We investigated actual daily life upper limb (UL) activity in relation to observed UL motor function and perceived UL activity in chronic stroke in order to better understand and improve UL activity in daily life. In 60 patients, we collected (1) observed UL motor function (Fugl-Meyer Assessment (FMA-UE)), (2) perceived UL activity (hand subscale of the Stroke Impact Scale (SIS-Hand)), and (3) daily life UL activity (bilateral wrist-worn accelerometers for 72 h) data. Data were compared between two groups of interest, namely (1) good observed (FMA-UE >50) function and good perceived (SIS-Hand >75) activity (good match, n = 16) and (2) good observed function but low perceived (SIS-Hand ≤75) activity (mismatch, n = 15) with Mann–Whitney U analysis. The mismatch group only differed from the good match group in perceived UL activity (median (Q1–Q3) = 50 (30–70) versus 93 (85–100); p < 0.001). Despite similar observed UL motor function and other clinical characteristics, the affected UL in the mismatch group was less active in daily life compared to the good match group (p = 0.013), and the contribution of the affected UL compared to the unaffected UL for each second of activity (magnitude ratio) was lower (p = 0.022). We conclude that people with chronic stroke with low perceived UL activity indeed tend to use their affected UL less in daily life despite good observed UL motor function.

A large proportion of chronic stroke survivors still struggle with upper limb (UL) problems in daily activities, typically reaching tasks. During three-dimensional reaching movements, the deXtreme robot offers error enhancement forces. Error enhancement aims to improve the quality of movement. We investigated clinical and patient-reported outcomes and assessed the quality of movement before and after a 5 h error enhancement training with the deXtreme robot. This pilot study had a pre-post intervention design, recruiting 22 patients (mean age: 57 years, mean days post-stroke: 1571, male/female: 12/10) in the chronic phase post-stroke with UL motor impairments. Patients received 1 h robot treatment for five days and were assessed at baseline and after training, collecting (1) clinical, (2) patient-reported, and (3) kinematic (KINARM, BKIN Technologies Ltd., Kingston, ON, Canada) outcome measures. Our analysis revealed significant improvements (median improvement (Q1–Q3)) in (1) UL Fugl–Meyer assessment (1.0 (0.8–3.0), p < 0.001) and action research arm test (2.0 (0.8–2.0), p < 0.001); (2) motor activity log, amount of use (0.1 (0.0–0.3), p < 0.001) and quality of use (0.1 (0.1–0.5), p < 0.001) subscale; (3) KINARM-evaluated position sense (−0.45 (−0.81–0.09), p = 0.030) after training. These findings provide insight into clinical self-reported and kinematic improvements in UL functioning after five hours of error enhancement UL training.

Background: Chronic stroke and spinal cord injury (SCI) lead to persistent motor impairments that reduce independence and quality of life. Although rehabilitation is essential to address these challenges, the amount of therapy provided during the chronic phase remains limited, while the long-term costs of care are substantial. Objective: The INTeRAcT (Intensive Rehabilitation Programme Integrating Advanced Technology) trial investigates a high-dose, intensive-targeted, and personalized rehabilitation program through an integrated clinical, health economic, and process evaluation. Methods: This single-blind randomized controlled trial will include 100 adults in the chronic phase after stroke or SCI. Participants will be randomized to either the INTeRAcT intervention group (n=50) or a control group receiving usual care (n=50). The intervention group will receive 90 hours of personalized motor rehabilitation over 3 weeks, including upper and lower limb therapy, with and without technology, cardiovascular fitness training, and self-management education. Both groups then resume usual care and are followed for 9 months. Clinical assessments are performed at baseline (T0), after 3 weeks (T1, postintervention), and after 9-months follow-up (T2) by a blinded assessor. The primary outcome is independence in daily life, assessed using the Functional Independence Measure for stroke and the Spinal Cord Independence Measure for SCI. Secondary outcomes include the EQ-5D-5L, Canadian Occupational Performance Measure, Goal Attainment Scaling, Fatigue Severity Scale, and stroke-specific measures such as the Action Research Arm Test, Fugl-Meyer Assessment, 6-Minute and 10-Meter Walk-Test, and the Stroke Self-Efficacy Questionnaire. Group differences in clinical change will be analyzed using multivariate linear models. Health economic data will be collected using diaries and questionnaires, capturing direct and indirect costs. Cost-effectiveness will be assessed through a trial-based cost-utility analysis over 9 months and a Markov model over a lifetime horizon. The process evaluation follows the UK Medical Research Council framework, using mixed methods with quantitative and qualitative data from diaries, interviews, and observations, analyzed descriptively and thematically. Results: The funding of the project started in February 2023. Protocol version 5 (accepted March 15, 2024). Participant recruitment occurred between June 2023 and September 2024, with a total of 102 participants enrolled. Data collection ended in July 2025. Data analysis is ongoing. Conclusions: This protocol outlines a randomized controlled trial integrating clinical, health economic, and process evaluations to assess a high-dose, individualized rehabilitation program. The findings will provide evidence on effectiveness, cost-effectiveness, and implementation feasibility in chronic stroke and SCI, supporting the optimization of long-term neurorehabilitation care.

Introduction: Chronic stroke and spinal cord injury are both associated with persistent motor impairments, resulting in reduced independence in daily life and lower quality of life. Although rehabilitation is essential to address these challenges, the amount of therapy provided during the chronic phase remains limited, while the long-term cost of care is substantial. Here, we describe the INTeRAcT protocol: a randomised controlled trial with a clinical, health economic and process evaluation, designed to assess the effectiveness of a high-dose, intensive-targeted and personalised rehabilitation programme. Methods and analysis: In this single-blind randomised controlled trial, we aim to recruit 100 adults in the chronic phase after stroke or spinal cord injury. Participants will be randomised to either the INTeRAcT intervention group (n=50) or a control group receiving usual care (n=50). The intervention group will receive 90 hours of personalised motor rehabilitation over three weeks, including upper and lower limb therapy, with and without advanced technology, cardiovascular fitness training, and self-management education. After the intervention, both groups return to usual care and are followed up for nine months. Clinical outcomes will be assessed by a blinded assessor at baseline (T0), post-intervention (T1), and at nine-month follow-up (T2), with additional data collected throughout for the health economic and process evaluations. The primary clinical outcome is independence in daily life, assessed using the Functional Independence Measure for participants with stroke, and the Spinal Cord Independence Measure for those with spinal cord injury. Secondary clinical outcomes include the EuroQol 5D-5L, Canadian Occupational Performance Measure, Goal Attainment Scaling, and the Fatigue Severity Scale. Additional stroke-specific secondary outcomes are the Action Research Arm Test, Fugl-Meyer Assessment, Functional Ambulation Categories, the 6 Minute Walk Test, 10 Meter Walk Test, and the Stroke Self-Efficacy Questionnaire. A multivariate linear model will be used to compare clinical changes between the two groups. Health economic data will be collected using diaries and questionnaires, capturing direct and indirect costs such as healthcare use, medication, transport, productivity loss, and informal care. Effects will be measured via the EQ-5D-5L and expressed in Quality-Adjusted Life Years. Cost-effectiveness will be assessed through a trial-based cost-utility analysis over a nine-month horizon and a Markov model over a lifetime horizon, complemented by scenario analyses and a budget-impact analysis. The process evaluation, guided by the UK Medical Research Council framework, adopts a mixed-methods approach combining quantitative and qualitative data from structured diaries, semi-structured interviews, and observations. Quantitative data will be presented descriptively, while qualitative data will be examined using both content and thematic analysis. Ethics and dissemination: Ethical approval was obtained from the central and local ethics committees on 10 July 2023. The currently approved protocol is version 5, dated 15 March 2024. All participants provide written informed consent prior to enrolment. Study findings will be disseminated through peer-reviewed journals and presentations at national and international conferences, as well as at various stakeholder events. Trial registration number: NCT05970367 (31 July 2023) ARTICLE SUMMARY: Strengths and limitations of this study: This protocol combines clinical, process, and health economic evaluations to comprehensively assess a complex, high-dose and individually tailored motor rehabilitation intervention, addressing key evidence gaps regarding effectiveness, implementation, contextual factors and cost-effectiveness in chronic stroke and spinal cord injury care. Clinical outcome assessments will be conducted by a blinded assessor, reducing the risk of measurement bias. The rehabilitation programme combines a standardised structure with individual goal-setting, developed in collaboration with clinical practice and grounded in evidence-based principles, enhancing feasibility and clinical applicability. Although the trial is conducted in a single clinical centre, the inclusion of both stroke and spinal cord injury populations enhances generalisability across neurological conditions, while the process evaluation will identify contextual factors to support future implementation in other settings.