strokes produce important physical , psychological and social consequences , in spite of 
 advances in prevention and early care1 . 

several studies highlight the importance of cognitive activities such as attention , memory 
 and action observation on the nervous system plasticity2 , 3 .
the experiences and the 
 information generated by these cognitive activities influence motor learning4 , 5 . 
 hence , the importance of providing the patient with learning experiences and sensory stimuli 
 enriched by the interaction with a therapist6 .
after stroke , achieving patients functionality ( e.g. being able to turn a door handle ) has 
 become the focus of the therapeutic action .
the emphasis of treatment has virtually always 
 been focused on performing the task , regardless of how it was executed , whereas the 
 qualitative aspects of the activity have not been considered to be important7 , 8 . 

taking into account the 
 knowledge on motor learning which highlights not only the motor processes but also the 
 sensory and cognitive strategies5 , it is 
 possible to direct the therapeutic performance to  recovery  instead of  compensation  .
this 
 implies focusing the intervention more on the quality of execution rather than on the final 
 result , promoting an adequate activation of the existing patterns prior to the injury5 , 9 .
a therapeutic strategy that addresses these approaches is the cognitive therapeutic 
 exercise based on the neurocognitive rehabilitation theory described by the neurologist 
 carlo perfetti10 , 11 .
this theory connects the activation of cognitive processes with 
 sensory - motor recovery by means of the patient learning new interaction patterns with their 
 surroundings10 , 11 .
although its effectiveness in orthopedic rehabilitation has been 
 recently demonstrated12,13,14 , there is a need 
 for well - designed studies in neurological patients .
a prior randomized clinical trial15 in acute stroke used a protocol with an 
 unclear and non - specific methodology and it concluded without statistically significant 
 evidence between the two groups .
recently , significant differences were found on upper limb 
 functions from chronic stroke patients , regarding activities of daily living and quality of 
 life16 .
our study has implemented a protocol based on the neurocognitive approach considering and 
 acting on the individual s motor , sensory and cognitive characteristics .
the aim was to 
 determine its feasibility and evaluate whether subjects treated with this protocol improved 
 qualitative upper extremity ( ue ) movement .
we hypothesized that subjects who received the 
 neurocognitive protocol would show greater improvements on motor , sensory and cognitive 
 functional aspects when compared with those treated with a conventional protocol , and these 
 positive changes would also demonstrate clinical and significant improvements on ue 
 functionality with maintenance at follow - up .
the 
 inclusion criteria were : diagnosis of subacute ischemic stroke ( from 15 days to 3 months , 
 middle cerebral artery territory ) , age between 25 and 80 , mini - mental test 24 , motor 
 deficits in ue caused by stroke ( motricity index < 99 ) and enough trunk control to be able 
 to sit with dorsal support .
exclusion criteria were : global aphasia , somatoagnosia or 
 neglect , modified ashworth scale > 2 and carrying out other types of therapies at the same 
 time as the study with the exception of the occupational therapy treatment applied to all 
 participants of the study .
the study was approved by the hospital s 
 clinical investigation ethics committee ( register number : ac-11 - 094 ) and conducted according 
 to the helsinki declaration . following enrollment , participants were randomized consecutively for 10 months by a random 
 number table into two groups : the control group ( cg ) which received conventional physical 
 therapy and the experimental group ( eg ) with the neurocognitive protocol .
the evaluator was 
 a widely experienced and trained physical therapist in assessing and treating stroke 
 patients .
the 
 percentage of adherence rate of 80 and 100% required for treatment and assessments ( a ) , 
 respectively , as well as the percentage of retention rate of 85% were established and 
 controlled by both therapists .
a panel of scales was applied at the beginning of the study ( a1 ) , at 5 weeks ( a2 ) , at the 
 end of the treatment in the 10th week ( a3 ) and at a follow - up 10 weeks later ( a4 ) .
the 
 primary outcome was the motor evaluation scale for upper extremity in stroke patients 
 ( mesupes ) score to assess ue functionality .
the result is 
 obtained by adding together the points at each assessment ( a1234 ) .
each item is scored 
 from 0 ( inability to adapt muscle tone to the movement ) to 5 ( ability to correct and 
 complete motion without help ) .
mesupes - hand consists of 9 wrist and finger items scored on a 
 3-pointed rating scale : no movement or incorrect=0 ; movement incomplete=1 ; movement 
 complete=28 , 17 . the minimal detectable change ( mdc ) for the total score with 95% 
 confidence level was calculated and resulted in a score difference of 8 to be necessary for 
 a genuine change of function
additional outcomes included : the motricity index test , validated for the quantitative 
 assessment of paretic ue muscle strength . in this study
the arm score is the result of adding together the 
 points for the 3 arm test + 1 at each assessment ( a1234)18 . the revised nottingham sensory assessment is a standardized scale 
 for evaluating sensory impairment in stroke patients19 .
the kinesthesia subscale is applied bilaterally on the shoulder , 
 elbow , wrist and metacarpal - phalangeal joint at each assessment ( a1234 ) .
it is scored 
 from 0 ( absent sensation ) to 3 ( correct position ) .
the light touch subscale displays the 
 result of adding together every assessment score on the shoulder , elbow , wrist and palm .
it 
 is scored on a 3 point rating scale : absent sensation=0 ; impaired sensation=1 ; normal 
 sensation=219 .
the kinesthetic and 
 visual imagery questionnaire assesses the cognitive aspect of imagining a movement in its 
 two main dimensions , visual and kinesthetic20 .
it shows the result of adding together the points of each upper 
 extremity item at each assessment with the exception of a2 when no change was expected to be 
 observed .
both dimensions evaluated shoulder elevation , forward shoulder flexion , elbow 
 flexion / extension , thumb - fingers opposition on a score from 1 ( no image or sensation ) to 5 
 ( image as clear as seeing or as intense as executing the action)20 . the values obtained with mesupes at a1 allowed the blinded evaluator to determine the level 
 of motor involvement required by every participant ( passive , active - assisted or active ) .
the 
 evaluator also recommended sensory and cognitive difficulties of the exercises , but those 
 recommendations were only followed by the physical therapist in the eg treatment . in both groups the intervention consisted of passive , active - assisted and active 
 mobilizations with freedom of directions .
proprioceptive joint information was provided on 
 the shoulder , elbow , wrist and fingers segments in addition to tactile information , using 
 different textured surfaces ( rough , fine , etc . ) , on palms and fingers21 , 22 .
both groups 
 performed a 30-minute treatment with 3 individual sessions / week for 10 weeks23 , 24 .
fifteen minutes were dedicated to shoulder , elbow and wrist and 15 
 minutes to the affected hand .
the participant was positioned in a supine position for the 
 first part and in a sitting position for the second one8 . during ue mobilizations and the contact with different surfaces , eg participants received 
 the proposal of sensory discrimination tasks organized in a hierarchy ( from lower to higher 
 difficulty)12 , 13 , 22 , 25 , 26 ( table 1table 
 1.hierarchy of sensory tasks with cognitive 
 activationsensory taskdifficulty level ( low to 
 high)cognitive activity 
 requiredkinestheticjoint movement discriminationrecognition of change between presence and absence of movement :  tell 
 me when you feel the changerecognition of the 
 presence or absence of the movement :  tell me when you feel that the joint x 
 movessimple parameter joint movement discriminationrecognition of the joint moved :  which joint has been moved?recognition of the direction of movement of the joint x :  in which 
 direction is it moving?complex parameter joint movement discriminationrecognition of the distance of movement in the joint x : 
  how far has it moved ?
; in what position are you?recognition of the static position ( spatial relations ) :  where is your elbow in 
 relation to your shoulder?copying spatial relations 
 with the contralateral extremity :  try to imitate exactly the same position with 
 your other armtactilecontact discriminationrecognition of change between presence and absence of contact  tell me when there 
 is a changerecognition of the presence or absence 
 of contact  tell me if you feel there is an area in contact with your palm and 
 fingerscontact location discriminationrecognition of 
 the contact location :  where do you feel the contact?tactile surface 
 discriminationrecognition of similarities 
 and/or differences :  is this tactile surface the same or different from the one 
 you felt before?recognition of touch ( surface 
 categorization )  what does this tactile surface feel like ? ; what surface do you 
 think it is ?  ) .
resolution of these tasks 
 involved cognitive activation of learning strategies such as observation , motor imagery , 
 imitation , etc12 , 13 , 25,26,27 .
every task was proposed 
 as a problem to be resolved with closed eyes13 , 22 , 25 , 26 .
the physical therapist began with the 
 most suitable task for each participant and continued with the following one after the 
 satisfactory completion of the first task5 , 12 , 13 .
in addition , the physical therapist could constantly adapt the 
 protocol to the individual s level based on daily observation but always under the protocol 
 guidelines , designed by an experienced physical therapist and based on the neurocognitive 
 theory12 , 13 .
no discrimination tasks were established in the cg although mobilizations and different 
 surfaces were proposed28 , 29 .
hence , cg participants received the same type of 
 information ( propioceptive and tactile ) but they were not asked to resolve any problem nor 
 to be aware of their body sensations .
individual characteristics and therapy adherence were expressed as mean  standard 
 deviation ( sd ) . the therapy adherence rate ( % ) was also reported .
outcome measure data were 
 reported as score differences between the post and pre - study ( a4a1 ) for each participant , 
 the a1 and a4 median ( md ) for each group as well as between each assessment ( md of a2a1 , 
 a3a2 and a4a3 ) .
nonparametric statistical tests were employed . the pearson  
 test and mann - whitney u test
the wilcoxon signed rank test allowed pre - post clinical evolution from the 
 beginning to the end of the study to be determined in both groups and the mann - whitney u 
 test was used to compare the changes between groups on a1 and a4 .
a significance level of 
 0.05 has been used in all analyses but considered only in an exploratory sense .
seven subjects with involvement of the right middle cerebral artery and one of the left 
 were finally considered for analysis .
one subject withdrew after a2 because of personal 
 reasons and was discarded ( retention rate=89% ) .
the average age was 53.4  9.6  years old , 
 seven males and one woman , all of whom were right - handed .
no statistically significant differences between groups were 
 found relating to gender ( p=1 ) and injured hemisphere ( p=1 ) nor age ( p=0.89 ) and time from 
 stroke onset to treatment ( p=0.89 ) .
all the participants attended at least 80% of the 
 treatment sessions and all four assessments .
this represents an adherence intervention rate of 95.8% in the 10-week treatment period and 
 an assessment rate of 100% in the 20-week study period .
although not statistically significant , there were more relevant pre - post study 
 improvements in the eg on mesupes arm and hand subscales .
these changes appeared earlier and 
 lasted throughout the study in the eg . despite random assignment , significant differences 
 between groups were found at a1 with lower hand values in the cg ( p=0.03 ) . in terms of the 
 minimal detectable change ( mdc ) , all the participants of the eg and 2 of the cg ( participant 
 1 and 4 ) reached pre - post clinical changes .
the secondary outcome measures showed neither 
 statistically significant differences ( p>0.05 ) between groups nor pre - post study changes 
 for each group ( table 2table 2.change of functionality , muscle strength , 
 sensory discrimination and motor imagery abilityoutcome measurescg ( n=4)eg 
 ( n=4)mesupes - armpre18 ( 12 , 29.5)32.5 
 ( 29 , 35.5)post22 ( 11 , 
 34.5)38 ( 36 , 40)45.5mesupes - handpre2 ( 0.5 , 
 4.5)8.5 ( 8 , 12.5)post6.5 ( 0 , 15.5)17.5 ( 15 , 18)4.59mipre39.5 
 ( 26.5 , 54.5)67 ( 58.5 , 73)post51 ( 32 , 76)77 ( 77 , 
 85)11.510rnsa - light touchpre8 ( 6 , 8)4 ( 3.5 , 
 5.5)post8 ( 6 , 8)6.5 ( 5 , 8)02.5rnsa - kinesthesiapre8.5 ( 8 , 
 10.5)10 ( 8.5 , 10.5)post11 ( 10 , 12)12 ( 11 , 
 12)2.52kviq - visualpre17 ( 14 , 19.5)13.5 ( 10.5 , 
 16.5)post19.5 ( 19 , 
 20)20 ( 14.5 , 20)2.56.5kviq - kinesthesiapre18 
 ( 17 , 19.5)18 ( 15 , 20)post19.5 ( 17.5 , 20)18.5 ( 14 , 
 20)1.50.5all data are expressed as medians with 
 interquartile range : md ( min , max)cg : control group ; eg : experimental group ; 
 mesupes : motor evaluation scale for upper extremity in stroke patients ; mi : motricity 
 index test ; rnsa : revised nottingham sensory assessment ; kviq : kinesthetic and visual 
 imagery questionnairetested by wilcoxon signed rank test .
in particular , muscle strength improvements 
 were found mainly in the first 5 weeks for both groups , the same as the kinesthetic results 
 in the cg .
the kinesthetic improvements in the eg were reached at the end of the treatment 
 period as well as the maximum visual image results for both groups .
all data are expressed as medians with 
 interquartile range : md ( min , max ) cg : control group ; eg : experimental group ; 
 mesupes : motor evaluation scale for upper extremity in stroke patients ; mi : motricity 
 index test ; rnsa : revised nottingham sensory assessment ; kviq : kinesthetic and visual 
 imagery questionnaire tested by wilcoxon signed rank test . significance level of 
 0.05 primary and secondary outcome results of each participant in both groups are shown in table 3table 
 3.primary and secondary outcome results of each 
 participantoutcome measurescga1a2a3a4a4a1ega1a2a3a4a4a1mesupes - armp.1373838392p.5364040404p.214101086p.6353840405p.3101315144p.7283033368p.4222828308p.8303034366mesupes - handp.1613171812p.5816171810p.210001p.6161717182p.300000p.791114134p.436151310p.881117179mip.16477778521p.57393939320p.2342934295p.6737777774p.31924293516p.75673777721p.44567676722p.86173777716rnsa - light touchp.188880p.578881p.244640p.644484p.388880p.744451p.488880p.835652rnsa - kinesthesiap.1121212120p.510912100p.29109101p.6111012121p.381011124p.7101212122p.481111102p.87911125kviq - visualp.11920201p.5111292p.21519194p.610202010p.32020200p.71612204p.41320196p.81720203kviq - kinesthesiap.12020200p.51412113p.21720203p.62020173p.31920190p.71616204p.41720161p.82020200a : assessment ; cg : control group ; eg : 
 experimental group ; p : participant ; mesupes : motor evaluation scale for upper 
 extremity in stroke patients ; mi : motricity index test ; rnsa : revised nottingham 
 sensory assessment ; kviq : kinesthetic and visual imagery 
 questionnaire .
a : assessment ; cg : control group ; eg : 
 experimental group ; p : participant ; mesupes : motor evaluation scale for upper 
 extremity in stroke patients ; mi : motricity index test ; rnsa : revised nottingham 
 sensory assessment ; kviq : kinesthetic and visual imagery 
 questionnaire
this study aims to show the influence of motor , sensory and cognitive aspects on ue 
 recovery in subacute stroke patients through the comparison between a neurocognitive 
 protocol and a conventional treatment .
the combined use of a panel of scales is also 
 proposed as it allows the different components involved in motor control to be segregated 
 and assessed . in particular , mesupes has allowed us to determine the individual s initial 
 and successive states in terms of movement quality concerning functional tasks .
the 
 preliminary results of both groups suggest the use of mesupes to obtain stratified sampling 
 in larger studies .
thus , by obtaining more accurate information , the adaptation of the 
 protocol to the characteristics of each individual is facilitated .
the high adherence of 
 participants in treatment and assessments sessions could be explained by both these 
 factors . although the results were not statistically significant , due partially to the small sample 
 studied , they are of important clinical relevance .
furthermore , it resulted in a considerable improvement in the 
 functional autonomy of the ue . in particular , all the eg participants and 2 of the cg showed 
 the score differences ( mdc ) needed to obtain a clinical change .
the mesupes scale shows improvements in both groups indicating that neurocognitive and 
 conventional treatments have been useful to ue functionality ( table 2 ) ; but also demonstrating that the neurocognitive one ( eg ) 
 promotes more benefits in all segments ( shoulder , elbow , wrist and hand ) .
this group 
 presented superior pre - post changes on arm and hand subscales . in previous studies by lang 
 et al.30,31,32 , a higher recovery of the 
 proximal segments is questioned and lack of differences between proximal and distal joints 
 is reported .
our pilot study highlights a greater distal recovery , where the changes for the 
 hands were higher , and occurred earlier in the eg , as a probable consequence of giving 
 greater importance to their treatment .
this is consistent with perfetti s concept of the 
 hand10 , 11 , considered as an essential element for the interaction with the 
 objects inside the action , in which the movements of the more proximal segments are involved 
 and acquire their significance .
to do so , it should be noted that the exercises proposed for 
 the hands included kinesthetic and tactile information due to their importance concerning 
 hand functionality25 , 26 .
the evolution of both groups supports the importance of starting 
 treatment as soon as possible33,34,35 and maintaining 
 it for at least 10 weeks .
with exception of some studies on chronic stroke , there is little 
 evidence on the effectiveness of rehabilitation beyond this period , because no further 
 treatments are usually maintained 3 months after the stroke36 . in the present study , these months coincide with the period 
 between a3 and a4 , in which there was an overall stabilization of the evolution of ue 
 functionality in the cg , while improvements in the eg were still observed .
in addition , the 
 improvements from a1 to a4 may indicate the importance of both motor learning strategies 
 through the discrimination tasks5 , 37 and also the need to extend the treatment 
 beyond this period of time for a better recovery38 . in concordance with previous studies34 , 35 that show the 
 correlation between the individual s initial state and the prognosis , we have also found 
 that subjects with mild or moderate severity have a better functional outcome reached in a 
 shorter time compared to those with higher severity , despite the fact that these subjects 
 are also expected to show an evident improvement at the end of the rehabilitation .
earlier and superior improvements in muscle strength were found in the eg . these gains 
 obtained mainly in the first 5 weeks for both groups did not correlate with increased 
 functionality throughout the 10 weeks of treatment .
this is evidenced by the mesupes scale 
 for all segments in the eg and for the hand in the cg .
this would indicate that although 
 muscle strength , assessed by the motricity index , is gained at the beginning in all 
 segments , more time is needed to translate its gains into functionality improvement through 
 training28 .
moreover , it would indicate 
 that favorable progression in ue movement depends mainly on parameters such as accuracy , 
 fluidity , coordination or correlation between joints7 , 
 32 , 39 , 
 40 .
all of these are qualitative 
 aspects in which sensory discrimination has an important role25 , 26 .
there are still few studies about the effects of passive movement in brain areas during the 
 processing of tactile and kinesthetic information ; but van de winckel et al.25 , 26 
 have already observed that , under both normal and stroke conditions , passive sensory 
 discrimination causes the activation of parietal , pre - motor and motor areas in a similar way 
 as active exploration .
there are different studies about sensory treatment protocols on 
 stroke patients for recovering sensory impairments21 , 
 22 . on the other hand ,
our pilot study 
 aims for movement recovery by sensory processing tasks . despite the need for more 
 homogeneous research into the impact of sensory impairments on motor and functional ue 
 recovery41
the importance of maintaining the 
 treatment during at least 10 weeks is also supported by sensory results .
the light touch trend of 
 improving after the treatment period could be an indicator of the learning factor which is 
 highlighted in the neurocognitive protocol . in the eg , kinesthetic maximum values were 
 obtained at the end of 10 weeks , unlike the cg where improvements were mainly in the first 5 
 weeks .
considering that kinesthesic median values at a1 in both groups were high , there was 
 not a great deal of margin for improvement ( table 
 2 ) .
these results lead us to highlight the role of tactile and kinesthetic 
 discrimination in improving ue functionality .
finally , the cognitive element assessed has been the ability to imagine the ue movement . as 
 in some studies20 , 43 ,
the values of healthy ue were higher in its two dimensions ( visual 
 and kinesthetic ) .
these results suggest that motor and sensory deficits affect the capacity 
 to imagine the body part involved , despite still being in the subacute phase ( 15 days to 3 
 months ) , but this capability changes within a short period of time ( days or a few weeks ) . in 
 the present study
both groups evolved favorably and similarly over the 10 
 weeks of treatment , until almost reaching the maximum score of the visual image .
we can 
 hypothesize that , unlike the kinesthetic image , this component is altered in early stages 
 ( acute and subacute ) .
conversely , the constant arrival of pathological information as well 
 as the probable difficulty in remembering the correct movement sensations would subsequently 
 cause a kinesthetic image disorder .
the recovery of motor memory needs a better and stable 
 representation of the primary motor area achieved with guided therapeutic exercises44 .
a potential limitation in the study is 
 that other cognitive elements also activated in the discriminatory tasks , such as memory or 
 attention , were not evaluated .
some studies45 , 46 have demonstrated the facilitation of 
 tactile processing in the primary sensory area through attention
. other limitations of this study include the lack of neuroimaging techniques to gather 
 further data and a small sample size that resulted in unequal comparison groups with respect 
 to mesupes outcomes despite random assignment .
this study used a blinded evaluator to 
 decrease the likelihood of biased assessment measures .
in general , our results support the protocol feasibility and the use of a panel of scales 
 in order to obtain more accurate evidence of the neurocognitive approach effectiveness by 
 means of a larger study . despite the fact that some clinical trials have been recently 
 published about neurocognitive treatment using a similar approach , their results are not 
 easily comparable to ours , because chanubol et al.15 and lee et al.16 
 performed protocols without establishing clearly either the selection criteria of exercises 
 level or their progression .
sensory and cognition assessments were not applied and the other 
 assessments were only performed before and after treatment . despite the lack of statistical significance , this pilot study indicates that upper 
 extremity movement deficits improve when exercises with motor , sensory and cognitive 
 components are performed following a neurocognitive approach .
a careful selection of the 
 appropriate difficulty for each individual as well as the guidance of a therapist in the 
 cognitive and sensory processes allow greater and prolonged improvements over time on the 
 upper extremity , especially for the hand function .
the neurocognitive approach is a safe , 
 useful and easily applicable way to work with stroke patients in any rehabilitation center . 

although further research is necessary , the feasibility of the proposed protocol facilitates 
 the carrying out of a clinical trial to consolidate evidence of these findings .
 [ purpose ] this study aims to describe a protocol based on neurocognitive therapeutic 
 exercises and determine its feasibility and usefulness for upper extremity functionality 
 when compared with a conventional protocol . 
 [ subjects and methods ] eight subacute stroke 
 patients were randomly assigned to a conventional ( control group ) or neurocognitive 
 ( experimental group ) treatment protocol . 
 both lasted 30 minutes , 3 times a week for 10 
 weeks and assessments were blinded . 
 outcome measures included : motor evaluation scale for 
 upper extremity in stroke patients , motricity index , revised nottingham sensory assessment 
 and kinesthetic and visual imagery questionnaire . 
 descriptive measures and nonparametric 
 statistical tests were used for analysis . [ results ] 
 the results indicate a more favorable 
 clinical progression in the neurocognitive group regarding upper extremity functional 
 capacity with achievement of the minimal detectable change . 
 the functionality results are 
 related with improvements on muscle strength and sensory discrimination ( tactile and 
 kinesthetic ) . 
 [ conclusion ] despite not showing significant group differences between pre 
 and post - treatment , the neurocognitive approach could be a safe and useful strategy for 
 recovering upper extremity movement following stroke , especially regarding affected hands , 
 with better and longer lasting results . 
 although this work shows this protocol s 
 feasibility with the panel of scales proposed , larger studies are required to demonstrate 
 its effectiveness . 