A controlled trial of the retraining of the sensory function of the hand in stroke patients

Efficacy of Multimodal Sensory Therapy in Adult Acquired Brain Injury: A Systematic Review

Adults who experience an acquired brain injury often experience disorders of consciousness, physical difficulties, and maladaptive behaviours. Multimodal sensory therapy may benefit brain injured patients, however the extent this therapy can facilitate rehabilitation is not well understood. This systematic review aimed to synthesize multimodal sensory therapy research for adults affected by acquired brain injury. PRISMA guidelines were followed and searches for work published up until July 2021 were undertaken in 5 databases, finding 1054 articles. 43 articles were included in the study. Results describe 29 studies related to coma following an acquired brain injury and 14 to no coma studies (mostly stroke). Multimodal sensory therapy was mostly used as a coma arousal technique following traumatic brain injury, finding positive effects. Multimodal sensory therapy was less applied in stroke, no coma rehabilitation, where most studies found improvement in somatosensory sensation and motor control in an affected limb. In several no coma studies, effects were maintained after several months. The most common senses stimulated in coma studies were audio (N = 30), tactile (N = 28), visual (N = 26), olfactory (N = 22), and gustatory (N = 17), while the most common senses stimulated in stroke, no coma studies were proprioception (N = 7), tactile (N = 8), and stereognosis (N = 4). Multimodal sensory therapy can be beneficial for patients, especially those in a minimally conscious state or attempting physical rehabilitation following stroke. Negative findings are infrequent in the current literature base. Multimodal sensory therapy appears to be a low-risk intervention with positive outcomes.

The effects of cognitive, physical, and somatosensory rehabilitation after right temporo-parietal tumor resection on cognitive, motor, somatosensory, and electrophysiological parameters: A case report

INTRODUCTION

This report examines the effects of a multimodal rehabilitation program which includes cognitive, physical, and somatosensory rehabilitation after right temporo-parietal tumor resection on cognitive, motor, somatosensory, and electrophysiological parameters.

CASE DESCRIPTION

A 22-year-old patient presented with sensory loss in the dominant left hand and reduced writing ability after right temporo-parietal lobe resection. Cognitive, motor, and sensory evaluations were carried out pre and post-treatment. The patient's spontaneous electroencephalo-gram (EEG) and an EEG during application of transcutaneous electrical nerve stimulation (TENS) (TENS EEG) were recorded. As a reference for the patient's electrophysiological values, EEGs of 4 healthy individuals were also taken. Over a period of 1 year, the patient received multimodal rehabilitation which includes cognitive, physical, and somato-sensory rehabilitation on 2 days each week.

OUTCOMES

An improvement of the patient's cognitive capacities, motor strength, superficial, deep and cortical sensations was achieved. After rehabilitation, an increase in parietal and occipital alpha activity as well as in frontal and parietal beta activity was seen both in spontaneous EEG and in TENS EEG. With increasing TENS intensity, alpha and beta power increased as well.

CONCLUSION

Our findings suggest that a multimodal rehabilitation program may improve cognitive, sensory, and motor effects after resection due to tumor surgery.

Efficacy and feasibility of SENSory relearning of the UPPer limb (SENSUPP) in people with chronic stroke: A pilot randomized controlled trial

BACKGROUND

Sensorimotor impairments of the upper limb (UL) are common after stroke, but there is a lack of evidence-based interventions to improve functioning of UL.

OBJECTIVE

To evaluate (1) the efficacy of sensory relearning and task-specific training compared to task-specific training only, and (2) the feasibility of the training in chronic stroke.

DESIGN

A pilot randomized controlled trial.

SETTING

University hospital outpatient clinic.

PARTICIPANTS

Twenty-seven participants (median age; 62 years, 20 men) were randomized to an intervention group (IG; n = 15) or to a control group (CG; n = 12).

INTERVENTION

Both groups received training twice weekly in 2.5-hour sessions for 5 weeks. The training in the IG consisted of sensory relearning, task-specific training, and home training. The training in the CG consisted of task-specific training.

MAIN OUTCOME MEASURES

Primary outcome was sensory function (touch thresholds, touch discrimination, light touch, and proprioception). Secondary outcomes were dexterity, ability to use the hand in daily activities, and perceived participation. A blinded assessor conducted the assessments at baseline (T1), post intervention (T2), and at 3-month follow-up (T3). Nonparametric analyses and effect-size calculations (r) were performed. Feasibility was evaluated by a questionnaire.

RESULTS

After the training, only touch thresholds improved significantly from T1 to T2 (p = .007, r = 0.61) in the IG compared to the CG. Within the IG, significant improvements were found from T1 to T2 regarding use of the hand in daily activities (p = .001, r = 0.96) and movement quality (p = .004, r = 0.85) and from T1 to T3 regarding satisfaction with performance in meaningful activities (p = .004, r = 0.94). The CG significantly improved the performance of using the hand in meaningful activities from T1 to T2 (p = .017, r = 0.86). The training was well tolerated by the participants and performed without any adverse events.

CONCLUSIONS

Combined sensory relearning and task-specific training may be a promising and feasible intervention to improve UL sensorimotor function after stroke.

Explicit versus implicit lower extremity sensory retraining for post-stroke chronic sensory deficits: a randomized controlled trial

PURPOSE

Sensory impairment post-stroke limits rehabilitation of balance and gait. This study aims to compare the effect of explicit sensory retraining (ESR) versus implicit repeated exposure (IRE) to stimuli of the lower extremity, assessing their effects on sensation, balance, and gait in individuals with chronic post-stroke sensory impairment.

MATERIALS AND METHODS

A two-arm parallel double-blind multicenter randomized controlled trial was conducted in physical therapy outpatient clinics. Volunteers with chronic sensory impairment post-stroke participated in 10 sessions of 45 min ESR or IRE, according to a detailed protocol. Outcome measures assessed sensation, balance, mobility, and participation.

RESULTS

A total of 64 participants were recruited (ESR, n = 34; IRE, n = 30). The intention-to-treat pre-post analysis demonstrated clinically meaningful changes for both interventions (10-31% improvement for the various measures), with no between-group difference or time × group interaction. The effect size for the time effect varied, with the largest being 0.63 for the miniBEST.

CONCLUSIONS

Sensory rehabilitation treatment by either ESR or IRE led to similar clinically significant changes in the performance of the lower extremity and participation in subjects with sensory loss post-stroke. Both treatment protocols are easy to implement in an outpatient clinic.  .

CLINICALTRIALS.GOV REGISTRATION

NCT01988220. Implications for rehabilitationStandardized, structured, sensory-focused training can improve balance and gait in subjects with chronic post-stroke sensory impairment.Both explicit and implicit learning-based sensory protocols focused on the lower extremity effectively improved balance, mobility, and gait abilities, resulting in enhanced participation of individuals in the chronic post-stroke phase.A series of ten 45-minute treatment sessions in outpatient clinics lead to clinically significant improvements.

Investigation of the effect of sensorimotor exercises on proprioceptive perceptions among children with spastic hemiplegic cerebral palsy

STUDY DESIGN

This is a blinded randomized clinical trial.

INTRODUCTION

Sensorimotor exercises may be an effective, noninvasive treatment modality for treating patients with pediatric spastic hemiplegic cerebral palsy (CP).

PURPOSE OF THE STUDY

We aim to evaluate the effect of sensorimotor exercises on the proprioceptive capability among children with spastic hemiplegic CP.

METHODS

This randomized clinical trial was performed on children with spastic hemiplegic CP. Thirty children aged 8 to 12 years old, with spastic hemiplegic CP, were randomly selected and equally divided into experimental and control groups (N = 15 for each). A joint positioning test was used to measure the patients' baseline proprioceptive ability. The exercise program included sensory and motor exercises which lasted for 8 weeks (three 60-min sessions per week). The data were analyzed by using Welch and paired-sample t-test at the significance level of P < .05.

RESULTS

The results indicated that the proprioceptive capability of the upper limb could significantly improve (P = .001, effect size = 0.41, observed power = 0.99) by using simultaneous exercising of the sensorimotor complex. The mean increased from 8.53 ± 1.6 to 10.53 ± 1.19 in the experimental group, whereas it changed from 6.66 ± 3.44 to 6.73 ± 3.15 in the control group.

DISCUSSION

In consistent with other studies, the exercises used in the present study enhanced the proprioceptive capability but not sensory performance of the hands of children with hemiplegic. Synchronous sensory and motor training in children with hemiplegic CP may improve the function and organization of the somatosensory cortex and reduce sensory disturbances. Although parents were subjectively satisfied with the outcome of the exercises, such as independency and life style, however these recordings were not measured in this study.

CONCLUSION

Implementing simultaneous sensorimotor exercises can improve the proprioceptive capability of the hand. Therefore, these exercises can be used in the rehabilitation programs to meet the children's needs with hemiplegic CP.

Effect of Immersive Virtual Reality-Based Bilateral Arm Training in Patients with Chronic Stroke

Virtual reality (VR)-based therapies are widely used in stroke rehabilitation. Although various studies have used VR techniques for bilateral upper limb training, most have been only semi-immersive and have only been performed in an artificial environment. This study developed VR content and protocols based on activities of daily living to provide immersive VR-based bilateral arm training (VRBAT) for upper limb rehabilitation in stroke patients. Twelve patients with chronic stroke were randomized to a VRBAT group or a normal bilateral arm training (NBAT) group and attended 30-min training sessions five times a week for four weeks. At the end of the training, there was a significant difference in upper limb function in both groups (p < 0.05) and in the upper limb function sensory test for proprioception in the NBAT group (p < 0.05). There was no significant between-group difference in upper limb muscle activity after training. The relative alpha and beta power values for electroencephalographic measurements were significantly improved in both groups. These findings indicate that both VRBAT and NBAT are effective interventions for improving upper limb function and electroencephalographic activity in patients with chronic stroke.

SENSory re-learning of the UPPer limb (SENSUPP) after stroke: development and description of a novel intervention using the TIDieR checklist

Background

Sensorimotor impairments of upper limb (UL) are common after stroke, leading to difficulty to use the UL in daily life. Even though many have sensory impairments in the UL, specific sensory training is often lacking in stroke rehabilitation. Thus, the aim of this paper is to provide a detailed description of the novel intervention “SENSory re-learning of the UPPer limb after stroke (SENSUPP)” that we have developed to improve functioning in the UL in persons with mild to moderate impairments after stroke.

Methods

The SENSUPP protocol was designed using information from literature reviews, clinical experience and through consultation of experts in the field. The protocol integrates learning principles based on current neurobiological knowledge and includes repetitive intensive practice, difficulty graded exercises, attentive exploration of a stimulus with focus on the sensory component, and task-specific training in meaningful activities that includes feedback. For reporting the SENSUPP protocol, the Template for Intervention Description and Replication (TIDieR) checklist was used.

Results

The essential features of the SENSUPP intervention comprise four components: applying learning principles based on current neurobiological knowledge, sensory re-learning (exercises for touch discrimination, proprioception and tactile object recognition), task-specific training in meaningful activities, and home-training. The training is performed twice a week, in 2.5-h sessions for 5 weeks.

Conclusion

Since there is close interaction between the sensory and motor systems, the SENSUPP intervention may be a promising method to improve UL functioning after stroke. The TIDieR checklist has been very useful for reporting the procedure and development of the training.

Trial registration

ClinicalTrials.govNCT03336749. Registered on 8 November 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05375-6.

Digital therapeutics in neurology

Digital therapeutics (DTx) is a section of digital health defined by the DTx Alliance as “delivering evidence-based therapeutic interventions to patients that are driven by software to prevent, manage, or treat a medical disorder or disease. They are used independently or in concert with medications, devices, or other therapies to optimize patient care and health outcomes”. Chronic disabling diseases could greatly benefit from DTx. In this narrative review, we provide an overview of DTx in the care of patients with neurological dysfunctions.

Smart Protocols for Physical Therapy of Foot Drop Based on Functional Electrical Stimulation: A Case Study

Functional electrical stimulation (FES) is used for treating foot drop by delivering electrical pulses to the anterior tibialis muscle during the swing phase of gait. This treatment requires that a patient can walk, which is mostly possible in the later phases of rehabilitation. In the early phase of recovery, the therapy conventionally consists of stretching exercises, and less commonly of FES delivered cyclically. Nevertheless, both approaches minimize patient engagement, which is inconsistent with recent findings that the full rehabilitation potential could be achieved by an active psycho-physical engagement of the patient during physical therapy. Following this notion, we proposed smart protocols whereby the patient sits and ankle movements are FES-induced by self-control. In six smart protocols, movements of the paretic ankle were governed by the non-paretic ankle with different control strategies, while in the seventh voluntary movements of the paretic ankle were used for stimulation triggering. One stroke survivor in the acute phase of recovery participated in the study. During the therapy, the patient’s voluntary ankle range of motion increased and reached the value of normal gait after 15 sessions. Statistical analysis did not reveal the differences between the protocols in FES-induced movements.

Integrating Tactile Feedback Technologies Into Home-Based Telerehabilitation: Opportunities and Challenges in Light of COVID-19 Pandemic

The COVID-19 pandemic has highlighted the need for advancing the development and implementation of novel means for home-based telerehabilitation in order to enable remote assessment and training for individuals with disabling conditions in need of therapy. While somatosensory input is essential for motor function, to date, most telerehabilitation therapies and technologies focus on assessing and training motor impairments, while the somatosensorial aspect is largely neglected. The integration of tactile devices into home-based rehabilitation practice has the potential to enhance the recovery of sensorimotor impairments and to promote functional gains through practice in an enriched environment with augmented tactile feedback and haptic interactions. In the current review, we outline the clinical approaches for stimulating somatosensation in home-based telerehabilitation and review the existing technologies for conveying mechanical tactile feedback (i.e., vibration, stretch, pressure, and mid-air stimulations). We focus on tactile feedback technologies that can be integrated into home-based practice due to their relatively low cost, compact size, and lightweight. The advantages and opportunities, as well as the long-term challenges and gaps with regards to implementing these technologies into home-based telerehabilitation, are discussed.

Validity and Reliability of the Semmes-Weinstein Monofilament Test and the Thumb Localizing Test in Patients With Stroke

Background: Somatosensory impairment is common in patients who have had a stroke and can affect their motor function and activities of daily living (ADL). Therefore, detecting and treating somatosensory impairments properly is considered to be very important, and various examinations have been developed. However, the reliability and validity of few of them have been verified due to differences in the procedure of each examiner or poor quantification by the examination itself.

Objective: We hypothesized that, with fixed procedures two convenient clinical examinations, the Semmes-Weinstein Monofilament Test (SWMT) and the Thumb Localizing Test (TLT), could provide reliable assessments of light touch sensation and proprioception. The purpose of this study was to verify the reliability and validity of these two examinations as indices of somatosensory impairment of the upper extremity (UE) in patients with chronic post-stroke hemiparesis.

Methods: Fifty patients with chronic stroke (median time after onset of stroke, 848 [474–1708] days, mean age 57 [standard deviation 14] years) were enrolled at Keio University Hospital from 2017 to 2018. Examiners learned the original method of the SWMT and the TLT rigorously and shared it with each other. The TLT procedure was partially modified by dividing the location of the patient's thumb into four spaces. Two examiners evaluated the SWMT and the TLT for 2 days, and intra-rater and inter-rater reliabilities were calculated using weighted kappa statistics. In addition to this, the evaluator size score of the SWMT was assessed with Bland-Altman analysis to evaluate systematic bias. The Stroke Impairment Assessment Set (SIAS) sensory items were used to assess validity, and Spearman's rank correlation coefficients were calculated.

Results: Intra/inter-rater agreements of the SWMT grade score were 0.89 (thumb, 95%CI: 0.83–0.95)/ 0.75 (0.60–0.91) and 0.80 (index finger, 0.67–0.93)/0.79 (0.66–0.92), and of the TLT they were 0.83 (navel level proximal space, 0.71–0.95)/ 0.83 (0.73–0.92), 0.90 (navel level distal space, 0.85–0.96)/ 0.80 (0.69–0.90), 0.80 (shoulder level proximal space, 0.68–0.92)/ 0.77 (0.65–0.89), and 0.87 (shoulder level distal space, 0.80–0.93)/ 0.80 (0.68–0.92) (P < 0.001, each item). All of them showed substantial agreement, but the MDC of the SWMT evaluator size was 1.28 to 1.79 in the inter-rater test and 1.94–2.06 in the intra-rater test. The SWMT grade score showed a strong correlation with the SIAS light touch sensation item (r = 0.65, p < 0.001), as did the TLT with the SIAS position sense item (r = −0.70–0.62, p < 0.001 each space).

Conclusions: The reliability and validity of the SWMT and the TLT were verified. These tests can be used as reliable sensory examinations of the UE in patients with chronic stroke, and especially for the SWMT, it is more reliable for screening.

Feasibility Case Study for Treating a Patient with Sensory Ataxia Following a Stroke with Kinesthetic Illusion Induced by Visual Stimulation

Background: Sensory ataxia is a disorder of movement coordination caused by sensory deficits, especially in kinesthetic perception. Visual stimulus-induced kinesthetic illusion (KINVIS) is a method used to provide vivid kinesthetic perception without peripheral sensory input by using a video showing pre-recorded limb movements while the actual limb remains stationary. We examined the effects of KINVIS intervention in a patient with sensory ataxia. Case: The patient was a 59-year-old man with a severe proprioceptive deficit caused by left thalamic hemorrhage. During KINVIS intervention, a computer screen displayed a pre-recorded mirror image video of the patient’s unaffected hand performing flexion–extension movements as if it were attached to the patient’s affected forearm. Kinematics during the flexion–extension movements of the paretic hand were recorded before and after 20-min interventions. Transcranial magnetic stimulation was applied to the affected and non-affected hemispheres. The amplitude of the motor-evoked potential (MEP) at rest was recorded for the muscles of both hands. After the intervention, the total trajectory length and the rectangular area bounding the trajectory of the index fingertip decreased. The MEP amplitude of the paretic hand increased, whereas the MEP amplitude of the non-paretic hand was unchanged. Discussion: The changes in kinematics after the intervention suggested that KINVIS therapy may be a useful new intervention for sensory ataxia, a condition for which few effective treatments are currently available. Studies in larger numbers of patients are needed to clarify the mechanisms underlying this therapeutic effect.

Sensory retraining improves light touch threshold of the paretic hand in chronic stroke survivors: a single-subject A-B design

Background: Light touch, one of the primary and basic sensations, is often neglected in sensory retraining programmes for stroke survivors.Objective: This study aimed to investigate the effects of sensory retraining on the light touch threshold of the hand, dexterity and upper limb motor function of chronic stroke survivors.Methods: Five chronic stroke survivors with sensory impairment participated in this single-subject A-B design study. In baseline (A) phase, they only received standard rehabilitation. In the treatment (B) phase, they received a 6-week sensory retraining intervention in addition to standard rehabilitation. In both phases, they were evaluated every 3 days. Light touch threshold, manual dexterity and upper limb motor function were assessed using Semmes-Weinstein Monofilaments, Box-Block Test and Fugl-Meyer Assessment, respectively. Visual analysis, nonparametric Mann-Whitney U test and, c-statistic were used for assessing the changes between phases.Results: All participants indicated changes in trend or slope of the total score of light touch or both between the two phases. The results of the c-statistic also showed the statistical difference in the total score of light touch between baseline and treatment in all participants (p < 0.001). Also, the results of the c-statistic and Mann-Whitney U test supported the difference of manual dexterity and motor function of the upper limb between baseline and treatment in all participants (p < 0.001).Conclusion: Current findings showed that sensory retraining may be an effective adjunctive intervention for improving the light touch threshold of the hand, dexterity and upper limb motor function in chronic stroke survivors.

Effects of Training for Finger Perception on Functional Recovery of Hemiplegic Upper Limbs in Acute Stroke Patients

Background

Stroke causes severe disability, including motor and sensory impairments. We hypothesized that upper limb functional recovery after stroke may be augmented by combining treatments for motor and sensory functions. In order to examine this hypothesis, we conducted a controlled trial on rehabilitation for sensory function to the plegic hand.

Methods

The sensory training program consisted of several types of discrimination tasks performed under blind conditions. The sensory training program was performed for 20 min per day, 5 days a week. An experimental group of 31 patients followed this sensory program, while a control group of 25 patients underwent standard rehabilitation. The efficacy of the intervention was evaluated by the tactile-pressure threshold, handgrip strength, and the completion time of manipulating objects. A two-way repeated measures analysis of variance was used to assess interactions between group and time. Moreover, to provide a meaningful analysis for comparisons, effect sizes were calculated using Cohen's d.

Results

The mean change in the tactile pressure threshold was significantly larger in the experimental group than in the control group (p < 0.05, d = 0.59). Moreover, the completion times to manipulate a middle-sized ball (d = 0.53) and small ball (d = 0.80) and a small metal disc (d = 0.81) in the experimental group were significantly different from those in the control group (p < 0.05).

Conclusion

The present results suggest that the sensory training program to enhance finger discrimination ability contributes to improvements in not only sensory function but also manual function in stroke patients. The trial is registered with the UMIN Clinical Trials Registry (UMIN000032025).

Neuromuscular electrical stimulation-enhanced rehabilitation is associated with not only motor but also somatosensory cortical plasticity in chronic stroke patients: an interventional study

Background:

Somatosensory function has been frequently overlooked in clinics and research in the field of chronic stroke. The effects of neurorehabilitation interventions on sensory processing have still to be investigated using electrophysiological means.

This study investigated the effect of hybrid assistive neuromuscular dynamic stimulation (HANDS) therapy utilizing closed-loop electromyography-controlled neuromuscular electrical stimulation (NMES), on sensory changes and cortical plasticity among patients with chronic stroke.

Methods:

This study was a prespecified analysis of 23 participants involved in an ongoing large interventional study. Patients with severe upper limb hemiplegia dues to chronic stroke underwent 3 weeks of inpatient HANDS therapy, where daily treatment consisted of 8 h of NMES combined with wrist splinting, 90 min of comprehensive occupational therapy, and the practice of bimanual activities of daily living. Somatosensory evoked potentials (SEPs) and functional sensory assessments, including the Semmes–Weinstein monofilament test (SWMT) and thumb localizing test (TLT), were compared pre and post-treatment.

Results:

While no significant recovery of tactile sensation was observed, significant improvements in proprioception and motor function were induced. The number of cortical peaks significantly increased in the median nerve, but not in the tibial nerve. A total of 9 out of 11 participants who initially lacked certain peaks responded to treatment. Further analysis revealed a significant improvement in latency and amplitude of SEP peaks.

Conclusions:

Our results suggest that NMES-based neurorehabilitation induces certain plastic changes in the primary sensory cortex and in cortices associated with sensorimotor processing in people with chronic stroke sequelae, which may explain the observed improvements in proprioception.

The effect of sensory-motor training on hand and upper extremity sensory and motor function in patients with idiopathic Parkinson disease

STUDY DESIGN

Blinded randomized controlled trial.

INTRODUCTION

Patients with Parkinson disease (PD) have sensory problems, but there is still no accurate understanding of the effects of sensory-motor interventions on PD.

PURPOSE OF THE STUDY

To investigate the effects of sensory-motor training (SMT) on hand and upper extremity sensory and motor function in patients with PD.

METHODS

Forty patients with PD were allocated to the SMT group or the control group (CG) (mean ages ± standard deviation: SMT, 61.05 ± 13.9 years; CG, 59.15 ± 11.26 years). The CG received the common rehabilitation therapies, whereas the SMT group received SMT. The SMT included discrimination of temperatures, weights, textures, shapes, and objects and was performed 5 times each week for 2 weeks.

RESULTS

Significantly reducing the error rates in the haptic object recognition test (dominant hand [DH]: F = 15.36, P = .001, and effect size [ES] = 0.29; nondominant hand [NDH]: F = 9.33, P = .004, and ES = 0.21) and the error means in the wrist proprioception sensation test (DH: F = 9.11, P = .005, and ES = 0.19; NDH: F = 13.04, P = .001, and ES = 0.26) and increasing matched objects in the hand active sensation test (DH: F = 12.15, P = .001, and ES = 0.24; NDH: F = 5.03, P = .03, and ES = 0.12) founded in the SMT. Also, the DH (F = 6.65, P = .01, and ES = 0.15), both hands (F = 7.61, P = .009, and ES = 0.17), and assembly (F = 7.02, P = .01, and ES = 0.15) subtests of fine motor performance, as well as DH (F = 10.1, P = .003, and ES = 0.21) and NDH (F = 8.37, P = .006, and ES = 0.18) in upper extremity functional performance, were improved in the SMT.

DISCUSSION

SMT improved hand and upper extremity sensory-motor function in patients with PD.

CONCLUSION

The SMT group showed improved sensory and motor function. But these results were limited to levels 1 to 3 of the Hoehn and Yahr Scale.

Vision does not always help stroke survivors compensate for impaired limb position sense

BACKGROUND

Position sense is commonly impaired after stroke. Traditional rehabilitation methods instruct patients to visualize their limbs to compensate for impaired position sense.

OBJECTIVE

Our goal was to evaluate how the use of vision influences impaired position sense.

METHODS

We examined 177 stroke survivors, an average of 12.7 days (+/- 10 days (SD)) post-stroke, and 133 neurologically-intact controls with a robotic assessment of position sense. The robot positioned one limb (affected) and subjects attempted to mirror-match the position using the opposite limb (unaffected). Subjects completed the test without, then with vision of their limbs. We examined three measures of position sense: variability (Var), contraction/expansion (C/E) and systematic shift (Shift). We classified stroke survivors as having full compensation if they performed the robotic task abnormally without vision but corrected performance within the range of normal with vision. Stroke survivors were deemed to have partial compensation if they performed the task outside the range of normal without and with vision, but improved significantly with vision. Those with absent compensation performed the task abnormally in both conditions and did not improve with vision.

RESULTS

Many stroke survivors demonstrated impaired position sense with vision occluded [Var: 116 (66%), C/E: 91 (51%), Shift: 52 (29%)]. Of those stroke survivors with impaired position sense, some exhibited full compensation with vision [Var: 23 (20%), C/E: 42 (46%), Shift: 32 (62%)], others showed partial compensation [Var: 37 (32%), C/E: 8 (9%), Shift: 3 (6%)] and many displayed absent compensation (Var: 56 (48%), C/E: 41 (45%), Shift: 17 (33%)]. Stroke survivors with an affected left arm, visuospatial neglect and/or visual field defects were less likely to compensate for impaired position sense using vision.

CONCLUSIONS

Our results indicate that vision does not help many stroke survivors compensate for impaired position sense, at least within the current paradigm. This contrasts with historical reports that vision helps compensate for proprioceptive loss following neurologic injuries.

A Cortico- Basal Ganglia Model for choosing an optimal rehabilitation strategy in Hemiparetic Stroke

To facilitate the selection of an optimal therapy for a stroke patient with upper extremity hemiparesis, we propose a cortico-basal ganglia model capable of performing reaching tasks under normal and stroke conditions. The model contains two hemispherical systems, each organized into an outer sensory-motor cortical loop and an inner basal ganglia (BG) loop, controlling their respective hands. The model is trained to simulate two therapeutic approaches: the constraint induced movement therapy (CIMT) in which the intact is arrested, and Bimanual Reaching in which the movements of the intact arm are found to aid the affected arm. Which of these apparently mutually conflicting approaches is right for a given patient? Based on our study on the effect of lesion size on arm performance, we hypothesize that the choice of the therapy depends on the lesion size. Whereas bimanual reaching is more suitable for smaller lesion size, CIMT is preferred in case of larger lesion sizes. By virtue of the model's ability to capture the experimental results effectively, we believe that it can serve as a benchmark for the development and testing of various rehabilitation strategies for stroke.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

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

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

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

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

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

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods/design

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

Discussion

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

Trial registration

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

Electronic supplementary material

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

Tactile-STAR: A Novel Tactile STimulator And Recorder System for Evaluating and Improving Tactile Perception

Many neurological diseases impair the motor and somatosensory systems. While several different technologies are used in clinical practice to assess and improve motor functions, somatosensation is evaluated subjectively with qualitative clinical scales. Treatment of somatosensory deficits has received limited attention. To bridge the gap between the assessment and training of motor vs. somatosensory abilities, we designed, developed, and tested a novel, low-cost, two-component (bimanual) mechatronic system targeting tactile somatosensation: the Tactile-STAR-a tactile stimulator and recorder. The stimulator is an actuated pantograph structure driven by two servomotors, with an end-effector covered by a rubber material that can apply two different types of skin stimulation: brush and stretch. The stimulator has a modular design, and can be used to test the tactile perception in different parts of the body such as the hand, arm, leg, big toe, etc. The recorder is a passive pantograph that can measure hand motion using two potentiometers. The recorder can serve multiple purposes: participants can move its handle to match the direction and amplitude of the tactile stimulator, or they can use it as a master manipulator to control the tactile stimulator as a slave. Our ultimate goal is to assess and affect tactile acuity and somatosensory deficits. To demonstrate the feasibility of our novel system, we tested the Tactile-STAR with 16 healthy individuals and with three stroke survivors using the skin-brush stimulation. We verified that the system enables the mapping of tactile perception on the hand in both populations. We also tested the extent to which 30 min of training in healthy individuals led to an improvement of tactile perception. The results provide a first demonstration of the ability of this new system to characterize tactile perception in healthy individuals, as well as a quantification of the magnitude and pattern of tactile impairment in a small cohort of stroke survivors. The finding that short-term training with Tactile-STAR can improve the acuity of tactile perception in healthy individuals suggests that Tactile-STAR may have utility as a therapeutic intervention for somatosensory deficits.

Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery

Stroke is one of the leading causes for disability worldwide. Motor function deficits due to stroke affect the patients' mobility, their limitation in daily life activities, their participation in society and their odds of returning to professional activities. All of these factors contribute to a low overall quality of life. Rehabilitation training is the most effective way to reduce motor impairments in stroke patients. This multiple systematic review focuses both on standard treatment methods and on innovating rehabilitation techniques used to promote upper extremity motor function in stroke patients. A total number of 5712 publications on stroke rehabilitation was systematically reviewed for relevance and quality with regards to upper extremity motor outcome. This procedure yielded 270 publications corresponding to the inclusion criteria of the systematic review. Recent technology-based interventions in stroke rehabilitation including non-invasive brain stimulation, robot-assisted training, and virtual reality immersion are addressed. Finally, a decisional tree based on evidence from the literature and characteristics of stroke patients is proposed. At present, the stroke rehabilitation field faces the challenge to tailor evidence-based treatment strategies to the needs of the individual stroke patient. Interventions can be combined in order to achieve the maximal motor function recovery for each patient. Though the efficacy of some interventions may be under debate, motor skill learning, and some new technological approaches give promising outcome prognosis in stroke motor rehabilitation.

Effectiveness of unilateral and symmetrical bilateral task training for arm during the subacute phase after stroke: a randomized controlled trial

Objective: To evaluate the effect of an arm training programme combining repetition of unilateral and symmetrical bilateral tasks for people in the subacute phase after stroke.

Design: Randomized controlled trial.

Setting: Inpatient functional rehabilitation unit.

Subjects: Forty-one people who had had a stroke, in the subacute phase, receiving conventional arm occupational and physical therapy, were randomized to an experimental group (n=20) and a control group (n=21).

Interventions: In addition to the usual arm therapy in the rehabilitation unit, the experimental group received an arm therapy programme (15-20 45-min sessions) based on repetition of unilateral and symmetrical bilateral tasks. The control group received additional usual arm therapy of a similar duration and frequency to the experimental treatment.

Main measures: The effect of the programme was judged on the basis of: (1) arm impairments (motor function, grip strength, gross and fine manual dexterity and motor co-ordination), (2) arm disabilities in tasks related to daily activities, and (3) functional independence in activities of daily living (ADL) and instrumental ADL (IADL).

Results: Although both experimental and control groups of participants improved similarly during the study period, the statistical analyses did not show any difference between the groups at the end of the treatment for the different dependent variables evaluated: (1) arm impairments: p=0.43-0.79; (2) arm disabilities: p=0.16-0.90; and (3) functional independence: p=0.63 and 0.90.

Conclusions: An arm training programme based on repetition of unilateral and symmetrical bilateral practice did not reduce impairment and disabilities nor improve functional outcomes in the subacute phase after stroke more than the usual therapy.

Does Proprioceptive Loss Influence Recovery of the Upper Extremity After Stroke?

Stroke patients with motor paralysis and proprioceptive deficits are considered to have a worse functional outcome than those with pure motor paralysis, but the mechanism of this detrimental effect is not clear. In order to clarify it, we compared the motor and functional recovery of the affected upper extremity in stroke patients having pure motor paralysis with that of such patients with both motor and proprioceptive deficits. Forty patients undergoing stroke rehabilitation were studied: 20 with pure motor deficits and 20 also with proprioceptive deficits. They were assessed on four occasions during the first six weeks of rehabilitation. Motor impairment was assessed with the Fugl-Meyer subscale of the upper extremity, disability with the Frenchay Arm Test, and proprio ception by the Thumb Localization Test. Significant within-group improvement of the motor and functional abilities was demonstrated in both groups, between admission to six weeks later (p < 0.001, either group). However, no significant difference was found between the two groups, although pure motor patients had a slightly better outcome. It was concluded that the proprioception deficit did not influence limb recovery in the first six weeks of rehabilitation. Therefore, the upper extremity of all patients should be treated and given a similar chance because significant improvement can be expected in all cases. Key Words: Upper Extremity—Stroke—Proprioception—Rehabilitation.

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.

Somatosensory deficits after stroke: a scoping review

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

Improving proprioceptive deficits after stroke through robot-assisted training of the upper limb: a pilot case report study

The purpose of this study was to determine whether a conventional robot-assisted therapy of the upper limb was able to improve proprioception and motor recovery of an individual after stroke who exhibited proprioceptive deficits. After robotic sensorimotor training, significant changes were observed in kinematic performance variables. Two quantitative parameters evaluating position sense improved after training. Range of motion during shoulder and wrist flexion improved, but only wrist flexion remained improved at 3-month follow-up. These preliminary results suggest that intensive robot-aided rehabilitation may play an important role in the recovery of sensory function. However, further studies are required to confirm these data.

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

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

Measuring change in somatosensation across the lifespan

OBJECTIVE

The study aim was to determine natural variability in somatosensation across age groups using brief measures. We validated measures in a community-dwelling population as part of the National Institutes of Health (NIH) Toolbox for Assessment of Neurological and Behavioral Function (NIH Toolbox; http://www.nihtoolbox.org).

METHOD

Participants included community-dwelling children and adults (N=367, ages 3-85 yr) across seven sites. We tested haptic recognition, touch detection-discrimination, and proprioception using brief affordable measures as required by the NIH Toolbox.

RESULTS

Accuracy improved from young children to young adults; from young to older adults, the pattern reversed slightly. We found significant differences between adults and older adults. One proprioception test (kinesthesia; p=.003) showed gender differences (females more accurate). We provide expected score ranges for age groups as a basis for understanding age-related expectations for somatosensory perception.

CONCLUSION

The age-related patterns of somatosensory perception from this study refine decision making about performance.

Differences in two-point discrimination and sensory threshold in the blind between braille and text reading: a pilot study

[Purpose] This study investigated two-point discrimination (TPD) and the electrical sensory threshold of the blind to define the effect of using Braille on the tactile and electrical senses. [Subjects and Methods] Twenty-eight blind participants were divided equally into a text-reading and a Braille-reading group. We measured tactile sensory and electrical thresholds using the TPD method and a transcutaneous electrical nerve stimulator. [Results] The left palm TPD values were significantly different between the groups. The values of the electrical sensory threshold in the left hand, the electrical pain threshold in the left hand, and the electrical pain threshold in the right hand were significantly lower in the Braille group than in the text group. [Conclusion] These findings make it difficult to explain the difference in tactility between groups, excluding both palms. However, our data show that using Braille can enhance development of the sensory median nerve in the blind, particularly in terms of the electrical sensory and pain thresholds.

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

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

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation

BACKGROUND AND PURPOSE

The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA).

METHOD

Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale.

RESULTS

The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation.

DISCUSSION AND CONCLUSION

The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.

Assessment-driven selection and adaptation of exercise difficulty in robot-assisted therapy: a pilot study with a hand rehabilitation robot

Background

Selecting and maintaining an engaging and challenging training difficulty level in robot-assisted stroke rehabilitation remains an open challenge. Despite the ability of robotic systems to provide objective and accurate measures of function and performance, the selection and adaptation of exercise difficulty levels is typically left to the experience of the supervising therapist.

Methods

We introduce a patient-tailored and adaptive robot-assisted therapy concept to optimally challenge patients from the very first session and throughout therapy progress. The concept is evaluated within a four-week pilot study in six subacute stroke patients performing robot-assisted rehabilitation of hand function. Robotic assessments of both motor and sensory impairments of hand function conducted prior to the therapy are used to adjust exercise parameters and customize difficulty levels. During therapy progression, an automated routine adapts difficulty levels from session to session to maintain patients’ performance around a target level of 70%, to optimally balance motivation and challenge.

Results

Robotic assessments suggested large differences in patients’ sensorimotor abilities that are not captured by clinical assessments. Exercise customization based on these assessments resulted in an average initial exercise performance around 70% (62% ± 20%, mean ± std), which was maintained throughout the course of the therapy (64% ± 21%). Patients showed reduction in both motor and sensory impairments compared to baseline as measured by clinical and robotic assessments. The progress in difficulty levels correlated with improvements in a clinical impairment scale (Fugl-Meyer Assessment) (r _s = 0.70), suggesting that the proposed therapy was effective at reducing sensorimotor impairment.

Conclusions

Initial robotic assessments combined with progressive difficulty adaptation have the potential to automatically tailor robot-assisted rehabilitation to the individual patient. This results in optimal challenge and engagement of the patient, may facilitate sensorimotor recovery after neurological injury, and has implications for unsupervised robot-assisted therapy in the clinic and home environment.

Trial registration: ClinicalTrials.gov, NCT02096445

Electronic supplementary material

The online version of this article (doi:10.1186/1743-0003-11-154) contains supplementary material, which is available to authorized users.

Implications of CI therapy for visual deficit training

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

Assessing and treating higher level somatosensory impairments post stroke

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

Determination of interventions for upper extremity tactile impairment in children with cerebral palsy: a systematic review

AIM

This study reviewed interventions suitable for treating tactile dysfunction in children with cerebral palsy (CP).

METHOD

A systematic review was conducted of six databases, searched for population: ('brain injury' OR 'cerebral palsy' OR 'stroke' OR 'cerebrovascular accident') and intervention: ('tactile' OR 'sensation'). Inclusion criteria were: (1) published after 1950 in English; (2) participants older than 4 years with brain injury; (3) upper limb intervention; and (4) examined tactile registration or perception.

RESULTS

Of 2938 studies identified, 30 met the inclusion criteria. Results from included studies indicated that tactile function improved in adults with stroke after transfer enhanced training (t[47]=2.75, p=0.004), stimulus specific training (p<0.001), ice therapy (F=5.71, p=0.028), mirror therapy (F=7.7, p=0.009), and functional deafferentation using an anaesthetic cream (t=3.76; p<0.01). No intervention reported improvement in tactile dysfunction for children with CP.

INTERPRETATION

Research is required to develop tactile interventions for children with CP that integrate methodology from effective approaches for adults after stroke. Stimulus specific training, transfer enhanced training, and mirror therapy are promising. Other approaches are less suitable for children because of invasiveness (electrical stimulation), safety (ice therapy), or limitation of bimanual function (eutectic mixture of local anaesthetics, pneumatic cuff).

Sensory impairment after stroke: Exploring therapists' clinical decision making

BACKGROUND

Stroke survivors experience sensory impairments that significantly limit upper-limb functional use. Lack of clear research-based guidelines about their management exacerbates the uncertainty in occupational therapists' decision making to support these clients.

PURPOSE

This study explores occupational therapists' clinical decision making regarding upper-limb, post-stroke sensory impairments that can ultimately inform approaches to support therapists working with such clients.

METHOD

Twelve therapists participated in a qualitative descriptive study. Transcripts of semi-structured interviews were analyzed using content analysis.

FINDINGS

Three overarching categories were identified: deciding on the focus of interventions (describing intervention choices), it all depends (outlining factors considered when choosing interventions), and managing uncertainty in decision making (describing uncertainty and actions taken to resolve it).

IMPLICATIONS

Providing training about post-stroke sensory impairment and decision making may improve therapists' decision making and ultimately improve client outcomes. Further research is needed to understand the impact of uncertainty on occupational therapy decision making and resulting care practices.

Precision grip in congenital and acquired hemiparesis: similarities in impairments and implications for neurorehabilitation

Background: Patients with congenital and acquired hemiparesis incur long-term functional deficits, among which the loss of prehension that may impact their functional independence. Identifying, understanding, and comparing the underlying mechanisms of prehension impairments represent an opportunity to better adapt neurorehabilitation.

Objective: The present review aims to provide a better understanding of precision grip deficits in congenital and acquired hemiparesis and to determine whether the severity and type of fine motor control impairments depend on whether or not the lesions are congenital or acquired in adulthood.

Methods: Using combinations of the following key words: fingertip force, grip force, precision grip, cerebral palsy, stroke, PubMed, and Scopus databases were used to search studies from 1984 to 2013.

Results: Individuals with both congenital and acquired hemiparesis were able to some extent to use anticipatory motor control in precision grip tasks, even if this control was impaired in the paretic hand. In both congenital and acquired hemiparesis, the ability to plan efficient anticipatory motor control when the less-affected hand is used provides a possibility to remediate impairments in anticipatory motor control of the paretic hand.

Conclusion: Surprisingly, we observed very few differences between the results of studies in children with congenital hemiplegia and stroke patients. We suggest that the underlying specific strategies of neurorehabilitation developed for each one could benefit the other.

Neurocognitive robot-assisted therapy of hand function

Neurocognitive therapy, according to the Perfetti method, proposes exercises that challenge motor, sensory as well as cognitive functions of neurologically impaired patients. At the level of the hand, neurocognitive exercises typically involve haptic exploration and interaction with objects of various shapes and mechanical properties. Haptic devices are thus an ideal support to provide neurocognitive exercises under well-controlled and reproducible conditions, and to objectively assess patient performance. Here we present three neurocognitive robot-assisted exercises which were implemented on the ReHapticKnob, a high-fidelity two-degrees-of-freedom hand rehabilitation robot. The exercises were evaluated for feasibility and acceptance in a pilot study on five patients suffering from different neurological disorders. Results showed that all patients were able to take part in the neurocognitive robot-assisted therapy, and that the proposed therapy was well accepted by patients, as assessed through subjective questionnaires. Force/torque and position measurements provided insights on the motor strategy employed by the patients during the exploration of virtual object properties, and served as objective assessment of task performance. The fusion of the neurocognitive therapy concept with robot-assisted rehabilitation enriches therapeutic approaches through the focus on haptics, and could provide novel insights on sensorimotor impairment and recovery.

Remote vibrotactile noise improves light touch sensation in stroke survivors' fingertips via stochastic resonance

Background and purpose

Stroke rehabilitation does not often integrate both sensory and motor recovery. While subthreshold noise was shown to enhance sensory signal detection at the site of noise application, having a noise-generating device at the fingertip to enhance fingertip sensation and potentially enhance dexterity for stroke survivors is impractical, since the device would interfere with object manipulation. This study determined if remote application of subthreshold vibrotactile noise (away from the fingertips) improves fingertip tactile sensation with potential to enhance dexterity for stroke survivors.

Methods

Index finger and thumb pad sensation was measured for ten stroke survivors with fingertip sensory deficit using the Semmes-Weinstein Monofilament and Two-Point Discrimination Tests. Sensation scores were measured with noise applied at one of three intensities (40%, 60%, 80% of the sensory threshold) to one of four locations of the paretic upper extremity (dorsal hand proximal to the index finger knuckle, dorsal hand proximal to the thumb knuckle, dorsal wrist, volar wrist) in a random order, as well as without noise at beginning (Pre) and end (Post) of the testing session.

Results

Vibrotactile noise of all intensities and locations instantaneously and significantly improved Monofilament scores of the index fingertip and thumb tip (p < .01). No significant effect of the noise was seen for the Two-Point Discrimination Test scores.

Conclusions

Remote application of subthreshold (imperceptible) vibrotactile noise at the wrist and dorsal hand instantaneously improved stroke survivors’ light touch sensation, independent of noise location and intensity. Vibrotactile noise at the wrist and dorsal hand may have enhanced the fingertips’ light touch sensation via stochastic resonance and interneuronal connections. While long-term benefits of noise in stroke patients warrants further investigation, this result demonstrates potential that a wearable device applying vibrotactile noise at the wrist could enhance sensation and grip ability without interfering with object manipulation in everyday tasks.

Occupational Therapy for Upper Limb Post-Stroke Sensory Impairments: A Survey

Purpose:

Upper limb post-stroke sensory impairments have an impact on a significant number of stroke survivors. There is limited research in this area and it is unclear how occupational therapists are addressing sensory impairments in clinical practice. This study aimed to investigate the clinical practice patterns of occupational therapists, perceived barriers to providing interventions and information sources used when addressing upper limb post-stroke sensory impairments.

Methods:

A survey was sent to 500 randomly selected occupational therapists in the United States.

Findings:

The majority of the 145 respondents reported frequently assessing sensation, and half reported providing interventions for sensory impairments. Interventions primarily focused on providing passive sensory stimulation followed by compensatory strategies. Most therapists provided patient/caregiver education about safety. Therapists cited lack of knowledge and skills, patients' short length of stay and lack of time as barriers to utilizing interventions. Most therapists reported not being up to date with current research and requested continuing education to support practice.

Conclusion:

This survey established a profile of American occupational therapists' practice with people with upper limb post-stroke sensory impairments. Therapists have a need for information and training in all aspects of the management of upper limb post-stroke sensory impairment. Further research, evaluating the effectiveness of interventions and exploring therapists' clinical decision making when choosing interventions, is also needed.

Comparison of Two-point Discrimination Perception in Stroke Patients with and without Diabetes Mellitus

[Purpose] The aim of this study was to compare two-point discrimination (TPD) perception in stroke patients with diabetes mellitus (DM) and without diabetes mellitus (non-DM). [Subjects] The subjects were 53 poststroke hemiparetic patients (21 stroke patients with DM; 32 stroke patients without DM). [Methods] TPD was measured on the tips of the first through fifth fingers on both the affected and unaffected sides. [Result] Comparison of TPD between fingers on the unaffected side and affected side fingers showed significantly poorer responses in all five fingers on the affected side. TPD was also significantly poorer in the DM group compared with the non-DM group in all five fingers on the affected side, but no differences were observed for the unaffected side. [Conclusion] These findings suggest that TPD was significantly poorer in the fingers on the affected side vs. the unaffected side in poststroke hemiparetic patients. DM caused a significantly poorer TPD in the fingers on the affected side in poststroke patients but had no significant effect on the fingers on the unaffected side.