Estimating minimal clinically important differences of upper-extremity measures early after stroke

Integrative rehabilitation of residents chronic post-stroke in skilled nursing facilities: the design and evaluation of the BrightArm Duo

PURPOSE

To describe the novel BrightArm Duo bimanual upper extremity (UE) rehabilitation system; to determine its technology acceptance and clinical benefit for older hemiplegic participants.

METHODS

The system table tilted to adjust arm gravity loading. Participants wore arm supports that sensed grasp strength and wrist position on the table. Wrist weights further increased shoulder exertion. Games were designed to improve UE strength, motor function, cognition and emotive state and adapted automatically to each participant. The system underwent feasibility trials spanning 8 weeks in two skilled nursing facilities (SNFs). Participants were evaluated pre-therapy and post-therapy using standardized clinical measures. Computerized measures of supported arm reach, table tilt and number of arm repetitions were stored on a remote server.

OUTCOMES

Seven participants had significant improvements in their active range of shoulder movement, supported arm reach, shoulder strength, grasp strength and their ability to focus. The group demonstrated higher arm function measured with FMA (p = 0.01) and CAHAI (p = 0.05), and had an improvement in depression (Becks Depression Inventory, II). BrightArm Duo technology was well accepted by participants with a rating of 4.4 out of 5 points.

CONCLUSIONS

Given these findings, it will be beneficial to evaluate the BrightArm Duo application in SNF maintenance programs. Implications for Rehabilitation Integrative rehabilitation that addresses both physical and cognitive domains is promising for post-stroke maintenance in skilled nursing facilities. Simultaneous bilateral arm exercise may improve arm function in older hemiplegic patients several years after stroke. Virtual reality games that adapt to the patient can increase attention and working memory while decreasing depression in elderly.

Upper extremity recovery after ischaemic and haemorrhagic stroke: Part of the SALGOT study

Introduction

The purpose was to explore if there are differences in extent of change in upper extremity motor function and activity capacity, in persons with ischaemic versus haemorrhagic stroke, during the first year post stroke.

Patients and methods

One hundred seventeen persons with stroke (ischaemic n = 98, haemorrhagic n = 19) and reduced upper extremity function 3 days after onset were consecutively included to the Stroke Arm Longitudinal Study at the University of Gothenburg (SALGOT) from a stroke unit. Upper extremity motor function (Fugl-Meyer Assessment Scale for Upper Extremity (FMA-UE)) and activity capacity (Action Research Arm Test (ARAT)) were assessed at 6 assessments during the first year; age and initial stroke severity were recorded. Differences between groups in extent of change over time of upper extremity motor function and activity capacity were analysed with mixed models repeated measurements method.

Results

Significant improvements were found in function and activity in both groups within the first month (p = 0.001). Higher age and more severe stroke had a negative impact on recovery in both groups. Larger improvements of function and activity were seen in haemorrhagic stroke compared to ischaemic, both from 3 days to 3- and 12 months, and from 1 month to 3 months. Both groups reached similar levels of function and activity at 3 months post stroke.

Conclusion

Although persons with haemorrhagic stroke had initially lower scores than those with ischaemic stroke, they had a larger improvement within the first 3 months, and thereafter both groups had similar function and activity.

Cross cultural adaptations and psychometric domains of Brazilian version of PROFILE PD for Parkinson's disease

PURPOSE

The PROFILE PD scale was developed specifically to evaluate patients with Parkinson's disease (PD) within the context of the International Classification of Functioning, Disability and Health, directly applied to physical therapy practice. The study aimed to translate and cross-culturally adapt the PROFILE PD scale to Portuguese-Brazil, and to analyze its psychometric domains.

METHODS

Fifty participants with PD participated in the study. We assessed the clarity of the Brazilian version of the scale by physiotherapists, presence of floor and ceiling effects, interrater and test-retest reliabilities, in addition to discriminant, concurrent (UPDRS) and construct validity, internal consistence, minimal detectable change (MDC), and responsiveness.

RESULTS

The scale was considered highly clear for physical therapists. The interrater ICC was 0.74 and Wk was 0.89 for the total score. For test-retest reliability, the total ICC score was 0.99. The analysis of concurrent validity showed the Spearman correlation between Brazilian version of PROFILE PD and UPDRS (ρ = 0.77; p < 0.001). Factor analyses demonstrated that the test comprises a single scale. Brazilian version of PROFILE PD was able to discriminate the subject with PD in mild and moderate stages, and in mild and severe stages. A high internal consistency was found (α = 0.99). MDC was 2.41 points and there were no floor and ceiling effects. Also, the scale was responsive to physical therapy intervention, with improvement in 8 points after two months (effect size = 0.85).

CONCLUSION

The Brazilian version of PROFILE PD is an instrument reliable, valid, and responsive to physical therapy intervention, that can be used to quantify impairments and limitations in patients with PD and can provide an overall summary of the impact of disease, useful for physiotherapy practice. Implications for Rehabilitation PROFILE PD is a reliable and valid instrument to be applied in Brazilian Parkinson disease patients. This scale is design specially to be used in physical therapy practice within the contexts surrounding the International Classification of Functioning, Disability and Health. PROFILE PD was able to discriminate between patients in mild and moderate stages of disease which is difficult in clinical practice mainly because the scale used for this relies on balance and gait rather than a global profile.

Quantifying Change During Outpatient Stroke Rehabilitation: A Retrospective Regression Analysis

OBJECTIVE

To examine change and individual trajectories for balance, upper extremity motor capacity, and mobility in people poststroke during the time they received outpatient therapies.

DESIGN

Retrospective analyses of an observational cohort using hierarchical linear modeling.

SETTING

Outpatient rehabilitation.

PARTICIPANTS

Persons poststroke (N=366).

INTERVENTIONS

Usual outpatient physical and occupational therapy.

MAIN OUTCOMES MEASURES

Berg Balance Scale (BBS), Action Research Arm Test (ARAT), and walking speed were used to assess the 3 domains. Initial scores at the start of outpatient therapy (intercepts), rate of change during outpatient therapy (slopes), and covariance between slopes and intercepts were modeled as random effects. Additional variables modeled as fixed effects were duration (months of outpatient therapy), time (days poststroke), age (y), and inpatient status (if the patient went to an inpatient rehabilitation facility [IRF]).

RESULTS

A patient with average age and time started at 37 points on the BBS with a change of 1.8 points per month, at 35 points on the ARAT with a change of 2 points per month, and with a walking speed of .59m/s with a change of .09m/s per month. When controlling for other variables, patients started with lower scores on the BBS and ARAT or had slower walking speeds at admission if they started outpatient therapy later than average or went to an IRF.

CONCLUSIONS

Patients generally improved over the course of outpatient therapy, but there was considerable variability in individual trajectories. Average rates of change across all 3 domains were small.

Increasing Access to Cost Effective Home-Based Rehabilitation for Rural Veteran Stroke Survivors

INTRODUCTION

An estimated 750,000 Americans experience a stroke annually. Most stroke survivors require rehabilitation. Limited access to rehabilitation facilities has a pronounced burden on functional outcomes and quality of life. Robotic devices deliver reproducible therapy without the need for real-time human oversight. This study examined the efficacy of using home-based, telerobotic-assisted devices (Hand and Foot Mentor: HM and FM) to improve functional ability and reduce depression symptoms, while improving access and cost savings associated with rehabilitation.

METHODS

Twenty stroke survivors performed three months of home-based rehabilitation using a robotic device, while a therapist remotely monitored progress. Baseline and end of treatment function and depression symptoms were assessed. Satisfaction with the device and access to therapy were determined using qualitative surveys. Cost analysis was performed to compare home-based, robotic-assisted therapy to clinic-based physical therapy.

RESULTS

Compared to baseline, significant improvement in upper extremity function (30.06%, p= 0.046), clinically significant benefits in gait speed (29.03%), moderate improvement in depressive symptoms (28.44%) and modest improvement in distance walked (30.2%) were observed. Participants indicated satisfaction with the device. Home-based robot therapy expanded access to post-stroke rehabilitation for 35% of the people no longer receiving formal services and increased daily access for the remaining 65%, with a cost savings of $2,352 (64.97%) compared to clinic-based therapy.

CONCLUSION

Stroke survivors made significant clinically meaningful improvements in the use of their impaired extremities using a robotic device in the home. Home-based, robotic therapy reduced costs, while expanding access to a rehabilitation modality for people who would not otherwise have received care.

Dose response of task-specific upper limb training in people at least 6 months poststroke: A phase II, single-blind, randomized, controlled trial

OBJECTIVE

The objectives of this work were to (1) determine whether higher doses of motor therapy in chronic poststroke hemiparesis result in better outcomes, compared to lower doses, and (2) evaluate potential modifiers of the dose-response relationship.

METHODS

Eighty-five adults with upper extremity paresis ≥6 months poststroke were randomized to one of four dose groups in this single-blind, parallel, randomized, control trial. The dosing parameter manipulated was amount of task-specific training, as indexed by the number of task repetitions. Groups received 3,200, 6,400, 9,600, or individualized maximum (IM) repetitions, during 1-hour sessions, 4 days/week for 8 weeks. The intervention was an individualized, progressive, task-specific upper-limb training program designed to improve upper-limb functional motor capacity. The primary outcome was the slope of the Action Research Arm Test (ARAT) during the intervention. Effects of dose and potential modifiers of the dose-response relationship were evaluated with hierarchical linear models.

RESULTS

ARAT scores for the 3,200, 9,600, and IM groups improved over time as indicated by slopes (ΔARAT/week, mean ± standard errors) of 0.40 ± 0.15, 0.31 ± 0.16, and 0.66 ± 0.14, respectively (p < 0.05). The slope of the 6,400 group was smaller (-0.05 ± 0.15) and significantly different from the 3,200 and IM groups (p < 0.001). Initial motor capacity, neglect, and other tested characteristics did not modify the dose-response relationship.

INTERPRETATION

Overall, treatment effects were small. There was no evidence of a dose-response effect of task-specific training on functional capacity in people with long-standing upper-limb paresis poststroke. Ann Neurol 2016;80:342-354.

Can Neurological Biomarkers of Brain Impairment Be Used to Predict Poststroke Motor Recovery? A Systematic Review

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.

Changes in Upper-Extremity Functional Capacity and Daily Performance During Outpatient Occupational Therapy for People With Stroke

OBJECTIVE

This study explored how upper-extremity (UE) functional capacity and daily performance change during the course of outpatient rehabilitation in people with stroke.

METHOD

Fifteen participants receiving outpatient occupational therapy services for UE paresis poststroke were enrolled. UE motor capacity was measured with the Action Research Arm Test (ARAT), and UE performance was measured using bilateral, wrist-worn accelerometers. Measurements were taken at or near the start of therapy, at every 10th visit or every 30 days throughout the duration of services, and at discharge.

RESULTS

Three patterns were observed: (1) increase in ARAT scores and more normalized accelerometry profiles, (2) increase in ARAT scores but no change in accelerometry profiles, and (3) no change in ARAT scores or in accelerometry profiles.

CONCLUSION

UE performance in daily life was highly variable, with inconsistencies between change in UE capacity and change in UE performance. UE capacity and performance are important constructs to assess separately during rehabilitation.

Combining levodopa and virtual reality-based therapy for rehabilitation of the upper limb after acute stroke: pilot study Part II

INTRODUCTION

This study aimed to evaluate the safety and efficacy of a combination of levodopa and virtual reality (VR)-based therapy for the enhancement of upper limb recovery following acute stroke.

METHODS

This was a pilot single-blinded case series of acute stroke patients with upper extremity hemiparesis. Patients were randomised to standard care with concomitant administration of either levodopa alone (control group) or combination therapy consisting of VR-based motivational visuomotor feedback training with levodopa neuromodulation (VR group). Main clinical outcome measures were the Fugl-Meyer Upper Extremity (FM-UE) assessment and Action Research Arm Test (ARAT). Kinematic measurements of affected upper limb movement were evaluated as a secondary measure of improvement.

RESULTS

Of 42 patients screened, four patients were enrolled in each of the two groups. Two patients dropped out from the control group during the trial. Patients receiving combination therapy had clinically significant improvements in FM-UE assessment scores of 16.5 points compared to a 3.0-point improvement among control patients. Similarly, ARAT scores of VR group patients improved by 15.3 points compared to a 10.0-point improvement in the control group. Corresponding improvements were noted in kinematic measures, including hand-path ratio, demonstrating that the quality of upper limb movement improved in the VR group.

CONCLUSION

Our results suggest that VR-based therapy and pharmacotherapy may be combined for acute stroke rehabilitation. Bedside acquisition of kinematic measurements allows accurate assessment of the quality of limb movement, offering a sensitive clinical tool for quantifying motor recovery during the rehabilitation process after acute stroke.

Minimal clinically important difference of the lower-extremity fugl-meyer assessment in chronic-stroke

BACKGROUND

The Minimal Clinically Important Difference (MCID), the smallest difference in the treatment outcome, augments both clinical and research practice. The MCID of the Fugl-Meyer assessment: Lower extremity (FMA-LE), an important motor measure in stroke, is not known.

OBJECTIVE

To estimate MCID score of FMA-LE using an anchor-based approach in chronic poststroke hemiparetic (>6 months) stroke subjects.

METHODS

DESIGN

A prospective, observational study.

SETTING

Occupational therapy department of a rehabilitation institute.

PARTICIPANTS

Sixty-five poststroke hemiparetic subjects (Mean age = 44.22 years, 42 men, Mean poststroke duration = 16.42 months).

INTERVENTION

The conventional motor therapy based on neurophysiological approaches was provided for the affected lower extremity (30 sessions, 45 min each, 3/week).

OUTCOME MEASURES

FMA-LE, Functional ambulation classification (FAC), and global rating of patient-perceived changes (GRPPC).

RESULT

The estimated MCID of FMA-LE was found to be a score of 6 using both FAC (sensitivity 90, specificity 94) and GRPPC (sensitivity 87, specificity 91).

CONCLUSION

In chronic poststroke hemiparetic subjects, the computed MCID of FMA-LE is a score of 6. The subjects who achieve a change in a score of 6 on FMA-LE would perceive a meaningful recovery of lower-extremity function than those who do not. The reference value may be utilized in stroke rehabilitation.

The Fugl-Meyer assessment of the upper extremity: reliability, responsiveness and validity of the Danish version

OBJECTIVE

To translate the Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) into Danish and to establish the inter-tester reliability, responsiveness, Minimal Clinically Important Difference (MCID) and concurrent validity of the FMA-UE in a population of stroke patients.

METHOD

The translation was conducted in accordance with the principles outlined by the ISPOR Task Force for Translation and Cultural Adaption. Inter-rater reliability was assessed at baseline. Each patient was tested by two examiners and inter class correlation (ICC) was calculated. Responsiveness was assessed using receiver operating characteristic (ROC) curve statistics. The FMA-UE change score was used to assess sensitivity and specificity and to correctly determine which patients had improved. The MCID and the area under the curve (AUC) were established using the ROC. The FMA-UE's concurrent validity with the Motor Assessment Scale was determined using Spearman's rank correlation.

SETTING

The study took place at Skive Neurorehabilition, Denmark from May 2014 to February 2015.

PARTICIPANTS

Inpatients, who were in the acute to sub-acute stage of stroke and aged > 18 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The FMA-UE.

RESULTS

In 50 inpatients the ICC was 0.95, AUC was 0.87, with a sensitivity of 77%, a specificity of 89% and an MCID ≥ 4. Concurrent validity was high, with r = 0.94-0.95.

CONCLUSION

The FMA-UE was successfully translated into Danish. An MCID ≥ 4 was found. This study provides evidence that the FMA-UE is a reliable, responsive and valid instrument for measuring upper limb impairment after stroke. Implications for rehabilitation One of the most widely recognized measures of upper extremity motor impairment post-stroke is the Fugl-Meyer Assessment of the Upper Extremity (FMA-UE). The psychometric properties of a measurement depends on the population and setting in which it is used. In this study, the FMA-UE is translated into Danish and the psychometric properties of FMA-UE is determined in a Danish population of patients with stroke. The FMA-UE is now available to use for clinicians in Denmark.

Does the addition of virtual reality training to a standard program of inpatient rehabilitation improve sitting balance ability and function after stroke? Protocol for a single-blind randomized controlled trial

Background

Sitting ability and function are commonly impaired after stroke. Balance training has been shown to be helpful, but abundant repetitions are required for optimal recovery and patients must be motivated to perform rehabilitation exercises repeatedly to maximize treatment intensity. Virtual reality training (VRT), which allows patients to interact with a virtual environment using computer software and hardware, is enjoyable and may encourage greater repetition of therapeutic exercises. However, the potential for VRT to promote sitting balance has not yet been explored. The objective of this study is to determine if supplemental VRT-based sitting balance exercises improve sitting balance ability and function in stroke rehabilitation inpatients.

Methods/Design

This is a single-site, single-blind, parallel-group randomized control trial. Seventy six stroke rehabilitation inpatients who cannot stand independently for greater than one minute but can sit for at least 20 minutes (including at least one minute without support) are being recruited from a tertiary-care dedicated stroke rehabilitation unit. Participants are randomly allocated to experimental or control groups. Both participate in 10–12 sessions of 30–45 minutes of VRT performed in sitting administered by a single physiotherapist, in addition to their traditional therapy. The experimental group plays five games which challenge sitting balance while the control group plays five games which minimize trunk lean. Outcome measures of sitting balance ability (Function in Sitting Test, Ottawa Sitting Scale, quantitative measures of postural sway) and function (Reaching Performance Scale, Wolf Motor Function Test, quantitative measures of the limits of stability) are administered prior to, immediately following, and one month following the intervention by a second physiotherapist blind to the participant’s group allocation.

Discussion

The treatment of sitting balance post-stroke with VRT has not yet been explored. Results from the current study will provide important evidence for the use of low-cost, accessible VRT as an adjunct intervention to increase sitting balance in lower-functioning patients receiving inpatient rehabilitation. The motivating and enjoyable attributes of VRT may increase exercise dosage, leading to improved function and optimal results from rehabilitation.

Trial Registration

https://clinicaltrials.gov/; Identifier: NCT02285933. Registered 06 November 2014.

Funded by the Heart & Stroke Foundation of Canada and a generous donation from Tony & Elizabeth Graham.

H-GRASP: the feasibility of an upper limb home exercise program monitored by phone for individuals post stroke

PURPOSE

To investigate the feasibility of a phone-monitored home exercise program for the upper limb following stroke.

METHODS

A pre-post double baseline repeated measures design was used. Participants completed an 8-week home exercise program that included behavioural strategies to promote greater use of the affected upper limb. Participants were monitored weekly by therapists over the phone. The following feasibility outcomes were collected: Process (e.g. recruitment rate); Resources (e.g. exercise adherence rate); Management (e.g. therapist monitoring) and Scientific (e.g. safety, effect sizes). Clinical outcomes included: The Chedoke Arm and Hand Inventory, Motor Activity Log, grip strength and the Canadian Occupational Performance Measure.

RESULTS

Eight individuals with stroke were recruited and six participants completed the exercise program. All but one of the six participants met the exercise target of 60 minutes/day, 6 days/week. Participants were stable across the baseline period. The following post-treatment effect sizes were observed: CAHAI (0.944, p = 0.046); MALQ (0.789, p = 0.03) grip strength (0.947, p = 0.046); COPM (0.789, p = 0.03). Improvements were maintained at three and six month follow ups.

CONCLUSIONS

Community dwelling individuals with stroke may benefit from a phone-monitored upper limb home exercise program that includes behavioural strategies that promote transfer of exercise gains into daily upper limb use. Implications for Rehabilitation A repetitive, task-oriented home exercise program that utilizes telephone supervision may be an effective method for the treatment of the upper limb following stroke This program is best suited for individuals with mild to moderate level impairment and experience a sufficient level of challenge from the exercises An exercise program that includes behavioural strategies may promote transfer of exercise gains into greater use of the affected upper limb during daily activities.

Effect of a Task-Oriented Rehabilitation Program on Upper Extremity Recovery Following Motor Stroke: The ICARE Randomized Clinical Trial

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.

Feasibility of high-repetition, task-specific training for individuals with upper-extremity paresis

OBJECTIVE. We investigated the feasibility of delivering an individualized, progressive, high-repetition upper-extremity (UE) task-specific training protocol for people with stroke in the inpatient rehabilitation setting. METHOD. Fifteen patients with UE paresis participated in this study. Task-specific UE training was scheduled for 60 min/day, 4 days/wk, during occupational therapy for the duration of a participant's inpatient stay. During each session, participants were challenged to complete ≥300 repetitions of various tasks. RESULTS. Participants averaged 289 repetitions/session, spending 47 of 60 min in active training. Participants improved on impairment and activity level outcome measures. CONCLUSION. People with stroke in an inpatient setting can achieve hundreds of repetitions of task-specific training in 1-hr sessions. As expected, all participants improved on functional outcome measures. Future studies are needed to determine whether this high-repetition training program results in better outcomes than current UE interventions.

Forced Aerobic Exercise Enhances Motor Recovery After Stroke: A Case Report

OBJECTIVE

Previously, we demonstrated that forced aerobic exercise (FE) increases the pattern of neural activation in Parkinson's disease. We sought to evaluate whether FE, when coupled with repetitive task practice, could promote motor recovery poststroke.

METHOD

A 46-yr-old man with ischemic stroke exhibited chronic residual upper-extremity deficits, scoring 35/66 on the Fugl-Meyer Assessment (FMA) at baseline. He completed 24 training sessions comprising 45 min of FE on a motorized stationary bicycle followed by 45 min of upper-extremity repetitive task practice.

RESULTS

From baseline to end of treatment, the FMA score improved by 20 points, perceived level of recovery on the Stroke Impact Scale increased by 20 percentage points, and cardiovascular function measured by peak oxygen uptake improved 30%. These improvements persisted 4 wk after the intervention ceased.

CONCLUSION

FE may be a safe and feasible rehabilitation approach to augment recovery of motor and nonmotor function while improving aerobic fitness in people with chronic stroke.

User Evaluation of a Dynamic Arm Orthosis for People With Neuromuscular Disorders

This paper presents the results of an online survey conducted with users of a functional upper extremity orthosis called the Wilmington Robotic EXoskeleton (WREX). The WREX is a passive anti-gravity arm orthosis that allows people with neuromuscular disabilities to move their arms in three dimensions. The paper also describes the design of a novel lightweight 3-D printed WREX used for ambulatory children. Three different versions of the WREX are now offered to patients. Two can be mounted on a wheelchair and one to a body jacket for ambulatory patients. An online user survey with 55 patients was conducted to determine the benefits of the various WREXs. The survey asked ten questions related to upper extremity function with and without the WREX as well as subjective impressions of the device. Results show a statistically significant improvement in arm function for everyday tasks with the WREX.

Constraint-induced movement therapy for upper extremities in people with stroke

BACKGROUND

In people who have had a stroke, upper limb paresis affects many activities of daily life. Reducing disability is therefore a major aim of rehabilitative interventions. Despite preserving or recovering movement ability after stroke, sometimes people do not fully realise this ability in their everyday activities. Constraint-induced movement therapy (CIMT) is an approach to stroke rehabilitation that involves the forced use and massed practice of the affected arm by restraining the unaffected arm. This has been proposed as a useful tool for recovering abilities in everyday activities.

OBJECTIVES

To assess the efficacy of CIMT, modified CIMT (mCIMT), or forced use (FU) for arm management in people with hemiparesis after stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group trials register (last searched June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library Issue 1, 2015), MEDLINE (1966 to January 2015), EMBASE (1980 to January 2015), CINAHL (1982 to January 2015), and the Physiotherapy Evidence Database (PEDro; January 2015).

SELECTION CRITERIA

Randomised control trials (RCTs) and quasi-RCTs comparing CIMT, mCIMT or FU with other rehabilitative techniques, or none.

DATA COLLECTION AND ANALYSIS

One author identified trials from the results of the electronic searches according to the inclusion and exclusion criteria, three review authors independently assessed methodological quality and risk of bias, and extracted data. The primary outcome was disability.

MAIN RESULTS

We included 42 studies involving 1453 participants. The trials included participants who had some residual motor power of the paretic arm, the potential for further motor recovery and with limited pain or spasticity, but tended to use the limb little, if at all. The majority of studies were underpowered (median number of included participants was 29) and we cannot rule out small-trial bias. Eleven trials (344 participants) assessed disability immediately after the intervention, indicating a non-significant standard mean difference (SMD) 0.24 (95% confidence interval (CI) -0.05 to 0.52) favouring CIMT compared with conventional treatment. For the most frequently reported outcome, arm motor function (28 studies involving 858 participants), the SMD was 0.34 (95% CI 0.12 to 0.55) showing a significant effect (P value 0.004) in favour of CIMT. Three studies involving 125 participants explored disability after a few months of follow-up and found no significant difference, SMD -0.20 (95% CI -0.57 to 0.16) in favour of conventional treatment.

AUTHORS' CONCLUSIONS

CIMT is a multi-faceted intervention where restriction of the less affected limb is accompanied by increased exercise tailored to the person's capacity. We found that CIMT was associated with limited improvements in motor impairment and motor function, but that these benefits did not convincingly reduce disability. This differs from the result of our previous meta-analysis where there was a suggestion that CIMT might be superior to traditional rehabilitation. Information about the long-term effects of CIMT is scarce. Further trials studying the relationship between participant characteristics and improved outcomes are required.

Physical Function and Disability After Acute Care and Critical Illness Hospitalizations in a Prospective Cohort of Older Adults

OBJECTIVES

To investigate associations between acute care and critical illness hospitalizations and performance on physical functional measures and activities of daily living (ADLs).

DESIGN

Prospective cohort study.

SETTING

Large health maintenance organization.

PARTICIPANTS

Two thousand nine hundred twenty-six participants in Adult Changes in Thought, a study of aging enrolling dementia-free individuals aged 65 and older not living in a nursing home from 1994 to September 30, 2008 (N = 2,926).

MEASUREMENTS

The exposure of interest was hospitalization during study participation, subdivided by presence of critical illness. Outcomes included gait speed, grip strength, chair stand speed, and difficulty and dependence in performing ADLs measured at biennial visits.

RESULTS

Median time between hospital discharge and the next study visit was 311 days (interquartile range (IQR) 151-501 days) after acute care hospitalization and 359 days (IQR 181-420 days) after critical illness hospitalization. Gait speed was slower after acute care (-0.05 m/s, 95% confidence interval (CI) = 0.01-0.04 m/s slower, P < .001) and critical illness (-0.16 m/s, 95% CI = -0.22 to -0.10, P < .001). Grip was weaker after acute care hospitalization (-0.8 kg, 95% CI = -1.0 to -0.6, P < .001) but not significantly different after critical illness hospitalization. Chair-stand speed was slower after acute care hospitalization (-0.04 stands/s, 95% CVI = -0.05 to -0.04, P < .001) and critical illness hospitalization (-0.09, 95% CI = -0.15 to -0.03, P = .003). The odds of difficulty with (odds ratio (OR) = 1.4, 95% CI = 1.2-1.6, P < .001) or dependence in (OR = 2.0, 95% CI = 1.2-3.2, P = .006) one or more ADLs was higher after acute care hospitalization, as were the odds of difficulty with (OR = 1.9, 95% CI = 1.1-3.6, P = .03) or dependence in (OR = 7.9, 95% CI = 2.5-25.7, P = .001) one or more ADLs after critical illness.

CONCLUSION

In older adults, hospitalization, especially for critical illness, was associated with clinically relevant decline in gait and chair stand speed and strongly associated with difficulty with and dependence in ADLs.

Individual prediction of chronic motor outcome in the acute post-stroke stage: Behavioral parameters versus functional imaging

Several neurobiological factors have been found to correlate with functional recovery after brain lesions. However, predicting the individual potential of recovery remains difficult. Here we used multivariate support vector machine (SVM) classification to explore the prognostic value of functional magnetic resonance imaging (fMRI) to predict individual motor outcome at 4-6 months post-stroke. To this end, 21 first-ever stroke patients with hand motor deficits participated in an fMRI hand motor task in the first few days post-stroke. Motor impairment was quantified assessing grip force and the Action Research Arm Test. Linear SVM classifiers were trained to predict good versus poor motor outcome of unseen new patients. We found that fMRI activity acquired in the first week post-stroke correctly predicted the outcome for 86% of all patients. In contrast, the concurrent assessment of motor function provided 76% accuracy with low sensitivity (<60%). Furthermore, the outcome of patients with initially moderate impairment and high outcome variability could not be predicted based on motor tests. In contrast, fMRI provided 87.5% prediction accuracy in these patients. Classifications were driven by activity in ipsilesional motor areas and contralesional cerebellum. The accuracy of subacute fMRI data (two weeks post-stroke), age, time post-stroke, lesion volume, and location were at 50%-chance-level. In conclusion, multivariate decoding of fMRI data with SVM early after stroke enables a robust prediction of motor recovery. The potential for recovery is influenced by the initial dysfunction of the active motor system, particularly in those patients whose outcome cannot be predicted by behavioral tests.

Constraint-induced movement therapy after stroke

Constraint-induced movement therapy (CIMT) was developed to overcome upper limb impairments after stroke and is the most investigated intervention for the rehabilitation of patients. Original CIMT includes constraining of the non-paretic arm and task-oriented training. Modified versions also apply constraining of the non-paretic arm, but not as intensive as original CIMT. Behavioural strategies are mostly absent for both modified and original CIMT. With forced use therapy, only constraining of the non-paretic arm is applied. The original and modified types of CIMT have beneficial effects on motor function, arm-hand activities, and self-reported arm-hand functioning in daily life, immediately after treatment and at long-term follow-up, whereas there is no evidence for the efficacy of constraint alone (as used in forced use therapy). The type of CIMT, timing, or intensity of practice do not seem to affect patient outcomes. Although the underlying mechanisms that drive modified and original CIMT are still poorly understood, findings from kinematic studies suggest that improvements are mainly based on adaptations through learning to optimise the use of intact end-effectors in patients with some voluntary motor control of wrist and finger extensors after stroke.

How Do Fugl-Meyer Arm Motor Scores Relate to Dexterity According to the Action Research Arm Test at 6 Months Poststroke?

OBJECTIVE

To determine the optimal cutoff scores for the Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) with regard to predicting no, poor, limited, notable, or full upper-limb capacity according to frequently used cutoff points for the Action Research Arm Test (ARAT) at 6 months poststroke.

DESIGN

Prospective.

SETTING

Rehabilitation center.

PARTICIPANTS

Patients (N=460) with a first-ever ischemic stroke at 6 months poststroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Based on the ARAT classification of poor to full upper-limb capacity, receiver operating characteristic curves were used to calculate the area under the curve, optimal cutoff points for the FMA-UE were determined, and a weighted kappa was used to assess the agreement.

RESULTS

FMA-UE scores of 0 through 22 represent no upper-limb capacity (ARAT 0-10); scores of 23 through 31 represent poor capacity (ARAT 11-21); scores of 32 through 47 represent limited capacity (ARAT 22-42); scores of 48 through 52 represent notable capacity (ARAT 43-54); and scores of 53 through 66 represent full upper-limb capacity (ARAT 55-57). Overall, areas under the curve ranged from .916 (95% confidence interval [CI], .890-.943) to .988 (95% CI, .978-.998; P<.001).

CONCLUSIONS

There is considerable overlap in the area under the curve between the ARAT and FMA-UE. FMA-UE scores >31 points correspond to no to poor arm-hand capacity (ie, ≤21 points) on the ARAT, whereas FMA-UE scores >31 correspond to limited to full arm-hand capacity (ie, ≥22 points) on the ARAT.

Test-retest reliability and rater agreements of assessment of capacity for myoelectric control version 2.0

The Assessment of Capacity for Myoelectric Control (ACMC) is an observation-based tool that evaluates ability to control a myoelectric prosthetic hand. Validity evidence led to ACMC version 2.0, but the test-retest reliability and minimal detectable change (MDC) of the ACMC have never been evaluated. Investigation of rater agreements in this version was also needed because it has new definitions in certain rating categories and items. Upper-limb prosthesis users (n = 25, 15 congenital, 10 acquired; mean age 27.5 yr) performed one standardized activity twice, 2 to 5 wk apart. Activity performances were videorecorded and assessed by two ACMC raters. Data were analyzed by weighted kappa, intraclass correlation coefficient (ICC), and Bland-Altman method. For test-retest reliability, weighted kappa agreements were fair to excellent (0.52 to 1.00), ICC2,1 was 0.94, and one user was located outside the limits of agreement in the Bland-Altman plot. MDC95 was less than or equal to 0.55 logits (1 rater) and 0.69 logits (2 raters). For interrater reliability, weighted kappa agreements were fair to excellent in both sessions (0.44 to 1.00), and ICC2,1 was 0.95 (test) and 0.92 (retest). Intrarater agreement (rater 1) was also excellent (ICC3,1 0.98). Evidence regarding the reliability of the ACMC is satisfactory and MDC95 can be used to indicate change.

Effects of a 3-year nurse-based case management in aged patients with acute myocardial infarction on rehospitalisation, mortality, risk factors, physical functioning and mental health. a secondary analysis of the randomized controlled KORINNA study

Background

Home-based secondary prevention programs led by nurses have been proposed to facilitate patients’ adjustment to acute myocardial infarction (AMI). The objective of this study was to conduct secondary analyses of the three-year follow-up of a nurse-based case management for elderly patients discharged from hospital after an AMI.

Methods

In a single-centre randomized two-armed parallel group trial of hospitalized patients with AMI ≥65 years, patients hospitalized between September 2008 and May 2010 in the Hospital of Augsburg, Germany, were randomly assigned to case management or usual care. The case-management intervention consisted of a nurse-based follow-up for three years including home visits and telephone calls. Study endpoints were time to first unplanned readmission or death, clinical parameters, functional status, depressive symptoms and malnutrition risk. Persons who assessed three-year outcomes and validated readmission data were blinded. The intention-to-treat approach was applied to the statistical analyses which included Cox Proportional Hazards models.

Results

Three hundred forty patients were allocated to receive case-management (n = 168) or usual care (n = 172). During three years, in the intervention group there were 80 first unplanned readmissions and 6 deaths, while the control group had 111first unplanned readmissions and 3 deaths. The intervention did not significantly affect time to first unplanned readmission or death (Hazard Ratio 0.89, 95% confidence interval (CI) 0.67–1.19; p = 0.439), blood pressure, cholesterol level, instrumental activities of daily life (IADL) (only for men), and depressive symptoms. However, patients in the intervention group had a significantly better functional status, as assessed by the HAQ Disability Index, IADL (only for women), and hand grip strength, and better SCREEN-II malnutrition risk scores than patients in the control group.

Conclusions

A nurse-based management among elderly patients with AMI did not significantly affect time to unplanned readmissions or death during a three-year follow-up. However, the results indicate that functional status and malnutrition risk can be improved.

Trial registration

Current Controlled Trials ISRCTN02893746

The HAAPI (Home Arm Assistance Progression Initiative) Trial: A Novel Robotics Delivery Approach in Stroke Rehabilitation

BACKGROUND

Geographical location, socioeconomic status, and logistics surrounding transportation impede access of poststroke individuals to comprehensive rehabilitative services. Robotic therapy may enhance telerehabilitation by delivering consistent and state-of-the art therapy while allowing remote monitoring and adjusting therapy for underserved populations. The Hand Mentor Pro (HMP) was incorporated within a home exercise program (HEP) to improve upper-extremity (UE) functional capabilities poststroke.

OBJECTIVE

To determine the efficacy of a home-based telemonitored robotic-assisted therapy as part of a HEP compared with a dose-matched HEP-only intervention among individuals less than 6 months poststroke and characterized as underserved.

METHODS

In this prospective, single-blinded, multisite, randomized controlled trial, 99 hemiparetic participants with limited access to UE rehabilitation were randomized to either (1) the experimental group, which received combined HEP and HMP for 3 h/d ×5 days ×8 weeks, or (2) the control group, which received HEP only at an identical dosage. Weekly communication between the supervising therapist and participant promoted compliance and progression of the HEP and HMP prescription. The Action Research Arm Test and Wolf Motor Function Test along with the Fugl-Meyer Assessment (UE) were primary and secondary outcome measures, respectively, undertaken before and after the interventions.

RESULTS

Both groups demonstrated improvement across all UE outcomes.

CONCLUSIONS

Robotic + HEP and HEP only were both effectively delivered remotely. There was no difference between groups in change in motor function over time. Additional research is necessary to determine the appropriate dosage of HMP and HEP.

Tele-Supervised FES-Assisted Exercise for Hemiplegic Upper Limb

Stroke survivors often have upper limb (UL) hemiparesis, limiting their ability to perform activities of daily life (ADLs). Intensive, task-oriented exercise therapy (ET) can improve UL function, but motivation to perform sufficient ET is difficult to maintain. Here, we report on a trial in which a workstation was deployed in the homes of chronic stroke survivors to enable tele-coaching of ET in the guise of computer games. Participants performed six weeks of 1 h/day, five days/week ET. Hand opening and grasp were assisted with functional electrical stimulation (FES). The primary outcome measure was the Action Research Arm Test (ARAT). Secondary outcome measures included a quantitative test of UL function performed on the workstation, grasp force measurements and transcranial magnetic stimulation (TMS). Improvements were seen in the functional tests, but surprisingly, not in the TMS responses. An important finding was that participants commencing with intermediate functional scores improved the most.

CONCLUSIONS

(1) Daily, tele-supervised FES-ET in chronic stroke survivors is feasible with commercially-available technology. (2) The intervention can significantly improve UL function, particularly in people who start with an intermediate level of function. (3) Significant improvements in UL function can occur in the absence of changes in TMS responses.

Health-related physical fitness assessment in a community-based cancer rehabilitation setting

PURPOSE

Assessment of physical fitness is important in order to set goals, appropriately prescribe exercise, and monitor change over time. This study aimed to determine the utility of a standardized physical fitness assessment for use in cancer-specific, community-based exercise programs.

METHODS

Tests anticipated to be feasible and suitable for a community setting and a wide range of ages and physical function were chosen to measure body composition, aerobic fitness, strength, flexibility, and balance. Cancer Exercise Trainers/Specialists at cancer-specific, community-based exercise programs assessed new clients (n = 60) at enrollment, designed individualized exercise programs, and then performed a re-assessment 3-6 months later (n = 34).

RESULTS

Resting heart rate, blood pressure, body mass index, waist circumference, handgrip strength, chair stands, sit-and-reach, back scratch, single-leg standing, and timed up-and-go tests were considered suitable and feasible tests/measures, as they were performed in most (≥88 %) participants. The ability to capture change was also noted for resting blood pressure (-7/-5 mmHg, p = 0.02), chair stands (+4, p < 0.01), handgrip strength (+2 kg, p < 0.01), and sit-and-reach (+3 cm, p = 0.03). While the submaximal treadmill test captured a meaningful improvement in aerobic fitness (+62 s, p = 0.17), it was not completed in 33 % of participants. Change in mobility, using the timed up-and-go was nominal and was not performed in 27 %.

CONCLUSION

Submaximal treadmill testing, handgrip dynamometry, chair stands, and sit-and-reach tests were feasible, suitable, and provided meaningful physical fitness information in a cancer-specific, community-based, exercise program setting. However, a shorter treadmill protocol and more sensitive balance and upper body flexibility tests should be investigated.

Does Action Observation Training With Immediate Physical Practice Improve Hemiparetic Upper-Limb Function in Chronic Stroke?

Background. The mirror neuron network provides a neural mechanism to prime the motor system through action observation in stroke survivors. Objective. To examine whether action observation training with immediate physical practice improves upper-limb function in chronic stroke. Methods. In a within-subject design, 14 chronic stroke survivors were assessed at baseline, then participated in 2 weeks of relaxation-sham plus physical practice (control) and reassessed. Thereafter, they participated in 2 weeks of action observation training coupled with immediate physical practice (intervention), followed by a final assessment. Duration of each action observation video sequence (priming exposure) was 30 s followed immediately by practice of the observed motor skill. Results. There were significant improvements in control and intervention phases on primary outcome measures—Upper Extremity Fugl-Meyer Motor Assessment (FMA) and Functional Test of the Hemiparetic Upper Extremity (FTHUE)—as well as secondary outcome measures of self-perceptions of arm use. Gains in the primary outcomes were greater during the intervention phase (action observation + physical practice; FMA, 10.64; FTHUE level, 0.79, and tasks, 1.57) than during the control phase (relaxation-sham plus physical practice; FMA, 6.64; FTHUE level, 0.43, and tasks, 1.00). Interviews with participants highlighted the added value of watching an actor perform the movement before physically attempting to perform the action. Conclusions. This study provides preliminary evidence of the additive value of action observation plus physical practice over relaxation-sham plus physical practice. There appears to be capacity for further recovery of upper-limb function in chronic stroke that persists at least in the short term.

Predictors of motor, daily function, and quality-of-life improvements after upper-extremity robot-assisted rehabilitation in stroke

OBJECTIVE

A subgroup of patients benefiting most from robot-assisted therapy (RT) has not yet been described. We examined the predictors of improved outcomes after RT.

METHOD

Sixty-six patients with stroke receiving RT were analyzed. The outcome measures were the Fugl-Meyer Assessment (FMA), Wolf Motor Function Test (WMFT), Motor Activity Log (MAL), and Stroke Impact Scale (SIS). The potential predictors were age, side of lesion, time since onset, Modified Ashworth Scale (MAS) scores, accelerometer data, Box and Block Test (BBT) scores, and kinematic parameters.

RESULTS

BBT scores were predictive of FMA (29%) and MAL (9%-15%) improvements. Reduced shoulder flexion synergy, as measured by less shoulder abduction during forward reach, and MAS-distal were predictive of WMFT-function improvements. MAS-distal was predictive of SIS-physical improvements. Demographic variables did not predict outcomes.

CONCLUSION

Manual dexterity was a valuable predictor of motor impairment and daily function after RT. Outcomes at different levels may have different predictors.

Constraint-induced movement therapy: trial sequential analysis applied to Cochrane collaboration systematic review results

BACKGROUND

Trial sequential analysis (TSA) may establish when firm evidence about the efficacy of interventions is reached in a cumulative meta-analysis, combining a required information size with adjusted thresholds for conservative statistical significance. Our aim was to demonstrate TSA results on randomized controlled trials (RCTs) included in a Cochrane systematic review on the effectiveness of constraint-induced movement therapy (CIMT) for stroke patients.

METHODS

We extracted data on the functional independence measure (FIM) and the action research arm test (ARAT) from RCTs that compared CIMT versus other rehabilitative techniques. Mean differences (MD) were analyzed using a random-effects model. We calculated the information size and the cumulative Z-statistic, applying the O'Brien-Fleming monitoring boundaries.

RESULTS

We included data from 14 RCTs. In the conventional meta-analysis (seven trials, 233 patients), the effect of CIMT on FIM was reported as significant (MD 2.88, 95% CI 0.08 to 5.68; P = 0.04). The diversity-adjusted required information size was 142 patients, and the cumulative Z-score did not cross the trial sequential monitoring boundary for benefit (adjusted 95% CI -0.02 to 5.78). The effect of CIMT on ARAT (nine trials, 199 patients) was reported as significant (MD 7.78, 95% CI 1.19 to 14.37; P = 0.02). However, the diversity-adjusted required information size was 252 patients, and the Z-score did not cross the trial sequential monitoring boundary for benefit (adjusted 95% CI -0.06 to 15.62).

CONCLUSIONS

Although conventional meta-analyses of CIMT reached statistical significance, their overall results remain inconclusive and might be spurious. Researchers should not be overconfident on CIMT efficacy based on the results of meta-analyses and derived recommendations.

Training finger individuation with a mechatronic-virtual reality system leads to improved fine motor control post-stroke

Background

Dexterous manipulation of the hand, one of the features of human motor control, is often compromised after stroke, to the detriment of basic functions. Despite the importance of independent movement of the digits to activities of daily living, relatively few studies have assessed the impact of specifically targeting individuated movements of the digits on hand rehabilitation. The purpose of this study was to investigate the impact of such finger individuation training, by means of a novel mechatronic-virtual reality system, on fine motor control after stroke.

Methods

An actuated virtual keypad (AVK) system was developed in which the impaired hand controls a virtual hand playing a set of keys. Creation of individuated digit movements is assisted by a pneumatically actuated glove, the PneuGlove. A study examining efficacy of the AVK system was subsequently performed. Participants had chronic, moderate hand impairment resulting from a single stroke incurred at least 6 months prior. Each subject underwent 18 hour-long sessions of extensive therapy (3x per week for 6 weeks) targeted at finger individuation. Subjects were randomly divided into two groups: the first group (Keypad: N = 7) utilized the AVK system while the other group (OT: N = 7) received a similarly intensive dose of occupational therapy; both groups worked directly with a licensed occupational therapist. Outcome measures such as the Jebsen-Taylor Hand Function Test (JTHFT), Action research Arm Test (ARAT), Fugl-Meyer Upper Extremity Motor Assessment/Hand subcomponent (FMUE/FMH), grip and pinch strengths were collected at baseline, post-treatment and one-month post-treatment.

Results

While both groups exhibited some signs of change after the training sessions, only the Keypad group displayed statistically significant improvement both for measures of impairment (FMH: p = 0.048) and measures of task performance (JTHFT: p = 0.021). Additionally, the finger individuation index – a measure of finger independence – improved only for the Keypad group after training (p = 0.05) in the subset (Keypad: N = 4; OT: N = 5) of these participants for which it was measured.

Conclusions

Actively assisted individuation therapy comprised of non task-specific modalities, such as can be achieved with virtual platforms like the AVK described here, may prove to be valuable clinical tools for increasing the effectiveness and efficiency of therapy following stroke.

Electronic supplementary material

The online version of this article (doi:10.1186/1743-0003-11-171) contains supplementary material, which is available to authorized users.

Implications of CI therapy for visual deficit training

We address here the question of whether the techniques of Constraint Induced (CI) therapy, a family of treatments that has been employed in the rehabilitation of movement and language after brain damage might apply to the rehabilitation of such visual deficits as unilateral spatial neglect and visual field deficits. CI therapy has been used successfully for the upper and lower extremities after chronic stroke, cerebral palsy (CP), multiple sclerosis (MS), other central nervous system (CNS) degenerative conditions, resection of motor areas of the brain, focal hand dystonia, and aphasia. Treatments making use of similar methods have proven efficacious for amblyopia. The CI therapy approach consists of four major components: intensive training, training by shaping, a "transfer package" to facilitate the transfer of gains from the treatment setting to everyday activities, and strong discouragement of compensatory strategies. CI therapy is said to be effective because it overcomes learned nonuse, a learned inhibition of movement that follows injury to the CNS. In addition, CI therapy produces substantial increases in the gray matter of motor areas on both sides of the brain. We propose here that these mechanisms are examples of more general processes: learned nonuse being considered parallel to sensory nonuse following damage to sensory areas of the brain, with both having in common diminished neural connections (DNCs) in the nervous system as an underlying mechanism. CI therapy would achieve its therapeutic effect by strengthening the DNCs. Use-dependent cortical reorganization is considered to be an example of the more general neuroplastic mechanism of brain structure repurposing. If the mechanisms involved in these broader categories are involved in each of the deficits being considered, then it may be the principles underlying efficacious treatment in each case may be similar. The lessons learned during CI therapy research might then prove useful for the treatment of visual deficits.

The effects of modified constraint-induced movement therapy combined with trunk restraint in subacute stroke: a double-blinded randomized controlled trial

OBJECTIVE

To investigate the effects of a modified constraint-induced movement therapy (mCIMT) with trunk restraint in subacute stroke patients.

DESIGN

Double-blind, randomized controlled trial.

SETTING

Rehabilitation clinic.

PARTICIPANTS

Eighteen subacute stroke patients with moderate motor impairment.

INTERVENTIONS

The patients were treated with either mCIMT combined with trunk restraint or mCIMT for 5 days per week for 4 weeks. The mCIMT combined with trunk restraint group participated in structured intervention sessions for use of the more affected upper-extremity in task-oriented activities with trunk restraint for 1 hour per day, and with the less affected upper-extremity restrained for 5 hours per day weeks. The mCIMT group followed the same protocol without trunk restraint.

MAIN OUTCOME MEASURES

The outcome measures included the action research arm test (ARAT), the Fugl-Meyer assessment (FMA), the modified Barthel index (MBI), the motor activity log (MAL) and the maximal elbow extension angle during reaching (MEEAR) were completed at baseline and post intervention.

RESULTS

The mCIMT combined with trunk restraint group exhibited more improved in the ARAT, FMA, MBI, MAL and MEEAR compared with the mCIMT group. Statistical analyses showed significantly different in ARAT (P = 0.046), FMA (P = 0.008), MBI (P = 0.001), MAL-AOU (P = 0.024), MAL-QOM (P = 0.010) and MEEAR (P = 0.001) between groups.

CONCLUSIONS

These results suggest that mCIMT combined with trunk restraint is more helpful to improve upper-extremity function than mCIMT only in subacute stroke patients with moderate motor impairment.

Comparison of three tools to measure improvements in upper-limb function with poststroke therapy

BACKGROUND

Functional ability is regularly monitored poststroke to assess improvement and the efficacy of clinical trials. The balance between implementation times and sensitivity has led to multidomain tools that aim to assess upper-limb function comprehensively.

OBJECTIVE

This study implemented 3 common multidomain tools to investigate their suitability across a broad spectrum of movement ability after stroke.

METHODS

Forty-nine hemiparetic patients (18 females), aged 22 to 83 years and 24.7 ± 39.2 months poststroke, were assessed before and after a 14-day upper-limb rehabilitation program of Wii-based Movement Therapy. Assessments included the upper-limb motor subscale of the Fugl-Meyer Assessment (F-M), the Wolf Motor Function Test (WMFT), and the Motor Assessment Scale (MAS) upper-limb sections 6 to 8. The MAS was analyzed both with and without the hierarchical system. Patients were stratified with low, moderate, or high motor-function.

RESULTS

Upper-limb function improved significantly for the pooled cohort for all assessments (P < .001), although ceiling effects were evident for the F-M, floor effects for the WMFT, and both floor and ceiling effects for MAS. When analyzed by stratified subgroup these improvements were significant for all groups with the F-M, for the moderate and high motor-function groups with both the WMFT and the MAS scored without hierarchical system, but only for the high motor-function group with the hierarchically scored MAS.

CONCLUSION

These results suggest that no single test is suitable for measuring function and improvement across the spectrum of poststroke upper-limb dysfunction and that assessment tool selection should be based on the level of residual motor-function of individual patients.

Influences of hand dominance on the maintenance of benefits after home-based modified constraint-induced movement therapy in individuals with stroke

Objective:

To investigate the influence of hand dominance on the maintenance of gains after home-based modified constraint-induced movement therapy (mCIMT).

Method:

Aprevious randomized controlled trial was conducted to examine the addition of trunk restraint to the mCIMT. Twenty-two chronic stroke survivors with mild to moderate motor impairments received individual home-based mCIMT with or without trunk restraints, five times per week, three hours daily over two weeks. In this study, the participants were separated into dominant group, which had their paretic upper limb as dominant before the stroke (n=8), and non-dominant group (n=14) for analyses. The ability to perform unimanual tasks was measured by the Wolf Motor Function Test (WMFT) and the Motor Activity Log (MAL), whereas the capacity to perform bimanual tasks was measured using the Bilateral Activity Assessment Scale (BAAS).

Results:

Analysis revealed significant positive effects on the MAL amount of use and quality of the movement scales, as well as on the BAAS scores after intervention, with no differences between groups. Both groups maintained the bimanual improvements during follow-ups (BAAS-seconds 0.1, 95% CI -10.0 to 10.0), however only the dominant group maintained the unilateral improvements (MAL-amount of use: 1.5, 95% CI 0.7 to 2.3; MAL-quality: 1.3, 95% CI 0.5 to 2.1).

Conclusions:

Upper limb dominance did not interfere with the acquisition of upper limb skills after mCIMT. However, the participants whose paretic upper limb was dominant demonstrated better abilities to maintain the unilateral gains. The bilateral improvements were maintained, regardless of upper limb dominance.

Reliability and validity of two versions of the upper extremity functional index

PURPOSE

To examine the reliability, validity, and sensitivity to change of the 20-item version and the Rasch-refined 15-item version of the Upper Extremity Functional Index (UEFI-20 and UEFI-15, respectively) and to determine the impact of arm dominance on the positive minimal clinically important difference (pMCID).

METHODS

Adults with upper-extremity (UE) dysfunction completed the UEFI-20, Upper Extremity Functional Scale (UEFS), Pain Limitation Scale, and Pain Intensity Scale at their initial physiotherapy assessment (Time 1); 24-48 hours later (Time 2); and 3 weeks into treatment or at discharge, whichever came first (Time 3). Demographics, including working status, were obtained at Time 1. Global ratings of change (GRC) were provided by the treating physiotherapist and patient at Time 3. The UEFI-15 was calculated from relevant items in the UEFI-20. The intra-class correlation coefficient (ICC) and minimal detectable change (MDC) quantified test-retest reliability (Time 1-Time 2). Cross-sectional convergent validity was determined by the association (Pearson's r) between Time 1 measures of function and pain. Known-groups validity was evaluated with a one-way ANOVA across three levels of working status. Longitudinal validity was determined by the association (Pearson's r) between function and pain change scores (Time 1-Time 3). Receiver operating characteristic (ROC) curves estimated the pMCID using Time 1-Time 3 change scores and average patient/therapist GRC.

RESULTS

Reliability for the UEFI-20 and UEFI-15 was the same (ICC=0.94 for both measures). MDC values were 9.4/80 for the UEFI-20 and 8.8/100 for the UEFI-15. Cross-sectional, known-groups, and longitudinal validity were confirmed for both UEFI measures. pMCID values were 8/80 for the UEFI-20 and 6.7/100 for the UEFI-15; pMCID was higher for people whose non-dominant arm was affected.

CONCLUSIONS

Both UEFI measures show acceptable reliability and validity. Arm dominance affects pMCID. The UEFI-15 is recommended because it measures only one dimension: UE function.

Case report: post-stroke interventional BCI rehabilitation in an individual with preexisting sensorineural disability

Therapies involving new technologies such as brain-computer interfaces (BCI) are being studied to determine their potential for interventional rehabilitation after acute events such as stroke produce lasting impairments. While studies have examined the use of BCI devices by individuals with disabilities, many such devices are intended to address a specific limitation and have been studied when this limitation or disability is present in isolation. Little is known about the therapeutic potential of these devices for individuals with multiple disabilities with an acquired impairment overlaid on a secondary long-standing disability. We describe a case in which a male patient with congenital deafness suffered a right pontine ischemic stroke, resulting in persistent weakness of his left hand and arm. This patient volunteer completed four baseline assessments beginning at 4 months after stroke onset and subsequently underwent 6 weeks of interventional rehabilitation therapy using a closed-loop neurofeedback BCI device with visual, functional electrical stimulation, and tongue stimulation feedback modalities. Additional assessments were conducted at the midpoint of therapy, upon completion of therapy, and 1 month after completing all BCI therapy. Anatomical and functional MRI scans were obtained at each assessment, along with behavioral measures including the Stroke Impact Scale (SIS) and the Action Research Arm Test (ARAT). Clinically significant improvements in behavioral measures were noted over the course of BCI therapy, with more than 10 point gains in both the ARAT scores and scores for the SIS hand function domain. Neuroimaging during finger tapping of the impaired hand also showed changes in brain activation patterns associated with BCI therapy. This case study demonstrates the potential for individuals who have preexisting disability or possible atypical brain organization to learn to use a BCI system that may confer some rehabilitative benefit.

Design and validation of the RiceWrist-S exoskeleton for robotic rehabilitation after incomplete spinal cord injury

Robotic devices are well-suited to provide high intensity upper limb therapy in order to induce plasticity and facilitate recovery from brain and spinal cord injury. In order to realise gains in functional independence, devices that target the distal joints of the arm are necessary. Further, the robotic device must exhibit key dynamic properties that enable both high dynamic transparency for assessment, and implementation of novel interaction control modes that significantly engage the participant. In this paper, we present the kinematic design, dynamical characterization, and clinical validation of the RiceWrist-S, a serial robotic mechanism that facilitates rehabilitation of the forearm in pronation-supination, and of the wrist in flexion-extension and radial-ulnar deviation. The RiceWrist-Grip, a grip force sensing handle, is shown to provide grip force measurements that correlate well with those acquired from a hand dynamometer. Clinical validation via a single case study of incomplete spinal cord injury rehabilitation for an individual with injury at the C3-5 level showed moderate gains in clinical outcome measures. Robotic measures of movement smoothness also captured gains, supporting our hypothesis that intensive upper limb rehabilitation with the RiceWrist-S would show beneficial outcomes.

Therapeutic synergism in the treatment of post-stroke arm paresis utilizing botulinum toxin, robotic therapy, and constraint-induced movement therapy

Botulinum toxin type A (BtxA) injection, constraint-induced movement therapy (CIMT), and robotic therapy (RT) each represent promising approaches to enhance arm motor recovery after stroke. To provide more effective treatment for a 50-year-old man with severe left spastic hemiparesis, we attempted to facilitate CIMT with adaptive approaches to extend the wrist and fingers using RT for 10 consecutive weeks after BtxA injection. This combined treatment resulted in substantial improvements in arm function and the amount of arm use in activities of daily living, and may be effective for stroke patients with severe arm paresis. However, we were unable to sufficiently prove the efficacy of combined treatment based only on a single case. To fully elucidate the efficacy of the combined approach for patients with severe hemiparesis after stroke, future studies of a larger number of patients are needed.