Carryover effects of cyclical stretching of the digits on hand function in stroke survivors

Combining Cyproheptadine Hydrochloride With Targeted Muscle Activation Training to Treat Upper Extremity Stroke: A Randomized, Placebo-Controlled Trial

OBJECTIVE

To examine a treatment for upper extremity impairment in stroke survivors that combines administration of cyproheptadine hydrochloride with repetitive practice focused on control of muscle activation patterns.

DESIGN

Double-blind, randomized controlled trial.

SETTINGS

Laboratory within a free-standing rehabilitation hospital.

PARTICIPANTS

A total of 94 stroke survivors with severe, chronic hand impairment were randomly assigned to 1 of 4 treatment groups.

INTERVENTIONS

Participants received either a placebo or cyproheptadine hydrochloride in identical pill form. The daily dosage of cyproheptadine/placebo was gradually increased from 8 to 24 mg/d over 3 weeks and then maintained over the next 6 weeks while participants completed 18 therapy sessions. Therapy consisted of either (1) active practice of muscle activation patterns to play "serious" computer games or control a custom hand exoskeleton or (2) passive, cyclical finger stretching imposed by the exoskeleton.

MAIN OUTCOME MEASURES

Hand control was evaluated with the primary outcome measure of time to complete the Graded Wolf Motor Function Test (GWMFT) and secondary outcome measures including finger strength and spasticity.

RESULTS

Across the 88 participants who completed the study, a repeated-measures analysis of variance revealed a significant effect of GroupxEvaluation interaction on GWMFT (F=1.996, P=.026). The 3 groups receiving cyproheptadine and/or actively practicing muscle activation pattern control exhibited significant reduction in mean time to complete the GWMFT tasks; roughly one-third of these participants experienced at least a 10% reduction in completion time. Gains were maintained at the 1-month follow-up evaluation. The group receiving placebo and passive stretching did not show improvement. No significant differences among groups were observed in terms of changes in strength or spasticity.

CONCLUSIONS

Despite chronic, severe impairment, stroke survivors were able to complete the therapy focused on muscle activations and achieved statistically significant improvement in hand motor control. Cyproheptadine hydrochloride is a potential complementary treatment modality for stroke survivors with hand impairment.

A Hand Exoskeleton for Stroke Survivors' Activities of Daily Life. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021;2021:6734-6737. [PMID: 34892653 DOI: 10.1109/embc46164.2021.9629805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Stroke is a leading cause of disability in the U.S. Hand impairment is a common consequence of stroke, potentially impacting all facets of life as the hands are the primary means of interacting with the world. Typically, therapy is the prescribed treatment after stroke. However, a majority of stroke survivors have limited recovery and thus chronic impairment. Assistive, rather than therapeutic, devices may help these individuals restore lost function and improve independence and engagement in society. Current assistive devices, however, typically fail to address the greatest barriers to successful use with stroke survivors. In the hand, weakness and incoordination arise from a seemingly paradoxical combination of limited voluntary activation of muscles and involuntary neuromuscular hyperexcitability. Thus, profound strength deficits can be accompanied by substantial forces opposing the intended movement. The assistive device presented in this paper can provide both sufficient flexion and extension assistance to overcome these barriers. A single actuator for each digit provides flexion or extension assistance through push-pull cables guided along the dorsal side of the hand. User intent can be decoded from Electromyographic (EMG) signals to drive the device throughout the movement. EMG control is customized to the capabilities of each user by examining the voluntary EMG workspace.

Pilot Test of Dosage Effects in HEXORR II for Robotic Hand Movement Therapy in Individuals With Chronic Stroke

Impaired use of the hand in functional tasks remains difficult to overcome in many individuals after a stroke. This often leads to compensation strategies using the less-affected limb, which allows for independence in some aspects of daily activities. However, recovery of hand function remains an important therapeutic goal of many individuals, and is often resistant to conventional therapies. In prior work, we developed HEXORR I, a robotic device that allows practice of finger and thumb movements with robotic assistance. In this study, we describe modifications to the device, now called HEXORR II, and a clinical trial in individuals with chronic stroke. Fifteen individuals with a diagnosis of chronic stroke were randomized to 12 or 24 sessions of robotic therapy. The sessions involved playing several video games using thumb and finger movement. The robot applied assistance to extension movement that was adapted based on task performance. Clinical and motion capture evaluations were performed before and after training and again at a 6-month followup. Fourteen individuals completed the protocol. Fugl-Meyer scores improved significantly at the 6 month time point compared to baseline, indicating reductions in upper extremity impairment. Flexor hypertonia (Modified Ashworth Scale) also decreased significantly due to the intervention. Motion capture found increased finger range of motion and extension ability after the intervention that continued to improve during the followup period. However, there was no change in a functional measure (Action Research Arm Test). At the followup, the high dose group had significant gains in hand displacement during a forward reach task. There were no other significant differences between groups. Future work with HEXORR II should focus on integrating it with functional task practice and incorporating grip and squeezing tasks.

Trial Registration:ClinicalTrials.gov, NCT04536987. Registered 3 September 2020 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/record/NCT04536987.

HandMATE: Wearable Robotic Hand Exoskeleton and Integrated Android App for At Home Stroke Rehabilitation

We have developed HandMATE (Hand Movement Assisting Therapy Exoskeleton); a wearable motorized hand exoskeleton for home-based movement therapy following stroke. Each finger and the thumb is powered by a linear actuator which provides flexion and extension assistance. Force sensitive resistors integrated into the design measure grasp and extension initiation force. An assistive therapy mode is based on an admittance control strategy. We evaluated our control system via subject and bench testing. Errors during a grip force tracking task while using the HandMATE were minimal (<1%) and comparable to unassisted healthy hand performance. We also outline a dedicated app we have developed for optimal use of HandMATE at home. The exoskeleton communicates wirelessly with an Android tablet which features guided exercises, therapeutic games and performance feedback. We surveyed 5 chronic stroke patients who used the HandMATE device to further evaluate our system, receiving positive feedback on the exoskeleton and integrated app.

The reliability of the graded Wolf Motor Function Test for stroke

Introduction

The graded Wolf Motor Function Test assesses upper limb function following stroke. Clinical utility is limited by the requirement to video record for scoring purposes. This study aimed to (a) assess whether video recording is required through examination of inter-rater reliability and agreement; and (b) assess intra-rater reliability and agreement.

Method

A convenience sample of 30 individuals were recruited following stroke. The graded Wolf Motor Function Test was administered within 2 weeks of rehabilitation commencement and at 3 months. Two occupational therapists scored participants through either direct observation or video. Inter- and intra-rater reliability and agreement were examined for item-level and summary scores.

Results

Excellent inter-rater reliability ( n = 28) was found between scoring through direct observation and by video (intraclass correlation coefficients >0.9), and excellent intra-rater reliability ( n = 21) was found (intraclass correlation coefficients >0.9) for item-level and summary scores. Low agreement was found between raters at the item level. Adequate agreement was found for total functional ability, with increased measurement error found for total performance time.

Conclusion

The graded Wolf Motor Function Test is a reliable measure of upper limb function. Video recording may not be required by therapists. In view of low agreement, future studies should assess the impact of standardised training.

Development of an Integrated Actuated Hand Orthosis and Virtual Reality System for Home-Based Rehabilitation

Stroke survivors often require a lengthy and costly rehabilitation regimen to regain some of the hand function lost due to stroke. Financial, travel, and scheduling issues can limit access to clinical therapy, thereby depriving individuals of care. Interventions are needed which can extend from the clinic into the home. Home-based rehabilitation strategies, however, must promote sensorimotor learning while maintaining user engagement. Virtual reality, in combination with actuated orthoses, has the potential to provide solutions to these issues. The orthosis can facilitate appropriate therapy while the virtual reality can provide a conduit for maintaining human interaction and engagement in the home environment. In this paper, we describe the development of such an integrated system for hand and upper extremity rehabilitation.

A systematic review of the application and psychometric properties of the graded Wolf Motor Function Test

Introduction

Adapted from the Wolf Motor Function Test, the graded Wolf Motor Function Test is an upper limb activity assessment for use following stroke and brain injury. The aim of this systematic review was to identify and appraise evidence where the test has been used or has undergone psychometric evaluation.

Method

A systematic review of five databases was conducted to identify studies reporting the graded Wolf Motor Function Test using a keyword search. Intervention and clinical measurement studies were eligible for inclusion. Data quality was assessed using the adapted Critical Appraisal Skills Programme questions and the Consensus-based Standards for the Selection of Health Measurement Instruments Risk of Bias checklist.

Results

Twelve studies, of mostly low quality, were included. Studies included one randomised controlled trial, 10 pre- and post-studies and one clinical measurement study. All studies involved participants following stroke. Reliability was the only measurement property assessed in two studies, which were of a ‘doubtful’ and ‘poor’ quality.

Conclusion

Low quality studies impede the ability of clinicians and researchers to best determine the applicability of the graded Wolf Motor Function Test to patient groups and research contexts. Further exploration of the psychometric properties of the graded Wolf Motor Function Test is recommended across stroke populations using rigorous design methods.