................................................................................... 63
10.2.16 Telerehabilitation .................................................................................................................... 64
10.2.17 Exercise Therapy...................................................................................................................... 66
10.3 Robotic Devices for Movement Therapy ................................................................................. 67
10.4 Virtual Reality and Computer Brain Interface Technology ....................................................... 78
10.4.1 Virtual Reality (VR) .................................................................................................................... 78
10.4.2 Computer Brain Interface Technology (CBI).............................................................................. 82
10.5 Treatment for Spasticity or Contracture in the Upper Extremity .............................................. 83
10.5.1 Splinting ..................................................................................................................................... 84
10.5.2 Stretching Programs to Prevent Contracture Formation .......................................................... 85
10.5.3 Botulinum Toxin Injections ........................................................................................................ 86
10.5.4 Electrical Stimulation Combined with Botulinum Toxin Injection............................................. 91
10.5.5 Nerve Block and Spasticity ........................................................................................................ 92
10.5.6 Physical Therapy in the Treatment of Spasticity ....................................................................... 92
10.5.7 Electrical Stimulation ................................................................................................................. 93
10.5.8 Shock Wave Treatment ............................................................................................................. 94
10.5.9 Centrally Acting Muscle Relaxants ............................................................................................ 95
10.6 EMG/Biofeedback ................................................................................................................. 96
10.7 Neuromuscular Electrical Stimulation (NMES) ........................................................................ 98
10.8 Brain Stimulation................................................................................................................. 106
10.8.1 Invasive Motor Cortex Stimulation (MCS) ............................................................................... 106
10.8.2 Non-Invasive Motor Cortex Stimulation.................................................................................. 107
10.9 Drugs and Medical Interventions ......................................................................................... 126
10.9.1 Stimulants ................................................................................................................................ 126
10.9.2 Levodopa ................................................................................................................................. 128
10.9.3 Antidepressants ....................................................................................................................... 128

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10.9.4 Steroids .................................................................................................................................... 131
10.9.5 Antibiotics................................................................................................................................ 132
10.9.6 Ozonated Autohemotherapy .................................................................................................. 132
10.9.7 Peptides ................................................................................................................................... 133
10.9.8 Neuroprotectants .................................................................................................................... 134
10.9.9 Statins ...................................................................................................................................... 135
10.10 Alternative and Complementary Medicine ......................................................................... 136
10.10.1 Acupuncture .......................................................................................................................... 136
10.11.2 Meridian Acupressure ........................................................................................................... 141
10.11.3 Traditional Chinese Herbal Medicine (TCHM) ....................................................................... 142
10.11.4 Massage Therapy................................................................................................................... 144
10.11.5 Cupping.................................................................................................................................. 145
10.11 Treatment of Hand Edema ................................................................................................. 145
Summary ....................................................................................................................................... 148
References..................................................................................................................................... 155

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Introduction
Impaired upper extremity function is a common and often devastating problem for stroke survivors. In
the population-based Copenhagen Stroke Study (Nakayama, Jorgensen, Raaschou, & Olsen, 1994), 32%
of stroke patients had severe arm paresis at admission and 37% had mild paresis. In 64 out of 491 (13%)
stroke survivors, the arm remained entirely non-functional despite comprehensive rehabilitation efforts.
Regaining lost function in the upper extremities may be more difficult to achieve than return of normal
function (ambulation) in the lower extremities (Hiraoka, 2001). Similarly, Barecca (2001) noted that
“Rehabilitation of the hemiplegic upper limb remains difficult to achieve, with only 5% of stroke survivors
who have complete paralysis regaining functional use of their impaired arm and hand (Dombovy, 1993;
Gowland, 1982; Kwakkel, van Dijk, & Wagenaar, 2000) . Limited rehabilitation resources, time
constraints, and a lack of early motor recovery in the arm and hand tend to focus therapy on improving
balance, gait and general mobility.”
There is much discussion regarding which patients benefit the most from therapy. Kwakkel et al. (2003)
reported that 11.6% of patients had achieved complete functional recovery at 6 months, while 38% had
some dexterity. There is also evidence that motor rehabilitation of chronic stroke patients remains
successful several months or years after the acute stroke (Hummelsheim & Eickhof, 1999; Kraft, Fitts, &
Hammond, 1992). In terms of patients with less severe initial impairment (defined as a Chedoke-
McMaster Stroke Assessment (CMSA) score of stage 4 or greater), Barecca (2001) recommended that an
aggressive restorative program geared towards regaining function in the affected upper extremity be
adopted (See Table 10.1.1 for the CMSA stages of motor recovery).
Table 10.1.1 Stages of Motor Recovery of the Chedoke-McMaster Stroke Assessment (Gowland et al.,
1993):
Stage Characteristics
1 Flaccid paralysis is present. Phasic stretch reflexes are absent or hypoactive. Active movement cannot be elicited
reflexly with a facilitatory stimulus or volitionally.
2 Spasticity is present and is felt as a resistance to passive movement. No voluntary movement is present, but a
facilitatory stimulus will elicit primitive movement patterns reflexly. These primitive patterns are the stereotyped
flexion and extension synergies.
3 Spasticity is marked. The primitive synergistic movement patterns can be elicited voluntarily, but are obligatory.
In most cases, the flexion synergy dominates the arm, the extension synergy the leg. There are strong and weak
components within each synergy.
4 Spasticity decreases. Synergy patterns can be reversed if movement takes place in the weaker synergy first.
Movements combining antagonistic synergies can be performed when the prime movers are the strong
components of the synergy.
5 Spasticity wanes, but it is evident with rapid movement and at the extremes of range. Synergy patterns can be
reversed even if the movement takes place in the stronger synergy first. Movements utilizing the weak
components of both synergies acting as prime movers can be performed. Most movements become
environmentally specific.
6 Coordination and patterns of movement are near normal. Spasticity as demonstrated by resistance to passive
movement is no longer present. A great variety of environmentally specific patterns of movement are now
possible. Abnormal patterns of movement with faulty timing emerge when rapid or complex actions are
requested.
7 Normal. A “normal” variety of rapid, age-appropriate complex movement patterns are possible with normal
timing, coordination, strength, and endurance. There is no evidence of functional impairment compared with the
normal side. There is a “normal” sensory-perceptual-motor system.

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Previous Reviews
Two reviews pooled the results of RCTs quantitatively (Barecca et al., 2001; Hiraoka, 2001). Barecca
(2001) reported the following pooled effect sizes associated with upper extremity treatments: Z=4.87
for sensorimotor training (including 4 RCTs); Z=3.43 for EMG-electrical stimulation (including 3 RCTs);
and Z=4.44 for electrical stimulation (including 2 RCTs). Hiraoka (2001) included 14 RCTs evaluating
upper extremity therapies and found an overall effect size (d) of 0.33, suggestive of a small to medium
impact of therapy. Subgroup analyses suggested that there was no treatment effect of
neurodevelopmental treatment compared with conventional physical therapy (d=-0.01); there was a
medium effect of conventional physical therapy compared to no therapy (d=0.51) and a large effect of
EMG biofeedback treatment compared to conventional physical therapy (d=0.85).
10.1 Consensus Panel Treatment and Recommendations

Barecca et al. (2001) provided consensus treatment recommendations for management of the post-
stroke arm and hand, based on a synthesis of best evidence. After reviewing the evidence, the panel
came to a consensus agreement that a hemiplegic upper extremity must be at least at CMSA stage 4
before full rehabilitation efforts designed to restore function in the arm are attempted. The panel
concluded that attempts to rehabilitate the upper extremity of a person with a score of less than 4 will
not succeed. A more palliative compensatory approach is recommended in such cases.
2001 Consensus Panel Recommendations for Patients with Severe Impairment
“For the client with severe motor, sensory and functional deficits in the involved limb after stroke, the
effectiveness literature indicates that additional treatment for the upper limb will not result in any
significant neurological change. The evidence to date suggests that interventions may not lead to
meaningful functional use of the affected limb at this stage of motor recovery.”
1. Maintain a comfortable, pain-free, mobile arm and hand

• emphasize proper positioning, support while at rest and careful handling of the upper limb
during functional activities.
• engage in classes overseen by professional rehabilitation clinicians in an institutional or
community setting that teach the client and caregiver to perform self-range of motion
exercises.
• avoid use of overhead pullies that appear to contribute to shoulder tissue injury
• use some means of external support for the upper limb in stages 1 or 2 during transfers and
mobility
• place upper limb in a variety of positions that include placing arm and hand within the
client’s visual field.
• Use some means of external support to protect the upper limb during wheelchair use.”
2. To maximize functional independence, stroke survivors with persistent motor and sensory
deficits and their caregivers should be taught compensatory techniques and environmental
adaptations that enable performance of important tasks and activities with the less affected arm
and hand.

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2001 Consensus Panel Recommendations for Patients with Moderate Impairment
“For clients with moderate impairments who demonstrate high motivation and potential for
functional motor gains
1. Engage in repetitive and intense use of novel tasks that challenge the stroke survivor to acquire
necessary motor skills to use the involved upper limb during functional tasks and activities.
2. Engage in motor-learning training including the use of imagery.”
Conclusions Regarding Management of the Post Stroke Arm and Hand
There is consensus opinion that in severely impaired upper extremities (less than stage 4) the focus
of treatment should be on compensation.
For those upper extremities with signs of some recovery (stage 4 or better) there is consensus that
attempts to restore function through therapy should be made.
Attempts to regain function in the affected upper extremity should be limited to those individuals
already showing signs of some recovery.
10.2 Upper Extremity Interventions

A variety of treatment interventions to improve motor recovery in the upper extremity have been
evaluated. They are presented in sections 10.2.1 to 10.2.17.
10.2.1 Neurodevelopmental Techniques

A variety of treatment approaches are in use currently. Arguably, the Bobath concept (a
neurodevelopmental technique also referred to as Neurodevelopmental Treatment (NDT) is the most
commonly used approach.
There are a number of approaches that are considered to be neurodevelopmental techniques. These
include Bobath/NDT, Brunnstrom’s Movement Therapy and Proprioceptive Neuromuscular Facilitations.
The concept of Bobath/NDT emphasizes that abnormal muscle tone or patterns should be inhibited and
normal patterns should be used in order to facilitate functional and voluntary movements, which is in
direct opposition to Brunnstrom’s approach. Therapy approaches aimed at the rehabilitation of the
lower extremity are also discussed in Chapter 9.
Table 10.2.1.1 Neurodevelopmental Techniques

Approach Description
Bobath/Neurodevelopmental Aims to reduce spasticity and synergies by using inhibitory postures and movements in order to
Treatment facilitate normal autonomic responses that are involved in voluntary movement (Bobath 1990).
Brunnstrom’s Movement Emphasizes synergistic patterns of movement that develop during recovery from hemiplegia.
Therapy Encourages the development of flexor and extensor synergies during early recovery, assuming
that synergistic activation of the muscle will result in voluntary movement (Brunnström 1970).
Proprioceptive Emphasizes use of the patient's stronger movement patterns to strengthen weaker motions.

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Neuromuscular Facilitation PNF techniques use manual stimulation and verbal instructions to induce desired movement
(PNF) patterns and enhance motor function (Voss et al. 1985).
In their review of neurodevelopmental techniques versus other treatment approaches, Barreca et al.
(2003b) included five RCTs (Basmajian et al., 1987; Dickstein, Hocherman, Pillar, & Shaham, 1986;
Gelber, Josefczyk, Herrman, Good, & Verhulst, 1995; Logigian, Samuels, Falconer, & Zagar, 1983; van der
Lee et al., 1999) and concluded that neurodevelopmental techniques were not superior to other types
of interventions for the paretic upper limb post stroke. Van Peppen et al. (2004) conducted a systematic
review of specific neurological treatment approaches and also concluded that compared to a Bobath
approach, no one particular program was favoured over another with respect to improvement in
functional outcomes (activities of daily living; ADLs), muscle strength, tone, or dexterity, although motor
relearning programs were associated with shorter lengths of hospital stays.
Paci (2003) conducted a review of 15 trials including six RCTs and six non-RCTs and three case series to
determine the effectiveness of NDT for adults with post-stroke hemiplegia. The author concluded that
there is no evidence to support NDT as being the superior type of treatment.
We found twelve studies that evaluated the effectiveness of neurodevelopmental techniques, eleven of
which were RCTs. Another systematic review (Luke, Dodd, & Brock, 2004) which included the results
from 8 trials (5 RCTs) came to similar conclusions.
A summary of RCTs evaluating neurodevelopmental techniques are presented in Table 10.2.1.2.
Table 10.2.1.2 Summary of RCTs Evaluating Neurodevelopmental Techniques

Author, Year Intervention Main Outcome(s)
Study Design (PEDro Score) Result
Sample Size
Platz et al. (2005) E1: Augmented therapy time (Arm BASIS) • Fugl Meyer Assessment: Arm (-)
RCT (8) E2: Augmented therapy time (Bobath)
N=62 C: No augmented therapy time
Platz et al. (2009) E1: Impairment-oriented training • Fugl Meyer Assessment (-)
RCT (8) E2: Passive therapy (with splints) • TEMPA (-)
N=148 C: Conventional therapy
Langhammer & Stanghelle (2000) E: Motor Relearning Programme (MRP) • Hospital stays (+MRP)
Langhammer & Stanghelle(2003) C: Bobath • Motor Assessment Scale (+MPR) at post, (-) at
Langhammer & Stanghelle (2011) 1 and 4yr follow-up
RCT (8) • Sodring Motor Evaluation Scale (+MPR) at
N=61 post, (-) at 1 and 4yr follow-up
• Life Quality Test (-)
• Quality of Movement (+MPR)
van Vliet et al. (2005) E: Motor Relearning Programme (MRP) • Rivemead Motor Assessment (-)
RCT (7) C: Bobath • Motor Assessment Scale (-)
N=120
Timmerman et al. (2013) E: Regular + Mirror therapy • Frenchay Arm Test (-)
RCT (7) C: Neurodevelopmental Bobath therapy • Functional Assessment Scale (-)
NStart=42 • Wolf Motor Function Test (-)
NEnd=42
van der Lee et al. (1999) E: Neurodevelopmental Therapy • Action Research Arm Test (+) forced-use
RCT (7) C: Forced-use therapy
N=66

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Walker et al. (2012) E: Neuropsychological approach to dressing • Nottingham Stroke Dressing Assessment (-)
RCT (7) C: Dressing without a task-oriented approach • 10-hole peg transfer test (-)
NStart=70
NEnd=64
Basmajian et al. (1987) E: Physical Therapy based on neuro-facilitated• Upper Extremity Function Test (-)
RCT (6) techniques • Finger Oscillation Test (-)
N=29 C: EMG
Pandian et al. (2012) E: Brunnstrom hand manipulation treatment • Fugl-Meyer Assessment for Hand (+)
6 (RCT) (BHM)
N=30 C: Motor relearning program (MRP)
Gelber et al. (1995) E: Bobath • FIM (-)
RCT (5) C: Traditional techniques • Box and Block Test (-)
N=20 • Nine Hole Peg Test (-)
• LOS (-)
Dickstein et al.(1986) E1: Proprioceptive neuromuscular facilitation • Barthel Index (-)
RCT (5) E2: Bobath • Muscle tone (-)
N=131 C: Traditional techniques • Active Range of Motion (-)
Logigian et al. (1983) E: Facilitated therapy • Barthel Index (-)
RCT (4) C: traditional techniques • Manual muscle test (-)
N=42
Hafsteinsdóttir et al. (2005) E: Neurodevelopmental Treatment (NDT) • Barthel Index (-)
Hafsteinsdóttir et al. (2007) C: Traditional techniques • Quality of Life (-)
PCT • Health-related Quality of Life (-)
No Score • Visual Analogue Scale for Depression (-)
NStart=326
NEnd=286
- Indicates non-statistically significant differences between treatment groups
+ Indicates statistically significant differences between treatment groups
Discussion
The results from two recent, high quality RCTs assessing similar treatment approaches and outcomes
differed. Langhammer and Stanghelle (2000) reported improvements in upper extremity function and a
shorter length of hospital stay associated with motor relearning, while van Vilet et al. (2005) did not
report a significant difference between treatment approaches. van Vliet et al. (2005) speculate that
earlier, more intensive training provided in the Langhammer and Stanghelle (2000) study as well as a
higher (albeit non-statistically significant) baseline difference may have contributed to the differences.
The content of the treatment programs within the two studies may also have differed. Platz et al. (2005)
failed to demonstrate an effect of augmented arm therapy (in addition to regular rehabilitation) upon
motor recovery, regardless of the treatment approach (BASIS arm training or Bobath) or following
passive, conventional or impairment-oriented training.
Hafsteinsdóttir et al. (2007), Dickstein et al. (1986), and Gelber et al. (1995) reported that the Bobath
approach was not superior to that of non-NDT approach. There were no differences between the groups
on measures of independence or quality of life. Furthermore, Timmerman et al. (2013); van der Lee et
al. (1999); and Basmajian et al. (1987) noted no significant difference between neurodevelopmental
techniques and various control therapies on arm motor function. Pandian et al. (2012) found that the
Brunnstrom hand manipulation treatment was associated with improved Fugl-Meyer Hand Assessment
scores when compared to a motor relearning program.
Conclusions Regarding Neurodevelopmental Techniques

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There is level 1a evidence that neurodevelopmental techniques are not superior to other therapeutic
approaches.
There is level 1b evidence that when compared to the Bobath treatment approach, Motor Relearning
Programme may be associated with improvements in short-term motor functioning, shorter lengths
of hospital stay and better movement quality.
There is level 1b evidence that Brunnstrom hand manipulation treatment is preferable over a motor
relearning program.
Neurodevelopmental techniques are not superior or inferior compared with other therapeutic
approaches in treatment of the hemiparetic upper extremity.
Motor relearning programs may be superior to the Bobath method, while Brunnstrom hand
manipulation treatment may be superior to motor relearning programs for patients post stroke.
10.2.2 Bilateral Arm Training

The use of bilateral training techniques with the upper limb following stroke has been encouraged
recently with the development of new theories regarding neural plasticity. Bilateral arm training is a
technique whereby patients practice the same activities with both upper limbs simultaneously.
Theoretically, the use of the intact limb helps to promote functional recovery of the impaired limb
through facilitative coupling effects between the upper limbs. Practicing bilateral movements may allow
the activation of the intact hemisphere to facilitate the activation of the damaged hemisphere through
neural networks linked via the corpus callosum (Morris et al., 2008; Summers et al., 2007).
A Cochrane review by Coupar et al. (2010), which included the results from 18 RCTs, and 549
participants, reported that there was no significant improvement in ADL function (standardized mean
difference of 0.25, 95% CI: -0.14 to 0.63), functional movement of the arm (SMD=-0.07, 95% CI -0.42 to
0.28) or hand, (SMD -0.04, 95% CU -0.50 to 0.42) of bilateral arm training compared with usual care
following stroke.
Cauraugh et al. (2010) conducted a meta-analysis, including the results from 25 studies, the majority of
which were RCTs. The overall treatment effect was a standardized mean difference (SMD) of 0.734,
representing a large effect. The effect size was influenced by the type of treatment (pure bilateral,
Bilateral Arm Training with Rhythmic Auditory Cueing (BATRAC), coupled bilateral and electromyography
(EMG) -triggered neuromuscular stimulation and active/passive movement using robotics). BATRAC and
EMG-triggered stimulation studies were associated with the largest SMD.
Van Delden et al. (2012) evaluated the effectiveness of bilateral versus unilateral upper limb therapy
and whether or not it was affected by severity of paresis. The review included the results from 9 RCTs.
Pooled analyses of 452 patients were conducted for the Fugl-Meyer Assessment (FMA), Action Research
Arm test (ARAT), Motor Assessment Scale (MAS) and Motor Activity Log (MAL). Across all severity
categories, unilateral training was superior when outcomes were assessed using the ARAT, but there
were no differences in the scores of patients who had severe or moderate paresis. There were no
significant differences in improvement between groups of either severe or moderate patients on MAS or
FMA scores, suggesting both training approaches were effective. Improvements in MAL scores favored
patients in the unilateral training group, although only the mild subgroup was represented.

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The results of controlled trials evaluating bilateral arm training are summarized in Table 10.2.2.1.
Table 10.2.2.1 Summary of Controlled Trials Evaluating Bilateral Arm Training

Sample Size
Morris et al. (2008) E: Bilateral training • ARAT (-)
RCT (7) C: Unilateral training • Rivermead Motor Assessment (-)
N=106 • Nine Hole Peg Test (+)
• Modified Barthel Index (-)
Morris & van Wijck (2012) E: Bilateral training • 9HPT: 6wk (+), 18wk (-)
RCT (7) C: Unilateral training • ARAT (-)
N=106
Whitall et al. (2011) E: Bilateral training • Fugl Meyer (-)
RCT (7) C: Unilateral training • Wolf Motor Function Test (-)
N=111
Wu et al. (2013) E1: Bilateral robotic training • Motor Activity Log (-)
RCT (7) E2: Unilateral robotic training • Wolf Motor Function Test (FAS subscale) (-)
NStart=53 C: Conventional therapy • ABILHAND (-)
NEnd=53
TPS=chronic
Brunner et al. (2012) E: Bilateral training • ARAT (-)
RCT (7) C: mCIMT • 9HPT (-)
N=30 • Motor Activity Log (-)
Desrosiers et al. (2005) E: Symmetrical bilateral tasks • Fugl Meyer (-)
RCT (7) C: Conventional therapy • Grip strength (-)
N=41 • Box and Block Test (-)
• Purdue Pegboard Test (-)
• Finger-to-Nose Test (-)
• TEMPA (-)
• Functional Independence Measure (-)
• The Assessment of Motor and Process Skills (-)
Yang et al. (2012) E1: Unilateral robot assisted training • Fugl Meyer Score (-)
RCT (7) E2: Bilateral robot assisted training • Medical Research Council (-)
N=21 C: Standard training group
TPS=chronic
Luft et al. (2004) E: Bilateral arm training + rhythmic auditory• Fugl Meyer (-)
RCT (7) cueing • Wolf Motor Arm Test (-)
N=21 C: Therapeutic exercises. • University of Maryland Arm Questionnaire for Stroke
(-)
• Elbow and Shoulder Strength (-)
Dispa et al. (2013) E: Bilateral therapy • Fugl Meyer (-)
RCT (7) C: Unilateral therapy • Purdue pegboard Test (-)
NStart=10 • ABIL-hand questionnaire (-)
NEnd=10 • STAIS-stroke questionnaire (-)
McCombe et al.(2014) E: Bilateral + Unilateral training • Wolf Motor Function Test (+)
RCT (7) C: Unilateral training • University of Maryland Arm Questionnaire (+)
NStart=30 • Fugl Meyer (-)
NEnd=26 • Box and Block Test (-)
Lin et al. (2010) E: Bilateral training • Fugl Meyer (+)
RCT (6) C: Unilateral training • FIM (-)

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N=33 • Motor Assessment Log (-)
Stinear et al. (2008) E: Active-passive bilateral therapy • Fugl Meyer (+)
RCT (6) C: Self-directed motor practice • Grip strength (-)
N=32
Whitall et al. (2011) E: Bilateral arm training with rhythmic • Fugl Meyer Assessment (-)
RCT (6) auditory cueing • Wolf Motor Function Test (-)
NStart=111 C: Dose matched unilateral therapeutic • Stroke Impact Scale: Post-intervention (-); 4mo follow-
NEnd=92 exercises up: Emotion (-), Hand (-), Strength (-), Total score (+)
• Isokinetic strength: Elbow extension (-)
• Isometric strength: Shoulder extension (-); Wrist
extension (+); Elbow flexion (-)
van Delden et al. (2015) E1: Modified CIMT + unilateral training • Bimanual coordination task: C vs. E2 (+)
RCT (6) E2: Rhythmic movement + bilateral training• Unimanual reference task: E1 vs. E2 (+); E1 vs. C (+)
NStart=60 C: Control
NEnd=52
Lee et al. (2013) E: Bilateral training + Nervous system • FIM (+)
RCT (6) rehabilitation
NStart=26 C: Nervous system rehabilitation
NEnd=26
Stinear et al. (2014) E: Bilateral training • Modified Ashworth Scale (-)
RCT (6) C: Cutaneous electrical stimulation (no • Stroke Impact Scale (-)
NStart=57 neurophysiological effects)
NEnd=51
Shim et al. (2015) E: Bilateral training • Motor Function Test (+)
RCT (6) C: Unilateral training • FIM (+)
NStart=20 • Affected hand amount of sedentary and moderate
NEnd=20 activity (+)
van Delden et al. (2013) E1: Modified CIMT + unilateral training • Action Research Arm Test (-)
RCT (6) E2: Rhythmic movement + bilateral training• Nine Hole Peg Test (-)
NStart=60 C: Control • Motricity Index (-)
NEnd=55 • Fugl Meyer (-)
• Motor Activity Log (-)
• Stroke Impact Scale: bilateral vs. control for
emotion (+), strength (+)
Hsieh et al. (2016) E: Bilateral arm priming + task-oriented • Fugl-Meyer Assessment (-)
RCT (6) training • Box and Block Test (-)
NStart=31 C: Task-oriented training alone • Grip Strength (-)
NEnd=31 • Modified Rankin Scale (-)
• Functional Independence Measure (-)
• Activities of Daily Living (-)
• Mobility (-)
• Fatigue (-)
• Stroke Impact Scale (+)
Wu et al. (2011) E1: dCIT • Normalized Movement Unit for unilateral and
RCT (5) E2: Bilateral training bilateral tasks: E1/E2 vs. C (+); E1 v. E2 (-)
N=66 C: Control • Peak Velocity for unilateral and bilateral tasks: E2 vs.
C (+); E1 vs. E2/C (-)
• Wolf Motor Function Test- Time and Functional
Ability: E1 vs. C (+); E1/C vs. E2 (-)
• Motor Activity Log- Amount of Use and Quality of
Movement: E1 vs. E2/C (+); E2 vs. C (-)
Song et al. (2015) E1: Task-oriented bilateral arm training • Box and Block Test (+)

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RCT (5) E2: BATRAC • Jebsen Taylor Hand Function Test (+)
NStart=40 • Modified Barthel Index (+)
NEnd=40
Stoykov et al. (2009) E: Bilateral training • Motor Assessment Scale (-)
RCT (5) C: Unilateral training • Motor Status Scale (-)
N=21
Summers et al. (2007) E: Bilateral training • Modified Motor Assessment Scale (+)
RCT (5) C: Unilateral training
N=12
Cauraugh & Kim (2002) E1: Electrical stimulation + bilateral training• Box and Block Test: E1 vs. E2/C (+); E2 vs. C (+)
RCT (5) E2: Electrical stimulation + unilateral
N=25 training
C: Control
Byl et al. (2013) E: Bilateral orthosis • Upper Limb Fugl Meyer Assessment (-)
RCT (5) C: Unilateral orthosis
NStart=18
NEnd=15
Han & Kim (2016) E: Bilateral arm training • Box and Block Test (-)
RCT (5) C: Unilateral arm training • Elbow Amplitude (-)
NStart=25 • Shoulder Amplitude (+)
NEnd=25
Singer et al.(2013) E: Bilateral training + EMG-ES • Fugl Meyer (-)
RCT (4) C: Unilateral training + EMG-ES • Arm Motor Ability Test (-)
NStart=24
NEnd=21
Kim et al. (2013) E1: Bilateral robotic training • Fugl-Meyer Assessment (-)
RCT (3) E2: Unilateral robotic training
N=15 C: Usual Care
Anandabai et al. (2013) E: Bimanual training • Fugl Meyer (-)
PCT C: Unilateral training • Wolf Motor Function Test (-)
NStart=30
NEnd=30
Discussion
In a large multicentre RCT, Whitall et al. (2011) evaluated the effect of bilateral arm training on upper
limb functional recovery. Results failed to show a difference between bilateral training and unilateral
training, indicating that training with both arms does not provide additional benefits for improving
impairment in the affected upper limb (Whitall et al., 2011). While the results of another large RCT also
found no significant difference between bilateral arm training and unilateral arm training interventions
in arm function, finger dexterity was improved in the bilateral arm training group (Morris et al., 2008). In
addition to these, many additional studies including those by Dispa et al. (2013), Stoykov et al. (2009),
Han & Kim (2016), Desrosiers et al. (2005), Byl et al. (2013), and Anandabai et al. (2013) have found no
difference between bilateral arm training and unilateral training on various functional outcomes.
Bilateral training was also shown to have no significant effect when compared to cutaneous electrical
stimulation (Stinear et al., 2014). Some studies show conflicting evidence when comparing bilateral
training to unilateral training and various other conventional therapies, with some outcomes being no
different while others favoring the bilateral arm training group (K. C. Lin et al., 2010; McCombe Waller et
al., 2014; Stinear et al., 2008). On the other hand, studies by Shim et al. (2015) and Summers et al.
(2007) found significant differences between the groups in favour of the bilateral arm training group,

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although both of these studies had very small sample sizes, indicating low validity and credibility due to
insufficient power.
Coupling bilateral arm training with rhythmic auditory cueing (BATRAC) was also found to be non-
superior over conventional therapy with regards to its effectiveness on upper limb motor function in
both chronic and acute stroke patients (Luft et al., 2004; van Delden et al., 2015; van Delden et al.,
2013). However, van Delden et al. (2013) found that the BATRAC group had a significantly more
favourable score on the Stroke Impact Scale than conventional therapy. This suggests that while the
BATRAC protocol may not improve functional outcomes, it may provide improvements on measures of
independence.
Overall, studies reveal that in comparison with modified constraint-induced movement therapy (mCIMT)
delivered alone or in combination with other treatment, bilateral arm training does not improve upper
limb motor function (Brunner et al., 2012; van Delden et al., 2013). Distributed constraint-induced
therapy (dCIT) has been found to evoke significantly greater changes in the Motor Activity Log measure
compared to bilateral arm training and to conventional therapy in one study (Wu et al., 2011); however,
the apparent lack of effectiveness of mCIMT suggests that more research is needed to come to a
definitive conclusion about dCIT (van Delden et al., 2013).
In one study, when bilateral arm training was supplemented with electrical stimulation, findings
revealed an improvement in manual dexterity and function when compared to a control group
(Cauraugh & Kim, 2002). However, no significant difference in general arm motor function was found
when this treatment was compared with unilateral arm training (Singer et al., 2013). Due to low
methodological quality and statistical power, further evidence is required to come to a conclusion
regarding the effectiveness of bilateral training with electrical stimulation.
According to three studies (H. Kim et al., 2013; C. Y. Wu, C. L. Yang, et al., 2013; Yang CL, 2012), bilateral
robotic training did not improve motor function significantly more than unilateral robotic training or
conventional therapy.
In a recent study by Hsieh et al. (2016), bilateral arm priming was coupled with task-oriented training
and was compared to task-oriented training alone. The results indicated that there was no significant
difference between groups in terms of motor function, although there was a significant benefit in
measures of independence for the bilateral arm training group. When bilateral training was coupled
with nervous system rehabilitation, it was also shown to improve independence in participants when
compared to nervous system rehabilitation alone (M.-H. Lee et al., 2013).
Conclusions Regarding Bilateral Arm Training
There is level 1a evidence that bilateral training is not more effective than unilateral training for
upper limb motor function outcomes.
There is level 1a evidence that bilateral training is not more effective than conventional therapies
such as modified constraint induced movement therapy and cutaneous electrical stimulation.
There is level 1a evidence that bilateral arm training with rhythmic auditory cueing (BATRAC) is not
more effective than unilateral arm training.

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Bilateral arm training on its own or in combination with other therapies is likely not more effective
for improving upper limb motor function than unilateral arm training or other conventional
therapies.
10.2.3 Arm and Leg Training

In this section, we examined studies that investigated the effectiveness of providing arm training in
comparison to leg training for upper limb function
The results of controlled trials evaluating arm training versus leg training are summarized in Table
10.2.3.1.
Table 10.2.3.1 Summary of Controlled Trials Evaluating Arm and Leg Training for the Upper Extremity
Sample Size
Blennerhassett & Dite (2004b) E1: Upper extremity task related practice • Jebsen Taylor Hand Function (+)
RCT (9) E2: Lower extremity task-related practice • Motor Assessment Scale (+)
N=30 (1 hour a day x 5 days x 4 weeks)
Kwakkel et al. (1999) E1: Arm training • Barthel Index: E1 vs. C (+), E2 vs. C (+)
RCT (8) E2: Leg training • Action Research Arm Test (+)
Higgins et al. (2006) E1: Upper extremity task related practice • Box and Block Test (-)
RCT (8) E2: Lower extremity task-related practice
N=47 (90 min x 3 sessions/week x 6 weeks)
Sanchez-Sanchez et al. (2017) E1: Upper extremity function training • Fugl Meyer Score (+)
RCT (8) E2: Lower extremity function training • Wolf Motor Function Test (+)
NStart=15 • Grip Strength (-)
NEnd=14 • Muscle Tone (-)
•
Mares et al. (2014) E1: Functional strength training for upper limb • Action Research Arm Test: post (+), follow-
RCT (8) E2: Functional strength training for lower limb up (+)
NStart=52
NEnd=44
Pang et al. (2006) E1: Arm training • Fugl Meyer Score (+)
RCT (7) E2: Leg training • Wolf Motor Function Test (+)
NStart=63
NEnd=60
Discussion
Based on the results of 5 randomized controlled trials, additional upper extremity task practice, function
training or strength training offers significantly greater benefits in arm function than what is obtained
from comparable leg rehabilitation (Blennerhassett & Dite, 2004a; Kwakkel et al., 1999; Mares et al.,
2014; Pang et al., 2006; Sánchez-Sánchez et al., 2017). One study by Higgins et al. (2006) found no
significant difference between upper extremity and lower extremity task practice on the Box and Block
Test, a measure of function and dexterity for the upper body.
Conclusions Regarding Arm and Leg Training

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There is level 1a evidence that arm function training, task practice, and strength training provide
significant functional improvements in the arm after stroke in comparison to similar leg training.
Arm training is likely more effective than leg training for improving arm function after stroke.
10.2.4 Additional/Enhanced Therapy

In this section, we examined studies that investigated the effectiveness of providing supplementary
therapy targeting the upper extremity in addition to usual care or conventional therapy.
The results of controlled trials evaluating additional/enhanced therapy are summarized in Table
10.2.4.1.
Table 10.2.4.1 Summary of Controlled Trials Evaluating Additional/Enhanced Therapy for the Upper
Extremity
Sample Size
Kwakkel et al. (1999) E1: Arm training • Action Research Arm Test: E1 vs C (+)
RCT (8) E2: Leg training • Barthel Index: E1 vs C (-)
Ross et al. (2009) E: Additional task-specific motor training • Action Research Arm Test (-)
RCT (8) C: Standard care • Summed Manual Muscle Test (-)
NStart=39
NEnd=37
Harris et al. (2009) E: Graded repetitive upper limb supplementary • Chedoke Arm and Hand Activity Inventory (+)
RCT (8) program (GRASP) • Grip Strength (+)
N=103 C: Education • Paretic Upper Limb Use (+)
Duncan et al. (2003) E: Supervised home program • Fugl Meyer Score (-)
RCT (8) C: Usual care • Grip Strength (-)
N=92 • Functional Reach (-)
• Wolf Motor Function Test (-)
Lincoln et al. (1999) E: Additional physiotherapy • Rivermead Motor Assessment (arm) (-)
RCT (7) C: Routine physiotherapy • Action Research Arm Test (-)
N=282 • Barthel Index (-)
English et al. (2015) E1: Group Circuit Classes of task-specific training 5• Wolf Motor Function Test (-)
RCT (7) days a week • Functional Independence Measure (-)
NStart=283 E2: Usual Physiotherapy 7 days a week • Stroke Impact Scale (-)
NEnd=261 C: Individual Physiotherapy 5 days a week • Health related quality of life (-)
Platz et al. (2001) E: Arm ability training • Test d'Évaluation des Membres Supérieurs de
RCT(7) C: Routine therapy Personnes Âgées (TEMPA) (+)
N=60
Liu et al. (2014) E: Self-regulation • FIM motor (+)
RCT (7) C: Conventional functional rehabilitation • FIM: cognitive (-)
NStart=46 • Fugl Meyer: upper limb (-), lower limb (-)
NEnd=44
Rodgers et al. (2003) E: Stroke unit care + enhanced upper limb rehab • Action Research Arm Test (-)
RCT (7) C: Conventional stroke unit care • Motricity Index (-)

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N=123 • Frenchay Arm Test (-)
• Upper limb pain (-)
• Barthel Index (-)
• Nottingham E-ADL (-)
Donaldson et al. (2009) E: Functional strength training + conventional • Action Research Arm test (-)
RCT (6) therapy
Nstart=30 C: Conventional therapy
NEnd=19
Han et al. (2013) E1: 1 hour of standard arm training per day • Fugl Meyer Score: E3 vs. E1 (+); E3 vs. E2 (-
6 (RCT) E2: 2 hours of standard arm training per day ); E1 vs. E2 (+)
N=32 E3: 3 hours of standard arm training per day • Barthel Index (-)
Sunderland et al. (1992) E: Enhanced therapy Severe Group:
Sunderland et al. (1994) C: Conventional therapy • Extended Motricity Index: 6mo (-)
RCT (6) • Motor Club Assessment: 6mo (-)
N=132 • Nine Hole Peg Test: 6mo (-)
• Frenchay Arm Test: 6mo (-)
Mild Group:
• Extended Motricity Index: 6mo (+)
• Motor Club Assessment: 6mo (-)
• Nine Hole Peg Test: 6mo (+)
• Frenchay Arm Test: 6mo (-)
De Diego et al. (2013) E: Conventional training + home training • Fugl Meyer Score (-)
RCT (6) C: Conventional training • Motor Activity Log (-)
NStart=21 • Stroke Impact Scale (-)
NEnd=21
Fluet et al. (2014) E: Hand + finger training • Wolf Motor Function Test (-)
RCT (6) C: Finger training • Jebsen Taylor Hand Test (-)
NStart=41 • Kinematic measures of shoulder and elbow
NEnd=40 function: Finger fractionation; Hammer-
Task simulation (Time-to-task completion;
Reaching trajectory smoothness; End point
deviation) (+)
Repsaite et al. (2015) E: Differential training + standard rehabilitation • Wolf Motor Function Test (+)
RCT (5) C: Standard rehabilitation
NStart=27
NEnd=27
Trombly et al. (1986) E1: Resisted Grasp • Range of Motion (-)
RCT (4) E2: Resisted Extension • Speed of Reversal of Movement (-)
N=20 C: Ballistic Extension • Ability to Rapidly Reverse Movement (-)
Dickstein et al. (1997) E: Repeated movement therapy • Barthel Index (-)
RCT (3) C: Conventional therapy • Fugl Meyer Score (-)
N=27 • Frenchay Tests (-)
Mazzoleni et al. (2013) E: Shoulder/elbow training + wrist training • Fugl Meyer (-)
PCT C: Shoulder/elbow training • Motricity Index (-)
NStart=64 • Movement velocity (+)
NEnd=64 • Movement distance (-)
Smedes et al. (2014) E: Manual mobilization therapy + conventional • Passive wrist extension (+)
PCT therapy • Active wrist extension (+)
NStart=18 C: Conventional therapy • Frenchay Arm Test (+)
NEnd=18
Minagawa et al. (2015) E: Hair brushing movement + conventional • Range of Motion: shoulder abduction (+),
PCT therapy external rotation (+)

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NStart=62 C: Conventional therapy
NEnd=62
Discussion
A variety of treatments were delivered in varying durations and intensities, making general conclusions
difficult to draw for additional therapy of the upper limb in general. Additionally, most of the
interventions were non-specific in nature.
The majority of RCTs examined found no significant difference between additional therapy and
conventional therapy for upper limb motor function (Dickstein et al., 1997; Donaldson et al., 2009;
English et al., 2015; Lincoln et al., 1999; Rodgers et al., 2003; Ross et al., 2009). The additional therapies
studied included task-specific motor training, enhanced rehabilitation, and functional strength training,
among other more broadly defined therapies. Studies by Duncan et al. (2003) and De Diego et al. (2013)
found that there was no significant improvement in motor function in participants receiving a therapist-
supervised home program, or a home training program, respectively, in comparison to those receiving
usual care. Self-regulation was also not found to be superior to conventional rehabilitation on motor
function or on measures of independence, except for the FIM motor subsection (Liu & Chan, 2014).
Results from a Cochrane review agree with these findings, suggesting no statistically significant result
related to the use of home-based therapy programmes on the functional improvement of the upper
limb (Coupar, Pollock, Legg, Sackley, & van Vliet, 2012). However, the conclusions derived from this
Cochrane review are based on only four poor quality studies, suggesting that future higher-quality RCTs
are needed prior to making clinical recommendations.
Kwakkel et al. (1999) found that arm training provided additional improvements in upper limb motor
function than conventional therapy, as did Platz et al. (2001), Han et al. (2013), and Repsaite et al.
(2015). An RCT by Harris et al. (2009) found that Graded repetitive upper limb supplementary program
(GRASP) was superior to education on the Chedoke Arm and Hand Activity Inventory, as well as for grip
strength and paretic upper limb use. However, this result should be interpreted with caution because
the control group did not receive a conventional active therapy.
Variation between studies may account for some of the differences in results between studies. For
example, Han et al. (2013) demonstrated a significant difference in arm motor function between groups
receiving only 1 hour of arm training a day and those receiving 2 or 3 hours a day, with no significant
difference between those receiving 2 and 3 hours of training a day. This indicates the relevance of
duration within interventions for upper limb rehabilitation. Furthermore, Sunderland et al., (1992) and
(1994) also demonstrated that participants may differ in outcome after the same intervention based on
stroke severity. They found that while participants who had sustained a severe stroke did not improve
significantly more from enhanced therapy than those in the conventional therapy group, those with mild
stroke, had made significant gains on the Extended Motricity Index and the Nine Hole Peg Test.
Therefore, because of the large variation between studies on so many variables, it can be difficult to
come to a definite conclusion for all additional therapies.
Conclusions Regarding Additional/Enhanced Therapies
There is level 1a evidence that additional upper limb therapy is not superior to conventional therapy
at improving upper extremity motor function or functional independence.

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There is level 1b evidence that a therapist-supervised in-home program is not more effective than
usual care at improving upper limb motor function.
Additional upper limb therapy does not appear to be superior to conventional therapy for
improving upper limb motor function or functional independence.
10.2.5 Strength Training

Studies which evaluated treatments directed at specifically increasing strength in the upper extremity
have been compiled below. A much larger pool of studies has been published on strength training in the
lower extremity.
RCTs that evaluated strength training and assessed measures of strength, are summarized in Table
10.2.5.1.
Table 10.2.5.1 Summary of RCTs Evaluating Strength Training for Upper Extremity
Sample Size
Da Silva (2015) E: Strength training • TEMPA (+)
RCT (8) C: Standard care • Glumerohumeral flexion strength (+)
NStart=20 • Active shoulder Range of Motion (+)
NEnd=20 • Fugl Meyer Scores (+)
Hendy & Kidgell (2014) E1: Anodal tDCS + strength training • Extensor carpi radialis strength (+)
RCT (7) E2: sham tDCS + strength training
NStart=10 C: Anodal tDCS
NEnd=10
Patten et al. (2013) E: Functional Task Practice and Power Training • Wolf Motor Function Test (-)
USA C: Functional Task Practice • Ashworth Scale (-)
RCT (7) • Functional Independence Measure (+)
N=19
Corti et al. (2012) E1: Power Training • Shoulder Flexion and Elbow Extension (+)
RCT (7) E2: Functional Task Practice
N=14
Lin et al. (2015) E: Bilateral Isometric Handgrip Force Training • Fugl-Meyer Assessment-Upper Extremity (+)
RCT (7) with Visual Feedback • Wolf Motor Function Test (+)
NStart=33 C: Routine Therapy • Motor Assessment Scale (+)
NEnd=33 • Barthel Index (+)
Thielman et al. (2013b) E: Progressive resistive strength training • Activate range of motion for shoulder and
RCT (6) C: Task-related training elbow (+)
NStart=16 • Wolf Motor Function Test at 1 yr (+)
NEnd=16 • Reaching at 1 yr (+)
Winstein et al. (2004) E1: Strength training • Fugl Meyer Assessment: E1/E2 vs. C (+)
RCT (6) E2: Functional task practice • Functional test of the hemiparetic upper
N=64 C: Standard care extremity: E1/E2 vs. C (+)
Trombly et al. (1986) E1: Resisted Grasp • Finger Extension Range of Motion (-)
RCT (4) E2: Resisted Extension • Speed of Reversal of Movement (-)
N=20 C: Ballistic Extension • Ability to Rapidly Reverse Movement (-)
Awad et al. (2015) E: Shoulder Strength Training, Trunk Control • Shoulder Abduction Peak Torque (+)
RCT (4) Training, and Additional Strengthening • Shoulder External Rotator Peak Torque (+)
NStart=30 Exercises. • Supraspinatus Peak Force (+)
NEnd=23 C: Shoulder Strength Training and Trunk Control • Upper Trapezius Peak Force (+)

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Training. • Serratus Anterior Peak Force (+)
• Scapular Upward Rotation Angle (+)
• Spinal Lateral Deviation Angle (+)
Discussion
Strength training was found to improve motor function and shoulder range of motion of the impaired
upper extremity in studies by (Awad et al., 2015; da Silva et al., 2015; C. H. Lin et al., 2015; Thielman,
2013b). Additionally, Winstein et al. (2004) found that strength training and functional task practice
offered similar improvements in motor function when compared to standard care. However, a study by
Patten et al. (2013) found that when functional task practice and power training were combined, there
was no significant difference on motor function outcomes when combined to functional task practice
alone.
Hendy & Kidgell (2014) found a significant increase in extensor carpi radialis strength from strength
training, while Corti et al. (2012) found that power training offered greater shoulder flexion and elbow
extension than functional task practice. On the other hand, Trombly et al. (1986) found that there was
no significant difference in finger range of motion observed after patients received resisted grasp,
resisted extension, or ballistic extension.
Harris & Eng (2010) conducted a systematic review and meta-analysis of strength training on upper limb
strength, function and ADL performance following stroke. Fourteen studies were identified in total, of
which six (306 subjects) evaluated the effect on grip strength. There was a significant effect associated
with training (standardized mean difference=0.95, 95% CI 0.05 to 1.85, p=0.04). Two trials assessed
other measures of strength with conflicting results.
Conclusions Regarding Strength Training
There is level 1a evidence from a meta-analysis that strength training increases grip strength
following stroke.
There is level 1a evidence that strength training improves upper limb motor function and shoulder
range of motion.
Strength training likely helps improve grip strength, motor function, and shoulder range of motion
following stroke.
10.2.6 Repetitive/Task- Specific Training Techniques

It is well established that task-specific practice is required for motor learning to occur (Schmidt, 1991).
According to Classen et al. (1998), focal transcranial magnetic stimulation and functional magnetic
resonance imaging have shown that task-specific training, in comparison to traditional stroke
rehabilitation, yields long-lasting cortical reorganization specific to the corresponding areas being used.
More specifically, Karni et al. (1995), using functional magnetic resonance imaging, and Classen et al.
(1998), using transcranial magnetic stimulation, both reported a slowly evolving, long-term, experience-
dependent reorganization of the adult primary motor cortex following daily practice of task-specific
motor activities. Also of interest is that task-specific sessions (i.e., thumb and hand movements), as
short as 15 minutes in duration, are also effective in inducing lasting cortical representational changes

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(Bütefisch, Hummelsheim, Denzler, & Mauritz, 1995; Classen et al., 1998). According to Page (2003),
intensity alone does not account for the differences between traditional stroke and task-specific
rehabilitation. For example, Galea et al. (2001) reported that stroke patients who underwent a 3-week
long program consisting of 45-minute task-specific, upper limb training showed improvements in
measures of motor function, dexterity, and increased use of the more affected upper limbs. According
to Page (2003), other, task-specific, low-intensity regimens designed to improve use and function of the
affected limb have also reported significant improvements (Smith et al., 1999; Whitall et al., 2000;
Winstein et al., 2001).
A summary of controlled trials evaluating repetitive/task-specific training are presented in Table

10.2.6.1.
Table 10.2.6.1 Summary of Controlled Trials Evaluating Repetitive/Task- Specific Techniques for the
Upper Extremity
Sample Size
Arya et al. (2012) E: Task-specific training • Fugl Meyer Score (+)
MTST Trial C: Standard training using the Bobath approach • Action Research Arm Test (+)
RCT (9)
NStart=103
NEnd=102
Kim et al. (2015) E: Target reach training with visual biofeedback, • Fugl-Meyer Upper Extremity (+)
RCT (8) routine occupational and physical therapy • Wolf Motor Function Test (+)
NStart=44 C: Routine occupational and physical therapy • Reaching speed (+)
NEnd=40 • Range of Motion of the shoulder (+)
• Reach distance (-)
Hung et al. (2016) E: Robotic training + task-specific training • Fugl-Meyer Assessment (+)
RCT (8) C: Robotic training + impairment oriented • Stroke Impairment Scale (+)
NStart=21 training
NEnd=21
Graef et al. (2016) E: Task-oriented training • Upper-Extremity Performance Test (+)
RCT (8) C: Non task-oriented training • Shoulder Strength (-)
NStart=28 • Grip Strength (-)
NEnd=27 • Shoulder Active Range of Motion (-)
• Fugl-Meyer Assessment (-)
• Modified Ashworth Scale (-)
Winstein et al. (2016) E1: Structured, task-oriented upper extremity • Wolf Motor Function Test: E1 vs E2 (-); E1
ICARE Trial training vs C (-); E2 vs C (-)
RCT (7) E2: Dose-equivalent occupational therapy • Stroke Impact Scale: E1 vs E2 (-); E1 vs C
NStart=361 C: Monitoring-only occupational therapy (-); E2 vs C (-)
NEnd=361
Shimodozono et al. (2013) E: Repetitive functional exercise • Action Research Arm Test (+)
RCT (7) C: Conventional rehabilitation • Grasp and pinch (+)
NStart=52 • Fugl Meyer (+)
NEnd=49
Cauraugh & Kim (2003) E1: Blocked practice + active stimulation • Box and Block Test (+)
RCT (6) E2: Random practice + active stimulation • Reaction Time (+)
N=64 C: No active stimulation assistance
Zondervan et al. (2014) E: Self-guided, high-repetition home therapy • Fugl-Meyer Assessment (-)

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RCT (6) with mechanical arm exerciser • Motor Activity Log (-)
NStart=16 C: Conventional therapy • Visual Analogue Scale (-)
NEnd=16 • Ashworth Scale (-)
Hubbard et al. (2015) E: Task-specific training and standard care • Upper Limb Motor Assessment Scale (-)
RCT (6) C: Standard Care • Modified Rankin Scale (-)
NStart=23
NEnd=23
Thielman (2012) E1: Task-Related Training • Wolf Motor Function Test (-)
RCT (6) E2: Resistive Exercise Training • Fugl Meyer Assessment (-)
NStart=16
NEnd=16
Thielman et al. (2013a)
Kim et al. (2016) E: Electromyogram triggered neuromuscular • Fugl-Meyer Assessment (+)

RCT (6) stimulation with task oriented training on • Box and Block Test (+)
NStart=20 paretic arm • Jebsen-Taylor Hand Function Test for
NEnd=20 C: Electromyogram triggered neuromuscular short sentences and stacking checkers (+)
stimulation
Brkic et al. (2016) E: Repetitive upper limb functional task practice • Action Research Arm Test (+)
RCT (5) C: Conventional rehabilitation • Grip Strength (+)
NStart=24
NEnd=22
Boyd et al. (2010) E: Task-specific training • Change in reaction and movement time
RCT (5) C: General arm training (+)
N=18
Jeon et al. (2016) E: Repetitive bilateral and unilateral • Flexion and abduction range of motion
RCT (5) movements with strength exercises (+)
NStart=12 C: Conventional rehabilitation • Visual analogue scale (+)
NEnd=12
Lang et al. (2016) E1: 3200 repetitions of task-specific upper limb • Action Research Arm Test (-)
RCT (5) training • Stroke Impact Scale (-)
NStart=85 E2: 6400 repetitions of task-specific upper limb • Canadian Occupational Performance
NEnd=82 training Measure (-)
E3: 9600 repetitions of task-specific upper limb • Likert Scale evaluating perceived change
training and its meaningfulness (-)
C: Individualized maximum repititions
Taub et al. (2013) E1: Shaping training + transfer package (TP) • Motor Activity Log: E1/E2 vs. E3/C (+)
RCT (5) E2: Repetitive task practice + TP • Wolf Motor Function Test: E1/E2 vs. E3/C
NStart=45 E3: Repetitive task practice (+)
NEnd=40 C: Shaping training
Song et al. (2015) E1: Task-oriented bilateral arm training • Box and Block Test (+)
RCT (5) E2: BATRAC • Jebsen Taylor Hand Function Test (+)
NEnd=40
Thielman et al. (2004) E: Progressive resistive exercises • Kinematic analysis of arm movement (+)
RCT (4) C: Task-related training • Modified Ashworth Scale (-)
N=12 • Rivermead Motor Assessment (-)
Mani et al. (2014) E1: Right hemisphere damage (RHD) reaching • Arm performance: contralesional (-),
PCT tasks ipsilateral (-)
NStart=30 E2: Left hemisphere damage (LHD) reaching • Leftward reaching frequency: E1 vs. E2
NEnd=30 tasks (+)

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Urbin et al. (2015) E1: Task-specific training as an inpatient (13 • Action Research Arm Test (+; E1)
PCT sessions) • Use ratio, magnitude ratio, variation
NStart=35 E2: Task-specific training as an outpatient (28 ratio, median paretic upper extremity
NEnd=35 sessions) acceleration magnitude, upper extremity
acceleration variability (+; E1)
• Higher acceleration metric in ratio,
magnitude ratio, variation ratio, median
paretic upper extremity acceleration
magnitude, upper extremity acceleration
variability (+; E2)
Tretriluxana et al. (2015) E: Observation for 6 min, perform task for 4 • Movement time (-)
PCT min. for 4 sessions • Reaction Time (-)
NStart=12 C: Observation for 1 min, perform task for 1
NEnd=12 min. for 24 sessions.

Discussion
The majority of studies investigating task-specific training found a significant improvement in upper limb
motor function. Of note is a study by Arya et al. (2012), with a large sample size, in which task-specific
training was compared to standard training, and was found to be superior on the Fugl Meyer
Assessment and the Action Research Arm Test. Similarly, Kim et al. (2015) compared target reach
training with visual biofeedback to conventional therapy, while Hung et al. (2016) compared task-
specific training with robotic training to impairment-oriented training with robotic training, with both
groups finding a significant improvement in the group receiving task-specific training. Shimodozono et
al. (2013) likewise found a significant improvement for upper limb motor outcomes in those receiving
repetitive function exercise in comparison to conventional therapy, while Kim et al. (2016) found a
similar finding when comparing EMG-NMES with task-oriented training to EMG-NMES alone.
Some studies also found no significant difference on upper limb motor function outcomes between
groups receiving task-oriented therapy and those receiving other therapies or conventional therapy. For
example, Graef et al. (2016) found that those receiving task-oriented training did not have significantly
improved grip strength, range of motion, upper limb motor function, and spasticity. The study by
Winstein et al. (2016), also known as the ICARE Trial, is a very large, multicenter trial which found that
structured, task-oriented upper extremity training did not offer significant improvements in upper limb
motor function when compared to those receiving dose-equivalent occupational therapy, or to those
receiving monitoring-only occupational therapy. Likewise, Zondervan et al. (2014) found that self-
guided, high-repetition home therapy with a mechanical arm exerciser did not provide significantly
improved upper limb motor function in comparison to conventional therapy, while Thielman et al.
(2012) found a similar result when comparing task-related training to resistive exercise training.
Barreca et al. (2003a) reviewed 2 studies (Bütefisch et al., 1995; Dickstein et al., 1997) which
investigated repetitive training for the upper extremity, including repeated practice of elbow, wrist and
finger flexion and extension, concluding that there was a positive treatment effect found.
A recent Cochrane review authored by French et al. (2007) evaluated the effect of task-specific training
on both upper and lower-extremity function. Trials were included if one of the intervention arms
included “an active motor sequence [that] was performed repetitively within a single training session,
and where the practice was aimed towards a clear functional goal.” Eight and five RCTs, respectively,

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were identified that assessed arm and hand function. Pooled results indicated that task-specific training
was not associated with improvement in either hand or arm function. The standardized mean
differences were small (0.17 and 0.16) and not statistically significant. A more recent Cochrane review,
including 14 trials, also found that there was no significant improvement on measures of hand or arm
motor function (French et al., 2010).
Timmermans et al. (2010) conducted a review that examined the effectiveness of task-oriented training
following stroke. Fifteen components were identified to characterize task-oriented training. They
included exercises that were functional, directed towards a clear goal, repeated frequently, performed
in a context-specific environment, and followed by feedback. Sixteen studies representing 528 patients
were included. From 3 to 11 training components were reported within the included studies. The
components associated with largest effect sizes were "distributed practice" and "feedback”. There was
no correlation between the number of task-oriented training components used in a study and the
treatment effect size. "Random practice" and "use of clear functional goals" were associated with the
largest effect sizes at follow-up.
Many of the treatments reviewed were non-specific in nature, not well described and were evaluated
on patients at different stages of neurological recovery. Sample sizes were generally small. Furthermore,
the interventions varied across studies, severely limiting comparability. Often, multiple outcomes were
assessed, some of which demonstrated a benefit, while others did not; typically there was improvement
on impairment level outcomes, which did not transfer to functional improvements (disability level). The
conclusions that we draw pertain only to the subset of interventions that were assessed, and cannot be
generalized to any other specific treatment.
Conclusions Regarding Repetitive Task-Specific Training Techniques
There is level 1a evidence that task-related practice may be superior to conventional training at
improving upper extremity motor function.
There is level 1b evidence that task-related training may not be superior to resistive training or
bilateral arm training at improving general upper limb motor function; however, it may improve
reaching arm movements.
There is level 1b evidence that combining task practice with active stimulation may improve manual
dexterity and reaction time.
Due to the variation in the treatment protocols, it is unclear whether repetitive task-specific
training in combination with additional treatments improves upper extremity function.
10.2.7 Trunk Restraint

Reaching movements performed with the affected arm in patients are often accompanied by
compensatory trunk or shoulder girdle movements, which extend the reach of the arm (Michaelsen,
Luta, Roby-Brami, & Levin, 2001). Restriction of compensatory trunk movements may encourage
recovery of “normal” reaching patterns in the hemiparetic arm when reaching for objects placed within
arm’s length (Michaelsen & Levin, 2004). Several trials have evaluated the effectiveness of trunk
restraint combined with task-specific training to improve the movement quality of reaching tasks.
The results of RCTs evaluating trunk restraint therapy are summarized in Table 10.2.7.1.

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Table 10.2.7.1 RCTs Examining Trunk Restraint to Improve Upper Limb Motor Function
Sample Size
Bang et al. (2015) E: CIMT + trunk resistant training • Action Research Arm Test (+)
RCT (9) C: CIMT • Fugl Meyer (+)
NEnd=18 • Motor Activity Log: Amount of Use (+),
Quality of Movement (+)
Lima et al. (2014) E: mCIMT + trunk resistant training • Motor Activity Log: Amount of Use (-),
RCT (8) C: mCIMT Quality of Movement (-)
NStart=22 • Bilateral Activity Assessment Scale (-)
NEnd=15 • Wolf Motor Function Test (-)
• Global strength (-)
• Stroke Specific Quality of Life Scale (-)
• Reach and grasp (-)
Michaelsen el al. (2006) E: Trunk-restraint with object-related reach-to- • Upper extremity performance test (+)
RCT (7) grasp training • Fugl Meyer Arm Section (+)
NStart=30 C: Non-restraint training • Box and Block Test (-)
NEnd=10
de Oliveira et al. (2015) E: Trunk resistant training with harness • Modified Ashworth Scale (-)
RCT (7) C: Trunk resistant training without harness • Fugl Meyer Score (-)
NStart=22 • Barthel Index (-)
NEnd=20
Wu et al. (2012) E1: CIMT + trunk restraint • Kinematics: E1&E2 vs. C (+)
RCT (5) E2: CIMT • Action Research Arm Test: E1&E2 vs. C (+)
N=57 C: Control • Fugl Meyer: E1&E2 vs. C (+)
Woodbury et al. (2009) E: CIMT + trunk restraint • Fugl Meyer (-)
RCT (5) C: CIMT • Wolf Motor Function Test (-)
N=11 • Kinematic analyses of reaching (+)
Wu et al. (2012) E1: Distributed constraint-induced therapy and • Action Research Arm Test: E1/E2 vs C (+)
5 (RCT) trunk restraint • Frenchay Activities Index: E1/E2 vs C (+)
E2: Distributed constraint-induced therapy • Hand domain of Stroke Impact Scale:
C: Dose-matched control intervention E1/E2 vs C (+)
• Motor Activity Log (+)
Michaelsen & Levin (2004) E: Trunk restraint group • Velocity peak, wrist peak velocity (-)
RCT (5) C: No restraint • Movement time and time to peak
N=28 velocity (-)
• Trunk rotation (-)
• Shoulder horizontal adduction and
shoulder flexion (-)
• Trunk displacement (+)
• Elbow Extension (+)
Thielman (2010) E: Trunk restraint • Reaching Performance Scale Near Target
RCT (4) C: Sensory feedback (+)
N=16 • Reaching Performance Scale Far Target (-)
Discussion

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One recent study by Bang et al. (2015) suggested that combing constraint-induced movement therapy
(CIMT) with trunk restraint training improved upper limb motor function when compared to CIMT alone;
however, these results have not been replicated by other studies (De Oliveira Cacho et al., 2015; Lima et
al., 2014; Woodbury et al., 2009; Wu et al., 2012). When trunk restraint therapy was combined with
object-related reach-to-grasp training, results have demonstrated an improvement in general upper
limb function but not in manual dexterity when compared to non-restraint training (Michaelsen et al.,
2006).
In a recent systematic review and meta-analysis, Wee et al. (2014) evaluated the effect of trunk restraint
therapy on upper extremity recovery in patients with chronic stroke. The review included six RCTs,
involving a total of 187 participants. The meta-analysis was conducted on several upper limb functional
outcomes including the FMA, shoulder flexion, elbow extension, Motor Activity Log-Amount of Use,
Motor Activity Log-Quality of Movement, trunk displacement, and reaching trajectory smoothness and
straightness. The overall results indicated that the majority of the measures showed no preference of
trunk displacement over the control condition, with only the FMA and shoulder flexion demonstrating
significant effects. It is also pertinent to note that the outcomes evaluated in the review were measured
in three studies on average. Shoulder flexion and elbow extension were evaluated in four studies each,
while reaching trajectory straightness was evaluated in two studies. Although all studies included in the
review scored ≥6 on the Physiotherapy Evidence Database (PEDro) tool, signifying high methodological
quality, the authors indicated that there is still insufficient evidence to demonstrate a beneficial effect of
trunk restraint therapy on upper extremity motor function. Future studies investigating the effects of
this intervention during the acute stage of stroke are encouraged.
Conclusions Regarding Trunk Restraint
There is conflicting level 1a evidence regarding the efficacy of trunk restraint therapy on upper
extremity function when combined with constraint induced movement therapy or delivered alone.
Trunk restraint may improve some aspects of upper limb motor function but not others (i.e. elbow
extension, reaching trajectory, trunk displacement).
10.2.8 Sensorimotor Training and Somatosensory Stimulation

Somatosensory deficits are common following stroke. Connell et al. (2008) reported that among 70
patients with first-ever stroke, 7-53% had impaired tactile sensation, 31-89% impaired stereognosis, and
34-64% impaired proprioception. Sensorimotor impairment is associated with slower recovery following
stroke; therefore, therapies to increase sensory stimulation may help to improve motor performance.
Stimulation can be applied using a variety of methods including transcutaneous electrical nerve
stimulation (TENS), vibration therapy, peripheral nerve/afferent stimulation, thermal stimulation, or
transcutaneous electrical acupoint stimulation (TEAS)/electroacupuncture.
Transcutaneous Electrical Nerve Stimulation (TENS)
The application of electrical stimulation at a sensory level may help to enhance plasticity of the brain,
which in turn may help with motor recovery (Sonde, Gip, Fernaeus, Nilsson, & Viitanen, 1998). Robbins
et al. (2006) described the current intensity of TENS to be beneath motor threshold, although capable of
generating a “pins-and-needles sensation”. Similar to acupuncture, TENS is one method through which
to achieve increased afferent stimulation.

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A Cochrane review Pomeroy et al. (2006) examined the use of all forms of electrostimulation (ES) in the
recovery of functional ability following stroke. This review assessed the efficacy of functional electrical
stimulation (both as a form of neuromuscular retraining and as a form of neuroprosthesis/orthosis),
transcutaneous electrical nerve stimulation (TENS), EMG and electroacupuncture. The primary outcome
included nine measures of functional motor ability and two ADL measures. The review included four
planned treatment contrasts: 1) ES vs. no treatment; 2) ES vs. placebo stimulation; 3) ES vs. conventional
therapy and 4) One type of ES vs. an alternative type of ES. With respect to the assessment of
treatments specific to the upper extremity and neuromuscular electrical stimulation, five outcomes
were associated with a statistically significant treatment effect. With one exception, all of the pooled
analyses were based on the results from only one study. The results from pooled analyses with positive
results are presented in Table 10.2.8.1. The authors concluded that there was insufficient evidence to
guide practice on the efficacy of ES.
Table 10.2.8.1 Pooled Analysis from 2006 Cochrane Review Assessing Efficacy of ES as a Therapy for
the Upper Extremity
Treatment Contrast Standardized Mean Difference (95% CI)
Outcome Assessed
ES vs. No treatment
Motor reaction time 1.18 (0.00, 2.37)
Isometric torque 1.02 (0.46, 1.59)
Box & Block test 1.28 (0.00, 2.56) *
Upper Extremity Drawing test -1.40 (-2.25, -0.56) (favours no treatment)
ES vs. Placebo
Jebsen Hand Function test feeding 1.36 (0.24, 2.48)
ES vs. Conventional Therapy No outcomes were statistically significant
Comparison of Different Forms of ES No comparisons conducted or reported
* All 3 studies included in the pooled analysis were authored by the same person (Cauraugh)
Laufer & Gabyzon (2011) conducted a systematic review of the effectiveness of TENS for motor
recovery, including the findings from 15 studies. Seven of these studies examined treatments focused on
the upper extremity, while two included both the upper and lower extremities. The majority of studies
recruited participants in the chronic stage of stroke. The outcomes assessed in these studies included
movement kinematics during reaching, pinch force, the Jebsen-Talyor Hand Function test, the ARAT, the
Barthel Index, and the Modified Motor Assessment Scale. The authors stated while there was much
variability in the stimulation protocols and the timing and selection of outcome measures to enable
definitive conclusions, there was still evidence that TENS treatment, when combined with rehabilitation
therapies, may help to improve motor recovery.
Vibration Therapy
Vibration therapy is investigated for its potential therapeutic effects on balance, muscle strength after
stroke, although the protocol has not been established (Liao, Ng, Jones, Chung, & Pang, 2015).
Peripheral Nerve Stimulation/ Afferent Stimulation

Repetitive peripheral magnetic stimulation (rpMS) for upper limb rehabilitation, like functional
neuromuscular stimulation, generates repetitive contraction-relaxation cycles to enhance
proprioceptive input to the affected arm (Krewer, Hartl, MÃ¼ller, & Koenig, 2014). Repetitive pMS is
also believed to penetrate to deeper regions of muscles and be more tolerable than functional

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neuromuscular stimulation. It has also been suggested that PNS stimulates the somatosensory cortex
and elicits cortical reorganisation of the primary motor cortex, thereby modifying motor function
(Conforto, Kaelin-Lang, & Cohen, 2002; Wu, Seo, & Cohen, 2006).
Based on a review of studies investigating peripheral nerve stimulation after stroke, outcomes related to
upper limb motor function improved in those receiving the intervention in comparison to a control
(Obiglio et al., 2016). The review included 5 RCTs and a total of 224 patients.
Thermal Stimulation
Thermal stimulation can be applied in both rehabilitation clinics and home-care-based settings, and may
work through neurofacilitation techniques (Tai et al., 2014). It may be combined with teaching
compensatory strategies, augmented exercise therapy, and task-oriented programs, in a way that is
thought to enhance its effect.
Transcutaneous Electrical Acupoint Stimulation (TEAS) / Electroacupuncture

TEAS and electroacupuncture use similar mechanisms of action, by which acupoints are stimulated by
electrical impulses that are given through needles (Zhao et al., 2015). Previous studies on animal and
human models have determined that EA may block pain through activating bioactive chemicals which in
turn desensitize peripheral nociceptors and reduce proinflammatory cytokines (Zhao et al., 2015).
The results of RCTs evaluating sensorimotor stimulation treatments are summarized in Table 10.2.8.1.
Table 10.2.8.1 Summary of Results from RCTs Evaluating Sensorimotor Training or Stimulation for the
Upper Extremity
Sample Size
TENS
Page et al. (2012) E1: 30 minutes of electrical stimulation • Fugl-Meyer Assessment: E3 vs E2 (+); E3 vs E1
RCT (7) therapy with repetitive task specific (+); E2 vs E1 (-)
N=32 practice • Arm Motor Ability Test: E3 vs E2 (+); E3 vs E1
E2: 60 minutes of electrical stimulation (+); E2 vs E1 (-)
therapy with repetitive task specific • Action Research Arm Test: E3 vs E2 (+); E3 vs E1
practice (+); E2 vs E1 (-)
E3: 120 minutes of electrical stimulation
therapy with repetitive task specific
practice
Celnik et al. (2007) E1: Single session of peripheral nerve • Jebsen-Taylor Hand Function Test (1hr) (+)
RCT (6) stimulation • Jebsen-Taylor Hand Function Test (24hr) (+)
N=9 E2: No stimulation
C: Asynchronous nerve stimulation
Tekeoglu et al. (1998) E: Rehabilitation + TENS • Barthel Index (+)
RCT (6) C: Rehabilitation
N=60
Kim et al. (2013a) E: TENS + task related training • Fugl Meyer Score (+)
RCT (7) C: Placebo + Task related training • Manual Function Test (+)
NStart=30 • Box and Block Test (+)
NEnd=30 • Modified Ashworth Scale (-)
Sonde et al. (1998) E: TENS + physiotherapy • Fugl Meyer (+)
RCT (5) C: Physiotherapy • Pain (-)

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Bütefisch et al. (1995) E: Enhanced specific therapy + TENS • Grip strength (-)
RCT (3) C: Enhanced non-specific therapy • Peak force of Isometric hand extension (-)
N=27 • Peak acceleration of isometric hand extension (-)
Vibration Therapy
Stein et al. (2010) E: Stochastic resonance stimulation • Fugl Meyer (-)
RCT (10) (combination of subthreshold electrical • Motor Activity Log (-)
N=30 stimulation and vibration) • Action Research Arm Test (-)
C: Sham stimulation
Tavernese et al. (2013) E: Segmental muscle vibration + standard • Velocity of movement (+)
RCT (8) therapy • Angular velocity at shoulder (+)
NStart=44 C: Standard therapy • Movement duration (+)
NEnd=44 • Normalized jerk (+)
• Elbow angle, shoulder angle, shoulder
abduction (-)
Paoloni et al. (2014) E: Segmental muscle vibration + • Muscle onset time (+)
RCT (8) conventional therapy • Co-contraction index (+)
NStart=22 C: Conventional therapy • Muscle modulation: anterior deltoid (+), biceps
NEnd=22 brachii (+)
• Maximal voluntary contraction muscle
activation (+)
Caliandro et al. (2012) E: Focal muscle vibration • Wolf Motor Function Test (+)
RCT (7) C: Sham
NStart=49
NEnd=36
Costantino et al. (2017) E: 300 Hz vibrations on the upper limbs •Hand Grip Strength (+)
RCT (7) C: Sham vibrations •Modified Ashworth Scale (+)
NStart=32 • Disabilities of the Arm, Shoulder and Hand Score
NEnd=32 (+)
• Functional Independence Measure (+)
• Fugl-Meyer Assessment (+)
• Jebsen Taylor Hand Function Test (+)
Jung-Sun et al. (2016) E1: Whole-body vibration and task-related • Fugl-Meyer Assessment: E1/E2 vs C (+)
RCT (6) training • Grip Strength: E1 vs C (+); E2 vs C (+); E1 vs E2
NStart=45 E2: Whole-body vibration (+)
NEnd=45 C: Conventional Therapy • Wolf Motor Function Test: E1 vs. E2/C (+)
• Modified Ashworth Scale: E1 vs. E2/C (+)
Peripheral Nerve Stimulation/Afferent Stimulation
Krewer et al. (2014) E: Repetitive peripheral magnetic • Modified Tardieu Scale: Post 1st session: Elbow
RCT (9) stimulation flexors (-), Elbow extensors (-), Wrist flexors (+),
NStart=63 C: Sham stimulation Wrist extensors (-); Post 2nd session (-); Post-
NEnd=44 intervention (-); 2wk post-intervention: Elbow
flexors (-), Elbow extensors (+), Wrist flexors (-),
Wrist extensors (-)
• Fugl Meyer Assessment (-)
Ikuno et al. (2012) E: Peripheral sensory nerve stimulation + • Wolf Motor Function Test (-)
RCT (8) task-specific therapy • Wolf Motor Function Test: Mean Time (+)
N=22 C: Task-specific therapy • Box and Block Test (-)
• Pinch Strength (-)

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• Grip Strength (-)
dos Santos-Fontes et al. E: Peripheral nerve stimulation • Jebsen Taylor Test (+)
(2013) C: Sham nerve stimulation
RCT (8)
NStart=20
NEnd=20
Klaiput et al. (2009) E: Peripheral Sensory Stimulation • Pinch Strength (+)
RCT (8) C: Sham stimulation
N=20
Lin et al. (2014) E: Mirror therapy + Mesh glove • Modified Ashworth Scale (-)
RCT (7) C: Mirror therapy • Box and Block Test (+)
NStart=16 • FIM (-)
NEnd=16 • Action Research Arm Test (+)
Fleming et al. (2015) E: Active Somatosensory Stimulation • Action Research Arm Test (+)
RCT (7) C: Sham Somatosensory Stimulation • Fugl Meyer Assessment (-)
NStart=33 • Motor Activity Log (-)
NEnd=30
Lin et al. (2014) E1: Mirror therapy + Mesh glove • Fugl Meyer Score: E1 vs. E2 (-), E1 vs. C (+)
RCT (7) E2: Mirror therapy • Box and Block Test: E1 vs. E2 (+), E1 vs C (+)
NStart=43 C: Therapeutic exercises • Wolf Motor Function Test: E1 vs. E2(-)
NEnd=42
Hunter et al. (2011) E: Mobilization and Tactile Stimulation (3 • Motricity Index (-)
RCT (7) dose levels) • Action Research Arm Test (-)
Cambier et al. (2003) E: Intermittent pneumatic compression • Nottingham Sensory Assessment (+)
RCT (7) C: Sham short-wave therapy • Fugl Meyer (+)
N=23 • Ashworth Scale (-)
• Visual Analog Scale (-)
Lee et al. (2015) E1: Mirror Therapy with Mesh Glove • Extensor Digitorum Muscle Tone: E1 vs E2/C (+)
RCT (7) Afferent Stimulation • Muscle stiffness on the flexor carpi radialis: E1
NStart=48 E2: Mirror Therapy vs C (+)
NEnd=47 C: Mirror Therapy with Sham Stimulation • Box and Block Test: E1/C vs E2 (+)
• Functional Independence Measure: E1/C vs E2
(+)
• Revised Nottingham Sensory Assessment (-)
McDonnell et al. (2007) E: Task-specific training with afferent • Fugl Meyer Score (-)
RCT (7) stimulation • Action Research Arm Test (-)
N=20 C: Task-specific training without afferent • Dexterity (+)
stimulation
Feys et al. (1998) E: Sensorimotor stimulation • Fugl Meyer: 6wk (-), 6mo (+), 12mo (+)
RCT (6) C: Control • Action Research Arm Test (-)
Wu et al. (2006) E: Single session of peripheral nerve • Jebsen-Taylor Hand Function Test (+)
RCT (6) (somatosensory) stimulation
N=9 C: No stimulation
Conforto et al. (2002) E: Single session of medial nerve • Pinch muscle strength (+)
RCT (6) (somatosensory) stimulation
N=8 C: Sham stimulation
Jongbloed et al. (1989) E: Sensorimotor integrative approach • Barthel Index (-)
RCT (5) C: Functional approach • Sensorimotor Integration Test: 8 subsets (-)
N=90

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Thermal Stimulation
Tai et al. (2014) E: Painful thermal stimulation • Cortical map size (+)
RCT (8) C: Innocuous thermal stimulation • Motor evoked potential (+)
NStart=16 • Motor threshold (-)
NEnd=16
Chen et al. (2005) E: Thermal stimulation + standard therapy • Brunnstrom (+)
RCT (7) C: Standard therapy • Modified Ashworth Scale (-)
NStart=46 • Grasping (-)
NEnd=29 • Sensation (+)
Wu et al. (2010) E: Thermal stimulation • UE-STREAM (+)
RCT (6) C: No stimulation • Action Research Arm Test (+)
N=23
Lima et al. (2015) E: Hypothermia Interention and sensory •
Fugl-Meyer Assessment (+)
PCT training •
Nottingham Sensory Assessment
NStart=29 C: Sensory training proprioceoption of affected upper extremity
NEnd=27 and two-point discriminiation (+)
• Blindfolded Functional Test (+)
TEAS/electroacupuncture
Zhao et al.(2015) E1: Transcutaneous electrical acupoint • MAS (wrist): Simulation groups vs. control at 2,
RCT (9) stimulation (TEAS) (100Hz) 3, and 4wk, and 1mo (+)
NStart=60 E2: Transcutaneous electrical acupoint • MAS (wrist): E1 vs E2 at 2wk (+)
NEnd=51 stimulation (TEAS) (2Hz) • MAS (wrist): E1 vs. E2 at 3 and 4wk and at 1mo (-
C: Sham stimulation )
• MAS (wrist): E2 vs Cat 4wk (+)
• Disability Assessment Scale (-)
• Global Assessment Scale (-)
Hsieh et al. (2007) E: Electroacupuncture • FIM (-)
RCT (8) C: No acupuncture • Fugl-Meyer (+)
N=63
Hsing et al. (2012) E: Scalp electro-acupuncture • BI (-)
RCT (7) C: sham acupuncture • Rankin score (-)
N=62
Wen et al. (2014) E: Electroacupuncture + moxibustion • Fugl Meyer Assessment (-)
RCT (7) C: Basic therapy
NStart=300
NEnd=276
Zhang et al. (2017) E1: Neuronavigation-assisted aspiration + • Fugl-Meyer Assessment: E1+E2+E3 vs. C (+)
RCT (7) electro-acupuncture • Modified Ashworth Scale: E1 vs. C (+), E2 vs. E3
NStart=240 E2: Neuronavigation-assisted aspiration (+)
NEnd=233 E3: Electro-acupuncture • Barthel Index: E1 vs. E2+E3 (+)
C: Conventional therapy
Au-Yeung et al. (2014) E1: Electroacupoint stimulation • Hand grip strength: E1 vs. C (+), E2 vs. C (-), E1
RCT (6) E2: Sham stimulation vs. E2 (-)
NStart=73 C: Conventional therapy (control) • Index grip pinch: E1 vs. C (+), E2 vs. C (-), E1 vs.
NEnd=60 E2 (-)
• Action Research Arm Test (-)
Li et al. (2012) E: Electroacupuncture + massage • Numeric pain rating scale (+)
RCT (6) C: Rehabilitation therapy • Fugl-Meyer (-)
N=120 • Modified Rankin Scale (+)
Wang et al. (2014) E: Electroacupuncture • R1 and R2 component of elbow joint (+)
RCT (6) C: No stimulation with no needle

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NStart=20 manipulation • R1 and R2 component of wrist joint (-)
NEnd=15
Si et al. (1998) E: Heparin + electroacupuncture • Chinese Stroke Scale (+)
RCT (5) C: Heparin
N=42
Moon et al. (2003) E1: Electroacupuncture • Modified Ashworth scale (E1 vs E2, C) (+)
RCT (5) E2: Moxibustion •
N=35 C: Routine acupuncture
Yao et al. (2014) E: Relaxed needling + electroacupuncture • Neurological Function Deficit Scale (+)
RCT (5) C: Ordinary needling • Fugl Meyer Assessment (+)
NStart=68
NEnd=65
Mukherjee et al. (2007) E: Electroacupuncture + strength training • MAS (+)
RCT (4) C: Strength training • VASRT (+)
N=7 • SASRT (+)

Discussion
Page et al. (2012) conducted a study in which varying dosages of transcutaneous electrical stimulation
were administered with repetitive task specific practice. The researchers found that those receiving 30
minutes of electrical stimulation did not improve on upper limb motor function when compared to
those receiving 60 minutes of electrical stimulation. However, there was a significant difference
between those receiving 30 minutes and those receiving 120 minutes of transcutaneous electrical
stimulation, as well as between those receiving 60 minutes and those receiving 120 minutes of
transcutaneous electrical stimulation. Outcomes measured motor function, and included the Fugl-Meyer
Assessment, Arm Motor Ability Test, and the Action Research Arm Test. This suggests that duration of
transcutaneous electrical stimulation may play an important role in the effectiveness of the
intervention. Transcutaneous electrical nerve stimulation (TENS) was shown to be more effective than a
control for improving upper limb motor function (Celnik et al., 2007; Kim, In, & Cho, 2013b; Sonde et al.,
1998). There are mixed results on whether TENS improves independence in patients post stroke with a
study by Tekeoglu et al. (1998) indicating that it does, while another study by Sonde et al. (1998)
indicating that it does not. A systematic review by de Kroon et al. (2002) evaluated six RCTs from which
only 2 reported a motor function outcome, and with only one reporting a positive effect. Furthermore,
four of the six studies found a positive increase in motor control after the intervention, with researchers
discussing that this is the only significant effect of TENS for upper limb recovery that they found.
The effectiveness of vibration therapy for improving upper limb motor function has been demonstrated
in studies by Caliandro et al. (2012); Costantino et al. (2017); and Jung-Sun et al. (2016). However, a
study with high methodological quality by Stein et al. (2010) found no signficant difference in motor
function in those receiving stochastic resonance stimulation with subthreshold electrical stimulation and
vibration when compared to sham stimulation.
Peripheral nerve/afferent stimulation more often produced a significant difference on the Fugl-Meyer
Assessment, Jebsen-Taylor Hand Function Test, Wolf Motor Function Test, or the Action Research Arm
Test than a sham therapy in patients after stroke (Cambier et al., 2003; dos Santos-Fontes et al., 2013;
Wu et al., 2006). However, when peripheral nerve/afferent stimulation was compared to a conventional
therapy, it was more likely to produce a negative result on the above measures of function (Feys et al.,
1998; Hunter et al., 2011; Ikuno et al., 2012; Y.-y. Lee et al., 2015; K. C. Lin, P. C. Huang, et al., 2014).

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On the other hand, scores based on the Box and Block test, a motor function test that is more focused
on dexterity, more often improved in patients receiving mirror with mesh glove therapy in comparison
to mirror therapy alone (Y.-y. Lee et al., 2015; K. Lin, P. Huang, Y. Chen, C. Wu, & W. Huang, 2014; K. C.
Lin, Y. T. Chen, et al., 2014).
Four studies examining thermal stimulation were found (Chen et al., 2005; Lima et al., 2015; Tai et al.,
2014; Wu et al., 2010) from which two examined upper limb motor function outcome (Lima et al., 2015;
Wu et al., 2010). Wu et al. (2010) found a significant improvement in upper limb motor function in those
receiving thermal stimulation in comparison to those not receiving it, while Lima et al. (2015) found a
significant improvement in those undergoing hypothermia and sensory training in comparison to those
only receiving sensory training.
Electroacupuncture was found to be no more effective for imporving upper limb motor function than
conventional therapy based on the results of three studies with high methological quality and large
sample sizes (Li et al., 2012; Wen et al., 2014; Y. Zhang et al., 2017). Two studies with smaller sample
sizes found an improvement in upper limb motor function between receiving electroacupuncture and no
acupuncture (R. L. Hsieh et al., 2007) or typical acupuncture (Yao & Ouyang, 2014). However, the results
of these two studies are less credible because Hsieh et al. (2007) did not have an active or sham control
group, while Yao et al. (2014) used both relaxed needling with electrocupuncture as the intervention,
while the control was typical acupuncture rather than relaxed needling.
A review of sensory-motor training by Steultjens et al. (2003) included three RCTs (Feys et al., 1998)
(Jongbloed et al., 1989; Kwakkel et al., 1999), one case control trial (Turton & Fraser, 1990), and one
noncontrolled trial (Whitall, Waller, Silver, & Macko, 2000). The authors concluded that sensory-motor
training was not effective for improving ADLs, extended ADLs, social participation, or arm and hand
function.
In a more recent review, including the results of 14 RCTs (Schabrun & Hillier, 2009), the authors
distinguished between passive forms of sensory retraining through electrical stimulation and active
forms, primarily through specific exercises. The included trials assessed the outcomes of function,
sensation and prorioception in both the upper and lower extremity. However, only 2 of the included
trials assessed sensation in the upper extremity, which reported ambiguous results.
A recent Cochrane review included the results from 13 studies (467 participants) examining a variety of
treatments for sensory impairment following stroke and concluded that there was insufficient high-
quality evidence available to recommend the use of any of them (Doyle, Bennett, Fasoli, & McKenna,
2010). Treatments with preliminary evidence of benefit included mirror therapy, thermal stimulation
and intermittent pneumatic compression.
Conclusions Regarding Sensorimotor Training/Somatosensory Stimulation
There is level 1a evidence that transcutaneous electrical nerve stimulation (TENS) improves upper
limb motor function.
There is level 1a evidence that focal or whole-body vibration therapy improves upper limb motor
function.
There is level 1a evidence that peripheral nerve/afferent stimulation does not significantly improve
overall upper limb motor function.

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There is level 1a evidence that mesh glove therapy improves motor function and dexterity based on
the Box and Block test.
There is level 1b evidence that thermal stimulation is effective for upper limb motor function.
There is level 1a evidence that electroacupuncture is not more effective than an active control for
improving upper limb motor function.
Transcutaneous electrical nerve stimulation, vibration therapy, mesh glove, and thermal
stimulation may improve upper limb motor function.
Peripheral nerve stimulation and electroacupuncture may not improve upper limb motor function.
10.2.9 Mental Practice/ Motor Imagery

The use of mental practice or motor imagery as a means to enhance performance following stroke was
adapted from the field of sports psychology were the technique has been shown to improve athletic
performance, when used as an adjunct to standard training methods. The technique, as the name
suggests, involves rehearsing a specific task or series of tasks, mentally. A series of small trials have
adapted and evaluated the effects of mental practice as a treatment following stroke. The ability of the
treatment to improve motor function or ADL performance is the outcome most frequently assessed in
these studies. The most plausible mechanism to explain the success of the technique is that stored
motor plans for executing movements can be accessed and reinforced during mental practice (Page,
Levine, Sisto, & Johnston, 2001). Mental practice can be used to supplement conventional therapy and
can be used at any stage of recovery.
Zimmermann-Schlatter et al. (2008) also assessed the efficacy of motor imagery in recovery post stroke.
The authors included the results from only 4 RCTs (Liu, Chan, Lee, & Hui-Chan, 2004; Page & Levine,
2006; Page, Levine, & Leonard, 2007; Page et al., 2001) in which the duration and frequency of
treatment lasted from 10 minutes to one-hour per day, with 3 to 5 sessions per week for 3 to 6 weeks.
Mean time of stroke onset ranged from several days to several years. Three of these studies reported
improvements in the mean ARAT and FMA scores. Two of these studies also found higher mean change
scores than the minimally clinically relevant difference in the ARAT and FMA scores. These authors
concluded that although there was evidence of benefit of treatment, larger and more rigorous studies
are required to confirm these findings.
Nilsen et al. (2010) conducted a systematic review on the use of mental practice as a treatment for
motor recovery, including the results from 15 studies, 4 of which were classified as Level 1 (i.e., RCTs).
Although the authors concluded that there was evidence that mental practice was effective, especially
when combined with upper-extremity therapy, they also discussed the problems in summarizing the
results of heterogeneous trials. Studies varied with respect to treatment protocols, patient
characteristics, eligibility criteria, dosing, methods used to achieve mental practice (audiotapes, written
instruction, pictures) the chronicity of stroke, and outcomes assessed. The authors cautioned that
additional research must be conducted before specific recommendations regarding treatment can be
made.

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A Cochrane review on the subject (Barclay-Goddard, Stevenson, Poluha, & Thalman, 2011), restricted to
RCTs (n=6) concluded that there was limited evidence that mental practice in addition to other
rehabilitation therapies was effective compared with the same therapies without mental practice. There
were significant treatment effects for the outcomes associated with both impairment and disability.
A meta-analysis (Cha, Yoo, Jung, Park, & Park, 2012) included the results from 5 RCTs and assessed the
additional benefit of mental practice combined with functional task training. The outcomes assessed in
the individual studies included the FMA, ARAT and Barthel index. The estimated treatment effect size
when the studies were pooled was 0.51 (95% CI 0.27 to 0.750, indicating a moderate effect.
However, a meta-analysis by Machado et al. (2015) found that compared to the control, mental practice
was not more effective at improving upper limb motor function when used as an adjunct therapy, based
on the results of 7 RCTs.
The results of RCTs evaluating mental practice are summarized in Table 10.2.9.1.
Table 10.2.9.1 Summary of Controlled Trials Evaluating Mental Practice/ Motor Imagery Therapy for
the Upper Extremity
Sample Size
Mihara et al. (2013) E: Mental practice • Fugl Meyer Score (+)
RCT (9) C: Sham intervention • Action Research Arm test (-)
NStart=20
NEnd=20
Ang et al.(2014) E1: Motor imagery + brain computer interface + • Fugl Meyer Score (-)
RCT (8) haptic knob
NStart=22 E2: Brain computer interface
NEnd=21 E3: Haptic knob
Bovend'Eerdt et al. (2010) E: Conventional therapy + Mental practice • Goal Attainment Scale (-)
RCT (8) C: Conventional therapy • Barthel Index (-)
N=50 • Rivermead Mobility (-)
• Nottingham Extended ADL (-)
Oostra et al. (2013) E: Mental practice + physical training • Action Research Arm Test (+)
RCT (8) C: Physical training
NStart=20
NEnd=20
Ietswaart et al. (2011) E1: Motor imagery • Action Research Arm Test (-)
RCT (7) E2: Attention placebo
N=121 C: Usual care
Park et al. (2016) E: Nintendo Wii + mental practice • Fugl-Meyer Assessment (-)
RCT (7) C: Nintendo Wii • Motor Activity Log (-)
NStart=30
NEnd=30
Park et al. (2015) E: Mental practice + mCIT • Fugl Meyer Score (+)
RCT (7) C: mCIT • Action Research Arm Test (+)
NEnd=26
Liu et al. (2014) E: Motor imagery + mental practice of affected • Action Research Arm test (+)
RCT (7) hand

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NStart=20 C: Motor imagery + mental practice of
NEnd=20 unaffected hand
You et al.(2013) E: Mental activity training + EMG • Range of Motion (-)
RCT (7) C: Functional electrical stimulation • Modified Ashworth Scale (-)
NStart=18 • Fugl Meyer Score (+)
NEnd=16 • Modified Barthel Index (-)
• Motor Activity Log: Amount of Use (-),
Quality of Movement (-)
Oh et al. (2016) E: Mental Practice and Conventional Therapy • Fugl-Meyer Assessment of the Upper
RCT (7) followed by Conventional Therapy alone Extremity (-)
NStart=10 C: Conventional Therapy alone followed by • Motor Activity Log (-)
NEnd=10 Mental Practice and Conventional Therapy
Page et al. (2005a) E: Mental practice • Action Research Arm Test (+)
RCT (6) C: Relaxation techniques • Motor Activity Log: Amount of Use (+),
N =11 Quality of Movement (+)
Page et al. (2007) E: Mental practice • Fugl Meyer Score (+)
RCT (6) C: Sham intervention • Action Research Arm test (+)
N=32
Page et al. (2011) E: Audiotaped mental practice • Fugl Meyer Score (-)
RCT (6) C: Audiotaped sham intervention • Action Research Arm Test (-)
N=29
Park et al. (2015) E: Mental practice • Fugl Meyer Score (+)
RCT (6) C: Physical therapy • Action Research Arm Test (+)
NEnd=29
Page et al. (2007) E: Mental Practice • Fugl-Meyer Assessment (+)
RCT (6) C: Sham Relaxation Exercise Intervention • Action Research Arm Test (+)
N=32
Page et al. (2001) E: Occupational therapy + imagery training • Fugl Meyer Score (+)
RCT (5) C: Occupational therapy • Action Research Arm Test (+)
N=13
Liu et al. (2009) E: Mental Imagery • Improvement in Trained Tasks (+)
5 (RCT) C: Conventional Functional Rehabilition
N=35
Riccio et al. (2010) E: Mental practice then conventional rehab • Motricity Index: crossover point (+), post
RCT (5) C: Conventional rehab then mental practice therapy (-)
N=36 • Arm Function Test: crossover point (+),
post therapy (-)
Lee et al. (2012) E: Mental practice + standard care • Fugl Meyer Score (+)
RCT (5) C: Standard care • Brunnstrom stages (+)
N=26 • Manual Function Test (+)
Page et al. (2000) E: Occupational therapy + Imagery training • Fugl Meyer Scores (+)
RCT (4) C: Occupational therapy
N=16
Liu et al. (2004) E: Mental Imagery • Fugl Meyer Score (-)
RCT (4) C: Functional training • Colour Trials Test (-)
N=46
Page et al. (2009) E: Mental practice + mCIT • Action Research Arm Test: post and
RCT (4) C: mCIT follow-up (+)
N=10 • Fugl Meyer Score: post and follow-up (+)
Müller et al. (2007) E1: Mental practice • Jebsen Hand Function Test: E1/E2 vs. C (+)

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RCT (4) E2: Motor practice • Pinch grip: E1/E2 vs. C (+)
Dijkerman et al. (2004) E1: Mental task practice • Barthel Index (-)
PCT E2: Visual imagery task practice • Hospital Anxiety and Depression Scores (-)
N=20 C: No mental imagery practice • Recovery of Locus Control (-)
• Performance of Practiced Reaching (+)
Rajesh et al.(2015) E: Motor Imagery + conventional therapy • Motor Activity Log (+)
PCT C: Conventional therapy • Stroke Specific Quality of Life (+)
NStart=30
NEnd=30
Discussion
Overall, the studies that have been compiled investigated the effectiveness of a variety of mental
practice/motor imagery training techniques on upper limb motor function in individuals with stroke.
Most of the studies of higher methodological quality that were included demonstrated that mental
practice improved upper limb motor function on at least one measure (Liu et al., 2014; Mihara et al.,
2013; Oostra et al., 2013; Page & Levine, 2006; Page et al., 2007; S.J. Page et al., 2005a; Park, Lee, Cho,
Kim, & Yang, 2015; Y. Park et al., 2015; You & Lee, 2013). Some of the other higher methodological
quality studies also showed no significant improvement in upper limb motor function (Ang et al., 2014;
Bovend'Eerdt et al., 2010; Ietswaart et al., 2011; Page et al., 2011; Park & Park, 2016). From these five
studies, two investigated motor imagery rather than mental practice (Ang et al., 2014; Ietswaart et al.,
2011), one paired mental practice with the Nintendo Wii (Park & Park, 2016), and one audiotaped the
mental practice and the sham practice (Page et al., 2011). Therefore, there may be a difference in the
type of intervention that was provided in the studies that found a significant difference between groups
as opposed to those that did not. Measures of independence and daily living indicated an even split,
with some finding an effect, and others not.
It is also noteworthy to mention that it is unclear whether some of the same participants took part in
multiple studies conducted by the same group (Page, 2000; Page et al., 2011; Page et al., 2009; Page et
al., 2007; S.J. Page et al., 2005a; Page et al., 2001). To improve the quality, studies with larger samples
are required in the future for larger statistical power. Many of these trials were conducted in the chronic
phase, so it is recommended that studies include patients in the acute phase post stroke in the future.
Kho et al. (2014) conducted a recent meta-analysis on the effects of mental imagery on motor recovery
of the upper extremity following a stroke. A total of six studies were included in the analysis, of which
only five were RCTs and one was a controlled clinical trial. The pooled effects from three studies
regarding the FMA showed no significant effect favouring the intervention. Conversely, when evaluating
the ARAT measured in four studies, the findings revealed a significant effect in favour of mental imagery
(Kho et al., 2014).The authors suggested that a possible explanation for the lack of effect observed on
the FMA may be due to a ceiling effect in performance, given that a large proportion of participants had
mild motor impairment.
Conclusions Regarding Mental Practice
There is level 1a evidence that mental practice therapy is effective for improving upper extremity
motor function; however, the evidence for its effect on activities of daily living is limited and
conflicting.

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There is level 1a evidence that motor imagery is not effective for improving upper extremity motor
function.
Mental practice may improve upper limb motor function after stroke, while motor imagery likely
does not.
10.2.10 Splinting
Splints may be applied to achieve various objectives, including reduction in spasticity, reduction in pain,
prevention of contracture, and prevention of edema (Lannin & Herbert, 2003).
The effectiveness of the use of splints to improve upper extremity function is reviewed in this section.
The use of splints to prevent the development of contracture, or reduce spasticity following stroke is
reviewed in section 10.5.1.
In a systematic review of hand splinting for adults with stroke, Lannin and Herbert (2003) included the
results from 19 studies, of which only 4 were RCTs. The authors concluded that there was insufficient
evidence to either support or refute the effectiveness of hand splinting for a variety of outcomes for
adults following stroke.
Tyson and Kent (2011) conducted a systematic review on the effect of upper limb orthotics following
stroke, which included the results from 4 RCTs representing 126 subjects. The treatment effects
associated with measures of disability, impairment, range of motion, pain, and spasticity were small and
not statistically significant.
The results of RCTs evaluating splinting interventions for upper extremity function are summarized in
Table 10.2.10.1.
Table 10.2.10.1 Summary of RCTs Evaluating Splinting/Orthoses-Aided Therapies for the Upper
Extremity
Sample Size
Lannin et al. (2003) E: Hand splint • Contracture formation (-)
RCT (8) C: No hand splint
N=28
Bartolo et al. (2014) E: Arm orthosis • Range of Motion: abduction and adduction
RCT (8) C: Conventional physiotherapy (+), flexion and extension (+)
NStart=28 • Normalized jerk (+)
NEnd=28 • Fugl Meyer Score (-)
Lannin et al. (2007) E1: Extension splint • Wrist contracture (-)
RCT (7) E2: Neutral splint
N=63 C: No splint
Kim et al. (2015) E: Taping • Manual Function Test (+)
RCT (7) C: No taping • Modified Motor Assessment Scale (+)
NStart=30
NEnd=30
Barry et al. (2012) E: Dynamic hand orthosis • Grip strength (-)
RCT (7) C: Manual assisted therapy • Action Research Arm Test (-)
N=19 • Box and Block Test (-)

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• Stroke Impact Scale (-)
Page et al. (2013) E: Myomo brace • Fugl Meyer Scale (-)
RCT (6) C: Repetitive task practice • Canadian Occupational Performance
NStart=16 Measure (-)
NEnd=16 • Stroke Impact Scale (-)
Poole et al. (1990) E: Splint • Fugl Meyer (-)
RCT (5) C: No splint
N=19
Choi et al. (2016) E: Hand Splints and a General Rehabilitation • Visual Analogue Scale (+)
RCT (5) Program • Volume of Hand (+)
NStart=30 C: General Rehabilitation Program • Modified Ashworth Scale (-)
NEnd=30
Lannin et al. (2016) E: Task-specific training + training with the • Motor Assessment Scale (-)
RCT (5) Saebo-Flex device • Box and Block Test (-)
NStart=9 C: Task-specific training • Grip Strength (-)
NEnd=6
TPS=acute
Choi et al. (2016) E: Dorsal Resting Hand Splint • Modified Ashworth Scale (+)
RCT (4) C: Volar Resting Hand Splint • Active Range of Motion (+)
NStart=52
NEnd=52

Discussion
Ten studies were reviewed to determine whether various interventions related to splinting can improve
upper limb motor function. Various splinting interventions were included such as a hand splint, arm
orthosis, taping, Myomo brace, and the Saebo-Flex device. Of the studies that reported motor function
outcomes, all indicated no benefit of splinting for upper limb motor function when compared to
conventional therapy (Barry et al., 2012; Bartolo et al., 2014; Lannin et al., 2016; Page, Persch, &
Murray, 2013; Poole et al., 1990).
Conclusions Regarding Splinting
There is level 1a that hand splinting/taping/orthoses do not improve upper extremity motor
function.
Splinting, taping, and orthoses likely do not improve upper limb motor function.
10.2.11 Constraint-Induced Movement Therapy (CIMT)

CIMT refers to a set of rehabilitation techniques designed to reduce functional deficits in the more
affected upper extremity of stroke survivors. The two key features of CIMT are restraint of the
unaffected hand/arm and increased practice/use of the affected hand/arm (Fritz, Light, Patterson,
Behrman, & Davis, 2005). Since stroke survivors may experience “learned non-use” of the affected
upper extremity within a short period of time (Taub, 1980), CIMT is designed to overcome learned non-
use by promoting neuroplasticity and use-dependent cortical reorganization (Taub, Uswatte, & Pidikiti,
1999). While the biological mechanism(s) responsible for the benefit are unknown and the contribution
from intense practice is difficult to disassociate from the effect of constraining the unaffected limb, this

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form of treatment shows promise, especially for survivors with moderate upper limb disability following
stroke.
Several reviews have been published on the effectiveness of CIMT (Barreca et al., 2003a; Hakkennes &
Keating, 2005; Taub & Morris, 2001) and while the results have been generally positive, uncertainty of
its effectiveness remain due to the small number of trials published, the small sample sizes of the
studies, heterogeneity of patient characteristics, duration and intensity of treatment, and outcomes
assessed.
A meta-analysis conducted by Van Peppen et al. (2004) concluded that CIMT was associated with
improvements in dexterity, as measured by the Arm Motor Activity Test or the ARAT, but not in terms of
ADL performance, as measured by the FIM or Barthel Index scores. Hakkennes and Keating (2005)
included the results from 14 RCTs and concluded that there was a benefit associated with treatment,
although larger well-designed studies are still required. Several treatment contrasts were examined
including traditional CIMT versus alternative therapy or control, modified CIMT versus alternative
therapy or control and traditional CIMT versus modified CIMT, although pooled estimates of the
treatment sizes for the subgroups were not provided.
Taub et al. (2003) noted that constraint-induced movement therapy has limitations as in the
improvement seen does not restore the stroke patients’ movement to their motor status prior to the
stroke. The same authors note that constraint-induced movement therapy “produces a variable
outcome that depends on the severity of initial impairment. If patients with residual motor function are
categorized on the basis of their active range of motion, the higher functioning individuals tend to
improve more than persons who are more disabled (Taub et al., 1999)… For patients with the lowest
motor functioning, constraint-induced therapy does improve movement at the shoulder and elbows.
Because these people have little or no ability to move the fingers, there is no adequate motor basis for
carrying out training of hand function. Consequently, because most daily activities that are carried out by
the upper extremity are performed by the hand, there is relatively little translation of the therapy
induced movement in proximal joint function into an increase in the actual amount of use of the more
affected extremity in the real life situation… Thus, constraint-induced therapy is clearly not a complete
answer to motor deficits after stroke. The work so far does show that motor function in a large
percentage of patients with chronic stroke is substantially modifiable,” (Taub, Uswatte, & Morris, 2003).
van der Lee (2001) suggests that the positive results attributed to CIMT may simply reflect a greater
intensity of training of the affected arm and questions the concept of non-use implying that it may not
be a distinct entity, but rather the result of sensory disorders or hemineglect.
According to Dromerick et al. (2000), constraint of the unaffected arm with the use of a mitten (6 hours
per day for 14 days), and ‘forced use’ of the affected arm soon after stroke (approximately six days), is
feasible. However, trials reporting small but significant reductions in arm impairment, especially for
patients with sensory disorders and hemineglect (Ploughman & Corbett, 2004; van der Lee et al., 1999),
have also reported a high number of deviations from the randomized treatment schedule, due to
patients’ noncompliance. This led to trials investigating the effectiveness of modified or shorter periods
of constraint-induced therapy treatment.
There is promising evidence that the drawbacks to stroke patient participation in CIMT (i.e., required
practice intensity and duration of restraint) may be overcome through modifications to the basic
procedures. These include a less intense, modified therapy schedule, termed mCIMT, that combines
structured functional practice with the affected limb, with restricted use of the less affected limb (Page,
Sisto, Levine, & McGrath, 2004), as well as forced use therapy, which employs constraint without

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intensive training of the affected limb (Ploughman & Corbett, 2004). Page et al. (2005b; 2002; 2004)
provide one example of the distinction between CIMT and mCIMT: CIMT is defined by the i) restriction
of a patient’s less affected upper-limb throughout 90% of waking hours during a 2-week period and ii)
participation in an intensive upper-extremity therapy program for 6 hours per day, using the affected
limb during the same 2-week period. In contrast, mCIMT involves restriction of the unaffected limb for
periods of 5 hours per day, 5 days per week for 2 weeks combined with structured, ½ hour therapy
sessions, 3 days per week. However, other criteria for defining mCIMT have also been used, which
overlap with CIMT, blurring the distinction. Lin et al. (2007) cite mCIMT as 2 hours of therapy per day for
10-15 consecutive weekdays, with restraint for 6 hours per day. There also exist trials, presented in the
following tables, in which the intervention was provided for periods of up to 10 weeks.
The optimal timing of treatment remains uncertain. While there is evidence that patients treated in the
acute phase of stroke may benefit preferentially (Taub & Morris, 2001), there is also evidence that it
may, in fact, be harmful (Dromerick et al., 2009). Grotta et al. (2004) suggest that the greatest benefit is
likely to be conferred during the chronic stages of stroke and that the treatment has shown to be
harmful in animal studies of “forced use” immediately post stroke.
The results from the largest and most rigorously conducted trial-The Extremity Constraint Induced
Therapy Evaluation (EXCITE), may provide the strongest evidence of a benefit of CIMT treatment, to
date. The study recruited 222 subjects with moderate disability 3 to 9 months following stroke, over 3
years from 7 institutions in the US. Treatment was provided for up to 6 hours a day, 5 days a week for 2
weeks. Patients were reassessed up to 24 months following treatment. At 12 months, compared with
the control group who received usual care, subjects in the treatment group had significantly higher
scores on sections of the WMFT and the Motor Activity Log. At 24 months these gains were maintained.
While these results are encouraging, the number of patients for whom this treatment may be suitable,
remains uncertain (Cramer, 2007). In the EXCITE trial, only 6.3% of patients screened were eligible.
While larger estimates of 20-25% have been suggested, it remains uncertain if subjects with greater
disability would benefit from treatment.
A Cochrane review (Sirtori, Corbetta, Moja, & Gatti, 2009) examined the benefit of all forms of CIMT
including studies that used the traditional protocol as described by Taub, in addition to trials of modified
CIMT and forced use. The review included the results from 19 trials involving 619 subjects. The primary
outcome was disability, which was measured as arm motor function. The authors reported that there
was a significant improvement in arm motor function, assessed immediately following the intervention,
but not at 3-6 months post-intervention. A subgroup analysis compared the benefit of CIMT in terms of
time since stroke onset (0-3 months and >9 months). No studies were included that measured disability
3-9 months following stroke. The associated effect sizes were not statistically significant for either
subgroup. The authors caution that the findings cannot be considered robust due to the small sample
sizes and poor methodological quality of the primary studies.
The same group of authors (Corbetta, Sirtori, Moja, & Gatti, 2010) updated their Cochrane review and
included the results from 4 recently published trials. Disability was the primary outcome. Among the 8
studies (n=276) that included an upper extremity assessment of function, or an ADL instrument, there
was no significant treatment effect associated with CIMT. There was a moderate treatment effect
associated with arm motor function. However, this review did not include sub analysis based on
chronicity of stroke or type of CIMT treatment (i.e. forced use vs. traditional CIMT vs. modified CIMT).
Shi et al. (2011) conducted a review examining modified CIMT compared with traditional rehabilitation
strategies. The results from 13 RCTs (278 patients) were included. The mean differences in scores

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favoured patients in the CIMT group on the following outcome measures: FMA (7.8), ARAT (14.2) FIM (7)
and the Motor Activity Log (amount of use: 0.78), suggesting that the treatment can be used to reduce
post stroke disability. The authors noted that none of the included RCTs included information on
compliance with the study protocol. Furthermore, the study did not differentiate between different
stroke phases as the analysis combined patients from acute to chronic stroke stages.
Nijland et al. (2011) conducted a systematic review of CIMT, limited to trials that evaluated the
effectiveness of treatment initiated within the first 2 weeks of stroke. The review included the results
from 5 RCTs (106 subjects). There was evidence of a benefit of treatment assessed using the ARAT, FMA
(arm section) and the Motor Activity Log. Although there were only a small number of studies that
examined the contrast, the authors suggested that low-intensity (<3 hours of therapy/day) CIMT was
superior to high-intensity (>3 hours of therapy/day) CIMT.
Peurala et al. (2012) examined the impact of CIMT and mCIMT on activity and participation measures, as
defined by the ICF. The review included the results from 30 trials. The authors identified 4 broad
categories of treatment intensity: 60-72 and 20-56 hours over 2 weeks, 30 hours over 3 weeks and 15-
30 hours over 10 weeks. Significant improvements were associated with Motor Activity Log scores for all
intensity categories; however this was not the case with the other. Outcomes examined include: FIM,
WMFT scores, ARAT and the SIS. ARAT scores were significantly improved at both treatment intensity
categories (20-56 hrs x 2 weeks & 15-30 hrs x 10 weeks). FIM scores were significantly increased in only
1 of 3 treatment intensity categories (15-30 hours x 10 weeks) and there were no significant
improvements in SIS scores, regardless of treatment intensity.
To enable better examination of the included studies, they were classified according to type of
treatment (CIMT or mCIMT) as well as chronicity of stroke (subacute (<6 months), chronic (>6 months)).
We used the authors' own declaration of the type of therapy that was provided (i.e. mCIMT or CIMT).
A review by Etoom et al. (2016) found that after analyzing 36 trials, CIMT produced a significant effect
when compared to a control intervention, although there was a high level of heterogeneity. The authors
suggested that the significant effect found may have been skewed by publication bias. However, studies
in this review that investigated the effectiveness of CIMT during the first 6 months after stroke overall
found a nonsignificant effect (Etoom et al., 2016). The results are summarized in tables 10.2.11.1 to
10.2.11.4.
A summary of the results from RCTs that evaluated CIMT during the subacute stage post stroke is
presented in Table 10.2.11.1.
Table 10.2.11.1 Summary of RCTs Evaluating CIMT in the Subacute (<6months) Phase Following Stroke
Author, Year Intervention CIMT Main Outcome(s)
Study Design Intensity/Duration Result
(PEDro Score)
Sample Size
Thrane et al. E: CIMT 3hr/d x 10d • Wolf Motor Function Test (-)
(2015) C: Usual Care • Stroke Impact Scale (-)
RCT (7) • Fugl-Meyer Assessment (-)
NStart=47 •
NEnd=47
Yoon et al. E1: CIMT, Mirror Therapy (MT), and 6h/d x 5d/wk x 2wk • Brunnstrom Recovery Stage (-
(2014) Conventional Therapy (CT) )
RCT (7) E2: CIMT and Conventional Therapy (CT) • Wolf Motor Function Test (+)

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NStart=26 C: Conventional Therapy (CT) • Fugl Meyer Assessment (-)
NEnd=26 • Modified Barthel Index (+)
Dromerick et al. E: CIMT 2hrs/d x 5d/wk x 2wk • Action Research Arm Test (+)
(2000) C: Traditional upper extremity therapy • FIM (-)
RCT (6) • Barthel Index (-)
N=20
Ro et al. (2006) E: CIMT 3hr/d x 6d/wk x 2wk • Grooved Pegboard test (+)
RCT (6) C: Traditional rehabilitation • Fugl Meyer Score (+)
N=8 • Motor Activity Log (+)
VECTORS E1: High-intensity CIMT E1: 3hr/d x 5/wk x 2wk • Action Research Arm Test:
Dromerick et al. E2: Standard CIMT E2: 2hr/d x 5/wk x 2wk E2/C vs E1 (+)
(2009) C: ADL and UE bilateral training Exercises
RCT (6)
N=52
Boake et al. E: CIMT 3hr/d x 6d/wk x 2wk • Fugl Meyer Motor recovery (-)
(2007) C: Traditional rehabilitation • Grooved Pegboard test (-)
RCT (5) • Motor Activity Log: Quality of
N=23 Movement (+)
Page et al. E: CIMT 0.5h/d x 3d/wk x 10wk • Action Research Arm Test (-)
(2005b) C: Regular rehabilitation • Fugl Meyer Assessment (-)
RCT (5) • Motor Activity Log (-)
N=10
Ploughman & E: Forced Use Therapy (Constraint without 1h/d initially, increasing • Chedoke McMaster
Corbett (2004) Shaping) to 6h/d by 2wk Impirment Inventory (+)
RCT (5) C: Conventional Therapy
N=23
Song et al. E: Scalp cluster acupuncture and Constraint 5-6 h/d x 6 d/wk x 2 wk • Fugl-Meyer Assessment (-)
(2016) Induced Movement Therapy
RCT (5) C: Body acupuncture and traditional
NStart=30 rehabilitation therapy
NEnd=30
Shah et al. E: CIMT 80% of working hours • Motor Activity Log (+)
(2016a) C: Motor Relearning Program • Nine Hole Peg Test (-)
RCT (5) • Fugl-Meyer Assessment (-)
NStart=45
NEnd=40
Seok et al. E1: CIMT with Visual Biofeedback 1 h/d x 2 wk • Grasp Strength: E1 vs C (+); E2
(2016) E2: Visual Biofeedback vs C (-); E1 vs E2 (-)
RCT (5) C: Conventional Occuptional Therapy • Pinch Strength: E1 vs C (+); E2
NStart=32 vs C (-); E1 vs E2 (-)
NEnd=30 • Wolf Motor Function Test: E1
v C (+); E2 vs C (+); E1 vs E2 (-)
• Fugl-Meyer Assessment-
Upper Extremity: E1 vs C (+);
E2 vs C (+); E1 vs E2 (-)
Batool et al. E: CIMT 2 h/d x 6 d/wk x 3wk • Modified Ashworth Scale (+)
(2015) C: Motor Relearning Programme • Functional Independence
RCT (5) Measure (+)
NStart=42
NEnd=42
Azab et al. (2009) E: CIMT 6 h/d x 4 wk • Barthel Index (+)

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PCT C: Conventional Therapy
N=27
Both Dromerick et al. (2000) and Ro et al. (2006) had high methodological quality and reported
significant improvements in upper extremity motor function measured by the Action Research Arm Test
and the Fugl Meyer Assessment. Furthermore, a study by Yoon et al. (2014) found that CIMT with mirror
therapy was superior to conventional therapy. However, one higher quality study by Thrane et al. (2015)
and several other studies of lower quality did not support these conclusions (Boake et al., 2007; S. J.
Page, P. Levine, & A. C. Leonard, 2005; Seok et al., 2016; Shah, Kumar, & Muragod, 2016b) as they found
no significant difference in motor function of the affected limb between CIMT and a control group.
In a more recent study (Dromerick et al., 2009) including 2 CIMT groups (standard and high intensity),
participants in the higher-intensity group fared, on average, worse than those in either the control
group or the standard CIMT group, demonstrating an inverse dose-response curve. The authors
proposed possible explanations to explain their results, including implementation of intervention too
early following stroke, overtraining, and a blocked rather than distributed practice schedule.
A summary of the results from RCTs that evaluated CIMT in the chronic stages post stroke is presented
in Table 10.2.11.2.
Table 10.2.11.2 Summary of RCTs Evaluating CIMT in the Chronic (>6 months) Phase Following Stroke
Author, Year Intervention CIMT Main Outcome(s)
Study Design Intensity/Duration Result
(PEDro Score)
Sample Size
Wolf et al. (2006) E: CIMT + shaping procedure 6hr/d x 5x/wk x 2wk • Wolf Motor Function Test (+)
Wolf et al. C: Usual care • Motor Activity Log: Amount of Use (+),
(2008) Quality of Movement (+)
RCT (8) • Functional ability measures (-)
EXCITE • Quality/frequency of performance of 30
N=222 daily activities (-)
Dahl et al. E: CIMT 6hr/d x 5x/wk x 2wk • Wolf Motor Function Test: post (+), 6mo (-)
(2008) C: Community-based rehabilitation • Motor Activity Log (-)
RCT (8) • FIM (-)
N=30 • SIS (-)
Wolf et al. (2010) E1: CIMT early (3-9 months post 90% of waking time for • Wolf Motor Function Test (+), at 24 mo (-)
USA stroke) 2 weeks • Motor Activity Log (+), at 24 mo (-)
8 (RCT) E2: CIMT delayed (15 to 21 months • Stroke Impact Scale Hand and Activities
post stroke) Domains Score (+), at 24 mo (-)
Sawaki et al. E: Early CIMT 90% of day for 2 weeks • Grip strength (+)
(2008) C: Delayed CIMT • Wolf Motor Function Test (-)
RCT (8)
N=30
Underwood et al. E: CIMT + shaping procedure 6hr/d x 5x/wk x 2wk • Pain scale of Fugl Meyer (-)
(2006) C: Usual care • Wolf Motor Function Test (-)
RCT (8)
N=41
Richards et al. E1: Traditional CIMT (CIMT-6) + E1: 6hr/d in clinic x • Wolf Motor Function Test: E1 vs C1 (-); E2
(2006) donepezil 5d/wk x 2wk vs C2 (-)

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RCT (7) C1: Traditional CIMT (CIMT-6) + E2: 1hr/d in clinic • Motor Activity Log: Amount of Use E1 vs C1
N=39 placebo x5d/wk x 2wk (+); E2 vs C2 (-)
E2: Shortened CIMT (CIMT-1) + All groups wore a • Motor Activity Log: Quality of Movement
repetitive transcranial magnetic padded mitt on E1 vs C1 (+); E2 vs C2 (-)
stimulation (rTMS) unaffected arm for
C1: Shortened CIMT (CIMT-1) + 90% of waking hours
sham rTMS
Brogårdh & E: CIMT and using mitt at home for 6h/d x 2wk, mitt worn • Modified Motor Assessment Scale (-)
Bengt another 3 months every other day for 90% of waking • Sollerman Hand Function Test (-)
(2006) C: CIMT time. • Motor Activity Log (-)
RCT (7)
N=16
van der Lee et al. E: Intensive forced use therapy + 6hr/d x 5d/wk x 2wk • Action Research Arm Test: post (+)
(1999) immobilization of the unaffected • Motor Activity Log: during (+)
RCT (7) arm
N=66 C: Intensive bimanual training
based on Neurodevelopmental
therapy
Wu et al. (2013) E1: CIMT + eye patching (EP) 2hr/d x 5d/wk x 3wk • Time at peak velocity: E1 vs. C (+), E1 vs. E2
RCT (7) E2: CIMT (+)
NStart=27 C: Conventional therapy • Reaction time: E2 vs. C (+)
NEnd=24
Nadeau et al. E1: CIMT-6hr + cycloserine E1: 6hr/d x 5d/wk x • Fugl Meyer: E1/E2 vs C1/C2 (-)
(2014) C1: CIMT-6hr + placebo 2wk • Wolf Motor Function Test: E1/E2 vs C1/C2
RCT (7) E2: CIMT-2hr + cycloserine E2: 2hr/d x 3d/wk x (-)
NStart=24 C2: CIMT-2hr + placebo 10wk • Motor Activity Log: E1/E2 vs C1/C2 (-)
NEnd=22
Wu et al. (2007) E: CIMT 2hr/d x 5d/wk x 3wk • Motor Activity Log (+)
RCT (6) C: Regular interdisciplinary rehab • Fugl Meyer Score (-)
N=47
Khan et al. (2011) E1: CIMT 15-20 hr/wk x 4wk • Wolf Motor Function Test: Post-
RCT (6) E2: Therapeutic Climbing Intervention: E1 vs E2 (+); E1 vs C (-); E2 vs
N=44 C: Conventional Neurological C (-); 6 months: E1 vs C (-)
Therapy • Motor Activity Log (-)
• Shoulder Pain: E1 vs E2 (+); 6 months: E1 vs
E2 (+)
• Isometric Strenth (-)
• Active Range of Motion (-)
Alberts et al. E: Immediate CIT 6hr/d x 5d/wk x 2wk • Maximum precision grip (+)
(2004) C: Delayed CIT • Wolf Motor Function Test (-)
RCT (6) • Arm and Hand Section (-)
N=10
Suputtitada et al. E: CIMT 6hr/d x 5 d/wk x 14d • Action Research Arm Test (+)
(2004) C: Bimanual-upper-extremity • Pinch test (+)
RCT (6) training based on NDT approach
N=69
Taub et al. (1993) E: Unaffected upper extremity 6hr/d x 5d/wk x 2wk • Emory Test: post (+), 2yr (+)
RCT (6) restrained in a sling + practice • Arm Motor Activity Rest Test: post (+), 2yr
N=9 using impaired upper extremity (+)
C: Procedures designed to focus • Motor Activity Log: increase in ability to
attention use of impaired upper use affected upper extremity (+)
extremity

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Huseyinsinoglu E: CIMT 3hr/d x 10 weekdays • Motor Activity Log: Amount of Use (+),
et al. (2012) C: Bobath Quality of Movement (+)
RCT (6) • Wolf Motor Function Test (-)
N=24 • FIM (-)
Wittenberg et al. E: Intense CIMT E: 6hr/d x 10d • Motor Activity Log (+)
(2003) C: Less intense CIMT C: 3hr/d x 10d • Wolf Motor Function Test (-)
RCT (5) • Assessment of Motor and Process Skills (-)
N=16
Wu et al. (2011) E1: Distributed CIMT 2h/d x 5d/wk x 3wk • Unilateral and Bilateral Smoothness while
Taiwan E2: Bilateral Arm Training Reaching: E1/E2 vs C (+)
5 (RCT) C: Routine Tehrapy • Unilateral and Bilateral Force Movement
Initiation while Reaching: E2 vs E1/C (+)
• Motor Activity Log: E1 vs E2/C (+)
• Wolf Motor Function Test: E1 vs E2/C (+)
Lin et al. (2007) E: CIT 2hr/d x 5d/wk x 3wk • Fugl Meyer (+)
Lin et al. (2009) C: Traditional therapy • FIM (+)
Lin et al. (2010) (neurodevelopmental) • Motor Activity Log (-)
RCT (5)
N=35/32/13
Takebayashi et E: CIMT + transfer package 4.5hr for 2wk • Fugl Meyer Score: post (-), follow-up (+)
al. (2013) C: CIMT • Motor Activity Log: Amount of Use: post
RCT (5) (+), follow-up (+)
NStart=23
NEnd=21
Souza et al. E1: CIMT high intensity E1: 3hr x 3-4x/wk for • Fugl Meyer Assessment (-)
(2015) E2: CIMT low intensity 10 sessions over 22d • Motor Activity Log (-)
RCT (5) E2: 1hr x 3-4x/wk for
Nstart=24 10 sessions over 22d
Nend=19
Lin et al. (2008) E: CIMT 2h/d x 5d/wk x 3wk • Fugl Meyer Assessment (+)
RCT (5) C: Traditional Intervention • Functional Independence Measure (+)
• Nottingham Extended Activities of Daily
Living Scale (-), mobility subsection (+)
Sterr et al. (2002) E1: Longer CIMT + ‘shaping E1: 6hr/d for a target • Motor Activity Log (+)
RCT (4) procedure’ of 90% of waking time • Wolf Motor Function Test (-)
N=15 E2: Shorter CIMT + ‘shaping E2: 3hr/d x 2wk • Quality of Movement (+)
procedure’ • Amount of Use (+)
Taub et al. (2006) E: CIMT 6h/d x 10d, restraint • Motor Activity Log (+)
PCT C: Placebo, General Fitness for 90% of waking time
N=41 Program
Overall, the majority of studies examined showed a positive effect for CIMT in the chronic phase of
stroke for upper limb motor function. These studies included: Wolf et al. (2006), Wolf et al. (2008), Dahl
et al. (2008), van der Lee et al. (1999), Suputtitada et al. (2004), Taub et al. (1993), Wu et al. (2011), Lin
et al. (2007), Lin et al. (2009), Lin et al. (2010), Lin et al. (2008). Studies which found no significant impact
on upper limb motor function included Underwood et al. (2006); Khan et al. (2011); Huseyinsinolu et al.
(2012). Studies investigating duration or intensity of CIMT included those by Brogard & Bengt (2006),
Wittenberg et al. (2003), Souza et al. (2015), and Sterr et al. (2002). Outcomes of these studies indicated
that there is either no difference between varying intensities or durations of CIMT between groups on

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upper limb motor outcomes, or mixed results. Other studies have investigated early versus delayed
CIMT including Wolf et al. (2010), Sawaki et al. (2008), and Alberts et al. (2004), and results were mixed
with some positive and negative upper limb motor outcomes.
Combination therapy of CIMT with pharmacological agents was studied by Nadeau et al. (2014), to
determine the benefit of cycloserine on the paretic upper extremity compared to placebo therapy. The
study also investigated the effects of intervention intensity by delivering CIMT at a frequency of 6 hours
per day or 2 hours per day. Results revealed no significant difference between the groups receiving
cycloserine and those receiving placebo regarding their effect on upper limb motor function as
measured by the FMA, WMFT and MAL (Nadeau et al., 2014). A similar study evaluated the effects of
donepezil and repetitive transcranial magnetic stimulation (rTMS) compared to placebo and sham
stimulation (Richards et al., 2006). Both groups receiving either the drug or the placebo performed CIMT
for 6 hours per day, while those receiving rTMS or sham stimulation performed CIMT for 1 hour per day.
There was a significant improvement in the MAL favouring the group receiving CIMT for 6 hours per day
compared to the rTMS group performing less frequent CIMT. However, after 2 weeks of therapy, motor
skill gains for both groups were equivalent, and at 6 months the gains made were not maintained by
either group (Richards et al., 2006). In contrast, Abo et al. (2014) found that when rTMS was compared
to CIMT, the results were in favour of rTMS as demonstrated by significantly greater improvements on
the FMA, and the Functional Assessment Score, but not on the WMFT.
A recent systematic review and meta-analysis by McIntyre et al. (2012) evaluated the effect of CIMT on
impaired upper extremity motor function in patients with stroke in the chronic phase. A total of 16
studies were included in the analysis, ranging in methodological quality from 4 (fair) to 8 (excellent) as
measured by the PEDro. The time post-stroke also ranged from 6.7 months to 10 years. The meta-
analysis revealed a significant effect favouring CIMT regarding both the Amount of Use and the Quality
of Movement subscales of the MAL (McIntyre et al., 2012). Similarly, the same effects were found on the
FMA and on the ARAT, however the WMFT and the FIM were not found to favour CIMT over the control
(McIntyre et al., 2012).
A summary of the results from RCTs that evaluated mCIMT in the subacute (<6 months) stage post
stroke is presented in Table 10.2.11.3.
Table 10.2.11.3 Summary of RCTs Evaluating Modified CIMT in the Subacute (<6 months) Phase
Following Stroke
Author, Year Intervention CIMT Intensity/Duration Main Outcome(s)
Study Design (PEDro Result
Score)
Sample Size
Myint et al. (2008) E: mCIMT 4 hrs/day x 10 days • Action Research Arm Test (+)
RCT (7) C: Traditional rehabilitation • Motor Activity Log (+)
N=43
Treger et al. (2012) E: mCIMT 4 hrs/day x 2 days/wks • Functional Independence
RCT (7) C: Traditional rehabilitation Measure (-)
N=28 • Manual Function Test (-)
Kwakkel et al. (2016) E1: Electromyographic 3h/d x 5d/wk x 3wk • Action Research Arm Test: E1
RCT (7) Neuromuscular Stimulation on vs C1 (-); E2 vs C2 (+)
NStart=159 finger extensors • Fugl-Meyer Assessment: E1 vs
NEnd=159 E2: Modified Contraint Induced C1 (-); E2 vs C2 (-)
Movement Therapy • Wolf Motor Function Test: E1

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C1: Unfavourable prognosis vs C1 (-); E2 vs C2 (-)
based on voluntary finger • Motricity Index: E1 vs C1 (-); E2
extension. Received usual care. vs C2 (-)
C2: Favourable prognosis based • Erasmus modified Nottingham
on voluntary finger extension. Sensory Assessment: E1 vs C1 (-
Received usual care. ); E2 vs C2 (-)
• Nine-Hole Peg Test: E1 vs C1 (-
); E2 vs C2 (-)
• Frenchay Arm Test: E1 vs C1 (-);
E2 vs C2 (-)
• Motor Activity Log- Quality of
Movement: E1 vs C1 (-); E2 vs
C2 (-)
• Motor Activity Log- Amount of
Use: E1 vs C1 (-); E2 vs C2 (-)
• Stroke Impact Scale- Hand: E1
vs C1 (-); E2 vs C2 (+)
El-Helow et al. (2014) E: Modified Constraint Induced 6h/d x 2wk • Fugl-Meyer Assessment (+)
RCT (6) Movement Therapy • Action Research Arm Test (+)
NStart=60 C: Conventional Rehabilitation
NEnd=60
Liu et al. (2016) E1: Modified Constraint Induced 1h/d x 5d/wk x 2 wk • Action Research Arm Test: E2
RCT (6) Movement Therapy vs E1 (+); E2 vs C (+)
NStart=90 E2: Self-Regulated Modified • Fugl-Meyer Assessment: E2 vs
NEnd=86 Constraint Induced Movement E1 (+); E2 vs C (+)
Therapy • Independent Activities of Daily
C: Conventional Therapy Living: E2 vs E1 (+); E2 vs C (+)
• Motor Activity Log: E2 vs E1 (+);
E2 vs C (+)
• Self-Pereived Quality of Arm
Use: 1 month, E2 vs E1 (+); E2
vs C (+)
Hammer & Lindmark E: Restraining sling and Standard 6 h/d x 5d/wk x 2wk • Motor Activity Log (-)
(2009) Rehabilitation
RCT (6) C: Standard Rehabilitation
NStart=30
NEnd=26
Hammer & Lindmark E: Restraining sling and Standard 6 h/d x 5d/wk x 2wk • Fugl-Meyer (-)
(2009) Rehabilitation • Action Research Arm Test (-)
RCT (6) C: Standard Rehabilitation • Motor Assessment Scale (-)
NStart=30 • 16-Hole Peg Test (-)
NEnd=26 • Grip strength ratio (-)
Brogårdh et al. (2009) E: Shortened CIMT (mitt use) 90% of waking time for 12 • Motor Assessment Scale (-)
RCT (5) C: No mitt use days • Sollerman Hand Function Tst (-)
N=24 • 2-Point Discrimination Test (-)
• Motor Activity Log Test (-)
Several studies found an improvement in Action Research Arm Test scores in those receiving mCIMT in
the early phase after stroke compared to those receiving conventional therapy (El-Helow et al., 2014;
Kwakkel et al., 2016; K. P. Liu et al., 2016; Myint et al., 2008). However, many studies also found no

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significant improvement in those receiving mCIMT when compared to conventional therapy on other
motor function based outcomes that focus more on improvements of impairment (Brogardh et al.,
2009; Hammer & Lindmark, 2009; Kwakkel et al., 2016; Treger et al., 2012).
This suggests that mCIMT optimizes already preserved function through adaptation strategies, but that
it doesn’t improve neurological impairment in the early stage after stroke.
A summary of the results from RCTs that evaluated mCIMT in the chronic (>6 months) stages post stroke
is presented in Table 10.2.11.4.
Table 10.2.11.4 Summary of RCTs Evaluating Modified CIMT in the Chronic (>6 months) Phase
Following Stroke
Author, Year Intervention CIMT Intensity/Duration Main Outcome(s)
Study Design (PEDro Result
Score)
Sample Size
Smania et al. (2012) E: mCIMT 2hr/d x 5d/wk x 2wk • Wolf Motor Function Test (+)
RCT (8) C: Dose-match task-specific • Motor Activity Log (+)
N=66 therapy
Lin et al. (2007) E: mCIMT 6hr/d x 5hr/d x 3wk. • Motor Activity Log (+)
RCT (7) C: Traditional rehab • FIM (+)
N=32
Hsieh et al. (2016) E: Modified Constraint- 20 sessions x 105min/d x 5 d/wk x • Wolf Motor Function Test
RCT (7) Induced Therapy 4 wk Functional Ability Score (+)
NStart=34 C: Regular Therapy • Wolf Motor Function Test
NEnd=34 Times (-)
• Nottingham Extended Activities
of Daily Living (+)
• Functional Independence
Measure (-)
Barzel et al. (2015) E: Home CIMT 5h/wk x 4wk • Motor Activity Log Quality of
RCT (6) C: Standard Therapy Movement(+)
NStart=156 • Motor Activity Log Amount of
NEnd=156 Arm Usage (+)
• Nine Hole Peg Test (-)
• Instrumental Activities of Daily
Living (-)
Wu et al. (2007) E: mCIMT 2hr/d x 5d/wk x 3wk • Motor Activity Log (+)
RCT (6) C: Regular occupational • FIM (+)
N=30 therapy
Page et al. (2004) E1: mCIMT 30 min/d x 3d/wk x 10 wk • Fugl-Meyer Assessment (+)
RCT (6) E2: Traditional Rehabilitation • Action Research Arm Test (+)
N=17 C: No Therapy
Page et al. (2004) E1: mCIMT + physical and 5hr/d x 5d/wk x 10wk • Fugl Meyer: mCIMT at post (+)
RCT (6) occupational therapy • Action Research Arm Test:
N=17 E2: Traditional rehab mCIMT at post (+)
C: No therapy
Page et al. (2002) E1: mCIMT + physical and 5hr/d x 5d/wk x 10wk • Fugl Meyer Score: mCIMT at

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RCT (5) occupational therapy post (+)
N=14 E2: Traditional rehab • Action Research Arm Test:
C: No therapy mCIMT at post (+)
Doussoulin et al. E1: mCIMT group therapy 3 h/d x 10 d • Motor Activity Log (+)
(2017) E2: mCIMT individual therapy • Action Research Arm Test (+)
RCT (5) • Functional Independence
NStart=36 Measure Motor (+)
NEnd=36 • Functional Independence
Measure Total (+)
Page et al. (2008) E1: mCIT + physical and 5hr/d x 5d/wk x 10wk • Fugl Meyer Assessment (-)
RCT (5) occupational therapy • Action Research Arm Test (+)
N=35 E2: Traditional rehab
C: No therapy
Yadav et al. (2016) E: mCIMT and conventional 3hr/d x 3d/wk x 4wk • Fugl-Meyer Assessment: 1mo
RCT (5) rehabilitation (+); 3mo (+)
NStart=65 C: Conventional rehabilitation • Amount of Use: 1mo (+); 3mo
NEnd=60 (+)
• Quality of Use: 1mo (+); 3mo
Wu et al. (2007) E: mCIMT + a restraining mitt 2hr/d x 5d/wk x 3wk • Fugl Meyer Assessment (+)
RCT (5) on the unaffected hand • FIM (+)
N=26 C: Traditional therapy • Motor Activity Log (+)
Hayner et al. (2010) E: mCIMT 6hr/d x 10d • Wolf Motor Function Test (-)
RCT (4) C: Bilateral training • COPM (-)
N=12
Wang et al. (2011) E1: mCIMT 3hr/d x 5d/wk x 4wk • Wolf Motor Function Test:
RCT (4) E2: Intensive conventional mCIMT (+)
N=30 therapy
C: Conventional therapy
Uswatte et al. (2006) E1: Sling and Task-practice 6hr/d x 2 wk • Motor Activity Log (-)
PCT E2: Sling and Shaping • Wolf Motor Function Test (-)
N=17 E3: Half-glove and Shaping
E4: Shaping Only
Compared to conventional therapy, mCIMT in the chronic stage after stroke has demonstrated its
effectiveness on upper limb motor function outcomes based on the results of studies by Smania et al.
(2012), Hsieh et al. (2016), Page et al. (2004), Page et al. (2004), Page et al. (2002), Doussoulin et al.
(2017), Page et al. (2008), Yadav et al. (2016), Wu et al. (2007), and Wang et al. (2011). Barzel et al.
(2015), Wu et al. (2007), and Lin et al. (2007) found that mCIMT provided improvements on the Motor
Activity Log, which is a self-reported measurement of arm function, when compared to conventional
therapy. One RCT found that mCIMT was not superior to bilateral training for upper limb motor function
(Hayner et al., 2010). This is one of few studies examining mCIMT with the inclusion of a control group
receiving the same duration, frequency and intensity of therapy as the treatment group. The authors
suggested that the intensity, rather than the type of therapy, explained the gains made in both groups
which resulted in a lack of significant difference between the groups on the outcomes measured. The
addition of a third group consisting of conventional therapy at a lower intensity may have helped to
elucidate the effect of treatment.
Conclusions Regarding Constraint-Induced Movement Therapy

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There is level 1b and level 2 evidence that there is no benefit of CIMT in the early stage of stroke for
improving upper limb motor function or dexterity.
There is level 1a evidence that CIMT in the chronic phase of stroke may help improve upper
extremity motor function. The evidence regarding the ideal frequency of CIMT is currently unclear.
There is level 1a evidence that mCIMT in the early phase of stroke may improve adaptation
strategies as it optimizes already preserved function. However, mCIMT does not improve
neurological impairment in the early stage of stroke.
There is level 1a evidence that mCIMT in the chronic phase of stroke may improve upper limb
function relative to conventional therapy.
Constraint-induced movement therapy (CIMT) may be ineffective in the acute stage of stroke, but
likely effective in the chronic phase for improving upper extremity motor function.
Modified constraint-induced movement therapy (mCIMT) may improve adaption to preserved

function, but not neurological impairment in the early stage of stroke. However, mCIMT may
improve upper limb motor function in the chronic phase.
10.2.12 Mirror Therapy

Mirror therapy is a technique that uses visual feedback about motor performance to improve
rehabilitation outcomes. Ramachandran et al. (1995) first used this method to understand the effect of
vision on phantom sensation in arm amputees. This method has since been adapted from its original use
(as a method to “re-train the brain”) as a means to enhance upper-limb function following stroke and to
reduce pain (Sathian, Greenspan, & Wolf, 2000). In mirror therapy, patients place a mirror beside the
unaffected limb, blocking their view of the affected limb and creating an illusion of two limbs which are
functioning normally. It is believed that by viewing the reflection of the unaffected arm in the mirror,
this may act as substitute for the decreased or absent peripheral and prioprioceptive input to the
affected arm.
The effectiveness of mirror therapy was evaluated recently in a Cochrane review (Thieme, Mehrholz,
Pohl, Behrens, & Dohle, 2012). The results from 14 RCTs (567 subjects) were included. A modest benefit
of treatment was reported in terms of motor function, but the treatment effect was difficult to isolate
due to the variability of control conditions. Improvement in performance of ADLs (SMD=0.33, 95% CI
0.05 to 0.60, p=0.02), pain (SMD=-1.1, 95% CI -2.10 to -0.09, p=0.03) and neglect (SMD=1.22, 95% CI
0.24 to 2.19, p=0.01) were also noted.
A summary of the results from RCTs evaluating mirror therapy is presented in Table 10.2.12.1.
Table 10.2.12.1 Summary of Controlled Trials Evaluating Mirror Therapy for the Upper Extremity
Sample Size
Arya et al. (2015) E: Task-based mirror therapy • Fugl-Meyer Assessment of the Upper
RCT (8) C: Standard Rehabilitation Extremity (+): wrist and hand (+); arm (-)
NStart=33
NEnd=32

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Yavuzer et al. (2008) E: Mirror Therapy and conventional • Brunnstrom Stages for the Hand and Upper
RCT (7) stroke rehabilitation Extremity (+)
N=40 C: Sham Therapy and conventional • Funtional Indepence Measure for Self Care
stroke rehabilitation (+)
Timmerman et al. (2013) E: Mirror therapy + conventional • Frenchay Arm Test (-)
RCT (7) therapy • Wolf Motor Function Test (-)
NStart=42 C: Neurodevelopmental Bobath
NEnd=42 therapy
Yoon et al. (2014) E1: CIMT + Mirror therapy • Box and Block Test: E1 vs E2 (+)
RCT (7) E2: CIMT • Nine Hole Peg Test: E1 vs E2 (+)
NStart=26 C: Control conventional therapy • Grip strength: E1 vs E2 (+)
NEnd=26
Ji et al. (2014) E1: Mirror therapy + rTMS • Fugl Meyer Score: E1 vs. E2 (+), E2 vs. C (+)
RCT (7) E2: Mirror therapy • Box and Block Test: E1 vs. E2 (+), E2 vs. C (+)
NStart=35 C: Sham therapy
NEnd=35
Invernizzi et al. (2013) E: Mirror therapy • Action Research Arm Test (+)
RCT (7) C: Conventional therapy • Motricity Index (+)
NStart=26 • Fugl Meyer Scores (+)
NEnd=25
Altschuler et al. (1999) E: Mirror therapy • Brunnstrom stages (+)
RCT (7) C: Sham therapy • Fugl Meyer self-care Score (+)
N=40 • Modified Ashworth Scale (-)
Dohle et al. (2009) E: Mirror therapy • Fugl Meyer Score (-)
RCT (7) C: Control therapy
N=36
Michielsen et al. (2011) E: Mirror therapy • Action Research Arm Test (-)
RCT (7) C: Control therapy • ABILHAND (-)
N=40 • Grip force (-)
• Tardieu Scale (-)
• Fugl Meyer Score (+)
Kojima et al. (2014) E: Neuromuscular stimulation + • Fugl Meyer Assessment: Phase 1 (+); Phase 2
RCT (7) mirror therapy then PT + OT (-)
NStart=13 C: PT + OT then neuromuscular • Maximum active range of wrist extension:
NEnd=13 stimulation + mirror therapy Phase 1 (-); Phase 2 (+)
• Hand Ratio (-)
• Box and Block Test (-)
Samuelkamaleshkumar et al. (2014) E: Mirror therapy + bilateral arm • Fugl Meyer score (+)
RCT (7) training • Brunnstrom stage (+)
NStart=20 C: Control group • Box and Block Test (+)
Selles et al. (2014) E1: Mirror + bimanual training • Peak velocity: Bimanual no mirror vs.
RCT (7) E2: Bimanual training affected (+), bimanual mirror vs. affected (+)
NStart=103 E3: Mirror therapy for unaffected
NEnd=93 hand
E4: Bimanua
C: No mirror therapy for unaffected
hand
Lin et al. (2014) E1: Mirror therapy + mesh glove • Fugl Meyer Score: E1/E2 vs. C (+)

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RCT (7) E2: Mirror therapy • Box and Block Test: E1/C vs. E2 (+)
NStart=43 C: Control therapy • Maximum shoulder abduction: E1/E2 vs. C
NEnd=42 (+)
• Normalized shoulder flexion: E2 vs. C (+)
Rodrigues et al. (2016) E: Mirror Therapy and Bilateral • TEMPA (-)
RCT (7) Training
NStart=16 C: Bilateral Training
NEnd=16
Colomer et al. (2016) E: Mirror Therapy • Nottingham Sensory Assessment Tactile
RCT (7) C: Passive Mobilization Subscale (+)
NStart=34 • Fugl-Meyer Assessment (-)
NEnd=31 • Nottingham Sensory Assessment
Kinesthetic and Stereognosis Subscale
(+)
Thieme et al. (2012) E1: Individual mirror therapy • Action Research Arm Test (-)
RCT (6) E2: Group mirror therapy • Fugl Meyer Score (-)
NStart=60 C: Sham mirror therapy • Barthel Index (-)
• Modified Ashworth Scale (+)
Kim et al. (2015) E: FES + mirror therapy • Box and Block Test (-)
RCT (6) C: FES + sham mirror therapy • Fugl Meyer Assessment: Shoulder, elbow
NStart=28 and forearm (-); Wrist (+); Hand (+); Co-
NEnd=23 ordination (-)
• Brunnstrom Motor Recovery Stage: Upper
extremity (-); Hand (+)
• Manual Function Test: Shoulder function (-);
Hand function (+)
Park et al. (2015) E: Mirror therapy • Manual Function Test (+)
RCT (6) C: Non-reflecting mirror • FIM (+)
NStart=30
NEnd=30
Wu et al. (2013) E: Mirror therapy • Fugl Meyer Score (+)
RCT (6) C: Conventional therapy • Reaction time (+)
NStart=33 • Total displacement (+)
• ABILHAND (-)
Cristina et al. (2015) E: Mirror therapy • Modified Ashworth Scale: writ (+)
RCT (6) C: Conventional therapy • Bhakta finger flexion scale (+)
NStart=15
NEnd=15
Pervane Vural et al. (2016) E: Mirror Therapy and conventional • Fugl-Meyer Assessment wrist and hand (+)
RCT (6) rehabilitation • Visual Analog Scale (+)
NStart=30 C: Conventional rehabilitation • Brunnstrom Recovery Scale (+)
NEnd=30 • Functional Independence Measure (+)
• Modified Ashworth Scale (+)
Gurbuz et al. (2016) E: Mirror Therapy • Brunnstrom Stage (-)
RCT (6) C: Conventional Therapy • Fugl-Meyer Assessment (+)
NStart=31 • Function Independence Measure (-)
NEnd=31
Harmsen et al. (2015) E: Mirror Therapy-based action • Movement time of the reaching movement
RCT (6) observation (+)

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NStart=37 C: Control Observation
NEnd=37
Cho et al. (2015) E: Mirror therapy + tDCS • Box and Block Test (+)
RCT (5) C: Sham mirror therapy + tDCS • Grip strength (+)
NStart=30 • Jebsen Taylor Hand Function (-)
NEnd=27 Fugl Meyer Assessment (-)
Radajewska et al. (2017) E: Mirror therapy and conventional • Frenchday Arm Test (+)
NStart=60 C: Conventional rehabilitation
NEnd=60
Lim et al. (2016) E: Mirror Therapy • Fugl Meyer Assessment (+)
RCT (5) C: Sham Therapy • Modified Barthel Index (+)
NStart=60 • Brunnstrom Recovery Scale (-)
NEnd=60
Yun et al. (2011) E1: NMES + mirror therapy • Fugl Meyer Score: E1 vs E2/E3 (+)
RCT (4) E2: NMES • Hand flexion (-)
N=60 E3: Mirror therapy • Wrist flexion (-)
• Wrist extension (-)
Radajewska et al. (2013) E: Mirror therapy • Frenchay Arm Test (+)
RCT (3) C: Conventional therapy
NStart=60
NEnd=60
Harmsen et al. (2015) E: Mirror therapy action observation • Movement time (+)
PCT C: Action observation
Nstart=37
Nend=37
Kim et al. (2016) E: Mirror Therapy • Action Research Arm Test (+)
PCT C: Conventional Therapy • Fugl-Meyer Assessment (+)
NStart=25 • Box and Box Test (+)
NEnd=25 • Functional Independence Measure (+)
Yeldan et al. (2015) E: Mirror Therapy and • Fugl-Meyer Assessment (-)
PCT neurodevelopmental treatment • Motricity Index (-)
NStart=8 C: Neurodevelopmental treatment • Stroke Upper Limb Capacity Scale (-)
NEnd=8 • Barthel Index (-)
Discussion
Overall, a positive effect of mirror therapy on upper extremity motor function has been found. Studies
by Ji et al. (2014), Invernizzi et al. (2013), Altschuler et al. (1999), Park et al. (2015), Wu et al. (2013),
Pervane Vural et al. (2016), Gurbuz et al. (2016), Lim et al. (2016), and Yun et al. (2011) demonstrated
that mirror therapy is superior to conventional, control, or sham therapies for improving upper limb
motor function. In addition, a study by Arya et al. (2015) found that task-based mirror therapy was
superior to standard therapy based on functional outcomes of the arm and hand. Yoon et al. (2014)
found that mirror therapy with CIMT was superior to CIMT on various motor function tests, and
Samuelkamaleshkumar et al. (2014) found that mirror therapy with bilateral arm training were superior
to a control group. Studies by Michielsen et al. (2011), Lin et al. (2014), and Kim et al. (2015) found some
positive and some negative motor function outcomes. Studies by Dohle et al. (2009), Colomer et al.
(2016), and Thieme et al. (2012) found that there was no difference between mirror therapy and sham
on motor function outcomes. A study by Timmerman et al. (2013) also found no significant difference on

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the Wolf Motor Function Test when comparing mirror therapy and conventional therapy to the Bobath
method.
On the studies that found a significant difference between mirror-based therapy and a control group,
they more often found an improvement on the wrist and hand Fugl-Meyer subscales rather than on the
shoulder, elbow, forearm, and coordination subscales.
Conclusions Regarding Mirror Therapy
There is level 1a evidence that mirror therapy improves upper limb motor function following stroke,
especially for the wrist and hand.
There is level 1b evidence that Mirror therapy in combination with conventional therapy is not
superior to the Bobath method for upper limb motor function.
There is conflicting level 1a evidence regarding the effect of mirror therapy on spasticity.
Mirror therapy is likely effective for improving upper limb motor function.
10.2.13 Feedback Therapy

As with athletic performance, feedback can be used as a means to improve motor learning following
stroke. There are two types of feedback, intrinsic and extrinsic. Intrinsic feedback refers to the use of a
person’s own sensory-perceptual information to enhance their performance during a given task. It may
take the form of touch, sound, pressure, and/or proprioception. Extrinsic feedback can augment the
effect of intrinsic and refers to feedback provided from the environment. Extrinsic feedback can be both
verbal and non-verbal. Comments from a therapist would be an example of extrinsic verbal feedback.
Extrinsic feedback can be further classified as either knowledge of results (KR) or knowledge of
performance (KP). KR is often given at the end of a task and is feedback related to the outcome of the
performance of that task. A patient’s performance time on a particular task is an example of KR. KP is
information about the movement characteristics that led to the performance outcome. For example, the
position of the hand when a patient is reaching towards a glass of water.
Subramanian et al. (2010) conducted a systematic review which included the results from 9 studies.
Results show evidence that external feedback, particularly KP, in the forms of verbal, virtual
environments, videotape, robotics, audition, or vision, improved motor learning of the more affected
upper limb.
A summary of the results of RCTs evaluating feedback therapy are presented in Table 10.2.13.1.
Table 10.2.13.1 Summary of Controlled Trials Evaluating Feedback Therapy for the Upper Extremity
Sample Size
Piron et al. (2010) E: Feedback in virtual environment • Fugl Meyer Score (+)
RCT (8) C: Bobath therapy
N=50
Yang et al. (2016) E1: Repetitive Transcranial Magnetic • Fugl-Meyer Assessment (-)
RCT (8) stimulation with sensory cueing • Action Research Arm Test (-)
NStart=60 E2: Repetitive Transcranial Magnetic • Modified Barthel Index (-)

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NEnd=60 stimulation
C: Conventional Rehabilitation
Abdollahi et al. (2014) E: Hepatic and visual error • Fugl Meyer Score: Phase 1 (+); Phase 2 (-)
RCT (7) augmentation • Wolf Motor Function Test (+)
NStart=27 C: No error augmentation
NEnd=26
Lin et al. (2015) E: Bilateral Isometric Handgrip Force • Fugl-Meyer Assessment-Upper Extremity
RCT (7) Training with Visual Feedback (+)
NStart=33 C: Routine Therapy • Wolf Motor Function Test (+)
NEnd=33 • Motor Assessment Scale (+)
• Barthel Index (+)
Bang (2016) E: Auditory feedback with constraint • Action Research Arm Test (+)
RCT (7) induced movement therap (CIMT) • Fugl-Meyer Assessment for the upper limb
NStart=20 C: Constraint induced movement (+)
NEnd=20 therapy (CIMT) • Modified Barthel Index (+)
• Motor Action Log Amount of Use (+)
• Motor Action Log Quality of Movement (-)
• Modifed Ashworth Scale (-)
Durham et al. (2014) E1: External focus (EF) feedback • Reach to grasp task: Peak velocity (+); Peak
RCT (6) E2: Internal focus (IF) feedback deceleration (-); Peak aperture (-)
NStart=42 • Push object task: Peak velocity; Peak
NEnd=42 deceleration (+); Peak aperture; Movement
duration (+)
• Raise object task (-)
Mukherjee et al. (2013) E: Visual feedback for reaching tasks • Approximate entropy (-)
RCT (6) C: No feedback for reaching tasks • Movement variability (-)
NStart=12 • Movement time (-)
NEnd=12
Ballester et al. (2016) E: Reinforcement-induced movement • Fugl-Meyer Assessment (+)
RCT (6) therapy + feedback movement
NStart=23 amplification
NEnd=18 C: Reinforcement-induced movement
therapy
Cirstea & Levin (2007) E1: 20% Knowledge of Results about • Range of Shoulder Movements: E2 vs E1 (+)
RCT (6) Movemet Precision • Improved Elbow and Shoulder Temporal
N=28 E2: Faded Knowledge of Performance Interjoint Co-ordination: E2 vs E1 (+)
about arm joint movements
C: Nondisabled control practiced same
task as E1.
Cirstea et al. (2006) E1: Knowledge of Results and reaching • Fugl-Meyer Assessment (-)
RCT (6) task • Performance Test for the Elderly (TEMPA) (-)
N=37 E2: Knowledge of Performance with • Precision in movement: E1 vs C (+); E2 vs E1
reaching task (-); E2 vs C (-)
C: Control with nonreaching task • Movement time and variability: E2 vs C (+);
E1 vs C (-); E1 vs E2 (-)
• Composite Spasticity Index for Elbow (-)
Cruz et al. (2014) E: Rehab device then vibratory • Range of Motion (-)
RCT (5) feedback • Correct movements (-)
NStart=44 C: Vibratory feedback then rehab
NEnd=43 device
van Vugt et al. (2016) E: Jittered auditory feedback with • The Nine Hole Pegboard Test (-)

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RCT (5) random delays post-treatment and • Finger Tapping (-)
NStart=43 piano treatment • Finger Tapping Speed (-)
NEnd=34 C: Normal auditory feedback and
piano treatment
Gilmore & Spaulding (2007) E: Verbal and Visual Feedback • Klein-Bell Activities of Daily Living Scale (-)
RCT (5) C: Verbal Feedback • Canadian Occupational Performance
N=10 Measure (-)
Kim et al. (2014) E: Auditory rhythmic stimulation • Range of Motion: elbow extension (+)
PCT C: No rhythmic auditory stimulation • Muscle activation (+)
NStart=16
NEnd=16
Discussion
Several methods of feedback therapy have been used for upper extremity rehabilitation for individuals
with stroke. Most studies investigated the effectiveness of external feedback, using methods such as
visual stimuli, performance based reports, and auditory stimuli. Overall more studies indicated some
benefit to feedback therapy than not.
Three studies investigated the use of auditory feedback for upper limb motor function, specifically Bang
et al. (2016), van Vugt et al. (2016), and Kim et al. (2014). Bang et al. (2016) found a significant benefit to
auditory feedback with CIMT to CIMT alone for upper limb motor function and spasticity. Likewise, Kim
et al. (2014) also found a positive effect in terms of range of motion for auditory rhythmic stimulation
compared to a control not receiving auditory stimulation. However, van Vugt et al. (2016) found that
there was no significant difference between groups receiving jittered auditory feedback with random
delays post-treatment and piano treatment compared to those only receiving piano treatment on the
Nine-Hole Peg Test, a measure of upper limb function and dexterity.
Two studies investigated the use of visual feedback, both finding a significant improvement in upper
limb motor function based on the Fugl-Meyer Assessment and Wolf Motor Function Test (Abdollahi et
al., 2014; C. H. Lin et al., 2015). Abdollahi et al. (2014) compared hepatic and visual error augmentation
to a control while Lin et al. (2015) compared bilateral isometric handgrip force training with visual
feedback to routine therapy.
Four studies investigated studies which used knowledge of results (KR) or knowledge of performance
(KP) (Ballester et al., 2016; Cirstea et al., 2006; Cirstea & Levin, 2007; Piron et al., 2010). Piron et al.
(2010) compared knowledge of results and performance-based feedback in a virtual environment to
Bobath therapy and found that feedback was significantly superior based on upper limb motor function
scores. Ballester et al. (2016) compared feedback movement amplification with reinforcement-induced
movement therapy to reinforcement-induced movement therapy and found a similar result. Cristea &
Levin (2007) compared knowledge of results to knowledge of performance, and found that knowledge
of performance was superior for improving range of motion of the shoulder. On the other hand, a study
by Cristea et al. (2006) with similar interventions found no significant difference between groups for
Lastly, a study by Yang et al. (2016) investigated repetitive transcranial magnetic stimulation with
sensory cueing through vibrations in comparison to repetitive transcranial magnetic stimulation alone.
There was no significant difference on upper limb motor function outcomes between groups.

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Conclusions Regarding Feedback Therapy
There is level 1a evidence that feedback is effective for improving upper limb motor function, and
that it is ineffective for improving spasticity.
Feedback may improve upper limb motor function post stroke.
10.2.14 Action Observation

Action observation is a form of therapy whereby a motor task is performed by an individual while
watching a mirror image of another individual perform the same task. The therapy is designed to
increase cortical excitability in the primary motor cortex by activating central representations of actions
through the mirror neuron system ((E. Kim & K. Kim, 2015a). Although action observation has been
evaluated mainly in healthy volunteers, a number of studies have evaluated its benefit in motor
relearning following stroke.
A summary of the results of RCTs evaluating action observation are presented in Table 10.2.14.1.
Table 10.2.14.1 Summary of RCTs Evaluating Action Observation for the Upper Extremity
Sample Size
Franceschini et al. (2012) E: Video footage • Box and Block Test (+)
RCT (8) C: Static images • Frenchay Arm Test (-)
• FIM (-)
Cowles et al. (2013) E: Action observation • Motricity Index (-)
RCT (7) C: Conventional therapy • Action Research Arm Test: conventional (+)
N=29
Sale et al. (2014) E: Action observation • Box and Block Test (+)
RCT (7) C: Standard rehabilitation • FIM (+)
NStart=67
NEnd=67
Kim et al. (2016) E: Action observation training with CBI • Fugl-Meyer Assessment of Upper Extremity -
RCT (7) and functional electrical stimulation Shoulder (+)
NStart=34 C: Conventional training • Fugl-Meyer Assessment of Upper Extremity -
NEnd=30 Wrist (+)
• Motor Activity Log – Activity of Use (+)
• Motor Activity Log – Quality of Movement
(+)
• Modified Barthel Index (+)
• Wrist Flexion (+)
Kim and Kim (2015a) E: Action observation + occupational • Wolf Motor Function Test (-)
RCT (6) therapy
NStart=12 C: Placebo observation + occupational
NEnd=12 therapy
Lee et al. (2013) E1: Action observation • Number of drinking motions: Post-
RCT (6) E2: Action practice intervention: E1 vs. C (+), E2 vs. C (+), E3 vs. C
NStart=33 E3: Action observation + action (+), E1 vs. E2 (-), E1 vs. E3 (+), E2 vs. E3 (-);
NEnd=33 practice 1wk post-intervention: E1 vs. C (+), E2 vs. C
C: No treatment (+), E3 vs. C (+), E1 vs. E2 (-), E1 vs. E3 (-), E2

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vs. E3 (-)
Celnik et al. (2007) E1: Physical therapy + congruent • Motor Memory: E1 vs. E2/C (+)
RCT (5) action observation • Kinematic Assessment: E1 vs. E2/C (+)
N=8 E2: Physical therapy + incongruent
action observation
C: Physical therapy
Zhu et al. (2015) E: Upper Limb Action Observation • Fugl-Meyer Assessment (+)
RCT (5) Therapy • Barthel Index (+)
NStart=70 C: Conventional Rehabilitation Therapy • Modified Ashworth Scale (+)
NEnd=61
Ertelt et al. (2007) E: Action observation therapy • Frenchay Arm Test (+)
RCT (5) C: Traditional therapy • Wolf Motor Function Test (+)
N=15 • Stroke Impact Scale (+)
Kuk et al. (2016) E: Video clip of a motor task followed • Box and Block Test (+)
RCT (5) by execution of the same motor task
NStart=22 C: Pictures of landscapes followed by
NEnd=20 execution of the motor task
Kim et al. (2015b) E: Purposeful Action Observation • Average Velocity (-)
RCT (4) C: Purposeful Action without Action • Trajectory Ratio (-)
NStart=12 Observation • Motion Angle (-)
NEnd=12
Sun et al. (2016) E: Motor Imagery Practice guided by • Fugl-Meyer Assessment (+)
PCT daily synchronous action observation • Pinch Strength Test (+)
NStart=10 C: Motor Imagery Practice guided by
NEnd=10 daily asynchronous action observation
Discussion
Of the studies included to assess action observation, only one RCT was adequately powered
(Franceschini et al., 2012). The study compared the effects of watching video footage of physical upper
limb movements to those when patients observed static images of the same movements. The findings
showed a significant difference between the groups on manual dexterity a measured by the Box and
Block Test (BBT) and motor function through the Fugl Meyer Assessment, but not on the Frenchay Arm
Test, another measure of motor function. Studies by Sale et al. (2014), Lee et al. (2013), Zhu et al.
(2015), Ertelt et al. (2007), and Kuk et al. (2016) also supported the idea that action observation may
improve upper limb motor function outcomes. However, most of these studies have low methodological
quality and are severely underpowered, as mentioned above. Furthermore, studies by Cowles et al.
(2013) and Kim & Kim (2015b) found that there was no significant difference between action
observation and a control group.
A study by Kim et al. (2016) examining action observation in combination with computer-brain interface-
based functional electrical stimulation found a significant improvement on upper limb motor functions
in this group when compared to a conventional training group.
Conclusions Regarding Action Observation
There is conflicting level 1a evidence regarding the effect of action observation on upper motor
function.

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There is level 1b evidence that action observation with brain–computer interface-based functional
electrical stimulation is effective for improving upper limb motor function.
Evidence for the use of action observation is conflicting, although the combination of action
observation with brain-computer interface-based functional electrical stimulation may be effective
for upper limb motor rehabilitation.
10.2.15 Music Therapy

Music therapy is a promising rehabilitation technique for improving function of the hemiparetic arm
following stroke. It involves many components of conventional upper limb rehabilitation interventions
including repetitive task practice, finger individualization, as well as tactile and auditory feedback (van
Wijck et al., 2012). The rehabilitation program can also be shaped by increasing the tempo of the songs
or incorporating more difficult musical pieces based on individual performance. Additionally, music
therapy may be more emotionally involving than traditional upper limb interventions which could lead
to increased engagement of the patient (Van Vugt, Ritter, Rollnik, & Altenmuller, 2014).
RCTs evaluating the use of music therapy for upper extremity rehabilitation following stroke are
summarized in Table 10.2.15.1.
Table 10.2.15.1 Summary of RCTs Evaluating Music Therapy for the Upper Extremity

Sample Size
Thielbar et al. (2014) E: Virtual keyboard music playing • ARAT (-)
RCT (6) C: High intensity, task oriented • Fugl Meyer Assessment: Upper extremity (+);
NStart=14 occupational therapy Hand (-)
NEnd=14 • Jebsen Taylor Hand Function Test (+)
• Grip strength (-)
• Lateral pinch strength (-)
• 3-point pinch strength (-)
Altenmüller et al. (2009) E: MIDI piano and electronic drum • Box and Block Test (+)
RCT (5) training + conventional therapy • 9 Hole Pegboard Test (+)
NStart=62 C: Conventional therapy only • Action Research Arm Test (+)
NEnd=62 • Arm Paresis Score (+)
• Finger/Hand tapping (+)
Tong et al. (2015) E: Audible Musical Instrumental • Fugl-Meyer Assessment (-)
RCT (5) Training • Wolf Motor Function Test (+)
NStart=33 C: Mute Musical Instrumental
NEnd=30 Training
Van Vugt et al. (2014) E: Playing piano together • Un-paced finger tapping scores: middle finger
RCT (4) C: Playing piano sequentially (-), index finger (-)
NStart=36 • Paced finger tapping score: index to thumb (-)
NEnd=28 • Nine Hole Peg Test (-)
Scholz et al. (2016) E: Musical Sonification Therapy • Fugl-Meyer Assessment (-)

RCT (4) C: Sham Movement Training • Action Research Arm Test (-)
NStart=25 • Nine Hold Peg Test (-)

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Jun et al. (2013) E: Music movement therapy • Range of motion (+)
RCT (4) C: Routine intervention • Muscle strength (-)
NStart=40 • Modified Barthel Index (-)
NEnd=30
Discussion
Overall, there is conflicting evidence for the effectiveness of music therapy for motor function and
dexterity. This may be because of the large variation in intervention type and the low power of some of
these studies. Thielbar et al. (2014) compared virtual playing of keyboard music to high intensity, task
oriented occupational therapy, and found that the music group performed significantly better than the
control group on some motor function outcomes, but not on others. The authors proposed that while
the occupational therapy group practised a wider variety of motor skills, the music playing group
repeated the same movement task which resulted in greater refinement of a specific motor skill. This
improved hand motor control and was also found to generalize to the manipulation of real world objects
measured by the Jebsen Taylor Hand Function Test. Despite this, no between group differences were
found for measures of hand strength. Tong et al. (2015) also found mixed motor function outcomes
when comparing audible musical instrumental training to mute musical instrumental training.
Altenmuller et al. (2009) found a positive effect of musical instrument digital interface (MIDI) piano and
electronic drum set in terms of upper limb motor function and dexterity in comparison to conventional
training.
Jun et al. (2013) found that music movement therapy was superior to routine therapy only in terms of
improving range of motion. The main activities of the music movement therapy included singing along
to a song and playing basic percussion instruments (tambourines, maracas) with the less affected arm.
Although greater improvement was found for the music group for range of motion, no between group
differences were found for functional ability and muscle strength. These results indicate that music
therapy not involving repetitive movements of the affected arm may not be effective for improving
motor function. Furthermore, it is important to note that a major limiting factor to music therapy as an
upper limb rehabilitation intervention is the severity of hemiparesis. In order to benefit from this
treatment, individuals must have a certain level of control over the affected arm in addition to being
able to individualize finger movements, particularly if a piano is used (Morris & Van Wijck, 2012). In
addition, Van Vugt et al. (2014) found no difference in upper limb dexterity between playing piano
together or sequentially, and Scholz et al. (2016) found no significant difference in upper limb motor
function between musical sonification therapy and sham movement training.
Conclusions Regarding Music Therapy
There is level 1a and level 1b evidence that music therapy can improve some aspects of upper
extremity motor function but not muscle strength when compared to conventional rehabilitation.
Music therapy may improve upper limb motor function but not muscle strength.
10.2.16 Telerehabilitation
It is known that distance to a rehabilitation centre can impede patients from receiving the care they
need once they are discharged from the hospital. Therefore, providing rehabilitation services remotely
via a kiosk or by telephone can limit the challenge of location and transportation especially for patients
isolated from these services. This form of service provision has been termed “telerehabilitaiton”. It is an

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intervention that can be delivered for a longer duration and at a reduced cost when compared to
therapies provided in the inpatient rehabilitation setting (Benvenuti et al., 2014).
The studies investigating telerehabilitation for rehabilitation of the upper limb following stroke are
presented in Table 10.2.16.1.
Table 10.2.16.1 Summary of Controlled Trials Evaluating Telerehabilitation for the Upper Extremity
Sample Size
Wolf et al. (2015) E: Telerehabilitation with home • Fugl Meyer Assessment (-)
RCT (7) exercise program + robotic assistance • Action Research Arm Test (-)
NStart=99 training • Wolf Motor Function Test: Performance
NEnd=92 C: Telerehabilitation with home time: Total (+), Fine (+), Gross (-); Functional
exercise program only ability (-); Mean number of tasks: Total (+),
Fine (+), Gross (-)
Emmerson et al. (2017) E: Home exercise program using an • Wolf Motor Function Test (-)
RCT (7) electronic tablet with automated • Grip Strength (-)
NStart=62 reminders • Functional Score (-)
NEnd=58 C: Paper-based home exercise
program
Majeed et al. (2015) E: Bilateral Self-telerehabilitation • Fugl-Meyer Assessment (-)
RCT (6) program and Error augmentation
NStart=28 through a robotically-applied force
NEnd=28 C: Bilateral Self-telerehabilitation
program
Benvenuti et al. (2014) E: Kiosk telerehab • Motricity Index (+)
PCT C: No kiosk availability • Nine Hole Peg Test (+)
NStart=256 • Wolf Motor Function Test (+)
NEnd=188 • Nottingham Extended Activities of Daily
Living (+)
• Barthel Index (+)
Discussion
In a multicenter RCT conducted by Wolf et al. (2015), therapists made use of weekly phone calls or e-
mails to administer telerehabilitation to groups receiving only home exercise practice or home exercise
practice with robotic assistance. None of the upper limb motor function outcomes assessed indicated a
difference between the two groups. Emmerson et al. (2017) also found a similar result when comparing
a home exercise program using an electronic tablet with automated reminders to a paper-based home
exercise program. Majeed et al. (2015) compared bilateral self-telerehabilitation program and error
augmentation through a robotically-applied force to a bilateral self-telerehabilitation program, also
finding no difference between groups in upper limb motor function.
One large prospective controlled trial (PCT) made use of community based kiosks to administer the
telerehabilitation intervention (Benvenuti et al., 2014). The kiosks were designed to be easily accessible
and allowed patients to perform upper extremity exercises with supervision and feedback delivered
through videoconferencing. Benvenuti et al. (2014) found telerehabilitation to improve upper extremity
motor outcomes to a significantly greater degree than conventional outpatient rehabilitation. Patients

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receiving telerehabilitation were found to exercise more when compared to patients receiving
conventional rehabilitation, suggesting that the telerehabilitation program provided extra motivation.
A systematic review by Johansson & Wild (2010) found four studies that examined the effectiveness of
telerehabilitation-related interventions for upper limb motor function. The results were mixed, and the
methodological quality of the studies found was low. The authors concluded that telerehabilitation may
be effective for improving physical health of patients who have sustained a stroke, although additional
evidence is needed.
Conclusions Regarding Telerehabilitation
There is level 1a evidence that telerehabilitation interventions are not effective for improving upper
Home-based telerehabilitation interventions are likely not effective for improving upper limb motor
function.
10.2.17 Exercise Therapy

Physical therapy is one of the key disciplines in interdisciplinary stroke rehabilitation (Veerbeek et al.,
2014). Engaging in exercise programs could improve fitness, reduce sedentary behaviour, and may be
beneficial for reducing post-stroke symptoms.
The results of two RCT evaluating exercise therapy for upper extremity rehabilitation is presented in
Table 10.2.17.1.
Table 10.2.17.1 Summary of RCT(s) Evaluating Exercise Therapy for the Upper Extremity
Sample Size
English et al. (2015) E1: Circuit class (3hr/d morning and • Wolf Motor Function Test (-)
RCT (8) afternoon) • FIM (-)
NStart=283 E2: Seven day therapy (7d/wk)
NEnd=261 C: Usual care (5d/wk)
Wang et al. (2016) E: Low intensity aerobic training and a • Barthel Index (+)
RCT (5) rehabilitation training program • Functional Ambulation Category (+)
NStart=42 C: Rehabilitation training program • Frenchay Activities Index (+)
NEnd=34 • Fugl-Meyer Assessment (+)
Discussion
English et al. (2015) allocated patients to receive different intensities of conventional physical therapy or
intensive circuit class training. Both of the group exercise programs were shown to significantly improve
upper limb motor function; however, no significant differences between the two groups were found
regarding FIM and Wolf Motor Function Test scores.
Wang et al. (2016) compared low intensity aerobic training to a rehabilitation training program and
found a significant improvement in upper limb motor function in those receiving the aerobic training.

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The lack of difference found between different therapies reported in English et al. (2015) was
inconsistent with the results of a recent meta-analysis conducted by Veerbeek et al. (2014) which found
that more therapy time leads to better recovery of stroke symptoms. English et al. (2015) suggest that
this discrepancy may be due to their broad inclusion and exclusion criteria.
Although group programs can be provided with a lower ratio of staff to patients and may be more
feasible than individual therapy, individual therapy allows therapists to more easily shape the
intervention to the needs of the patient (English & Veerbeek, 2015). Further research is required to
determine the benefit of different therapy intensities.
Conclusions Regarding Exercise Therapy
There is conflicting evidence regarding the effectiveness of additional exercise therapy for improving
Additional research is needed to evaluate the effectiveness of additional exercise therapy for upper
10.3 Robotic Devices for Movement Therapy

Robotic devices can be used to assist the patient in a number of circumstances. First of all, the robot can
aid with passive range of motion to help maintain range and flexibility, to temporarily reduce hypertonia
or resistance to passive movement. The robot can also assist when the patient has active movements,
but cannot complete a movement independently. Robotics may be most appropriate for patients with
dense hemiplegia, although robotics can be used with higher-level patients who wish to increase
strength by providing resistance during the movement. According to Lum et al. (2002) “even though
unassisted movement may be the most effective technique in patients with mild to moderate
impairments, active- assisted movement (with robotic devices) may be beneficial in more severely
impaired patients…especially during the acute and subacute phases when patients are experiencing
spontaneous recovery,”. Krebs et al. (2002) noted that robotic devices rely on the repetition of specific
movements to improve functional outcomes.
A systematic review of robot-aided therapy on recovery of the hemiparetic arm on recovery was
conducted (Prange, Jannink, Groothuis-Oudshoorn, Hermens, & Ijzerman, 2006). The authors included
the results from 8 studies evaluating the MIT-Manus, MIME and ARM Guide and concluded that robotic
devices improved short and long term motor function of the paretic shoulder and elbow beyond that
which could be achieved through therapy alone.
A Cochrane review (Mehrholz, Hadrich, Platz, Kugler, & Pohl, 2012) included the results from 19 trials
(328 subjects) evaluating electromechanical and robot-assisted arm training devices. Compared with
routine therapy, usually conventional physical therapy, the authors reported significantly greater
improvement in activities of daily living (SMD=0.43; 95% CI 0.11 to 0.75, p <0.009) and arm function
(SMD=0.45; 95% CI 0.20 to 0.69, p<0.001), but not arm strength (SMD=0.48; 95% CI -0.04 to 0.04,
p=0.82).
A table of various robotic devices used in stroke rehabilitation is outlined below (see Table 10.3.1).
Table 10.3.1 Robotic devices used for upper limb rehabilitation post-stroke

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Robotic Devices Description
InMotion robot MIT-Manus was one of the first robotic devices to be developed. It features a 2-degree-of-
(Massacheusetts Insittute of freedom robot manipulator that assists in shoulder and elbow movement by guiding the
Technology/MIT-Manus) patient’s hand in a horizontal plane, while visual, auditory and tactile feedback is provided
during goal-directed movements. A commercially available unit (InMotion 2) of this device is also
available.
Mirror-Image Motion MIME is a 6 degree of freedom robotic device developed “to provide therapy that combines
Enabler Robots (MIME) bimanual movements with unilateral passive, active-assisted and resisted movements of the
hemiparetic upper extremity,” (Burgar et al. 2011). The unit applies force to the more affected
forearm during goal-directed movements.
ARMin This exoskeleton robot has 7 degrees of freedom and also provides intensive and task-specific
training to target improvements in motor function.
Assisted Rehabilitation and This unit uses a motor and chain drive to move the user’s hand along a linear rail, which assists
Measurement (ARM) Guide reaching in a straight-line trajectory.
Bi-Manu-Track This arm-training device enables bilateral and passive and active practice of forearm and wrist
movement.
Neuro-Rehabilitation-Robot The NeReBot device was developed in Italy designed to produce sensorimotor stimulation. The 3
(NeReBot) degrees of freedom device can perform spatial movements of the shoulder and elbow, is
portable and can be used when the patient is either prone or sitting.
Robot-mediated therapy This device is a three-degree of freedom haptic interface arm with a wrist attachment
system (GENTLE/s) mechanism, two embedded computers, a monitor and speakers and an overhead arm support
system. The affected arm is de-weighted through a free moving elbow splint attached to the
overhead frame. The subject is connected to the device by a wrist splint. Exercises such as hand-
to-mouth and reaching movements can then be practised, while feedback is provided.
Amadeo This device assists in hand rehabilitation, having an end-effecter design. It helps with finger
movements to allow for synchronization.
MusicGlove The glove is used with a game that promotes specific pinching movements to match musical
notes displayed on a screen.
Results of the studies evaluating the efficiency of these devices at improving upper limb motor function
are presented in table 10.3.2. The time post-stroke (TPS) has been extracted from all selected studies
and divided in three stages of stroke recovery: acute (<3 months), subacute (3-6 months), and chronic
(>6 months).
Table 10.3.2 Summary of Results From Studies Evaluating Sensorimotor Training: Robotic Devices
Sample Size
MIT-Manus / InMotion
Lo et al. (2010) E1: Intensive robot assisted therapy • Fugl Meyer: E1 vs. C (-), E1 vs. E2 (-)
RCT (7) E2: Intensive comparison therapy • Wolf Motor Function Test: E1 vs. C (-), E1 vs. E2
N=127 C: Usual care (-)
TPS=chronic • Stroke Impact Scale: E1 vs. C (+), E1 vs. E2 (-)
• Modified Ashworth Scale: E1 vs. C (-), E1 vs. E2
(-)
Ang et al. (2014) E: Brain Computer Interface Coupled with • Fugl-Meyer Assessment (-)
RCT (7) MIT-Manus shoulder-elbow robotic
NStart=26 feedback
NEnd=25 C: Training with the MIT-Manus
TPS=chronic
Volpe et al. (1999) E: Robot • Motor Status score: shoulder/elbow at d/c (+),

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RCT (6) C: Sham treatment and at 3yr follow-up (+)
N=20 • Motor Status score: wrist/hand at d/c/ (-), and
TPS=acute at 3yr follow-up (-)
• Motor Power score: shoulder and elbow at d/c
(+)
• Fugl Meyer: shoulder/elbow at d/c (-), and at
3yr follow-up (-)
• Fugl Meyer: wrist/hand at d/c (-), and at 3yr
follow-up (-)
Volpe et al. (2000) E: Robotic training • Motor Power score: shoulder and elbow (+),
RCT (6) C: Exposure to the robotic device without wrist and hand (-)
N=56 training • Motor Status score: shoulder and elbow (+),
TPS=acute wrist and hand (-)
• FIM: motor (+)
Conroy et al. (2011) E1: Robot-assisted planar reaching • Fugl Meyer score (-)
RCT (6) E2: Robot-assisted planar and vertical
N=62 reaching
TPS=chronic C: Intensive conventional arm therapy
Sale et al. (2014) E: Robot aided therapy + reaching tasks • Fugl Meyer Score (+)
RCT (6) C: Reaching tasks • Motricity Index (+)
NStart=53
NEnd=53
TPS=acute
Fasoli et al. (2004) E: Robot assisted movement training • Fugl Meyer score (+)
RCT (6) C: Robot exposure • Motor status score: shoulder/elbow (-),
N=56 wrist/hand (-)
TPS=acute • Medical Research Council score (-)
McCabe et al. (2015) E1: Robotic training + motor learning • Arm Motor Ability Test (-)
RCT (6) E2: Motor learning + functional electrical • Fugl-Meyer Assessment (-)
NStart=39 stimulation
NEnd=35 C: Motor learning
TPS=chronic
Abdullah et al. (2011) E: Robot assisted therapy • Chedoke Arm and Hand Activity Inventory (-)
RCT (5) C: Dose-matched conventional therapy
N=20
TPS=acute
Volpe et al. (2008) E: Sensorimotor arm training delivered by • Fugl Meyer: Shoulder (-); elbow (-); wrist (-);
RCT (5) robotic device hand (-)
N=21 C: Sensorimotor arm training delivered by • Motor Power Scale: Shoulder (-); elbow (-)
TPS=chronic a therapist
Stein et al. (2004) E1: Robot-aided progressive resistance • Fugl Meyer score (-)
RCT (5) traininig • Strength (-)
N=49 E2: Active-assisted robot-aided exercise
TPS=chronic
Volpe et al. (2000) E: Robot assisted movement training • Fugl Meyer Score (-)
RCT (5) C: Conventional therapy • Motor Power Scale: shoulder/elbow (-)
N=21
TPS=chronic
Rabadi et al. (2008) E1: Robot-unilateral group • Fugl Meyer Score (-)
RCT (5) E2: Ergometer (bilateral) group
TPS=acute

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MIME
Lum et al. (2002) E: Robot assisted movement training • Fugl Meyer Score: 1mo (+), 2mo (+), 6mo (-)
RCT (6) C: Conventional therapy • Strength upper extremity: 2mo (+)
N=27 • Reach upper extremity: 2mo (+)
TPS=chronic • FIM: 6mo (+)
Burgar et al. (2000) E: Robotic device therapy • Fugl Meyer Score (-)
RCT (5) C: Conventional care (physical therapy) • FIM (-)
N=21 • BI (-)
TPS=chronic
Burgar et al. (2011) E1: High intensity robotic therapy • Fugl Meyer Score (-)
RCT (5) E2: Low intensity robotic therapy • FIM: at post E1 vs. C (+); at 6mo E1 vs. C (-)
N=54 C: Conventional therapy • Modified Ashworth Scale: at 6mo (+)
TPS=acute
Lum et al. (2006) E1: Robot-unilateral • Fugl Meyer Score: E vs. C (+), E1 vs. E3 (+)
RCT (4) E2: Robot-bilateral • Motor Status Score: E vs. C (+)
N=30 E3: Robot-combined • FIM (-)
TPS=subacute C: Conventional therapy • Modified Ashworth Scale (-)
ARMin
Klamroth-Marganska et al. E: Robotic therapy • Fugl Meyer (+)
(2014) C: Conventional treatment • Strength (+)
RCT (8) • Motor Activity Log: Amount of Use (-), Quality of
NStart=77 Movement (-)
TPS=chornic • Goal attainment score (-)
• Wolf Motor Function test (-)
Brokaw et al. (2014) E: Robotic therapy • Fugl Meyer Score (-)
RCT (3) C: Conventional therapy • Action Research Arm Test (+)
NStart=12 • Box and Bock Test (-)
NEnd=10
TPS=chronic
ARM Guide
Kahn et al. (2006) E: Active-assistive reaching exercise using • Rango Los Amigos Functional Test (-)
4 (RCT) a robotic device
N=19 C: Task-matched amount of reaching
without assistance
Bi-Manu-Track
Hesse et al. (2005) E: Computerized arm training enabling • Fugl Meyer Score (+)
RCT (8) repetitive practice
N=44 C: Electrical stimulation
TPS=subacute
Hesse et al. (2008) E: Computerized arm trainer • Fugl Meyer Score (-)
RCT (8) C: Electrical stimulation • Barthel Index (-)
N=54
TPS=subacute
Hesse et al. (2014) E: Group robot therapy + individual arm • Box and Block Test (-)
RCT (8) therapy • Action Research Arm Test (-)
NStart=50 C: Individual arm therapy
NEnd=46
TPS=acute
Hsieh et al. (2011) E1: High intensity robot-assisted therapy • Fugl Meyer Score: E1 vs E2 (+), E2 vs. C (-)
RCT (8) E2: Low intensity robot-assisted therapy • Motor Activity Log: Quality of Movement: E1 vs
N=18 C: Conventional therapy C (+)

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TPS=chronic • Motor Activity Log: Amount of Use: (-)
• ABILHAND (-)
• Medical Research Council Scale (-)
Hsieh et al. (2014) E1: Robotic training + dCIT • Fugl Meyer Score: E1 vs. E2 (+), E1 vs. C (+), E2
RCT (8) E2: Robotic therapy vs. C (+)
NStart=48 C: Conventional therapy • Wolf Motor Function Test: Functional Ability
NEnd=48 Scale: E1 vs. E2 (+), E1 vs. C (+), E2 vs. C (-)
TPS=chronic • Wolf Motor Function Test: Performance Time:
E1 vs. E2 (-), E1 vs. C (-), E2 vs. C (-)
• Motor Activity Log: Amount of Use (-)
• Motor Activity Log: Quality of Movement (-)
Liao et al. (2012) E: Robotic therapy • Fugl Meyer Score (+)
RCT (7) C: Dose-matched conventional therapy • Motor Activity Log (+)
N=20 • ABILHAND (+)
TPS=chronic
Hsieh et al. (2012) E1: High intensity robotic therapy • Fugl Meyer Score: E1 vs E2 (+), E1 vs C (+)
RCT (7) E2: Low intensity robotic therapy • Medical Research Council Scale (-)
N=54 C: Conventional therapy • Motor Activity Log (-)
TPS=chronic • Stroke Impact Scale (-)
Fan et al. (2016) E: Robot-assisted bilateral arm therapy • Fugl-Meyer Assessment (-)
RCT (4) C: Dose-matched control therapy • Wolf Motor Function Test (-)
NStart=6
NEnd=6
TPS=chronic
NeReBot
Masiero et al. (2014) E: Robotic therapy •Fugl Meyer Score (-)
RCT (7) C: Standard therapy •Box and Block test (-)
NStart=34 • Frenchay Arm Test (-)
NEnd=30 • Medical Research Council Scale (-)
TPS=chronic • FIM (-)
Masiero et al. (2006) E: Additional sensorimotor robotic • Fugl Meyer Score: shoulder (+), elbow (+)
RCT (5) training • Motricity Index: upper extremity (+)
N=35 C: Exposure to robotic device with no • FIM: motor component (+)
TPS=acute training • Medical Research Council Scale (-)
Masiero et al. (2007) E: Robotic Training • Fugl Meyer Score: upper extremity (+), wrist (-)
RCT (5) C: Exposure to robotic device • Medical Research Council: deltoid (+), biceps (+),
N=20 wrist (-)
TPS=acute • FIM (+)
• Trunk Control Test (-)
Masiero et al. (2011) E: Robotic arm therapy • Medical Research Council Scale: wrist flexor (+)
RCT (5) C: Conventional therapy • Fugl Meyer Score (-)
N=21 • FIM (-)
TPS=acute • Modified Ashworth Scale (-)
• Frenchay Arm Test (-)
Continuous Passive Motion (CPM)
Hu et al. (2009) E: EMG-driven robot • Fugl Meyer: shoulder/elbow (+)
RCT (5) C: Passive motion device • Modified Ashworth Scale: elbow/wrist (+)
N=27
TPS=chronic
Volpe et al. (2004) E: Continuos Passive Motion Device • Fugl Meyer Pain (-)

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RCT (4) C: Control • Motor Status score: elbow/shoulder (-)
TPS=acute
GENTLE/s
Timmermans et al. (2014) E: Robotic arm training • Fugl Meyer Score: arm and hand (-)
RCT (8) C: Task oriented arm training • Action Research Arm test: arm and hand (-)
NStart=22 • Motor Activity Log: arm and hand (-)
NEnd=22
TPS=chronic
Lemmens et al. (2014) E: Robotic therapy • Fugl Meyer Score: motor (-)
RCT (7) C: No robotic therapy • Action Research Arm Test (-)
NEnd=16
TPS=chronic
Coote et al. (2008) E: Robot-mediated therapy • Rate of recovery during robot-mediated therapy
RCT (6) C: Sling suspension phase phase basd on Fugl-Meyer scores (+)
N=20
Amadeo
Sale et al. (2014) E: Amadeo robotic therapy + • Box and Block Test (+)
RCT (7) physiotherapy • Fugl-Meyer Assessment (+)
NStart=20 C: Occupational therapy
NEnd=20
TPS=acute
Hwang et al. (2012) E: Active robot training • Jebsen-Taylor Hand Function (-)
RCT (6) C: Early passive therapy • Fugl Meyer Score (-)
TPS=chronic • Nine Hole Peg Test (-)
MusicGlove
Friedman et al. (2014) E1: IsoTrainer • Wolf Motor Function Test (-)
RCT (6) E2: Music glove training • Fugl-Meyer Assessment (-)
NStart=12 C: Control • Action Research Arm Test (-)
NEnd=12 • Box and Block Test: E2 vs C (+); E1 vs E2 (-); E1 vs
TPS=chronic C (-)
• Nine Hole Peg Test: E2 vs C (+); E1 vs E2 (-); E1 vs
C (-)
Zondervan et al. (2016) E: Home-based training with a MusicGlove • Motor Activity Log – Quality of Movement (+)
RCT (6) C: Conventional tabletop exercise • Motor Activity Log – Amount of Use (+)
NStart=18 • Box and Block Test (-)
NEnd=17 • 9-Hole Peg Test (-)
TPS=chronic • Action Research Arm Test (-)
Other Devices
Shin et al. (2016) E: SmartGlove virtual reality task training • Fugl-Meyer Assessment (+)
RCT (8) C: Conventional therapy • Jebsen Taylor Hand Function Test (+)
NStart=46 • Stroke Impact Scale (+)
NEnd=46 • Purdue Pegboard Test (-)
Kutner et al. (2010) E: Robot therapy (Hand Mentor) • Stroke Impact Scale: mood (+)
N=30
TPS=subacute-chronic
Reinkensmeyer et al. (2012) E: Robotic training (Pneu-WREX) • Fugl Meyer Score (-)
RCT (7) C: Conventional tabletop therapy • Nottingham sensory test (-)

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N=26 • Grip strength (-)
TPS=chronic • Box and Block Test (-)
Susanto et al. (2015) E: Robotic paretic hand therapy • Wolf Motor Function Test: post (+), follow-up (-)
RCT (7) (exoskeleton device)
NStart=19 C: Task therapy without robotic aid
NEnd=19
TPS=chronic
Prange et al. (2015) E: Arm training with robot (ArmeoBoom) • Stroke Upper Limb Capacity Scale (-)
RCT (7) C : Conventional training • Reaching Distance (-)
NEnd=68
TPS=acute
Wolf et al. (2015) E: Telemonitored robotic assisted home • Wolf Motor Function Test (+)
RCT (6) exercise therapy program (Hand Mentor) • Fugl-Meyer Assessment (-)
NStart=99 C: Dose-matched usual care home • Action Research Arm Test (-)
NEnd=92 program
TPS=acute
Linder et al. (2015) E: Robot-assisted therapy program + • Stroke Impact Scale (+)
RCT (5) home exercise program (Hand
NStart=99 Mentor)
NEnd=99 C: Home exercise program
TPS=acute
Lee et al. (2016) E: Robotic-assisted therapy (Neuro-X) • Manuel Muscle Test (-)
RCT (4) C: Conventional rehabilitation • Manuel Function Test (-)
NStart=58 • Modified Barthel Index (-)
NEnd=44
TPS=acute
Bustamante Valles et al. E: Rehabilitation using a technology- • Fugl-Meyer Assessment for upper extremity (-)
(2016) assisted rehabilitation gymnasium • Box and Block Test (-)
RCT (3) C: Traditional therapy •
NStart=27
NEnd=20
TPS=chronic
Fukuda et al. (2016) E: Multiple hybrid assistive limb robots • Brunnstorm Stage (+)
PCT C: Single hybrid assistive limb robot • Barthel Index (+)
NStart=23 • Functional Indepedence Measure (+)
NEnd=23
TPS=acute
Fluet et al. (2015) E: Robotic and virtually simulated • Fugl-Meyer Assessment (+)
PCT training • Wolf Motor Function Test (+)
NStart=21 C: Repetitive task practice • Reach to Grasp (+)
NEnd=21
TPS=chronic
Discussion
Robotic therapies show promise for helping to provide safe and intensive rehabilitation to patients who
have mild to severe motor impairment. Robotic devices can be used to provide rehabilitation that is of
high-intensity, repetitive and task-specific in a manner that is similar to physical therapy. A number of
different devices have thus far been evaluated: MIT-Manus, MIME, ARMin, Bi-Manu-Track, NeReBot,
CPM, GENTLE/s, Amadeo, ARM Guide, and hand and arm exoskeletons.

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MIT-Manus
Of all the 13 identified RCT’s, 7 were conducted in the chronic phase and all of them found that there
was no significant difference on upper limb motor outcomes between an intervention involving MIT-
Manus/InMotion therapies in comparison to a control (Ang et al., 2014; Conroy et al., 2011; Lo et al.,
2010; McCabe et al., 2015; Stein et al., 2004; Volpe et al., 2000; Volpe et al., 2008). The other six RCT’s
were conducted in the acute phase, of which 4 found that there was no significant difference on upper
limb motor outcomes between an intervention involving MIT-Manus/InMotion therapies in comparison
to a control. Two of the studies done in the acute phase did find a significant difference between robot
aided therapy with reaching tasks in comparison to reaching tasks (Sale et al., 2014) and robot assisted
movement training in comparison with robot exposure (Fasoli et al., 2004) on the Fugl-Meyer
Assessment. Overall, this suggests that Manus/InMotion therapies are not more effective than a control
for improving upper limb motor function.
MIME
Only 4 RCTs included in this review evaluated the MIME device of which 2 were conducted in the
chronic phase of stroke, 1 included patients in the acute phase of stroke, and 1 included patients in the
subacute phase of stroke. Lum et al. (2002) showed that chronic stroke patients benefited from training
with the MIME, as scores showed greater improvements in strength, reach, and upper limb motor
function when compared to conventional therapy. Conversely, Burgar et al. (2000) did not find a
beneficial effect of using the MIME over conventional therapy at improving upper limb motor function
in chronic stroke survivors. The literature is currently limited to draw strong conclusions regarding the
efficacy of the MIME on upper limb motor function in the acute and subacute stroke populations since
only one study was found during each stroke phase and the power of these studies as well as the
methodological quality was low (Burgar et al., 2011; Lum et al., 2006). However, Burgar et al. (2011)
found no significant difference in upper limb motor function between those in the acute phase receiving
high intensity robot therapy, low intensity robotic therapy, and those receiving conventional therapy,
although an improvement in spasticity was found. Lum et al. (2006) found that for patients in the
subacute phase, robot-unilateral therapy, robot-bilateral therapy, and robot-combined therapy were
superior to conventional therapy for upper limb motor function.
ARMin
Only two RCTs using the ARMin were found, both evaluating the effect of the device compared to
conventional therapy in chronic stroke individuals (Brokaw et al., 2014; Klamroth-Marganska et al.,
2014). The studies demonstrated mixed findings regarding the effectiveness of the device in improving
motor function of the upper limbs and manual dexterity. More RCTs are needed to determine whether
the ARMin is superior to conventional therapy at improving upper limb motor function in chronic and
acute stroke individuals.
ARM Guide
One RCT was found that assessed active-assistive reaching exercise using a robotic device in comparison
to task-matched conventional reaching (Kahn et al., 2006). The results of this trial indicated no
significant benefit of the intervention for upper limb motor function. However, the power and
methodological quality of the trial were low indicating that additional studies are needed to provide a
clear picture regarding the effectiveness of ARM Guide therapy.
Bi-Manu-Track
A total of 8 RCTs investigated the effect of the Bi-Manu-Track on upper limb motor function in stroke
individuals. One RCT was acute (Hesse et al., 2014), two were subacute (Hesse et al., 2008; Hesse et al.,

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2005), and the remaining 5 were conducted in the chronic phase (Fan et al., 2016; Hsieh et al., 2014;
Hsieh et al., 2011; Hsieh et al., 2012; Liao et al., 2012).
The trial conducted in the acute phase by Hesse et al. (2014) did not find any significant difference
between group robot therapy with individual arm therapy in comparison to individual arm therapy on
The trials conducted in the subacute phase had conflicting results, with Hesse et al. (2005) finding a
positive effect, and Hesse et al. (2008) finding no significant difference between computerized arm
trainer and electrical stimulation for upper limb motor function.
Hsieh et al. (2014) and Liao et al. (2012) found that robotic therapy improved upper limb motor function
more than conventional therapy. Hsieh et al. (2011) and Hsieh et al. (2012) found similar results, and
they also found that higher intensity robotic therapy was superior to lower intensity robotic therapy.
NeReBot
Of the studies found, one RCT was conducted during the chronic phase (Masiero, Armani, et al., 2014),
and the other 3 were conducted during the acute phase (Masiero et al., 2011; Masiero et al., 2006;
Masiero et al., 2007).
Two acute stroke studies found that robotic training compared to exposure to the robotic device
(without training on the device) improved motor function of the upper extremity but not that of the
wrist (Masiero et al., 2006; Masiero et al., 2007). One study also found that there was no significant
difference between use of the robotic device and conventional therapy on measures of motor function,
spasticity, and independence (Masiero et al., 2011).
Regarding chronic stroke individuals, one study found no significant difference between robotic therapy
and conventional therapy on motor function (Masiero, Poli, et al., 2014).
CPM
Continuous passive motion devices were found to evoke significantly greater changes in shoulder and
elbow motor function and spasticity (elbow and wrist) in patient with chronic stroke (Hu et al., 2009),
but not in acute stroke patients (Volpe et al., 2004).
GENTLE/s
Two studies analyzing the effectiveness of GENTLE/s devices in the chronic stroke population found that
there was a lack of superiority of the robotic device over standard arm therapy regarding upper limb
motor function and manual dexterity (Lemmens et al., 2014; Timmermans et al., 2014). A third study,
also in the chronic phase, found that rate of recovery improved based on motor function outcomes in
comparison to a control (Coote et al., 2008).
Amadeo
One study evaluating chronic stroke individuals showed no significant difference between patients using
the Amadeo for active robot training and those performing passive therapy on functional motor
outcomes and spasticity (Hwang et al., 2012). However, another study with participants during the acute
phase after stroke found a significant improvement in upper limb motor function and dexterity following
Amadeo robotic therapy with physiotherapy in comparison to occupational therapy (Sale et al., 2014).
ARM Guide

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The ARM Guide was not found to be effective at improving upper limb motor function based on one
study (Kahn et al., 2006).
Music Glove
One study in the chronic phase found that while Music Glove training was not superior to control on
some measures of upper limb motor function, other measures of motor function which also account for
dexterity indicated that Music Glove training was superior to conventional therapy (Friedman et al.,
2014). However, another study by Zondervan et al. (2016) found that a home-based training program
with MusicGlove was not superior to conventional exercise on any of the above mentioned outcomes.
Other Devices
A variety of additional robotic devices were studied, including the SmartGlove, Hand Mentor, Pneu-
WREX, exoskeleton device, ArmeoBoom, and the Neuro-X among others. The phase post stroke of these
studies varied, as did the results. Further trials are required to come to any conclusions regarding the
effectiveness of these robotic devices.
Summary
Summarizing the results from the above studies can be challenging as a variety of devices were assessed
using patients in the acute, sub-acute and chronic stages of stroke. The population groups also differed
in other ways in addition to time of recruitment. The majority of these studies were also not adequately
powered as many were pilot trials and functioned to evaluate the preliminary efficiency of a particular
device with respect to its effect primarily on upper limb motor function. While many of these trials had
low sample sizes, some had large samples, creating additional differences to be taken into account when
synthesizing the evidence. The studies also examined interventions at varying intensities and durations
and compared them to varying control groups. Furthermore, studies assessed had differing outcomes,
making it difficult to weigh all studies equally. Overall, these differences between studies increases the
variability of the results and this may explain why the evidence is conflicting.
Robot-assisted therapy was evaluated in a systematic review and meta-analysis by Norouzi-Gheidari et

al. (2012) where the results of 12 studies were pooled for analysis. Outcomes such as the Fugl-Meyer,
FIM, Motor Power scale, and the Motor Status scale were extracted and the effect sizes estimated. The
methodological quality ranged from 2 to 7 on the PEDro scale. From the 12 studies, six evaluated the
effects of the MIT-Manus, two evaluated the MIME, and the remaining 4 evaluated a different robotic
device each (i.e. REHAROB, T-WREX, ARM Guide, and the NeReBot). When the robotic therapy was
delivered in addition to the conventional therapy, the effect significantly favoured the robotic therapy
when the Fugl-Meyer was considered. However, further analysis revealed that this effect may have been
driven by the fact that the majority of the studies were evaluated in an acute-subacute population and
all of which were positive for the robotic device, and only one study evaluated a chronic stroke
population showing no significant effect of the intervention. When the robotic device was delivered in
place of the conventional therapy, no significant overall effect regarding the Fugl-Meyer was found,
regardless of the stroke phase. Whether the robotic therapy was delivered in addition to conventional
therapy or instead of it, no significant effect was found regarding the FIM. Conversely, a significant
effect favouring the robotic therapy was determined when the intervention supplemented conventional
therapy as measured by the Motor Power Scale, but not when the intervention substituted conventional
therapy. A similar effect resulted when the studies were pooled for the Motor Status Scale, favouring
rehabilitation with a robotic device in addition to conventional therapy. This study therefore suggest
that robotic devices may be more beneficial for rehabilitation when they are additional to conventional
therapy. Furthermore, not all stroke patients may benefit from using a robotic device for upper limb
rehabilitation and therefore stroke phase is to be considered prior to providing the intervention.

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A recent systematic review identified 34 RCTs of low to very low quality which evaluated nineteen
different electromechanical assisted devices for their efficacy at improving upper limb motor function
(Mehrholz, Pohl, Platz, Kugler, & Elsner, 2015). Results demonstrate that robotic devices targeting arm
and hand movement allowed for improvements in activities of daily living and recovery of impaired
function and muscle strength (Mehrholz et al., 2015).
Conclusions Regarding Robotics in the Rehabilitation for Movement Therapy
There is level 1a and 2 evidence in the acute phase and level 1a evidence in the chronic phase that
MIT-Manus/InMotion therapies are no more effective than a control for improving upper limb motor
function in the chronic phase.
There is level 2 evidence that Mirror-Image Motion Enabler Robots (MIME) are effective in the acute
phase, level 2 evidence that (MIME) are not effective in the subacute phase, and level 1a conflicting
evidence for the effectiveness in the chronic phase for improving upper limb motor function.
There is conflicting level 1b and 2 evidence for the use of ARMin during the chronic phase for
There is level 2 evidence that ARM Guide is not effective for improving upper limb motor function.
There is level 1b evidence during the acute phase that Bi-Manu-Track is not effective, level 1a
conflicting evidence for the subacute phase, and level 1a evidence during the chronic phase that Bi-
Manu-Track is effective for improving upper limb motor function.
There is conflicting level 2 evidence for the use of NeReBot during the acute phase, and level 1b
evidence that NeReBot is not effective during the chronic phase for improving upper limb motor
function.
There is level 2 evidence that Continuous Passive Motion (CPM) is not effective during the acute
phase, and there is level 2 evidence that CPM is effective during the chronic phase for improving
There is level 1a evidence that the use of GENTLE during the chronic phase is not effective for
There is level 1b evidence that the use of Amadeo during the acute phase is effective, while there is
level 1b evidence that the use of Amadeo during the chronic phase is not effective for improving
There is conflicting level 1a evidence regarding the effectiveness of MusicGlove during the chronic
phase.
There is conflicting evidence as to whether the use of robotic devices is effective for improving

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10.4 Virtual Reality and Computer Brain Interface Technology
Virtual reality (VR), also known as virtual environment, is a technology that allows individuals to
experience and interact with three-dimensional environments. The most common forms of virtual
environments simulators are head-mounted displays (immersion) or with conventional computer
monitors or projector screens (nonimmersion) (Sisto, Forrest, & Glendinning, 2002). According to
Merians et al. (2002), a computerized virtual environment has opened the doors to an “…exercise
environment where the intensity of practice and positive feedback can be consistently and systematically
manipulated and enhanced to create the most appropriate, individualized motor learning approach.
Adding computerized VR to computerized motor learning activities provides a three-dimensional spatial
correspondence between the amount of movement in the real world and the amount of movement seen
on the computer screen. This exact representation allows for visual feedback and guidance for the
patient.”
10.4.1 Virtual Reality (VR)

Henderson et al. (2007) conducted a systematic review that included 6 studies evaluating immersive and
nonimmersive VR technology for rehabilitation of the upper extremity. The authors concluded that
immersive VR may be more effective at improving upper limb function compared to no therapy, while
the results from studies examining nonimmersive VR are conflicting.
A Cochrane review, which included results from 19 RCTs (565 subjects) and of which 8 examined upper-
limb training, reported a moderate treatment effect for arm function (SMD=0.53, 95% CI 0.25 to 0.81)
(Laver, George, Thomas, Deutsch, & Crotty, 2011). Only two of the studies used readily available
commercial devices (Playstation EyeToy and Nintendo Wii), while the remainder used customised VR
programs.
In a recent systematic review, Laver et al. (2015) sought to determine the efficacy of virtual reality on
upper limb motor function. In total, 37 trials were included in the analysis, consisting of 1019
participants. The results revealed that there were no significant effects of virtual reality on grip strength
or global motor function. The authors also noted that the participants were relatively young and in the
chronic phase of stroke (>1 year), therefore the effect of virtual reality during the acute phase of stroke
could not be determined.
Table 10.4.1.1 Summary of RCTs Evaluating Virtual Reality Technology

Sample Size
Crosbie et al. (2012) E: Virtual reality training • Motricity Index (-)
RCT (8) C: Conventional therapy • Action Research Arm Test (-)
N=18
Choi et al. (2014) E: Virtual reality therapy • Fugl Meyer (-)
RCT (8) C: Occupational therapy • Box and Block Test (-)
NStart=20 • Manual Function Test (-)
NEnd=20 • Grip strength (-)
McNulty et al. (2015) E: Nintendo Wii-based movement therapy • Wolf Motor Function Test (-)
RCT (7) C: Modified constraint induced movement • Motore Activity Log – Quality of Life (-)
NStart=41 therapy • Fugl-Meyer Assessment (-)
Da Silva Ribeiro et al. (2015) E: Nintendo Wii training • SF-36: Physical Functioning (+), Vitality (+)

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RCT (7) C: Conventional physical therapy • Fugl-Meyer Assessment (-)
NStart=30
NEnd=30
Saposnik et al. (2010) E: Nintendo Wii gaming system • Wolf Motor Function Test (+)
RCT (7) C: Recreational therapy • Box and Block Test (-)
N=22 • Stroke Impact Scale (-)
Fan et al. (2014) E1: Virtual reality • Contractions of biceps bracii: E1 vs E3 (+), E1
RCT (7) E2: Occupational therapy vs. C (+), E1 vs. E2 (-)
NStart=27 E3: placebo board game • Flexor carpi radialis contraction: E1 vs. C (+)
NEnd=20 C: Control
Lee et al. (2014) E1: Transcranial direct current stimulation • Manual Function Test: E1 vs. E2 (+)
RCT (7) (tDCS) • Fugl Meyer Score (+)
NStart=64 E2: Virtual reality • Manual Muscle Test (-)
NEnd=59 C: Occupational therapy • Box and Block Test (-)
Standen et al. (2016) E: Home-based virtual reality training • Wolf Motor Function Test (+)
RCT (7) C: Conventional home-based rehabilitation • Motor Activity Log (+)
NStart=27 • 9 Hole Peg Test (-)
NEnd=22 • Activities of Daily Living (-)
Kong et al. (2016) E: Nintendo Wii virtual reality training • Fugl-Meyer Assessment (-)
NStart=105 • Stroke Impact Scale (-)
NEnd=97 • Functional Independence Measure (-)
Lee et al. (2016) E: Virtual reality-based rehabilitation • Fugl-Meyer Assessment (+)
RCT (7) C: Group-based rehabilitation • Manuel Function Test (+)
NStart=26 • Box and Block Test (-)
Lee et al. (2016) E: Virtual reality-based bilateral training • Jebsen Taylor Hand Function Test (+)
RCT (6) C: Bilateral training • Box and Block Test (+)
NStart=20 • Grooved Pegboard Test (+)
NEnd=18 • Strength (+)
Yavuzer et al. (2008) E: Playstation EyeToy games • Brunnstrom score (-)
RCT (6) C: Conventional therapy • FIM: self care (+)
N=20
Lee & Chun (2014) E1: tDCS • Manual Function Test (+)
RCT (6) E2: Virtual reality training • Fugl Meyer Score (+)
NStart=64 E3: tDCS + virtual reality
NEnd=59
Kiper et al. (2014) E: Reinforced feedback in virtual • Fugl Meyer Score (+)
RCT (6) environment • FIM (+)
NStart=46 C: Traditional rehabilitation • Kinematic characteristics (velocity): time (+),
NEnd=44 peak (+), speed (-)
Thielbar et al. (2014) E: Virtual reality glove • Action Research Arm Test (-)
RCT (6) C: Occupational therapy
NStart=14
NEnd=14
Lee et al. (2013) E: Virtual reality games • Manual Muscle Test (-)
RCT (6) C: Control conventional therapy • Modified Ashworth Scale (-)
NStart=14 • FIM (-)
NEnd=14
Fluet et al. (2015) E: Virtual reality training • Fugl Meyer Score (-)
RCT (6) C: Repetitive task training • Wolf Motor Function Test (-)

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NStart=21 • Reaching trajectory smoothness (-)
NEnd=16
Shin et al. (2015) E: Conventional therapy + virtual reality • Fugl Meyer Score (-)
RCT (6) rehabilitation • Short Form Health Survey: role limitation (+)
NStart=35 C: Conventional therapy
NEnd=32
Choi et al. (2016) E: Virtual reality rehabilitation program + • Fugl-Meyer Assessment (+)
RCT (6) conventional occupational therapy • Brunnstrom Stage (+)
NStart=24 C: Conventional occupation therapy alone • Manuel Muscle Test (+)
• Quality of Life (-)
Saposnik et al. (2016) E: Task-oriented using Nintendo Wii • Wolf Motor Function Test (-)
RCT (6) C: Traditional task-oriented training • Barthel Index (-)
NStart=141 • Functional Independence Measure (-)
NEnd=121 • Grip Strength (-)
Givon et al. (2016) E: Virtual reality video game therapy • Action Research Arm Test (-)
RCT (6) C: Traditional therapy
NStart=47
NEnd=43
Lee et al. (2016) E: Virtual reality training + conventional • Trunk Impairment Scale (-)
RCT (5) rehabilitation • Functional Reach Test (-)
NStart=14 C: Conventional rehabilitation • Fugl-Meyer Assessment (-)
NEnd=10
Jang et al. (2005) E: Virtual reality training • Box and Block test (+)
RCT (5) C: No Virtual reality training • Fugl Meyer Score (+)
N=10 • Manual Function Test (+)
Lee et al. (2014) E: Asymmetric training using virtual reality • Fugl Meyer score (+)
RCT (5) C: Symmetric movements with both hands • Box and Block test (+)
NStart=30 and no virtual reality training • Grip strength (+)
• Range of Motion: flexion (+), extension (+),
deviation (-)
Duff et al. (2013) E: Virtual reality reaching therapy • Fugl Meyer (+)
RCT (5) C: Control standard treatment • Kinematic impairment measure (+)
NStart=25
NEnd=21
HyeonHui et al. (2013) E: Virtual reality training • Range of Motion: shoulder flexion (+),
RCT (5) C: Occupational therapy shoulder extension (+), shoulder abduction
NStart=40 (+), elbow flexion (+), wrist flexion (+)
NEnd=35 • Fugl Meyer (+)
• Box and Block test (+)
Shin et al. (2014) E: Occupational therapy + virtual reality • Fugl Meyer Score (-)
RCT (5) training • Modified Barthel Index (-)
NStart=103 C: Occupational therapy • Range of Motion (-)
NEnd=93
Yin et al. (2014) E: Virtual reality + conventional therapy • Fugl Meyer Score (-)
NEnd=21
Samuel et al. (2016) E: Occupational and physical therapy + • Fugl-Meyer Assessment (-)
RCT (4) virtual reality training • Action Research Arm Testing (-)
NStart=8 C: Occupational and physical therapy

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NEnd=6
Bower et al. (2015) E: Motion gaming rehabilitation • Functional Independence Measure: Mobility
RCT (4) C: No gaming treatment (+), Transfers (+), Stairs (-)
NStart=20 • 6 Minute Walk Test (+)
NEnd=16 • Functional Reach (-)
• Motor Assessment Scale (-)
• Step Test (-)
Lam et al. (2006) E1: 2DVR computer based training • Mass Transit Railway: skills (-), self-efficacy (-)
RCT (4) programme
N=58 E2: Video modelling-based
psychoeducational programme
C: Control
Adie et al. (2017) E: Home-based Nintendo Wii program • Action Research Arm Test (-)
RCT (3) C: Home-based exercise program • Quality of Life (-)
NStart=235 • Occupational Performance (-)
NEnd=235
Broeren et al. (2008) E: Semi-immersive workbench with haptic • Box and Block Test (-)
RCT (3) and stereoscopic glasses • ABILHAND (-)
N=22 C: No VR treatment • Trail Making Test (-)
• Kinematics (+)
Trinh et al. (2016) E: Nintendo Wii-based movement therapy • Wolf Motor Function Test (-)
PCT C: Modified constraint induced movement • Motor Activity Log (-)
NStart=46 therapy
NEnd=46
Fluet et al. (2015) E: Robotic and virtually simulated arm and • Wolf Motor Function Test (-)
PCT finger training • Fugl-Meyer Assessment (-)
NStart=21 C: Traditional arm and finger training • Finger extension (+)
NEnd=21 training (repetitive task practice) • Peak hand velocity (+)
• Reach to lift time, reaching path length,
reaching trajectory smoothness, trunk
excursion, sagittal shoulder excursion, elbow
excursion (-)
Discussion
Virtual reality training is an innovative new treatment approach, which may enhance cortical
reorganization following stroke. The studies evaluated in this review include patients from all phases of
stroke, however, the majority evaluate the effects of virtual reality in chronic stroke patients. The RCTs
of high quality (i.e. PEDro > 6) demonstrate conflicting results for certain outcomes of motor function
such as the Fugl-Meyer Assessment, but no significant difference between a virtual reality intervention
and a control on other measures of motor function such as the Action Research Arm Test, the Box and
Block Test, and the Wolf Motor Function Test.
Two studies of high methodological quality and with large sample sizes detected no effect when
comparing Nintendo Wii virtual reality training to conventional training on measures of upper limb
motor function (Kong et al., 2016; Saposnik et al., 2016). Furthermore, many of the studies which found
a significant difference on one measure of motor function found no significant difference on other
measures of motor function (Lee et al., 2014; M. M. Lee et al., 2016; Saposnik et al., 2010; Standen et
al., 2016). Overall, the evidence that virtual reality training is not superior to conventional therapy is
stronger than the evidence suggesting that there is a significant difference.

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Conclusions Regarding Virtual Reality Technology
There is level 1a evidence that virtual reality does not improve upper limb motor function in the
chronic stroke phase.
Virtual reality therapy may not improve upper limb motor function in chronic stroke patients.
10.4.2 Computer Brain Interface Technology (CBI)

Computer-brain-interface (CBI) technology has only recently emerged as a potential rehabilitative
treatment option for stroke patients. Thus far, only a few studies have evaluated the effects of this
technology on upper limb motor impairments.
The results of controlled trials evaluating CBI are summarized in Table 10.4.2.1.
Table 10.4.2.1 Summary of Controlled Trials Evaluating Computer Brain Interface Technology for the
Upper Extremity
Sample Size
Ramos-Murguialday et al. (2013) E: Brain machine interface • Modified Fugl Meyer Score: arm and hand
RCT (8) C: Sham (+)
NEnd=30 • Goal Assessment Scale (-)
• Ashworth Scale (-)
Ang et al. (2014) E1: Brain-computer interface (BCI) with • Fugl Meyer Score (-)
RCT (8) haptic knob (HK)
NStart=22 E2: Haptic knob (HK)
NEnd=21 C: Standard Arm Therapy (SAT)
Ang et al. (2015) E: Brain computer interface + robotic • Fugl-Meyer Score (-)
RCT (7) training
NStart=26 C: Robotic training
NEnd=25
Young et al. (2016) E: Brain computer interface training • Stroke Impact Scale (-)
RCT (5) C: No training • Action Research Arm Test (-)
NStart=19 • 9 Hole Peg Test (-)
NEnd=10
Discussion
The use of CBI technology is still relatively new and largely untested. Studies by Ang et al. (2014), Ang et
al. (2015), and Young et al. (2016) found that CBI was not superior to a control on outcomes of upper
limb motor function. However, a study by Ramos-Murguialday et al. (2013) found that the group
receiving brain machine interface improved more than the group receiving a sham on an assessment of
arm and hand motor function. More studies are needed to determine how and if this technology is
useful to facilitate upper limb recovery.
Conclusions Regarding Computer Brain Interface Technology

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There is level 1a evidence that computer brain interface technology is not effective for improving
upper limb motor function post-stroke.
Computer-brain-interface technology is likely not effective for improving upper limb motor function
although more research is required to come to a more definitive result.
10.5 Treatment for Spasticity or Contracture in the Upper Extremity

Stroke survivors often display a constellation of signs and symptoms that together constitute the upper
motor neuron syndrome. The syndrome consists of negative signs including weakness, loss of dexterity,
fatigue, and positive signs including increased muscle stretch reflexes, abnormal cutaneous reflexes and
spasticity. Spasticity is classically defined as a velocity dependent increase of tonic stretch reflexes
(muscle tone) with exaggerated tendon jerks. Spasticity can be painful, interfere with functional
recovery in the upper extremity and hinder rehabilitation efforts. However, Gallichio (2004) cautioned
that a reduction in spasticity does not necessarily lead to improvements in function. Van Kuijk et al.
(2002) noted that for most stroke patients, “…spasticity is a variable phenomenon in time and apparent
in only certain muscle groups, and therefore, low threshold and “reversible” focal treatment techniques
seem to be the preferable first option”.
A study by Watkins et al. (2002) reported that 39% of patients with a first-ever stroke were spastic 12
months after their stroke. Sommerfeld et al. (2004) reported that of 95 patients assessed initially (mean
5.4 days) after an acute stroke, 77 (81%) were hemiplegic and 20 (21%) were spastic. Overall, upper
extremity spasticity alone (n=13) was more common than lower extremity spasticity alone (n=1) or
spasticity in both upper and lower extremities (n=6). At three months post-stroke, 64 patients (67%)
were still hemiparetic, and 18 (19%) were still spastic. At that point, there were more patients with
spasticity in both extremities (n=10) than in the upper extremity alone (n=7) or in the lower extremity
alone (n=1). The authors also reported that severe disabilities were found in almost the same number of
nonspastic patients as spastic patients.
There are a number of interventions used for limb spasticity. These include oral antispasticity agents,
injections of phenol to motor nerves or alcohol to muscle bellies, and physical modalities such as
stretching, orthoses, casting, cold application and surgery. The mainstay of treatment for spasticity has
been physical therapy. Traditional pharmacotherapies for spasticity include centrally acting depressants
(baclofen, benzodiazepines, clonidine, and tizanidine) and muscle relaxants (dantrolene). There is
evidence from RCTs published in the 1960’s and 1970’s that these treatments are only partially effective
in treating spasticity and most have negative side effects of weakness and sedation with the exception
of dantrolene. More recently, Tizanidine hydrochloride was used to successfully treat spasticity among
47 chronic stroke patients, although, due to a number of side effects (i.e. elevated transaminases,
dizziness, lethargy, and hypertension), only a small percentage of patients reached the maximum daily
dose (Gelber, Good, Dromerick, Sergay, & Richardson, 2001). Motor point or nerve blocks with phenol
or alcohol have been used but are often associated with variable success rates, and high rates of
neuropathic pain. Botulinum toxin type A, a potent neurotoxin that prevents the release of acetylcholine
from the pre-synaptic axon, has more recently been studied as a potentially useful treatment for stroke
related spasticity. Intrathecal drug therapy refers to the injection of a drug into the subarachnoid space
of the central nervous system and requires the implantation of a programmable device into the
subcutaneous tissue surrounding the abdominal wall. Intrathecal baclofen, the most commonly used
intrathecal drug for relieving spasticity associated with stroke has not been well studied, particularly for
spasticity of the upper extremity.

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10.5.1 Splinting
Splints have been widely used in clinical practice with the aim of the prevention of contractures and
reduction of spasticity; however, they have not been well studied to date.
In a systematic review by Steultjens et al. (2003), the authors concluded that based on the results of 2
RCTs (Langlois, Pederson, & MacKinnon, 1991; Rose & Shah, 1987), 2 case-controlled trials (McPherson,
Kreimeyer, Aalderks, & Gallagher, 1982; Poole et al., 1990) and one uncontrolled trial (Gracies et al.,
2000) there was insufficient evidence at the time of publication to support the effectiveness of splinting
for decreasing muscle tone.
Tyson and Kent (2011) conducted a systematic review on the effect of upper limb orthotics following
stroke, which included the results from 4 RCTs and represented 126 participants. Overall, the treatment
effects associated with measures of disability, impairment, range of motion, pain, and spasticity were
small and not statistically significant.
The results of RCTs evaluating splinting interventions are summarized in Table 10.5.1.1.
Table 10.5.1.1 Summary of RCTs Evaluating Splinting Therapies for Spasticity in the Upper Extremity
Sample Size
Lannin et al. (2003) E: Hand splint + conventional therapy • Contracture: wrist (-), finger flexor muscles (-)
N=28
Lannin et al. (2007) E1: Extension splint • Contracture: wrist (-)
RCT (7) E2: Neutral splint
N=63 C: No splint
Basaran et al.(2012) E1: Volar splint • Modified Ashworth Scale (-)
RCT (6) E2: Dorsal splint • Passive range of motion (-)
N=39 C: No splint
Suat et al. (2011) E: Hand splint • Functional Reach Test (-)
NStart=19
NEnd=19
Rose et al. (1987) E1: Dorsal orthosis • Passive range of motion: dorsal/volar vs. control (+)
RCT (4) E2: Volar orthosis • Spontaneous flexion: dorsal vs. control (+), volar vs.
N=30 C: No orthosis control (-)
Jung et al. (2011) E: Hand stretching/splint device • Modified Ashworth Scale (+)
NStart=21
NEnd=21
Langlois et al. (1991) E1: Spint 22hr/d • Spasticity (-)
RCT (3) E2: Splint 12hr/d
N=9 E3: Splint 6hr/d
Amini et al. (2016) E1: Splint • Active Range of Motion: E2 vs E1 (+)
PCT E2: Botulinum Toxin-A • Fugl-Meyer Assessment (+)
NStart=39 E3: Splint and Botulinum Toxin-A • Modified Ashworth Scale for elbow and wrist
NEnd=29 (+)
• Passive Range of Motion for elbow and wrist (-
)

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Discussion
Seven RCTs were identified examining the benefits of splinting. The focus of each of these studies was
different (finger, wrist and elbow). Most of the studies failed to support the benefit of splinting in
reducing spasticity, avoiding contracture and improving arm reach (Basaran et al., 2012; Langlois et al.,
1991; Lannin et al., 2007; Lannin et al., 2003; Rose & Shah, 1987; Suat et al., 2011). Results should be
taken with caution due to short treatment periods, typically between 4-6 weeks, along with low power.
Conclusions Regarding Splinting
There is level 1a evidence that splinting does not reduce the development of contracture nor reduce
spasticity in the upper extremity.
Hand splints alone likely do not reduce spasticity or prevent contracture.
10.5.2 Stretching Programs to Prevent Contracture Formation

Spastic contracture following stroke relates to hypertonicity or increased active tension of the muscle.
Contracture may also occur as a result of atrophic changes in the mechanical properties of muscles.
Since surgery is the only treatment option once a contracture has developed, prevention is encouraged.
Stretching may help to prevent contracture formation and, although well-accepted as a treatment
strategy, has not been thoroughly studied as of yet.
Table 10.5.2.1 Summary of RCTs Evaluating Stretching Programs to Prevent Contracture Formation in
the Upper Extremity
Sample Size
Tseng et al. (2007) E1: RN assisting • Joint angles: RN groups vs. usual are (+)
RCT (7) E2: RN supervising • Activity function: RN groups vs usual care (+)
N=59 C: Usual care
Santamato et. al (2015) E: 50-200 U Botox + adhesive tape for 10d • MAS (finger): 2wk (+), 1mo (+)
RCT (7) C: 50-200 U Botox + manual muscle • MAS (wrist): 2wk (+), 1mo (+)
NStart=70 stretching • Finger position scores: 2wk (+), 1mo (+)
NEnd=70 • Disability Assessment Scale: 1mo (+)
Kim et al. (2013) E: Hand modified stretching device • Modified Ashworth Scale (+)
RCT (6) C: Control
NStart=15
NEnd=15
Jang et al. (2016) E: Additional hand and wrist stretching • Modified Ashworth Scale (+)
RCT (5) using a device • Fugl-Meyer Assessment (+)
NStart=21 C: Standard outpatient care • Active Range of Motion (-)
NEnd=21
You et al. (2014) E1: Stretching program + joint stabilizing • Muscle thickness: E1 vs. C (+), E1 vs. E2 (+), E2
RCT (5) exercise (combo) vs. C (-)
NStart=45 E2: Stretching program • Arm function: E1 vs. C (+), E1 vs. E2 (+), E2 vs. C
NEnd=41 C: Traditional therapy (-)

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Discussion
Few studies have been published examining the benefit of stretching regimen for the prevention of
contracture formation. Tseng et al. (2007) found that having a nurse assisting with or supervising
exercises was significantly more beneficial than the provision of usual care in terms of improvement in
joint angles and activity function. Spasticity was also improved following use of a hand modified
stretching device compared to the control group which did not receive a device (E. H. Kim et al., 2013).
Stretching with joint stabilization improved muscle thickness and arm function compared to traditional
therapy; however, a stretching program delivered alone was not significantly different compared to
conventional therapy (You et al., 2014). Interestingly, all of the studies described above evaluated
participants who were in the chronic phase post stroke. Additional hand and wrist stretching using a
device improved spasticity and upper limb motor function, but not range of motion, compared to
standard outpatient care (Jang et al., 2016).
Conclusions Regarding Stretching Programs to Prevent Contracture Formation
There is level 1b evidence that a nurse-led stretching program may improve range of motion in the
upper extremity and reduce pain in the chronic stage of stroke.
There is level 1b and 2 evidence that a hand stretching device may improve spasticity in the upper
limb.
Stretching programs may improve upper limb spasticity.
10.5.3 Botulinum Toxin Injections

Botulinum toxin works by weakening spastic muscles through blocking the release of acetylcholine at
the neuromuscular junction. The benefits of botulinum toxin injections are generally dose-dependent
and last approximately 2 to 4 months (Brashear et al., 2002; Francisco, Boake, & Vaughn, 2002; Simpson
et al., 1996; Smith, Ellis, White, & Moore, 2000). One of the advantages of botulinum toxin is that it is
safe to use on small, localized areas or muscles, such as those in the upper extremity. Unlike chemical
neurolysis with phenol or alcohol, botulinum toxin is not associated with skin sensory loss or dysesthesia
(Suputtitada & Suwanwela, 2005). Dynamic EMG studies can be helpful in determining which muscles
should be injected (Bell & Williams, 2003).
Van Kuijk et al. (2002) evaluated the benefit of botulinum toxin for the treatment of upper extremity
spasticity with focal neuronal or neuromuscular blockade. This review included 10 studies (4 RCTs and 6
uncontrolled observational studies). The authors found that there was evidence of the effectiveness of
botulinum toxin treatment on reducing muscle tone (as measured by the modified Ashworth Scale) and
improving passive range of motion at all arm-hand levels in chronic patients for approximately 3 to 4
months. However, the authors concluded that, while overall the effectiveness of botulinum toxin for
improving functional abilities was not justified, specific stroke groups may benefit from botulinum toxin
injections in the upper extremity.
While many controlled studies have demonstrated a reduction in spasticity following treatment with
botulinum toxin, it is less clear whether treatment is associated with improvement in upper extremity
function. Francis et al.(2004) suggested several reasons for these results, including that underlying
muscle weakness and not spasticity contribute to the limitation in function. However, it is speculated
that the most likely reasons were insufficiently sensitive outcome measures and under-powered studies.

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A meta-analysis by the same authors included the results from two RCTs (Bakheit et al., 2001; Bakheit et
al., 2000) which suggested that there was a benefit, albeit modest, of BTX-A on improved function. The
authors of this review pooled the data and assessed the effect using the arm section of the Barthel Index
(dressing, grooming and eating), and reported a modest improvement in upper arm function following
botulinum toxin. Pooling was only possible for two RCTs due to heterogeneity of interventions and
outcomes.
Cardoso et al.(2005) conducted a meta-analysis investigating BTX-A as a treatment for upper limb
spasticity following stroke. They included five RCTs (Bakheit et al., 2001; Bakheit et al., 2000; Brashear et
al., 2002; Simpson et al., 1996; Smith et al., 2000) and reported that there was a significantly greater
reduction in spasticity for patients who underwent BTX-A treatment compared to patients receiving the
placebo treatment, as measured by the modified Ashworth Scale and the Global Assessment Scale. The
authors concluded that BTX-A reduces spasticity and that the treatment was tolerated well, although
the effects of long-term use of BTX-A are unknown. Levy et al. (2007) reported additional benefits when
a course of constraint-induced movement therapy followed treatment with BTX-A. Unfortunately the
gains in motor function were lost at the end of 24 weeks at which point spasticity returned.
A summary of the results from RCTs investigating Botulinum toxin for spasticity is presented in Table
10.5.3.1.
Table 10.5.3.1 Summary of RCTs Evaluating Botulinum Toxin Injection and Spasticity in the Upper
Extremity
Sample Size
Seo et al. (2015) E1: 360 U Neu-BoNT-A • MAS: 4, 8, and 12 wk (-)
RCT (10) E2: 360 U Botox • Disability Assessment Scale (-)
NStart=196 • Carer burden Scale (-)
NEnd=170 • Global Assessment of intervention benefit (-)
Kaji et al.(2010) E1: 120 U Botox • Modified Ashworth Scale: E2 vs. C2 (+), E1 vs. C1 (-)
RCT (9) C1: Placebo • Disability Assessment Scale: both groups (+)
N=109 E2: 200 U Botox
C2: Placebo
McCrory et al. (2009) E: 500-1,000U of Dysport • The Assessment of Quality of Life scale: 20wk (-)
RCT (9) C: Placebo x 2 occasions
N=96
Wolf et al. (2012) E: 300U Botox + therapy • Wolf Motor Function test (-)
RCT (9) C: Placebo +therapy
N=25
Gracies et al.(2014) E1: 10000 U Botox • Modified Frenchay Scale (-)
RCT (9) E2: 15000 U Botox
NStart=24 C: Placebo
NEnd=24
Wissel et al.(2016) E: OnabotulinumtoxinA + • Pain Numeric Rating Scale (+)
RCT (8) standard care • Goal Attainment Scale (-)
NStart=273 C: Placebo injection + standard
NEnd=273 care
Picelli et al. (2014) E1: Injections under sonographic • MAS (wrist): all groups (+)
RCT (8) guidance • Tardieu Spasticity angle: all groups (+)
NStart=60 E2: Injection using electrical • PROM (wrist): all groups (+)
NEnd=60 stimulation guidance • PROM (proximal interphalangeal joints): all groups (+)

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C: Injection using manual needle
placement
Shaw et al. (2011) E: 100-200 U Dysport + 4 weeks • ARAT scores (-)
RCT (8) therapy • Modified Ashworth Scale (+)
N=333 C: Therapy only
Bakheit et al. (2000) E1: 500 U of Dysport • Modified Ashworth Scale: all groups at 4wk (+) and
RCT (8) E2: 1000 U of Dysport 16wk in the elbow and wrist and in the fingers E2 vs. C
N=82 E3: 1500 U of Dysport (+)
C: Placebo • Rivermead Motor Assessment: 4wk (-), 16wk (-)
Bakheit et al.(2001) E: Total of 1000 IU of BtxA • Summed Modified Ashworth Scale score: 4wk (+)
RCT (8) (Dysport) into 5 muscles of the • Magnitude of benefit in wrist and finger joints: 16wk
N=59 affected arm follow-up (+)
C: Placebo injections • Joint ROM: 4wk (-)
• Muscle pain: 4wk (-)
• Goal-attainment: 4wk (-)
• Barthel Index: 4wk (-)
• Elbow PROM: 16wk (+)
Simpson et al. (1996) E1: Single treatment of 75 U • Decrease in wrist flexor tone: 300 BTX-A group at 2,4
RCT (8) E2: 150 U and 6wk (+)
N=37 E3: 300 units of BTX-A • Global Assessment of Response to Treatment: all BTX-
C: Placebo A groups at 4 and 6wk (+)
Simpson et al. (2009) E1: Up to 500 U of BT-X • Decrease in wrist flexor tone: BT-X at 6wk (+)
RCT (8) E2: Tinzanidine
N=60 C: Placebo
Gracies et al. (2015) E1: Single 500U • Modified Ashworth Scale: E1+E2 vs. C (+)
RCT (8) AbobotulinumtoxinA • Physician Global Assessment: E1+E2 vs. C (+)
NStart=243 E2: Single 1000U • Disability Assessment Scale: E1 vs. E2 (-)
NEnd=229 AbobotulinumtoxinA
C: Placebo
Hesse et al. (2012) E: 150U Xeomin + therapy • Modified Ashworth Scale score (+)
RCT (7) C: Therapy only • REPAS (+)
N=18
Bhakta et al. (2000) E: Total of 1000 IU Dysport (n=20) • Disability: 2 and 6wk (+)
Bhakata et al. (2008) C: Placebo (n=20) divided between • Caregiver burden: 2, 6 and 12wk (+)
RCT (7) elbow, wrist, and finger flexors • MAS (finger): 2, 6, and 12wk (+)
N=40 • MAS (elbow): 2wk (+)
• Pain (-)
• Associated reactions (+)
Brashear et al. (2002) E: Botulinum toxin A (50 U) • Disability Assessment scores: 6wk (+)
RCT (7) C: Placebo
N=126
Smith et al. (2000) E1: 500 U of botulinum toxin • Modified Ashworth Scale at fingers: E1/E2/E3 (+)
RCT (7) E2: 1000 U of botulinum toxin • Passive range of movement at wrist: E1/E2/E3 (+)
N=25 E3: 1500 U of botulinum toxin C: • Finger curl distance at rest: E1/E2/E3 (+)
Pacebo
Francisco et al. (2002) E1: High volume BTX-A (50 units/1 • Modified Ashworth Scale: 4, 8 and 12wk (-)
RCT (7) mL saline:1.2 mL delivered per 4
N=13 (10 stroke) muscles)
E2: Low volume BTX-A (100 units/1
mL saline)
Brashear et al. (2004) E: 10000 U of BTX-B • Modified Ashworth scale: 2wk (+), 4, 8, 12, and 16wk (-
RCT (7) C: Placebo )

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N=15 • Global Assessment of Change (-)
Childers et al. (2004) E1: 90U BTX • Muscle tone: 1-6wk (+)
RCT (7) E2: 180U BTX • FIM (-)
N=91 E3: 360U BTX • SF-36 (-)
C: Placebo
Pennati et al. (2015) E: Robot and Botulinum toxin • Modified Ashworth Scale (+)
RCT (7) neurolysis with dose • Functional Independence Measure (+)
NStart=15 dependant on muscle group • Fugl-Meyer Assessment (-)
NEnd=15 affected • Box and Block Test (-)
C: Robotic training
Nam et al. (2015) E: New botulinum toxin type A • Modified Ashworth Scale (-)
RCT (7) (NABOTA) up to 360 U depending • Response Rate (-)
NStart=197 on degree of spasticity and muscle
NEnd=177 group
C: Omabotulinum toxin A (Botox)
up to 360 U depending on degree
of spasticity and muscle group
Elovic et al. (2016) E: 400U incobotulinumtoxinA • Ashworth Scale (+)
RCT (6) C: Placebo • Disability Assessment Scale (+)
NStart=317
NEnd=299
Meythaler et al. (2009) E: 100 U Botox + therapy • Motor Activity Log: Quality of Use (+), Amount of Use (-
RCT (6) C: Saline + therapy )
Jahangir et al. (2007) E: 50 U Botox • Modified Ashworth Scale: 3mo (+)
RCT (6) C: Placebo • Barthel Index (-)
N=27 • EQ-5D (-)
Suputtitada & Suwanwela E1: 350U BTX • Modified Ashworth scale: E2/E3(+)
(2005) E2: 500U BTX • ARAT: at 8wk and 24wk E2 (+)
RCT (6) E3: 1000U BTX • Barthel Index: at 8 and 24wk E2 (+)
N=45 C: Placebo
Ward et al. (2014) E: Onabotulinumtoxin A + standard • Goal attainment scale: 12wk and 52wk (-), 21wk and
RCT (6) care (varying dosages) 24wk (+)
NStart=274 C: placebo injections + standard • Resistance to passive movement: 24wk (+)
NEnd=273 care (varying dosages)
Werner et al. (2013) E: 150 U BTX-A • MAS: at 4wk and 6mo (+)
RCT (4) C: No injections
NStart=18
NEnd=18
Santamato et al. (2014) E: BoNT-A injection using • MAS: wrist (+), fingers (+), flexor carpi radialis (+)
RCT (4) ultrasound guidance (dosages
NStart=30 determined by investigator)
NEnd=30 C: BoNT-A manual injection via
palpitation and anatomical
landmarks (dosages determined by
investigator)
Dressler et al. (2015) E: IncobotulinumtoxinA (BTX-A) • Ashworth Scale (+)
PCT (215±114 MU) and additional
NStart=218 conventional treatment
NEnd=194 C: Conventional treatment
(268±155 MU)
Lim et al. (2016) E1: Subacute 200U of botulinum • Modified Ashworth Scale: E1 vs. E2 (+)

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PCT toxin • Modified Tardieu Scale: E1 vs. E2 (+)
NStart=19 E2: Chronic 200U of botulinum • Manuel Muscle Testing (-)
NEnd=18 toxin • Wrist Range of Motion: E1 vs. E2 (+)
• Brunnstrom Stage (-)
Discussion
Assessing the effectiveness of botulinum toxin in the treatment of upper limb spasticity is difficult owing
to the broad range of doses and types of agents administered. Among the RCTs reviewed, many
assessed a single dose, administered to several sites, of botulinum toxin A as either Dysport ®, Botox® or
Xeomin® versus placebo. A single trial assessed the benefit of BT-type B (10,000 U BT-B) (Childers et al.,
2004). The dose equivalent is approximately 300-500 Units of Dysport which is equal 100 units of Botox
(O'Brien, 2002). Among the trials of relatively high methodological quality, the majority of studies found
an improvement in spasticity between those receiving Botulinum and those not, as well as between
groups receiving higher and lower dosages. Specifically, Kaji et al. (2010), Shaw et al. (2011), Bakheit et
al. (2001), Hesse et al. (2012), Bhakta et al. (2000), Bhakta et al. (2008), Brashear et al. (2004), Pennati et
al. (2015), Elovic et al. (2016), Meythaler et al. (2009) and Jahangir et al. (2007), found that measures of
spasticity were higher in those receiving Botulinum toxin in comparison to those receiving a control.
Studies by Bakheit et al. (2000), Gracies et al. (2015), Smith et al. (2000), and Suputtitada & Suwanwela
(2005) also found significant differences in improvement of spasticity between groups receiving varying
dosages of Botulinum toxin.
In terms of studies that didn’t find a significant difference in spasticity outcomes between groups, Seo et
al. (2015) and Nam et al. (2015) compared different types of Botulinum toxin at the same dosages.
Francisco et al. (2002) found no difference in spasticity between varying dosages of Botulinum toxin A.
Studies by Wolf et al. (2012), Gracies et al. (2014), Shaw et al. (2011), and Pennati et al. (2015) found
that there was no significant improvement on measures of motor function after treatment with
Botulinum toxin A when compared to a control.
Rosales et al. (2008) conducted a meta-analysis to evaluate the effect of Botulinum Toxin Type A on
upper limb spasticity following stroke. A total of 11 studies were included in the analysis, revealing that
at the 4-6 week follow-up, treatment with Botulinum Toxin Type A was favoured over the control for
treating spasticity as measured by the Modified Ashworth Scale (MAS). Furthermore, the studies that
evaluated a change in the MAS score of more than 1 point were pooled for analysis, with results
demonstrating a significant effect favouring Botox. The same effect was found when the Global
Assessment Scale was measured.
Another review by Ivanhoe & Eaddy-Rose (2009) found 13 articles which when analyzed indicated that
BTX-A statistically improved spasticity of the elbow, wrist, fingers, and shoulder, with the duration of
treatment lasting from 10 to 20 weeks.
Conclusion Regarding Botulinum Toxin Injections
There is level 1a evidence that treatment with botulinum toxin significantly reduces spasticity in the
upper extremity in stroke survivors.

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There is level 1a evidence that treatment with botulinum toxin does not improve upper limb motor
function.
Botulinum toxin likely decreases spasticity, but likely does not improve upper limb motor function.
10.5.4 Electrical Stimulation Combined with Botulinum Toxin Injection

Three studies were found which evaluated the efficacy of botulinum toxin injection combined with
therapies such as electrical stimulation, occupational therapy, and modified constraint induced
movement therapy, summarized in Table 10.5.4.1.
Table 10.5.4.1 Summary of RCT(s) Evaluating Combined Therapy with Botulinum Toxin Injection in the
Upper Extremity
Sample Size
Hesse et al. (1998) E1: 1000 U Btx A + electrical stimulation • Muscle Tone Reduction: elbow joint for E1 (-)
RCT (7) E2: 1000 U of Btx A • Reduction in difficulties while cleaning palm: E1 vs.
N=24 E3: Placebo + electrical stimulation E2/C (+)
C: Placebo • Difficulties putting arm through sleeve: reduction
between botox groups vs. C (+)
Marvulli et al. (2016) E: Botulinum toxin A therapy • Modified Ashworth Scale (+)
RCT (6) (118±34 U) + occupational therapy + • Range of Motion (+)
NStart=36 electrical stimulation • Action Research Arm Test (+)
NEnd=36 C: Botulinum toxin A therapy
(116±36 U)+ occupational therapy
Sun et al. (2010) E: 1,000 U Dysport + mCIMT • MAS (+)
RCT (6) C: 1,000 U Dysport + conventional rehab • Motor Activity Log: Amount of Use (+)
N=32
Discussion
Botulinum toxin A with occupational therapy and electrical stimulation was found to improve spasticity,
range of motion and upper limb motor function in comparison to receiving Botox A with occupational
therapy (Marvulli et al., 2016). Similarly, Hesse et al. (1998) found that those receiving 1000 U Btx A
along with electrical stimulation had fewer difficulties on some tasks than those who had only received
Btx A and those receiving placebo. Lastly, a study by Sun et al. (2010) also found that 1000 U of Dysport
with modified constraint induced movement therapy (mCIMT) improved spasticity compared to the
same dosage of Dysport with conventional therapy.
Conclusions Regarding Other Therapies Combined with Botulinum Toxin Injections
There is level 1a evidence that electrical stimulation combined with botulinum toxin injection is
associated with reductions in spasticity.
There is level 1b evidence that modified constraint induced movement therapy combined with
botulinum toxin injection is associated with reductions in spasticity.

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Botulinum toxin in combination with electrical stimulation or modified constraint induced
movement therapy likely improves muscle tone in the upper extremity.
10.5.5 Nerve Block and Spasticity

One method of decreasing spasticity is by injecting alcohol orphenol into a specific nerve (i.e. the
musculocutaneous nerve) thus decreasing spasticity of the innervated muscles. One of the side effects
of this treatment is a loss of sensation; therefore, this treatment is not widely used in clinical practice. A
commonly reported side effect is pain (Kong & Chua, 1999).
Thus far, no RCTs were found which have investigated nerve block therapy for spasticity. However, two
pre-post studies reported that spasticity was improved from baseline to post-therapy along with elbow
passive range of motion following intramuscular nerve block on the hemiplegic upper limb (Kong &
Chua, 1999, 2002).
Conclusions Regarding Nerve Block Treatment
There is level 4 evidence that nerve blocks with ethyl alcohol improves elbow and finger passive
range of motion and can decrease spasticity in the upper extremity in stroke survivors.
More research is needed to determine whether nerve block treatment decreases spasticity in the
upper extremity.
10.5.6 Physical Therapy in the Treatment of Spasticity

As previously mentioned, physical therapy is a mainstay in the treatment of spasticity. Common physical
modalities used in the treatment of spasticity include stretching, orthoses, casting, and cold application.
The results of RCTs evaluating physical therapy are summarized in Table 10.5.6.1.
Table 10.5.6.1 Summary of Physical Therapy in the Upper Extremity

Sample Size
Horsley et al. (2007) E: 30-min daily stretch + routine retraining • Contracture (-)
RCT (8) C: Routine retraining • Visual Analog Scale (VAS) (-)
N=40 • Motor Assessment Scale (-)
Carey (1990) E: Manual stretch • Joint movement tracking test (-)
RCT (4) C: No treatment • Force tracking test (-)
N=24
Discussion
Two RCTs evaluated the effect of stretching therapy on spasticity and upper limb function. The results
showed no benefit of the treatment over the control regarding contracture, pain, and upper limb motor
function (Carey, 1990; Horsley et al., 2007).
Conclusions Regarding Physical Therapy

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There is level 1a evidence that physical therapy may not improve motor function or contracture.
Physical therapy may not decrease spasticity, or pain, or contracture, or improve upper extremity
motor function.
10.5.7 Electrical Stimulation

Electrical stimulation provided as an adjunct to physical therapy has been found to be an effective
treatment for lower-limb spasticity (see Chapter 9). The mechanism of action appears to be relaxation of
agonist muscles and strengthening of antagonist muscles (Sahin, Ugurlu, & Albayrak, 2012). This
treatment has also been well studied in the upper extremity and to date, there are a number of RCTs
that have evaluated the effects of electrical stimulation on upper limb spasticity (Table 10.5.7.1).
Table 10.5.7.1 Summary of RCTs Evaluating Electrical Stimulation for spasticity

Sample Size
De Jong et al. (2013) E: Arm stretch positioning + NMES • Modified Ashworth Scale (-)
RCT (8) C: Sham stretch positioning + Sham NMES
N=46
Barker et al. (2008) E1: SMART Arm + NMES • Modified Ashworth Scale: E1 vs. C (+); E2 vs. C (+)
RCT (7) E2: SMART Arm
Boyaci et al. (2013) E1: Active NMES • Spasticity (wrist flexor): E1 vs. C (-); E2 vs. C (+);
RCT (7) E2: Passive NMES E1 vs. E2 (-)
N=31 C: Conventional therapy • Spasticity (finger flexor): E1 vs C (-); E2 vs C (-); E1
vs E2 (-)
Chan et al. (2009) E: Occupational therapy + NMES • Modified Ashworth Scale: shoulder (-), elbow (-),
RCT (7) C: Occupational therapy + placebo NMES wrist (-)
N=20
Gharib et al. (2015) E: Repetitive task practice + electrical • Jebsen Taylor Hand Function Test (+)
RCT (7) stimulation • Modified Ashworth Scale (+)
NStart=40 C: Repetitive task practice • Range of Motion (+)
NEnd=40
Karakus et al. (2013) E: Standard therapy + NMES • Modified Ashworth Scale: elbow (-), wrist (-),
RCT (7) C: Standard therapy finger (-)
N=28
Mangold et al. (2009) E: Conventional therapy + NMES • Modified Ashworth Scale: finger flexor (-), wrist
RCT (6) C: Conventional therapy flexor (-)
N=23
De Kroon et al. (2004) E: NMES on wrist flexors + extensors • Modified Ashworth Scale (-)
RCT (6) C: NMES on wrist extensors
N=28
Sahin et al. (2012) E: Stretching + NMES • Modified Ashworth Scale (+)
RCT (5) C: Stretching
N=42
Hara et al. (2006) E: Standard therapy + NMES • Modified Ashworth Scale: E (+)
RCT (5) C: Standard therapy
N=14

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Hara et al. (2008) E: Standard therapy + NMES • Modified Ashworth Scale: E (+)
N=20
Hesse et al. (1998) E1: Botulinum toxin A • Modified Ashworth Scale: elbow (-), wrist (-),
RCT (5) E2: Placebo Botulinum toxin A finger (-)
N=24 E3: Placebo Botulinum toxin A + NMES
Kim & Lee (2014) E1: BF-NMES + mirror therapy • Modified Ashworth Scale: wrist extensor (-), wrist
RCT (5) E2: NMES + mirror therapy flexor (-), elbow extensor (-), elbow flexor (-)
N=29 C: Usual care
Lin & Yan (2011) E: Standard therapy + NMES • Modified Ashworth Scale: 2wk (-), 3wk (+), 1mo
RCT (4) C: Standard therapy (+), 3mo (-), 6mo (-)
N=37
Ring & Rosenthal (2005) E: Standard therapy + NMES • Modified Ashworth Scale (-)
N=22
Discussion
Neuromuscular electrical stimulation (NMES) has been used in rehabilitation of both upper and lower
limb function and spasticity after stroke. A recent systematic review and meta-analysis incorporating the
studies included above evaluated the effects of NMES on upper limb spasticity (Stein et al., 2004).
Findings show that NMES was not more efficacious at improving wrist or elbow spasticity compared to
conventional therapy (Barker et al., 2008; Boyaci et al., 2013; Chan et al., 2009; de Kroon et al., 2004;
Hesse et al., 1998; Kim & Lee, 2014; Mangold et al., 2009). Combining NMES with mirror therapy,
botulinum toxin A, or robotic devices (SMART Arm device) also showed no superior effect over the
comparator therapy (Barker et al., 2008; Hesse et al., 1998; Kim & Lee, 2014).
Conclusions Regarding Electrical Stimulation Combined with Physical Therapy
There is level 1a evidence that neuromuscular electrical stimulation does not reduce wrist or elbow
spasticity.
Neuromuscular electrical stimulation (NMES) may not reduce wrist or elbow spasticity.
10.5.8 Shock Wave Treatment

Shock wave therapy has been demonstrated to effectively treat a variety of bone and tendon diseases
by reducing hypertonia and may be an attractive treatment option for stroke patients compared to
botulinum toxin.
The results of one RCT evaluating shock wave therapy are summarized in Table 10.5.8.1.
Table 10.5.8.1 Summary of RCT(s) Evaluating Shockwave Therapy in the Upper Extremity
Sample Size
Santamato et al. (2013) E: Botox + extracorporeal shockwave • Modified Ashworth Scale (MAS) (+)
Italy therapy • Spasm Frequency Scale (+)

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RCT (8) C: Botox + electrical stimulation therapy • Visual Analogue Scale (+)
N=16
Dymarek et al. (2016) E: Extracorporeal shock wave • Modified Ashworth Scale (+)
RCT (7) stimulation
NStart=60 C: Placebo
NEnd=60
Discussion
Two studies have been found indicating the effectiveness of shock wave therapy for improving spasticity
in the upper limb post stroke (Dymarek et al., 2016; Santamato et al., 2013). A single treatment of shock
wave therapy and botox was compared among a small group of patients to botox with electrical
stimulation therapy (Santamato et al., 2013). Spasticity in the hand was effectively reduced for a period
of more than 12 weeks, with no adverse effects. In the study by Dymarek et al. (2016), extracorporeal
shock wave stimulation was found to improve upper limb spasticity in comparison to a placebo.
Conclusions Regarding Shock Wave Therapy
There is level 1a evidence that extracorporeal shock wave therapy improves upper limb spasticity.
Extracorporeal shockwave therapy likely improves upper limb spasticity.
10.5.9 Centrally Acting Muscle Relaxants

Tolperisone is a centrally acting muscle relaxant, similar in action to lidocaine, which acts by reducing
sodium influx through nerve membranes. It may be superior to other muscle relaxants in that it does not
cause sedation or muscle weakness, nor does it impair attention-related brain functions. Tolperisone
and its analogue eperisone have been used successfully in patients with spinal cord injury.
The results of one RCT evaluating tolperisone for spasticity in the upper extremity post stroke are
Table 10.5.9.1 Summary of RCT(s) Evaluating Tolperisone Therapy for Spastcitiy in the Upper Extremity
Sample Size
Stamenova et al. (2005) E: Daily dose of 300-900 mg of tolperisone • Modified Ashworth Scale (MAS) (+)
RCT (8) C: Placebo
N=120
Discussion
One RCT found that a daily dose of tolperisone was significantly more effective at reducing upper limb
spasticity than placebo injections when delivered over a period of 12 weeks (Stamenova et al., 2005).
Further research is needed to determine the effect of tolperisone for improving upper limb impairments
and contracture. Eperisone, was found to improve upper limb muscle tone in 75% of patients, while only

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44% of patients improved in tone when receiving only physiotherapy (Tariq et al., 2005). Currently, it is
unclear whether eperisone is significantly beneficial for tone reduction in the upper extremity.
Conclusions Regarding Centrally Acting Muscle Relaxants
There is level 1b evidence that tolperisone can reduce spasticity following stroke.
Further research is needed to determine the benefits of tolperisone on upper limb muscle tone.
10.6 EMG/Biofeedback
EMG/biofeedback uses instrumentation applied to an individual’s muscle(s) with external electrodes to
capture motor unit electrical potentials. As the instrumentation converts the potentials into visual or
audio information, the individual has a visual depiction or auditory indication of how much they are
activating their muscle(s). Moreland and Thomson (1994) published a research overview and meta-
analysis on the efficacy of electromyographic biofeedback compared with conventional physical therapy
for upper extremity function in stroke patients. They concluded that neither therapy was superior over
the other.
The results of RCTs evaluating EMG/biofeedback therapy are presented in Table 10.6.1.
Table 10.6.1 Summary of RCTs Evaluating EMG/Biofeedback Therapy for the Upper Extremity
Sample Size
Crow et al. (1989) E: EMG/Biofeedback Therapy • Action Research Arm test: post (+), 6wk follow-
RCT (8) C: Sham EMG/biofeedback up (-)
N=40
Garrido-Montenegro et al. E: EMG/Biofeedback + conventional • Barthel Index (+)
(2016) occupational therapy • Instrumental Activities of Daily Living (+)
RCT (8) C: Occupational therapy • Action Research Arm Test (+)
NStart=14 • Motor Activity Log (+)
NEnd=14
Hemmen & Seelen (2007) E: EMG biofeedback + movement imagery • Fugl-Meyer Score (-)
RCT (7) C: Conventional electrostimulation • Action Research Arm test (-)
N=27
Armagan et al.(2003) E: EMG/Biofeedback Therapy • Active range of motion (+)
RCT (7) C: Sham EMG/biofeedback • Changes in EMG surface potentials (+)
N=27 • Brunnstrom stages (-)
• Complex movement (-)
Dorsch et al. (2014) E: EMG stimulation • MAS (-)
RCT (7) C: Usual therapy • Manual Muscle Test (-)
NStart=33
NEnd=30
You et al. (2013) E: Mental training + EMG stimulation • Range of Motion (-)
RCT (7) C: FES • MAS (-)
NStart=18 • Fugl Meyer Score (+)
NEnd=16 • Motor Activity Log: Amount of Use (-),Quality of
Movement (-)

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Chang-Yong et al. (2015) E: Target reaching training with biofeedback • Fugl Meyer Score (+)
RCT (7) + routine therapy • Wolf Motor Function Test (+)
NStart=44 C: Routine therapy • Reach speed (+)
NEnd=40 • Reaching angle (+)
• Maximum reach distance (-)
Thielbar et al. (2017) E: EMG-driven actuated glove + • Hand Aperture (+)
RCT (6) occupational therapy • Action Research Arm Test (-)
NStart=23 C: Occupational therapy • Wolf Motor Function Test (-)
NEnd=22 • Fugl-Meyer Assessment (-)
• Chedoke McMaster Stroke Assessment (-)
• Grip/Pinch Strength (-)
Basmajian et al. (1987) E: EMG/Biofeedback Therapy • Upper extremity function test (-)
RCT (6) C: Physical Therapy using neuro-facilitatory • Finger Oscillation test (-)
N=29
Cordo et al. (2013) E1: AMES robot + torque biofeedback • Fugl Meyer Score (-)
RCT (6) E2: AMES robot + EMG biofeedback • Flexion torque strength (+)
NStart=46 • Extension strength (-)
Hurd et al. (1980) E: Actual myofeedback • Active range of motion (-)

RCT (6) C: Simulated myofeedback • Muscle activity (-)
N=24
Basmajian et al.(1982) E: EMG/Biofeedback Therapy • Upper extremity function test (-)
RCT (6) C: Physical Therapy using neuro- • Min rate of manipulation test (-)
N=37 physiological approach • 9-hole peg test (-)
Inglis et al. (1984) E: EMG/Biofeedback+ physiotherapy • Active range of motion (+)
RCT (5) C: Physiotherapy • Brunnstrom (+)
N=30 • Muscle strength (+)
Kim et al. (2015) E: Mirror therapy (MT) + Biofeedback FES • Grip strength (+)
RCT (5) C: MT + FES without biofeedback
NStart=33
NEnd=29
Greenberg & Fowler (1980) E: EMG/Biofeedback Therapy • Active elbow extension (-)
RCT (5) C: Conventional Occupational Therapy
N=20
Mroczek et al. (1978) E: EMG biofeedback • Range of Motion (-)
RCT (5) C: Physical therapy
N=9
Rayegani et al. (2014) E: OT + EMG + biofeedback • Jebsen Taylor Hand Test (-)
RCT (5) E2: OT + neurofeedback
NStart=46 C: OT
NEnd=30
Lee et al. (1976) E1: True myofeedback • Peak amplitude (-)
RCT (4) E2: Placebo myofeedback
N=18 C: No myofeedback with conventional
training.
Prevo et al. (1982) E: EMG/Biofeedback Therapy • Proximal and distal agonists (-)
RCT (3) C: Conventional Therapy
N=28

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Discussion
Over the past few years, more studies have attempted to delineate the potential benefit of
EMG/biofeedback technology within the stroke rehabilitation field. Various studies have found a
significant effect of EMG/Biofeedback during rehabilitation, predominantly for improved motor function
(Armagan et al., 2003; Chang-Yong et al., 2015; Crow et al., 1989; Garrido-Montenegro et al., 2016; You
& Lee, 2013) although a study by Armagan et al. (2003) found that EMG/Biofeedback therapy improved
active range of motion when compared to those receiving sham EMG/Biofeedback. The largest trial of
these was that by Chang-Yong et al. (2015) which compared target reaching training with biofeedback to
routine therapy in a total of 40 patients. Both the Fugl-Meyer score and the Wolf Motor Function Test
were found to be superior in the intervention group.
However, there were more studies that found no significant difference between EMG/Biofeedback and
conventional therapy than studies that found one (Basmajian et al., 1982; Basmajian et al., 1987; Dorsch
et al., 2014; Hemmen & Seelen, 2007; Hurd et al., 1980; Thielbar et al., 2017). In a study by Cordo et al.
(2013) AMES robot with torque biofeedback was not found to be superior to AMES robot with EMG
biofeedback in a total of 43 patients on the Fugl Meyer score and the Box and Block Test, both measures
of upper limb motor function.
Overall, the evidence suggests that biofeedback through EMG technology, either delivered alone or in
combination with other treatments, may not improve upper limb motor function, manual dexterity, or
spasticity. More high-powered RCTs are required to determine whether or not this method of
rehabilitation is beneficial for improving other aspects of upper limb function.
Conclusions Regarding Efficacy of EMG/Biofeedback Therapy
There is level 1a evidence that EMG/biofeedback therapy does not improve upper extremity motor
function or spasticity.
EMG/biofeedback therapy is likely not effective for improving upper limb motor function or
spasticity.
10.7 Neuromuscular Electrical Stimulation (NMES)

Neuromuscular electrical stimulation (NMES) can be used to improve motor recovery, reduce pain and
spasticity, strengthen muscles and increase range of motion following stroke. NMES is a technique that
uses trains of electrical pulses to generate muscle contraction by stimulating motor axons. Three forms
of NMES are available: 1) cyclic NMES, which contracts paretic muscles on a pre-set schedule and does
not require participation on the part of the patient; 2) electromyography (EMG) triggered NMES, which
may be used for patients who are able to partially activate a paretic muscle and may have a greater
therapeutic effect; 3) Functional electrical stimulation (FES), which refers to the application of NMES to
help achieve a functional task. FES can be used to improve or restore volitional grasp and manipulation
functions required for typical ADLs (Popovic, Popovic, & Keller, 2002), or can be intended as a
permanent assistive device (i.e., neuroprosthesis) for helping patients perform ADL.
RCTs evaluating electrical stimulation were categorized according to chronicity of stroke. Patients were
considered to be suacute if they had suffered a stroke within 6 months and chronic if their stroke had

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occurred greater than 6 months prior to inclusion in the study. The results are presented in Tables
10.8.2 and 10.8.3.
Table 10.8.2 Summary of Studies Evaluating Electrical Stimulation (FES, NMES) for the Hemiparetic
Upper Extremity in Subacute Stroke (< 6 months)
Sample Size
Karakus et al. (2013) E: FES + standard rehabilitation • Brunnstrom (+)
RCT (8) C: Standard rehabilitation • Motricity Index (+)
NStart=28 • Modified Ashworth Scale (-)
NEnd=28
Shimodozono et al. (2014) E1: Continuous NMES + repetitive • Fugl Meyer Score: all (+)
RCT (8) facilitative exercise • Range of Motion: all elbow extension (+), all
NStart=27 E2 Repetitive facilitative exercise shoulder flexion (-), wrist flexion (-)
NEnd=24 C: Conventional therapy
Kojima et al. (2014) E: Mirror therapy + EMG-triggered NMES • Fugl Meyer Score (+)
RCT crossover (7) first • Range of Motion: 4wk (+)
NStart=13 C: Mirror therapy + EMG-triggered NMES
NEnd=13 delayed
Kwakkel et al. (2016) E1: EMG-NMES (unfavourable prognosis) • Action Research Arm Test: E1 vs. C1 (-), E2 vs. C2
RCT (7) E2: Modified constraint-induced movement (+)
NStart=159 therapy (favourable prognosis) • Fugl-Meyer Assessment: E1 vs. C1 (-), E2 vs. C2 (-)
NEnd=159 C1: Unfavourable prognosis based on • Motricity Index: E1 vs. C1 (-), E2 vs. C2 (-)
preservation or return of voluntary finger • Stroke Impact Scale: E1 vs. C1 (-), E2 vs. C2 (+)
extension early after stroke (received usual • Wolf Motor Function Test: E1 vs. C1 (-), E2 vs. C2
care) (-)
C2: Favourable prognosis based on • Motor Activity Log: E1 vs. C1 (-), E2 vs. C2 (-)
preservation or return of voluntary finger
extension early after stroke (received usual
care)
Powell et al. (1999) E: Cyclic electrical stimulation + standard • Action Research Arm test: grasp (+), grip (+)
N=60 C: Standard rehabilitation
Manigandan et al. (2014) E1: Cyclic electrical stimulation to • Shoulder subluxation (+)
RCT (7) supraspinatus and posterior deltoid • Active abduction range: without elbow flexion
NStart=24 E2: Cyclic electrical stimulation to (+), with flexion (+)
NEnd=24 supraspinatus, posterior deltoid, and long
head of biceps
Wilson et al. (2016) E1: Cyclic Neuromuscular Electrical • Fugl-Meyer Assessment (-)
RCT (6) Stimulation • Modified Arm Motor Assessment Task (-)
NStart=122 E2: Electromyographically-triggered
NEnd=96 Neuromuscular Electrical Stimulation
E3: Sensory Stimulation
Hayward et al. (2013) E: SensoriMotor Active Rehabilitation • Motor Assessment Scale (-)
6 (RCT) Training (SMART) with outcome trigger • Upper Arm Function (-)
N=8 electrical stimulation (OT-stim)
C: SensoriMotor Active Rehabilitation
Training (SMART)
Shindo et al. (2011) E: EMG-triggered NMES + splint • Fugl-Meyer Score: wrist/hand distal (+),
RCT (6) C: Splint wrist/hand proximal (-)

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• Action Research Arm Test (+)
Knutson et al. (2012) E1: Contralaterally controlled FES • Maximum finger extension angle (-)
RCT (6) E2: Cyclic NMES • Tracking error (% of AROM) (-)
N=21 • Fugl Meyer Score (-)
• Arm Motor Abilities Test Score (-)
Lin & Yan (2011) E: Cyclic NMES + standard rehabilitation • Fugl-Meyer Score (+)
RCT (6) C: Standard rehabilitation • Barthel Index (+)
N=46
Hsu et al. (2010) E1: High dose NMES (60 minutes/session) • Fugl Meyer Assessment: E1/E2 vs. C (+); E1 vs. E2
RCT (6) E2: Low dose NMES (30 minutes/session) (-)
N=66 C: No treatment • Action Research Arm Test: E1/E2 vs. C (+); E1 vs.
E2 (-)
• Grasp: E1/E2 vs. C (+); E1 vs. E2 (-)
• Grip: E1/E2 vs. C (+); E1 vs. E2 (-)
• Pinch: E1/E2 vs. C (+); E1 vs. E2 (-)
• Gross Movement: E1/E2 vs. C (+); E1 vs. E2 (-)
Kowalczewski et al. (2007) E1: High intensity FES exercise therapy • Wolf Motor Function Test (+)
RCT (6) E2: Low intensity FES exercise therapy • Motor Activity Log (-)
N=19 • Fugl-Meyer Score (-)
Popovic et al. (2004) E: Early (acute) FES • Upper Extremity Function test: acute (+)
RCT (6) C: Delayed (chronic) FES • Drawing test: acute (+)
N=41
Popovic et al. (2003) E: FES • Upper Extremity Function test (+)
RCT (6) C: Standard therapy • Drawing test (+)
N=28
Chae et al. (1998) E: Cyclic NMES or EMG-triggered NMES or • Fugl-Meyer Score: post (+), 12wk follow-up (-)
RCT (6) EMG-controlled NMES + routine
N=46 rehabilitation
C: Sham stimulation + routine rehabilitation
Miyasaka et al. (2016) E: NMES + robotic training • Fugl-Meyer Assessment (-)
RCT (5) C: Robotic training • Range of Motion (-)
NStart=30
NEnd=30
Mangold et al. (2009) E: FES • ADL subscore of Extended Barthel Index (-)
RCT (5) C: Conventional therapy • Chedoke McMaster Stroke Assessment (-)
N=23
Thrasher et al. (2008) E: FES + conventional therapy • Rehabilitation Engineering Laboratory Hand
RCT (5) C: Conventional therapy Function Test (+)
N=21
Alon et al. (2007) E: FES + task specific training •
Box and Block Test (+)
RCT (5) C: Task specific training •
Jebsen-Taylor light object lift (+)
N=15 • Modified Fugl-Meyer: 12wk (+)
Francisco et al. (1998) E: EMG-triggered NMES + standard therapy • Fugl-Meyer Score (+)
RCT (5) C: Conventional Therapy • Upper extremity FIM scores (+)
N=9
Malhotra et al. (2013) E: NMES • Passive Range of Motion (-)
RCT (5) C: No stimulation
NStart=90
NEnd=65
Faghri & Rodgers (1997) E: FES + conventional therapy • Range of motion (+)

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N=26 • Shoulder muscle tone (+)
Heckmann et al. (1997) E: EMG-triggered ES + standard therapy • Range of motion (+)

N=28
Faghri et al. (1994) E: Cyclic NMES + conventional therapy • Arm tone (+)
RCT (4) C: Conventional Therapy • EMG activity (+)
N=26
Bowman et al. (1979) E: Conventional therapy + positional • Range of motion (+)
RCT (3) feedback stimulation therapy
N=30 C: Conventional Therapy
Table 10.8.3 Summary of Studies Evaluating Electrical Stimulation (FES, NMES) for the Hemiparetic
Upper Extremity in Chronic Stroke (> 6 months)
Sample Size
Gharib et al. (2014) E: Electrical stimulation + repetitive • Modified Ashworth Scale (+)
RCT (9) task training • Jebsen Taylor Hand Function Test (+)
NStart=40 C: Sham electrical stimulation + • Range of Motion (+)
NEnd=40 repetitive task practice
Chae et al. (2009) E1: Percutaneous intramuscular (ie. • ARM Motor Ability Test (-)
RCT (8) Cyclic EMG triggered/controlled) ES
N=26 E2: Percutaneous ES for sensory
stimulation only
Lee et al. (2015) E: NMES + robotic therapy • Modified Ashworth Scale (+)
RCT (8) C: Sham NMES + robotic therapy • Wolf Motor Function Test (+)
NStart=39 • Stroke Impairment Scale (+)
NEnd=39 • Fugl-Meyer Assessment (-)
Barker et al. (2008) E1: Device training with EMG- • Modified Ashworth Scale (+)
RCT (8) triggered stimulation
NStart=42 E2: Device training
NEnd=33 C: Control
Chan et al. (2009) E: Bilateral arm training + FES • Fugl-Meyer Score (+)
RCT (7) C: Bilateral arm training + sham FES • Functional test for the Hemiplegic Upper Extremity (+)
N=20
Weber et al. (2010) E: FES + botulinum toxin-A + home • Motor Activity Log (-)
RCT (7) based exercise program • Action Research Arm Test (-)
N=23 C: Botulinum toxin-A + home-based
exercise program
De Kroon & Ijzerman (2008) E1: EMG-triggered NMES • Action Research Arm test (-)
RCT (7) E2: Cyclic NMES • Grip Strength (-)
N=22 • Fugl-Meyer Score (-)
• Motricity Index (-)
Boyaci et al. (2013) E1: EMG-triggered (active) NMES • Fugl Meyer Score: E1 vs. C (+), E2 vs. C (+), E1 vs. E2 (-)
RCT (7) E2: Passive NMES • Motor Activity Log (Amount of Use): E1 vs. C (+), E2 vs.
NStart=31 C: Control C (-), E1 vs. E2 (-)
NEnd=31 • Motor Activity Log (Quality of Movement): E1 vs. C (-),

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E2 vs. C (-), E1 vs. E2 (-)
• Spasticity (wrist flexor): E1 vs. C (-), E2 vs. C (+), E1 vs.
E2 (-)
• Spasticity (finger flexor): E1 vs. C (-), E2 vs. C (-), E1 vs.
E2 (-)
• Range of Motion (active wrist extension): E1 vs. C (+),
E2 vs. C (+), E1 vs. E2 (-)
• Range of Motion (active MCP joint extension): E1 vs. C
(+), E2 vs. C (-), E1 vs. E2 (-)
• Grip strength: E1 vs. C (+), E2 vs. C (-), E1 vs. E2 (-)
Kimberley et al. (2004) E: EMG-triggered NMES • Box & Block test (+)
RCT (7) C: Sham • Motor Activity Log (+)
N=16 • Jebsen Taylor Hand Function test (+)
Hu et al. (2015) E: EMG-driven NMES robot • Fugl-Meyer Assessment (+)
RCT (6) C: EMG-driven robot • Action Research Arm Test (+)
NEnd=26
Ring & Rosenthal (2005) E: Neuroprosthetic FES • Modified Ashworth Scores (+)
RCT(6) C: Control • Box & Block test (+)
N=22 • Jebsen Taylor Hand Function test (+)
De Kroon et al. (2004) E1: Electical stimulation to the • Arm Research Arm test (-)
RCT (6) extensor and flexor muscles • Motricity Index (-)
N=30 E2: Eletrical stimulation to the • Ashworth Scale (-)
extensors only
Knutson et al. (2016) E1: Contralaterally controlled FES •Fugl-Meyer Assessment (-)
RCT (5) (CCFES) •Arm Motor Abilities Test (-)
NStart=80 E2: Cyclic NMES • Box and Block Test (+)
NEnd=64
Cauraugh and Kim (2003) E1: EMG-triggered NMES + blocked • Box and Block Test: E1 vs. C (+), E2 vs. C (+), E1 vs. E2 (-)
RCT (5) practice • Reaction time: E1 vs. C (+), E2 vs. C (+), E1 vs. E2 (-)
N=34 E2: EMG-triggered NMES + random • Sustained wrist/finger contraction: E1 vs. C (+), E2 vs. C
practice (+), E1 vs. E2 (-)
C: Control (no NMES)
Kim et al. (2015) E1: FES with biofeedback + mirror • Box and Block Test (+)
RCT (5) therapy • Jebsen Taylor Hand test (+)
NStart=33 E2: FES + mirror therapy • Stroke Specific Quality of Life (+)
NEnd=29 C: Conventional rehabilitation • Grip strength (+)
Baygutalp et al. (2014) E: NMES + conventional therapy • Modified Ashworth Scale: post (-), 2mo follow-up (-)
RCT (5) C: Conventional therapy • Barthel Index (-)
NStart=30 • Brunnstrom (-)
NEnd=30 • Pain: post (+), at discharge (+), at 2mo follow-up (+)
Doucet and Griffin (2013) E1: High frequency NMES (40Hz) • Lateral pinch strength (+)
RCT (5) E2: Low frequency NMES (20Hz) • Minnesota Manual Dexterity Test (+)
NStart=16 • Endurance of thumb adduction (+)
NEnd=16
Hara et al. (2008) E: FES • ROM (+)
RCT (5) C: Control • Modified Ashworth Scale (+)
N=20
Mann et al. (2005) E: Neuromuscular Electrical • Action Research Arm Test (+)
5 (RCT) Stimulation
N=22 C: Passive Extension Exercises
Gabr et al. (2005) E: EMG-triggered NMES • Fugl Meyer Score (+)

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RCT (4) C: Home exercise • Action Research Arm test (-)
N=12
Hara et al. (2006) E: FES • Modified Ashworth Scale (-)
RCT (4) C: Control • Range of Motion (+)
N=14
Cauraugh et al. (2000) E: EMG-triggered NMES + passive • Box and Block test (+)
RCT (4) range of motion + stretching • Motor Assessment scale (-)
N=11 exercises • Fugl-Meyer upper extremity (-)
C: Passive range of motion +
stretching exercises
King (1996) E: NMES • Tone reduction (+)
RCT (4) C: Passive stretch
N=21
Bhatt et al. (2007) E1: EMG-triggered ES • Jebson Taylor tests (-)
RCT (3) E2: Tracking training • Box & Block test (-)
N=20 E3: EMG-triggered ES + tracking • Finger tracking test (-)
training
Inobe et al. (2013) E: ES • Fugl Meyer Score: upper extremities (+), distal and
PCT C: Sham ES proximal upper extremities (+)
NStart=7
NEnd=7
Discussion
Among the studies evaluating FES/NMES in the subacute stage of stroke, most assessed the same
treatment comparison, electrical stimulation versus physical therapy alone or sham stimulation. The
results indicated that FES/NMES was associated with improvements in motor function, range of motion,
ADL and dexterity in acute to subacute strokes (Alon et al., 2007; Faghri, 1997; Faghri et al., 1994;
Francisco et al., 1998; Heckmann et al., 1997; Karakus et al., 2013; Lin & Yan, 2011; Popovic et al., 2003;
Powell et al., 1999; Thrasher et al., 2008). In the chronic phase, FES/NMES may be advantageous at
recovering impaired manual dexterity, coordination and range of motion however, improvements in
motor function in general following FES/NMES are less clear (Bhatt et al., 2007; Cauraugh et al., 2000;
Conforto et al., 2002; de Kroon & Ijzerman, 2008; de Kroon et al., 2004; Inobe & Kato, 2013; Kim & Lee,
2015; Ring & Rosenthal, 2005; Weber et al., 2010; Wu et al., 2006). Despite improvements observed
during both phases of stroke recovery, limited evidence indicates that recovery may be more significant
when FES was delivered early (<6 months) compared to when it was delivered at a later chronic stage
(>6 months) (Popovic et al., 2004). More research is needed to verify this effect. Furthermore, in
unfavourable patients, EMG-NMES was found to have no effect when compared to those receiving usual
care on measures of upper limb motor function and dexterity (Kwakkel et al., 2016).
Two studies compared a high intensity NMES or FES exercise therapy (60 minutes) against a low
intensity exercise program (Hsu et al., 2010; Kowalczewski et al., 2007). Both studies found that there
was no significant difference between groups in upper limb motor function in patients during the
acute/subacute phase post stroke.
EMG-triggered and cyclic neuromuscular electrical stimulation (NMES)/electrical stimulation delivered

to patients in the acute-subacute stroke phase led to improvements in upper limb functional
impairments (Chae et al., 1998; Kojima et al., 2014; Shimodozono et al., 2014; Shindo et al., 2011).
However, the findings are less clear when range of motion is considered given that only elbow extension

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was found to improve and not shoulder/wrist flexion when continuous NMES was delivered in
combination with repetitive facilitative exercise in the subacute phase of stroke (Shimodozono et al.,
2014). In individuals with chronic stroke, a similar beneficial effect on upper limb motor function was
found following EMG-triggered NMES or electrical stimulation (Chan et al., 2009; Gharib et al., 2014; Hu
et al., 2015; Kim, Lee, & Lee, 2015; Kimberley et al., 2004; Y. H. Lee et al., 2015; Ring & Rosenthal, 2005).
Unlike in subacute stroke patients however, EMG-triggered NMES was not found to be superior to cyclic
or passive NMES at improving upper limb motor function in the chronic phase (Boyaci et al., 2013; de
Kroon & Ijzerman, 2008; Wilson et al., 2016). Contralaterally controlled FES (FES) was also not found to
be superior to cyclic NMES on measures of upper limb motor function, although it did show a benefit for
dexterity. Furthermore, Wilson et al. (2016) also found that neither cyclic NMES nor EMG-triggered
NMES were superior to sensory stimulation. Delivering higher frequency NMES (40Hz) evoked greater
improvements in manual dexterity relative to lower frequency NMES (20Hz) (Doucet & Griffin, 2013).
Three recent meta-analyses have investigated the effect of NMES on functional recovery post-stroke.
These studies include patients in the acute to chronic stage post-stroke and protocols involving upper
and lower limbs. Nascimento, (2014) analyzed data from 16 RCTs and concluded that there were
significant improvements associated with cyclic NMES on both strength and activity level after stroke
(Nascimento et al., 2014). This review used a broader definition of cyclic NMES that included EMG-
triggered NMES. The effects were maintained up to 36 weeks after 6 weeks of therapy when compared
to no treatment or a placebo (Nascimento et al., 2014). This review did not provide separate analysis for
the upper extremity studies.
A review of 18 RCTs by Howlett et al. (2015) included 9 RCTs of FES targeted for improvement of upper
limb function however, only 8 were analyzed. Outcomes used for analyses include those that reflect the
International Classification of Function domain of activity performance (i.e. Motor Assessment Scale for
Stroke (Barker et al., 2008), Arm Motor Ability Test (Daly et al., 2005), Box and Block Test (S.J. Page et
al., 2012), Action Reserch Arm Test (Mann et al., 2005), Upper Extremity Function Test (Popovic et al.,
2004; Popovic et al., 2003), and the Wolf Motor Function Test (Tarkka, Pitkanen, Popovic, Vanninen, &
Kononen, 2011). Due to the variation in outcomes included, the results were measured in terms of
“activity”. Pooled analyses demonstrate a significant effect favouring the FES treatment over the control
therapy (i.e. no treatment or placebo) on upper limb activity. Despite the positive findings, results are to
be interpreted with caution since all studies were poorly powered, and the methodological quality
averaged to 5.5 (out of a total score of 10 on the PEDro scale). Furthermore, 3 studies included patients
in the acute phase of stroke, while the remainder 5 studies evaluated patients in the chronic stage with
a time post-stroke ranging from 6 to 46 months. Lastly, although all outcomes measured “activity”, not
all outcomes assess the same aspects of “activity” or function. For instance, the Box and Block Test
assesses manual dexterity, while the Upper Extremity Function Test measures general upper limb
function. Combining all measures does not provide an accurate representation of the effect of FES on
upper limb impairment following stroke.
Analyses involving only the upper limb in the most recent review showed that various NMES treatments
had no effect on spasticity in the wrist or elbow, or on range of motion in the wrist when combined with
other treatments (Stein, Fritsch, Robinson, Sbruzzi, & Plentz, 2015). The only significant result was a
positive relationship of NMES on range of motion in the elbow. Among the limitations of these studies, a
lack of blinding of therapists and participants was most prevalent. However, the authors noted that this
may be considered as an inherent drawback to studies involving a physically active intervention such as
electrical stimulation. Other problematic factors included a lack of allocation concealment and
intention-to-treat analysis, and the inclusion of studies of low methodological quality and statistical
power.

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Conclusions Regarding FES/NMES Therapy for Upper Extremity
There is level 1a and level 2 evidence that FES/NMES may improve upper limb motor function, range
of motion, and manual dexterity when offered in combination with conventional therapy or
delivered alone in subacute stroke. The evidence is also indicative of a beneficial effect on range of
motion and manual dexterity when FES/NMES was offered to chronic stroke patients either alone or
in combination with other therapies.
Despite improvements in both stages of stroke recovery, level 1b evidence indicates that delivering
FES early (<6 months) may be more beneficial at recovering impaired motor function than delivering
FES after 6 months post-stroke.
There is level 1b evidence that EMG-NMES in the subacute phase is not more effective than usual
care for patients with an unfavourable prognosis based on voluntary finger extension.
There is level 1a evidence that high intensity NMES or FES exercise is no more effective for improving
upper limb motor function than low intensity NMES or FES in the subacute phase.
There is level 1a and level 2 evidence that both EMG-triggered and cyclic approaches to
NMES/electrical stimulation may improve upper limb motor function and range of motion in
subacute and chronic stroke patients; however, evidence indicates no superior benefit of EMG-
triggered NMES over cyclic or passive NMES at improving upper limb motor function in chronic (level
1a) and subacute (level 1b) stroke patients.
There is level 1b evidence that Contralaterally Controlled FES is not superior to cyclic NMES for
improving upper limb motor function, although it may improve dexterity.
There is level 1b evidence that coupling continuous NMES with repetitive facilitative exercise may be
beneficial at improving general upper extremity function and range of motion during elbow
extension but not during shoulder or wrist flexion in subacute stroke patients.
There is level 1b evidence that high frequency NMES may be superior to low frequency NMES at
improving endurance of thumb adduction, lateral pinch strength and manual dexterity in chronic
stroke individuals.
Both functional electrical stimulation (FES) and neuromuscular electrical stimulation (NMES) may
help improve impaired upper extremity motor function during all phases of stroke (i.e. from acute
to chronic).
FES may be more beneficial at improving impaired motor function when delivered early (<6 months)
than late (>6 months).
There is no significant difference in the benefits observed following different NMES delivery
modalities (i.e. cyclic, EMG-triggered, and passive).

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10.8 Brain Stimulation
Brain stimulation has been increasingly studied as a means to improve motor recovery, particularly in
the hand, and to alleviate pain in chronic stroke. Both invasive and non-invasive methods are available.
10.8.1 Invasive Motor Cortex Stimulation (MCS)

Since Tsubokawa et al. (1991) discovered that stimulation of the motor cortex via implanted electrodes
was sufficient to induce muscle contraction, its use was extended to potentially treat various
neurological conditions including stroke. However, due to the invasive nature of this technique and the
complications associated with the procedure, the evidence for its use in the stroke population is limited.
The trials that have evaluated the use of invasive motor cortex stimulation for improving motor function
post stroke are summarized in table 10.8.1.1.
Table 10.8.1.1 Summary of RCTs Evaluating Invasive Stimulation for the Upper Extremity
Sample Size
Dawson et al. (2016) E: Impanted vagus nerve stimulation • Fugl-Meyer Assessment (+)
RCT (7) + upper limb therapy • Action Research Arm Test (-)
NStart=20 C: Upper limb therapy • Grip Strength (-)
NEnd=20 • 9 Hole Peg Test (-)
Brown et al. (2006) E: Motor cortex stimulation • Fugl Meyer Scale (+)
RCT (6) C: Rehabilitation • Stroke Impact Scale (+)
N=10
Levy et al. (2016) E: Cortical implant with epidural 6- • Upper Extremity Fugl-Meyer (-)
RCT (6) contact lead perpendicular to the • Arm Motor Ability Test (-)
NStart=164 primary motor cortex and a pulse
NEnd=128 generator
C: No implant
Huang et al. (2008) E1: Motor cortex stimulation (50Hz) • Fugl Meyer Score (+)
RCT (5) C1: Rehabilitation therapy • Box and Block Test (+)
N=24 E2: Motor cortex stimulation (101Hz) • Stroke Impact Scale (-)
C2: Rehabilitation therapy • Arm Motor Ability Test (-)
Levy et al. (2008) E: Motor cortex stimulation • Fugl Meyer Score (+)
RCT (5) C: Control • Arm Motor Ability Test (+)
N=24
Discussion
Motor Cortex Stimulation (MCS) was found to improve upper limb motor function post stroke in some
studies, but not in others. Brown et al. (2006) reported efficacious gains in upper limb motor function in
patients who received MCS compared to a control group who received standard care. However, the
results of this study are to be interpreted with caution because the study was highly underpowered,
with only 10 patients included.

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In another study, Huang et al. (2008) reported a significant effect of group, with significantly favourable
gains for the treatment groups on the Fugl-Meyer Assessment and Box and Block Test (BBT), but no
significant improvement on the Arm Motor Ability Test (AMAT). Huang et al. (2008) suggest that the
difference in BBT and AMAT may also have been due to sensitivity of proximal performance. Although
grip strength did not show any improvement, the authors suggest that gains may have been more
proximal than distal.
Dawson et al. (2016) also found an improvement in those receiving implanted vagus nerve stimulation
and upper limb therapy in comparison to those only receiving upper limb therapy on the Fugl-Meyer
Assessment for upper limb motor function. However, no significant difference between groups was
found on the Action Research Arm Test, Nine Hole Peg Test, and the Box and Block Test. This suggests
that vagus nerve stimulation may improve overall upper limb motor function, but not dexterity or grip
strength.
Lastly, a large study by Levy et al. (2016) found no significant difference on upper limb motor function
outcomes between patients receiving a cortical implant providing primary motor cortex stimulation with
a pulse generator when compared to those not receiving an implant.
Adverse events have also been reported in patients receiving MCS. Brown et al. (2006) evaluated the
safety of MCS and did not report any deaths or neurological deterioration, and although there were two
cases of infection, the authors stated that these were due to a protocol violation and a faulty lead and
therefore are not typical of the MCS itself. One seizure also occurred in the study conducted by Huang et
al. (2008), but the authors believe that it was caused by the anesthetic rather than the treatment.
Additional prospective multicenter double-blind RCTs are needed to establish definitive data regarding
the use of MCS for the recovery of impaired motor function post stroke.
Conclusions Regarding Invasive Motor Cortex Stimulation (MCS)
There is level 1a evidence that motor cortex stimulation does not improve upper limb motor
function.
There is level 1b evidence that vagus nerve stimulation can improve overall upper limb motor
function, but not dexterity or grip strength.
Motor Cortex Stimulation via implanted electrodes may not improve upper limb function in patients
post-stroke. More studies are needed to conclude on the effectiveness of vagus nerve stimulation
for upper limb motor function.
10.8.2 Non-Invasive Motor Cortex Stimulation

In the preceding section, the efficacy of motor cortex stimulation by surgically implanted devices in the
relief of central pain following stroke, is reviewed. Cortical stimulation can also be achieved non-
invasively through the use of single or repetitive transcranial magnetic stimulation (TMS and rTMS) and
transcranial direct-current stimulation (tDCS) to help improve motor recovery.

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10.8.2.1 Repetitive Transcranial Magnetic Stimulation (rTMS)
TMS is a novel approach to neurorehabilitation following stroke. TMS may be delivered in a single pulse,
in paired pulses or as repetitive trains of stimulation. Repetitive TMS (rTMS) produces effects which last
longer than the period of stimulation. When TMS is applied in the form of trains of stimuli (rTMS) to the
motor cortex, it can facilitate or suppress targeted regions of the brain, depending on the stimulation
parameters. Low stimulation frequencies (1 Hz or lower) decrease cortical excitability and inhibit the
targeted cortex, while high frequency (10 to 20Hz) stimulation increases excitability and has a
facilitatory effect.
The stimulation process is both painless and non-invasive, and involves the use of a coil that produces a
magnetic field which passes through the skull to the cerebral cortex. Repetitive TMS induces sustained
increases in cortical excitability through mechanisms that are still not well defined; however, inhibition
of the unaffected hemisphere theoretically results in decreased inhibitory projections to the affected
hemisphere, increasing intracortical excitability within the ipsilesional cortical tissue that ultimately
would translate into an improvement in motor function (Fregni et al., 2006). Alternatively, excitatory
rTMS may target the affected hemisphere directly, thereby increasing intracortical excitability (Hoyer &
Celnik, 2011). Repetitive TMS has also been used to identify those patients who might benefit from long-
term motor cortex stimulation long term using implantable devices.
A recent meta-analysis (Hsu, Cheng, Liao, Lee, & Lin, 2012) including the results of 18 RCTs and
representing data from 392 patients, examined the effectiveness of rTMS for improving motor function
following stroke. The authors reported a clinically significant treatment effect. The outcomes evaluated
included finger tapping tasks, the Nine Hole Peg Test, hand grip strength and the Wolf Motor Function
test. The treatment effects associated with treatment in the acute, subacute and chronic stages of
stroke were 0.79, 0.63 and 0.66, respectively. Low-frequency rTMS (1 Hz) over the unaffected
hemisphere appeared to be more effective than high-frequency rTMS (10 Hz) over the unaffected
hemisphere (treatment effect =0.69 vs. 0.41).
A systematic review with meta-analysis by Graef et al. (2016) investigated whether there is a significant
difference between rTMS with upper limb training in comparison to sham rTMS with upper limb
training. The review included 11 studies, and overall found no significant difference between groups for
upper limb motor function or spasticity.
A growing number of studies have investigated the effects of both single and repetitive TMS with the
aim of improving function of the upper extremity and lower extremity. The results of RCTs evaluating
rTMS for the upper extremity are presented in Table 10.8.2.1.1.
Table 10.8.2.1.1 Summary of RCTs Examining rTMS

Author, Year Intervention Outcome(s) and Result(s)
Study Design (PEDro Score)
Sample Size
Wang et al. (2014) E1: 1Hz rTMS premotor •
Wolf Motor Function Test: E1 vs. E2 (+), E1 vs. C
RCT (9) E2: 1Hz rTMS motor (+), E2 vs. C (+)
NStart=44 C: Sham • Fugl Meyer Score: E1 vs. E2 (+), E1 vs. C (+), E2 vs.
NEnd=44 C (+)
Lüdemann-Podubecká et al E1: 1Hz contralesional rTMS + motor • Wolf Motor Function Test: E2 vs. C2 (-), E1 vs. C1
(2015) training, lesioned dominant hemisphere (+)
RCT (9) E2: 1Hz contralesional rTMS + motor • Motor Evaluation Scale for Upper: E2 vs. C2 (-), E1
NStart=40 training, lesioned non-dominant vs. C1 (+)

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NEnd=40 hemisphere
C1: Contralesional sham + motor
training, lesioned dominant hemisphere
C2: Contralesional sham + motor
training, lesioned non-dominant
hemisphere
Hosomi et al. (2016) E: rTMS • Brunnstorm Stage (-)
RCT (8) C: Sham • Fugl-Meyer Assessment (-)
NStart=41 • National institute for Health Stroke Scale (-)
NEnd=39 • Grip Power (-)
Yang et al. (2016) E1: Repetitive Transcranial Magnetic • Fugl-Meyer Assessment (-)
RCT (8) stimulation with sensory cueing • Action Research Arm Test (-)
NStart=60 E2: Repetitive Transcranial Magnetic • Modified Barthel Index (-)
NEnd=60 stimulation
C: Conventional Rehabilitation
Seniów et al. (2012) E: rTMS + PT • Wolf Motor Function Test (upper) (-)
RCT (8) C: Sham + PT • Fugl Meyer Assessment (-)
N=40
Khedr et al. (2009) E1: 1Hz rTMS • Grip strength: rTMS vs. sham (+)
RCT (8) E2: 3Hz rTMS • Pegboard task: rTMS vs. sham (+)
N=36 C: Sham • Barthel Index: rTMS vs. sham (+)
• NIHSS: rTMS vs. sham (+)
Khedr et al. (2010) E1: 3Hz rTMS • Grip strength: rTMS vs. C (+), E1 vs. E2 (-)
RCT (8) E2: 10Hz rTMS • NIHSS: rTMS vs. C (+), E1 vs. E2 (-)
N=48 C: Sham • Modified Rankin Scale: rTMS vs. C (+), E1 vs. E2 (-)
Sasaki et al. (2013) E1: 10Hz rTMS lesioned hemisphere • Grip strength: E1 vs. C (+), E2 vs. C (-)
RCT (8) E2: 1Hz rTMS non-lesioned hemisphere • Tapping frequency: E1 vs. C (+), E2 vs. C (-)
NStart=29 C: Sham
NEnd=29
Barros Galvao et al. (2014) E: Inhibitory rTMS • Modified Ashworth Scale (-)
RCT (8) C: Sham • Fugl Meyer Assessment (-)
NStart=20 • Stroke Specific Quality of Life Scale (-)
NEnd=18 • FIM (-)
• Wrist range of motion (-)
Sasaki et al. (2014) E: Bilateral high and low frequency rTMS • Brunnstrom (+)
RCT (8) C: High frequency rTMS • Grip strength (-)
NStart=58 • Tapping frequency (-)
NEnd=58
Pomeroy et al. (2007) E1: rTMS + voluntary muscle contraction • Flexion/extension torque (-)
RCT (8) (VMC) • Action Research Arm Test (-)
N=27 E2: rTMS + placebo VMC
E3: Sham rTMS + VMC
C: Sham rTMS + placebo VMC
Ludemann-Podubecka et al. E: Inhibitory rTMS • Wolf Motor Function Test (+)
(2015) C: Sham • Motor Evaluation Scale (+)
RCT (7) • Finger Tapping (-)
NStart=40
NEnd=33
Abo et al. (2014) E: Inhibitory rTMS + OT training • Fugl Meyer Score (+)
RCT (7) (NEURO) • Wolf Motor Function Test (-)
NStart=66 C: CIMT • Functional Assessment Score (+)
NEnd=66

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Higgins et al. (2013) E: Inhibitory rTMS • Box and Block Test (-)
RCT (7) C: Sham • Motor Acitivity Log (-)
NStart=11 • Wolf Motor Function Test (-)
NEnd=11
Emara et al. (2010) E1: 5Hz rTMS • Finger tapping test: rTMS vs. C (+)
RCT (7) E2: 1Hz rTMS • Activities Index: rTMS vs. C (+)
N=60 C: Sham • Modified Rankin Scale: rTMS vs. C (+)
Takeuchi et al. (2008) E: Inhibitory rTMS + pinch force motor • Pinch acceleration (+)
RCT (7) training • Pinch force (+)
N=20 C: Sham + pinch force motor training
Liepert et al. (2007) E: Inhibitory rTMS • Grip strength (-)
RCT (7) C: Sham • 9-hole peg test (+)
N=12
Fregni et al. (2006) E: Inhibitory rTMS • Jebsen-Taylor Hand Function test (+)
RCT (7) C: Sham
N=15
Zheng et al. (2015) E: 1 Hz rTMS + virtual reality (VR) • Fugl Meyer Score (+)
RCT (7) training • Wolf Motor Function Test (+)
NStart=112 C: Sham + VR training • Modififed Barthel Index (+)
NEnd=108 • SF-36 (+)
Cassidy et al. (2015) E1: 6Hz rTMS • Box and Block Test: E1/E2 vs. C (+)
RCT (7) E2: 1Hz rTMS
NStart=11 C: Sham
NEnd=11
Du et al. (2016) E1: 1200 10s pulses 3Hz ipsilesional • Fugl-Meyer Assessment: E1/E2 vs. C (+)
RCT (7) rTMS • Medical Research Council Score: E2 vs. C (+)
NStart=69 E2: 1200 30s pulses 1Hz contralesion • National Institute of Health Stroke Scale: E1/E2
NEnd=55 rTMS vs. C (+)
C: Sham rTMS • Modified Rankin Scale: E1/E2 vs. C (+)
• Barthel Index: E1/E2 vs. C (+)
Li et al. (2016) E1: 1Hz rTMS • Fugl-Meyer Assessment: E1/E2 vs. C (+)
RCT (7) E2: 10Hz rTMS • Wolf Motor Function Test (-)
NStart=127 C: Sham
NEnd=127
Ludemann-Podubecka et al. E: 1 Hz rTMS • Jebsen Taylor Hand Function Test (+)
(2016) C: Sham • Box and Block Test (-)
RCT (7)
NStart=10
NEnd=10
D’Agata et al. (2016) E: Inhibitory tDCS + rTMS + Mirror • Action Research Arm Test (+)
RCT (6) Therapy
NStart=34 C:Sham tDCS + Mirror Therapy
NEnd=34
Ji et al. (2014) E1: Mirror therapy+ excitatory rTMS • Fugl Meyer Score: E1 vs. E2 (+), E2 vs. C (+)
RCT (7) E2: Mirror therapy • Box and Block Test: E1 vs. E2 (+), E2 vs. C (+)
NStart=35 C: Sham
NEnd=35
Sung et al. (2013) E1: Inhibitory rTMS + iTBS • Wolf Motor Function test: E(all) vs. C (+), E1 vs. E2
RCT (6) E2: Sham rTMS + iTBS (+), E1 vs. E3 (+)
NStart=54 E3: Inhibitory rTMS + sham iTBS • Fugl-Meyer Assessment: E(all) vs. C (+), E1 vs. E2

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NEnd=54 C: Sham rTMS + sham iTBS (+), E1 vs. E3 (+)
• FIM (-)
Conforto et al. (2012) E: Inhibitory rTMS • Jebsen-Taylor Hand Function test (+)
RCT (6) C: Sham • Pinch Force (+)
N=29 • Fugl-Meyer (upper) (+)
• Modified Ashworth (-)
Malcolm et al. (2007) E: Excitatory rTMS • Wolf Motor Function Test (-)
RCT (6) C: Sham • Motor Activity Log (-)
N=19
Takeuchi et al. (2009) E1: Bilateral (dual) rTMS + pinch force • Pinch force: E1 vs. E3 (+), E1 vs. E2(+)
RCT (6) motor training • Acceleration: E1 vs. E3 (+), E1 vs. E2(+)
N=30 E2: Excitatory rTMS affected
hemisphere + pinch force motor training
E3: Inhibitory rTMS unaffected
hemisphere + pinch force motor training
Takeuchi et al. (2005) E: Inhibitory rTMS • Hand and pinch force (-)
RCT (6) C: Sham • Hand acceleration (+)
N=20
Kim et al. (2014) E: Excitatory rTMS • Manual Function Test (+)

RCT (6) C: Sham
NStart=31
NEnd=31
Khedr et al. (2005) E: rTMS • Barthel Index (+)
RCT (6) C: Sham • NIHSS (+)
N=52 • Scandinavian Stroke Impact Scale (+)
Chang et al. (2010) E: rTMS • Motricity Index (+)
RCT (5) C: Sham • Fugl-Meyer (-)
N=28
Rose et al. (2014) E: rTMS + functional task practice (FTP) • Wolf Motor Function Test (-)
RCT (5) C: Sham + FTP • Lateral pinch (-)
NStart=22 • Palmar pinch (-)
NEnd=19 • Fugl Meyer Assessment (-)
• Motor Activity Log: quality of movement (-)
• Motor Acitivity Log: amount of use (-)
Lindenberg et al. (2010) E: rTMS • Fugl Meyer (Upper) (+)
RCT (4) C: Sham • Wolf Motor Function test (+)
N=20
Mansur et al. (2005) E: rTMS • Simple reaction time (+)
RCT (4) C: Sham • Four-choice reaction time (+)
N=10 • Finger tapping test (-)
• Perdue Pegboard test (+)
Kim et al. (2016) E1: rTMS responders based on self-care • Modified Barthel Index: E1 vs. E2/C (+)
PCT score of Modified Barthel Index • National Institute of Health Stroke Scale: E1/E2
NStart=82 E2: rTMS non-responders based on self- vs. C (+)
NEnd=82 care score of Modified Barthel Index • Brunnstrom Stage: E1/E2 vs. C (+)
C: Usual care • Upper Limb Mobility: E1 vs. E2/C (+)
Guo et al. (2016) E: 10Hz rTMS + usual care • National Institute for Health Stroke Scale (-)
PCT C: usual care • Barthel Index (-)

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NStart=15 • Fugl-Meyer Assessment (+)
NEnd=15
Etoh et al. (2016) E1: Exercise + rTMS • Fugl-Meyer Assessment (-)
PCT E2: Exercise + NMES + Vibration • Action Research Arm Test (-)
NStart=33 E3: Exercise + NMES + Vibration + rTMS • Modfied Ashworth Scale (-)
NEnd=33
Discussion
Most of the trials evaluating rTMS or TMS examined the effect of brain stimulation on upper extremity
motor function. Among these trials, treatment periods were short, usually lasting for 2 weeks, and were
most often conducted on patients during the chronic stage of stroke. A number of studies also
investigated the intensity of rTMS provided. Research from Khedr et al. (2009; 2010) investigated rTMS
at frequencies of 1Hz versus 3Hz and 3Hz versus 10Hz, respectively. The results from the former study
suggested that 10 consecutive days of 1Hz was more efficacious than 3Hz, with patients who received
1Hz performing better on the Pegboard Task and on the National Institutes of Health Stroke Scale
(NIHSS); however, the authors were unable to provide an explanation for this difference (Khedr et al.,
2009). In a later study, Khedr et al. (2010) compared 3Hz with 10Hz, and reported no significant
differences between protocols but a significant improvement in favour of rTMS compared to a sham
rTMS condition was found. The authors note that 3Hz was performed at 130% resting motor threshold
(RMT) whereas 10Hz was performed at 100% RMT due to safety concerns which may have balanced the
results between the two conditions. Khedr et al. (2010) also highlighted that misestimating the motor
threshold, as well as the lack of a surrogate marker informing clinicians when rTMS has activated the
cortex, may lead to patients being stimulated suboptimally. Sasaki et al. (2013) reported greater
functional improvements in patients who received high-frequency compared with low-frequency rTMS,
and noted that patients in the acute stage of stroke may benefit from a high-frequency approach over
the ipsilesional hemisphere, adding that developmental proteins reappear during the early phases of
stroke and interhemisphere inhibition is abnormally high.
The location of rTMS application may also influence recovery. Wang et al. (2014) examined rTMS applied
to the primary motor cortex (M1) and dorsal premotor cortex (PMd). The results suggest that rTMS over
the M1 is more effective in promoting recovery then rTMS over the PMd; however, both intervention
approaches were significantly more efficacious than sham rTMS over the M1. The discrepancy between
these two regions of the brain may be explained by differences in excitability between pyramidal tract
neurons and neurons with distant interconnected projections (C. C. Wang et al., 2014).
Emara et al. (2010) investigated the use of different intensities on the ipsilesional and contralesional
areas of the brain. Although no direct comparisons were made between the ipsilesional and
contralesional conditions, ANOVA analyses revealed a significant group by time interaction with greater
improvement indicated in both rTMS groups compared to a sham rTMS condition. An increase in the
cumulative number of sessions may also play a role; Emara et al. (2010) randomized participants to
receive 10 daily sessions of either sham, 5Hz ipsilesional or 1Hz contralesional rTMS, and reported
statistically significant improvement in upper extremity motor function in the active stimulation groups
compared to the sham control group. The authors noted that patients in the contralesional 1Hz
condition received twice as many treatment sessions as compared to previous studies, which may be
important for sustaining the positive effect of rTMS. Further research is required to investigate the
neurological reactions across different areas of the brain after rTMS therapy.

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Lüdemann-Podubecka et al. (2015) compared 1Hz rTMS with a sham condition, targeting the
contralesional hemisphere, for a total of 3 weeks. All participants also received daily 30-minute motor
training sessions. In terms of participants with lesioned non-dominant hemispheres, the study did not
find a significant difference between the two conditions for either the unaffected hand or the affected
hand; however, in terms of participants with lesioned dominant hemispheres, changes in motor function
of the affected hand differed significantly between groups as indicated by WMFT and Motor Evaluation
Scale for Upper Extremity in Stroke Patients (MESUPES) scores at 3 weeks and 6 months, at and 1 week,
respectively. Within-group analyses revealed that participants with lesioned dominant hemispheres
receiving rTMS and participants with lesioned non-dominant hemispheres receiving either sham or rTMS
therapy showed significant changes in motor function of the affected hand over the three-week training
period and 6 months thereafter. The authors concluded that motor recovery of the affected upper
extremity may depend on hemispheric dominance, and that 1Hz rTMS over the contralesional M1 area
improves motor ability in the affected hand in patients with a lesion in the dominant hemisphere, but
not in those with lesioned non-dominant hemispheres (Ludemann-Podubecka et al., 2015).
Other studies have sought to improve motor function by implementing a physiotherapy program
alongside an rTMS intervention with varying intensities. Takeuchi et al. (2008) reported significant gains
in pinch force and acceleration after rTMS and motor training compared to sham rTMS. A potential
mechanism for this may be due to the lasting effects of rTMS with motor training during elevated levels
of excitability in the motor cortex, allowing for reorganisation and therefore acquirement of functional
ability (Takeuchi et al., 2008). Mixed results were reported by Chang et al. (2010), who combined rTMS
with conventional physiotherapy and occupational therapy. Results indicated significant improvement in
Motricity Index upper-extremity scores compared to a sham rTMS protocol, but no other between-
group differences were observed. However, both Seniow et al. (2012) and Barros Galvao et al. (2014)
investigated the effectiveness of rTMS in addition to physiotherapy, and reported that although both
groups demonstrated significant improvements, there were no between-group differences on measures
of upper extremity function. While it may be that physiotherapy was the common denominator in
reducing spasticity and increasing motor function to a clinically meaningful degree, the study period may
have been too short and patients may have experienced a time lag between changes in spasticity and
function; therefore, studies including a longer follow-up time may be better able to detect functional
improvements (Barros GalvÃ£o et al., 2014). Furthermore, Rose et al. (2014) also reported no significant
between-group differences on all measures of upper extremity function in their study investigating rTMS
coupled with functional task practice.
Zheng et al. (2015) combined low-frequency (1 Hz) rTMS and sham rTMS with a virtual reality training
protocol and reported significantly higher scores on the WMFT, FMA, modified Barthel Index, and the
SF-36 Physical Functioning subscale among those receiving low-frequency rTMS. It has been suggested
that rTMS can change synaptic efficacy and facilitate practice-dependent plasticity, thereby improving
motor regeneration, and when combined with VR training, may produce a synergistic effect (Zheng et
al., 2015).
Studies investigating the effectiveness of low-frequency rTMS in comparison to sham found conflicting
results on upper limb motor function and dexterity outcomes. For example, studies such as those by
Wang et al. (2014), Ludemann-Podubecka et al. (2015), Zheng et al. (2015), Du et al.(2016) found a
significant difference between groups. However, studies such as those by Hosomi et al. (2016), Yang et
al. (2016), and Seniow et al. (2012), found no significant difference. Two studies (Barros GalvÃ£o et al.,
2014; Liepert et al., 2007) found that low-frequency rTMS did not improve upper limb spasticity.

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All studies investigating high-frequency rTMS found a significant effect when compared to sham rTMS,
including on outcomes such as upper limb motor function, dexterity, and grip strength (Cassidy et al.,
2015; Chang et al., 2010; Emara et al., 2010; Ji et al., 2014; Khedr et al., 2010; Kim, Lee, & Song, 2014; Li,
Chai, Xu, & Li, 2016; Sasaki et al., 2013).
None of the studies comparing high-frequency and low-frequency rTMS found a significant difference on
measures of motor function or grip strength (Cassidy et al., 2015; Emara et al., 2010; Khedr et al., 2010;
J. Li et al., 2016; Sasaki et al., 2013).
Two studies investigated both high-frequency and low-frequency rTMS at the same time compared to
high-frequency rTMS alone, specifically Sasaki et al. (2014) and Takeuchi et al. (2009). Based on the
results from the study by Sasaki et al. (2014), there was an improvement in upper limb motor function,
but not in grip strength between the groups.
Conclusions Regarding Repetitive Transcranial Magnetic Stimulation
There is level 1a conflicting evidence regarding the effectiveness of low-frequency (1Hz) rTMS for the
improvement of upper limb motor function and dexterity. There is also level 1a evidence that
inhibiting rTMS does not improve upper limb spasticity when compared to sham stimulation.
There is level 1a evidence that high-frequency rTMS (≥5 Hz) improves upper limb motor function,
dexterity, and grip strength when compared to sham stimulation.
There is level 1a evidence that there is no significant difference between inhibitory and excitatory
rTMS for improving upper limb motor function or grip strength.
There is level 1b evidence that dual rTMS (the combination of both inhibitory and excitatory rTMS)
improves upper limb motor function, but not grip strength when compared to sham stimulation.
It is unclear whether low-frequency (1 Hz) Repetitive Transcranial Magnetic Stimulation (RTMS) is

effective, while high-frequency (5 Hz) and Dual RTMS Repetitive Transcranial Magnetic Stimulation
is likely effective for improving upper limb motor function.
10.8.2.2 Theta Burst Stimulation (TBS)

Theta Burst Stimulation (TBS) is a novel form of rTMS that provides a low-intensity output that can incite
or reduce cortical excitability (Talelli, Greenwood, & Rothwell, 2007). As poor upper limb recovery is
associated with a reduction of excitability in the ipsilesional primary motor cortex M1 and increased
excitability in the contralesional M1, TBS can be used to rebalance hemispheric activity. This can be
achieved through the use of intermittent TBS (iTBS) which can facilitate M1 excitability, or continuous
TBS (cTBS), which can suppress M1 excitability (Ackerley, Stinear, Barber, & Byblow, 2010). Individually,
both are found to be successful despite the limited literature on TBS and upper limb function. The use of
cTBS has been found to improve reaction times of the paretic limb (Meehan, Dao, Linsdell, & Boyd,
2011), although other studies have not reported any clinical effects despite a reduction in motor evoked
potentials of the contralesional hemisphere (Talelli et al., 2007). Not only can TBS be used for functional
or strength gains, but previous literature has also reported alleviation of spasticity. Research by Kim et
al. (2016) revealed that intermittent TBS of the ipsilesional motor hotspot for the carpi radialis muscle
resulted in a significant reduction in spasticity of the wrist with benefits lasting for at least 30 minutes
post treatment. Furthermore, other studies have reported positive improvements of TBS in the

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treatment of other motor disorders such as ataxia, with decreases in intracortical inhibition and
increases in intracortical facilitation observed (Bonni, Ponzo, Caltagirone, & Koch, 2014).
The results of controlled trials evaluating TBS are detailed in Table 10.8.2.2.1.
Table 10.8.2.2.1 Summary of Controlled Trials Examining TBS for the Upper Extremity
Author, Year Intervention Outcome(s) and Result(s)
Sample Size
Sung et al. (2013) E1: rTMS + iTBS • Finger Flexor Medical Research Council
RCT (9) E2: sham rTMS + iTBS Scale (+)
NStart=54 E3: rTMS + sham iTBS • Wolf Motor Function test: E(all) vs. C (+),
NEnd=54 C: Sham rTMS + sham iTBS. E1 vs. E2 (+), E1 vs. E3 (+)
• Fugl-Meyer Assessment: E(all) vs. C (+),
E1 vs. E2 (+), E1 vs. E3 (+)
• Simple reaction time (+)
Ackerley et al. (2016) E: iTBS • Action Research Arm Test (+)
RCT (8) C: Sham TBS • Fugl-Meyer Assessment (-)
NStart=18
NEnd=18
Kim et al. (2015) E: iTBS • Modified Ashworth Scale (+)
RCT (8) C: Sham TBS • Peak torque (+)
NStart=15 • Peak torque angle (+)
NEnd=15 • Work (-)
• Modified Tardieu Scale: R1 (+), R2 (-)
Di Lazzaro et al. (2016) E: cTBS + robotic therapy • Fugl-Meyer Assessment (-)

RCT (7) C: Sham TBS + robotic therapy
NStart=20
NEnd=17
Talelli et al. (2012) E1: iTBS • Nine Hole Peg Test (-)
RCT (7) C1: Sham iTBS • Jebsen Taylor Hand test (-)
N=41 E2: cTBS
C2: Sham cTBS
Hsu et al. (2013) E: iTBS • Fugl Meyer Assessment (upper) (+)
RCT=7 C: Sham • Action Research Arm Test (-)
N=12
Di Lazzaro et al. (2014) E: cTBS • Action Research Arm Test (-)
RCT (6) C: Sham • Nine Hole Peg Test (-)
NStart=12 • Jebsen Taylor hand test (-)
NEnd=12 • Grasp strength (-)
• Pinch strength (-)
Volz et al. (2016) E: iTBS • Grip Strength (+)
RCT (5) C: Sham TBS • Jebsen Taylor Hand Function Test (-)
NStart=26
NEnd=17
Lai et al. (2015) E1: iTBS (MEP+, MRC>1) • Wolf Motor Function Test: E1 vs E2 (+);
PCT E2: iTBS (MEP-, MRC>1) E1 vs C (+)
NStart=72 E3: iTBS (MEP-, MR=0) • Finger Tapping: E1 v E2 (+); E1 vs E3 (+);
NEnd=72 C: Sham (MEP+, MRC>1) E1 v C (+)
Kim et al. (2015) E: iTBS • Modified Ashworth Scale (+)
PCT C: Sham • Peak torque (+)

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NStart=15 • Peak torque angle (+)
NEnd=15 • Work (-)
• Modified Tardieu Scale: R1 (+), R2 (-)
Discussion
Intermittent TBS was investigated by six RCTs and two prospective controlled trials. Two studies
examined the effectiveness of iTBS in the acute/subacute phase (Hsu et al., 2013; Volz et al., 2016). The
results of the studies indicated that while iTBS improved upper limb motor function when compared to
sham, measures of dexterity were not improved in the iTBS group over the sham group.
Four RCTs examined the effectiveness of iTBS in the chronic phase in comparison to a sham group
(Ackerley et al., 2016; D. H. Kim et al., 2015; Sung et al., 2013; Talelli et al., 2012). The results of the
studies were conflicting, with Sung et al. (2013) finding positive outcomes for upper limb motor
function, Ackerley et al. (2016) finding no improvement in upper limb motor function, but an
improvement in dexterity, Hsu et al. (2013) finding an improvement in upper limb motor function, but
not dexterity, and Kim et al. (2015) finding an improvement in upper limb spasticity. Kim et al. (2015)
observed a transient reduction of spasticity for up to 30 minutes after iTBS over the hotspot of the
affected flexor carpi radialis muscle within the ipsilesional hemisphere. Although the mechanism for this
remains unclear, iTBS may encourage neural activity projection to local inhibitory interneurons of the
spinal cord (D. H. Kim et al., 2015). A reduction in spasticity was not observed according to
electrophysiological measurements which suggested that the H-reflex has high variability and low
reliability, and interneurons at the spinal level may not be directly involved (D. H. Kim et al., 2015).
Three RCTs examined the effectiveness of continuous TBS (cTBS) in comparsion to sham, and three
studies were conducted during the chronic phase post stroke (Di Lazzaro et al., 2016; Di Lazzaro et al.,
2014; Talelli et al., 2012). All three found no significant differences between groups on measures of
upper limb motor function and dexterity.
Although the studies by Hsu et al. (2013) and Kim et al. (2015) evaluated stimulation of the ipsilesional
hemispheres, other studies have investigated stimulation of both the affected and unaffected
hemispheres. Sung et al. (2013) reported that 1Hz of rTMS over the contralesional M1 followed by iTBS
(three pulses of 50Hz) over the ipsilesional M1 was more effective than iTBS plus sham rTMS and 1Hz
rTMS plus sham iTBS. This would suggest that doubling treatment load is beneficial in enhancing upper
extremity function with no adverse events reported. In particular, the authors noted a decrease in
excitability in the contralesional M1 and an increase in the ipsilesional M1, supporting the suggestion
that an inhibitory-facilitatory approach might be most efficacious (Sung et al., 2013).
Lai et al. (2015) reported that predictors for the success of iTBS interventions on upper extremity motor
enhancement depend on hand grip strength at pre-treatment and the presence of positive motor-
evoked potentials (MEPs). The authors note that these predictors were independent of stroke type, time
post stroke, and size of lesion. Patients who exhibited no MEPs nor any movement in the paretic hand
may have experienced disruption of the key motor pathway and contralesional inhibition (C. J. Lai et al.,
2015). It was suggested by Lai et al. (2015) that patients fitting this criteria may benefit from training-
dependent neuroplasticity such as robot-training, nerve stimulation, or behavioural interventions
alongside rTMS/TBS in order to maximise enhancements.
Conclusions Regarding Theta Burst Stimulation

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There is level 1b and level 2 evidence that iTBS improves upper limb motor function, but not
dexterity, in the acute or subacute period after stroke.
There is conflicting level 1a evidence that iTBS improves upper limb motor function and dexterity in
the chronic phase after stroke. There is level 1b and level 2 evidence that iTBS improves spasticity in
the chronic phase after stroke.
There is level 1a evidence that cTBS does not improve upper extremity motor function or dexterity
following stroke.
Intermittent Theta Burst Stimulation (iTBS) may improve upper limb motor function in the
acute/subacute phase as well as during the chronic phase post stroke. While iTBS may not be
effective for improving dexterity in the acute/subacute phase, it is likely effective during the chronic
phase.
Continuous Theta Burst Stimulation (cTBS) may not be effective for improving upper limb motor
function or dexterity after stroke.
10.8.2.3 Transcranial Direct Current Stimulation (tDCS)

Another form of noninvasive electrical stimulation is transcranial direct-current stimulation (tDCS). This
procedure involves the application of mild electrical currents (1-2 mA) conducted through 2 saline
soaked, surface electrodes applied to the scalp, overlaying the area of interest and the contralateral
forehead above the orbit. Anodal stimulation increases cortical excitability while cathode stimulation
decreases it (Alonso-Alonso, Fregni, & Pascual-Leone, 2007). In contrast to TMS, tDCS does not induce
action potentials, but instead modulates the resting membrane potential of the neurons (Alonso-Alonso
et al., 2007). tDCS is a good candidate for study since unlike TMS, it does not elicit somatosensory
changes that would alert a subject to the fact a real, rather than sham treatment was being applied.
A meta-analysis (Bastani & Jaberzadeh, 2012) examined the effectiveness of tDCS to improve motor
function in both healthy individuals and those following stroke. Four RCTs were included (Boggio et al.,
2007; Fregni et al., 2005; Hummel et al., 2005; Kim, Ohn, Yang, Park, & Jung, 2009). All but the Kim et al.
(2009) included subjects in the chronic stage of stroke and all subjects exhibited mild to moderate
baseline hand impairment. The pooled standardized mean difference for hand function was 0.39 (95% CI
-0.17 to 0.9, p=0.17) indicating a small but non-significant treatment effect.
Another review and meta-analysis authored by Butler et al. (2013), restricted to the examination of
anodal tDCS, included the results from 8 RCTs, all of which examined motor function in the upper
extremity following stroke (Butler et al., 2013). Outcomes assessed among the trials included the
Jebsen-Taylor Hand Function test, BBT, pinch and grip strength and reaction time. Overall, compared
with sham stimulation, anodal tDCS was associated with a small to moderate significant treatment effect
(SMD=0.49, 95% CI 0.18 to 0.81, p=0.005).
The results of trials evaluating tDCS are detailed in Tables 10.8.2.3.1 to 10.8.2.3.4.
Table 10.8.2.3.1 Summary of Studies Examining Anodal tDCS for the Upper Extremity

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Author, Year Main Outcome(s) Result
Sample Size
Hesse et al. (2011) E1: Anodal tDCS • Fugl Meyer score (-): E1 vs E2 (-); E1 vs C (-); E2 vs C
RCT (10) E2: Cathodal tDCS (-)
N=96 C: Sham
Viana et al. (2014) E: Virtual reality + anodal tDCS • Fugl Meyer Assessment (-)
RCT (9) C: Virtual reality + sham • Wolf Motor Function Test (-)
NEnd=20 • Stroke Specific Quality of Life (+)
Khedr et al. (2013) E1: Anodal tDCS • Orgogozo’s MCA Scale: E1 vs. C (+), E2 vs. C (-), E1
RCT (9) E2: Cathodal tDCS vs. E2 (-)
NStart=40 C: Sham • Barthel Index: E1 vs. C (+), E2 vs. C (-), E1 vs. E2 (-)
NEnd=40 • Muscle strength (-)
Triccas et al. (2015) E: Anodal tDCS + robotic ArmeoSpring • Fugl-Meyer Assessment (-)
RCT (8) C: Sham tDCS + robotic ArmeoSpring • Action Research Arm Test (-)
Ilic et al. (2016) E: Anodal tDCS + occupational • Modified Jebsen-Taylor Hand Function Test (+)
RCT (8) therapy • Fugl-Meyer Assessment (-)
NStart=26 C: Sham tDCS + occupational • Grip Strength (-)
NEnd=25 therapy
Powell et al. (2016) E1: Anodal tDCS followed by peripheral • Fugl-Meyer Assessment (-)
RCT (8) nerve stimulation • Stroke Impact Scale (-)
NStart=11 E2: Peripheral nerve stimulation
NEnd=10 followed by tDCS
Au-Yeung et al. (2014) E1: Anodal tDCS • Purdue Pegboard Test (-)
RCT (8) E2: Cathodal tDCS • Pinch strength (-)
NStart=10 C: Sham
NEnd=10
Figlewski et al. (2016) E: Constraint-induced movement • Wolf Motor Function Test: Functional Ability (+),
RCT (7) therapy + Anodal tDCS Grip Strength (-), Arm Strength (-)
NStart=44 C: Constraint-induced movement
NEnd=44 therapy + Sham tDCS
Lee et al. (2014) E1: cathodal tDCS • Manual Function Test: E1 vs. E2 (+)
RCT (7) E2: Virtual reality • Fugl Meyer Assessment (+)
NStart=64 E3: tDCS + virtual reality • Modified Barthel Index (-)
NEnd=59 • Manual Muscle Test (-)
Mortensen et al. (2016) E: Anodal tDCS + occupational therapy • Grip Strength (+)
RCT (7) C: Sham tDCS + occupational therapy • Activities of Daily Living (-)
NStart=16 • Jebsen-Taylor Hand Function Test (-)
NEnd=15
Hendy & Kidgell. (2014) E1: Anodal tDCS + strength training • Extensor carpi radialis strength (+)
RCT (7) E2: sham tDCS + strength training
NEnd=10

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Kim et al. (2009) E: Anodal tDCS • Box & Block Test (+)
RCT (7) C: Sham • Finger acceleration (+)
N=10
Kim et al. (2010) E1: Anodal tDCS • Fugl-Meyer Score (-)
RCT (7) E2: Cathodal tDCS • Barthel Index (-)
N=18 C: Sham
Wang et al. (2014) E1: Anodal tDCS + real methylphenidate • Purdue Pegboard Test: E1 vs. E3 (+), E1 vs. E2 (+)
RCT (7) E2: Sham tDCS + real methylphenidate
NStart=9 E3: Anodal tDCS + sham
NEnd=9 methylphenidate
Hendy et al. (2014) E1: Strength training + anodal tDCS • Maximum voluntary dynamic strength for wrist
RCT (7) E2: Strength training + sham extensors (-)
NEnd=10
Sattler et al. (2015) E: Repetitive peripheral nerve • Jebsen Hand Function Test (+)
RCT (7) stimulation + anodal tDCS • Grip Strength (-)
NStart=20 C: Repetitive peripheral nerve • 9 Hole Peg Test (-)
NEnd=20 stimulation • Hand Tapping Test (-)
Allman et al. (2016) E: Anodal tDCS • Action Research Arm Test (+)
RCT (7) C: Sham tDCS • Wolf Motor Function Test (+)
NEnd=24
Fregni et al. (2005) E1: Anodal tDCS • Jebsen-Taylor Hand Function test: E1 vs C (+); E2 vs.
RCT (7) E2: Cathodal tDCS C (+); E1 vs E2 (-)
N=6 C: Sham
Kim et al. (2009) E: Anodal tDCS • Box & Block Test (+)
RCT (7) C: Sham • Finger acceleration (+)
N=10
Straudi et al. (2016) E: Robot-assisted therapy + anodal tDCS • Fugl-Meyer Assessment (-)
RCT (6) C: Robot-assisted therapy + sham tDCS • Box and Block Test (-)
NStart=23 • Motor Acivity Log (-)
NEnd=23
Ang et al. (2015) E: Anodal tDCS + motor imagery • Fugl-Meyer Assessment (-)
RCT (6) computer brain interface with robotic
NStart=19 feedback
NEnd=19 C: Sham tDCS + motor imagery computer
brain interface with robotic feedback
Sik et al. (2015) E1: Anodal tDCS + PT + OT • Wolf Motor Function Test: E1/E2 vs. C (+), E1 vs. E2
RCT (6) E2: Anodal-cathodal tDCS + PT + OT (-)
NStart=36 C: Sham tDCS + PT + OT • Jebsen Taylor Hand Function Test (-)
NEnd=31 • Kocaeli Functional Evaluation Test (-)
Bolognini et al. (2015) E1: Anodal tDCS left P2: Anodal tDCS • Ideomotor Apraxia Test (-)
RCT (6) right PPC • Jebsen Taylor Hand Function Test (-)
NStart=12 C: Sham tDCS
NEnd=12
Cunningham et al. (2015) E: anodal tDCS + CIMT • 9 Hole Peg Test (-)
RCT (6) C: Sham tDCS + CIMT • Motor Activity Log (-)
NEnd=12

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Tanaka et al. (2011) E: Anodal tDCS • Grip strength (-)
RCT (6) C: Sham
N=8
Fusco et al. (2014) E: Anodal tDCS • Hand dexterity and force (-)
RCT (6) C: Sham • Grip and pinch force (-)
NStart=18 • Nine hole peg test (-)
NEnd=16
Stagg et al. (2012) E1: Anodal tDCS • Grip strength: E1 vs C (+); E2 vs C (+); E1 vs E2 (-)
RCT (6) E2: Cathodal tDCS
N=13 C: Sham
Boggio et al. (2007) E1: Anodal tDCS • Jebsen-Taylor Hand Function test: E1 vs, C (+), E2 vs.
RCT (6) E2: Cathodal tDCS C (+)
N=4 C: Sham
Lindenberg et al. (2010) E: Anodal tDCS • Fugl-Meyer (upper) (+)
RCT (4) C: Sham • Wolf Motor Function test (+)
N=20
Kasashima-Shindo et al. E: Anodal tDCS + brain computer • Fugl Meyer Assessment (-)
(2015) interface • Modified Ashworth Scale (-)
PCT C: Brain computer interface
NStart=18
NEnd=16
Table 10.8.2.3.2 Summary of Controlled Trials Examining Cathodal tDCS for the Upper Extremity
Sample Size
N=96 C: Sham •
Wu et al.(2013) E: Cathodal tDCS • Modified Ashworth Scale (+)

RCT (9) C: Sham
NStart=90
NEnd=90
Khedr et al.(2013) E1: Anodal tDCS • Orgogozo’s MCA Scale: E1 vs. C (+), E2 vs. C (-), E1
Rocha et al. (2016) E1: Anodal tDCS • Fugl-Meyer Assessment: E1/E2 vs. C (+)
RCT (8) E2: Cathodal tDCS • Motor Acivity Log (-)
NStart=21 C: Sham tDCS • Grip Strength (-)
NEnd=21
NStart=10 C: Sham
NEnd=10
Del Felice et al. (2016) E1: Cathodal tDCS • Motor Assessment Scale (-)
RCT (8) E2: Dual tDCS • European Stroke Scale (-)
NStart=10 C: Sham tDCS • Action Research Arm Test (-)

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NEnd=10 • Barthel index (-)
Lee et al. (2014) E1: cathodal tDCS • Manual Function Test: E1 vs. E2 (+)
RCT (7) E2: Virtual reality • Fugl Meyer Assessment (+)
NStart=64 E3: tDCS + virtual reality • Modified Barthel Index (-)
NEnd=59 • Manual Muscle Test (-)
N=6 C: Sham
N=18 C: Sham
Kwon et al. (2016) E1: Cathodal tDCS + rTMS • Movement Accuracy (-)
RCT (7) E2: Anodal tDCS + rTMS • Movement time: E1 vs E2 (+); E1 vs C (+)
NStart=20 C: Sham tDCS + rTMS
NEnd=20
Fusco et al. (2013) E1: Dual tDCS (anodal and cathodal) • 9-hole peg test: E vs. C (+)
RCT (7) E2: Anodal tDCS • Grasp force (-)
N=9 E3: Cathodal tDCS
C: Sham
Zimerman et al. (2012) E: Cathodal tDCS • Grip strength (-)
RCT (6) C: Sham
N=12
Hummel et al. (2005) E: Cathodal tDCS • Jebsen-Taylor Hand Function test (+)
RCT (6) C: Sham
N=6
Fusco et al. (2014) E: Cathodal tDCS + active electrode • Canadian Neurologic Scale (-)
RCT (6) C: Sham • Nine Hole Peg Test (-)
NStart=14 • Barthel Index (-)
NEnd=11 • Fugl Meyer Assessment (-)
Lee & Chun (2014) E1: Cathodal tDCS • Manual Function Test (+)
RCT (6) E2: Virtual reality training • Fugl Meyer Score (+)
NStart=64 E3: tDCS + virtual reality
NEnd=59
Lee et al. (2015) E: Cathodal tDCS + physical therapy • Fugl-Meyer Assessment (+)
RCT (6) C: Physical therapy
NStart=24
NEnd=24
N=13 C: Sham
Boggio et al. (2007) E1: Anodal tDCS • Jebsen-Taylor Hand Function test: E1 vs, C (+), E2 vs.
N=4 C: Sham
Table 10.8.2.3.3 Summary of Studies Examining Anodal versus Cathodal tDCS for the Upper Extremity

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Sample Size
N=96 C: Sham
Khedr et al.(2013) E1: Anodal tDCS • Orgogozo’s MCA Scale: E1 vs. C (+), E2 vs. C (-), E1
Rocha et al. (2016) E1: Anodal tDCS + CIMT • Fugl-Meyer Assessment: E1/E2 vs. C (+)
RCT (8) E2: Cathodal tDCS + CIMT • Motor Activity Log (-)
NStart=21 C: Sham tDCS + CIMT • Grip Strength (-)
NEnd=21
NStart=10 C: Sham
NEnd=10
Ochi et al. (2013) E: Anodal tDCS on affected hemisphere • Modified Ashworth Scale: finger (+)
RCT (7) + robot assisted arm training • Fugl Meyer Score (-)
N=18 C: Cathodal tDCS on unaffected • Motor Activity Log (-)
hemisphere + robot assited arm training
Kwon et al. (2016) E1: Cathodal tDCS + rTMS • Movement Accuracy (-)
RCT (7) E2: Anodal tDCS + rTMS • Movement time: E1 vs E2 (+); E1 vs C (+)
NStart=20 C: Sham tDCS + rTMS
NEnd=20
C: Sham
N=18 C: Sham
N=6 C: Sham
Sik et al. (2015) E1: Anodal tDCS + PT + OT • Wolf Motor Function Test (-)
RCT (6) E2: Anodal-cathodal tDCS + PT + OT • Jebsen Taylor Hand Function Test (-)
NStart=36 C: Sham tDCS + PT + OT • Kocaeli Functional Evaluation Test (-)
NEnd=31
N=13 C: Sham
Boggio et al. (2007) E1: Anodal tDCS • Jebsen-Taylor Hand Function test: E1 vs C (+); E2 vs
N=4 C: Sham
Table 10.8.2.3.4 Summary of Studies Examining Dual tDCS for the Upper Extremity

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Sample Size
Lefebvre et al. (2013) E: Dual tDCS (anodal and cathodal) • Learning Index (+)
RCT (8) C: Sham • Performance Index (-)
NStart=18 • Purdue Pegboard Test (+)
NEnd=18 • Haximal hand grip force (+)
Lefebvre et al. (2014) E: Dual tDCS (anodal and cathodal) • Purdue Pegboard Test (+)
RCT (8) C: Sham • Precision grip (+)
NStart=19 • Dexterity (+)
NEnd=19
Del Felice et al. (2016) E1: Anodal or Cathodal tDCS • Medical Research Council Scale: E2 vs. E1 (+)
RCT (8) E2: Dual tDCS • Motor Assessment Scale (-)
NStart=10 C: Sham tDCS • European Stroke Scale (-)
NEnd=10 • Action Research Arm Test (-)
• Barthel index (-)
Goodwill et al. (2016) E: dual tDCS + upper limb training • Tardieu Scale (-)
RCT (7) C: Sham tDCS + upper limb training • Grip Strength (-)
NStart=16
NEnd=15
C: Sham
D’Agata et al. (2016) E1: rTMS + tDCS (dual) + mirror therapy • Action Research Arm Test (-)
RCT (6) E2: dual-tDCS + mirror Therapy + rTMS
NStart=34 C: Sham tDCS + mirror Therapy
NEnd=34
Sik et al. (2015) E1: Anodal tDCS + PT + OT • Wolf Motor Function Test: E1/E2 vs. C (+), E1 vs. E2
RCT (6) E2: Anodal-cathodal tDCS + PT + OT (-)
NStart=36 C: Sham tDCS + PT + OT • Jebsen Taylor Hand Function Test (-)
NEnd=31 • Kocaeli Functional Evaluation Test (-)
Cha et al. (2014) E: Dual tDCS (anodal and cathodal) • Fugl Meyer Assessment (+)
RCT (6) C: Conventional training • Box and Block Test (+)
NStart=20
NEnd=20
Lefebvre et al. (2015) E: Dual tDCS • Purdue Pegboard Test (+)
RCT Crossover (5) C: Sham tDCS
NStart=19
NEnd=19
Discussion
Similar to rTMS, the majority of tDCS studies were directed at improving movement or function of the
upper extremity. The length and intensity of stimulation was consistent across most studies (20 minutes
at 1 mA). Many of the studies examined a one-time session of either anodal and/or cathodal stimulation
compared with sham treatment and the majority did not include concurrent therapy.

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Studies examining the effectiveness of anodal tDCS when compared to sham tDCS indicated that there
was no significant difference between the groups on outcomes of motor function, spasticity, or grip
strength. As an example, a study by Hesse et al. (2011) with a large sample size and high methodological
quality compared anodal tDCS to sham and found no significant difference on measures of upper limb
motor function. However, outcomes related to dexterity were mixed between studies (Allman et al.,
2016; Au-Yeung et al., 2014; Boggio et al., 2007; Bolognini et al., 2015; Fregni et al., 2005; Fusco et al.,
2014; Ilic et al., 2016; Kim et al., 2009; Lee & Chun, 2014; Mortensen et al., 2016; Sattler et al., 2015; Şik
et al., 2015; Straudi et al., 2016; Triccas et al., 2015; C. C. Wang et al., 2014).
Studies examining the effectiveness of cathodal tDCS when compared to sham tDCS found that
outcomes were conflicting for upper limb motor function, grip strength, dexterity, and for measures of
independence or daily living. For example, two of the trials examining spasticity had relatively large
sample sizes in comparison to the other studies, although Wu et al. (2013) found an improvement in
spasticity between cathodal tDCS sham, whereas Lee et al. (2014) did not. Although patients in the
cathodal tDCS condition demonstrated significant improvement in bilateral arm function over the course
of the study, Hesse et al. (2011) did not report any differences between groups in function or muscle
strength. It was noted that the majority of patients in the study presented with infarcts with both
cortical and subcortical involvement whereas the majority of tDCS literature with positive results
focusing mostly on patients with only subcortical deficits and therefore intact cortical connectivity
(Hesse et al., 2011). Similarly, the results from Au-Yeung et al. (2014) did not yield any differences in
dexterity or pinch strength. The application of tDCS to only one motor area may not have been sufficient
in improving dexterity which requires motor function and coordination (Au-Yeung et al., 2014). The
authors also note that patients did not receive any additional motor training and so a combination with
tDCS may allow for greater dexterity and an increase in strength (Au-Yeung et al., 2014).
Various studies also examined whether anodal and cathodal tDCS differed significantly. Studies by Hesse
et al. (2011), Rocha et al. (2016), Ochi et al. (2013), Kim et al. (2010), Fregni et al. (2005), Sik et al. (2015)
found no significant difference between anodal and cathodal tDCS on measures of upper limb motor
function. Various studies also found that there was no significant difference between anodal and
cathodal tDCS on measures of dexterity (Fregni et al., 2005; Fusco et al., 2013; Şik et al., 2015), grip
strength (Rocha et al., 2016; Stagg et al., 2012), and measures of independence or daily living (Khedr et
al., 2013; Kim et al., 2010).
An emerging approach is the combination of both anodal and cathodal tDCS, also known as dual tDCS.
Based on the studies examining dual tDCS in comparison to sham tDCS, various studies indicated a
significant improvement in those receiving dual tDCS on measures of dexterity (Fusco et al., 2013;
Lefebvre et al., 2015; Lefebvre et al., 2013; Lefebvre et al., 2014). Two studies found that dual tDCS
improved grip force (Lefebvre et al., 2013; Lefebvre et al., 2014) while two studies found that dual tDCS
did not improve grip force (Fusco et al., 2013; Goodwill et al., 2016). There was insufficient evidence to
investigate other outcomes, so additional studies are needed to establish conclusions for other outcome
measures. As performance on the PPT continued to improve, the authors suggest that dual tDCS may be
useful in facilitating patients in an optimal state for training (Lefebvre et al., 2014). This optimal state
could be achieved through enhancement of synaptic plasticity and neural activity in the motor cortex
(Cha et al., 2014). However, Fusco et al. (2013) reported that anodal tDCS was the most effective in the
improvement of dexterity while cathodal and dual tDCS demonstrated little effect. Lefebvre et al. (2013)
suggest that dual tDCS may induce a reduction in cortical excitability in the contralesional hemisphere
and facilitation of excitability within the ipsilesional hemisphere thereby improving motor functioning
through a rebalancing of interhemispheric interaction.

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A more novel approach of combining and comparing tDCS with virtual reality (VR) training was
conducted by two RCTs with mixed results. Viana et al. (2014) reported significant improvements in
spasticity of the wrist and quality of life in patients who received VR and tDCS compared to those who
received VR and a sham tDCS. The authors suggest that application of tDCS over the injured hemisphere,
specifically, the primary motor cortex, may have increased neural activity. It was also noted that there
may have been a ceiling effect in responsiveness on the FMA and the insufficient sample size could
potentially have affected the between group differences (Viana et al., 2014). In contrast, Lee and Chun
(2014) reported significant improvements on the FMA and Manual Function Test (MFT) for VR and tDCS
combined compared to VR and tDCS alone but moreover, patients in the VR-only group outperformed
patients in the tDCS-only group on the FMA and MFT. However, the tDCS group demonstrated greater
hand functionality than the VR condition. It was noted by the authors that the VR protocol required
movement of the proximal arm and a task facilitating hand movement may lead to even greater
improvements. The observed efficacy of the combined condition may have been the result of cortical
reorganisation after VR and receptor activity of N-methyl-D-aspartate, and sodium and calcium voltage-
dependent channels mediated after tDCS (Lee & Chun, 2014).
A systematic review conducted by Elsner et al. (2016) revealed evidence favouring the use of tDCS over
sham tDCS or a differing control condition, but there was no evidence of lasting effects at follow-up. It
was also reported that ADLs were found to improve after tDCS treatment, but this effect was not
maintained after excluding studies that were at a high risk for bias (Elsner et al., 2016). Another meta-
analysis, authored by Butler et al. (2013), was restricted to the examination of anodal tDCS and included
the results from eight RCTs, all of which examined motor function in the upper extremity following
stroke. Outcomes assessed included the Jebsen-Taylor Hand Function test, BBT, pinch and grip strength,
and reaction time. Butler et al. (2013) reported a significant increase in pooled scores favouring tDCS
from baseline to post-treatment, although only a small to moderate effect size (0.40) was obtained.
Furthermore, a small to moderate effect size (0.49) was found in the improvement of the contralateral
limb favouring tDCS compared to sham tDCS despite a significant increase in pooled scores. Future
meta-analyses are needed to determine the efficacy of cathodal and dual tDCS as well as anodal. Butler
et al. (2013) also recommend that future reviews and meta-analyses should investigate additional
factors such as the intensity of tDCS, lesion location, and time post stroke.
Conclusions Regarding Transcranial Direct Current Stimulation
There is level 1a evidence that anodal tDCS does not improve upper limb motor function, spasticity,
or grip strength. There is conflicting level 1a evidence regarding whether anodal tDCS improves
dexterity.
There is level 1a conflicting evidence for the effectiveness of cathodal tDCS for improving upper limb
motor function, dexterity grip strength, and activities of daily living.
There is level 1a evidence that anodal and cathodal tDCS do not significantly differ on measures of
motor function, dexterity, or on measures of independence/daily living.
There is level 1a evidence that dual tDCS (both anodal and cathodal tDCS administered at the same
time) is effective for improving dexterity. There is level 1a conflicting evidence regarding the
effectiveness of dual tDCS for improving grip force.
There is level 1b evidence that coupling methylphenidate with tDCS may improve hand function
relative to when tDCS or methylphenidate are delivered alone.

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There is level 1b evidence that combining tDCS with computer brain interface training may not
improve spasticity or upper extremity motor function.
Anodal Transcranial Direct Current Stimulation (tDCS) is likely not effective for improving upper
limb motor function, spasticity, and grip strength, with uncertainty regarding its effectiveness for
dexterity.
The effectiveness of Cathodal Transcranial Direct Current Stimulation (tDCS) remains uncertain for
upper limb motor function, dexterity, and activities of daily living.
Dual Transcranial Direct Current Stimulation is likely effective for dexterity.
10.9 Drugs and Medical Interventions

Medications used to augment the rehabilitation process following stroke have mainly been examined for
their potential benefit in terms of global recovery and depression. The results from these trials have
been published in other chapters (Mobility, Depression, and Aphasia). However, a small group of studies
that evaluated the efficacy of drugs for their effect on the upper extremity has also been identified.
These drugs include stimulants (amphetamines and methylphenidate), Levodopa and anti-depressants
(citalopram and reboxetine). A systematic review (Berends et al., 2009) evaluated the benefit of drugs
influencing neurotransmitters on motor recovery following stroke. Six studies evaluating a broad range
of drugs were included (antidepressant, amphetamine/methylphenidate and Levodopa). The outcomes
assessed included the Barthel Index and the FIM. Methylphenidate, tarazadone and nortriptyline were
associated with improved motor function. While recognizing that the studies differed in many respects,
the authors concluded that there was insufficient evidence to recommend their use.
10.9.1 Stimulants
Amphetamines have shown promise in aiding recovery following stroke as they have the potential to
accelerate motor recovery following motor cortex lesions in the rat model (Feeney, Gonzalez, & Law,
1982), especially when combined with task-specific training. Stimulants such as amphetamines have
been reported to enhance plasticity through axonal sprouting (Papadopoulos et al., 2009). Four RCTs
have examined the effects of either amphetamine or methylphenidate on motor recovery in the upper
extremity, the results of which are detailed in Table 10.9.1.1.
Table 10.9.1.1. Summary of RCTs Examining Stimulants for the Upper Extremity
Sample Size
Platz et al. (2005) E: d-amphetamine (10mg) + arm training • TEMPA: post (+), follow-up (-)
RCT (9) C: Placebo + arm training
N=31
Tardy et al. (2006) E: Methylpenidate (20mg) • Finger tapping scores (+)
RCT (9) C: Placebo • Hand grip strength (-)
N=8
Schuster et al. (2011) E: Dexamphetamine + physiotherapy • Chedoke-McMaster Stroke Assessment: ADL (+)
RCT (9) C: Placebo + physiotherapy • Chedoke-McMaster Stroke Assessment: hand
N=16 scores (+)
Wang et al. (2011) E1: Real tDCS + methylphenidate • Purdue Pegboard Test: E1 vs. E2 (+), E1 vs. E3 (+)

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RCT (7) E2: Real tDCS + placebo drug
N=9 E3: Sham tDCS + methylphenidate
C: Sham tDCS + placebo drug
Discussion
Amphetamines were investigated for their effect on upper extremity function in two RCTs. Platz et al.
(2005) compared dextroamphetamine (d-amphetamine) with a placebo and tested effects of upper
extremity function using the TEMPA, a timed test of upper-extremity performance with tasks based on
ADLs. Both groups received arm ability training which may lead to gains in motor recovery, however, no
differences were found between groups. Furthermore, there was no new acquisition or facilitation of
skills associated with d-amphetamine use which may have been due to its effect on attentional systems
with high arousal, resulting in non-clinical attentional difficulties (Platz, Kim, et al., 2005). Short-term
gains in favour d-amphetamines were reported by Schuster et al. (2011) on the CMSA Hand and ADL
subscales after 1 week, but these were not sustained at 6 month and 12 month follow-ups. Despite the
lack of statistical significance, there was trend in favour of the experimental group. Timing may have
been a causal factor, with previous studies reporting positive results with a start date of less than 30
days post stroke, whereas this study began intake at a mean of 37.9 days post stroke (Schuster et al.,
2011). The authors also noted that the small sample size may have influenced the results, particularly as
the types of physiotherapy were specific to each patient.
One RCT also examined the effect of methylphenidate (Tardy et al., 2006), which is in the same class of
drug as amphetamines, but it does not produce the same side effect profile as amphetamines (insomnia,
lack or appetite). In comparison with a placebo group, Tardy et al. (2006) reported significantly higher
finger tapping scores, with the authors explaining this effect as the result of dopaminergic and
noradrenergic modulation. Further research is required to understand the neuronal reactions of
methylphenidate in post-stroke patients.
Wang et al. (2014) combined the use of methylphenidate with tDCS whilst also studying each
intervention separately. The results indicated that methylphenidate plus tDCS was most effective in
restoring hand function compared to each intervention separately. Furthermore, post-hoc analyses
revealed that methylphenidate alone did not result in significant improvements, whereas tDCS and
methylphenidate in combination with tDCS did. Interestingly, all three groups did not differ with regards
to evoked potentials of cortical excitability. Although the authors conclude the mechanism behind these
results remains unclear, they propose that methylphenidate strengthened and enhanced the effects of
tDCS.
Conclusions Regarding Stimulants
There is level 1a evidence that delivering stimulants in combination with additional therapy may
improve upper extremity function; however, level 1b evidence suggests that grip strength may not
improve.
There is Level 1b evidence that stimulants may only be effective at improving impaired upper limb
function in the short term.
Stimulants may help improve impaired upper limb function; however, the effects may not be

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10.9.2 Levodopa
Levodopa is a dopamine precursor which, once it crosses the blood-brain barrier, is converted to
dopamine (which cannot cross the blood-brain barrier). Levodopa is used as a prodrug to increase
dopamine levels, most commonly in the treatment of Parkinson’s disease. However, there have been
two RCTs conducted evaluating Levodopa for upper extremity function post stroke, the details of which
are detailed in Table 10.9.2.1.
Table 10.9.2.1 Summary of RCTs Examining Levodopa for the Upper Extremity
Sample Size
Restemeyer et al. (2007) E: Levodopa (100mg) • Nine Hole Peg Test (-)
RCT (9) C: Placebo (100mg) • Grip strength (-)
N=10 • Action Research Arm Test (-)
Rosser et al. (2008) E: Levodopa (100mg) + cabidopa (25mg) • Reaction time (+)
RCT (5) C: Placebo
N=18
Discussion
Mixed results were reported from the two RCTs conducted to investigate the effect of Levodopa on
upper extremity functions. Rosser et al. (2008) reported a significant improvement in reaction time
performance after patients were treated with three consecutive doses of Levodopa compared to
performance after receiving a placebo. The mechanism for this improvement may be the result of
dopamine release leading to a strengthening of task-relevant synapses and suppression of task-
irrelevant synapses (Rosser et al., 2008). However, this study did not include a follow-up assessment;
therefore potential long-term benefits were not evaluated. Restemeyer et al. (2007) did not report any
significant differences in function when comparing patients’ performance after receiving 100mg of
Levodopa or placebo. However, the authors note that patients were prescribed only a single dose of
Levodopa and this may not be sufficient to support or induce changes in neuroplasticity. Furthermore,
baseline Action Research Arm Test scores were high, thereby indicating a ceiling effect and that prior
function was at a sufficient level (Restemeyer et al., 2007). Further research with varying dosage over
extended periods of time is recommended.
Conclusions Regarding Levodopa
There is level 1b evidence that Levodopa may not improve arm and hand function however, level 2
evidence suggests that reaction time may be improved.
More research is needed to determine the effects of Levodopa on impaired upper limb motor
function.
10.9.3 Antidepressants
Beyond their ability to improve depression following stroke, antidepressants can be used to enhance
upper extremity motor recovery through changes in neurotransmission. There is evidence suggesting
that serotoninergic modulation may be involved in motor recovery post stroke. Previous research has

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suggested that patients who have reacted well to antidepressant treatment may also demonstrate
improvements in upper limb motor functioning (Chemerinski, Robinson, & Kosier, 2001). Furthermore,
there are reports that single doses of selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine
and paroxetine, have resulted in activation of the motor cortices (Dam et al., 1996; Pariente et al., 2001)
therefore, manipulation of neurochemicals may influence aspects of function other than psychological
distress. Moreover, there is evidence to suggest that noradrenergic reuptake inhibitors (NRIs) increase
motor cortex excitability (Plewnia et al., 2002). Results of RCTs evaluating antidepressants for upper
extremity outcomes are reported in Table 10.9.3.1 and results regarding the lower extremities are
presented in Chapter 9.
Table 10.9.3.1 Summary of RCTs Examining Antidepressants for the Upper Extremity
Sample Size
Chollet et al. (2011) E: Fluoxetine (20mg) • Fugl Meyer Motor Scale (+)
RCT (9) C: Placebo • NIHSS (-)
N=118 • Modified Rankin Scale (+)
Robinson et al. (2000) E1: Nortriptyline (100mg) • FIM: E1 vs. E2 (+), E1 vs. C (+)
RCT (8) E2: Fluoxetine (40mg)
N=104 C: Placebo
Zittel et al. (2008) E: Citalopram • Nine Hole Peg Test (+)
RCT (8) C: Placebo • Hand grip strength (-)
N=8
Mikami et al. (2011) Additional analysis of Robinson et al. 2000 During 1yr follow-up:
RCT (8) E1: Nortriptyline (100mg) • Modified Rankin Scale: E1 vs. C (+), E2 vs. C
N=104 E2: Fluoxetine (40mg) (+)
C: Placebo
Zittel et al. (2007) E: Reboxetine • Tapping speed (+)
RCT (6) C: Placebo • Grip strength (+)
N=10
Mohammadianinejad et al. (2014) E: Lithium carbonate (300mg) • NIHSS (+)
RCT (6) C: Placebo • Fugl Meyer Scores: Hand (+)
NStart=80
NEnd=66
Discussion
SSRIs have long been used in the treatment of depression. Zittel et al. (2008) revealed a significant
improvement in dexterity after patients had received Citalopram compared to a placebo. Furthermore,
the authors revealed a trend towards even greater improvement among patients who also received
physiotherapy. The results did not yield any significant improvement in strength, suggesting that
Citalopram’s modification of serotonergic transmission is associated with coordination and dexterity. In
a multicentre RCT assessing the effect of Fluoxetine on motor recovery compared to a placebo, Chollet
et al. (2011) reported significantly greater improvement on the Fugl-Meyer Motor Scale (FMMS) and
Modified Rankin Scale (mRS) among patients receiving Fluoxetine. A potential explanation for these
results could be that the main function of the serotonergic system is to facilitate motor output which
would allow for greater efficiency, especially when combined with physical training (Chollet et al., 2011).
No side effects were reported for Citalopram (Zittel et al., 2008) but transient digestive disorders such as

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nausea, diarrhea and pain were reported in more patients treated with Fluoxetine than placebo (Chollet
et al., 2011).
In comparison with Nortriptyline, a Tricyclic antidepressant, Robinson et al. (2000) reported greater
improvements on the FIM in patients who received Nortriptyline compared to who received Fluoxetine
or a placebo. Interestingly, there were no significant differences between patients with or without
depression regardless of the type of treatment provided (Nortriptyline, Fluoxetine or placebo). Robinson
et al. (2000) suggest that the 12 week study period may have been insufficient to observe improvements
in impairment between depressed and non-depressed patients. Further analyses of this dataset by
Mikami et al. (2011) revealed that patients receiving antidepressant treatment, regardless of type
(Nortriptyline or Fluoxetine), outperformed patients given a placebo on the mRS at 1-year follow-up.
Mikami et al. (2011) note that previous literature suggests that both tricyclic antidepressants and SSRIs
inhibit microglial production of proinflammatory cytokines thereby resulting in neurogenesis and
synaptic plasticity. The authors propose that both types of antidepressant may be of benefit to stroke
patients independent of presence of depression.
A single dose of an NRI such as Reboxetine was found to be efficacious in improving grip strength and
tapping speed compared to a placebo (Zittel et al., 2007). In contrast with their 2008 study of SSRIs,
Zittel et al. (2007) did not report a significant difference between groups on the 9HPT, suggesting that
NRIs may not be as effective in treating dexterity. Reboxetine was well-tolerated with only one patient
experiencing transient nausea. It is worth noting that this study only recruited chronic stroke patients;
future research may be advised to explore the effects of Reboxetine in acute and sub-acute populations.
Mohammadianinejad et al. (2014) investigated the use of Lithium Carbonate and reported no
differences in improvement in upper limb motor function when compared with a placebo. However, a
subgroup analysis of patients with a lesion located near the middle cerebral artery revealed a significant
improvement on the NIHSS and FMA Hand subscale compared to placebo patients. Previous research
suggests that Lithium enhances neuronal growth in cortical grey matter and increases grey matter
volume; therefore, if the motor cortex was affected by a cortical stroke, this may explain improvements
in motor ability (Mohammadianinejad et al., 2014). It was proposed by Mohammadianinejad et al.
(2014) that further research with longer study periods is required to investigate whether patients with
non-cortical strokes could benefit from Lithium treatment.
Conclusions Regarding Antidepressants
There is level 1a evidence that fluoxetine and nortriptyline may improve overall disability and upper
There is level 1a that citalopram, reboxetine and lithium carbonate may enhance impaired arm and
hand function however, level 1b evidence indicates that citalopram may not be effective at
improving hand grip strength.
Antidepressants may help improve impaired upper extremity motor function following a stroke.

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10.9.4 Steroids
Corticosteroids have been used to treat pain and functional limitations in hemiplegic patients, with pain
potentially hindering the rehabilitation of physical functioning (Dogan, Demirtas, & Ozgirgin, 2013).
Previous literature has reported significant gains in muscle mass and strength in terms of lower limb
recovery after administration of anabolic steroids (Okamoto et al., 2011), but literature concerning
upper limb function is limited. Only two studies, one RCT and one prospective controlled trial, have
investigated the use of steroids on upper limb recovery; results of the controlled trials are summarized
in Table 10.9.4.1.
Table 10.9.4.1 Summary of Controlled Trials Examining Steroids for the Upper Extremity
Sample Size
Yasar et al. (2011) E1: Intra-Articular Steroid Injection • VAS (-)
RCT (9) E2: Suprascapular Nerve Block Injection • Range of Motion (Passive) (-)
NStart=26 • Range of Motion (at onset of pain) (-)
NEnd=26
Doğan et al. (2013) E1: Steroid injection + physical theray • Range of Motion (shoulder joint): E2 vs. E1 (+),
PCT E2: Hydraulic distension + steroid injection + E2 vs. C (+)
NStart=60 physical therpy • Shoulder pain: E2 vs. E1 (+), E2 vs. C (+)
NEnd=60 C: Physical therapy • Self care: E2 vs. E1 (+), E2 vs. C (+)
Discussion
Yasar et al. (2011) found steroid and nerve block injections to be equivalently effective, as patients
demonstrated significant improvements in range of motion and decreases in shoulder pain after
receiving either intervention. Previous research suggests that steroids may have anti-inflammatory
properties while suprascapular nerve block may provide transient cessation of nociceptive signals from
the shoulder (Yasar et al., 2011). Despite no side effects being reported, this study adopted a short
follow-up time and recruited a small group of patients with no placebo group, so the results should be
interpreted with caution. Dogan et al. (2013) reported that patients who received hydraulic distension,
steroid injection and physical therapy combined into a triple-intervention approach demonstrated even
greater improvements in upper limb motor outcomes than those who received steroid injection plus
physical therapy or physical therapy only. Although spasticity was more prevalent in both experimental
groups compared to the control group, greater range of motion was also reported in both at 1 month
post-intervention. The authors suggest that the suppression of pain may have influenced the pain
experienced from any spasticity that may have been present. By combining steroid injections with
hydraulic distension, inflammation may have been suppressed and joint volume increased, thereby
leading to decreased pressure on the supraspinatus and periarticular soft tissue (Dogan et al., 2013).
Conclusions Regarding Steroids
There is level 1b evidence that intra-articular steroid injections may not improve pain or range of
motion of the upper extremity; however, limited level 2 evidence provides conflicting findings.
Further research is needed to determine if steroid injections are beneficial at reducing upper limb
pain and improving range of motion following a stroke.

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10.9.5 Antibiotics
Although no studies have been conducted exploring the use of antibiotics, their use as an adjuvant
alongside other rehabilitative therapies has been proposed. D-cycloserine, an antibiotic used in the
treatment of tuberculosis, was found to be a high-affinity agonist of the N-methyl-D-aspartate (NMDA)
glutamate receptor which was identified as an important component in long-term learning and
potentiation (Nadeau et al., 2014). There is one RCT investigated the combination of constraint induced
movement therapy (CIMT) with D-cycloserine, the results of which are summarized in Table 10.9.5.1.
Table 10.9.5.1 Summary of RCT(s) Examining Antibiotics for the Upper Extremity
Sample Size
Nadeau et al. (2014) Group A: • Fugl Meyer Score (-)
RCT (7) E: CIMT (6hr/d, 5d/wk, 2wk) + d-cycloserine • Wolf Motor Function Test (-)
NStart=24 C: CIMT (6hr/d, 5d/wk, 2wk) + placebo • Motor Activity Log (-)
NEnd=22 Group B: • Stroke Impact Scale (-)
E: CIMT (2hr/d, 3d/wk, 10wks) + d-cycloserine • Geriatric Depression Scale (-)
C: CIMT (2hr/d, 3d/wk, 10wks) + placebo • Caregiver Strain Index (-)
Discussion
Nadeau et al. (2014) reported no significant differences between d-cycloserine and placebo groups, nor
between the more-condensed and less-condensed CIMT conditions on all outcome measures; however,
all four groups demonstrated significant decreases in WMFT scores. The lack of treatment efficacy may
have been the result of a ceiling effect on neuroplasticity, which may in turn have limited the amount of
recovery achieved as previous studies have suggested that loss of corticospinal and corticobulbar fibers
may impose limitations on recovery (Nadeau et al., 2014). The authors also suggest that the dosage of d-
cycloserine administered may have been too low. Further research with different dosages and types of
antibiotics may be warranted.
Conclusions Regarding Antibiotics
There is level 1b evidence that d-cycloserine delivered in combination with constraint-induced

movement therapy may not improve upper extremity motor function.
Further research is needed to determine the effects of d-cycloserine on post-stroke upper extremity
motor function.
10.9.6 Ozonated Autohemotherapy

Ozonated autohemotherapy is a novel treatment that involves the transfusion of oxidated blood.
Previous research suggests that ozone therapy can improve circulation, decrease blood viscosity, and
maintain energy metabolism in brain tissues thereby reducing cellular apoptosis (X. N. Wu et al., 2013).
There is currently a lack of literature assessing the use of ozonated autohemotherapy in stroke patients,
and even more so in terms of post-stroke motor function. Only one prospective controlled trial

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investigated the use of ozonated autohemotherapy for upper extremity function, as detailed in Table
10.9.6.1.
Table 10.9.6.1 Summary of Controlled Trial(s) Examining Ozonated Autohemotherapy for the Upper
Extremity
Sample Size
Wu et al.(2013) E: Ozonated autohemotherapy • NIHSS (+)
PCT C: Conventional rehabilitation • Modified Rankin Scale (+)
NStart=86 • Central motor conduction time (+)
NEnd=86
Discussion
Wu et al. (2013) reported significant increases in motor-evoked potential of the upper limb and shorter
central motor conduction times for those in the intervention group compared to the control group.
However, it should be noted this intervention can induce pain and has technical limitations (X. N. Wu et
al., 2013). Further studies are required to investigate the use of ozonated autohemotherapy in treating
upper extremity dysfunction and to seek clarification on the biological mechanisms as to why this may
be a potentially successful approach. Despite the efficacious nature of ozonated autohemotherapy on
upper extremity motor function post stroke, the mechanisms underlying its beneficial effect remain
unclear (X. N. Wu et al., 2013).
Conclusions Regarding Ozonated Autohemotherapy
There is limited level 2 evidence that ozonated autohemotherapy may improve general motor
disability.
Evidence for the use of ozonated autohemotherapy for improving post-stroke upper limb motor
function is currently limited.
10.9.7 Peptides
Cerebrolysin contains low molecular weight neuropeptides and free amino acids which are believed to
have neuroprotective properties and to reduce excitotoxicity, inhibit free radical formation, reduce
neuroinflammation, and activate calpain apoptosis (Muresanu et al., 2016).
Randomized controlled trials investigating the effectiveness of Cerebrolysin are summarized in Table
10.9.7.1.
Table 10.9.7.1 Summary of Controlled Trial(s) Examining Peptide Use in Stroke Recovery
Sample Size
Muresanu et al. (2016) E: Cerebrolysin + physical/occupational • Fugl-Meyer Assessment (+)
RCT (9) therapy

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NStart=208 C: Placebo + physical/occupational therapy
NEnd=196
Chang et al. (2016) E: Cerebrolysin + conventional therapy • Action Research Arm Test (+)
RCT (6) C: Placebo + conventional therapy • National Institute of Health Stroke Scale (+)
NStart=70 • Barthel Index (+)
NEnd=66 • Modified Rankin Scale (+)
Discussion
Two studies were found to investigate cerebrolysin in stroke patients (Chang et al., 2016; Muresanu et
al., 2016). The study by Muresanu et al. (2016)) had a large sample size and was a multi-center trial with
high methodological quality. The study found that cerebrolysin in combination with
physical/occupational therapy was superior to placebo with physical/occupational therapy for improving
upper limb motor function, based on the Fugl-Meyer Assessment (Muresanu et al., 2016). The other
study by Chang et al. (2016), which also had a moderately large sample size, found that cerebrolysin
with conventional therapy improved upper limb motor function and dexterity through the Action
Research Arm Test, and also that it improved measures of independence/ daily living through
improvements on the Barthel Index and the Modified Rankin Scale.
Conclusions Regarding Cerebrolysin
There is level 1a evidence that Cerebrolysin improves upper limb motor function.
There is level 1b evidence that Cerebrolysin improves dexterity and measures of independence/daily
living.
Cerebrolysin may improve upper limb motor function, dexterity, and measures of
10.9.8 Neuroprotectants
NeuroAid is made of 9 herbal and 5 animal components and is widely used after stroke in China, as it is
believed to protect neurons and encourage plasticity (Kong et al., 2009).
The mechanism behind the possible action of Phosphodiesterase-5 Inhibitor (PF-3049423) is unknown
but it has been suggested that it may upregulate neurogenesis, synaptogenesis, angiogenesis, and
improve regional blood flow (Di Cesare, Mancuso, Woodward, Bednar, & Loudon, 2016).
The studies examining the effectiveness of neuroprotectants including NeuroAid and PF-3049423 are
Table 10.10.8.1 Summary of Controlled Trial(s) Examining Neuroprotectant Use in Stroke Recovery
Sample Size
Kong et al. (2009) E: NeuroAid • Fugl Meyer Score (-)
RCT (8) C: Placebo • NIHSS (-)

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N=40 • FIM (-)
Di Cesare et al. (2016) E: PF-3049423 (phosphodiesterase-5 • Modified Rankin Scale (-)
RCT (6) inhibitor) • Barthel Index (-)
NStart=139 C: Placebo • National Institute of Health Stroke Scale (-)
• Grip Strength (-)
Venketasubramanian et al. E: MLC601 - Chinese Medicine NeuroAid • Modified Rankin Scale (-)
(2015) C: Placebo
Cohort
NStart=880
NEnd=862
Discussion
Both Kong et al. (2009) and Venketasubramanian et al. (2015) investigated the effectiveness of
NeuroAid, and both found that it was no more effective than placebo for improving level of
independence or activities of daily living. Kong et al. (2009) also found that it did not improve upper limb
motor function.
Di Cesare et al. (2016) examined the effectiveness of phosphodiesterase-5 inhibitor, and found that it
did not significantly improve dexterity, grip strength, or level of independence or activities of daily living.
Further studies are required to gain further knowledge regarding the effectiveness of neuroprotectants
and to further understand the mechanism of action.
Conclusions Regarding Neuroprotectants
There is level 1b evidence that NeuroAid does not improve upper limb motor function.
There is level 1b evidence that phosphodiesterase-5 inhibitor does not improve dexterity, grip
strength, or level of independence/daily living.
NeuroAid may not improve upper limb motor function and phosphodiesterase-5 inhibitor may not
improve dexterity, grip strength, or level of independence/daily living.
10.9.9 Statins
Statins are also believed to have a neuroprotective function, and in the table below the effectiveness of
statins are examined.
Table 10.9.9.1 Summary of Controlled Trial(s) Examining Statin Use in Stroke Recovery
Sample Size
Zhang et al. (2017) E: Atorvastatin • Modified Rankin Scale (+)
RCT (6) C: Placebo • Barthel Index (+)
NStart=78
NEnd=75

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Discussion
Only Zhang et al. (2017) explored the effectiveness of statins such as Atorvastatin against a placebo, and
found that Atorvastatin led to improvements in the level of independence/ activities of daily living.
Serum brain-derived neurotrophic factor (BDNF) levels and functional recovery were both assessed.
Conclusions Regarding Statins
There is level 1b evidence that Atorvastatin improves level of independence / activities of daily
living.
Evidence for the use of Atorvastatin for improving outcomes after stroke is limited.
10.10 Alternative and Complementary Medicine

Traditional Chinese Medicine (TCM) includes a variety of treatments including acupuncture, massage
and Chinese herbal medicines. Several studies have been conducted on the use of TCM, mostly in the
acute stage of stroke (Wang et al., 2013). The majority of these studies have been written in the Chinese
language and published in Chinese journals, though Wang et al. (2013) found that institutions in the
United Kingdom are among the top 10 locations of first authors of articles written in English.
10.10.1 Acupuncture
The use of acupuncture has recently gained attention as an adjunct to stroke rehabilitation in Western
countries even though acupuncture has been a primary treatment in China for about 2000 years (Baldry,
2005). In China, acupuncture is an acceptable, time-efficient, simple, safe and economical form of
treatment used to ameliorate motor, sensation, verbal communication and further neurological
functions in post-stroke patients,” (Wu et al., 2002). According to Rabinstein and Shulman (2003),
“Acupuncture is a therapy that involves stimulation of defined anatomic locations on the skin by a variety
of techniques, the most common being stimulation with metallic needles that are manipulated either
manually or that serve as electrodes conducting electrical currents”. The traditional concept is that life
energy flows through channels that connect all organs to each other. Disease is explained as an
imbalance in the energy flow, and acupuncture treatment is believed to restore the healthy energy by
stimulating specific points along the channels (Rabinstein & Shulman, 2003). There is a range of possible
acupuncture mechanisms that may contribute to the effects experienced by stroke patients (Park,
James, & White, 2006). For example, acupuncture may stimulate the release of neurotransmitters (Han
& Terenius, 1982) and have an effect on the deep structure of the brain (Wu et al., 2002). Lo et al.
(2005) established acupuncture, when applied for at least 10 minutes, led to long-lasting changes in
cortical excitability and plasticity even after the needle stimulus was removed. A study using positron
emission tomography (PET) to observe cerebral function after electroacupuncture treatments showed
that glucose metabolism changed significantly immediately after treatment, and after three weeks of
daily electroacupuncture treatments in multiple cerebral motor areas (Fang, Ning, Xiong, & Shulin,
2012). From these results, Fang et al. (2012) concluded that electroacupuncture participated in
modulating motor plasticity.
De Qi is a numbness or tingling sensation experienced by patients and considered to be an important

aspect of TCM. When De Qi is not achieved, it is suggested that the effects of acupuncture are

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diminished. De Qi has been suggested to be a relatively stable predictor of therapeutic effectiveness of
acupuncture for stroke recovery (Bai, Cui, Zou, & Lao, 2013).
While the exact mechanisms are not all well-defined, there are biological responses that occur both at
local areas being stimulated and at remote areas of the body. With respect to stroke rehabilitation, the
benefit of acupuncture has been evaluated most frequently for pain relief and recovery from
hemiparesis. Evidence from several RCTs and meta-analyses shows the effectiveness of acupuncture
remains unclear.
Syndrome differentiation, one of the most important principles of TCM diagnosis and treatment, is a
way of classifying patients’ symptoms and determines the disharmony in the body and consequent
treatment. A meta-analysis of an acute stroke subgroup of 44 RCTs showed no differences between
trials using fixed acupoints prescriptions and trials using individualized treatment prescriptions based on
patients’ symptoms (Cao, Bourchier, & Liu, 2012).
Sze et al. (2002) included 14 RCTs in a meta-analysis of the efficacy of acupuncture. This study found
that acupuncture in conjunction with stroke rehabilitation had no additional effect on motor recovery
compared to stroke rehab alone, but small positive effect on disability was found. However, it was noted
that the benefits reported could be explained by a placebo effect, or poor study quality. Similar to the
previous reviews, the authors concluded that the efficacy of acupuncture alone remains uncertain,
mainly because of the poor quality of available studies.
A review of the effectiveness of acupuncture as a specific treatment for shoulder pain included the
results from 7 RCTs, all published in China (J. A. Lee et al., 2012). The treatment contrasts included
acupuncture + exercise vs. exercise, acupuncture + exercise vs. drug treatment, acupuncture + exercise
vs. exercise + drug treatment and electroacupuncture vs. TENS. Duration of treatment ranged from 10
to 32 days. Measures of motor function, range of motion and pain were assessed. Across the studies,
patients in the treatment group reported significantly greater reductions in pain and improvement in
motor function compared with patients in the control group.
A large number of studies examining acupuncture were identified, although a number of RCTs not
included in this review were published in non-English languages. The methodological quality of the RCTs
are generally poor (Zhao, Du, Liu, & Wang, 2012), leading to inconclusive evidence. The results of RCTs
with PEDro scores greater than 3 are presented in Table 10.11.1.1.
Table 10.11.1.1 Summary of RCTS with PEDro Scores >3 Assessing Acupuncture for the Upper
Extremity
PEDro Score Result
Sample Size
Wayne et al. (2005) E: Acupuncture • Fugl-Meyer (-)
RCT (9) C: Sham • Modified Ashworth scores (-)
N=33 • ROM (-)
• BI (-)
Bai et al. (2013) E1: Acupuncture • Fugl Meyer Assessment (-),
RCT (9) E2: Physical therapy • Fugl-Meyer Assessment (28d follow-up, E1
NStart=120 E3: Acupuncture + physical therapy vs. E2) (+)
• Modified Barthel Index (28d follow-up, E1
vs. E2) (+)

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Chen et al. (2016) E: Acupuncture • National Institute of Health Stroke Scale (+)
RCT (8) C: Not specified • Fugl-Meyer Assessment (+)
NStart=250
NEnd=250
Zhuangl et al. (2012) E1: Acupuncture • Fugl-Meyer (-)
RCT (7) E2: Physiotherapy • BI (-)
N=295 E3: Acupuncture + physiotherapy • Neurologic Defect Scale (-)
Gosman-Hedstom et al. (1998) E1: Superficial acupuncture At 3 and 12 month follow-up:
RCT (7) E2: Deep acupuncture • Neurological Score (-)
N=104 C: No acupuncture • Barthel Index (-)
• Sunnaas Index (-)
• Nottingham Health Profile (-)
Sze et al. (2002) E: Acupuncture + Standard Therapy At 0, 5 and 10 weeks:
RCT (7) C: Standard Therapy • Fugl-Meyer (-)
• FIM(-)
• Abbreviated Mental Test (-)
• NIH stroke scale(-)
Hopwood et al. (2008) E: Acupuncture + usual care • Barthel Index (-)
RCT (7) C: Mock TENS + usual care • Motricity Index (-)
N=105 • NHP (-)
Ni et al. (2013) E: Standard Acupuncture with Shixuan & • Finger grip strength (+)
RCT (7) Xiaohai acupoints • Fugl Meyer Assessment (+)
NStart=165 C: Standard Acupuncture only
NEnd=165
Liu et al. (2016) E: Manual acupuncture + standard care • National Institute of Health Stroke Scale (-)
RCT (6) C: Standard care • Fugl-Meyer Assessment (-)
NStart=38 • Functional Independence Measure (-)
NEnd=31 • Barthel Index (-)
• Modified Ranking Scale (-)
Han et al. (2015) E: Meridian sinew row needling • Fugl-Meyer Assessment (+)
RCT (6) combined with dermal needling • Modified Ashworth Scale (+)
NStart=488 C: Cerebroprotein hydrolysate and
NEnd=488 piracetam injections
Fragoso & Ferreira (2012) E1: Acupuncture at Tianquan (PC2) • Maximal Isometric Voluntary Contraction
RCT (6) E2: Acupuncture at Quchi (LI11) during elbow flexion (-)
N=32
Alexander et al. (2004) E: Acupuncture + Standard Rehabilitation • Fugl-Meyer (-)
RCT (6) C: Standard Rehabilitation • FIM (-)
N=32
Kjendhal et al. (1997) E: Acupuncture • Motor Assessment Scale (+)
RCT (6) C: Standard Therapy • Sunnaas Index (+)
N=41 • Nottingham Health Profile (+)
Naeser et al. (1992) E: Acupuncture • Boston Motor Inventory (+ for patients with
RCT (6) C: Sham Acupuncture lesions in less than half of the motor
N=16 pathways areas)
Cui et al. (2014) E: Yin Yang manipulation • Elbow spasm (+)
RCT (6) C: Conventional needling manipulation • Clinical Spasticity Index (+)
NStart=60 • Integral electric discharge of involved
NEnd=60 muscle (+)

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Song et al. (2016) E: Scalp cluster acupuncture + constraint- • Fugl-Meyer Assessment (-)
RCT (5) induced movement therapy
NStart=30 C: Body acupuncture + traditional
NEnd=30 rehabilitation
Zhao et al. (2009) E: Experimental acupuncture • Spasticity (+)
RCT (5) C: Traditional acupuncture • Fugl-Meyer (+)
N=131 • Barthel Index (+)
Sallstrom et al. (1996) E: Acupuncture + Multidisciplinary • Motor Assessment Scale (+)

RCT (5) rehabilitation • ADL scores (+)
N=45 C:Multidisciplinary rehabilitation • Nottingham Health Profile (+)
Hu et al. (1993) E: Acupuncture • Neurological Scoring used by Scandinavian
RCT (4) C: Supportive Therapy + Conventional Stroke Group: day 28 (+)
N=30 Rehabilitation • Neurological Scoring used by Scandinavian
Stroke Group: day 90 (+)
Li et al. (2015) E: Acupuncture with a twisting angle • Fugl-Meyer Assessment (-)
PCT less than 900 + blood circulation
NStart=14 medication
NEnd=14 C: Blood circulation medication
Discussion
A large number of RCTs were reviewed. The majority of them assessed outcomes associated with motor
recovery, ADLs and spasticity. There was also great variation in the treatment contrasts examined.
The majority of studies investigating the effectiveness of acupuncture for improving upper limb motor
function found that there was no significant benefit to acupuncture when compared to a control
(Alexander et al., 2004; Bai et al., 2013; Li et al., 2015; C. H. Liu et al., 2016; Sze et al., 2002; Wayne et al.,
2005; Zhuangl et al., 2012). Chen et al. (2016) found a significant improvement in upper limb motor
function in those receiving acupuncture, although the therapy that the control group received was not
specified. Ni et al. (2013) found a significant improvement in upper limb motor function in those
receiving standard acupuncture with Shixuan & Xiaohai acupoints, as opposed to standard acupuncture
alone. Additionally, Han et al. (2015) found a significant improvement in upper limb motor function in
those receiving Meridian sinew row needling combined with dermal needling in comparison to those
receiving Cerebroprotein hydrolysate and piracetam injections.
All studies of high methodological quality investigating the improvement in level of independence and
activities of daily living between those receiving acupuncture and those receiving a control found that
there was no significant difference (Alexander et al., 2004; Bai et al., 2013; Gosman-Hedstrom et al.,
1998; Hopwood et al., 2008; C. H. Liu et al., 2016; Wayne et al., 2005; Zhuangl et al., 2012).
Wayne et al. (2005) used a previously validated form of acupuncture that allows for successful patient
blinding to treatment (Wayne et al., 2005). Although there were statistically significant results in favour
of acupuncture treatment on a per protocol basis, a small sample size, ambiguous findings, and negative
significance on ITT analysis effect the interpretation of results. The choice of outcome measure (Barthel
Index) could be criticized as being unresponsive to subtle improvements in upper limb function.
The lack of an appropriate control treatment adds to the inconsistent effects of acupuncture. That is,
does acupuncture itself provide therapeutic benefits or are its therapeutic benefits revealed only as an

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additive benefit to physiotherapy? A high-quality RCT conducted by Bai et al. (2013) revealed no
significant differences between acupuncture, physical therapy, and a combination of both after 28 days
of therapy. However, at 56 days of therapy, Fugl-Meyer Assessment and Modified Barthel Index (MBI)
scores were significantly higher in the physiotherapy group compared to the acupuncture group, but no
differences were observed between both of these groups and the combined
physiotherapy+acupuncture group. Although the authors highlight that all three groups improved over
time, acupuncture may not be as efficacious as physiotherapy. A similar study conducted by Zhuangl et
al. (2012) did not find any significant differences in FMA and MBI scores between all three groups after
14 and 28 days of therapy. The authors suggest that as physiotherapy did not result in significantly
greater gains or improvements; acupuncture may be an equivalent alternative and could be a useful
option for individuals who do not have access to a physiotherapist or the equipment required for
physiotherapy. A combination of the two therapies did result in a favourable trend but this did not reach
statistical significance. Zhuangl et al. (2012) suggest that future research should concentrate on longer
follow-up times to assess for potential long-term benefits.
Credible sham treatments are required in order to effectively evaluate the benefits of acupuncture. For
example, studies such as those by Chen et al. (2016) may find positive improvements in the group
receiving acupuncture on measures of upper limb motor function, however, the therapy the control
group received, if received, is not specified. Zhuangl et al. (2012) point out that sham acupuncture may
or may not have a physiological effect with previous research suggesting no differences between “sham”
and “real” acupuncture. Also, as reported by the literature, several different methods of acupuncture
have been used including classical Chinese acupuncture (Kjendahl et al., 1997; Sallstrom et al., 1996),
and electroacupuncture (R.L. Hsieh, L.Y. Wang, & W.C. Lee, 2007; Johansson et al., 2001; S.K. Moon et
al., 2003; M. Mukherjee, L.K. McPeak, J.B. Redford, C. Sun, & W. Liu, 2007; Q.M. Si, G.C. Wu, & X.D. Cao,
1998; Wong, Su, Tang, Cheng, & Liaw, 1999). Furthermore, different acupoints may be influential as Ni
et al. (2013) reported significantly greater improvements in finger-grip strength and FMA scores among
patients who received additional acupuncture of the Shixuan and Xiaohai points, associated with blood
flow, and the medial antebrachial cutaneous nerve and ulnar nerve stem respectively. A distinction
between the different methods and their intended effects needs to be addressed. Third, Hu et al. (1993)
have reported that patients with the most severe impairment showed the greatest improvements, the
use of a homogenous sample and evaluation of patient characteristics that would most benefit from
acupuncture is recommended. Again, the lack of consensus regarding what constitutes an appropriate
control for acupuncture therapy makes interpreting these results difficult as subliminal stimulation and
placement of electrodes may produce unspecific responses.
A systematic review conducted by Fu et al.(2012), has suggested that criteria for RCTs may not be
suitable for evaluating studies of TCM and acupuncture. The authors reported issues such as: difficulty in
recruitment, higher costs associated with these studies due to patients’ suspicions of placebo and
unwillingness to take other CHM; lack of standardized terminology; difficulty creating CHM placebo
packets that are similar in smell and appearance; efficacy of Chinese herbal medicines; interventions are
often nonspecific and outcome measures are subjective (Fu et al., 2012). A computed search strategy
conducted by Cai et al. (2012) showed that of 70% of all acupuncture RCTs are published in China, the
number of Chinese RCTs ranking first in the Central Register of Controlled Trials (CENTRAL) and MEDLINE
databases, while only 11% of Chinese RCTs are recognized in the Science Citation Index (SCI). The
authors suggest that the quality of RCTs conducted in China may not be recognized by international
standards, and the quality rather than quantity should be emphasized in future publications.
Conclusions Regarding Acupuncture

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There is level 1a evidence from high-quality, high-powered studies that acupuncture does not
improve upper extremity motor function or performance of activities of daily living.
There is conflicting level 1a evidence regarding the effect of acupuncture on spasticity.
Acupuncture likely does not improve upper limb motor function or level of independence.
10.11.2 Meridian Acupressure

Meridian acupressure is a form of treatment whereby finger pressure is applied to meridian points on
the body. Meridians are either yin or yang, depending on the direction they flow on the body's surface.
The yang meridians run from the fingers to the face or from the face to the feet. Yin meridians run from
the feet to the torso or from the torso to the fingertips on the inside, yin side, of the arms. Theoretically,
acupressure increases blood (qi) flow to the upper extremity, thus improving function. Although used in
clinical practice in eastern parts of the world, only a few studies have examined its use on upper
extremity recovery following stroke, the results of which are summarized in Table 10.11.2.1.
Table 10.11.2.1 Summary of RCTS Assessing Meridian Acupuncture for the Upper Extremity
PEDro Score Result
Sample Size
Yue et al. (2013) E: Acupressure • Barthel Index (+)
RCT (6) C: Routine care • Fugl Meyer Sores (+)
N=78
Hua-feng et al. (2014) E: Yin Yang manipulation • Elbow spasm (+)
RCT (6) C: Conventional needling manipulation • Clinical Spasticity Index (+)
NStart=60 • Integral electric discharge of involved
NEnd=60 muscle (+)
Kang et al. (2009) E: Meridian acupressure • Grip power (+)
RCT (5) C: Standard care • Pain (+)
N=56 • Passive range of motion (+)
Discussion
The results of acupressure appear to be promising for improving upper-limb function and level of
independence in activities of daily living. Yue et al (2013) reported significantly greater improvements in
Barthel Index and Fugl-Meyer Assessment scores in the intervention group compared to a standard care
control group at three months post intervention. However, there was no significant between group
differences at 1 month post intervention, that acupressure requires greater time to demonstrate
treatment efficacy (Yue et al., 2013). Kang et al. (2009) also reported significant gains in upper extremity
range of motion, grip strength, and a reduction in pain following meridian acupressure compared to
standard care. Hua-feng et al. (2014) investigated the therapeutic efficacy of balancing yin-yang
manipulation with conventional needling manipulation, and reported significant between-group
differences, favouring balancing yin-yang manipulation, on outcomes of upper extremity function,
including spasticity and electromyography. The mechanisms as to why acupressure may be efficacious
for the improvement of upper limb function remains unclear, Yue et al. (2013) suggest that the
stimulation of acupoints may assist in the releasing of neurohormones and neurotransmitters, and could
potentially generate electromagnetic signals. It has also been postulated that acupressure may stimulate

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the release of endorphins, thereby reducing pain (Kang et al., 2009). Further research is required to
assess the efficacy of acupressure and to investigate the potential hormonal reactions in order to bring
clarity to the mechanisms underlying this intervention.
Conclusions Regarding Meridian Acupressure
There is level 1a and limited level 2 evidence that meridian acupressure may improve spasticity,
upper limb motor function, range of motion of the upper limb, and performance of activities of daily
living.
Limited evidence indicates a potential benefit of meridian acupressure on upper limb motor
function, performance of activities of daily living, and pain post-stroke.
10.11.3 Traditional Chinese Herbal Medicine (TCHM)

Traditional Chinese Herbal Medicine (TCHM) has been used routinely in China for the past 30 years in
the treatment of ischemic stroke, despite a lack of empirical evidence investigating its safety and
effectiveness. Traditional medicines may help to promote stroke recovery by reducing cerebral edema,
dilating cardiocerebral vessels, inhibiting the aggregation of platelets, improving circulation and
enhancing ischemic reperfusion injury (Sze, Yeung, Wong, & Lau, 2005).
Wu et al. (2007) assessed the strength of the existing evidence regrding the 59 TCHMs used following
stroke. Only 22 medicines have been evaluated by either a RCT or controlled trial. The most commonly
evaluated medicines were: Milk vetch, Mailuoning, Ginko biloba, Danshen agents, Xuesetong, Puerarin
and Acanthopanax. The use of TCHM was not associated with an improvement in the odds of death or
dependency (OR=0.86, 95% CI, 0.35 to 2.11); however, there was an increase in the odds of neurological
deficit improvement after treatment (OR= 3.93, 95% CI3.14 to 3.65), although the methodological
quality of the trials was generally poor. Only 3 RCTs were described as being definitively randomized,
double-blind and placebo controlled.
Dan Shen is one of the most widely used forms of TCHM. It comes from the root of the plant Salvia
militorrhiza. An updated Cochrane review identified six RCTs that compared Dan Shen to a placebo or
open placebo control following ischemic stroke (B. Wu et al., 2007). After two weeks of therapy Dan
Shen compounds were associated with significant neurological improvements (OR=3.02, 95% CI 1.73 to
5.26). No deaths were reported. However, the quality of the trials was poor and too few patients were
included to provide reliable estimates of the treatment effect. The authors of the review recommended
that additional high-quality RCTs need to be performed.
Pooled analysis of modified Edinburgh-Scandinavian Stroke Scale (MESSS) scores and TNA-α levels in a
systematic review on Qingkailing, an acclaimed famous CHM to treat cerebrovascular conditions,
suggested Qingkailing to be beneficial for patients with ischemic stroke when combined with
conventional treatment (Cheng et al., 2012). However, no significant difference in terms of mortality
between the two groups.
The results of RCTs evaluating CHM are summarized in Table 10.11.3.1.
Table 10.11.3.1 Summary of RCTS Assessing Traditional Chinese Herbal Medicine for the Upper
Extremity

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PEDro Score Result
Sample Size
Chen et al. (2012) E: Astalagus Membranaceus • FIM (+)
RCT (9) C: Placebo • Barthel Index (-)
N=68 • Modified Rankin Scale (-)
Goto et al. (2009) E: Tokishakuyakusan • Stroke Impairment Assessment Scale (+)
RCT (6) C: No treatment • FIM (+)
N=31
Yu et al. (2015) E: Di Huang Yin Zi (DHYZ) Herbal Drug • Barthel index (+)
RCT (4) + physio/occupational therapy • Fugl-Meyer Assessment (+)
NStart=100 C: Placebo + physio/occupational
NEnd=87 therapy
Discussion
Tokishakuyakusan was associated with prevention of worsening impairment and disability in the chronic
phase of stroke among a small sample of elderly (> 80 years) stroke patients living in an institution (Goto
et al., 2009). The mechanism through which benefit is conferred is not well-understood. Based on
previous studies, Goto et al. (2009) suggest that the anti-oxidant, antiplatelet and muscle weakness
amelioration properties of Tokishakuyakusan which may contribute towards potential positive
outcomes. It is also believed to be neuroprotective and may enhance the synthesis and release of
neurotransmitters including acetylcholine, dopamine and norepinephrine.
The Chinese herb Astragalus membranaceus (AM) has anti-inflammatory and antioxidatative properties
which are thought to help reduce brain edema if administered within the first few hours following
stroke onset, thereby helping to improve functional recovery. The results from one small, but
methodologically rigorous study indicate there is emerging evidence to support that this treatment may
be effective following hemorrhagic stroke. Chen et al. (2012) reported significantly higher FIM gains
among those taking AM which may have been the result of decreased inflammation; however, no
differences in Barthel Index or Modified Rankin Scale were observed when compared with a placebo
group.
Di Huang Yin Zi (DHYZ) is a herbal drug was shown in a study by Yu et al. (2015) to improve upper limb
motor function and level of independence in comparison to a placebo.
Conclusions Regarding Traditional Chinese Herbal Medicine
There is level 1b conflicting evidence regarding the effectiveness of Astralagus Membranaceus for
improving functional independence and performance in activities of daily living after hemorrhagic
stroke.
There is level 1b evidence that Tokishakuyakusan improves functional independence and

performance in activities of daily living in the chronic stage of stroke.
Limited evidence regarding the use of Traditional Chinese Herbal Medicine suggests potential
benefits of improved functional independence after stroke.

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10.11.4 Massage Therapy
“Massage is the practice of applying structured pressure, tension, motion or vibration — manually or
with mechanical aids — to the soft tissues of the body, including muscles, connective tissue, tendons,
ligaments, joints and lymphatic vessels, to achieve a beneficial response. As a form of therapy, massage
can be applied to parts of the body or successively to the whole body, to heal injury, relieve
psychological stress, manage pain, and improve circulation. Where massage is used for its physical and
psychological benefits, it may be termed "therapeutic massage therapy" or manipulative therapy.”
Massage is among the most frequently used alternative nursing interventions and has been used as a
complementary form of treatment following stroke (Holland & Pokorny, 2001). Several studies have
evaluated the efficacy of massage therapy; the results of the controlled trials are summarized in Table
10.11.4.1.
Table 10.11.4.1 Summary of Controlled Trials Assessing Massage Therapy for the Upper Extremity
PEDro Score Result
Sample Size
Yang et al. (2016) E: Chinese massage therapy • Fugl-Meyer Assessment (-)
RCT (8) C: Placebo • Modified Barthel Index (-)
NStart=90
NEnd=79
Thanakiatpinyo et al. (2014) E: Thai massage • Modified Ashworth Scale (-)
RCT (7) C: Physical therapy • Barthel Index (-)
NStart=50 • Anxiety and depression scores (-)
NEnd=45 • Quality of life (-)
Fox et al. (2006) E: Marma therapy • Motricity Index: 6wk (+), 12wk (+)
PCT C: Standard care • Nine Hole Peg Test: 12 wk (+ for control)
N=30
Van der Riet et al. (2015) E: Hot compression + thai massage + • Barthel Index (+)
PCT strength training • Visual Analog Scale (-)
NStart=40 C: Education
NEnd=40
Discussion
Yang et al. (2016) found that Chinese massage therapy did not improve upper limb motor function or
performance on activities of daily living when compared to those receiving a placebo.
Thanakiatpinyo et al. (2014) investigated the use of traditional Thai massage compared with physical
therapy and reported no differences between groups in regards to quality of life, spasticity, or level of
independence. Although the findings are promising, it should be noted that both upper and lower
extremity limbs were treated and evaluated without stratification, therefore future research should
investigate Thai massage with a focus on upper extremity function.
Van der Riet et al. (2015) found that those receiving a hot compression, thai massage, and strength
training had improved Barthel Index scores compared to those only receiving education alone. This
suggests that hot compression with thai massage and strength training may improve performance of
activities of daily living, although further studies are needed to confirm this observation.

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Fox et al. (2006) was the only study that reported on the effectiveness of Marma therapy, a stroke-
specific form of massage therapy. The Marma therapy group demonstrated significantly greater
Motricity Index scores, indicating improvement in upper limb function. However, outcomes measuring
hand dexterity using the 9-Hole Peg Test were found to be in favour of the control group. Further
research regarding Marma therapy is warranted.
Conclusions Regarding Massage Therapy
There is level 1a evidence that Chinese or Thai massage therapy does not improve functional
independence or performance on activities of daily living.
There is level 1b evidence that Chinese or Thai massage therapy does not improve upper limb motor
function, spasticity, or quality of life.
Massage Therapy likely does not improve functional independence, spasticity, hand dexterity, or
quality of life after a stroke.
10.11.5 Cupping
Cupping therapy is a technique which uses glass or plastic cups to create localized pressure by a vacuum.
The vacuum inside the cups causes blood to form within the underlying area, which helps with healing in
that area. Cupping is used most frequently for lower back pain. There are two types of cupping - wet and
dry. In dry cupping, a vacuum is created which pulls the skin into the cup. In wet cupping, the skin is
lacerated such that blood is drawn into the cup. Cupping is believed to help release harmful toxins by
triggering the lymphatic system, and clearing the blood vessels.
A systematic review including the results from 5 studies (3 RCTs and 2 uncontrolled trials), all originating
from China, examined the use of cupping in stroke rehabilitation (Lee, Choi, Shin, Han, & Ernst, 2010).
Both wet and dry cupping were used as a treatment for painful shoulder, hand edema, upper limb
myodynamia, aphasia, and hiccup following stroke, with acupuncture as the control condition in the
RCTs.. Although there was a benefit of treatment with respect to shoulder pain intensity and range of
motion and reduction of myodynamia, the authors concluded that there was insufficient evidence to
support the effectiveness of cupping treatment.
10.11 Treatment of Hand Edema

Hand edema following stroke with hemiparesis is associated with pain and stiffness, which can lead to a
decrease in active motion and disuse. Hand edema may be an isolated problem or occur as a symptom
of shoulder-hand syndrome. The etiology of the development of hand edema is unclear. The most
widely accepted explanation is that of increased venous congestion related to prolonged dependency
and loss of muscle pumping function in the paretic limb (Leibovitz et al., 2007).
Diagnosis is difficult and depends, in part, on the method of assessment. Estimates of the incidence of
hand edema vary widely. Tepperman et al. (1984) reported that 83% of 85 acute stroke patients
suffered from hand edema not associated with shoulder-hand syndrome. More recently, Post et al.
(2003) reported that based on volumetric assessments, 33% of 96 stroke patients had hand edema,
compared to 50% of patients assessed through clinical evaluation. Volumetric assessments of the hand

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appear to provide the best estimation; while the reliability of clinical evaluation through visual
inspection is poor. A change of 12 mL or more is considered clinically significant (Post et al., 2003).
Using data from the same patient group as Post et al. (2003), Boomkamp-Koppen et al. (2005) reported
a significant correlation between the presence of hand edema and measures of hand function (as
measured by the Frenchay arm test). Patients without hand edema were more likely to have good hand
function. Significant predictors of hand function following stroke included the degree of motor
impairment, hypertonia, tactile inattention, and edema. In contrast, Gebruers et al. (2011) reported
finding no relationship between activity limitations and the presence of edema in a cohort of 130 acute
stroke patients followed over a period of 3 months. There were no statistically significant differences on
a variety of clinical indications, including stroke severity and Fugl-Meyer Scale scores between the group
of patients who developed edema and those who did not. The authors concluded that the theory
suggesting that disuse in the paretic limb is the major cause of the development of hand edema is
unlikely to be true. The incidence of edema was also lower in this study.
Leibovitz et al. (2007) compared the circumference of the hand in three places (mid-finger, hand and
wrist) among subjects post stroke (m=188) and non-paretic institutionalized controls (n=70). Hand
edema was detected in 37% of post stroke subjects compared with only 2% of control subjects.
Three different treatment approaches to aid in the reduction of hand edema following stroke have been
studied, including passive range of motion exercises, neuromuscular stimulation and intermittent
pneumatic compression. The results of a single RCT are presented in table 10.12.1.
Table 10.12.1 Summary of RCT(s) Assessing Treatments for Hand Edema

PEDro Score Result
Sample Size
Roper et al. (1999) E: Intermittent pneumatic compression + • Motricity index (-)
RCT (5) standard physiotherapy • Hand volume (-)
N=37 C: Standard physiotherapy
+ Indicates a statistically significant difference between treatment groups
- Indicates a non-statistically significant difference between treatment groups
Discussion
Only one low-scoring RCT has been completed on the treatment of hand edema. Intermittent pneumatic
compression combined with standard physiotherapy did not add any value when compared to standard
physiotherapy alone according to hand volume and Motricity Index scores although greater
improvements favoured the combined treatment group (Roper et al., 1999). One possible explanation
was the working pressure of 50mmHg, 4 hours a day, was not sufficient for a treatment effect given that
previous research used pressures of 80 to 130mmHg (Roper et al., 1999). However, the authors note
that higher pressure can lead to discomfort. Further research is required to determine the efficacy of
pneumatic compression but at the present, Roper et al. (1999) suggest this method not be
recommendable in treating hand edema.
Conclusions Regarding Intermittent Pneumatic Compression for Hand Edema
There is level 1b evidence that intermittent pneumatic compression does not reduce hand edema or
strength in the upper extremity following stroke.

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Intermittent pneumatic compression does not appear to reduce hand edema or improve upper limb
strength post stroke.

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Summary
1. There is consensus opinion that in severely impaired upper extremities (less than stage 4) the
focus of treatment should be on compensation.
2. For those upper extremities with signs of some recovery (stage 4 or better) there is consensus that
attempts to restore function through therapy should be made.
3. There is level 1a evidence that neurodevelopmental techniques are not superior to other
therapeutic approaches.
4. There is level 1b evidence that when compared to the Bobath treatment approach, Motor
Relearning Programme may be associated with improvements in short-term motor functioning,
shorter lengths of hospital stay and better movement quality.
5. There is level 1b evidence that Brunnstrom hand manipulation treatment is preferable over a
motor relearning program.
6. There is level 1a evidence that bilateral training is not more effective than unilateral training for
7. There is level 1a evidence that bilateral training is not more effective than conventional therapies
such as modified constraint induced movement therapy and cutaneous electrical stimulation.
8. There is level 1a evidence that bilateral arm training with rhythmic auditory cueing (BATRAC) is
not more effective than unilateral arm training.
9. There is level 1a evidence that arm function training, task practice, and strength training provide
significant functional improvements in the arm after stroke in comparison to similar leg training.
10. There is level 1a evidence that additional upper limb therapy is not superior to conventional
therapy at improving upper extremity motor function or functional independence.
11. There is level 1b evidence that a therapist-supervised in-home program is not more effective than
usual care at improving upper limb motor function.
12. There is level 1a evidence from a meta-analysis that strength training increases grip strength
following stroke.
13. There is level 1a evidence that strength training improves upper limb motor function and shoulder
range of motion.
14. There is level 1a evidence that task-related practice may be superior to conventional training at
improving upper extremity motor function.
15. There is level 1b evidence that task-related training may not be superior to resistive training or
bilateral arm training at improving general upper limb motor function; however, it may improve
reaching arm movements.
16. There is level 1b evidence that combining task practice with active stimulation may improve
manual dexterity and reaction time.

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17. There is conflicting level 1a evidence regarding the efficacy of trunk restraint therapy on upper
extremity function when combined with constraint induced movement therapy or delivered
alone.
18. There is level 1a evidence that transcutaneous electrical nerve stimulation (TENS) improves upper
19. There is level 1a evidence that focal or whole-body vibration therapy improves upper limb motor
function.
20. There is level 1a evidence that peripheral nerve/afferent stimulation does not significantly
improve overall upper limb motor function.
21. There is level 1a evidence that mesh glove therapy improves motor function and dexterity based
on the Box and Block test.
22. There is level 1b evidence that thermal stimulation is effective for upper limb motor function.
23. There is level 1a evidence that electroacupuncture is not more effective than an active control for
24. There is level 1a evidence that mental practice therapy is effective for improving upper extremity
motor function; however, the evidence for its effect on activities of daily living is limited and
conflicting.
25. There is level 1a evidence that motor imagery is not effective for improving upper extremity
motor function.
26. There is level 1a that hand splinting/taping/orthoses do not improve upper extremity motor
function.
27. There is level 1b and level 2 evidence that there is no benefit of CIMT in the early stage of stroke
for improving upper limb motor function or dexterity.
28. There is level 1a evidence that CIMT in the chronic phase of stroke may help improve upper
extremity motor function. The evidence regarding the ideal frequency of CIMT is currently
unclear.
29. There is level 1a evidence that mCIMT in the early phase of stroke may improve adaptation
strategies as it optimizes already preserved function. However, mCIMT does not improve
neurological impairment in the early stage of stroke.
30. There is level 1a evidence that mCIMT in the chronic phase of stroke may improve upper limb
function relative to conventional therapy.
31. There is level 1a evidence that mirror therapy improves upper limb motor function following
stroke, especially for the wrist and hand.
32. There is level 1b evidence that Mirror therapy in combination with conventional therapy is not
superior to the Bobath method for upper limb motor function.

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33. There is conflicting level 1a evidence regarding the effect of mirror therapy on spasticity.
34. There is level 1a evidence that feedback is effective for improving upper limb motor function, and
that it is ineffective for improving spasticity.
35. There is conflicting level 1a evidence regarding the effect of action observation on upper motor
function.
36. There is level 1b evidence that action observation with brain-computer interface-based functional
electrical stimulation is effective for improving upper limb motor function.
37. There is level 1a and level 1b evidence that music therapy can improve some aspects of upper
extremity motor function but not muscle strength when compared to conventional rehabilitation.
38. There is level 1a evidence that telerehabilitation interventions are not effective for improving
39. There is conflicting evidence regarding the effectiveness of additional exercise therapy for
40. There is level 1a and 2 evidence in the acute phase and level 1a evidence in the chronic phase that
MIT-Manus/InMotion therapies are no more effective than a control for improving upper limb
motor function in the chronic phase.
41. There is level 2 evidence that Mirror-Image Motion Enabler Robots (MIME) are effective in the
acute phase, level 2 evidence that (MIME) are not effective in the subacute phase, and level 1a
conflicting evidence for the effectiveness in the chronic phase for improving upper limb motor
function.
42. There is conflicting level 1b and 2 evidence for the use of ARMin during the chronic phase for
43. There is level 2 evidence that ARM Guide is not effective for improving upper limb motor function.
44. There is level 1b evidence during the acute phase that Bi-Manu-Track is not effective, level 1a
conflicting evidence for the subacute phase, and level 1a evidence during the chronic phase that
Bi-Manu-Track is effective for improving upper limb motor function.
45. There is conflicting level 2 evidence for the use of NeReBot during the acute phase, and level 1b
evidence that NeReBot is not effective during the chronic phase for improving upper limb motor
function.
46. There is level 2 evidence that Continuous Passive Motion (CPM) is not effective during the acute
phase, and there is level 2 evidence that CPM is effective during the chronic phase for improving
47. There is level 1a evidence that the use of GENTLE during the chronic phase is not effective for

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48. There is level 1b evidence that the use of Amadeo during the acute phase is effective, while there
is level 1b evidence that the use of Amadeo during the chronic phase is not effective for improving
49. There is conflicting level 1a evidence regarding the effectiveness of MusicGlove during the chronic
phase.
50. There is level 1a evidence that virtual reality does not improve upper limb motor function in the
chronic stroke phase.
51. There is level 1a evidence that computer brain interface technology is not effective for improving
upper limb motor function post-stroke.
52. There is level 1a evidence that splinting does not reduce the development of contracture nor
reduce spasticity in the upper extremity.
53. There is level 1b evidence that a nurse-led stretching program may improve range of motion in
the upper extremity and reduce pain in the chronic stage of stroke.
54. There is level 1b and 2 evidence that a hand stretching device may improve spasticity in the upper
limb.
55. There is level 1a evidence that treatment with botulinum toxin significantly reduces spasticity in
the upper extremity in stroke survivors.
56. There is level 1a evidence that treatment with botulinum toxin does not improve upper limb
motor function.
57. There is level 1a evidence that electrical stimulation combined with botulinum toxin injection is
associated with reductions in spasticity.
58. There is level 1b evidence that modified constraint induced movement therapy combined with
botulinum toxin injection is associated with reductions in spasticity.
59. There is level 4 evidence that nerve blocks with ethyl alcohol improves elbow and finger passive
range of motion and can decrease spasticity in the upper extremity in stroke survivors.
60. There is level 1a evidence that physical therapy may not improve motor function or contracture.
61. There is level 1a evidence that neuromuscular electrical stimulation does not reduce wrist or
elbow spasticity.
62. There is level 1a evidence that extracorporeal shock wave therapy improves upper limb spasticity.
63. There is level 1b evidence that tolperisone can reduce spasticity following stroke.
64. There is level 1a evidence that EMG/biofeedback therapy does not improve upper extremity
motor function or spasticity.
65. There is level 1a and level 2 evidence that FES/NMES may improve upper limb motor function,
range of motion, and manual dexterity when offered in combination with conventional therapy or

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delivered alone in subacute stroke. The evidence is also indicative of a beneficial effect on range
of motion and manual dexterity when FES/NMES was offered to chronic stroke patients either
alone or in combination with other therapies.
66. Despite improvements in both stages of stroke recovery, level 1b evidence indicates that
delivering FES early (<6 months) may be more beneficial at recovering impaired motor function
than delivering FES after 6 months post-stroke.
67. There is level 1b evidence that EMG-NMES in the subacute phase is not more effective than usual
care for patients with an unfavourable prognosis based on voluntary finger extension.
68. There is level 1a evidence that high intensity NMES or FES exercise is no more effective for
improving upper limb motor function than low intensity NMES or FES in the subacute phase.
69. There is level 1a and level 2 evidence that both EMG-triggered and cyclic approaches to
NMES/electrical stimulation may improve upper limb motor function and range of motion in
subacute and chronic stroke patients; however, evidence indicates no superior benefit of EMG-
triggered NMES over cyclic or passive NMES at improving upper limb motor function in chronic
(level 1a) and subacute (level 1b) stroke patients.
70. There is level 1b evidence that Contralaterally Controlled FES is not superior to cyclic NMES for
improving upper limb motor function, although it may improve dexterity.
71. There is level 1b evidence that coupling continuous NMES with repetitive facilitative exercise may
be beneficial at improving general upper extremity function and range of motion during elbow
extension but not during shoulder or wrist flexion in subacute stroke patients.
72. There is level 1b evidence that high frequency NMEs may be superior to low frequency NMES at
improving endurance of thumb adduction, lateral pinch strength and manual dexterity in chronic
stroke individuals.
73. There is level 1a evidence that motor cortex stimulation does not improve upper limb motor
function.
74. There is level 1b evidence that vagus nerve stimulation can improve overall upper limb motor
function, but not dexterity or grip strength.
75. There is level 1a conflicting evidence regarding the effectiveness of low-frequency (1Hz) rTMS for
the improvement of upper limb motor function and dexterity.There is also level 1a evidence that
inhibiting rTMS does not improve upper limb spasticity when compared to sham stimulation.
76. There is level 1a evidence that high-frequency rTMS (≥5 Hz) improves upper limb motor function,
dexterity, and grip strength when compared to sham stimulation.
77. There is level 1a evidence that there is no significant difference between inhibitory and excitatory
rTMS for improving upper limb motor function or grip strength.
78. There is level 1b evidence that dual rTMS (the combination of both inhibitory and excitatory
rTMS) improves upper limb motor function, but not grip strength when compared to sham
stimulation.

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79. There is level 1b and level 2 evidence that iTBS improves upper limb motor function, but not
dexterity, in the acute or subacute period after stroke.
80. There is conflicting level 1a evidence that iTBS improves upper limb motor function and dexterity
in the chronic phase after stroke. There is level 1b and level 2 evidence that iTBS improves
spasticity in the chronic phase after stroke.
81. There is level 1a evidence that cTBS does not improve upper extremity motor function or dexterity
following stroke.
82. There is level 1a evidence that anodal tDCS does not improve upper limb motor function,
spasticity, or grip strength. There is conflicting level 1a evidence regarding whether anodal tDCS
improves dexterity.
83. There is level 1a conflicting evidence for the effectiveness of cathodal tDCS for improving upper
limb motor function, dexterity grip strength, and activities of daily living.
84. There is level 1a evidence that anodal and cathodal tDCS do not significantly differ on measures
of motor function, dexterity, or on measures of independence/daily living.
85. There is level 1a evidence that dual tDCS (both anodal and cathodal tDCS administered at the
same time) is effective for improving dexterity. There is level 1a conflicting evidence regarding
the effectiveness of dual tDCS for improving grip force.
86. There is level 1b evidence that coupling methylphenidate with tDCS may improve hand function
relative to when tDCS or methylphenidate are delivered alone.
87. There is level 1b evidence that combining tDCS with computer brain interface training may not
improve spasticity or upper extremity motor function.
88. There is level 1a evidence that delivering stimulants in combination with additional therapy may
improve upper extremity function; however, level 1b evidence suggests that grip strength may
not improve.
89. There is Level 1b evidence that stimulants may only be effective at improving impaired upper limb
function in the short term.
90. There is level 1b evidence that Levodopa may not improve arm and hand function however, level
2 evidence suggests that reaction time may be improved.
91. There is level 1a evidence that fluoxetine and nortriptyline may improve overall disability and
upper extremity motor function.
92. There is level 1a that citalopram, reboxetine and lithium carbonate may enhance impaired arm
and hand function however, level 1b evidence indicates that citalopram may not be effective at
improving hand grip strength.
93. There is level 1b evidence that intra-articular steroid injections may not improve pain or range of
motion of the upper extremity; however, limited level 2 evidence provides conflicting findings.

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94. There is level 1b evidence that d-cycloserine delivered in combination with constraint-induced
movement therapy may not improve upper extremity motor function.
95. There is limited level 2 evidence that ozonated autohemotherapy may improve general motor
disability.
96. There is level 1a evidence that Cerebrolysin improves upper limb motor function.
97. There is level 1b evidence that Cerebrolysin improves dexterity and measures of
98. There is level 1b evidence that NeuroAid does not improve upper limb motor function.
99. There is level 1b evidence that phosphodiesterase-5 inhibitor does not improve dexterity, grip
strength, or level of independence/daily living.
100. There is level 1b evidence that Atorvastatin improves level of independence / activities of daily
living.
101. There is level 1a evidence from high-quality, high-powered studies that acupuncture does not
improve upper extremity motor function or performance of activities of daily living.
102. There is conflicting level 1a evidence regarding the effect of acupuncture on spasticity.
103. There is level 1a and limited level 2 evidence that meridian acupressure may improve spasticity,
upper limb motor function, range of motion of the upper limb, and performance of activities of
daily living.
104. There is level 1b conflicting evidence regarding the effectiveness of Astralagus Membranaceus for
improving functional independence and performance in activities of daily living after hemorrhagic
stroke.
105. There is level 1b evidence that Tokishakuyakusan improves functional independence and
performance in activities of daily living in the chronic stage of stroke.
106. There is level 1a evidence that Chinese or Thai massage therapy does not improve functional
independence or performance on activities of daily living.
107. There is level 1b evidence that Chinese or Thai massage therapy does not improve upper limb
motor function, spasticity, or quality of life.
108. There is level 1b evidence that intermittent pneumatic compression does not reduce hand edema
or strength in the upper extremity following stroke.

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References
Abdollahi, F., Case Lazarro, E. D., Listenberger, M., Kenyon, R. V., Kovic, M., Bogey, R. A., . . . Patton, J. L.
(2014). Error augmentation enhancing arm recovery in individuals with chronic stroke: A
randomized crossover design. Neurorehabilitation and Neural Repair, 28(2), 120-128. doi:
10.1177/1545968313498649
Abdullah, H. A., Tarry, C., Lambert, C., Barreca, S., & Allen, B. O. (2011). Results of clinicians using a
therapeutic robotic system in an inpatient stroke rehabilitation unit. J.Neuroeng.Rehabil., 8, 50.
doi: 1743-0003-8-50 [pii];10.1186/1743-0003-8-50 [doi]
Abo, M., Kakuda, W., Momosaki, R., Harashima, H., Kojima, M., Watanabe, S., . . . Sasanuma, J. (2014).
Randomized, multicenter, comparative study of NEURO versus CIMT in poststroke patients with
upper limb hemiparesis: the NEURO-VERIFY Study. International Journal of Stroke, 9(5), 607-612.
doi: 10.1111/ijs.12100
Ackerley, S. J., Byblow, W. D., Barber, P. A., MacDonald, H., McIntyre-Robinson, A., & Stinear, C. M.
(2016). Primed Physical Therapy Enhances Recovery of Upper Limb Function in Chronic Stroke
Patients. Neurorehabil Neural Repair, 30(4), 339-348. doi: 10.1177/1545968315595285
Ackerley, S. J., Stinear, C. M., Barber, P. A., & Byblow, W. D. (2010). Combining theta burst stimulation
with training after subcortical stroke. Stroke, 41(7), 1568-1572. doi: STROKEAHA.110.583278
[pii];10.1161/STROKEAHA.110.583278 [doi]
Adie, K., Schofield, C., Berrow, M., Wingham, J., Humfryes, J., Pritchard, C., . . . Allison, R. (2017). Does
the use of Nintendo Wii SportsTM improve arm function? Trial of WiiTM in Stroke: a randomized
controlled trial and economics analysis. Clin Rehabil, 31(2), 173-185. doi:
10.1177/0269215516637893
Alberts, J. L., Butler, A. J., & Wolf, S. L. (2004). The effects of constraint-induced therapy on precision
grip: a preliminary study. Neurorehabil.Neural Repair, 18(4), 250-258. doi: 18/4/250
[pii];10.1177/1545968304271370 [doi]
Alexander, D. N., Cen, S., Sullivan, K. J., Bhavnani, G., Ma, X., & Azen, S. P. (2004). Effects of acupuncture
treatment on poststroke motor recovery and physical function: a pilot study.
Neurorehabil.Neural Repair, 18(4), 259-267. doi: 18/4/259 [pii];10.1177/1545968304271568
[doi]
Allman, C., Amadi, U., Winkler, A. M., Wilkins, L., Filippini, N., Kischka, U., . . . Johansen-Berg, H. (2016).
Ipsilesional anodal tDCS enhances the functional benefits of rehabilitation in patients after
stroke. Sci Transl Med, 8(330), 330re331. doi: 10.1126/scitranslmed.aad5651
Alon, G., Levitt, A. F., & McCarthy, P. A. (2007). Functional electrical stimulation enhancement of upper
extremity functional recovery during stroke rehabilitation: a pilot study. Neurorehabil.Neural
Repair, 21(3), 207-215. doi: 1545968306297871 [pii];10.1177/1545968306297871 [doi]
Alonso-Alonso, M., Fregni, F., & Pascual-Leone, A. (2007). Brain stimulation in poststroke rehabilitation.
Cerebrovasc.Dis., 24 Suppl 1, 157-166. doi: 000107392 [pii];10.1159/000107392 [doi]
Altenmuller, E., Marco-Pallares, J., Munte, T. F., & Schneider, S. (2009). Neural reorganization underlies
improvement in stroke-induced motor dysfunction by music-supported therapy. Ann N Y Acad
Sci, 1169, 395-405. doi: 10.1111/j.1749-6632.2009.04580.x
Altschuler, E. L., Wisdom, S. B., Stone, L., Foster, C., Galasko, D., Llewellyn, D. M., & Ramachandran, V. S.
(1999). Rehabilitation of hemiparesis after stroke with a mirror. Lancet, 353(9169), 2035-2036.
doi: S0140673699009204 [pii]
Amini, M., Shamili, A., Frough, B., Pashmdarfard, M., & Fallahzadeh Abarghouei, A. (2016). Combined
effect of botulinum toxin and splinting on motor components and function of people suffering a
stroke. Med J Islam Repub Iran, 30, 373.

www.ebrsr.com
Anandabai, J., & Gupta, M. (2013). Effects of bimanual functional practice training versus unimanual
functional practice training on functonal performance of upper extremity in chronic stroke.
Journal of Physiotherapy & Sports Medicine, 2(1), 15-30.
Ang, K. K., Chua, K. S. G., Phua, K. S., Wang, C., Chin, Z. Y., Kuah, C. W. K., . . . Guan, C. (2015). A
Randomized Controlled Trial of EEG-Based Motor Imagery Brain-Computer Interface Robotic
Rehabilitation for Stroke. Clinical EEG and Neuroscience, 46(4), 310-320. doi:
10.1177/1550059414522229
Ang, K. K., Guan, C., Phua, K. S., Wang, C., Zhao, L., Teo, W. P., . . . Chew, E. (2015). Facilitating effects of
transcranial direct current stimulation on motor imagery brain-computer interface with robotic
feedback for stroke rehabilitation. Archives of Physical Medicine and Rehabilitation, 96(3), S79-
S87. doi: 10.1016/j.apmr.2014.08.008
Ang, K. K., Guan, C., Phua, K. S., Wang, C., Zhou, L., Tang, K. Y., . . . Geok Chua, K. S. (2014). Brain-
computer interface-based robotic end effector system for wrist and hand rehabilitation: Results
of a three-armed randomized controlled trial for chronic stroke. Frontiers in Neuroengineering,
7(JUL). doi: 10.3389/fneng.2014.00030
Armagan, O., Tascioglu, F., & Oner, C. (2003). Electromyographic biofeedback in the treatment of the
hemiplegic hand: a placebo-controlled study. Am.J.Phys.Med.Rehabil., 82(11), 856-861. doi:
10.1097/01.PHM.0000091984.72486.E0 [doi];00002060-200311000-00006 [pii]
Arya, K. N., Pandian, S., Kumar, D., & Puri, V. (2015). Task-Based Mirror Therapy Augmenting Motor
Recovery in Poststroke Hemiparesis: A Randomized Controlled Trial. J Stroke Cerebrovasc Dis,
24(8), 1738-1748. doi: 10.1016/j.jstrokecerebrovasdis.2015.03.026
Arya, K. N., Verma, R., Garg, R. K., Sharma, V. P., Agarwal, M., & Aggarwal, G. G. (2012). Meaningful task-
specific training (MTST) for stroke rehabilitation: a randomized controlled trial. Top.Stroke
Rehabil., 19(3), 193-211. doi: 932212059861377R [pii];10.1310/tsr1903-193 [doi]
Au-Yeung, S. S., & Hui-Chan, C. W. (2014). Electrical acupoint stimulation of the affected arm in acute
stroke: a placebo-controlled randomized clinical trial. Clinical rehabilitation, 28(2), 149-158.
Au-Yeung, S. S., Wang, J., Chen, Y., & Chua, E. (2014). Transcranial direct current stimulation to primary
motor area improves hand dexterity and selective attention in chronic stroke. Am J Phys Med
Rehabil, 93(12), 1057-1064. doi: 10.1097/PHM.0000000000000127
Awad, A., Shaker, H., Shendy, W., & Fahmy, M. (2015). Effect of shoulder girdle strengthening on trunk
alignment in patients with stroke. Journal of Physical Therapy Science, 27(7), 2195-2200. doi:
10.1589/jpts.27.2195
Azab, M., Al-Jarrah, M., Nazzal, M., Maayah, M., Sammour, M. A., & Jamous, M. (2009). Effectiveness of
constraint-induced movement therapy (CIMT) as home-based therapy on Barthel Index in
patients with chronic stroke. Top Stroke Rehabil, 16(3), 207-211. doi: 10.1310/tsr1603-207
Bai, L., Cui, F., Zou, Y., & Lao, L. (2013). Acupuncture De Qi in Stable Somatosensory Stroke Patients:
Relations with Effective Brain Network for Motor Recovery. Evidence-Based Complementary and
Alternative Medicine, 2013.
Bakheit, A. M., Pittock, S., Moore, A. P., Wurker, M., Otto, S., Erbguth, F., & Coxon, L. (2001). A
randomized, double-blind, placebo-controlled study of the efficacy and safety of botulinum
toxin type A in upper limb spasticity in patients with stroke. Eur.J.Neurol., 8(6), 559-565. doi: 277
[pii]
Bakheit, A. M., Thilmann, A. F., Ward, A. B., Poewe, W., Wissel, J., Muller, J., . . . Neumann, C. (2000). A
randomized, double-blind, placebo-controlled, dose-ranging study to compare the efficacy and
safety of three doses of botulinum toxin type A (Dysport) with placebo in upper limb spasticity
after stroke. Stroke, 31(10), 2402-2406.
Baldry, P. (2005). The integration of acupuncture within medicine in the UK--the British Medical
Acupuncture Society's 25th anniversary. Acupunct Med, 23(1), 2-12.

www.ebrsr.com
Ballester, B. R., Maier, M., San Segundo Mozo, R. M., Castaneda, V., Duff, A., & PF, M. J. V. (2016).
Counteracting learned non-use in chronic stroke patients with reinforcement-induced
movement therapy. J Neuroeng Rehabil, 13(1), 74. doi: 10.1186/s12984-016-0178-x
Bang, D. H. (2016). Effect of Modified Constraint-Induced Movement Therapy Combined with Auditory
Feedback for Trunk Control on Upper Extremity in Subacute Stroke Patients with Moderate
Impairment: Randomized Controlled Pilot Trial. Journal of Stroke and Cerebrovascular Diseases,
25(7), 1606-1612.
Bang, D. H., Shin, W. S., & Choi, S. J. (2015). The effects of modified constraint-induced movement
therapy combined with trunk restraint in subacute stroke: a double-blinded randomized
controlled trial. Clinical rehabilitation, 29(6), 561-569. doi: 10.1177/0269215514552034
Barclay-Goddard, R. E., Stevenson, T. J., Poluha, W., & Thalman, L. (2011). Mental practice for treating
upper extremity deficits in individuals with hemiparesis after stroke.
Cochrane.Database.Syst.Rev.(5), CD005950. doi: 10.1002/14651858.CD005950.pub4 [doi]
Barecca, S., Bohannon, R., Charness, A., Fasoli, S., Gowland, C., Griffiths, J. A., . . . O'Brien, M. A. (2001).
Management of the post stroke hemiplegic arm and hand: treatment recommendations of the
2001 consensus panel. Heart and Stroke Foundation of Ontario.
Barker, R. N., Brauer, S. G., & Carson, R. G. (2008). Training of reaching in stroke survivors with severe
and chronic upper limb paresis using a novel nonrobotic device: a randomized clinical trial.
Stroke, 39(6), 1800-1807. doi: STROKEAHA.107.498485 [pii];10.1161/STROKEAHA.107.498485
[doi]
Barreca, S., Wolf, S. L., Fasoli, S., & Bohannon, R. (2003a). Treatment interventions for the paretic upper
limb of stroke survivors: a critical review. Neurorehabil.Neural Repair, 17(4), 220-226. doi:
10.1177/0888439003259415 [doi]
Barreca, S., Wolf, S. L., Fasoli, S., & Bohannon, R. (2003b). Treatment interventions for the paretic upper
limb of stroke survivors: a critical review. Neurorehabil Neural Repair, 17(4), 220-226. doi:
10.1177/0888439003259415
Barros GalvÃ£o, S. C., Borba Costa dos Santos, R., Borba dos Santos, P., Cabral, M. E., & Monte-Silva, K. t.
(2014). Efficacy of Coupling Repetitive Transcranial Magnetic Stimulation and Physical Therapy
to Reduce Upper-Limb Spasticity in Patients With Stroke: A Randomized Controlled Trial.
Archives of Physical Medicine & Rehabilitation, 95(2), 222-229. doi: 10.1016/j.apmr.2013.10.023
Barry, J. G., Ross, S. A., & Woehrle, J. (2012). Therapy incorporating a dynamic wrist-hand orthosis versus
manual assistance in chronic stroke: a pilot study. J.Neurol.Phys.Ther., 36(1), 17-24. doi:
10.1097/NPT.0b013e318246203e [doi]
Bartolo, M., De, N. A., Sebastiano, F., Spicciato, F., Tortola, P., Nilsson, J., & Pierelli, F. (2014). Arm weight
support training improves functional motor outcome and movement smoothness after stroke.
Functional Neurology, 29(1), 15-21.
Barzel, A., Ketels, G., Stark, A., Tetzlaff, B., Daubmann, A., Wegscheider, K., . . . Scherer, M. (2015).
Home-based constraint-induced movement therapy for patients with upper limb dysfunction
after stroke (HOMECIMT): a cluster-randomised, controlled trial. The Lancet Neurology, 14(9),
893-902. doi: 10.1016/s1474-4422(15)00147-7
Basaran, A., Emre, U., Karadavut, K. I., Balbaloglu, O., & Bulmus, N. (2012). Hand splinting for poststroke
spasticity: a randomized controlled trial. Top.Stroke Rehabil., 19(4), 329-337. doi:
J6V07232144X6718 [pii];10.1310/tsr1904-329 [doi]
Basmajian, J. V., Gowland, C., Brandstater, M. E., Swanson, L., & Trotter, J. (1982). EMG feedback
treatment of upper limb in hemiplegic stroke patients: a pilot study. Arch.Phys.Med.Rehabil.,
63(12), 613-616.
Basmajian, J. V., Gowland, C. A., Finlayson, M. A., Hall, A. L., Swanson, L. R., Stratford, P. W., . . .
Brandstater, M. E. (1987). Stroke treatment: comparison of integrated behavioral-physical
therapy vs traditional physical therapy programs. Arch.Phys.Med.Rehabil., 68(5 Pt 1), 267-272.

www.ebrsr.com
Bastani, A., & Jaberzadeh, S. (2012). Does anodal transcranial direct current stimulation enhance
excitability of the motor cortex and motor function in healthy individuals and subjects with
stroke: a systematic review and meta-analysis. Clin Neurophysiol., 123(4), 644-657. doi: S1388-
2457(11)00668-7 [pii];10.1016/j.clinph.2011.08.029 [doi]
Batool, S., Soomro, N., Amjad, F., & Fauz, R. (2015). To compare the effectiveness of constraint induced
movement therapy versus motor relearning programme to improve motor function of
hemiplegic upper extremity after stroke. Pak J Med Sci, 31(5), 1167-1171. doi:
10.12669/pjms.315.7910
Baygutalp, F., & Senel, K. (2014). EFFECT OF NEUROMUSCULAR ELECTRICAL STIMULATION IN
HEMIPLEGIC UPPER EXTREMITY REHABILITATION. Turkish Journal of Geriatrics-Turk Geriatri
Dergisi, 17(1), 50-56.
Bell, K. R., & Williams, F. (2003). Use of botulinum toxin type A and type B for spasticity in upper and
lower limbs. Phys.Med.Rehabil.Clin.N.Am., 14(4), 821-835.
Benvenuti, F., Stuart, M., Cappena, V., Gabella, S., Corsi, S., Taviani, A., . . . Weinrich, M. (2014).
Community-Based Exercise for Upper Limb Paresis: A Controlled Trial With Telerehabilitation.
Neurorehabilitation and Neural Repair, 28(7), 611-620. doi: 10.1177/1545968314521003
Berends, H. I., Nijlant, J. M., Movig, K. L., Van Putten, M. J., Jannink, M. J., & Ijzerman, M. J. (2009). The
clinical use of drugs influencing neurotransmitters in the brain to promote motor recovery after
stroke; a Cochrane systematic review. Eur.J.Phys.Rehabil.Med., 45(4), 621-630. doi: R33092118
[pii]
Bhakta, B. B., Cozens, J. A., Chamberlain, M. A., & Bamford, J. M. (2000). Impact of botulinum toxin type
A on disability and carer burden due to arm spasticity after stroke: a randomised double blind
placebo controlled trial. J.Neurol.Neurosurg.Psychiatry, 69(2), 217-221.
Bhakta, B. B., O'Connor, R. J., & Cozens, J. A. (2008). Associated reactions after stroke: a randomized
controlled trial of the effect of botulinum toxin type A. J Rehabil Med, 40(1), 36-41. doi:
10.2340/16501977-0120
Bhatt, E., Nagpal, A., Greer, K. H., Grunewald, T. K., Steele, J. L., Wiemiller, J. W., . . . Carey, J. R. (2007).
Effect of finger tracking combined with electrical stimulation on brain reorganization and hand
function in subjects with stroke. Exp.Brain Res., 182(4), 435-447. doi: 10.1007/s00221-007-1001-
5 [doi]
Blennerhassett, J., & Dite, W. (2004a). Additional task-related practice improves mobility and upper limb
function early after stroke: a randomised controlled trial. Aust J Physiother, 50(4), 219-224.
Blennerhassett, J., & Dite, W. (2004b). Additional task-related practice improves mobility and upper limb
function early after stroke: a randomised controlled trial. Aust.J.Physiother., 50(4), 219-224.
Boake, C., Noser, E. A., Ro, T., Baraniuk, S., Gaber, M., Johnson, R., . . . Levin, H. S. (2007). Constraint-
induced movement therapy during early stroke rehabilitation. Neurorehabil.Neural Repair,
21(1), 14-24. doi: 21/1/14 [pii];10.1177/1545968306291858 [doi]
Boggio, P. S., Nunes, A., Rigonatti, S. P., Nitsche, M. A., Pascual-Leone, A., & Fregni, F. (2007). Repeated
sessions of noninvasive brain DC stimulation is associated with motor function improvement in
stroke patients. Restor.Neurol.Neurosci., 25(2), 123-129.
Bolognini, N., Convento, S., Banco, E., Mattioli, F., Tesio, L., & Vallar, G. (2015). Improving ideomotor
limb apraxia by electrical stimulation of the left posterior parietal cortex. Brain, 138(2), 428-439.
doi: 10.1093/brain/awu343
Bonni, S., Ponzo, V., Caltagirone, C., & Koch, G. (2014). Cerebellar theta burst stimulation in stroke
patients with ataxia. Funct Neurol, 29(1), 41-45.
Boomkamp-Koppen, H. G., Visser-Meily, J. M., Post, M. W., & Prevo, A. J. (2005). Poststroke hand
swelling and oedema: prevalence and relationship with impairment and disability. Clin.Rehabil.,
19(5), 552-559.

www.ebrsr.com
Bovend'Eerdt, T. J., Dawes, H., Sackley, C., Izadi, H., & Wade, D. T. (2010). An integrated motor imagery
program to improve functional task performance in neurorehabilitation: a single-blind
randomized controlled trial. Arch.Phys.Med.Rehabil., 91(6), 939-946. doi: S0003-9993(10)00149-
8 [pii];10.1016/j.apmr.2010.03.008 [doi]
Bower, K. J., Louie, J., Landesrocha, Y., Seedy, P., Gorelik, A., & Bernhardt, J. (2015). Clinical feasibility of
interactive motion-controlled games for stroke rehabilitation. J Neuroeng Rehabil, 12, 63. doi:
10.1186/s12984-015-0057-x
Bowman, B. R., Baker, L. L., & Waters, R. L. (1979). Positional feedback and electrical stimulation: an
automated treatment for the hemiplegic wrist. Arch.Phys.Med.Rehabil., 60(11), 497-502.
Boyaci, A., Topuz, O., Alkan, H., Ozgen, M., Sarsan, A., Yildiz, N., & Ardic, F. (2013). Comparison of the
effectiveness of active and passive neuromuscular electrical stimulation of hemiplegic upper
extremities: a randomized, controlled trial. International Journal of Rehabilitation Research,
36(4), 315-322. doi: 10.1097/MRR.0b013e328360e541
Boyd, L. A., Vidoni, E. D., & Wessel, B. D. (2010). Motor learning after stroke: is skill acquisition a
prerequisite for contralesional neuroplastic change? Neurosci.Lett., 482(1), 21-25. doi: S0304-
3940(10)00856-6 [pii];10.1016/j.neulet.2010.06.082 [doi]
Brashear, A., Gordon, M. F., Elovic, E., Kassicieh, V. D., Marciniak, C., Do, M., . . . Turkel, C. (2002).
Intramuscular injection of botulinum toxin for the treatment of wrist and finger spasticity after a
stroke. N.Engl.J.Med., 347(6), 395-400. doi: 10.1056/NEJMoa011892 [doi];347/6/395 [pii]
Brashear, A., McAfee, A. L., Kuhn, E. R., & Fyffe, J. (2004). Botulinum toxin type B in upper-limb
poststroke spasticity: a double-blind, placebo-controlled trial. Arch.Phys.Med.Rehabil., 85(5),
705-709. doi: S0003999303010207 [pii]
Brkic, L., Shaw, L., van Wijck, F., Francis, R., Price, C., Forster, A., . . . Rodgers, H. (2016). Repetitive arm
functional tasks after stroke (RAFTAS): a pilot randomised controlled trial. Pilot and Feasibility
Studies, 2(1), 50. doi: 10.1186/s40814-016-0088-5
Broeren, J., Claesson, L., Goude, D., Rydmark, M., & Sunnerhagen, K. S. (2008). Virtual rehabilitation in
an activity centre for community-dwelling persons with stroke. The possibilities of 3-dimensional
computer games. Cerebrovasc.Dis., 26(3), 289-296. doi: 000149576 [pii];10.1159/000149576
[doi]
Brogardh, C., & Sjolund, B. H. (2006). Constraint-induced movement therapy in patients with stroke: a
pilot study on effects of small group training and of extended mitt use. Clin Rehabil, 20(3), 218-
227. doi: 10.1191/0269215506cr937oa
Brogardh, C., Vestling, M., & Sjolund, B. H. (2009). Shortened constraint-induced movement therapy in
subacute stroke - no effect of using a restraint: a randomized controlled study with independent
observers. J Rehabil Med, 41(4), 231-236. doi: 10.2340/16501977-0312
Brokaw, E., Nichols, D., Holley, R., & Lum, P. (2014). Robotic therapy provides a stimulus for upper limb
motor recovery after stroke that is complementary to and distinct from conventional therapy.
Neurorehabilitation and Neural Repair, 28(4), 367-376.
Brown, J. A., Lutsep, H. L., Weinand, M., & Cramer, S. C. (2006). Motor cortex stimulation for the
enhancement of recovery from stroke: a prospective, multicenter safety study. Neurosurgery,
58(3), 464-473. doi: 10.1227/01.NEU.0000197100.63931.04 [doi];00006123-200603000-00007
[pii]
Brunner, I. C., Skouen, J. S., & Strand, L. I. (2012). Is modified constraint-induced movement therapy
more effective than bimanual training in improving arm motor function in the subacute phase
post stroke? A randomized controlled trial. Clin.Rehabil., 26(12), 1078-1086. doi:
0269215512443138 [pii];10.1177/0269215512443138 [doi]
Burgar, C. G., Lum, P. S., Scremin, A. M., Garber, S. L., Van der Loos, H. F., Kenney, D., & Shor, P. (2011).
Robot-assisted upper-limb therapy in acute rehabilitation setting following stroke: Department
of Veterans Affairs multisite clinical trial. J.Rehabil.Res.Dev., 48(4), 445-458.

www.ebrsr.com
Burgar, C. G., Lum, P. S., Shor, P. C., & HF, M. V. d. L. (2000). Development of robots for rehabilitation
therapy: the Palo Alto VA/Stanford experience. J.Rehabil.Res.Dev., 37(6), 663-673.
Bustamante Valles, K., Montes, S., Madrigal Mde, J., Burciaga, A., Martinez, M. E., & Johnson, M. J.
(2016). Technology-assisted stroke rehabilitation in Mexico: a pilot randomized trial comparing
traditional therapy to circuit training in a Robot/technology-assisted therapy gym. J Neuroeng
Rehabil, 13(1), 83. doi: 10.1186/s12984-016-0190-1
Bütefisch, C., Hummelsheim, H., Denzler, P., & Mauritz, K. H. (1995). Repetitive training of isolated
movements improves the outcome of motor rehabilitation of the centrally paretic hand.
J.Neurol.Sci., 130(1), 59-68. doi: 0022-510X(95)00003-K [pii]
Butler, A. J., Shuster, M., O'Hara, E., Hurley, K., Middlebrooks, D., & Guilkey, K. (2013). A meta-analysis of
the efficacy of anodal transcranial direct current stimulation for upper limb motor recovery in
stroke survivors. J.Hand Ther., 26(2), 162-170. doi: S0894-1130(12)00085-3
[pii];10.1016/j.jht.2012.07.002 [doi]
Byl, N. N., Abrams, G. M., Pitsch, E., Fedulow, I., Kim, H., Simkins, M., . . . Rosen, J. (2013). Chronic stroke
survivors achieve comparable outcomes following virtual task specific repetitive training guided
by a wearable robotic orthosis (UL-EX07) and actual task specific repetitive training guided by a
physical therapist. Journal of Hand Therapy, 26(4), 343-352. doi: 10.1016/j.jht.2013.06.001
Cai, Y., Shen, J., Zhong, D., Li, Y., & Wu, T. (2012). Status quo, issues, and challenges for acupuncture
research evidence: An overview of clinical and fundamental studies. Journal of Evidence-Based
Medicine, 5(1), 12-24.
Caliandro, P., Celletti, C., Padua, L., Minciotti, I., Russo, G., Granata, G., . . . Camerota, F. (2012). Focal
muscle vibration in the treatment of upper limb spasticity: a pilot randomized controlled trial in
patients with chronic stroke. Arch.Phys.Med.Rehabil., 93(9), 1656-1661. doi: S0003-
9993(12)00255-9 [pii];10.1016/j.apmr.2012.04.002 [doi]
Cambier, D. C., De, C. E., Danneels, L. A., & Witvrouw, E. E. (2003). Treating sensory impairments in the
post-stroke upper limb with intermittent pneumatic compression. Results of a preliminary trial.
Clin.Rehabil., 17(1), 14-20.
Cao, H., Bourchier, S., & Liu, J. (2012). Does Syndrome Differentiation Matter? A Meta-Analysis of
Randomized Controlled Trials in Cochrane Reviews of Acupuncture. Medical Acupuncture, 24(2),
68-76.
Cardoso, E., Rodrigues, B., Lucena, R., Oliveira, I. R., Pedreira, G., & Melo, A. (2005). Botulinum toxin type
A for the treatment of the upper limb spasticity after stroke: a meta-analysis. Arq
Neuropsiquiatr., 63(1), 30-33. doi: S0004-282X2005000100006 [pii];/S0004-
282X2005000100006 [doi]
Carey, J. R. (1990). Manual stretch: effect on finger movement control and force control in stroke
subjects with spastic extrinsic finger flexor muscles. Arch.Phys.Med.Rehabil., 71(11), 888-894.
Cassidy, J. M., Chu, H., Anderson, D. C., Krach, L. E., Snow, L., Kimberley, T. J., & Carey, J. R. (2015). A
Comparison of Primed Low-frequency Repetitive Transcranial Magnetic Stimulation Treatments
in Chronic Stroke. Brain Stimul, 8(6), 1074-1084. doi: 10.1016/j.brs.2015.06.007
Cauraugh, J., Light, K., Kim, S., Thigpen, M., & Behrman, A. (2000). Chronic motor dysfunction after
stroke: recovering wrist and finger extension by electromyography-triggered neuromuscular
stimulation. Stroke, 31(6), 1360-1364.
Cauraugh, J. H., & Kim, S. (2002). Two coupled motor recovery protocols are better than one:
electromyogram-triggered neuromuscular stimulation and bilateral movements. Stroke, 33(6),
1589-1594.
Cauraugh, J. H., & Kim, S. B. (2003). Stroke motor recovery: active neuromuscular stimulation and
repetitive practice schedules. J.Neurol.Neurosurg.Psychiatry, 74(11), 1562-1566.

www.ebrsr.com
Cauraugh, J. H., Lodha, N., Naik, S. K., & Summers, J. J. (2010). Bilateral movement training and stroke
motor recovery progress: a structured review and meta-analysis. Hum.Mov Sci., 29(5), 853-870.
doi: S0167-9457(09)00099-2 [pii];10.1016/j.humov.2009.09.004 [doi]
Celnik, P., Hummel, F., Harris-Love, M., Wolk, R., & Cohen, L. G. (2007). Somatosensory stimulation
enhances the effects of training functional hand tasks in patients with chronic stroke.
Arch.Phys.Med.Rehabil., 88(11), 1369-1376. doi: S0003-9993(07)01338-X
[pii];10.1016/j.apmr.2007.08.001 [doi]
Cha, H., Ji, S., Kim, M., & Chang, J. (2014). Effect of transcranial direct current stimulation of function in
patients with stroke. Journal of Physical Therapy Science, 26(3), 363-365.
Cha, Y. J., Yoo, E. Y., Jung, M. Y., Park, S. H., & Park, J. H. (2012). Effects of functional task training with
mental practice in stroke: a meta analysis. NeuroRehabilitation., 30(3), 239-246. doi:
K854243227314017 [pii];10.3233/NRE-2012-0751 [doi]
Chae, J., Bethoux, F., Bohine, T., Dobos, L., Davis, T., & Friedl, A. (1998). Neuromuscular stimulation for
upper extremity motor and functional recovery in acute hemiplegia. Stroke, 29(5), 975-979.
Chae, J., Harley, M. Y., Hisel, T. Z., Corrigan, C. M., Demchak, J. A., Wong, Y. T., & Fang, Z. P. (2009).
Intramuscular electrical stimulation for upper limb recovery in chronic hemiparesis: an
exploratory randomized clinical trial. Neurorehabil Neural Repair., 23(6), 569-578.
Chan, M. K., Tong, R. K., & Chung, K. Y. (2009). Bilateral upper limb training with functional electric
stimulation in patients with chronic stroke. Neurorehabil.Neural Repair, 23(4), 357-365. doi:
1545968308326428 [pii];10.1177/1545968308326428 [doi]
Chang-Yong, K., Jung-Sun, L., Jong-Hun, L., Yang-Gu, K., Shin, A. R., Young-Hun, S., & Hyun Kun, H. (2015).
Effect of spatial target reaching training based on visual biofeedback on the upper extremity
function of hemiplegic stroke patients. Journal of Physical Therapy Science, 27(4), 1091-1096.
doi: 10.1589/jpts.27.1091
Chang, W. H., Kim, Y. H., Bang, O. Y., Kim, S. T., Park, Y. H., & Lee, P. K. (2010). Long-term effects of rTMS
on motor recovery in patients after subacute stroke. J.Rehabil.Med., 42(8), 758-764. doi:
10.2340/16501977-0590 [doi]
Chang, W. H., Park, C. H., Kim, D. Y., Shin, Y. I., Ko, M. H., Lee, A., . . . Kim, Y. H. (2016). Cerebrolysin
combined with rehabilitation promotes motor recovery in patients with severe motor
impairment after stroke. BMC Neurol, 16, 31. doi: 10.1186/s12883-016-0553-z
Chemerinski, E., Robinson, R. G., & Kosier, J. T. (2001). Improved recovery in activities of daily living
associated with remission of poststroke depression. Stroke, 32(1), 113-117.
Chen, C. C., Lee, H. C., Chang, J. H., Chen, S. S., Li, T. C., Tsai, C. H., . . . Hsieh, C. L. (2012). Chinese Herb
Astragalus membranaceus Enhances Recovery of Hemorrhagic Stroke: Double-Blind, Placebo-
Controlled, Randomized Study. Evidence-Based Complementary and Alternative Medicine, 2012.
Chen, J. C., Liang, C. C., & Shaw, F. Z. (2005). Facilitation of sensory and motor recovery by thermal
intervention for the hemiplegic upper limb in acute stroke patients: a single-blind randomized
clinical trial. Stroke, 36(12), 2665-2669. doi: 01.STR.0000189992.06654.ab
[pii];10.1161/01.STR.0000189992.06654.ab [doi]
Chen, L., Fang, J., Jin, X., Keeler, C. L., Gao, H., Fang, Z., & Chen, Q. (2016). Acupuncture treatment for
ischaemic stroke in young adults: protocol for a randomised, sham-controlled clinical trial. BMJ
Open, 6(1), e010073. doi: 10.1136/bmjopen-2015-010073
Chen, L., Fang, J., Ma, R., Gu, X., Chen, L., Li, J., & Xu, S. (2016). Additional effects of acupuncture on
early comprehensive rehabilitation in patients with mild to moderate acute ischemic stroke: a
multicenter randomized controlled trial. BMC Complement Altern Med, 16, 226. doi:
10.1186/s12906-016-1193-y
Cheng, F., Wang, X., Lu, Y., Zhong, X., Zhao, Y., & Wang, Q. (2012). Chinese medicine injection Qingkailing
for treatment of acute ischemia stroke: A systematic review of randomized controlled trials.
Evidence-based Complementary and Alternative Medicine., %2012., Article.

www.ebrsr.com
Childers, M. K., Brashear, A., Jozefczyk, P., Reding, M., Alexander, D., Good, D., . . . Molloy, P. T. (2004).
Dose-dependent response to intramuscular botulinum toxin type A for upper-limb spasticity in
patients after a stroke. Arch.Phys.Med.Rehabil., 85(7), 1063-1069. doi: S0003999304000127 [pii]
Cho, H. S., & Cha, H. G. (2015). Effect of mirror therapy with tDCS on functional recovery of the upper
extremity of stroke patients. Journal of Physical Therapy Science, 27(4), 1045-1047.
Choi, J. B., & Ma, S. R. (2016). The Effect of Resting Hand Splint on Hand Pain and Edema among Patients
with Stroke. Journal of Ecophysiology and Occupational Health, 16(1-2). doi:
10.18311/jeoh/2016/15635
Choi, J. H., Han, E. Y., Kim, B. R., Kim, S. M., Im, S. H., Lee, S. Y., & Hyun, C. W. (2014). Effectiveness of
commercial gaming-based virtual reality movement therapy on functional recovery of upper
extremity in subacute stroke patients. Annals of Rehabilitation Medicine, 38(4), 485-493. doi:
10.5535/arm.2014.38.4.485
Choi, Y. H., Ku, J., Lim, H., Kim, Y. H., & Paik, N. J. (2016). Mobile game-based virtual reality rehabilitation
program for upper limb dysfunction after ischemic stroke. Restorative Neurology and
Neuroscience, 34(3), 455-463. doi: 10.3233/RNN-150626
Chollet, F., Tardy, J., Albucher, J. F., Thalamas, C., Berard, E., Lamy, C., . . . Loubinoux, I. (2011).
Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebo-
controlled trial. Lancet Neurol., 10(2), 123-130. doi: S1474-4422(10)70314-8
[pii];10.1016/S1474-4422(10)70314-8 [doi]
Cirstea, C. M., Ptito, A., & Levin, M. F. (2006). Feedback and cognition in arm motor skill reacquisition
after stroke. Stroke, 37(5), 1237-1242. doi: 10.1161/01.STR.0000217417.89347.63
Cirstea, M. C., & Levin, M. F. (2007). Improvement of arm movement patterns and endpoint control
depends on type of feedback during practice in stroke survivors. Neurorehabil Neural Repair,
21(5), 398-411. doi: 10.1177/1545968306298414
Classen, J., Liepert, J., Wise, S. P., Hallett, M., & Cohen, L. G. (1998). Rapid plasticity of human cortical
movement representation induced by practice. J.Neurophysiol., 79(2), 1117-1123.
Colomer, C., E, N. O., & Llorens, R. (2016). Mirror therapy in chronic stroke survivors with severely
impaired upper limb function: a randomized controlled trial. Eur J Phys Rehabil Med, 52(3), 271-
278.
Conforto, A. B., Anjos, S. M., Saposnik, G., Mello, E. A., Nagaya, E. M., Santos, J., . . . Cohen, L. G. (2012).
Transcranial magnetic stimulation in mild to severe hemiparesis early after stroke: A proof of
principle and novel approach to improve motor function. Journal of Neurology.259.(7.) (pp
1399.-1405.),, %2012.
Conforto, A. B., Kaelin-Lang, A., & Cohen, L. G. (2002). Increase in hand muscle strength of stroke
patients after somatosensory stimulation. Ann.Neurol., 51(1), 122-125. doi: 10.1002/ana.10070
[pii]
Connell, L. A., Lincoln, N. B., & Radford, K. A. (2008). Somatosensory impairment after stroke: frequency
of different deficits and their recovery. Clin.Rehabil., 22(8), 758-767. doi: 22/8/758
[pii];10.1177/0269215508090674 [doi]
Conroy, S. S., Whitall, J., Dipietro, L., Jones-Lush, L. M., Zhan, M., Finley, M. A., . . . Bever, C. T. (2011).
Effect of gravity on robot-assisted motor training after chronic stroke: a randomized trial.
Arch.Phys.Med.Rehabil., 92(11), 1754-1761. doi: S0003-9993(11)00410-2
[pii];10.1016/j.apmr.2011.06.016 [doi]
Coote, S., Murphy, B., Harwin, W., & Stokes, E. (2008). The effect of the GENTLE/s robot-mediated
therapy system on arm function after stroke. Clin Rehabil, 22(5), 395-405. doi:
10.1177/0269215507085060
Corbetta, D., Sirtori, V., Moja, L., & Gatti, R. (2010). Constraint-induced movement therapy in stroke
patients: systematic review and meta-analysis. Eur.J.Phys.Rehabil.Med., 46(4), 537-544. doi:
R33102419 [pii]

www.ebrsr.com
Cordo, P., Wolf, S., Jau-Shin, L., Bogey, R., Stevenson, M., Hayes, J., & Roth, E. (2013). Treatment of
Severe Hand Impairment Following Stroke by Combining Assisted Movement, Muscle Vibration,
and Biofeedback. Journal of Neurologic Physical Therapy, 37(4), 194-203. doi:
10.1097/NPT.0000000000000023
Corti, M., McGuirk, T. E., Wu, S. S., & Patten, C. (2012). Differential effects of power training versus
functional task practice on compensation and restoration of arm function after stroke.
Neurorehabil Neural Repair, 26(7), 842-854. doi: 10.1177/1545968311433426
Costantino, C., Galuppo, L., & Romiti, D. (2017). Short-term effect of local muscle vibration treatment
versus sham therapy on upper limb in chronic post-stroke patients: a randomized controlled
trial. Eur J Phys Rehabil Med, 53(1), 32-40. doi: 10.23736/s1973-9087.16.04211-8
Coupar, F., Pollock, A., Legg, L. A., Sackley, C., & van Vliet, P. (2012). Home-based therapy programmes
for upper limb functional recovery following stroke. Cochrane Database Syst Rev(5), Cd006755.
doi: 10.1002/14651858.CD006755.pub2
Coupar, F., Pollock, A., Van Wijck, F., Morris, J., & Langhorne, P. (2010). Simultaneous bilateral training
for improving arm function after stroke. Cochrane Database of Systematic Reviews, 4.
Cowles, T., Clark, A., Mares, K., Peryer, G., Stuck, R., & Pomeroy, V. (2013). Observation-to-imitate plus
practice could add little to physical therapy benefits within 31 days of stroke: translational
randomized controlled trial. Neurorehabil Neural Repair., 27(2), 173-182.
Cramer, S. C. (2007). The EXCITE trial: a major step forward for restorative therapies in stroke. Stroke,
38(7), 2204-2205. doi: STROKEAHA.107.486555 [pii];10.1161/STROKEAHA.107.486555 [doi]
Crosbie, J. H., Lennon, S., McGoldrick, M. C., McNeill, M. D., & McDonough, S. M. (2012). Virtual reality
in the rehabilitation of the arm after hemiplegic stroke: a randomized controlled pilot study.
Clin.Rehabil., 26(9), 798-806. doi: 0269215511434575 [pii];10.1177/0269215511434575 [doi]
Crow, J. L., Lincoln, N. B., Nouri, F. M., & De, W. W. (1989). The effectiveness of EMG biofeedback in the
treatment of arm function after stroke. Int.Disabil.Stud., 11(4), 155-160.
Cruz, V. T., Bento, V., Ruano, L., Ribeiro, D. D., Fontao, L., Mateus, C., . . . Coutinho, P. (2014). Motor task
performance under vibratory feedback early poststroke: single center, randomized, cross-over,
controled clinical trial. Scientific Reports, 4. doi: 10.1038/srep05670
Cui, H.-f., Gao, G.-q., Wang, Y.-l., Yu, X.-h., Guo, L., & Ren, S. (2014). Therapeutic efficacy analysis of
balancing yin-yang manipulation for post-stroke upper limb spasticity. Journal of Acupuncture
and Tuina Science, 12(6), 369-374. doi: 10.1007/s11726-014-0808-4
Cui, H. F., Gao, G. Q., Wang, Y. L., Yu, X. H., Guo, L., & Ren, S. (2014). Therapeutic efficacy analysis of
balancing yin-yang manipulation for post-stroke upper limb spasticity. Journal of Acupuncture
and Tuina Science, 12(6), 369-374. doi: 10.1007/s11726-014-0808-4
Cunningham, D. A., Varnerin, N., Machado, A., Bonnett, C., Janini, D., Roelle, S., . . . Plow, E. B. (2015).
Stimulation targeting higher motor areas in stroke rehabilitation: A proof-of-concept,
randomized, double-blinded placebo-controlled study of effectiveness and underlying
mechanisms. Restorative Neurology and Neuroscience, 33(6), 911-926. doi: 10.3233/RNN-
150574
D'Agata, F., Peila, E., Cicerale, A., Caglio, M. M., Caroppo, P., Vighetti, S., . . . Massazza, G. (2016).
Cognitive and neurophysiological effects of non-invasive brain stimulation in stroke patients
after motor rehabilitation. Frontiers in Behavioral Neuroscience, 10, 11.
da Silva, P. B., Antunes, F. N., Graef, P., Cechetti, F., & Pagnussat, A. D. (2015). Strength Training
Associated with Task-Oriented Training to Enhance Upper-Limb Motor Function in Elderly
Patients with Mild Impairment After Stroke A Randomized Controlled Trial. American Journal of
Physical Medicine & Rehabilitation, 94(1), 11-19. doi: 10.1097/phm.0000000000000135
da Silva Ribeiro, N. M., Ferraz, D. D., Pedreira, E., Pinheiro, I., da Silva Pinto, A. C., Neto, M. G., . . .
Masruha, M. R. (2015). Virtual rehabilitation via Nintendo Wii(R) and conventional physical

www.ebrsr.com
therapy effectively treat post-stroke hemiparetic patients. Top Stroke Rehabil, 22(4), 299-305.
doi: 10.1179/1074935714z.0000000017
Dahl, A. E., Askim, T., Stock, R., Langorgen, E., Lydersen, S., & Indredavik, B. (2008). Short- and long-term
outcome of constraint-induced movement therapy after stroke: a randomized controlled
feasibility trial. Clin.Rehabil., 22(5), 436-447. doi: 22/5/436 [pii];10.1177/0269215507084581
[doi]
Daly, J. J., Hogan, N., Perepezko, E. M., Krebs, H. I., Rogers, J. M., Goyal, K. S., . . . Ruff, R. L. (2005).
Response to upper-limb robotics and functional neuromuscular stimulation following stroke.
J.Rehabil.Res.Dev., 42(6), 723-736.
Dam, M., Tonin, P., De Boni, A., Pizzolato, G., Casson, S., Ermani, M., . . . Battistin, L. (1996). Effects of
fluoxetine and maprotiline on functional recovery in poststroke hemiplegic patients undergoing
rehabilitation therapy. Stroke, 27(7), 1211-1214.
Daniel, K. Z., Renee, A., Barbara, B., Nizan, F., David, J. R., & Steven, C. C. (2014). Machine-Based, Self-
guided Home Therapy for Individuals With Severe Arm Impairment After Stroke: A Randomized
Controlled Trial. Neurorehabilitation and Neural Repair, 29(5), 395-406. doi:
10.1177/1545968314550368
Dawson, J., Pierce, D., Dixit, A., Kimberley, T. J., Robertson, M., Tarver, B., . . . Engineer, N. (2016). Safety,
Feasibility, and Efficacy of Vagus Nerve Stimulation Paired With Upper-Limb Rehabilitation After
Ischemic Stroke. Stroke, 47(1), 143-150. doi: 10.1161/STROKEAHA.115.010477
de Diego, C., Puig, S., & Navarro, X. (2013). A sensorimotor stimulation program for rehabilitation of
chronic stroke patients. Restorative Neurology and Neuroscience, 31(4), 361-371. doi:
10.3233/rnn-120250
de Jong, L. D., Dijkstra, P. U., Gerritsen, J., Geurts, A. C., & Postema, K. (2013). Combined arm stretch
positioning and neuromuscular electrical stimulation during rehabilitation does not improve
range of motion, shoulder pain or function in patients after stroke: a randomised trial. Journal of
Physiotherapy, 59(4), 245-254.
de Kroon, J. R., & Ijzerman, M. J. (2008). Electrical stimulation of the upper extremity in stroke: cyclic
versus EMG-triggered stimulation. Clin.Rehabil., 22(8), 690-697. doi: 22/8/690
[pii];10.1177/0269215508088984 [doi]
de Kroon, J. R., Ijzerman, M. J., Lankhorst, G. J., & Zilvold, G. (2004). Electrical stimulation of the upper
limb in stroke: stimulation of the extensors of the hand vs. alternate stimulation of flexors and
extensors. Am.J.Phys.Med.Rehabil., 83(8), 592-600. doi: 00002060-200408000-00003 [pii]
de Kroon, J. R., van der Lee, J. H., MJ, I. J., & Lankhorst, G. J. (2002). Therapeutic electrical stimulation to
improve motor control and functional abilities of the upper extremity after stroke: a systematic
review. Clin Rehabil, 16(4), 350-360. doi: 10.1191/0269215502cr504oa
De Oliveira Cacho, R., Cacho, E. W. A., Ortolan, R. L., Cliquet, A., & Borges, G. (2015). Trunk restraint
therapy: The continuous use of the harness could promote feedback dependence in poststroke
patients. Medicine (United States), 94(12), e641. doi: 10.1097/MD.0000000000000641
Del Felice, A., Daloli, V., Masiero, S., & Manganotti, P. (2016). Contralesional Cathodal versus Dual
Transcranial Direct Current Stimulation for Decreasing Upper Limb Spasticity in Chronic Stroke
Individuals: A Clinical and Neurophysiological Study. Journal of Stroke & Cerebrovascular
Diseases, 25(12), 2932-2941. doi: 10.1016/j.jstrokecerebrovasdis.2016.08.008
Desrosiers, J., Bourbonnais, D., Corriveau, H., Gosselin, S., & Bravo, G. (2005). Effectiveness of unilateral
and symmetrical bilateral task training for arm during the subacute phase after stroke: a
randomized controlled trial. Clin.Rehabil., 19(6), 581-593.
Di Cesare, F., Mancuso, J., Woodward, P., Bednar, M. M., & Loudon, P. T. (2016). Phosphodiesterase-5
Inhibitor PF-03049423 Effect on Stroke Recovery: A Double-Blind, Placebo-Controlled
Randomized Clinical Trial. J Stroke Cerebrovasc Dis, 25(3), 642-649. doi:
10.1016/j.jstrokecerebrovasdis.2015.11.026

www.ebrsr.com
Di Lazzaro, V., Capone, F., Di Pino, G., Pellegrino, G., Florio, L., Zollo, L., . . . Sterzi, S. (2016). Combining
Robotic Training and Non-Invasive Brain Stimulation in Severe Upper Limb-Impaired Chronic
Stroke Patients. Front Neurosci, 10, 88. doi: 10.3389/fnins.2016.00088
Di Lazzaro, V., Dileone, M., Capone, F., Pellegrino, G., Ranieri, F., Musumeci, G., . . . Fregni, F. (2014).
Immediate and Late Modulation of Interhemipheric Imbalance With Bilateral Transcranial Direct
Current Stimulation in Acute Stroke. Brain Stimulation, 7(6), 841-848. doi:
10.1016/j.brs.2014.10.001
Dickstein, R., Heffes, Y., Laufer, Y., Abulaffio, N., & Shabtai, E. L. (1997). Repetitive practice of a single
joint movement for enhancing elbow function in hemiparetic patients. Percept.Mot.Skills, 85(3
Pt 1), 771-785.
Dickstein, R., Hocherman, S., Pillar, T., & Shaham, R. (1986). Stroke rehabilitation. Three exercise therapy
approaches. Phys.Ther., 66(8), 1233-1238.
Dijkerman, H. C., Ietswaart, M., Johnston, M., & MacWalter, R. S. (2004). Does motor imagery training
improve hand function in chronic stroke patients? A pilot study. Clinical rehabilitation, 18(5),
538-549.
Dispa, D., Lejeune, T., & Thonnard, J.-L. (2013). The effect of repetitive rhythmic precision grip task-
oriented rehabilitation in chronic stroke patients: a pilot study. International Journal of
Rehabilitation Research, 36(1), 81.
Dogan, A., Demirtas, R., & Ozgirgin, N. (2013). Intraarticular hydraulic distension with steroids in the
management of hemiplegic shoulder. Turkish Journal of Medical Sciences, 43(2), 304-310. doi:
10.3906/sag-1110-22
Dohle, C., Pullen, J., Nakaten, A., Kust, J., Rietz, C., & Karbe, H. (2009). Mirror therapy promotes recovery
from severe hemiparesis: a randomized controlled trial. Neurorehabil.Neural Repair, 23(3), 209-
217. doi: 1545968308324786 [pii];10.1177/1545968308324786 [doi]
Dombovy, M. L. (1993). Rehabilitation and the course of recovery after stroke. Stroke population,
cohorts and clinical trials.Boston, Butterworth-Heinemann.
Donaldson, C., Tallis, R., Miller, S., Sunderland, A., Lemon, R., & Pomeroy, V. (2009). Effects of
conventional physical therapy and functional strength training on upper limb motor recovery
after stroke: a randomized phase II study. Neurorehabil.Neural Repair, 23(4), 389-397. doi:
1545968308326635 [pii];10.1177/1545968308326635 [doi]
Dorsch, S., Ada, L., & Canning, C. G. (2014). EMG-triggered electrical stimulation is a feasible
intervention to apply to multiple arm muscles in people early after stroke, but does not improve
strength and activity more than usual therapy: a randomized feasibility trial. Clinical
rehabilitation, 28(5), 482-490. doi: 10.1177/0269215513510011
dos Santos-Fontes, R. L., de Andrade, K. N. F., Sterr, A., & Conforto, A. B. (2013). Home-Based Nerve
Stimulation to Enhance Effects of Motor Training in Patients in the Chronic Phase After Stroke: A
Proof-of-Principle Study. Neurorehabilitation and Neural Repair, 27(6), 483-490. doi:
10.1177/1545968313478488
Doucet, B. M., & Griffin, L. (2013). High- Versus Low-Frequency Stimulation Effects on Fine Motor
Control in Chronic Hemiplegia: A Pilot Study. Topics in stroke rehabilitation, 20(4), 299-307. doi:
10.1310/tsr2004-299
Doussoulin, A., Arancibia, M., Saiz, J., Silva, A., Luengo, M., & Salazar, A. P. (2017). Recovering functional
independence after a stroke through Modified Constraint-Induced Therapy. Neurorehabilitation,
40(2), 243-249. doi: 10.3233/NRE-161409
Doyle, S., Bennett, S., Fasoli, S. E., & McKenna, K. T. (2010). Interventions for sensory impairment in the
upper limb after stroke. Cochrane Database of Systematic Reviews, 6.
Dressler, D., Rychlik, R., Kreimendahl, F., Schnur, N., & Lambert-Baumann, J. (2015). Long-term efficacy
and safety of incobotulinumtoxinA and conventional treatment of poststroke arm spasticity: a

www.ebrsr.com
prospective, non-interventional, open-label, parallel-group study. BMJ Open, 5(12), e009358.
doi: 10.1136/bmjopen-2015-009358
Dromerick, A. W., Edwards, D. F., & Hahn, M. (2000). Does the application of constraint-induced
movement therapy during acute rehabilitation reduce arm impairment after ischemic stroke?
Stroke, 31(12), 2984-2988.
Dromerick, A. W., Lang, C. E., Birkenmeier, R. L., Wagner, J. M., Miller, J. P., Videen, T. O., . . . Edwards, D.
F. (2009). Very Early Constraint-Induced Movement during Stroke Rehabilitation (VECTORS): A
single-center RCT. Neurology, 73(3), 195-201. doi: WNL.0b013e3181ab2b27
[pii];10.1212/WNL.0b013e3181ab2b27 [doi]
Du, J., Tian, L., Liu, W., Hu, J., Xu, G., Ma, M., . . . Liu, X. (2016). Effects of repetitive transcranial magnetic
stimulation on motor recovery and motor cortex excitability in patients with stroke: a
randomized controlled trial. European Journal of Neurology, 23(11), 1666-1672. doi:
10.1111/ene.13105
Duff, M., Chen, Y., Cheng, L., Liu, S., Blake, P., Wolf, S., & Rikakis, T. (2013). Adaptive mixed reality
rehabilitation improves quality of reaching movements more than traditional reaching therapy
following stroke. Neurorehabilitation and Neural Repair, 27(4), 306-315.
Duncan, P., Studenski, S., Richards, L., Gollub, S., Lai, S. M., Reker, D., . . . Johnson, D. (2003).
Randomized clinical trial of therapeutic exercise in subacute stroke. Stroke, 34(9), 2173-2180.
doi: 10.1161/01.STR.0000083699.95351.F2 [doi];01.STR.0000083699.95351.F2 [pii]
Durham, K., Sackley, C., Wright, C., Wing, A., Edwards, M., & van, V. P. (2014). Attentional focus of
feedback for improving performance of reach-to-grasp after stroke: A randomised crossover
study. Physiotherapy (London), 100(2), 108-115.
Dymarek, R., Taradaj, J., & Rosinczuk, J. (2016). The Effect of Radial Extracorporeal Shock Wave
Stimulation on Upper Limb Spasticity in Chronic Stroke Patients: A Single-Blind, Randomized,
Placebo-Controlled Study. Ultrasound Med Biol, 42(8), 1862-1875. doi:
10.1016/j.ultrasmedbio.2016.03.006
El-Helow, M., Zamzam, M., Fathalla, M., El-Badawy, M., El Nahhas, N., El-Nabil, L., . . . Von Wild, K.
(2014). Efficacy of modified constraint-induced movement therapy in acute stroke. . European
Journal of Physical and Rehabilitation Medicine, 51(4), 371-379. doi: 0000-0002-7871-8341
Elovic, E. P., Munin, M. C., Kanovsky, P., Hanschmann, A., Hiersemenzel, R., & Marciniak, C. (2016).
Randomized, placebo-controlled trial of incobotulinumtoxina for upper-limb post-stroke
spasticity. Muscle Nerve, 53(3), 415-421. doi: 10.1002/mus.24776
Elsner, B., Kugler, J., Pohl, M., & Mehrholz, J. (2016). Transcranial direct current stimulation for
improving spasticity after stroke: A systematic review with meta-analysis. J Rehabil Med, 48(7),
565-570. doi: 10.2340/16501977-2097
Emara, T. H., Moustafa, R. R., Elnahas, N. M., Elganzoury, A. M., Abdo, T. A., Mohamed, S. A., & Eletribi,
M. A. (2010). Repetitive transcranial magnetic stimulation at 1Hz and 5Hz produces sustained
improvement in motor function and disability after ischaemic stroke. Eur.J.Neurol., 17(9), 1203-
1209. doi: ENE3000 [pii];10.1111/j.1468-1331.2010.03000.x [doi]
Emmerson, K. B., Harding, K. E., & Taylor, N. F. (2017). Home exercise programmes supported by video
and automated reminders compared with standard paper-based home exercise programmes in
patients with stroke: a randomized controlled trial. Clin Rehabil, 31(8), 1068-1077. doi:
10.1177/0269215516680856
English, C., Bernhardt, J., Crotty, M., Esterman, A., Segal, L., & Hillier, S. (2015). Circuit class therapy or
seven-day week therapy for increasing rehabilitation intensity of therapy after stroke (CIRCIT): a
randomized controlled trial. International Journal of Stroke, 10(4), 594-602. doi:
10.1111/ijs.12470
English, C., & Veerbeek, J. (2015). Is more physiotherapy better after stroke? International Journal of
Stroke, 10(4), 465-466. doi: 10.1111/ijs.12474

www.ebrsr.com
Ertelt, D., Small, S., Solodkin, A., Dettmers, C., McNamara, A., Binkofski, F., & Buccino, G. (2007). Action
observation has a positive impact on rehabilitation of motor deficits after stroke. Neuroimage,
36, T164-T173.
Etoh, S., Noma, T., Takiyoshi, Y., Arima, M., Ohama, R., Yokoyama, K., . . . Kawahira, K. (2016). Effects of
repetitive facilitative exercise with neuromuscular electrical stimulation, vibratory stimulation
and repetitive transcranial magnetic stimulation of the hemiplegic hand in chronic stroke
patients. International Journal of Neuroscience, 126(11), 1007-1012.
Etoom, M., Hawamdeh, M., Hawamdeh, Z., Alwardat, M., Giordani, L., Bacciu, S., . . . Foti, C. (2016).
Constraint-induced movement therapy as a rehabilitation intervention for upper extremity in
stroke patients: systematic review and meta-analysis. Int J Rehabil Res, 39(3), 197-210. doi:
10.1097/MRR.0000000000000169
Faghri, P. D. (1997). The effects of neuromuscular stimulation-induced muscle contraction versus
elevation on hand edema in CVA patients. J.Hand Ther., 10(1), 29-34.
Faghri, P. D., Rodgers, M. M., Glaser, R. M., Bors, J. G., Ho, C., & Akuthota, P. (1994). The effects of
functional electrical stimulation on shoulder subluxation, arm function recovery, and shoulder
pain in hemiplegic stroke patients. Arch.Phys.Med.Rehabil., 75(1), 73-79. doi: 0003-
9993(94)90341-7 [pii]
Fan, S. C., Su, F. C., Chen, S. S., Hou, W. H., Sun, J. S., Chen, K. H., . . . Hsu, S. H. (2014). Improved Intrinsic
Motivation and Muscle Activation Patterns in Reaching Task Using Virtual Reality Training for
Stroke Rehabilitation: A Pilot Randomized Control Trial. Journal of Medical and Biological
Engineering, 34(4), 399-407. doi: 10.5405/jmbe.1502
Fan, Y. T., Lin, K. C., Liu, H. L., Wu, C. Y., Wai, Y. Y., & Lee, T. H. (2016). Neural correlates of motor
recovery after robot-assisted stroke rehabilitation: a case series study. Neurocase, 22(5), 416-
425. doi: 10.1080/13554794.2016.1215469
Fang, Z., Ning, J., Xiong, C., & Shulin, Y. (2012). Effects of Electroacupuncture at Head Points on the
Function of Cerebral Motor Areas in Stroke Patients: A PET Study. Evidence-Based
Complementary and Alternative Medicine, 2012.
Fasoli, S. E., Krebs, H. I., Ferraro, M., Hogan, N., & Volpe, B. T. (2004). Does shorter rehabilitation limit
potential recovery poststroke? Neurorehabil Neural Repair, 18(2), 88-94. doi:
10.1177/0888439004267434
Feeney, D. M., Gonzalez, A., & Law, W. A. (1982). Amphetamine, haloperidol, and experience interact to
affect rate of recovery after motor cortex injury. Science, 217(4562), 855-857.
Feys, H. M., De Weerdt, W. J., Selz, B. E., Cox Steck, G. A., Spichiger, R., Vereeck, L. E., . . . Van Hoydonck,
G. A. (1998). Effect of a therapeutic intervention for the hemiplegic upper limb in the acute
phase after stroke: a single-blind, randomized, controlled multicenter trial. Stroke, 29(4), 785-
792.
Figlewski, K., Blicher, J. U., Nielsen, J. F., Severinsen, K., & Andersen, H. (2016). Transcranial direct
current stimulation combined with constraint induced movement therapy facilitates motor
function in chronic stroke patients. European Journal of Neurology, 23, 75.
Fleming, M. K., Sorinola, I. O., Roberts-Lewis, S. F., Wolfe, C. D., Wellwood, I., & Newham, D. J. (2015).
The effect of combined somatosensory stimulation and task-specific training on upper limb
function in chronic stroke: a double-blind randomized controlled trial. Neurorehabil Neural
Repair, 29(2), 143-152. doi: 10.1177/1545968314533613
Fluet, G. G., Merians, A. S., Qiu, Q., Davidow, A., & Adamovich, S. V. (2014). Comparing integrated
training of the hand and arm with isolated training of the same effectors in persons with stroke
using haptically rendered virtual environments, a randomized clinical trial. Journal of
NeuroEngineering and Rehabilitation, 11(1). doi: 10.1186/1743-0003-11-126
Fluet, G. G., Merians, A. S., Qiu, Q., Rohafaza, M., Van Wingerden, A. M., & Adamovich, S. V. (2015).
Does training with traditionally presented and virtually simulated tasks elicit differing changes in

www.ebrsr.com
object interaction kinematics in persons with upper extremity hemiparesis? Topics in stroke
rehabilitation, 22(3), 176-184.
Fluet, G. G., Merians, A. S., Qiu, Q., Rohafaza, M., VanWingerden, A. M., & Adamovich, S. V. (2015). Does
training with traditionally presented and virtually simulated tasks elicit differing changes in
object interaction kinematics in persons with upper extremity hemiparesis? Topics in stroke
rehabilitation, 22(3), 176.
Fox, M., Dickens, A., Greaves, C., Dixon, M., & James, M. (2006). Marma therapy for stroke rehabilitation
-- a pilot study. J.Rehabil.Med., 38(4), 268-271. doi: MU787T487J8V7366
[pii];10.1080/16501970600630820 [doi]
Fragoso, A. P. S., & Ferreira, A. S. (2012). Immediate effects of acupuncture on biceps brachii muscle
function in healthy and post-stroke subjects. Chinese Medicine (United Kingdom).7.,, %2012.
Franceschini, M., Ceravolo, M. G., Agosti, M., Cavallini, P., Bonassi, S., Dall'Armi, V., . . . Sale, P. (2012).
Clinical relevance of action observation in upper-limb stroke rehabilitation: a possible role in
recovery of functional dexterity. A randomized clinical trial. Neurorehabil.Neural Repair, 26(5),
456-462. doi: 1545968311427406 [pii];10.1177/1545968311427406 [doi]
Francis, H. P., Wade, D. T., Turner-Stokes, L., Kingswell, R. S., Dott, C. S., & Coxon, E. A. (2004). Does
reducing spasticity translate into functional benefit? An exploratory meta-analysis.
J.Neurol.Neurosurg.Psychiatry, 75(11), 1547-1551. doi: 75/11/1547
[pii];10.1136/jnnp.2003.025551 [doi]
Francisco, G., Chae, J., Chawla, H., Kirshblum, S., Zorowitz, R., Lewis, G., & Pang, S. (1998).
Electromyogram-triggered neuromuscular stimulation for improving the arm function of acute
stroke survivors: a randomized pilot study. Arch.Phys.Med.Rehabil., 79(5), 570-575. doi: S0003-
9993(98)90074-0 [pii]
Francisco, G. E., Boake, C., & Vaughn, A. (2002). Botulinum toxin in upper limb spasticity after acquired
brain injury: a randomized trial comparing dilution techniques. Am.J.Phys.Med.Rehabil., 81(5),
355-363. doi: 00002060-200205000-00007 [pii]
Fregni, F., Boggio, P. S., Mansur, C. G., Wagner, T., Ferreira, M. J., Lima, M. C., . . . Pascual-Leone, A.
(2005). Transcranial direct current stimulation of the unaffected hemisphere in stroke patients.
NeuroReport, 16(14), 1551-1555. doi: 00001756-200509280-00004 [pii]
Fregni, F., Boggio, P. S., Valle, A. C., Rocha, R. R., Duarte, J., Ferreira, M. J., . . . Pascual-Leone, A. (2006).
A sham-controlled trial of a 5-day course of repetitive transcranial magnetic stimulation of the
unaffected hemisphere in stroke patients. Stroke, 37(8), 2115-2122. doi:
01.STR.0000231390.58967.6b [pii];10.1161/01.STR.0000231390.58967.6b [doi]
French, B., Thomas, L., Leathley, M., Sutton, C., McAdam, J., Forster, A., . . . Watkins, C. (2010). Does
repetitive task training improve functional activity after stroke? A Cochrane systematic review
and meta-analysis. J Rehabil Med, 42(1), 9-14. doi: 10.2340/16501977-0473
French, B., Thomas, L. H., Leathley, M. J., Sutton, C. J., McAdam, J., Forster, A., . . . Watkins, C. L. (2007).
Repetitive task training for improving functional ability after stroke. Cochrane Database Syst
Rev(4), Cd006073. doi: 10.1002/14651858.CD006073.pub2
Friedman, N., Chan, V., Reinkensmeyer, A. N., Beroukhim, A., Zambrano, G. J., Bachman, M., &
Reinkensmeyer, D. J. (2014). Retraining and assessing hand movement after stroke using the
MusicGlove: comparison with conventional hand therapy and isometric grip training. Journal of
NeuroEngineering and Rehabilitation, 11. doi: 10.1186/1743-0003-11-76
Fritz, S. L., Light, K. E., Patterson, T. S., Behrman, A. L., & Davis, S. B. (2005). Active finger extension
predicts outcomes after constraint-induced movement therapy for individuals with hemiparesis
after stroke. Stroke, 36(6), 1172-1177. doi: 01.STR.0000165922.96430.d0
[pii];10.1161/01.STR.0000165922.96430.d0 [doi]
Fu, Q. H., Pei, J., Jia, Q., Song, Y., Gu, Y.-H., & You, X.-X. (2012). Acupuncture treatment programs for
post-stroke motor rehabilitation in community hospitals: Study protocol of a multicenter,

www.ebrsr.com
randomized, controlled trial. Journal of Chinese Integrative Medicine.10 (5) (pp 516.-524.),,
%2012.
Fukuda, H., Morishita, T., Ogata, T., Saita, K., Hyakutake, K., Watanabe, J., . . . Inoue, T. (2016). Tailor-
made rehabilitation approach using multiple types of hybrid assistive limb robots for acute
stroke patients: A pilot study. Assistive Technology, 28(1), 53-56. doi:
10.1080/10400435.2015.1080768
Fusco, A., Assenza, F., Iosa, M., Izzo, S., Altavilla, R., Paolucci, S., & Vernieri, F. (2014). The Ineffective
Role of Cathodal tDCS in Enhancing the Functional Motor Outcomes in Early Phase of Stroke
Rehabilitation: An Experimental Trial. Biomed Research International. doi: 10.1155/2014/547290
Fusco, A., De Angelis, D., Morone, G., Maglione, L., Paolucci, T., Bragoni, M., & Venturiero, V. (2013). The
ABC of tDCS: Effects of Anodal, Bilateral and Cathodal Montages of Transcranial Direct Current
Stimulation in Patients with Stroke-A Pilot Study. Stroke Res Treat, 2013, 837595. doi:
10.1155/2013/837595
Gabr, U., Levine, P., & Page, S. J. (2005). Home-based electromyography-triggered stimulation in chronic
stroke. Clin.Rehabil., 19(7), 737-745.
Galea, M., Miller, K., & Kilbreath, S. (2001). Early task-related training enhances upper limb function
following stroke. Paper presented at the Poster presented at the annual meeting of the Society
for Neural Control of Movement, Sevilla, Spain.
Gallichio, J. E. (2004). Pharmacologic management of spasticity following stroke. Phys.Ther., 84(10), 973-
981.
Garrido-Montenegro, M., Álvarez-Espinoza, E., & Vergara-Ruiz, S. (2016). Use of EMG biofeedback for
basic activities of daily living training in stroke patients. Pilot randomized clinical trial. Revista
Facultad de Medicina, 64(3), 477-483. doi: 10.15446/revfacmed.v64n3.56213
Gebruers, N., Truijen, S., Engelborghs, S., & De Deyn, P. P. (2011). Is activity loss predictive for
development of upper limb oedema after stroke? J.Rehabil.Med., 43(5), 398-403. doi:
10.2340/16501977-0780 [doi]
Gelber, D. A., Good, D. C., Dromerick, A., Sergay, S., & Richardson, M. (2001). Open-label dose-titration
safety and efficacy study of tizanidine hydrochloride in the treatment of spasticity associated
with chronic stroke. Stroke, 32(8), 1841-1846.
Gelber, D. A., Josefczyk, B., Herrman, D., Good, D. C., & Verhulst, S. J. (1995). Comparison of two therapy
approaches in the rehabilitation of the pure motor hemiparetic stroke patient.
Gharib, N. M., Aboumousa, A. M., Elowishy, A. A., Rezk-Allah, S. S., & Yousef, F. S. (2015). Efficacy of
electrical stimulation as an adjunct to repetitive task practice therapy on skilled hand
performance in hemiparetic stroke patients: a randomized controlled trial. Clinical
rehabilitation, 29(4), 355-364.
Gharib, N. M. M., Aboumousa, A. M., Elowishy, A. A., Rezk-Allah, S. S., & Yousef, F. S. (2014). Efficacy of
electrical stimulation as an adjunct to repetitive task practice therapy on skilled hand
performance in hemiparetic stroke patients: A randomized controlled trial. Clinical
Gilmore, P. E., & Spaulding, S. J. (2007). Motor learning and the use of videotape feedback after stroke.
Top Stroke Rehabil, 14(5), 28-36. doi: 10.1310/tsr1405-28
Givon, N., Zeilig, G., Weingarden, H., & Rand, D. (2016). Video-games used in a group setting is feasible
and effective to improve indicators of physical activity in individuals with chronic stroke: A
randomized controlled trial. Clinical rehabilitation, 30(4), 383-392. doi:
http://dx.doi.org/10.1177/0269215515584382
Goodwill, A. M., Teo, W.-P., Morgan, P., Daly, R. M., & Kidgell, D. J. (2016). Bihemispheric-tDCS and
upper limb rehabilitation improves retention of motor function in chronic stroke: A pilot study.
Frontiers in Human Neuroscience, 10, 14.

www.ebrsr.com
Gosman-Hedstrom, G., Claesson, L., Klingenstierna, U., Carlsson, J., Olausson, B., Frizell, M., . . .
Blomstrand, C. (1998). Effects of acupuncture treatment on daily life activities and quality of life:
a controlled, prospective, and randomized study of acute stroke patients. Stroke, 29(10), 2100-
2108.
Goto, H., Satoh, N., Hayashi, Y., Hikiami, H., Nagata, Y., Obi, R., & Shimada, Y. (2009). A Chinese herbal
medicine, tokishakuyakusan, reduces the worsening of impairments and independence after
stroke: a 1-year randomized, controlled trial. Evidence Based Complementary and
AlternativeMedicine, 2011, 34.
Gowland, C. (1982). Recovery of motor function following stroke: profile and predictors. Physiotherapy
Canada, 34(2), 77-84.
Gracies, J. M., Bayle, N., Goldberg, S., & Simpson, D. M. (2014). Botulinum Toxin Type B in the Spastic
Arm: A Randomized, Double-Blind, Placebo-Controlled, Preliminary Study. Archives of Physical
Medicine and Rehabilitation, 95(7), 1303-1311. doi: 10.1016/j.apmr.2014.03.016
Gracies, J. M., Brashear, A., Jech, R., McAllister, P., Banach, M., Valkovic, P., . . . International
Abobotulinumtoxin, A. A. U. L. S. S. G. (2015). Safety and efficacy of abobotulinumtoxinA for
hemiparesis in adults with upper limb spasticity after stroke or traumatic brain injury: a double-
blind randomised controlled trial. Lancet Neurol, 14(10), 992-1001. doi: 10.1016/S1474-
4422(15)00216-1
Gracies, J. M., Marosszeky, J. E., Renton, R., Sandanam, J., Gandevia, S. C., & Burke, D. (2000). Short-
term effects of dynamic lycra splints on upper limb in hemiplegic patients.
[pii];10.1053/apmr.2000.16346 [doi]
Graef, P., Michaelsen, S. M., Dadalt, M. L., Rodrigues, D. A., Pereira, F., & Pagnussat, A. S. (2016). Effects
of functional and analytical strength training on upper-extremity activity after stroke: a
randomized controlled trial. Braz J Phys Ther, 20(6), 543-552. doi: 10.1590/bjpt-rbf.2014.0187
Graef, P., Michaelsen, S. M., Dadalt, M. L. R., Rodrigues, D. A. M. S., Pereira, F., & Pagnussat, A. S. (2016).
Effects of functional and analytical strength training on upper-extremity activity after stroke: a
randomized controlled trial. Brazilian Journal of Physical Therapy, 20(6), 543-552. doi:
10.1590/bjpt-rbf.2014.0187
Greenberg, S., & Fowler, R. S., Jr. (1980). Kinesthetic biofeedback: a treatment modality for elbow range
of motion in hemiplegia. Am.J.Occup.Ther., 34(11), 738-743.
Grotta, J. C., Noser, E. A., Ro, T., Boake, C., Levin, H., Aronowski, J., & Schallert, T. (2004). Constraint-
induced movement therapy. Stroke, 35(11 Suppl 1), 2699-2701. doi:
10.1161/01.STR.0000143320.64953.c4 [doi];01.STR.0000143320.64953.c4 [pii]
Guo, Z., Jin, Y., Peng, H., Xing, G., Liao, X., Wang, Y., . . . Mu, Q. (2016). Ipsilesional High Frequency
Repetitive Transcranial Magnetic Stimulation Add-On Therapy Improved Diffusion Parameters of
Stroke Patients with Motor Dysfunction: A Preliminary DTI Study. Neural Plasticity, 2016. doi:
10.1155/2016/6238575
Gurbuz, N., Afsar, S. I., Ayas, S., & Cosar, S. N. (2016). Effect of mirror therapy on upper extremity motor
function in stroke patients: a randomized controlled trial. J Phys Ther Sci, 28(9), 2501-2506. doi:
10.1589/jpts.28.2501
Hafsteinsdottir, T. B., Algra, A., Kappelle, L. J., & Grypdonck, M. H. (2005). Neurodevelopmental
treatment after stroke: a comparative study. J Neurol Neurosurg Psychiatry, 76(6), 788-792. doi:
10.1136/jnnp.2004.042267
Hafsteinsdottir, T. B., Kappelle, J., Grypdonck, M. H., & Algra, A. (2007). Effects of Bobath-based therapy
on depression, shoulder pain and health-related quality of life in patients after stroke. J Rehabil
Med, 39(8), 627-632. doi: 10.2340/16501977-0097

www.ebrsr.com
Hakkennes, S., & Keating, J. L. (2005). Constraint-induced movement therapy following stroke: a
systematic review of randomised controlled trials. Australian Journal of Physiotherapy, 51(4),
221-231.
Hammer, A., & Lindmark, B. (2009). Is forced use of the paretic upper limb beneficial? A randomized
pilot study during subacute post-stroke recovery. Clin Rehabil, 23(5), 424-433. doi:
10.1177/0269215508101734
Han, C., Wang, Q., Meng, P. P., & Qi, M. Z. (2013). Effects of intensity of arm training on hemiplegic
upper extremity motor recovery in stroke patients: a randomized controlled trial. Clin Rehabil,
27(1), 75-81. doi: 10.1177/0269215512447223
Han, J. S., & Terenius, L. (1982). Neurochemical basis of acupuncture analgesia.
Annu.Rev.Pharmacol.Toxicol., 22, 193-220. doi: 10.1146/annurev.pa.22.040182.001205 [doi]
Han, K. J., & Kim, J. Y. (2016). The effects of bilateral movement training on upper limb function in
chronic stroke patients. Journal of Physical Therapy Science, 28(8), 2299-2302. doi:
10.1589/jpts.28.2299
Han, S.-k., Hao, H.-y., Liu, F.-h., Li, Q., Li, X.-f., & Yang, W.-H. (2015). Effect of meridian sinew row
needling combined with dermal needling on spasticity of post-stroke patients with upper limb
hemiparalysis: a multi-center randomized controlled trial. World Journal of Acupuncture -
Moxibustion, 25(1), 13-18. doi: https://doi.org/10.1016/S1003-5257(15)30003-9
Hara, Y., Ogawa, S., & Muraoka, Y. (2006). Hybrid power-assisted functional electrical stimulation to
improve hemiparetic upper-extremity function. Am.J.Phys.Med.Rehabil., 85(12), 977-985. doi:
10.1097/01.phm.0000247853.61055.f8 [doi];00002060-200612000-00009 [pii]
Hara, Y., Ogawa, S., Tsujiuchi, K., & Muraoka, Y. (2008). A home-based rehabilitation program for the
hemiplegic upper extremity by power-assisted functional electrical stimulation. Disabil.Rehabil.,
30(4), 296-304. doi: 779500685 [pii];10.1080/09638280701265539 [doi]
Harmsen, W. J., Bussmann, J. B., Selles, R. W., Hurkmans, H. L., & Ribbers, G. M. (2015). A Mirror
Therapy-Based Action Observation Protocol to Improve Motor Learning After Stroke.
Harris, J. E., & Eng, J. J. (2010). Strength Training Improves Upper-Limb Function in Individuals With
Stroke A Meta-Analysis. Stroke, 41(1), 136-140.
Harris, J. E., Eng, J. J., Miller, W. C., & Dawson, A. S. (2009). A self-administered Graded Repetitive Arm
Supplementary Program (GRASP) improves arm function during inpatient stroke rehabilitation: a
multi-site randomized controlled trial. Stroke, 40(6), 2123-2128. doi: STROKEAHA.108.544585
Hayner, K., Gibson, G., & Giles, G. M. (2010). Comparison of constraint-induced movement therapy and
bilateral treatment of equal intensity in people with chronic upper-extremity dysfunction after
cerebrovascular accident. Am.J.Occup.Ther., 64(4), 528-539.
Hayward, K. S., Barker, R. N., Brauer, S. G., Lloyd, D., Horsley, S. A., & Carson, R. G. (2013). SMART Arm
with outcome-triggered electrical stimulation: a pilot randomized clinical trial. Top Stroke
Rehabil., 20(4), 289-298.
Heckmann, J., Mokrusch, T., Kr+Âckel, A., Warnke, S., Von Stockert, T., & Neundoerfer, B. (1997). EMG-
triggered electrical muscle stimulation in the treatment of central hemiparesis after a stroke.
European journal of physical medicine & rehabilitation, 7(5), 138-141.
Hemmen, B., & Seelen, H. A. (2007). Effects of movement imagery and electromyography-triggered
feedback on arm hand function in stroke patients in the subacute phase. Clin.Rehabil., 21(7),
587-594. doi: 21/7/587 [pii];10.1177/0269215507075502 [doi]
Henderson, A., Korner-Bitensky, N., & Levin, M. (2007). Virtual reality in stroke rehabilitation: a
systematic review of its effectiveness for upper limb motor recovery. Top.Stroke Rehabil., 14(2),
52-61. doi: R477437HG74GW833 [pii];10.1310/tsr1402-52 [doi]

www.ebrsr.com
Hendy, A. M., & Kidgell, D. J. (2014). Anodal-tDCS applied during unilateral strength training increases
strength and corticospinal excitability in the untrained homologous muscle. Experimental Brain
Research, 232(10), 3243-3252. doi: 10.1007/s00221-014-4016-8
Hesse, S., Heß, A., Cordula, W. C., Kabbert, N., & Buschfort, R. (2014). Effect on arm function and cost of
robot-assisted group therapy in subacute patients with stroke and a moderately to severely
affected arm: A randomized controlled trial. Clinical rehabilitation, 28(7), 637-647. doi:
http://dx.doi.org/10.1177/0269215513516967
Hesse, S., Kuhlmann, H., Wilk, J., Tomelleri, C., & Kirker, S. G. (2008). A new electromechanical trainer for
sensorimotor rehabilitation of paralysed fingers: a case series in chronic and acute stroke
patients. J.Neuroeng.Rehabil., 5, 21. doi: 1743-0003-5-21 [pii];10.1186/1743-0003-5-21 [doi]
Hesse, S., Mach, H., Frohlich, S., Behrend, S., Werner, C., & Melzer, I. (2012). An early botulinum toxin A
treatment in subacute stroke patients may prevent a disabling finger flexor stiffness six months
later: a randomized controlled trial. Clin.Rehabil., 26(3), 237-245. doi: 0269215511421355
[pii];10.1177/0269215511421355 [doi]
Hesse, S., Reiter, F., Konrad, M., & Jahnke, M. T. (1998). Botulinum toxin type A and short-term electrical
stimulation in the treatment of upper limb flexor spasticity after stroke: a randomized, double-
blind, placebo-controlled trial. Clin.Rehabil., 12(5), 381-388.
Hesse, S., Waldner, A., Mehrholz, J., Tomelleri, C., Pohl, M., & Werner, C. (2011). Combined Transcranial
Direct Current Stimulation and Robot-Assisted Arm Training in Subacute Stroke Patients An
Exploratory, Randomized Multicenter Trial. Neurorehabilitation and Neural Repair, 25(9), 838-
846.
Hesse, S., Werner, C., Pohl, M., Rueckriem, S., Mehrholz, J., & Lingnau, M. L. (2005). Computerized Arm
Training Improves the Motor Control of the Severely Affected Arm After Stroke A Single-Blinded
Randomized Trial in Two Centers. Stroke, 36(9), 1960-1966.
Higgins, J., Koski, L., & Xie, H. (2013). Combining rTMS and task-oriented training in the rehabilitation of
the arm after stroke: A pilot randomized controlled trial. Stroke Research and Treatment. doi:
10.1155/2013/539146
Higgins, J., Salbach, N. M., Wood-Dauphinee, S., Richards, C. L., Cote, R., & Mayo, N. E. (2006). The effect
of a task-oriented intervention on arm function in people with stroke: a randomized controlled
trial. Clin.Rehabil., 20(4), 296-310.
Hiraoka, K. (2001). Rehabilitation effort to improve upper extremity function in post-stroke patients: A
meta-analysis. Journal of Physical Therapy Science, 13(1), 5-9.
Holland, B., & Pokorny, M. E. (2001). Slow stroke back massage: its effect on patients in a rehabilitation
setting. Rehabil.Nurs., 26(5), 182-186.
Hopwood, V., Lewith, G., Prescott, P., & Campbell, M. J. (2008). Evaluating the efficacy of acupuncture in
defined aspects of stroke recovery: a randomised, placebo controlled single blind study.
J.Neurol., 255(6), 858-866. doi: 10.1007/s00415-008-0790-1 [doi]
Horsley, S. A., Herbert, R. D., & Ada, L. (2007). Four weeks of daily stretch has little or no effect on wrist
contracture after stroke: a randomised controlled trial. Aust.J.Physiother., 53(4), 239-245.
Hosomi, K., Morris, S., Sakamoto, T., Taguchi, J., Maruo, T., Kageyama, Y., . . . Saitoh, Y. (2016). Daily
Repetitive Transcrial Magnetic Stimulation for Poststroke Upper Limb Paresis in the Subacute
Periodan. Journal of Stroke and Cerebrovascular Diseases, 25(7), 1655-1664. doi:
10.1016/j.jstrokecerebrovasdis.2016.02.024
Howlett, O. A., Lannin, N. A., Ada, L., & McKinstry, C. (2015). Functional Electrical Stimulation Improves
Activity After Stroke: A Systematic Review With Meta-Analysis. Archives of Physical Medicine
and Rehabilitation, 96(5), 934-943. doi: 10.1016/j.apmr.2015.01.013
Hoyer, E. H., & Celnik, P. A. (2011). Understanding and enhancing motor recovery after stroke using
transcranial magnetic stimulation. Restor Neurol Neurosci, 29(6), 395-409. doi: 10.3233/rnn-
2011-0611

www.ebrsr.com
Hsieh, R. L., Wang, L. Y., & Lee, W. C. (2007). Additional therapeutic effects of electroacupuncture in
conjunction with conventional rehabilitation for patients with first-ever ischaemic stroke.
J.Rehabil.Med., 39(3), 205-211. doi: 10.2340/16501977-0032 [doi]
Hsieh, R. L., Wang, L. Y., & Lee, W. C. (2007). Additional therapeutic effects of electroacupuncture in
conjunction with conventional rehabilitation for patients with first-ever ischaemic stroke. J
Rehabil Med, 39(3), 205-211. doi: 10.2340/16501977-0032
Hsieh, Y. W., Liing, R. J., Lin, K. C., Wu, C. Y., Liou, T. H., Lin, J. C., & Hung, J. W. (2016). Sequencing
bilateral robot-assisted arm therapy and constraint-induced therapy improves reach to press
and trunk kinematics in patients with stroke. J Neuroeng Rehabil, 13, 31. doi: 10.1186/s12984-
016-0138-5
Hsieh, Y. W., Lin, K. C., Horng, Y. S., Wu, C. Y., Wu, T. C., & Ku, F. L. (2014). Sequential combination of
robot-assisted therapy and constraint-induced therapy in stroke rehabilitation: a randomized
controlled trial. Journal of Neurology, 261(5), 1037-1045. doi: 10.1007/s00415-014-7345-4
Hsieh, Y. W., Wu, C. Y., Liao, W. W., Lin, K. C., Wu, K. Y., & Lee, C. Y. (2011). Effects of treatment intensity
in upper limb robot-assisted therapy for chronic stroke: a pilot randomized controlled trial.
Neurorehabil.Neural Repair, 25(6), 503-511. doi: 1545968310394871
[pii];10.1177/1545968310394871 [doi]
Hsieh, Y. W., Wu, C. Y., Lin, K. C., Yao, G., Wu, K. Y., & Chang, Y. J. (2012). Dose-response relationship of
robot-assisted stroke motor rehabilitation: the impact of initial motor status. Stroke, 43(10),
2729-2734. doi: STROKEAHA.112.658807 [pii];10.1161/STROKEAHA.112.658807 [doi]
Hsing, W. T., Imamura, M., Weaver, K., Fregni, F., & Azevedo Neto, R. S. (2012). Clinical effects of scalp
electrical acupuncture in stroke: a sham-controlled randomized clinical trial. J Altern
Complement Med, 18(4), 341-346. doi: 10.1089/acm.2011.0131
Hsu, S. S., Hu, M. H., Wang, Y. H., Yip, P. K., Chiu, J. W., & Hsieh, C. L. (2010). Dose-response relation
between neuromuscular electrical stimulation and upper-extremity function in patients with
stroke. Stroke, 41(4), 821-824. doi: STROKEAHA.109.574160
Hsu, W. Y., Cheng, C. H., Liao, K. K., Lee, I. H., & Lin, Y. Y. (2012). Effects of repetitive transcranial
magnetic stimulation on motor functions in patients with stroke: a meta-analysis. Stroke, 43(7),
1849-1857. doi: 10.1161/strokeaha.111.649756
Hsu, Y. F., Huang, Y. Z., Lin, Y. Y., Tang, C. W., Liao, K. K., Lee, P. L., . . . Lee, I. H. (2013). Intermittent theta
burst stimulation over ipsilesional primary motor cortex of subacute ischemic stroke patients: A
pilot study. Brain Stimulation, 6(2), 166-174. doi: 10.1016/j.brs.2012.04.007
Hu, H. H., Chung, C., Liu, T. J., Chen, R. C., Chen, C. H., Chou, P., . . . Tsuei, J. J. (1993). A randomized
controlled trial on the treatment for acute partial ischemic stroke with acupuncture.
Neuroepidemiology, 12(2), 106-113.
Hu, X. L., Tong, K. Y., Song, R., Zheng, X. J., & Leung, W. W. (2009). A comparison between
electromyography-driven robot and passive motion device on wrist rehabilitation for chronic
stroke. Neurorehabil.Neural Repair, 23(8), 837-846. doi: 1545968309338191
[pii];10.1177/1545968309338191 [doi]
Hu, X. L., Tong, R. K. Y., Ho, N. S. K., Xue, J. J., Rong, W., & Li, L. S. W. (2015). Wrist Rehabilitation Assisted
by an Electromyography-Driven Neuromuscular Electrical Stimulation Robot after Stroke.
Huang, M., Harvey, R. L., Stoykov, M. E., Ruland, S., Weinand, M., Lowry, D., & Levy, R. (2008). Cortical
stimulation for upper limb recovery following ischemic stroke: a small phase II pilot study of a
fully implanted stimulator. Top.Stroke Rehabil., 15(2), 160-172. doi: X8H3137733K12678
[pii];10.1310/tsr1502-160 [doi]

www.ebrsr.com
Hubbard, I. J., Carey, L. M., Budd, T. W., Levi, C., McElduff, P., Hudson, S., . . . Parsons, M. W. (2015). A
Randomized Controlled Trial of the Effect of Early Upper-Limb Training on Stroke Recovery and
Brain Activation. Neurorehabil Neural Repair, 29(8), 703-713. doi: 10.1177/1545968314562647
Hummel, F., Celnik, P., Giraux, P., Floel, A., Wu, W. H., Gerloff, C., & Cohen, L. G. (2005). Effects of non-
invasive cortical stimulation on skilled motor function in chronic stroke. Brain, 128(Pt 3), 490-
499. doi: awh369 [pii];10.1093/brain/awh369 [doi]
Hummelsheim, H., & Eickhof, C. (1999). Repetitive sensorimotor training for arm and hand in a patient
with locked-in syndrome. Scand.J.Rehabil.Med., 31(4), 250-256.
Hung, C.-s., Hsieh, Y.-w., Wu, C.-y., Lin, Y.-t., Lin, K.-c., & Chen, C.-l. (2016). The Effects of Combination of
Robot-Assisted Therapy With Task-Specific or Impairment-Oriented Training on Motor Function
and Quality of Life in Chronic Stroke. PM&R, 8(8), 721-729. doi:
https://doi.org/10.1016/j.pmrj.2016.01.008
Hunter, S. M., Hammett, L., Ball, S., Smith, N., Anderson, C., Clark, A., . . . Pomeroy, V. M. (2011). Dose-
response study of mobilisation and tactile stimulation therapy for the upper extremity early
after stroke: a phase I trial. Neurorehabil.Neural Repair, 25(4), 314-322. doi: 1545968310390223
[pii];10.1177/1545968310390223 [doi]
Hurd, W. W., Pegram, V., & Nepomuceno, C. (1980). Comparison of actual and simulated EMG
biofeedback in the treatment of hemiplegic patients. Am.J.Phys.Med., 59(2), 73-82.
Huseyinsinoglu BE, O. A., Krespi Y. (2012). Bobath Concept versus constraint-induced movement therapy
to improve arm functional recovery in stroke patients: a randomized controlled trial. Clin
Rehabil, 26(8), 705-715.
Hwang, C. H., Seong, J. W., & Son, D. S. (2012). Individual finger synchronized robot-assisted hand
rehabilitation in subacute to chronic stroke: a prospective randomized clinical trial of efficacy.
Clin.Rehabil., 26(8), 696-704. doi: 0269215511431473 [pii];10.1177/0269215511431473 [doi]
HyeonHui, S., & GyuChang, L. (2013). Additional Virtual Reality Training Using Xbox Kinect in Stroke
Survivors with Hemiplegia. American Journal of Physical Medicine & Rehabilitation, 92(10), 871-
880. doi: 10.1097/PHM.0b013e3182a38e40
Ietswaart, M., Johnston, M., Dijkerman, H. C., Joice, S., Scott, C. L., MacWalter, R. S., & Hamilton, S. J.
(2011). Mental practice with motor imagery in stroke recovery: randomized controlled trial of
efficacy. Brain, 134(Pt 5), 1373-1386. doi: awr077 [pii];10.1093/brain/awr077 [doi]
Ikuno, K., Kawaguchi, S., Kitabeppu, S., Kitaura, M., Tokuhisa, K., Morimoto, S., . . . Shomoto, K. (2012).
Effects of peripheral sensory nerve stimulation plus task-oriented training on upper extremity
function in patients with subacute stroke: a pilot randomized crossover trial. Clin.Rehabil.,
26(11), 999-1009. doi: 0269215512441476 [pii];10.1177/0269215512441476 [doi]
Ilic, N. V., Dubljanin-Raspopovic, E., Nedeljkovic, U., Tomanovic-Vujadinovic, S., Milanovic, S. D.,
Petronic-Markovic, I., & Ilic, T. V. (2016). Effects of anodal tDCS and occupational therapy on fine
motor skill deficits in patients with chronic stroke. Restor Neurol Neurosci, 34(6), 935-945. doi:
10.3233/rnn-160668
Inglis, J., Donald, M. W., Monga, T. N., Sproule, M., & Young, M. J. (1984). Electromyographic
biofeedback and physical therapy of the hemiplegic upper limb. Arch.Phys.Med.Rehabil., 65(12),
755-759.
Inobe, J., & Kato, T. (2013). Effectiveness of finger-equipped electrode (FEE)-triggered electrical
stimulation improving chronic stroke patients with severe hemiplegia. Brain Injury, 27(1), 114-
119. doi: 10.3109/02699052.2012.729283
Invernizzi, M., Negrini, S., Carda, S., Lanzotti, L., Cisari, C., & Baricich, A. (2013). The value of adding
mirror therapy for upper limb motor recovery of subacute stroke patients: a randomized
controlled trial. European Journal of Physical and Rehabilitation Medicine, 49(3), 311-317.
Ivanhoe, C. B. E.-R., N. K. (2009). Botulinum Toxin Type A and Post-stroke Spasticity of the Upper Limbs.
US Neurology, 5(1), 38-40. doi: http://doi.org/10.17925/USN.2009.05.01.38

www.ebrsr.com
Jahangir, A. W., Tan, H. J., Norlinah, M. I., Nafisah, W. Y., Ramesh, S., Hamidon, B. B., & Raymond, A. A.
(2007). Intramuscular injection of botulinum toxin for the treatment of wrist and finger
spasticity after stroke. Med.J.Malaysia, 62(4), 319-322.
Jang, S. H., You, S. H., Hallett, M., Cho, Y. W., Park, C. M., Cho, S. H., . . . Kim, T. H. (2005). Cortical
reorganization and associated functional motor recovery after virtual reality in patients with
chronic stroke: an experimenter-blind preliminary study. Arch.Phys.Med.Rehabil., 86(11), 2218-
2223. doi: S0003-9993(05)00411-9 [pii];10.1016/j.apmr.2005.04.015 [doi]
Jang, Y. Y., Kim, T. H., & Lee, B. H. (2016). Effects of Brain-Computer Interface-controlled Functional
Electrical Stimulation Training on Shoulder Subluxation for Patients with Stroke: A Randomized
Controlled Trial. Occupational Therapy International, 23(2), 175-185.
Jeon, H.-J., An, S., Yoo, J., Park, N.-H., & Lee, K. H. (2016). The effect of Monkey Chair and Band exercise
system on shoulder range of motion and pain in post-stroke patients with hemiplegia. Journal of
Physical Therapy Science, 28(8), 2232-2237. doi: 10.1589/jpts.28.2232
Ji, S. G., Cha, H. G., & Kim, M. K. (2014). Stroke recovery can be enhanced by using repetitive transcranial
magnetic stimulation combined with mirror therapy. Journal of Magnetics, 19(1), 28-31. doi:
10.4283/JMAG.2014.19.1.028
Johansson, B. B., Haker, E., von Arbin, M., Britton, M., LÃ¥ngstrÃ¶m, G. Ã., TerÃ©nt, A., . . . Asplund, K.
(2001). Acupuncture and Transcutaneous Nerve Stimulation in Stroke Rehabilitation A
Randomized, Controlled Trial. Stroke, 32(3), 707-713.
Johansson, T., & Wild, C. (2010). Telemedicine in acute stroke management: systematic review. Int J
Technol Assess Health Care, 26(2), 149-155. doi: 10.1017/s0266462310000139
Jongbloed, L., Stacey, S., & Brighton, C. (1989). Stroke rehabilitation: sensorimotor integrative treatment
versus functional treatment. Am.J.Occup.Ther., 43(6), 391-397.
Jun, E. M., Roh, Y. H., & Kim, M. J. (2013). The effect of music-movement therapy on physical and
psychological states of stroke patients. Journal of Clinical Nursing, 22(1-2), 22-31. doi:
10.1111/j.1365-2702.2012.04243.x
Jung, Y. J., Hong, J. H., Kwon, H. G., Song, J. C., Kim, C., Park, S., . . . Jang, S. H. (2011). The effect of a
stretching device on hand spasticity in chronic hemiparetic stroke patients. Neurorehabilitation,
29(1), 53-59. doi: 10.3233/NRE-2011-0677
Kahn, L. E., Zygman, M. L., Rymer, W. Z., & Reinkensmeyer, D. J. (2006). Robot-assisted reaching exercise
promotes arm movement recovery in chronic hemiparetic stroke: a randomized controlled pilot
study. J.Neuroeng.Rehabil., 3, 12. doi: 1743-0003-3-12 [pii];10.1186/1743-0003-3-12 [doi]
Kaji, R., Osako, Y., Suyama, K., Maeda, T., Uechi, Y., & Iwasaki, M. (2010). Botulinum toxin type A in post-
stroke upper limb spasticity. Curr.Med.Res.Opin., 26(8), 1983-1992. doi:
10.1185/03007995.2010.497103 [doi]
Kang, H. S., Sok, S. R., & Kang, J. S. (2009). Effects of Meridian acupressure for stroke patients in Korea.
J.Clin Nurs., 18(15), 2145-2152. doi: JCN2522 [pii];10.1111/j.1365-2702.2008.02522.x [doi]
Karakus, D., Erso, Z. M., Koyuncu, G., Turk, D., Sasmaz, F. M., & Akyu, Z. M. (2013). Effects of functional
electrical stimulation on wrist function and spasticity in stroke: A randomized controlled study.
[Inmede fonksiyonel elektrik stimulasyonunun el bilegi fonksiyonlari{dotless} ve spastisiteye
etkisi: Randomize kontrollu bir cali{dotless}sma.]. Turkiye Fiziksel Tip ve Rehabilitasyon Dergisi,
59(2), 97-102.
Karni, A., Meyer, G., Jezzard, P., Adams, M. M., Turner, R., & Ungerleider, L. G. (1995). Functional MRI
evidence for adult motor cortex plasticity during motor skill learning. Nature, 377(6545), 155-
158. doi: 10.1038/377155a0 [doi]
Kasashima-Shindo, Y., Fujiwara, T., Ushiba, J., Matsushika, Y., Kamatani, D., Oto, M., . . . Liu, M. (2015).
Brain-computer interface training combined with transcranial direct current stimulation in
patients with chronic severe hemiparesis: Proof of concept study. Journal of Rehabilitation
Medicine, 47(4), 318-324.

www.ebrsr.com
Khan, C. M., Oesch, P. R., Gamper, U. N., Kool, J. P., & Beer, S. (2011). Potential effectiveness of three
different treatment approaches to improve minimal to moderate arm and hand function after
stroke--a pilot randomized clinical trial. Clin Rehabil, 25(11), 1032-1041. doi:
10.1177/0269215511399795
Khedr, E., Shawky, O., El-Hammady, D., Rothwell, J., Darwish, E., Mostafa, O., & Tohamy, A. (2013).
Effect of anodal versus cathodal transcranial direct current stimulation on, stroke rehabilitation:
A pilot randomized controlled trial. Neurorehabilitation and Neural Repair, 27(7), 592-601.
Khedr, E. M., Abdel-Fadeil, M. R., Farghali, A., & Qaid, M. (2009). Role of 1 and 3 Hz repetitive
transcranial magnetic stimulation on motor function recovery after acute ischaemic stroke.
Eur.J.Neurol., 16(12), 1323-1330. doi: ENE2746 [pii];10.1111/j.1468-1331.2009.02746.x [doi]
Khedr, E. M., Ahmed, M. A., Fathy, N., & Rothwell, J. C. (2005). Therapeutic trial of repetitive transcranial
magnetic stimulation after acute ischemic stroke. Neurology, 65(3), 466-468. doi: 65/3/466
[pii];10.1212/01.wnl.0000173067.84247.36 [doi]
Khedr, E. M., Etraby, A. E., Hemeda, M., Nasef, A. M., & Razek, A. A. (2010). Long-term effect of
repetitive transcranial magnetic stimulation on motor function recovery after acute ischemic
stroke. Acta Neurol.Scand., 121(1), 30-37. doi: ANE1195 [pii];10.1111/j.1600-0404.2009.01195.x
[doi]
Kho, A. Y., Liu, K. P., & Chung, R. C. (2014). Meta-analysis on the effect of mental imagery on motor
recovery of the hemiplegic upper extremity function. Australian occupational therapy journal,
61(2), 38-48. doi: 10.1111/1440-1630.12084
Kim, B. R., & Lee, J. (2014). The usefulness of transcranial magnetic stimulation and diffusion tensor
tractography for evaluation of stroke recovery. PM and R, 1), S293.
Kim, C.-Y., Lee, J.-S., Lee, J.-H., Kim, Y.-G., Shin, A. R., Shim, Y.-H., & Ha, H. K. (2015). Effect of spatial
target reaching training based on visual biofeedback on the upper extremity function of
hemiplegic stroke patients. Journal of Physical Therapy Science, 27(4), 1091-1096. doi:
10.1589/jpts.27.1091
Kim, D. H., Shin, J. C., Jung, S., Jung, T. M., & Kim, D. Y. (2015). Effects of intermittent theta burst
stimulation on spasticity after stroke. NeuroReport, 26(10), 561-566. doi:
10.1097/WNR.0000000000000388
Kim, D. Y., Lim, J. Y., Kang, E. K., You, D. S., Oh, M. K., Oh, B. M., & Paik, N. J. (2010). Effect of transcranial
direct current stimulation on motor recovery in patients with subacute stroke.
Am.J.Phys.Med.Rehabil., 89(11), 879-886. doi: 10.1097/PHM.0b013e3181f70aa7
[doi];00002060-201011000-00004 [pii]
Kim, D. Y., Ohn, S. H., Yang, E. J., Park, C. I., & Jung, K. J. (2009). Enhancing motor performance by anodal
transcranial direct current stimulation in subacute stroke patients. Am.J.Phys.Med.Rehabil.,
88(10), 829-836. doi: 10.1097/PHM.0b013e3181b811e3 [doi];00002060-200910000-00008 [pii]
Kim, E., & Kim, K. (2015a). Effect of purposeful action observation on upper extremity function in stroke
patients. J Phys Ther Sci, 27(9), 2867-2869. doi: 10.1589/jpts.27.2867
Kim, E., & Kim, K. (2015b). Effects of purposeful action observation on kinematic patterns of upper
extremity in individuals with hemiplegia. Journal of Physical Therapy Science, 27(6), 1809-1811.
Kim, E. B., & Kim, Y. D. (2015). Effects of kinesiology taping on the upper-extremity function and
activities of daily living in patients with hemiplegia. J Phys Ther Sci, 27(5), 1455-1457. doi:
10.1589/jpts.27.1455
Kim, E. H., Jang, M. C., Seo, J. P., Jang, S. H., Song, J. C., & Jo, H. M. (2013). The effect of a hand-
stretching device during the management of spasticity in chronic hemiparetic stroke patients.
Annals of Rehabilitation Medicine, 37(2), 235-240. doi: 10.5535/arm.2013.37.2.235
Kim, H., Lee, G., & Song, C. (2014). Effect of Functional Electrical Stimulation with Mirror Therapy on
Upper Extremity Motor Function in Poststroke Patients. Journal of Stroke & Cerebrovascular
Diseases, 23(4), 655-661. doi: 10.1016/j.jstrokecerebrovasdis.2013.06.017

www.ebrsr.com
Kim, H., Miller, L. M., Fedulow, I., Simkins, M., Abrams, G. M., Byl, N., & Rosen, J. (2013). Kinematic data
analysis for post-stroke patients following bilateral versus unilateral rehabilitation with an upper
limb wearable robotic system. IEEE Trans Neural Syst Rehabil Eng, 21(2), 153-164. doi:
10.1109/tnsre.2012.2207462
Kim, J.-r., Jung, M.-y., Yoo, E.-y., Park, J.-H., Kim, S.-H., & Lee, J. (2014). Effects of Rhythmic Auditory
Stimulation During Hemiplegic Arm Reaching in Individuals with Stroke: An Exploratory Study.
Hong Kong Journal of Occupational Therapy, 24(2), 64-71. doi: 10.1016/j.hkjot.2014.11.002
Kim, J. H., & Lee, B.-H. (2015). Mirror Therapy Combined With Biofeedback Functional Electrical
Stimulation for Motor Recovery of Upper Extremities After Stroke: A Pilot Randomized
Controlled Trial. Occupational Therapy International, 22(2), 51-60. doi: 10.1002/oti.1384
Kim, J. R., Jung, M. Y., Yoo, E. Y., Park, J. H., Kim, S. H., & Lee, J. (2014). Effects of Rhythmic Auditory
Stimulation During Hemiplegic Arm Reaching in Individuals with Stroke: An Exploratory Study.
Hong Kong Journal of Occupational Therapy, 24(2), 64-71. doi: 10.1016/j.hkjot.2014.11.002
Kim, K., Lee, H. Y., & Lee, J. H. (2015). Three-dimensional angular kinematics of the paretic lower limb
according to different orthotic angles of an ankle-foot-orthosis in stroke patients. Physiotherapy
(United Kingdom), 101, eS750-eS751.
Kim, M. K. (2014). Repetitive Transcranial Magnetic Stimulation Combined with Task Oriented Training
to Improve Upper Extremity Function After Stroke. Journal of Magnetics, 19(2), 170-173. doi:
10.4283/jmag.2014.19.2.170
Kim, S. H., Park, J. H., Jung, M. Y., & Yoo, E. Y. (2016). Effects of Task‐Oriented Training as an Added
Treatment to Electromyogram‐Triggered Neuromuscular Stimulation on Upper Extremity
Function in Chronic Stroke Patients. Occupational Therapy International, 23(2), 165-174. doi:
10.1002/oti.1421
Kim, S. Y., Shin, S. B., Lee, S. J., Kim, T. U., & Hyun, J. K. (2016). Factors Associated With Upper Extremity
Functional Recovery Following Low-Frequency Repetitive Transcranial Magnetic Stimulation in
Stroke Patients. Ann Rehabil Med, 40(3), 373-382. doi: 10.5535/arm.2016.40.3.373
Kim, T., Kim, S., & Lee, B. (2016). Effects of action observational training plus brain–computer interface‐
based functional electrical stimulation on paretic arm motor recovery in patient with stroke: A
randomized controlled trial. Occupational Therapy International, 23(1), 39-47. doi:
http://dx.doi.org/10.1002/oti.1403
Kim, T. H., In, T. S., & Cho, H. Y. (2013a). Task-related training combined with transcutaneous electrical
nerve stimulation promotes upper limb functions in patients with chronic stroke. Tohoku J Exp
Med, 231(2), 93-100.
Kim, T. H., In, T. S., & Cho, H. Y. (2013b). Task-related training combined with transcutaneous electrical
nerve stimulation promotes upper limb functions in patients with chronic stroke. Tohoku Journal
of Experimental Medicine, 231(2), 93-100. doi: 10.1620/tjem.231.93
Kimberley, T. J., Lewis, S. M., Auerbach, E. J., Dorsey, L. L., Lojovich, J. M., & Carey, J. R. (2004). Electrical
stimulation driving functional improvements and cortical changes in subjects with stroke.
Exp.Brain Res., 154(4), 450-460. doi: 10.1007/s00221-003-1695-y [doi]
King TI, I. I. (1996). The effect of neuromuscular electrical stimulation in reducing tone.
Am.J.Occup.Ther., 50(1), 62-64.
Kiper, P., Agostini, M., Luque-Moreno, C., Tonin, P., & Turolla, A. (2014). Reinforced Feedback in Virtual
Environment for Rehabilitation of Upper Extremity Dysfunction after Stroke: Preliminary Data
from a Randomized Controlled Trial. Biomed Research International. doi: 10.1155/2014/752128
Kjendahl, A., Sallstrom, S., Osten, P. E., Stanghelle, J. K., & Borchgrevink, C. F. (1997). A one year follow-
up study on the effects of acupuncture in the treatment of stroke patients in the subacute stage:
a randomized, controlled study. Clin Rehabil., 11(3), 192-200.

www.ebrsr.com
Klaiput, A., & Kitisomprayoonkul, W. (2009). Increased pinch strength in acute and subacute stroke
patients after simultaneous median and ulnar sensory stimulation. Neurorehabil.Neural Repair,
23(4), 351-356. doi: 1545968308324227 [pii];10.1177/1545968308324227 [doi]
Klamroth-Marganska, V., Blanco, J., Campen, K., Curt, A., Dietz, V., Ettlin, T., . . . Riener, R. (2014). Three-
dimensional, task-specific robot therapy of the arm after stroke: a multicentre, parallel-group
randomised trial. Lancet Neurology, 13(2), 159-166. doi: 10.1016/s1474-4422(13)70305-3
Knutson, J. S., Gunzler, D. D., Wilson, R. D., & Chae, J. (2016). Contralaterally Controlled Functional
Electrical Stimulation Improves Hand Dexterity in Chronic Hemiparesis: A Randomized Trial.
Stroke, 47(10), 2596-2602.
Knutson, J. S., Harley, M. Y., Hisel, T. Z., Hogan, S. D., Maloney, M. M., & Chae, J. (2012). Contralaterally
controlled functional electrical stimulation for upper extremity hemiplegia: an early-phase
randomized clinical trial in subacute stroke patients. Neurorehabil.Neural Repair, 26(3), 239-246.
doi: 1545968311419301 [pii];10.1177/1545968311419301 [doi]
Kojima, K., Ikuno, K., Morii, Y., Tokuhisa, K., Morimoto, S., & Shomoto, K. (2014). Feasibility study of a
combined treatment of electromyography-triggered neuromuscular stimulation and mirror
therapy in stroke patients: A randomized crossover trial. Neurorehabilitation, 34(2), 235-244.
doi: 10.3233/nre-131038
Kong, K. H., & Chua, K. S. (1999). Neurolysis of the musculocutaneous nerve with alcohol to treat
poststroke elbow flexor spasticity. Arch.Phys.Med.Rehabil., 80(10), 1234-1236. doi: S0003-
9993(99)90021-7 [pii]
Kong, K. H., & Chua, K. S. (2002). Intramuscular neurolysis with alcohol to treat post-stroke finger flexor
spasticity. Clin Rehabil, 16(4), 378-381.
Kong, K. H., Loh, Y. J., Thia, E., Chai, A., Ng, C. Y., Soh, Y. M., . . . Tjan, S. Y. (2016). Efficacy of a virtual
reality commercial gaming device in upper limb recovery after stroke: A randomized, controlled
study. Topics in stroke rehabilitation, 23(5), 333-340.
Kong, K. H., Wee, S. K., Ng, C. Y., Chua, K., Chan, K. F., Venketasubramanian, N., & Chen, C. (2009). A
double-blind, placebo-controlled, randomized phase II pilot study to investigate the potential
efficacy of the traditional chinese medicine Neuroaid (MLC 601) in enhancing recovery after
stroke (TIERS). Cerebrovasc.Dis., 28(5), 514-521. doi: 000247001 [pii];10.1159/000247001 [doi]
Kowalczewski, J., Gritsenko, V., Ashworth, N., Ellaway, P., & Prochazka, A. (2007). Upper-extremity
functional electric stimulation-assisted exercises on a workstation in the subacute phase of
stroke recovery. Arch.Phys.Med.Rehabil., 88(7), 833-839. doi: S0003-9993(07)00264-X
[pii];10.1016/j.apmr.2007.03.036 [doi]
Kraft, G. H., Fitts, S. S., & Hammond, M. C. (1992). Techniques to improve function of the arm and hand
in chronic hemiplegia. Arch.Phys.Med.Rehabil., 73(3), 220-227. doi: 0003-9993(92)90067-7 [pii]
Krebs, H. I., Volpe, B. T., Ferraro, M., Fasoli, S., Palazzolo, J., Rohrer, B., . . . Hogan, N. (2002). Robot-
aided neurorehabilitation: from evidence-based to science-based rehabilitation. Top.Stroke
Rehabil., 8(4), 54-70.
Krewer, C., Hartl, S., MÃ¼ller, F., & Koenig, E. (2014). Effects of Repetitive Peripheral Magnetic
Stimulation on Upper-Limb Spasticity and Impairment in Patients With Spastic Hemiparesis: A
Randomized, Double-Blind, Sham-Controlled Study. Archives of Physical Medicine &
Rehabilitation, 95(6), 1039-1047. doi: 10.1016/j.apmr.2014.02.003
Kuk, E. J., Kim, J. M., Oh, D. W., & Hwang, H. J. (2016). Effects of action observation therapy on hand
dexterity and EEG-based cortical activation patterns in patients with post-stroke hemiparesis.
Top Stroke Rehabil, 23(5), 318-325. doi: 10.1080/10749357.2016.1157972
Kutner, N. G., Zhang, R., Butler, A. J., Wolf, S. L., & Alberts, J. L. (2010). Quality-of-life change associated
with robotic-assisted therapy to improve hand motor function in patients with subacute stroke:
a randomized clinical trial. Phys.Ther., 90(4), 493-504. doi: ptj.20090160
[pii];10.2522/ptj.20090160 [doi]

www.ebrsr.com
Kwakkel, G., Kollen, B. J., van der Grond, J., & Prevo, A. J. (2003). Probability of regaining dexterity in the
flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. Stroke,
34(9), 2181-2186. doi: 10.1161/01.STR.0000087172.16305.CD
[doi];01.STR.0000087172.16305.CD [pii]
Kwakkel, G., van Dijk, G. M., & Wagenaar, R. C. (2000). Accuracy of physical and occupational therapists'
early predictions of recovery after severe middle cerebral artery stroke. Clin.Rehabil., 14(1), 28-
41.
Kwakkel, G., Wagenaar, R. C., Twisk, J. W., Lankhorst, G. J., & Koetsier, J. C. (1999). Intensity of leg and
arm training after primary middle-cerebral-artery stroke: a randomised trial. Lancet, 354(9174),
191-196. doi: S0140-6736(98)09477-X [pii];10.1016/S0140-6736(98)09477-X [doi]
Kwakkel, G., Winters, C., van Wegen, E. E., Nijland, R. H., van Kuijk, A. A., Visser-Meily, A., . . .
Consortium, E. X.-S. (2016). Effects of Unilateral Upper Limb Training in Two Distinct Prognostic
Groups Early After Stroke: The EXPLICIT-Stroke Randomized Clinical Trial. Neurorehabil Neural
Repair, 30(9), 804-816. doi: 10.1177/1545968315624784
Kwon, T. G., Park, E., Kang, C., Chang, W. H., & Kim, Y. H. (2016). The effects of combined repetitive
transcranial magnetic stimulation and transcranial direct current stimulation on motor function
in patients with stroke. Restorative Neurology and Neuroscience, 34(6), 915-923. doi:
10.3233/RNN-160654
Lai, C. J., Wang, C. P., Tsai, P. Y., Chan, R. C., Lin, S. H., Lin, F. G., & Hsieh, C. Y. (2015). Corticospinal
integrity and motor impairment predict outcomes after excitatory repetitive transcranial
magnetic stimulation: A preliminary study. Archives of Physical Medicine and Rehabilitation,
96(1), 69-75.
Lai, S., Panarese, A., Spalletti, C., Alia, C., Ghionzoli, A., Caleo, M., & Micera, S. (2015). Quantitative
Kinematic Characterization of Reaching Impairments in Mice After a Stroke. Neurorehabilitation
and Neural Repair, 29(4), 382-392. doi: 10.1177/1545968314545174
Lam, Y. S., Man, D. W., Tam, S. F., & Weiss, P. L. (2006). Virtual reality training for stroke rehabilitation.
NeuroRehabilitation., 21(3), 245-253.
Lang Catherine, E., Strube Michael, J., Bland Marghuretta, D., Waddell Kimberly, J., Cherry‐Allen Kendra,
M., Nudo Randolph, J., . . . Birkenmeier Rebecca, L. (2016). Dose response of task‐specific upper
limb training in people at least 6 months poststroke: A phase II, single‐blind, randomized,
controlled trial. Annals of Neurology, 80(3), 342-354. doi: 10.1002/ana.24734
Langhammer, B., & Stanghelle, J. K. (2000). Bobath or motor relearning programme? A comparison of
two different approaches of physiotherapy in stroke rehabilitation: a randomized controlled
study. Clin.Rehabil., 14(4), 361-369.
Langhammer, B., & Stanghelle, J. K. (2003). Bobath or motor relearning programme? A follow-up one
and four years post stroke. Clin.Rehabil., 17(7), 731-734.
Langhammer, B., & Stanghelle, J. K. (2011). Can physiotherapy after stroke based on the Bobath concept
result in improved quality of movement compared to the motor relearning programme.
Physiother.Res.Int., 16(2), 69-80. doi: 10.1002/pri.474 [doi]
Langlois, S., Pederson, L., & MacKinnon, J. R. (1991). The Effects of Splinting on the Spastic Hemiplegic is
Hand: Report of a Feasibility Study. Canadian Journal of Occupational Therapy, 58(1), 17-25.
Lannin, N. A., Cusick, A., Hills, C., Kinnear, B., Vogel, K., Matthews, K., & Bowring, G. (2016). Upper limb
motor training using a Saebo() orthosis is feasible for increasing task-specific practice in hospital
after stroke. Aust Occup Ther J, 63(6), 364-372. doi: 10.1111/1440-1630.12330
Lannin, N. A., Cusick, A., McCluskey, A., & Herbert, R. D. (2007). Effects of splinting on wrist contracture
after stroke: a randomized controlled trial. Stroke, 38(1), 111-116. doi:
01.STR.0000251722.77088.12 [pii];10.1161/01.STR.0000251722.77088.12 [doi]
Lannin, N. A., & Herbert, R. D. (2003). Is hand splinting effective for adults following stroke? A systematic
review and methodologic critique of published research. Clin.Rehabil., 17(8), 807-816.

www.ebrsr.com
Lannin, N. A., Horsley, S. A., Herbert, R., McCluskey, A., & Cusick, A. (2003). Splinting the hand in the
functional position after brain impairment: a randomized, controlled trial.
Arch.Phys.Med.Rehabil., 84(2), 297-302. doi: 10.1053/apmr.2003.50031
[doi];S0003999302048499 [pii]
Laufer, Y., & Elboim-Gabyzon, M. (2011). Does sensory transcutaneous electrical stimulation enhance
motor recovery following a stroke? A systematic review. Neurorehabil.Neural Repair, 25(9), 799-
809. doi: 1545968310397205 [pii];10.1177/1545968310397205 [doi]
Laver, K. E., George, S., Thomas, S., Deutsch, J. E., & Crotty, M. (2011). Virtual reality for stroke
rehabilitation. Cochrane.Database.Syst.Rev.(9), CD008349. doi:
10.1002/14651858.CD008349.pub2 [doi]
Laver, K. E., George, S., Thomas, S., Deutsch, J. E., & Crotty, M. (2015). Virtual reality for stroke
rehabilitation. Cochrane Database of Systematic Reviews(2), N.PAG.
Lee, D., Lee, M., Lee, K., & Song, C. (2014). Asymmetric training using virtual reality reflection equipment
and the enhancement of upper limb function in stroke patients: a randomized controlled trial. J
Stroke Cerebrovasc Dis, 23(6), 1319-1326. doi: 10.1016/j.jstrokecerebrovasdis.2013.11.006
Lee, D., Roh, H., Park, J., Lee, S., & Han, S. (2013). Drinking behavior training for stroke patients using
action observation and practice of upper limb function. J Phys Ther Sci, 25(5), 611-614. doi:
10.1589/jpts.25.611
Lee, D. G., & Lee, D. Y. (2015). Effects of adjustment of transcranial direct current stimulation on motor
function of the upper extremity in stroke patients. J Phys Ther Sci, 27(11), 3511-3513. doi:
10.1589/jpts.27.3511
Lee, G. (2013). Effects of Training Using Video Games on the Muscle Strength, Muscle Tone, and
Activities of Daily Living of Chronic Stroke Patients. Journal of Physical Therapy Science, 25(5),
595-597.
Lee, J.-S., Kim, C.-Y., & Kim, H.-D. (2016). Short-Term Effects of Whole-Body Vibration Combined with
Task-Related Training on Upper Extremity Function, Spasticity, and Grip Strength in Subjects
with Poststroke Hemiplegia: A Pilot Randomized Controlled Trial. American Journal of Physical
Medicine & Rehabilitation, 95(8), 608-617. doi: 10.1097/phm.0000000000000454
Lee, J. A., Park, S. W., Hwang, P. W., Lim, S. M., Kook, S., Choi, K. I., & Kang, K. S. (2012). Acupuncture for
shoulder pain after stroke: a systematic review. J.Altern.Complement Med., 18(9), 818-823. doi:
10.1089/acm.2011.0457 [doi]
Lee, K. H., Hill, E., Johnston, R., & Smiehorowski, T. (1976). Myofeedback for muscle retraining in
hemiplegic patients. Arch.Phys.Med.Rehabil., 57(12), 588-591.
Lee, K. W., Kim, S. B., Lee, J. H., Lee, S. J., & Yoo, S. W. (2016). Effect of Upper Extremity Robot-Assisted
Exercise on Spasticity in Stroke Patients. Ann Rehabil Med, 40(6), 961-971. doi:
10.5535/arm.2016.40.6.961
Lee, M.-H., Kim, K.-D., Park, S.-J., Choi, Y.-C., Jang, S.-H., Lee, J.-H., & Kim, J.-S. (2013). The Effects of
Bilateral Activities of the Upper Extremities on Stroke Patients’ Daily Living Activities.
Journal of Physical Therapy Science, 25(2), 161-164. doi: 10.1589/jpts.25.161
Lee, M., Son, J., Kim, J., Pyun, S. B., Eun, S. D., & Yoon, B. (2016). Comparison of individualized virtual
reality- and group-based rehabilitation in older adults with chronic stroke in community
settings: a pilot randomized controlled trial. European Journal of Integrative Medicine, 8(5), 738-
746.
Lee, M. M., Cho, H. Y., & Song, C. H. (2012). The mirror therapy program enhances upper-limb motor
recovery and motor function in acute stroke patients. Am.J.Phys.Med.Rehabil., 91(8), 689-696,
quiz. doi: 10.1097/PHM.0b013e31824fa86d [doi]
Lee, M. M., Shin, D. C., & Song, C. H. (2016). Canoe game-based virtual reality training to improve trunk
postural stability, balance, and upper limb motor function in subacute stroke patients: a
randomized controlled pilot study. J Phys Ther Sci, 28(7), 2019-2024. doi: 10.1589/jpts.28.2019

www.ebrsr.com
Lee, M. S., Choi, T. Y., Shin, B. C., Han, C. H., & Ernst, E. (2010). Cupping for stroke rehabilitation: a
systematic review. J.Neurol.Sci., 294(1-2), 70-73. doi: S0022-510X(10)00160-7
[pii];10.1016/j.jns.2010.03.033 [doi]
Lee, S., & Chun, M. (2014). Combination transcranial direct current stimulation and virtual reality
therapy for upper extremity training in patients with subacute stroke. Archives of Physical
Medicine and Rehabilitation, 95(3), 431-438.
Lee, S., Kim, Y., & Lee, B. H. (2016). Effect of Virtual Reality-based Bilateral Upper Extremity Training on
Upper Extremity Function after Stroke: A Randomized Controlled Clinical Trial. Occup Ther Int,
23(4), 357-368. doi: 10.1002/oti.1437
Lee, Y.-y., Lin, K.-c., Wu, C.-y., Liao, C.-h., Lin, J.-c., & Chen, C.-l. (2015). Combining Afferent Stimulation
and Mirror Therapy for Improving Muscular, Sensorimotor, and Daily Functions After Chronic
Stroke: A Randomized, Placebo-Controlled Study. American Journal of Physical Medicine &
Rehabilitation, 94(10S), 859-868. doi: 10.1097/phm.0000000000000271
Lee, Y. H., Park, S. H., Yoon, E. S., Lee, C. D., Wee, S. O., Fernhall, B., & Jae, S. Y. (2015). Effects of
combined aerobic and resistance exercise on central arterial stiffness and gait velocity in
patients with chronic poststroke hemiparesis. Am J Phys Med Rehabil, 94(9), 687-695. doi:
10.1097/phm.0000000000000233
Lefebvre, S., Dricot, L., Laloux, P., Gradkowski, W., Desfontaines, P., Evrard, F., . . . Vandermeeren, Y.
(2015). Neural substrates underlying stimulation-enhanced motor skill learning after stroke.
Brain, 138(1), 149-163. doi: 10.1093/brain/awu336
Lefebvre, S., Laloux, P., Peeters, A., Desfontaines, P., Jamart, J., & Vandermeeren, Y. (2013). Dual-tDCS
enhances online motor skill learning and long-term retention in chronic stroke patients.
Frontiers in Human Neuroscience, 6. doi: 10.3389/fnhum.2012.00343
Lefebvre, S., Thonnard, J., Laloux, P., Peeters, A., Jamart, J., & Vandermeeren, Y. (2014). Single session of
dual-tDCS transiently improves precision grip and dexterity of the paretic hand after stroke.
Leibovitz, A., Baumoehl, Y., Roginsky, Y., Glick, Z., Habot, B., & Segal, R. (2007). Edema of the paretic
hand in elderly post-stroke nursing patients. Arch.Gerontol.Geriatr., 44(1), 37-42. doi: S0167-
4943(06)00025-2 [pii];10.1016/j.archger.2006.02.005 [doi]
Lemmens, R. J., Timmermans, A. A., Janssen-Potten, Y. J., Pulles, S. A., Geers, R. P., Bakx, W. G., . . .
Seelen, H. A. (2014). Accelerometry measuring the outcome of robot-supported upper limb
training in chronic stroke: a randomized controlled trial. PLoS ONE [Electronic Resource], 9(5),
e96414.
Levy, C. E., Giuffrida, C., Richards, L., Wu, S., Davis, S., & Nadeau, S. E. (2007). Botulinum toxin a,
evidence-based exercise therapy, and constraint-induced movement therapy for upper-limb
hemiparesis attributable to stroke: a preliminary study. Am.J.Phys.Med.Rehabil., 86(9), 696-706.
doi: 10.1097/PHM.0b013e31813e2b4d [doi];00002060-200709000-00003 [pii]
Levy, R., Ruland, S., Weinand, M., Lowry, D., Dafer, R., & Bakay, R. (2008). Cortical stimulation for the
rehabilitation of patients with hemiparetic stroke: a multicenter feasibility study of safety and
efficacy. J.Neurosurg., 108(4), 707-714. doi: 10.3171/JNS/2008/108/4/0707 [doi]
Levy, R. M., Harvey, R. L., Kissela, B. M., Winstein, C. J., Lutsep, H. L., Parrish, T. B., . . . Venkatesan, L.
(2016). Epidural Electrical Stimulation for Stroke Rehabilitation: Results of the Prospective,
Multicenter, Randomized, Single-Blinded Everest Trial. Neurorehabil Neural Repair, 30(2), 107-
119. doi: 10.1177/1545968315575613
Li, H., Chai, W., Xu, G., & Li, Z. (2016). Evaluation on curative effect of modified constraint-induced
movement therapy in rehabilitation of activity of daily living in patients with sub-acute stroke.
[Chinese]. Journal of Jilin University Medicine Edition, 42(6), 1183-1188.
Li, J., Meng, X. M., Li, R. Y., Zhang, R., Zhang, Z., & Du, Y. F. (2016). Effects of different frequencies of
repetitive transcranial magnetic stimulation on the recovery of upper limb motor dysfunction in

www.ebrsr.com
patients with subacute cerebral infarction. Neural Regeneration Research, 11(10), 1584-1590.
doi: 10.4103/1673-5374.193236
Li, N., Tian, F., Wang, C., Yu, P., Zhou, X., Wen, Q., . . . Huang, L. (2012). Therapeutic effect of
acupuncture and massage for shoulder-hand syndrome in hemiplegia patients: a clinical two-
center randomized controlled trial. J Tradit Chin Med, 32(3), 343-349.
Li, Y., Wang, Y., Zhang, H., Wu, P., & Huang, W. (2015). The Effect of Acupuncture on the Motor Function
and White Matter Microstructure in Ischemic Stroke Patients. Evid Based Complement Alternat
Med, 2015, 164792. doi: 10.1155/2015/164792
Liao, L. R., Ng, G. Y., Jones, A. Y., Chung, R. C., & Pang, M. Y. (2015). Effects of Vibration Intensity,
Exercise, and Motor Impairment on Leg Muscle Activity Induced by Whole-Body Vibration in
People With Stroke. Phys Ther, 95(12), 1617-1627. doi: 10.2522/ptj.20140507
Liao, W. W., Wu, C. Y., Hsieh, Y. W., Lin, K. C., & Chang, W. Y. (2012). Effects of robot-assisted upper limb
rehabilitation on daily function and real-world arm activity in patients with chronic stroke: a
randomized controlled trial. Clin.Rehabil., 26(2), 111-120. doi: 0269215511416383
[pii];10.1177/0269215511416383 [doi]
Liepert, J., Zittel, S., & Weiller, C. (2007). Improvement of dexterity by single session low-frequency
repetitive transcranial magnetic stimulation over the contralesional motor cortex in acute
stroke: a double-blind placebo-controlled crossover trial. Restor.Neurol.Neurosci., 25(5-6), 461-
465.
Lim, K. B., Lee, H. J., Yoo, J., Yun, H. J., & Hwang, H. J. (2016). Efficacy of Mirror Therapy Containing
Functional Tasks in Poststroke Patients. Ann Rehabil Med, 40(4), 629-636. doi:
10.5535/arm.2016.40.4.629
Lim, K. M., Jung, J., & Shim, S. (2016). The effect of bilateral trainings on upper extremities muscle
activation on level of motor function in stroke patients. J Phys Ther Sci, 28(12), 3427-3431. doi:
10.1589/jpts.28.3427
Lima, N. M., Menegatti, K. C., Yu, E., Sacomoto, N. Y., Oberg, T. D., & Honorato, D. C. (2015). Motor and
sensory effects of ipsilesional upper extremity hypothermia and contralesional sensory training
for chronic stroke patients. Top Stroke Rehabil, 22(1), 44-55. doi:
10.1179/1074935714Z.0000000023
Lima, R. C. M., Michaelsen, S. M., Nascimento, L. R., Polese, J. C., Pereira, N. D., & Teixeira-Salmela, L. F.
(2014). Addition of trunk restraint to home-based modified constraint-induced movement
therapy does not bring additional benefits in chronic stroke individuals with mild and moderate
upper limb impairments: A pilot randomized controlled trial. Neurorehabilitation, 35(3), 391-
404. doi: 10.3233/nre-141130
Lin, C.-H., Chou, L.-W., Luo, H.-J., Tsai, P.-Y., Lieu, F.-K., Chiang, S.-L., & Sung, W.-H. (2015). Effects of
Computer-Aided Interlimb Force Coupling Training on Paretic Hand and Arm Motor Control
following Chronic Stroke: A Randomized Controlled Trial. Plos One, 10(7), e0131048. doi:
10.1371/journal.pone.0131048
Lin, C. H., Chou, L. W., Luo, H. J., Tsai, P. Y., Lieu, F. K., Chiang, S. L., & Sung, W. H. (2015). Effects of
Computer-Aided Interlimb Force Coupling Training on Paretic Hand and Arm Motor Control
following Chronic Stroke: A Randomized Controlled Trial. PLoS One, 10(7), e0131048. doi:
10.1371/journal.pone.0131048
Lin, K., Huang, P., Chen, Y., Wu, C., & Huang, W. (2014). Combining afferent stimulation and mirror
therapy for rehabilitating motor function, motor control, ambulation, and daily functions after
stroke. Neurorehabilitation and Neural Repair, 28(2), 153-162.
Lin, K. C., Chang, Y. F., Wu, C. Y., & Chen, Y. A. (2009). Effects of constraint-induced therapy versus
bilateral arm training on motor performance, daily functions, and quality of life in stroke
survivors. Neurorehabil.Neural Repair, 23(5), 441-448. doi: 1545968308328719
[pii];10.1177/1545968308328719 [doi]

www.ebrsr.com
Lin, K. C., Chen, Y. A., Chen, C. L., Wu, C. Y., & Chang, Y. F. (2010). The effects of bilateral arm training on
motor control and functional performance in chronic stroke: a randomized controlled study.
Lin, K. C., Chen, Y. T., Huang, P. C., Wu, C. Y., Huang, W. L., Yang, H. W., . . . Lu, H. J. (2014). Effect of
mirror therapy combined with somatosensory stimulation on motor recovery and daily function
in stroke patients: A pilot study. Journal of the Formosan Medical Association, 113(7), 422-428.
doi: 10.1016/j.jfma.2012.08.008
Lin, K. C., Chung, H. Y., Wu, C. Y., Liu, H. L., Hsieh, Y. W., Chen, I. H., . . . Wai, Y. Y. (2010). Constraint-
induced therapy versus control intervention in patients with stroke: a functional magnetic
resonance imaging study. Am.J.Phys.Med.Rehabil., 89(3), 177-185. doi:
10.1097/PHM.0b013e3181cf1c78 [doi];00002060-201003000-00002 [pii]
Lin, K. C., Huang, P. C., Chen, Y. T., Wu, C. Y., & Huang, W. L. (2014). Combining afferent stimulation and
mirror therapy for rehabilitating motor function, motor control, ambulation, and daily functions
after stroke. Neurorehabil Neural Repair, 28(2), 153-162. doi: 10.1177/1545968313508468
Lin, K. C., Wu, C. Y., & Liu, J. S. (2008). A randomized controlled trial of constraint-induced movement
therapy after stroke. Acta Neurochir.Suppl, 101, 61-64.
Lin, K. C., Wu, C. Y., Liu, J. S., Chen, Y. T., & Hsu, C. J. (2009). Constraint-induced therapy versus dose-
matched control intervention to improve motor ability, basic/extended daily functions, and
quality of life in stroke. Neurorehabil.Neural Repair, 23(2), 160-165. doi: 1545968308320642
[pii];10.1177/1545968308320642 [doi]
Lin, K. C., Wu, C. Y., Wei, T. H., Lee, C. Y., & Liu, J. S. (2007). Effects of modified constraint-induced
movement therapy on reach-to-grasp movements and functional performance after chronic
stroke: a randomized controlled study. Clin Rehabil, 21(12), 1075-1086. doi:
10.1177/0269215507079843
Lin, Z., & Yan, T. (2011). Long-term effectiveness of neuromuscular electrical stimulation for promoting
motor recovery of the upper extremity after stroke. J.Rehabil.Med., 43(6), 506-510. doi:
10.2340/16501977-0807 [doi]
Lincoln, N. B., Parry, R. H., & Vass, C. D. (1999). Randomized, controlled trial to evaluate increased
intensity of physiotherapy treatment of arm function after stroke. Stroke, 30(3), 573-579.
Lindenberg, R., Renga, V., Zhu, L. L., Nair, D., & Schlaug, G. (2010). Bihemispheric brain stimulation
facilitates motor recovery in chronic stroke patients. Neurology, 75(24), 2176-2184. doi:
WNL.0b013e318202013a [pii];10.1212/WNL.0b013e318202013a [doi]
Linder, S. M., Rosenfeldt, A. B., Bay, R. C., Sahu, K., Wolf, S. L., & Alberts, J. L. (2015). Improving Quality
of Life and Depression After Stroke Through Telerehabilitation. American Journal of
Occupational Therapy, 69(2), 1-11. doi: 10.5014/ajot.2015.014498
Liu, C. H., Hsieh, Y. T., Tseng, H. P., Lin, H. C., Lin, C. L., Wu, T. Y., . . . Zhang, H. (2016). Acupuncture for a
first episode of acute ischaemic stroke: an observer-blinded randomised controlled pilot study.
Acupunct Med, 34(5), 349-355. doi: 10.1136/acupmed-2015-010825
Liu, H., Song, L. P., & Zhang, T. (2014). Mental Practice Combined with Physical Practice to Enhance Hand
Recovery in Stroke Patients. Behavioural Neurology. doi: 10.1155/2014/876416
Liu, K. P., Balderi, K., Leung, T. L., Yue, A. S., Lam, N. C., Cheung, J. T., . . . Mok, V. C. (2016). A randomized
controlled trial of self-regulated modified constraint-induced movement therapy in sub-acute
stroke patients. Eur J Neurol, 23(8), 1351-1360. doi: 10.1111/ene.13037
Liu, K. P., Chan, C. C., Lee, T. M., & Hui-Chan, C. W. (2004). Mental imagery for promoting relearning for
people after stroke: a randomized controlled trial. Arch.Phys.Med.Rehabil., 85(9), 1403-1408.
doi: S0003999304002709 [pii]
Liu, K. P. Y., & Chan, C. C. H. (2014). Pilot Randomized Controlled Trial of Self-Regulation in Promoting
Function in Acute Poststroke Patients. Archives of Physical Medicine and Rehabilitation, 95(7),
1262-1267. doi: 10.1016/j.apmr.2014.03.018

www.ebrsr.com
Lo, A. C., Guarino, P. D., Richards, L. G., Haselkorn, J. K., Wittenberg, G. F., Federman, D. G., . . . Peduzzi,
P. (2010). Robot-assisted therapy for long-term upper-limb impairment after stroke.
N.Engl.J.Med., 362(19), 1772-1783. doi: NEJMoa0911341 [pii];10.1056/NEJMoa0911341 [doi]
Lo, Y. L., Cui, S. L., & Fook-Chong, S. (2005). The effect of acupuncture on motor cortex excitability and
plasticity. Neurosci.Lett., 384(1-2), 145-149. doi: S0304-3940(05)00479-9
[pii];10.1016/j.neulet.2005.04.083 [doi]
Logigian, M. K., Samuels, M. A., Falconer, J., & Zagar, R. (1983). Clinical exercise trial for stroke patients.
Arch.Phys.Med.Rehabil., 64(8), 364-367.
Ludemann-Podubecka, J., Bosl, K., & Nowak, D. A. (2016). Inhibition of the contralesional dorsal
premotor cortex improves motor function of the affected hand following stroke. Eur J Neurol,
23(4), 823-830. doi: 10.1111/ene.12949
Ludemann-Podubecka, J., Bosl, K., Theilig, S., Wiederer, R., & Nowak, D. A. (2015). The Effectiveness of 1
Hz rTMS Over the Primary Motor Area of the Unaffected Hemisphere to Improve Hand Function
After Stroke Depends on Hemispheric Dominance. Brain Stimul, 8(4), 823-830. doi:
10.1016/j.brs.2015.02.004
Luft, A. R., McCombe-Waller, S., Whitall, J., Forrester, L. W., Macko, R., Sorkin, J. D., . . . Hanley, D. F.
(2004). Repetitive bilateral arm training and motor cortex activation in chronic stroke: a
randomized controlled trial. JAMA, 292(15), 1853-1861. doi: 292/15/1853
[pii];10.1001/jama.292.15.1853 [doi]
Luke, C., Dodd, K. J., & Brock, K. (2004). Outcomes of the Bobath concept on upper limb recovery
following stroke. Clin.Rehabil., 18(8), 888-898.
Lum, P., Reinkensmeyer, D., Mahoney, R., Rymer, W. Z., & Burgar, C. (2002). Robotic devices for
movement therapy after stroke: current status and challenges to clinical acceptance. Topics in
stroke rehabilitation, 8(4), 40-53.
Lum, P. S., Burgar, C. G., Shor, P. C., Majmundar, M., & Van der Loos, M. (2002). Robot-assisted
movement training compared with conventional therapy techniques for the rehabilitation of
upper-limb motor function after stroke. Arch Phys Med Rehabil, 83(7), 952-959.
Lum, P. S., Burgar, C. G., Van der Loos, M., Shor, P. C., Majmundar, M., & Yap, R. (2006). MIME robotic
device for upper-limb neurorehabilitation in subacute stroke subjects: A follow-up study.
Machado, S., Lattari, E., de Sa, A., Rocha, N., Yuan, T.-F., Paes, F., . . . Arias-Carrion, O. (2015). Is Mental
Practice an Effective Adjunct Therapeutic Strategy for Upper Limb Motor Restoration After
Stroke? A Systematic Review and Meta- Analysis. CNS & Neurological Disorders - Drug Targets,
14(5), 567-575. doi: 10.2174/1871527314666150429112702
Majeed, Y. A., Abdollahi, F., Awadalla, S., & Patton, J. (2015). Multivariate outcomes in a three week
bimanual self-telerehabilitation with error augmentation post-stroke. Conf Proc IEEE Eng Med
Biol Soc, 2015, 1425-1431. doi: 10.1109/embc.2015.7318637
Malcolm, M. P., Triggs, W. J., Light, K. E., Gonzalez Rothi, L. J., Wu, S., Reid, K., & Nadeau, S. E. (2007).
Repetitive transcranial magnetic stimulation as an adjunct to constraint-induced therapy: an
exploratory randomized controlled trial. Am.J.Phys.Med.Rehabil., 86(9), 707-715. doi:
10.1097/PHM.0b013e31813e0de0 [doi];00002060-200709000-00004 [pii]
Malhotra, S., Rosewilliam, S., Hermens, H., Roffe, C., Jones, P., & Pandyan, A. D. (2013). A randomized
controlled trial of surface neuromuscular electrical stimulation applied early after acute stroke:
effects on wrist pain, spasticity and contractures. Clinical rehabilitation, 27(7), 579-590. doi:
10.1177/0269215512464502
Mangold, S., Schuster, C., Keller, T., Zimmermann-Schlatter, A., & Ettlin, T. (2009). Motor training of
upper extremity with functional electrical stimulation in early stroke rehabilitation.
[doi]

www.ebrsr.com
Mani, S., Przybyla, A., Good, D. C., Haaland, K. Y., & Sainburg, R. L. (2014). Contralesional Arm Preference
Depends on Hemisphere of Damage and Target Location in Unilateral Stroke Patients.
Neurorehabilitation and Neural Repair, 28(6), 584-593. doi: 10.1177/1545968314520720
Manigandan, J., Ganesh, G., Pattnaik, M., & Mohanty, P. (2014). Effect of electrical stimulation to long
head of biceps in reducing gleno humeral subluxation after stroke. Neurorehabilitation, 34(2),
245-252.
Mann, G. E., Burridge, J. H., Malone, L. J., & Strike, P. W. (2005). A pilot study to investigate the effects of
electrical stimulation on recovery of hand function and sensation in subacute stroke patients.
Neuromodulation., 8(3), 193-202. doi: 10.1111/j.1525-1403.2005.05238.x [doi]
Mansur, C. G., Fregni, F., Boggio, P. S., Riberto, M., Gallucci-Neto, J., Santos, C. M., . . . Pascual-Leone, A.
(2005). A sham stimulation-controlled trial of rTMS of the unaffected hemisphere in stroke
patients. Neurology, 64(10), 1802-1804. doi: 64/10/1802
[pii];10.1212/01.WNL.0000161839.38079.92 [doi]
Mares, K., Cross, J., Clark, A., Vaughan, S., Barton, G. R., Poland, F., . . . Pomeroy, V. M. (2014). Feasibility
of a randomized controlled trial of functional strength training for people between six months
and five years after stroke: FeSTivaLS trial. Trials, 15. doi: 10.1186/1745-6215-15-322
Marvulli, R., Mastromauro, L., Romanelli, E., Lopopolo, A., Dargenio, M., Fomarelli, F., . . . Ianieri, G.
(2016). How botulinum toxin type A- occupational therapy (OT)-functional electrical stimulation
(FES) modify spasticity and functional recovery in patients with upper limb spasticity post stroke.
Clinical Immunology, Endocrine and Metabolic Drugs, 3(1), 62-67.
Masiero, S., Armani, M., Ferlini, G., Rosati, G., & Rossi, A. (2014). Randomized Trial of a Robotic Assistive
Device for the Upper Extremity During Early Inpatient Stroke Rehabilitation. Neurorehabilitation
and Neural Repair, 28(4), 377-386. doi: 10.1177/1545968313513073
Masiero, S., Armani, M., & Rosati, G. (2011). Upper-limb robot-assisted therapy in rehabilitation of acute
stroke patients: focused review and results of new randomized controlled trial.
Masiero, S., Celia, A., Armani, M., & Rosati, G. (2006). A novel robot device in rehabilitation of post-
stroke hemiplegic upper limbs. Aging Clin.Exp.Res., 18(6), 531-535. doi: 3298 [pii]
Masiero, S., Celia, A., Rosati, G., & Armani, M. (2007). Robotic-assisted rehabilitation of the upper limb
after acute stroke. Arch.Phys.Med.Rehabil., 88(2), 142-149. doi: S0003-9993(06)01482-1
[pii];10.1016/j.apmr.2006.10.032 [doi]
Masiero, S., Poli, P., Rosati, G., Zanotto, D., Iosa, M., Paolucci, S., & Morone, G. (2014). The value of
robotic systems in stroke rehabilitation. Expert Review of Medical Devices, 11(2), 187-198. doi:
10.1586/17434440.2014.882766
Mazzoleni, S., Sale, P., Franceschini, M., Bigazzi, S., Carrozza, M., Dario, P., & Posteraro, F. (2013). Effects
of proximal and distal robot-assisted upper limb rehabilitation on chronic stroke recovery.
Neurorehabilitation, 33(1), 33-39.
McCabe, J., Monkiewicz, M., Holcomb, J., Pundik, S., & Daly, J. J. (2015). Comparison of Robotics,
Functional Electrical Stimulation, and Motor Learning Methods for Treatment of Persistent
Upper Extremity Dysfunction After Stroke: A Randomized Controlled Trial. Archives of Physical
Medicine and Rehabilitation, 96(6), 981-990. doi: https://doi.org/10.1016/j.apmr.2014.10.022
McCombe Waller, S., Whitall, J., Jenkins, T., Magder, L. S., Hanley, D. F., Goldberg, A., & Luft, A. R.
(2014). Sequencing bilateral and unilateral task-oriented training versus task oriented training
alone to improve arm function in individuals with chronic stroke. BMC Neurology, 14(1). doi:
10.1186/s12883-014-0236-6
McCrory, P., Turner-Stokes, L., Baguley, I. J., De, G. S., Katrak, P., Sandanam, J., . . . Hughes, A. (2009).
Botulinum toxin A for treatment of upper limb spasticity following stroke: a multi-centre
randomized placebo-controlled study of the effects on quality of life and other person-centred
outcomes. J.Rehabil.Med., 41(7), 536-544. doi: 10.2340/16501977-0366 [doi]

www.ebrsr.com
McDonnell, M. N., Hillier, S. L., Miles, T. S., Thompson, P. D., & Ridding, M. C. (2007). Influence of
combined afferent stimulation and task-specific training following stroke: a pilot randomized
controlled trial. Neurorehabil.Neural Repair, 21(5), 435-443. doi: 1545968307300437
[pii];10.1177/1545968307300437 [doi]
McIntyre, A., Viana, R., Janzen, S., Mehta, S., Pereira, S., & Teasell, R. (2012). Systematic review and
meta-analysis of constraint-induced movement therapy in the hemiparetic upper extremity
more than six months post stroke. Topics in stroke rehabilitation, 19(6), 499-513.
McNulty, P. A., Thompson-Butel, A. G., Faux, S. G., Lin, G., Katrak, P. H., Harris, L. R., & Shiner, C. T.
(2015). The efficacy of Wii-based Movement therapy for upper limb rehabilitation in the chronic
poststroke period: A randomized controlled trial. International Journal of Stroke, 10(8), 1253-
1260.
McPherson, J. J., Kreimeyer, D., Aalderks, M., & Gallagher, T. (1982). A comparison of dorsal and volar
resting hand splints in the reduction of hypertonus. Am.J.Occup.Ther., 36(10), 664-670.
Meehan, S. K., Dao, E., Linsdell, M. A., & Boyd, L. A. (2011). Continuous theta burst stimulation over the
contralesional sensory and motor cortex enhances motor learning post-stroke. Neurosci Lett,
500(1), 26-30. doi: 10.1016/j.neulet.2011.05.237
Mehrholz, J., Hadrich, A., Platz, T., Kugler, J., & Pohl, M. (2012). Electromechanical and robot-assisted
arm training for improving generic activities of daily living, arm function, and arm muscle
strength after stroke. Cochrane.Database.Syst.Rev., 6, CD006876. doi:
10.1002/14651858.CD006876.pub3 [doi]
Mehrholz, J., Pohl, M., Platz, T., Kugler, J., & Elsner, B. (2015). Electromechanical and robot-assisted arm
training for improving activities of daily living, arm function, and arm muscle strength after
stroke. Cochrane Database Syst Rev(11), Cd006876. doi: 10.1002/14651858.CD006876.pub4
Merians, A. S., Jack, D., Boian, R., Tremaine, M., Burdea, G. C., Adamovich, S. V., . . . Poizner, H. (2002).
Virtual reality-augmented rehabilitation for patients following stroke. Phys.Ther., 82(9), 898-915.
Meythaler, J. M., Vogtle, L., & Brunner, R. C. (2009). A preliminary assessment of the benefits of the
addition of botulinum toxin a to a conventional therapy program on the function of people with
longstanding stroke. Arch.Phys.Med.Rehabil., 90(9), 1453-1461. doi: S0003-9993(09)00357-8
[pii];10.1016/j.apmr.2009.02.026 [doi]
Michaelsen, S. M., Dannenbaum, R., & Levin, M. F. (2006). Task-specific training with trunk restraint on
arm recovery in stroke: randomized control trial. Stroke, 37(1), 186-192.
Michaelsen, S. M., & Levin, M. F. (2004). Short-term effects of practice with trunk restraint on reaching
movements in patients with chronic stroke: a controlled trial. Stroke, 35(8), 1914-1919. doi:
10.1161/01.STR.0000132569.33572.75 [doi];01.STR.0000132569.33572.75 [pii]
Michaelsen, S. M., Luta, A., Roby-Brami, A. s., & Levin, M. F. (2001). Effect of trunk restraint on the
recovery of reaching movements in hemiparetic patients. Stroke, 32(8), 1875-1883.
Michielsen, M. E., Selles, R. W., van der Geest, J. N., Eckhardt, M., Yavuzer, G., Stam, H. J., . . . Bussmann,
J. B. (2011). Motor recovery and cortical reorganization after mirror therapy in chronic stroke
patients: a phase II randomized controlled trial. Neurorehabil.Neural Repair, 25(3), 223-233. doi:
1545968310385127 [pii];10.1177/1545968310385127 [doi]
Mihara, M., Hattori, N., Hatakenaka, M., Yagura, H., Kawano, T., Hino, T., & Miyai, I. (2013). Near-
infrared Spectroscopy-mediated Neurofeedback Enhances Efficacy of Motor Imagery-based
Training in Poststroke Victims A Pilot Study. Stroke, 44(4), 1091-+. doi:
10.1161/strokeaha.111.674507
Mikami, K., Jorge, R. E., Adams, H. P., Jr., Davis, P. H., Leira, E. C., Jang, M., & Robinson, R. G. (2011).
Effect of antidepressants on the course of disability following stroke. Am.J.Geriatr.Psychiatry,
19(12), 1007-1015. doi: 10.1097/JGP.0b013e31821181b0 [doi]

www.ebrsr.com
Mirela Cristina, L., Matei, D., Ignat, B., & Popescu, C. D. (2015). Mirror therapy enhances upper extremity
motor recovery in stroke patients. Acta Neurologica Belgica. doi:
http://dx.doi.org/10.1007/s13760-015-0465-5
Miyasaka, H., Orand, A., Ohnishi, H., Tanino, G., Takeda, K., & Sonoda, S. (2016). Ability of electrical
stimulation therapy to improve the effectiveness of robotic training for paretic upper limbs in
patients with stroke. Medical Engineering and Physics, 38(11), 1172-1175.
Mohammadianinejad, S. E., Majdinasab, N., Sajedi, S. A., Abdollahi, F., Moqaddam, M. M., & Sadr, F.
(2014). The Effect of Lithium in Post-Stroke Motor Recovery: A Double-Blind, Placebo-
Controlled, Randomized Clinical Trial. Clinical Neuropharmacology, 37(3), 73-78. doi:
10.1097/wnf.0000000000000028
Moon, S. K., Whang, Y. K., Park, S. U., Ko, C. N., Kim, Y. S., Bae, H. S., & Cho, K. H. (2003). Antispastic
effect of electroacupuncture and moxibustion in stroke patients. Am.J.Chin Med., 31(3), 467-
474. doi: S0192415X03001077 [pii];10.1142/S0192415X03001077 [doi]
Moon, S. K., Whang, Y. K., Park, S. U., Ko, C. N., Kim, Y. S., Bae, H. S., & Cho, K. H. (2003). Antispastic
effect of electroacupuncture and moxibustion in stroke patients. Am J Chin Med, 31(3), 467-474.
doi: 10.1142/S0192415X03001077
Moreland, J., & Thomson, M. A. (1994). Efficacy of electromyographic biofeedback compared with
conventional physical therapy for upper-extremity function in patients following stroke: a
research overview and meta-analysis. Phys.Ther., 74(6), 534-543.
Morris, J. H., van, W. F., Joice, S., Ogston, S. A., Cole, I., & MacWalter, R. S. (2008). A comparison of
bilateral and unilateral upper-limb task training in early poststroke rehabilitation: a randomized
controlled trial. Arch.Phys.Med.Rehabil., 89(7), 1237-1245. doi: S0003-9993(08)00212-8
[pii];10.1016/j.apmr.2007.11.039 [doi]
Morris, J. H., & Van Wijck, F. (2012). Responses of the less affected arm to bilateral upper limb task
training in early rehabilitation after stroke: a randomized controlled trial. Arch Phys Med
Rehabil, 93(7), 1129-1137. doi: 10.1016/j.apmr.2012.02.025
Mortensen, J., Figlewski, K., & Andersen, H. (2016). Combined transcranial direct current stimulation and
home-based occupational therapy for upper limb motor impairment following intracerebral
hemorrhage: a double-blind randomized controlled trial. Disability & Rehabilitation, 38(7), 637-
643. doi: 10.3109/09638288.2015.1055379
Mroczek, N., Halpern, D., & McHugh, R. (1978). Electromyographic feedback and physical therapy for
neuromuscular retraining in hemiplegia. Arch.Phys.Med.Rehabil., 59(6), 258-267.
Mukherjee, M., Koutakis, P., Siu, K. C., Fayad, P. B., & Stergiou, N. (2013). Stroke Survivors Control the
Temporal Structure of Variability During Reaching in Dynamic Environments. Annals of
Biomedical Engineering, 41(2), 366-376. doi: 10.1007/s10439-012-0670-9
Mukherjee, M., McPeak, L. K., Redford, J. B., Sun, C., & Liu, W. (2007). The effect of electro-acupuncture
on spasticity of the wrist joint in chronic stroke survivors. Arch.Phys.Med.Rehabil., 88(2), 159-
166. doi: S0003-9993(06)01485-7 [pii];10.1016/j.apmr.2006.10.034 [doi]
Mukherjee, M., McPeak, L. K., Redford, J. B., Sun, C., & Liu, W. (2007). The effect of electro-acupuncture
on spasticity of the wrist joint in chronic stroke survivors. Arch Phys Med Rehabil, 88(2), 159-
166. doi: 10.1016/j.apmr.2006.10.034
Müller, K., Butefisch, C. M., Seitz, R. J., & Homberg, V. (2007). Mental practice improves hand function
after hemiparetic stroke. Restor.Neurol.Neurosci., 25(5-6), 501-511.
Muresanu, D. F., Heiss, W. D., Hoemberg, V., Bajenaru, O., Popescu, C. D., Vester, J. C., . . . Guekht, A.
(2016). Cerebrolysin and Recovery After Stroke (CARS): A Randomized, Placebo-Controlled,
Double-Blind, Multicenter Trial. Stroke, 47(1), 151-159. doi: 10.1161/strokeaha.115.009416
Myint, J. M., Yuen, G. F., Yu, T. K., Kng, C. P., Wong, A. M., Chow, K. K., . . . Chun, P. W. (2008). A study of
constraint-induced movement therapy in subacute stroke patients in Hong Kong. Clin.Rehabil.,
22(2), 112-124. doi: 22/2/112 [pii];10.1177/0269215507080141 [doi]

www.ebrsr.com
Nadeau, S. E., Davis, S. E., Wu, S. S., Dai, Y., & Richards, L. G. (2014). A pilot randomized controlled trial
of d-cycloserine and distributed practice as adjuvants to constraint-induced movement therapy
after stroke. Neurorehabilitation and Neural Repair, 28(9), 885-895. doi:
http://dx.doi.org/10.1177/1545968314532032
Naeser, M. A., Alexander, M. P., Stiassny-Eder, D., Galler, V., Hobbs, J., & Bachman, D. (1992). Real
versus sham acupuncture in the treatment of paralysis in acute stroke patients: a CT scan lesion
site study. Neurorehabilitation and Neural Repair, 6(4), 163-174.
Nakayama, H., Jorgensen, H. S., Raaschou, H. O., & Olsen, T. S. (1994). Recovery of upper extremity
function in stroke patients: the Copenhagen Stroke Study. Arch.Phys.Med.Rehabil., 75(4), 394-
398.
Nam, C. W., Lee, J. H., & Cho, S. H. (2015). The effect of non-elastic taping on balance and gait function
in patients with stroke. J Phys Ther Sci, 27(9), 2857-2860. doi: 10.1589/jpts.27.2857
Nascimento, L. R., Michaelsen, S. M., Ada, L., Polese, J. C., & Teixeira-Salmela, L. F. (2014). Cyclical
electrical stimulation increases strength and improves activity after stroke: a systematic review.
Journal of Physiotherapy, 60(1), 22-30. doi: 10.1016/j.jphys.2013.12.002
Ni, H. H., Cui, X., Hu, Y. S., Wu, Y., Huang, D. Q., Qu, P. Y., . . . Shi, J. C. (2013). Effect of combining
acupuncture and functional training on post-stroke functional impairment of hand. Journal of
Acupuncture and Tuina Science, 11(6), 349-352. doi: 10.1007/s11726-013-0726-x
Nijland, R., Kwakkel, G., Bakers, J., & van, W. E. (2011). Constraint-induced movement therapy for the
upper paretic limb in acute or sub-acute stroke: a systematic review. Int.J.Stroke, 6(5), 425-433.
doi: 10.1111/j.1747-4949.2011.00646.x [doi]
Nilsen, D. M., Gillen, G., & Gordon, A. M. (2010). Use of mental practice to improve upper-limb recovery
after stroke: a systematic review. Am.J.Occup.Ther., 64(5), 695-708.
Norouzi-Gheidari, N., Archambault, P. S., & Fung, J. (2012). Effects of robot-assisted therapy on stroke
rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J Rehabil Res
Dev, 49(4), 479-496.
O'Brien, C. F. (2002). Treatment of spasticity with botulinum toxin. The Clinical journal of pain, 18(6),
S182-S190.
Obiglio, M., Mendelevich, A., Jeffrey, S., Drault, E., Garcete, A., Kramer, M., . . . Peralta, F. (2016).
[Peripheral nerve stimulation effectiveness in the upper limb function recovery of patients with
a stroke sequel: systematic review and meta-analysis]. Rev Neurol, 62(12), 530-538.
Ochi, M., Saeki, S., Oda, T., Matsushima, Y., & Hachisuka, K. (2013). Effects of anodal and cathodal
transcranial direct current stimulation combined with robotic therapy on severely affected arms
in chronic stroke patients. Journal of Rehabilitation Medicine, 45(2), 137-140.
Oh, H. S., Kim, E. J., Kim, D. Y., & Kim, S. J. (2016). Effects of Adjuvant Mental Practice on Affected Upper
Limb Function Following a Stroke: Results of Three-Dimensional Motion Analysis, Fugl-Meyer
Assessment of the Upper Extremity and Motor Activity Logs. Ann Rehabil Med, 40(3), 401-411.
doi: 10.5535/arm.2016.40.3.401
Okamoto, S., Sonoda, S., Tanino, G., Tomida, K., Okazaki, H., & Kondo, I. (2011). Change in thigh muscle
cross-sectional area through administration of an anabolic steroid during routine stroke
rehabilitation in hemiplegic patients. Am J Phys Med Rehabil, 90(2), 106-111. doi:
10.1097/PHM.0b013e31820172bf
Oostra, K., Oomen, A., Vingerhoets, G., & Vanderstraeten, G. (2013). Mental practice with motor
imagery in gait rehabilitation ollowing stroke: A randomized controlled trial. Annals of Physical
and Rehabilitation Medicine, 56, e45.
Paci, M. (2003). Physiotherapy based on the Bobath concept for adults with post-stroke hemiplegia: a
review of effectiveness studies. J.Rehabil.Med., 35(1), 2-7.

www.ebrsr.com
Page, S., Persch, A., & Murray, C. (2013). Paretic upper extremity movement gains are retained 3 months
after training with an electrical stimulation neuroprosthesis. Archives of Physical Medicine and
Rehabilitation, 94 (10), e33.
Page, S. J. (2000). Imagery improves upper extremity motor function in chronic stroke patients: A pilot
study. Occupational Therapy Journal of Research.
Page, S. J. (2003). Intensity versus task-specificity after stroke: how important is intensity?
Am.J.Phys.Med.Rehabil., 82(9), 730-732. doi: 10.1097/01.PHM.0000078226.36000.A5
[doi];00002060-200309000-00016 [pii]
Page, S. J., Dunning, K., Hermann, V., Leonard, A., & Levine, P. (2011). Longer versus shorter mental
practice sessions for affected upper extremity movement after stroke: a randomized controlled
trial. Clin.Rehabil., 25(7), 627-637. doi: 0269215510395793 [pii];10.1177/0269215510395793
[doi]
Page, S. J., Hill, V., & White, S. (2013). Portable upper extremity robotics is as efficacious as upper
extremity rehabilitative therapy: a randomized controlled pilot trial. Clinical rehabilitation, 27(6),
494-503. doi: 10.1177/0269215512464795
Page, S. J., Levin, L., Hermann, V., Dunning, K., & Levine, P. (2012). Longer versus shorter daily durations
of electrical stimulation during task-specific practice in moderately impaired stroke.
[pii];10.1016/j.apmr.2011.09.016 [doi]
Page, S. J., Levin, L., Hermann, V., Dunning, K., & Levine, P. (2012). Longer versus shorter daily durations
of electrical stimulation during task-specific practice in moderately impaired stroke. Arch Phys
Med Rehabil, 93(2), 200-206. doi: 10.1016/j.apmr.2011.09.016
Page, S. J., & Levine, P. (2006). Back from the brink: electromyography-triggered stimulation combined
with modified constraint-induced movement therapy in chronic stroke. Arch.Phys.Med.Rehabil.,
87(1), 27-31. doi: S0003-9993(05)00997-4 [pii];10.1016/j.apmr.2005.07.307 [doi]
Page, S. J., Levine, P., & Khoury, J. C. (2009). Modified constraint-induced therapy combined with mental
practice: thinking through better motor outcomes. Stroke, 40(2), 551-554. doi:
STROKEAHA.108.528760 [pii];10.1161/STROKEAHA.108.528760 [doi]
Page, S. J., Levine, P., & Leonard, A. (2007). Mental practice in chronic stroke: results of a randomized,
placebo-controlled trial. Stroke, 38(4), 1293-1297. doi: 01.STR.0000260205.67348.2b
[pii];10.1161/01.STR.0000260205.67348.2b [doi]
Page, S. J., Levine, P., Leonard, A., Szaflarski, J. P., & Kissela, B. M. (2008). Modified constraint-induced
therapy in chronic stroke: results of a single-blinded randomized controlled trial. Phys Ther,
88(3), 333-340.
Page, S. J., Levine, P., & Leonard, A. C. (2005a). Effects of mental practice on affected limb use and
function in chronic stroke. Arch.Phys.Med.Rehabil., 86(3), 399-402. doi: S000399930401247X
[pii];10.1016/j.apmr.2004.10.002 [doi]
Page, S. J., Levine, P., & Leonard, A. C. (2005). Modified constraint-induced therapy in acute stroke: a
randomized controlled pilot study. Neurorehabil Neural Repair, 19(1), 27-32. doi:
10.1177/1545968304272701
Page, S. J., Levine, P., & Leonard, A. C. (2005b). Modified constraint-induced therapy in acute stroke: a
randomized controlled pilot study. Neurorehabil.Neural Repair, 19(1), 27-32. doi: 19/1/27
[pii];10.1177/1545968304272701 [doi]
Page, S. J., Levine, P., Sisto, S. A., & Johnston, M. V. (2001). Mental practice combined with physical
practice for upper-limb motor deficit in subacute stroke. Physical Therapy, 81(8), 1455-1462.
Page, S. J., Sisto, S., Johnston, M. V., & Levine, P. (2002). Modified constraint-induced therapy after
subacute stroke: a preliminary study. Neurorehabil.Neural Repair, 16(3), 290-295.

www.ebrsr.com
Page, S. J., Sisto, S., Levine, P., & McGrath, R. E. (2004). Efficacy of modified constraint-induced
movement therapy in chronic stroke: a single-blinded randomized controlled trial.
Arch.Phys.Med.Rehabil., 85(1), 14-18. doi: S0003999303004817 [pii]
Pandian, S., Arya, K. N., & Davidson, E. W. (2012). Comparison of Brunnstrom movement therapy and
Motor Relearning Program in rehabilitation of post-stroke hemiparetic hand: a randomized trial.
J Bodyw Mov Ther, 16(3), 330-337. doi: 10.1016/j.jbmt.2011.11.002
Pang, M. Y., Harris, J. E., & Eng, J. J. (2006). A community-based upper-extremity group exercise program
improves motor function and performance of functional activities in chronic stroke: a
randomized controlled trial. Arch Phys Med Rehabil., 87(1), 1-9.
Paoloni, M., Tavernese, E., Fini, M., Sale, P., Franceschini, M., Santilli, V., & Mangone, M. (2014).
Segmental muscle vibration modifies muscle activation during reaching in chronic stroke: A pilot
study. Neurorehabilitation, 35(3), 405-414. doi: 10.3233/NRE-141131
Papadopoulos, C. M., Tsai, S. Y., Guillen, V., Ortega, J., Kartje, G. L., & Wolf, W. A. (2009). Motor recovery
and axonal plasticity with short-term amphetamine after stroke. Stroke, 40(1), 294-302. doi:
10.1161/strokeaha.108.519769
Pariente, J., Loubinoux, I., Carel, C., Albucher, J. F., Leger, A., Manelfe, C., . . . Chollet, F. (2001).
Fluoxetine modulates motor performance and cerebral activation of patients recovering from
stroke. Ann Neurol, 50(6), 718-729.
Park, J., James, M. A., & White, A. (2006). Acupuncture May Be Ineffective for Stroke--Reply. Archives of
Internal Medicine, 166(8), 930.
Park, J., Lee, N., Cho, M., Kim, D., & Yang, Y. (2015). Effects of mental practice on stroke patients' upper
extremity function and daily activity performance. J Phys Ther Sci, 27(4), 1075-1077. doi:
10.1589/jpts.27.1075
Park, J. H., & Park, J. H. (2016). The effects of game-based virtual reality movement therapy plus mental
practice on upper extremity function in chronic stroke patients with hemiparesis: a randomized
controlled trial. J Phys Ther Sci, 28(3), 811-815. doi: 10.1589/jpts.28.811
Park, Y., Chang, M., Kim, K. M., & An, D. H. (2015). The effects of mirror therapy with tasks on upper
extremity function and self-care in stroke patients. Journal of Physical Therapy Science, 27(5),
1499-1501.
Patten, C., Condliffe, E. G., Dairaghi, C. A., & Lum, P. S. (2013). Concurrent neuromechanical and
functional gains following upper-extremity power training post-stroke. J Neuroeng Rehabil, 10,
1. doi: 10.1186/1743-0003-10-1
Pennati, G. V., Da Re, C., Messineo, I., & Bonaiuti, D. (2015). How could robotic training and botolinum
toxin be combined in chronic post stroke upper limb spasticity? A pilot study. Eur J Phys Rehabil
Med, 51(4), 381-387.
Pervane Vural, S., Nakipoglu Yuzer, G. F., Sezgin Ozcan, D., Demir Ozbudak, S., & Ozgirgin, N. (2016).
Effects of Mirror Therapy in Stroke Patients With Complex Regional Pain Syndrome Type 1: A
Randomized Controlled Study. Arch Phys Med Rehabil, 97(4), 575-581. doi:
10.1016/j.apmr.2015.12.008
Peurala, S. H., Kantanen, M. P., SjÃ¶gren, T., Paltamaa, J., Karhula, M., & Heinonen, A. (2012).
Effectiveness of constraint-induced movement therapy on activity and participation after stroke:
a systematic review and meta-analysis of randomized controlled trials. Clinical rehabilitation,
26(3), 209-223.
Picelli, A., Lobba, D., Midiri, A., Prandi, P., Melotti, C., Baldessarelli, S., & Smania, N. (2014). Botulinum
toxin injection into the forearm muscles for wrist and fingers spastic overactivity in adults with
chronic stroke: a randomized controlled trial comparing three injection techniques. Clinical
Piron, L., Turolla, A., Agostini, M., Zucconi, C. S., Ventura, L., Tonin, P., & Dam, M. (2010). Motor learning
principles for rehabilitation: a pilot randomized controlled study in poststroke patients.

www.ebrsr.com
[doi]
Platz, T., Eickhof, C., van, K. S., Engel, U., Pinkowski, C., Kalok, S., & Pause, M. (2005). Impairment-
oriented training or Bobath therapy for severe arm paresis after stroke: a single-blind,
multicentre randomized controlled trial. Clin.Rehabil., 19(7), 714-724.
Platz, T., Kim, I. H., Engel, U., Pinkowski, C., Eickhof, C., & Kutzner, M. (2005). Amphetamine fails to
facilitate motor performance and to enhance motor recovery among stroke patients with mild
arm paresis: interim analysis and termination of a double blind, randomised, placebo-controlled
trial. Restor.Neurol.Neurosci., 23(5-6), 271-280.
Platz, T., van, K. S., Mehrholz, J., Leidner, O., Eickhof, C., & Pohl, M. (2009). Best conventional therapy
versus modular impairment-oriented training for arm paresis after stroke: a single-blind,
multicenter randomized controlled trial. Neurorehabil.Neural Repair, 23(7), 706-716. doi:
1545968309335974 [pii];10.1177/1545968309335974 [doi]
Platz, T., Winter, T., Muller, N., Pinkowski, C., Eickhof, C., & Mauritz, K. H. (2001). Arm ability training for
stroke and traumatic brain injury patients with mild arm paresis: a single-blind, randomized,
controlled trial. Arch.Phys.Med.Rehabil., 82(7), 961-968. doi: S0003999301028854 [pii]
Plewnia, C., Hoppe, J., Hiemke, C., Bartels, M., Cohen, L. G., & Gerloff, C. (2002). Enhancement of human
cortico-motoneuronal excitability by the selective norepinephrine reuptake inhibitor reboxetine.
Neurosci Lett, 330(3), 231-234.
Ploughman, M., & Corbett, D. (2004). Can forced-use therapy be clinically applied after stroke? An
exploratory randomized controlled trial. Arch.Phys.Med.Rehabil., 85(9), 1417-1423. doi:
S0003999304002679 [pii]
Pomeroy, V. M., Cloud, G., Tallis, R. C., Donaldson, C., Nayak, V., & Miller, S. (2007). Transcranial
magnetic stimulation and muscle contraction to enhance stroke recovery: a randomized proof-
of-principle and feasibility investigation. Neurorehabil.Neural Repair, 21(6), 509-517. doi:
1545968307300418 [pii];10.1177/1545968307300418 [doi]
Pomeroy, V. M., King, L., Pollock, A., Baily-Hallam, A., & Langhorne, P. (2006). Electrostimulation for
promoting recovery of movement or functional ability after stroke.
Cochrane.Database.Syst.Rev.(2), CD003241. doi: 10.1002/14651858.CD003241.pub2 [doi]
Poole, J. L., Whitney, S. L., Hangeland, N., & Baker, C. (1990). The effectiveness of inflatable pressure
splints on motor function in stroke patients. Occupational Therapy Journal of Research, 10(6),
360-366.
Popovic, D. B., Popovic, M. B., Sinkjaer, T., Stefanovic, A., & Schwirtlich, L. (2004). Therapy of paretic arm
in hemiplegic subjects augmented with a neural prosthesis: a cross-over study. Can.J.Physiol
Pharmacol., 82(8-9), 749-756. doi: y04-057 [pii];10.1139/y04-057 [doi]
Popovic, M. B., Popovic, D. B., Sinkjaer, T., Stefanovic, A., & Schwirtlich, L. (2003). Clinical evaluation of
Functional Electrical Therapy in acute hemiplegic subjects. J.Rehabil.Res.Dev., 40(5), 443-453.
Popovic, M. R., Popovic, D. B., & Keller, T. (2002). Neuroprostheses for grasping. Neurol.Res., 24(5), 443-
452.
Post, M. W., Visser-Meily, J. M., Boomkamp-Koppen, H. G., & Prevo, A. J. (2003). Assessment of oedema
in stroke patients: comparison of visual inspection by therapists and volumetric assessment.
Disabil.Rehabil., 25(22), 1265-1270. doi: 10.1080/09638280310001603992
[doi];MBF6XG4HAKHN8763 [pii]
Powell, E. S., Carrico, C., Westgate, P. M., Chelette, K. C., Nichols, L., Reddy, L., . . . Sawaki, L. (2016).
Time configuration of combined neuromodulation and motor training after stroke: A proof-of-
concept study. Neurorehabilitation, 39(3), 439-449. doi: 10.3233/nre-161375
Powell, J., Pandyan, A. D., Granat, M., Cameron, M., & Stott, D. J. (1999). Electrical stimulation of wrist
extensors in poststroke hemiplegia. Stroke, 30(7), 1384-1389.

www.ebrsr.com
Prange, G. B., Jannink, M. J., Groothuis-Oudshoorn, C. G., Hermens, H. J., & Ijzerman, M. J. (2006).
Systematic review of the effect of robot-aided therapy on recovery of the hemiparetic arm after
stroke. J.Rehabil.Res.Dev., 43(2), 171-184.
Prange, G. B., Kottink, A. I., Buurke, J. H., Eckhardt, M. M., van Keulen-Rouweler, B. J., Ribbers, G. M., &
Rietman, J. S. (2015). The effect of arm support combined with rehabilitation games on upper-
extremity function in subacute stroke: a randomized controlled trial. Neurorehabil Neural
Repair, 29(2), 174-182. doi: 10.1177/1545968314535985
Prevo, A. J., Visser, S. L., & Vogelaar, T. W. (1982). Effect of EMG feedback on paretic muscles and
abnormal co-contraction in the hemiplegic arm, compared with conventional physical therapy.
Scand.J.Rehabil.Med., 14(3), 121-131.
Rabadi, M., Galgano, M., Lynch, D., Akerman, M., Lesser, M., & Volpe, B. (2008). A pilot study of activity-
based therapy in the arm motor recovery post stroke: a randomized controlled trial.
Clin.Rehabil., 22(12), 1071-1082. doi: 22/12/1071 [pii];10.1177/0269215508095358 [doi]
Rabinstein, A. A., & Shulman, L. M. (2003). Acupuncture in clinical neurology. Neurologist., 9(3), 137-148.
Radajewska, A., Opara, J., Bilinski, G., Kaczorowska, A., Nawrat-Szoltysik, A., Kucinska, A., & Lepsy, E.
(2017). Effectiveness of Mirror Therapy for Subacute Stroke in Relation to Chosen Factors.
Rehabil Nurs, 42(4), 223-229. doi: 10.1002/rnj.275
Radajewska, A., Opara, J., MaLecki, A., & Szczygie, L. J. (2013). The effects of mirror therapy on arm and
hand function in subacute stroke inpatients. Journal of the Neurological Sciences, 333, e563.
Rajesh, T. (2015). Effects of motor imagery on upper extremity functional task performance and quality
of life among stroke survivors. Asia Pacific Disability Rehabilitation Journal, 26(1), 109-124. doi:
10.5463/DCID.v26i1.225
Ramachandran, V. S., Rogers-Ramachandran, D., & Cobb, S. (1995). Touching the phantom limb. Nature,
377(6549), 489.
Ramos-Murguialday, A., Broetz, D., Rea, M., Laer, L., Yilmaz, O., Brasil, F. L., . . . Birbaumer, N. (2013).
Brain-Machine Interface in Chronic Stroke Rehabilitation: A Controlled Study. Annals of
Neurology, 74(1), 100-108. doi: 10.1002/ana.23879
Rayegani, S., Raeissadat, S., Sedighipour, L., Rezazadeh, I., Bahrami, M., Eliaspour, D., & Khosrawi, S.
(2014). Effect of neurofeedback and electromyographic-biofeedback therapy on improving hand
function in stroke patients. Topics in stroke rehabilitation, 21(2), 137-151. doi: 10.1310/tsr2102-
137
Reinkensmeyer DJ, W. E., Chan V, Chou C, Cramer SC, Bobrow JE. (2012). Comparison of three-
dimensional, assist-as-needed robotic arm/hand movement training provided with Pneu-WREX
to conventional tabletop therapy after chronic stroke. Am J Phys Med Rehabil., 91(11), S232-
241.
Repsaite, V., Vainoras, A., Berskiene, K., Baltaduoniene, D., Daunoraviciene, A., & Sendzikaite, E. (2015).
The effect of differential training-based occupational therapy on hand and arm function in
patients after stroke: Results of the pilot study. Neurologia I Neurochirurgia Polska, 49(3), 150-
155. doi: 10.1016/j.pjnns.2015.04.001
Restemeyer, C., Weiller, C., & Liepert, J. (2007). No effect of a levodopa single dose on motor
performance and motor excitability in chronic stroke. A double-blind placebo-controlled cross-
over pilot study. Restor Neurol Neurosci, 25(2), 143-150.
Riccio, I., Iolascon, G., Barillari, M. R., Gimigliano, R., & Gimigliano, F. (2010). Mental practice is effective
in upper limb recovery after stroke: a randomized single-blind cross-over study.
Eur.J.Phys.Rehabil.Med., 46(1), 19-25. doi: R33102131 [pii]
Richards, L., Gonzalez Rothi, L. J., Davis, S., Wu, S. S., & Nadeau, S. E. (2006). Limited dose response to
constraint-induced movement therapy in patients with chronic stroke. Clin.Rehabil., 20(12),
1066-1074. doi: 20/12/1066 [pii];10.1177/0269215506071263 [doi]

www.ebrsr.com
Ring, H., & Rosenthal, N. (2005). Controlled study of neuroprosthetic functional electrical stimulation in
sub-acute post-stroke rehabilitation. J Rehabil Med., 37(1), 32-36.
Ro, T., Noser, E., Boake, C., Johnson, R., Gaber, M., Speroni, A., . . . Levin, H. S. (2006). Functional
reorganization and recovery after constraint-induced movement therapy in subacute stroke:
case reports. Neurocase., 12(1), 50-60. doi: G356652044P8K081
[pii];10.1080/13554790500493415 [doi]
Robbins, S. M., Houghton, P. E., Woodbury, M. G., & Brown, J. L. (2006). The therapeutic effect of
functional and transcutaneous electric stimulation on improving gait speed in stroke patients: a
meta-analysis. Arch.Phys.Med.Rehabil., 87(6), 853-859. doi: S0003-9993(06)00175-4
[pii];10.1016/j.apmr.2006.02.026 [doi]
Robinson, R. G., Schultz, S. K., Castillo, C., Kopel, T., Kosier, J. T., Newman, R. M., . . . Starkstein, S. E.
(2000). Nortriptyline versus fluoxetine in the treatment of depression and in short-term
recovery after stroke: a placebo-controlled, double-blind study. Am.J.Psychiatry, 157(3), 351-
359.
Rocha, S., Silva, E., Foerster, A., Wiesiolek, C., Chagas, A. P., Machado, G., . . . Monte-Silva, K. (2016). The
impact of transcranial direct current stimulation (tDCS) combined with modified constraint-
induced movement therapy (mCIMT) on upper limb function in chronic stroke: a double-blind
randomized controlled trial. Disability and rehabilitation, 38(7), 653-660.
Rodgers, H., Mackintosh, J., Price, C., Wood, R., McNamee, P., Fearon, T., . . . Curless, R. (2003). Does an
early increased-intensity interdisciplinary upper limb therapy programme following acute stroke
improve outcome? Clin.Rehabil., 17(6), 579-589.
Rodrigues, L. C., Farias, N. C., Gomes, R. P., & Michaelsen, S. M. (2016). Feasibility and effectiveness of
adding object-related bilateral symmetrical training to mirror therapy in chronic stroke: A
randomized controlled pilot study. Physiother Theory Pract, 32(2), 83-91. doi:
10.3109/09593985.2015.1091872
Roper, T. A., Redford, S., & Tallis, R. C. (1999). Intermittent compression for the treatment of the
oedematous hand in hemiplegic stroke: a randomized controlled trial. Age Ageing, 28(1), 9-13.
Rosales, R. L., & Chua-Yap, A. S. (2008). Evidence-based systematic review on the efficacy and safety of
botulinum toxin-A therapy in post-stroke spasticity. J Neural Transm (Vienna), 115(4), 617-623.
doi: 10.1007/s00702-007-0869-3
Rose, D. K., Patten, C., McGuirk, T. E., Lu, X., & Triggs, W. J. (2014). Does inhibitory repetitive transcranial
magnetic stimulation augment functional task practice to improve arm recovery in chronic
stroke? Stroke Research and Treatment, 2014. doi: 10.1155/2014/305236
Rose, V., & Shah, S. (1987). A Comparative Study on the Immediate Effects of Hand Orthoses on
Reducation of Hypertonus. Australian occupational therapy journal, 34(2), 59-64.
Ross, L. F., Harvey, L. A., & Lannin, N. A. (2009). Do people with acquired brain impairment benefit from
additional therapy specifically directed at the hand? A randomized controlled trial. Clin.Rehabil.,
23(6), 492-503. doi: 0269215508101733 [pii];10.1177/0269215508101733 [doi]
Rosser, N., Heuschmann, P., Wersching, H., Breitenstein, C., Knecht, S., & Floel, A. (2008). Levodopa
improves procedural motor learning in chronic stroke patients. Arch.Phys.Med.Rehabil., 89(9),
1633-1641. doi: S0003-9993(08)00434-6 [pii];10.1016/j.apmr.2008.02.030 [doi]
Sahin, N., Ugurlu, H., & Albayrak, I. (2012). The efficacy of electrical stimulation in reducing the post-
stroke spasticity: a randomized controlled study. Disabil.Rehabil., 34(2), 151-156. doi:
10.3109/09638288.2011.593679 [doi]
Sale, P., Franceschini, M., Mazzoleni, S., Palma, E., Agosti, M., & Posteraro, F. (2014). Effects of upper
limb robot-assisted therapy on motor recovery in subacute stroke patients. Journal of
NeuroEngineering and Rehabilitation, 11. doi: 10.1186/1743-0003-11-104

www.ebrsr.com
Sallstrom, S., Kjendahl, A., +ÿsten, P. E., Kvalvik Stanghelle, J., & Borchgrevink, C. F. (1996). Acupuncture
in the treatment of stroke patients in the subacute stage: a randomized, controlled study.
Complementary Therapies in Medicine, 4(3), 193-197.
Samuel, G. S., Oey, N. E., Choo, M., Ju, H., Chan, W. Y., Kok, S., . . . Ng, Y. S. (2016). Combining levodopa
and virtual reality-based therapy for the rehabilitation of upper limb after acute stroke: pilot
study part II. Singapore Med J. doi: 10.11622/smedj.2016111
Samuelkamaleshkumar, S., Reethajanetsureka, S., Pauljebaraj, P., Benshamir, B., Padankatti, S. M., &
David, J. A. (2014). Mirror Therapy Enhances Motor Performance in the Paretic Upper Limb After
Stroke: A Pilot Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation,
95(11), 2000-2005. doi: 10.1016/j.apmr.2014.06.020
Sánchez-Sánchez, M. L., Ruescas-Nicolau, M.-A., Pérez-Miralles, J.-A., Marqués-Sulé, E., & Espí-López, G.-
V. (2017). Pilot randomized controlled trial to assess a physical therapy program on upper
extremity function to counteract inactivity in chronic stroke. Topics in stroke rehabilitation,
24(3), 183-193. doi: 10.1080/10749357.2016.1245395
Santamato, A., Micello, M. F., Panza, F., Fortunato, F., Baricich, A., Cisari, C., . . . Ranieri, M. (2014). Can
botulinum toxin type A injection technique influence the clinical outcome of patients with post-
stroke upper limb spasticity? A randomized controlled trial comparing manual needle placement
and ultrasound-guided injection techniques. Journal of the Neurological Sciences, 347(1-2), 39-
43. doi: 10.1016/j.jns.2014.09.016
Santamato, A., Micello, M. F., Panza, F., Fortunato, F., Picelli, A., Smania, N., . . . Ranieri, M. (2015).
Adhesive taping vs. daily manual muscle stretching and splinting after botulinum toxin type A
injection for wrist and fingers spastic overactivity in stroke patients: a randomized controlled
trial. Clinical rehabilitation, 29(1), 50-58. doi: 10.1177/0269215514537915
Santamato, A., Notarnicola, A., Panza, F., Ranieri, M., Micello, M. F., Manganotti, P., . . . Fiore, P. (2013).
SBOTE study: extracorporeal shock wave therapy versus electrical stimulation after botulinum
toxin type a injection for post-stroke spasticity-a prospective randomized trial. Ultrasound in
Medicine & Biology, 39(2), 283-291.
Saposnik, G., Cohen, L. G., Mamdani, M., Pooyania, S., Ploughman, M., Cheung, D., . . . Bayley, M. (2016).
Efficacy and safety of non-immersive virtual reality exercising in stroke rehabilitation (EVREST): a
randomised, multicentre, single-blind, controlled trial. The Lancet Neurology, 15(10), 1019-1027.
Saposnik, G., Teasell, R., Mamdani, M., Hall, J., McIlroy, W., Cheung, D., . . . Bayley, M. (2010).
Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation: a pilot
randomized clinical trial and proof of principle. Stroke, 41(7), 1477-1484. doi:
Sasaki, N., Kakuda, W., & Abo, M. (2014). Bilateral high- and low-frequency rTMS in acute stroke
patients with hemiparesis: A comparative study with unilateral high-frequency rTMS. Brain
Injury, 28(13-14), 1682-1686. doi: 10.3109/02699052.2014.947626
Sasaki, N., Mizutani, S., Kakuda, W., & Abo, M. (2013). Comparison of the effects of high- and low-
frequency repetitive transcranial magnetic stimulation on upper limb hemiparesis in the early
phase of stroke. J Stroke Cerebrovasc Dis., 22(4), 413-418.
Sathian, K., Greenspan, A. I., & Wolf, S. L. (2000). Doing it with mirrors: a case study of a novel approach
to neurorehabilitation. Neurorehabil Neural Repair, 14(1), 73-76. doi:
10.1177/154596830001400109
Sattler, V., Acket, B., Raposo, N., Albucher, J. F., Thalamas, C., Loubinoux, I., . . . Simonetta-Moreau, M.
(2015). Anodal tDCS Combined With Radial Nerve Stimulation Promotes Hand Motor Recovery
in the Acute Phase After Ischemic Stroke. Neurorehabil Neural Repair, 29(8), 743-754. doi:
10.1177/1545968314565465

www.ebrsr.com
Sawaki, L., Butler, A. J., Leng, X., Wassenaar, P. A., Mohammad, Y. M., Blanton, S., . . . Wittenberg, G. F.
(2008). Constraint-induced movement therapy results in increased motor map area in subjects 3
to 9 months after stroke. Neurorehabil Neural Repair, 22(5), 505-513.
Schabrun, S. M., & Hillier, S. (2009). Evidence for the retraining of sensation after stroke: a systematic
review. Clin.Rehabil., 23(1), 27-39. doi: 23/1/27 [pii];10.1177/0269215508098897 [doi]
Schmidt, R. A. (1991). Motor learning & performance: From principles to practice: Human Kinetics Books.
Scholz, D. S., Rohde, S., Nikmaram, N., Bruckner, H. P., Grobbach, M., Rollnik, J. D., & Altenmuller, E. O.
(2016). Sonification of arm movements in stroke rehabilitation - a novel approach in neurologic
music therapy. Frontiers in Neurology, 7 (JUN) (no pagination)(106).
Schuster, C., Maunz, G., Lutz, K., Kischka, U., Sturzenegger, R., & Ettlin, T. (2011). Dexamphetamine
improves upper extremity outcome during rehabilitation after stroke: a pilot randomized
controlled trial. Neurorehabil Neural Repair., 25(8), 749-755.
Selles, R., Michielsen, M., Bussmann, J., Stam, H., Hurkmans, H., Heijnen, I., . . . Ribbers, G. (2014).
Effects of a mirror-induced visual illusion on a reaching task in stroke patients: Implications for
mirror therapy training. Neurorehabilitation and Neural Repair, 28(7), 652-659.
Seniow, J., Bilik, M., Lesniak, M., Waldowski, K., Iwanski, S., & Czlonkowska, A. (2012). Transcranial
magnetic stimulation combined with physiotherapy in rehabilitation of poststroke hemiparesis:
a randomized, double-blind, placebo-controlled study. Neurorehabil.Neural Repair, 26(9), 1072-
1079. doi: 1545968312445635 [pii];10.1177/1545968312445635 [doi]
Seo, H. G., Paik, N. J., Lee, S. U., Oh, B. M., Chun, M. H., Kwon, B. S., & Bang, M. S. (2015). Neuronox
versus BOTOX in the treatment of post-stroke upper limb spasticity: A multicenter randomized
controlled trial. Plos One, 10(6).
Seo, K. C., & Kim, H. A. (2015). The effects of ramp gait exercise with PNF on stroke patients’ dynamic
balance. Journal of Physical Therapy Science, 27(6), 1747-1749.
Seok, H., Lee, S. Y., Kim, J., Yeo, J., & Kang, H. (2016). Can Short-Term Constraint-Induced Movement
Therapy Combined With Visual Biofeedback Training Improve Hemiplegic Upper Limb Function
of Subacute Stroke Patients? Ann Rehabil Med, 40(6), 998-1009. doi:
10.5535/arm.2016.40.6.998
Shah, M. V., Kumar, S., & Muragod, A. R. (2016a). Effect of Constraint Induced Movement Therapy v/s
Motor Relearning Program for Upper Extremity Function in Sub Acute Hemiparetic Patients-a
Randomized Clinical Trial. Indian Journal of Physiotherapy and Occupational Therapy - An
International Journal, 10(1), 71. doi: 10.5958/0973-5674.2016.00016.2
Shah, M. V., Kumar, S., & Muragod, A. R. (2016b). Effect of Constraint Induced Movement Therapy v/s
Motor Relearning Program for Upper Extremity Function in Sub Acute Hemiparetic Patients-a
Randomized Clinical Trial. Indian Journal of Physiotherapy & Occupational Therapy, 10(1), 71-75.
doi: 10.5958/0973-5674.2016.00016.2
Shaw, L. C., Price, C. I., van Wijck, F. M., Shackley, P., Steen, N., Barnes, M. P., . . . Rodgers, H. (2011).
Botulinum Toxin for the Upper Limb after Stroke (BoTULS) Trial: effect on impairment, activity
limitation, and pain. Stroke, 42(5), 1371-1379. doi: STROKEAHA.110.582197
Shi, Y. X., Tian, J. H., Yang, K. H., & Zhao, Y. (2011). Modified constraint-induced movement therapy
versus traditional rehabilitation in patients with upper-extremity dysfunction after stroke: a
systematic review and meta-analysis. Arch.Phys.Med.Rehabil., 92(6), 972-982. doi: S0003-
9993(11)00022-0 [pii];10.1016/j.apmr.2010.12.036 [doi]
Shim, S., & Jung, J. (2015). Effects of bilateral training on motor function, amount of activity and activity
intensity measured with an accelerometer of patients with stroke. Journal of Physical Therapy
Science, 27(3), 751-754.
Shimodozono, M., Noma, T., Matsumoto, S., Miyata, R., Etoh, S., & Kawahira, K. (2014). Repetitive
facilitative exercise under continuous electrical stimulation for severe arm impairment after sub-

www.ebrsr.com
acute stroke: A randomized controlled pilot study. Brain Injury, 28(2), 203-210. doi:
10.3109/02699052.2013.860472
Shimodozono, M., Noma, T., Nomoto, Y., Hisamatsu, N., Kamada, K., Miyata, R., . . . Kawahira, K. (2013).
Benefits of a repetitive facilitative exercise program for the upper paretic extremity after
subacute stroke: A randomized controlled trial. Neurorehabilitation and Neural Repair, 27(4),
296-305.
Shin, J. H., Bog Park, S., & Ho Jang, S. (2015). Effects of game-based virtual reality on health-related
quality of life in chronic stroke patients: A randomized, controlled study. Computers in Biology
and Medicine, 63, 92-98. doi: 10.1016/j.compbiomed.2015.03.011
Shin, J. H., Kim, M. Y., Lee, J. Y., Jeon, Y. J., Kim, S., Lee, S., . . . Choi, Y. (2016). Effects of virtual reality-
based rehabilitation on distal upper extremity function and health-related quality of life: A
single-blinded, randomized controlled trial. Journal of NeuroEngineering and Rehabilitation, 13
(1) (no pagination)(125).
Shin, J. H., Ryu, H., & Jang, S. H. (2014). A task-specific interactive game-based virtual reality
rehabilitation system for patients with stroke: a usability test and two clinical experiments.
Journal of NeuroEngineering and Rehabilitation, 11. doi: 10.1186/1743-0003-11-32
Shindo, K., Fujiwara, T., Hara, J., Oba, H., Hotta, F., Tsuji, T., . . . Liu, M. (2011). Effectiveness of hybrid
assistive neuromuscular dynamic stimulation therapy in patients with subacute stroke: a
randomized controlled pilot trial. Neurorehabil.Neural Repair, 25(9), 830-837. doi:
1545968311408917 [pii];10.1177/1545968311408917 [doi]
Si, Q. M., Wu, G. C., & Cao, X. D. (1998). Effects of electroacupuncture on acute cerebral infarction.
Acupunct.Electrother.Res., 23(2), 117-124.
Si, Q. M., Wu, G. C., & Cao, X. D. (1998). Effects of electroacupuncture on acute cerebral infarction.
Acupunct Electrother Res, 23(2), 117-124.
Şik, B. Y., Dursun, N., Dursun, E., Sade, I., & Şahİn, E. (2015). Transcranial direct current stimulation: The
effects on plegic upper extremity motor function of patients with stroke. Journal of Neurological
Sciences, 32(2), 320-334.
Simpson, D. M., Alexander, D. N., O'Brien, C. F., Tagliati, M., Aswad, A. S., Leon, J. M., . . . Monaghan, E.
P. (1996). Botulinum toxin type A in the treatment of upper extremity spasticity: a randomized,
double-blind, placebo-controlled trial. Neurology, 46(5), 1306-1310.
Simpson, D. M., Gracies, J. M., Yablon, S. A., Barbano, R., Brashear, A., & Bo, N. T. T. Z. D. S. T. (2009).
Botulinum neurotoxin versus tizanidine in upper limb spasticity: a placebo-controlled study. J
Neurol Neurosurg Psychiatry, 80(4), 380-385. doi: 10.1136/jnnp.2008.159657
Singer, B. J., Vallence, A. M., Cleary, S., Cooper, I., & Loftus, A. M. (2013). The effect of EMG triggered
electrical stimulation plus task practice on arm function in chronic stroke patients with
moderate-severe arm deficits. Restorative Neurology and Neuroscience, 31(6), 681-691. doi:
10.3233/rnn-130319
Sirtori, V., Corbetta, D., Moja, L., & Gatti, R. (2009). Constraint-induced movement therapy for upper
extremities in stroke patients. Cochrane.Database.Syst.Rev.(4), CD004433. doi:
10.1002/14651858.CD004433.pub2 [doi]
Sisto, S. A., Forrest, G. F., & Glendinning, D. (2002). Virtual reality applications for motor rehabilitation
after stroke. Top.Stroke Rehabil., 8(4), 11-23.
Smania, N., Gandolfi, M., Marconi, V., Calanca, A., Geroin, C., Piazza, S., . . . Picelli, A. (2012). Applicability
of a new robotic walking aid in a patient with cerebral palsy. Case report.
Eur.J.Phys.Rehabil.Med., 48(1), 147-153. doi: R33112449 [pii]
Smedes, F., van der Salm, A., Koel, G., & Oosterveld, F. (2014). Manual mobilization of the wrist: A pilot
study in rehabilitation of patients with a chronic hemiplegic hand post-stroke. Journal of Hand
Therapy, 27(3), 209-216. doi: 10.1016/j.jht.2013.12.011

www.ebrsr.com
Smith, S. J., Ellis, E., White, S., & Moore, A. P. (2000). A double-blind placebo-controlled study of
botulinum toxin in upper limb spasticity after stroke or head injury. Clin.Rehabil., 14(1), 5-13.
Sommerfeld, D. K., Eek, E. U.-B., Svensson, A. K., Holmqvist, L. W. n., & von Arbin, M. H. (2004). Spasticity
After Stroke Its Occurrence and Association With Motor Impairments and Activity Limitations.
Stroke, 35(1), 134-139.
Sonde, L., Gip, C., Fernaeus, S. E., Nilsson, C. G., & Viitanen, M. (1998). Stimulation with low frequency
(1.7 Hz) transcutaneous electric nerve stimulation (low-tens) increases motor function of the
post-stroke paretic arm. Scand.J.Rehabil.Med., 30(2), 95-99.
Song, J., Nair, V. A., Young, B. M., Walton, L. M., Nigogosyan, Z., Remsik, A., . . . Prabhakaran, V. (2015).
DTI measures track and predict motor function outcomes in stroke rehabilitation utilizing BCI
technology. Frontiers in Human Neuroscience, 9(APR), 1-13. doi: 10.3389/fnhum.2015.00195
Song, Y., Kang, L., Dong, H., & Chen, Y. (2016). Combined rehabilitation with scalp cluster acupuncture
and constraint-induced movement therapy significantly improved functional recovery in
patients with acute ischemic stroke. Int J Clin Exp Med, 9(10), 19797-19802.
Song, Y., Kang, L., Dong, H., & Chen, Y. (2016). Combined rehabilitation with scalp cluster acupuncture
and constraint-induced movement therapy significantly improved functional recovery in
patients with acute ischemic stroke. International Journal of Clinical and Experimental Medicine,
9(10), 19797-19802.
Souza, W. C., Conforto, A. B., Orsini, M., Stern, A., & Andre, C. (2015). Similar effects of two modified
constraint-induced therapy protocols on motor impairment, motor function and quality of life in
patients with chronic stroke. Neurology International, 7(1), 2-7.
Stagg, C. J., Bachtiar, V., O'Shea, J., Allman, C., Bosnell, R. A., Kischka, U., . . . Johansen-Berg, H. (2012).
Cortical activation changes underlying stimulation-induced behavioural gains in chronic stroke.
Brain, 135(Pt 1), 276-284. doi: awr313 [pii];10.1093/brain/awr313 [doi]
Stamenova, P., Koytchev, R., Kuhn, K., Hansen, C., Horvath, F., Ramm, S., & Pongratz, D. (2005). A
randomized, double-blind, placebo-controlled study of the efficacy and safety of tolperisone in
spasticity following cerebral stroke. Eur.J.Neurol., 12(6), 453-461. doi: ENE1006
[pii];10.1111/j.1468-1331.2005.01006.x [doi]
Standen, P. J., Threapleton, K., Richardson, A., Connell, L., Brown, D. J., Battersby, S., . . . Burton, A.
(2016). A low cost virtual reality system for home based rehabilitation of the arm following
stroke: a randomised controlled feasibility trial. Clinical rehabilitation, 31(3), 340-350. doi:
10.1177/0269215516640320
Stein, C., Fritsch, C. G., Robinson, C., Sbruzzi, G., & Plentz, R. D. (2015). Effects of Electrical Stimulation in
Spastic Muscles After Stroke: Systematic Review and Meta-Analysis of Randomized Controlled
Trials. Stroke, 46(8), 2197-2205. doi: 10.1161/strokeaha.115.009633
Stein, J., Hughes, R., D'Andrea, S., Therrien, B., Niemi, J., Krebs, K., . . . Harry, J. (2010). Stochastic
resonance stimulation for upper limb rehabilitation poststroke. Am.J.Phys.Med.Rehabil., 89(9),
697-705. doi: 10.1097/PHM.0b013e3181ec9aa8 [doi];00002060-201009000-00001 [pii]
Stein, J., Krebs, H. I., Frontera, W. R., Fasoli, S. E., Hughes, R., & Hogan, N. (2004). Comparison of two
techniques of robot-aided upper limb exercise training after stroke. Am J Phys Med Rehabil.,
83(9), 720-728.
Sterr, A., Elbert, T., Berthold, I., Kolbel, S., Rockstroh, B., & Taub, E. (2002). Longer versus shorter daily
constraint-induced movement therapy of chronic hemiparesis: an exploratory study.
Arch.Phys.Med.Rehabil., 83(10), 1374-1377. doi: S0003999302000540 [pii]
Steultjens, E. M., Dekker, J., Bouter, L. M., van de Nes, J. C., Cup, E. H., & van den Ende, C. H. (2003).
Occupational therapy for stroke patients: a systematic review. Stroke, 34(3), 676-687. doi:
10.1161/01.STR.0000057576.77308.30 [doi];01.STR.0000057576.77308.30 [pii]

www.ebrsr.com
Stinear, C. M., Barber, P. A., Coxon, J. P., Fleming, M. K., & Byblow, W. D. (2008). Priming the motor
system enhances the effects of upper limb therapy in chronic stroke. Brain, 131(Pt 5), 1381-
1390. doi: awn051 [pii];10.1093/brain/awn051 [doi]
Stinear, C. M., Petoe, M. A., Anwar, S., Barber, P. A., & Byblow, W. D. (2014). Bilateral Priming
Accelerates Recovery of Upper Limb Function After Stroke A Randomized Controlled Trial.
Stroke, 45(1), 205-210. doi: 10.1161/strokeaha.113.003537
Stock, R., Thrane, G., Anke, A., & Askim, T. (2015). The effect of early versus late constraint-induced
movement therapy on motor function: Results from a randomized controlled trial with 12-
month follow-up. International Journal of Stroke, 10, 93.
Stoykov, M. E., Lewis, G. N., & Corcos, D. M. (2009). Comparison of bilateral and unilateral training for
upper extremity hemiparesis in stroke. Neurorehabil Neural Repair., 23(9), 945-953.
Straudi, S., Fregni, F., Martinuzzi, C., Pavarelli, C., Salvioli, S., & Basaglia, N. (2016). tDCS and Robotics on
Upper Limb Stroke Rehabilitation: Effect Modification by Stroke Duration and Type of Stroke.
Biomed Research International, 2016, 1-8. doi: 10.1155/2016/5068127
Suat, E., Engin, S. I., Nilgun, B., Yavuz, Y., & Fatma, U. (2011). Short- and long-term effects of an inhibitor
hand splint in poststroke patients: a randomized controlled trial. Top Stroke Rehabil, 18(3), 231-
237. doi: 10.1310/tsr1803-231
Subramanian, S. K., Massie, C. L., Malcolm, M. P., & Levin, M. F. (2010). Does provision of extrinsic
feedback result in improved motor learning in the upper limb poststroke? A systematic review
of the evidence. Neurorehabil.Neural Repair, 24(2), 113-124. doi: 1545968309349941
[pii];10.1177/1545968309349941 [doi]
Summers, J. J., Kagerer, F. A., Garry, M. I., Hiraga, C. Y., Loftus, A., & Cauraugh, J. H. (2007). Bilateral and
unilateral movement training on upper limb function in chronic stroke patients: A TMS study.
J.Neurol.Sci., 252(1), 76-82. doi: S0022-510X(06)00487-4 [pii];10.1016/j.jns.2006.10.011 [doi]
Sun, S. F., Hsu, C. W., Sun, H. P., Hwang, C. W., Yang, C. L., & Wang, J. L. (2010). Combined botulinum
toxin type A with modified constraint-induced movement therapy for chronic stroke patients
with upper extremity spasticity: a randomized controlled study. Neurorehabil.Neural Repair,
24(1), 34-41. doi: 1545968309341060 [pii];10.1177/1545968309341060 [doi]
Sun, Y., Wei, W., Luo, Z., Gan, H., & Hu, X. (2016). Improving motor imagery practice with synchronous
action observation in stroke patients. Topics in stroke rehabilitation, 23(4), 245-253.
Sunderland, A., Fletcher, D., Bradley, L., Tinson, D., Hewer, R. L., & Wade, D. T. (1994). Enhanced physical
therapy for arm function after stroke: a one year follow up study. J Neurol Neurosurg
Psychiatry., 57(7), 856-858.
Sunderland, A., Tinson, D. J., Bradley, E. L., Fletcher, D., Langton, H. R., & Wade, D. T. (1992). Enhanced
physical therapy improves recovery of arm function after stroke. A randomised controlled trial.
J.Neurol.Neurosurg.Psychiatry, 55(7), 530-535.
Sung, W. H., Wang, C. P., Chou, C. L., Chen, Y. C., Chang, Y. C., & Tsai, P. Y. (2013). Efficacy of coupling
inhibitory and facilitatory repetitive transcranial magnetic stimulation to enhance motor
recovery in hemiplegic stroke patients. Stroke, 44(5), 1375-1382. doi:
10.1161/strokeaha.111.000522
Suputtitada, A., & Suwanwela, N. C. (2005). The lowest effective dose of botulinum A toxin in adult
patients with upper limb spasticity. Disabil.Rehabil., 27(4), 176-184. doi: GRWYQ6Y59H774MGP
[pii];10.1080/09638280400009360 [doi]
Suputtitada, A., Suwanwela, N. C., & Tumvitee, S. (2004). Effectiveness of constraint-induced movement
therapy in chronic stroke patients. J.Med.Assoc.Thai., 87(12), 1482-1490.
Susanto, E. A., Tong, R. K. Y., Ockenfeld, C., & Ho, N. S. K. (2015). Efficacy of robot-assisted fingers
training in chronic stroke survivors: a pilot randomized-controlled trial. Journal of
NeuroEngineering and Rehabilitation, 12. doi: 10.1186/s12984-015-0033-5

www.ebrsr.com
Sze, F. K., Wong, E., Yi, X., & Woo, J. (2002). Does acupuncture have additional value to standard
poststroke motor rehabilitation? Stroke, 33(1), 186-194.
Sze, F. K., Yeung, F. F., Wong, E., & Lau, J. (2005). Does Danshen improve disability after acute ischaemic
stroke? Acta Neurol.Scand., 111(2), 118-125. doi: ANE369 [pii];10.1111/j.1600-
0404.2004.00369.x [doi]
Tai, I., Chiou-Lian, L., Miao-Ju, H., Ruey-Tay, L., Mao-Hsiung, H., Chuan-Li, L., . . . Jau-Hong, L. (2014).
Effect of Thermal Stimulation on Corticomotor Excitability in Patients with Stroke. American
Journal of Physical Medicine & Rehabilitation, 93(9), 801-808. doi:
10.1097/PHM.0000000000000105
Takako, M., Ayako, T., Takako, I., Yukari, H., & Shinji, N. (2015). Increasing upper-limb joint range of
motion in post-stroke hemiplegic patients by daily hair-brushing. British Journal of Neuroscience
Nursing, 11(3), 112-117.
Takebayashi, T., Koyama, T., Amano, S., Hanada, K., Tabusadani, M., Hosomi, M., . . . Domen, K. (2013). A
6-month follow-up after constraint-induced movement therapy with and without transfer
package for patients with hemiparesis after stroke: a pilot quasi-randomized controlled trial.
Clinical rehabilitation, 27(5), 418-426. doi: 10.1177/0269215512460779
Takeuchi, N., Chuma, T., Matsuo, Y., Watanabe, I., & Ikoma, K. (2005). Repetitive transcranial magnetic
stimulation of contralesional primary motor cortex improves hand function after stroke. Stroke,
36(12), 2681-2686. doi: 01.STR.0000189658.51972.34
[pii];10.1161/01.STR.0000189658.51972.34 [doi]
Takeuchi, N., Tada, T., Toshima, M., Chuma, T., Matsuo, Y., & Ikoma, K. (2008). Inhibition of the
unaffected motor cortex by 1 Hz repetitive transcranical magnetic stimulation enhances motor
performance and training effect of the paretic hand in patients with chronic stroke.
J.Rehabil.Med., 40(4), 298-303. doi: 10.2340/16501977-0181 [doi]
Takeuchi, N., Tada, T., Toshima, M., Matsuo, Y., & Ikoma, K. (2009). Repetitive transcranial magnetic
stimulation over bilateral hemispheres enhances motor function and training effect of paretic
hand in patients after stroke. J.Rehabil.Med., 41(13), 1049-1054. doi: 10.2340/16501977-0454
[doi]
Talelli, P., Greenwood, R. J., & Rothwell, J. C. (2007). Exploring Theta Burst Stimulation as an intervention
to improve motor recovery in chronic stroke. Clin Neurophysiol, 118(2), 333-342. doi:
10.1016/j.clinph.2006.10.014
Talelli, P., Wallace, A., Dileone, M., Hoad, D., Cheeran, B., Oliver, R., . . . Rothwell, J. C. (2012). Theta
burst stimulation in the rehabilitation of the upper limb: a semirandomized, placebo-controlled
trial in chronic stroke patients. Neurorehabil.Neural Repair, 26(8), 976-987. doi:
1545968312437940 [pii];10.1177/1545968312437940 [doi]
Tanaka, S., Takeda, K., Otaka, Y., Kita, K., Osu, R., Honda, M., . . . Watanabe, K. (2011). Single session of
transcranial direct current stimulation transiently increases knee extensor force in patients with
hemiparetic stroke. Neurorehabil.Neural Repair, 25(6), 565-569. doi: 1545968311402091
[pii];10.1177/1545968311402091 [doi]
Tardy, J., Pariente, J., Leger, A., Dechaumont-Palacin, S., Gerdelat, A., Guiraud, V., . . . Loubinoux, I.
(2006). Methylphenidate modulates cerebral post-stroke reorganization. Neuroimage., 33(3),
913-922. doi: S1053-8119(06)00801-9 [pii];10.1016/j.neuroimage.2006.07.014 [doi]
Tariq, M., Akhtar, N., Ali, M., Rao, S., Badshah, M., & Irshad, M. (2005). Eperisone compared to
physiotherapy on muscular tone of stroke patients: a prospective randomized open study.
J.Pak.Med.Assoc., 55(5), 202-204.
Tarkka, I. M., Pitkanen, K., Popovic, D. B., Vanninen, R., & Kononen, M. (2011). Functional electrical
therapy for hemiparesis alleviates disability and enhances neuroplasticity. Tohoku J.Exp.Med.,
225(1), 71-76. doi: JST.JSTAGE/tjem/225.71 [pii]

www.ebrsr.com
Taub, E. (1980). Somatosensory deafferentation research with monkeys: implications for rehabilitation
medicine. Behavioral Psychology in Rehabilitation Medicine: Clinical Applications.New York, NY:
Williams & Wilkins, 371, 401.
Taub, E., Miller, N. E., Novack, T. A., Cook, E. W., III, Fleming, W. C., Nepomuceno, C. S., . . . Crago, J. E.
(1993). Technique to improve chronic motor deficit after stroke. Arch.Phys.Med.Rehabil., 74(4),
347-354.
Taub, E., & Morris, D. M. (2001). Constraint-induced movement therapy to enhance recovery after
stroke. Curr.Atheroscler.Rep., 3(4), 279-286.
Taub, E., & Uswatte, G. (2003). The case for CI therapy. J.Rehabil.Res.Dev., 40(6), xiii-xixv.
Taub, E., Uswatte, G., King, D. K., Morris, D., Crago, J. E., & Chatterjee, A. (2006). A placebo-controlled
trial of constraint-induced movement therapy for upper extremity after stroke. Stroke, 37(4),
1045-1049. doi: 10.1161/01.STR.0000206463.66461.97
Taub, E., Uswatte, G., Mark, V. W., Morris, D. M., Barman, J., Bowman, M. H., . . . Bishop-McKay, S.
(2013). Method for Enhancing Real-World Use of a More Affected Arm in Chronic Stroke
Transfer Package of Constraint-Induced Movement Therapy. Stroke, 44(5), 1383-+. doi:
10.1161/strokeaha.111.000559
Taub, E., Uswatte, G., & Morris, D. M. (2003). Improved motor recovery after stroke and massive cortical
reorganization following constraint-induced movement therapy. Physical medicine and
rehabilitation clinics of North America, 14(1), S77-S91.
Taub, E., Uswatte, G., & Pidikiti, R. (1999). Constraint-Induced Movement Therapy: a new family of
techniques with broad application to physical rehabilitation--a clinical review. J.Rehabil.Res.Dev.,
36(3), 237-251.
Tavernese, E., Paoloni, M., Mangone, M., Mandic, V., Sale, P., Franceschini, M., & Santilli, V. (2013).
Segmental muscle vibration improves reaching movement in patients with chronic stroke. A
randomized controlled trial. Neurorehabilitation, 32(3), 591-599. doi: 10.3233/nre-130881
Tekeoglu, Y., Adak, B., & Goksoy, T. (1998). Effect of transcutaneous electrical nerve stimulation (TENS)
on Barthel Activities of Daily Living (ADL) index score following stroke. Clin.Rehabil., 12(4), 277-
280.
Tepperman, P. S., Greyson, N. D., Hilbert, L., Jimenez, J., & Williams, J. I. (1984). Reflex sympathetic
dystrophy in hemiplegia. Arch Phys Med Rehabil, 65(8), 442-447.
Thanakiatpinyo, T., Suwannatrai, S., Suwannatrai, U., Khumkaew, P., Wiwattamongkol, D., Vannabhum,
M., . . . Kuptniratsaikul, V. (2014). The efficacy of traditional Thai massage in decreasing
spasticity in elderly stroke patients. Clinical Interventions in Aging, 9, 1311-1319. doi:
10.2147/cia.s66416
Thielbar, K. O., Lord, T. J., Fischer, H. C., Lazzaro, E. C., Barth, K. C., Stoykov, M. E., . . . Kamper, D. G.
(2014). Training finger individuation with a mechatronic-virtual reality system leads to improved
fine motor control post-stroke. Journal of NeuroEngineering and Rehabilitation, 11. doi:
10.1186/1743-0003-11-171
Thielbar, K. O., Triandafilou, K. M., Fischer, H. C., O'Toole, J. M., Corrigan, M. L., Ochoa, J. M., . . .
Kamper, D. G. (2017). Benefits of Using a Voice and EMG-Driven Actuated Glove to Support
Occupational Therapy for Stroke Survivors. IEEE Trans Neural Syst Rehabil Eng, 25(3), 297-305.
doi: 10.1109/tnsre.2016.2569070
Thielman, G. (2010). Rehabilitation of reaching poststroke: a randomized pilot investigation of tactile
versus auditory feedback for trunk control. J Neurol Phys Ther, 34(3), 138-144.
Thielman, G. (2013a). Insights into upper limb kinematics and trunk control one year after task-related
training in chronic post-stroke individuals. J Hand Ther, 26(2), 156-160; quiz 161. doi:
10.1016/j.jht.2012.12.003

www.ebrsr.com
Thielman, G. (2013b). Insights into upper limb kinematics and trunk control one year after task-related
training in chronic post-stroke individuals. Journal of Hand Therapy, 26(2), 156-160. doi:
10.1016/j.jht.2012.12.003
Thielman, G., & Bonsall, P. (2012). Rehabilitation of the Upper Extremity after Stroke: A Case Series
Evaluating REO Therapy and an Auditory Sensor Feedback for Trunk Control. Stroke Res Treat,
2012, 348631. doi: 10.1155/2012/348631
Thielman, G. T., Dean, C. M., & Gentile, A. M. (2004). Rehabilitation of reaching after stroke: task-related
training versus progressive resistive exercise. Arch Phys Med Rehabil., 85(10), 1613-1618.
Thieme, H., Mehrholz, J., Pohl, M., Behrens, J., & Dohle, C. (2012). Mirror therapy for improving motor
function after stroke. Cochrane.Database.Syst.Rev., 3, CD008449. doi:
10.1002/14651858.CD008449.pub2 [doi]
Thrane, G., Askim, T., Stock, R., Indredavik, B., Gjone, R., Erichsen, A., & Anke, A. (2015). Efficacy of
Constraint-Induced Movement Therapy in Early Stroke Rehabilitation: A Randomized Controlled
Multisite Trial. Neurorehabil Neural Repair, 29(6), 517-525. doi: 10.1177/1545968314558599
Thrasher, T. A., Zivanovic, V., McIlroy, W., & Popovic, M. R. (2008). Rehabilitation of reaching and
grasping function in severe hemiplegic patients using functional electrical stimulation therapy.
[pii];10.1177/1545968308317436 [doi]
Timmermans, A. A., Lemmens, R. J., Monfrance, M., Geers, R. P., Bakx, W., Smeets, R. J., & Seelen, H. A.
(2014). Effects of task-oriented robot training on arm function, activity, and quality of life in
chronic stroke patients: a randomized controlled trial. Journal of Neuroengineering &
Rehabilitation, 11, 45.
Timmermans, A. A., Spooren, A. I., Kingma, H., & Seelen, H. A. (2010). Influence of task-oriented training
content on skilled arm-hand performance in stroke: a systematic review. Neurorehabil.Neural
Repair, 24(9), 858-870. doi: 1545968310368963 [pii];10.1177/1545968310368963 [doi]
Timmermans, A. A., Verbunt, J. A., van Woerden, R., Moennekens, M., Pernot, D. H., & Seelen, H. A.
(2013). Effect of mental practice on the improvement of function and daily activity performance
of the upper extremity in patients with subacute stroke: a randomized clinical trial. Journal of
the American Medical Directors Association, 14(3), 204-212.
Tong, Y., Forreider, B., Sun, X., Geng, X., Zhang, W., Du, H., . . . Ding, Y. (2015). Music-supported therapy
(MST) in improving post-stroke patients' upper-limb motor function: a randomised controlled
pilot study. Neurological Research, 37(5), 434-440. doi: 10.1179/1743132815Y.0000000034
Treger, I., Aidinof, L., Lehrer, H., & Kalichman, L. (2012). Modified constraint-induced movement therapy
improved upper limb function in subacute poststroke patients: a small-scale clinical trial.
Top.Stroke Rehabil., 19(4), 287-293. doi: GNP32W5R51284K73 [pii];10.1310/tsr1904-287 [doi]
Tretriluxana, J., Taptong, J., & Chaiyawat, P. (2015). Dyad Training Protocol on Learning of Bimanual Cup
Stacking in Individuals with Stroke: Effects of Observation Duration. J Med Assoc Thai, 98 Suppl
5, S106-112.
Triccas, L. T., Burridge, J. H., Hughes, A., Verheyden, G., Desikan, M., & Rothwell, J. (2015). A double-
blinded randomised controlled trial exploring the effect of anodal transcranial direct current
stimulation and uni-lateral robot therapy for the impaired upper limb in sub-acute and chronic
stroke. Neurorehabilitation, 37(2), 181-191. doi: 10.3233/NRE-151251
Trinh, T., Scheuer, S. E., Thompson-Butel, A. G., Shiner, C. T., & McNulty, P. A. (2016). Cardiovascular
fitness is improved poststroke with upper-limb wii-based movement therapy but not dose-
matched constraint therapy. Topics in stroke rehabilitation, 23(3), 208-216.
Trombly, C. A., Thayer-Nason, L., Bliss, G., Girard, C. A., Lyrist, L. A., & Brexa-Hooson, A. (1986). The
effectiveness of therapy in improving finger extension in stroke patients. Am J Occup Ther, 40(9),
612-617.

www.ebrsr.com
Tseng, C. N., Chen, C. C., Wu, S. C., & Lin, L. C. (2007). Effects of a range-of-motion exercise programme.
J.Adv.Nurs., 57(2), 181-191. doi: JAN4078 [pii];10.1111/j.1365-2648.2006.04078.x [doi]
Tsubokawa, T., Katayama, Y., Yamamoto, T., Hirayama, T., & Koyama, S. (1991). Chronic motor cortex
stimulation for the treatment of central pain. Acta Neurochir.Suppl (Wien.), 52, 137-139.
Turton, A., & Fraser, C. (1990). The use of home therapy programmes for improving recovery of the
upper limb following stroke. Br J Occup Ther, 53(11), 458-463.
Tyson, S. F., & Kent, R. M. (2011). The effect of upper limb orthotics after stroke: a systematic review.
NeuroRehabilitation., 28(1), 29-36. doi: R872026N11054V74 [pii];10.3233/NRE-2011-0629 [doi]
Underwood, J., Clark, P. C., Blanton, S., Aycock, D. M., & Wolf, S. L. (2006). Pain, fatigue, and intensity of
practice in people with stroke who are receiving constraint-induced movement therapy.
Phys.Ther., 86(9), 1241-1250. doi: 86/9/1241 [pii];10.2522/ptj.20050357 [doi]
Urbin, M. A., Waddell, K. J., & Lang, C. E. (2015). Acceleration metrics are responsive to change in upper
extremity function of stroke survivors. Arch Phys Med Rehabil, 96(5), 854-861. doi:
10.1016/j.apmr.2014.11.018
Uswatte, G., Taub, E., Morris, D., Barman, J., & Crago, J. (2006). Contribution of the shaping and restraint
components of Constraint-Induced Movement therapy to treatment outcome.
Neurorehabilitation, 21(2), 147-156.
van Delden, A. E., Peper, C. E., Beek, P. J., & Kwakkel, G. (2012). Unilateral versus bilateral upper limb
exercise therapy after stroke: a systematic review. J.Rehabil.Med., 44(2), 106-117. doi:
10.2340/16501977-0928 [doi]
van Delden, A. E. Q., Beek, P. J., Roerdink, M., Kwakkel, G., & Peper, C. E. (2015). Unilateral and Bilateral
Upper-Limb Training Interventions After Stroke Have Similar Effects on Bimanual Coupling
Strength. Neurorehabilitation and Neural Repair, 29(3), 255-267. doi:
10.1177/1545968314543498
van Delden, A. E. Q., Peper, C. E., Nienhuys, K. N., Zijp, N. I., Beek, P. J., & Kwakkel, G. (2013). Unilateral
Versus Bilateral Upper Limb Training After Stroke The Upper Limb Training After Stroke Clinical
Trial. Stroke, 44(9), 2613-2616. doi: 10.1161/strokeaha.113.001969
van der Lee, J. H. (2001). Constraint-induced therapy for stroke: more of the same or something
completely different? Curr.Opin.Neurol., 14(6), 741-744.
van der Lee, J. H., Wagenaar, R. C., Lankhorst, G. J., Vogelaar, T. W., Deville, W. L., & Bouter, L. M.
(1999). Forced use of the upper extremity in chronic stroke patients: results from a single-blind
randomized clinical trial. Stroke, 30(11), 2369-2375.
van der Riet, P., Maguire, J., Dedkhard, S., & Sibbritt, D. (2015). Are traditional Thai therapies better than
conventional treatment for stroke rehabilitation? A quasi-experimental study. European Journal
of Integrative Medicine, 7(1), 16-22.
van Kuijk, A. A., Geurts, A. C., Bevaart, B. J., & van, L. J. (2002). Treatment of upper extremity spasticity in
stroke patients by focal neuronal or neuromuscular blockade: a systematic review of the
literature. J.Rehabil.Med., 34(2), 51-61.
Van Peppen, R. P., Kwakkel, G., Wood-Dauphinee, S., Hendriks, H. J., Van der Wees, P. J., & Dekker, J.
(2004). The impact of physical therapy on functional outcomes after stroke: what's the
evidence? Clin.Rehabil., 18(8), 833-862.
van Vliet, P. M., Lincoln, N. B., & Foxall, A. (2005). Comparison of Bobath based and movement science
based treatment for stroke: a randomised controlled trial. J.Neurol.Neurosurg.Psychiatry, 76(4),
503-508. doi: 76/4/503 [pii];10.1136/jnnp.2004.040436 [doi]
van Vliet, P. M., Lincoln, N. B., & Foxall, A. (2005). Comparison of Bobath based and movement science
based treatment for stroke: a randomised controlled trial. J Neurol Neurosurg Psychiatry, 76(4),
503-508. doi: 10.1136/jnnp.2004.040436

www.ebrsr.com
Van Vugt, F. T., Kafczyk, T., Kuhn, W., Rollnik, J. D., Tillmann, B., & Altenmuller, E. (2016). The role of
auditory feedback in music-supported stroke rehabilitation: A single-blinded randomised
controlled intervention. Restorative Neurology and Neuroscience, 34(2), 297-311.
Van Vugt, F. T., Ritter, J., Rollnik, J. D., & Altenmuller, E. (2014). Music-supported motor training after
stroke reveals no superiority of synchronization in group therapy. Frontiers in Human
Neuroscience, 8. doi: 10.3389/fnhum.2014.00315
van Wijck, F., Knox, D., Dodds, C., Cassidy, G., Alexander, G., & MacDonald, R. (2012). Making music after
stroke: using musical activities to enhance arm function. Ann N Y Acad Sci, 1252, 305-311. doi:
10.1111/j.1749-6632.2011.06403.x
Veerbeek, J. M., van Wegen, E., van Peppen, R., van der Wees, P. J., Hendriks, E., Rietberg, M., &
Kwakkel, G. (2014). What Is the Evidence for Physical Therapy Poststroke? A Systematic Review
and Meta-Analysis. Plos One, 9(2). doi: 10.1371/journal.pone.0087987
Venketasubramanian, N., Young, S. H., Tay, S. S., Umapathi, T., Lao, A. Y., Gan, H. H., . . . Chen, C. L. H.
(2015). CHInese medicine NeuroAiD efficacy on stroke recovery - Extension study (CHIMES-E): A
multicenter study of long-term efficacy. Cerebrovascular Diseases, 39(5-6), 309-318.
Viana, R., Laurentino, G., Souza, R., Fonseca, J., Silva, F. E., Dias, S., . . . Monte-Silva, K. (2014). Effects of
the addition of transcranial direct current stimulation to virtual reality therapy after stroke: A
pilot randomized controlled trial. Neurorehabilitation, 34(3), 437-446.
Volpe, B. T., Ferraro, M., Lynch, D., Christos, P., Krol, J., Trudell, C., . . . Hogan, N. (2004). Robotics and
other devices in the treatment of patients recovering from stroke. Curr.Atheroscler.Rep., 6(4),
314-319.
Volpe, B. T., Krebs, H. I., Hogan, N., Edelstein, O. L., Diels, C., & Aisen, M. (2000). A novel approach to
stroke rehabilitation: robot-aided sensorimotor stimulation. Neurology, 54(10), 1938-1944.
Volpe, B. T., Krebs, H. I., Hogan, N., Edelsteinn, L., Diels, C. M., & Aisen, M. L. (1999). Robot training
enhanced motor outcome in patients with stroke maintained over 3 years. Neurology, 53(8),
1874-1876.
Volpe, B. T., Lynch, D., Rykman-Berland, A., Ferraro, M., Galgano, M., Hogan, N., & Krebs, H. I. (2008).
Intensive sensorimotor arm training mediated by therapist or robot improves hemiparesis in
patients with chronic stroke. Neurorehabil.Neural Repair, 22(3), 305-310. doi:
1545968307311102 [pii];10.1177/1545968307311102 [doi]
Volz, L. J., Rehme, A. K., Michely, J., Nettekoven, C., Eickhoff, S. B., Fink, G. R., & Grefkes, C. (2016).
Shaping Early Reorganization of Neural Networks Promotes Motor Function after Stroke. Cereb
Cortex, 26(6), 2882-2894. doi: 10.1093/cercor/bhw034
Walker, M. F., Sunderland, A., Fletcher-Smith, J., Drummond, A., Logan, P., Edmans, J. A., . . . Taylor, J. L.
(2012). The DRESS trial: a feasibility randomized controlled trial of a neuropsychological
approach to dressing therapy for stroke inpatients. Clin.Rehabil., 26(8), 675-685. doi:
0269215511431089 [pii];10.1177/0269215511431089 [doi]
Wang, B. H., Lin, C. L., Li, T. M., Lin, S. D., Lin, J. G., & Chou, L. W. (2014). Selection of acupoints for
managing upper-extremity spasticity in chronic stroke patients. Clin Interv Aging, 9, 147-156.
doi: 10.2147/CIA.S53814
Wang, C. C., Wang, C. P., Tsai, P. Y., Hsieh, C. Y., Chan, R. C., & Yeh, S. C. (2014). Inhibitory repetitive
transcranial magnetic stimulation of the contralesional premotor and primary motor cortices
facilitate poststroke motor recovery. Restorative Neurology and Neuroscience, 32(6), 825-835.
doi: 10.3233/RNN-140410
Wang, J., Cui, M., Jiao, H., Tong, Y., Xu, J., Zhao, Y., . . . Liu, J. (2013). Content analysis of systematic
reviews on effectiveness of Traditional Chinese Medicine. Journal of Traditional Chinese
Medicine, 33(2), 156-163.
Wang, Q., Zhao, J. L., Zhu, Q. X., Li, J., & Meng, P. P. (2011). Comparison of conventional therapy,
intensive therapy and modified constraint-induced movement therapy to improve upper

www.ebrsr.com
extremity function after stroke. J.Rehabil.Med., 43(7), 619-625. doi: 10.2340/16501977-0819
[doi]
Wang, Q. M., Cui, H., Han, S. J., Black-Schaffer, R., Volz, M. S., Lee, Y. T., . . . Fregni, F. (2014).
Combination of transcranial direct current stimulation and methylphenidate in subacute stroke.
Neurosci Lett, 569, 6-11. doi: 10.1016/j.neulet.2014.03.011
Ward, A. B., Wissel, J., Borg, J., Ertzgaard, P., Herrmann, C., Kulkarni, J., . . . Group, B. S. (2014).
Functional goal achievement in post-stroke spasticity patients: the BOTOX(R) Economic
Spasticity Trial (BEST). J Rehabil Med, 46(6), 504-513. doi: 10.2340/16501977-1817
Watkins, C. L., Leathley, M. J., Gregson, J. M., Moore, A. P., Smith, T. L., & Sharma, A. K. (2002).
Prevalence of spasticity post stroke. Clin.Rehabil., 16(5), 515-522.
Wayne, P. M., Krebs, D. E., Macklin, E. A., Schnyer, R., Kaptchuk, T. J., Parker, S. W., . . . Stason, W. B.
(2005). Acupuncture for upper-extremity rehabilitation in chronic stroke: a randomized sham-
controlled study. Arch.Phys.Med.Rehabil., 86(12), 2248-2255. doi: S0003-9993(05)00914-7
[pii];10.1016/j.apmr.2005.07.287 [doi]
Weber, D. J., Skidmore, E. R., Niyonkuru, C., Chang, C. L., Huber, L. M., & Munin, M. C. (2010). Cyclic
functional electrical stimulation does not enhance gains in hand grasp function when used as an
adjunct to onabotulinumtoxinA and task practice therapy: a single-blind, randomized controlled
pilot study. Arch.Phys.Med.Rehabil., 91(5), 679-686. doi: S0003-9993(10)00078-X
[pii];10.1016/j.apmr.2010.01.010 [doi]
Wee, S., Hughes, A., Warner, M., & Burridge, J. (2014). Trunk restraint to promote upper extremity
recovery in stroke patients: A systematic review and meta-analysis. Neurorehabilitation and
Neural Repair, 28(7), 660-677.
Wen, Q., Zhao, Y., Wang, C.-w., Xing, D.-b., LÜ, J.-q., Pan, H., . . . Li, N. (2014). Effects of acupuncture
intervention on omalgia incidence rate of ischemic stroke in acute stage. World Journal of
Acupuncture - Moxibustion, 24(1), 19-25. doi: 10.1016/s1003-5257(14)60037-4
Werner, C., Mach, H., Frohlich, S., Behrend, S., Melzer, I., & Hesse, S. (2013). An early botulinum toxin A
treatment in subacute stroke patients may prevent a disabling finger flexor stiffness six months
later: A randomized controlled trial. Toxicon, 68, 122.
Whitall, J., Waller, S. M., Silver, K. H., & Macko, R. F. (2000). Repetitive bilateral arm training with
rhythmic auditory cueing improves motor function in chronic hemiparetic stroke. Stroke, 31(10),
2390-2395.
Whitall, J., Waller, S. M., Sorkin, J. D., Forrester, L. W., Macko, R. F., Hanley, D. F., . . . Luft, A. (2011).
Bilateral and unilateral arm training improve motor function through differing neuroplastic
mechanisms: a single-blinded randomized controlled trial. Neurorehabil.Neural Repair, 25(2),
118-129. doi: 1545968310380685 [pii];10.1177/1545968310380685 [doi]
Wilson, R. D., Page, S. J., Delahanty, M., Knutson, J. S., Gunzler, D. D., Sheffler, L. R., & Chae, J. (2016).
Upper-Limb Recovery after Stroke: A Randomized Controlled Trial Comparing EMG-Triggered,
Cyclic, and Sensory Electrical Stimulation. Neurorehabilitation and Neural Repair, 30(10), 978-
987.
Winstein, C. J., Rose, D. K., Tan, S. M., Lewthwaite, R., Chui, H. C., & Azen, S. P. (2004). A randomized
controlled comparison of upper-extremity rehabilitation strategies in acute stroke: a pilot study
of immediate and long-term outcomes. Archives of Physical Medicine and Rehabilitation, 85(4),
620-628.
Winstein, C. J., Wolf, S. L., Dromerick, A. W., & et al. (2016). Effect of a task-oriented rehabilitation
program on upper extremity recovery following motor stroke: The icare randomized clinical trial.
JAMA, 315(6), 571-581. doi: 10.1001/jama.2016.0276
Wissel, J., Ganapathy, V., Ward, A. B., Borg, J., Ertzgaard, P., Herrmann, C., . . . Gillard, P. (2016).
OnabotulinumtoxinA Improves Pain in Patients With Post-Stroke Spasticity: Findings From a

www.ebrsr.com
Randomized, Double-Blind, Placebo-Controlled Trial. J Pain Symptom Manage, 52(1), 17-26. doi:
10.1016/j.jpainsymman.2016.01.007
Wittenberg, G. F., Chen, R., Ishii, K., Bushara, K. O., Eckloff, S., Croarkin, E., . . . Cohen, L. G. (2003).
Constraint-induced therapy in stroke: magnetic-stimulation motor maps and cerebral activation.
Neurorehabil.Neural Repair, 17(1), 48-57.
Wolf, S. L., Milton, S. B., Reiss, A., Easley, K. A., Shenvi, N. V., & Clark, P. C. (2012). Further assessment to
determine the additive effect of botulinum toxin type A on an upper extremity exercise program
to enhance function among individuals with chronic stroke but extensor capability.
[pii];10.1016/j.apmr.2011.10.026 [doi]
Wolf, S. L., Sahu, K., Bay, R. C., Buchanan, S., Reiss, A., Linder, S., . . . Alberts, J. (2015). The HAAPI (Home
Arm Assistance Progression Initiative) Trial. Neurorehabilitation & Neural Repair, 29(10), 958-
968. doi: 10.1177/1545968315575612
Wolf, S. L., Sahu, K., Bay, R. C., Buchanan, S., Reiss, A., Linder, S., . . . Alberts, J. (2015). The HAAPI (Home
Arm Assistance Progression Initiative) Trial: A Novel Robotics Delivery Approach in Stroke
Rehabilitation. Neurorehabil Neural Repair, 29(10), 958-968. doi: 10.1177/1545968315575612
Wolf, S. L., Thompson, P. A., Winstein, C. J., Miller, J. P., Blanton, S. R., Nichols-Larsen, D. S., . . . Sawaki,
L. (2010). The EXCITE stroke trial: comparing early and delayed constraint-induced movement
therapy. Stroke, 41(10), 2309-2315. doi: 10.1161/STROKEAHA.110.588723
Wolf, S. L., Winstein, C. J., Miller, J. P., Taub, E., Uswatte, G., Morris, D., . . . Nichols-Larsen, D. (2006).
Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after
stroke: the EXCITE randomized clinical trial. JAMA, 296(17), 2095-2104. doi: 296/17/2095
[pii];10.1001/jama.296.17.2095 [doi]
Wolf, S. L., Winstein, C. J., Miller, J. P., Thompson, P. A., Taub, E., Uswatte, G., . . . Clark, P. C. (2008).
Retention of upper limb function in stroke survivors who have received constraint-induced
movement therapy: the EXCITE randomised trial. Lancet Neurol., 7(1), 33-40. doi: S1474-
4422(07)70294-6 [pii];10.1016/S1474-4422(07)70294-6 [doi]
Wong, A. M., Su, T. Y., Tang, F. T., Cheng, P. T., & Liaw, M. Y. (1999). Clinical trial of electrical
acupuncture on hemiplegic stroke patients. Am.J.Phys.Med.Rehabil., 78(2), 117-122.
Woodbury, M. L., Howland, D. R., McGuirk, T. E., Davis, S. B., Senesac, C. R., Kautz, S., & Richards, L. G.
(2009). Effects of trunk restraint combined with intensive task practice on poststroke upper
extremity reach and function: a pilot study. Neurorehabil Neural Repair, 23(1), 78-91.
Wu, B., Liu, M., Liu, H., Li, W., Tan, S., Zhang, S., & Fang, Y. (2007). Meta-analysis of traditional Chinese
patent medicine for ischemic stroke. Stroke, 38(6), 1973-1979. doi: STROKEAHA.106.473165
Wu, C. W., Seo, H. J., & Cohen, L. G. (2006). Influence of electric somatosensory stimulation on paretic-
hand function in chronic stroke. Arch.Phys.Med.Rehabil., 87(3), 351-357. doi: S0003-
9993(05)01430-9 [pii];10.1016/j.apmr.2005.11.019 [doi]
Wu, C. Y., Chen, C. L., Tang, S. F., Lin, K. C., & Huang, Y. Y. (2007). Kinematic and clinical analyses of
upper-extremity movements after constraint-induced movement therapy in patients with
stroke: a randomized controlled trial. Arch.Phys.Med.Rehabil., 88(8), 964-970. doi: S0003-
9993(07)00355-3 [pii];10.1016/j.apmr.2007.05.012 [doi]
Wu, C. Y., Chen, C. L., Tsai, W. C., Lin, K. C., & Chou, S. H. (2007). A randomized controlled trial of
modified constraint-induced movement therapy for elderly stroke survivors: changes in motor
impairment, daily functioning, and quality of life. Arch.Phys.Med.Rehabil., 88(3), 273-278. doi:
S0003-9993(06)01529-2 [pii];10.1016/j.apmr.2006.11.021 [doi]
Wu, C. Y., Chen, Y. A., Chen, H. C., Lin, K. C., & Yeh, I. L. (2012). Pilot trial of distributed constraint-
induced therapy with trunk restraint to improve poststroke reach to grasp and trunk kinematics.

www.ebrsr.com
[pii];10.1177/1545968311415862 [doi]
Wu, C. Y., Chuang, L. L., Lin, K. C., Chen, H. C., & Tsay, P. K. (2011). Randomized trial of distributed
constraint-induced therapy versus bilateral arm training for the rehabilitation of upper-limb
motor control and function after stroke. Neurorehabil.Neural Repair, 25(2), 130-139. doi:
1545968310380686 [pii];10.1177/1545968310380686 [doi]
Wu, C. Y., Huang, P. C., Chen, Y. T., Lin, K. C., & Yang, H. W. (2013). Effects of Mirror Therapy on Motor
and Sensory Recovery in Chronic Stroke: A Randomized Controlled Trial. Archives of Physical
Medicine and Rehabilitation, 94(6), 1023-1030. doi: 10.1016/j.apmr.2013.02.007
Wu, C. Y., Lin, K. C., Chen, H. C., Chen, I. H., & Hong, W. H. (2007). Effects of modified constraint-induced
movement therapy on movement kinematics and daily function in patients with stroke: a
kinematic study of motor control mechanisms. Neurorehabil.Neural Repair, 21(5), 460-466. doi:
1545968307303411 [pii];10.1177/1545968307303411 [doi]
Wu, C. Y., Wang, T. N., Chen, Y. T., Lin, K. C., Chen, Y. A., Li, H. T., & Tsai, P. L. (2013). Effects of
constraint-induced therapy combined with eye patching on functional outcomes and movement
kinematics in poststroke neglect. Am J Occup Ther, 67(2), 236-245. doi:
10.5014/ajot.2013.006486
Wu, C. Y., Yang, C. L., Chen, M., Lin, K. C., & Wu, L. L. (2013). Unilateral versus bilateral robot-assisted
rehabilitation on arm-trunk control and functions post stroke: a randomized controlled trial.
Journal of NeuroEngineering and Rehabilitation, 10, 35.
Wu, D., Qian, L., Zorowitz, R., Zhang, L., Qu, Y., & Yuan, Y. (2013). Effects on decreasing upper-limb
poststroke muscle tone using transcranial direct current stimulation: A randomized sham-
controlled study. Archives of Physical Medicine and Rehabilitation, 94(1), 1-8.
Wu, H. C., Lin, Y. C., Hsu, M. J., Liu, S. M., Hsieh, C. L., & Lin, J. H. (2010). Effect of thermal stimulation on
upper extremity motor recovery 3 months after stroke. Stroke, 41(10), 2378-2380. doi:
Wu, M. T., Sheen, J. M., Chuang, K. H., Yang, P., Chin, S. L., Tsai, C. Y., . . . Yang, C. F. (2002). Neuronal
specificity of acupuncture response: a fMRI study with electroacupuncture. Neuroimage., 16(4),
1028-1037. doi: S1053811902911456 [pii]
Wu, X. N., Li, Z. S., Liu, X. Y., Peng, H. Y., Huang, Y. J., Luo, G. Q., & Peng, K. R. (2013). Major ozonated
autohemotherapy promotes the recovery of upper limb motor function in patients with acute
cerebral infarction. Neural Regeneration Research, 8(5), 461-468. doi: 10.3969/j.issn.1673-
5374.2013.05.010
Yadav, R. K., Sharma, R., Borah, D., & Kothari, S. Y. (2016). Efficacy of Modified Constraint Induced
Movement Therapy in the Treatment of Hemiparetic Upper Limb in Stroke Patients: A
Randomized Controlled Trial. J Clin Diagn Res, 10(11), YC01-YC05. doi:
10.7860/JCDR/2016/23468.8899
Yang CL, L. K., Chen HC, Wu CY, Chen CL. (2012). Pilot comparative study of unilateral and bilateral
robot-assisted training on upper-extremity performance in patients with stroke. Am J Occup
Ther., 66(2), 198-206.
Yang, N. Y., Fong, K. N., Li-Tsang, C. W., & Zhou, D. (2016). Effects of repetitive transcranial magnetic
stimulation combined with sensory cueing on unilateral neglect in subacute patients with right
hemispheric stroke: A randomized controlled study. Clin Rehabil. doi:
10.1177/0269215516679712
Yang, Y. J., Zhang, J., Hou, Y., Jiang, B. Y., Pan, H. F., Wang, J., . . . Cheng, J. (2016). Effectiveness and
safety of Chinese massage therapy (Tui Na) on post-stroke spasticity: A prospective multicenter
randomized controlled trial. Clin Rehabil. doi: 10.1177/0269215516663009
Yao, W. J., & Ouyang, B. S. (2014). Effect of relaxing needling plus rehabilitation training on post-stroke
upper limb dysfunction. Journal of Acupuncture and Tuina Science, 12(3), 146-149.

www.ebrsr.com
Yasar, E., Vural, D., Safaz, I., Balaban, B., Yilmaz, B., Goktepe, A. S., & Alaca, R. (2011). Which treatment
approach is better for hemiplegic shoulder pain in stroke patients: intra-articular steroid or
suprascapular nerve block? A randomized controlled trial. Clin Rehabil, 25(1), 60-68. doi:
10.1177/0269215510380827
Yavuzer, G., Selles, R., Sezer, N., Sutbeyaz, S., Bussmann, J. B., Koseoglu, F., . . . Stam, H. J. (2008). Mirror
therapy improves hand function in subacute stroke: a randomized controlled trial.
[pii];10.1016/j.apmr.2007.08.162 [doi]
Yeldan, I., Huseyinsinoglu, B. E., Akinci, B., Tarakci, E., Baybas, S., & Ozdincler, A. R. (2015). The effects of
very early mirror therapy on functional improvement of the upper extremity in acute stroke
patients. J Phys Ther Sci, 27(11), 3519-3524. doi: 10.1589/jpts.27.3519
Yin, C. W., Sien, N. Y., Ying, L. A., Chung, S., & Leng, D. T. M. (2014). Virtual reality for upper extremity
rehabilitation in early stroke: a pilot randomized controlled trial. Clinical rehabilitation, 28(11),
1107-1114. doi: 10.1177/0269215514532851
Yoon, J. A., Koo, B. I., Shin, M. J., Shin, Y. B., Ko, H. Y., & Shin, Y. I. (2014). Effect of constraint-induced
movement therapy and mirror therapy for patients with subacute stroke. Annals of
Rehabilitation Medicine, 38(4), 458-466. doi: 10.5535/arm.2014.38.4.458
You, S. J., & Lee, J. H. (2013). Effects of Mental Activity Training Linked With Electromyogram-triggered
Electrical Stimulation on Paretic Upper Extremity Motor Function in Chronic Stroke Patients: A
Pilot Trial. Turkiye Fiziksel Tip Ve Rehabilitasyon Dergisi-Turkish Journal of Physical Medicine and
Rehabilitation, 59(2), 133-139. doi: 10.4274/tftr.58751
You, Y. Y., Her, J. G., Woo, J. H., Ko, T., & Chung, S. H. (2014). The Effects of Stretching and Stabilization
Exercise on the Improvement of Spastic Shoulder Function in Hemiplegic Patients. Journal of
Physical Therapy Science, 26(4), 491-495.
Young, B. M., Stamm, J. M., Song, J., Remsik, A. B., Nair, V. A., Tyler, M. E., . . . Prabhakaran, V. (2016).
Brain-Computer Interface Training after Stroke Affects Patterns of Brain-Behavior Relationships
in Corticospinal Motor Fibers. Front Hum Neurosci, 10, 457. doi: 10.3389/fnhum.2016.00457
Yu-wei, H., Ching-yi, W., Wei-en, W., Keh-chung, L., Ku-chou, C., Chih-chi, C., & Chien-ting, L. (2016).
Bilateral robotic priming before task-oriented approach in subacute stroke rehabilitation: a pilot
randomized controlled trial. Clinical rehabilitation, 31(2), 225-233. doi:
10.1177/0269215516633275
Yu, M., Sun, Z. J., Li, L. T., Ge, H. Y., Song, C. Q., & Wang, A. J. (2015). The beneficial effects of the herbal
medicine Di-huang-yin-zi (DHYZ) on patients with ischemic stroke: A Randomized, Placebo
controlled clinical study. Complement Ther Med, 23(4), 591-597. doi:
10.1016/j.ctim.2015.06.003
Yue, S., Jiang, X., & Wong, T. (2013). Effects of a nurse-led acupressure programme for stroke patients in
China. J Clin Nurs, 22(7-8), 1182-1188. doi: 10.1111/j.1365-2702.2012.04127.x
Yun, G. J., Chun, M. H., Park, J. Y., & Kim, B. R. (2011). The synergic effects of mirror therapy and
neuromuscular electrical stimulation for hand function in stroke patients. Ann.Rehabil.Med.,
35(3), 316-321. doi: 10.5535/arm.2011.35.3.316 [doi]
Zhang, J., Mu, X., Breker, D. A., Li, Y., Gao, Z., & Huang, Y. (2017). Atorvastatin treatment is associated
with increased BDNF level and improved functional recovery after atherothrombotic stroke. Int J
Neurosci, 127(1), 92-97. doi: 10.3109/00207454.2016.1146882
Zhang, Y., Al-Aref, R., Fu, H., Yang, Y., Feng, Y., Zhao, C., . . . Sun, G. (2017). Neuronavigation-Assisted
Aspiration and Electro-Acupuncture for Hypertensive Putaminal Hemorrhage: A Suitable
Technique on Hemiplegia Rehabilitation. Turk Neurosurg, 27(4), 500-508. doi: 10.5137/1019-
5149.JTN.16456-15.1

www.ebrsr.com
Zhao, J. G., Cao, C. H., Liu, C. Z., Han, B. J., Zhang, J., Li, Z. G., . . . Xu, Z. H. (2009). Effect of acupuncture
treatment on spastic states of stroke patients. J.Neurol.Sci., 276(1-2), 143-147. doi: S0022-
510X(08)00489-9 [pii];10.1016/j.jns.2008.09.018 [doi]
Zhao, W. L., Wang, C., Li, Z. Z., Chen, L., Li, J. B., Cui, W. D., . . . Zhao, Y. (2015). Efficacy and Safety of
Transcutaneous Electrical Acupoint Stimulation to Treat Muscle Spasticity following Brain Injury:
A Double-Blinded, Multicenter, Randomized Controlled Trial. Plos One, 10(2). doi:
10.1371/journal.pone.0116976
Zhao, X. F., Du, Y., Liu, P. G., & Wang, S. (2012). Acupuncture for stroke: evidence of effectiveness,
safety, and cost from systematic reviews. Topics in stroke rehabilitation, 19(3), 226-233.
Zheng, C. J., Liao, W. J., & Xia, W. G. (2015). Effect of Combined Low-frequency Repetitive Transcranial
Magnetic Stimulation and Virtual Reality Training on Upper Limb Function in Subacute Stroke: a
Double-blind Randomized Controlled Trail. Journal of Huazhong University of Science and
Technology-Medical Sciences, 35(2), 248-254. doi: 10.1007/s11596-015-1419-0
Zhu, Y., Zhang, T., & Tian, Q. (2015). Effects of electromyographic biofeedback combined with
acupuncture on lower limb function of patients after stroke. Chinese Journal of Rehabilitation
Medicine, 30(6), 576-579. doi: 10.3969/j.issn.1001-1242.2015.06.012
Zhuangl, L. X., Xu, S. F., D'Adamo, C. R., Jia, C., He, J., Han, D. X., & Lao, L. X. (2012). An effectiveness
study comparing acupuncture, physiotherapy, and their combination in poststroke
rehabilitation: a multicentered, randomized, controlled clinical trial. Alternative therapies in
health and medicine.18.(3) (pp 8.-14),, %2012, May-Jun.
Zimerman, M., Heise, K. F., Hoppe, J., Cohen, L. G., Gerloff, C., & Hummel, F. C. (2012). Modulation of
training by single-session transcranial direct current stimulation to the intact motor cortex
enhances motor skill acquisition of the paretic hand. Stroke, 43(8), 2185-2191. doi:
10.1161/STROKEAHA.111.645382
Zimmermann-Schlatter, A., Schuster, C., Puhan, M. A., Siekierka, E., & Steurer, J. (2008). Efficacy of
motor imagery in post-stroke rehabilitation: a systematic review. J.Neuroeng.Rehabil., 5, 8. doi:
1743-0003-5-8 [pii];10.1186/1743-0003-5-8 [doi]
Zittel, S., Weiller, C., & Liepert, J. (2007). Reboxetine improves motor function in chronic stroke. A pilot
study. J.Neurol., 254(2), 197-201. doi: 10.1007/s00415-006-0326-5 [doi]
Zittel, S., Weiller, C., & Liepert, J. (2008). Citalopram improves dexterity in chronic stroke patients.
[pii];10.1177/1545968307312173 [doi]
Zondervan, D. K., Friedman, N., Chang, E., Zhao, X., Augsburger, R., Reinkensmeyer, D. J., & Cramer, S. C.
(2016). Home-based hand rehabilitation after chronic stroke: Randomized, controlled single-
blind trial comparing the music glove with a conventional exercise program. Journal of
Rehabilitation Research and Development, 53(4), 457-472.
Zun, W., Lei, W., Hong-Juan, F., Li-Xia, Z., Xiao-Jun, Z., & Tong, W. (2016). Effect of Early Low Intensity
Ergometer Aerobic Training on Activity of Daily Living among Severely Impaired Non-Elderly
Stroke Hemiplegia: A Pilot Study. International Medical Journal, 23(3), 288-292.

www.ebrsr.com

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EBRSR

[Evidence-Based Review of Stroke Rehabilitation]

Last Updated: March 2018

• Modified constraint-induced movement therapy (mCIMT) may improve adaption to preserved

• Feedback may improve upper limb motor function post stroke.

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• Hand splints alone likely do not reduce spasticity or prevent contracture.

• Stretching programs may improve upper limb spasticity.

• Botulinum toxin in combination with electrical stimulation or modified constraint induced

• Extracorporeal shockwave therapy likely improves upper limb spasticity.

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• It is unclear whether low-frequency (1 Hz) Repetitive Transcranial Magnetic Stimulation (RTMS)

• Dual Transcranial Direct Current Stimulation is likely effective for dexterity.

• Further research is needed to determine the effects of d-cycloserine on post-stroke upper

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Dr. Robert Teasell

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10.1 Consensus Panel Treatment and Recommendations

2001 Consensus Panel Recommendations for Patients with Severe Impairment

1. Maintain a comfortable, pain-free, mobile arm and hand

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2. Engage in motor-learning training including the use of imagery.”

Conclusions Regarding Management of the Post Stroke Arm and Hand

10.2 Upper Extremity Interventions

10.2.1 Neurodevelopmental Techniques

Table 10.2.1.1 Neurodevelopmental Techniques

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A summary of RCTs evaluating neurodevelopmental techniques are presented in Table 10.2.1.2.

Table 10.2.1.2 Summary of RCTs Evaluating Neurodevelopmental Techniques

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Conclusions Regarding Neurodevelopmental Techniques

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10.2.2 Bilateral Arm Training

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Table 10.2.2.1 Summary of Controlled Trials Evaluating Bilateral Arm Training

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Conclusions Regarding Bilateral Arm Training

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10.2.3 Arm and Leg Training

Conclusions Regarding Arm and Leg Training

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10.2.4 Additional/Enhanced Therapy

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Conclusions Regarding Additional/Enhanced Therapies

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10.2.5 Strength Training

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Conclusions Regarding Strength Training

10.2.6 Repetitive/Task- Specific Training Techniques

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A summary of controlled trials evaluating repetitive/task-specific training are presented in Table

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Kim et al. (2016) E: Electromyogram triggered neuromuscular • Fugl-Meyer Assessment (+)

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- Indicates non-statistically significant differences between treatment groups

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Conclusions Regarding Repetitive Task-Specific Training Techniques