Recovery of standing balance and functional mobility after stroke. Skeletal and body composition changes in hemiplegic patients. Impact of Time on Improvement of Outcome After Stroke Progressive Hemiosteoporosis on the Paretic Side and Increased Bone Mineral Density in the Nonparetic Arm the First Year after Severe Stroke
 Bone mineral density alterations in upper and lower extremities 12 months after stroke measured by peripheral quantitative computed tomography and DXA. Effects of early and intensive neuro-rehabilitative treatment on muscle synergies in acute post-stroke patients: a pilot study Upright activity and higher motor function may preserve bone mineral density within 6 months of stroke: a longitudinal study Unraveling the interaction between pathological upper limb synergies and compensatory trunk movements during reach-to-grasp after stroke: a cross-sectional study Recovery of Gait After Stroke: What Changes? Bone Mineral Density in Patients with Stroke Time Course of Trunk, Arm, Leg, and Functional Recovery After Ischemic Stroke Saturated muscle activation contributes to compensatory reaching strategies after stroke. Analysis and Comparison of the Psychometric Properties of Three Balance Measures for Stroke Patients Sensory Loss in Hospital-Admitted People With Stroke: Characteristics, Associated Factors, and Relationship With Function High intensity strength training improves strength and functional performance after stroke. Early prediction of functional outcome after stroke Bihemispheric brain stimulation facilitates motor recovery in chronic stroke patients
OBJECTIVE To examine the extent to which recovery of functional balance and mobility is accompanied by change in a few specific physiologic measures of postural control . DESIGN Longitudinal prospect i ve study . SETTING Laboratory setting in Ontario . PARTICIPANTS Twenty-seven volunteers ( age , 64.2+/-13.7y ) undergoing 4 weeks of rehabilitation after stroke participated . At initial testing , patients were 32.7+/-18.4 days poststroke and exhibited a moderate level of motor recovery ( lower-extremity and postural control , stages 3 - 4 on the Chedoke-McMaster Stroke Assessment Impairment Inventory ) . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Three functional measures ( Berg Balance Scale , Clinical Outcome Variables Scale , gait speed ) were assessed . Three physiologic measures ( electromyographic data of hamstrings and soleus muscles bilaterally , postural sway , arm acceleration )  were taken while subjects stood quietly on a force platform and while they performed a rapid shoulder flexion movement of the nonparetic upper extremity . RESULTS After 1 month of rehabilitation , there was an overall significant improvement in all outcome measures ( functional , physiologic ) . However , 10 patients failed to show any improvement in the electromyographic activation of hamstrings muscle on the paretic side in response to the rapid arm movement . These patients compensated by increasing the anticipatory activation of the nonparetic hamstrings . CONCLUSION After stroke , patients showed improvement in both physiologic and functional measures of balance and mobility over a 1-month period . We have identified some patients who may be using compensatory strategies to increase function . The factors that may predict those patients who are likely to use compensatory strategies awaits further study Hemiplegic patients are prone to bone loss and alterations in fat and lean mass , which ultimately affect their rehabilitation status and propensity in bone fractures . The present study aim ed to evaluate body composition and bone mineral density ( BMD ) in stroke patients within 1st year post-stroke . Fifty-eight hemiplegic patients ( 36 men and 22 women ) were enrolled in this prospect i ve study . Dual-energy X-ray absorptiometry was used to assess total-body and lower-extremity BMDs ( g/cm(2 ) ) , lean mass ( g ) , and fat mass ( g ) after 3 , 6 and 12 mo of stroke that led to hemiplegia . The Modified Ashworth Scale and the functional ambulation category were used to evaluate spasticity and ambulatory category of patients , respectively . Both sexes exhibited total-body and paretic lower-limb BMD loss , fat mass gain , and lean mass waste during the 1st 12 mo poststroke , and in most cases , statistically significant differences were found between 3 and 6 mo ; however , the pattern of changes was different between males and females . Therefore , it is suggested that disability because of hemiplegia led to alterations in muscle function , which triggered skeletal and body composition changes and rendered these patients particularly prone to increased fracture risk Background and Purpose — Longitudinal conducted studies show that neurologic and functional recovery show faster recovery in the first weeks poststroke . The aim of the present study was to study the effects of progress of time on observed improvements in motor strength , synergisms , and activities during the first 16 weeks poststroke . Methods — Based on data from a previous study , 101 patients with first-ever ischemic middle cerebral artery strokes were prospect ively investigated during the first 16 weeks after stroke . Progress of time was categorized into 8 biweekly time intervals and was used as the independent covariate in a first-order longitudinal regression model . The biweekly time change ( progress of time ) was related to improvement in upper and lower limb motor recovery assessed with Fugl-Meyer score and Motricity Index , reduction in visuospatial inattention based on the letter cancellation task , and improvement in walking ability , dexterity , and activities of daily living measured with the Functional Ambulation Categories , Action Research Arm test , and Barthel Index . Results — Time explained a significant change of 8.4 ( 42 % ) measurement units on the Barthel Index for the first 10 weeks poststroke , 1.1 ( 22 % ) measurement units on Functional Ambulation Categories , and 19 % on the Action Research Arm test for the first 6 and 8 weeks poststroke . Approximately 25 % ( for Fugl-Meyer – arm ) to 26 % ( for Motricity Index – arm ) of the significant change in measurements units was explained by time alone for the upper limb compared with 33 % for Fugl-Meyer – leg and 39 % for Motricity Index – leg of the lower limb . Time accounted for a reduction of 16 % in the letter cancellation task . Observed associations did not change after controlling for covariates such as age , gender , hemisphere of stroke , type of stroke , or intervention . Conclusion — Progress of time is an independent covariate that reflects spontaneous recovery of body functions and activities explaining ≈16 % to 42 % of the observed improvements in the first 6 to 10 weeks after stroke onset Abstract : Fractures are a common and serious complication after stroke and the risk of hip fractures among stroke patients is 2 to 4 times greater than among other elderly people . The aim of this study was to investigate prospect ively the change in bone mineral density ( BMD ) after severe stroke and to study the association between motor impairment , disability and the development of hemiosteoporosis . The study comprised 24 stroke patients , with no persistent paresis from previous strokes or previous osteoporotic fractures , included 1 month after stroke onset .  BMD , motor function , ambulation and activities of daily living ( ADL )  were assessed at 1 , 4 , 7 and 12 months after stroke onset . At inclusion , the patients ’ BMD was normal for their age . During the study , there was a significant loss of BMD in the total body ( −2.0 % ; p<0.05 ) , but not in the head or spine . BMD differed significantly between the paretic and the non-paretic arm at inclusion ( −4.8 % ; p<0.001 ) . Decrease in BMD was most pronounced in the affected humerus ( −17.4 % ; p<0.001 ) and proximal femur ( −12.2 % ; p<0.01 ) . BMD decreased significantly in both lower extremities during follow-up , but the losses were more pronounced on the paretic side ( p<0.01 ) . In the nonaffected ultradistal radius there was a significant increase in BMD from inclusion to the end of the study ( + 5.8 % ; p<0.01 ) . There was no pattern in the bone losses correlating with presumptive risk factors for hemiosteoporosis such as motor function , ability to perform ADL or ambulation . Two patients had fractures at follow-up , both on the paretic side . Loss of bone mineral density in the paretic extremities is thus pronounced and progressive during the first year after stroke , indicating that loss of BMD is probably an important risk factor for post-stroke fractures . Surprisingly , BMD in the nonaffected arm increased significantly during the first year after stroke , most likely due to increased physical activity , and perhaps a redistribution of bone minerals from the paretic extremities To evaluate the loss of trabecular and cortical bone mineral density ( BMD ) and geometric parameters of bone strength expressed by stress-strain index ( SSI ) in the proximal and distal forearm and the alterations of BMD in the hip of hemiplegic patient and 12 mo after stroke . Sixty-seven hemiplegic patients ( 43 men and 24 women ) with a history of single completed strokes associated with unilateral weakness were enrolled in this prospect i ve study . All patients underwent bone densitometry measurements at 3 , 6 , and 12 mo after the initial episode of stroke . Both paretic and normal forearms were examined by peripheral quantitative computed tomography ( pQCT ) at the 4 % and 20 % sites of the forearm length and both hips were examined by dual-energy X-ray absorptiometry ( DXA ) including the area of femoral neck and greater trochanter . The diagnosis of stroke was confirmed by cranial computed tomography . Motor function was assessed by the functional ambulation category ( FAC ) and spasticity by the modified Ashworth scale ( MAS ) . We found statistically significant trabecular and cortical bone density reductions during the course of our study in the forearm , which was more profound on the paretic side . Trabecular bone loss and SSI measured at 4 % of the paretic forearm in the male group represented a 12-mo decrease of 14.01 % and 28.61 % , respectively , and in the female group 9.29 % and 19.17 % , respectively . Cortical bone and SSI measured at the 20 % site of paretic forearm in the male group corresponded to a 12-mo decrease of 4.02 % and 7.43 % , respectively , and in the female group 2.59 % and 6.97 % , respectively . Paretic femoral neck and trochanter measurements in males showed a reduction of 11.76 % and 10.38 % , respectively , and in females 13.04 % and 12.6 % , respectively . A significant loss of BMD and bone strength was found during the first year after stroke in both trabecular and cortical bone at the forearm and at the neck and great trochanter on the paretic hip . Most prominent BMD reduction was evident in men compared with perimenopausal women in the same age Background After a stroke , patients show significant modifications of neural control of movement , such as abnormal muscle co-activation , and reduced selectivity and modulation of muscle activity . Nonetheless , results reported in literature do not allow to unequivocally explain whether and , in case , how a cerebrovascular accident affects muscle synergies underlying the control of the upper limb . These discrepancies suggest that a complete underst and ing of the modular re-organization of muscle activity due to a stroke is still lacking . This pilot study aim ed at investigating the effects of the conjunction between the natural ongoing of the pathology and the intense robot-mediated treatment on muscle synergies of the paretic upper limb of subacute post-stroke patients . Methods Six subacute patients , homogenous with respect to the age and the time elapsed from the trauma , and ten healthy age-matched subjects were enrolled . The protocol consisted in achieving planar movement of the upper limb while h and ling the end-effector of a robotic platform . Patients underwent 6 weeks long treatment while clinical scores , kinematics of the end-effector and muscle activity were recorded . Then we verified whether muscle coordination underlying the motor task was significantly affected by the cerebrovascular accident and how muscle synergies were modified along the treatment . Results Results show that although muscle synergies in subacute stroke patients were qualitatively comparable to those of healthy subjects , those underlying the movement of the shoulder can reflect the functional deficit induced by the pathology . Moreover , the improvement of motor performance due to the treatment was achieved in conjunction with slight modifications of muscle synergies . In this regard , modifications of muscle synergies appeared to be influenced by the different recovering mechanisms across patients presumably due to the heterogeneity of lesions , sides and location of the accident . Conclusions The results support the hypothesis that muscle synergies reflect the injury of the cerebrovascular accident and could document the effects of the functional recovery due to a suitable and customized treatment . Therefore , they open up new possibilities for the development of more effective neuro-rehabilitation protocol Purpose Bone fragility contributes to increased fracture risk , but little is known about the emergence of post-stroke bone loss . We investigated skeletal changes and relationships with physical activity , stroke severity , motor control and lean mass within 6 months of stroke . Methods This is a prospect i ve observational study . Participants were non-diabetic but unable to walk within 2 weeks of first stroke .  Distal tibial volumetric bone mineral density ( vBMD , primary outcome ) , bone geometry and microstructure ( high-resolution peripheral quantitative computed tomography ) were assessed at baseline and 6 months , as were secondary outcomes total body bone mineral content and lean mass ( dual energy X-ray absorptiometry ) , bone metabolism ( serum osteocalcin , N-terminal propeptide of type 1 procollagen ( P1NP ) , C-terminal telopeptide of type 1 collagen ( CTX ) ) , physical activity ( PAL2 accelerometer ) and motor control ( Chedoke McMaster )  which were also measured at 1 and 3 months . Results Thirty-seven participants ( 69.7 years ( SD 11.6 ) , 37.8 % females , NIHSS 12.6 ( SD 4.7 ) ) were included . The magnitude of difference in vBMD between paretic and non-paretic legs increased within 6 months , with a greater reduction observed in paretic legs ( mean difference = 1.5 % ( 95 % CI 0.5 , 2.6 ) , p = 0.007 ) . At 6 months , better motor control was associated with less bone loss since stroke ( r = 0.46 , p = 0.02 ) . A trend towards less bone loss was observed in people who regained independent walking compared to those who did not ( p = 0.053 ) . Higher baseline daily count of st and ing up was associated with less change in bone turnover over 6 months : osteocalcin ( r = −0.51 , p = 0.01 ) , P1NP ( r = −0.47 , p = 0.01 ) , CTX ( r = −0.53 , p = 0.01 ) . Conclusion Better motor control and walking recovery were associated with reduced bone loss . Interventions targeting these impairments from early post-stroke are warranted . Clinical trial registration URL : http://www.anzctr.org.au . Unique identifier : ACTRN12612000123842 The aim of the present study was to identify how pathological limb synergies between shoulder and elbow movements interact with compensatory trunk movements during a functional movement with the paretic upper limb after stroke .  3D kinematic joint and trunk angles were measured during a reach-to-grasp movement in 46 patients with stroke and 12 healthy individuals . We used principal component analyses ( PCA ) to identify components representing linear relations between the degrees of freedom of the upper limb and trunk across patients with stroke and healthy participants . Using multivariate logistic regression analysis , we investigated whether component scores were related to the presence or absence of basic limb synergies as indicated by the arm section of the Fugl-Meyer motor assessment  ( FMA ) . Four and three principal components were extracted in patients with stroke and healthy individuals , respectively . Visual inspection revealed that the contribution of joint and trunk angles to each component differed substantially between groups . The presence of the flexion synergy ( Shoulder Abduction and Elbow Flexion ) was reflected by component 1 , whereas the compensatory role of trunk movements for lack of shoulder and elbow movements was reflected by components 2 and 3 respectively . The presence or absence of basic limb synergies as determined by means of the FMA was significantly related to components 2 ( p = 0.014 ) and 3 ( p = 0.003 ) in patients with stroke . These significant relations indicate that PCA is a useful tool to identify clinical ly meaningful interactions between compensatory trunk movements and pathological synergies in the elbow and shoulder during reach-to-grasp after stroke Background . Little is known about whether changes in coordination patterns of muscle activation after stroke are related to functional recovery of walking . Objective . The present study investigated the longitudinal relationship between changes in neuromuscular activation patterns of paretic muscles in hemiplegic gait and improvement in walking ability after stroke . Methods . Thirteen patients diagnosed with a first unilateral ischemic stroke had their recovery of walking measured by the Rivermead Mobility Index , Functional Ambulation Categories , Barthel Index , Trunk Control Test , Motricity Index , and comfortable walking speed . Surface electromyography ( SEMG )  of the erector spinae , gluteus maximus , gluteus medius , rectus femoris , vastus lateralis , semitendinosus , gastrocnemius , and tibialis anterior muscles of both legs was used to quantify coordination patterns in comfortable walking mode . All clinical and electromyography-related measurements were taken at 3 , 6 , 9 , 12 , and 24 weeks poststroke . Timing parameters of the SEMG patterns were calculated , using an objective burst detection algorithm , and analyzed with the measures of functional recovery . Results . All functional measures , except Trunk Control Test , showed statistically significant improvement over time , whereas SEMG patterns did not change significantly over time . Conclusion . The lack of significant change in SEMG patterns over time suggests that functional gait improvements may be more related to compensatory strategies in muscle activation of the unaffected leg and biomechanical changes than by restitution of muscle coordination patterns in the affected leg Şahin L , Özoran K , Gündüz OH , Uçan H , Yücel M : Bone mineral density in patients with stroke . Am J Phys Med Rehabil 2001;80:592–596 . ObjectiveS troke is an acute neurologic dysfunction of vascular origin , characterized by loss of voluntary movement , sensory disturbances , and neurologic findings in the contralateral half of the body . Acute and long-term complications because of immobilization are seen in all organ systems . The aim of this study was to determine any differences between the affected and unaffected sides ’ bone mineral densities of acute and chronic stroke patients . Design In this study , we determined the bone mineral densities ( BMD ) of 30 male patients with acute ( 0 - 20 days ) and 30 male patients with chronic ( 6 months or longer ) stroke and compared the densities with the normal side . Upper and lower limb BMDs were measured by dual-energy x-ray absorptiometry . Additionally , patients were evaluated for the degree of spasticity , the phases of motor improvement , and the activities of daily living . Results In acute-phase stroke patients , BMD of the affected side was not significantly different from BMD of the normal side . BMD of both upper limbs of acute stroke patients was not different from normal side upper limb BMD of chronic stroke patients . In both acute and chronic stroke patients , affected and unaffected side lower limb BMDs ( femur total BMD scores ) were not significantly different . However , in chronic stroke patients , affected side BMD of Ward ’s region was significantly higher compared with the normal side . There is no correlation between BMD and Brunnstrom phases , Ashworth scales , and the degree of activities of daily living . Conclusions Higher BMD of the affected side Ward ’s region in chronic cerebrovascular accident patients may be related to spasticity and changes in walking pattern , which increase the mechanical stress loading of the Ward ’s region Background . Patterns of recovery provide useful information concerning the potential of physical recovery over time and therefore the setting of realistic goals for rehabilitation programs . Objective . To compare the time course of trunk recovery with the patterns of recovery of arm , leg , and functional ability . Methods . Consecutive stroke patients were recruited in 2 acute neurology wards . Participants were evaluated at 1 week , 1 month , and 3 and 6 months after stroke . Patients were assessed with the Trunk Impairment Scale , Fugl-Meyer arm and leg test , and Barthel Index . Results . Thirty-two patients were included in the study . There were no dropouts . Repeated measures analysis of the recovery patterns of motor and functional performance revealed the most striking improvement for all measures from 1 week to 1 month ( P value between .0021 and < .0001 ) and a significant improvement from 1 month to 3 months after stroke ( P value ranges from .0008 to < .0001 ) . No significant improvement was found between 3 and 6 months after stroke for any of the measures . Statistical analysis revealed no significant difference between time course of trunk , arm , leg , and functional recovery ( P = .2565 ) . No significant differences in level of motor and functional recovery were found at the different time points . Conclusions . Separate analyses of motor and functional recovery patterns after stroke confirm the importance of the first month for recovery . Contrary to common belief , the time course of recovery of the trunk is similar to the recovery of arm , leg , and functional ability The control and execution of movement could potentially be altered by the presence of stroke-induced weakness if muscles are incapable of generating sufficient power . The purpose of this study was to identify compensatory strategies during a forward ( sagittal ) reaching task for 20 persons with chronic stroke and 10 healthy age-matched controls . We hypothesized that the paretic anterior deltoid would be maximally activated ( i.e. , saturated ) during a reaching task and that task completion would require activation of additional muscles , result ing in compensatory movements out of the sagittal plane . For reaching movements by control subjects , joint motion remained largely in the sagittal plane and h and trajectories were smooth and direct . Movement characteristics of the nonparetic arm of stroke subjects were similar to control subjects except for small increases in the abduction angle and the percentage that anterior deltoid was activated . In contrast , reaching movements of the paretic arm of stroke subjects were characterized by increased activation of all muscles , especially the lateral deltoid , in addition to the anterior deltoid , with result ing shoulder abduction power and segmented and indirect h and motion . For the paretic arm of stroke subjects , muscle and kinetic compensations increased with impairment severity and weaker muscles were used at a higher percentage of their available muscle activity . These results suggest that the inability to generate sufficient force with the typical agonists involved during a forward reaching task may necessitate compensatory muscle recruitment strategies to complete the task Background and Purpose — This study compared the psychometric properties of 3 clinical balance measures , the  Berg Balance Scale ( BBS ) , the Balance subscale of the Fugl-Meyer test ( FM-B ) , and the Postural Assessment Scale for Stroke Patients ( PASS ) , in stroke patients with a broad range of neurological and functional impairment from the acute stage up to 180 days after onset . Methods — One hundred twenty-three stroke patients were followed up prospect ively with the 3 balance measures 14 , 30 , 90 , and 180 days after stroke onset ( DAS ) . Reliability ( interrater reliability and internal consistency ) and validity ( concurrent validity , convergent validity , and predictive validity ) of each measure were examined . A comparison of the responsiveness of each of the 3 measures was made on the basis of the entire group of patients and 3 separate groups classified by degree of neurological severity . Results — The FM-B and BBS showed a significant floor or ceiling effect at some DAS points , whereas the PASS did not show these effects . The BBS , FM-B , and PASS all had good reliability and validity for patients at different recovery stages after stroke . The results of effect size demonstrated fair to good responsiveness of all 3 measures within the first 90 DAS but , as expected , only a low level of responsiveness at 90 to 180 DAS . The PASS was more responsive to changes in severe stroke patients at the earliest period after stroke onset , 14 to 30 DAS . Conclusions — All 3 measures tested showed very acceptable levels of reliability , validity , and responsiveness for both clinicians and research ers . The PASS showed slightly better psychometric characteristics than the other 2 measures Objective : To characterize the nature of sensory impairments after stroke , identify associated factors , and assess the relationships between sensory impairment , disability , and recovery . Methods : Prospect i ve cross-sectional survey of 102 people with hemiparesis following their first stroke .  Tactile and proprioceptive sensation  in the affected arm and leg were measured using the Rivermead Assessment of Somatosensory Perception 2 - 4 weeks post-stroke . Demographics , stroke pathology , weakness , neglect , disability , and recovery were documented . Results : Tactile impairment was more common than proprioceptive ( P < .000 ) , impairment of discrimination was more common than detection ( P < .000 ) , and tactile sensation was more severely impaired in the leg than the arm ( P < .000 ) . No difference in proprioception between the arm and leg ( P = .703 ) or between proximal and distal joints ( P = .589 , P = .705 ) was found . The degree of weakness and the degree of stroke severity were significantly associated with sensory impairment ; demographics , stroke side and type , and neglect were not associated . All the sensory modalities were significantly related to independence , mobility , and recovery ( r = 0.287 [ P < .011 ] to r = 0.533 [ P < .000 ] ) . Conclusion : Sensory impairments of all modalities are common after stroke , although tactile impairment is more frequent than proprioceptive loss , especially in the leg . They are associated with the degree of weakness and the degree of stroke severity but not demographics , stroke pathology , or neglect , and they are related to mobility , independence in activities of daily living , and recovery OBJECTIVE To evaluate the effects of a progressive resistance strength training program on changes in muscle strength , gait , and balance in older individuals 1 yr after stroke , seven individuals were recruited who were greater than 60-yr-old , 1 yr after stroke , living at home , and able to follow verbal comm and s. DESIGN Subjects participated in a 12-wk 2x per wk resistance training program at 70 % of 1 repetition maximum . RESULTS Lower limb strength improved 68 % on the affected side and 48 % on the intact side during training , with the largest increases observed for hip extension ( affected side : 88 % , P < 0.01 ; intact side : 103 % , P < 0.001 ) . Repeated chair st and time decreased 21 % ( P < 0.02 ) . Motor performance assessed by the Motor Assessment Scale improved 9 % ( P < 0.04 ) and static and dynamic balance ( Berg balance scale ) improved 12 % ( P < 0.004 ) . Progressive resistance training in individuals 1 yr after stroke improves affected and intact side lower limb strength and was associated with gains in chair st and time , balance , and motor performance . CONCLUSIONS These results support the concept that strength training is an appropriate intervention to improve the quality of physical function in older community dwelling stroke survivors Objectives : ( I ) To obtain biomechanical parameters and assessment scores applied at a very early stage after stroke that predict best the functional outcome after rehabilitation . ( II ) To evaluate the predictive value of changes ( i.e. increase or decrease ) of these parameters during the first week in relation to the predictive value of their absolute scores . Design : Prospect i ve outcome study . Subjects : Forty-one stroke patients , admitted to the stroke unit within 24 hours . Main outcome measures : Barthel Index , Rivermead Motor Assessment , Motor Club Assessment and Functional movement activities , NIH-Stroke scale ( NIH-SS ) , Grip strength . Results : Parameters assessed within the first hours after stroke correlated only weakly with the outcome . The best model predicting functional outcome and independence in activities of daily living of stroke patients after 6 months was that including NIH-SS , grip strength , age and previous stroke explaining 79 % of the variance . These parameters assessed on day 7 post-stroke are more predictive than the difference between stroke onset and day 7 post-stroke . Conclusion : Parameters for predicting outcome should not be assessed before day 7 post-stroke Objective : Motor recovery after stroke depends on the integrity of ipsilesional motor circuits and interactions between the ipsilesional and contralesional hemispheres . In this sham-controlled r and omized trial , we investigated whether noninvasive modulation of regional excitability of bilateral motor cortices in combination with physical and occupational therapy improves motor outcome after stroke . Methods : Twenty chronic stroke patients were r and omly assigned to receive 5 consecutive sessions of either 1 ) bihemispheric transcranial direct current stimulation ( tDCS ) ( anodal tDCS to upregulate excitability of ipsilesional motor cortex and cathodal tDCS to downregulate excitability of contralesional motor cortex ) with simultaneous physical/occupational therapy or 2 ) sham stimulation with simultaneous physical/occupational therapy .  Changes in motor impairment ( Upper Extremity Fugl-Meyer ) and motor activity ( Wolf Motor Function Test ) assessment s were outcome measures while functional imaging parameters were used to identify neural correlates of motor improvement . Results : The improvement of motor function was significantly greater in the real stimulation group ( 20.7 % in Fugl-Meyer and 19.1 % in Wolf Motor Function Test scores ) when compared to the sham group ( 3.2 % in Fugl-Meyer and 6.0 % in Wolf Motor Function Test scores ) . The effects outlasted the stimulation by at least 1 week . In the real-stimulation group , stronger activation of intact ipsilesional motor regions during paced movements of the affected limb were found postintervention whereas no significant activation changes were seen in the control group . Conclusions : The combination of bihemispheric tDCS and peripheral sensorimotor activities improved motor functions in chronic stroke patients that outlasted the intervention period . This novel approach may potentiate cerebral adaptive processes that facilitate motor recovery after stroke . Classification of evidence : This study provides Class I evidence that for adult patients with ischemic stroke treated at least 5 months after their first and only stroke , bihemispheric tDCS and simultaneous physical/occupational therapy given over 5 consecutive sessions significantly improves motor function as measured by the Upper Extremity Fugl-Meyer assessment ( raw change treated 6.1 ± 3.4 , sham 1.2 ± 1.0 )
In subacute and chronic stroke studies , the skeletal sites in the paretic limbs sustained a more pronounced decline in bone quality than did their counterparts in the non-paretic limbs .
The rate of changes showed a decelerating trend as post-stroke duration increased , but the timing of achieving the steady rate differed across skeletal sites .
The magnitude of bone changes in the paretic upper limb was more pronounced than the paretic lower limb .
There was a strong relationship between muscle strength/mass and bone density/strength index .
Muscle spasticity seemed to have a negative impact on bone integrity in the paretic upper limb , but its influence on bone properties in the paretic lower limb was uncertain .
Substantial bone changes in the paretic limbs occurred particularly in the first few months after stroke onset .
Early intervention , muscle strength training , and long-term management strategies may be important to enhance bone health post-stroke .
To systematic ally review available evidence related to the characteristics of bone changes  post-stroke and the relationship between various aspects of muscle function ( e.g. , strength , spasticity ) and bone properties after stroke onset .