SENSe: Study of the Effectiveness of Neurorehabilitation on Sensation: a randomized controlled trial

Effectiveness of somatosensory interventions on somatosensory, motor and functional outcomes in the upper limb post-stroke: A systematic review and meta-analysis

BACKGROUND

Research mainly focuses on motor recovery of the upper limb after stroke. Less attention has been paid to somatosensory recovery.

OBJECTIVE

To review and summarize the effect of upper limb somatosensory interventions on somatosensory impairment, motor impairment, functional activity and participation after stroke.

METHODS

Biomedical databases Ovid Medline, EMBASE, Web of Science, PEDro, and OTseeker were searched with an update in May 2018. Randomized controlled trials investigating the effect of somatosensory-specific interventions focusing on exteroceptive, proprioceptive or higher cortical somatosensory dysfunction, or any combination were eligible for inclusion. Quality of included studies were assessed using Physiotherapy Evidence Database (PEDro) scale. Standardized Mean Differences and Mean Differences and 95% confidence intervals were calculated and combined in meta-analyses.

RESULTS

Active somatosensory interventions did not show a significant effect on somatosensation and activity, but demonstrated a significant improvement in motor impairment (SMD = 0.73, 95% CI = 0.14 to 1.32). No study evaluating active somatosensory intervention included participation. Passive somatosensory interventions significantly improved light touch sensation (SMD = 1.13, 95% CI = 0.20 to 2.05). Passive somatosensory interventions did not show significant effects on proprioception and higher cortical somatosensation, motor impairment, activity and participation.

CONCLUSIONS

To date, there is low quality evidence suggesting active somatosensory interventions having a beneficial effect on upper limb impairment and very low quality evidence suggesting passive somatosensory interventions improving upper limb light touch sensation. There is a need for further well-designed trials of somatosensory rehabilitation post stroke.

Experiences of Upper Limb Somatosensory Retraining in Persons With Stroke: An Interpretative Phenomenological Analysis

Purpose

The aim of this study was to explore experiences of upper limb somatosensory discrimination retraining in persons with stroke.

Methods

A qualitative methodology was used within the context of a randomized control trial of somatosensory retraining: the CoNNECT trial. Participants in the CoNNECT trial completed a treatment program, known as SENSe therapy, to retrain upper limb somatosensory discrimination and recognition skills, and use of these skills in personally valued activities. Eight participants were interviewed on their experience of this therapy. Data were analyzed using Interpretative Phenomenological Analysis (IPA).

Results

Five themes represented participants’ experiences of upper limb somatosensory retraining after stroke: (1) loss of sensation and desire to reclaim normality; (2) harnessing positivity in the therapeutic relationship and specialized therapy; (3) facing cognitive and emotional challenges; (4) distinct awareness of gains and differences in bodily sensations; and (5) improved functioning: control and choice in daily performance. Persons with stroke experienced somatosensory retraining as a valuable treatment that provided them with sensory and functional gains.

Conclusion

Upper limb somatosensory retraining is a treatment that persons with stroke perceived as challenging and rewarding. People who have experienced stroke believed that somatosensory retraining therapy assisted them to improve their sensation, functional arm use, as well as daily performance and participation in life.

Experience of Engagement in a Somatosensory Discrimination Intervention for Children with Hemiplegic Cerebral Palsy: A Qualitative Investigation

Background: To successfully modify an intervention from an adult population for use with children with cerebral palsy, it is important to understand the components that support a child's motivation and engagement. Method: Ten children who had participated in the Sense© intervention (mean age = 11 years 2 m [SD = 2 years]; four males; Manual Ability Classification System level I = 1, II = 9) and their primary caregivers (N = 11, 10 females) were interviewed. Transcripts were analyzed using framework analysis. Results: Key themes were identified in the core domains of the Synthesis of Child, Occupational Performance and Environment in Time model. Child: children's somatosensory discrimination ability improved; Motivation: incorporating child's goals was essential, as were real-world gains; Environmental: parents were interested in having more involvement in the intervention. Conclusion: The most engaging elements of the intervention for children were the attainment of their self-selected goals. Opportunities to modify the intervention for improved partnership with parents were identified.

Sensory retraining of the leg after stroke: systematic review and meta-analysis

OBJECTIVE

This systematic review aimed to investigate the effects of interventions intended for retraining leg somatosensory function on somatosensory impairment, and secondary outcomes of balance and gait, after stroke.

DATA SOURCES

Databases searched from inception to 16 January 2019 included Cochrane Library, PubMed, MEDLINE, CINAHL, EMBASE, PEDro, PsycINFO, and Scopus. Reference lists of relevant publications were also manually searched.

REVIEW METHODS

All types of quantitative studies incorporating interventions that intended to improve somatosensory function in the leg post stroke were retrieved. The Quality Assessment Tool for Quantitative Studies was used for quality appraisal. Standardised mean differences were calculated and meta-analyses were performed using preconstructed Microsoft Excel spreadsheets.

RESULTS

The search yielded 16 studies, comprising 430 participants, using a diverse range of interventions. In total, 10 of the included studies were rated weak in quality, 6 were rated moderate, and none was rated strong. Study quality was predominantly affected by high risk of selection bias, lack of blinding, and the use of somatosensory measures that have not been psychometrically evaluated. A significant heterogeneous positive summary effect size (SES) was found for somatosensory outcomes (SES: 0.52; 95% confidence interval (CI): 0.04 to 1.01; I2 = 74.48%), which included joint position sense, light touch, and two-point discrimination. There was also a significant heterogeneous positive SES for Berg Balance Scale scores (SES: 0.62; 95% CI: 0.10 to 1.14; I2 = 59.05%). Gait SES, mainly of gait velocity, was not significant.

CONCLUSION

This review suggests that interventions used for retraining leg somatosensory impairment after stroke significantly improved somatosensory function and balance but not gait.

Does Sensory Retraining Improve Sensation and Sensorimotor Function Following Stroke: A Systematic Review and Meta-Analysis

Background: Reduced sensation is experienced by one in two individuals following stroke, impacting both the ability to function independently and overall quality of life. Repetitive activation of sensory input using active and passive sensory-based interventions have been shown to enhance adaptive motor cortical plasticity, indicating a potential mechanism which may mediate recovery. However, rehabilitation specifically focusing on somatosensory function receives little attention.

Objectives: To investigate sensory-based interventions reported in the literature and determine the effectiveness to improve sensation and sensorimotor function of individuals following stroke.

Methods: Electronic databases and trial registries were searched from inception until November 2018, in addition to hand searching systematic reviews. Study selection included randomized controlled trials for adults of any stroke type with an upper and/or lower limb sensorimotor impairment. Participants all received a sensory-based intervention designed to improve activity levels or impairment, which could be compared with usual care, sham, or another intervention. The primary outcomes were change in activity levels related to sensorimotor function. Secondary outcomes were measures of impairment, participation or quality of life.

Results: A total of 38 study trials were included (n = 1,093 participants); 29 explored passive sensory training (somatosensory; peripheral nerve; afferent; thermal; sensory amplitude electrical stimulation), 6 active (sensory discrimination; perceptual learning; sensory retraining) and 3 hybrid (haptic-based augmented reality; sensory-based feedback devices). Meta-analyses (13 comparisons; 385 participants) demonstrated a moderate effect in favor of passive sensory training on improving a range of upper and lower limb activity measures following stroke. Narrative syntheses were completed for studies unable to be pooled due to heterogeneity of measures or insufficient data, evidence for active sensory training is limited however does show promise in improving sensorimotor function following stroke.

Conclusions: Findings from the meta-analyses and single studies highlight some support for the effectiveness of passive sensory training in relation to sensory impairment and motor function. However, evidence for active sensory training continues to be limited. Further high-quality research with rigorous methods (adequately powered with consistent outcome measures) is required to determine the effectiveness of sensory retraining in stroke rehabilitation, particularly for active sensory training.

Sensory Function, Measured as Active Discriminative Touch, is Associated With Dexterity after Stroke

BACKGROUND

Reduced dexterity is common after stroke, which can affect the ability to perform upper limb daily activities. To improve upper limb function after stroke, it is important to understand which factors are most associated with dexterity.

OBJECTIVE

To evaluate how several factors are associated with dexterity after stroke.

DESIGN

Cross-sectional study.

SETTING

A university hospital.

PARTICIPANTS

A convenience sample of 75 persons (54 men and 21 women, mean age 66 years) with mild to moderate impairments of the upper limb after stroke.

METHODS

Dexterity and potentially associated factors (age, gender, affected hand, social situation, vocational situation, grip strength, spasticity, sensory function, and pain) were evaluated by linear regression models.

MAIN OUTCOME MEASUREMENTS

Dexterity was measured with the mini Sollerman Hand Function Test, sensory function with both the Fugl-Meyer Assessment of the Upper Extremity (to assess light touch and proprioception) and the Shape Texture Identification Test (to assess active discriminative touch), spasticity with the Modified Ashworth Scale, and grip strength with the Grippit dynamometer.

RESULTS

Active discriminative touch had the strongest association with dexterity, explaining 46% of the variance. When spasticity and grip strength were added, the explained variance increased to 57% in the final multivariate model.

CONCLUSIONS

This study indicates that sensory function in terms of active discriminative touch is a major contributing factor to dexterity in persons with mild to moderate stroke, whereas spasticity and grip strength may be of lesser importance.

LEVEL OF EVIDENCE

III.

Initial severity of somatosensory impairment influences response to upper limb sensory retraining post-stroke

BACKGROUND

Somatosensory loss occurs often following stroke. A proportional recovery model is proposed for spontaneous motor recovery, with implication for treatment planning. It is currently unknown if initial severity of sensory impairment influences stroke survivors' response to treatment to improve sensation.

OBJECTIVE

To examine if initial (pre-treatment) severity of upper limb somatosensory impairment is related to sensation outcomes following treatment.

METHODS

Regression analysis was used to investigate the relationship between initial and post-treatment sensation performance. Data were pooled from two randomized controlled trials of somatosensory discrimination retraining (N = 80). Upper limb somatosensation was measured using standardized tests of sensory discrimination: Fabric Matching Test, Wrist Position Sense Test, and functional Tactile Object Recognition Test.

RESULTS

Post-treatment somatosensory improvement patterns were proportional to the extent of initial pre-treatment somatosensory impairment (Texture discrimination: B = 0.74, 95% CIs [0.52, 0.96]; Proprioception: B = 0.35, 95% CIs [0.24, 0.47]; Object recognition: B = 0.85, 95% CIs [0.75, 0.95]).

CONCLUSIONS

The effect of somatosensory retraining on post-treatment sensation was proportional to the extent of upper limb initial somatosensory impairment. Findings suggest sensory retraining can benefit stroke survivors of varying severity of sensory impairment, including those with more severe somatosensory loss.

The effectiveness of somatosensory retraining for improving sensory function in the arm following stroke: a systematic review

OBJECTIVE

The aim of this study was to evaluate if somatosensory retraining programmes assist people to improve somatosensory discrimination skills and arm functioning after stroke.

DATA SOURCES

Nine databases were systematically searched: Medline, Cumulative Index to Nursing and Allied Health Literature, PsychInfo, Embase, Amed, Web of Science, Physiotherapy Evidence Database, OT seeker, and Cochrane Library.

REVIEW METHODS

Studies were included for review if they involved (1) adult participants who had somatosensory impairment in the arm after stroke, (2) a programme targeted at retraining somatosensation, (3) a primary measure of somatosensory discrimination skills in the arm, and (4) an intervention study design (e.g. randomized or non-randomized control designs).

RESULTS

A total of 6779 articles were screened. Five group trials and five single case experimental designs were included ( N = 199 stroke survivors). Six studies focused exclusively on retraining somatosensation and four studies focused on somatosensation and motor retraining. Standardized somatosensory measures were typically used for tactile, proprioception, and haptic object recognition modalities. Sensory intervention effect sizes ranged from 0.3 to 2.2, with an average effect size of 0.85 across somatosensory modalities. A majority of effect sizes for proprioception and tactile somatosensory domains were greater than 0.5, and all but one of the intervention effect sizes were larger than the control effect sizes, at least as point estimates. Six studies measured motor and/or functional arm outcomes ( n = 89 participants), with narrative analysis suggesting a trend towards improvement in arm use after somatosensory retraining.

CONCLUSION

Somatosensory retraining may assist people to regain somatosensory discrimination skills in the arm after stroke.

Haptic Exploratory Procedures of Children and Youth with and without Cerebral Palsy

Aims: Compare haptic exploratory procedures (EPs) and exploratory movements (EMs) of children. This study also tested the interrater reliability of a novel digital recording method. Methods: Participants were 31 children with typical development (TD) (aged 6 years 1 month to 15 years 9 months; 14 male) and 23 children with spastic unilateral cerebral palsy (CP) (aged 6 years to 15 years 5 months; 13 males; right hemiplegia, n = 12). Results: There were no statistically significant differences between groups for expected EP (p = .15), additional EPs (p = .78), or EMs (p = .69) but there was for mean duration of exploration (p < .001) and accuracy (p < .001). This suggests that although children with CP performed similar haptic EPs for each object as children with TD, they took more time and were less accurate in their identification. There was substantial agreement between the two raters' observations of expected EP, κ = .64, p < .0005. Conclusion: Children with CP performed similar haptic EPs as their TD peers. However, despite similarities, the results indicate that for children with CP manual ability was not the primary determinant of accuracy or speed of identification. This study provides evidence for a reliable method of recording haptic EPs.

COMbined Physical and somatoSEnsory training after stroke: Development and description of a novel intervention to improve upper limb function

BACKGROUND AND PURPOSE

After stroke, reach-to-grasp goal-directed movements are disrupted as a result of both residual motor and somatosensory impairments. This report describes the rationale and development of a new upper limb stroke rehabilitation intervention known as COMPoSE: "COMbined Physical and somatoSEnsory training," designed to improve somatosensory and motor deficits in the upper limb after stroke. A standardized training matrix has been developed to facilitate intervention delivery.

METHODS

The COMPoSE intervention was developed through the following stages: (a) Definition and operationalization of somatosensory and motor variables used in training sensation and movement after stroke; (b) development of methods to give feedback to enhance skill acquisition; and (c) Combination of somatosensory and motor variables, and feedback, into a standardized training matrix. The reporting of the COMPoSE intervention adheres to the recommendations of the Template for Intervention Description and Replication checklist to facilitate replication of the intervention in the future.

RESULTS

The essential features of COMPoSE include combined somatosensory-motor training variables (grasp pressure, distance, object size, crushability, surface texture, and friction), feedback, and calibration using a haptic device providing measures of grasp pressure, use of anticipation trials, and high-dose repetitive task practice. Ten treatment sessions are delivered over 3 weeks, using a standardized matrix for treatment delivery.

CONCLUSION

COMPoSE is a new intervention that combines somatosensory and movement training, delivered synchronously, within the same intervention, and within the same task.

Discovering the sense of touch: protocol for a randomised controlled trial examining the efficacy of a somatosensory discrimination intervention for children with hemiplegic cerebral palsy

BACKGROUND

Of children with hemiplegic cerebral palsy, 75% have impaired somatosensory function, which contributes to learned non-use of the affected upper limb. Currently, motor learning approaches are used to improve upper-limb motor skills in these children, but few studies have examined the effect of any intervention to ameliorate somatosensory impairments. Recently, Sense© training was piloted with a paediatric sample, seven children with hemiplegic cerebral palsy, demonstrating statistically and clinically significant change in limb position sense, goal performance and bimanual hand-use. This paper describes a protocol for a Randomised Controlled Trial of Sense© for Kids training, hypothesising that its receipt will improve somatosensory discrimination ability more than placebo (dose-matched Goal Directed Therapy via Home Program). Secondary hypotheses include that it will alter brain activation in somatosensory processing regions, white-matter characteristics of the thalamocortical tracts and improve bimanual function, activity and participation more than Goal Directed Training via Home Program.

METHODS AND DESIGN

This is a single blind, randomised matched-pair, placebo-controlled trial. Participants will be aged 6-15 years with a confirmed description of hemiplegic cerebral palsy and somatosensory discrimination impairment, as measured by the sense©_assess Kids. Participants will be randomly allocated to receive 3h a week for 6 weeks of either Sense© for Kids or Goal Directed Therapy via Home Program. Children will be matched on age and severity of somatosensory discrimination impairment. The primary outcome will be somatosensory discrimination ability, measured by sense©_assess Kids score. Secondary outcomes will include degree of brain activation in response to a somatosensory task measured by functional MRI, changes in the white matter of the thalamocortical tract measured by diffusion MRI, bimanual motor function, activity and participation.

DISCUSSION

This study will assess the efficacy of an intervention to increase somatosensory discrimination ability in children with cerebral palsy. It will explore clinically important questions about the efficacy of intervening in somatosensation impairment to improve bimanual motor function, compared with focusing on motor impairment directly, and whether focusing on motor impairment alone can affect somatosensory ability.

TRIAL REGISTRATION

This trial is registered with the Australian New Zealand Clinical Trials Registry, registration number: ACTRN12618000348257. World Health Organisation universal trial number: U1111-1210-1726.

Effects of Somatosensory Impairment on Participation After Stroke

OBJECTIVE

Our objective was to determine the effect of loss of body sensation on activity participation in stroke survivors.

METHOD

Participants (N = 268) were assessed at hospital admission for somatosensory and motor impairment using the National Institutes of Health Stroke Scale. Participation was assessed using the Activity Card Sort (ACS) in the postacute phase. Between-group differences in activity participation were analyzed for participants with and without somatosensory impairment and with or without paresis.

RESULTS

Somatosensory impairment was experienced in 33.6% of the sample and paresis in 42.9%. ACS profiles were obtained at a median of 222 days poststroke. Somatosensory loss alone (z = 1.96, p = .048) and paresis in upper and lower limbs without sensory loss (z = 4.62, p < .001) influenced activity participation.

CONCLUSION

Somatosensory impairment is associated with reduced activity participation; however, paresis of upper and lower limbs can mask the contribution of sensory loss.

Assessing body sensations in children: Intra-rater reliability of assessment and effects of age

Introduction

This article examines the effect of age and gender on somatosensory capacity for children and adolescents, and provides preliminary normative data and reliability for the SenScreen© Kids, a new standardised measure of touch, wrist position sense and haptic object recognition.

Method

A cross-sectional study of 88 typically developing children aged 6–15 years (mean 10.3 years; SD 2.6 years) was used to determine the developmental effects of age and gender on somatosensory capacity. Intra-rater reliability was assessed in 22 of the 88 participants at two time points (mean 8.8 years; SD 2.6 years).

Results

Statistically significant differences were observed between age groups for tactile discrimination, wrist position sense and haptic object recognition, but not for touch registration for which all except one participant achieved a maximum score. There was no effect of gender. Three of four SenScreen Kids subtests demonstrated good intra-rater agreement between time points.

Conclusions

Somatosensory capacity increased with age for typically developing children aged 6–15 years. Three subtests of the SenScreen Kids demonstrated good intra-rater reliability with typically developing children. Further investigation of reliability is required, and all subtests require psychometric testing with clinical populations.

Greater Cortical Thickness Is Associated With Enhanced Sensory Function After Arm Rehabilitation in Chronic Stroke

Objective. Somatosensory function is critical to normal motor control. After stroke, dysfunction of the sensory systems prevents normal motor function and degrades quality of life. Structural neuroplasticity underpinnings of sensory recovery after stroke are not fully understood. The objective of this study was to identify changes in bilateral cortical thickness (CT) that may drive recovery of sensory acuity. Methods. Chronic stroke survivors (n = 20) were treated with 12 weeks of rehabilitation. Measures were sensory acuity (monofilament), Fugl-Meyer upper limb and CT change. Permutation-based general linear regression modeling identified cortical regions in which change in CT was associated with change in sensory acuity. Results. For the ipsilesional hemisphere in response to treatment, CT increase was significantly associated with sensory improvement in the area encompassing the occipital pole, lateral occipital cortex (inferior and superior divisions), intracalcarine cortex, cuneal cortex, precuneus cortex, inferior temporal gyrus, occipital fusiform gyrus, supracalcarine cortex, and temporal occipital fusiform cortex. For the contralesional hemisphere, increased CT was associated with improved sensory acuity within the posterior parietal cortex that included supramarginal and angular gyri. Following upper limb therapy, monofilament test score changed from 45.0 ± 13.3 to 42.6 ± 12.9 mm ( P = .063) and Fugl-Meyer score changed from 22.1 ± 7.8 to 32.3 ± 10.1 ( P < .001). Conclusions. Rehabilitation in the chronic stage after stroke produced structural brain changes that were strongly associated with enhanced sensory acuity. Improved sensory perception was associated with increased CT in bilateral high-order association sensory cortices reflecting the complex nature of sensory function and recovery in response to rehabilitation.

Rehabilitation robots for the treatment of sensorimotor deficits: a neurophysiological perspective

The past decades have seen rapid and vast developments of robots for the rehabilitation of sensorimotor deficits after damage to the central nervous system (CNS). Many of these innovations were technology-driven, limiting their clinical application and impact. Yet, rehabilitation robots should be designed on the basis of neurophysiological insights underlying normal and impaired sensorimotor functions, which requires interdisciplinary collaboration and background knowledge.

Recovery of sensorimotor function after CNS damage is based on the exploitation of neuroplasticity, with a focus on the rehabilitation of movements needed for self-independence. This requires a physiological limb muscle activation that can be achieved through functional arm/hand and leg movement exercises and the activation of appropriate peripheral receptors. Such considerations have already led to the development of innovative rehabilitation robots with advanced interaction control schemes and the use of integrated sensors to continuously monitor and adapt the support to the actual state of patients, but many challenges remain. For a positive impact on outcome of function, rehabilitation approaches should be based on neurophysiological and clinical insights, keeping in mind that recovery of function is limited. Consequently, the design of rehabilitation robots requires a combination of specialized engineering and neurophysiological knowledge. When appropriately applied, robot-assisted therapy can provide a number of advantages over conventional approaches, including a standardized training environment, adaptable support and the ability to increase therapy intensity and dose, while reducing the physical burden on therapists. Rehabilitation robots are thus an ideal means to complement conventional therapy in the clinic, and bear great potential for continued therapy and assistance at home using simpler devices.

This review summarizes the evolution of the field of rehabilitation robotics, as well as the current state of clinical evidence. It highlights fundamental neurophysiological factors influencing the recovery of sensorimotor function after a stroke or spinal cord injury, and discusses their implications for the development of effective rehabilitation robots. It thus provides insights on essential neurophysiological mechanisms to be considered for a successful development and clinical inclusion of robots in rehabilitation.

Implementation of evidence-based weekend service recommendations for allied health managers: a cluster randomised controlled trial protocol

BACKGROUND

It is widely acknowledged that health policy and practice do not always reflect current research evidence. Whether knowledge transfer from research to practice is more successful when specific implementation approaches are used remains unclear. A model to assist engagement of allied health managers and clinicians with research implementation could involve disseminating evidence-based policy recommendations, along with the use of knowledge brokers. We developed such a model to aid decision-making for the provision of weekend allied health services. This protocol outlines the design and methods for a multi-centre cluster randomised controlled trial to evaluate the success of research implementation strategies to promote evidence-informed weekend allied health resource allocation decisions, especially in hospital managers.

METHODS

This multi-centre study will be a three-group parallel cluster randomised controlled trial. Allied health managers from Australian and New Zealand hospitals will be randomised to receive either (1) an evidence-based policy recommendation document to guide weekend allied health resource allocation decisions, (2) the same policy recommendation document with support from a knowledge broker to help implement weekend allied health policy recommendations, or (3) a usual practice control group. The primary outcome will be alignment of weekend allied health service provision with policy recommendations. This will be measured by the number of allied health service events (occasions of service) occurring on weekends as a proportion of total allied health service events for the relevant hospital wards at baseline and 12-month follow-up.

DISCUSSION

Evidence-based policy recommendation documents communicate key research findings in an accessible format. This comparatively low-cost research implementation strategy could be combined with using a knowledge broker to work collaboratively with decision-makers to promote knowledge transfer. The results will assist managers to make decisions on resource allocation, based on evidence. More generally, the findings will inform the development of an allied health model for translating research into practice.

TRIAL REGISTRATION

This trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) ( ACTRN12618000029291 ). Universal Trial Number (UTN): U1111-1205-2621.

Does sensorimotor upper limb therapy post stroke alter behavior and brain connectivity differently compared to motor therapy? Protocol of a phase II randomized controlled trial

Background

The role of somatosensory feedback in motor performance has been warranted in the literature. Although sensorimotor deficits are common after stroke, current rehabilitation approaches primarily focus on restoring upper limb motor ability. Evidence for integrative sensorimotor rehabilitation approaches is scarce, as is knowledge about neural correlates of somatosensory impairments after stroke and the effect of rehabilitation on brain connectivity level. Therefore, we aim to investigate changes in sensorimotor function and brain connectivity following a sensorimotor therapy program compared to an attention-matched motor therapy program for the upper limb after stroke.

Methods

An assessor-blinded randomized controlled trial will be conducted. Sixty inpatient rehabilitation patients up to eight weeks after stroke will be included. Patients will be randomized to either an experimental group receiving sensorimotor therapy or a control group receiving attention-matched motor therapy for the upper limb, with both groups receiving conventional therapy. Thus, all patients will receive extra therapy, a total of 16 1-h sessions over four weeks. Patients will be assessed at baseline, after four weeks of training, and after four weeks of follow-up. Primary outcome measure is the Action Research Arm Test. Secondary outcome measures will consist of somatosensory, motor and cognitive assessments, and a standardized resting-state functional magnetic resonance imaging protocol.

Discussion

The integration of sensory and motor rehabilitation into one therapy model might provide the added value of this therapy to improve sensorimotor performance post stroke. Insight in the behavioral and brain connectivity changes post therapy will lead to a better understanding of working mechanisms of therapy and will provide new knowledge for patient-tailored therapy approaches.

Trial registration

ClinicalTrials.gov, NCT03236376. Registered on 8 August 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2609-4) contains supplementary material, which is available to authorized users.

SENSory re-learning of the UPPer limb after stroke (SENSUPP): study protocol for a pilot randomized controlled trial

Background

Many stroke survivors suffer from sensory impairments of their affected upper limb (UL). Although such impairments can affect the ability to use the UL in everyday activities, very little attention is paid to sensory impairments in stroke rehabilitation. The purpose of this trial is to investigate if sensory re-learning in combination with task-specific training may prove to be more effective than task-specific training alone to improve sensory function of the hand, dexterity, the ability to use the hand in daily activities, perceived participation, and life satisfaction.

Methods/design

This study is a single-blinded pilot randomized controlled trial (RCT) with two treatment arms. The participants will be randomly assigned either to sensory re-learning in combination with task-specific training (sensory group) or to task-specific training only (control group). The training will consist of 2.5 h of group training per session, 2 times per week for 5 weeks. The primary outcome measures to assess sensory function are as follows: Semmes-Weinstein monofilament, Shape/Texture Identification (STI™) test, Fugl-Meyer Assessment—upper extremity (FMA-UE; sensory section), and tactile object identification test. The secondary outcome measures to assess motor function are as follows: Box and Block Test (BBT), mini Sollerman Hand Function Test (mSHFT), Modified Motor Assessment Scale (M-MAS), and Grippit. To assess the ability to use the hand in daily activities, perceived participation, and life satisfaction, the Motor Activity Log (MAL), Canadian Occupational Performance Measure (COPM), Stroke Impact Scale (SIS) participation domain, and Life Satisfaction checklist will be used. Assessments will be performed pre- and post-training and at 3-month follow-up by independent assessors, who are blinded to the participants’ group allocation. At the 3-month follow-up, the participants in the sensory group will also be interviewed about their general experience of the training and how effective they perceived the training.

Discussion

The results from this study can add new knowledge about the effectiveness of sensory re-learning in combination with task-specific training on UL functioning after stroke. If the new training approach proves efficient, the results can provide information on how to design a larger RCT in the future in persons with sensory impairments of the UL after stroke.

Trial registration

ClinicalTrials.gov, NCT03336749. Registered on 8 November 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2628-1) contains supplementary material, which is available to authorized users.

Development of a System Architecture for Evaluation and Training of Proprioceptive Deficits of the Upper Limb

Proprioception plays a fundamental role in maintaining posture and executing movement, and the quantitative evaluation of proprioceptive deficits in poststroke patients is important. But currently it is not widely performed due to the complexity of the evaluation tools required for a reliable assessment. The aims of this pilot study were to (a) develop a system architecture for upper limb evaluation and training of proximal and distal sense of position in the horizontal plane and (b) test the system in healthy and pathological subjects. Two robotic devices for evaluation and training of, respectively, wrist flexion/extension and shoulder-elbow manipulation were employed. The system we developed was applied in a group of 12 healthy subjects and 10 patients after stroke. It was able to quantitatively evaluate upper limb sense of position in the horizontal plane thanks to a set of quantitative parameters assessing position estimation errors, variability, and gain. In addition, it was able to distinguish healthy from pathological conditions. The system could thus be a reliable method to detect changes in the sense of position of patients with sensory deficits after stroke and could enable the implementation of novel training approaches for the recovery of normal proprioception.

Changing practice in the assessment and treatment of somatosensory loss in stroke survivors: protocol for a knowledge translation study

BACKGROUND

The treatment of somatosensory loss in the upper limb after stroke has been historically overshadowed by therapy focused on motor recovery. A double-blind randomized controlled trial has demonstrated the effectiveness of SENSe (Study of the Effectiveness of Neurorehabilitation on Sensation) therapy to retrain somatosensory discrimination after stroke. Given the acknowledged prevalence of upper limb sensory loss after stroke and the evidence-practice gap that exists in this area, effort is required to translate the published research to clinical practice. The aim of this study is to determine whether evidence-based knowledge translation strategies change the practice of occupational therapists and physiotherapists in the assessment and treatment of sensory loss of the upper limb after stroke to improve patient outcomes.

METHOD/DESIGN

A pragmatic, before-after study design involving eight (n = 8) Australian health organizations, specifically sub-acute and community rehabilitation facilities. Stroke survivors (n = 144) and occupational therapists and physiotherapists (~10 per site, ~n = 80) will be involved in the study. Stroke survivors will be provided with SENSe therapy or usual care. Occupational therapists and physiotherapists will be provided with a multi-component approach to knowledge translation including i) tailoring of the implementation intervention to site-specific barriers and enablers, ii) interactive group training workshops, iii) establishing and fostering champion therapists and iv) provision of written educational materials and online resources. Outcome measures for occupational therapists and physiotherapists will be pre- and post-implementation questionnaires and audits of medical records. The primary outcome for stroke survivors will be change in upper limb somatosensory function, measured using a standardized composite measure.

DISCUSSION

This study will provide evidence and a template for knowledge translation in clinical, organizational and policy contexts in stroke rehabilitation.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) retrospective registration ACTRN12615000933550 .

Motor and sensory effects of ipsilesional upper extremity hypothermia and contralesional sensory training for chronic stroke patients

As hypothermia by immersion can reduce the sensory nerve conduction velocity, this study hypothesized that the reduction of sensory input to the ipsilesional upper extremity (UE) using cryotherapy would reduce the inhibitory activity of the contralesional hemisphere in chronic stroke subjects.

OBJECTIVE

In this study, hypothermia was applied by immersing the ipsilesional UE in association with sensory training of the contralesional UE of stroke patients to assess the immediate (e.g. sensorimotor function, hemodynamics, and levels of comfort) and long-term (sensory and motor performances of the UEs) effects.

METHODS

The sample included 27 stroke patients allocated into group 1 (n = 14), which received conventional physiotherapy for the affected UE, and group 2 (n = 13), which underwent 10 sessions of immersion hypothermia of the ipsilesional wrist and hand. Assessments were performed pre- and post-treatment and at follow-up using esthesiometry, the Fugl-Meyer Assessment (FMA), the Nottingham Sensory Assessment, functional tests, tactile and weight discrimination, motor sequence, level of comfort, and hemodynamic parameters.

RESULTS

The immediate effects of hypothermia using immersion of the ipsilesional UE in association with sensory training of the contralesional UE were hemodynamic stability during and after hypothermia, the absence of sensory abnormalities in the contralesional UE, hypoesthesia in the ipsilesional extremity (dermatomes C6 and C8) (P < 0.05), the maintenance of acceptable levels of comfort, and good patient compliance to the technique. The long-term effects included significant increases in scores on tests performed without functional vision, in scores on blindfolded functional tests, and in tactile localization and joint position sense for the contralesional hand in group 2 as well as the maintenance of these gains at long-term follow-up (5 weeks). Improvement was also found in the tactile function of the C6 and C7 dermatomes of the contralesional hand (P < 0.05).

CONCLUSIONS

The use of immersion hypothermia on the ipsilesional UE in association with sensory training of the contralesional UE improved motor function and sensitivity in the contralesional UE of individuals with chronic stroke. Immersion hypothermia of the ipsilesional UE in chronic stroke patients is a safe, practical, inexpensive, and easily applied technique.

Multisensory stimulation improves functional recovery and resting-state functional connectivity in the mouse brain after stroke

Stroke causes direct structural damage to local brain networks and indirect functional damage to distant brain regions. Neuroplasticity after stroke involves molecular changes within perilesional tissue that can be influenced by regions functionally connected to the site of injury. Spontaneous functional recovery can be enhanced by rehabilitative strategies, which provides experience-driven cell signaling in the brain that enhances plasticity. Functional neuroimaging in humans and rodents has shown that spontaneous recovery of sensorimotor function after stroke is associated with changes in resting-state functional connectivity (RS-FC) within and across brain networks. At the molecular level, GABAergic inhibitory interneurons can modulate brain plasticity in peri-infarct and remote brain regions. Among this cell-type, a decrease in parvalbumin (PV)-immunoreactivity has been associated with improved behavioral outcome. Subjecting rodents to multisensory stimulation through exposure to an enriched environment (EE) enhances brain plasticity and recovery of function after stroke. Yet, how multisensory stimulation relates to RS-FC has not been determined. In this study, we investigated the effect of EE on recovery of RS-FC and behavior in mice after stroke, and if EE-related changes in RS-FC were associated with levels of PV-expressing neurons. Photothrombotic stroke was induced in the sensorimotor cortex. Beginning 2 days after stroke, mice were housed in either standard environment (STD) or EE for 12 days. Housing in EE significantly improved lost tactile-proprioceptive function compared to mice housed in STD environment. RS-FC in the mouse was measured by optical intrinsic signal imaging 14 days after stroke or sham surgery. Stroke induced a marked reduction in RS-FC within several perilesional and remote brain regions. EE partially restored interhemispheric homotopic RS-FC between spared motor regions, particularly posterior secondary motor. Compared to mice housed in STD cages, EE exposure lead to increased RS-FC between posterior secondary motor regions and contralesional posterior parietal and retrosplenial regions. The increased regional RS-FC observed in EE mice after stroke was significantly correlated with decreased PV-immunoreactivity in the contralesional posterior motor region. In conclusion, experimental stroke and subsequent housing in EE induces dynamic changes in RS-FC in the mouse brain. Multisensory stimulation associated with EE enhances RS-FC among distinct brain regions relevant for recovery of sensorimotor function and controlled movements that may involve PV/GABA interneurons. Our results indicate that targeting neural circuitry involving spared motor regions across hemispheres by neuromodulation and multimodal sensory stimulation could improve rehabilitation after stroke.

A neurocognitive approach for recovering upper extremity movement following subacute stroke: a randomized controlled pilot study

[Purpose] This study aims to describe a protocol based on neurocognitive therapeutic exercises and determine its feasibility and usefulness for upper extremity functionality when compared with a conventional protocol. [Subjects and Methods] Eight subacute stroke patients were randomly assigned to a conventional (control group) or neurocognitive (experimental group) treatment protocol. Both lasted 30 minutes, 3 times a week for 10 weeks and assessments were blinded. Outcome measures included: Motor Evaluation Scale for Upper Extremity in Stroke Patients, Motricity Index, Revised Nottingham Sensory Assessment and Kinesthetic and Visual Imagery Questionnaire. Descriptive measures and nonparametric statistical tests were used for analysis. [Results] The results indicate a more favorable clinical progression in the neurocognitive group regarding upper extremity functional capacity with achievement of the minimal detectable change. The functionality results are related with improvements on muscle strength and sensory discrimination (tactile and kinesthetic). [Conclusion] Despite not showing significant group differences between pre and post-treatment, the neurocognitive approach could be a safe and useful strategy for recovering upper extremity movement following stroke, especially regarding affected hands, with better and longer lasting results. Although this work shows this protocol's feasibility with the panel of scales proposed, larger studies are required to demonstrate its effectiveness.

Change in Functional Arm Use Is Associated With Somatosensory Skills After Sensory Retraining Poststroke

OBJECTIVE. We investigated changes in functional arm use after retraining for stroke-related somatosensory loss and identified whether such changes are associated with somatosensory discrimination skills.

METHOD. Data were pooled (N = 80) from two randomized controlled trials of somatosensory retraining. We used the Motor Activity Log to measure perceived amount of arm use in daily activities and the Action Research Arm Test to measure performance capacity. Somatosensory discrimination skills were measured using standardized modality-specific measures.

RESULTS. Participants’ arm use improved after somatosensory retraining (z = −6.80, p &lt; .01). Change in arm use was weakly associated with somatosensation (tactile, β = 0.31, p &lt; .01; proprioception, β = −0.17, p &gt; .05; object recognition, β = 0.13, p &lt; .05).

CONCLUSION. Change in daily arm use was related to a small amount of variance in somatosensory outcomes. Stroke survivors’ functional arm use can increase after somatosensory retraining, with change varying among survivors.

Somatosensory Discrimination Intervention Improves Body Position Sense and Motor Performance in Children With Hemiplegic Cerebral Palsy

OBJECTIVE. This study examined the use of the adult neuroscience-based Sense© intervention with children with hemiplegic cerebral palsy (HCP) to improve upper-limb somatosensory discrimination, motor function, and goal performance.

METHOD. Seventeen children with HCP (9 boys, 8 girls; mean age = 10.2 yr) participated in this pilot matched-pairs trial with random allocation and 6-mo follow-up (intervention, n = 7; control, n = 10). The intervention group received Sense training 3×/wk for 6 wk (18 hr). Outcome measures included Goal Attainment Scaling, Sense_assess© Kids, and the Assisting Hand Assessment.

RESULTS. The intervention group improved in goal performance, proprioception, and bimanual hand use and maintained improvement at 6-mo follow-up. The control group improved in occupational performance by 6-mo follow-up.

CONCLUSION. This study established the feasibility of using the Sense intervention in a pediatric setting and adds preliminary evidence to suggest that improving somatosensory function can improve motor function and goal performance among children with HCP.

Does sensory relearning improve tactile function after carpal tunnel decompression? A pragmatic, assessor-blinded, randomized clinical trial

Despite surgery for carpal tunnel syndrome being effective in 80%-90% of cases, chronic numbness and hand disability can occur. The aim of this study was to investigate whether sensory relearning improves tactile discrimination and hand function after decompression. In a multi-centre, pragmatic, randomized, controlled trial, 104 patients were randomized to a sensory relearning ( n = 52) or control ( n = 52) group. A total of 93 patients completed a 12-week follow-up. Primary outcome was the shape-texture identification test at 6 weeks. Secondary outcomes were touch threshold, touch localization, dexterity and self-reported hand function. No significant group differences were seen for the primary outcome (Shape-Texture Identification) at 6 weeks or 12 weeks. Similarly, no significant group differences were observed on secondary outcomes, with the exception of self-reported hand function. A secondary complier-averaged-causal-effects analysis showed no statistically significant treatment effect on the primary outcome. Sensory relearning for tactile sensory and functional deficits after carpal tunnel decompression is not effective.

LEVEL OF EVIDENCE

II.

Upper Extremity Proprioception After Stroke: Bridging the Gap Between Neuroscience and Rehabilitation

Proprioception is an important aspect of function that is often impaired in the upper extremity following stroke. Unfortunately, neurorehabilitation has few evidence based treatment options for those with proprioceptive deficits. The authors consider potential reasons for this disparity. In doing so, typical assessments and proprioceptive intervention studies are discussed. Relevant evidence from the field of neuroscience is examined. Such evidence may be used to guide the development of targeted interventions for upper extremity proprioceptive deficits after stroke. As researchers become more aware of the impact of proprioceptive deficits on upper extremity motor performance after stroke, it is imperative to find successful rehabilitation interventions to target these deficits and ultimately improve daily function.

Test-retest reliability of the Shape/Texture Identification testTM in people with chronic stroke

OBJECTIVE

To evaluate the test-retest reliability of the Shape/Texture Identification test (STI-test^TM) in persons with chronic stroke.

DESIGN

A test-retest design.

SETTING

University hospital outpatient setting.

PARTICIPANTS

Forty-five persons (mean age 65 years) with mild to moderate impairments in the arm and hand > 6 months post stroke.

INTERVENTIONS

Not applicable.

MAIN MEASURE

The STI-test^TM was used to assess active touch of the hand. It consists of two subtests: identification of shapes and identification of textures, each in three different sizes. Both hands were assessed twice, one week apart. The reliability of the data was evaluated with weighted Kappa statistics and the Svensson rank-invariant method (percentage agreement, systematic and random disagreements).

RESULTS

The median total score of the STI-test^TM was 5 points (min-max 0-6 points) for the more affected hand and 6 points (min-max 3-6 points) for the less affected hand at both test occasions. The weighted Kappa coefficient was 0.94 for the more affected hand and 0.55 for the less affected hand. The percentage agreement for the more affected hand was 69% for the subtest shapes and 82% for the subtest textures, and for the less affected hand 62% and 91%, respectively. There were no systematic or random disagreements for any of the subtests.

CONCLUSION

The STI-test^TM is reliable to assess active touch of the hand after stroke.

Same Intervention-Different Reorganization: The Impact of Lesion Location on Training-Facilitated Somatosensory Recovery After Stroke

BACKGROUND

The brain may reorganize to optimize stroke recovery. Yet relatively little is known about neural correlates of training-facilitated recovery, particularly after loss of body sensations.

OBJECTIVE

Our aim was to characterize changes in brain activation following clinically effective touch discrimination training in stroke patients with somatosensory loss after lesions of primary/secondary somatosensory cortices or thalamic/capsular somatosensory regions using functional magnetic resonance imaging (fMRI).

METHODS

Eleven stroke patients with somatosensory loss, 7 with lesions involving primary (S1) and/or secondary (S2) somatosensory cortex (4 male, 58.7 ± 13.3 years) and 4 with lesions primarily involving somatosensory thalamus and/or capsular/white matter regions (2 male, 58 ± 8.6 years) were studied. Clinical and MRI testing occurred at 6 months poststroke (preintervention), and following 15 sessions of clinically effective touch discrimination training (postintervention).

RESULTS

Improved touch discrimination of a magnitude similar to previous clinical studies and approaching normal range was found. Patients with thalamic/capsular somatosensory lesions activated preintervention in left ipsilesional supramarginal gyrus, and postintervention in ipsilesional insula and supramarginal gyrus. In contrast, those with S1/S2 lesions did not show common activation preintervention, only deactivation in contralesional superior parietal lobe, including S1, and cingulate cortex postintervention. The S1/S2 group did, however, show significant change over time involving ipsilesional precuneus. This change was greater than for the thalamic/capsular group (P = .012; d = -2.43; CI = -0.67 to -3.76).

CONCLUSION

Different patterns of change in activation are evident following touch discrimination training with thalamic/capsular lesions compared with S1/S2 cortical somatosensory lesions, despite common training and similar improvement.

The State-of-the-Science on Somatosensory Function and Its Impact on Daily Life in Adults and Older Adults, and Following Stroke

The aim was to identify and synthesize research evidence about how adults and older adults process somatosensory information in daily activities, and the interventions available to regain somatosensory function following stroke. We developed two interacting concept maps to address the research questions. The scoping review was conducted from 2005 to 2015 across Web of Science, AMED, CINAHL, Embase, Medline, and PsychInfo databases. Search terms included somatosensory, perception, performance, participation, older adult, stroke, intervention, discrimination, learning, and neuroplasticity. Contributions from 103 articles for Concept 1 and 14 articles for Concept 2 are reported. Measures of somatosensory processing, performance, and participation used are identified. Interventions available to treat somatosensory loss are summarized in relation to approach, outcome measures, and theory/mechanisms underlying. A gap exists in the current understanding of how somatosensory function affects the daily lives of adults. A multidisciplinary approach that includes performance and participation outcomes is recommended to advance the field.

The effects of intensive bimanual training with and without tactile training on tactile function in children with unilateral spastic cerebral palsy: A pilot study

Children with unilateral spastic cerebral palsy (USCP) often have tactile impairments. Intensive bimanual training improves the motor abilities, but the effects on the sensory system have not been studied. Here we compare the effects of bimanual training with and without tactile training on tactile impairments. Twenty children with USCP (6-15.5 years; MACS: I-III) were randomized to receive either bimanual therapy (HABIT) or HABIT+tactile training (HABIT+T). All participants received 82 h of standardized HABIT. In addition 8 sessions of 1h were provided to both groups. The HABIT+T group received tactile training (without vision) using materials of varied shapes and textures. The HABIT group received training with the same materials without tactile directed training (full vision). Primary outcomes included grating orientation task/GOT and stereognosis. Secondary outcomes included two-point discrimination/TPD, Semmes-Weinstein monofilaments/SWM. The GOT improved in both groups after training, while stereognosis of the more-affected hand tended to improve (but p=0.063). No changes were found in the TPD and the SWM. There were no group×test interactions for any measure. We conclude tactile spatial resolution can improve after bimanual training. Either intensive bimanual training alone or incorporation of materials with a diversity of shapes/textures may drive these changes.

Somatosensory deficits after stroke: a scoping review

In the past years, there have been increasing research activities focusing on somatosensory symptoms following stroke. However, as compared to the large number of clinical and neuroimaging studies on motor symptoms, the number of studies tracing somatosensory symptoms after stroke and their recovery is rather small. It is an ongoing discussion, to which extent somatosensory deficits after stroke influence patient's long-term outcome in motor and sensory performance and functional independence in activities of daily living. Modern brain imaging techniques allow for studying the impact of stroke lesion localization and size on acute and persisting clinical impairment. Here, we review the literature on somatosensory symptoms after stroke. We summarize epidemiological information on frequency and characteristics of somatosensory symptoms affecting all parts of the body in the acute and chronic stage of stroke. We further give an overview of brain imaging studies of stroke affecting the somatosensory system. Finally, we identify open questions which need to be addressed in future research and summarize the implications for clinical practice.

Somatotopic mismatch of hand representation following stroke: is recovery possible?

Well-organized somatotopic representation of the hand is required to interpret input from cutaneous mechanoreceptors. Previous reports have identified patients with various distortions of somatotopic representation after stroke. Importantly, those patients were investigated years after the stroke, indicating that afferent signal regained access to the cortical circuits; however, further plastic changes, which would re-establish somatotopic order and ability to correctly localize tactile stimuli, did not follow. Thus, it was not known whether somatotopic organization could be restored in such patients and whether there is a potential for new rehabilitation strategies. This is the first case report demonstrating normalization of somatotopic representation.

The Effect of Treatment on Stereognosis in Children With Hemiplegic Cerebral Palsy

PURPOSE

To determine if rehabilitation alone or combined with surgery or botulinum toxin injection improved stereognosis in children with hemiplegic cerebral palsy.

METHODS

Inclusion criteria were children with spastic hemiplegic cerebral palsy who had stereognosis testing 2 separate times with documentation of intervening treatment. Sixty-three children were included, 30 girls and 33 boys at an average age of 9.1 years (range, 4.4-16.0 years). Twelve standardized objects were used for manual identification. Baseline and postintervention stereognosis results were recorded for the hemiplegic and the dominant limb of each patient. The patients were separated into 3 groups based on intervening treatment: surgery with rehabilitation (27 patients), botulinum toxin injection with rehabilitation (19 subjects), and rehabilitation alone (7 subjects). Results were also analyzed by patient age group.

RESULTS

Baseline testing of the hemiplegic limb revealed that 27 patients (43%) exhibited severe stereognosis impairment (0-4 objects identified correctly), 18 (28%) were moderately impaired (5-8 objects), 13 (21%) were mildly impaired (9-11 objects), and 5 (8%) had intact stereognosis (12 objects). There was no statistically significant difference in change in stereognosis scores postintervention among the 3 different treatment groups or between patients who had surgery and those who did not have surgery. There was no statistically significant difference in stereognosis function or postintervention change based on patient age at time of testing.

CONCLUSIONS

In this study, 92% of children with spastic hemiplegic cerebral palsy had stereognosis impairment with a wide spectrum of severity. After operative or nonoperative treatment interventions, stereognosis as a secondary outcome measure was not changed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Examining Differences in Patterns of Sensory and Motor Recovery After Stroke With Robotics

BACKGROUND AND PURPOSE

Developing a better understanding of the trajectory and timing of stroke recovery is critical for developing patient-centered rehabilitation approaches. Here, we quantified proprioceptive and motor deficits using robotic technology during the first 6 months post stroke to characterize timing and patterns in recovery. We also make comparisons of robotic assessments to traditional clinical measures.

METHODS

One hundred sixteen subjects with unilateral stroke were studied at 4 time points: 1, 6, 12, and 26 weeks post stroke. Subjects performed robotic assessments of proprioceptive (position sense and kinesthesia) and motor function (unilateral reaching task and bimanual object hit task), as well as several clinical measures (Functional Independence Measure, Purdue Pegboard, and Chedoke-McMaster Stroke Assessment).

RESULTS

One week post stroke, many subjects displayed proprioceptive (48% position sense and 68% kinesthesia) and motor impairments (80% unilateral reaching and 85% bilateral movement). Interindividual recovery on robotic measures was highly variable. However, we characterized recovery as early (normal by 6 weeks post stroke), late (normal by 26 weeks post stroke), or incomplete (impaired at 26 weeks post stroke). Proprioceptive and motor recovery often followed different timelines. Across all time points, robotic measures were correlated with clinical measures.

CONCLUSIONS

These results highlight the need for more sensitive, targeted identification of sensory and motor deficits to optimize rehabilitation after stroke. Furthermore, the trajectory of recovery for some individuals with mild to moderate stroke may be much longer than previously considered.

Design, Fabrication, and Administration of the Hand Active Sensation Test (HASTe)

The concept of personalizing neurologic rehabilitation, based on individual impairments, has experienced a recent surge. In parallel, the number of outcome measures of upper extremity motor performance has grown. However, clinicians and researchers lack practical, quantitative measures of the hand's natural role as a receptor of the environment. The Hand Active Sensation Test (HASTe), developed by Williams and colleagues in 2006, is a valid and reliable measure of haptic performance. Though not available commercially, the HASTe can be fabricated from inexpensive materials, and it has been used successfully to identify impairments in haptic touch in individuals with stroke. (Williams, 2006). This paper presents the methods of design and fabrication of the HASTe testing kit, as well as a visual screen to be used during administration, and instructions for the tests administration and scoring.

Individuals Poststroke Do Not Perceive Their Spatiotemporal Gait Asymmetries as Abnormal

BACKGROUND

Following stroke, spatiotemporal gait asymmetries persist into the chronic phases, despite the neuromuscular capacity to produce symmetric walking patterns. This persistence of gait asymmetry may be due to deficits in perception, as the newly established asymmetric gait pattern is perceived as normal.

OBJECTIVE

The purpose of this study was to determine the effect of usual overground gait asymmetry on the ability to consciously and unconsciously perceive the presence of gait asymmetry in people poststroke.

DESIGN

An observational study was conducted.

METHODS

Thirty people poststroke walked overground and on a split-belt treadmill with the belts moving at different speeds (0%-70% difference) to impose varied step length and stance time asymmetries. Conscious awareness and subconscious detection of imposed gait patterns were determined for each participant, and the asymmetry magnitudes at those points were compared with overground gait.

RESULTS

For both spatial and temporal asymmetry variables, the asymmetry magnitude at the threshold of awareness was significantly greater than the asymmetry present at the threshold of detection or during overground gait. Participants appeared to identify belt speed differences using the type of gait asymmetry they typically exhibited (ie, step length or stance time asymmetries during overground gait).

LIMITATIONS

Very few individuals with severe spatiotemporal asymmetry were tested, and participants were instructed to identify asymmetric belt speeds rather than interlimb movements.

CONCLUSIONS

The data suggest that asymmetry magnitudes need to exceed usual overground levels to reach conscious awareness. Therefore, it is proposed that the spatiotemporal asymmetry that is specific to each participant may need to be augmented beyond what he or she usually has during walking in order to promote awareness of asymmetric gait patterns for long-term correction and learning.

Upper extremity proprioception in healthy aging and stroke populations, and the effects of therapist- and robot-based rehabilitation therapies on proprioceptive function

The world’s population is aging, with the number of people ages 65 or older expected to surpass 1.5 billion people, or 16% of the global total. As people age, there are notable declines in proprioception due to changes in the central and peripheral nervous systems. Moreover, the risk of stroke increases with age, with approximately two-thirds of stroke-related hospitalizations occurring in people over the age of 65. In this literature review, we first summarize behavioral studies investigating proprioceptive deficits in normally aging older adults and stroke patients, and discuss the differences in proprioceptive function between these populations. We then provide a state of the art review the literature regarding therapist- and robot-based rehabilitation of the upper extremity proprioceptive dysfunction in stroke populations and discuss avenues of future research.

Assessing and treating higher level somatosensory impairments post stroke

Poststroke somatosensory impairment is prevalent, yet commonly used clinical measures lack the sensitivity needed to quantify impairment and detect change due to intervention. This selective review, prepared and presented as a part of the I-Treat Conference (June 22, 2013, Columbus, Ohio), discusses the prevalence of somatosensory impairment after stroke, highlights measures of higher level somatosensory processing, and briefly reviews sensorimotor rehabilitation. The goal of this article is to encourage dialogue regarding the development and use of measures of higher level somatosensory function that will enable personalization of sensorimotor rehabilitation.

How do somatosensory deficits in the arm and hand relate to upper limb impairment, activity, and participation problems after stroke? A systematic review

BACKGROUND

The association between somatosensory impairments and outcome after stroke remains unclear.

PURPOSE

The aim of this study was to systematically review the available literature on the relationship between somatosensory impairments in the upper limb and outcome after stroke.

DATA SOURCES

The electronic databases PubMed, CINAHL, EMBASE, Cochrane Library, PsycINFO, and Web of Science were systematically searched from inception until July 2013.

STUDY SELECTION

Studies were included if adult patients with stroke (minimum n=10) were examined with reliable and valid measures of somatosensation in the upper limb to investigate the relationship with upper limb impairment, activity, and participation measures. Exclusion criteria included measures of somatosensation involving an overall score for upper and lower limb outcome and articles including only lower limb outcomes.

DATA EXTRACTION

Eligibility assessment, data extraction, and quality evaluation were completed by 2 independent reviewers. A cutoff score of ≥65% of the maximal quality score was used for further inclusion in this review.

DATA SYNTHESIS

Six articles met all inclusion criteria. Two-point discrimination was shown to be predictive for upper limb dexterity, and somatosensory evoked potentials were shown to have predictive value in upper limb motor recovery. Proprioception was significantly correlated with perceived level of physical activity and social isolation and had some predictive value in functional movements of the upper limb. Finally, the combination of light touch and proprioception impairment was shown to be significantly related to upper limb motor recovery as well as handicap situations during activities of daily living.

LIMITATIONS

Heterogeneity of the included studies warrants caution when interpreting results.

CONCLUSIONS

Large variation in results was found due to heterogeneity of the studies. However, somatosensory deficits were shown to have an important role in upper limb motor and functional performance after stroke.