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Recent Advances in PT Management of Vascular Brain Diseases

Recommended Articles for Presentation

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🧠 SECTION 1: ANEURYSM - PT Management

Article 1 - Case Report (Direct PT Focus)

• Authors: Thamke MV, Samal S, Vaidya BP
• Journal: Cureus | Year: 2024 | PMID: 38686235
• Key Points:
  • 65-year-old female post DACA aneurysm clipping developed right-side disability
  • PT intervention: therapeutic exercises, gait training, balance exercises, and functional training
  • Significant improvements in motor function, mobility, and functional independence
  • Highlights the value of early and focused physiotherapy post-aneurysm clipping
• Why present it: This is the most directly relevant paper - it shows a complete PT program after cerebral aneurysm surgery with measurable outcomes.

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Article 2 - RCT (Neurostimulation for Aneurysmal Vasospasm)

• Authors: Rigoard P, Billot M, Moens M et al.
• Journal: Int J Environ Res Public Health | Year: 2023 | PMID: 37239562
• Key Points:
  • Prospective double-blind RCT (n=60)
  • Tested transcutaneous electrical trigeminal nerve stimulation (TNS) - a non-invasive PT modality - to reduce cerebral vasospasm after aneurysmal SAH
  • TNS did not significantly reduce infarction rate vs. sham at 3 months (23% vs. 27%)
  • Raises an important discussion: negative RCT results are publishable and useful - they refocus research
• Why present it: Great for discussing how physical/electrotherapeutic modalities are being tested in the acute aneurysm phase, and the importance of evidence-based PT.

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🫀 SECTION 2: CEREBRAL THROMBOSIS/STROKE - PT Advances

Article 3 - Cochrane Review (Highest Level of Evidence)

• Authors: Laver KE, Lange B, George S, Deutsch JE, Saposnik G et al.
• Journal: Cochrane Database of Systematic Reviews | Year: 2025 | PMID: 40537150
• Key Points:
  • 190 RCTs, 7,188 participants - the largest VR rehabilitation meta-analysis to date
  • VR slightly improves upper limb function vs. alternative therapy (SMD 0.20, low certainty)
  • VR moderately reduces activity limitation (SMD 0.21, moderate certainty)
  • VR slightly improves balance (SMD 0.26, low certainty)
  • Little to no effect on gait speed or quality of life
• Why present it: This is the gold-standard Cochrane review - shows VR as a promising but not yet definitive tool in PT; excellent for showing where the field stands in 2025.

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Article 4 - Systematic Review (Robotic Rehabilitation & Neuroplasticity)

• Authors: Calabrò RS, Calderone A, Simoncini L et al.
• Journal: Neuroscience and Biobehavioral Reviews | Year: 2026 | PMID: 41213447
• Key Points:
  • 25 studies reviewed (2014-2025) using neurophysiology/neuroimaging to confirm neuroplasticity
  • Robot-Assisted Gait Training (RAGT) and exoskeletons improve gait, balance, and cortical activation in stroke
  • BCI (Brain-Computer Interface) + VR + neuromodulation combinations show additive benefit
  • Changes in corticospinal excitability documented
• Why present it: Best evidence linking robotic PT directly to brain neuroplasticity - shows the mechanism behind advanced rehabilitation tech.

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Article 5 - Meta-Analysis (Acupuncture + Robot Therapy)

• Authors: Li G, Wang Q, Li L et al.
• Journal: Frontiers in Neurology | Year: 2026 | PMID: 42037705
• Key Points:
  • Meta-analysis of 20 RCTs, 1,594 patients
  • Combination therapy (acupuncture + robot) significantly superior to robot alone on:
    • Fugl-Meyer Upper Extremity: +9.80 points (95% CI: 8.04-11.56)
    • Fugl-Meyer Lower Extremity: +4.00 points
    • Barthel Index: +8.29 points
  • Patients with poorer baseline function benefited most (FMA-UE < 20)
• Why present it: Shows that combining traditional (acupuncture) and advanced (robotic) PT modalities produces superior outcomes - relevant to integrative PT.

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Article 6 - RCT (Robotic Bilateral vs. Unilateral Rehab)

• Authors: Mauro MC, Fasano A, Germanotta M et al.
• Journal: IEEE Trans Neural Syst Rehabil Eng | Year: 2024 | PMID: 39269794
• Key Points:
  • Pilot RCT using quantitative EEG to measure brain symmetry during robot rehab
  • Bilateral robotic training restored interhemispheric symmetry in delta/theta bands (not maintained at follow-up)
  • Both groups showed clinical improvement; bilateral group showed neural reorganization
• Why present it: Bridges the gap between clinical PT outcomes and neuroimaging evidence - great for a neuro-PT presentation.

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Article 7 - Systematic Review (Early Mobilization - Timing)

• Authors: Miranda JMA, Borges VM, Bazan R et al.
• Journal: Topics in Stroke Rehabilitation | Year: 2023 | PMID: 34927568
• Key Points:
  • 7 studies, 8,663 patients
  • Optimal timing: >24 hours post-stroke (not ultra-early) for safe mobilization
  • Duration: 15-45 minutes/session, 1-3 times/day
  • Priority activities: sitting → standing → walking (progressive mobilization)
  • Reduces complications and improves functional capacity
• Why present it: Establishes the evidence base for when and how to start PT after stroke - foundational and clinically actionable.

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Article 8 - RCT (Early Mobilization Post-Thrombolysis/Thrombectomy)

• Authors: Yen HC, Pan GS, Jeng JS, Chen WS
• Journal: Neurorehabilitation and Neural Repair | Year: 2024 | PMID: 38426480
• Key Points:
  • RCT of 122 patients treated with IVT or mechanical thrombectomy
  • Early mobilization (30 min/day, 5 days/week) was safe after both procedures
  • IVT + early mobilization group showed significantly better FIM-motor scores within 1 month
  • Key finding: PT is safe even after thrombolysis and thrombectomy for cerebral thrombosis
• Why present it: Directly addresses PT management after the main medical treatment for cerebral thrombosis (thrombolysis/thrombectomy) - very clinically relevant.

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Suggested Presentation Structure

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• Slide 1: Article Title + Authors + Journal + Timeline + Database + Keywords
• Slide 2: Introduction
• Slide 3: Methodology (table)
• Slide 4: Inclusion & Exclusion Criteria
• Slide 5: Outcome Measures / Study Procedure
• Slide 6: Results
• Slide 7: Conclusion + Limitations

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SLIDE CONTENT — PT Management of Vascular Diseases of the Brain

Pattern: Title Slide → [For each article: Article Info → Introduction → Methodology → Inclusion/Exclusion → Outcome Measures → Results → Conclusion]

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🔷 TITLE SLIDE

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ARTICLE 1 of 8

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SLIDE 1-A — Article Info

• Received: January 2024
• Accepted: February 2024
• Published: March 2024

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SLIDE 1-B — Introduction

• Distal Anterior Cerebral Artery (DACA) aneurysms are rare, accounting for only 1–4% of all intracranial aneurysms. When ruptured, they cause subarachnoid hemorrhage leading to significant neurological disability.
• Surgical clipping of cerebral aneurysms, while life-saving, commonly results in post-operative motor deficits, impaired balance, reduced functional independence, and muscle weakness on the affected side.
• Physiotherapy plays a vital role in the rehabilitation of such patients by targeting motor recovery, balance, gait, and activities of daily living (ADLs).
• Early, goal-directed PT intervention — including therapeutic exercises, gait training, balance exercises, and functional training — is essential for optimal recovery following neurosurgical procedures involving cerebrovascular pathology.
• This case study specifically analyzes the effectiveness of a structured physiotherapy program in a post-aneurysm-clipping elderly patient who developed right-sided disability.

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SLIDE 1-C — Methodology

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SLIDE 1-D — Inclusion & Exclusion Criteria

• 65-year-old female
• Post-surgical right-side disability following DACA aneurysm clipping
• Diminished functional independence on presentation
• Weak muscles and restricted mobility
• Motor dysfunction: right hemiparesis

• Impaired gait and balance
• Reduced ADL performance
• Medically stable and able to participate in physiotherapy
• Patient consent obtained for rehabilitation program

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SLIDE 1-E — Outcome Measures

• Motor function (upper and lower limb strength and coordination)
• Functional Independence Measure (FIM)
• Ambulation and mobility status

• Baseline assessment at admission
• Regular reassessments during rehabilitation to modify treatment plan as needed

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SLIDE 1-F — Results

• Significant improvement was observed in motor function, mobility, and functional independence throughout the intervention period.

• Single case report — results cannot be generalized to all patients
• No control comparison available
• Long-term follow-up not reported
• Specific numeric outcome scores not detailed in the report

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SLIDE 1-G — Conclusion

• Physiotherapy played a key role in significantly improving the patient's recovery, quality of life, and right-side disability following DACA aneurysm clipping surgery.
• Early and focused physiotherapy — including therapeutic exercises, gait training, balance exercises, and functional training — was effective in managing neurological impairments.
• The case clearly highlights the value of early and individualized PT intervention in achieving better rehabilitation outcomes in patients after cerebral aneurysm surgery.
• Physiotherapy should be initiated early and tailored to the patient's specific neurological deficits and functional limitations post-surgery.

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ARTICLE 2 of 8

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SLIDE 2-A — Article Info

• Published: May 16, 2023

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SLIDE 2-B — Introduction

• Cerebral vasospasm remains the most frequent and devastating complication after aneurysmal subarachnoid hemorrhage (SAH), causing secondary cerebral ischemia and severe long-term neurological sequelae.
• Pathophysiology: Vasodilator peptide (CGRP) release and nitric oxide depletion at precapillary sphincters of cerebral arteries — both innervated by the trigeminal nerve and the trigemino-cervical nucleus complex.
• Hypothesis: Trigeminal nerve modulation via transcutaneous electrical stimulation (TNS) could influence cerebral blood flow through a sympatholytic effect, potentially reducing vasospasm and its consequences.
• This study is significant from a PT perspective as it tests a non-invasive electrotherapeutic modality in the acute phase of aneurysmal SAH — expanding the potential role of physical therapy in vascular brain disease.
• It is one of the first double-blind RCTs to rigorously evaluate a physical/electrotherapeutic intervention in the hyperacute aneurysm phase.

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SLIDE 2-C — Methodology

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SLIDE 2-D — Inclusion & Exclusion Criteria

• Confirmed aneurysmal subarachnoid hemorrhage
• WFNS (World Federation of Neurosurgical Societies) scale grade 1–4
• Admitted to ICU following aneurysm treatment (clipping or coiling)
• Moderate to severe vasospasm on Transcranial Doppler (TCD)
• Informed consent obtained from patient or surrogate

• WFNS grade 5 (most severe neurological state)
• Contraindications to TNS (implanted pacemaker, scalp wounds, metal implants)
• Pre-existing neurological or psychiatric disorders unrelated to SAH
• Pregnancy
• Inability to provide or obtain informed consent

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SLIDE 2-E — Outcome Measures

• 10 consecutive days of transcutaneous trigeminal nerve stimulation
• Applied over the forehead/temple region targeting trigeminal branches
• Compared against identical-appearing sham device

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SLIDE 2-F — Results

• TNS group: 7 out of 30 patients (23%) had vasospasm-related infarctions
• Sham group: 8 out of 30 patients (27%) had vasospasm-related infarctions
• No statistically significant difference (p = 0.99)

• No significant difference in DCI rates between TNS and sham groups
• TNS was safe — no serious adverse events related to the stimulation were reported

• TNS did NOT significantly reduce cerebral infarction secondary to vasospasm in this pilot trial
• As a negative RCT, this is valuable — it demonstrates that promising electrotherapeutic concepts must be rigorously tested before clinical adoption

• Pilot study — underpowered to detect small effects
• Only one stimulation protocol tested
• Optimal parameters (frequency, intensity) not yet established
• Larger multicenter RCTs are required

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SLIDE 2-G — Conclusion

• External trigeminal nerve stimulation (TNS) did not significantly reduce the rate of cerebral infarction due to vasospasm after aneurysmal SAH compared to sham stimulation in this proof-of-concept pilot study.
• It would be premature to recommend trigeminal neurostimulation in routine clinical practice for vasospasm prevention.
• However, TNS was safe and well-tolerated — there were no serious adverse effects.
• The concept of trigeminal modulation influencing cerebral vascular tone is physiologically sound and should be the subject of further refined research with larger samples and optimized protocols.

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ARTICLE 3 of 8

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SLIDE 3-A — Article Info

• Search conducted up to: September 2023
• Published: June 20, 2025

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SLIDE 3-B — Introduction

• Stroke is the leading cause of long-term disability globally, with approximately 80% of survivors experiencing upper limb motor dysfunction affecting functional independence.
• Virtual Reality (VR) uses advanced human-computer interfaces allowing users to interact with computer-generated environments — ranging from non-immersive game-based systems (e.g., Nintendo Wii) to fully immersive rehabilitation-specific applications.
• VR rehabilitation promotes neuroplasticity through intensive, task-specific, goal-oriented, repetitive practice with real-time visual and sensory feedback — addressing core principles of motor learning.
• This is the 5th edition Cochrane review (2025) and the most comprehensive evidence synthesis on VR for stroke rehabilitation to date — covering 190 RCTs and 7,188 participants.
• First randomized trial of VR for stroke was published in 2004; two decades of evidence now synthesized in this review.

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SLIDE 3-C — Methodology

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SLIDE 3-D — Inclusion & Exclusion Criteria

• Randomized controlled trials (RCTs) only
• Adult participants (≥18 years) with diagnosis of stroke (ischemic or hemorrhagic)
• VR intervention compared to alternative therapy or no intervention/usual care
• Any type of VR application — immersive or non-immersive
• Any stage post-stroke (acute, subacute, or chronic)
• Upper limb, lower limb, or cognitive outcomes reported

• Studies comparing two different types of VR without a non-VR control group
• Participants with mixed aetiology (e.g., acquired brain injury) unless stroke-only data extractable
• Non-randomized study designs
• Studies involving pediatric populations
• Animal studies

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SLIDE 3-E — Outcome Measures

• Upper limb function and activity (e.g., Fugl-Meyer UE, Action Research Arm Test — ARAT)

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SLIDE 3-F — Results

• Most studies small and heterogeneous; high risk of bias in many
• No single optimal VR protocol established
• Long-term effects beyond 6 months poorly studied

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SLIDE 3-G — Conclusion

• VR is a promising adjunct to conventional PT for stroke rehabilitation — supported by moderate-certainty evidence for reducing activity limitation and low-certainty evidence for improving upper limb function and balance.
• VR has little-to-no effect on gait speed or quality of life based on current evidence.
• The addition of VR to usual care is likely beneficial beyond usual care alone.
• The evidence base has grown substantially (190 trials, 7,188 participants), but quality remains mostly low-to-moderate by GRADE standards.

• Small, heterogeneous studies dominate the evidence base
• High risk of bias in many included trials
• No standardized VR protocol across studies
• Long-term effects poorly studied

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ARTICLE 4 of 8

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SLIDE 4-A — Article Info

• Published: January 2026

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SLIDE 4-B — Introduction

• Neurological diseases — particularly stroke — are among the most common causes of impaired lower limb function, disrupting motor brain networks and causing deficits in gait, balance, and coordination.
• Conventional physiotherapy (walking practice, balance training) remains essential but has limitations in dosage, intensity, and repetition delivery for severe deficits.
• Advances in robotic technologies — including Robot-Assisted Gait Training (RAGT), powered exoskeletons, Brain-Computer Interface (BCI) integration, and Virtual Reality feedback — offer new possibilities for high-intensity, repetitive, sensory-enriched rehabilitation.
• This systematic review specifically investigated whether robotic PT produces measurable neuroplastic changes (confirmed by neurophysiology/neuroimaging) — not just functional improvements — in stroke and other neurological disorders.
• Understanding the neural mechanisms of robotic PT is essential for designing neuroplasticity-targeted, evidence-based rehabilitation programs.

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SLIDE 4-C — Methodology

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SLIDE 4-D — Inclusion & Exclusion Criteria

• Robotic rehabilitation targeting lower limb function
• Neurological disorder populations (stroke, spinal cord injury, cerebral palsy, traumatic brain injury)
• Must report neurophysiological (EEG, TMS, EMG) or neuroimaging (fMRI) measures of neuroplasticity
• Studies published 2014–2025
• Published in English in peer-reviewed journals

• Upper limb robotic rehabilitation only (no lower limb component)
• Studies without any neuroplasticity or neuroimaging outcomes
• Non-robotic interventions (conventional PT only)
• Conference abstracts or non-peer-reviewed publications
• Non-neurological populations (e.g., orthopedic conditions)
• Animal studies

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SLIDE 4-E — Outcome Measures

• Cortical activation changes (fMRI, functional NIRS)
• Corticospinal excitability (TMS-evoked Motor Evoked Potentials — MEPs)
• Resting-state functional connectivity (EEG, fMRI)
• Corticomotor reorganization patterns

• Gait speed and endurance (10MWT, 6MWT)
• Balance (Berg Balance Scale, BESTest)
• Motor function (Fugl-Meyer Assessment, ASIA Scale)
• Functional independence (FIM, Barthel Index)

• Lokomat, Ekso, ReWalk (RAGT)
• Powered ankle-foot exoskeletons
• BCI-FES combinations
• VR-augmented robotic training

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SLIDE 4-F — Results

• RAGT and exoskeleton-based therapies produced measurable increases in cortical activation and improvements in functional connectivity across multiple studies
• Corticospinal excitability changes (TMS-MEP) documented consistently across stroke populations

• BCI integration + VR feedback + neuromodulation (rTMS/tDCS) when added to robotic training further enhanced neuroplasticity and clinical outcomes
• Combined approaches showed additive effects on both neural reorganization and functional gains

• Consistent improvements in gait, balance, and motor function aligned with neuroplastic changes
• Results supported across stroke, SCI, CP, and TBI populations

• Heterogeneous populations, protocols, and outcome measures
• Small sample sizes in many individual studies; variable quality

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SLIDE 4-G — Conclusion

• Robotic rehabilitation — particularly RAGT and exoskeleton-based therapy — promotes measurable neuroplasticity in neurological disorders, with convergent evidence from neurophysiology and neuroimaging.
• Combining robotics with BCI, VR, or neuromodulation produces additive neuroplastic effects and superior clinical outcomes compared to robotic training alone.
• These findings support the use of tailored, multimodal robotic rehabilitation strategies in neurological recovery — including post-stroke rehabilitation after cerebral thrombosis.

• Heterogeneous populations and protocols across included studies
• Small sample sizes in many individual studies
• Variable quality and risk of bias
• Long-term neuroplastic effects not well-studied

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ARTICLE 5 of 8

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SLIDE 5-A — Article Info

• Search date: Up to November 29, 2025
• Published: 2026

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SLIDE 5-B — Introduction

• Post-stroke hemiplegia — motor paralysis on one side of the body — is one of the most disabling consequences of ischemic stroke, with persistent motor impairment affecting the majority of survivors.
• Rehabilitation robots (RR) provide high-repetition, task-specific, dose-controlled training that promotes neuroplasticity-based motor recovery through sensorimotor coupling.
• Acupuncture is a traditional medicine intervention with proposed neuromodulatory effects — including enhanced cortical excitability, improved sensorimotor integration, and anti-inflammatory effects at neural level.
• The combination of acupuncture with robotic therapy has been studied in multiple RCTs in China, but cumulative evidence has not been rigorously synthesized with modern meta-analytic methods.
• This meta-analysis of 20 RCTs and 1,594 patients provides the first high-quality synthesis of this combined PT approach for post-stroke hemiplegia.

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SLIDE 5-C — Methodology

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SLIDE 5-D — Inclusion & Exclusion Criteria

• Randomized controlled trials (RCTs)
• Adults with hemiplegia in subacute phase of ischemic stroke
• Intervention: combined acupuncture AND rehabilitation robot therapy
• Outcomes: Fugl-Meyer Assessment (FMA) and/or Barthel Index (BI) reported
• Published in any language

• Non-randomized or quasi-randomized study designs
• Hemorrhagic stroke patients
• Chronic stroke phase (>6 months post-onset)
• Acupuncture alone or robot therapy alone (without the combination)
• Insufficient or unreportable data for meta-analysis
• Duplicate publications or overlapping datasets

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SLIDE 5-E — Outcome Measures

• Effective Rate (proportion of patients achieving clinical response — as defined by each study)

• Mean Difference (MD) with 95% Confidence Interval for continuous outcomes
• Risk Ratio (RR) with 95% CI for dichotomous outcomes
• Random-effects model to account for heterogeneity
• Sensitivity analyses to confirm result robustness
• Subgroup analysis by baseline FMA-UE severity (FMA-UE <20 vs. ≥20)

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SLIDE 5-F — Results

• Patients with poorer baseline function (FMA-UE < 20) experienced greater benefit from combination therapy

• All studies from China — generalizability to other populations uncertain
• Heterogeneity in acupuncture protocols and robot types used
• High risk of performance bias (blinding difficult in acupuncture trials)

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SLIDE 5-G — Conclusion

• Acupuncture combined with rehabilitation robot is an effective and safe intervention for improving motor function and ADLs in patients with post-ischemic stroke hemiplegia in the subacute phase.
• The combination produced significantly greater improvements than robot therapy alone or conventional PT on all three key outcomes: Fugl-Meyer UE, Fugl-Meyer LE, and Barthel Index.
• Patients with the most severe baseline impairment (FMA-UE < 20) gained the greatest benefit — suggesting this combination is particularly valuable for severely affected stroke patients.
• The 17% higher effective rate (RR = 1.17) indicates meaningful clinical advantage.

• All included studies from China — may limit generalizability
• Heterogeneity in acupuncture and robot protocols
• Short follow-up periods in most studies
• Performance bias risk due to inability to blind acupuncture

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ARTICLE 6 of 8

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SLIDE 6-A — Article Info

• Published: 2024

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SLIDE 6-B — Introduction

• Upper limb motor impairment after stroke is caused by disruption of interhemispheric balance — the unaffected hemisphere becomes overactive (increased inhibition via transcallosal pathways) while the affected hemisphere shows reduced cortical excitability.
• Robot-assisted rehabilitation provides high-dose, precisely controlled, repetitive movement training shown to be superior in inducing neuroplasticity compared to conventional therapy.
• Bilateral robotic training (training both arms simultaneously with a bilateral exoskeleton) theoretically restores interhemispheric balance through bilateral sensorimotor coupling — reinforcing the connection between both motor cortices.
• This pilot RCT used Quantitative EEG (qEEG) — specifically the Brain Symmetry Index (pdBSI) — to directly measure whether bilateral vs. unilateral robotic training restores interhemispheric symmetry.
• This is one of the few studies linking robotic PT directly to measurable brain reorganization using EEG biomarkers.

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SLIDE 6-C — Methodology

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SLIDE 6-D — Inclusion & Exclusion Criteria

• Confirmed diagnosis of ischemic stroke (CT or MRI)
• Subacute phase of stroke (within 6 months of onset)
• Upper limb motor deficit present (hemiparesis)
• Able to tolerate 30 sessions of robotic rehabilitation
• No severe cognitive impairment or aphasia affecting cooperation

• Hemorrhagic stroke
• Severe spasticity in the upper limb (Modified Ashworth Scale > 2)
• Significant pain or musculoskeletal disorders in upper extremities
• Implanted metal devices or cardiac pacemaker (EEG and robot contraindication)
• Pre-existing neurological or psychiatric disorders unrelated to stroke
• Unable to complete the 30-session protocol

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SLIDE 6-E — Outcome Measures

• Pairwise-derived Brain Symmetry Index (pdBSI) via quantitative EEG
  • Measures electrical asymmetry between hemispheres
  • Assessed in: Delta, Theta, Alpha, Beta frequency bands
  • Conditions: Eyes-open and eyes-closed

• T0 — Baseline (before first session)
• T0.5 — After the very first treatment session
• T1 — After 30 sessions (post-intervention)
• T2 — 1-week follow-up

• Fugl-Meyer Assessment Upper Extremity (FMA-UE)
• Modified Ashworth Scale (MAS) — spasticity
• Functional Independence Measure (FIM)
• Box and Block Test (BBT) — manual dexterity

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SLIDE 6-F — Results

• Both bilateral (BG) and unilateral (UG) groups showed significant clinical improvement in upper limb function (FMA-UE) after 30 sessions
• No statistically significant difference between groups in clinical scales

• Only the Bilateral Group (BG) showed significantly reduced pdBSI in delta and theta frequency bands after 30 sessions → indicating restoration of interhemispheric symmetry
• Unilateral Group (UG): No significant change in pdBSI
• In sensorimotor channels specifically: No significant between-group difference in pdBSI change

• EEG symmetry changes were NOT maintained at 1-week follow-up

• Interhemispheric symmetry (pdBSI) restoration correlates with upper limb clinical improvement
• pdBSI proposed as a promising EEG biomarker for monitoring neuroplasticity during stroke rehabilitation

• Small pilot study (n=19) — limited statistical power
• Short follow-up duration

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SLIDE 6-G — Conclusion

• Both bilateral and unilateral robotic rehabilitation produce equivalent clinical improvements in upper limb function in subacute stroke patients.
• However, bilateral training uniquely restores interhemispheric EEG symmetry (in delta/theta bands), suggesting a distinct and superior neuroplastic mechanism compared to unilateral training.
• The pairwise-derived Brain Symmetry Index (pdBSI) shows strong promise as a neurophysiological biomarker to monitor brain reorganization during stroke PT and to guide individualized treatment decisions.

• Small pilot study (n=19) — needs replication in larger RCT
• EEG symmetry changes not maintained at 1-week follow-up (durability unclear)
• Short-term follow-up only (no long-term data)
• No sham control group
• Predominantly male sample — limited generalizability

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ARTICLE 7 of 8

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SLIDE 7-A — Article Info

• Received: 2021
• Published: March 2023

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SLIDE 7-B — Introduction

• Early mobilization (EM) is defined as out-of-bed activities initiated in the acute phase of stroke, including headboard elevation, sitting, standing, and walking — typically within the first 24–72 hours.
• Prolonged immobility after stroke leads to major complications — deep vein thrombosis (DVT), aspiration pneumonia, pressure sores, muscle deconditioning, and prolonged disability.
• International stroke rehabilitation guidelines recommend early PT mobilization, but the optimal timing, intensity, and type of activities in the acute phase remain areas of active debate (especially following the AVERT trial results).
• Physiotherapists are the primary professionals responsible for initiating and progressing early mobilization in stroke units — making this a core PT skill.
• This systematic review evaluated the effectiveness and safety of early mobilization in the acute stroke phase, synthesizing evidence from 7 clinical trials involving 8,663 patients.

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SLIDE 7-C — Methodology

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SLIDE 7-D — Inclusion & Exclusion Criteria

• Randomized or quasi-randomized clinical trials
• Stroke patients in the acute phase of illness
• Early mobilization as the primary PT intervention
• Functional outcomes reported (e.g., modified Rankin Scale, Barthel Index)
• Published up to June 2020 in NLM, LILACS, MEDLINE, PEDro, or Science Direct

• Non-clinical trial designs (observational studies, case series, case reports)
• Chronic or subacute stroke patients only
• Mobilization studies conducted outside the acute phase
• Studies without extractable functional outcome data
• Duplicate publications

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SLIDE 7-E — Outcome Measures

• Modified Rankin Scale (mRS) at 3 months post-stroke (measures disability and degree of functional independence)

• Functional capacity at discharge and follow-up
• Complications: DVT, aspiration pneumonia, falls, adverse events
• Length of hospital stay
• Mortality rate

• Headboard elevation (passive)
• Sitting out of bed (active)
• Standing (with/without assistance)
• Walking (supervised and independent)

• Adverse events (falls, cardiac events, oxygen desaturation, neurological deterioration) monitored and reported for each included study

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SLIDE 7-F — Results

• Optimal start: >24 hours post-stroke (NOT ultra-early at <24 hours)
• Based on hemodynamic stability and safety criteria
• The AVERT trial confirmed that very early mobilization (<24h) may be detrimental

• Two studies showed early mobilization (>24h, once stable) significantly improves functional capacity after stroke (mRS improvement at 3 months)

• Duration: 15–45 minutes per session
• Frequency: 1–3 sessions per day
• Activity Progression: Sitting → Standing → Walking

• Early mobilization was generally safe when initiated after hemodynamic stabilization
• Acceptable adverse event rates when timing criteria were followed

• Only 7 studies met criteria — limited evidence base
• Heterogeneity in mobilization definitions and protocols

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SLIDE 7-G — Conclusion

• Early mobilization in the acute stroke phase is effective and safe when initiated >24 hours after stroke onset in hemodynamically stable patients.

• Start: >24 hours post-stroke (after hemodynamic stabilization)
• Duration: 15–45 minutes per session
• Frequency: 1–3 sessions per day
• Progression: Sitting → Standing → Walking
• Ultra-early mobilization (<24 hours) should be avoided — evidence from the AVERT trial suggests it may worsen functional outcomes.

• Only 7 studies met inclusion criteria
• Heterogeneity in mobilization protocols and timing definitions
• Variable risk of bias across included trials
• Evidence base could not support a definitive meta-analysis

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ARTICLE 8 of 8

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SLIDE 8-A — Article Info

• Published: March 2024

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SLIDE 8-B — Introduction

• Intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are the two primary medical treatments for acute ischemic stroke caused by cerebral thrombosis — they recanalize occluded vessels and reduce disability when given early.
• Following IVT or MT, there is clinical concern that early out-of-bed PT mobilization may increase the risk of hemorrhagic complications, vessel re-occlusion, or hemodynamic instability.
• As a result, physiotherapists are often delayed or hesitant to initiate early mobilization in post-thrombolysis/thrombectomy patients, despite general stroke rehabilitation guidelines supporting early PT.
• Dedicated RCT evidence specifically in patients who received IVT or MT is scarce — most early mobilization trials excluded or did not separate these subgroups.
• This RCT directly addresses whether early PT mobilization is safe and effective in the two most common interventions for acute cerebral thrombosis — filling a critical evidence gap.

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SLIDE 8-C — Methodology

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SLIDE 8-D — Inclusion & Exclusion Criteria

• First-ever acute ischemic stroke (confirmed by MRI/CT)
• Treated with IV thrombolysis (IVT) OR mechanical thrombectomy (MT)
• Admitted to stroke unit
• Hemodynamically stable within 24–72 hours of treatment
• Able to participate in rehabilitation protocol

• Previous stroke with residual disability
• Severe hemorrhagic transformation following thrombolysis (symptomatic ICH)
• Medical instability (uncontrolled BP, O₂ saturation <92%, severe cardiac arrhythmia)
• Severe cognitive impairment preventing participation
• Pre-existing major mobility limitations (prior to this stroke)
• Refusal to provide informed consent

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SLIDE 8-E — Outcome Measures

• FIM-motor (Functional Independence Measure — Motor Domain) Measures: mobility, transfers, locomotion, and self-care independence (scored 13–91)

• PASS (Postural Assessment Scale for Stroke Patients) — balance and postural control
• FAC (Functional Ambulation Category) — walking independence level (0–5 scale)
• Total length of stay in stroke unit (days)

• Baseline (pre-intervention, within 24–72h)
• 2-week post-stroke
• 4-week post-stroke
• 3-month post-stroke

• Symptomatic hemorrhagic transformation
• Falls during PT sessions
• Re-occlusion events
• Neurological deterioration

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SLIDE 8-F — Results

• Early Mobilization (EM) group showed significantly better FIM-motor scores than control within 1 month post-stroke (p < 0.05)
• EM group also demonstrated better PASS scores at 2-week and 4-week assessments
• Conclusion: Early PT is SAFE and MORE EFFECTIVE than standard care after IV thrombolysis

• Both EM and control groups showed improved FIM-motor and PASS scores over time
• However, the EM advantage did NOT reach statistical significance in the MT cohort
• Further larger studies are needed for post-MT patients

• No significant increase in hemorrhagic complications, falls, or adverse events in the early mobilization groups
• Early PT mobilization was confirmed safe after both IVT and MT

• Single-center study; limited external validity
• MT cohort possibly underpowered
• Longest follow-up was 3 months only

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SLIDE 8-G — Conclusion

• Early physical therapy mobilization (within 24–72 hours) is safe after both IV thrombolysis and mechanical thrombectomy for acute ischemic stroke.

• After IV thrombolysis: Early mobilization produced significantly better functional independence (FIM-motor) within 1 month — strongly supports early PT initiation post-IVT
• After Mechanical Thrombectomy: Both groups improved but EM advantage was not statistically significant in this cohort — larger studies needed

• Single center (National Taiwan University Hospital)
• MT cohort relatively small (n=62) — possibly underpowered
• Follow-up limited to 3 months
• EM protocol matched standard care in duration; only timing and progression differed

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SUMMARY TABLE (Optional Last Slide)

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NEW ARTICLES — PT Management of Aneurysms & Cerebral Thrombosis

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NEW ARTICLE 1

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SLIDE A — Article Info

• Enrollment: December 2017 – January 2019
• Published: August 2021

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SLIDE B — Introduction

• Aneurysmal subarachnoid hemorrhage (aSAH) survivors often live with long-term residual physical and cognitive disability, even after successful aneurysm treatment (clipping or coiling).
• Critical illness following aSAH results in rapid skeletal muscle wasting (particularly quadriceps), especially in patients confined to the ICU — leading to persistent weakness, poor physical performance, and worse functional outcomes at discharge.
• Neuromuscular Electrical Stimulation (NMES) is a PT modality that delivers electrical impulses to motor nerves, producing involuntary muscle contractions — proven to attenuate muscle atrophy in ICU patients with various conditions.
• Combined with high-protein nutritional supplementation (HPRO), NMES may preserve muscle mass and neuromotor function during the critical first two weeks after aSAH.
• This Phase 2 RCT is one of the first studies to test a PT intervention (NMES) in the hyperacute ICU phase of aneurysmal SAH — addressing an important and under-researched gap.

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SLIDE C — Methodology

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SLIDE D — Inclusion & Exclusion Criteria

• Confirmed aneurysmal subarachnoid hemorrhage
• Hunt-Hess (HH) grade > 1 (moderate to severe clinical grading)
• Modified Fisher score > 1 (significant hemorrhage on CT)
• BMI < 40 kg/m² (to allow reliable CT muscle measurement)
• Admitted to ICU following aneurysm treatment

• Hunt-Hess grade 1 (mild SAH — low risk of disability)
• BMI ≥ 40 kg/m² (limits CT cross-sectional area measurement accuracy)
• Contraindications to NMES (implanted cardiac pacemaker, skin wounds over electrode sites)
• Pre-existing severe neuromuscular disease
• Inability to obtain informed consent (patient or surrogate)

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SLIDE E — Outcome Measures

• % change in quadriceps muscle cross-sectional area measured by CT scan from baseline to post-bleed day 14 (measures acute muscle wasting in the ICU)

• NMES: Bilateral quadriceps, 2 sessions/day × 30 minutes, PBD 0–14
• Protein target: 1.8 g/kg/day (vs. standard intake in control group)

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SLIDE F — Results

• NMES + HPRO group: 6.5 ± 4.1% quadriceps atrophy
• Standard of care group: 12.5 ± 6.4% quadriceps atrophy
• p = 0.01 — NMES + HPRO significantly reduced acute muscle wasting

• HPRO group received significantly more protein: 1.5 ± 0.5 g/kg/day vs. 0.9 ± 0.4 g/kg/day (p < 0.01)
• Higher atrophy correlated with lower daily protein intake (ρ = -0.45, p = 0.03)

• SPPB score: NMES + HPRO = 12 [10, 12] vs. SOC = 9 [4, 12] — (p = 0.01) — better physical performance
• mRS score: NMES + HPRO = 1 [0, 2] vs. SOC = 2 [1, 3] — (p = 0.04) — better global functional outcome

• Small sample (n=25) — Phase 2 pilot; insufficient power for definitive conclusions
• Single center; short follow-up (90 days only)

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SLIDE G — Conclusion

• NMES combined with high-protein supplementation appears feasible and safe in the acute ICU phase after aneurysmal subarachnoid hemorrhage.
• The intervention significantly reduced quadriceps muscle wasting at 2 weeks and led to better physical performance (SPPB) and lower disability (mRS) at 3 months compared to standard care.
• This study demonstrates that early PT intervention (NMES) can begin in the ICU immediately after aSAH — before conventional rehabilitation is possible — and may translate into meaningful long-term functional gains.

• Phase 2 pilot — small sample (n=25), underpowered for definitive efficacy
• Single-center study limits generalizability
• 90-day follow-up only — long-term impact unknown
• Difficulty blinding for NMES intervention

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NEW ARTICLE 2

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SLIDE A — Article Info

• Study Period: April 2014 – March 2019
• Published: October 2024

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SLIDE B — Introduction

• Aneurysmal subarachnoid hemorrhage (aSAH) causes significant neurological disability, with many survivors failing to return to independent function even after aneurysm treatment.
• Early mobilization — initiating out-of-bed physical activity early in the hospital course — is a well-established PT strategy in general stroke rehabilitation to reduce complications and improve functional recovery.
• However, in aSAH patients, early mobilization is often delayed due to concerns about cerebral vasospasm, elevated intracranial pressure, and hemodynamic instability in the post-bleed period.
• Evidence specifically examining the optimal timing of walking training in aSAH patients is limited, and most guidelines extrapolate from general ischemic stroke populations.
• This large multicenter study (718 patients, 450 eligible) with propensity score matching provides the most direct evidence on the relationship between early walking training and functional outcomes specifically in aSAH.

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SLIDE C — Methodology

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SLIDE D — Inclusion & Exclusion Criteria

• Confirmed diagnosis of aneurysmal subarachnoid hemorrhage
• Received physical therapy (PT) with or without occupational therapy (OT) during admission
• Admitted to participating centers between April 2014 and March 2019
• Walking training initiated at some point during hospitalization (either within or after 14 days)
• Adequate documentation for propensity score matching variables

• aSAH patients who did NOT receive any PT/OT during admission
• Missing data for propensity score matching variables
• Death before discharge (outcome not assessable)
• Re-admission cases where baseline status was unclear
• Age <18 years

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SLIDE E — Outcome Measures

• Modified Rankin Scale (mRS) at discharge
  • Favorable outcome: mRS 0–2 (no significant disability to slight disability — independent)
  • Unfavorable outcome: mRS 3–5 (moderate to severe disability — dependent)

• Early Mobilization: Walking training started ≤ 14 days after aSAH onset
• Delayed Mobilization: Walking training started > 14 days after aSAH onset

• Propensity Score Matching to control for confounders (age, severity, aneurysm characteristics, complications)
• Risk difference (RD) with 95% Confidence Interval
• Comparison of favorable outcome rates between matched groups

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SLIDE F — Results

• Early mobilization group (n=229): 50.9% of total patients
• Delayed mobilization group (n=221): 49.1% of total patients

• Retrospective design — causal inference limited
• Propensity score matching cannot fully control for unmeasured confounders
• Specific PT protocols not standardized across centers
• Discharge mRS only — no long-term follow-up outcome

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SLIDE G — Conclusion

• Initiating walking training within 14 days of aneurysmal SAH onset is associated with significantly better functional outcomes at discharge compared to delayed mobilization.
• Early mobilization produced a 28.7% absolute increase in the rate of favorable outcomes (mRS 0–2) — a clinically and statistically highly significant finding.
• This is the largest study (450 patients, multicenter, Japan) specifically examining PT mobilization timing in aSAH — providing strong real-world evidence.

• Retrospective study — propensity matching does not equal randomization
• PT protocols varied across participating centers
• No data on long-term follow-up (beyond discharge)
• Inability to account for all confounding variables

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NEW ARTICLE 3

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SLIDE A — Article Info

• Published: December 2023

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SLIDE B — Introduction

• Subdural hematoma (SDH) occurs when blood accumulates under the dura mater, commonly caused by an arterial weak point or brain surface aneurysm rupture — raising intracranial pressure and compressing neural tissue.
• Pneumocephalus (air in cranial compartments) most often accompanies neurotrauma with skull base fractures, and when combined with SDH and SAH, creates a complex, high-risk clinical picture.
• The combination of SDH + SAH + pneumocephalus results in severe neurological deficits including hemiplegia, with variable and often prolonged recovery timelines.
• Physiotherapy rehabilitation — encompassing early mobilization, progressive strengthening, and functional training — is a critical component of recovery management in such complex neurosurgical presentations.
• The severity, medical/surgical care required, and amount of physiotherapy needed in patients with acute SAH or SDH varies significantly, highlighting the need for individualized, case-specific PT approaches.

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SLIDE C — Methodology

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SLIDE D — Inclusion & Exclusion Criteria

• 65-year-old male
• Diagnosis: Left hemiplegia secondary to SDH + SAH with pneumocephalus
• Etiology: Aneurysm rupture (brain surface arterial weak point)
• Post-acute neurosurgical management — medically stabilized before PT initiation

• Left-sided hemiplegia with significant lower limb weakness
• Impaired functional mobility (unable to walk independently)
• Reduced ability to perform activities of daily living (ADLs)
• Patient motivated and cooperative for rehabilitation

• No uncontrolled intracranial hypertension
• No active hemorrhagic expansion
• Hemodynamically stable at time of PT initiation

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SLIDE E — Outcome Measures

• Lower limb muscle strength (graded by Medical Research Council scale — MRC)
• Functional mobility and ambulation status

• Baseline (on PT admission)
• Regular reassessments throughout rehabilitation
• Final outcome assessment at discharge

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SLIDE F — Results

• The patient underwent a structured progressive physiotherapy rehabilitation program following management of left hemiplegia secondary to aneurysmal SDH + SAH + pneumocephalus.

• Substantial improvement in lower limb muscle strength documented across the course of rehabilitation
• Progressed from complete dependence (unable to stand/walk) to functional mobility with assistive device

• Patient achieved independent sitting balance and supervised standing by intermediate phase
• Gait with assistance achieved by advanced phase
• Significant improvement in ADL performance — increased independence in transfers and basic self-care

• Physiotherapy was identified as a critical treatment component in facilitating early and rapid recovery
• Enhanced muscle strength and functional capacity documented pre- to post-intervention

• Single case report — not generalizable
• No quantified numerical outcome scores reported
• No control comparison available
• Long-term follow-up not provided

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SLIDE G — Conclusion

• Physiotherapy is a critical treatment component to enhance muscle strength, facilitate early recovery, and manage the clinical manifestations of complex presentations involving SDH, SAH, and pneumocephalus secondary to aneurysm rupture.
• Early mobilization combined with progressive rehabilitation — from passive ROM to active gait training — produced substantial improvements in lower limb strength and functional performance in this patient.
• This case reinforces the principle that even in complex multi-pathology presentations (SDH + SAH + pneumocephalus), early PT can be safely initiated once the patient is medically stabilized.

• Single case — results cannot be generalized to all patients
• No standardized outcome scoring reported
• Follow-up period not documented
• Absence of control comparison

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NEW ARTICLE 4

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SLIDE A — Article Info

• Published: November 2022

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SLIDE B — Introduction

• Survival rates for aneurysmal subarachnoid hemorrhage (aSAH) have increased significantly in recent years due to advances in neurosurgical and endovascular management.
• However, many survivors continue to develop cognitive dysfunctions — particularly mental fatigue, memory problems, and emotional difficulties — that severely affect quality of life and community reintegration.
• Commonly used clinical outcome measures (e.g., modified Rankin Scale) often fail to capture these cognitive and subjective impairments, underestimating the true burden of disability after aSAH.
• Understanding the trajectory of recovery over 1 and 3 years is essential for planning appropriate long-term rehabilitation and PT programs — including cognitive rehabilitation, fatigue management, and return-to-work planning.
• This prospective cohort study used broad, patient-centered outcome measures to capture the full spectrum of recovery — highlighting areas where PT and rehabilitation support is needed long after acute hospitalization.

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SLIDE C — Methodology

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SLIDE D — Inclusion & Exclusion Criteria

• Confirmed diagnosis of aneurysmal subarachnoid hemorrhage
• Treated at Sahlgrenska University Hospital (single center)
• Survived to 1-year follow-up assessment
• Consented to long-term outcome assessment at 1 and/or 3 years

• Death before 1-year follow-up
• Inability to participate in outcome assessments (severe cognitive/language impairment preventing questionnaire completion)
• Non-aneurysmal subarachnoid hemorrhage

• Patients who developed Delayed Cerebral Ischemia (DCI) during acute phase were analyzed separately for their long-term outcomes

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SLIDE E — Outcome Measures

• Age at time of aSAH
• Development of Delayed Cerebral Ischemia (DCI) in acute phase
• Hunt-Hess grade at admission
• Aneurysm treatment method (clipping vs. coiling)

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SLIDE F — Results

• GOS-E improved in 15% of patients between 1 and 3 years
• GOS-E worsened in 12% of patients between 1 and 3 years
• Majority remained stable — highlighting that recovery is not a linear process

• 57% of patients reported significant mental fatigue at 1 year (Mental Fatigue Scale)
• Mental fatigue was the most prevalent and persistent long-term complaint

• Patients <60 years at time of aSAH reported significantly more self-assessed problems — including pain and headache — compared to patients >60 years (p < 0.01)

• Patients who developed DCI during the acute phase reported significantly more dissatisfaction at 3 years (p < 0.05)
• At 1 year, no significant difference was seen between DCI and non-DCI patients

• Single center; observational design
• Some dropout between 1-year (n=62) and 3-year (n=54) assessments

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SLIDE G — Conclusion

• Cognitive dysfunction — especially mental fatigue — is common and persistent after aSAH, affecting more than half of patients at 1 year and persisting to 3 years.
• Patient outcome after aSAH is a dynamic process — both improvement and deterioration can occur between 1 and 3 years — emphasizing the need for long-term, continued rehabilitation support.
• Delayed Cerebral Ischemia (DCI) in the acute phase is a significant predictor of worse long-term quality of life — highlighting the link between acute management (including PT-based interventions to prevent DCI) and long-term outcomes.
• Standard outcome tools (e.g., mRS) underestimate the real burden of cognitive and fatigue-related disability in aSAH — broader, patient-centered tools are needed.

• Single-center; prospective but observational (no control group)
• Loss to follow-up between 1 and 3 years
• No formal rehabilitation protocol described — outcomes reflect natural recovery + whatever PT patients received

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NEW ARTICLE 5

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SLIDE A — Article Info

• Published: March 2026

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SLIDE B — Introduction

• Post-stroke severe upper limb paresis (absence of voluntary movement in wrist/fingers) is one of the most refractory deficits in stroke rehabilitation, with conventional PT often producing limited motor recovery.
• Repetitive Transcranial Magnetic Stimulation (rTMS) is a non-invasive brain stimulation technique used alongside PT — it modulates cortical excitability by delivering repetitive magnetic pulses to targeted motor cortex areas.
• After stroke, the contralesional (unaffected) hemisphere exerts excessive inhibition on the lesioned hemisphere through transcallosal pathways. Targeting the contralesional dorsal premotor cortex (dPMC) with inhibitory rTMS may release this inhibition and enhance recovery.
• This pilot RCT compared two rTMS approaches as PT adjuncts:
  • Contralesional dorsal premotor cortex (dPMC) stimulation
  • Ipsilesional primary motor cortex (M1) stimulation (standard approach)
• Both combined with upper extremity PT rehabilitation for 6 weeks — testing which neural target drives better motor recovery in the most severe stroke patients.

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SLIDE C — Methodology

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SLIDE D — Inclusion & Exclusion Criteria

• Chronic stroke (≥ 6 months post-stroke onset — ischemic or hemorrhagic, including from aneurysm)
• Severe hand paresis defined as:
  • Absence of 10° of distal extension in wrist, fingers, OR thumb, OR
  • No motor evoked potentials (MEPs) in paretic muscles on TMS testing
• Age ≥ 18 years
• Medically stable for outpatient rehabilitation

• Implanted metal devices or cardiac pacemaker (TMS contraindication)
• History of seizures or epilepsy
• Cognitive impairment preventing participation in PT protocol
• Active major psychiatric disorder
• Botulinum toxin injection to upper limb within 3 months
• Bilateral stroke or brainstem lesion
• Pregnancy

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SLIDE E — Outcome Measures

• Upper Extremity Fugl-Meyer Assessment (UE-FMA) (measures motor recovery from 0 = complete paralysis to 66 = normal)

• Frequency: 5-Hz (facilitatory rTMS)
• Target: dPMC (Group 1) vs. M1 (Group 2)
• Combined with 6 weeks of structured upper extremity PT immediately after each rTMS session

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SLIDE F — Results

• Both groups achieved similar gains on the overall Fugl-Meyer UE score
• No statistically significant difference between dPMC stimulation and M1 stimulation groups (p > 0.05)

• Wrist subscore changes favored the ipsilesional M1 group (p = 0.011)
• Suggests M1 stimulation may be superior for distal wrist recovery in severe cases

• No significant differences in Wolf Motor Function Test or Stroke Impact Scale-16 between groups

• Both groups achieved sustained motor improvements — confirming that rTMS + PT produces meaningful recovery even in severe, chronic stroke with absent MEPs
• Stimulating contralesional dPMC was not superior to standard M1 stimulation, but both approaches worked

• Very small pilot (n=16); imbalance in baseline MEP status between groups
• Chronic stroke only — may not apply to acute/subacute phase
• Short-term outcome (6 weeks); no long-term follow-up

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SLIDE G — Conclusion

• Stimulation of the contralesional dorsal premotor cortex (dPMC) was not superior to the standard ipsilesional primary motor cortex (M1) target for upper extremity rehabilitation in severe chronic stroke.
• However, both rTMS approaches — combined with PT — yielded sustained motor improvements, even in the most severely affected chronic stroke patients with absent MEPs.
• For distal wrist recovery specifically, M1 stimulation showed an advantage (p = 0.011) — suggesting that target selection may matter more for specific motor domains than global upper limb function.
• rTMS as a PT adjunct holds promise for severe stroke after cerebrovascular events (including post-aneurysm hemorrhagic stroke) where conventional PT alone may be insufficient.

• Very small pilot sample (n=16) — underpowered
• Baseline imbalance in MEP status between groups
• Chronic stroke population only — acute/subacute applicability unclear
• No long-term follow-up data

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QUICK REFERENCE TABLE — All 5 New Articles