Visual Stimulation Through Video Therapy to Enhance Lower Limb Motor Recovery After Stroke

Stroke frequently results in persistent lower limb motor impairment affecting gait and functional mobility (1-2). While video-based therapies have shown proof of concept for upper limb rehabilitation after stroke, their effectiveness for lower limb motor recovery remains insufficiently documented (3-5).

This study is a single-center pilot trial using a Single-Case Experimental Design (SCED) with multiple baseline durations, chosen to account for the high interindividual variability observed in subacute and chronic post-stroke patients undergoing rehabilitation (6). This design allows each participant to serve as their own control through repeated measurements over time (6).

Participants are included between 1 month and 1 year post-stroke while receiving inpatient or outpatient rehabilitation in a Physical Medicine and Rehabilitation department. All participants initially undergo a control phase combining standardized rehabilitation with sham video therapy (placebo condition). The duration of this baseline phase is randomized (1, 2, or 3 weeks) across participants.

The experimental phase consists of 5 weeks of intensive video therapy added to usual care, with five sessions per week. A post-intervention sham phase is followed by a follow-up period lasting up to 21 weeks post-intervention, with repeated assessments conducted at weeks 13, 17, and 21 to evaluate maintenance of treatment effects.

The primary objective is to evaluate changes in functional mobility, assessed using repeated measurements of the Timed Up and Go test. Secondary objectives include evaluation of gait endurance, motor impairment, muscle tone, balance, and quality of life

.

• Active Videotherapy (Device): During active videotherapy sessions, the image inversion program is activated, superimposing movements of the non-paretic limb onto the paretic limb, which is hidden behind the screen. Participants are instructed to imagine and attempt to reproduce the observed movements using their paretic limb. Each participant completes 25 sessions over 5 weeks (5 sessions per week).
• Sham videotherapy (Device): During sham videotherapy sessions, participants are seated facing the IVS4 screen without activation of the image inversion program. Participants perform lower limb movements while directly viewing their paretic limb in real time on the screen, corresponding to an action observation condition without visual illusion.

Primary outcomes

• 1. Timed Up and Go Test (TUG) [5-week]: Time required to stand up from a chair, walk 3 meters, return, and sit down (in seconds)

Secondary outcomes

• 2. 2-Minute Walk Test (2MWT) [Weeks 1, 2, 3, 8, 13, 17, and 21]: Walking endurance assessed by the distance walked in 2 minutes (in meters).
• 3. Fugl-Meyer Assessment - Lower Limb Section [Weeks 1, 2, 3, 8, 13, 17, and 21]: Motor function of the hemiplegic lower limb, assessed with the Fugl-Meyer scale (score from 0 to 34)
• 4. Muscle Strength - Foot Dorsiflexors and extensors [Weeks 1, 2, 3, 8, 13, 17, and 21]: Muscle strength of the foot dorsiflexors and extensors, measured in Newtons using a handheld dynamometer
• 5. Muscle Tone - Modified Ashworth Scale (MAS) [Weeks 1, 2, 3, 8, 13, 17, and 21]: Spasticity assessment of dorsiflexors and extensors of the foot using the Modified Ashworth Scale (score 0-5).
• 6. Muscle Tone - Modified Tardieu Scale [Weeks 1, 2, 3, 8, 13, 17, and 21]: Spasticity assessment of dorsiflexors and extensors of the foot using the Modified Tardieu Scale (score 0-5).
• 7. Postural Balance - PASS (Postural Assessment Scale for Stroke Patients) [Weeks 1, 2, 3, 8, 13, 17, and 21]: Balance ability assessed using the PASS scale (score 0-36).
• 8. Quality of Life - Stroke Specific Quality of Life Scale (SS-QOL) [Weeks 1, 2, 3, 8, 13, 17, and 21]: Quality of life assessed with the SS-QOL scale (score range: 49-245).

Sex: All, ages: 18 Years to 80 Years

Inclusion Criteria:

* \- First or recurrent hemispheric ischemic or hemorrhagic stroke in the subacute or chronic phase (from 1 month to 1 year post-stroke).
* Currently receiving rehabilitation care in a Physical Medicine and Rehabilitation (PM\&R) department
* Able to walk 3 meters back and forth, with or without an assistive device.
* Provided informed consent, signed jointly with the investigator.

Exclusion Criteria:

* \- Severe hemispatial neglect.
* Severe spasticity impairing proper positioning (Modified Ashworth Scale > 3).
* Severe general disabling medical conditions.
* Associated cerebellar syndrome.
* Major comprehension disorders, psychiatric illness, or cognitive impairments that could interfere with study participation.
* Participants under full legal guardianship (tutorship).
* Pregnant or breastfeeding women.

• Etienne OJARDIAS, Dr, Principal investigator, Centre Hospitalier Universitaire de Saint Etienne