Motor Imagery Added to Robot-Assisted Hand Rehabilitation After Stroke

Design and setting This is a two-arm, parallel-group randomized controlled trial conducted at NRL Physical Therapy Medical Center. Institutional permission for the study site has been obtained.

Participants Forty individuals aged 18 years or older with a diagnosis of stroke and impairment of upper extremity and hand function will be enrolled. Written informed consent will be obtained from all participants before any study procedure. Randomization Participants will be allocated 1:1 to the experimental or the control group using a sealed envelope method, resulting in 20 participants per group. Interventions Both groups will receive robot-assisted hand rehabilitation delivered with a soft robotic hand rehabilitation glove (Syrebo). Sessions will be individual, supervised by a physiotherapist, delivered three days per week for six weeks, and will last approximately 40 to 60 minutes each. In addition to robot-assisted hand rehabilitation, participants in the experimental group will perform motor imagery training, in which they will be asked to mentally rehearse hand opening and closing, grasping, object holding, and hand movements used in daily life before physically performing them. Verbal guidance will be provided during motor imagery when needed. The control group will not receive motor imagery training. Attendance will be monitored by the investigator using a session log. Sessions will be terminated in case of pain, excessive fatigue, discomfort, or if the participant does not wish to continue. Outcome assessment Assessments will be performed before the start of the intervention program and repeated after the six-week program is completed. A sociodemographic and clinical information form will record age, sex, education, marital status, occupation, time since stroke, affected side, hand dominance, comorbidities, medications, and previous rehabilitation. Independence in activities of daily living will be assessed with the Barthel Index, hand function related activity limitation with the Duruoz Hand Index, gross manual dexterity with the Box and Block Test, and spasticity of the wrist and finger flexors with the Modified Ashworth Scale. Variables The independent variable is the rehabilitation program (robot-assisted hand rehabilitation alone versus robot-assisted hand rehabilitation plus motor imagery). The dependent variables are the Barthel Index score, the Duruoz Hand Index score, the Box and Block Test score, and the Modified Ashworth Scale grade. Statistical analysis Data will be analysed with SPSS version 23.0. Descriptive statistics will be presented as mean, standard deviation, frequency, and percentage. A p value below 0.05 will be considered statistically significant. Sample size and effect size calculations were performed with G*Power. Ethics and data protection Personal information will be kept confidential, data will be recorded in coded form, and will be used for scientific purposes only. Participants may withdraw at any time. No blood sampling, drug administration, or surgical procedure will be performed.

Inclusion criteria

• Aged 18 years or older
• Diagnosis of stroke
• Impairment of upper extremity function, particularly hand function
• Modified Ashworth Scale grade of 2 or below in the wrist and finger flexors
• Hand and finger range of motion sufficient for safe application of the robotic hand rehabilitation glove
• Attention and cooperation sufficient to participate in motor imagery training

Exclusion criteria

• Severe cognitive, visual, or hearing impairment
• Additional neurological or orthopaedic disease affecting the upper extremity
• Modified Ashworth Scale grade above 2 in the wrist and finger flexors
• Marked contracture, advanced joint restriction, or pain preventing the intervention
• Skin problems, open wounds, or infection preventing the use of the robotic hand rehabilitation glove
• Inability to attend the intervention program regularly