The Role of Continuous Theta Burst Stimulation on Primary Motor Cortex in Improving Bladder Function in Post-stroke Patients: A Case Report.

Neurogenic bladder (NB) is a frequently encountered post-stroke complication, characterized by symptoms, such as urinary incontinence, dysuria, increased frequency, and urgency. Here, we present a case of a 75-year-old male with urgent urination, frequent urination, urinary incontinence, conspicuous discomfort during urination, and an unpleasant smell in the urine following a stroke. By reviewing the patient's previous medical records of stroke and ruling out other potential causes for bladder dysfunction, a diagnosis of NB could be established. We implemented conventional physical therapy, pelvic floor muscle training with the electromyography biofeedback device, and continuous theta burst stimulation (cTBS) on the contralesional primary motor cortex area to manage bladder function. To the best of our knowledge, this is the first case report on cTBS applied to manage NB after stroke. Our treatment has demonstrated remarkable efficacy in enhancing bladder and kidney function, improving the overall quality of life, and alleviating anxiety and depression symptoms in this patient. This case study concludes that the noninvasive neuromodulation approach exhibits significant potential in the clinical field when addressing this specific patient population.

Neuroimaging prognostic factors for treatment response to motor imagery training after stroke.

The efficacy of motor imagery training for motor recovery is well acknowledged, but with substantial inter-individual variability in stroke patients. To help optimize motor imagery training therapy plans and screen suitable patients, this study aimed to explore neuroimaging biomarkers explaining variability in treatment response. Thirty-nine stroke patients were randomized to a motor imagery training group (n = 22, received a combination of conventional rehabilitation therapy and motor imagery training) and a control group (n = 17, received conventional rehabilitation therapy and health education) for 4 weeks of interventions. Their demography and clinical information, brain lesion from structural MRI, spontaneous brain activity and connectivity from rest fMRI, and sensorimotor brain activation from passive motor task fMRI were acquired to identify prognostic factors. We found that the variability of outcomes from sole conventional rehabilitation therapy could be explained by the reserved sensorimotor neural function, whereas the variability of outcomes from motor imagery training + conventional rehabilitation therapy was related to the spontaneous activity in the ipsilesional inferior parietal lobule and the local connectivity in the contralesional supplementary motor area. The results suggest that additional motor imagery training treatment is also efficient for severe patients with damaged sensorimotor neural function, but might be more effective for patients with impaired motor planning and reserved motor imagery.

Motor network reorganization after motor imagery training in stroke patients with moderate to severe upper limb impairment.

BACKGROUND: Motor imagery training (MIT) has been widely used to improve hemiplegic upper limb function in stroke rehabilitation. The effectiveness of MIT is associated with the functional neuroplasticity of the motor network. Currently, brain activation and connectivity changes related to the motor recovery process after MIT are not well understood. AIM: We aimed to investigate the neural mechanisms of MIT in stroke rehabilitation through a longitudinal intervention study design with task-based functional magnetic resonance imaging (fMRI) analysis. METHODS: We recruited 39 stroke patients with moderate to severe upper limb motor impairment and randomly assigned them to either the MIT or control groups. Patients in the MIT group received 4 weeks of MIT therapy plus conventional rehabilitation, while the control group only received conventional rehabilitation. The assessment of Fugl-Meyer Upper Limb Scale (FM-UL) and Barthel Index (BI), and fMRI scanning using a passive hand movement task were conducted on all patients before and after treatment. The changes in brain activation and functional connectivity (FC) were analyzed. Pearson's correlation analysis was conducted to evaluate the association between neural functional changes and motor improvement. RESULTS: The MIT group achieved higher improvements in FM-UL and BI relative to the control group after the treatment. Passive movement of the affected hand evoked an abnormal bilateral activation pattern in both groups before intervention. A significant Group × Time interaction was found in the contralesional S1 and ipsilesional M1, showing a decrease of activation after intervention specifically in the MIT group, which was negatively correlated with the FM-UL improvement. FC analysis of the ipsilesional M1 displayed the motor network reorganization within the ipsilesional hemisphere, which correlated with the motor score changes. CONCLUSIONS: MIT could help decrease the compensatory activation at both hemispheres and reshape the FC within the ipsilesional hemisphere along with functional recovery in stroke patients.

Effects of transcutaneous electrical acupoint stimulation on upper-limb impairment after stroke: A randomized, controlled, single-blind trial.

OBJECTIVE: To evaluate the effects of transcutaneous electrical acupoint stimulation (TEAS) on upper limb motor recovery during post-stroke rehabilitation. DESIGN: Single-blind, randomized controlled trial. SETTING: Four inpatient rehabilitation facilities. SUBJECTS: A total of 204 stroke patients with unilateral upper limb motor impairment were randomly 1:1 allocated to TEAS or sham TEAS group. Baseline demographic and clinical characteristics were comparable between the two groups. INTERVENTIONS: Both groups received conventional physical and occupational therapies. TEAS and sham TEAS therapy were administered to two acupoints (LI10 and TE5) with a pulse duration of 300 µs at 2 Hz on the affected forearm for 30 times over 6 weeks. OUTCOME MEASURES: The upper-extremity Fugl-Meyer score (primary outcome), manual muscle testing, modified Ashworth scale, Lindmark hand function score, and Barthel index were evaluated by blinded assessors at baseline, 2, 4, 6, 10, and 18 weeks. RESULTS: The number of patients who completed the treatment was 99 and 97 in the TEAS and the sham group. No significant between-group difference was found in the Upper-Extremity Fugl-Meyer score, Modified Ashworth Scale, Lindmark hand function score, and Barthel Index after intervention and during follow-up. However, the TEAS group exhibited 0.29 (95% CI 0.02 to 0.55) greater improvements in Manual Muscle Testing of wrist extension than the sham group (p = 0.037) at 18 weeks. CONCLUSIONS: Administration of TEAS therapy to hemiplegic forearm could not improve the upper extremity motor recovery. However, TEAS on the forearm might provide potential benefits for strength improvement of the wrist.

FER-PCVT: Facial Expression Recognition with Patch-Convolutional Vision Transformer for Stroke Patients.

Early rehabilitation with the right intensity contributes to the physical recovery of stroke survivors. In clinical practice, physicians determine whether the training intensity is suitable for rehabilitation based on patients' narratives, training scores, and evaluation scales, which puts tremendous pressure on medical resources. In this study, a lightweight facial expression recognition algorithm is proposed to diagnose stroke patients' training motivations automatically. First, the properties of convolution are introduced into the Vision Transformer's structure, allowing the model to extract both local and global features of facial expressions. Second, the pyramid-shaped feature output mode in Convolutional Neural Networks is also introduced to reduce the model's parameters and calculation costs significantly. Moreover, a classifier that can better classify facial expressions of stroke patients is designed to improve performance further. We verified the proposed algorithm on the Real-world Affective Faces Database (RAF-DB), the Face Expression Recognition Plus Dataset (FER+), and a private dataset for stroke patients. Experiments show that the backbone network of the proposed algorithm achieves better performance than Pyramid Vision Transformer (PvT) and Convolutional Vision Transformer (CvT) with fewer parameters and Floating-point Operations Per Second (FLOPs). In addition, the algorithm reaches an 89.44% accuracy on the RAF-DB dataset, which is higher than other recent studies. In particular, it obtains an accuracy of 99.81% on the private dataset, with only 4.10M parameters.

Synthesis, Characterization, and Electrochemical Properties of La-Doped α-Fe2O3 Nanoparticles.

La-doped α-Fe2O3 nanoparticles were synthesized by a hydrothermal method. The effects of pH value on the morphology, structure, and electrochemical stability of the La-doped α-Fe2O3 nanoparticles were investigated by X-ray diffraction, transmission electron microscopy, Fourier-transform infrared spectrum, and electrochemical methods. The results show that the La-doped α-Fe2O3 nanoparticles exhibit a uniform spherical morphology at pH = 6, and are agglomerated with a poor dispersion at pH = 4 and 8. The iron oxide lattice is distorted by the La-doping, which increases the Fe-O bond strength. The decreased Fe-O bond length and the increased Fe-O bond energy at pH = 6 improve the electrochemical stability of α-Fe2O3. The waterborne coating modified with La-doped α-Fe2O3 nanoparticles exhibits a steady corrosion resistance.

Effects of high frequency rTMS of contralesional dorsal premotor cortex in severe subcortical chronic stroke: protocol of a randomized controlled trial with multimodal neuroimaging assessments.

BACKGROUND: Previous studies have revealed that low frequency repeated transcranial magnetic stimulation (rTMS) on the contralesional primary motor cortex (cM1) is less effective in severe stroke patients with poor neural structural reserve than in patients with highly reserved descending motor pathway. This may be attributed to the fact that secondary motor cortex, especially contralesional dorsal premotor cortex (cPMd), might play an important compensatory role in the motor function recovery of severely affected upper extremity. The main purpose of this study is to compare the effectiveness of low frequency rTMS on cM1 and high frequency rTMS on cPMd in subcortical chronic stroke patients with severe hemiplegia. By longitudinal analysis of multimodal neuroimaging data, we hope to elucidate the possible mechanism of brain reorganization following different treatment regimens of rTMS therapy, and to determine the cut-off of stimulation strategy selection based on the degree of neural structural reserve. METHODS/DESIGN: The study will be a single-blinded randomized controlled trial involving a total of 60 subcortical chronic stroke patients with severe upper limb motor impairments. All patients will receive 3 weeks of conventional rehabilitation treatment, while they will be divided into three groups and receive different rTMS treatments: cM1 low frequency rTMS (n = 20), cPMd high frequency rTMS (n = 20), and sham stimulation group (n = 20). Clinical functional assessment, multimodal functional MRI (fMRI) scanning, and electrophysiological measurement will be performed before intervention, 3 weeks after intervention, and 4 weeks after the treatment, respectively. DISCUSSION: This will be the first study to compare the effects of low-frequency rTMS of cM1 and high-frequency rTMS of cPMd. The outcome of this study will provide a theoretical basis for clarifying the bimodal balance-recovery model of stroke, and provide a strategy for individualized rTMS treatment for stroke in future studies and clinical practice. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR1900027399. Registered on 12 Nov 2019, http://www.chictr.org.cn/showproj.aspx?proj=43686 .

Exploring Alternative Measurements of Cardiorespiratory Fitness in Patients With Mild Ischemic Stroke at Acute Phase.

BACKGROUND: While emerging studies have suggested an association of cardiorespiratory fitness (CRF) with stroke risk and overall health outcomes, little is known regarding the optimum methods of CRF measurement in patients with mild acute ischemic stroke. OBJECTIVE: The aim of this study was to explore the association between the 6-min walk distance (6MWD) and other measurements related to CRF in patients with mild ischemic stroke at the acute stage. METHODS: A total of 30 patients with stroke and 71 healthy subjects matched for age and grip strength (GS) were prospectively recruited. All patients were within 14 days after stroke onset and presented mild motor impairment (with a full score of Fugl-Meyer Motor Assessment). Demographic data of both groups and clinical information of the stroke group were documented, and the CRF comparison between the two groups was conducted. Each participant underwent a one-time assessment of 6MWD and a series of measurements related to CRF, including GS, 10-m walk test (10mWT), five-times sit-to-stand time (FTSST), functional reaching test (FRT), Berg Balance Scale (BBS), and waistline. Pearson's product-moment correlation coefficient test and multiple linear regression were performed to explore the indicators of CRF. RESULTS: Significant moderate correlations (0.3 < r <0.6) were found between 6MWD and GS of left hand (GS-left) (r = 0.573, p = 0.001), GS of right hand (GS-right) (r = 0.524, p = 0.003), FTSST (r = -0.551, p = 0.002), 10mWT (r = 0.554, p = 0.001), and FRT (r = 0.449, p = 0.021) in the patient group. While 6MWD displayed significant moderate correlations with waistline (r = 0.364, p = 0.002), 10mWT (r = 0.512, p < 0.001), FTSST (r = -0.573, p < 0.001), and FRT (r = 0.550, p < 0.001) in the healthy group. All these dependent variables were entered into a stepwise multiple linear regression analysis to evaluate their values in estimating CRF as measured by 6MWD in each group. Analyses suggested that GS-left (p = 0.002) and FTSST (p = 0.003) were the indicators of CRF in the patient group with stroke and explained 51.4% of the variance of 6MWD (R 2 = 0.514); FTSST (p < 0.001), 10mWT (p < 0.001), and FRT (p = 0.021) were the indicators of CRF in the healthy group and explained 58.9% of variance of 6MWD (R 2 = 0.589). CONCLUSIONS: Our data confirmed that CRF is impaired in patients with mild ischemic stroke at the acute phase. Moreover, GS-left may be an optional indicator of CRF in patients with mild acute ischemic stroke, but not in healthy people. CLINICAL TRIAL REGISTRATION: www.chictr.org.cn, identifier: ChiCTR2000031379.

Relation Between Sensorimotor Rhythm During Motor Attempt/Imagery and Upper-Limb Motor Impairment in Stroke.

Motor attempt (MA)/motor imagery (MI)-based brain-computer interface (BCI) is a newly developing rehabilitation technology for motor impairment. This study aims to explore the relationship between electroencephalography sensorimotor rhythm and motor impairment to provide reference for a BCI design. Twenty-eight stroke survivors with varying levels of motor dysfunction and spasticity status in the subacute or chronic stage were enrolled in the study to perform MA and MI tasks. Event-related desynchronization (ERD)/event-related synchronization (ERS) during and immediately after motor tasks were calculated. The Fugl-Meyer assessment scale (FMA) and the modified Ashworth scale (MAS) were applied to characterize upper-limb motor dysfunction and spasticity. There was a positive correlation between FMA total scores and ERS in the contralesional hemisphere in the MI task (P < .05) and negative correlations between FMA total scores and ERD in both hemispheres in the MA task (P < .05). Negative correlations were found between MAS scores of wrist flexors and ERD in the ipsilesional hemisphere (P < .05) in the MA task. It suggests that motor dysfunction may be more correlated to ERS in the MI task and to ERD in the MA task while spasticity may be more correlated to ERD in the MA task.

The Differences Between Motor Attempt and Motor Imagery in Brain-Computer Interface Accuracy and Event-Related Desynchronization of Patients With Hemiplegia.

Background: Motor attempt and motor imagery (MI) are two common motor tasks used in brain-computer interface (BCI). They are widely researched for motor rehabilitation in patients with hemiplegia. The differences between the motor attempt (MA) and MI tasks of patients with hemiplegia can be used to promote BCI application. This study aimed to explore the accuracy of BCI and event-related desynchronization (ERD) between the two tasks. Materials and Methods: We recruited 13 patients with stroke and 3 patients with traumatic brain injury, to perform MA and MI tasks in a self-control design. The BCI accuracies from the bilateral, ipsilesional, and contralesional hemispheres were analyzed and compared between different tasks. The cortical activation patterns were evaluated with ERD and laterality index (LI). Results: The study showed that the BCI accuracies of MA were significantly (p < 0.05) higher than MI in the bilateral, ipsilesional, and contralesional hemispheres in the alpha-beta (8-30 Hz) frequency bands. There was no significant difference in ERD and LI between the MA and MI tasks in the 8-30 Hz frequency bands. However, in the MA task, there was a negative correlation between the ERD values in the channel CP1 and ipsilesional hemispheric BCI accuracies (r = -0.552, p = 0.041, n = 14) and a negative correlation between the ERD values in channel CP2 and bilateral hemispheric BCI accuracies (r = -0.543, p = 0.045, n = 14). While in the MI task, there were negative correlations between the ERD values in channel C4 and bilateral hemispheric BCI accuracies (r = -0.582, p = 0.029, n = 14) as well as the contralesional hemispheric BCI accuracies (r = -0.657, p = 0.011, n = 14). As for motor dysfunction, there was a significant positive correlation between the ipsilesional BCI accuracies and FMA scores of the hand part in 8-13 Hz (r = 0.565, p = 0.035, n = 14) in the MA task and a significant positive correlation between the ipsilesional BCI accuracies and FMA scores of the hand part in 13-30 Hz (r = 0.558, p = 0.038, n = 14) in the MI task. Conclusion: The MA task may achieve better BCI accuracy but have similar cortical activations with the MI task. Cortical activation (ERD) may influence the BCI accuracy, which should be carefully considered in the BCI motor rehabilitation of patients with hemiplegia.

Electroencephalography Mu Rhythm Changes and Decreased Spasticity After Repetitive Peripheral Magnetic Stimulation in Patients Following Stroke.

Background: Spasticity is common among patients with stroke. Repetitive peripheral magnetic stimulation (rPMS) is a painless and noninvasive therapy that is a promising approach to reducing spasticity. However, the central mechanism of this therapy remains unclear. Changes in cortical activity and decreased spasticity after rPMS intervention require further exploration. The aim of this study was to explore the electroencephalography (EEG) mu rhythm change and decrease in spasticity after rPMS intervention in patients with stroke. Materials and methods: A total of 32 patients with spasticity following stroke were recruited in this study and assigned to the rPMS group (n = 16) or sham group (n = 16). The modified Ashworth scale, modified Tardieu scale, and Fugl-Meyer assessment of the upper extremity were used to assess changes in upper limb spasticity and motor function. Before and after the rPMS intervention, EEG evaluation was performed to detect EEG mu rhythm changes in the brain. Results: After one session of rPMS intervention, spasticity was reduced in elbow flexors (p < 0.05) and wrist flexors (p < 0.05). Upper limb motor function measured according to the Fugl-Meyer assessment was improved (p < 0.05). In the rPMS group, the power of event-related desynchronization decreased in the mu rhythm band (8-12 Hz) in the contralesional hemisphere (p < 0.05). Conclusions: The results indicate that rPMS intervention reduced spasticity. Cortical activity changes may suggest this favorable change in terms of its neurological effects on the central nervous system.

Mirror Visual Feedback Combining Vibrotactile Stimulation Promotes Embodiment Perception: An Electroencephalogram (EEG) Pilot Study.

As one determinant of the efficacy of mirror visual feedback (MVF) in neurorehabilitation, the embodiment perception needs to be sustainable and enhanced. This study explored integrating vibrotactile stimulation into MVF to promote the embodiment perception and provide evidence of the potential mechanism of MVF. In the experiment, the participants were instructed to keep their dominant hand still (static side), while open and close their non-dominant hand (active side) and concentrate on the image of the hand movement in the mirror. They were asked to tap the pedal with the foot of the active side once the embodiment perception is generated. A vibrotactile stimulator was attached on the hand of the active side, and three conditions were investigated: no vibration (NV), continuous vibration (CV), and intermittent vibration (IV). The effects were analyzed on both objective data, including latency time (LT) and electroencephalogram (EEG) signals, and subjective data, including embodiment questionnaire (EQ). Results of LT and EQ suggested a stronger subjective sense of embodiment under the condition of CV and IV, comparing with NV. No significant difference was found between CV and IV. EEG analysis showed that in the hemisphere of the static side, the desynchronization of CV and IV around the central-frontal region (C3 and F3) in the alpha band (8-13 Hz) was significantly prominent compared to NV, and in the hemisphere of the active side, the desynchronization of three conditions was similar. The network analysis of EEG data indicated that there was no significant difference in the efficiency of neural communication under the three conditions. These results demonstrated that MVF combined with vibrotactile stimulation could strengthen the embodiment perception with increases in motor cortical activation, which indicated an evidence-based protocol of MVF to facilitate the recovery of patients with stroke.

Longitudinal Electroencephalography Analysis in Subacute Stroke Patients During Intervention of Brain-Computer Interface With Exoskeleton Feedback.

BACKGROUND: Brain-computer interface (BCI) has been regarded as a newly developing intervention in promoting motor recovery in stroke survivors. Several studies have been performed in chronic stroke to explore its clinical and subclinical efficacy. However, evidence in subacute stroke was poor, and the longitudinal sensorimotor rhythm changes in subacute stroke after BCI with exoskeleton feedback were still unclear. MATERIALS AND METHODS: Fourteen stroke patients in subacute stage were recruited and randomly allocated to BCI group (n = 7) and the control group (n = 7). Brain-computer interface training with exoskeleton feedback was applied in the BCI group three times a week for 4 weeks. The Fugl-Meyer Assessment of Upper Extremity (FMA-UE) scale was used to assess motor function improvement. Brain-computer interface performance was calculated across the 12-time interventions. Sensorimotor rhythm changes were explored by event-related desynchronization (ERD) changes and topographies. RESULTS: After 1 month BCI intervention, both the BCI group (p = 0.032) and the control group (p = 0.048) improved in FMA-UE scores. The BCI group (12.77%) showed larger percentage of improvement than the control group (7.14%), and more patients obtained good motor recovery in the BCI group (57.1%) than did the control group (28.6%). Patients with good recovery showed relatively higher online BCI performance, which were greater than 70%. And they showed a continuous improvement in offline BCI performance and obtained a highest value in the last six sessions of interventions during BCI training. However, patients with poor recovery reached a platform in the first six sessions of interventions and did not improve any more or even showed a decrease. In sensorimotor rhythm, patients with good recovery showed an enhanced ERD along with time change. Topographies showed that the ipsilesional hemisphere presented stronger activations after BCI intervention. CONCLUSION: Brain-computer interface training with exoskeleton feedback was feasible in subacute stroke patients. Brain-computer interface performance can be an index to evaluate the efficacy of BCI intervention. Patients who presented increasingly stronger or continuously strong activations (ERD) may obtain better motor recovery.

Motor Imagery Training After Stroke Increases Slow-5 Oscillations and Functional Connectivity in the Ipsilesional Inferior Parietal Lobule.

Background. Reorganization in motor areas have been suggested after motor imagery training (MIT). However, motor imagery involves a large-scale brain network, in which many regions, andnot only the motor areas, potentially constitute the neural substrate for MIT. Objective. This study aimed to identify the targets for MIT in stroke rehabilitation from a voxel-based whole brain analysis of resting-state functional magnetic resonance imaging (fMRI). Methods. Thirty-four chronic stroke patients were recruited and randomly assigned to either an MIT group or a control group. The MIT group received a 4-week treatment of MIT plus conventional rehabilitation therapy (CRT), whereas the control group only received CRT. Before and after intervention, the Fugl-Meyer Assessment Upper Limb subscale (FM-UL) and resting-state fMRI were collected. The fractional amplitude of low-frequency fluctuations (fALFF) in the slow-5 band (0.01-0.027 Hz) was calculated across the whole brain to identify brain areas with distinct changes between 2 groups. These brain areas were then targeted as seeds to perform seed-based functional connectivity (FC) analysis. Results. In comparison with the control group, the MIT group exhibited more improvements in FM-UL and increased slow-5 fALFF in the ipsilesional inferior parietal lobule (IPL). The change of the slow-5 oscillations in the ipsilesional IPL was positively correlated with the improvement of FM-UL. The MIT group also showed distinct alternations in FCs of the ipsilesional IPL, which were correlated with the improvement of FM-UL. Conclusions. The rehabilitation efficiency of MIT was associated with increased slow-5 oscillations and altered FC in the ipsilesional IPL. Clinical Trial Registration. http://www.chictr.org.cn . Unique Identifier. ChiCTR-TRC-08003005.

Computer vision technology-based face mirroring system providing mirror therapy for Bell's palsy patients.

Purpose: Mirror therapy (MT) is an effective adjunct treatment for Bell's palsy (BP); however, a bifold mirror-based apparatus hindered the effectiveness. Besides, few studies have reported the related factors of facial embodiment. The aim of this study was to evaluate the feasibility of a novel face mirroring System (FMS) and the effects on facial embodiment in BP patients, comparing with conventional mirror book (MB) therapy.Method: This was a within-subject design trial. Thirty-six BP patients were recruited and received investigations on user experience and perception of facial embodiment after each facial task (reset, facial expression, and enunciation) when using both FMS and MB separately and randomly.Results: Data of questionnaires showed FMS had a better user experience and perception of facial embodiment comparing with MB. Patients agreed more strongly on the statements of facial embodiment for facial expression and enunciation tasks when using both apparatuses, comparing with rest.Conclusions: The FMS is a feasible and optimal setup to provide MT for BP patients. Moreover, speech paired motor training is a superior strategy for facilitating facial embodiment.Implications for RehabilitationThe Face Mirroring System is a feasible and optimal apparatus for mirror therapy in Bell's palsy patients.Perception of facial embodiment can be increased via combining multiple sensory feedbacks.Speech paired motor tasks have considerable potential to facilitate facial embodiment.

The Reorganization of Resting-State Brain Networks Associated With Motor Imagery Training in Chronic Stroke Patients.

A number of studies have suggested that motor imagery training (MIT) has a positive influence on the upper extremity motor recovery in stroke patients, but little is known about its neural basis. To investigate the cortical motor network plasticity after MIT, 34 chronic hemiplegic subjects with subcortical stroke were recruited and randomly allocated to either the conventional rehabilitation therapy (CRT) or the CRT + MIT. The patients were assessed with the upper limb section of Fugl-Meyer assessment Scale (FM-UL) and resting-state fMRI before and after the 4 weeks of treatment. Seed-based functional connectivity (FC) of the ipsilesional primary motor cortex (M1) and graph-theory based analysis were used to explore the relationships between the motor recovery and reorganization of motor networks. We found that the patients in the MIT group showed more improvement in the FM-UL scores compared with the CRT group. Both groups presented increased inter-hemispheric and decreased intra-hemispheric FC of the ipsilesional M1 after intervention. However, the MIT group showed increased FC of the ipsilesional M1 with the ipsilesional precentral and postcentral gyri, middle cingulate gyrus and supramarginal gyrus after intervention, while the CRT group showed decreased FC in these regions. In addition, the clustering coefficient was significantly increased in the MIT group but not in the CRT group, and the increment of clustering coefficient was significantly positively correlated with improvement of FM-UL scores. Therefore, MIT might contribute to the motor recovery in stroke patients through the following network reorganization, i.e., promoting the efficiency of regional neuronal communication and the reorganization of intrinsic FC of the ipsilesional M1 involving widely distributed motor network in both hemispheres.

Effectiveness of interventions to improve hand motor function in individuals with moderate to severe stroke: a systematic review protocol.

INTRODUCTION: The human hand is extremely involved in our daily lives. However, the rehabilitation of hand function after stroke can be rather difficult due to the complexity of hand structure and function, as well as neural basis that supports hand function. Specifically, in individuals with moderate to severe impairment following a stroke, previous evidence for effective treatments that recover hand function in this population is limited, and thus has never been reviewed. With the progress of rehabilitation science and tool development, results from more and more clinical trials are now available, thereby justifying conducting a systematic review. METHODS AND ANALYSIS: This systematic review protocol is consistent with the methodology recommended by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols and the Cochrane handbook for systematic reviews of interventions. Electronic searches will be carried out in the PubMed, CINAHL, Physiotherapy Evidence Database and Cochrane Library databases, along with manual searches in the reference lists from included studies and published systematic reviews. The date range parameters used in searching all databases is between January 1999 and January 2019. Randomised controlled trials (RCTs) published in English, with the primary outcome focusing on hand motor function, will be included. Two reviewers will screen all retrieved titles, abstracts and full texts, perform the evaluation of the risk bias and extract all data independently. The risk of bias of the included RCTs will be evaluated by the Cochrane Collaboration's tool. A qualitative synthesis will be provided in text and table, to summarise the main results of the selected publications. A meta-analysis will be considered if there is sufficient homogeneity across outcomes. The quality of the included publications will be evaluated by the Grading of Recommendations Assessment, Development and Evaluation system from the Cochrane Handbook for Systematic Reviews of Interventions. ETHICS AND DISSEMINATION: No ethical approval is needed, and the results of this review will be disseminated via peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: CRD42019128285.

Effects of camera-based mirror visual feedback therapy for patients who had a stroke and the neural mechanisms involved: protocol of a multicentre randomised control study.

INTRODUCTION: As a combination of visual stimulation and motor imagery, mirror visual feedback (MVF) is an effective treatment for motor impairment after stroke; however, few studies have investigated its effects on relevant cognitive processes such as visual perception and motor imagery. Camera-based MVF (camMVF) overcomes the intrinsic limitations of real mirrors and is recognised as an optimal setup. This study aims to investigate the effects of camMVF as an adjunct treatment for stroke patients, compare camMVF outcomes with those of conventional therapy and elucidate neural mechanisms through which MVF influences cognition and brain networks. METHODS AND ANALYSIS: This will be a multicentre, single-blinded, randomised controlled trial including 90 patients randomised into three groups: camera-based mirror visual feedback intervention group (30), shielded mirror visual feedback intervention group (30) and conventional group (30). Patients in each group will receive a 60 min intervention 5 days per week over 4 weeks. The primary outcome will be the Fugl-Meyer Assessment Upper Limb subscale measurement. Secondary outcomes include the modified Ashworth Scale, Grip Strength test, Modified Barthel Index, Functional Independence Measure, Berg Balance Scale, 10-metre walking test, hand-laterality task and electroencephalography . ETHICS AND DISSEMINATION: Ethics approval was granted by the Huashan Hospital Institutional Review Board on 15 March (KY2017-230). We plan to submit the results to a peer-reviewed journal and present them at conferences, rehabilitation forums and to the general public. TRIAL REGISTRATION NUMBER: ChiCTR-INR-17013644; Pre-results.

Camera-Based Mirror Visual Input for Priming Promotes Motor Recovery, Daily Function, and Brain Network Segregation in Subacute Stroke Patients.

BACKGROUND: Camera technique-based mirror visual feedback (MVF) is an optimal interface for mirror therapy. However, its efficiency for stroke rehabilitation and the underlying neural mechanisms remain unclear. OBJECTIVE: To investigate the possible treatment benefits of camera-based MVF (camMVF) for priming prior to hand function exercise in subacute stroke patients, and to reveal topological reorganization of brain network in response to the intervention. METHODS: Twenty subacute stroke patients were assigned randomly to the camMVF group (MG, N = 10) or a conventional group (CG, N = 10). Before, and after 2 and 4 weeks of intervention, the Fugl-Meyer Assessment Upper Limb subscale (FMA_UL), the Functional Independence Measure (FIM), the modified Ashworth Scale (MAS), manual muscle testing (MMT), and the Berg Balance Scale (BBS) were measured. Resting-state electroencephalography (EEG) signals were recorded before and after 4-week intervention. RESULTS: The MG showed more improvements in the FMA_UL, the FMA_WH (wrist and hand), and the FIM than the CG. The clustering coefficient (CC) of the resting EEG network in the alpha band was increased globally in the MG after intervention but not in the CG. Nodal CC analyses revealed that the CC in the MG tended to increase in the ipsilesional occipital and temporal areas, and the bilateral central and parietal areas, suggesting improved local efficiency of communication in the visual, somatosensory, and motor areas. The changes of nodal CC at TP8 and PO8 were significantly positively correlated with the motor recovery. CONCLUSIONS: The camMVF-based priming could improve the motor recovery, daily function, and brain network segregation in subacute stroke patients.