Time-Course of Changes in Arm Impairment After Stroke: Variables Predicting Motor Recovery Over 12 Months

Wearable Integrated Volitional Control Electrical Stimulation Device as Treatment for Paresis of the Upper Extremity in Early Subacute Stroke Patients: A Randomized Controlled Non-inferiority Trial

OBJECTIVE

To investigate the effect of a wearable integrated volitional control electrical stimulation (WIVES) device that has been developed as more compact and simpler to use in daily life compared with conventional integrated volitional control electrical stimulation (IVES) devices.

DESIGN

Randomized controlled non-inferiority trial.

SETTING

Convalescent rehabilitation ward.

PARTICIPANTS

Patients with paresis of the upper extremity (UE) after early subacute stroke (N=20).

INTERVENTIONS

Eligible patients were randomized to receive IVES treatment or WIVES treatment for 8 hours per day for 28 days in daily living, in addition to standard rehabilitation treatment. In both groups, the extensor digitorum communis on the affected side was the target muscle for stimulation.

MAIN OUTCOME MEASURE

Primary outcomes were assessed with Fugl-Meyer Assessment of the UE (FMA-UE) before and after treatment. Non-inferiority was determined with a specified margin of non-inferiority.

RESULTS

Twenty patients completed the trial (IVES group: n=10, WIVES group: n=10). FMA-UE improved in both groups. The mean change in FMA-UE was 4.7 for the IVES group and 6.0 for the WIVES group (P>.05, 95% confidence interval: -6.73 to 4.13). The mean difference between the groups was 1.3, and the upper 95% confidence interval did not exceed the non-inferiority margin.

CONCLUSION

The effectiveness of WIVES treatment is non-inferior to that of IVES treatment. As a portable device, IVES may facilitate the use of affected upper extremities in daily living and may help improve paresis of the UE.

Trajectories of arm recovery early after stroke: an exploratory study using latent class growth analysis

AIM

To investigate trajectories of recovery of motor arm function after stroke during inpatient rehabilitation.

MATERIALS AND METHODS

Data were available from 74 consecutively-admitted stroke survivors receiving inpatient rehabilitation from an inception cohort study. Heterogeneity of arm recovery in the first 4-weeks was investigated using latent class analysis and weekly Box and Block Test (BBT) scores. Optimal number of clusters were determined; characterised and cluster associated factors explored.

RESULTS

A 4-cluster model was identified, including 19 participants with low baseline arm function and minimal recovery ('LOWstart/LOWprogress', 26%), 15 with moderate function and low recovery ('MODstart/LOWprogress', 20%), 15 with low function and high recovery ('LOWstart/HIGHprogress', 20%), and 25 with moderate function and recovery ('MODstart/MODprogress', 34%). Compared to LOWstart/LOWprogress: LOWstart/HIGHprogress presented earlier post-stroke (β, 95%CI) (-4.81 days, -8.94 to -0.69); MODstart/MODprogress had lower modified Rankin Scale scores (-0.74, -1.15 to -0.32); and MODstart/LOWprogress, LOWstart/HIGHprogress and MODstart/MODprogress had higher admission BBT (23.58, 18.82 to 28.34; 4.85, 0.85 to 9.61; 28.02, 23.82 to 32.21), Upper Limb-Motor Assessment Scale (9.60, 7.24 to 11.97; 3.34, 0.97 to 5.70; 10.86, 8.77 to 12.94), Action Research Arm Test (31.09, 22.86 to 39.33; 12.69, 4.46 to 20.93; 38.01, 30.76 to 45.27), and Manual Muscle Test scores (10.64, 7.07 to 14.21; 6.24, 2.67 to 9.81; 11.87, 8.72 to 15.01).

CONCLUSIONS

We found unique patterns of arm recovery with distinct characteristics for each cluster. Better understanding of patterns of arm recovery can guide future models and intervention development.KEY MESSAGESArm recovery early after stroke follows four distinct trajectories that relate to time post stroke, initial stroke severity and baseline level of motor arm function.Identification of recovery patterns gives insight into the uniqueness of individual's recovery.This study offers a novel approach on which to build and develop future models of arm recovery.

Sensitivity to Change and Responsiveness of the Upper Extremity Fugl-Meyer Assessment in Individuals With Moderate to Severe Acute Stroke

BACKGROUND

The Fugl-Meyer Assessment-Upper Extremity (FMA-UE) is a widely used outcome measure for quantifying motor impairment in stroke recovery. Meaningful change (responsiveness) in the acute to subacute phase of stroke recovery has not been determined.

OBJECTIVE

Determine responsiveness and sensitivity to change of the FMA-UE from 1-week to 6-weeks (subacute) after stroke in individuals with moderate to severe arm impairment who received standard clinical care.

METHODS

A total of 51 participants with resulting moderate and severe UE hemiparesis after stroke had FMA-UE assessment at baseline (within 2 weeks of stroke) and 6-weeks later. Sensitivity to change was assessed using Glass's delta, standardized response means (SRM), standard error of measure (SEM), and minimal detectable change (MDC). Responsiveness was assessed with the minimal clinically important difference (MCID), estimated using receiver operating characteristic curve analysis with patient-reported global rating of change scales (GROC) and a provider-reported modified Rankin Scale (mRS) as anchors.

RESULTS

The MCID estimates were 13, 12, and 9 anchored to the GROC Arm Weakness, GROC Recovery, and mRS. Glass's delta and the SRM revealed large effect sizes, indicating high sensitivity to change, (∆ = 1.24, 95% CI [0.64, 1.82], SRM = 1.10). Results for the SEM and MDC were 2.46 and 6.82, respectively.

CONCLUSION

The estimated MCID for the FMA-UE for individuals with moderate to severe motor impairment from 1 to 6-weeks after stroke is 13. These estimates will provide clinical context for FMA-UE change scores by helping to identify the change in upper-extremity motor impairment that is both beyond measurement error and clinically meaningful.

Assessment of Passive Upper Limb Stiffness and Its Function in Post-Stroke Individuals Wearing an Inertial Sensor during the Pendulum Test

This article proposes the evaluation of the passive movement of the affected elbow during the pendulum test in people with stroke and its correlation with the main clinical scales (Modified Ashworth Scale, Motor Activity Log, and Fulg Meyer). An inertial sensor was attached to the forearm of seven subjects, who then passively flexed and extended the elbow. Joint angles and variables that indicate viscoelastic properties, stiffness (K), damping (B), E1 amp, F1 amp, and relaxation indices were collected. The results show that the FM scale is significantly correlated with the natural frequency (p = 0.024). The MAL amount-of-use score correlates with the natural frequency (p = 0.024). The variables E1 amp, F1 amp, RI, and ERI are not correlated with the clinical scales, but they correlate with each other; the variable E1 amp correlates with F1 amp (p = 0.024) and RI (p = 0.024), while F1 amp correlates with ERI (p = 0.024). There was also a correlation between the natural frequency and K (r = 0.96, p = 0.003). Non-linear results were found for the properties of the elbow joint during the pendulum test, which may be due to the presence of neural and non-neural factors. These results may serve as a reference for future studies if alternative scales do not provide an accurate reflection.

Baseline Function and Rehabilitation Are as Important as Stroke Severity as Long-term Predictors of Cognitive Performance Post-stroke

OBJECTIVE

Although individuals with low stroke severity tend to recover well, cognitive impairment is common independent of stroke size or location. In this study, the patterns of recovery for individual cognitive domains and factors associated with outcome were examined.

DESIGN

A prospectively enrolled cohort of patients with minor stroke was administered cognitive testing at 1, 6, and 12 mos postinfarct. Composite T scores were generated for global cognition and well as independent cognitive domains at each time point. Paired t tests compared changes in scores over time. Regression models identified factors associated with improvement.

RESULTS

A total of 46 patients, with an average NIH Stroke Scale score of 2.7, were enrolled. Average age was 61.3 yrs. Patients improved overall between 1 and 6 mos; however, distinct patterns of recovery were seen for different cognitive domains. The most significant improvement was in spatial memory. Verbal memory scores remained low longitudinally. Motor speed and executive function increased, then plateaued. Despite a mean education of 13.6 yrs, only 36% of global cognition scores were higher than or equal to the normative mean at 12 mos, and only 57% of patients improved their global scores from 6 to 12 mos. Late recovery was associated with lower NIH Stroke Scale scores, higher 1-mo Montreal Cognitive Assessment scores, and rehabilitation. Baseline function predicted overall long-term recovery.

CONCLUSION

Patterns of recovery are distinct for individual cognitive domains for patients with minor stroke. Stroke severity and rehabilitation influence trajectory. Premorbid baseline predicts long-term outcome.

Wearable Sensors Improve Prediction of Post-Stroke Walking Function Following Inpatient Rehabilitation

OBJECTIVE

A primary goal of acute stroke rehabilitation is to maximize functional recovery and help patients reintegrate safely in the home and community. However, not all patients have the same potential for recovery, making it difficult to set realistic therapy goals and to anticipate future needs for short- or long-term care. The objective of this study was to test the value of high-resolution data from wireless, wearable motion sensors to predict post-stroke ambulation function following inpatient stroke rehabilitation.

METHOD

Supervised machine learning algorithms were trained to classify patients as either household or community ambulators at discharge based on information collected upon admission to the inpatient facility (N=33-35). Inertial measurement unit (IMU) sensor data recorded from the ankles and the pelvis during a brief walking bout at admission (10 meters, or 60 seconds walking) improved the prediction of discharge ambulation ability over a traditional prediction model based on patient demographics, clinical information, and performance on standardized clinical assessments.

RESULTS

Models incorporating IMU data were more sensitive to patients who changed ambulation category, improving the recall of community ambulators at discharge from 85% to 89-93%.

CONCLUSIONS

This approach demonstrates significant potential for the early prediction of post-rehabilitation walking outcomes in patients with stroke using small amounts of data from three wearable motion sensors.

CLINICAL IMPACT

Accurately predicting a patient's functional recovery early in the rehabilitation process would transform our ability to design personalized care strategies in the clinic and beyond. This work contributes to the development of low-cost, clinically-implementable prognostic tools for data-driven stroke treatment.

Assisted Movement With Proprioceptive Stimulation Augments Recovery From Moderate-To-Severe Upper Limb Impairment During Subacute Stroke Period: A Randomized Clinical Trial

BACKGROUND

Robotic assisted movement has become an accepted method of treating the moderately-to-mildly impaired upper limb after stroke.

OBJECTIVE

To determine whether, during the subacute phase of recovery, a novel type of robotic assisted training reduces moderate-to-severe impairment in the upper limb beyond that resulting from spontaneous recovery and prescribed outpatient therapy.

METHODS

A prospective, randomized, double-blinded, placebo-controlled, semi-crossover study of 83 participants. Over 6- to 9-weeks, participants received 18, 30-min training sessions of the hand and wrist. The test intervention consisted of assisted motion, biofeedback, and antagonist muscle vibration delivered by a robotic device. Test Group participants received the test intervention, and Control Group participants received a placebo intervention designed to have no effect. Subsequently, Control Group participants crossed over to receive the test intervention.

RESULTS

At enrollment, the average age (±SD) of participants was 57.0 ± 12.8 year and weeks since stroke was 11.6 ± 5.4. The average Fugl-Meyer baseline score of Test Group participants was 20.9, increasing by 10.8 with training, and in Control Group participants was 23.7 increasing by 6.4 with training, representing a significant difference (4.4) in change scores (P = .01). During the crossover phase, Control Group participants showed a significant increase in FMA-UL score (i.e., 4.7 ± 6.7 points, P = .003) as well as in other, more specific measures of impairment.

CONCLUSIONS

Robotic impairment-oriented training, as used in this study, can significantly enhance recovery during the subacute phase of recovery. Spontaneous recovery and prescribed outpatient therapy during this phase do not fully exploit the potential for remediating moderate-to-severe upper limb impairment.ClinicalTrials.gov Registry: NCT00609115-Subacute stroke rehabilitation with AMES.

Revisiting the Proportional Recovery Model in View of the Ceiling Effect of Fugl-Meyer Assessment

BACKGROUND AND PURPOSE

The aim of this study was to verify the validity of the proportional recovery model in view of the ceiling effect of the Fugl-Meyer Assessment.

METHODS

We reviewed the medical records of patients enrolled in the Korean Stroke Cohort for Functioning and Rehabilitation between August 2012 and May 2015. Recovery proportion was defined as the actual change in Fugl-Meyer Assessment score of the upper extremity between 7 days and 6 months poststroke, relative to the initial neurological impairment. We then used logistic regression to identify clinical factors attributable to a ceiling effect of the Fugl-Meyer Assessment score of the upper extremity and propensity score matching to verify the validity of the proportional recovery rule.

RESULTS

We screened 10 636 patients and analyzed 849 patients (mean age, 65.4±11.9 years; female, 320 [37.7%]) with first-ever ischemic stroke. We found, through logistic regression analysis, that a one-unit increase in the initial neurological impairment and the age at stroke onset affected the odds ratio (1.0386 and 0.9736, respectively) of achieving the full Fugl-Meyer Assessment score of the upper limb at 6 months poststroke. We also demonstrated, through propensity score matching, that the difference in initial neurological impairment of the upper extremity resulted in discrepancy of the recovery proportion (0.92±0.20 [0-1] versus 0.81±0.31 [0-1], P<0.001).

CONCLUSIONS

We demonstrated that the ceiling effect of the Fugl-Meyer Assessment score of the upper extremity is pronounced in patients with mild initial motor deficits of the upper extremity and that the recovery proportion varies according to the initial motor deficit of the upper limb using logistic regression analysis and propensity score matching, respectively. These results suggest that the proportional recovery model is not valid.

Upper limb kinematics during the first year after stroke: the stroke arm longitudinal study at the University of Gothenburg (SALGOT)

Background

Reduction of compensation and improved movement quality indicate recovery after stroke. Since clinical measures alone are often inadequate to distinguish between behavioral recovery and compensation, kinematic analysis of functional tasks has been recommended.

Objective

To quantify longitudinal changes and residual deficits in movement performance and quality during the first year after stroke using kinematic analysis of drinking task.

Methods

A total of 56 participants with first ever stroke causing upper extremity impairment were extracted from a non-selected stroke unit cohort (Stroke Arm Longitudinal Study at the University of Gothenburg-SALGOT). Participants needed to able to perform the drinking task with the more-affected arm at least on 2 occasions out of 6 (3 days, 10 days, 4 weeks, and 3, 6, and 12 months) during the first year to be included. A cohort of 60 healthy individuals was used as reference. Longitudinal changes were analyzed using linear mixed models.

Results

Movement time, number of movement units, peak angular velocity of the elbow, peak hand velocity, and trunk displacement improved significantly over the first 3 months with a peak at 6 months. Movement time and peak hand velocity reached levels comparable to healthy at 3 months, but number of movement units, peak elbow angular velocity, trunk displacement, and arm abduction remained different from healthy over the first year after stroke.

Conclusions

Even when the recovery patterns of kinematics follow the known nonlinear pattern, not all kinematic measures reach the levels in par with healthy controls at one year post stroke. Since the number of movement units, peak angular velocity, trunk displacement, and arm abduction remained impaired over the first year, they might be the most suited measures to distinguish behavioral recovery from compensation strategies.

Trial registration

ClinicalTrials: NCT01115348. 4 May 2010. Retrospectively registered.

Can robot-based measurements improve prediction of motor performance after robot-assisted upper-limb rehabilitation in patients with moderate-to-severe sub-acute stroke?

PURPOSE

Patients with moderate-to-severe stroke-related upper limb impairment can benefit from repetitive robot-assisted training. However, predicting motor performance in these patients from baseline measurements, including robot-based parameters would help clinicians to provide optimal treatments for each individual.

METHODS

Forty-six patients with sub-acute stroke underwent a 16-session upper limb rehabilitation combining usual care and robotic therapy. Motor outcomes (Fugl-Meyer Assessment Upper Extremity (FMA) score) were retrospectively analysed and potential predictors of motor outcome (including baseline FMA scores, kinematics and number of repetitions performed in the first session etc.) were determined.

RESULTS

The 16-sessions upper limb combined training program led to significantly improved clinical outcomes (gains of 13.8±11.2 for total FMA score and 7.3±6.7 for FMA Shoulder/Elbow score). For the prediction model, time since stroke poorly explained the FMA total score (R2 < 35%). The model however found that time since stroke and initial value of FMA Shoulder/Elbow score were predictors of the FMA Shoulder/Elbow score: (R2 = 59.6%).

CONCLUSION

This study found that clinical prediction of motor outcomes after moderate-to-severe upper-limb paresis is limited. However, initial proximal motor impairment severity predicted proximal motor performance. The value of baselines kinematics and of the number of repeated movements at initiation in the prediction would need further studies.

Robot-Assisted Therapy in Upper Extremity Hemiparesis: Overview of an Evidence-Based Approach

Robot-mediated therapy is an innovative form of rehabilitation that enables highly repetitive, intensive, adaptive, and quantifiable physical training. It has been increasingly used to restore loss of motor function, mainly in stroke survivors suffering from an upper limb paresis. Multiple studies collated in a growing number of review articles showed the positive effects on motor impairment, less clearly on functional limitations. After describing the current status of robotic therapy after upper limb paresis due to stroke, this overview addresses basic principles related to robotic therapy applied to upper limb paresis. We demonstrate how this innovation is an evidence-based approach in that it meets both the improved clinical and more fundamental knowledge-base about regaining effective motor function after stroke and the need of more objective, flexible and controlled therapeutic paradigms.

Which clinical and sociodemographic determinants are associated with self-perceived manual ability at one year after stroke?

Purpose: To evaluate the impact of multiple potential sociodemographic and clinical stroke-related determinants on self-perceived manual ability in an unselected sample of individuals 12 months after first-ever stroke.Methods: A cross-sectional sample of 68 participants (mean age 66) with UE impairments were followed up at 12 months post stroke. Stroke severity at onset was moderate for the majority. Manual ability was assessed by the patient-reported outcome measure ABILHAND Questionnaire. Determinants included in the multivariate regression analysis were age, gender, living situation, vocational situation, affected hand, stroke severity at onset and UE disability (motor function, sensory function, joint motion, pain, grip strength, spasticity and activity capacity) at 12 months post stroke.Results: The strongest associated determinants with self-perceived manual ability were UE motor function and UE activity capacity at 12 months post-stroke. UE motor function together with age and grip strength explained 65% of the variance in one final multivariate model. UE activity capacity and grip strength explained 62% of the variance in a second final model.Conclusion: In order to understand self-perceived difficulties in manual ability in daily activities in persons with stroke, assessments of UE motor function and activity capacity are recommended.Implications for rehabilitationThe ultimate goal of the upper extremity rehabilitation after stroke is to regain ability to use the UE in daily activities that are important to the individual in his or her own environment.This requires a good understanding of factors that are associated with self-perceived manual ability in order to tailor effective rehabilitation interventions.Upper extremity motor function and activity capacity are the strongest determinants associated with self-perceived manual ability one year after stroke.These factors are recommended to be included in the assessment battery in stroke to fully understand the disability in daily life.

Assessment of attention function recovery in patients after stroke using sequential desk-top tasks

Background/Aims:

The course of recovery of performance with attention function has not been sufficiently investigated during the period for rehabilitation after stroke. A sequential desk-top task was applied, whose performance required the spatiotemporal attention function step by step, to patients after stroke. The relationship between the sequential task and conventional assessments of cognitive function was also assessed.

Methods:

A sequential desk-top task with 13 levels of peg-carrying performance, which involved attention function, was applied to 24 patients with a disturbance of attention function after stroke. The outcomes of the sequential task were compared with the results of the Mini-Mental State Examination, Trail Making Test Part A and B, Hamamatsu type Japanese syllabary selection test sentence (Syllabary), Paced Auditory Serial Addition Test, Ponsford's Attentional Rating Scale, and Functional Independence Measure.

Findings:

All participants showed significant progress in the level of the sequential desk-top task. The levels achieved in the sequential task were correlated with the scores of Mini-Mental State Examination, Trail Making Test Part A, Paced Auditory Serial Addition Test, Syllabary, and Functional Independence Measure.

Conclusions:

The results of the sequential desk-top task suggested the recovery course of the attention function, and the results of the task predicted the functional recovery revealed by other test batteries.

Early Shortening of Wrist Flexor Muscles Coincides With Poor Recovery After Stroke

Background. The mechanism and time course of increased wrist joint stiffness poststroke and clinically observed wrist flexion deformity is still not well understood. The components contributing to increased joint stiffness are of neural reflexive and peripheral tissue origin and quantified by reflexive torque and muscle slack length and stiffness coefficient parameters. Objective. To investigate the time course of the components contributing to wrist joint stiffness during the first 26 weeks poststroke in a group of patients, stratified by prognosis and functional recovery of the upper extremity. Methods. A total of 36 stroke patients were measured on 8 occasions within the first 26 weeks poststroke using ramp-and-hold rotations applied to the wrist joint by a robot manipulator. Neural reflexive and peripheral tissue components were estimated using an electromyography-driven antagonistic wrist model. Outcome was compared between groups cross-sectionally at 26 weeks poststroke and development over time was analyzed longitudinally. Results. At 26 weeks poststroke, patients with poor recovery (Action Research Arm Test [ARAT] ≤9 points) showed a higher predicted reflexive torque of the flexors (P < .001) and reduced predicted slack length (P < .001) indicating shortened muscles contributing to higher peripheral tissue stiffness (P < .001), compared with patients with good recovery (ARAT ≥10 points). Significant differences in peripheral tissue stiffness between groups could be identified around weeks 4 and 5; for neural reflexive stiffness, this was the case around week 12. Conclusions. We found onset of peripheral tissue stiffness to precede neural reflexive stiffness. Temporal identification of components contributing to joint stiffness after stroke may prompt longitudinal interventional studies to further evaluate and eventually prevent these phenomena.

Evolution of upper limb kinematics four years after subacute robot-assisted rehabilitation in stroke patients

Purpose: To assess functional status and robot-based kinematic measures four years after subacute robot-assisted rehabilitation in hemiparesis. Materials and methods: Twenty-two patients with stroke-induced hemiparesis underwent a ≥3-month upper limb combined program of robot-assisted and occupational therapy from two months post-stroke, and received community-based therapy after discharge. Four years later, 19 (86%) participated in this follow-up study. Assessments 2, 5 and 54 months post-stroke included Fugl-Meyer (FM), Modified Frenchay Scale (MFS, at Month 54) and robot-based kinematic measures of targeting tasks in three directions, north, paretic and non-paretic: distance covered, velocity, accuracy (root mean square (RMS) error from straight line) and smoothness (number of velocity peaks; upward changes in accuracy and smoothness represent worsening). Analysis was stratified by FM score at two months: ≥17 (Group 1) or <17 (Group 2). Correlation between impairment (FM) and function (MFS) was explored at 54 months. Results: FM scores were stable from 5 to 54 months (+1[-2;4], median [1st; 3rd quartiles], ns). Kinematic changes (three directions pooled) were: distance -1[-17;2]% (ns); velocity, -8[-32;28]% (ns); accuracy, +6[-13;98]% (ns); smoothness, +44[-6;126]% (p < 0.05). Group 2 showed decline vs. Group 1 (p < 0.001) in FM (Group 1, +3[1;5], p < 0.01; Group 2, -7[-11;-1], ns) and accuracy (Group 1, -3[-27;38]%, ns; Group 2, +29[17;140]%, p < 0.001). At 54 months, FM and MFS were highly correlated (Pearson's rho = 0.89; p < 0.001). Conclusions: While impairment appeared stable four years after robot-assisted upper limb training during subacute post-stroke phase, movement kinematics deteriorated despite community-based therapy, especially in more severely impaired patients. Trial registration: EudraCT 2016-005121-36. Registration: 2016-12-20. Date of enrolment of the first participant to the trial: 2009-11-24.

Kinematic upper extremity performance in people with near or fully recovered sensorimotor function after stroke

Background: Clinical scales for upper extremity motor function may not capture improvement among higher functioning people with stroke. Objective: To describe upper extremity kinematics in people with stroke who score within the upper 10% of the Fugl-Meyer Assessment (FMA-UE) and explore the ceiling effects of the FMA-UE. Design: A cross-sectional study design was used. Participants: People with stroke were included from the Stroke Arm Longitudinal Study at University of Gothenburg together with 30 healthy controls. The first analysis included participants who achieved FMA-UE score > 60 within the first year of stroke (assessed at 3 days, 2 weeks, 4 weeks, 3 months, or 12 months post stroke). The second analysis included participants with submaximal FMA-UE (60-65 points, n = 24) or maximal FMA-UE score (66 points, n = 21) at 3 months post stroke. Measurements: The kinematic analysis of a standardized drinking task included movement time, velocity and strategy, joint angles of the elbow, and shoulder and trunk displacement. Results: The high FMA-UE stroke group showed deficits in seven of eight kinematic variables. The submaximal FMA-UE stroke group was slower, had lower tangential and angular peak velocity, and used more trunk displacement than the controls. In addition, the maximal FMA-UE stroke group showed larger trunk displacement and arm abduction during drinking and lower peak angular velocity of the elbow. Conclusions: Participants with near or fully recovered sensorimotor function after stroke still show deficits in movement kinematics; however, the FMA-UE may not be able to detect these impairments.

A Longitudinal Electromyography Study of Complex Movements in Poststroke Therapy. 2: Changes in Coordinated Muscle Activation

Fine motor control is achieved through the coordinated activation of groups of muscles, or "muscle synergies." Muscle synergies change after stroke as a consequence of the motor deficit. We investigated the pattern and longitudinal changes in upper limb muscle synergies during therapy in a largely unconstrained movement in patients with a broad spectrum of poststroke residual voluntary motor capacity. Electromyography (EMG) was recorded using wireless telemetry from 6 muscles acting on the more-affected upper body in 24 stroke patients at early and late therapy during formal Wii-based Movement Therapy (WMT) sessions, and in a subset of 13 patients at 6-month follow-up. Patients were classified with low, moderate, or high motor-function. The Wii-baseball swing was analyzed using a non-negative matrix factorization (NMF) algorithm to extract muscle synergies from EMG recordings based on the temporal activation of each synergy and the contribution of each muscle to a synergy. Motor-function was clinically assessed immediately pre- and post-therapy and at 6-month follow-up using the Wolf Motor Function Test, upper limb motor Fugl-Meyer Assessment, and Motor Activity Log Quality of Movement scale. Clinical assessments and game performance demonstrated improved motor-function for all patients at post-therapy (p < 0.01), and these improvements were sustained at 6-month follow-up (p > 0.05). NMF analysis revealed fewer muscle synergies (mean ± SE) for patients with low motor-function (3.38 ± 0.2) than those with high motor-function (4.00 ± 0.3) at early therapy (p = 0.036) with an association trend between the number of synergies and the level of motor-function. By late therapy, there was no significant change between groups, although there was a pattern of increase for those with low motor-function over time. The variability accounted for demonstrated differences with motor-function level (p < 0.05) but not time. Cluster analysis of the pooled synergies highlighted the therapy-induced change in muscle activation. Muscle synergies could be identified for all patients during therapy activities. These results show less complexity and more co-activation in the muscle activation for patients with low motor-function as a higher number of muscle synergies reflects greater movement complexity and task-related phasic muscle activation. The increased number of synergies and changes within synergies by late-therapy suggests improved motor control and movement quality with more distinct phases of movement.

Changes in arm-hand function and arm-hand skill performance in patients after stroke during and after rehabilitation

BACKGROUND

Arm-hand rehabilitation programs applied in stroke rehabilitation frequently target specific populations and thus are less applicable in heterogeneous patient populations. Besides, changes in arm-hand function (AHF) and arm-hand skill performance (AHSP) during and after a specific and well-described rehabilitation treatment are often not well evaluated.

METHOD

This single-armed prospective cohort study featured three subgroups of stroke patients with either a severely, moderately or mildly impaired AHF. Rehabilitation treatment consisted of a Concise_Arm_and_hand_ Rehabilitation_Approach_in_Stroke (CARAS). Measurements at function and activity level were performed at admission, clinical discharge, 3, 6, 9 and 12 months after clinical discharge.

RESULTS

Eighty-nine stroke patients (M/F:63/23; mean age:57.6yr (+/-10.6); post-stroke time:29.8 days (+/-20.1)) participated. All patients improved on AHF and arm-hand capacity during and after rehabilitation, except on grip strength in the severely affected subgroup. Largest gains occurred in patients with a moderately affected AHF. As to self-perceived AHSP, on average, all subgroups improved over time. A small percentage of patients declined regarding self-perceived AHSP post-rehabilitation.

CONCLUSIONS

A majority of stroke patients across the whole arm-hand impairment severity spectrum significantly improved on AHF, arm-hand capacity and self-perceived AHSP. These were maintained up to one year post-rehabilitation. Results may serve as a control condition in future studies.

Prediction of Walking and Arm Recovery after Stroke: A Critical Review

Clinicians often base their predictions of walking and arm recovery on multiple predictors. Multivariate prediction models may assist clinicians to make accurate predictions. Several reviews have been published on the prediction of motor recovery after stroke, but none have critically appraised development and validation studies of models for predicting walking and arm recovery. In this review, we highlight some common methodological limitations of models that have been developed and validated. Notable models include the proportional recovery model and the PREP algorithm. We also identify five other models based on clinical predictors that might be ready for further validation. It has been suggested that neurophysiological and neuroimaging data may be used to predict arm recovery. Current evidence suggests, but does not show conclusively, that the addition of neurophysiological and neuroimaging data to models containing clinical predictors yields clinically important increases in predictive accuracy.

Reliability of maximal grip strength measurements and grip strength recovery following a stroke

STUDY DESIGN

Clinical measurement.

PURPOSE

The test-retest reliability of maximal grip strength measurements (MGSM) is examined in subjects for 12 weeks post-stroke together with maximal grip strength recovery and the maximal-grip and upper-extremity strength measurements' relationship with capacity and performance test scores.

METHODS

A Jamar dynamometer and the Motricity Index (MI) were used for strength measurements. The Chedoke Arm and Hand Activity Inventory and ABILHAND questionnaire for evaluating capacities and performances.

RESULTS

MGSM were reliable (Intraclass Correlation Coefficients = 0.97-0.99, Minimal Detectable Differences = 2.73-4.68 kg). Among the 34 participants, 47% did not have a measurable grip strength one week post-stroke but 50% of these recovered some strength within the first eight weeks. The MGSM and MI scores were correlated with scores of tests of capacity and performance (Spearman's Rank Correlation Coefficients = 0.69-0.94).

CONCLUSIONS

MGSM are reliable in the first weeks after a stroke.

LEVEL OF EVIDENCE

N/A.

Dynamometry for the measurement of grip, pinch, and trunk muscles strength in subjects with subacute stroke: reliability and different number of trials

Background

Muscle strength is usually measured in individuals with stroke with Portable dynamometers (gold standard). However, no studies have investigated the reliability, the standard error of measurement (SEM) and the minimal detectable difference (MDD_95%) of the dynamometry for the measurement of hand grip, pinch grip and trunk strength in subjects with subacute stroke.

Objective

1) To investigate the intra and inter-rater reliability, the SEM and the MDD_95% of the portable dynamometers for the measurement of grip, pinch and trunk strength in subjects with subacute stroke, and 2) to verify whether the use of different number of trials (first trial and the average of the first two and three trials) affected the results.

Method

32 subjects with subacute stroke (time since stroke onset: 3.6 months, SD=0.66 months) were evaluated. Hand grip, 3 pinch grips (i.e. pulp-to-pulp/palmar/lateral) and 4 trunk muscles (i.e. flexors, extensors, lateral flexors and rotators) strength were bilaterally assessed (except trunk flexors/extensors) with portable dynamometry by two independent examiners over two sessions (1-2 weeks apart). One-way ANOVAs and intraclass correlation coefficients (ICC_2,k) were used for analysis (α=0.05). SEM and MDD_95% were also calculated.

Results

For all muscular groups and sources of outcome values, including one trial, after familiarization, similar results were found (0.01≤F≤0.08; 0.92≤p≤0.99) with significant and adequate values of intra-rater (0.64≤ICC≤0.99; 0.23≤95%CI≤0.99) and inter-rater (0.66≤ICC≤0.99; 0.25≤95%CI≤0.99) reliability. SEM and MDD_95% were considered low (0.39≤EPM≤2.21 Kg; 0.96≤MMD_95%≤6.12 Kg) for all outcome scores.

Conclusion

Only one trial, following familiarization, demonstrated adequate intra-rater and inter-rater reliability of the portable dynamometers for the measurement of hand grip, pinch grip and trunk strength in subjects with subacute stroke.

Estimation of tissue stiffness, reflex activity, optimal muscle length and slack length in stroke patients using an electromyography driven antagonistic wrist model

BACKGROUND

About half of all chronic stroke patients experience loss of arm function coinciding with increased stiffness, reduced range of motion and a flexed wrist due to a change in neural and/or structural tissue properties. Quantitative assessment of these changes is of clinical importance, yet not trivial. The goal of this study was to quantify the neural and structural properties contributing to wrist joint stiffness and to compare these properties between healthy subjects and stroke patients.

METHODS

Stroke patients (n=32) and healthy volunteers (n=14) were measured using ramp-and-hold rotations applied to the wrist joint by a haptic manipulator. Neural (reflexive torque) and structural (connective tissue stiffness and slack lengths and (contractile) optimal muscle lengths) parameters were estimated using an electromyography driven antagonistic wrist model. Kruskal-Wallis analysis with multiple comparisons was used to compare results between healthy subjects, stroke patients with modified Ashworth score of zero and stroke patients with modified Ashworth score of one or more.

FINDINGS

Stroke patients with modified Ashworth score of one or more differed from healthy controls (P<0.05) by increased tissue stiffness, increased reflexive torque, decreased optimal muscle length and decreased slack length of connective tissue of the flexor muscles.

INTERPRETATION

Non-invasive quantitative analysis, including estimation of optimal muscle lengths, enables to identify neural and non-neural changes in chronic stroke patients. Monitoring these changes in time is important to understand the recovery process and to optimize treatment.

Use of a robotic device for the rehabilitation of severe upper limb paresis in subacute stroke: exploration of patient/robot interactions and the motor recovery process

This pioneering observational study explored the interaction between subacute stroke inpatients and a rehabilitation robot during upper limb training. 25 stroke survivors (age 55 ± 17 years; time since stroke, 52 ± 21 days) with severe upper limb paresis carried out 16 sessions of robot-assisted shoulder/elbow training (InMotion 2.0, IMT, Inc., MA, USA) combined with standard therapy. The values of 3 patient/robot interaction parameters (a guidance parameter: Stiffness, a velocity-related parameter: Slottime, and Robotic Power) were compared between sessions 1 (S1), 4 (S4), 8 (S8), 12 (S12), and 16 (S16). Pre/post Fugl-Meyer Assessment (FMA) scores were compared in 18 patients. Correlations between interaction parameters and clinical and kinematic outcome measures were evaluated. Slottime decreased at S8 (P = 0.003), while Guidance decreased at S12 (P = 0.008). Robotic Power tended to decrease until S16. FMA scores improved from S1 to S16 (+49%, P = 0.002). Changes in FMA score were correlated with the Stiffness parameter (R = 0.4, P = 0.003). Slottime was correlated with movement velocity. This novel approach demonstrated that a robotic device is a useful and reliable tool for the quantification of interaction parameters. Moreover, changes in these parameters were correlated with clinical and kinematic changes. These results suggested that robot-based recordings can provide new insights into the motor recovery process.

Robotic-locomotor training as a tool to reduce neuromuscular abnormality in spinal cord injury: the application of system identification and advanced longitudinal modeling

In this study, the effect of the LOKOMAT, a robotic-assisted locomotor training system, on the reduction of neuromuscular abnormalities associated with spasticity was examined, for the first time in the spinal cord injury (SCI) population. Twenty-three individuals with chronic incomplete SCI received 1-hour training sessions in the LOKOMAT three times per week, with up to 45 minutes of training per session; matched control group received no intervention. The neuromuscular properties of the spastic ankle were then evaluated prior to training and after 1, 2, and 4 weeks of training. A parallel-cascade system identification technique was used to determine the reflex and intrinsic stiffness of the ankle joint as a function of ankle position at each time point. The slope of the stiffness vs. joint angle curve, i.e. the modulation of stiffness with joint position, was then calculated and tracked over the four-week period. Growth Mixture Modeling (GMM), an advanced statistical method, was then used to classify subjects into subgroups based on similar trends in recovery pattern of slope over time, and Random Coefficient Regression (RCR) was used to model the recovery patterns within each subgroup. All groups showed significant reductions in both reflex and intrinsic slope over time, but subjects in classes with higher baseline values of the slope showed larger improvements over the four weeks of training. These findings suggest that LOKOMAT training may also be useful for reducing the abnormal modulation of neuromuscular properties that arises as secondary effects after SCI. This can advise clinicians as to which patients can benefit the most from LOKOMAT training prior to beginning the training. Further, this study shows that system identification and GMM/RCR can serve as powerful tools to quantify and track spasticity over time in the SCI population.

The Contribution of Kinematics in the Assessment of Upper Limb Motor Recovery Early After Stroke

Background. Kinematic assessment of upper limb motor recovery after stroke may be related to clinical scores while being more sensitive and reliable than clinical evaluation alone. Objective. To identify the potential of kinematics in assessing upper limb recovery early poststroke. Methods. Thirteen patients were included within 1 month poststroke and evaluated once a week for 6 weeks and at 3 months with ( a) the Fugl-Meyer Assessment (FMA) and ( b) kinematic analysis of reach-to-grasp movements. The link between clinical and kinematic data was identified using mixed model with random coefficient analysis. Results. Movement time, trajectory length, directness, smoothness, mean and maximum velocity of the hand were sensitive to change over time and distinguished between movements of paretic, nonparetic, and healthy control limbs. The FMA score increased with movement smoothness over time, explaining 62.5% of FMA variability. Conclusion. Kinematic analysis of reach-to-grasp movements is relevant to assess upper limb recovery early poststroke, and is linked to the FMA. Kinematics could provide more accurate real-time indicators of patients’ recovery as compared with the sole use of clinical scores, although it remains challenging to establish the universality of the reaching model in relation to motor recovery after stroke.

Attentional focus of feedback for improving performance of reach-to-grasp after stroke: a randomised crossover study

OBJECTIVE

To investigate whether feedback inducing an external focus (EF) of attention (about movement effects) was more effective for retraining reach-to-grasp after stroke compared with feedback inducing an internal focus (IF) of attention (about body movement). It was predicted that inducing an EF of attention would be more beneficial to motor performance.

DESIGN

Crossover trial where participants were assigned at random to two feedback order groups: IF followed by EF or EF followed by IF.

SETTING

Research laboratory.

PARTICIPANTS

Forty-two people with upper limb impairment after stroke.

INTERVENTION

Participants performed three reaching tasks: (A) reaching to grasp a jar; (B) placing a jar forwards on to a table; and (C) placing a jar on to a shelf. Ninety-six reaches were performed in total over one training session.

MAIN OUTCOME MEASURES

Kinematic measures were collected using motion analysis. Primary outcome measures were movement duration, peak velocity of the wrist, size of peak aperture and peak elbow extension.

RESULTS

Feedback inducing an EF of attention produced shorter movement durations {first feedback order group: IF mean 2.53 seconds [standard deviation (SD) 1.85]; EF mean 2.12 seconds (SD 1.63), mean difference 0.41 seconds; 95% confidence interval -0.68 to 1.5; P=0.008}, an increased percentage time to peak deceleration (P=0.01) when performing Task B, and an increased percentage time to peak velocity (P=0.039) when performing Task A compared with feedback inducing an IF of attention. However, an order effect was present whereby performance was improved if an EF of attention was preceded by an IF of attention.

CONCLUSIONS

Feedback inducing an EF of attention may be of some benefit for improving motor performance of reaching in people with stroke in the short term; however, these results should be interpreted with caution. Further research using a randomised design is recommended to enable effects on motor learning to be assessed.

Functional recovery of the paretic upper limb after stroke: who regains hand capacity?

OBJECTIVE

To describe recovery of upper limb capacity after stroke during inpatient rehabilitation based on the Stroke Upper Limb Capacity Scale (SULCS).

DESIGN

Prospective observational study.

SETTING

Inpatient department of a rehabilitation center.

PARTICIPANTS

Patients with stroke (N=299) admitted to a specialized stroke rehabilitation center.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Upper limb capacity was assessed at the start and end of the rehabilitation phase with the SULCS (range, 0-10). The following demographic and clinical characteristics were registered: age, sex, side of stroke, stroke type, time since stroke, and length of stay in the rehabilitation center.

RESULTS

On admission, 125 patients had no hand capacity (SULCS score, 0-3), 58 had basic hand capacity (SULCS score, 4-7), and 116 had advanced hand capacity (SULCS score, 8-10). Of the patients without initial hand capacity, 41% regained some hand capacity (SULCS score, ≥4) at discharge. Of these, patients with SULCS scores of 2 and 3 had 29 and 97 times greater chance of regaining some hand capacity compared with patients with an initial SULCS score of 0, respectively. Of the patients with initial basic hand capacity, 78% regained advanced hand capacity at discharge. The SULCS score on admission explained 51% of the SULCS score variance at discharge, while time since stroke was negatively associated with upper limb recovery, explaining an additional 7% of the SULCS score variance at discharge.

CONCLUSIONS

Even patients with minimal proximal shoulder and elbow control of the upper paretic limb on admission in a rehabilitation center have a fair chance of regaining some hand capacity in the long-term after stroke, whereas patients without such proximal arm control have a much poorer prognosis for regaining hand capacity.

Diffusion tensor imaging predicts long-term motor functional outcome in patients with acute supratentorial intracranial hemorrhage

BACKGROUND/AIM

It remains unclear how wallerian degeneration of the pyramidal tract (PT) in the acute phase of supratentorial intracranial hemorrhage (ICH) correlates with the long-term functional outcome. The aim of this study was to quantify and predict the long-term neuromotor outcome using diffusion tensor imaging (DTI) during the early stages of ICH.

METHODS

Twenty-seven patients with a hemiparetic ICH were prospectively studied using DTI either within 3 days or at 2 weeks after onset. A region-of-interest-based analysis was performed for fractional anisotropy (FA) of the PT in the cerebral peduncle. The degree of paresis was assessed upon admission and at 6 months using paresis grading (PG), and the functional outcome was evaluated using the modified Rankin Scale (mRS). The activities of daily living were evaluated using the Functional Independence Measure (FIM).

RESULTS

The FA values within 3 days and after 2 weeks of ICH onset were significantly decreased at the affected side (p = 0.001, reduced by 11%; p < 0.001, reduced by 14%, respectively), but the mean diffusivity at the same time points remained unchanged (p = 0.05 and p = 0.136, respectively). The ratio of the FA (rFA) at the affected side to that of the unaffected side within 3 days was negatively correlated with the PG (p < 0.001, r = -0.642), positively correlated with the FIM scores (p = 0.004, r = 0.532), and negatively correlated with the mRS scores at the end of follow-up (median = 17 months) (p = 0.010, r = -0.490). The rFA at 2 weeks was positively correlated with the FIM (p < 0.001, r = 0.661) and negatively correlated with mRS scores and PG at the end of follow-up (p < 0.001, r = -0.653; p < 0.001, r = -0.700). For both patients with good and poor outcomes based on the PG, the area under the receiver operating characteristic (ROC) curve for rFA at 2 weeks was greater than the area under the ROC for rFA within 3 days, and the cutoff point for the rFA at 2 weeks was set at 0.875 (sensitivity 76%, specificity 89%).

CONCLUSIONS

This study demonstrated that the use of DTI during the early stages of ICH may predict motor outcomes at 6 months after ICH. Moreover, as compared to use of DTI within 3 days of ICH onset, the application of DTI at 2 weeks after ICH could more accurately predict the motor outcomes and daily living activities of patients.

Prediction of stroke motor recovery using reflex stiffness measures at one month

This study characterizes the recovery patterns of motor impairment after stroke, and uses neuromuscular measures of the elbow joint at one month after the event to predict the ensuing recovery patterns over 12 months. Motor impairment was assessed using the Fugl-Meyer Assessment (FMA) of the upper extremity at various intervals after stroke. A parallel-cascade system identification technique characterized the intrinsic and reflex stiffness at various elbow angles. We then used "growth-mixture" modeling to identify three distinct recovery classes for FMA. While class 1 and class 3 subjects both started with low FMA, those in class 1 increased FMA significantly over 12-month recovery period, whereas those in class 3 presented no improvement. Class 2 subjects started with high FMA and also exhibited significant FMA improvement, but over a smaller range and at a slower recovery rate than class 1. Our results showed that the one-month reflex stiffness was able to distinguish between classes 1 and 3 even though both showed similarly low month-1 FMA. These findings demonstrate that, using reflex stiffness, we were able to accurately predict arm function recovery in stroke subjects over one year and beyond. This information is clinically significant and can be helpful in developing targeted therapeutic interventions.

Cognitive impairments and depressive symptoms did not impede upper limb recovery in a clinical repetitive task practice program after stroke: a pilot study

OBJECTIVE

We examined whether cognitive impairments or depressive symptoms impeded improvement in upper limb function in a clinical repetitive task practice program.

DESIGN

Participants had mild to moderate upper limb impairment after stroke (n = 20). We characterized baseline cognitive function and depressive symptoms using the Repeatable Battery of Neuropsychological Status and the Hamilton Rating Scale for Depression. We measured upper limb function at baseline, week 4, and week 24 using the Action Research Arm Test.

RESULTS

Participants with and without cognitive impairments improved significantly over time (F(1,17) = 84.48, P < 0.001) regardless of cognitive status (t(31) = 1.42, P = 0.16) or time since stroke (t(17) = 0.07, P = 0.95). Participants with and without depressive symptoms improved significantly over time (F(1,18) = 86.29, P < 0.001), but participants with depressive symptoms demonstrated greater improvement than did participants with no depressive symptoms (t(31) = 3.19, P = 0.003), regardless of time since stroke (t(17) = 0.06, P = 0.95).

CONCLUSIONS

Preliminary findings suggest that cognitive impairments and depressive symptoms may not impede benefit from repetitive task practice after stroke.

Arm motor control as predictor for hypertonia after stroke: a prospective cohort study

OBJECTIVES

To analyze the development of hypertonia in the hemiparetic elbow flexors, and to explore the predictive value of arm motor control on hypertonia in a cohort of first-ever stroke survivors in the first 6 months poststroke.

DESIGN

A prospective cohort study.

SETTING

A cohort of stroke survivors from a large, university-affilliated hospital in The Netherlands.

PARTICIPANTS

Patients (N=50) with first-time ischemic strokes and initial arm paralysis who were admitted to a stroke unit.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

At 48 hours, 10 to 12 days, 3 and 6 months poststroke, hypertonia and arm motor control were assessed using the Modified Ashworth Scale and the Fugl-Meyer Assessment arm score.

RESULTS

The incidence rate of hypertonia reached its maximum before the third month poststroke (30%). Prevalence was 42% at 3 and 6 months. Participants with poor arm motor control at 48 hours poststroke were 13 times more likely to develop hypertonia in the first 6 months poststroke than those with moderate to good arm motor control. These results were not confounded by the amount of arm function training received.

CONCLUSIONS

Hypertonia develops in a large proportion of patients with stroke, predominantly within the first 3 months poststroke. Poor arm motor control is a risk factor for the development of hypertonia.

SALGOT--Stroke Arm Longitudinal study at the University of Gothenburg, prospective cohort study protocol

Background

Recovery patterns of upper extremity motor function have been described in several longitudinal studies, but most of these studies have had selected samples, short follow up times or insufficient outcomes on motor function. The general understanding is that improvements in upper extremity occur mainly during the first month after the stroke incident and little if any, significant recovery can be gained after 3-6 months. The purpose of this study is to describe the recovery of upper extremity function longitudinally in a non-selected sample initially admitted to a stroke unit with first ever stroke, living in Gothenburg urban area.

Methods/Design

A sample of 120 participants with a first-ever stroke and impaired upper extremity function will be consecutively included from an acute stroke unit and followed longitudinally for one year. Assessments are performed at eight occasions: at day 3 and 10, week 3, 4 and 6, month 3, 6 and 12 after onset of stroke. The primary clinical outcome measures are Action Research Arm Test and Fugl-Meyer Assessment for Upper Extremity. As additional measures, two new computer based objective methods with kinematic analysis of arm movements are used. The ABILHAND questionnaire of manual ability, Stroke Impact Scale, grip strength, spasticity, pain, passive range of motion and cognitive function will be assessed as well. At one year follow up, two patient reported outcomes, Impact on Participation and Autonomy and EuroQol Quality of Life Scale, will be added to cover the status of participation and aspects of health related quality of life.

Discussion

This study comprises a non-selected population with first ever stroke and impaired arm function. Measurements are performed both using traditional clinical assessments as well as computer based measurement systems providing objective kinematic data. The ICF classification of functioning, disability and health is used as framework for the selection of assessment measures. The study design with several repeated measurements on motor function will give us more confident information about the recovery patterns after stroke. This knowledge is essential both for optimizing rehabilitation planning as well as providing important information to the patient about the recovery perspectives.

Trial registration

ClinicalTrials.gov: NCT01115348

The ACT-4D: a novel rehabilitation robot for the quantification of upper limb motor impairments following brain injury

Rehabilitation robots and other controlled diagnostic devices are useful tools to objectively quantify debilitating, post-stroke impairments. The goal of this paper is to describe the design of the ACT-4D rehabilitation robot which can quantify arm impairments during functional movement. The robot can instantly switch between a compliant mode that minimizes impedance of voluntary movement, and a stiff mode that applies controlled position/speed perturbations to the elbow (up to 75 Nm or 450 deg/s at 4500 deg/s(2)). It has a limited range of movement of the shoulder and elbow, which is further reduced when a damper is needed to enhance the positional stiffness of the base robot. In recent experiments, the ACT-4D has been used successfully for the quantification of elbow impairments.

Comparison of an intermittent high-intensity vs continuous low-intensity physiotherapy service over 12 months in community-dwelling people with stroke: a randomized trial

Objective: This study compared two modes of physiotherapy service over 12 months in community-dwelling people with stroke, either following a train—wait train paradigm by providing bouts of intense physiotherapy, or a continuous less intense programme.

Design: Randomized trial.

Setting: Community-dwelling people with stroke.

Interventions: Fifty patients, first-time stroke, discharged home, following inpatient rehabilitation, allocated to two groups, A and B. Over 12 months, Group A (n = 25) received three two-month blocks of therapy at home, each block contained four 30 to 45 minute sessions per week, totalling 96 sessions. Group B (n = 25) continuously received two 30 to 45 minute sessions per week, totalling 104 sessions.

Main outcome measures: Primary Rivermead Mobility Index (0—15), secondary upper- and lower-limb motor functions, Activities of Daily Living competence, tone and number of falls.

Results: Both groups were comparable at onset, the mean age in Group A (B) was 62.4 (61.9) years. A and B patients equally improved functions over time, between group differences did not occur. The initial (terminal) Rivermead Mobility Index was 9.4 ± 2.8 (12.2 ± 2.1) in Group A, and 8.5 ± 3.5 (11.2 ± 2.7) in Group B. More Group B patients fell seriously (7 versus 1).

Conclusions: The intermittent high-intensity and continuous low-intensity therapy protocols were equally effective, the sheer intensity seems more important than the time-mode of application. The relatively young patients functionally improved in the first year after stroke, the reduced risk of serious falls in the intermittent high-intensity group should be validated.

The use of kinematic and parametric information to highlight lack of movement and compensation in the upper extremities during activities of daily living

A problem that is common to the study of upper limb kinematics and gait analysis is the translation of the evidence from kinematic measurements into easily interpretable information on the status of the patient, such as the amount of compensation or lack of motion. In this study parameters that can be helpful in the rapid and clear identification of limited wrist motion and compensation were derived from kinematic data. A group of six subjects (group A) with no hand impairment, average age 32.5 ys SD 10.7 ys, and another group of five subjects (group B), average age 34.2 ys SD 16.8 ys, having suffered from distal radius fracture were tested during a cyclic activity of daily living. The activity simulated page turning. Thorax, shoulder, elbow and wrist angles were measured during this task using a motion capture system. Corresponding angle ranges were also calculated. The active range of motion (AROM) found for Group B was generally lower than that of Group A, particularly for elbow supination and wrist movements, with wrist flexion/extension statistically smaller for group B (P=0.02). Additional parameters that took into account lack of movements at the wrist and compensation from shoulder elevation, rotation and elbow pronation/supination proved to be more useful at identifying those subjects of group B outside the normative range and can provide clinicians with a rapid and efficient tool that can shorten the analysis process and help make more informed decisions on therapeutic treatments.

Effect of baseline spastic hemiparesis on recovery of upper-limb function following botulinum toxin type A injections and postinjection therapy

OBJECTIVE

To determine whether baseline hand spastic hemiparesis assessed by the Chedoke-McMaster Assessment influences functional improvement after botulinum toxin type A (BTX-A) injections and postinjection therapy.

DESIGN

Prospective cohort study.

SETTING

Outpatient spasticity clinic.

PARTICIPANTS

Participants (N=14) with spastic hemiparesis divided into 2 groups: Chedoke-McMaster Assessment Hand-Higher Function (stage> or =4, n=5) and Chedoke-McMaster Assessment Hand-Lower Function (stage=2 or 3, n=9).

INTERVENTIONS

Upper-limb BTX-A injections followed by 6 weeks of postinjection therapy.

MAIN OUTCOME MEASURES

Primary outcomes were Motor Activity Log-28 and Motor Activity Log items. Secondary outcomes were Action Research Arm Test (ARAT), Motor Activity Log-Self-Report, and Modified Ashworth Scale (MAS). Measures were assessed at baseline (preinjection), 6 weeks, 9 weeks, and 12 weeks postinjection.

RESULTS

Primary and secondary outcomes improved significantly over time in both groups. Although no significant differences in ARAT or MAS change scores were noted between groups, Chedoke-McMaster Assessment Hand-Higher Function group demonstrated greater change on Motor Activity Log-28 (P=.013) from baseline to 6 weeks and Motor Activity Log items (P=.006) from baseline to 12 weeks compared to Chedoke-McMaster Assessment Hand-Lower Function group.

CONCLUSIONS

BTX-A injections and postinjection therapy improved hand function and reduced spasticity for both Chedoke-McMaster Assessment Hand-Higher Function and Chedoke-McMaster Assessment Hand-Lower Function groups. Clinicians should expect to see larger gains for persons with less baseline impairment.