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Atun-Einy O, Kafri M. Physical therapists' perspectives of the construct of motor learning, and their motor learning-based practice: a qualitative study. Physiother Theory Pract 2019; 37:1377-1390. [PMID: 31742466 DOI: 10.1080/09593985.2019.1693676] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: The perceptions and beliefs of physical therapists play an important role in their clinical behavior. These clinician-related aspects may contribute to the knowledge-action gap in the field of motor learning (ML). Accordingly, this study explored how a sample of physical therapists perceive ML in their practice.Methods: A qualitative phenomenological study was conducted. Twelve physical therapists with a wide range of work experience were purposefully selected. Data were collected through semi-structured interviews and analyzed using content analysis methodology. Themes and categories were identified.Results: We identified five key themes: 1) 'ML within the scope of PT' showed that participants perceived ML as a fundamental part of the profession; 2) 'Understanding of ML' showed that participants had difficulty understanding the field comprehensively; 3) 'Self-efficacy toward the topic of ML' revealed that participants had low self-efficacy about their knowledge of the topic; 4) 'Features of ML implementation' showed that physical therapists tended to implement ML intuitively; and 5) 'Barriers to implementation and ways to facilitate it' showed that lack of knowledge was perceived as a main barrier to implementation.Conclusions: Physical therapists' perceptions of and experiences with ML showed the complexity of the field and the lack of clarity regarding its theoretical content and clinical applications. There is a need to reinforce knowledge of ML among physical therapists at different levels of professional development and to promote self-efficacy toward its use, possibly by increasing ML knowledge and education while emphasizing its clinical context.
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Affiliation(s)
- Osnat Atun-Einy
- Department of Physical Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Michal Kafri
- Department of Physical Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
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Fasoli SE, Adans-Dester CP. A Paradigm Shift: Rehabilitation Robotics, Cognitive Skills Training, and Function After Stroke. Front Neurol 2019; 10:1088. [PMID: 31681154 PMCID: PMC6804158 DOI: 10.3389/fneur.2019.01088] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/27/2019] [Indexed: 11/27/2022] Open
Abstract
Introduction: Robot-assisted therapy for upper extremity (UE) impairments post-stroke has yielded modest gains in motor capacity and little evidence of improved UE performance during activities of daily living. A paradigm shift that embodies principles of motor learning and exercise dependent neuroplasticity may improve robot therapy outcomes by incorporating active problem solving, salience of trained tasks, and strategies to facilitate the transfer of acquired motor skills to use of the paretic arm and hand during everyday activities. Objective: To pilot and test the feasibility of a novel therapy protocol, the Active Learning Program for Stroke (ALPS), designed to complement repetitive, robot-assisted therapy for the paretic UE. Key ALPS ingredients included training in the use of cognitive strategies (e.g., STOP, THINK, DO, CHECK) and a goal-directed home action plan (HAP) to facilitate UE self-management and skill transfer. Methods: Ten participants with moderate impairments in UE function >6 months after stroke received eighteen 1-h treatment sessions 2–3/x week over 6–8 weeks. In addition to ALPS training, individuals were randomly assigned to either robot-assisted therapy (RT) or robot therapy and task-oriented training (RT-TOT) to trial whether the inclusion of TOT reinforced participants' understanding and implementation of ALPS strategies. Results: Statistically significant group differences were found for the upper limb subtest of the Fugl-Meyer Assessment (FMA-UE) at discharge and one-month follow-up favoring the RT group. Analyses to examine overall effects of the ALPS protocol in addition to RT and RT-TOT showed significant and moderate to large effects on the FMA-UE, Motor Activity Log, Wolf Motor Function Test, and hand portion of the Stroke Impact Scale. Conclusion: The ALPS protocol was the first to extend cognitive strategy training to robot-assisted therapy. The intervention in this development of concept pilot trial was feasible and well-tolerated, with good potential to optimize paretic UE performance following robot-assisted therapy.
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Affiliation(s)
- Susan E Fasoli
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, Massachusetts General Hospital Institute of Health Professions, Boston, MA, United States
| | - Catherine P Adans-Dester
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, United States
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Kumari N, Taylor D, Signal N. The Effect of Cerebellar Transcranial Direct Current Stimulation on Motor Learning: A Systematic Review of Randomized Controlled Trials. Front Hum Neurosci 2019; 13:328. [PMID: 31636552 PMCID: PMC6788395 DOI: 10.3389/fnhum.2019.00328] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 09/06/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Cerebellar transcranial direct current stimulation (ctDCS) appears to modulate motor performance in both adaptation and motor skill tasks; however, whether the gains are long-lasting is unclear. Objectives: This systematic review aims to evaluate the effect of ctDCS with respect to different time scales of motor learning. Methods: Ten electronic databases (CINAHL, MEDLINE, SPORT Discus, Scopus, Web of Science, Cochrane via OVID, Evidence-Based Reviews (EBM) via OVID, AMED: Allied and Complementary Medicine, PsycINFO, and PEDro) were systematically searched. Studies evaluating the effect of ctDCS compared to sham ctDCS on motor learning in healthy individuals were selected and reviewed. Two authors independently reviewed the quality of the included studies using the revised Cochrane's risk-of-bias tool. The results were extracted with respect to the time scale in which changes in motor performance were evaluated. Results: Seventeen randomized controlled trials met the eligibility criteria of which 65% of the studies had a “high” risk-of-bias, and 35% had “some concerns.” These studies included data from 629 healthy participants. Of the studies that evaluated the effect of anodal ctDCS during and immediately after the stimulation, four found enhanced, three found impaired, and ten found no effect on gains in motor performance. Of the studies that evaluated the effect of anodal ctDCS after a break of 24 h or more, seven found enhanced, two found impaired, and one found no effect on gains in motor performance. Of the studies that evaluated the effect of cathodal ctDCS across a range of time scales, five found impaired, one found enhanced, and five found no effect on gains in motor performance. Conclusions: In healthy individuals, anodal ctDCS appears to improve short to longer-term motor skill learning, whereas it appears to have no effect on gains in motor performance during and immediate after the stimulation. ctDCS may have potential to improve motor performance beyond the training period. The challenge of the motor task and its characteristics, and the stimulation parameters are likely to influence the effect of ctDCS on motor learning.
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Affiliation(s)
- Nitika Kumari
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
| | - Denise Taylor
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
| | - Nada Signal
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
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Abstract
Background and Purpose- For stroke rehabilitation, task-specific training in animal models and human rehabilitation trials is considered important to modulate neuroplasticity, promote motor learning, and functional recovery. Little is known about what constitutes an effective dosage of therapy. Methods- This is a parallel group, 4 arms, single-blind, phase IIb, randomized controlled trial of 4 dosages of arm therapy delivered in an outpatient setting chronically after stroke. Participants were randomized into groups that varied in duration of scheduled therapy (ie, 0, 15, 30, or 60 hours). Forty-one participants completed the study. Planned primary analyses used linear mixed effects regression to model changes from baseline to postintervention in the Motor Activity Log-Quality of Movement rating and the Wolf Motor Function Test time score over 3 weeks of training as a function of therapy dosage. Results- We observed a dose response for the Motor Activity Log-Quality of Movement: the model that included dose and dose by week interaction significantly better fit the data than the model that included week only (log-likelihood test, P=0.0026). In addition, the greater the dosage of training, the greater the change in Motor Activity Log-Quality of Movement, with the dose by week interaction parameter equal to 0.0045 ( P=0.0016; 95% CI, 0.0018-0.0071). Over the 3 weeks of therapy, there was a gain of 0.92 in Motor Activity Log-Quality of Movement for the 60-hour group compared to the 0-hour group. There was no dose response for the Wolf Motor Function Test. Conclusions- For mild-to-moderately impaired stroke survivors, the dosage of patient-centered, task-specific practice systematically influences the gain in quality of arm use but not functional capacity. We caution that we may have been underpowered for the functional capacity outcome. These findings highlight the importance of recovery outcomes that capture arm use in the natural environment. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT01749358.
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Affiliation(s)
- Carolee Winstein
- Department of Neurology, Keck School of Medicine (C.W.), University of Southern California, Los Angeles
| | - Bokkyu Kim
- Department of Physical Therapy Education and Department of Neurology, SUNY Upstate Medical University, Syracuse, NY (B.K.)
| | - Sujin Kim
- Department of Physical Therapy, Jeonju University, South Korea (S.K.)
| | - Clarisa Martinez
- From the Division of Biokinesiology and Physical Therapy, Herman Ostrow School of Dentistry (N.S., C.M.), University of Southern California, Los Angeles
| | - Nicolas Schweighofer
- From the Division of Biokinesiology and Physical Therapy, Herman Ostrow School of Dentistry (N.S., C.M.), University of Southern California, Los Angeles
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Carey L, Walsh A, Adikari A, Goodin P, Alahakoon D, De Silva D, Ong KL, Nilsson M, Boyd L. Finding the Intersection of Neuroplasticity, Stroke Recovery, and Learning: Scope and Contributions to Stroke Rehabilitation. Neural Plast 2019; 2019:5232374. [PMID: 31191637 PMCID: PMC6525913 DOI: 10.1155/2019/5232374] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 02/04/2019] [Accepted: 03/24/2019] [Indexed: 11/17/2022] Open
Abstract
Aim Neural plastic changes are experience and learning dependent, yet exploiting this knowledge to enhance clinical outcomes after stroke is in its infancy. Our aim was to search the available evidence for the core concepts of neuroplasticity, stroke recovery, and learning; identify links between these concepts; and identify and review the themes that best characterise the intersection of these three concepts. Methods We developed a novel approach to identify the common research topics among the three areas: neuroplasticity, stroke recovery, and learning. A concept map was created a priori, and separate searches were conducted for each concept. The methodology involved three main phases: data collection and filtering, development of a clinical vocabulary, and the development of an automatic clinical text processing engine to aid the process and identify the unique and common topics. The common themes from the intersection of the three concepts were identified. These were then reviewed, with particular reference to the top 30 articles identified as intersecting these concepts. Results The search of the three concepts separately yielded 405,636 publications. Publications were filtered to include only human studies, generating 263,751 publications related to the concepts of neuroplasticity (n = 6,498), stroke recovery (n = 79,060), and learning (n = 178,193). A cluster concept map (network graph) was generated from the results; indicating the concept nodes, strength of link between nodes, and the intersection between all three concepts. We identified 23 common themes (topics) and the top 30 articles that best represent the intersecting themes. A time-linked pattern emerged. Discussion and Conclusions Our novel approach developed for this review allowed the identification of the common themes/topics that intersect the concepts of neuroplasticity, stroke recovery, and learning. These may be synthesised to advance a neuroscience-informed approach to stroke rehabilitation. We also identified gaps in available literature using this approach. These may help guide future targeted research.
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Affiliation(s)
- Leeanne Carey
- Occupational Therapy, School of Allied Health, Human Sciences and Sport, College of Science, Health and Engineering, La Trobe University, Bundoora, VIC 3086, Australia
- Neurorehabilitation and Recovery, Stroke Division, Florey Institute of Neuroscience and Mental Health, Heidelberg VIC 3084, Australia
| | - Alistair Walsh
- Occupational Therapy, School of Allied Health, Human Sciences and Sport, College of Science, Health and Engineering, La Trobe University, Bundoora, VIC 3086, Australia
- Neurorehabilitation and Recovery, Stroke Division, Florey Institute of Neuroscience and Mental Health, Heidelberg VIC 3084, Australia
| | - Achini Adikari
- Research Centre for Data Analytics and Cognition, La Trobe University, Bundoora, VIC 3086, Australia
| | - Peter Goodin
- Neurorehabilitation and Recovery, Stroke Division, Florey Institute of Neuroscience and Mental Health, Heidelberg VIC 3084, Australia
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC 3050, Australia
| | - Damminda Alahakoon
- Research Centre for Data Analytics and Cognition, La Trobe University, Bundoora, VIC 3086, Australia
| | - Daswin De Silva
- Research Centre for Data Analytics and Cognition, La Trobe University, Bundoora, VIC 3086, Australia
| | - Kok-Leong Ong
- Research Centre for Data Analytics and Cognition, La Trobe University, Bundoora, VIC 3086, Australia
| | - Michael Nilsson
- Occupational Therapy, School of Allied Health, Human Sciences and Sport, College of Science, Health and Engineering, La Trobe University, Bundoora, VIC 3086, Australia
- Faculty of Health and Medicine and Centre for Rehab Innovations, The University of Newcastle, Callaghan NSW 2308, Australia
- LKC School of Medicine, Nanyang Technological University (NTU), 308232, Singapore
| | - Lara Boyd
- Djavad Mowafaghian Centre for Brain Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada V6T 1Z3
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Stewart JC, Lewthwaite R, Rocktashel J, Winstein CJ. Self-efficacy and Reach Performance in Individuals With Mild Motor Impairment Due to Stroke. Neurorehabil Neural Repair 2019; 33:319-328. [PMID: 30880592 DOI: 10.1177/1545968319836231] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Persistent deficits in arm function are common after stroke. An improved understanding of the factors that contribute to the performance of skilled arm movements is needed. One such factor may be self-efficacy (SE). OBJECTIVE To determine the level of SE for skilled, goal-directed reach actions in individuals with mild motor impairment after stroke and whether SE for reach performance correlated with actual reach performance. METHODS A total of 20 individuals with chronic stroke (months poststroke: mean 58.1 ± 38.8) and mild motor impairment (upper-extremity Fugl-Meyer [FM] motor score: mean 53.2, range 39 to 66) and 6 age-matched controls reached to targets presented in 2 directions (ipsilateral, contralateral). Prior to each block (24 reach trials), individuals rated their confidence on reaching to targets accurately and quickly on a scale that ranged from 0 ( not very confident) to 10 ( very confident). RESULTS Overall reach performance was slower and less accurate in the more-affected arm compared with both the less-affected arm and controls. SE for both reach speed and reach accuracy was lower for the more-affected arm compared with the less-affected arm. For reaches with the more-affected arm, SE for reach speed and age significantly predicted movement time to ipsilateral targets ( R2 = 0.352), whereas SE for reach accuracy and FM motor score significantly predicted end point error to contralateral targets ( R2 = 0.291). CONCLUSIONS SE relates to measures of reach control and may serve as a target for interventions to improve proximal arm control after stroke.
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Affiliation(s)
| | - Rebecca Lewthwaite
- 2 Rancho Los Amigos National Rehabilitation Center, Downey, CA, USA.,3 University of Southern California, Los Angeles, CA, USA
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Krishnan C, Dharia AK, Augenstein TE, Washabaugh EP, Reid CE, Brown SR, Ranganathan R. Learning new gait patterns is enhanced by specificity of training rather than progression of task difficulty. J Biomech 2019; 88:33-37. [PMID: 30905405 DOI: 10.1016/j.jbiomech.2019.03.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 03/08/2019] [Indexed: 10/27/2022]
Abstract
The use of motor learning strategies may enhance rehabilitation outcomes of individuals with neurological injuries (e.g., stroke or cerebral palsy). A common strategy to facilitate learning of challenging tasks is to use sequential progression - i.e., initially reduce task difficulty and slowly increase task difficulty until the desired difficulty level is reached. However, the evidence related to the use of such sequential progressions to improve learning is mixed for functional skill learning tasks, especially considering situations where practice duration is limited. Here, we studied the benefits of sequential progression using a functional motor learning task that has been previously used in gait rehabilitation. Three groups of participants (N = 43) learned a novel motor task during treadmill walking using different learning strategies. Participants in the specific group (n = 21) practiced only the criterion task (i.e., matching a target template that was scaled-up by 30%) throughout the training. Participants in the sequential group (n = 11) gradually progressed to the criterion task (from 3% to 30% in increments of 3%), whereas participants in the random group (n = 11) started at 3% and progressed in random increments (involving both increases and decreases in task difficulty) to the criterion task. At the end of training, kinematic tracking performance on the criterion task was evaluated in all participants both with and without visual feedback. Results indicated that the tracking error was significantly lower in the specific group, and no differences were observed between the sequential and the random progression groups. The findings indicate that the amount of practice in the criterion task is more critical than the difficulty and variations of task practice when learning new gait patterns during treadmill walking.
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Affiliation(s)
- Chandramouli Krishnan
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI, USA; Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA; Michigan Robotics Institute, University of Michigan, Ann Arbor, MI, USA; School of Kinesiology, University of Michigan, Ann Arbor, MI, USA.
| | - Aastha K Dharia
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Thomas E Augenstein
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI, USA; Mechanical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Edward P Washabaugh
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI, USA; Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Courtney E Reid
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Scott R Brown
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Rajiv Ranganathan
- Department of Kinesiology, Michigan State University, East Lansing, MI, USA
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Buitrago JA, Bolaños AM, Caicedo Bravo E. A motor learning therapeutic intervention for a child with cerebral palsy through a social assistive robot. Disabil Rehabil Assist Technol 2019; 15:357-362. [DOI: 10.1080/17483107.2019.1578999] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
| | | | - Eduardo Caicedo Bravo
- School of Electrical and Electronic Engineering, University of Valle, Cali, Colombia
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59
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Lewthwaite R, Winstein CJ, Lane CJ, Blanton S, Wagenheim BR, Nelsen MA, Dromerick AW, Wolf SL. Accelerating Stroke Recovery: Body Structures and Functions, Activities, Participation, and Quality of Life Outcomes From a Large Rehabilitation Trial. Neurorehabil Neural Repair 2019; 32:150-165. [PMID: 29554849 DOI: 10.1177/1545968318760726] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Task-oriented therapies have been developed to address significant upper extremity disability that persists after stroke. Yet, the extent of and approach to rehabilitation and recovery remains unsatisfactory to many. OBJECTIVE To compare a skill-directed investigational intervention with usual care treatment for body functions and structures, activities, participation, and quality of life outcomes. METHODS On average, 46 days poststroke, 361 patients were randomized to 1 of 3 outpatient therapy groups: a patient-centered Accelerated Skill Acquisition Program (ASAP), dose-equivalent usual occupational therapy (DEUCC), or usual therapy (UCC). Outcomes were taken at baseline, posttreatment, 6 months, and 1 year after randomization. Longitudinal mixed effect models compared group differences in poststroke improvement during treatment and follow-up phases. RESULTS Across all groups, most improvement occurred during the treatment phase, followed by change more slowly during follow-up. Compared with DEUCC and UCC, ASAP group gains were greater during treatment for Stroke Impact Scale Hand, Strength, Mobility, Physical Function, and Participation scores, self-efficacy, perceived health, reintegration, patient-centeredness, and quality of life outcomes. ASAP participants reported higher Motor Activity Log-28 Quality of Movement than UCC posttreatment and perceived greater study-related improvements in quality of life. By end of study, all groups reached similar levels with only limited group differences. CONCLUSIONS Customized task-oriented training can be implemented to accelerate gains across a full spectrum of patient-reported outcomes. While group differences for most outcomes disappeared at 1 year, ASAP participants achieved these outcomes on average 8 months earlier (ClinicalTrials.gov: Interdisciplinary Comprehensive Arm Rehabilitation Evaluation [ICARE] Stroke Initiative, at www.ClinicalTrials.gov/ClinicalTrials.gov . Identifier: NCT00871715).
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Affiliation(s)
- Rebecca Lewthwaite
- 1 University of Southern California, Los Angeles, CA, USA.,2 Rancho Los Amigos National Rehabilitation Center, Downey, CA, USA
| | | | | | | | - Burl R Wagenheim
- 2 Rancho Los Amigos National Rehabilitation Center, Downey, CA, USA
| | | | - Alexander W Dromerick
- 4 Georgetown University, Washington, DC, USA.,5 MedStar National Rehabilitation Hospital, Washington, DC, USA.,6 VA Medical Center, Washington, DC, USA
| | - Steven L Wolf
- 3 Emory University, Atlanta, GA, USA.,7 VA Center on Visual and Neurocognitive Rehabilitation, Decatur, GA, USA
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Crum EO, Baltz MJ, Krause DA. The use of motor learning and neural plasticity in rehabilitation for ataxic hemiparesis: A case report. Physiother Theory Pract 2019; 36:1256-1265. [PMID: 30686101 DOI: 10.1080/09593985.2019.1566941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background and Purpose: Although the principles of neural plasticity for stroke rehabilitation are well established, specific intervention plans for patients with ataxia following a lacunar infarct are not well described. The purpose of this case report is to describe the intervention program for a patient with ataxic hemiparesis based on principles of motor learning and neural plasticity. Case Description: An 83-year-old, socially active male presented to the emergency department with right-sided upper extremity weakness and ataxia. The patient's acute hospital course included 4 days in a stoke unit, followed by 13 days in inpatient rehabilitation. Intervention: A 3-phase graded mobility and coordination plan was used during inpatient rehabilitation. Interventions included function-based training with repeated ambulation, coordination activities for the upper and lower extremities, and strengthening to help the patient achieve his goal of walking "without gait deviations." The concepts of motor learning and neural plasticity were utilized for timing and feedback on patient errors when implementing this novel program. Outcomes: The patient's level of assistance for mobility and activities of daily living improved from minimal assistance to modified independence without use of an assistive device. The Dynamic Gait Index score improved from 16/24 to 20/24 suggesting a decreased fall risk. Discussion: This case report describes a novel intervention strategy for a patient with ataxia following a lacunar stroke. The application of the principles of neural plasticity and motor learning was the foundation for a function-based plan of care.
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Affiliation(s)
- Ellen O Crum
- Michigan Medicine, Department of Physical Medicine and Rehabilitation, University Hospital , Ann Arbor, MI, USA
| | - Mathew J Baltz
- Michigan Medicine, Department of Physical Medicine and Rehabilitation, University Hospital , Ann Arbor, MI, USA
| | - David A Krause
- Physical Therapy, Mayo Clinic, College of Medicine and Science , Rochester, MN, USA
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Serel Arslan S, Azola A, Sunday K, Vose A, Plowman E, Tabor L, Singer M, Robison R, Humbert IA. Effects of Submental Surface Electrical Stimulation on Swallowing Kinematics in Healthy Adults: An Error-Based Learning Paradigm. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2018; 27:1375-1384. [PMID: 30076418 PMCID: PMC6436455 DOI: 10.1044/2018_ajslp-17-0224] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/20/2018] [Accepted: 04/25/2018] [Indexed: 06/08/2023]
Abstract
PURPOSE Hyoid bone and laryngeal approximation aid airway protection (laryngeal vestibule closure) while moving toward their peak superior and anterior positions during swallowing. Submental surface electrical stimulation (SES) is a therapeutic technique that targets the muscles that move the hyoid bone during swallowing. It is unknown whether submental SES only increases peak hyoid bone swallowing positions but not peak laryngeal swallowing positions, which could require faster or greater laryngeal movement to achieve adequate laryngeal vestibule closure. METHOD We examined the effects of submental SES on hyo-laryngeal kinematics in 30 healthy adults who swallowed 50 times using an error-based learning paradigm. RESULTS Submental SES did not alter any hyo-laryngeal swallowing kinematic. However, submental SES significantly changed the starting position of the hyoid bone just prior to the swallow onset (more anterior; p = .003). On average, submental SES immediately prior to swallow onset can position the hyoid approximately 20% closer to its peak swallowing point. CONCLUSIONS These findings indicate that electrical stimulation of the agonists for hyoid movement might not alter swallowing outcomes tested in this study. However, submental SES could have clinical utility by minimizing swallowing impairments related to reduced hyoid swallowing range of motion in individuals with dysphagia.
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Affiliation(s)
| | - Alba Azola
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD
| | - Kirstyn Sunday
- Swallowing Systems Core, Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
| | - Alicia Vose
- Swallowing Systems Core, Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Department of Physical Therapy, University of Florida, Gainesville
| | - Emily Plowman
- Swallowing Systems Core, Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Department of Physical Therapy, University of Florida, Gainesville
| | - Lauren Tabor
- Swallowing Systems Core, Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Department of Physical Therapy, University of Florida, Gainesville
| | - Michele Singer
- Swallowing Systems Core, Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Department of Physical Therapy, University of Florida, Gainesville
| | - Raele Robison
- Swallowing Systems Core, Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Department of Physical Therapy, University of Florida, Gainesville
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Adhikari SP, Bimali I, Baidya S, Shakya NR. Community-based rehabilitation for physically impaired earthquake victims: An evidence-based practice protocol and its pre-post experimental study. J Family Med Prim Care 2018; 7:1327-1333. [PMID: 30613520 PMCID: PMC6293879 DOI: 10.4103/jfmpc.jfmpc_112_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND A natural disaster like earthquake is a sudden event that causes not only the loss of life but also mental, emotional, and physical disabilities. An earthquake of 7.8 magnitudes hit Nepal and injured more than 18,500 people in 2015. There was a critical need to develop rehabilitation protocols. Therefore, we aimed to structure community-based rehabilitation protocols for physically impaired earthquake victims and to investigate immediate effect of the intervention to address disability and reduce public health burden. MATERIALS AND METHODS Evidence-based rehabilitation protocols for various injuries were structured to address the victims' impairments and activity limitations. The protocols were administered to 13 victims of one of the most affected community sites, for 60 min/day, 12 days in 2 weeks at their own doors. Local resources were used to make the protocols sustainable. An immediate effect of the protocols was evaluated within the group. The World Health Organization Disability Assessment Schedule, numerical pain rating scale, and time up and go (TUG) test were used to measure disability level, pain, and mobility status, respectively. Wilcoxon's signed rank test was used to analyze pre-post data. RESULTS All participants completed the rehabilitation without adverse effects. The treatment demonstrated significant reduction in disability level (P < 0.001, effect size = 0.63) and pain level (P = 0.007). However, change with TUG was not significant. CONCLUSION The evidence-based, structured community rehabilitation protocols demonstrated benefits in improving the victim's quality of life. Follow-ups will be continued to explore sustainability and long-term effects of the interventions.
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Affiliation(s)
- Shambhu P. Adhikari
- Department of Physiotherapy, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal, South Asia, Nepal
| | - Inosha Bimali
- Department of Physiotherapy, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal, South Asia, Nepal
| | - Sumana Baidya
- Department of Physiotherapy, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal, South Asia, Nepal
| | - Nishchal R. Shakya
- Department of Physiotherapy, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal, South Asia, Nepal
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Schuster-Amft C, Eng K, Suica Z, Thaler I, Signer S, Lehmann I, Schmid L, McCaskey MA, Hawkins M, Verra ML, Kiper D. Effect of a four-week virtual reality-based training versus conventional therapy on upper limb motor function after stroke: A multicenter parallel group randomized trial. PLoS One 2018; 13:e0204455. [PMID: 30356229 PMCID: PMC6200191 DOI: 10.1371/journal.pone.0204455] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 08/20/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Virtual reality-based training has found increasing use in neurorehabilitation to improve upper limb training and facilitate motor recovery. OBJECTIVE The aim of this study was to directly compare virtual reality-based training with conventional therapy. METHODS In a multi-center, parallel-group randomized controlled trial, patients at least 6 months after stroke onset were allocated either to an experimental group (virtual reality-based training) or a control group receiving conventional therapy (16x45 minutes within 4 weeks). The virtual reality-based training system replicated patients´ upper limb movements in real-time to manipulate virtual objects. Blinded assessors tested patients twice before, once during, and twice after the intervention up to 2-month follow-up for dexterity (primary outcome: Box and Block Test), bimanual upper limb function (Chedoke-McMaster Arm and Hand Activity Inventory), and subjective perceived changes (Stroke Impact Scale). RESULTS 54 eligible patients (70 screened) participated (15 females, mean age 61.3 years, range 20-81 years, time since stroke 3.0±SD 3 years). 22 patients were allocated to the experimental group and 32 to the control group (3 drop-outs). Patients in the experimental and control group improved: Box and Block Test mean 21.5±SD 16 baseline to mean 24.1±SD 17 follow-up; Chedoke-McMaster Arm and Hand Activity Inventory mean 66.0±SD 21 baseline to mean 70.2±SD 19 follow-up. An intention-to-treat analysis found no between-group differences. CONCLUSIONS Patients in the experimental and control group showed similar effects, with most improvements occurring in the first two weeks and persisting until the end of the two-month follow-up period. The study population had moderate to severely impaired motor function at entry (Box and Block Test mean 21.5±SD 16). Patients, who were less impaired (Box and Block Test range 18 to 72) showed higher improvements in favor of the experimental group. This result could suggest that virtual reality-based training might be more applicable for such patients than for more severely impaired patients. TRIAL REGISTRATION ClinicalTrials.gov NCT01774669.
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Affiliation(s)
- Corina Schuster-Amft
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
- Institute for Rehabilitation and Performance Technology, Bern University of Applied Sciences, Burgdorf, Switzerland
| | - Kynan Eng
- Institute of Neuroinformatics, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Zorica Suica
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
| | - Irene Thaler
- Department of Physiotherapy, Insel Group, Bern University Hospital, Berne, Switzerland
| | - Sandra Signer
- Physiotherapy Department, Buergerspital Solothurn, Solothurn, Switzerland
| | - Isabelle Lehmann
- Department of Physiotherapy, Insel Group, Bern University Hospital, Berne, Switzerland
| | - Ludwig Schmid
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
- Physiotherapy Department, Zurcher RehaZentrum Lengg, Zurich, Switzerland
| | - Michael A. McCaskey
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
- Institute of Human Movement Sciences, ETH Zurich, Zurich, Switzerland
| | - Miura Hawkins
- Institute of Neuroinformatics, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Martin L. Verra
- Department of Physiotherapy, Insel Group, Bern University Hospital, Berne, Switzerland
| | - Daniel Kiper
- Institute of Neuroinformatics, University of Zurich and ETH Zurich, Zurich, Switzerland
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Winstein C, Varghese R. Been there, done that, so what’s next for arm and hand rehabilitation in stroke? NeuroRehabilitation 2018; 43:3-18. [DOI: 10.3233/nre-172412] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Carolee Winstein
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA
| | - Rini Varghese
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA
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Abstract
PURPOSES To present the history and aims of the STEP conferences; describe the interdependence of prevention, prediction, plasticity, and participation; reflect on where we stand today regarding those 4 Ps; and discuss how future neurorehabilitation should look for individuals with movement disorders. KEY POINTS Physical therapists have focused primarily on tertiary prevention, emphasizing primary/secondary prevention far less. Predicting optimal response to intervention is essential for primary prevention. Research examining neurorehabilitation effects mediated by brain plasticity is evolving from an emphasis on impairment outcomes toward examination of participation outcomes. CLINICAL PRACTICE RECOMMENDATIONS:: (1) Capitalize on primary and secondary prevention. (2) Administer simple, environmentally relevant predictive measures. (3) Partner with researchers to examine exercise-induced brain plasticity effects via neuroimaging. (4) Encourage physical activity to promote secondary prevention of lifestyle-related diseases and enhance participation. (5) Integrate psychological/social sciences with physiological sciences to move forward with advances in mindful health and patient-centered practices.
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Adhikari SP, Tretriluxana J, Chaiyawat P, Jalayondeja C. Enhanced Upper Extremity Functions with a Single Session of Action-Observation-Execution and Accelerated Skill Acquisition Program in Subacute Stroke. Stroke Res Treat 2018; 2018:1490692. [PMID: 30009017 PMCID: PMC6020497 DOI: 10.1155/2018/1490692] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/31/2018] [Accepted: 05/17/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Action-observation-execution (AOE) primes physical training. We examined the immediate effect of AOE with accelerated skill acquisition program (ASAP) on dexterity in subacute stroke. METHODS Twelve individuals from 1 to 6 months after stroke were allocated into two groups by matching age and side of stroke. After AOE of 30 minutes, the experimental group received ASAP for 60 minutes whereas the control group received dose-equivalent usual care. The movement time (MT) and functional ability (FA) of hand items of the Wolf motor function test (WMFT), hand functions and global recovery of stroke impact scale (SIS), and intrinsic motivation items of stroke rehabilitation motivation scale were assessed at baseline, after training, and during one-week follow-up. Data were analyzed within and between the groups. RESULTS AOE significantly decreased MT of flipping cards of WMFT and hand functions of SIS. Total MT was markedly reduced. AOE with ASAP demonstrated significant group-by-time interactions on MT of lifting pencil of WMFT, total MT, and global recovery. Grip strength, FA, and hand functions were significantly improved only in the experimental group. Both groups improved motivation significantly. CONCLUSIONS The AOE with ASAP enhanced dexterity, which persisted for at least a week. This intervention might improve dexterity in subacute stroke. TRIAL REGISTRATION NUMBER This trial is registered with TCTR20161007001.
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Affiliation(s)
- Shambhu Prasad Adhikari
- Faculty of Physical Therapy, Mahidol University, Thailand
- Department of Physiotherapy, Kathmandu University School of Medical Sciences, Nepal
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Jacobs JV, Henry SM, Horak FB. What If Low Back Pain Is the Most Prevalent Parkinsonism in the World? Front Neurol 2018; 9:313. [PMID: 29770123 PMCID: PMC5940750 DOI: 10.3389/fneur.2018.00313] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/19/2018] [Indexed: 01/28/2023] Open
Abstract
Low back pain (LBP) has a point prevalence of nearly 10% and ranks highest in global disease burden for years lived with disability; Parkinson’s disease (PD) ranks in the top 100 most disabling health conditions for years lost and years lived with disability (1). Recent evidence suggests that people with chronic, recurrent LBP exhibit many postural impairments reminiscent of a neurological postural disorder such as PD. We compare and contrast postural impairments associated with LBP and PD in order to inform treatment strategies for both conditions. The literature suggests that both LBP and PD associate with impaired proprioceptive function, sensory orientation during standing balance, anticipatory postural adjustments, automatic postural responses, and striatal-cortical function. Although postural impairments are similar in nature for LBP and PD, the postural impairments with LBP appear more specific to the trunk than for PD. Likewise, although both health conditions associate with altered striatal-cortical function, the nature of the altered neural structure or function differ for PD and LBP. Due to the high prevalence of LBP associated with PD, focused treatment of LBP in people with PD may render benefit to their postural impairments and disabilities. In addition, LBP would likely benefit from being considered more than just a musculoskeletal injury; as such, clinicians should consider including approaches that address impairments of postural motor control.
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Affiliation(s)
- Jesse V Jacobs
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, VT, United States
| | - Sharon M Henry
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, VT, United States.,Department of Rehabilitation Therapy, University of Vermont Medical Center, Burlington, VT, United States
| | - Fay B Horak
- Department of Neurology, School of Medicine, Oregon Health & Science University, Veterans Affairs Portland Health Care System, Portland, OR, United States
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68
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Atun-Einy O, Kafri M. Implementation of motor learning principles in physical therapy practice: Survey of physical therapists' perceptions and reported implementation. Physiother Theory Pract 2018; 35:633-644. [PMID: 29589787 DOI: 10.1080/09593985.2018.1456585] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION The field of motor learning (ML) plays a pivotal role in physical therapy (PT), and its implementation has been shown to improve intervention outcomes. The objective of this study was to assess physical therapists' ML-related self-efficacy, self-reported implementation, and environmental workplace factors. An additional aim was to report the psychometric properties of a questionnaire that was developed to assess the above-mentioned constructs. METHODS An observational, cross-sectional survey was completed by 289 physical therapists (average age: 38.7 (9.7), with 11.3 (9.7) years of experience and 74% female). Construct validity, internal consistency, and test-retest reliability were tested. The main outcome measures were the scores of the three scales of the questionnaire, referring to self-efficacy in ML, implementation of ML principles, and workplace environment features. RESULTS The questionnaire had sound psychometric qualities. Respondents perceived ML as an integral part of PT. ML-related self-efficacy and implementation of ML principles were moderate (2.95/5 (0.7) and 3.04/5(0.8), respectively). PT practice had a significant effect on ML-related self-efficacy (p = 0.035) and implementation (p = 0.0031). Respondents who had undergone ML training in their graduate program reported higher ML-related self-efficacy (p = 0.007). Respondents who had postgraduate training in ML reported significantly more extensive implementation (p = 0.024). Lack of knowledge and lack of time were perceived as the major barriers to implementation. CONCLUSIONS Level of self-efficacy might be insufficient to support the systematic implementation of ML principles in practice. Addressing impeding individual- and organizational-level factors might facilitate ML self-efficacy and implementation. Postgraduate education facilitates ML implementation.
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Affiliation(s)
- Osnat Atun-Einy
- a Department of Physical Therapy, Faculty of Social Welfare and Health Sciences , University of Haifa , Haifa , Israel
| | - Michal Kafri
- a Department of Physical Therapy, Faculty of Social Welfare and Health Sciences , University of Haifa , Haifa , Israel
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69
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Furlan L, Sterr A. The Applicability of Standard Error of Measurement and Minimal Detectable Change to Motor Learning Research-A Behavioral Study. Front Hum Neurosci 2018; 12:95. [PMID: 29623034 PMCID: PMC5875129 DOI: 10.3389/fnhum.2018.00095] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 02/27/2018] [Indexed: 11/13/2022] Open
Abstract
Motor learning studies face the challenge of differentiating between real changes in performance and random measurement error. While the traditional p-value-based analyses of difference (e.g., t-tests, ANOVAs) provide information on the statistical significance of a reported change in performance scores, they do not inform as to the likely cause or origin of that change, that is, the contribution of both real modifications in performance and random measurement error to the reported change. One way of differentiating between real change and random measurement error is through the utilization of the statistics of standard error of measurement (SEM) and minimal detectable change (MDC). SEM is estimated from the standard deviation of a sample of scores at baseline and a test–retest reliability index of the measurement instrument or test employed. MDC, in turn, is estimated from SEM and a degree of confidence, usually 95%. The MDC value might be regarded as the minimum amount of change that needs to be observed for it to be considered a real change, or a change to which the contribution of real modifications in performance is likely to be greater than that of random measurement error. A computer-based motor task was designed to illustrate the applicability of SEM and MDC to motor learning research. Two studies were conducted with healthy participants. Study 1 assessed the test–retest reliability of the task and Study 2 consisted in a typical motor learning study, where participants practiced the task for five consecutive days. In Study 2, the data were analyzed with a traditional p-value-based analysis of difference (ANOVA) and also with SEM and MDC. The findings showed good test–retest reliability for the task and that the p-value-based analysis alone identified statistically significant improvements in performance over time even when the observed changes could in fact have been smaller than the MDC and thereby caused mostly by random measurement error, as opposed to by learning. We suggest therefore that motor learning studies could complement their p-value-based analyses of difference with statistics such as SEM and MDC in order to inform as to the likely cause or origin of any reported changes in performance.
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Affiliation(s)
- Leonardo Furlan
- Brain and Behaviour Research Group, School of Psychology, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Annette Sterr
- Brain and Behaviour Research Group, School of Psychology, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom.,Neurology Clinical Division, Clinics Hospital, São Paulo University, São Paulo, Brazil
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70
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Rowe VT, Neville M. Client Perceptions of Task-Oriented Training at Home: “I Forgot I Was Sick”. OTJR-OCCUPATION PARTICIPATION AND HEALTH 2018. [DOI: 10.1177/1539449218762729] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Task-oriented training is a contemporary intervention based on behavioral neuroscience and recent models of motor learning. It can logically be guided by the theory of occupational adaptation. This report presents the perceptions of four participants who underwent task-oriented training at home (TOTE Home) for upper extremity hemiparesis following a stroke. Guided by principles of motor learning and the theory of occupational adaptation, a directed content analysis was used with field notes recorded during the TOTE Home. Three themes emerged: salience of the activity within context, desire for mastery by creating the just right challenge, and adapted self-perception of abilities. While motor learning principles informed the method of task practice and feedback, it was the person’s desire to perform meaningful, relevant activities that drove the adaptive process. This study provided insight in the perceptions and experiences of participants undergoing TOTE Home.
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72
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Abstract
The last decade has witnessed an increase in the number of moderate to large-scale nonpharmacologic stroke recovery trials. While a majority, having tested the superiority of a particular evidence-based intervention, returned negative findings, the rehabilitation research community has gained an important perspective for future efforts. We offer our interpretation first, on why most of the past decade’s trials failed in the sense of not supporting the primary superiority hypothesis, and, second, we provide our perspective on how to solve this problem and thereby inform the next generation of neurorehabilitation clinical trials. The first large-scale randomized controlled trial (RCT) ever conducted in neurorehabilitation was the Extremity Constraint Induced Movement Therapy Evaluation (EXCITE) trial. The majority of stroke recovery trials that followed were based on a prevailing, but as yet immature science of brain-behavior mechanisms for recovery and limited practical know-how about how to select the most meaningful outcomes. The research community had been seduced by a set of preclinical studies, ignited by the 1990’s revolution in neuroscience and an oversimplified premise that high doses of task-oriented training was the most important ingredient to foster recovery. Here, we highlight recent qualitative and quantitative evidence, both mechanistic and theory-driven, that integrates crucial social and personal factors to inform a more mature science better suited for the next generation of recovery-supportive rehabilitation clinical trials.
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73
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Winstein C. The ATTEND trial: An alternative explanation with implications for future recovery and rehabilitation clinical trials. Int J Stroke 2017; 13:112-116. [DOI: 10.1177/1747493017743061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Over the past decade, ATTEND is one of only a handful of moderate to large-scale nonpharmacologic stroke recovery trials with a focus on rehabilitation. While unique in some respects, its test of superiority for the experimental intervention returned negative/neutral results, with no differences in outcome between the experimental intervention and an appropriate control group – a result not uncommon to the majority of moderate to large stroke rehabilitation intervention trials (i.e. six out of eight conducted in the past decade). The authors offer a number of potential explanations for the negative outcome, all of which have merit. We choose not to dwell on these possibilities, but rather offer a radically different explanation, one which has implications for future rehabilitation clinical trials. Our premise is that the process of neurorehabilitation is complex and multifaceted, but most importantly, for success, it requires a genuine collaboration between the patient and the clinician or caregiver to effect optimal recovery. This collaborative relationship must be defined by the unique perspective of each patient. By doing so, we acknowledge the importance of the individual patient’s values, goals, perspectives, and capacity. Rehabilitation scientists can design what arguably is a scientifically sound intervention that is evidence-based and even with preliminary data supporting its efficacy, but if the patient does not value the target outcome, does not fully engage in the therapy, or does not expect the intervention to succeed, the likelihood of success is poor. We offer this opinion, not to be critical, but to suggest a paradigm shift in the way in which we conduct stroke recovery and rehabilitation trials.
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Affiliation(s)
- Carolee Winstein
- Department of Biokinesiology and Physical Therapy and Department of Neurology, University of Southern California, Los Angeles, USA
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74
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Sequence-specific implicit motor learning using whole-arm three-dimensional reach movements. Exp Brain Res 2017; 236:59-67. [PMID: 29075834 PMCID: PMC6530897 DOI: 10.1007/s00221-017-5107-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 10/12/2017] [Indexed: 10/18/2022]
Abstract
Implicit motor learning is essential to the acquisition of motor skills. Examination of implicit motor learning, however, has largely involved single-finger button presses or two-dimensional movements of a computer mouse or joystick. The purpose of this study was to examine sequence-specific implicit motor learning during practice of a three-dimensional (3D) whole-arm reach task. Fifteen young, non-disabled individuals completed two consecutive days of practice of a 3D target task presented in a virtual environment with the dominant, right arm. Stimuli were displayed one at a time and alternated between an eight-target random sequence and an eight-target repeated sequence. Movement of the shoulder and elbow was required to successfully capture a target. Performance was indicated by time to complete a sequence (response time) and analyzed by sequence type (random, repeated). Kinematic data (total distance to complete a sequence, peak velocity, and time to peak velocity) were used to determine how movement changed over time. Results showed significant improvements in performance early in practice, regardless of sequence type. However, individuals completed the repeated sequence faster than the random sequence, indicating sequence-specific implicit motor learning. The difference in response time between the sequence types was driven by the total distance of the hand path; the distance traveled for the repeated sequence was shorter than the distance of the random sequence. Examination of implicit motor learning using 3D reach movements provides the opportunity to study learning using whole-arm movements, an important component of many real-world, functional tasks.
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75
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Rowe VT, Neville M. Task Oriented Training and Evaluation at Home. OTJR-OCCUPATION PARTICIPATION AND HEALTH 2017; 38:46-55. [DOI: 10.1177/1539449217727120] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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76
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Bisson T, Newsam CJ. Short-duration, high-intensity bouts of physical therapy to increase self-efficacy, confidence, and function in an individual with incomplete spinal cord injury: A case report. Physiother Theory Pract 2017; 33:888-895. [PMID: 28792298 DOI: 10.1080/09593985.2017.1357155] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
High intensity and frequency of task-specific practice is required to produce functional change in individuals with neurologic conditions. Self-efficacy is an important predictor of engagement in physical activity in individuals with spinal cord injury. Combining these two rehabilitation concepts has the potential for lasting functional improvement. The purpose of this case report is to describe the management of a patient with incomplete spinal cord injury (iSCI) using a model of concentrated bouts of physical therapy with an emphasis on techniques to increase self-efficacy. The patient is a 70-yr old female who sustained C5/C6 vertebral fractures in a fall, resulting in incomplete tetraplegia. She participated in a pilot program of 1 week of intensive physical therapy every 10-12 weeks over the course of 5.5 months. Interventions included functional activities important to the patient, therapeutic exercise, and home exercise program. Confidence and self-efficacy were shaped using patient-directed discussions and active problem solving. The patient improved on all measures of gait, balance, and participation, and also reported increased confidence and self-management of her condition. A high-intensity, periodic model of care delivery combined with a capacity-building approach may be an effective method to improve confidence, motivation, and function in persons with iSCI.
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Affiliation(s)
- Teresa Bisson
- a Department of Physical Therapy , Rancho Los Amigos National Rehabilitation Center , Downey , CA , USA.,b Program in Physical Therapy, University of Minnesota , Minneapolis , MN , USA
| | - Craig J Newsam
- c Doctor of Physical Therapy, Mount Saint Mary's University , Los Angeles , CA , USA
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77
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Russell W, Pritchard-Wiart L, Manns PJ. Clinician perspectives on cross-education in stroke rehabilitation. Disabil Rehabil 2017; 40:2644-2649. [DOI: 10.1080/09638288.2017.1356382] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- William Russell
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Lesley Pritchard-Wiart
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Patricia J. Manns
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
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78
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Harris SR, Winstein CJ. The Past, Present, and Future of Neurorehabilitation: From NUSTEP Through IV STEP and Beyond. Pediatr Phys Ther 2017; 29 Suppl 3:S2-S9. [PMID: 28654472 DOI: 10.1097/pep.0000000000000376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSES To present the history and aims of the STEP conferences; describe the interdependence of prevention, prediction, plasticity, and participation; reflect on where we stand today regarding those 4 Ps; and discuss how future neurorehabilitation should look for individuals with movement disorders. KEY POINTS Physical therapists have focused primarily on tertiary prevention, emphasizing primary/secondary prevention far less. Predicting optimal response to intervention is essential for primary prevention. Research examining neurorehabilitation effects mediated by brain plasticity is evolving from an emphasis on impairment outcomes toward examination of participation outcomes. CLINICAL PRACTICE RECOMMENDATIONS:: (1) Capitalize on primary and secondary prevention. (2) Administer simple, environmentally relevant predictive measures. (3) Partner with researchers to examine exercise-induced brain plasticity effects via neuroimaging. (4) Encourage physical activity to promote secondary prevention of lifestyle-related diseases and enhance participation. (5) Integrate psychological/social sciences with physiological sciences to move forward with advances in mindful health and patient-centered practices.
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Affiliation(s)
- Susan R Harris
- Department of Physical Therapy (Dr Harris), Faculty of Medicine, University of British Columbia, Vancouver, Canada; and Division of Biokinesiology & Physical Therapy, and Department of Neurology, Keck School of Medicine (Dr Winstein), and Motor Behavior & Neurorehabilitation Laboratory, Ostrow School of Dentistry, University of Southern California, Los Angeles
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79
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McCain K, Shearin S. A Clinical Framework for Functional Recovery in a Person With Chronic Traumatic Brain Injury: A Case Study. J Neurol Phys Ther 2017. [PMID: 28628551 DOI: 10.1097/npt.0000000000000190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE This case study describes a task-specific training program for gait walking and functional recovery in a young man with severe chronic traumatic brain injury. CASE DESCRIPTION The individual was a 26-year-old man 4 years post-traumatic brain injury with severe motor impairments who had not walked outside of therapy since his injury. He had received extensive gait training prior to initiation of services. His goal was to recover the ability to walk. INTERVENTION The primary focus of the interventions was the restoration of walking. A variety of interventions were used, including locomotor treadmill training, electrical stimulation, orthoses, and specialized assistive devices. A total of 79 treatments were delivered over a period of 62 weeks. OUTCOMES At the conclusion of therapy, the client was able to walk independently with a gait trainer for approximately 1km (over 3000 ft) and walked in the community with the assistance of his mother using a rocker bottom crutch for distances of 100m (330 ft). DISCUSSION Specific interventions were intentionally selected in the development of the treatment plan. The program emphasized structured practice of the salient task, that is, walking, with adequate intensity and frequency. Given the chronicity of this individual's injury, the magnitude of his functional improvements was unexpected.Video Abstract available for additional insights from the Authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A175).
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Affiliation(s)
- Karen McCain
- Department of Physical Therapy (K.M.), David M. Crowley Rehabilitation Research Lab (K.M., S.S.), and Neurologic Physical Therapy Residency (K.M.), UT Southwestern School of Health Professions, Dallas, Texas
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Johanson ME. Rehabilitation After Surgical Reconstruction to Restore Function to the Upper Limb in Tetraplegia: A Changing Landscape. Arch Phys Med Rehabil 2017; 97:S71-4. [PMID: 27233593 DOI: 10.1016/j.apmr.2016.03.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 03/28/2016] [Accepted: 03/30/2016] [Indexed: 10/21/2022]
Abstract
Upper limb reconstructive surgical procedures for individuals with tetraplegia are performed in many centers internationally. Most recipients of surgery return to local communities and nonsurgical centers for postoperative rehabilitation and long-term follow-up. This supplement focuses on the clinical significance of upper extremity reconstruction, addressing issues related to the availability and choice for surgery, preoperative assessments, postoperative training paradigms, and appropriate outcome measures. Comprehensive intervention protocols are described in terms of dose, timing, specific activities, modalities, and related outcomes. Shared knowledge of current rehabilitation practice, as it relates to reconstructive surgery, can expand treatment options communicated to patients, increase the availability of postoperative muscle reeducation programs, and motivate long-term follow-up assessments.
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81
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Rowe VT, Winstein CJ, Wolf SL, Woodbury ML. Functional Test of the Hemiparetic Upper Extremity: A Rasch Analysis With Theoretical Implications. Arch Phys Med Rehabil 2017; 98:1977-1983. [PMID: 28434819 DOI: 10.1016/j.apmr.2017.03.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 03/22/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the measurement properties of the Functional Test of the Hemiparetic Upper Extremity (FTHUE) and examine how its score may or may not inform design of a rehabilitation program. DESIGN The FTHUE was recently used in the Interdisciplinary Comprehensive Arm Rehabilitation Evaluation randomized controlled trial. This circumstance provided the opportunity to examine the psychometric properties of the FTHUE as it pertains to contemporary poststroke rehabilitation and recovery models. SETTING Outpatient rehabilitation clinic. PARTICIPANTS Participants (N=109; mean age, 61.2±13.5y; mean days poststroke, 46±20.3) with resultant hemiparesis in the upper extremity. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Dimensionality was examined with confirmatory factor analysis (CFA), and person and item measures were derived with Rasch item response analysis. Therapists' notes were also reviewed. RESULTS The CFA results support unidimensionality, and 16 of 17 items fit the Rasch model. The Rasch person separation (2.17) and item separation (4.50) indices, ability strata (3.22), person reliability (.82), and item reliability (.95) indicate good measurement properties. Item difficulties ranked from -6.46 to 3.43 logits; however, there was a substantial ceiling effect of person measures. Post hoc examination of therapists' written observations indicated that the scoring criteria are not sensitive to the movement strategy used for task completion. CONCLUSIONS The FTHUE's item difficulty hierarchy indicated that scores adequately distinguished the ability to perform simple versus complex motor movements of functional tasks. However, the FTHUE scoring method did not allow inclusion of the type of movement strategy used to accomplish task items. Therefore, we suggest modifications to the FTHUE that would allow it to be used for collaborative treatment planning and align well with more contemporary perspectives on treatment theory.
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Affiliation(s)
- Veronica T Rowe
- Department of Occupational Therapy, University of Central Arkansas, Conway, AR.
| | - Carolee J Winstein
- Division of Biokinesiology and Physical Therapy, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA; Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Steven L Wolf
- Departments of Rehabilitation Medicine, Medicine, and Cell Biology, Emory School of Medicine, Atlanta, GA; VA Center on Visual and Neurocognitive Rehabilitation, Atlanta, GA
| | - Michelle L Woodbury
- Department of Health Science and Research, Medical University of South Carolina, Charleston, SC
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82
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Stilwell P, Harman K. Contemporary biopsychosocial exercise prescription for chronic low back pain: questioning core stability programs and considering context. THE JOURNAL OF THE CANADIAN CHIROPRACTIC ASSOCIATION 2017; 61:6-17. [PMID: 28413219 PMCID: PMC5381485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This commentary explores the importance of considering the biopsychosocial model and contextual factors when prescribing exercise. Diverse exercise programs for patients with chronic low back pain (CLBP) produce similar outcomes, without one specific exercise protocol demonstrating clear superiority. One clear barrier to positive outcomes is poor exercise adherence. We suggest that there are certain common contextual factors present in all exercise prescription scenarios that may impact adherence and health-related outcomes. While challenging common core stability exercise prescription, we present an argument for enhancing and intentionally shaping the following contextual factors: the therapeutic alliance, patient education, expectations and attributions of therapeutic success or failure, and mastery or cognitive control over a problem. Overall, this commentary argues that to improve exercise adherence and outcomes in the CLBP population, the context in which exercise is delivered and the meaning patients embody need to be considered and shaped by clinicians.
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McCain KJ, Shearin S. The impact of modified standardized task-specific training (MSTT) on gait outcomes in persons with subacute stroke: A case report. COGENT MEDICINE 2017. [DOI: 10.1080/2331205x.2017.1417669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Karen J. McCain
- Department of Physical Therapy, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8876, Dallas, TX, 75390, USA
| | - Staci Shearin
- Department of Physical Therapy, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 8876, Dallas, TX, 75390, USA
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Levac DE, Glegg SMN, Sveistrup H, Colquhoun H, Miller P, Finestone H, DePaul V, Harris JE, Velikonja D. Promoting Therapists' Use of Motor Learning Strategies within Virtual Reality-Based Stroke Rehabilitation. PLoS One 2016; 11:e0168311. [PMID: 27992492 PMCID: PMC5167266 DOI: 10.1371/journal.pone.0168311] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 11/30/2016] [Indexed: 12/03/2022] Open
Abstract
PURPOSE Therapists use motor learning strategies (MLSs) to structure practice conditions within stroke rehabilitation. Virtual reality (VR)-based rehabilitation is an MLS-oriented stroke intervention, yet little support exists to assist therapists in integrating MLSs with VR system use. METHOD A pre-post design evaluated a knowledge translation (KT) intervention incorporating interactive e-learning and practice, in which 11 therapists learned how to integrate MLSs within VR-based therapy. Self-report and observer-rated outcome measures evaluated therapists' confidence, clinical reasoning and behaviour with respect to MLS use. A focus group captured therapists' perspectives on MLS use during VR-based therapy provision. RESULTS The intervention improved self-reported confidence about MLS use as measured by confidence ratings (p <0.001). Chart-Stimulated Recall indicated a moderate level of competency in therapists' clinical reasoning about MLSs following the intervention, with no changes following additional opportunities to use VR (p = .944). On the Motor Learning Strategy Rating Instrument, no behaviour change with respect to MLS use was noted (p = 0.092). Therapists favoured the strategy of transferring skills from VR to real-life tasks over employing a more comprehensive MLS approach. CONCLUSION The KT intervention improved therapists' confidence but did not have an effect on clinical reasoning or behaviour with regard to MLS use during VR-based therapy.
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Affiliation(s)
- Danielle E. Levac
- Department of Physical Therapy, Movement Sciences and Rehabilitation, Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts, United States of America
| | - Stephanie M. N. Glegg
- Therapy Department, Sunny Hill Health Centre for Children, Vancouver, British Columbia, Canada
| | - Heidi Sveistrup
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Heather Colquhoun
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Patricia Miller
- School of Rehabilitation Sciences, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Hillel Finestone
- Physiatry, Élisabeth Bruyère Hospital and Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Vincent DePaul
- School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
| | - Jocelyn E. Harris
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Diana Velikonja
- Regional Rehabilitation Center, Hamilton Health Sciences, Hamilton, Ontario, Canada
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85
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Morgan C, Darrah J, Gordon AM, Harbourne R, Spittle A, Johnson R, Fetters L. Effectiveness of motor interventions in infants with cerebral palsy: a systematic review. Dev Med Child Neurol 2016; 58:900-9. [PMID: 27027732 DOI: 10.1111/dmcn.13105] [Citation(s) in RCA: 191] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2016] [Indexed: 12/01/2022]
Abstract
AIM To systematically review the evidence on the effectiveness of motor interventions for infants from birth to 2 years with a diagnosis of cerebral palsy or at high risk of it. METHOD Relevant literature was identified by searching journal article databases (PubMed, Embase, CINAHL, Cochrane, Web of Knowledge, and PEDro). Selection criteria included infants between the ages of birth and 2 years diagnosed with, or at risk of, cerebral palsy who received early motor intervention. RESULTS Thirty-four studies met the inclusion criteria, including 10 randomized controlled trials. Studies varied in quality, interventions, and participant inclusion criteria. Neurodevelopmental therapy was the most common intervention investigated either as the experimental or control assignment. The two interventions that had a moderate to large effect on motor outcomes (Cohen's effect size>0.7) had the common themes of child-initiated movement, environment modification/enrichment, and task-specific training. INTERPRETATION The published evidence for early motor intervention is limited by the lack of high-quality trials. There is some promising evidence that early intervention incorporating child-initiated movement (based on motor-learning principles and task specificity), parental education, and environment modification have a positive effect on motor development. Further research is crucial.
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Affiliation(s)
- Catherine Morgan
- Cerebral Palsy Alliance, The University of Sydney, Sydney, NSW, Australia
| | - Johanna Darrah
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Andrew M Gordon
- Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, NY, USA
| | - Regina Harbourne
- Rangos School of Health Sciences, Duquesne University, Pittsburgh, PA, USA
| | - Alicia Spittle
- Department of Physiotherapy, University of Melbourne, Parkville, Vic., Australia.,Victorian Infant Brain Studies, Murdoch Childrens Research Institute, Parkville, Vic., Australia
| | - Robert Johnson
- Norris Medical Library, University of Southern California, Los Angeles, CA, USA
| | - Linda Fetters
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA
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86
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Kim B, Winstein C. Can Neurological Biomarkers of Brain Impairment Be Used to Predict Poststroke Motor Recovery? A Systematic Review. Neurorehabil Neural Repair 2016; 31:3-24. [PMID: 27503908 DOI: 10.1177/1545968316662708] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background There is growing interest to establish recovery biomarkers, especially neurological biomarkers, in order to develop new therapies and prediction models for the promotion of stroke rehabilitation and recovery. However, there is no consensus among the neurorehabilitation community about which biomarker(s) have the highest predictive value for motor recovery. Objective To review the evidence and determine which neurological biomarker(s) meet the high evidence quality criteria for use in predicting motor recovery. Methods We searched databases for prognostic neuroimaging/neurophysiological studies. Methodological quality of each study was assessed using a previously employed comprehensive 15-item rating system. Furthermore, we used the GRADE approach and ranked the overall evidence quality for each category of neurologic biomarker. Results Seventy-one articles met our inclusion criteria; 5 categories of neurologic biomarkers were identified: diffusion tensor imaging (DTI), transcranial magnetic stimulation (TMS), functional magnetic resonance imaging (fMRI), conventional structural MRI (sMRI), and a combination of these biomarkers. Most studies were conducted with individuals after ischemic stroke in the acute and/or subacute stage (~70%). Less than one-third of the studies (21/71) were assessed with satisfactory methodological quality (80% or more of total quality score). Conventional structural MRI and the combination biomarker categories ranked "high" in overall evidence quality. Conclusions There were 3 prevalent methodological limitations: (a) lack of cross-validation, (b) lack of minimal clinically important difference (MCID) for motor outcomes, and (c) small sample size. More high-quality studies are needed to establish which neurological biomarkers are the best predictors of motor recovery after stroke. Finally, the quarter-century old methodological quality tool used here should be updated by inclusion of more contemporary methods and statistical approaches.
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Affiliation(s)
- Bokkyu Kim
- University of Southern California, Los Angeles, CA, USA
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87
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Evaluation of a Task-Based Intervention After Tendon Transfer to Restore Lateral Pinch. Arch Phys Med Rehabil 2016; 97:S144-53. [PMID: 27233589 DOI: 10.1016/j.apmr.2015.12.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Revised: 09/18/2015] [Accepted: 12/07/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To quantify changes in pinch force and brachioradialis (BR) activation after a task-based training program designed to improve pinch force after BR to flexor pollicis longus (FPL) transfer. DESIGN One-group repeated-measures design compared pinch force and BR activation pre- and posttraining. Significant differences were tested with Wilcoxon signed-rank tests for pairwise comparisons at the P≤.05 level. SETTING Testing occurred in a Veterans Affairs Medical Center research laboratory and training was in a home setting. PARTICIPANTS Participants with cervical spinal cord injury (SCI) and previous BR to FPL transfer were enrolled in the study (N=8). Six patients completed the training program and posttraining measures. INTERVENTIONS The 10-week training was a home program that included novel activities to increase BR activation and practice producing pinch force in a variety of upper limb postures. Participants were provided with the task-based training equipment and instructed to practice 3 times per week. MAIN OUTCOME MEASURES Fine-wire electromyography of the transferred BR was recorded in maximum effort pinch force (N). Secondary measures included the strength and activation of the antagonist elbow extensor. RESULTS Pinch force increased 3.7N (.38kg) and BR muscle activation increased 10% (P≤.05) after the training. There was no increase in elbow extension strength, but participants with previous posterior deltoid to triceps transfer achieved greater activation of the antagonist elbow extensor. CONCLUSIONS The findings from this pilot study suggest that outcomes of tendon transfer and conventional therapy can be improved for patients with chronic cervical SCI.
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88
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Winstein CJ, Wolf SL, Dromerick AW, Lane CJ, Nelsen MA, Lewthwaite R, Cen SY, Azen SP. Effect of a Task-Oriented Rehabilitation Program on Upper Extremity Recovery Following Motor Stroke: The ICARE Randomized Clinical Trial. JAMA 2016; 315:571-81. [PMID: 26864411 PMCID: PMC4795962 DOI: 10.1001/jama.2016.0276] [Citation(s) in RCA: 209] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
IMPORTANCE Clinical trials suggest that higher doses of task-oriented training are superior to current clinical practice for patients with stroke with upper extremity motor deficits. OBJECTIVE To compare the efficacy of a structured, task-oriented motor training program vs usual and customary occupational therapy (UCC) during stroke rehabilitation. DESIGN, SETTING, AND PARTICIPANTS Phase 3, pragmatic, single-blind randomized trial among 361 participants with moderate motor impairment recruited from 7 US hospitals over 44 months, treated in the outpatient setting from June 2009 to March 2014. INTERVENTIONS Structured, task-oriented upper extremity training (Accelerated Skill Acquisition Program [ASAP]; n = 119); dose-equivalent occupational therapy (DEUCC; n = 120); or monitoring-only occupational therapy (UCC; n = 122). The DEUCC group was prescribed 30 one-hour sessions over 10 weeks; the UCC group was only monitored, without specification of dose. MAIN OUTCOMES AND MEASURES The primary outcome was 12-month change in log-transformed Wolf Motor Function Test time score (WMFT, consisting of a mean of 15 timed arm movements and hand dexterity tasks). Secondary outcomes were change in WMFT time score (minimal clinically important difference [MCID] = 19 seconds) and proportion of patients improving ≥25 points on the Stroke Impact Scale (SIS) hand function score (MCID = 17.8 points). RESULTS Among the 361 randomized patients (mean age, 60.7 years; 56% men; 42% African American; mean time since stroke onset, 46 days), 304 (84%) completed the 12-month primary outcome assessment; in intention-to-treat analysis, mean group change scores (log WMFT, baseline to 12 months) were, for the ASAP group, 2.2 to 1.4 (difference, 0.82); DEUCC group, 2.0 to 1.2 (difference, 0.84); and UCC group, 2.1 to 1.4 (difference, 0.75), with no significant between-group differences (ASAP vs DEUCC: 0.14; 95% CI, -0.05 to 0.33; P = .16; ASAP vs UCC: -0.01; 95% CI, -0.22 to 0.21; P = .94; and DEUCC vs UCC: -0.14; 95% CI, -0.32 to 0.05; P = .15). Secondary outcomes for the ASAP group were WMFT change score, -8.8 seconds, and improved SIS, 73%; DEUCC group, WMFT, -8.1 seconds, and SIS, 72%; and UCC group, WMFT, -7.2 seconds, and SIS, 69%, with no significant pairwise between-group differences (ASAP vs DEUCC: WMFT, 1.8 seconds; 95% CI, -0.8 to 4.5 seconds; P = .18; improved SIS, 1%; 95% CI, -12% to 13%; P = .54; ASAP vs UCC: WMFT, -0.6 seconds, 95% CI, -3.8 to 2.6 seconds; P = .72; improved SIS, 4%; 95% CI, -9% to 16%; P = .48; and DEUCC vs UCC: WMFT, -2.1 seconds; 95% CI, -4.5 to 0.3 seconds; P = .08; improved SIS, 3%; 95% CI, -9% to 15%; P = .22). A total of 168 serious adverse events occurred in 109 participants, resulting in 8 patients withdrawing from the study. CONCLUSIONS AND RELEVANCE Among patients with motor stroke and primarily moderate upper extremity impairment, use of a structured, task-oriented rehabilitation program did not significantly improve motor function or recovery beyond either an equivalent or a lower dose of UCC upper extremity rehabilitation. These findings do not support superiority of this program among patients with motor stroke and primarily moderate upper extremity impairment. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00871715.
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89
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Snow NJ, Peters S, Borich MR, Shirzad N, Auriat AM, Hayward KS, Boyd LA. A reliability assessment of constrained spherical deconvolution-based diffusion-weighted magnetic resonance imaging in individuals with chronic stroke. J Neurosci Methods 2016; 257:109-20. [DOI: 10.1016/j.jneumeth.2015.09.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/12/2015] [Accepted: 09/16/2015] [Indexed: 11/26/2022]
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Furlan L, Conforto AB, Cohen LG, Sterr A. Upper Limb Immobilisation: A Neural Plasticity Model with Relevance to Poststroke Motor Rehabilitation. Neural Plast 2015; 2016:8176217. [PMID: 26843992 PMCID: PMC4710952 DOI: 10.1155/2016/8176217] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 10/13/2015] [Accepted: 10/19/2015] [Indexed: 11/26/2022] Open
Abstract
Advances in our understanding of the neural plasticity that occurs after hemiparetic stroke have contributed to the formulation of theories of poststroke motor recovery. These theories, in turn, have underpinned contemporary motor rehabilitation strategies for treating motor deficits after stroke, such as upper limb hemiparesis. However, a relative drawback has been that, in general, these strategies are most compatible with the recovery profiles of relatively high-functioning stroke survivors and therefore do not easily translate into benefit to those individuals sustaining low-functioning upper limb hemiparesis, who otherwise have poorer residual function. For these individuals, alternative motor rehabilitation strategies are currently needed. In this paper, we will review upper limb immobilisation studies that have been conducted with healthy adult humans and animals. Then, we will discuss how the findings from these studies could inspire the creation of a neural plasticity model that is likely to be of particular relevance to the context of motor rehabilitation after stroke. For instance, as will be elaborated, such model could contribute to the development of alternative motor rehabilitation strategies for treating poststroke upper limb hemiparesis. The implications of the findings from those immobilisation studies for contemporary motor rehabilitation strategies will also be discussed and perspectives for future research in this arena will be provided as well.
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Affiliation(s)
- Leonardo Furlan
- School of Psychology, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Adriana Bastos Conforto
- Neurology Clinical Division, Clinics Hospital, São Paulo University, Avenida Dr. Enéas C. Aguiar 255/5084, 05403-010 São Paulo, SP, Brazil
- Instituto de Ensino e Pesquisa, Hospital Israelita Albert Einstein, Avenida Albert Einstein 627/701, 05601-901 São Paulo, SP, Brazil
| | - Leonardo G. Cohen
- Human Cortical Physiology and Stroke Rehabilitation Section, National Institutes of Neurological Disorders and Stroke, National Institutes of Health, Building 10, Room 7D54, Bethesda, MD 20892, USA
| | - Annette Sterr
- School of Psychology, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
- Neurology Clinical Division, Clinics Hospital, São Paulo University, Avenida Dr. Enéas C. Aguiar 255/5084, 05403-010 São Paulo, SP, Brazil
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Chen JL, Fujii S, Schlaug G. The use of augmented auditory feedback to improve arm reaching in stroke: a case series. Disabil Rehabil 2015; 38:1115-1124. [PMID: 26314746 DOI: 10.3109/09638288.2015.1076530] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE After practice, augmented feedback is the most important factor that facilitates motor learning. We assess the potential effectiveness of two types of augmented auditory feedback on the re-learning of arm reaching in individuals with stroke: (a) real-time knowledge of performance (KP) feedback and (b) rhythmic cueing in the form of knowledge of results (KR) feedback. METHOD Five participants with stroke underwent short-term practice, reaching with their affected arm with KP, KR and no feedback, on separate days. We assessed range of motion of the upper extremity (shoulder, elbow) and trunk, mean error and variability of the performed trajectory, and movement time, before and after training. RESULTS All participants benefitted from practice with feedback, though the effects varied across participants and feedback type. In three participants, KP feedback increased elbow extension and reduced compensatory trunk flexion. In four participants, KR feedback reduced movement time taken to perform the reach. Of note, one participant benefitted mostly from KP feedback, which increased shoulder flexion and elbow extension, and decreased compensatory trunk flexion and mean error. CONCLUSIONS Within day practice with augmented auditory feedback improves reaching in individuals with stroke. This warrants further investigation with longer practice periods in a larger sample size. IMPLICATIONS FOR REHABILITATION After practice, augmented feedback is the second most important factor that facilitates motor learning. Music-based augmented auditory feedback has potential to enhance reaching abilities in individuals with stroke. Future studies are warranted to evaluate the long-term effectiveness of this feedback over a longer training period in a larger sample size.
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Affiliation(s)
- Joyce L Chen
- Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Physical Therapy and Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada.,Deparment of Neurology, Music, Neuroimaging and Stroke Recovery Laboratory, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Shinya Fujii
- Sunnybrook Research Institute, Toronto, Ontario, Canada.,Deparment of Neurology, Music, Neuroimaging and Stroke Recovery Laboratory, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.,Japan Society for the Promotion of Science, Tokyo, Japan
| | - Gottfried Schlaug
- Deparment of Neurology, Music, Neuroimaging and Stroke Recovery Laboratory, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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Kleynen M, Braun SM, Rasquin SMC, Bleijlevens MHC, Lexis MAS, Halfens J, Wilson MR, Masters RSW, Beurskens AJ. Multidisciplinary Views on Applying Explicit and Implicit Motor Learning in Practice: An International Survey. PLoS One 2015; 10:e0135522. [PMID: 26296203 PMCID: PMC4546413 DOI: 10.1371/journal.pone.0135522] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 07/22/2015] [Indexed: 12/27/2022] Open
Abstract
Background A variety of options and techniques for causing implicit and explicit motor learning have been described in the literature. The aim of the current paper was to provide clearer guidance for practitioners on how to apply motor learning in practice by exploring experts’ opinions and experiences, using the distinction between implicit and explicit motor learning as a conceptual departure point. Methods A survey was designed to collect and aggregate informed opinions and experiences from 40 international respondents who had demonstrable expertise related to motor learning in practice and/or research. The survey was administered through an online survey tool and addressed potential options and learning strategies for applying implicit and explicit motor learning. Responses were analysed in terms of consensus (≥ 70%) and trends (≥ 50%). A summary figure was developed to illustrate a taxonomy of the different learning strategies and options indicated by the experts in the survey. Results Answers of experts were widely distributed. No consensus was found regarding the application of implicit and explicit motor learning. Some trends were identified: Explicit motor learning can be promoted by using instructions and various types of feedback, but when promoting implicit motor learning, instructions and feedback should be restricted. Further, for implicit motor learning, an external focus of attention should be considered, as well as practicing the entire skill. Experts agreed on three factors that influence motor learning choices: the learner’s abilities, the type of task, and the stage of motor learning (94.5%; n = 34/36). Most experts agreed with the summary figure (64.7%; n = 22/34). Conclusion The results provide an overview of possible ways to cause implicit or explicit motor learning, signposting examples from practice and factors that influence day-to-day motor learning decisions.
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Affiliation(s)
- Melanie Kleynen
- Research Centre for Autonomy and Participation of Persons with a Chronic Illness, Faculty of Health, Zuyd University of Applied Sciences, Heerlen, The Netherlands
- Adelante Rehabilitation Centre, Department of Brain Injury, Hoensbroek, The Netherlands
- Department of Family Medicine, CAPHRI, School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Rehabilitation Medicine, CAPHRI, School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- * E-mail:
| | - Susy M. Braun
- Research Centre for Autonomy and Participation of Persons with a Chronic Illness, Faculty of Health, Zuyd University of Applied Sciences, Heerlen, The Netherlands
- Department of Health Services Research, CAPHRI, School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Sascha M. C. Rasquin
- Department of Rehabilitation Medicine, CAPHRI, School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Michel H. C. Bleijlevens
- Department of Health Services Research, CAPHRI, School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Innovation Platform Sevagram, Sevagram Zorgcentra, Heerlen, the Netherlands
| | - Monique A. S. Lexis
- Research Centre for Technology in Care, Zuyd University of Applied Sciences, Heerlen, The Netherlands
| | - Jos Halfens
- Adelante Rehabilitation Centre, Department of Brain Injury, Hoensbroek, The Netherlands
| | - Mark R. Wilson
- Department of Sport and Health Sciences, University of Exeter, Exeter, United Kingdom
| | - Rich S. W. Masters
- Institute of Human Performance, University of Hong Kong, Hong Kong, China
- Te Oranga School of Human Development and Movement Studies, University of Waikato, Hamilton, New Zealand
| | - Anna J. Beurskens
- Research Centre for Autonomy and Participation of Persons with a Chronic Illness, Faculty of Health, Zuyd University of Applied Sciences, Heerlen, The Netherlands
- Department of Family Medicine, CAPHRI, School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Development and Evaluation of Self-Management and Task-Oriented Approach to Rehabilitation Training (START) in the Home: Case Report. Phys Ther 2015; 95:934-43. [PMID: 25721121 DOI: 10.2522/ptj.20130617] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 02/17/2015] [Indexed: 02/09/2023]
Abstract
BACKGROUND The incidence of stroke and subsequent level of disability will increase, as age is the greatest risk factor for stroke and the world's population is aging. Hospital admissions are too brief for patients to regain necessary function. Research to examine therapy delivered within the home environment has the potential to expedite relearning of function and reduce health care expenditures. PURPOSE This case report describes the use of the knowledge-to-action cycle (KTA) to develop and evaluate an evidence-based approach for rehabilitation in the home that incorporates self-management and task-oriented functional training (TOFT) for people with stroke. CASE DESCRIPTION The KTA cycle was used to guide adaptation of evidence from self-management and TOFT into an approach titled START (Self-Management and Task-Oriented Approach to Rehabilitation Training). Three stakeholder symposiums identified barriers and supports to implementation. Clinical practice leaders were engaged as partners in the development of the intervention. An online learning management system housed the resources to support therapist training. Therapist focus groups were conducted and stroke outcomes were used to assess patient response. OUTCOMES Eight therapists completed 4 workshops and applied the home intervention in 12 people with stroke. A mentoring process for therapists included feedback from peers and experts after viewing treatment videos. Therapist response was determined from the focus groups; patient response was measured by standardized assessments. The therapists noted that the intervention was easier to implement with patients who were motivated and had minimal cognitive impairment. DISCUSSION The KTA cycle provided a structure for the development of this evidence-based rehabilitation intervention, which was feasible to implement in the home. Further evaluation needs to be undertaken to assess the effectiveness of START.
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Klatt BN, Carender WJ, Lin CC, Alsubaie SF, Kinnaird CR, Sienko KH, Whitney SL. A Conceptual Framework for the Progression of Balance Exercises in Persons with Balance and Vestibular Disorders. PHYSICAL MEDICINE AND REHABILITATION INTERNATIONAL 2015; 2:1044. [PMID: 27489886 PMCID: PMC4968039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
There is little information in peer-reviewed literature to specifically guide the choice of exercise for persons with balance and vestibular disorders. The purpose of this study is to provide a rationale for the establishment of a progression framework and propose a logical sequence in progressing balance exercises for persons with vestibular disorders. Our preliminary conceptual framework was developed by a multidisciplinary team of physical therapists and engineers with extensive experience with people with vestibular disorders. Balance exercises are grouped into six different categories: static standing, compliant surface, weight shifting, modified center of gravity, gait, and vestibulo-ocular reflex (VOR). Through a systematized literature review, interviews and focus group discussions with physical therapists and postural control experts, and pilot studies involving repeated trials of each exercise, exercise progressions for each category were developed and ranked in order of degree of difficulty. Clinical expertise and experience guided decision making for the exercise progressions. Hundreds of exercise combinations were discussed and research is ongoing to validate the hypothesized rankings. The six exercise categories can be incorporated into a balance training program and the framework for exercise progression can be used to guide less experienced practitioners in the development of a balance program. It may also assist clinicians and researchers to design, develop, and progress interventions within a treatment plan of care, or within clinical trials. A structured exercise framework has the potential to maximize postural control, decrease symptoms of dizziness/visual vertigo, and provide "rules" for exercise progression for persons with vestibular disorders. The conceptual framework may also be applicable to persons with other balance-related issues.
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Affiliation(s)
- BN Klatt
- Department of Physical Therapy, University of Pittsburgh, USA
| | - WJ Carender
- Department of Otolaryngology, University of Michigan Health System, USA
| | - CC Lin
- Department of Physical Therapy, University of Pittsburgh, USA
| | - SF Alsubaie
- Department of Physical Therapy, University of Pittsburgh, USA
| | - CR Kinnaird
- Department of Mechanical Engineering, University of Michigan, USA
| | - KH Sienko
- Department of Mechanical Engineering, University of Michigan, USA
- Department of Biomedical Engineering, University of Michigan, USA
| | - SL Whitney
- Department of Physical Therapy, University of Pittsburgh, USA
- Rehabilitation Research Chair, Department of Rehabilitation Sciences, King Saud University, Saudi Arabia
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Normann B, Fikke HK, ØBerg GK. Somatosensory impairments and upper limb function following stroke: Extending the framework guiding neurological physiotherapy. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2015. [DOI: 10.3109/21679169.2015.1031175] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Winstein CJ, Kay DB. Translating the science into practice: shaping rehabilitation practice to enhance recovery after brain damage. PROGRESS IN BRAIN RESEARCH 2015; 218:331-60. [PMID: 25890145 DOI: 10.1016/bs.pbr.2015.01.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The revolution in neuroscience provided strong evidence for learning-dependent neuroplasticity and presaged the role of motor learning as essential for restorative therapies after stroke and other disabling neurological conditions. The scientific basis of motor learning has continued to evolve from a dominance of cognitive or information processing perspectives to a blend with neural science and contemporary social-cognitive-psychological science, which includes the neural and psychological underpinnings of motivation. This transformation and integration across traditionally separate domains is timely now that clinician scientists are developing novel, evidence-based therapies to maximize motor recovery in the place of suboptimal solutions. We will review recent evidence pertaining to therapeutic approaches that spring from an integrated framework of learning-dependent neuroplasticity along with the growing awareness of protocols that directly address the patient's fundamental psychological needs. Of importance, there is mounting evidence that when the individual's needs are considered in the context of instructions or expectations, the learning/rehabilitation process is accelerated.
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Affiliation(s)
- Carolee J Winstein
- Division of Biokinesiology and Physical Therapy, Ostrow School of Dentistry, Los Angeles, CA, USA; Department of Neurology, Keck School of Medicine, Los Angeles, CA, USA; Neuroscience Graduate Program, University of Southern California, Los Angeles, CA, USA.
| | - Dorsa Beroukhim Kay
- Division of Biokinesiology and Physical Therapy, Ostrow School of Dentistry, Los Angeles, CA, USA; Neuroscience Graduate Program, University of Southern California, Los Angeles, CA, USA.
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