Recovery of patients is a priority as it enables these patients to perform activities of daily living independently, reducing the demand of caretakers and healthcare personnel and providing an opportunity for these patients to resume social participation, thus increasing their quality-of-life
[37]. Although restoring UL function in post-stroke patients is essential, regaining the full motor function may not always be achievable, depending on the extent of disability
[38]. In a stroke population with some residual muscle activity, exercise or physical therapy dependent brain plasticity has been found to restore the sensory-motor function
[39]. Several pilot studies have shown promisingly positive results of robot-assisted rehabilitation for recovery and plasticity following a stroke
[40]. Assistive technologies (prosthetic limbs and devices) are a viable option to replace the human body’s lost function
[41]). These technologies can move the disabled hand or electrically stimulate the muscle to create muscle contractions in limbs. Paralyzed or atrophied muscles can be restored with neuromuscular electrical stimulation (NMES) using long term implanted system or surface electrodes
[42]. Patients suffering from stroke or lower SCI or C1–C4 injury sometimes completely lose the muscle motor action due to motor neuron damage making the restricted use of NMES
[43]. Multidisciplinary and supportive services are required to rehabilitate hemiplegic patients in stable condition beginning 48 h after the disease onset
[44]. Generally, inpatient and outpatient services are beneficial for both patients and their families, but in a larger perspective, these services have their practice standards regarding diagnosis, prevention, treatment, and rehabilitation, which can vary
[44]. Speech, occupational, and physical therapies play an important role in improving the patients’ skills (motor, verbal, etc.), helping create such an environment where the patients with minimum interference of attendants can function. Further, the well-structured and autonomous physical rehabilitation systems help minimise all the infrastructural, mobility and accessibility barriers with orthotics, prosthetics, and electrics devices such as wheelchairs and walkers
[45]. Adaptive plasticity has been shown to play a crucial role in motor recovery after stroke for a long time. However, there has always been difficulty identifying the precise mechanisms and neural structures. For the last 15 years’ researchers have conducted numerous studies and controlled trials in animal models and actual stroke patients, concluding that there is a space for adaptive plasticity in the brain after injury or stroke
[46]. After the injury, there are various functional variations in the cerebral cortex and it undergoes significant structural changes for several weeks or months after injury/stroke onset
[46]. Results of the cortical reorganization indicate marked functional variations after stroke in primate models
[47]. Moreover, impaired limb repetitive task practices cause a modulatory impact on cortical plasticity. Training therapies can likely influence the reorganizational mechanisms in the cerebral cortex, thus promoting functional recovery
[47]. Immediate, multisensory, and intensive rehabilitative interventions in stroke patients effectively regain functional activities on impaired limbs. However, the mechanisms of neurological recovery after stroke are still not well understood
[48]. However, there is experimental evidence that intervention of more than one therapeutic technique is helpful for fast motor recovery, and cerebral plasticity undoubtedly plays a central role in rehabilitation of neural pathways. Various specific therapeutic UL exercises influence cerebral plasticity in stroke patients. In a well-designed rehabilitative system, there should be a feedback system, as it helps in achieving faster and better functional outcomes
[49].
Rehabilitation Therapies
The purpose of this entry is to provide a detailed overview of the stroke’s morbidity, prevalence, risk factors, social burden, and relevant economic aspects in terms of treatment and care services. This section of the entry has discussed various technology-enabled techniques Table 5 to rehabilitate the UL and restore its motor activity after stroke or injury.
Table 5. Included Stroke Rehabilitation Techniques.
Technique |
Focus |
Strategy |
Comparison with Conventional Therapy |
Disability |
FES (functional electric stimulation) [50] |
To study the effect of FES on UL rehabilitation |
Open-label block inpatient randomized control study |
Fast recovery than task traditional task-oriented physiotherapy |
Acute phase of stroke |
FES [51] |
Application of FES with bilateral training on UL |
Randomized double-blinded controlled study |
Test scores for FES intervention showed better improvement |
6 months after stroke onset |
FES therapy [52] |
FES therapy on triceps and anterior deltoid |
18 sessions of 60 min. therapy with diff. functional tasks |
FES therapeutic intervention improved functionality tests score by 4.5 points |
Hemorrhagic stroke |
NMES-neuromuscular electric stimulation [53][54][55][56][57] |
To study the effect of NMES application on hemiplegic patients |
Cyclic stimulation in randomized control studies |
Satisfactory results have been observed |
Acute/subacute phase of stroke but applicable in chronic phase as well |
FES [58] |
For analysing the effect of FES in patients with hemiplegia |
Randomly controlled FES session of 6 weeks for 6 h everyday |
UL motor functions were significantly improved |
Hemiplegia with subluxation |
FES-ET [59] |
Potency check of FES therapy |
Comparative controlled strategy |
Obtained satisfactory results |
Stroke subacute phase (UL hemiplegia) |
NIBS [60][61][62][63] |
To test the results of tDCS and tMS |
Modulation of cortical excitability |
Effective and feasible |
Motor disability due to Stroke |
NIBS [64] |
Application of tDCS for UL rehabilitation |
Placebo controlled mechanism |
Encouraging outcomes in terms of recovery duration |
Post ischemic stroke disability |
NIBS [65][66][67][68][69][70][71] |
Neuromodulation using NIBS |
Regulation of cortical excitability with r-tMS |
safe and effective |
UL disability after stroke |
NIBS [72][73][74] |
Application of anodal non-invasive t-DCS as motor therapy |
Meta analysis of 23 studies with >500 patients in total |
Positive but not-sufficient outcomes to reach any conclusion. |
UL disability due to chronic stroke |
Epidural stimulation invasive [75][76] |
To check the efficacy and feasibility of EECS |
Single blinded and multicenter study |
Better recovery rate was recorded as compared to the control group |
Moderate to severe ischemic stroke patients with UL disability |
Cortical electric stimulation [77][78] |
Rehabilitation of motor activity of UL |
Stimulation of motor cortex of animal models |
Satisfactory results were observed |
Disability of UL |
Stimulation of motor cortex [79][80][81][82] |
To understand the neurological characteristics through motor cortex & deep brain stimulation |
stroke subjects were included in the studies |
48–50% patients showed positive results |
Post stroke pain |
VR rehabilitation [83][84][85] |
To understand the effect of VR for stroke rehabilitation |
Stroke patients were included in the study |
General experience indicated positive results |
Post stroke disability |
VR [86][87][88] |
To analyse the efficacy of virtual rehabilitation |
Different databases were examined in a review |
Sufficient satisfactory results were observed |
Functional disability |
VR [89][90][91][92][93] |
Rehabilitation of motor activity |
PC-based VR systems were designed and pilot trials were performed |
Satisfactory improvements were observed in hand parameters |
Chronic stroke patients |
Task-oriented therapy [94] |
To test the functional and impairment efficacies of task-oriented therapy |
20 patients were included in a Single-blinded randomized study |
Group who received task-oriented exercises showed better recovery rate |
Post stroke UL disability |
Task-oriented therapy [95][96][97][98][99][100][101] |
Optimization of locomotor relearning |
Aerobic complex task trainings |
Motor abilities of the patients improved after therapy session |
Chronic stroke patients |
Robotic therapy [102] |
To design a robot based therapeutic system |
Robot based training |
Positive but not satisfactory |
Functional disability |
Robot assisted therapy [103][104][105][106][107] |
To compare the results of EULT and robotic therapy based on MIT robotic gym |
Repetitive functional therapy |
Not significant improvement was observed in UL functionality |
UL disability |
Tele rehabilitation [108][109] |
To check the feasibility of tele rehabilitation system |
Outpatient therapy |
As effective as clinical based therapies |
Motor disability |
Tele rehabilitation [110] |
To examine the efficacy of tele rehabilitation |
Different data bases from MADLINE, Cochrane, and Embase were collected and analyzed |
No adverse events were reported, considered to be an emerging field however more trials are needed |
Post stroke motor disability |
Tele rehabilitation [111][112][113] |
Use of tele rehabilitation for accommodating the stroke patients on large scale |
Activity based therapies |
Appears to be a holistic approach |
Patients of functional disability |
In a pilot study
[50], the role of Functional Electric Stimulation (FES) in the recovery of UL motor function was tested in the early stages of stroke. Randomized (Open-label block) trials were applied during inpatient treatment and continued at home. Seven patients received FES plus task-oriented therapy, and control group subjects (
n = 8) received only task-oriented therapies. All the patients could move their arms freely after the therapy session for 12 weeks. To check the improvement in arms’ functionality, box and block (B&B), Modified Fugl-Meyer (mF-M), and Jebsen Taylor light object lift (J-T) tests were recorded, and the results are shown in
Table 6.
Table 6. Improvement Analysis of UL
[44].
Test Type |
Baseline Score |
12th Week Score |
1. B&B |
|
|
FES group |
7.00 ± 0.00 |
48.00 ± 28.00 |
Control Group |
4.00 ± 0.50 |
25.5 ± 15.0 |
2. mF-M |
|
|
FES group |
23.0 ± 17 |
51.0 ± 44.0 |
Control Group |
20.5 ± 15.5 |
39.0 ± 33.25 |
3. J-T |
|
|
FES group |
60.0 ± 18.0 |
5.70 ± 4.20 |
Control Group |
60.0 ± 39.75 |
10.0 ± 7.87 |
In a randomized controlled (double-blinded) study
[51], the effectiveness of FES-functional electric stimulation with bilateral training activities was observed for the UL rehabilitation sample of 20 subjects recruited six months after stroke onset. They completed 15 sessions of training. Self-triggered mechanisms synchronized with bilateral UL activities (stretching activities = 10 min, occupational therapy = 60 min, and FES with bilateral task = 20 min) were applied on the participants of the FES group, and their motion was detected via accelerometer. In contrast, the control group participants received occupational and stretching therapies with placebo stimulation for the same duration. Functional test for hemiplegic UE (FTHUE), grip, Modified Ashworth scale, Fugal-Meyer test, forward-reaching distance, and active range of motion test were applied with the following outcomes
Table 7.
Table 7. Improvement analysis of UL
[50].
Test Type |
FES Group Mean Score |
Control Group Mean Score |
Pretraining |
Post-Training |
Pretraining |
Post-Training |
Fugl-Meyer test |
18.1 ± 7.8 |
25.8 ± 8.7 |
19.9 ± 10.00 |
22.0 ± 9.8 |
Forward reaching (cm) |
12.6 ± 7.6 |
20.4 ± 9.7 |
7.7 ± 9.7 |
11.9 ± 12.4 |
Grip power (kg) |
1.20 ± 1.9 |
2.20 ± 2.0 |
1.1 ± 1.59 |
2.00 ± 2.1 |
FTHUE |
2.5 ± 0.8 |
3.7 ± 0.5 |
2.8 ± 0.6 |
3.1 ± 0.6 |
Functional independence |
76.7 ± 12.0 |
80.2 ± 6.9 |
77.3 ± 12.0 |
77.6 ± 12.0 |
In 18 sessions by
[52], five hemiplegic stroke patients received FES therapy to their triceps, finger extensors, and anterior deltoid for one hour. Different functional tasks such as switching, pressing, and closing a drawer were performed with natural objects during each session. Saebo-MAS and Microsoft Kinect were used to collect the kinematic data. Action Research Arm Test and Fugl-Meyer tests were performed to check the pre and post arms’ functionality. Test score significantly improved for FES assisted therapy by 4.4 points. A feasibility study has shown that economical hardware amalgamated with modern FES controllers can substantially improve the UL motor function. Cyclic (1/2 channel stimulator) NMES-neuromuscular electric stimulation has been applied in numerous randomized controlled studies with encouraging results for acute/subacute patients suffering from hemiplegia
[53][54][55]. Patients with some residual muscle activity at baseline have shown more satisfactory results with the application of cyclic NMES
[56]. Hemiplegic patients with subluxation randomly assigned to experimental long and short duration subgroups for six weeks (6 h/day) received FES-functional electric stimulation therapy at posterior deltoid and supraspinatus muscles in a study by
[57]. They reported that the Fugl-Meyer score significantly improved the arm’s motor function. The effectiveness of FES-ET (functional electric stimulation exercise therapy) during the subacute phase of stroke was tested
[58] in a comparative controlled random low and high-intensity treatment study. Nineteen UL-Hemiplegic patients (men = 10 and women = 9) of the age 60.5 ± 5.8 years with average disease duration 48 ± 17 days received FES therapy with adequate encouraging outcomes. In the analysis of randomized controlled studies, FES is an effective treatment for patients > 18 years with a stroke duration time of 2 months. However, no significant improvement was observed in studies where FES treatment was initiated after one year of stroke onset
[59].
According to
[60], Transcranial Magnetic Stimulation (TMS) and transcranial direct current stimulation (tDCS) satisfactorily affect the cortical excitability and motor function, thus increasing the clinical arena for the beneficial and customarily use of NIBS as the neurorehabilitation treatment for stroke patients. TMS can alter the cortical activity by creating a transient magnetic field and depolarizing the neurons depending upon the field strength, coil shape, frequency, and duration
[61][62]. tDCS (transcranial direct current stimulation) (1–2 mA) using two-surface electrodes can depress or increase the regional excitability in the motor cortex through neuronal depolarization
[63][64]. According to
[65], NIBS (tMS and tDCS) can modulate the cortical excitability with satisfactory long-lasting effects. In placebo-controlled studies, almost 1000 stroke subjects have been included to achieve UL-motor recovery. High frequency > 3 Hz TMS and low frequency < 1 Hz r-TMS were applied to increase and decrease the excitability of the ischemic cortex, respectively; these non-stimuli have shown constructive effects on neurological scales, functional disability score, and treatment duration of the patients
[66]. Disturbed neural pathways are remodelled, and networks between the two hemispheres are modulated by applying NIBS (TMS and tDCS) in post-stroke neuro-rehabilitation by
[67]. Neurophysiological alterations have been reported in stroke patients by applying the NIBS-TMS technique
[67][68]. NIBS can directly increase the excitability of the motor cortex (ipsilesional). Motor recovery and learning can be increased by applying NIBS directly/indirectly
[69]. Pairing up the NIBS with motor training instead of alone results in prolonged functional neural plasticity and performance improvement in the ipsilesional motor cortex
[70]. These noninvasive brain stimulation techniques have proven beneficial for modulating brain function and plasticity. tDCS and r-TMS are powerful means to regulate cortical excitability, bring alterations in the motor cortex and thus enhance the motor function of UL after stroke. Neuromodulation with NIBS is a safe, effective, and feasible method to assist recovery from motor impairment after stroke or injury, and no side effects (seizures) have been reported so far
[71][72][73][74]. A total of 523 stroke patients were included in a review of 23 studies, including variables such as post-stroke duration, the number of tDCS sessions used, methodology, and type of motor therapy performed. Positive results have been recorded in patients with chronic stroke with the application of anodal tDCS for the motor recovery of UL. No data has been found for subacute stroke. The effect of anodal tDCS is still unclear for the recovery of hand function in the subacute phase of stroke by
[74].
In a single-blinded, prospective, and multicentre study, the safety, efficacy, and feasibility of Epidural Electrical Motor Cortex stimulation (EECS) were assessed for improving the motor function of UL in the ischemic stroke patients suffering from moderate to severe hemiparesis. A total of 104 patients in the experimental group and 60 patients in the control group were included within four months of stroke onset. Epidural six-contact lead was implanted for EECS in the patients of the experimental group perpendicular to the primary motor cortex and pulse generator. Both the groups received rehabilitation therapy for six weeks. Arm motor activity was tested using the arm motor ability test (AMAT), Fugl-Meyer scale, and follow-up assessments. Post hoc comparison tests were performed to determine the treatment effect difference between the control and experimental groups. Test results showed a better recovery rate among the patients of the experimental group who received the EECS therapy compared to the control group
[75][76]. For the rehabilitation of UL-upper limb’s motor activity, electric stimulation of the cortex is emerging as a reliable approach. It has been observed from different animal models that cortical stimulation and motor learning facilitate cortical remodelling and long-term potentiation by altering the intracortical inhibitory circuits
[76]. Neurological characteristics of the patients suffering from poststroke pain were identified, indicating the satisfactory response to MC-motor cortex stimulation
[77]. In this study, 31 patients were treated through the stimulation of the motor cortex; 15 (48%) patients showed an excellent response (>60% reduction in pain). In 13 patients, satisfactory/good pain control was achieved after stroke onset. There was no significant relationship observed between the sensory symptoms such as hypesthesia, dysesthesia, allodynia, hyperpathia, and pain control. However, it has been concluded that the pre-operative evaluation of the motor weakness in painful areas is beneficial for predicting the favourable response towards motor cortex stimulation in controlling the post-stroke pain
[77]. Intractable pains have been treated using DBS-deep brain stimulation for more than 50 years. A meta-analysis has been performed to understand better the role of deep brain stimulation in relieving post-stroke pain. Inclusion criteria were based on the clarity of protocol and patient characteristics. The stimulation trial was successful in 50% of patients suffering from post-stroke pain and 58% of patients with permanently implanted treatment for ongoing pain relief
[78]. DBS-deep brain stimulation is an effective and remarkably safe treatment for movement disorders. It is being applied to various psychiatric and neurologic disorders, including refractory epilepsy. A review examined the use of deep brain stimulation for the treatment of epilepsy using the known targets and mechanisms of seizure control and neuro modulation
[79]. Although deep neuromodulation for the treatment of epilepsy has a very long experimental history, precise stereotactic techniques and epileptogenic networks are now better understood. Robust trial designs are combined to improve the quality of evidence and make the DBS a feasible, trustworthy, and viable treatment option. However, the underlying mechanisms, stimulation parameters, and anatomical targets are still the areas of active investigation
[80][81][82].
Interactive video games and virtual reality have emerged as viable treatment approaches for stroke rehabilitation. Commercial gaming is rapidly being adopted in clinical settings for cognitive, speech and physical rehabilitation
[83]. In a case study the efficacy and reliability of virtual reality for UL activity and function were observed
[83].Twenty-nine stroke patients (women = 17, men = 12) aged 43–85 years were included in three different studies to investigate the effect of VR technology for the rehabilitation of stroke. All the included stroke subjects responded positively towards VR activity station. A considerable change in attitude was observed when stroke subjects were exposed to VR computer games
[84].
Besides functional activity, other factors such as balance, gait, cognitive function, global motor function, quality of life, and participation restriction were also examined. Results indicated that VR effectively improves UL function and daily life activities when used as a complement to usual care. Databases from different sources (Medline, AMED, Proquest, CINAHL, and Psych-Info) were collected
[84] to assess the utility of VR for stroke rehabilitation. A total of 11 studies met the inclusion criteria (5 = UL rehabilitation, 3 = gait and balance, 2 = cognitive interventions, and 1 = both UL and lower limb rehabilitation). VR was observed to be a safe and potentially exciting tool for stroke rehabilitation, but the evidence base has been found too limited by power and design issues to permit the definite assessment of its value
[85][86]. Although the findings of this entry are positive, the evidence level is still weak-moderate in terms of research quality.
Further controlled studies are warranted. Between 50 and 75% of stroke patients suffer from persistent motor impairment of affected UL. Hence, better training strategies for motor training functions need to be identified. Although virtual reality is emerging as a practical treatment approach, its effectiveness needs to be established appropriately. Immersive VR vs. no therapy in UL rehabilitation secured level-1b evidence, level-5 evidence for VR therapy vs. conventional therapy, level-4 evidence showed conflicting results for non-immersive VR vs. no therapy, and level-2b evidence for non-immersive VR therapy vs. conventional therapy
[86]. Current evidence of using VR for UL rehabilitation is limited in effectiveness, but it is sufficiently encouraging for justifying additional trials in the stroke population. A PC-based virtual reality system was developed to rehabilitate hand motor activity in stroke patients.
For these two I/P devices, Rutgers Master-RMII and Cyber-Glove were used to allow the patient to interact with the virtual environment. Different target levels based on performance were designed for increasing the patient’s motivation and individualizing the exercise difficulty. Pilot trials in the clinical environment were performed. The working protocol was applied on chronic patients for two weeks regularly. Experimental outcomes indicated a satisfactory improvement in hand parameters. Subjective evaluation was positive, indicating VR as a practical approach for stroke rehabilitation
[87][88]. Virtual reality is emerging as well accepted stroke rehabilitation therapy. A review assessed the safety, efficiency, and feasibility of VR therapy for the rehabilitation of UL motor activity. Thirty-seven randomized controlled studies with 1019 stroke subjects were included in this entry. VR was a more effective and satisfactory treatment than conventional therapy for improving the UL functional activity
[89][90]. VR environment is now considered a promising therapeutic approach for ADL rehabilitation after stroke, especially in the subacute phase. VR tools will have the potential to be used in homes, providing additional therapeutic practice besides formal therapy sessions. VR will likely be an important contributing factor in rehabilitation services in the near future. VR urges therapists to engage with the gaming groups and engineering applications to explore the innovative approaches for delivering viable rehabilitation programs
[91][92][93].
Functional safety and impairment efficacies of a task-oriented approach have been evaluated for the patients suffering from post-stroke UL disability. Twenty subjects were recruited in a single-blinded randomized cross-over study. Subjects were randomly divided into two groups (
n = 10 immediate) and (
n = 10 delayed intervention). The first group received task-oriented therapy for six weeks (3 h/week) followed by no-intervention control for six more weeks. However, there was a reverse order followed for the second group. Canadian Occupational Performance Measure (COPM) functional measures, MAL, and WMFT (Wolf motor function test) was used to measure the motor activity of UL. The score of functional change was higher for the task-oriented (TO) group. A TO approach appears to be a viable and effective post-stroke UL rehabilitation technique with considerable clinical functional improvement
[94]. In a review, various databases (Medline, Embase, Cochrane, and CINAHL) were searched to identify the studies related to the TO approach for post-stroke rehabilitation. To ensure the quality, only randomized controlled trials were included. They concluded that TO training for stroke patients is a reliable and safe way to enhance the functional outcomes and overall quality of life
[95][96]. Repetitive task training-RTT is an active practice approach to enhance motor activities in stroke patients. Cochrane, MEDLINE, Embase, AMED, and CINAHL randomized controlled group trials were assessed to determine repetitive task training-RTT effectiveness for UL. Low-quality evidence showed that repetitive task training enhances arm functionality (participants analysed = 749). Moderate quality evidence was recorded that RTT improves walking distance (Participants analysed = 610). Significant differences were found between the groups of upper and lower limb functionality. Intervention type, time, and dosage did not modify the effects. However, there was insufficient evidence to be sure about the adverse events
[97][98]. For optimising locomotor relearning in stroke patients (chronic), a treadmill was used as a task-oriented-TO training/exercise paradigm. There were beneficial effects observed in the training session of 6 months. Cardiometabolic fitness, ADL task performance, leg strength, and energy cost for hemiparetic gait were significantly enhanced
[99][100][101].
Post-stroke rehabilitation is progressing towards deriving more integrated therapeutic muscle training approaches to avoid long-term muscle impairments. In this regard, robot-assisted stroke rehabilitation has shown some promising results. Functional activities of robot-assisted therapy have been extensively examined, giving positive but unsatisfactory results during clinical trials
[102]. To address some of the limitations noted, state-of-the-art robot-assisted therapeutic systems have been proposed to rehabilitate the upper and lower limb after stroke
[102]. Robot-assisted muscle training devices are being used for post-stroke rehabilitation and to help improve arm functionalit
[103]. The effectiveness of robot-assisted and electromechanical arm training to improve daily living activities and muscle strength has been assessed.
Moreover, safety, feasibility, and acceptability factors have also been examined. Randomized controlled studies comparing the robot-assisted and electromechanical therapies were included along with placebo interventions/no-interventions after stroke. A total of 45 trials (participants = 1619) were included in the study. Participants who received both pieces of training after stroke onset improved their daily life activities, muscle strength and arm function. High-quality evidence was achieved due to the variations in duration, intensity, treatment and measurement used
[104]. Loss of UL functionality is a common consequence of stroke. Robot-assisted therapy may improve the muscle activity of the arm. The effectiveness of EULT-enhanced UL therapy and robot-assisted therapy using MIT robotic gym has been compared based on usual care and repetitive functional practice. There was no significant improvement in UL motor activity observed in the patients with severe functional disability. The result of the study did not support robotic therapy in routine clinical practice
[105][106][107].
The effectiveness of tele rehabilitation (TR) was assessed for outpatient therapy to improve poststroke residual activities such as motor function, disability, and speech. A comprehensive literature survey was conducted for three different databases. Complete studies addressing TR training sessions were reviewed. Thirty-four articles with 1025 stroke subjects were included in
[108]. Different types of TR were reported to be used in related studies, including VR therapy, speech therapy, robot assisted therapy, different motor training sessions, and community-based therapeutic sessions, which revealed that TR is less expensive and equally effective than clinic-based therapy practices. However, TR can be integrated with other therapies such as speech practice, VR, or robotic to achieve more satisfactory results
[109]. To examine whether telerehabilitation helps improve the functional ability of stroke patients to perform daily life activities compared to in-person (face to face therapy session) and usual care/no rehabilitation, a systematic review has been conducted (Cochrane group trials 2019, Cochrane library 2019, Cochrane controlled trials, MEDLINE, Embase, and eight additional databases).
A total of 1937 stroke subjects were included in 22 different trials. Comparisons greatly varied throughout the studies. However, no adverse events were reported related to TR. This is still an emerging field, and more definitive results are required. Results of the studies in which mixed evaluation methods were used are valuable
[109][110]. Although activity-based therapeutic sessions for the rehabilitation of stroke patients are very significant in improving functional capabilities and quality of life, some patients, due to various reasons (transportation difficulties, low compliance, and poor access, etc.), cannot receive these services. TR can play an essential role in resolving these issues by providing quality muscle training programs. The feasibility of TR has been assessed for an expanded telerehabilitation program. Thirteen stroke patients received home-based TR under the supervision of an expert physiotherapist. The resulting outcomes were evaluated using different tests (Modified Rankin score, Fugl-Meyer test). A home-based TR system provides a holistic approach for rehabilitation and stroke prevention. More work needs to be focused on extracting more reliable, credible, and satisfactory outcomes regarding TR
[111][112][113].