Upper extremity (UE) dysfunction is a common problem in patients with stroke. Recently, several neurorehabilitation approaches have been developed to improve the UE motor function (Langphorene P. Lancet Neurol, 2009). However, most approaches target either proximal or distal UE motor function, although interventions targeting both portions are necessary to restore functional UE in actual daily life. Therefore, we conducted stepwise intervention for both shoulder and finger function to improve UE motor function.

Two stroke patients with severe hemiparetic stroke participated in the study. Firstly, we attempted to improve shoulder function using brain machine interface (BMI) technology for 7 days (Fig. 1). After the shoulder BMI training, a combination of motor imagery and electrical stimulation (MI+ES) was conducted to improve finger function for 10 days (Fig. 2). Motor function of the affected UE was assessed with motor items of the Fugl–Meyer assessment UE motor score (FMA-UE). FMA-UE consists of 4 categories (A: Shoulder/Elbow/Forearm; B: Wrist; C: Hand; D: Coordination) and has a maximum score of 66.

The FMA-UE score increased remarkably after the stepwise intervention (Patient A: 17→33; Patient B: 11→25). The effect of shoulder BMI training is shown in Fig. 3. It became possible for patients to raise their arms above the shoulder position after the shoulder BMI training. Patients’ UE motor function was also further improved by the subsequent MI+ES intervention.

The improvement in UE motor function with our stepwise intervention for proximal and distal motor functions greatly exceeded the minimal clinically important difference in the subjects of this study.