Restorative Neurology and Neuroscience 31 (2013) 361–371 361

DOI 10.3233/RNN-120250
IOS Press

A sensorimotor stimulation program for

rehabilitation of chronic stroke patients
Cristina de Diegoa,1 , Silvia Puiga,1 and Xavier Navarrob,∗
a Physiotherapyand Occupational Therapy Neurological Center of Sant Cugat del Valles, Spain
b Institute
of Neurosciences and Department of Cell Biology, Physiology and Immunology, Universitat Autònoma
de Barcelona, and CIBERNED, Bellaterra, Spain

Abstract.
Purpose: The hypothesis of this study is that intensive therapy by means of a sensory and motor stimulation program of the upper
limb in patients with chronic hemiparesis and severe disability due to stroke increases mobility and sensibility, and improves
the use of the affected limb in activities of daily living (ADL).
Methods: The program consists of 16 sessions of sensory stimulation and functional activity training in the rehabilitation center,
and daily sessions of tactile stimulation, mental imaginery and practice of ADL at home, during 8 weeks. An experimental group
(EG) of 12 patients followed this program, compared with a control group (CG) of 9 patients under standard rehabilitation.
The efficacy of the program was evaluated by Fugl Meyer Assessment (FMA), Motor Activity Log (MAL) and Stroke Impact
Scale-16 (SIS-16) scores, and a battery of sensory tests.
Results: The results show that in both groups, the motor FMA and the SIS-16 improved during the 8 weeks, this improvement
being higher in the EG. Significant improvements were observed for the sensory tests in the EG.
Conclusion: The intensive sensorimotor stimulation program for the upper extremity may be an efficacious method for improving
function and use of the affected limb in ADL in chronic stroke patients.

Keywords: Rehabilitation, stroke, sensorimotor stimulation, upper limb, constraint therapy, chronic paralysis

1. Introduction
Stroke is a transient or permanent alteration in the
function of one or several areas of the brain as a con-
sequence of a circulatory disorder. The most frequent
cause of stroke is the interruption of blood flow in one
of the brain arteries. Patients who have suffered a stroke
usually present motor and sensory involvements, cog-
nitive and perceptive deficits, as well as emotional
disorders. About 20–25% of survivors 6 months after
the stroke are not able to walk without physical aid, and
1 Both authors equally contributed as first authors to this work.
∗ Corresponding
author: Dr. Xavier Navarro, Facultat de Medic-
ina, Universitat Autònoma de Barcelona, E-08193 Bellaterra,
Spain. Tel.: +34 935811966; Fax: +34 935812986; E-mail:
xavier.navarro@uab.cat.
55–75% cannot use the affected hand for their activities
of daily living (ADL), thus having an important impact
on their quality of life (Wolf et al., 2006; Doyle et al.,
2010). Deficits in the somatosensory system appear in
11–85% of patients after a stroke, affecting touch sen-
sation, proprioception and kinesthesia in most cases.
The somatosensory deficits contribute to dysfunctions
of movement and predict poor functional recovery of
motor impairments (Doyle et al., 2010).
After stroke there may be some degree of sponta-
neous recovery at short term due to edema absorption
and collateral revascularization. Once established the
deficits, further recovery months or years after the
stroke are interpreted as the consequence of plastic
reorganization mechanisms in the brain (Pascual-
Leone, 2001; Wieloch and Nikolich, 2006; Kleim and

0922-6028/13/$27.50 © 2013 – IOS Press and the authors. All rights reserved
362 C. de Diego et al. / A sensorimotor stimulation program for rehabilitation of chronic stroke patients
Jones, 2008). The existing guidelines of neurologi-
cal rehabilitation do not describe in detail the optimal
methodology to follow for the treatment of the upper
limb functional activity in chronic stages after stroke
(Van Vliet et al., 2005). The common believe is that
no significant amelioration of the affected arm func-
tion is expected in severely affected patients at a
chronic stage. Among the several interventions that
have been proposed to exert a potential beneficial effect
on arm function, constraint induced movement ther-
apy (CIMT) is the only rehabilitation method with
enough evidence of efficacy for stroke patients with
mild-to-moderate motor impairment of the affected
upper limb (Langhorne et al., 2009; 2011). However,
only 20–25% of stroke patients fulfill these criteria,
and most studies have discarded also patients who
presented severe spasticity, sensory impairments or
hemineglect (Langhorne et al., 2009; van der Lee et
al., 1999). Recent studies indicate a relation between
sensory and motor functions for the effective recovery
of motion after a stroke (Doyle et al., 2010; Laible
et al., 2012). Nevertheless, actual interventions that
demonstrate restoration of motor function are focused
on high-intensity, repetitive task-specific practice with
feedback on performance, but little attention has been
given to rehabilitation of somatosensory functions par-
ticularly in chronic hemiparesis (Smania et al., 2003;
Scalha et al., 2011). Therefore, it may be of interest to
develop new protocols of intensive therapy similarly
addressed to train motor tasks and to induce sensory
stimulation of different modalities.
The aim of this study was to investigate if an inten-
sive rehabilitation treatment by means of sensory and
motor stimulation of the upper limb in patients with
chronic hemiparesis and severe disability due to stroke
may be effective for improving function and use of the
affected limb in ADL.
2. Patients and methods
2.1. Participants
The sample of this study includes 21 patients
that suffered a stroke more than 6 months ago. All
patients provided informed consent to participate. The
patients were receiving conventional rehabilitation
therapy according to the Bobath concept, in sessions
of one hour at our rehabilitation center. Patients were
recruited between those attending our center, which
fulfilled the above criteria, and considering their avail-
ability and acceptance of following the study. The sam-
ple was randomized by a code closed in an envelope, in
an experimental group (EG) of 12 patients and a con-
trol group (CG) of 9 patients, according to the therapy
to be conducted. The average age of the EG was 61.9
(SD 9.7) years and that of the CG 60.6 (15.6) years. The
average time since the lesion occurred was 44.7 (24.5)
months in the EG and 60.7 (58.2) months in the CG.
These differences were, however, non significant. Due
to the difficulty to gather chronic stroke patients with
severe motor and sensory affectation in a clinic, in this
pilot study the two groups were not strictly equivalent.
2.2. Intervention protocol
The intervention protocol is divided into the work
that the patient does with the therapist during the reha-
bilitation sessions and the work that the patient does at
home helped by the family. The EG received 16 ses-
sions of the protocol of 1 hour at the center during 8
weeks, 2 sessions per week, and 1 daily session of 30
minutes of functional activity training at home. This
means that in the EG, the therapist devoted 16 hours of
work per patient and the patient invested 28 hours of
his/her time. The CG had the usual treatment according
to the Bobath concept, without prioritizing therapy of
the upper limb, with 2 sessions per week. The protocol
was conducted by two therapists (CD and SP) whilst a
third one not involved in the study blindly evaluated the
patients according to the assessment scales. To evalu-
ate the effects of the protocol, assessments on active
mobility and sensibility as well as the use of the upper
limb in the ADL were conducted at the beginning, at
the middle and at the end of the study. Figure 1 shows
the different parts in which the protocol is divided.
During the rehabilitation sessions at the center the
EG patients had restricted use of the unaffected upper
limb by using a rigid mitten that avoids both move-
ment and sensory inputs to the hand, subjected at the
patient’s back to avoid motion of elbow and shoul-
der joints (Fig. 2). This position makes the unaffected
upper limb out of the sight of the patient. This is a
difference with the traditional CIMT, which can be a
relevant aspect to consider in future research.
2.3. Rehabilitation session
Each rehabilitation session performed with the assis-
tance of one therapist was divided in two phases, the
 C. de Diego et al. / A sensorimotor stimulation program for rehabilitation of chronic stroke patients

Fig. 1. Schematic diagram of the rehabilitation program for the experimental group followed in the study, with indication of the maneuvers and procedures for sensory stimulation and
motor tasks practice.
363
364 C. de Diego et al. / A sensorimotor stimulation program for rehabilitation of chronic stroke patients
Fig. 2. Photographs of the patient position during the intervention protocol, with the unimpaired upper limb subjected by means of a mat and
an elastic band to the back.
first for sensory stimulation training and the second
for functional activities, whereas the home sessions
involved only practice of activities. This part was
adapted to the disabilities of each patient, in order to
demand the highest level of performance possible to
each one based on the motor control principles (Kleim
and Jones, 2008).
Sensory stimulation for 30 minutes: attempting to
improve the sensibility of the hand so the patient is
able to recognize texture, consistency, size and weight
of different objects. During the first 10 minutes, the
patient’s hand is prepared with specific movements to
reduce muscle tone (pressure at metacarpophalangeal
joints, passive mobilization of thenar and hypothenar
muscle groups and of interossei muscles) and with tac-
tile stimulation (see Fig. 1). Then, an active sensory
training of either proprioception or touch is chosen to
work with for 20 minutes. For the proprioceptive sen-
sibility the patient must hold (or the therapist puts on
his/her hand) different objects, which he/she has pre-
viously seen and felt (Fig. 3). The patient must place
them in order, from smaller to bigger size, consistency,
weight or shape. For tactile discrimination, the patient
must see, touch and name different textures with the
eyes open to help mental representation. After that, the
patient is given an eye mask and helped in touching the
different materials to be identified.
Functional activity training for 30 minutes: focused
to improve active mobility of the affected upper limb
and to use it in ADL. The therapist helps the patient
to move the arm following the course of the normal
movement avoiding compensations to carry out the
activity. It is beneficial for the patient to practice with
the weaker muscles while preventing overuse of hyper-
active muscles (Wolf et al., 2012). The patient must see
the object to be taken to help planning and carrying
out of the motion (Ansuini et al., 2006). The activities
chosen were related with the functions of the upper
limb (reaching, grasping, handling, support and trans-
port of objects), promoting motor learning, since they
are usual in daily living (Table 1). We used different
objects of daily life, varying in size, weight and shape,
and asked the patient to carry out the motion in dif-
ferent directions, and from different initial positions.
A single activity was practiced in each session for 15
minutes.
The last 15 minutes are allocated to work specifically
an ADL that the patient wishes to improve. Technical
aids are used to give the patient more autonomy.
2.4. Functional activity at home
With the objective of reinforcing what has been
worked in the rehabilitation sessions at the center, and
transferring the practiced activities to the patient envi-
ronment patients were asked to perform daily sessions
of training of 30 minutes duration during the 8 weeks
of the intervention. A recording form was given to the
patient to note the activities conducted at home and
observations regarding difficulties or improvements.
The work at home is divided in three parts:
– Tactile stimulation (10 min): a patient’s relative
stimulates areas of the affected hand of the patient
 C. de Diego et al. / A sensorimotor stimulation program for rehabilitation of chronic stroke patients
Fig. 3. Materials used for the sensory stimulation part of the protocol. a) Boxes and bottles of different sizes, b) tubes of different weights, c)
tissues of different textures, and d) sponges of different densities.
Table 1
Activities of daily living used during the functional stimulation
protocol
Motion Activity
Reaching Push objects placed on a table
Touch objects placed on a shelf at different height
Grasping Grasp different fruits from a basket
Take balls of different sizes from a box
Handling Open the lid of different recipients
Turn a box in the hand to read the labels at each side
Supporting Support with the hand to stand up from a chair
Support with the upper limb when loosing equilibrium
Carrying Carry a box in the hand
Carry a shopping bag with the forearm
with a toothbrush (Fig. 1). The patient must dis-
criminate with closed eyes the area that is being
stimulated at random. Depending on the percep-
tive ability of the patient, stimuli can be either
smooth or strong.
– Mental imagination (10 min): the patient must
imagine the ADL practiced at the treatment ses-
sion (e.g. close/open doors, comb one’s hair, etc.).
365
– Practice of the ADL carried out during the session
(10 min): the phase of the activity to be practiced
is always indicated. The activity is personalized
according to the daily routine and the motiva-
tion of the patient (e.g. close/open doors, clean
window glass, etc.).
2.5. Assessment tests
A therapist not involved in the administration of the
therapies and blind with regard to the treatment proto-
col followed by each group conducted the evaluations
of all the patients. In the EG, one baseline evaluation
was conducted two weeks before starting the treat-
ment, a second after 8 sessions and a last one after
the 16 sessions. In the CG, evaluations were made at
the beginning and at the end of the same period. Eval-
uation scales supplying information on both the upper
limb active mobility and the ADL have been used. A
battery of tactile and proprioceptive tests was used for
sensory assessment.
366 C. de Diego et al. / A sensorimotor stimulation program for rehabilitation of chronic stroke patients

The upper limb section of the Fugl Meyer Assess-
ment (FMA) scale was used to evaluate the arm motor
function, since it is one of the most common measures
of arm outcome (Langhorne et al., 2009; Scalha et al.,
2011).
Tactile sensibility evaluation was performed by
assessing whether the patient felt the contact of a
Semmes-Weinstein monofilament in one given point
of the upper limb while blindfolded.
Proprioceptive sensibility was evaluated by three
tests of sensory discrimination with the patient blind-
folded:
2.6. Data analysis
The results were analyzed by a researcher not
participating in the provision of the therapy, who
received a data file with numerical codes for the
patients. The results are given as mean and SEM.
The changes between groups were analyzed by mixed-
model ANOVA, and between time points of evaluation
in each group by repeated measures ANOVA with the
post-hoc Bonferroni’s test. Differences are considered
significant if p < 0.05.

– The direction of passive motion (flexion- 3. Results

extension–neutral) in the joints of the upper limb
(elbow, wrist, metacarpophalangeal and thumb).
– The consistency discrimination, by ordering from
less to more consistency 4 sponges using the
affected limb, without comparing with the non-
affected limb.
– The weight discrimination of objects (Scalha et
al., 2011), by ordering from less to more weight 5
tins that are given randomly using the affected
limb, without comparing with the non-affected
limb.
The Stroke Impact Scale (SIS-16) records the level
of the patient’s subjective difficulty, related with auton-
omy and independence, in developing 16 ADL.
The Motor Activity Log that reflects the patient’s
subjective sensibility as to the quantity of use (Amount
Scale-AS) and the motion quality (How Well Scale-
HWS) of the affected upper limb, has been used also
to evaluate the ADL.
The baseline evaluations did not show significant
differences between the two groups, although the
results showed large variability within each group for
the different evaluation scales (Table 2). The variabil-
ity among the patients included in the study is partly
due to heterogeneity of the symptoms caused by stroke,
and determined because no restrictive inclusion crite-
ria (concerning the degree of affectation of the patient)
were applied. For this reason, we focus the analyses in
comparing the evolution that each group had along the
study period.
Both the EG and the CG showed a significant
increase from baseline to final values of the FMA scale
(Fig. 4), without significant differences between both
groups. When analyzing the global results of the MAL
test (AS and HWS), the comparison of the increments
between EG and CG was not significant. However, the
evolution of the EG was significantly improved com-
pared with the CG in the results of MAL (AS + HWS)

Table 2
Results of the control and the experimental groups at the intervals tested of intervention in the tests performed: Fugl Meyer Asssessment (FMA),
Motor Activity Log (Amount of Use: MAL-AS, and How Well: MAL-HW), and Stroke Impact scale 16 (SIS-16). Values are the mean and
(standard error). In brackets the t values for paired comparisons to the previous test times in each group. There were no significant differences
between groups at baseline
Control group Experimental group
Pre 8th week
Pre 4th week 8th week

FMA 33.7 (7.3) 36.7 (7.6)# 3.0 (0.85) 24.3 (4.6) 26.3 (4.7) 29.4 (4.9)# $ F 10.190 5.1 (1.1)
[t 3.530] [t 3.176] [t 4.480/2.639]
MAL-AS 2.30 (0.44) 2.43 (0.27) 0.13 (0.25) 1.09 (0.35) 1.15 (0.37) 1.36 (0.42) F 3.480 0.27 (0.11)
[t 0.519] [t 0.551] [t 2.510/1.959]
MAL-HW 2.13 (0.33) 2.43 (0.36) 0.29 (0.23) 0.88 (0.34) 1.11 (0.33) 1.39 (0.44)# F 9.022 0.51 (0.14)
[t 1.251] [t 1.903] [t 4.240/2.337]
SIS-16 61.5 (9.3) 61.7 (9.2) 0.25 (3.12) 53.4 (2.9) 59.3 (3.0) 63.2 (3.1)#
[t 0.019] [t 3.870] [t 6.432/2.552] F 22.120 9.83 (1.91)
# p < 0.05 vs pre-treatment baseline; $ p < 0.05 vs 4 week.
 C. de Diego et al. / A sensorimotor stimulation program for rehabilitation of chronic stroke patients 367

Fig. 4. Results of the Fugl Meyer Assessment. A) Plots of individual values and B) mean and SEM values at baseline and final evaluation (8th
week) of the study for the Control Group (CG;
= 3.00 ± 0.85) and the Experimental Group (EG;
= 5.08 ± 1.07). #: p < 0.05 vs CG baseline;
*: p < 0.05 vs EG baseline.

Fig. 5. Results of the Motor Activity Log Amount Scale (AS) and How Well Scale (HWS) of the Experimental Group (EG) at the beginning,
4th week and at the end of the study. *: p < 0.05 vs EG baseline.

from the beginning to the 4th week and from the beginning and the 8th week in the EG (Fig. 5). The
4th to the 8th week of the treatment (Table 2). The Stroke Impact Scale showed a significant increase in
HWS in the MAL improved significantly between the the EG, but not in the CG, between the initial and final
368 C. de Diego et al. / A sensorimotor stimulation program for rehabilitation of chronic stroke patients

Fig. 6. Results of the Stroke Impact Scale-16 at the begin-

ning and at the end (8 weeks) of the study for the Control
Group (CG;
= 0.25 ± 3.12) and the Experimental Group (EG;

= 9.83 ± 1.91). *: p < 0.05 vs EG baseline.

evaluations (Fig. 6). Half of the subjects of the EG

showed improvement in the items that implicate the
upper extremity, such as dress the upper part of the
body, go shopping, get in and out of a car, and carry
objects with the affected hand. They also improved
activities that involve maintenance of balance in the
transference to standing and walking.
The EG showed significant improvements in the sen-
sory discrimination tests evaluated (Fig. 7). Patients
of the EG had a positive evolution with increased

Fig. 7. Results of the sensory tests performed in the EG at the begin-

ning, at the 4th and the 8th week of the study. A: Discrimination of
Semmens-Weinstein monofilaments. Three filaments (0.4, 0.5 and
0.7 mm) were randomly applied on the skin of the forearm, the hand
palm and the index fingertip. For each filament and location a score
of 2 was given if the stimulus was felt and well localized, of 1 if felt
but not well localized, and 0 if not felt. A total score was the sum
of all filament and location scores. B: Proprioceptive discrimination
of the direction of movement. The subject had to discriminate, with
eyes closed, the position of flexion, extension or neutral of the elbow,
wrist, metacarpophalangeal, and thumb joints. For each joint a score
of 2 was given if the motion and the position were perceived, of 1
if motion was perceived but the position was not ascertained, and 0
if motion was not felt. The maximal total score was 8 points. Cc:
Ability to discriminate the object consistency. Four sponges (20-25-
28-30 g/cm3 ; see Fig. 3d) had to be ordered. A score of 1 was for the Fig. 7.
correct order. *: p < 0.05 vs baseline.
 C. de Diego et al. / A sensorimotor stimulation program for rehabilitation of chronic stroke patients
scores from the beginning to the end in the tactile dis-
crimination test, and in the proprioceptive direction of
movement test. Half of the EG patients reached the
highest value of the tests at the end of the interven-
tion period. The discrimination of the object weight
was difficult to carry out for the patients, and was dis-
carded for analysis. The patients had also significant
improvement in the test for object consistency from the
beginning to the 4th and the 8th week (Fig. 7).
4. Discussion
The objective of this study was to evaluate the
viability and the effects of a specific sensorimotor stim-
ulation program for the rehabilitation of patients with
chronic stroke when it is generally considered that they
have reached a plateau of functional recovery and that
there and no more possibilities of improvement. The
protocol designed gives similar importance to motor
and sensory functions, since the sensory information
influences planning of movements through successive
projections to the prefrontal, premotor and motor cor-
tices (Rossini et al., 2003; Miller et al., 2010). On
the other hand, the program includes the use of men-
tal imagination in the work done at home in order to
accelerate the acquisition of new motor skills and to
activate the same neural network that is necessary for
planning and conducting movements (Pascual-Leone,
2001; Miller et al., 2010). The combination of sen-
sory stimulation, planning and conducting functional
activity and mental imagination has been shown to con-
tribute in the rehabilitation of motor functions (Smania
et al., 2003; Scalha et al., 2011). During the protocol,
the patients had restricted motion of the unaffected
upper limb to limit the normal inhibitory activity of
the healthy contralateral hemisphere on the affected
one (Kokotilo et al., 2010) and to revert the non-use
phenomenon of the affected side (Smania et al., 2003).
Moreover, the patients wear an eye mask during work
on sensory training, since vision is a dominant input
that can hide information given by other senses (touch,
proprioception, . . . ) within the metamodal integration
(Pascual-Leone, 2001). A part of this protocol is con-
ducted at the patient’s home in order to reinforce motor
learning through the transfer from motor execution to
ADL. Motivation is an important aspect when choos-
ing an activity to work with in rehabilitation, since
emotions affect motor planning through connections
between limbic association cortex and sensory areas
369
and other cortical areas such as prefrontal cortex (Pes-
soa, 2008). Therefore, activities trained in our protocol
followed the guidelines that favor motor learning, such
as the simulation of an ADL.
An important aspect of this study is the main crite-
ria for inclusion of the participants, i.e. patients who
were in a chronic stage after stroke and presented
severe motor and sensory disabilities. Several authors
have claimed on the necessity of research with this
population to determine their possibilities of recov-
ery (Welmer et al., 2008; Doyle et al., 2010). Studies
that refer to the recovery of chronic patients with
severe sensory-motor affectation are scarce (Carter,
2008; Dunning et al., 2008; Hesse et al., 2005; Page
et al., 2010), whereas those referring to patients with
mild involvement of the upper limb (Liepert et al.,
2000; Schaechter et al., 2002; van Delden et al., 2009;
Conforto et al., 2010) or using CIMT with criteria
that exclude patients with severe aphasia and severe
cognitive impairments (van der Lee, 1999; Barzel et
al., 2009) are more frequent in the literature. This
study aimed to show that patients with severe disabil-
ity after stroke may still present plastic changes in the
nervous system, providing some functional improve-
ments, if they are subjected to a specific rehabilitation
program.
Another relevant point is the combination of motor
with also somatosensory retraining. Previous stud-
ies have shown that severe sensory losses produce
dysfunctions similar to those of paresis, and often
predict a poor recovery of motor function, since the
sensory systems play important roles in motor control
(Tyson et al., 2008; Doyle et al., 2010; Scalha et al.,
2011). Indeed, reduction of sensory input as well as of
motor output following neural lesions are reflected in
profound plastic changes along the nervous system cir-
cuitry (Lundborg, 2003; Smania et al., 2003; Rossini
et al., 2003; Langer et al., 2012). Patients with severe
impairments of the upper limb reduce the use of the
hand and, thus, do not receive sensory inputs, so the
treatments must supply such loss if trying to reestablish
the normal brain connectivity.
The obtained results show a slightly higher ten-
dency to improve in the patients of group EG compared
with those of group CG along the 8 weeks of reha-
bilitation. We cannot exclude that the improvement
observed is due at least in part to the increased intensity
of rehabilitation therapy received by the EG patients.
Nonetheless, the maneuvers performed, focused on
the affected upper extremity, undoubtedly increased
370 C. de Diego et al. / A sensorimotor stimulation program for rehabilitation of chronic stroke patients
the inputs and outputs of the cortical areas, and
might induce beneficial activity and neural plasticity
mechanisms. A plausible explanation of the limited
recovery found is that chronic patients already devel-
oped compensatory strategies to supply their impaired
somatosensory function by using visual information
and for movement limitation using the non-affected
limb (Scalha et al., 2011; Welmer et al., 2008), so dura-
tion and intensity of the protocol must be enough to get
the optimal results. The increase in the FMA results in
this study is lower compared with the study of Van
der Lee et al. (1999), who applied a protocol based
on the Bobath concept and the CIMT in patients with
mild disability. It should be taken into account that
in that study, the CIMT group had 60 hours of non-
individualized treatment, whereas in our stimulation
program patients had only 16 hours of individualized
treatment. Therefore, individualized therapy may be
more effective than non-individualized therapy regard-
ing the total number of hours of treatment, because
it allows a better adaptation of the therapy to the
disabilities of the patient (Taub and Uswattw, 2000).
Page et al. (2010) treated chronic patients by practic-
ing repeated tasks with the aid of a neuromuscular
electrical stimulation device, and observed a lower
improvement of the FMA (initial average 23.3; final
average 26.0; average increase 2.85). On the other
hand, Grotta et al. (2004) stated that improvements
on the MAL test parallel the decrease of motor dys-
function detected by the FMA after the application of
CIMT, thus suggesting that the degree of use of the
affected limb may be related to the motor ability. The
same relation can be observed in the results of this
study (increase of MAL test 0.19 ± 0.08; increase of
FMA 5.08 ± 1.07).
Some limitations of this study have to be consid-
ered, including the small sample size and the difficulty
of evaluating sensory functions on a clinical basis in
stroke patients. It is complex in the clinical practice
to recruit a homogeneous group of patients, due to
the interaction of several variables, such as age, sex,
time elapsed from the lesion, symptoms, localization
of the lesion, as well as personal characteristics (emo-
tional state, motor abilities prior to the lesion, family
and social environment, financial status). Nevertheless,
after this pilot study, future ones are planned with a
larger population and more strict inclusion criteria,
thus diminishing both heterogeneity and variability.
Moreover, the combination of intensive rehabilita-
tion with non-invasive stimulation techniques, such
as transcranial magnetic stimulation (Hoyer and Cel-
nik, 2011) or direct current stimulation (Nair et al.,
2011), that can modulate neural plasticity should be
also explored.
In conclusion, the present pilot study may be used as
a reference for future studies that combine the appli-
cation of sensory and motor therapeutical strategies.
There is no full consensus yet regarding the most effec-
tive neurological treatment to be followed depending
on the phase after the stroke in which the patient is
(acute or chronic) or the level of disability (mild or
severe) (Langhorne et al., 2011). The improvements
of sensorimotor functions found in this pilot study
in chronic stroke patients, although mild, contradict
the clinical concept that function amelioration of the
affected arm is only possible within the first year
after the lesion. This point of view is frequent in the
environment of stroke patients, and slows down their
motivation for struggle on treatment at the long-term.
Acknowledgments
Our special thanks to the patients that took part in
the study, for their commitment and collaboration, to
the rehabilitation team of the Physiotherapy Neurolog-
ical Center of Sant Cugat del Valles (Barcelona, Spain)
for their support, and the help in language revision of
Jaume Navarro.
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