Comparing a Novel Neuroanimation Experience to Conventional Therapy for High-Dose Intensive Upper-Limb Training in Subacute Stroke: The SMARTS2 Randomized Trial

John W Krakauer, Tomoko Kitago, Jeff Goldsmith, Omar Ahmad, Promit Roy, Joel Stein, Lauri Bishop, Kelly Casey, Belen Valladares, Michelle D Harran, Juan Camilo Cortés, Alexander Forrence, Jing Xu, Sandra DeLuzio, Jeremia P Held, Anne Schwarz, Levke Steiner, Mario Widmer, Kelly Jordan, Daniel LudwigMeghan Moore, Marlena Barbera, Isha Vora, Rachel Stockley, Pablo Celnik, Steven Zeiler, Meret Branscheidt, Gert Kwakkel, Andreas R Luft

Research output: Contribution to journalArticleAcademicpeer-review


BACKGROUND: Evidence from animal studies suggests that greater reductions in poststroke motor impairment can be attained with significantly higher doses and intensities of therapy focused on movement quality. These studies also indicate a dose-timing interaction, with more pronounced effects if high-intensity therapy is delivered in the acute/subacute, rather than chronic, poststroke period.

OBJECTIVE: To compare 2 approaches of delivering high-intensity, high-dose upper-limb therapy in patients with subacute stroke: a novel exploratory neuroanimation therapy (NAT) and modified conventional occupational therapy (COT).

METHODS: A total of 24 patients were randomized to NAT or COT and underwent 30 sessions of 60 minutes time-on-task in addition to standard care. The primary outcome was the Fugl-Meyer Upper Extremity motor score (FM-UE). Secondary outcomes included Action Research Arm Test (ARAT), grip strength, Stroke Impact Scale hand domain, and upper-limb kinematics. Outcomes were assessed at baseline, and days 3, 90, and 180 posttraining. Both groups were compared to a matched historical cohort (HC), which received only 30 minutes of upper-limb therapy per day.

RESULTS: There were no significant between-group differences in FM-UE change or any of the secondary outcomes at any timepoint. Both high-dose groups showed greater recovery on the ARAT (7.3 ± 2.9 points; P = .011) but not the FM-UE (1.4 ± 2.6 points; P = .564) when compared with the HC.

CONCLUSIONS: Neuroanimation may offer a new, enjoyable, efficient, and scalable way to deliver high-dose and intensive upper-limb therapy.

Original languageEnglish
Pages (from-to)393-405
Number of pages13
JournalNeurorehabilitation and Neural Repair
Issue number5
Early online date20 Mar 2021
Publication statusPublished - May 2021

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