In this interesting meta-analysis about the effects of virtual reality technology on the functional outcome of upper limb motor weakness after stroke, Saposnik G et al mentioned that Virtual reality (VR) technology is a novel adjunctive therapy that could be applied in neurorehabilitation. (Stroke. 2011; 42:1380-1386). Eleven of 12 studies showed a significant benefit toward VR for the selected outcomes. The results showed that among observational studies, there was a 14.7% improvement in motor impairment and a 20.1% improvement in motor function after VR. The authors concluded their meta-analysis by stating that VR and video game applications are novel and potentially useful technologies that can be combined with conventional rehabilitation for upper arm improvement after stroke.

Evidences are needed for the effect of the new technologies on the rehabilitation of stroke patients who suffered from long term motor deficits especially of the upper limbs.

In this multicenter, randomized, controlled trial involving 127 patients with moderate-to-severe upper-limb impairment 6 months or more after a stroke, the authors randomly assigned 49 patients to receive intensive robot-assisted therapy, 50 to receive intensive comparison therapy, and 28 to receive usual care (New Eng J Med. on line publication on 16^th April 2010 to coincide with the meeting of the American Academy of Neurology).

Therapy consisted of 36 1-hour sessions over a period of 12 weeks. The primary outcome was a change in motor function, as measured on the Fugl-Meyer Assessment of Sensorimotor Recovery after Stroke, at 12 weeks. Secondary outcomes were scores on the Wolf Motor Function Test and the Stroke Impact Scale. Secondary analyses assessed the treatment effect at 36 weeks.

The study showed that at 12 weeks, the mean Fugl-Meyer score for patients receiving robot-assisted therapy was better than that for patients receiving usual care  and worse than that for patients receiving intensive comparison therapy, but the differences were not significant. The results on the Stroke Impact Scale were significantly better for patients receiving robot-assisted therapy than for those receiving usual care.

The study concluded that in patients with long-term upper-limb deficits after stroke, robot-assisted therapy did not significantly improve motor function at 12 weeks, as compared with usual care or intensive therapy. In secondary analyses, robot-assisted therapy improved outcomes over 36 weeks as compared with usual care but not with intensive therapy.

In his editorial ( www.nejm.org, April 16, 2010), Steven Cramer mentioned that these results challenge us to better stratify patients with long-term disabilities after stroke. He went to say that  such studies  ‘reinforce the theory that the adult brain has the capacity for clinically relevant plasticity even in the chronic phase after a stroke. The future holds great hope for the development of brain-repair protocols to greatly reduce the degree of disability after stroke’.

Two occupational therapists from University of British Columbia in Vancouver/Canada have performed a meta-analysis of randomized controlled trials related to the subject of strength training for the arm weakness following a stroke. This type of training is considered in rehabilitation as an important intervention with the potential to improve function

Electronic databases were searched from 1950 through April 2009. Strength training articles were assessed according to outcomes: strength, upper-limb function, and activities of daily living.

The reported results which were published recently (Stroke; 2010;41:136)  showed that from  the 650 trials identified, 13 were included in the review, totalling 517 individuals. A positive outcome for strength training was found for grip strength and upper-limb function.  No treatment effect was found for strength training on measures of activities of daily living. A significant effect for strength training on upper-limb function was found for studies including subjects with moderate and mild upper-limb motor impairment. No trials reported adverse effects.

The authors concluded that there is evidence that strength training can improve upper-limb strength and function without increasing tone or pain in individuals with stroke.

The study concluded that patients with severe stroke-related disability in the early period after stroke are prone to falls during rehabilitation. Multiple falls are most frequent in patients over 65 years of age.

The decrease in side-to-side differences in power generation and absorption reflects improved gait symmetry following treatment. The increased ability to produce work suggests improved gait efficiency following BTX-A treatment in conjunction with reduced spasticity. The inability to detect significant change in kinematic variables may be due to the small sample and large variability thus reducing statistical power. As recruitment continues, the importance of the trends observed should emerge to better describe the effects of BTX-A on gait and the sustainability of any benefits.

Twenty-one stroke patients with hemiplegia resulting from new-onset stroke and ten normal subjects were included in this study.

The SMART balance master system was used to assess the postural stability by measuring the ankle strategy, maximal stability, and velocity of center-of-gravity (COG) movement under the six different conditions.

Each patient was tested with and without an anterior AFO as compared with normal subjects. When wearing an anterior AFO, patients used ankle strategy more than hip strategy to maintain postural stability in all the six sensory conditions. An anterior AFO also provided stroke patients with better maximal stability under relatively challenging conditions.

The study concluded that in the early stage of recovery, the use of an anterior AFO may assist stroke patients with hemiplegia to improve their postural stability.