Effect of Different Therapeutic Modalities With Virtual Reality or Modified Constraint-induced Movement Therapy Compared With Usual Physical and Occupational Therapy on Motor Recovery of Paretic Limbs in Patients With Cerebrovascular Event
Phase: NA
Conditions: Stroke Sequelae
Sponsor: Coordinación de Investigación en Salud, Mexico

NATIONAL AUTONOMOUS UNIVERSITY OF MEXICO 
MASTER AND DOCTORATE PROGRAM IN MEDICAL, DENTAL AND HEALTH SCIENCES 
CHILDREN'S HOSPITAL OF MEXICO "FEDERICO GÓMEZ" 
MEXICAN SOCIAL SECURITY INSTITUTE 
 
 
 
 
Title: 
 
EFFECT OF DIFFERENT THERAPEUTIC MODALITIES SUPPORTED BY VIRTUAL 
REALITY OR RESTRICTION-INDUCED MOVEMENT THERAPY COMPARED TO USUAL 
PHYSICAL AND OCCUPATIONAL THERAPY ON MOTOR RECOVERY OF PARETIC 
LIMBS IN PATIENTS WITH CEREBRAL VASCULAR EVENT 
 
 
 
 
Number NCT: 05875116 
 
 
 
 
 
 
Date: July, 2023 
 
 
 
 
 

ABSTRACT 
 
 
EFFECT OF DIFFERENT THERAPEUTIC MODALITIES SUPPORTED BY VIRTUAL REALITY OR 
RESTRICTION-INDUCED MOVEMENT THERAPY COMPARED TO USUAL PHYSICAL AND 
OCCUPATIONAL THERAPY ON MOTOR RECOVERY OF PARETIC LIMBS IN PATIENTS WITH 
CEREBRAL VASCULAR EVENT 
 
Introduction. In Mexico and the world, the Cerebral Vascular Event (CVE) o stroke is one of the 
leading causes of morbidity and mortality. The main repercussion is the neurological disability that it 
produces in those who do not die, which generates expenses in the health systems due to the need 
for medical consultations, the use of medications and, usually, prolonged rehabilitation. In survivors, 
the most frequent neurological sequelae are aphasia and hemiparesis. The motor deficit of the 
affected hemibody occurs between 40-70% of the subjects and the greatest condition is usually 
predominantly in the thoracic extremity, of these, only 5 to 20% partially recover the functionality of the 
hand, their prognosis is poor. poor when there is total paralysis of the thoracic limb or a lack of 
effective clamp 4 weeks after the event, finding that only 11% of patients with severe weakness in the 
thoracic limb achieve good recovery in the hand; in the rest there is an impact on independence and 
activities of daily living. It is important to highlight that standing and walking tends to recover more 
easily than function of the thoracic limb. In general, around 30-66% present a partial recovery at 6 
months after the event. 
 
The lack of movement associated with CVE contributes to a deterioration of the corticospinal tract and 
with the passage of time there is greater Wallerian degeneration of the affected hemisphere. Several 
publications support the importance of maintaining the integrity and preservation of the tract by 
providing timely therapy that favors motor recovery. Rehabilitation programs are aimed at recovering 
to the greatest possible degree the functionality of the segments of the body; The usual techniques, 
such as physical and occupational therapy, are widely used throughout the world and have proven 
their usefulness, which is why, in general, they become the management to be compared when an 
alternative therapy is found for disabling diseases. 
 
One of these neurorehabilitation techniques is called movement restriction and induction therapy 
(TRIM), which consists of a standardized and intensive motor intervention, which has shown a 
substantial increase in the use and motor ability of the affected limb. The therapy consists of the 
restriction of the mobility of the unaffected upper extremity by means of a sling or some other 
attachment and then the training of the affected one is carried out with a technique called "Shaping", 
which focuses on the performance of fractionated functional tasks. with a gradual increase in difficulty. 
It has been shown to produce functional changes in brain metabolism, blood flow, and electrical 
excitability, with potential structural remodeling of the sensorimotor cortex, predominantly in anterior 
motor areas and the hippocampus. The results have shown to be positive in the rehabilitation of post-
Cerebral Vascular Event patients, and the skills obtained are maintained over time. 
 
Another relatively recent therapy is the one that is provided with the support of technology based on 
Virtual Reality. There are multiple publications that propose that it can significantly help brain 
neuroplasticity, translating greater motor learning at the cortical level, even producing a remodeling of 
the cortex and, therefore, greater motor recovery compared to other techniques. As a technique, it 

uses electronic equipment to reveal to the individual some of the normal or abnormal physiological 
events, in the form of auditory or visual signals, teaching him to manipulate involuntary events through 
displayed signals. Several studies show that the movement of the upper and lower limbs together with 
a specific objective translates into greater motor learning at the cortical level and therefore greater 
movement recovery. Biofeedback supported by computer systems (Virtual Reality) allows the total 
immersion of the patient in a "real" environment where he receives sound, visual and tactile sensory 
information, which produces a multimodal environment. Recent research on motor recovery in paretic 
limbs with the use of virtual reality shows an encouraging improvement, in addition to showing greater 
adherence due to the associated playful factor, which allows more treatment time without costs for 
health systems.  
 
According to some meta-analyses, the multiple existing publications related to these 2 types of 
therapies have been carried out in small populations, without considering demographic variants, 
affected brain territory or severity of the condition, among others, which has caused them to be 
considered inconsistent. and of little cost-benefit utility to be introduced in the rehabilitation units. That 
is why research on these "new" therapies continues to be carried out, seeking methodological support 
and consistent results, both clinical and cost. 
 
Research Question.  
What is the effect of different therapeutic modalities supported by Virtual Reality or Restriction and 
Induction of Movement compared with usual Physical and Occupational Therapy on motor recovery of 
paretic limbs in patients with Cerebrovascular Event? 
 
Secondary questions 
 
1. To determine the relationship between the therapeutic management group and motor evolution with 
changes in language (aphasy). 
2. To measure the level of patient satisfaction with the treatment received. 
3. To relate the level of patient satisfaction with adherence to treatment. 
 
Hypothesis.  
A therapeutic program supported in virtual reality will increase the motor function of the paretic 
thoracic extremity of patients with CVE by at least 38.6** average points measured with the Fugl 
Mayer scale compared with usual physical and occupational therapy. 
 
Aim.  
To measure the effect of different therapeutic modalities supported by Virtual Reality or Restriction 
and Induction of Movement compared with usual Physical and Occupational Therapy on the motor 
recovery of paretic limbs in patients with a Cerebral Vascular Event. 
 
Material and methods. 
Design: controlled, randomized, single-blind clinical trial. 
Place: external consultation and therapy service of the XXI Century Physical Medicine and 
Rehabilitation Unit (UMFRsXXI). 
Subjects: adults diagnosed with CVE and hemiparesis, with or without aphasia. 
Procedures: 

1. Clinical interview and random assignment to the type of therapy (evaluator 1); 
2. Assessment of the motor function of the paretic limbs with scales of Motor Index, quality of fine 
clamp and Fugl Meyer scale (evaluator 2 -blinded-), before, during (after session 6) and at the end of 
the therapy (after from session 12); 
3. Realization of rehabilitation programs for 1 hour, 2 times a week, 12 sessions (6 week total): 
a) Virtual reality with the support of Kinect ® and software: "tennis"® and "ski"® for shoulder, arm and 
hand, the "cover the cracks"® for thoracic member and foot, and "Star Wars- battles in the galaxy” ® 
for fine clamp of the hand. 
b) Movement restriction and induction therapy with a standardized program, but without the healthy 
arm immobilized. 
c) Regular physical and occupational therapy with the same standardized program, with the healthy 
arm immobilized. 
4. Evaluation of the quality of language with the Boston Aphasia Intensity Scale and evaluation of the 
Satisfaction or Pleasure perceived by the patient when performing the different types of therapy 
measured with the Intrinsic Motivation Inventory, both applied by the neuropsychologist, who will also 
be blinded to the treatment received by the patient. 
 
Statistics. According to the distribution of the quantitative variables, the analysis will be carried out 
using the ANOVA for repeated measures or Kuskal-Wallis test for the comparison between groups 
and ANOVA 1-factor or Friedman for the intragroup comparison (p<0.05). 
 
Infrastructure and group experience: financing was not obtained to acquire virtual reality equipment 
and additional materials for physical and occupational therapy, so we worked with 2 teams owned by 
the participants. The occupational therapy materials were those of the Medical Unit where the patient 
was treated. The participating personnel are experts in the area and contributed to the acquisition of 
materials and equipment, mainly the doctoral student. 
 
 
Keywords: aphasy, hemiparesis, modified constraint-induced movement therapy, occupational 
therapy, physical therapy, satisfaction, stroke, virtual reality. 

BACKGROUND 
 
 
VASCULAR CEREBRAL EVENT 
 
Definition 
 
The term Cerebral Vascular Event is used to designate a brain disease that results from a pathological 
process in which one or more of the blood vessels that supply the brain are affected1, 2. It is 
characterized by its sudden onset, with symptoms that they can last more than 24 hours, and can 
cause sequelae or death 3, 4. The rapid development of signs and symptoms usually correspond to a 
focal and sometimes global neurological condition, which persist for more than 24 hours or lead to 
death, without other apparent cause than a vascular origin 5, 6. 
  
The term cerebrovascular disease (CVE) refers to any alteration, temporary or permanent, of one or 
several areas of the brain as a consequence of a cerebral circulation disorder; while the term stroke or 
cerebral vascular event (CVE -stroke-) refers to acute cerebrovascular disease, and generically 
encompasses a group of disorders that include: cerebral ischemia, intracerebral hemorrhage (ICH) 
and subarachnoid hemorrhage (HS). The most widely used classification of CVE is the one that refers 
to its nature, dividing it into two groups: ischemic and hemorrhagic. Ischemia occurs as a 
consequence of the lack of blood supply to the brain, while hemorrhagic is due to extravasation of 
blood due to the rupture of an intracranial blood vessel 6, 7. 
 
 
Epidemiological aspects 
 
CVE is among the first 3 causes of mortality worldwide 3 and its incidence is 1.5-4 cases per 1,000 
inhabitants, and its prevalence is 8-20 cases per 1,000 inhabitants. This disease implies large 
monetary expenses. It is estimated that approximately 20% of survivors require special care during the 
three months following the event and almost 30% are left with permanent severe disability 3, 4. CVE is 
the second global cause of death with 9.7% of of which 4.95 million occur in low- and middle-income 
countries, according to data from the World Health Organization 8. The average age at which the first 
stroke occurs in men is 69.8 years, while in women it is 74.8 years 9. Its 2-year recurrence rate ranges 
from 10 to 22%, but it can increase up to 80% with the modification of risk factors 10, 11. If there are no 
adequate prevention interventions, it is estimated that by the year 2030 its incidence will increase up 
to 44% 12-14. 
 
In Mexico, it has been published that so far this century CVE is among the first 8 causes of death and, 
specifically, in Mexico City, it is among the first 5; being the sixth cause of death in men and the fourth 
in women. In the period from March to April 2008, the epidemiology of CVE was reported in some 
hospitals in the Federal District, and the prevalence was 11.15% 3. It has been considered that of the 
subjects who suffer an acute event, between 15 and 30 % die within thirty days 15. 
 
Data from the Mexican Ministry of Health show that the CVD mortality rate has increased since the 
year 2000, particularly in those under 65 years of age 13, 14. During 2007, 1% of all discharges from 
public hospitals were attributed to to CVD, while in 2008, the mortality rate was 28.3/100,000 
inhabitants 3, 12, 13. 

 
CVE, along with heart disease and diabetes, cause losses of billions of Wristars in annual income in 
most countries in the world, causing a 0.5% decrease in annual economic growth 8; In addition, it is 
the cause of frequent falls, with the clinical and economic implications that this entails 16. This 
condition represents the first cause of disability worldwide in the adult population and the second 
cause of dementia 17-19.  
 
Clinical manifestations 
 
Because the central nervous system has a somatotopic distribution, ischemia in the MCA territory will 
affect the contralateral side for motor activity and the ipsilateral side for sensory activity. After a CVE, 
the presentation of neurological impairment depends on the location and size of the lesion. The 
territory most frequently affected is that of the left middle cerebral artery (LMCA) and the most 
common motor deficit is hemiplegia or hemiparesis, with or without aphasia, affecting the extremities 
and muscles of the lower contralateral hemiface 2. The loss of voluntary movement can be 
accompanied by alterations in sensation throughout the length of one of the sides of the body, 
although there can be variations in the clinical presentation related to perilesional disorders 20. When 
the acute phase is over, almost always the limb The lower one has a greater tendency to recover than 
the upper one. At 3 months, a large percentage of hemiplegics already begins to walk, while the upper 
limb is more difficult to recover and, of these, approximately 40-45% experience major hand problems. 
In the condition of the upper extremity, 44% of patients recover motor activity and 40% present 
minimal or no recovery. The sensory pathways play an important role in motor control, since severe 
sensory alterations produce disability similar to paresis and a poor recovery of motor function, 
worsening the functional prognosis 21. 
 
After a stroke, people who survive have a high risk of developing a wide range of secondary 
conditions such as pain, depression, pressure ulcers and falls, among others, during the acute or post-
acute recovery period; there may also be balance disorders and functional dependence, which is why 
basic daily life activities oriented towards caring for one's own body are compromised, such as 
dressing, eating, etc., which causes incapacity for work and limitations in quality of life 16. 
 
 
NEURO-REHABILITATION 
 
Rehabilitation techniques aimed at improving hemiparesis vary their objectives, depending on the 
evaluations and the therapeutic approach, since a way is sought to explore the patient's capacities 
that can improve their autonomy. Neuromuscular rehabilitation is based on teaching-learning 
techniques such as performing and reproducing movements 22. 
  
The techniques called conventional can vary in programs and exercises, but in general they consider 
3 essential aspects: 1. They provide a progressive management respecting the levels in which the 
motor patterns were acquired, with this they integrate the previous neurosensory-motor schemes, 
considering a strategy proper posture. 2. Motor stimulation through various sensory and sensitive 
information: vestibular, kinesthetic and visual for support activities; of postural strategy and locomotion 
in a proximal distal progression; and tactile and visual for fine and differentiated voluntary movements 

in a disto-proximal progression. 3. Inhibition of pathological motor reactions and facilitation of motor 
skills altered by tonic and synkinetic disorders 22. 
 
For example, Bóbath and Brunnstrom proposed that the lack of inhibition of a damaged postural reflex 
mechanism caused increased muscle tone and allowed primary reflex activity to emerge; observed 
that if the position and posture of the proximal joints of the body were modified then muscle tone could 
be influenced, these stimuli helped to initiate the movement that the patient was unable to produce 
voluntarily and then try to control the volition of the joints synergies obtained by mixing the different 
movement patterns and causing changes in the patient's motor responses helped the hemiplegic side 
to avoid forgetting it, restore asymmetry and integrate it into functional movements 23. Kabath, Knott 
and Voss proposed the facilitation technique proprioceptive neuromuscular on the hypothesis that all 
voluntary effort is the response to a stimulation of the central nervous system from some sensitive 
receptors; Proprioceptive neuromuscular facilitation proposes improving awareness of movement by 
provoking a motor response through proprioceptive stimulation, such as skin pressure, joint traction 
and mobilization, rapid stretching, strengthening weak movements through synergistic movements, 
and the use of verbal guidelines 21, 23. 
 
Neurorehabilitation, then, is an attempt to manipulate the plasticity of the central nervous system in 
order to recover its functionality. Functional magnetic resonance imaging, among other studies, has 
made it possible to observe the neuroplastic changes that occur in association with rehabilitation 
therapies, as well as the continuous remodeling of neural connections and cortical maps. The only 
prerequisite is that the patient's brain has the potential capacity to compensate for the injuries 24. 
 
The recovery of a function after brain injury is based on two mechanisms: the compensatory process 
and the restitution process (both occur simultaneously in some cases). The compensatory process is 
functional reorganization or adaptation and is achieved by structuring the surviving neural circuits in a 
different way, allowing them to handle themselves in different ways and connections with other areas; 
therapy or training leads to redistribution of tasks to undamaged areas and reorganization of the 
cerebral cortex. In the neurophysiological process of restitution, which depends on brain plasticity, 
plastic reorganization occurs, first, from an alteration in synaptic sensitivity related to an unmasking of 
existing connections through changes in inhibitory dynamics, which occurs in seconds or minutes, in 
contrast to structural changes that can take days or weeks. And second, due to the reduction in the 
level of activity in the area of the lesion, the synaptic connections between the healthy and damaged 
site are weakened, which depresses the function in the undamaged structures, so that the stimulation 
and manipulation of the processes inhibitory become a stimulus for recovery 25. 
 
 
Modified Constraint-Induced Movement Therapy 
 
In conventional therapies, the healthy side is stimulated to replace the functions of the affected one, 
this was called "learning not to use" the paretic upper extremity. In contrast, Taub et al., demonstrated 
that if the movement of the healthy limb is restricted and the affected limb is trained, motor control is 
favored by means of the technique called "Shaping" and which consisted of the restriction of the 
mobility of the upper extremity not affected by putting a sling for a time that corresponded to 90% that 
the patient remained awake for a period of 12 days, and training the affected upper extremity for about 
seven hours a day, during the same days; this involved intense training but produced large changes in 

cortical reorganization and was correlated with improvement in motor function 26-30. A similar result 
was also observed in a group of patients with subacute or chronic CVD who received a non-intensive 
form of Movement Restriction Therapy (MRT), noting an increase in the activation of the injured 
hemisphere by magnetic resonance imaging after therapy and that persisted for at least 4 months 
after treatment 26, 28. 
 
The current neurorehabilitation proposal to promote the function of the upper extremity of the person 
with hemiplegia must start from motor learning approaches, through training strategies in specific 
tasks and performing specific functions with practice and constant repetition, the basic principle of this 
intervention modality seeks to work directly on the underlying modification of neural mechanisms. 
Therefore, it is necessary to describe the main applications of the healthy side restriction therapy for 
the improvement of spastic hand function in adults with hemiplegia. CIMT has repeatedly been 
associated with brain plastic changes (both functional and structural), demonstrating that with the use 
of the paretic limb, activation of the somatosensory cortex (p=<0.03) and other structures related to 
ipsilesional or contralesional brain motor outputs increases, along with an induction of middle cerebral 
artery blood flow. In addition, it is capable of producing changes in the organization of brain functions, 
through neuroplastic processes. In this sense, mention is made of neuroplasticity, conceptualizing it as 
the anatomo-functional adjustments that are made in order to return to functional recovery using other 
sectors that have not had a previously established function or that have remained silent. These 
changes occur days after a brain injury, modulated in turn by various strategies or therapies. Although 
it is agreed that a higher level of evidence is still lacking in the studies 25-27. 
 
 
Biofeedback and virtual reality. 
 
Virtual reality is defined as the approach between the user and the computer, involving a simulated 
environment in real time, scenario or activity that allows the user a pathway of interaction through 
multiple sensory channels 31. Virtual reality technology and its applications have expanded rapidly into 
many disciplines. The virtual environment that it uses can be enriched with complex and multimodal 
sensitive information for the user and can create a substantial sensation of reality 32. 
 
Biofeedback is the technique that uses electronic equipment to reveal to the individual some of the 
normal or abnormal physiological events, in the form of auditory or visual signals, teaching him to 
manipulate involuntary events through displayed signals. The term feedback was coined to designate 
a method of controlling the system aimed at restoring the results of its past function, but later the term 
was given a physiological context, referring to any technique that uses instruments that attempt to give 
an individual continuous signals and immediate changes in a bodily function of which one is usually 
unaware 31, such as electromyographic biofeedback, which showed greater motor activity compared to 
physical therapy in hemiplegic patients due to CVE 33. 
 
Biofeedback aims, mainly, to get a person to notice their own physiological state and can develop it by 
themselves or in a pathological situation, to modify it; Its objectives are the re-education of the motor 
order, of cognitive disorders and the fight against spasticity, but in order to take advantage of it the 
patient must have a minimum of understanding and motivation 34. 
 

In their first works, Taub et al., mentioned that the literature suggested that these therapies have a 
neutral, negative or variable effect on motor learning through mechanical tasks; however, they 
maintained that rehabilitation procedures that engage the mind in the recovery process could promote 
cortical reorganization 35. The specific task in training must be repetitive in patients with CVE to favor 
the neuroplasticity process, both in the brain injured as well as healthy, although it is currently 
considered that there is no specific program for the recovery of motor disability. It has been found that 
a rehabilitation program with virtual reality simulating activities of daily living compared to a 
conventional Occupational Therapy program applied to patients with CVE sequelae showed similar 
results in general motor recovery 34. Various results suggest that virtual reality is a complementary tool 
for existing programs that favors adherence to treatment by the patient due to the playful aspect. 
Therefore, it is urged to continue exploring the effects of the use of technology in the rehabilitation of 
neurological patients 34, 36. 
 
A challenge in neuromotor rehabilitation is to design effective methods to provide repetitive and 
specific therapy, the processes must be multimodal to facilitate recovery of function, they must involve 
cognitive functions, as well as being attractive (to maintain the patient's attention) and easy to 
understand. Biofeedback supported by computer systems allows compliance with these 
characteristics, achieving total immersion of the patient in a virtual environment of computerized 
graphics where he receives sound, visual and tactile sensory information, which produces a 
multimodal environment. Saposnik et al., conducted a randomized clinical study, in which they 
compared motor recovery of the upper extremity, in patients with CVE, using the Nintendo-Wii® video 
game console in the case group and occupational therapy activities in the control group; obtaining 
encouraging results in VR group, such as a similar recovery achieved in less time (which is reflected in 
a decrease of up to 7 seconds in the speed of movement execution) 36, 37. 
 
The inclusion of technology in rehabilitation not only allows innovative treatments, but also causes the 
patient to be motivated to meet the objectives set, favoring adherence to treatment 34, 36, 38. It has been 
observed that currently, there is a greater acceptance for the use of personalized gaming technologies 
used to support the rehabilitation of CVE survivors with moderate-severe disability, as a high level of 
pleasure or enjoyment was detected (qualified with scores between 6.8 - 8.1 of 10 -Likert-type scale -) 
and moderate perception of effort (scores between 11.6 - 12.9 of 20 -BORG scale-) when working with 
virtual reality computer systems during rehabilitation. Noting an improvement in the limitations due to 
the EVC and an increase in the spontaneous performance of activities at home when compared with 
the initial state of the patient (p < 0.05) 38. 
 
Virtual reality collaborates in an important way with neuroplasticity, especially at the level of the 
cerebral cortex. Numerous studies mention that the benefit in the recovery of the paretic limb is due to 
greater activation of cortical maps, better attachment and more motivation 34, even in the presence of 
pathological synergies, which are very difficult to correct with traditional rehabilitation 38. In Mexico 
there is a virtual reality program that has been used in some research, called the Gesture Therapy 
System, and although this treatment has shown good results for many patients, it is only useful for the 
upper limb and includes the stimulation of practically the entire movement of the limb 39, 40, which 
would make it difficult to quantify the handling of the segments, including the hand and fine forceps. 
However, it is a fact that virtual reality supported by video game equipment has increased its 
application in physical rehabilitation, especially commercial consoles, which have been implemented 

in some medical units 37, so it is considered relevant to carry out more research in this area. 
environment, but using accessible software 34,37, 38 that stimulates adherence on the part of the patient. 
 
Nevertheless, a meta-analysis (analysis of 40 reviews -19 Cochrane and 21 non-Cochrane-) mentions 
a moderate improvement with some techniques, including virtual reality; a "relative effectiveness" is 
described in relation to a small number of participants, as well as errors in the methodology 
(demographic variants, affected brain territory or severity of the condition, among others), 
inconsistency of results and little cost-benefit utility, suggesting the need to continue conducting 
studies 41. Another Cochrane review that included 37 trials and 1019 patients concluded that the 
evidence was low or very low, relating it to failures in the design of the interventions, the risk of bias 
could not be established because the studies were not clear, most of the participants were young and 
with more than one year since the EVC, in addition to the fact that some focus only on the upper limb 
(12 studies with 397 participants), finding that the differences were not significant for gait and global 
movement, but they were for the activities of daily living, so it is concluded that although the evidence 
suggests that virtual reality can be beneficial for the function of the upper limb and activities of daily 
life, there is still insufficient evidence on its effect on gait quality and global motor function. Nor can it 
be established yet which are the most important characteristics of virtual reality and what are its 
effects over time 42. 
 
 
Clinical evaluation of patients with CVE 
 
In patients with CVE and paresis of the extremities, different clinical scales are used to measure the 
changes that occur, spontaneously or related to rehabilitative management. There are multiple 
publications that support the relationship between the results of the Fugl-Meyer scale and the possible 
functionality of brain structures associated with movement. Cunningham described a good relationship 
(rs= −0.768; p=0.016; Spearman) between high scores with said scale and the functionality of the 
corticospinal tracts, preferably the contralateral 43. 
 
Similarly, studies carried out in our country have shown the advantages of virtual reality as support in 
the rehabilitative management of patients with CVE. Although the improvement has been insignificant 
in different measurements, a positive emotional component and better adherence to treatment are 
frequently described. In a study carried out at the National Institute of Neurology and Neurosurgery 
(INNN) an increase in the score measured with the Fugl-Meyer scale was found in patients managed 
with virtual reality (-initial- 13.41 to 31.91 -final-) compared to the group who received habitual 
occupational therapy (18 to 26.3); when measuring motor changes with the Motor Index, the findings 
were similar (virtual reality from 32.33 to 52.91 -initial/final- compared to the control group from 42.1 to 
52.6 -initial/final-). Changes in patient satisfaction were measured with the intrinsic motivation 
inventory, and those who underwent virtual reality therapy were more satisfied than the group with 
only therapy 34. 
 
As described in some reviews and meta-analyses, many studies focus only on the upper limb and/or 
the hand, perhaps because they are the most frequently difficult to recover or show sequelae even 
over time. In another study conducted in Korea, only the upper limb was managed and evaluated; in it, 
functionality was evaluated with the Fugl-Meyer scale and the modified Barthel index. However, as 

can be seen in the following table, the differences between the groups were only significant in hand 
scores, while the intragroup changes were significant in all evaluations 44. 
 
 
 
 
Variations between groups pre and post intervention.   
 
 
 
 
A lowercase “a” indicates a significant intragroup difference and “b” indicates a significant difference between 
groups. FMA = Fugl-Meyer scale. K-MBI = Korea Modified Barthel Index. CS = coordination and speed. MCAG = 
middle cerebral artery group. BGG = basal ganglia group. 
 
 
 
 
Few studies focused on the management and evaluation of the lower limb were identified, considering 
balance, mobility and gait, highlighting that the improvement was greater in the group managed with 
virtual reality, although only in some aspects such as balance and march duration. However, it is 
noteworthy in this work that the therapy was provided for short periods (20 minutes a day for 10 to 12 
sessions in a period of 3 weeks), identifying positive changes as shown in the following table 45. 
   
 
 
 
TMWT = 2 minute walk test. CMSA-leg = Chedoke McMaster CVD assessment in the leg domain. TUG = get up 
and go test. MCID = minimal clinically important difference. 
 
 

Regarding the evaluation and management of the lower limb related to stroke, a systematic 
review with meta-analysis of 15 randomized trials (341 patients) showed that when 
conventional therapy program was replaced with virtual reality technology (part or all) showed 
significant benefits in gait speed (0.15 m/s, 95% CI 0.10 to 0.19), balance (2.1 points -Berg 
Balance Scale-, 95% CI 1.8 to 2.5) and mobility (2.3 seconds on the time of completion of the 
Up and Go test, 95% CI 1.2 to 3.4). Although the benefits were small and there was 
insufficient evidence about gait speed and balance (due to high heterogeneity), the extra 
costs related to the use of virtual reality were also small and it is proposed that it can be 
applied to many patients in the same medical unit 45. Videogame consoles with virtual reality 
attachments represent a safe, potentially effective, easy-to-use, and attractive tool to favor 
rehabilitation and promote recovery after CVE 46. 
 
 
EXPERIENCE IN A REHABILITATION UNIT 
 
In the Physical Medicine and Rehabilitation Unit “XXI Century” (PMRUXXIc) of the Mexican 
Social Security Institute (IMSS, by its acronym in spanish), the CVE is second in demand for 
consultation and cause of neurological disability. Traditional rehabilitative treatment of 
hemiparesis can be lengthy and sometimes incomplete, predominantly in the upper extremity 
and especially the hand. These motor alterations affect the quality of life and consume 
resources in the institution. The usual treatments have shown relative benefits since they are 
based on facilitation/inhibition principles, with which the affected limb is “learned not to use”. 
Recent studies confirm that arm movement coupled with a specific objective translates into 
greater motor learning at the cortical level and therefore greater motor recovery compared to 
the aforementioned facilitation/inhibition techniques 33, 36. 
 
Research directed at this type of treatment in the PMRUXXIc, showed results consistent with 
what was described by other authors. In the studies, rehabilitation programs supported by 
virtual reality or movement restriction and induction were compared separately, and they were 
compared with groups of only physical and occupational therapy 47, 48. The Table 1 
summarizes the results of the clinical evaluation using the applied scales and their 
comparison with therapy alone. 
 
In the study, the intragroup differences were always significant (p<0.05; Friedman), but the 
comparison between groups in the virtual reality study was only significant in the hand motor 
index (p<0.05; Kruskal-Wallis) and close to the significance with the Fugl-Meyer scale 
(p>0.05; Kruskal-Wallis). The lowest scores were found in the group of physical and 
occupational therapy alone. These works present some of the deficiencies mentioned, such 
as the low number of patients, but they can be considered as pilot studies in order to establish 
the size of the sample, considering the values found in a population similar to the one that will 
be included in the present investigation. 
 
 

 
 
Table 1. Comparison of results measured in points of different scales in groups of patients with hemiparesis due 
to a cerebrovascular event managed with a rehabilitation program supported with virtual reality or Therapy with 
restriction and induction of movement modified or occupational therapy alone. 
 
Applied scales 
 
Therapy whit virtual 
reality (n=13) 
Therapy with 
restriction and 
induction of 
movement (n=23) 
Occupational therapy  
alone (n=10) 
Hand motor index 
I.V. 
20.77 
 
20.20 
F.V. 
24.92 
 
22.80 
Diff. 
4.15 
 
2.6 
Shoulder-elbow motor 
index 
I.V. 
41.15 
 
37.20 
F.V. 
47.85 
 
44.0 
Diff. 
6.7 
 
6.8 
Total motor index 
I.V. 
61.92 
 
56.40 
F.V. 
72.69 
 
66.90 
Diff. 
10.77 
 
10.5 
Fine Forceps Test 
I.V. 
4.30 + 1.03 
12 ± 4.99 
3.90 + 0.99 
F.V. 
7.38 + 1.19  
17.34 ± 4.27 
6.60 + 0.96 
Diff. 
3.007 
5.34 
2.8 
Fugl-Meyer Scale 
I.V. 
28.31 + 12.02 
9.34±3.7 
27.70 + 12.23 
F.V. 
41.07 + 9.28 
11.27±2.67 
38.60 + 11.8 
Diff. 
12.77 
1.93 
10.9 
 
                  V.I.: Initial Valoration V.F.: Final valoration Diff.: Difference. 
 
 
 

JUSTIFICATION 
 
 
 
Actually, the CVE continues to be one of the main causes of morbidity and mortality in Mexico and in 
the world; the neurological disability that it produces requires prolonged rehabilitation and the motor 
sequelae affect the quality of life of patients, due to gait problems, but above all hand problems. The 
lesions of the cortex in the affected territory during the CVE contribute to a deterioration of the 
corticospinal tract, and its Wallerian degeneration can spread over time if it is not stimulated, for this 
reason it is important to maintain the integrity and conservation of the corticospinal pathway. 
corticospinal tract, favoring motor recovery through therapy as soon as possible after the event was 
installed. 
 
Despite the existence of multiple rehabilitation treatments for the motor disability of patients with CVE, 
the sequelae continue to maintain their proportion. Therapy supported by Virtual Reality and Modified 
Constraint-Induced Movement (TMIRm, by its acronym in spanish) are relatively recent, but have 
not yet been incorporated into the usual clinical application in our country. Various publications 
highlight that in the investigations there are methodological deficiencies, variations in the 
characteristics of the subjects, such as the territory affected or the time of evolution, for which reason 
the evidence is usually insufficient, especially its effect on the quality of gait and overall motor function. 
This work aims to solve the deficiencies of other publications and measure the influence of treatments 
early in patients after a CVE, which, in the future, could influence a better recovery, both in brain 
functionality and in its clinical representation, with minor sequelae. 
 
 
 

  
 
 
RESEARCH QUESTION 
 
 
 
 
What is the effect of different therapeutic modalities supported by Virtual Reality or Restriction and 
Induction of Movement compared with usual Physical and Occupational Therapy on motor recovery of 
paretic limbs in patients with Cerebrovascular Event? 
 
Secondary questions 
 
1. To determine the relationship between the therapeutic management group and motor evolution with 
changes in language (aphasy). 
2. To measure the level of patient satisfaction with the treatment received. 
3. To relate the level of patient satisfaction with adherence to treatment. 
 
 
 
WORK HYPOTHESIS 
 
 
 
A therapeutic program supported in virtual reality will increase the motor function of the paretic 
thoracic extremity of patients with CVE by at least 38.6** average points measured with the Fugl-
Meyer scale compared with usual physical and occupational therapy. 
 
 
 
**The smallest difference in the improvement of the hemiparesis function calculated in points with the Fugl 
Meyer scale, found in patients with characteristics similar to those of the patients in this protocol, was taken. As 
well as the lowest standard deviation to cover all values 46, 47.  
 
 
 
 
AIM 
 
 
 
 
To measure the effect of different therapeutic modalities supported by Virtual Reality or Restriction 
and Induction of Movement compared with usual Physical and Occupational Therapy on the motor 
recovery of paretic limbs in patients with a Cerebral Vascular Event. 
 

VARIABLES 
 
 
Independent Variable 
 
Cerebral vascular event 
 
Conceptual definition. It is defined as a clinical syndrome characterized by the rapid development of 
signs and/or symptoms usually corresponding to a focal or global neurological condition (applicable to 
patients with loss of consciousness or acute headache), which persist for more than 24 hours or which 
lead to death, with no other apparent cause than a vascular origin” 1, 2.  
 
Operational definition. In this work, the patient who comes to request care at the outpatient clinic of the 
UMFR sXXI will be considered, with the interconsultation format 4-30/8 where it is indicated that the 
patient suffered a cerebral vascular event and who presents neurological data consistent with the 
diagnosis, mainly hemiparesis, with or without aphasia. The verification of the diagnosis will be made 
later in the office, with the support of the computed tomography and verified during the physical 
examination; It will also be verified that it covers the rest of the selection criteria. 
 
Indicators. What was described in the interconsultation format 4-30/8 and verified by clinic and skull 
tomography. 
 
Measurement scale. Qualitative, nominal. 
 
 
Virtual reality supported rehabilitation program. 
 
Conceptual definition. It is a concept based on biofeedback supported by computer systems that 
allows the total immersion of the patient in a "real" environment where he receives sound, visual and 
tactile sensory information, which produces a multimodal environment, through which the individual is 
revealed, some of the normal or abnormal physiological events, in the form of auditory or visual 
signals, teaching him to manipulate involuntary events through displayed signals. The set of 
rehabilitation techniques is carried out with the support of the team, hoping that the movements of the 
paretic limbs together with a specific objective translate into greater motor learning at the cortical level 
and therefore greater motor recovery 33, 36. 
 
Operational definition. For this investigation, a virtual reality equipment, commercial, Xbox One Kinect 
®, will be used with the software "tennis"® and "ski" ® for shoulder, arm and hand, "cap the cracks" ® 
for thoracic limb and foot and “Star Wars-battles in the galaxy” for fine hand forceps. The equipment 
will be connected to reference points on the body of the individual sitting or standing in front of the 
device, with which it will establish the displacement of the images on a normal television-type screen 
or with Googles and a manual device for the fine clamp. In front of the patient, visual images 
accompanied by chord sounds will be displayed, where a character represents himself, in such a way 
that when moving the limbs or the body, he will also observe a similar movement in front of him, with 
which he will realize if his movements are appropriate or not, having then the possibility of "forcing" to 
correct or "appreciate the changes" as you progress in training. The movement directed in this way will 
be carried out for 1 hour, 2 times a week, for 6 weeks (12 sessions). 

 
Indicators. The same equipment will always be used for each patient, with the same software, directed 
by the same therapist at pre-established times and days and which will be different days from those of 
the subjects who will receive the other therapies. 
 
Measurement scale. Qualitative, nominal.  
 
 
Rehabilitation program supported by the movement restriction and induction therapy. 
 
Conceptual definition. Movement restriction-induction therapy modified (Constraint-Induced Movement 
Therapy –mCIMT-) is a rehabilitation technique developed by Edward Taub et al., in which the 
recovery of a limb affected by a brain injury, mainly a CVE, can be induced by immobilizing the intact 
arm and training the injured arm 26-28. 
 
Operational definition. For the purposes of this investigation, a sling will be placed on the healthy 
thoracic limb so that it can carry out the therapeutic activities indicated in Annex 1 with the sick limb, 
without any help, not even from the therapist. 
 
Indicators. The therapy will be directed by the same therapist at pre-established times and days and 
that will be different days than those of the subjects who will receive the other therapies, it will be 
carried out for 1 hour, 2 times a week, for 6 weeks. The therapy program is shown in Annex 1 with the 
specific activities that will be standardized for all patients. 
 
Measurement scale. Qualitative, nominal. 
 
 
Rehabilitation program with regular physical and occupational therapy 
 
Conceptual definition. Physiotherapy (from the Greek φυσις physis, 'nature', and θεραπεία therapéia, 
'treatment') is a health discipline that offers a non-pharmacological therapeutic alternative, to alleviate 
symptoms of multiple ailments, both acute and chronic, through exercise therapeutic, heat, cold, light, 
water, manual techniques including massage and electricity; and the occupational is the set of 
techniques, methods and actions that, through activities applied for therapeutic purposes, prevents 
disease and maintains health, favors the restoration of function, makes up for disabling deficiencies 
and assesses the assumptions of behavior and its deep significance to achieve the greatest possible 
independence and reintegration of the individual in all its aspects: work, mental, physical and social. 
 
Operational definition. In the present investigation, a "usual" program has been developed in the 
rehabilitation unit where the work will be carried out. They are a series of standardized and 
individualized activities according to the state of the subject. For study purposes, the programs are 
presented in Annex 1, and will be provided without the support of virtual reality or the restriction-
induction technique of movement. 
 

Indicators. The therapists who will provide the neurorehabilitation programs will always be the same 
and will handle the same assigned patients, in the same workplace, with common materials, 1-hour 
sessions, 2 times a week for 6 weeks (12 sessions). 
 
Measurement scale. Qualitative, nominal. 
 
 
Dependent Variable 
 
Hemiplegia-Hemiparesis secondary to a Cerebral Vascular Event 
 
Conceptual definition. It is the loss of voluntary movement with alteration of muscle tone and 
sometimes sensation in the entire extension of one side of the body, it can be secondary to injuries, 
such as the cerebral vascular event that occurs in one hemisphere and affects the extremities and 
contralateral facial muscles. It behaves like an upper motor neuron syndrome with hypertonia, 
spasticity or rigidity 2. 
 
Operational definition. In this work, the motor or sensorimotor disorder of the hemibody secondary to a 
cerebral vascular event will be verified clinically and by imaging. The usual way of evaluating the 
hemibody is through internationally accepted functional scales, widely validated in Spanish. For 
muscle tone, strength, and movement, the Ashworth and Brunnstrom scales will be used. The 
modified Ashworth scale allows an assessment that, although subjective, is accepted as allowing a 
quantitative approach. It assesses resistance to passive movement, is easy to apply, works for any 
joint, and has a high inter-observer reliability rate; grades muscle tone in relation to the range of 
motion of a joint. The Brunnstrom scale is a facilitation method that uses certain synergistic patterns of 
the hemiplegic patient to create movements. In this way, it seeks the immediate achievement of more 
coordinated and normal voluntary primitive movements, enhancing fine motor skills. 
 
Indicators. 
 
Modified Ashworth scale for the measurement of limb muscle tone. 
 
Degree  
0 
No increase in muscle tone 
1- 
Slight increase in tone manifested by minimal resistance at the end of the range of motion 
during a flexion or extension movement 
1+ 
Slight increase in tone manifested by resistance in less than half the arc of movement 
2 
Increased pitch by more than half the range of motion, but the joint moves easily 
3 
Considerable increase in muscle tone with significant difficulty in joint movement 
4 
Stiffness in flexion or extension 
 
Brunnstrom scale 
 
Degree  
I 
Hypotonia. There are no movements. 
II 
Beginning of recovery. Beginning of basic synergies, mainly through associated reactions. 
The hypertonia begins. 

III 
Voluntary control of basic synergies. Hypertonia rises to the maximum. 
IV 
Beginning of movement combinations. The hypertonia begins to decrease. 
V 
More complex combinations. Decreased synergistic influence. The hypertonia continues to 
decrease. 
VI 
The hypertonia disappears. You can make isolated movements (very analytical). 
Coordination is almost identical to normal. 
VII 
There is no difference with the opposite side. 
 
Measurement scale. Qualitative, ordinal. 
 
 
Motor function of the thoracic limb and pelvic limb 
 
Conceptual definition. For the upper limb, it is the ability of a person to use the shoulder, arm, forearm 
and hand, through which multiple movements and voluntary actions necessary for survival and 
relationship with the environment are carried out, using the nervous and musculoskeletal system. , in 
response to the media. For the lower limb, they are the characteristics of the hip, thigh, knee, leg, 
ankle and foot joints to carry out activities that allow standing and displacement in a useful way; 
voluntary actions necessary for survival and relationship with the environment, as well as activities of 
daily human life 49. 
 
Operational definition. In the present investigation, instruments that translate the clinical evaluation 
and allow the results to be expressed in an objective and quantifiable way will be used. They are 
internationally accepted scales, translated and validated in Spanish, widely used in clinical research. 
They 
measure 
disability 
based 
on 
the 
patient's 
performance 
and 
allow 
classifying 
dependence/independence on it according to the severity of the sequelae or limitations. The scales 
will be: 
 
The Fugl Meyer scale. 
The Motor Index. 
 
The score for each of the dimensions is calculated by adding the partial score of each item and, finally, 
the sum of each dimension provides the total score. The following tables show the grades that are 
awarded according to the response presented by the patient during the evaluation. The scales are 
shown below and in Annex 2. 
 
Fugl-Meyer scale 
 
Domain 
Dimension 
Number 
of items 
Minimum-
maximum score 
Total 
score 
Motor function and 
balance 
Motor function in the upper 
limb 
33 
0 – 66 
114 
Motor function in the lower 
limb 
17 
0 – 34 
Balance 
7 
0 – 14 

Sensitivity 
Aesthetic sensitivity 
4 
0 – 8 
24 
Proprioceptive sensitivity 
8 
0 – 16 
Passive range of 
motion and joint 
pain 
Passive joint range of 
motion 
22 
0 – 44 
88 
Joint passive mobility pain 
22 
0 – 44 
Total 
 
113 
 
226 
 
 
Motor index 
 
Score  
Action/ Movement 
Initial 
valoration 
Intermedia 
valoration 
Final 
valoration 
Sitting patient 
0: no movement 
9: palpable contraction 
14: perform movement but not full range 
vs gravity 
19: full range of motion vs gravity but not 
vs resistance 
25: movement vs resistance but less than 
contralateral 
33: normal strength 
1. Shoulder abduction 
 
 
 
 
 
2. Elbow flexion 
 
Voluntary movement of 
90º 
 
 
 
0: no movement 
11: prehension starts 
19: takes the cube but is not able to hold it 
vs gravity 
22: he takes the cube and is able to hold it 
vs gravity but not vs resistance 
26: take the cube overcomes gravity and 
resistance but is less than the 
contralateral 
33: regular clamp 
3. Grasp 
 
Hand: 2.5 cm cube 
between thumb and other 
fingers. 
 
 
 
0: no movement 
9: palpable contraction 
14: perform movement but not full range 
vs gravity 
19: full range of motion vs gravity but not 
vs resistance 
25: movement vs resistance but less than 
contralateral 
33: normal strength 
4. Hip flexion 
 
 
 
5. Knee extension 
 
 
 
6. Ankle dorsiflexion 
 
 
 
Upper limb Index:1+2+3+(1)/100 
 
 
 
Lower limb index: 
4+5+6+(1)/100 
 
 
 
Total motor index: 
(Motor Index of UL + Motor Index of LL/2)/100 
 
 
 
 
 
 
Indicators. The application process is described in the procedures section. They will always be 
performed by the same doctor, who will ignore which therapy group the patient corresponds to, at the 
beginning, at 6 and 12 treatment sessions. 
 
 
The equivalence of the results for the Motor Index is considered based on 100 total points (sum of 
upper limb + lower limb divided by 2). 

 
Qualification  
Equivalence 
- 100 a  90 points. 
Independent patients with 
rehabilitation for work adjustment and 
activities of daily living. 
- 89 a 80 points. 
Independent patients with limitations, 
who need integral rehabilitation 
treatment. 
- 79  a 70 points. 
Semi-dependent patient who needs 
external help and orthotics. 
- 69 a 60 points. 
Patients with help-dependent 
limitation. 
- Less 60 points. 
Dependent patient needs prolonged 
rehabilitation. 
 
 
The equivalence of the results for the Fugl-Meyer scale is considered based on 100 total points, taking 
into account only the motor aspect of the lower and upper limb (maximum of 66 points for the upper 
limb + 34 points for the lower limb). The original equivalence established by the author in 1980 and the 
most recent one proposed by other authors are shown. 
 
Fugl-Meyer 
(1980) 
Duncan, Goldstein, 
Horner, Landsman, 
Samsa y Matchar 
(1994) 
<50 =    Severo 
0-35 =   Muy severo 
50-84 = Marcado 
36-55 = Severo 
85-94 = Moderado 
56-79 = Moderado 
95-99 = Leve 
>79 =    Leve 
 
Measurement scale. Qualitative, Ordinal.  
 
 
Manual function 
 
Conceptual definition. It is the ability of a person to carry out, through the distal effector segment of the 
thoracic extremity and the grasp, multiple movements as well as the voluntary actions necessary for 
survival and the relationship with the environment 48. 
 
Operational definition. In the present work, the evaluation of the manual function will be measured 
through motor acts by means of the quality test of the fine forceps. 
 
Indicators. The scales are shown below and in Annex 2; the application process is described in the 
procedures section. They will always be performed by the same physician, who will ignore which 
therapy group the patient corresponds to, at the beginning, at 6 and 12 treatment sessions. 
 
 
 

Fine forceps test 
 
Score 
Action/ 
Movement 
Initial 
valoration 
Intermedia 
valoration 
Final 
valoration 
0: inability to take the cube 
1: Grab with your whole hand 
2: Radial or tridigital clamp 
3: Forefinger thumb clamp 
1.4 cm 2 
 
 
 
2.5 cm 2 
 
 
 
3.1 cm 2 
 
 
 
 
A higher score corresponds to a better quality of the fine forceps, the changes in the scores in the 
different measurements are related to the evolution of the functionality of the hand, especially in 
relation to the performance of activities and the level of disability.  
 
Measurement scale. Quantitative, ordinal. 
 
 
Aphasia secondary to the Cerebral Vascular Event 
 
Conceptual definition. It is described as the loss or deterioration in the production or comprehension of 
oral or written language or both, caused by a brain lesion, frequently a Cerebral Vascular Event, 
although it may be secondary to other causes 1. 
 
Operational definition. In the present work, the evaluation of language will be carried out with the 
Boston Aphasia Intensity scale, which is a validated form for a simple test 49. 
 
Indicators. The scale is shown below and in annex 2; the application process is described in the 
procedures section. It will always be performed by the same doctor, who will ignore which therapy 
group the patient corresponds to, at the beginning, at 6 and 12 treatment sessions. 
 
Boston Aphasia Intensity Scale 
 
Description of language features 
Score 
Absence of speech or listening comprehension 
0 
Communication is made entirely from incomplete expressions. It requires inference, 
questions and guessing by the listener. The flow of information can be exchanged, it is 
limited and the weight of the conversation falls on the listener. 
1 
The patient can, with the help of the examiner, have a conversation on familiar topics. 
There is frequent failure to express an idea, but the patient shares the weight of the 
conversation with the examiner. 
2 
The patient can deal with virtually all problems of daily living, with little or no help. 
However, reduced speech and/or comprehension make conversation on certain types of 
topics extremely difficult or impossible. 
3 
There is some obvious loss of speech fluency or ease of understanding with no significant 
limitation of the ideas delivered to their mode of expression. 
4 
Minimal observable impairments in speech. The patient may present subjective difficulties 
that are not evident to the listener. 
5 
 
 
Measurement scale. Quantitative, ordinal. 

Patient satisfaction when performing rehabilitation therapy 
 
Conceptual definition. Feeling of well-being or pleasure that one has when a desire has been fulfilled 
or a need covered. In relation to therapy, this feeling is linked to the development of different 
therapeutic activities 50. 
 
Operational definition. For this research, the Intrinsic Motivation Inventory will be used, which is a 
multidimensional measurement device designed to evaluate the subjective experience of the 
participants related to an objective activity in experiments; It consists of a varied number of subscale 
items, all of which have been shown to be factor analytically consistent and stable across a variety of 
tasks, conditions, and settings. The general criteria for the inclusion of items in the subscales have 
been a factor loading of at least 0.6 in the appropriate subscale. The multiple investigations in which 
they are used suggest that the order effects of item presentation appear to be negligible, and the 
inclusion or exclusion of specific subscales appears to have no impact on the others. Therefore, it is 
used as the equivalent of satisfaction, pleasure in carrying out the activity, and potential adherence to 
treatment. The Task Assessment version will be used, the subscales it includes are: 
 
• Interest and satisfaction with the treatment 
• Perception of competence (of the patient versus the treatment) 
• Effort and importance of treatment 
• Stress or tension (caused by the treatment) 
 
In each one, different questions are answered (Annex 2), and the answer is qualified from 1 to 7 
points, where one is "not everything is true" and 7 is "very true". 
 
Indicators. The sum of the scores obtained by the patient indicates that higher scores correspond to 
better states in the subject and are comparable between groups of participants or the same subject on 
different occasions. 
 
Measurement scale. Qualitative, ordinal. 
 
 
Demographic variables 
 
Age 
 
Conceptual definition. It is the time that a person has lived, counting from birth, measured in years 51. 
 
Operational definition. For this study, the age reported by the patient measured in years or that found 
in the clinical record or any other legal document will be considered. 
 
Indicators. The age reported by the patient or obtained from the clinical record or legal documents. 
 
Measurement scale. Quantitative, ratio. 
 
 

Sex 
 
Conceptual definition. Set of anatomo-physiological characters that distinguish the male from the 
female among individuals of the same species 51. 
 
Operational definition. What is referred by the patient or written in the clinical file or legal documents 
will be considered in this study. 
 
Indicators. Referred by the patient or in the clinical record or legal documents. 
• 
Women 
• 
Man 
 
Measurement scale. Qualitative, nominal, dichotomous. 

SELECTION CRITERIA 
 
 
 
Inclusion criteria 
 
1. Adult patients between the ages of 35 and 70 with a clinically and tomographically proven diagnosis 
of a cerebral vascular event in the territory of the middle cerebral artery. 
2. Patients with hemiparesis secondary to the cerebrovascular event 
3. Patients with a maximum Ashworth of 2 and Brunnstrom of minimum 4 
3. Patients with or without aphasia 
4. Patients with a maximum evolution of 1 month from the start of the cerebrovascular event 
5. Patients with a cerebrovascular event of either sex 
6. Patients with a vascular event without cognitive deficit 
7. Patients who agree to participate by signing an informed consent, by them or their family member or 
person in charge (Annex 3). 
 
 
Exclusion Criteria. 
 
1. Patients with uncontrolled comorbidities, such as arterial hypertension or diabetes mellitus, etc. 
2. Patients with a known prior diagnosis of mental neurological disorder, such as dementia, psychiatric 
disorders, etc. 
3. Patients with previous hemiparesis not fully recovered from any etiology. 
 
 
Elimination criteria 
 
1. Patients who develop dementia or neurological-psychomotor complications during the study. 
2. Patients who present a new cerebrovascular event during the investigation 
3. Patients who do not complete at least 90% of the program 
4. Patients in whom a lack of family support or secondary gain is detected. 

STUDY TYPE AND DESIGN 
 
 
 
 
 
 
 
 
 
 
Type study 
 
 
 
 
Clinic 
 
 
 
 
 
 
 
Design Study 
 
 
 
 
Controlled clinical trial, randomized, single-blind. 
 
 

  
MATERIAL AND METHODS 
 
 
Population 
 
Adult patients with a clinically and tomography-confirmed diagnosis of a Cerebral Vascular Event, with 
body hemiparesis, with or without aphasia. 
 
 
Geographic scope 
 
Outpatient services and physical/occupational therapy of the Physical Medicine and Rehabilitation Unit 
XXI Century (PMRUcXXI). Southern Delegation of the Federal District, IMSS. 
 
 
Limits in time 
 
March 2020 to June 2024. 
 
 
Study General description 
 
Patients with a diagnosis of cerebrovascular event (CVE) will be recruited upon arrival at the 
PMRUcXXI in the first-time appointment area. The diagnosis will be verified and an appointment will 
be made to the office of one of the researchers (evaluator 1). During the appointment the purpose of 
the study will be explained and doubts will be clarified. Whether they accept or not, the patient will 
receive the consultation that is normally provided to this type of patient and the information will be 
recorded in the clinical record. If patient do not accept, after the consultation, the appropriate 
management for your condition will be prescribed and a subsequent appointment will be made with 
the corresponding doctor to continue the control. In case of agreeing to participate, a summary will be 
made in Annex 4, which includes demographic data, whether or not is a worker, the need for 
temporary disability for work and clinical data for the research file. The signature of the informed 
consent letter will be also requested (Annex 3). This physician 1 will assign the therapeutic modality by 
using a table of random numbers to: Group 1. Therapy supported by virtual reality; Group 2. Therapy 
supported by constraint-induced movement; o Group 3. Usual physical and occupational therapy. An 
appointment will then be made to be assessed by the second doctor (evaluator 2), who will remain 
blind to the treatment, and will measure the functionality of the thoracic and pelvic limbs with the 
different scales, described in the procedures section, including muscle tone, trophism, ranges of 
mobility, functionality of the limbs, as well as of the hand, coordination, balance, sensory aspects and 
language (Annex 2). The limb functionality scales will be applied before (initial assessment -V.I.), 
during (intermediate assessment -V.Int.- week 3, session 6) and after (final assessment -V.F.- week 6, 
session 12) of the performance of the different rehabilitation programs. At the same times, the Boston 
Aphasia Intensity Scale and the Intrinsic Motivational Inventory will be applied by a neuropsychologist 
blinded to the treatment. 
 

Procedures. 
 
1. Clinical assessment and randomization. Once the patient, family member or person responsible 
has expressed their willingness to participate by signing the informed consent letter, they will be sent 
to office 16 of the outpatient rehabilitation clinic where they will be received by doctor 1 (treating) who 
will perform a clinical summary that will include age, sex, occupation, somatometry and the need for 
temporary incapacity for work, will carry out their own clinical evaluation in the way that is usually 
practiced in the office and will record it in the clinical file. He will be the one who monitors the patient 
as the treating physician and who answers all the questions that the patient, family member or person 
in charge may have throughout the investigation or in relation to his own condition, for which reason 
he will insist that he not give any information to the patient, doctor who will evaluate you later 
(evaluator 2) and who does not comment on aspects related to the therapy you are receiving, who 
reserves any doubt until the consultation. In addition, he will not know the results of the assessment 
using all the scales that the doctor will perform 2. 
 
Finally, the invetigator will write the corresponding information on the information capture sheet 
(Annex 4. Information collection sheet) and will randomly assign to the different therapeutic modalities 
by using a table of random numbers, which will be placed in the corresponding place of annex: 
 
Group 1: Virtual reality 
Group 2: Constraint-induced motion. 
Group 3: Usual physical and occupational therapy. 
 
When finished, the sheet will be sent to the responsible investigator, who will take the patient to 
physician 2 for the evaluation of the affected hemibody and date for language, then he will take him to 
the corresponding therapists to carry out the assigned treatment. An appointment will be made with 
the neuropsychologist for the evaluation of language and satisfaction.  
 
 
2. Extremity motor assessment. The patient will be admitted to consulting room 22, by appointment, 
where he will be received by physician 2 (blinded evaluator), who will have the indication to address 
the patient specifically in relation to obtaining data during the physical examination (actions to obtain 
the evaluation with scales). He will introduce himself and establish a rapport with the subject, but 
remind him that this assessment is related to an investigation and insist that he not give more 
information than what he requests. The evaluating physician will not know the therapeutic modality 
that the patient will receive. Afterwards, he will ask you to sit on the examination table and the clinical 
review related to the functionality of the hemibody will begin. The evaluation will begin with the motor 
index scale, then the quality of the fine forceps will be measured, and finally the Fugl Meyer scale. The 
assessment will be made before starting therapy, half the number of sessions (3 weeks) and at the 
end of treatment (6 weeks). 
 
a) Evaluation with Fugl Meyer scale. This scale is specific to the Cerebral Vascular Event, 
designed with the objective of measuring the motor deficit, balance, sensitivity and state/pain 
of the joints of patients who present hemiplegia/hemiparesis as a consequence of the event. In 
clinical practice it helps to assess the severity of the deficit, describe motor recovery, plan 
rehabilitation treatment and monitor the clinical evolution of patients after a stroke.  

The result of this scale is measured in a numerical score, the higher numerical score 
corresponds to a better state of the patient's functioning. The scale is built to give ratings 
separately (both members, balance and sensitivity), but it can also be used globally, with a 
maximum of 226 points. The questionnaire must be administered by the evaluating physician, 
it contains 113 items encompassed in 5 domains that in turn cover three dimensions of the 
state of functioning and functionality in the EVC. For each item, the examiner must grant the 
corresponding qualifications indicated in each section. 
  
Fugl-Meyer scale (spanish versión). 
 
Dimension: Assessment of motor function in the upper limb. 
 
Dominio 
Item 
Ini. 
Val.  
Interm. 
Val  
Fin. 
Val.  
I. Osteotendinous reflexes 
0: no reflexes 
2: reflexes are obtained 
1. Biceps 
 
 
 
2. Triceps 
 
 
 
II. Flexor synergy 
 
0: does not perform the action 
1: does it partially 
2: it does it perfectly 
3. Scapular elevation 
 
 
 
4. Shoulder retraction 
 
 
 
5. Shoulder abduction 
 
 
 
6. External rotation of the shoulder 
 
 
 
7. Elbow flexion 
 
 
 
8. Supination of the forearm 
 
 
 
III. Extensor synergy 
0: does not perform the action 
1: does it partially 
2: it does it perfectly 
9. Adduction/internal rotation of the 
shoulder 
 
 
 
10. Elbow extension 
 
 
 
11. Forearm pronation 
 
 
 
IV. Movements combining synergies 
0: cannot perform the action 
1: carry out the action partially (the hand must 
pass thorn anterior superior iliac) 
2: it does it perfectly 
12. Hand towards lumbar spine 
 
 
 
0: arm is abducted immediately, or elbow is 
flexed at start of movement 
1: abduction or flexion of the elbow occurs at a 
later stage of the movement 
2: perform the action perfectly 
13. Shoulder flexed at 90º, elbow at 0º 
 
 
 
0: correct shoulder position and neither elbow 
flexion nor pronation/supination can be 
achieved. 
1: active pronation or supination can be 
performed partially (shoulder and elbow are 
correctly positioned). 
2: perform the action perfectly 
14. Forearm pronation/supination, 
elbow at 90º, shoulder at 0º 
 
 
 
V. Movements that do not combine 
synergies 
0: initial flexion occurs at the elbow, or some 
tendency to pronate the forearm. 
1: the movement can be carried out partially, 
or, if during the movement, the elbow is flexed, 
or the forearm cannot be maintained in 
pronation. 
2: it performs perfectly 
15. Shoulder abduction up to 90º, 
elbow at 0º, forearm pronated 
 
 
 
0: elbow flexion is initiated, or the shoulder is 
abducted 
1: elbow flexion or shoulder abduction occurs 
during shoulder flexion (later in the movement). 
16. Shoulder flexion between 90-180º, 
elbow at 0º and forearm in 
intermediate position 
 
 
 

2: it performs perfectly 
0: supination and pronation cannot be 
performed. 
1: properly positioned elbow and shoulder are 
properly positioned but supination is in range 
limited 
2: it performs perfectly 
17. Pronation/supination of the 
forearm, elbow at 0º and shoulder at 
30-90º of flexion 
 
 
 
VI. Reflexes 
0: at least 2 of the 3 reflexes are markedly 
hyperactive 
1: one reflex is markedly hyperactive or at least 
2 reflexes are present 
2: no more than one reflex is present and none 
is hyperactive 
18. Exploring Reflexes 
 
 
 
VII. Wrist 
0: patient is unable to dorsiflex to the required 
15 degrees 
1: dorsiflexion is performed but no resistance is 
applied 
2: position can be held with resistance 
19. Dorsiflexion of the wrist (elbow at 
90º and shoulder at 0º) 
 
 
 
0: there are no voluntary palmar flexion 
movements 
1: the patient is unable to actively complete the 
full range of motion of the wrist 
2: impeccable, repetitively completing the full 
range of joint movement. 
20. Dorsiflexion and palmar wrist 
(flexion/extension, elbow at 90º and 
shoulder at 0º) 
 
 
 
 
0: patient is unable to dorsiflex to the required 
15 degrees 
1: dorsiflexion is performed but no resistance is 
applied 
2: position can be held with resistance 
21. Dorsiflexion of the wrist (elbow at 
0º and shoulder flexed at 30º) 
 
 
 
 
0: there are no voluntary palmar flexion 
movements 
1: patient cannot actively complete full range 
wrist movement 
2: full movement. 
22. Dorsiflexion and palmar wrist 
(flexion/extension, elbow at 0º and 
shoulder in 30º) 
 
 
 
0: cannot perform 
1: erratic movement or incomplete 
circumduction 
2: fullmovement. 
23. Circular movements 
 
 
 
VIII. Hand 
0: no bending 
1: some flexion but does not redo the full 
movement 
2: full (active) flexion (compared to unaffected 
hand) 
24. Finger flexion 
 
 
 
0: no extension 
1: patient can perform active flexor grip but not 
full movement 
2: full (active) extension (compared to 
unaffected hand) 
25. Finger extension 
 
 
 
0: the required position cannot be achieved 
1: grip is weak 
2: Grip can be maintained with relatively large 
relative resistance 
26. MCF extension Grip 
 
 
 
 
0: the required position cannot be achieved 
1: grip is weak 
2: grip can be maintained with relatively large 
relative resistance 
27. Grab paper 
 
 
 
0: the function cannot be performed 
1: the pencil between the pads of the index 
finger and thumb can be held in place but not 
by light tugging 
2: the pencil grips firmly by holding the pull 
28. Pencil grip 
 
 
 

0: the function cannot be performed 
1: a can can be held between the index finger 
and thumb but not after a pull 
2: the can is held firmly after the pull. 
29. Can grip 
 
 
 
0: the function cannot be performed 
1: can hold tennis ball in place with ball grip but 
not after chuck 
2: the tennis ball can be held firmly after the 
pull 
30. Grab ball 
 
 
 
COORDINATION 
0: marked tremor 
1: light tremor 
2: no tremor 
31. Tremor 
 
 
 
0: pronounced or unsystematic dysmetria 
1: slight or systematic dysmetria 
2: no dysmetria 
32. Dysmetria 
 
 
 
0: activity is more than 6 seconds slower 
that with the unaffected hand 
1: between 2 and 5.9 seconds slower than with 
the unaffected hand 
2: less than 2 seconds apart 
33. Speed 
 
 
 
 
Sum of points obtained 
 
 
 
 
Partial 
score 
# 
/66 
points 
 
Dimension: Assessment of motor function in the lower limb 
 
Dominio 
Item 
Ini. 
Val.  
Interm. 
Val  
Fin. 
Val.  
REFLEXES 
0: not obtained 
2: are obtained 
34. Achilles reflexes 
 
 
 
35. Patellar reflexes 
 
 
 
FLEXOR SYNERGY 
(recumbent position supine) 
0: cannot perform it at all. 
1: perform the movement partially. 
2: perform the movement completely 
36. Hip flexion 
 
 
 
37. Knee flexion 
 
 
 
38. Ankle dorsiflexion 
 
 
 
EXTENSIONAL SYNERGY 
(recumbent position side) 
0: cannot perform it at all. 
1: perform the move partially. 
2: perform the move completely 
39. Hip extension 
 
 
 
40. Hip adduction 
 
 
 
41. Knee extension 
 
 
 
42. Ankle plantar flexion 
 
 
 
MOTION COMBINING SYNERGIES (position 
sitting) 
0: no movement active 
1: from the slightly extended position, the knee 
can be flexed but not more than 90º. 
2: knee flexion more than 90º 
43. Knee flexion (bring the ankle back 
and under the chair) 
 
 
 
0: no movement active 
1: incomplete active flexion (the heel should 
stay on the ground with the medial and lateral 
edges of the forefoot clear of the ground during 
dorsiflexion) 
2: normal dorsiflexion (active full range of motion 
with heel on the ground) 
44. Ankle dorsiflexion (raise the 
tip of the foot with the heel on the 
ground) 
 
 
 
MOVEMENTS WITHOUT SYNERGIES (in 
standing) 
0: the knee cannot be flexed without hip flexion. 
1: knee flexion begins without hip flexion but 
does not reach 90º or the hip begins to flex later 
in the movement. 
2: the knee is flexed more than 90º 
45. Knee flexion (heel back kick) 
 
 
 

0: no active movement. 
1: partial movement or with knee without 
extensión complete 
2: full motion (full joint range in dorsiflexion with 
knee extended and heel on the ground) 
46. Ankle dorsiflexion (raise the toe 
with the heel on the ground) 
 
 
 
REFLEXES (in position sitting) 
0: at least 2 of the 3 reflexes are markedly 
hyperactive 
1: a reflex is markedly overactive or at least 2 
reflections are present 
2: no more than one reflection is alive, and none 
is hyperactive 
47. Reflexes in the lower limbs (score 
only if 4 points are obtained in the 
previous section) 
 
 
 
COORDINATION 
0: marked tremor 
1: light tremor 
2: no tremor 
48. Tremor 
 
 
 
0: pronounced or unsystematic dysmetria 
1: slight or systematic dysmetria 
2: no dysmetria 
49. Dysmetria 
 
 
 
0: the activity is performed in more than 6 
seconds slower than by hand does not affect 
1: between 2 and 5.9 seconds slower than with 
the unaffected hand 
2: less than 2 seconds apart 
50. Speed 
 
 
 
 
Sum of points obtained 
 
 
 
 
Partial 
score 
# 
/34 
points 
 
 
Dimension: Assessment of balance 
 
Dominio 
Item 
Ini. 
Val.  
Interm. 
Val  
Fin. 
Val.  
0: do not sit without support 
1: sits without support for a short time 
2: sit without support for 5 minutes and adjust 
self posture 
51. Sitting without support with feet 
suspended 
 
 
 
0: does not maintain the posture to avoid falling 
1: partially holds the pose 
2: maintains posture properly 
52. Parachute reaction on the 
unaffected side 
 
 
 
0: does not maintain the posture to avoid falling 
1: partially holds the pose 
2: maintains posture properly 
53. Parachute reaction on the 
affected side 
 
 
 
0: does not stand up 
1: does not want important help from other 
person(s) 
2: can be maintained for at least one minute with 
minimal or token assistance from another person 
54. Standing with support 
 
 
 
0: does not stand up 
1: standing 1 minute without oscillations 
2: good balance (+1 minute safely) 
55. Standing without support 
 
 
 
0: holds the position for 1-2 sec 
1: balance 4-9 sec 
2: balance -10 sec 
56. Mono-standing on the leg does 
not affect 
 
 
 
0: holds the position for 1-2 sec 
1: balance 4-9 sec 
2: balance -10 sec 
57. Mono-standing on the affected leg 
 
 
 
 
Sum of points obtained 
 
 
 
 
Partial 
score 
# 
/14 
points 
 
 
 

Dimension: Sensitivity 
 
Dominio 
Item 
Ini. 
Val.  
Interm. 
Val  
Fin. 
Val.  
Exteroceptive 
0) Anesthesia 
1) Hypoesthesia 
2) Normal 
58. Arm 
 
 
 
59. Palm of the hand 
 
 
 
60. Leg 
 
 
 
61. Sole of foot 
 
 
 
Proprioceptive 
0) No answer is correct 
1) Diminished: ¾ of answers are correct 
2) All the answers are correct 
62. Shoulder 
 
 
 
63. Elbow 
 
 
 
64. Wrist 
 
 
 
65. Fingers 
 
 
 
66. Hip 
 
 
 
67. Knee 
 
 
 
68. Ankle 
 
 
 
69. Toes 
 
 
 
 
Sum of points obtained 
 
 
 
 
Partial 
score 
# 
/24 
points 
 
Dimension: Joint range and joint pain 
 
 
Joint range 
0: Just a few degrees of movement 
1: Decreased passive mobility 
2: Normal passive mobility 
Joint pain 
0: Pain in all ranges of motion and severe pain at 
the end of range of motion. 
1: Mild pain           2: No pain 
Dimension 
Dominio 
Val. 
Ini. 
Val 
Int. 
Val. 
Fin. 
Dominio 
Val. 
Ini. 
Val 
Int. 
Val. 
Fin. 
Shoulder 
70. Abduction 
 
 
 
71. Abduction 
 
 
 
 
72. Flexion 
 
 
 
73. Flexion 
 
 
 
 
74. External rotation 
 
 
 
75. External rotation 
 
 
 
 
76. Internal rotation 
 
 
 
77. Internal rotation 
 
 
 
Elbow 
78. Flexion 
 
 
 
79. Flexion 
 
 
 
 
80. Extension 
 
 
 
81. Extension 
 
 
 
Forearm 
82. Pronation 
 
 
 
83. Pronation 
 
 
 
 
84. Supination 
 
 
 
85. Supination 
 
 
 
Wrist 
86. Flexion 
 
 
 
87. Flexion 
 
 
 
 
88. Extension 
 
 
 
89. Extension 
 
 
 
Fingers 
90. Flexion 
 
 
 
91. Flexion 
 
 
 
 
92. Extension 
 
 
 
93. Extension 
 
 
 
Hip 
94. Flexion 
 
 
 
95. Flexion 
 
 
 
 
96. Abduction 
 
 
 
97. Abduction 
 
 
 
 
98. External rotation 
 
 
 
99. External rotation 
 
 
 
 
100. Internal rotation 
 
 
 
101. Internal rotation 
 
 
 
Knee 
102. Flexion 
 
 
 
103. Flexion 
 
 
 
 
104. Extension 
 
 
 
105. Extension 
 
 
 
Ankle 
106. Dorsiflexion 
 
 
 
107. Dorsiflexion 
 
 
 
 
108. Plantar flexion 
 
 
 
109. Plantar flexion 
 
 
 
Foot 
110. Eversion 
 
 
 
111. Eversion 
 
 
 
 
112. Inversion 
 
 
 
113. Inversion 
 
 
 
 
 
 
 
 
Sum of points   
 
 
 
 
 
 
 
Partial 
score 
# 
/ 44 
points 
 
 
 
 
 
TOTAL score 
# 
/226 
 
Ini. Val.: initial valoration; Interm. Val.: intermediate valoration; Fin. Val.: final valoration. 
 
The assessments will be made before starting the therapy (Initial value), at 6 sessions and at the end  
of therapy (12 sessions). 
 

b) Motor index scale. It is a method of scoring muscle strength on the hemiplegic side by assessing 
the action of six key muscles, in a sitting or lying position. It is examined: shoulder abduction and 
elbow flexion (upper limb), grasp (hand), hip flexion, dorsiflexion and ankle knee extension. The 
maximum score in the upper limb is 100 and in the lower limb 100. The global motor index score 
is obtained by adding the position obtained in the upper limb with the lower limb and dividing by 
two (Annex 2. Motor evaluation of plegic limbs /paretic). 
 
Score  
Action/ Movement 
Initial 
valoration 
Intermedia 
valoration 
Final 
valoration 
Sitting patient 
0: no movement 
9: palpable contraction 
14: perform movement but not full range 
vs gravity 
19: full range of motion vs gravity but not 
vs resistance 
25: movement vs resistance but less than 
contralateral 
33: normal strength 
1. Shoulder abduction 
 
 
 
 
 
2. Elbow flexion 
 
Voluntary movement of 90º 
 
 
 
0: no movement 
11: prehension starts 
19: takes the cube but is not able to hold it 
vs gravity 
22: he takes the cube and is able to hold it 
vs gravity but not vs resistance 
26: take the cube overcomes gravity and 
resistance but is less than the 
contralateral 
33: regular clamp 
3. Grasp 
 
Hand: 2.5 cm cube between 
thumb and other fingers. 
 
 
 
0: no movement 
9: palpable contraction 
14: perform movement but not full range 
vs gravity 
19: full range of motion vs gravity but not 
vs resistance 
25: movement vs resistance but less than 
contralateral 
33: normal strength 
4. Hip flexion 
 
 
 
5. Knee extension 
 
 
 
6. Ankle dorsiflexion 
 
 
 
Upper limb Index:1+2+3+(1)/100 
 
 
 
Lower limb index: 
4+5+6+(1)/100 
 
 
 
Total motor index: 
(Motor Index of UL + Motor Index of LL/2)/100 
 
 
 
 
c) Fine clamp quality test. The test evaluates the grip capacity between the thumb and 
forefinger achieved by the patient to take cubes of 1.4, 2.5 and 3.1 cm3; the rating is awarded 
from the inability to take the cube, support with the whole hand or another finger and only with 
the 2 fingers, as shown in the table (the higher the score, the better the grip quality): 
 
Score 
Action/ 
Movement 
Initial 
valoration 
Intermedia 
valoration 
Final 
valoration 
0: inability to take the 
cube 
1: Grab with your whole 
hand 
2: Radial or tridigital 
clamp 
3: Forefinger thumb 
clamp 
1.4 cm 2 
 
 
 
2.5 cm 2 
 
 
 
3.1 cm 2 
 
 
 

d) Language assessment (aphasia). The patient will be summoned to the psychology service, in 
which the neuropsychologist will carry out a structured conversation and questions not related 
to the treatment, for example, family or work situations, through which she will interpret the 
level of language, based on the description written in the Boston Aphasia Intensity Scale and 
will assign the corresponding rating in Annex 2. 
 
 
 
Boston Aphasia Intensity Scale 
 
Description of language features 
Score 
Absence of speech or listening comprehension 
0 
Communication is made entirely from incomplete expressions. It 
requires inference, questions and guessing by the listener. The flow of 
information can be exchanged, it is limited and the weight of the 
conversation falls on the listener. 
1 
The patient can, with the help of the examiner, have a conversation on 
familiar topics. There is frequent failure to express an idea, but the 
patient shares the weight of the conversation with the examiner. 
2 
The patient can deal with virtually all problems of daily living, with little 
or no help. However, reduced speech and/or comprehension make 
conversation on certain types of topics extremely difficult or impossible. 
3 
There is some obvious loss of speech fluency or ease of 
understanding with no significant limitation of the ideas delivered to 
their mode of expression. 
4 
Minimal observable impairments in speech. The patient may present 
subjective difficulties that are not evident to the listener. 
5 
 
 
 
e) Evaluation of satisfaction when performing rehabilitation therapy. The characterization of 
the patient's perception of satisfaction will be evaluated by the same neuropsychologist, who 
will be blinded to the treatment the patient is receiving, using the Intrinsic Motivation Inventory 
(IMI). The IMI is a multidimensional measurement device intended to assess the subjective 
experience of participants related to an objective activity in experiments; it has been used in 
various experiments related to intrinsic motivation and self-regulation. The instrument 
assesses participants' interest/enjoyment, perceived competence, effort, value/utility, felt 
pressure and strain, and perceived choice while performing a given activity, yielding six 
subscale scores. The concepts of perceived choice and perceived competence are theorized 
to be positive predictors of both self-report and behavioral measures of intrinsic motivation, and 
pressure/strain is theorized to be a negative predictor of intrinsic motivation. Effort is a 
separate variable that is relevant to some motivation questions, so it is used as relevant. The 
value/utility subscale is used in internalization studies, with the idea that people internalize and 
self-regulate with regard to activities that they experience as useful or valuable to themselves.  
 
 
The subscales and items are: 
 

Intrinsic Motivation Inventory (Assessment of satisfaction when performing rehabilitation therapy) 
(Spanish versión) 
 
Reality 
Virtual  
 
Restriction and Induction 
of Movement 
TF and TO 
habitual 
 
Patient perception 
Ini. 
Val. 
Interm. 
Val. 
Fin. 
Val. 
Ini. 
Val. 
Interm. 
Val. 
Fin. 
Val. 
Ini. 
Val. 
Interm. 
Val. 
Fin. 
Val. 
Interest and satisfaction with 
treatment 
 
 
 
 
 
 
 
 
 
 
As he worked on the task he thought 
how much he enjoyed it. 
 
 
 
 
 
 
 
 
 
I found the task very interesting. 
 
 
 
 
 
 
 
 
 
Doing homework was fun. 
 
 
 
 
 
 
 
 
 
I really enjoyed doing homework. 
 
 
 
 
 
 
 
 
 
I thought the homework was very 
boring (R). 
 
 
 
 
 
 
 
 
 
I seemed the task very interesting. 
 
 
 
 
 
 
 
 
 
I would describe the task as very 
pleasant. 
 
 
 
 
 
 
 
 
 
Perception of competence (of the 
patient versus the treatment) 
 
 
 
 
 
 
 
 
 
I think I'm very good at this task. 
 
 
 
 
 
 
 
 
 
I think I did very well in this activity, 
compared whit other 
 
 
 
 
 
 
 
 
 
I am satisfied with my performance in 
this task. 
 
 
 
 
 
 
 
 
 
I felt quite skilled at this task. 
 
 
 
 
 
 
 
 
 
After working on this task for a while, I 
felt quite competent. 
 
 
 
 
 
 
 
 
 
Effort and importance of treatment 
 
 
 
 
 
 
 
 
 
I felt it was my choice to do the task. 
 
 
 
 
 
 
 
 
 
I didn't really have the option to do 
task (R). 
 
 
 
 
 
 
 
 
 
I felt like I was doing what I wanted to 
do while working on the assignment. 
 
 
 
 
 
 
 
 
 
I felt that I had obligation to do task 
(R) 
 
 
 
 
 
 
 
 
 
I did the homework because I had no 
other option (R). 
 
 
 
 
 
 
 
 
 
Stress or strain (caused by 
treatment) 
 
 
 
 
 
 
 
 
 
I didn't feel nervous about doing task 
(R). 
 
 
 
 
 
 
 
 
 
I felt tense while doing task. 
 
 
 
 
 
 
 
 
 
I felt relaxed while doing task (R). 
 
 
 
 
 
 
 
 
 
I was anxious while doing task. 
 
 
 
 
 
 
 
 
 
I felt stressed while doing task. 
 
 
 
 
 
 
 
 
 
Ini. Val.: initial valoration; Interm. Val.: intermediate valoration; Fin. Val.: final valoration. 
 
Subscale scores can be used as dependent variables, predictors, or mediators, depending on 
the research questions being addressed. The higher the score, the higher the satisfaction. 
145 
 
3. Therapy programs. 
 
a. Virtual reality program. The activities indicated in the tennis and ski software for the upper limb, 
covering cracks for both limbs and Star Wars-battles in the galaxy for the hand and fine pincer, 

which will be carried out with the interface of the virtual reality equipment "connected" to the 
patient through movement sensors, with the multiperceptual feedback of the Kinect equipment 
or with googles. 
 
 
b. Movement restriction and induction therapy. The patient will be placed a sling on the "healthy" 
thoracic limb, attached to the thorax, through a bra, gently but firmly, in such a way that it does 
not alter circulation or compress peripheral nerves. It will be explained to you that you should 
do all your activities with the “sick” member, to the extent possible. The restriction of the 
healthy side forces the patient to put all his effort into carrying out the activities of daily life, 
simulated during the therapy. This restriction will be carried out for 1 hour in therapy in the 
medical unit. And the patient will be told to repeat it at home at least once a day for one to five 
hours, without receiving support from family members while wearing the sling. 
 
 
c. Regular physical and occupational therapy. The specific activities are shown in Annex 1. They 
include: 
 
o Motor management: tasks to promote mobility of the shoulder, elbow, pentadigital 
clamp, fine clamp, transfers; volitional movements, eye-motor coordination, hip, knee, 
ankle and gait mobility. 
o Sensory 
training: 
deep 
sensitivity, 
stereognosis, 
sensory 
discrimination, 
graphesthesia, topognosis and proprioception. 
 
 
 
4. Concentration and analysis of information. The results of the different evaluations will be noted 
on the information capture sheet (Annex 2 and 4); Subsequently, they will be entered into an Excel 
spreadsheet and finally exported for analysis to the SPSS V-19 program. 

STATISTICAL ASPECTS 
 
 
Sampling 
 
Non-probabilistic, of consecutive cases. 
 
 
Sample size 
 
The sample size calculation was performed to test the working hypothesis* (average difference of 38.6 
points and a SD 12.23), with a standardized effect size greater than 1 in a prefabricated table to 
establish mean differences (Appendix 1. 13 -A) 52, considering a unilateral hypothesis, in a finite 
population and without replacement, with a value α = 0.05 and β= 0.10.: 
 
For 17 patients plus 20% of possible losses, for a total of 19 patients per group. 
 
 
* The score of the motor evolution evaluated with the Fugl-Meyer scale was considered, with therapy supported 
by virtual reality, found in the study of the unit, considered as a pilot 47, 48. 
 
 
Statistic analysis 
 
Descriptive statistics will be carried out for the qualitative variables through tables, graphs and 
percentages; for the quantitative ones, measures of central tendency and its corresponding dispersion 
will be used, depending on the distribution of the data. The distribution of the numerical data will be 
compared with the distribution curve using the Shapiro-Wilk test, depending on the result, the ANOVA 
or Friedman test will be used for intragroup comparison; for compassion between groups, ANOVA of 
repeated measures or the Kruskal-Wallis test will be used. In case of detecting variables that could be 
potentially related to the result, correlation tests such as Pearson or Spearman will be applied. An α 
value of 0.05 will be considered. 

ETHICAL ASPECTS 
 
 
This research respects the institutional, national and international standards that govern research on 
human beings in our country. Including the General Health Law, TITLE FIVE Research for Health, sole 
chapter 53; the regulation of the General Law of Health in Matters of Research for Health 54; and the 
Official Mexican Standard NOM-012-SSA3-2012, which establishes the criteria for the execution of 
research projects for health in human beings 55. 
 
Considering what is specified in the regulation of the General Health Law, second title of the Ethical 
Aspects of Research in Human Beings chapter I, the present work was considered as research with 
greater than minimum risk, since the techniques to be contrasted, although they are considered as 
moderate therapeutic exercise, they are based on activities included in classic physical and 
occupational therapy -common in patients with a cerebrovascular event in the rehabilitation unit-, but 
they will be supported and carried out with unusual or computerized devices and changes are 
expected to occur in brain architecture, evident by clinical changes, since imaging studies will not be 
performed.  
 
Article 17. III. Research with greater than minimal risk: are those in which the 
probabilities of affecting the subject are significant, among which are considered: 
radiological and microwave studies, drug trials and modalities defined in article 65 of 
this Regulation, trials with new devices, studies that include surgical procedures, blood 
extraction of 2% of the circulating volume in neonates, amniocentesis and other 
invasive techniques or major procedures, those that use random methods of 
assignment to therapeutic schemes and those that are controlled with placebos, among 
others . 
 
The signature of the informed consent letter will be requested, by the patient or relatives. A detailed 
explanation of participation will be provided and anonymity will be ensured at all times. Likewise, it will 
be guaranteed that in case of not accepting or suspending the participation, this will not affect the 
management received by the institute. In this case, the patient will go to the regular consultation of the 
doctor in office 16. 
 
This research project was submitted for consideration by the local research and research ethics 
committee, where it was verified that it met the necessary requirements to be carried out and was 
authorized with the registration number R -2016–3702-44.  

RESOURCES 
 
 
 
 
Human Resources 
 
 
 
1. A PhD student and person in charge of the project 
2. A consultant with a doctorate in Medical Sciences and a specialist in rehabilitation medicine 
3. Two advisors with doctorates in medical sciences and specialists in Internal Medicine 
4. A physician specializing in rehabilitation medicine for blinded assessment of patients 
5. A doctor specializing in rehabilitation medicine for regular consultation and monitoring of patients 
6. A psychologist with a master's degree in neuropsychology for mental evaluation 
7. A physical therapist 
8. An occupational therapist 
 
 
 
Material resources 
 
1. Physical and occupational therapy materials: buckets, jars, wood, etc. 
2. A virtual reality equipment and accessories (googles, sensors). 
3. A 50 or 60-inch screen compatible with the Xbox One Kinect. 
4. Office supplies 
 
 
 
Economic resources 
 
The infrastructure of the rehabilitation unit will be used, which has spaces for the management of 
patients with cerebral vascular event, as well as most of the necessary supplies for the production of 
stationery and physical and occupational therapy materials. 
 
 
FINANCING 
 
Funding was not obtained to purchase virtual reality equipment and supplementary materials for 
physical and occupational therapy, so we worked with 2 equipment owned by the participants. The 
occupational therapy materials were those of the Medical Unit where the patient was treated. The 
participating personnel are experts in the area and contributed to the acquisition of materials and 
equipment, mainly the doctoral student.  
 

FEASIBILITY 
 
 
Approximately 32 patients per month with a diagnosis of cerebrovascular event and with the 
necessary characteristics to enter this study attend the rehabilitation unit. There is broad support from 
the authorities to carry out the research and permissions would be granted to the participants to carry 
out the activities in a timely manner. Therefore, it is considered that the study is feasible to be 
completed within the scheduled time. 
 
 
 
 
 
DIFFUSION 
 
 
At the conclusion of this work, the results will be disseminated in the different research forums of the 
IMSS, as well as within the rehabilitation units for their knowledge. It is also intended to be published 
in a journal with impact, as well as to take it to national or international congresses of the specialty. 
 
 
 
 
TRANSCENDENCE 
 
 
With the proposed methodology, it is expected that the results are considered generalizable to the 
population. It is intended that they be seriously considered as a therapeutic tool in the different 
rehabilitation units or medical units that have physical or occupational therapy personnel (first and 
second level), which could impact the care of these patients. It can even affect the cost of the same 
patient who would not have to go to a medical unit for check-ups or reinforcements, due to the fact 
that virtual reality equipment can currently be found in private homes, on the one hand; on the other, 
adherence to the treatment described (if verified) would allow a continuous evolution towards 
improvement with the need for sporadic medical review. 
  
 
 
BIOSECURITY ASPECTS 
 
 
 
 
Does not apply.

SCHEDULE OF ACTIVITIES 
 
 
 
Gantt chart  
 
Start month: Mz = March 2017 (an important delay in the scheduled activities is accepted, related to the 
    earthquake of 2017 and the pandemic in 2020) 
 
 
 
 
 
 
            2018-19*        2020-21* *             2022                2023            2024          2025 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
* México city, earthquake of 2017: structural damage and partial suspension of the therapy service of the physical medicine and 
rehabilitation unit 
** COVID19 pandemic: suspension of the therapy service for patients with stroke sequelae in the physical medicine and 
rehabilitation unit. 
 
T* = Tiempo    P* = Programado    R* = Realizado 
 
Month 
T* 
 
En-
Dc 
En-
Dc 
En-
Dc 
En 
… 
Dc 
En 
… 
Dc 
… 
En 
… 
Dc 
En 
… 
Dc 
En 
… 
Dc 
Modifications of research in  
P* 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
doctoral seminars 
R* 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Standardization of 
P* 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
procedures 
R* 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recruitment, evaluation and   P* 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
patient monitoring 
R* 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
 
 
Analysis and writing of 
P* 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
Results partial/final 
R* 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
Preparation of   
P* 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
final report  partial/final 
R* 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
 
 
 
 
 
 
 
manuscript writing 
P* 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
for publication 
R* 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
 
 
 
 
 
 
 
Send to publication 
P* 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
R* 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
 
 
 
 
 
 
 

 
 
REFERENCES 
 
1. 
Ropper AH, Samuels MA, Klein JP. Cap 34 Enfermedades Cerebrovasculares. En: Adams 
y Victor Principios de Neurología. 10° ed. México: Editorial McGraw-Hill Education; 2017. 
 
2. 
Smith WS, Johnston SC, Hemphill JC. Enfermedades cerebrovasculares. En: Kasper D, 
Fauci A, Hauser S, Longo D, Jameson JL, Loscalzo J. Principios de Medicina Interna. 19ed. 
México: McGraw-Hill Interamericana; 2016.  
 
3. 
Cabrera-Rayo A, Martínez-Olazo O, Laguna-Hernández G, Juárez-Ocaña R, Rosas-
Barrientos V, Loria-Castellanos J. Epidemiología de la enfermedad vascular cerebral en 
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http://dof.gob.mx/nota_detalle.php?codigo=5284148&fecha=04/01/2013 
 

 
 
ANNEX 1. REHABILITATION PROGRAM SENSORY-MOTOR (Spanish) 
 
Training Type 
 
Activity 
Material 
Objectives 
1. Motor 
 
Seated patient, with hip and knee 
flexion of approximately 
mind 90º, with support on the floor of 
both feet with placement of a sling on 
the healthy arm 
 
 
 
 
 
 
Place each of the objects in front of the patient at a 
distance of 10cm, ask him to take them with the affected 
hand for 5 seconds and release them, making sure that 
he does not replace the movement. 
 
-4 plastic buckets 
10 x 10cm 
8x 8 cm 
6x6 cm 
4x4 cm 
- Styrofoam spheres with the 
following diameters 
5 cm 
4cm 
3cm 
2cm 
- Cones with base diameter 
7.5cm 
6.5cm 
5cm 
3.5cm 
 
- Encourage the patient to 
perform the pentadigital clamp, 
promote relaxation of the hand 
flexor muscles 
 
- Promote volitional control 
Place a cube, a sphere and a cone in front of the patient 
at a distance of approximately 30 cm. The therapist will 
stand behind the patient asking him to try to pass the 
object behind his own shoulder. 
-Promote elbow and shoulder 
flexion movements. 
 
-Favor volitional control. 
 
Place in front of the patient and on the table 6 dominoes 
(horizontal) and a plastic container on one side of the 
extremity, ask the patient that with the shoulder in a 
functional position and elbow flexion at 90º, take the 
dominoes and place them in the bowl. 
 
 
Place 3 uncapped vials in an upright position in front of 
the patient and instruct them to change them upside 
down. 
 
 
Wooden dominoes 4 x 10 cm 
 
Plastic jar with 20cm length 
 
-Favor prono-supination 
movements 
 
Place 10 cones on the table, on the opposite side to the 
affected one at a distance of 30cm, instruct the patient to 
take them to the opposite side forming towers (the length 
of the tower will vary according to the patient's progress 
and their ability to release it) 
 
Place jars (filled with sand) in an upright position in front 
of the patient at a distance of 20 cm and instruct him to 
open and close them. 
 
 
- Cones of the size mentioned 
in Item 1.1 
 
- Bottle with lids with a diameter 
of: 
7cm 
5cm 
3cm 
2cm 
Favor the movements of ulnar 
and radial deviation, flexion and 
abduction of the shoulder 

 
 
Training Type 
 
Activity 
Material 
Objectives 
2. Seated motor patient with hip and 
knee flexion of approximately 90º, 
with both feet supported on the floor 
with sling placement on the healthy 
side. 
 
Give the patient a pencil and ask him to draw a straight 
line, and once the patient does it curve ask him to write 
his name. 
Pencil will initially be taken with 
adaptations that will be 
withdrawn according to the 
evolution of the patient. 
- Promote digital-digital clamp, 
eye-motor coordination. 
 
Take objects and try to cut and bring the food to the 
mouth. 
Fork 
Knife 
Soup spoon 
Coffee spoon 
Food 
Adjuncts 
- Favor tridigital clamp, 
pronosupination and 
movements of flexion, elbow 
extension, flexion and 
abduction of the shoulder. 
-Promote visual motor 
coordination 
Take the objects in front of the patient at a distance of 
5cm between them, ask him to take the objects and take 
them to the side of the affected limb, placing it in a 
container achieving maximum abduction of the patient. 
plastic buckets 
Spheres 
Cones(sizes mentioned above) 
-Favor pentadigital clamp, 
increase shoulder mobility arcs: 
Flexion and abduction, elbow 
extension and wrist flexion, 
MCF 
Place 5 spheres at one end of the table distal to the 
patient at a distance where it is possible to take them, ask 
him to collect them with each finger in a container which 
is located next to the affected finger, said container will be 
on a bench at a distance that the range of movement of 
the patient allows it, perform them with the eyes open, 
and then close them. 
-Spheres with a diameter 
of:4cm 
3cm 
2cm 
1cm 
- Container of 40 x 40cm 
-Favor end-to-end clamp, 
transfers, shoulder abduction 
movements, visual-motor 
coordination. 
Assemble a puzzle which will change the number of 
pieces and half according to the evolution of the patient, 
the pieces will be placed at a distance of 3cm between 
them, 10cm from where it was assembled. 
- Foami 10-12 piece 
-Cardboard paper: 24-30 
pieces 
-Favor eye-hand coordination, 
tweezers, flexo elbow 
extension movements, bottom 
figure. 
Place the table of nuts in front of the patient and instruct 
him to try to put or remove as many of them as possible, 
taking them from the healthy side to the affected side 
from distal to proximal. 
- Table of nuts 
-Table with a diameter of 6cm 
-Promote voluntary control, 
tweezers, eye-motor 
coordination. 
- Facilitate relaxation of the 
shoulder girdle 
Place the cylinders and the wooden base on the affected 
side on the opposite side of the affected limb and instruct 
the patient to take the cylinders and place them on their 
bases 
- Wooden cylinders of different 
diameters: 
4cm 
3cm 
2cm 
1cm 
- Favor pincers, shoulder 
abduction and adduction, eye-
motor coordination 
 
 

 
 
Training Type 
Activity 
Material 
Objectives 
3. Patient seated with hip and knee 
flexion of approximately 90º, with 
both feet resting on the floor, with 
sling placement on the healthy side. 
 
 
 
 
 
Place shoulder, elbow and hand in functional position or 
as close as possible to said position, place the left end of 
the table the jars and ask him to take them to the 
opposite end of where 
-Jars with height of: 
20cm 
10cm 
8cm 
4cm 
-Favor transfers, abduction 
and adduction of the 
shoulder. 
Place a ball in the palm of the hand and ask the patient to 
wrap his fingers around it with the minimum force 
required to perform the activity and release it. 
- Gel ball 
-Plastic flexible ball 
-Compact ball of 6cm diameter 
 
-Promote deep sensitivity 
and stereognosis. 
Play dominoes, chopsticks. The objects will be placed on 
the table at the end of the affected side of the patient. 
-Wooden domino of 5x2.5cm 
and 3.5 x 7xm. 
-Plastic Chinese chopsticks (the 
activities will alternate according 
to the evolution of the patient). 
-Promote fine motor activity 
Ask the patient to take the marble with each of the fingers 
and place them in the container in the manner of a digital-
digital clamp. 
-Marbles of diameters: 
4cm 
3cm 
2cm 
1cm 
-Favor digital digit clamp 
 
Place the material on the work table and fix it, ask the 
patient to slide the roll of cloth over the lines, favoring abd 
movements and shoulder rotation. 
-Tablecloth 90 x60cm with 
curved lines in the form of 8 
-Roll of cloth 
-Favor the movements of 
abd, flexion and rotation of 
the shoulder 
 
Training Type 
Activity 
Material 
Objectives 
4. Sensory Training: 
4.1 Place different objects in the palm of the patient's 
hand and ask him to identify the shapes of the objects 
themselves (done with eyes closed) 
-Plastic geometric figures 
-Square 5.5cm 
-Rectangle 3x5cm 
-Spheres 5 cm 
-Promote deep sensitivity, 
stereognosis 
4.2 Place a box full of rice, beans and some objects, 
introduce the patient's hand and ask him to retrieve them, 
which will be changed according to the evolution of the 
patient, starting with those of common use and later with 
geometric figures and the needles. 
-36 x 30cm container filled with 
sand, beans and wheat. 
- Soup spoon and coffee pot 
- Fork 
-Toothbrush, comb, plastic and 
metal keys, geometric figures, 
clicks, 5cm long needles with 
blunt tip. 
 
4.3 Pass different textures over the upper extremity and 
ask the patient to try to identify them. 
Fabrics of different textures: 
-Gentle 
-Smooth 
-Padded 
-Rough 
-Favor sensory 
discrimination 
 

 
 
4.4 Replicate the letters x, o, s, l, z and the numbers from 
1 to 5 on the patient's skin in different places on the limb 
and at different stages, asking the patient to identify the 
replicated letter or number. 
-Wooden pencil 
-Graphesthesia 
4.5 Patient with eyes closed, touch a part of the extremity 
very superficially and ask the patient to identify if he feels 
it, as well as to identify the stimulated site. 
-Cotton 
-Topognosia 
4.6 The therapist using the index or middle finger as a 
reference to move the patient's upper extremity and place 
it in a new place, ask the patient to bring it to the starting 
position by alternating periods with the patient standing 
and sitting. 
 
-Proprioception 
 

 
 
51
Anexo 2. 
GUIDE SHEETS (Spanish version) 
 
MOTOR ASSESSMENT SCALES  Date: _______  Patient number: ____  Group: ___ 
Fugl-Meyer scale (spanish versión). 
 
Dimension: Assessment of motor function in the upper limb. 
 
Dominio 
Item 
Ini. 
Val.  
Interm. 
Val  
Fin. 
Val.  
I. Osteotendinous reflexes 
0: no reflexes 
2: reflexes are obtained 
1. Biceps 
 
 
 
2. Triceps 
 
 
 
II. Flexor synergy 
 
0: does not perform the action 
1: does it partially 
2: it does it perfectly 
3. Scapular elevation 
 
 
 
4. Shoulder retraction 
 
 
 
5. Shoulder abduction 
 
 
 
6. External rotation of the shoulder 
 
 
 
7. Elbow flexion 
 
 
 
8. Supination of the forearm 
 
 
 
III. Extensor synergy 
0: does not perform the action 
1: does it partially 
2: it does it perfectly 
9. Adduction/internal rotation of the 
shoulder 
 
 
 
10. Elbow extension 
 
 
 
11. Forearm pronation 
 
 
 
IV. Movements combining synergies 
0: cannot perform the action 
1: carry out the action partially (the hand must 
pass thorn anterior superior iliac) 
2: it does it perfectly 
12. Hand towards lumbar spine 
 
 
 
0: arm is abducted immediately, or elbow is 
flexed at start of movement 
1: abduction or flexion of the elbow occurs at a 
later stage of the movement 
2: perform the action perfectly 
13. Shoulder flexed at 90º, elbow at 0º 
 
 
 
0: correct shoulder position and neither elbow 
flexion nor pronation/supination can be 
achieved. 
1: active pronation or supination can be 
performed partially (shoulder and elbow are 
correctly positioned). 
2: perform the action perfectly 
14. Forearm pronation/supination, 
elbow at 90º, shoulder at 0º 
 
 
 
V. Movements that do not combine 
synergies 
0: initial flexion occurs at the elbow, or some 
tendency to pronate the forearm. 
1: the movement can be carried out partially, 
or, if during the movement, the elbow is flexed, 
or the forearm cannot be maintained in 
pronation. 
2: it performs perfectly 
15. Shoulder abduction up to 90º, 
elbow at 0º, forearm pronated 
 
 
 
0: elbow flexion is initiated, or the shoulder is 
abducted 
1: elbow flexion or shoulder abduction occurs 
during shoulder flexion (later in the movement). 
2: it performs perfectly 
16. Shoulder flexion between 90-180º, 
elbow at 0º and forearm in 
intermediate position 
 
 
 
0: supination and pronation cannot be 
17. Pronation/supination of the 
 
 
 

 
 
52
performed. 
1: properly positioned elbow and shoulder are 
properly positioned but supination is in range 
limited 
2: it performs perfectly 
forearm, elbow at 0º and shoulder at 
30-90º of flexion 
VI. Reflexes 
0: at least 2 of the 3 reflexes are markedly 
hyperactive 
1: one reflex is markedly hyperactive or at least 
2 reflexes are present 
2: no more than one reflex is present and none 
is hyperactive 
18. Exploring Reflexes 
 
 
 
VII. Wrist 
0: patient is unable to dorsiflex to the required 
15 degrees 
1: dorsiflexion is performed but no resistance is 
applied 
2: position can be held with resistance 
19. Dorsiflexion of the wrist (elbow at 
90º and shoulder at 0º) 
 
 
 
0: there are no voluntary palmar flexion 
movements 
1: the patient is unable to actively complete the 
full range of motion of the wrist 
2: impeccable, repetitively completing the full 
range of joint movement. 
20. Dorsiflexion and palmar wrist 
(flexion/extension, elbow at 90º and 
shoulder at 0º) 
 
 
 
 
0: patient is unable to dorsiflex to the required 
15 degrees 
1: dorsiflexion is performed but no resistance is 
applied 
2: position can be held with resistance 
21. Dorsiflexion of the wrist (elbow at 
0º and shoulder flexed at 30º) 
 
 
 
 
0: there are no voluntary palmar flexion 
movements 
1: patient cannot actively complete full range 
wrist movement 
2: full movement. 
22. Dorsiflexion and palmar wrist 
(flexion/extension, elbow at 0º and 
shoulder in 30º) 
 
 
 
0: cannot perform 
1: erratic movement or incomplete 
circumduction 
2: fullmovement. 
23. Circular movements 
 
 
 
VIII. Hand 
0: no bending 
1: some flexion but does not redo the full 
movement 
2: full (active) flexion (compared to unaffected 
hand) 
24. Finger flexion 
 
 
 
0: no extension 
1: patient can perform active flexor grip but not 
full movement 
2: full (active) extension (compared to 
unaffected hand) 
25. Finger extension 
 
 
 
0: the required position cannot be achieved 
1: grip is weak 
2: Grip can be maintained with relatively large 
relative resistance 
26. MCF extension Grip 
 
 
 
 
0: the required position cannot be achieved 
1: grip is weak 
2: grip can be maintained with relatively large 
relative resistance 
27. Grab paper 
 
 
 
0: the function cannot be performed 
1: the pencil between the pads of the index 
finger and thumb can be held in place but not 
by light tugging 
2: the pencil grips firmly by holding the pull 
28. Pencil grip 
 
 
 

 
 
53
0: the function cannot be performed 
1: a can can be held between the index finger 
and thumb but not after a pull 
2: the can is held firmly after the pull. 
29. Can grip 
 
 
 
0: the function cannot be performed 
1: can hold tennis ball in place with ball grip but 
not after chuck 
2: the tennis ball can be held firmly after the 
pull 
30. Grab ball 
 
 
 
COORDINATION 
0: marked tremor 
1: light tremor 
2: no tremor 
31. Tremor 
 
 
 
0: pronounced or unsystematic dysmetria 
1: slight or systematic dysmetria 
2: no dysmetria 
32. Dysmetria 
 
 
 
0: activity is more than 6 seconds slower 
that with the unaffected hand 
1: between 2 and 5.9 seconds slower than with 
the unaffected hand 
2: less than 2 seconds apart 
33. Speed 
 
 
 
 
Sum of points obtained 
 
 
 
 
Partial 
score 
# 
/66 
points 
 
Dimension: Assessment of motor function in the lower limb 
 
Dominio 
Item 
Ini. 
Val.  
Interm. 
Val  
Fin. 
Val.  
REFLEXES 
0: not obtained 
2: are obtained 
34. Achilles reflexes 
 
 
 
35. Patellar reflexes 
 
 
 
FLEXOR SYNERGY 
(recumbent position supine) 
0: cannot perform it at all. 
1: perform the movement partially. 
2: perform the movement completely 
36. Hip flexion 
 
 
 
37. Knee flexion 
 
 
 
38. Ankle dorsiflexion 
 
 
 
EXTENSIONAL SYNERGY 
(recumbent position side) 
0: cannot perform it at all. 
1: perform the move partially. 
2: perform the move completely 
39. Hip extension 
 
 
 
40. Hip adduction 
 
 
 
41. Knee extension 
 
 
 
42. Ankle plantar flexion 
 
 
 
MOTION COMBINING SYNERGIES (position 
sitting) 
0: no movement active 
1: from the slightly extended position, the knee 
can be flexed but not more than 90º. 
2: knee flexion more than 90º 
43. Knee flexion (bring the ankle back 
and under the chair) 
 
 
 
0: no movement active 
1: incomplete active flexion (the heel should 
stay on the ground with the medial and lateral 
edges of the forefoot clear of the ground during 
dorsiflexion) 
2: normal dorsiflexion (active full range of motion 
with heel on the ground) 
44. Ankle dorsiflexion (raise the 
tip of the foot with the heel on the 
ground) 
 
 
 
MOVEMENTS WITHOUT SYNERGIES (in 
standing) 
0: the knee cannot be flexed without hip flexion. 
1: knee flexion begins without hip flexion but 
does not reach 90º or the hip begins to flex later 
in the movement. 
45. Knee flexion (heel back kick) 
 
 
 

 
 
54
2: the knee is flexed more than 90º 
0: no active movement. 
1: partial movement or with knee without 
extensión complete 
2: full motion (full joint range in dorsiflexion with 
knee extended and heel on the ground) 
46. Ankle dorsiflexion (raise the toe 
with the heel on the ground) 
 
 
 
REFLEXES (in position sitting) 
0: at least 2 of the 3 reflexes are markedly 
hyperactive 
1: a reflex is markedly overactive or at least 2 
reflections are present 
2: no more than one reflection is alive, and none 
is hyperactive 
47. Reflexes in the lower limbs (score 
only if 4 points are obtained in the 
previous section) 
 
 
 
COORDINATION 
0: marked tremor 
1: light tremor 
2: no tremor 
48. Tremor 
 
 
 
0: pronounced or unsystematic dysmetria 
1: slight or systematic dysmetria 
2: no dysmetria 
49. Dysmetria 
 
 
 
0: the activity is performed in more than 6 
seconds slower than by hand does not affect 
1: between 2 and 5.9 seconds slower than with 
the unaffected hand 
2: less than 2 seconds apart 
50. Speed 
 
 
 
 
Sum of points obtained 
 
 
 
 
Partial 
score 
# 
/34 
points 
 
Dimension: Assessment of balance 
 
Dominio 
Item 
Ini. 
Val.  
Interm. 
Val  
Fin. 
Val.  
0: do not sit without support 
1: sits without support for a short time 
2: sit without support for 5 minutes and adjust 
self posture 
51. Sitting without support with feet 
suspended 
 
 
 
0: does not maintain the posture to avoid falling 
1: partially holds the pose 
2: maintains posture properly 
52. Parachute reaction on the 
unaffected side 
 
 
 
0: does not maintain the posture to avoid falling 
1: partially holds the pose 
2: maintains posture properly 
53. Parachute reaction on the 
affected side 
 
 
 
0: does not stand up 
1: does not want important help from other 
person(s) 
2: can be maintained for at least one minute with 
minimal or token assistance from another person 
54. Standing with support 
 
 
 
0: does not stand up 
1: standing 1 minute without oscillations 
2: good balance (+1 minute safely) 
55. Standing without support 
 
 
 
0: holds the position for 1-2 sec 
1: balance 4-9 sec 
2: balance -10 sec 
56. Mono-standing on the leg does 
not affect 
 
 
 
0: holds the position for 1-2 sec 
1: balance 4-9 sec 
2: balance -10 sec 
57. Mono-standing on the affected leg 
 
 
 
 
Sum of points obtained 
 
 
 
 
Partial 
score 
# 
/14 
points 
 

 
 
55
Dimension: Sensitivity 
 
Dominio 
Item 
Ini. 
Val.  
Interm. 
Val  
Fin. 
Val.  
Exteroceptive 
0) Anesthesia 
1) Hypoesthesia 
2) Normal 
58. Arm 
 
 
 
59. Palm of the hand 
 
 
 
60. Leg 
 
 
 
61. Sole of foot 
 
 
 
Proprioceptive 
0) No answer is correct 
1) Diminished: ¾ of answers are correct 
2) All the answers are correct 
62. Shoulder 
 
 
 
63. Elbow 
 
 
 
64. Wrist 
 
 
 
65. Fingers 
 
 
 
66. Hip 
 
 
 
67. Knee 
 
 
 
68. Ankle 
 
 
 
69. Toes 
 
 
 
 
Sum of points obtained 
 
 
 
 
Partial 
score 
# 
/24 
points 
 
Dimension: Joint range and joint pain 
 
 
Joint range 
0: Just a few degrees of movement 
1: Decreased passive mobility 
2: Normal passive mobility 
Joint pain 
0: Pain in all ranges of motion and severe pain at 
the end of range of motion. 
1: Mild pain           2: No pain 
Dimension 
Dominio 
Val. 
Ini. 
Val 
Int. 
Val. 
Fin. 
Dominio 
Val. 
Ini. 
Val 
Int. 
Val. 
Fin. 
Shoulder 
70. Abduction 
 
 
 
71. Abduction 
 
 
 
 
72. Flexion 
 
 
 
73. Flexion 
 
 
 
 
74. External rotation 
 
 
 
75. External rotation 
 
 
 
 
76. Internal rotation 
 
 
 
77. Internal rotation 
 
 
 
Elbow 
78. Flexion 
 
 
 
79. Flexion 
 
 
 
 
80. Extension 
 
 
 
81. Extension 
 
 
 
Forearm 
82. Pronation 
 
 
 
83. Pronation 
 
 
 
 
84. Supination 
 
 
 
85. Supination 
 
 
 
Wrist 
86. Flexion 
 
 
 
87. Flexion 
 
 
 
 
88. Extension 
 
 
 
89. Extension 
 
 
 
Fingers 
90. Flexion 
 
 
 
91. Flexion 
 
 
 
 
92. Extension 
 
 
 
93. Extension 
 
 
 
Hip 
94. Flexion 
 
 
 
95. Flexion 
 
 
 
 
96. Abduction 
 
 
 
97. Abduction 
 
 
 
 
98. External rotation 
 
 
 
99. External rotation 
 
 
 
 
100. Internal rotation 
 
 
 
101. Internal rotation 
 
 
 
Knee 
102. Flexion 
 
 
 
103. Flexion 
 
 
 
 
104. Extension 
 
 
 
105. Extension 
 
 
 
Ankle 
106. Dorsiflexion 
 
 
 
107. Dorsiflexion 
 
 
 
 
108. Plantar flexion 
 
 
 
109. Plantar flexion 
 
 
 
Foot 
110. Eversion 
 
 
 
111. Eversion 
 
 
 
 
112. Inversion 
 
 
 
113. Inversion 
 
 
 
 
 
 
 
 
Sum of points   
 
 
 
 
 
 
 
Partial 
score 
# 
/ 44 
points 
 
 
 
 
 
TOTAL score 
# 
/226 
 
Ini. Val.: initial valoration; Interm. Val.: intermediate valoration; Fin. Val.: final valoration. 
 
 

 
 
56
Motor Index 
 
Action/ 
Movement 
Reality 
Virtual 
Restriction and 
Induction of 
Movement 
TF and TO 
habitual 
Score 
 
Ini. 
Val. 
Interm. 
Val. 
Fin. 
Val. 
Ini. 
Val. 
Interm. 
Val. 
Fin. 
Val. 
Ini. 
Val. 
Interm. 
Val. 
Fin. 
Val. 
Sitting patient 
0: no movement 
9: palpable contraction 
14: perform movement but not full 
range vs gravity 
19: full range of motion vs gravity 
but not vs resistance 
25: movement vs resistance but 
less than contralateral 
33: normal strength 
Shoulder 
abduction 
 
 
 
 
 
 
 
 
 
Elbow 
flexion 
 
Voluntary 
movement 
of 90º 
 
 
 
 
 
 
 
 
 
0: no movement 
11: prehension starts 
19: takes the cube but is not able to 
hold it vs gravity 
22: he takes the cube and is able to 
hold it vs gravity but not vs 
resistance 
26: take the cube overcomes 
gravity and resistance but is less 
than the contralateral 
33: regular clamp 
Grasp 
 
Hand: 2.5 
cm cube 
between 
thumb and 
other 
fingers 
 
 
 
 
 
 
 
 
 
0: no movement 
9: palpable contraction 
14: perform movement but not full 
range vs gravity 
19: full range of motion vs gravity 
but not vs resistance 
25: movement vs resistance but 
less than contralateral 
33: normal strength 
Hip flexion 
 
 
 
 
 
 
 
 
 
Knee 
extension 
 
 
 
 
 
 
 
 
 
Ankle 
dorsiflexion 
 
 
 
 
 
 
 
 
 
Upper limb Index:1+2+3+(1)/100 
 
 
 
 
 
 
 
 
 
Lower limb index: 
4+5+6+(1)/100 
 
 
 
 
 
 
 
 
 
Total motor index: 
(Motor Index of UL + Motor Index of LL/2)/100 
 
 
 
 
 
 
 
 
 
Ini. Val.: initial valoration; Interm. Val.: intermediate valoration; Fin. Val.: final valoration 
 
Fine clamp quality test (Spanish version) 
 
Action/ 
Movement 
Reality 
Virtual 
Restriction and 
Induction of 
Movement 
TF and TO 
habitual 
Score 
 
Ini. 
Val. 
Interm
. Val. 
Fin. 
Val. 
Ini. 
Val. 
Interm
. Val. 
Fin. 
Val. 
Ini. 
Val. 
Interm
. Val. 
Fin. 
Val. 
0: inability to take the cube 
1: Grab with your whole 
hand 
2: Radial or tridigital clamp 
3: Forefinger thumb clamp 
1.4 cm 2 
 
 
 
 
 
 
 
 
 
2.5 cm 2 
 
 
 
 
 
 
 
 
 
3.1 cm 2 
 
 
 
 
 
 
 
 
 
Ini. Val.: initial valoration; Interm. Val.: intermediate valoration; Fin. Val.: final valoration. 

 
 
57
LANGUAGE EVALUATION 
 
Boston aphasia intensity scale (Spanish version) 
 
 
 
Reality 
Virtual  
 
Restriction and 
Induction of 
Movement 
TF and TO 
habitual 
 
Description of language 
features 
Score 
Ini. 
Val. 
Interm. 
Val. 
Fin. 
Val. 
Ini. 
Val. 
Interm
. Val. 
Fin. 
Val. 
Ini. 
Val. 
Interm
. Val. 
Fin. 
Val. 
Absence of speech or 
listening comprehension 
0 
 
 
 
 
 
 
 
 
 
Communication is made 
entirely from incomplete 
expressions. It requires 
inference, questions and 
guessing by the listener. The 
flow of information can be 
exchanged, it is limited and 
the weight of the conversation 
falls on the listener. 
1 
 
 
 
 
 
 
 
 
 
The patient can, with the help 
of the examiner, have a 
conversation on familiar 
topics. There is frequent 
failure to express an idea, but 
the patient shares the weight 
of the conversation with the 
examiner. 
2 
 
 
 
 
 
 
 
 
 
The patient can deal with 
virtually all problems of daily 
living, with little or no help. 
However, reduced speech 
and/or comprehension make 
conversation on certain types 
of topics extremely difficult or 
impossible. 
3 
 
 
 
 
 
 
 
 
 
There is some obvious loss of 
speech fluency or ease of 
understanding with no 
significant limitation of the 
ideas delivered to their mode 
of expression. 
4 
 
 
 
 
 
 
 
 
 
Minimal observable 
impairments in speech. The 
patient may present 
subjective difficulties that are 
not evident to the listener. 
5 
 
 
 
 
 
 
 
 
 
 
Ini. Val.: initial valoration; Interm. Val.: intermediate valoration; Fin. Val.: final valoration. 
 
 
 
 

 
 
58
EVALUATION OF SATISFACTION WHEN PERFORMING REHABILITATION THERAPY 
 
Intrinsic Motivation Inventory (Spanish version) 
 
Cuestionario de Evaluación de Tareas 
 
 
Reality 
Virtual  
 
Restriction and 
Induction of Movement 
TF and TO 
habitual 
 
Patient perception 
Ini. 
Val. 
Interm. 
Val. 
Fin. 
Val. 
Ini. 
Val. 
Interm
. Val. 
Fin. 
Val. 
Ini. 
Val. 
Interm
. Val. 
Fin. 
Val. 
Interest and satisfaction with 
treatment 
 
 
 
 
 
 
 
 
 
 
As he worked on the task he 
thought how much he enjoyed it. 
 
 
 
 
 
 
 
 
 
I found the task very interesting. 
 
 
 
 
 
 
 
 
 
Doing homework was fun. 
 
 
 
 
 
 
 
 
 
I really enjoyed doing homework. 
 
 
 
 
 
 
 
 
 
I thought the homework was very 
boring (R). 
 
 
 
 
 
 
 
 
 
I seemed the task very interesting. 
 
 
 
 
 
 
 
 
 
I would describe the task as very 
pleasant. 
 
 
 
 
 
 
 
 
 
Perception of competence (of the 
patient versus the treatment) 
 
 
 
 
 
 
 
 
 
I think I'm very good at this task. 
 
 
 
 
 
 
 
 
 
I think I did very well in this activity, 
compared whit other 
 
 
 
 
 
 
 
 
 
I am satisfied with my performance 
in this task. 
 
 
 
 
 
 
 
 
 
I felt quite skilled at this task. 
 
 
 
 
 
 
 
 
 
After working on this task for a 
while, I felt quite competent. 
 
 
 
 
 
 
 
 
 
Effort and importance of 
treatment 
 
 
 
 
 
 
 
 
 
I felt it was my choice to do the 
task. 
 
 
 
 
 
 
 
 
 
I didn't really have the option to do 
task (R). 
 
 
 
 
 
 
 
 
 
I felt like I was doing what I wanted 
to do while working on the 
assignment. 
 
 
 
 
 
 
 
 
 
I felt that I had obligation to do task 
(R) 
 
 
 
 
 
 
 
 
 
I did the homework because I had 
no other option (R). 
 
 
 
 
 
 
 
 
 
Stress or strain (caused by 
treatment) 
 
 
 
 
 
 
 
 
 
I didn't feel nervous about doing 
task (R). 
 
 
 
 
 
 
 
 
 
I felt tense while doing task. 
 
 
 
 
 
 
 
 
 
I felt relaxed while doing task (R). 
 
 
 
 
 
 
 
 
 
I was anxious while doing task. 
 
 
 
 
 
 
 
 
 
I felt stressed while doing task. 
 
 
 
 
 
 
 
 
 
Ini. Val.: initial valoration; Interm. Val.: intermediate valoration; Fin. Val.: final valoration. 

 
 
59
ANNEX 3. Informed consent letter 
 
  
 
 
 
 
 
 
 
 
 
 
 
MEXICAN SOCIAL SECURITY INSTITUTE 
EDUCATION AND RESEARCH UNIT AND HEALTH  
POLICIES 
HEALTH RESEARCH COORDINATION 
INFORMED CONSENT LETTER 
(ADULTS) 
 
 
 
 
LETTER OF INFORMED CONSENT FOR PARTICIPATION IN RESEARCH PROTOCOLS 
 
Study name: 
EFFECT OF DIFFERENT THERAPEUTIC MODALITIES SUPPORTED BY VIRTUAL REALITY OR 
MOVEMENT 
RESTRICTION 
AND 
INDUCTION 
COMPARED 
TO 
USUAL 
PHYSICAL 
AND 
OCCUPATIONAL THERAPY ON MOTOR RECOVERY OF PARETIC LIMBS IN PATIENTS WITH 
CEREBRAL VASCULAR EVENT. 
 
External sponsor (if 
applicable): 
Does not apply 
Place and date: 
Mexico City, march 2017 
Número de registro: 
R -2016 – 3702 - 44 
Justification and objective of 
the study: 
The investigator has informed me that the present study is necessary because the cerebrovascular event 
in Mexico causes neurological disability, such as the person who suffers from it being unable to speak 
well or not walk. I understand that these problems have repercussions on the economic aspect of 
hospitals due to the rehabilitation that is usually long and also to the patient, due to transfers and 
problems with his autonomy. The therapies that will be applied in this study have proven their usefulness 
in patients with a vascular event and it has been explained to me that the objective of this study is to 
verify that it can also be performed routinely in this rehabilitation unit with good results and to know how 
much is that the IMSS could be saved in the management of the sequelae of the vascular event and also 
patients like me, in my routine activities, medical consultations and transportation. 
Procedures: 
I understand that if I participate, by chance I will be assigned to and perform one of the two 
neurorehabilitation therapies or the usual therapy (physical and occupational) in this unit. If it is in the 
movement restriction and induction therapy, they will immobilize my healthy arm for about 5 hours a day, 
so that I can carry out activities with my diseased arm and with this it is possible that there is 
improvement in my brain with damage. If it is in virtual reality therapy, I will be fitted with an electronic 
device that will allow me to carry out activities with the arm that I am not moving and see myself on a 
screen and that could also help me regain mobility with an effect on my injured brain. It has been 
explained to me that the physical and occupational therapy that is normally carried out in this unit also 
allows improvement of motor problems related to the brain event like mine, because in fact it is the 
therapy that has been carried out for a long time and has good results. . So I understand that any of the 3 
procedures can help me in recovery, but you want to know which one is better. 
Potential risks and discomfort:  
The doctor has explained to me that there is no real risk from performing therapy. Although I can feel 
some discomfort from having my healthy arm immobilized and feeling somewhat clumsier; Virtual reality 
is like a video game and in it you will most likely not feel discomfort, as well as in the usual therapies. 
Other discomforts or risks are not related to the therapy, but to my underlying problem or illnesses that I 
have suffered from before, such as high blood pressure or diabetes. I know that due to my age or my 
embolism I could have accidents or fall, and that this would not necessarily be related to this study, so I 
must be accompanied and I must carry out the activities at home with a person who supports me to avoid 
accidents, but that does not help me in the exercises. 
Possible benefits you will 
receive from participating in 
the study: 
I understand that the 3 types of therapy have been shown to improve the movement sequelae secondary 
to my vascular event, but it is possible that one of them is better than another, but ultimately the 
rehabilitation that I receive will help me in the recovery of my motor skills if the I do as they tell me and 
reinforce them at home. I have been told that, in addition to the improvement from the therapy, at the 
moment there is no greater benefit, since the differences are hardly being evaluated. In the future I will 
be contacted by phone and it is possible that I will be offered a new reinforcement with the therapy that 
has shown the greatest benefits.  
Information about results and 
treatment alternatives: 
It has been explained to me that if I so wish, in the end they will inform me of the results of the 
investigation, but that I myself will see my evolution with the therapies. In addition to rehabilitation, other 

 
 
60
treatments with drugs or different alternatives have not shown better results, which is why they are not 
used in rehabilitation units. 
Participation or withdrawal: 
I know that my participation is voluntary, so I can withdraw from the study at any time I want, without 
affecting the care I receive from the institute and I will continue to receive care with my treating physician. 
Privacy and confidentiality: 
I have been assured that my name will not be mentioned, nor will I be identified in any other way, in this 
work or any derivative of it, in publications or presentations in places where the results of different 
scientific investigations are disseminated. 
 
In case of collection of biological material (if applicable): 
           
Does not authorize the sample to be taken. 
 
Yes, I authorize the sample to be taken only for this study. 
 
Yes, I authorize the sample to be taken for this study and future studies. 
Availability of medical treatment 
in beneficiaries (if applicable): 
Does not apply 
Benefits at the end of the study: 
Due to the type of therapy that I will receive, my recovery may be different from that of other patients, 
but I will continue my care by the IMSS until my maximum benefit. 
 
In case of doubts or clarifications related to the study, you can contact: 
Responsible Investigator: 
María del Carmen Rojas Sosa; registration tag: 7267339; Southern Delegation, CDMX.; 
Phone: 55 2109 0980 
Collaborators: 
Juan 
Garduño 
Espinosa; 
Research 
Directorate; 
Children's 
Hospital 
of 
Mexico; 
juan.gardunoe@gmail.com 
Jose Antonio Zarate; registration tag: 5570263; UMFR siglo XXI; Phone: 1373 1675 
Norma de la Rosa Peña; registration tag: 99381087; UMFR siglo XXI; Phone: 2915 1185  
Cindy Cueva Sierra; registration tag: 99388872; UMFR siglo XXI; Phone: 6073 1827  
Alma Patricia Ortiz Islas; registration tag:; UMFR siglo XXI; Phone: 7048 2677. 
Evaristo Hinojosa Medina; registration tag: 5552648; Southern Delegation, CDMX, IMSS.; 
Phone: 5634 5259 
José Luis Olvera Gómez; registration tag: 8379491; Southern Delegation, CDMX, IMSS; 
Phone: 1849 6027 
 
In case of doubts or clarifications about your rights as a participant, you can contact: IMSS CNIC Research Ethics Commission; in Avenida 
Cuauhtémoc 330 4th floor Block “B” of the Congress Unit, Colonia Doctores. México, D.F., PC 06720. Phone (55) 56 27 69 00 extension 
21230, E-mail: comision.etica@imss.gob.mx 
 
 
__________ 
Name and signature of the subject 
 
 
___________________________________________ 
Name and signature of the person obtaining the 
consent 
 
Testigo 1 
 
 
Name, address, relationship and signature 
 
Testigo 2 
 
 
Name, address, relationship and signature 
 
This format constitutes a guide that must be completed according to the characteristics of each research protocol, without omitting relevant 
information from the study. 
Clave: 2810-009-013 
 
 

 
 
61
ANNEX 4. 
 
INFORMATION COLLECTION SHEET 
Folio No.: ___________ 
Phone: _______________  Address: ________________________________________ 
Name: ___________________________________ Affiliation: ____________________ 
Age: _______ Sex: _______ Treatment: _________________ Date: _______________ 
Diagnosis: ___________________________________________ 
Type of CVE:  
 
Ischemic: ( )       
Hemorrhagic: ( ) 
Affected side:  
 
Right:       ( )      
Left:   
 ( ) 
 
Clinical summary: 
nPPA: 
Alcoholism:   Yes ( )    No ( )        Smoking:  
Yes ( ) No ( ) 
Schooling:  Yes ( )    No ( )   
Works:  
Yes ( ) No ( )  
Specify:_______________________. 
Requires Disability:  
Yes ( )  
No ( )   
Specify:___________________. 
 
PPA:   
DM ( )  
HTA ( )  
Other: ( )  
Specify:___________________. 
Neurological diseases:  
Yes ( )  
No ( )   
Specify: ___________________. 
Psychiatric illnesses:  
Yes ( )  
No ( )   
Specify:____________________. 
 
AP:___________________________________________________________________
_______________________________________________________________. 
Physical exploration: 
______________________________________________________________________
_____________________________________________________________________. 
 
Treatment group: __________________________________ 
 
Modified Ashworth scale 
 
 
 
Brunnstrom scale 
Segment 
Ini. 
Val.  
Interm. 
Val  
Fin. 
Val.  
Superior 
limb 
 
 
 
Lower  
limb 
 
 
 
Ini.Val.= Initial valoration;  
Interm.Val.= Intermedia valoration;  
Fin.Val.= Final valoration 
Segment 
Ini. 
Val.  
Interm. 
Val  
Fin. 
Val.  
Superior 
limb 
 
 
 
Lower  
limb 
 
 
 
Ini.Val.= Initial valoration;  
Interm.Val.= Intermedia valoration;  
Fin.Val.= Final valoration 

 
 
62
Appendix 1