Clinical reality of measuring upper-limb ability in neurologic conditions: a systematic review

Roles of Handedness and Hemispheric Lateralization: Implications for Rehabilitation of the Central and Peripheral Nervous Systems: A Rapid Review

IMPORTANCE

Handedness and motor asymmetry are important features of occupational performance. With an increased understanding of the basic neural mechanisms surrounding handedness, clinicians will be better able to implement targeted, evidence-based neurorehabilitation interventions to promote functional independence.

OBJECTIVE

To review the basic neural mechanisms behind handedness and their implications for central and peripheral nervous system injury.

DATA SOURCES

Relevant published literature obtained via MEDLINE.

FINDINGS

Handedness, along with performance asymmetries observed between the dominant and nondominant hands, may be due to hemispheric specializations for motor control. These specializations contribute to predictable motor control deficits that are dependent on which hemisphere or limb has been affected. Clinical practice recommendations for occupational therapists and other rehabilitation specialists are presented.

CONCLUSIONS AND RELEVANCE

It is vital that occupational therapists and other rehabilitation specialists consider handedness and hemispheric lateralization during evaluation and treatment. With an increased understanding of the basic neural mechanisms surrounding handedness, clinicians will be better able to implement targeted, evidence-based neurorehabilitation interventions to promote functional independence. Plain-Language Summary: The goal of this narrative review is to increase clinicians' understanding of the basic neural mechanisms related to handedness (the tendency to select one hand over the other for specific tasks) and their implications for central and peripheral nervous system injury and rehabilitation. An enhanced understanding of these mechanisms may allow clinicians to better tailor neurorehabilitation interventions to address motor deficits and promote functional independence.

Measurement properties of outcome measures used in neurological telerehabilitation: A systematic review using COSMIN checklist

OBJECTIVE

To summarize the measurement properties (reliability, validity, and responsiveness) and the clinical utility of measurement tools used in telerehabilitation in individuals with neurological conditions.

DESIGN

Systematic review.

SUBJECTS

Individuals with neurological conditions.

INTERVENTION

Not applicable.

MAIN MEASURES

The methodological quality of the studies using the COSMIN Risk of Bias Checklist, the quality of the measurement properties using the criteria for good measurement properties, and the clinical utility of the measurements using the Tyson & Connell scale.

RESULTS

From the 22,188 identified studies, 47 were included. Forty-three measurement tools were identified. The main modes of administration were telephone and videoconference. Studies involved mostly individuals with stroke, multiple sclerosis, and Alzheimer's disease. Criterion validity and reliability were the most investigated measurement properties. None of the tools had their responsiveness investigated. Twenty-two measurement tools have at least one measurement property evaluated as "sufficient" in a study with appropriate methodological quality ("very good" or "adequate"). Nineteen measurement tools showed adequate clinical utility. Eight measurement tools, investigated in individuals with stroke, spinal cord injury or Alzheimer's disease, all administered by telephone, were recommended.

CONCLUSION

The present results can be used to assist in choosing appropriate measurement tools, both in research and clinical practice, during telerehabilitation in individuals with neurological conditions. Measurement error, content validity, structural validity, and responsiveness need to be further investigated. In addition, the measurement properties of tools used in telerehabilitation in other neurological conditions, such as Huntington's disease, should also be investigated.

REGISTRATION NUMBER

CRD42021257662.

Internet of Things (IoT) Enables Robot-Assisted Therapy as a Home Program for Training Upper Limb Functions in Chronic Stroke: A Randomized Control Crossover Study

OBJECTIVE

To compare the effects of using an Internet of things (IoT)-assisted tenodesis-induced-grip exoskeleton robot (TIGER) and task-specific motor training (TSMT) as home programs for the upper-limb (UL) functions of patients with chronic stroke to overturn conventional treatment modes for stroke rehabilitation.

DESIGN

A randomized 2-period crossover study.

SETTING

A university hospital.

PARTICIPANTS

Eighteen chronic stroke patients were recruited and randomized to receive either the IoT-assisted TIGER first or TSMT first at the beginning of the experiment (N=18).

INTERVENTION

In addition to the standard hospital-based therapy, participants were allocated to receive a 30-minute home-based, self-administered program of either IoT-assisted TIGER first or TSMT first twice daily for 4 weeks, with the order of both treatments reversed after a 12-week washout period. The exercise mode of the TIGER training included continuous passive motion and the functional mode of gripping pegs. The TSMT involved various movement components of the wrist and hand.

MAIN OUTCOME MEASURES

The outcome measures included the box and block test (BBT), the Fugl-Meyer assessment for upper extremity (FMA-UE), the motor activity log, the Semmes-Weinstein Monofilament test, the range of motion (ROM) of the wrist joint, and the modified Ashworth scale.

RESULTS

Significant treatment-by-time interaction effects emerged in the results for the BBT (F(1.31)=5.212 and P=.022), the FMA-UE (F(1.31)=6.807 and P=.042), and the ROM of the wrist extension (F(1.31)=8.618 and P=.009). The participants who trained at home with the IoT-assisted TIGER showed more improvement of their UL functions.

CONCLUSIONS

The IoT-assisted TIGER training has the potential for restoring the UL functions of stroke patients.

Effect of Self-Directed Home Therapy Adherence Combined with TheraBracelet on Poststroke Hand Recovery: A Pilot Study

Hand impairment is a common consequence of stroke, resulting in long-term disability and reduced quality of life. Recovery may be augmented through self-directed therapy activities at home, complemented by the use of rehabilitation devices such as peripheral sensory stimulation. The objective of this study was to determine the effect of adherence to self-directed therapy and the use of TheraBracelet (subsensory random-frequency vibratory stimulation) on hand function for stroke survivors. In a double-blind, randomized controlled pilot trial, 12 chronic stroke survivors were assigned to a treatment or control group (n = 6/group). All participants were instructed to perform 200 repetitions of therapeutic hand tasks 5 days/week while wearing a wrist-worn device 8 hours/day for 4 weeks. The treatment group received TheraBracelet vibration from the device, while the control group received no vibration. Home task repetition adherence and device wear logs, as well as hand function assessment (Stroke Impact Scale Hand domain), were obtained weekly. Repetition adherence was comparable between groups but varied among participants. Participants wore the device to a greater extent than adhering to completing repetitions. A linear mixed model analysis showed a significant interaction between repetition and group (p = 0.01), with greater adherence resulting in greater hand function change for the treatment group (r = 0.94; R ² = 0.88), but not for the control group. Secondary analysis revealed that repetition adherence was greater for those with lower motor capacity and greater self-efficacy at baseline. This pilot study suggests that adherence to self-directed therapy at home combined with subsensory stimulation may affect recovery outcomes in stroke survivors. This trial is registered with NCT04026399.

Informing the development of an outcome set and banks of items to measure mobility among individuals with acquired brain injury using natural language processing

BACKGROUND

The sheer number of measures evaluating mobility and inconsistencies in terminology make it challenging to extract potential core domains and items. Automating a portion of the data synthesis would allow us to cover a much larger volume of studies and databases in a smaller fraction of the time compared to the usual process. Thus, the objective of this study was to identify a comprehensive outcome set and develop preliminary banks of items of mobility among individuals with acquired brain injury (ABI) using Natural Language Processing (NLP).

METHODS

An umbrella review of 47 reviews evaluating the content of mobility measures among individuals with ABI was conducted. A search was performed on 5 databases between 2000 and 2020. Two independent reviewers retrieved copies of the measures and extracted mobility domains and items. A pre-trained BERT model (state-of-the-art model for NLP) provided vector representations for each sentence. Using the International Classification of Functioning, Disability, and Health Framework (ICF) ontology as a guide for clustering, a k-means algorithm was used to retrieve clusters of similar sentences from their embeddings. The resulting embedding clusters were evaluated using the Silhouette score and fine-tuned according to expert input.

RESULTS

The study identified 246 mobility measures, including 474 domains and 2109 items. Encoding the clusters using the ICF ontology and expert knowledge helped in regrouping the items in a way that is more closely related to mobility terminology. Our best results identified banks of items that were used to create a 24 comprehensive outcome sets of mobility, including Upper Extremity Mobility, Emotional Function, Balance, Motor Control, Self-care, Social Life and Relationships, Cognition, Walking, Postural Transition, Recreation, and Leisure Activities, Activities of Daily Living, Physical Functioning, Communication, Work/Study, Climbing, Sensory Functions, General Health, Fatigue, Functional Independence, Pain, Alcohol and Drugs Use, Transportation, Sleeping, and Finances.

CONCLUSION

The banks of items of mobility domains represent a first step toward establishing a comprehensive outcome set and a common language of mobility to develop the ontology. It enables researchers and healthcare professionals to begin exposing the content of mobility measures as a way to assess mobility comprehensively.

Measurement properties of the Brazilian version of the Stroke Upper Limb Capacity Scale (SULCS-Brazil)

BACKGROUND

The Stroke Upper Limb Capacity Scale (SULCS) is a clinically useful measure of upper-limb (UL) capacity, which assesses both basic and advanced capacities.

OBJECTIVES

To examine the reliability, construct validity, and interpretability of the SULCS-Brazil with community-dwelling individuals with stroke.

METHODS

The SULCS-Brazil and measures of impairment (handgrip strength and motor function of the paretic UL), capacity (manual and digital dexterities), and performance were applied during the first session, to establish construct validity (80 patients). The SULCS-Brazil was applied again during a second session (a sub-set of 30 patients), to investigate test-retest reliability. Test-retest reliability was evaluated using kappa statistics (k) for the individual items, intraclass correlation coefficient (ICC) for the total scores, standard error of measurement (SEM), minimal detectable change (MDC), and Bland-Altman plot. For the evaluation of construct validity, pre-defined hypotheses were created to estimate the strength of the correlations between the SULCS-Brazil scores and established measures of UL function, using Spearman correlation coefficients. Interpretability was investigated by evaluating both ceiling/ floor effects.

RESULTS

High level of agreement was found between the SUCLS-Brazil total scores obtained on both applications (ICC = 0.98; 95%CI:0.96-0.99) and 80% of the individual items had almost perfect agreement (k= 0.81-1.0). The SEM (0.46) and the MDC (1.27) showed clinically acceptable values. All pre-defined hypotheses were confirmed, indicating adequate construct validity of the SULCS-Brazil. No significant ceiling/floor effects were observed.

CONCLUSIONS

The SULCS-Brazil showed to be reliable and valid for the evaluation of upper-limb capacity of individuals with stroke.

Suitability of accelerometry as an objective measure for upper extremity use in stroke patients

Background

Upper limb (UL) paresis is one of the most common stroke consequences and significantly restricts patients in everyday life. Instruments objectively measuring direct arm use in stroke patients are lacking, but might be helpful to understand patients’ impairment. Aiming to examine whether accelerometry is a suitable objective measure for everyday UL use in stroke patients, we conducted a systematic review on the association between accelerometer-derived measurements and clinical scales.

Methods

Articles were systematically searched in PubMed, Scopus, Cochrane Library, PeDro and LIVIVO through December 12^th, 2021, screened for inclusion by AH, and subsequently independently screened by CK and MK. Disagreements were discussed until consensus. We included English and German peer-reviewed articles dealing with the validity of accelerometers as a measurement of UL use in stroke patients and eligible systematic reviews. Studies exclusively using accelerometry as an outcome parameter, book contributions, conference abstracts and case studies were excluded. Data extraction was conducted by AH and confirmed by CK focussing on study type, objective, accelerometer device, sample size, stroke status, assessments conducted, measurement method, wearing time and key results. We analysed all eligible articles regarding the correlation between accelerometry and other clinical assessments and the validity in accordance with the type of accelerometer.

Results

Excluding duplicates, the initial search yielded 477 records. In the 34 eligible studies accelerometers was used with a predominance of tri-axial accelerometery (n = 12) and only few with two-axial application (n = 4). Regarding measures to examine association to accelerometer data different clinical scales were applied depending on the setting, the degree of impairment and/or the status of stroke. Cut-off values to determine correlations varied largely; most significant correlations are reported for the MAL [Range 0.31- 0.84] and the ARAT [Range 0.15–0.79].

Conclusions

Accelerometers can provide reliable data about daily arm use frequency but do not supply information about the movements´ quality and restrictions on everyday activities of stroke patients. Depending on the context, it is advisable to use both, accelerometry and other clinical measures. According to the literature there is currently no accelerometer device most suitable to measure UL activity. High correlations indicate that multi-dimensional accelerometers should be preferred.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02743-w.

The effect of adding robot-assisted hand rehabilitation to conventional rehabilitation program following stroke: A randomized-controlled study

Objectives: This study aimed to investigate the effectiveness of adding robot-assisted hand therapy (HandTutor) to conventional rehabilitation program compared to a conventional rehabilitation program alone in stroke survivors.

Patients and methods: Between March 2012 and December 2012, a total of 33 stroke patients (21 males, 12 females; median age: 56 years; range, 38 to 73 years) were included in this prospective, randomized-controlled study. The patients were randomly divided into two groups as experimental (n=16) and control (n=17). Both groups received conventional rehabilitation for 3 h/day, for two days/week, totally for five weeks, while the experimental group received additional 1-hour robot-assisted hand therapy during each session. Outcome measures were the Fugl-Meyer Assessment, Box and Block Test, Nine-Hole Peg Test, Jebsen-Taylor Hand Function Test, grip strength, and pinch strength. All patients were assessed at baseline, at the end of the treatment, and three months after the treatment.

Results: Both groups showed statistically significant improvements in all the parameters (p<0.05). No significant differences were observed between the groups at any time points (p>0.05). The changes between baseline and three-month follow-up after the treatment revealed that adding robot-aided hand therapy led to greater changes in all the parameters related to functional activities and muscle strength, except for the Fugl-Meyer Assessment.

Conclusion: Adding robot-assisted therapy to conventional rehabilitation may provide greater changes in upper extremity rehabilitation of subacute stroke patients compared to conventional rehabilitation program alone.

Quality of mobility measures among individuals with acquired brain injury: an umbrella review

Background and objective

While several mobility measures exist, there is large variability across measures in how mobility is conceptualized, the source of information and the measurement properties making it challenging to select relevant mobility measures for individuals with acquired brain injury (ABI). Therefore, the objective was to conduct a comprehensive synthesis of existing evidence on the measurement properties, the interpretability and the feasibility of mobility measures from various sources of information (patients, clinicians, technology) using an umbrella review of published systematic reviews among individuals with ABI.

Methods

Ovid MEDLINE, CINHAL, Cochrane Library and EMBASE electronic databases were searched from 2000 to March 2020. Two independent reviewers appraised the methodological quality of the systematic reviews using the Joanna Briggs Institute critical appraisal checklist. Measurement properties and quality of evidence were applied according to COnsensus-based Standards for the Selection of Health Measurement Instrument (COSMIN) guidelines. Mobility measures were categorized using international standards with the international classification of functioning, disability and health (ICF).

Results

Thirty-five systematic reviews were included covering 147 mobility measures, of which 85% were mapped to the ICF Activity and Participation component. Results showed an acceptable overall "sufficient" rating for reliability, construct validity and responsiveness for 132 (90%), 127 (86%) and 76 (52%) of the measures, respectively; however, among these measures, ≤ 25% of the methods for evaluating these properties were rated as ‘high’ quality of evidence. Also, there was limited information that supports measure feasibility and scoring interpretability.

Conclusions

Future systematic reviews should report measures’ content validity to support the use of the measure in clinical care and research. More evaluations of the minimal important difference and floor and ceiling effects are needed to help guide clinical interpretation.

Registration information

International Prospective Register of Systematic Reviews (PROSPERO); ID: CRD42018100068.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03103-4.

Modified constraint-induced movement therapy during hospitalization in children with perinatal brachial plexus palsy: A randomized controlled trial

STUDY DESIGN

Prospective single-blind, randomized controlled study.

INTRODUCTION

Children with perinatal brachial plexus palsy (PBPP) have motion limitations in the affected upper extremity. Modified constraint-induced movement therapy (mCIMT) is one of the treatment options used for the improvement of the function of the affected limb.

PURPOSE OF THE STUDY

The purpose of this study was to compare the effect of mCIMT and conventional therapy in improving active range of motion (ROM) and functional use of the affected upper extremity in children with PBPP with injuries to upper and middle trunks in the hospital environment.

MATERIALS

26 patients received conventional rehabilitation program (control group) and 13 patients participated in a mCIMT program (study group). Children had a mean age 56.3 months (range 4-10 years). The mCIMT included 1 hour therapy sessions emphasizing the affected arm use for 14 consecutive days during hospitalization. Their normal arm was also constrained for 6 hour per day. All the patients were assessed at the baseline, one day, one month, and three months after completion of therapy using active ROM, active movement scale, hand dynamometer, box and blocks test.

RESULTS

The mCIMT group improved more than the control group in shoulder internal rotation, forearm supination, elbow flexion active ROMs, hand grip strength, and in upper extremity function.

CONCLUSION

mCIMT has a potential to promote functional gains for children with PBPP; this approach should be widely applied within routine clinical practice.

Cognitive Demands Influence Upper Extremity Motor Performance During Recovery From Acute Stroke

OBJECTIVE

To test the hypothesis that cognitive demands influence motor performance during recovery from acute stroke, we tested patients with acute stroke on 2 motor tasks with different cognitive demands and related task performance to cognitive impairment and neuroanatomic injury.

METHODS

We assessed the contralesional and ipsilesional upper extremities of a cohort of 50 patients with weakness after unilateral acute ischemic stroke at 3 time points with 2 tasks: the Box & Blocks Test, a task with greater cognitive demand, and Grip Strength, a simple and ballistic motor task. We compared performance on the 2 tasks, related motor performance to cognitive dysfunction, and used voxel-based lesion symptom mapping to determine neuroanatomic sites associated with motor performance.

RESULTS

Consistent across contralesional and ipsilesional upper extremities and most pronounced immediately after stroke, Box & Blocks scores were significantly more impaired than Grip Strength scores. The presence of cognitive dysfunction significantly explained up to 33% of variance in Box & Blocks performance but was not associated with Grip Strength performance. While Grip Strength performance was associated with injury largely restricted to sensorimotor regions, Box & Blocks performance was associated with broad injury outside sensorimotor structures, particularly the dorsal anterior insula, a region known to be important for complex cognitive function.

CONCLUSIONS

Together, these results suggest that cognitive demands influence upper extremity motor performance during recovery from acute stroke. Our findings emphasize the integrated nature of motor and cognitive systems and suggest that it is critical to consider cognitive demands during motor testing and neurorehabilitation after stroke.

Psychometric properties of the TEMPA for the assessment of arm motor activity capacity in hemiparetic Japanese patients after stroke

PURPOSE

To investigate the psychometric properties of the Test d'Evaluation des Membres Suprieurs de Personnes Agres (TEMPA) for the affected upper extremity in a population of Japanese patients with stroke.

MATERIALS AND METHODS

A prospective, cross-sectional, single-center study involving 30 patients with stroke was conducted. The inter-rater reliability, the validity, and the internal consistency were assessed. The Fugl-Meyer Assessment (FMA), the Action Research Arm Test (ARAT), the Motor Activity Log, and the Box-and-Block Test were employed for assessing the validity.

RESULTS

The English TEMPA instructions were successfully translated in accordance with the accepted principles of translation. The weighted Kappa coefficients for the functional rating scores were 0.87, 0.93, and 0.91 for combined total score, unilateral total score, and bilateral total scores. No statistically significant systematic disagreement was seen in the combined scores. The Spearman's rho values were higher than 0.70 regarding the gold standard tools (the FMA-UE motor domain and the ARAT). The Cronbach's alpha was 0.940 in the functional rating scale and 0.998 in the task analysis scale.

CONCLUSIONS

The most aspects of the Japanese TEMPA showed acceptable levels of inter-rater reliability and validity in patients with affected upper extremities after stroke.IMPLICATIONS FOR REHABILITATIONThe TEMPA is reliable and valid in measuring activity capacity of upper extremity in patients with stroke.The functional rating score of the TEMPA is recommended to assess activities related to daily living, especially when users need to focus on bimanual activities.The TEMPA may help guide intervention that improve bimanual activity as well as the affected arm activity.

Arm-Hand Boost Therapy During Inpatient Stroke Rehabilitation: A Pilot Randomized Controlled Trial

Objective: It was the aim to assess feasibility, safety, and potential efficacy of a new intensive, focused arm-hand BOOST program and to investigate whether there is a difference between early vs. late delivery of the program in the sub-acute phase post stroke. Methods: In this pilot RCT, patients with stroke were randomized to the immediate group (IG): 4 weeks (4 w) BOOST +4 w CONTROL or the delayed group (DG): 4 w CONTROL +4 w BOOST, on top of their usual inpatient care program. The focused arm-hand BOOST program (1 h/day, 5x/week, 4 weeks) consisted of group exercises with focus on scapula-setting, core-stability, manipulation and complex ADL tasks. Additionally, 1 h per week the Armeo®Power (Hocoma AG, Switzerland) was used. The CONTROL intervention comprised a dose-matched program (24 one-hour sessions in 4 w) of lower limb strengthening exercises and general reconditioning. At baseline, after 4 and 8 weeks of training, the Fugl-Meyer assessment upper extremity (FMA-UE), action research arm test (ARAT), and stroke upper limb capacity scale (SULCS) were administered. Results: Eighteen participants (IG: n = 10, DG: n = 8) were included, with a median (IQR) time post stroke of 8.6 weeks (5-12). No adverse events were experienced. After 4 weeks of training, significant between-group differences were found for FMA-UE (p = 0.003) and SULCS (p = 0.033) and a trend for ARAT (p = 0.075) with median (IQR) change scores for the IG of 9 (7-16), 2 (1-3), and 12.5 (1-18), respectively, and for the DG of 0.5 (-3 to 3), 1 (0-1), and 1.5 (-1 to 9), respectively. In the IG, 80% of patients improved beyond the minimal clinical important difference of FMA-UE after 4 weeks, compared to none of the DG patients. Between 4 and 8 weeks of training, patients in the DG tend to show larger improvements when compared to the IG, however, between-group comparisons did not reach significance. Conclusions: Results of this pilot RCT showed that an intensive, specific arm-hand BOOST program, on top of usual care, is feasible and safe in the sub-acute phase post stroke and suggests positive, clinical meaningful effects on upper limb function, especially when delivered in the early sub-acute phase post stroke. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT04584177.

Construct validity of the 9-Hole Peg Test and Purdue Pegboard Test in people with mild to moderately severe Parkinson's disease

OBJECTIVES

To evaluate the construct validity of two dexterity measures, the 9-Hole Peg Test (9HPT) and Purdue Pegboard Test (PPT) in people with Parkinson's disease (PD).

DESIGN

Cross-sectional observational study.

SETTING

Testing was conducted at the university or in participants' homes.

PARTICIPANTS

Thirty community dwelling people with mild to moderately severe PD and no major upper limb comorbidities or cognitive impairments.

INTERVENTIONS

Pegboard tests were administered in the 'on' and 'end-of-dose' phases of participants' PD medication cycles. Participants rated hand function with two self-report questionnaires - the Manual Ability Measure-36 (MAM-36) and a subset of upper limb items from the MDS-UPDRS. To explore construct validity, we compared 'on' phase pegboard scores with normative values for unimpaired men and women and investigated relationships between pegboard scores and hand function questionnaires.

RESULTS

In the 'on' phase, pegboard scores were poorer than normative values. Differences in individual subtest scores ranged between 10 and 41%. Correlations between self-reported hand function and pegboard scores were weak to moderately strong in the 'on' phase (r=0.21-0.51), and weak at 'end-of-dose' (r=0.13-0.22). Higher correlation coefficients were observed between hand function and PPT subtest scores than with hand function and 9HPT scores. Most participants reported difficulty with daily hand tasks.

CONCLUSIONS

We found evidence for construct validity supporting the use of the 9HPT and PPT to evaluate people with mild to moderately severe PD when 'on', but not at the 'end-of-dose'. Results also suggest that the PPT may be more sensitive to PD-related changes in dexterity than the 9HPT.

Effect of Additional Rehabilitation After Botulinum Toxin-A on Upper Limb Activity in Chronic Stroke: The InTENSE Trial

Supplemental Digital Content is available in the text.

The aim of this trial was to determine the effect of additional upper limb rehabilitation following botulinum toxin-A for upper limb activity in chronic stroke.

Measurement properties of self-report physical activity assessment tools for patients with stroke: a systematic review

BACKGROUND

Individuals with stroke demonstrate low levels of physical activity. Self-report measures of physical activity are frequently used and the choice of the best one to use for each purpose and context should take into account the measurement properties of these instruments.

OBJECTIVE

To summarize the measurement properties and clinical utility of self-report measures of physical activity of post-stroke subjects and to evaluate both the methodological quality of the studies and the quality of the measurement properties.

METHODS

Searches were made in MEDLINE, EMBASE, PEDro, LILACS, and SCIELO. Two reviewers independently screened studies that investigated measurement properties or clinical utility of self-report measures of physical activity in post-stroke subjects. The studies' methodological quality, quality of the measurement properties, and clinical utility were evaluated.

RESULTS

From the 11,826 identified studies, 19 were included. Six self-report tools were evaluated: The Activity card sort, Coded activity diary, Frenchay activities index (FAI), Human activity profile (HAP), Multimedia activity recall for children and adults, and the Nottingham leisure questionnaire. The methodological quality of the studies ranged from "poor" to "good". Most of the results regarding the quality of the measurement properties were doubtful. None of the self-report tools had their content validity investigated. The FAI and HAP showed the highest clinical utility scores.

CONCLUSIONS

Content validity needs to be better investigated to determine if the instruments actually measure the physical activity domain. Further studies with good methodological quality are required to assist clinicians and researchers in selecting the best instrument to measure physical activity levels.

Clinically Significant Gains in Skillful Grasp Coordination by an Individual With Tetraplegia Using an Implanted Brain-Computer Interface With Forearm Transcutaneous Muscle Stimulation

OBJECTIVE

To demonstrate naturalistic motor control speed, coordinated grasp, and carryover from trained to novel objects by an individual with tetraplegia using a brain-computer interface (BCI)-controlled neuroprosthetic.

DESIGN

Phase I trial for an intracortical BCI integrated with forearm functional electrical stimulation (FES). Data reported span postimplant days 137 to 1478.

SETTING

Tertiary care outpatient rehabilitation center.

PARTICIPANT

A 27-year-old man with C5 class A (on the American Spinal Injury Association Impairment Scale) traumatic spinal cord injury INTERVENTIONS: After array implantation in his left (dominant) motor cortex, the participant trained with BCI-FES to control dynamic, coordinated forearm, wrist, and hand movements.

MAIN OUTCOME MEASURES

Performance on standardized tests of arm motor ability (Graded Redefined Assessment of Strength, Sensibility, and Prehension [GRASSP], Action Research Arm Test [ARAT], Grasp and Release Test [GRT], Box and Block Test), grip myometry, and functional activity measures (Capabilities of Upper Extremity Test [CUE-T], Quadriplegia Index of Function-Short Form [QIF-SF], Spinal Cord Independence Measure-Self-Report [SCIM-SR]) with and without the BCI-FES.

RESULTS

With BCI-FES, scores improved from baseline on the following: Grip force (2.9 kg); ARAT cup, cylinders, ball, bar, and blocks; GRT can, fork, peg, weight, and tape; GRASSP strength and prehension (unscrewing lids, pouring from a bottle, transferring pegs); and CUE-T wrist and hand skills. QIF-SF and SCIM-SR eating, grooming, and toileting activities were expected to improve with home use of BCI-FES. Pincer grips and mobility were unaffected. BCI-FES grip skills enabled the participant to play an adapted "Battleship" game and manipulate household objects.

CONCLUSIONS

Using BCI-FES, the participant performed skillful and coordinated grasps and made clinically significant gains in tests of upper limb function. Practice generalized from training objects to household items and leisure activities. Motor ability improved for palmar, lateral, and tip-to-tip grips. The expects eventual home use to confer greater independence for activities of daily living, consistent with observed neurologic level gains from C5-6 to C7-T1. This marks a critical translational step toward clinical viability for BCI neuroprosthetics.

Using an interactive virtual environment to integrate a digital Action Research Arm Test, motor imagery and action observation to assess and improve upper limb motor function in patients with neuromuscular impairments: a usability and feasibility study protocol

INTRODUCTION

In the recent past, training systems using an interactive virtual environment have been introduced to neurorehabilitation. Such systems can be applied to encourage purposeful limb movements and will increasingly be used at home by the individual patient. Therefore, an integrated valid and reliable assessment tool on the basis of such a system to monitor the recovery process would be an essential asset.

OBJECTIVES

The aim of the study is to evaluate usability, feasibility and validity of the digital version of the Action Research Arm Test using the Bi-Manu-Trainer system as a platform. Additionally, the feasibility and usability of the implementation of action observation and motor imagery tasks into the Bi-Manu-Trainer software will be evaluated.

PATIENTS AND METHODS

This observational study is planned as a single-arm trial for testing the new assessment and the action observation and motor imagery training module. Therefore, 75 patients with Parkinson's disease, multiple sclerosis, stroke, traumatic brain injury or Guillain-Barré syndrome will be included. 30 out of the 75 patients will additionally take part in a 4-week training on the enhanced Bi-Manu-Trainer system. Primary outcomes will be the score on the System Usability Scale and the correlation between the conventional and digital Action Research Arm Test scores. Secondary outcomes will be hand dexterity, upper limb activities of daily living and quality of life.

HYPOTHESIS

We hypothesise that the digital Action Research Arm Test assessment is a valid and essential tool and that it is feasible to incorporate action observation and motor imagery into Bi-Manu-Trainer practice. The results are expected to give recommendations for necessary modifications and might also contribute knowledge concerning the application of action observation and motor imagery tasks using a training system such as the Bi-Manu-Trainer.

TRIAL REGISTRATION NUMBER

NCT03268304; Pre-results.

Function in unaffected arms of children with obstetric brachial plexus palsy

OBJECTIVE

The objective is to compare the fine and gross motor function of unaffected arms of children with obstetric brachial plexus palsy (OBBP) with typically developing children's dominant upper extremities.

METHODS

Fifty-three patients with OBBP and fifty-one typically developing children between the age of 4 and 13 were included in the study. For gross motor function evaluation in the upper extremity box-block test (BBT), for fine motor skill nine-hole peg (9HP) test was used. For grasp and pinch strength measurements, a Jamar dynamometer is used.

RESULTS

The patient group performed significantly worse in 9HP and BBT tests. When further divided into age groups, 4-8 age patient group performed significantly worse in 9HP and BBT tests, while there were no differences in children in the 9-13 age group.

CONCLUSIONS

The fine and gross motor functions of the unaffected arms of children with OBPP are significantly worse in children between the ages of four and eight but this deficit improves with age, and possibly with ongoing therapy.

The Adult Assisting Hand Assessment Stroke: Psychometric Properties of an Observation-Based Bimanual Upper Limb Performance Measurement

OBJECTIVE

To investigate interrater and intrarater reliability, measurement error, and convergent and discriminative validity of the Adult Assisting Hand Assessment Stroke (Ad-AHA Stroke).

DESIGN

Cross-sectional observational study.

SETTING

A total of 7 stroke rehabilitation centers.

PARTICIPANTS

Stroke survivors (reliability sample: n=30; validity sample: N=118) were included (median age 67y; interquartile range [IQR], 59-76); median time poststroke 81 days (IQR 57-117).

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURES

Ad-AHA Stroke, Action Research Arm Test (ARAT), upper extremity Fugl-Meyer Assessment (UE-FMA). The Ad-AHA Stroke is an observation-based instrument assessing the effectiveness of the spontaneous use of the affected hand when performing bimanual activities in adults poststroke. Reliability of Ad-AHA Stroke was examined using intraclass correlation coefficients (ICCs), Bland-Altman plots, and weighted kappa statistics for reliability on item level. SEM was calculated based on Ad-AHA units. Convergent validity was assessed by calculating Spearman rank correlation coefficients between Ad-AHA Stroke and ARA test and UE-FMA. Comparison of Ad-AHA Stroke scores between subgroups of patients according to hand dominance, neglect, and age evaluated discriminative validity.

RESULTS

Intrarater and interrater agreement showed an ICC of 0.99 (95% confidence interval, 0.99-0.99), an SEM of 2.15 and 1.64 out of 100, respectively, and weighted kappa for item scores were all above 0.79. The relation between Ad-AHA and other clinical assessments was strong (ρ=0.9). Patients with neglect had significantly lower Ad-AHA scores compared to patients without neglect (P=.004).

CONCLUSIONS

The Ad-AHA Stroke captures actual bimanual performance. Therefore, it provides an additional aspect of upper limb assessment with good to excellent reliability and low SEM for patients with subacute stroke. High convergent validity with the ARA test and UE-FMA and discriminative validity were supported.

Development of the assisting hand assessment for adults following stroke: a Rasch-built bimanual performance measure

AIMS

To describe the development of a new test of bimanual performance for adults following Stroke, the Adult-Assisting Hand Assessment Stroke, and to report the evidence of internal and external validity.

METHODS

Scale development included: (i) establishing the test situation; (ii) constructing test items; (iii) evaluating internal construct validity by use of Rasch measurement analysis on 144 assessments of adults with hemiparesis, mean age 53 years (SD11.45); and (iv) investigating external validity by correlation to the Jebsen and Taylor Test of Hand Function and the ABILHAND Stroke.

RESULTS

The Adult-Assisting Hand Assessment Stroke scale, scored on 19 items using a four-point rating scale, provided a valid measure of bimanual performance. The rating scale structure, goodness of fit, and principal component analysis demonstrated evidence of a unidimensional construct. The strong reliability and high person separation ratio indicated high probability for the scale to be responsive to change. Correlation to outcomes of the Jebsen and Taylor Test of Hand Function and the ABILHAND Stroke indicated strong external validity.

CONCLUSION

Using two hands together is a critical aspect for performance of most daily life tasks. However, assessments of hand function commonly focus on measuring aspects of unimanual function. The Adult-Assisting Hand Assessment Stroke has the potential to contribute new and clinically important knowledge to stroke rehabilitation by providing an observation-based valid functional measure of bimanual performance. Implications for rehabilitation Hand function assessments commonly focus on unimanual aspects, although the use of two hands together is critical to perform most daily life tasks. The Adult-Assisting Hand Assessment Stroke measures how effectively a patient with a hemiparesis uses his/her affected hand together with the unaffected hand to perform bimanual tasks. The Adult-Assisting Hand Assessment Stroke contributes a new and clinically important aspect to stroke rehabilitation by providing a valid bimanual observation-based measure to guide intervention and measure change over time.

Measures of upper limb function for people with neck pain. A systematic review of measurement and practical properties

There is a strong relationship between neck pain (NP) and upper limb disability (ULD). Optimal management of NP should incorporate upper limb rehabilitation and therefore include the use of an ULD measure in the assessment and management process. Clear guidance regarding the suitability of available measures does not exist. The aim of this study was to identify all available measures of ULD for populations with NP, critically evaluate their measurement properties and finally recommend a list of suitable measures. This two-phase systematic review is reported in accordance with the PRISMA statement. Phase one identified clearly reproducible measures of ULD for patients with NP. Phase two identified evidence of their measurement properties. In total, 11 papers evaluating the measurement properties of five instruments were included in this review. The instruments identified were the DASH questionnaire, the QuickDASH questionnaire, the NULI questionnaire, the SFA and the SAMP test. There was limited positive evidence of validity of the DASH, QuickDASH, NULI, SFA and SAMP. There was limited positive evidence of reliability of the NULI, SFA and SAMP. There was unknown evidence of responsiveness of the DASH and QuickDASH. Although all measures are supported by a limited amount of low quality evidence, the DASH, QuickDASH, NULI questionnaires, and the SAMP test are promising measures, but they require further robust evaluation.

Translation, cross-cultural adaptation and validation of the ABILHAND-Kids for the Brazilian Portuguese

ABSTRACT This study aimed to translate, to adapt cross-culturally and to validate the ABILHAND-Kids for the Brazilian Portuguese. ABILHAND-Kids was translated to Brazilian Portuguese and translated back by two certified translators in each phase. After the expert committee approval, the pre-test version was applied in 40 parents of children with cerebral palsy in order to verify item comprehension. Twenty-one volunteers were enrolled in the psychometric properties analysis. Reproducibility was verified by interrater and intrarater reliability and the validity was tested by investigating Box and Block Test, Purdue Pegboard Test and grip strength correlations. ABILHAND-Kids showed strong intrarater (ICC=0.91) and interrater (ICC=0.97) reliability and high internal consistency (Cronbach’s alfa: 0.99). ABILHAND-Kids showed significant correlations with Box and Block Test (performed by dominant upper extremity), Purdue Pegboard Test and grip strength. The Brazilian Portuguese version of ABILHAND-Kids is a reliable tool to measure upper extremities function of children with cerebral palsy, based on the perception of their parents.

Quantification of task-dependent cortical activation evoked by robotic continuous wrist joint manipulation in chronic hemiparetic stroke

Background

Cortical damage after stroke can drastically impair sensory and motor function of the upper limb, affecting the execution of activities of daily living and quality of life. Motor impairment after stroke has been thoroughly studied, however sensory impairment and its relation to movement control has received less attention. Integrity of the somatosensory system is essential for feedback control of human movement, and compromised integrity due to stroke has been linked to sensory impairment.

Methods

The goal of this study is to assess the integrity of the somatosensory system in individuals with chronic hemiparetic stroke with different levels of sensory impairment, through a combination of robotic joint manipulation and high-density electroencephalogram (EEG). A robotic wrist manipulator applied continuous periodic disturbances to the affected limb, providing somatosensory (proprioceptive and tactile) stimulation while challenging task execution. The integrity of the somatosensory system was evaluated during passive and active tasks, defined as ‘relaxed wrist’ and ‘maintaining 20% maximum wrist flexion’, respectively. The evoked cortical responses in the EEG were quantified using the power in the averaged responses and their signal-to-noise ratio.

Results

Thirty individuals with chronic hemiparetic stroke and ten unimpaired individuals without stroke participated in this study. Participants with stroke were classified as having severe, mild, or no sensory impairment, based on the Erasmus modification of the Nottingham Sensory Assessment. Under passive conditions, wrist manipulation resulted in contralateral cortical responses in unimpaired and chronic stroke participants with mild and no sensory impairment. In participants with severe sensory impairment the cortical responses were strongly reduced in amplitude, which related to anatomical damage. Under active conditions, participants with mild sensory impairment showed reduced responses compared to the passive condition, whereas unimpaired and chronic stroke participants without sensory impairment did not show this reduction.

Conclusions

Robotic continuous joint manipulation allows studying somatosensory cortical evoked responses during the execution of meaningful upper limb control tasks. Using such an approach it is possible to quantitatively assess the integrity of sensory pathways; in the context of movement control this provides additional information required to develop more effective neurorehabilitation therapies.

Effect of Virtual Reality-based Bilateral Upper Extremity Training on Upper Extremity Function after Stroke: A Randomized Controlled Clinical Trial

In the present study, we aimed to investigate the effect of virtual reality-based bilateral upper extremity training (VRBT) on paretic upper limb function and muscle strength in patients with stroke. Eighteen stroke survivors were assigned to either the VRBT group (n = 10) or the bilateral upper limb training group (BT, n = 8). Patients in the VRBT group performed bilateral upper extremity exercises in a virtual reality environment, whereas those in the BT group performed conventional bilateral upper extremity exercises. All training was conducted for 30 minutes day^-1 , 3 days a week, for a period of 6 weeks. Patients were assessed for upper extremity function and hand strength. Compared with the BT group, the VRBT group exhibited significant improvements in upper extremity function and muscle strength (p < 0.05) after the 6-week training programme. The Box and Block test results revealed that upper extremity function and elbow flexion in hand strength were significantly improved in terms of group, time and interaction effect of group by time. Furthermore, the VRBT group demonstrated significant improvements in upper extremity function, as measured by the Jebsen Hand Function Test and Grooved Pegboard test, and in the hand strength test, as measured by elbow extension, grip, palmar pinch, lateral pinch and tip pinch, in both time and the interaction effect of group by time. These results suggest that VRBT is a feasible and beneficial means of improving upper extremity function and muscle strength in individuals following stroke. Copyright © 2016 John Wiley & Sons, Ltd.

Cognitive and Neurophysiological Effects of Non-invasive Brain Stimulation in Stroke Patients after Motor Rehabilitation

The primary aim of this study was to evaluate and compare the effectiveness of two specific Non-Invasive Brain Stimulation (NIBS) paradigms, the repetitive Transcranial Magnetic Stimulation (rTMS), and transcranial Direct Current Stimulation (tDCS), in the upper limb rehabilitation of patients with stroke. Short and long term outcomes (after 3 and 6 months, respectively) were evaluated. We measured, at multiple time points, the manual dexterity using a validated clinical scale (ARAT), electroencephalography auditory event related potentials, and neuropsychological performances in patients with chronic stroke of middle severity. Thirty four patients were enrolled and randomized. The intervention group was treated with a NIBS protocol longer than usual, applying a second cycle of stimulation, after a washout period, using different techniques in the two cycles (rTMS/tDCS). We compared the results with a control group treated with sham stimulation. We split the data analysis into three studies. In this first study we examined if a cumulative effect was clinically visible. In the second study we compared the effects of the two techniques. In the third study we explored if patients with minor cognitive impairment have most benefit from the treatment and if cognitive and motor outcomes were correlated. We found that the impairment in some cognitive domains cannot be considered an exclusion criterion for rehabilitation with NIBS. ERP improved, related to cognitive and attentional processes after stimulation on the motor cortex, but transitorily. This effect could be linked to the restoration of hemispheric balance or by the effects of distant connections. In our study the effects of the two NIBS were comparable, with some advantages using tDCS vs. rTMS in stroke rehabilitation. Finally we found that more than one cycle (2-4 weeks), spaced out by washout periods, should be used, only in responder patients, to obtain clinical relevant results.

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

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

Measuring arm function early after stroke: is the DASH good enough?

OBJECTIVE

Despite a growing call to use patient-reported outcomes in clinical research, few are available for measuring upper limb function post-stroke. We examined the Disabilities of the Arm, Shoulder and Hand (DASH) to evaluate its measurement performance in acute stroke. In doing so, we compared results from traditional and modern psychometric methods.

METHODS

172 people with acute stroke completed the DASH. Those with upper limb impairments completed the DASH again at 6 weeks (n=99). Data (n=271) were analysed using two psychometric paradigms: traditional psychometric (Classical Test Theory, CTT) analyses examined data completeness, scaling assumptions, targeting, reliability and responsiveness; Rasch Measurement Theory (RMT) analyses examined scale-to-sample targeting, scale performance and person measurement.

RESULTS

CTT analyses implied the DASH was psychometrically robust in this sample. Data completeness was high, criteria for scaling assumptions were satisfied (item-total correlations 0.55-0.95), targeting was good, internal consistency reliability was high (Cronbach's α=0.99) and responsiveness was clinically moderate (effect size=0.51). However, RMT analyses identified important limitations: scale-to-sample targeting was suboptimal, 4 items had disordered response category thresholds, 16 items exhibited misfit, 3 pairs of items had high residual correlations (>0.60) and 84 person fit residuals exceeded the recommended range.

CONCLUSIONS

RMT methods identified limitations missed by CTT and indicate areas for improvement of the DASH as an upper limb measure for acute stroke. Findings, similar to those identified in multiple sclerosis, highlight the need for scales to have strong conceptual underpinnings, with their development and modification guided by sophisticated psychometric methods.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Validity of body-worn sensor acceleration metrics to index upper extremity function in hemiparetic stroke

BACKGROUND AND PURPOSE

Accelerometers have been used to capture real-world use of the paretic upper extremity in people with stroke. It may be possible to characterize different aspects of the recorded acceleration to gain insight about movement capabilities during task-specific behavior. These measures may be of value for guiding rehabilitation. We undertook a study to identify the acceleration characteristics that have a stable association with upper extremity function and sensitivity to within-participant fluctuations in function over multiple sessions of task-specific training.

METHODS

Twenty-seven adults 6 months or more poststroke with upper extremity paresis participated. Signals from wrist-worn accelerometers were sampled at 30 Hz during 7 sessions of task-specific training. Paretic upper extremity function was evaluated with the Action Research Arm Test. We used Spearman correlations to examine within-session associations between acceleration metrics and Action Research Arm Test performance. A mixed model was used to determine which metrics were sensitive to within-participant fluctuations in upper extremity function across the 7 training sessions.

RESULTS

Upper extremity function correlated with bilateral acceleration variability and use ratio during 5 and 6 sessions, respectively. Time accelerating between 76% and 100% of peak acceleration correlated with function in 6 sessions. Variability of the paretic upper extremity acceleration and the ratio of acceleration variability between upper extremities were associated with function during all 7 sessions. Variability in both the acceleration of the paretic upper extremity, and acceleration of the paretic and nonparetic extremities combined were sensitive to within-participant fluctuations in function across training sessions.

DISCUSSION AND CONCLUSIONS

Multiple features of the acceleration profile track with upper extremity function within and across sessions of task-specific training. It may be possible to monitor these features with accelerometers to index upper extremity function outside of clinical settings.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A91).

Measuring task performance after acquired brain injury: Construct and concurrent validity of 'Upper Limb Performance Analysis'

OBJECTIVE

This preliminary investigation studies selected aspects of validity of the Upper Limb Performance Analysis (ULPA), an occupation-based functional upper limb (UL) measure.

METHODS

The study investigated the ULPA-Task Performance Mastery (ULPA-TPM) in 35 community dwelling adults with upper motor neuron syndrome following acquired brain injury and 26 healthy controls. Construct and concurrent validity of the ULPA were determined via group discrimination between adults with and without ABI; and ABI participants who were and were not referred for UL spasticity management with botulinum toxin-A injections (injected and non-injected group). Concurrent validity was examined by investigating the relationships between the ULPA and an existing functional UL measure, the Action Research Arm Test, using Spearman's rank-order correlation.

RESULTS

Significant differences in UL performance were demonstrated between the ABI and the Control group on all ULPA sub-scales (including: Omission (z = -2.6 to -3.6, r_spb = 0.37-0.48), Accuracy (z = -5.8 to -6.0, r_spb = 0.78-0.82), Repetition (z = -5.1 to -5.4, r_spb = 0.63-0.73) and Timing errors (z = -5.9 to -6.2, r_spb = 0.77-0.88). Those in the Injected group demonstrated more task performance errors than the Non-injected group, with significant differences in Accuracy (z = -2.1 to -2.4, r_spb = 0.37-0.45), Repetition (z = -2.5 to -2.1, r_spb = 0.43) and Timing (z = -2.0, r_spb = 0.37).

CONCLUSIONS

This study demonstrated good construct and concurrent validity of the ULPA-TPM.

Acceleration metrics are responsive to change in upper extremity function of stroke survivors

OBJECTIVES

To (1) determine whether acceleration metrics derived from monitoring outside of treatment are responsive to change in upper extremity (UE) function; and secondarily to (2) compare metric values during task-specific training and while in the free-living environment, and (3) establish metric associations with an in-clinic measure of movement capabilities.

DESIGN

Before-after observational study.

SETTING

Inpatient hospital (primary purpose); outpatient hospital (secondary purpose).

PARTICIPANTS

Individuals (n=8) with UE hemiparesis <30 days poststroke (primary purpose); individuals (n=27) with UE hemiparesis ≥6 months poststroke (secondary purpose).

INTERVENTION

The inpatient sample was evaluated for UE movement capabilities and monitored with wrist-worn accelerometers for 22 hours outside of treatment before and after multiple sessions of task-specific training. The outpatient sample was evaluated for UE movement capabilities and monitored during a single session of task-specific training and the subsequent 22 hours outside clinical settings.

MAIN OUTCOME MEASURES

Action Research Arm Test (ARAT) and acceleration metrics quantified from accelerometer recordings.

RESULTS

Five metrics improved in the inpatient sample, along with UE function as measured on the ARAT: use ratio, magnitude ratio, variation ratio, median paretic UE acceleration magnitude, and paretic UE acceleration variability. Metric values were greater during task-specific training than in the free-living environment, and each metric was strongly associated with ARAT score.

CONCLUSIONS

Multiple metrics that characterize different aspects of UE movement are responsive to change in function. Metric values are different during training than in the free-living environment, providing further evidence that what the paretic UE does in the clinic may not generalize to what it does in everyday life.

Measures of upper limb function for people with neck pain: a systematic review of measurement and practical properties (protocol)

BACKGROUND

Upper limb disability is a common musculoskeletal condition frequently associated with neck pain. Recent literature has reported the need to utilise validated upper limb outcome measures in the assessment and management of patients with neck pain. However, there is a lack of clear guidance about the suitability of available measures, which may impede utilisation. This review will identify all available measures of upper limb function developed for use in neck pain patients and evaluate their measurement and practical properties in order to identify those measures that are most appropriate for use in clinical practice and research.

METHODS/DESIGN

This review will be performed in two phases. Phase one will identify all measures used to assess upper limb function for patients with neck pain. Phase two will identify all available studies of the measurement and practical properties of identified instrument. The COnsensus-based Standards for selection of health Measurement INstrument (COSMIN) will be used to evaluate the methodological quality of the included studies. To ensure methodological rigour, the findings of this review will be reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline.

DISCUSSION

Optimal management of patients with neck pain should incorporate upper limb rehabilitation. The findings of this study will assist clinicians who seek to utilise suitable and accurate measures to assess upper limb function for a patient with neck pain. In addition, the findings of this study may suggest new research directions to support the development of upper limb outcome measures for patients with neck pain.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015016624.

An overview of systematic reviews on upper extremity outcome measures after stroke

BACKGROUND

Although use of standardized and scientifically sound outcome measures is highly encouraged in clinical practice and research, there is still no clear recommendation on which tools should be preferred for upper extremity assessment after stroke. As the aims, objectives and methodology of the existing reviews of the upper extremity outcome measures can vary, there is a need to bring together the evidence from existing multiple reviews. The purpose of this review was to provide an overview of evidence of the psychometric properties and clinical utility of upper extremity outcome measures for use in stroke, by systematically evaluating and summarizing findings from systematic reviews.

METHODS

A comprehensive systematic search was performed including systematic reviews from 2004 to February 2014. A methodological quality appraisal of the reviews was performed using the AMSTAR-tool.

RESULTS

From 13 included systematic reviews, 53 measures were identified of which 13 met the standardized criteria set for the psychometric properties. The strongest level of measurement quality and clinical utility was demonstrated for Fugl-Meyer Assessment, Action Research Arm Test, Box and Block Test, Chedoke Arm and Hand Activity Inventory, Wolf Motor Function Test and ABILHAND.

CONCLUSIONS

This overview of systematic reviews provides a comprehensive systematic synthesis of evidence on which outcome measures demonstrate a high level of measurement quality and clinical utility and which can be considered as most suitable for upper extremity assessment after stroke. This overview can provide a valuable resource to assist clinicians, researchers and policy makers in selection of appropriate outcome measures.

Screening for mood disorders after stroke: a systematic review of psychometric properties and clinical utility

BACKGROUND

Routine mood screening is recommended after stroke. However, clinicians report difficulty selecting appropriate tools from the wide range available. We aimed to systematically review the psychometric properties and clinical utility of mood screening tools for stroke survivors.

METHOD

Electronic databases (AMED, EMBASE, CINAHL, Medline and PsycINFO) were searched to identify studies assessing the sensitivity and specificity of mood screening tools. Tools that demonstrated at least 80% sensitivity and 60% specificity with stroke survivors with identifiable cut-off scores indicating major and/or any mood disorder in at least one study were selected and clinical utility was assessed. Those with high clinical utility (against predefined criteria) were selected for recommendation.

RESULTS

Thirty papers examining 27 screening tools were identified and 16 tools met the psychometric and clinical utility criteria: 10 were verbal self-report tools, four were observational and two incorporated visual prompts for those with communication problems. Only the Stroke Aphasic Depression Questionnaire -Hospital version (SADQ-H) met all the psychometric and utility criteria. The nine-item Patient Health Questionnaire (PHQ-9) can detect major depression and the 15-item Geriatric Depression Scale (GDS-15) can identify milder symptoms; both are feasible to use in clinical practice. The Hospital Anxiety and Depression Scale (HADS) was the only tool able to identify anxiety accurately, but clinical utility was mixed.

CONCLUSIONS

Valid and clinically feasible mood screening tools for stroke have been identified but methodological inconsistency prevented recommendations about the optimal cut-off scores.

Assessment of movement quality in robot- assisted upper limb rehabilitation after stroke: a review

Studies of stroke patients undergoing robot-assisted rehabilitation have revealed various kinematic parameters describing movement quality of the upper limb. However, due to the different level of stroke impairment and different assessment criteria and interventions, the evaluation of the effectiveness of rehabilitation program is undermined. This paper presents a systematic review of kinematic assessments of movement quality of the upper limb and identifies the suitable parameters describing impairments in stroke patients. A total of 41 different clinical and pilot studies on different phases of stroke recovery utilizing kinematic parameters are evaluated. Kinematic parameters describing movement accuracy are mostly reported for chronic patients with statistically significant outcomes and correlate strongly with clinical assessments. Meanwhile, parameters describing feed-forward sensorimotor control are the most frequently reported in studies on sub-acute patients with significant outcomes albeit without correlation to any clinical assessments. However, lack of measures in coordinated movement and proximal component of upper limb enunciate the difficulties to distinguish the exploitation of joint redundancies exhibited by stroke patients in completing the movement. A further study on overall measures of coordinated movement is recommended.

Using mixed methods to evaluate efficacy and user expectations of a virtual reality-based training system for upper-limb recovery in patients after stroke: a study protocol for a randomised controlled trial

Background

In recent years, virtual reality has been introduced to neurorehabilitation, in particular with the intention of improving upper-limb training options and facilitating motor function recovery.

Methods/Design

The proposed study incorporates a quantitative part and a qualitative part, termed a mixed-methods approach: (1) a quantitative investigation of the efficacy of virtual reality training compared to conventional therapy in upper-limb motor function are investigated, (2a) a qualitative investigation of patients’ experiences and expectations of virtual reality training and (2b) a qualitative investigation of therapists’ experiences using the virtual reality training system in the therapy setting. At three participating clinics, 60 patients at least 6 months after stroke onset will be randomly allocated to an experimental virtual reality group (EG) or to a control group that will receive conventional physiotherapy or occupational therapy (16 sessions, 45 minutes each, over the course of 4 weeks). Using custom data gloves, patients’ finger and arm movements will be displayed in real time on a monitor, and they will move and manipulate objects in various virtual environments. A blinded assessor will test patients’ motor and cognitive performance twice before, once during, and twice after the 4-week intervention. The primary outcome measure is the Box and Block Test. Secondary outcome measures are the Chedoke-McMaster Stroke Assessments (hand, arm and shoulder pain subscales), the Chedoke-McMaster Arm and Hand Activity Inventory, the Line Bisection Test, the Stroke Impact Scale, the MiniMentalState Examination and the Extended Barthel Index. Semistructured face-to-face interviews will be conducted with patients in the EG after intervention finalization with a focus on the patients’ expectations and experiences regarding the virtual reality training. Therapists’ perspectives on virtual reality training will be reviewed in three focus groups comprising four to six occupational therapists and physiotherapists.

Discussion

The interviews will help to gain a deeper understanding of the phenomena under investigation to provide sound recommendations for the implementation of the virtual reality training system for routine use in neurorehabilitation complementing the quantitative clinical assessments.

Trial registration

Cliniclatrials.gov Identifier: NCT01774669 (15 January 2013)

Electronic supplementary material

The online version of this article (doi:10.1186/1745-6215-15-350) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

PURPOSE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

LIMITATIONS

Heterogeneity of the included studies warrants caution when interpreting results.

CONCLUSIONS

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

Investigating measures of intensity during a structured upper limb exercise program in stroke rehabilitation: an exploratory study

OBJECTIVES

To use 3 measures of intensity—time, observed repetitions, and wrist accelerometer activity counts—to describe the intensity of exercise carried out when completing a structured upper limb exercise program, and to explore whether a relationship exists between wrist accelerometer activity counts and observed repetitions.

DESIGN

Observational study design.

SETTING

Rehabilitation center research laboratory.

PARTICIPANTS

Community-dwelling stroke survivors (N=13) with upper limb hemiparesis.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Time engaged in exercise, total repetitions, and accelerometer activity counts for the affected upper limb.

RESULTS

Mean session time ± SD was 48.5±7.8 minutes. Participants were observed to be engaged in exercises for 63.8%±7.5% of the total session time. The median number of observed repetitions per session was 340 (interquartile range [IQR], 199-407), of which 251 (IQR, 80-309) were purposeful repetitions. Wrist accelerometers showed the stroke survivors' upper limbs to be moving for 75.7%±15.9% of the total session time. Purposeful repetitions and activity counts were found to be significantly correlated (ρ=.627, P<.05).

CONCLUSIONS

Stroke survivors were not actively engaged in exercises for approximately one third of each exercise session. Overall session time may not be the most accurate measure of intensity. Counting repetitions was feasible when using a structured exercise program and provides a clinically meaningful way of monitoring intensity and progression. Wrist accelerometers provided an objective measure for how much the arm moves, which correlated with purposeful repetitions. Further research using repetitions and accelerometers as measures of intensity is warranted.

Assessing upper limb function in multiple sclerosis

The need to fully assess upper limb function in multiple sclerosis (MS) has become increasingly clear with recent studies revealing a high prevalence of upper limb dysfunction in persons with MS leading to increased dependency and reduced quality of life. It is important that clinicians and researchers use tailored outcome measures to systematically describe upper limb (dys)function and evaluate potential deterioration or improvement on treatment. This topical review provides a comprehensive summary of currently used upper limb outcome measures in MS, classified according to the levels of the International Classification of Functioning (ICF). The clinical utility, strengths, weaknesses and psychometric properties of common upper limb outcome measures are discussed. Based on this information, recommendations for selecting appropriate upper limb outcome measures are given. The current shortcomings in assessment which need to be addressed are identified.

Upper limb assessment in multiple sclerosis: a systematic review of outcome measures and their psychometric properties

OBJECTIVE

To provide an overview of applied upper limb outcome measures in multiple sclerosis (MS) according to the International Classification of Functioning, Disability and Health (ICF) levels and to review their psychometric properties in MS.

DATA SOURCES

PubMed and Web of Knowledge.

STUDY SELECTION

Articles published until June 2013 were selected when written in English, published in the last 25 years, peer reviewed, including >5 persons with MS, and including standardized clinical upper limb outcome measures. Included articles were screened based on title/abstract and full text by 2 independent reviewers. In case of doubt, feedback from a third independent reviewer was obtained. Additionally, references lists were checked for relevant articles. Of the articles, 109 met the selection criteria and were included for data extraction.

DATA EXTRACTION

All reported clinical upper limb outcome measures were extracted from the included studies and classified according to the ICF levels by 2 independent reviewers. In addition, available psychometric properties (reliability, validity, responsiveness) in MS were summarized and discussed.

DATA SYNTHESIS

A diversity of outcome measures assessing impairments on the body functions and structures level (n=33), upper limb capacity (n=11), and performance (n=8) on the activity level were extracted from 109 articles. Hand grip strength and the nine-hole peg test (NHPT) were the most frequently used outcome measures. However, multiple outcome measures are necessary to encapsulate the multidimensional character of the upper limb function. The psychometric properties were insufficiently documented for most of the outcome measures, except for the NHPT.

CONCLUSIONS

The results of this review may help with the selection of appropriate outcome measures and may guide future research regarding the psychometric properties in MS.