**5. Final remarks**

*New Insight into Cerebrovascular Diseases - An Updated Comprehensive Review*

A third factor influencing recovery of motor function after stroke suggested by Sharma et al. [29] is discharge via the corticospinal tract to produce movement (**Figure 4C**). This network is involved in all physical movement but predominantly through the combination of the other two. That is, this neural network for producing movement is predominantly utilized via the mutual involvement of the neural network based on somatosensory feedback and the neural network preceding movement. As a specific example, Nilsen et al. [35] and López et al. [36] conducted a systematic review and found that combining mental practice and the use of motor imagery with physical movement improved intervention effects. Further, a Cochrane Review [37] also reported that mental practice interventions combined with motor therapy, including physical movement, were more effective than mental practice alone. We also reported that neurofeedback-based motor imagery training combined with physical movement contributed to improving upper extremity function in stroke patients [38]. These findings indicate that somatosensory feedback accompanying physical movement promotes the effects of motor imagery interventions. In other words, the neural network preceding movement and that for

somatosensory feedback may work together to enhance motor performance.

step-by-step intervention strategy is considered vital.

To summarize, the factors influencing motor function recovery accompanying the reorganization of the IVp area after a stroke are (1) somatosensory feedback to the paretic side; (2) movement-preceding activities, which utilize motor imagery and action observation; and (3) discharge via the corticospinal tract to produce movement. As (3) is ultimately effective through the combination of the neural networks involved in (1) and (2), information processing combined with somatosensory input to the paretic limb should take priority in motor therapy for hemiparetic stroke patients exhibiting motor paresis. Next, treatment should precede mental practice interventions utilizing motor imagery induction, based on estimations from that information processing and from motor practice producing movement through an exercise program based on those movement-preceding activities. This

Nevertheless, according to the Guidelines for the Management of Stroke [39], the following therapies are recommended for rehabilitation for upper limb dysfunction—for patients with mild paralysis, a therapy that suppresses the non-paralyzed upper limb and forces the use of the paralyzed upper limb in life is highly recommended (grade A). For moderate paralytic muscles (such as wrist and finger extensors), electrical stimulation is recommended (grade B). For patients with mild to moderate paralysis, training should be performed with repetition of certain movements (reach movement of the upper limb on the paralyzed side, goal-oriented movement, repetitive movement of both upper limbs, mirror therapy, repetitive facilitation exercise, etc.) is recommended (grade B). rTMS and tDCS may be considered, but care must be taken in patient selection and safety (grade C1).

Moreover, the following therapies are recommended for rehabilitation for gait disorders—increasing the amount of limb training associated with walking or of walking itself is strongly recommended to improve walking ability (grade A). For stroke hemiplegic patients with equinovarus feet, it is recommended to use short leg braces to improve walking (grade B). Botulinum therapy and intramuscular nerve block to the tibial nerve or the lower leg muscle using 5% phenol is recommended when the spastic equinovarus foot hinders walking and ADL (grade B). Tendon transfer may be considered for patients presenting with spastic equinus and abnormal gait (grade C1). Biofeedback using electromyogram and joint angle is also recommended to improve walking (grade B). Functional electrical stimulation is recommended for chronic stroke patients with drooping foot, but the duration of treatment effect is short (grade B). Treadmill training is recommended because it improves walking speed and endurance in ambulatory stroke patients (grade B).

**308**

In this chapter, we outlined the neural mechanisms underlying motor function recovery after stroke-related brain injury. We have also outlined the corresponding rehabilitation strategies based on the functional characteristics of the brain and advances in clinical practice guidelines. We discussed how, considering the functional characteristics of the primary motor area, it is important during the early stages after stroke to increase the somatosensory input to the paralyzed side and combine mental practices using motor imagery. The existing guidelines highlighted the importance of dose dependency, task dependency, and neuroplasticity, in promoting effective functional recovery in stroke rehabilitation. Understanding the rehabilitation strategies and key related mechanisms involved in stroke recovery is indispensable for the development of highly effective poststroke rehabilitation.
