The AsTex: clinimetric properties of a new tool for evaluating hand sensation following stroke

Assessment for Tactile Perception in Children With Cerebral Palsy

IMPORTANCE

Impaired tactile perception frequently accompanies motor deficits in children with cerebral palsy (CP). Assessing tactile perception precisely for children with CP remains challenging because of a lack of assessments with robust psychometric evidence or standard procedures.

OBJECTIVE

To develop a standardized assessment tool, the Tactile Perceptual Test (TPT), for measuring tactile perception in children with CP and to examine its psychometric properties.

DESIGN

Observational study design.

SETTING

University research laboratory and medical center.

PARTICIPANTS

Children with CP (n = 100) and typical development (TD; n = 50).

OUTCOMES AND MEASURES

The TPT includes four subtests measuring stereognosis, roughness, hardness, and heaviness. Three comparator instruments, Semmes-Weinstein monofilaments, Two-Point Discrimination, and the stereognosis subtest of the Revised Nottingham Sensory Assessment, were used for convergent validity.

RESULTS

Good test-retest reliability was confirmed for all of the TPT subtests. The values of minimal detectable change were acceptable. Moderate correlations between the TPT and comparator instruments were found, as expected. For known-groups validity, the significant difference was confirmed between children with CP and those with TD.

CONCLUSIONS AND RELEVANCE

The TPT is a reliable and valid measure for multiple subdomains of tactile perception in children with CP. This tactile assessment may help clarify tactile performance to provide appropriate, precise interventions. What This Article Adds: The TPT measures tactile perception in children with CP. It has four subdomains of tactile perception that could facilitate prioritization of tactile treatment of specific subdomains and thereby aid in the provision of appropriate interventions.

Characterizing Touch Discrimination Impairment from Pooled Stroke Samples Using the Tactile Discrimination Test: Updated Criteria for Interpretation and Brief Test Version for Use in Clinical Practice Settings

Somatosensory loss post-stroke is common, with touch sensation characteristically impaired. Yet, quantitative, standardized measures of touch discrimination available for clinical use are currently limited. We aimed to characterize touch impairment and re-establish the criterion of abnormality of the Tactile Discrimination Test (TDT) using pooled data and to determine the sensitivity and specificity of briefer test versions. Baseline data from stroke survivors (n = 207) and older neurologically healthy controls (n = 100) assessed on the TDT was extracted. Scores were re-analyzed to determine an updated criterion of impairment and the ability of brief test versions to detect impairment. Updated scoring using an area score was used to calculate the TDT percent maximum area (PMA) score. Touch impairment was common for the contralesional hand (83%) but also present in the ipsilesional hand (42%). The criterion of abnormality was established as 73.1 PMA across older adults and genders. High sensitivity and specificity were found for briefer versions of the TDT (25 vs. 50 trials; 12 or 15 vs. 25 trials), with sensitivity ranging between 91.8 and 96.4% and specificity between 72.5 and 95.0%. Conclusion: Updated criterion of abnormality and the high sensitivity and specificity of brief test versions support the use of the TDT in clinical practice settings.

Psychometric properties of light touch-pressure somatosensory measures in adults with neurological disorders: A systematic review

OBJECTIVES

To critically appraise the psychometric properties of light touch-pressure somatosensory assessments to provide guidance for tool selection for research or clinical purposes.

DATA SOURCES

MEDLINE, CINAHL, and PsycInfo were searched for research indexed from January 1990-November 2022. English language and human subject filters were applied. "Somatosensation", "psychometric property", and "nervous system-based health condition" search terms were combined. Grey literature and manual searches were conducted to ensure thoroughness.

REVIEW METHODS

The reliability, construct validity, and/or measurement error of light touch-pressure assessments was reviewed in adult populations with neurological disorders. Reviewers individually extracted and managed data including patient demographics, assessment characteristics, statistical methods, and psychometric properties. Methodological quality of results was evaluated using an adapted version of the COnsensus-based Standards for the selection of health Measurement INstruments checklist.

RESULTS

Thirty-three of 1938 articles were included for review. Fifteen light touch-pressure assessments demonstrated good or excellent reliability. Further, five of those 15 assessments achieved adequate validity and one of the 15 assessments achieved adequate measurement error. Over 80% of the summarized study ratings were determined to be of low or very low quality.

CONCLUSION

We recommend using electrical perceptual tests, the Semmes-Weinstein Monofilaments, the Graded and Redefined Assessment of Strength, Sensibility, and Prehension, and the Moving Touch Pressure Test given that they demonstrated good to excellent results in three psychometric properties. No other assessment achieved adequate ratings in more than two psychometric properties. This review highlights a fundamental need to develop sensory assessments that are reliable, valid, and sensitive to change.

Assessing Plantar Sensation in the Foot Using the Foot Roughness Discrimination Test (FoRDT): A Reliability and Validity Study in Stroke

BACKGROUND

The plantar foot represents a sensory dynamometric map and is essential for balance and gait control. Sensory impairments are common, yet often difficult to quantify in neurological conditions, particularly stroke. A functionally oriented and quantifiable assessment, the Foot Roughness Discrimination Test (FoRDT), was developed to address these shortcomings.

OBJECTIVE

To evaluate inter- and intrarater reliability, convergent and discriminant validity of the FoRDT.

DESIGN

Test-retest design.

SETTING

Hospital outpatient.

PARTICIPANTS

Thirty-two people with stroke (mean age 70 years) at least 3 months after stroke, and 32 healthy, age-matched controls (mean age 70).

MAIN OUTCOME MEASURES

Roughness discrimination thresholds were quantified utilizing acrylic foot plates, laser cut to produce graded spatial gratings. Stroke participants were tested on three occasions, and by two different raters. Inter- and intrarater reliability and agreement were evaluated with Intraclass Correlation Coefficients and Bland-Altman plots. Convergent validity was evaluated through Spearman rank correlation coefficients (rho) between the FoRDT and the Erasmus modified Nottingham Sensory Assessment (EmNSA).

RESULTS

Intra- and interrater reliability and agreement were excellent (ICC =0.86 [95% CI 0.72-0.92] and 0.90 [95% CI 0.76-0.96]). Discriminant validity was demonstrated through significant differences in FoRDT between stroke and control participants (P < .001). Stroke fallers had statistically significant higher FoRDT scores compared with nonfallers (P = .01). Convergent validity was demonstrated through significant and strong correlations (rho) with the Erasmus MC Nottingham Sensory Assessment (r = .69, P < .01). Receiver operator characteristic curve analysis indicated the novel test to have excellent sensitivity and specificity in predicting the presence of self-reported sensory impairments. Functional Reach test significantly correlated with FoRDT (r = .62, P < .01) whereas measures of postural sway and gait speed did not (r = .16-.26, P > .05).

CONCLUSIONS

This simple and functionally oriented test of plantar sensation is reliable, valid, and clinically feasible for use in an ambulatory, chronic stroke and older population. It offers clinicians and researchers a sensitive and robust sensory measure and may further support the evaluation of rehabilitation targeting foot sensation.

LEVEL OF EVIDENCE

III.

Measuring dexterity in the podiatrist population: a cross-sectional comparison of novice students and experienced podiatrists

BACKGROUND

There is no 'gold-standard' for the evaluation of dexterity for the health professional or podiatrist populations. This has resulted in a broad array of generalised tests to evaluate dexterity. Thus, the aim was to determine which objective generalised dexterity tests are best suited to evaluating dexterity in a podiatry student population.

METHODS

A cohort of Novice podiatry students and Experienced podiatrists were recruited and evaluated on a battery of dexterity tests selected to evaluate a variety of different elements. Group differences were evaluated statistically and regression undertaken on significant test outcomes.

RESULTS

A total of 108 participants were recruited with 54 participants in each of the Novice and Experienced groups. Five of the eight tests were able to discriminate dexterous ability of participants in the Novice and Experienced groups. These included the Grip-lift task, GPT, P-MVC, G-MVC and the AsTex® sensory discrimination test. These tests comprised a total of 11 significant dependent variables (p <  0.05). From the test battery, outcomes were able to predict 79% of the group membership. Age and experience did not explain within-group variability for the Experienced group.

CONCLUSION

Whilst the Experienced group displayed superior performance in strength and speed, the Novice group showed superior coordination and sensory ability. From these findings, we would recommend that outcomes from the Grooved Pegboard Test, Grip-lift task, Grip Strength test and Pinch Grip strength test be used to evaluate elements of dexterity in this population.

Early intensive hand rehabilitation is not more effective than usual care plus one-to-one hand therapy in people with sub-acute spinal cord injury ('Hands On'): a randomised trial

QUESTION

What is the effect of adding an intensive task-specific hand-training program involving functional electrical stimulation to a combination of usual care plus three 15-minute sessions per week of one-to-one hand therapy in people with sub-acute tetraplegia?

DESIGN

A parallel group, randomised, controlled trial. Participants were randomly assigned (1:1) via a computer-generated concealed block randomisation procedure to either a control or experimental intervention.

PARTICIPANTS

Seventy people with C2 to T1 motor complete or incomplete tetraplegia within 6 months of injury. Participants were recruited from seven spinal units in Australia and New Zealand.

INTERVENTION

Experimental participants received intensive training for one hand. Intensive training consisted of training with an instrumented exercise workstation in conjunction with functional electrical stimulation for 1hour per day, 5 days per week for 8 weeks. Both groups received usual care and 15minutes of one-to-one hand therapy three times per week without functional electrical stimulation.

OUTCOME MEASURES

The primary outcome was the modified Action Research Arm Test reflecting arm and hand function, which was assessed at the end of the intervention, that is, 11 weeks after randomisation. Secondary outcomes were measured at 11 and 26 weeks.

RESULTS

Sixty-six (94%) participants completed the post-intervention assessment and were included in the primary intention-to-treat analysis. The mean (SD) modified Action Research Arm Test score for experimental and control participants at the post-intervention assessment was 36.5 points (SD 16.0) and 33.2 points (SD 17.5), respectively, with an adjusted mean between-group difference of 0.9 points (95% CI -4.1 to 5.9).

CONCLUSION

Adding an intensive task-specific hand-training program involving functional electrical stimulation to a combination of usual care plus three 15-minute sessions per week of one-to-one hand therapy does not improve hand function in people with sub-acute tetraplegia.

REGISTRATION

Australian and New Zealand Trial Registry ACTRN12609000695202 and ClinicalTrials.gov NCT01086930. [Harvey LA, Dunlop SA, Churilov L, Galea MP, Spinal Cord Injury Physical Activity (SCIPA) Hands On Trial Collaborators (2017) Early intensive hand rehabilitation is not more effective than usual care plus one-to-one hand therapy in people with sub-acute spinal cord injury ('Hands On'): a randomised trial. Journal of Physiotherapy 63: 197-204].

SITAR: a system for independent task-oriented assessment and rehabilitation

INTRODUCTION

Over recent years, task-oriented training has emerged as a dominant approach in neurorehabilitation. This article presents a novel, sensor-based system for independent task-oriented assessment and rehabilitation (SITAR) of the upper limb.

METHODS

The SITAR is an ecosystem of interactive devices including a touch and force-sensitive tabletop and a set of intelligent objects enabling functional interaction. In contrast to most existing sensor-based systems, SITAR provides natural training of visuomotor coordination through collocated visual and haptic workspaces alongside multimodal feedback, facilitating learning and its transfer to real tasks. We illustrate the possibilities offered by the SITAR for sensorimotor assessment and therapy through pilot assessment and usability studies.

RESULTS

The pilot data from the assessment study demonstrates how the system can be used to assess different aspects of upper limb reaching, pick-and-place and sensory tactile resolution tasks. The pilot usability study indicates that patients are able to train arm-reaching movements independently using the SITAR with minimal involvement of the therapist and that they were motivated to pursue the SITAR-based therapy.

CONCLUSION

SITAR is a versatile, non-robotic tool that can be used to implement a range of therapeutic exercises and assessments for different types of patients, which is particularly well-suited for task-oriented training.

Peripheral neuropathy in the hands of people with diabetes mellitus

AIMS

Peripheral sensorimotor neuropathy is a recognised complication of diabetes mellitus however little attention has been given to its development in the hands. The aim of this study was to determine the prevalence of sensory impairment in the hands of participants with diabetes, the agreement between two measurement tools for assessing sensation and the association between hand sensibility, age, glycaemic control and end-organ damage.

METHODS

A total of 162 participants were recruited and divided into two cohorts based on a diagnosis of diabetes. Participants were tested for the presence of hand neuropathy using Semmes-Weinstein monofilaments and the AsTex™. Medical records of participants with diabetes were accessed retrospectively to determine glycaemic control and diabetes complications.

RESULTS

A highly statistically significant association was found between neuropathy and diabetes status (P<0.001) on monofilament testing. The prevalence of neuropathy was 64% compared to ∼10% amongst participants without diabetes. Age, male gender and diabetic retinopathy were associated with neuropathy. The AsTex™ identified participants with diminished protective sensation on monofilament testing.

CONCLUSIONS

This study demonstrates a relationship between diabetes and upper limb neuropathy. Age, male gender and retinopathy were associated with diminished hand sensation. The AsTex™ may have a role as a screening tool for identifying clinically significant hand neuropathy.

Early intensive hand rehabilitation is not more effective than usual care plus one-to-one hand therapy in people with sub-acute spinal cord injury ('Hands On'): a randomised trial

QUESTION

What is the effect of adding an intensive task-specific hand-training program involving functional electrical stimulation to a combination of usual care plus three 15-minute sessions per week of one-to-one hand therapy in people with sub-acute tetraplegia?

DESIGN

A parallel group, randomised, controlled trial. Participants were randomly assigned (1:1) via a computer-generated concealed block randomisation procedure to either a control or experimental intervention.

PARTICIPANTS

Seventy people with C2 to T1 motor complete or incomplete tetraplegia within 6 months of injury. Participants were recruited from seven spinal units in Australia and New Zealand.

INTERVENTION

Experimental participants received intensive training for one hand. Intensive training consisted of training with an instrumented exercise workstation in conjunction with functional electrical stimulation for 1 hour per day, 5 days per week for 8 weeks. Both groups received usual care and 15 minutes of one-to-one hand therapy three times per week without functional electrical stimulation.

OUTCOME MEASURES

The primary outcome was the modified Action Research Arm Test reflecting arm and hand function, which was assessed at the end of the intervention, that is, 11 weeks after randomisation. Secondary outcomes were measured at 11 and 26 weeks.

RESULTS

Sixty-six (94%) participants completed the post-intervention assessment and were included in the primary intention-to-treat analysis. The mean modified Action Research Arm Test score for experimental and control participants at the post-intervention assessment was 36.5 points (SD 16.0) and 33.2 points (SD 17.5), respectively, with an adjusted mean between-group difference of 0.9 points (95% CI -4.1 to 5.9).

CONCLUSION

Adding an intensive task-specific hand-training program involving functional electrical stimulation to a combination of usual care plus three 15-minute sessions per week of one-to-one hand therapy does not improve hand function in people with sub-acute tetraplegia.

REGISTRATION

Australian and New Zealand Trial Registry ACTRN12609000695202 and ClinicalTrials.gov NCT01086930.

Mitii™ ABI: study protocol of a randomised controlled trial of a web-based multi-modal training program for children and adolescents with an Acquired Brain Injury (ABI)

BACKGROUND

Acquired brain injury (ABI) refers to multiple disabilities arising from damage to the brain acquired after birth. Children with an ABI may experience physical, cognitive, social and emotional-behavioural impairments which can impact their ability to participate in activities of daily living (ADL). Recent developments in technology have led to the emergence of internet-delivered therapy programs. "Move it to improve it" (Mitii™) is a web-based multi-modal therapy that comprises upper limb (UL) and cognitive training within the context of meaningful physical activity. The proposed study aims to compare the efficacy of Mitii™ to usual care to improve ADL motor and processing skills, gross motor capacity, UL and executive functioning in a randomised waitlist controlled trial.

METHODS/DESIGN

Sixty independently ambulant children (30 in each group) at least 12 months post ABI will be recruited to participate in this trial. Children will be matched in pairs at baseline and randomly allocated to receive either 20 weeks of Mitii™ training (30 min per day, six days a week, with a potential total dose of 60 h) immediately, or be waitlisted for 20 weeks. Outcomes will be assessed at baseline, immediately post-intervention and at 20 weeks post-intervention. The primary outcomes will be the Assessment of Motor and Process Skills and 30 s repetition maximum of functional strength exercises (sit-to-stand, step-ups and half kneel to stand). Measures of body structure and functions, activity, participation and quality of life will assess the efficacy of Mitii™ across all domains of the International Classification of Functioning, Disability and Health framework. A subset of children will undertake three tesla (3T) magnetic resonance imaging scans to evaluate functional neurovascular changes, structural imaging, diffusion imaging and resting state functional connectivity before and after intervention.

DISCUSSION

Mitii™ provides an alternative approach to deliver intensive therapy for children with an ABI in the convenience of the home environment. If Mitii™ is found to be effective, it may offer an accessible and inexpensive intervention option to increase therapy dose.

TRIAL REGISTRATION

ANZCTR12613000403730.

Outcome measures for hand function naturally reveal three latent domains in older adults: strength, coordinated upper extremity function, and sensorimotor processing

Understanding the mapping between individual outcome measures and the latent functional domains of interest is critical to a quantitative evaluation and rehabilitation of hand function. We examined whether and how the associations among six hand-specific outcome measures reveal latent functional domains in elderly individuals. We asked 66 healthy older adult participants (38F, 28M, 66.1 ± 11.6 years, range: 45–88 years) and 33 older adults (65.8 ± 9.7 years, 44–81 years, 51 hands) diagnosed with osteoarthritis (OA) of the carpometacarpal (CMC) joint, to complete six functional assessments: hand strength (Grip, Key and Precision Pinch), Box and Block, Nine Hole Pegboard, and Strength-Dexterity tests. The first three principal components suffice to explain 86% of variance among the six outcome measures in healthy older adults, and 84% of variance in older adults with CMC OA. The composition of these dominant associations revealed three distinct latent functional domains: strength, coordinated upper extremity function, and sensorimotor processing. Furthermore, in participants with thumb CMC OA we found a blurring of the associations between the latent functional domains of strength and coordinated upper extremity function. This motivates future work to understand how the physiological effects of thumb CMC OA lead upper extremity coordination to become strongly associated with strength, while dynamic sensorimotor ability remains an independent functional domain. Thus, when assessing the level of hand function in our growing older adult populations, it is particularly important to acknowledge its multidimensional nature—and explicitly consider how each outcome measure maps to these three latent and fundamental domains of function. Moreover, this ability to distinguish among latent functional domains may facilitate the design of treatment modalities to target the rehabilitation of each of them.

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.

The prevalence and magnitude of impaired cutaneous sensation across the hand in the chronic period post-stroke

Sensation is commonly impaired immediately post-stroke but little is known about the long-term changes in cutaneous sensation that have the capacity to adversely impact independence and motor-function. We investigated cutaneous sensory thresholds across the hand in the chronic post-stroke period. Cutaneous sensation was assessed in 42 community-dwelling stroke patients and compared to 36 healthy subjects. Sensation was tested with calibrated monofilaments at 6 sites on the hand that covered the median, ulnar and radial innervation territories and included both glabrous (hairless) and hairy skin. The motor-function of stroke patients was assessed with the Wolf Motor Function Test and the upper-limb motor Fugl-Meyer Assessment. Impaired cutaneous sensation was defined as monofilament thresholds >3 SD above the mean of healthy subjects and good sensation was ≤ 3 SD. Cutaneous sensation was impaired for 33% of patients and was 40-84% worse on the more-affected side compared to healthy subjects depending on the site (p<0.05). When the stroke patient data were pooled cutaneous sensation fell within the healthy range, although ∼ 1/3 of patients were classified with impaired sensation. Classification by motor-function revealed low levels of impaired sensation. The magnitude of sensory loss was only apparent when the sensory-function of stroke patients was classified as good or impaired. Sensation was most impaired on the dorsum of the hand where age-related changes in monofilament thresholds are minimal in healthy subjects. Although patients with both high and low motor-function had poor cutaneous sensation, overall patients with low motor-function had poorer cutaneous sensation than those with higher motor-function, and relationships were found between motor impairments and sensation at the fingertip and palm. These results emphasize the importance of identifying the presence and magnitude of cutaneous sensory impairments in the chronic period after stroke.

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.

Age-related changes in cutaneous sensation in the healthy human hand

Cutaneous sensation deteriorates with age. It is not known if this change is consistent over the entire hand or if sensation is affected by changes in skin mechanics. Cutaneous perceptual thresholds were tested at eight sites in the glabrous skin and two in the hairy skin of both hands in 70 subjects (20-88 years), five male and five female per decade, using calibrated von Frey filaments, two-point discrimination, and texture discrimination. Venous occlusion at the wrist (40 ± 10 mmHg) and moisturizer were used to alter skin mechanics. Cutaneous thresholds increased significantly with age (p < 0.001); von Frey thresholds were 0.04 g [0.02-0.07] (median and interquartile range) in the 20s and 0.16 g [0.04-0.4] in the 80s, with differences between hands for older females (p = 0.044) but not males. The pattern of changes in cutaneous sensation varied according to the site tested with smaller changes on the fingers compared to the palm. Two-point discrimination deteriorated with age (p = 0.046), but with no interaction between sex, handedness, or changes in skin mechanics. There were no significant differences for texture discrimination. Changes in skin mechanics improved cutaneous thresholds in the oldest males after moisturizing (p = 0.001) but not otherwise. These results emphasize the complex pattern of age-related deterioration in cutaneous sensation with differences between sexes, the hands, sites on the hand, and the mode of testing. As the index fingertip is not a sensitive indicator of sensory decline, the minimum assessment of age-related changes in cutaneous sensation should include both hands, and sites on the palm.

COMBIT: protocol of a randomised comparison trial of COMbined modified constraint induced movement therapy and bimanual intensive training with distributed model of standard upper limb rehabilitation in children with congenital hemiplegia

INTRODUCTION

Children with congenital hemiplegia often present with limitations in using their impaired upper limb which impacts on independence in activities of daily living, societal participation and quality of life. Traditional therapy has adopted a bimanual training approach (BIM) and more recently, modified constraint induced movement therapy (mCIMT) has emerged as a promising unimanual approach. Evidence of enhanced neuroplasticity following mCIMT suggests that the sequential application of mCIMT followed by bimanual training may optimise outcomes (Hybrid CIMT). It remains unclear whether more intensely delivered group based interventions (hCIMT) are superior to distributed models of individualised therapy. This study aims to determine the optimal density of upper limb training for children with congenital hemiplegia.

METHODS AND ANALYSES

A total of 50 children (25 in each group) with congenital hemiplegia will be recruited to participate in this randomized comparison trial. Children will be matched in pairs at baseline and randomly allocated to receive an intensive block group hybrid model of combined mCIMT followed by intensive bimanual training delivered in a day camp model (COMBiT; total dose 45 hours direct, 10 hours of indirect therapy), or a distributed model of standard occupational therapy and physiotherapy care (SC) over 12 weeks (total 45 hours direct and indirect therapy). Outcomes will be assessed at 13 weeks after commencement, and retention of effects tested at 26 weeks. The primary outcomes will be bimanual coordination and unimanual upper-limb capacity. Secondary outcomes will be participation and quality of life. Advanced brain imaging will assess neurovascular changes in response to treatment. Analysis will follow standard principles for RCTs, using two-group comparisons on all participants on an intention-to-treat basis. Comparisons will be between treatment groups using generalized linear models.

TRIAL REGISTRATION

ACTRN12613000181707.

Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE): a randomized controlled trial protocol

BACKGROUND

Residual disability after stroke is substantial; 65% of patients at 6 months are unable to incorporate the impaired upper extremity into daily activities. Task-oriented training programs are rapidly being adopted into clinical practice. In the absence of any consensus on the essential elements or dose of task-specific training, an urgent need exists for a well-designed trial to determine the effectiveness of a specific multidimensional task-based program governed by a comprehensive set of evidence-based principles. The Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) Stroke Initiative is a parallel group, three-arm, single blind, superiority randomized controlled trial of a theoretically-defensible, upper extremity rehabilitation program provided in the outpatient setting.The primary objective of ICARE is to determine if there is a greater improvement in arm and hand recovery one year after randomization in participants receiving a structured training program termed Accelerated Skill Acquisition Program (ASAP), compared to participants receiving usual and customary therapy of an equivalent dose (DEUCC). Two secondary objectives are to compare ASAP to a true (active monitoring only) usual and customary (UCC) therapy group and to compare DEUCC and UCC.

METHODS/DESIGN

Following baseline assessment, participants are randomized by site, stratified for stroke duration and motor severity. 360 adults will be randomized, 14 to 106 days following ischemic or hemorrhagic stroke onset, with mild to moderate upper extremity impairment, recruited at sites in Atlanta, Los Angeles and Washington, D.C. The Wolf Motor Function Test (WMFT) time score is the primary outcome at 1 year post-randomization. The Stroke Impact Scale (SIS) hand domain is a secondary outcome measure.The design includes concealed allocation during recruitment, screening and baseline, blinded outcome assessment and intention to treat analyses. Our primary hypothesis is that the improvement in log-transformed WMFT time will be greater for the ASAP than the DEUCC group. This pre-planned hypothesis will be tested at a significance level of 0.05.

DISCUSSION

ICARE will test whether ASAP is superior to the same number of hours of usual therapy. Pre-specified secondary analyses will test whether 30 hours of usual therapy is superior to current usual and customary therapy not controlled for dose.

TRIAL REGISTRATION

www.ClinicalTrials.gov Identifier: NCT00871715

Reproducibility of tactile assessments for children with unilateral cerebral palsy

A systematic review identified tactile assessments used in children with cerebral palsy (CP), but their reproducibility is unknown. Sixteen children with unilateral CP and 31 typically developing children (TDC) were assessed 2-4 weeks apart. Test-retest percent agreements within one point for children with unilateral CP (and TDC) were Semmes-Weinstein monofilaments: 75% (90%); single-point localization: 69% (97%); static two-point discrimination: 93% (97%); and moving two-point discrimination: 87% (97%). Test-retest reliability for registration and unilateral spatial tactile perception tests was high in children with CP (intraclass correlation coefficient [ICC] = 0.79-0.96). Two tests demonstrated a learning effect for children with CP, double simultaneous and tactile texture perception. Stereognosis had a ceiling effect for TDC (ICC = 0) and variability for children with CP (% exact agreement = 47%-50%). The Semmes-Weinstein monofilaments, single-point localization, and both static and moving two-point discrimination are recommended for use in practice and research. Although recommended to provide a comprehensive assessment, the measures of double simultaneous, stereognosis, and tactile texture perception may not be responsive to change over time in children with unilateral CP.

Measures of sensation in neurological conditions: a systematic review

Objective: To systematically review the psychometric properties and clinical utility of measures of sensation in neurological conditions to inform future research studies and clinical practice.

Data sources: Electronic databases (MEDLINE, CINAHL, EMBASE and AMED) were searched from their inception to December 2010.

Review methods: Search terms were used to identify articles that investigated any sensory measures in neurological conditions. Data about their psychometric properties and clinical utility were extracted and analyzed independently. The strength of the psychometric properties and clinical utility were assessed following recommendations. 1

Results: Sixteen sensory measures were identified. Inter-rater reliability and redundancy of testing protocols are particular issues for this area of assessment. Eleven were rejected because they were not available for a researcher or clinician to use. Of the remaining five measures, the Erasmus MC modifications of the Nottingham Sensory Assessment and the Sensory section of the Fugl–Meyer Assessment showed the best balance of clinical utility and psychometric properties.

Conclusion: Many measures of sensory impairment have been used in research but few have been fully developed to produce robust data and be easy to use. At present, the sensory section of the Fugl–Meyer Assessment and the Erasmus MC modifications of the Nottingham Sensory Assessment show the most effective balance of usability and robustness, when delivered according to the operating instructions.

Early intensive hand rehabilitation after spinal cord injury ("Hands On"): a protocol for a randomised controlled trial

BACKGROUND

Loss of hand function is one of the most devastating consequences of spinal cord injury. Intensive hand training provided on an instrumented exercise workstation in conjunction with functional electrical stimulation may enhance neural recovery and hand function. The aim of this trial is to compare usual care with an 8-week program of intensive hand training and functional electrical stimulation.

METHODS/DESIGN

A multicentre randomised controlled trial will be undertaken. Seventy-eight participants with recent tetraplegia (C2 to T1 motor complete or incomplete) undergoing inpatient rehabilitation will be recruited from seven spinal cord injury units in Australia and New Zealand and will be randomised to a control or experimental group. Control participants will receive usual care. Experimental participants will receive usual care and an 8-week program of intensive unilateral hand training using an instrumented exercise workstation and functional electrical stimulation. Participants will drive the functional electrical stimulation of their target hands via a behind-the-ear bluetooth device, which is sensitive to tooth clicks. The bluetooth device will enable the use of various manipulanda to practice functional activities embedded within computer-based games and activities. Training will be provided for one hour, 5 days per week, during the 8-week intervention period. The primary outcome is the Action Research Arm Test. Secondary outcomes include measurements of strength, sensation, function, quality of life and cost effectiveness. All outcomes will be taken at baseline, 8 weeks, 6 months and 12 months by assessors blinded to group allocation. Recruitment commenced in December 2009.

DISCUSSION

The results of this trial will determine the effectiveness of an 8-week program of intensive hand training with functional electrical stimulation.

TRIAL REGISTRATION

NCT01086930 (12th March 2010)ACTRN12609000695202 (12th August 2009).