Potential predictors of motor and functional outcomes after distributed constraint-induced therapy for patients with stroke

Predictors of manual dexterity at 3 and 6 months after stroke: integration of clinical, neurophysiological, and neuroimaging factors

This retrospective study aimed to predict dexterity at 3 and 6 months post-stroke by integrating clinical, neurophysiological, and neuroimaging factors. We included 126 patients with first-ever, unilateral, and supratentorial stroke. Demographic, stroke characteristics, and initial clinical assessment variables [Mini-mental state examination and Fugl-Meyer Assessment Upper Extremity (FMA-UE)] were evaluated 2 weeks after stroke. Dexterity, measured using the Manual Function Test (MFT) hand subscore, was the primary outcome. The neurophysiological variables, upper limb somatosensory evoked potential (SEP) and motor evoked potential (MEP), were assessed 2 weeks post-stroke. The neuroimaging variable, fractional anisotropy (FA) of the corticospinal tract (CST), was assessed 3 weeks post-stroke. Multiple regression analysis revealed significant predictors for improved dexterity at 3 and 6 months post-stroke, including younger age, higher FMA-UE score, presence of waveforms in the SEP and MEP, and higher FA values in the CST (adjusted R 2  = 0.776, P  < 0.001 at 3 months; adjusted R 2  = 0.668, P  < 0.001 at 6 months; where MEP, SEP, and FA accounted together for an additional 0.079 and 0.166 of variance beyond age and FMA-UE, respectively). Subgroup analysis was conducted by categorizing the participants based on their initial hand function: those with no hand function (MFT hand subscore = 0) (N = 60) and those with a score >0 (N = 51). Initial FMA-UE was a primary predictive factor regardless of the time point or initial severity, whereas the presence of MEP was a significant predictor only in the group with no initial hand dexterity.

Effects of virtual reality-based motor control training on inflammation, oxidative stress, neuroplasticity and upper limb motor function in patients with chronic stroke: a randomized controlled trial

BACKGROUND

Immersive virtual reality (VR)-based motor control training (VRT) is an innovative approach to improve motor function in patients with stroke. Currently, outcome measures for immersive VRT mainly focus on motor function. However, serum biomarkers help detect precise and subtle physiological changes. Therefore, this study aimed to identify the effects of immersive VRT on inflammation, oxidative stress, neuroplasticity and upper limb motor function in stroke patients.

METHODS

Thirty patients with chronic stroke were randomized to the VRT or conventional occupational therapy (COT) groups. Serum biomarkers including interleukin 6 (IL-6), intracellular adhesion molecule 1 (ICAM-1), heme oxygenase 1 (HO-1), 8-hydroxy-2-deoxyguanosine (8-OHdG), and brain-derived neurotrophic factor (BDNF) were assessed to reflect inflammation, oxidative stress and neuroplasticity. Clinical assessments including active range of motion of the upper limb and the Fugl-Meyer Assessment for upper extremity (FMA-UE) were also used. Two-way mixed analyses of variance (ANOVAs) were used to examine the effects of the intervention (VRT and COT) and time on serum biomarkers and upper limb motor function.

RESULTS

We found significant time effects in serum IL-6 (p = 0.010), HO-1 (p = 0.002), 8-OHdG (p = 0.045), and all items/subscales of the clinical assessments (ps < 0.05), except FMA-UE-Coordination/Speed (p = 0.055). However, significant group effects existed only in items of the AROM-Elbow Extension (p = 0.007) and AROM-Forearm Pronation (p = 0.048). Moreover, significant interactions between time and group existed in item/subscales of FMA-UE-Shoulder/Elbow/Forearm (p = 0.004), FMA-UE-Total score (p = 0.008), and AROM-Shoulder Flexion (p = 0.001).

CONCLUSION

This was the first study to combine the effectiveness of immersive VRT using serum biomarkers as outcome measures. Our study demonstrated promising results that support the further application of commercial and immersive VR technologies in patients with chronic stroke.

Do somatosensory deficits predict efficacy of neurorehabilitation using neuromuscular electrical stimulation for moderate to severe motor paralysis of the upper limb in chronic stroke?

Background:

Various neurorehabilitation programs have been developed to promote recovery from motor impairment of upper extremities. However, the response of patients with chronic-phase stroke varies greatly. Prediction of the treatment response is important to provide appropriate and efficient rehabilitation. This study aimed to clarify whether clinical assessments, such as motor impairments and somatosensory deficits, before treatment could predict the treatment response in neurorehabilitation.

Methods:

The data from patients who underwent neurorehabilitation using closed-loop electromyography (EMG)-controlled neuromuscular electrical stimulation were retrospectively analyzed. A total of 66 patients with chronic-phase stroke with moderate to severe paralysis were included. The changes from baseline in the Fugl-Meyer Assessment–Upper Extremity (FMA-UE) and the Motor Activity Log-14 (MAL-14) of amount of use (AOU) and quality of movement (QOM) were used to assess treatment response, and multivariate logistic regression analysis was performed using the extracted candidate predictors, such as baseline clinical assessments, to identify predictors of FMA-UE and MAL-14 improvement.

Results:

FMA-UE and MAL-14 scores improved significantly after the intervention (FMA-UE p < 0.01, AOU p < 0.01, QOM p < 0.01). On multivariate logistic regression analysis, tactile sensory (p = 0.043) and hand function (p = 0.030) were both identified as significant predictors of FMA-UE improvement, tactile sensory (p = 0.047) was a significant predictor of AOU improvement, and hand function (p = 0.026) was a significant predictor of QOM improvement. The regression equations explained 71.2% of the variance in the improvement of FMA-UE, 69.7% of AOU, and 69.7% of QOM.

Conclusion:

Both motor and tactile sensory impairments predict improvement in motor function, tactile sensory impairment predicts improvement in the amount of paralytic hand use, and motor impairment predicts improvement in the quality of paralytic hand use following neurorehabilitation treatment in patients with moderate to severe paralysis in chronic-phase stroke. These findings may help select the appropriate treatment for patients with more severe paralysis and to maximize the treatment effect.

The Relationship between Neuropsychological Performance and Level of Direct Current Potential in Patients with Occupational Diseases from Exposure to Physical Factors

The aim of the study was to identify the peculiarities of neuropsychological indices disorders depending on changes in the level of constant potential in patients with occupational diseases as a result of physical factors.

Materials and methods. The study involved 60 patients with vibration disease caused by local vibration (group I), 106 patients with vibration disease caused by combined exposure to local and general vibration (group II), 101 civil aviation pilots with an established diagnosis of professional sensorineural hearing loss (group III), and 50 healthy men (group IV, comparison group) who were not exposed to vibration and noise due to the specifics of their professional activities. Methods of neuro-energy mapping and neuropsychological testing were used.

Results. In groups I–II, compared with group IV, an increase in local levels of constant potential (DC-potential level) in the central, right temporal, and central frontal parts of the brain (2.3 (6.5–3.8) mV; –0.3 (–2.1–2.1); 2.1 (–3.4–6.8) and –0.3 (–3.1–4.3); –2.24 (–6.4–3.8); 0.9 (–3.1–8.5) mV at p = 0.005, 0.007 and 0.004 respectively). Differences in the values of DC-potential level gradients in individuals of group III when compared with group IV reached the level of significance in the central, temporal, occipital leads relative to the central frontal (–5.0 (–13.1–3.8); –4.1 (–9.4–5.1); –2.1 (–10.9–6.6); –6.3 (–15.3–1.8) and 2.9 (–3.0–10.6); 2.2 (–4.5–13.8); 5.6 (–7.6–14.1); –1.4 (–7.5–3.9) mV at p = 0.008; 0.009; 0.009, and 0.007 respectively). Cognitive disorders in patients of groups I–III when compared with group IV correspond to a mild disorder of dynamic, constructive praxis and expressive speech (1.40 (0–1,6); 1.43 (0–1,7); 1.2 (0–1,5) and 0.3 (0–1); 0.2 (0–1); 0.06 (0–1) points at p = 0.008, 0.008 and 0.009 respectively).

Conclusions. A common neurofunctional sign of a mild impairment of the cognitive sphere in occupational diseases caused by physical factors is an increase in direct current potential level in the frontal-central and parieto-occipital regions, predominantly of the left hemisphere of the brain.

Is High-Intensity Interval Training Suitable to Promote Neuroplasticity and Cognitive Functions after Stroke?

Stroke-induced cognitive impairments affect the long-term quality of life. High-intensity interval training (HIIT) is now considered a promising strategy to enhance cognitive functions. This review is designed to examine the role of HIIT in promoting neuroplasticity processes and/or cognitive functions after stroke. The various methodological limitations related to the clinical relevance of studies on the exercise recommendations in individuals with stroke are first discussed. Then, the relevance of HIIT in improving neurotrophic factors expression, neurogenesis and synaptic plasticity is debated in both stroke and healthy individuals (humans and rodents). Moreover, HIIT may have a preventive role on stroke severity, as found in rodents. The potential role of HIIT in stroke rehabilitation is reinforced by findings showing its powerful neurogenic effect that might potentiate cognitive benefits induced by cognitive tasks. In addition, the clinical role of neuroplasticity observed in each hemisphere needs to be clarified by coupling more frequently to cellular/molecular measurements and behavioral testing.

Treatment Effects of Upper Limb Action Observation Therapy and Mirror Therapy on Rehabilitation Outcomes after Subacute Stroke: A Pilot Study

Background

Action observation therapy and mirror therapy, two promising rehabilitation strategies, are aimed at enhancing the motor learning and functional improvement of stroke patients through different patterns of visual feedback and observation.

Objective

This study investigated and compared the treatment effects of the action observation therapy, mirror therapy, and active control intervention on motor and functional outcomes of stroke patients.

Methods

Twenty-one patients with subacute stroke were recruited in this study. All patients were randomly assigned to the action observation therapy, mirror therapy, or active control intervention for 3 weeks. Outcome measures were conducted at baseline, immediately after treatment, and at 3-month follow-up. The primary outcome was the Fugl-Meyer Assessment, and secondary outcomes included the Box and Block Test, Functional Independence Measure, and Stroke Impact Scale. Descriptive analyses and the number of patients whose change score achieved minimal clinically important difference were reported.

Results

Both the action observation therapy and active control intervention showed similar improvements on the Fugl-Meyer Assessment, Box and Block Test, and Stroke Impact Scale. Moreover, the action observation therapy had a greater improvement on the Functional Independence Measure than the other 2 groups did. However, the mirror therapy group gained the least improvements on the outcomes.

Conclusion

The preliminary results found that the patients in the action observation therapy and active control intervention groups had comparable benefits, suggesting that the 2 treatments might be used as an alternative to each other. A further large-scale study with at least 20 patients in each group to validate the study findings is needed. This trial is registered with NCT02871700.

Predicting Improved Daily Use of the More Affected Arm Poststroke Following Constraint-Induced Movement Therapy

BACKGROUND

Constraint-induced movement therapy (CI therapy) produces, on average, large and clinically meaningful improvements in the daily use of a more affected upper extremity in individuals with hemiparesis. However, individual responses vary widely.

OBJECTIVE

The study objective was to investigate the extent to which individual characteristics before treatment predict improved use of the more affected arm following CI therapy.

DESIGN

This study was a retrospective analysis of 47 people who had chronic (> 6 months) mild to moderate upper extremity hemiparesis and were consecutively enrolled in 2 CI therapy randomized controlled trials.

METHODS

An enhanced probabilistic neural network model predicted whether individuals showed a low, medium, or high response to CI therapy, as measured with the Motor Activity Log, on the basis of the following baseline assessments: Wolf Motor Function Test, Semmes-Weinstein Monofilament Test of touch threshold, Motor Activity Log, and Montreal Cognitive Assessment. Then, a neural dynamic classification algorithm was applied to improve prognostic accuracy using the most accurate combination obtained in the previous step.

RESULTS

Motor ability and tactile sense predicted improvement in arm use for daily activities following intensive upper extremity rehabilitation with an accuracy of nearly 100%. Complex patterns of interaction among these predictors were observed.

LIMITATIONS

The fact that this study was a retrospective analysis with a moderate sample size was a limitation.

CONCLUSIONS

Advanced machine learning/classification algorithms produce more accurate personalized predictions of rehabilitation outcomes than commonly used general linear models.

Predictors of functional and motor outcomes following upper limb robot-assisted therapy after stroke

Robot-assisted therapy is an effective treatment for stroke patients and has recently gained popularity. Clinicians and researchers are trying to identify predictors to stratify patients for ensuring better stroke rehabilitation outcomes. However, previous studies have reported controversial results regarding the predictors of upper limb recovery after robot-assisted therapy. Our objective was to determine whether the demographic and clinical characteristics of stroke patients influence the motor and functional outcomes after robot-assisted therapy. We conducted a retrospective analysis of 48 hemiplegic patients who performed upper limb goal-directed tasks using RAPAEL Smart Glove (Neofect, Gyeonggi-do, Republic of Korea). Robot-assisted therapy was administered for 5 days a week over 4 weeks, and each session was for 30 minutes. The parameters of the primary outcomes after robot-assisted therapy were measured with the manual function test and functional independence measure. Correlation analysis showed that age, initial cognitive function, and the initial manual function test and the Modified Ashworth Scale for upper extremity scores were significant factors for independently predicting functional outcomes after robot-assisted therapy. Linear regression analysis revealed that the initial Mini-Mental State Examination (P < 0.001) and initial manual function test (P < 0.001) scores were significant predictors of the primary outcomes. In conclusion, our study suggests that stroke patients presenting with less spasticity, better initial cognitive function, and better initial motor function have a significant correlation with the functional outcomes after robot-assisted therapy.

Predictors of Clinically Important Changes in Actual and Perceived Functional Arm Use of the Affected Upper Limb After Rehabilitative Therapy in Chronic Stroke

OBJECTIVE

To identify the predictors of minimal clinically important changes in actual and perceived functional arm use of the affected upper limb after rehabilitative therapy.

DESIGN

Retrospective, observational cohort study.

SETTING

Outpatient rehabilitation settings.

PARTICIPANTS

A cohort of 94 patients with chronic stroke.

INTERVENTIONS

Patients received robot-assisted therapy, mirror therapy, or combined therapy for 4 weeks.

MAIN OUTCOME MEASURES

The primary outcome measures, assessed pre- and post intervention, included actual functional arm use measured by an accelerometer and perceived functional arm use measured by the Motor Activity Log (MAL). Candidate predictors included age, sex, time after stroke, side of stroke, and scores on the Fugl-Meyer Assessment, Modified Ashworth Scale, Medical Research Council scale, Wolf Motor Function Test, MAL (quality of movement), and Nottingham Extended Activities of Daily Living.

RESULTS

Being male (odds ratio [OR], 3.17; 95% CI, 1.13-8.87) and having a higher than median Medical Research Council score (OR, 2.68; 95% CI, 1.12-6.41) significantly predicted minimal clinically important changes assessed by an accelerometer. Fugl-Meyer Assessment scores (odds ratio, 1.06; 95% CI, 1.02-1.11) were a significant predictor of achieving clinically important changes in MAL amount of use. Wolf Motor Function Test (quality) scores (OR, 3.05; 95% CI, 1.38-6.77) could predict clinically important improvements in MAL quality of movement.

CONCLUSIONS

Predictors of clinically important changes in the use of the affected upper limb after robot-assisted therapy, mirror therapy, or combined therapy in patients with chronic stroke for 4 weeks differ for actual vs perceived use. Further studies are recommended to validate these findings in a larger sample.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Predicting shoulder function after constraint-induced movement therapy: a retrospective cohort study

Background Several predictors have been associated with upper extremity (UE) recovery after stroke, but characteristics that predict shoulder function after constraint-induced movement therapy (CIMT) have not yet been identified. Objectives To identify predictors associated with satisfactory shoulder function in patients with reduced shoulder function at admission to CIMT. Methods One hundred and seventy five patients were treated using CIMT while in a specialized inpatient hospital. Satisfactory shoulder function was defined according to the functional ability scale of the Wolf Motor Function test. Predictors of satisfactory shoulder function after CIMT were identified using multivariable logistic regression. Results Better distal arm function and good proximal shoulder function on admission to CIMT were strong predictors of satisfactory shoulder function, while age and time of admission to CIMT since stroke were not. Seventeen percent of all CIMT-participants with reduced shoulder function pre-CIMT reached a level of satisfactory shoulder function after CIMT. Discussion A substantial part of patients with reduced shoulder function reached a level of satisfactory shoulder function after CIMT. Intensive CIMT training, comprising tasks that require both distal and proximal UE function, may increase shoulder function in patients with a potential functional reserve.

Gross motor ability predicts response to upper extremity rehabilitation in chronic stroke

The majority of rehabilitation research focuses on the comparative effectiveness of different interventions in groups of patients, while much less is currently known regarding individual factors that predict response to rehabilitation. In a recent article, the authors presented a prognostic model to identify the sensorimotor characteristics predictive of the extent of motor recovery after Constraint-Induced Movement (CI) therapy amongst individuals with chronic mild-to-moderate motor deficit using the enhanced probabilistic neural network (EPNN). This follow-up paper examines which participant characteristics are robust predictors of rehabilitation response irrespective of the training modality. To accomplish this, EPNN was first applied to predict treatment response amongst individuals who received a virtual-reality gaming intervention (utilizing the same enrollment criteria as the prior study). The combinations of predictors that yield high predictive validity for both therapies, using their respective datasets, were then identified. High predictive classification accuracy was achieved for both the gaming (94.7%) and combined datasets (94.5%). Though CI therapy employed primarily fine-motor training tasks and the gaming intervention emphasized gross-motor practice, larger improvements in gross motor function were observed within both datasets. Poorer gross motor ability at pre-treatment predicted better rehabilitation response in both the gaming and combined datasets. The conclusion of this research is that for individuals with chronic mild-to-moderate upper extremity hemiparesis, residual deficits in gross motor function are highly responsive to motor restorative interventions, irrespective of the modality of training.

Effects of a Single Session of High Intensity Interval Treadmill Training on Corticomotor Excitability following Stroke: Implications for Therapy

Objective. High intensity interval treadmill training (HIITT) has been gaining popularity for gait rehabilitation after stroke. In this study, we examined the changes in excitability of the lower limb motor cortical representation (M1) in chronic stroke survivors following a single session of HIITT. We also determined whether exercise-induced changes in excitability could be modulated by transcranial direct current stimulation (tDCS) enhanced with a paretic ankle skill acquisition task. Methods. Eleven individuals with chronic stroke participated in two 40-minute treadmill-training sessions: HIITT alone and HITT preceded by anodal tDCS enhanced with a skill acquisition task (e-tDCS+HIITT). Transcranial magnetic stimulation (TMS) was used to assess corticomotor excitability of paretic and nonparetic tibialis anterior (TA) muscles. Results. HIIT alone reduced paretic TA M1 excitability in 7 of 11 participants by ≥ 10%. e-tDCS+HIITT increased paretic TA M1 excitability and decreased nonparetic TA M1 excitability. Conclusions. HIITT suppresses corticomotor excitability in some people with chronic stroke. When HIITT is preceded by tDCS in combination with a skill acquisition task, the asymmetry of between-hemisphere corticomotor excitability is reduced. Significance. This study provides preliminary data indicating that the cardiovascular benefits of HIITT may be achieved without suppressing motor excitability in some stroke survivors.

Kinematic measures of Arm-trunk movements during unilateral and bilateral reaching predict clinically important change in perceived arm use in daily activities after intensive stroke rehabilitation

Background

Kinematic analysis has been used to objectively evaluate movement patterns, quality, and strategies during reaching tasks. However, no study has investigated whether kinematic variables during unilateral and bilateral reaching tasks predict a patient’s perceived arm use during activities of daily living (ADL) after an intensive intervention. Therefore, this study investigated whether kinematic measures during unilateral and bilateral reaching tasks before an intervention can predict clinically meaningful improvement in perceived arm use during ADL after intensive poststroke rehabilitation.

Methods

The study was a secondary analysis of 120 subjects with chronic stroke who received 90–120 min of intensive intervention every weekday for 3–4 weeks. Reaching kinematics during unilateral and bilateral tasks and the Motor Activity Log (MAL) were evaluated before and after the intervention.

Results

Kinematic variables explained 22 and 11 % of the variance in actual amount of use (AOU) and quality of movement (QOM), respectively, of MAL improvement during unilateral reaching tasks. Kinematic variables also explained 21 and 31 % of the variance in MAL-AOU and MAL-QOM, respectively, during bilateral reaching tasks. Selected kinematic variables, including endpoint variables, trunk involvement, and joint recruitment and interjoint coordination, were significant predictors for improvement in perceived arm use during ADL (P < 0.05).

Conclusions

Arm–trunk kinematics may be used to predict clinically meaningful improvement in perceived arm use during ADL after intensive rehabilitation. Involvement of interjoint coordination and trunk control variables as predictors in bilateral reaching models indicates that a high level of motor control (i.e., multijoint coordination) and trunk stability may be important in obtaining treatment gains in arm use, especially for bilateral daily activities, in intensive rehabilitation after stroke.

Proximal Fugl-Meyer Assessment Scores Predict Clinically Important Upper Limb Improvement After 3 Stroke Rehabilitative Interventions

OBJECTIVE

To identify the baseline motor characteristics of the patients who responded to 3 prominent intervention programs.

DESIGN

Observational cohort study.

SETTING

Outpatient rehabilitation clinics.

PARTICIPANTS

Individuals with chronic stroke (N=174).

INTERVENTIONS

Participants received 30 hours of constraint-induced movement therapy (CIMT), robot-assisted therapy, or mirror therapy (MT).

MAIN OUTCOME MEASURES

The primary outcome measure was the change score of the Upper Extremity Fugl-Meyer Assessment (UE-FMA). The potential predicting variables were baseline proximal, distal, and total UE-FMA and Action Research Arm Test scores. We combined polynomial regression analyses and the minimal clinically important difference to stratify the patients as responders and nonresponders for each intervention approach.

RESULTS

Baseline proximal UE-FMA scores significantly predicted clinically important improvement on the primary outcome measure after all 3 interventions. Participants with baseline proximal UE-FMA scores of approximately <30 benefited significantly from CIMT and robot-assisted therapy, whereas participants with scores between 21 and 35 demonstrated significant improvement after MT. Baseline distal and total UE-FMA and Action Research Arm Test scores could also predict upper limb improvement after CIMT and MT, but not after robot-assisted therapy.

CONCLUSIONS

This study could inform clinicians about the selection of suitable rehabilitation approaches to help patients achieve clinically meaningful improvement in upper extremity function.

Surface peroneal nerve stimulation in lower limb hemiparesis: effect on quantitative gait parameters

OBJECTIVE

The objective of this study was to evaluate possible mechanisms for functional improvement and compare ambulation training with surface peroneal nerve stimulation vs. usual care via quantitative gait analysis.

DESIGN

This study is a randomized controlled clinical trial.

SETTING

The setting of this study is a teaching hospital of an academic medical center.

PARTICIPANTS

One hundred ten chronic stroke survivors (>12 wks poststroke) with unilateral hemiparesis participated in this study.

INTERVENTIONS

The subjects were randomized to a surface peroneal nerve stimulation device or usual care intervention. The subjects were treated for 12 wks and followed up for 6-mo posttreatment.

MAIN OUTCOME MEASURES

Spatiotemporal, kinematic, and kinetic parameters of gait were the main outcome measures.

RESULTS

Cadence (F3,153 = 5.81, P = 0.012), stride length (F3,179 = 20.01, P < 0.001), walking speed (F3,167 = 18.2, P < 0.001), anterior-posterior ground reaction force (F3,164 = 6.61, P = 0.004), peak hip power in preswing (F3,156 = 8.76, P < 0.001), and peak ankle power at push-off (F3,149 = 6.38, P = 0.005) all improved with respect to time. However, peak ankle ankle dorsiflexion in swing (F3,184 = 4.99, P = 0.031) worsened. In general, the greatest change for all parameters occurred during the treatment period. There were no significant treatment group × time interaction effects for any of the spatiotemporal, kinematic, or kinetic parameters.

CONCLUSIONS

Gait training with peroneal nerve stimulation and usual care was associated with improvements in peak hip power in preswing and peak ankle power at push-off, which may have resulted in improved cadence, stride length, and walking speed; however, there were no differences between treatment groups. Both treatment groups also experienced a decrease in peak ankle ankle dorsiflexion in swing, although the clinical implications of this finding are unclear.

Predictors of motor, daily function, and quality-of-life improvements after upper-extremity robot-assisted rehabilitation in stroke

OBJECTIVE

A subgroup of patients benefiting most from robot-assisted therapy (RT) has not yet been described. We examined the predictors of improved outcomes after RT.

METHOD

Sixty-six patients with stroke receiving RT were analyzed. The outcome measures were the Fugl-Meyer Assessment (FMA), Wolf Motor Function Test (WMFT), Motor Activity Log (MAL), and Stroke Impact Scale (SIS). The potential predictors were age, side of lesion, time since onset, Modified Ashworth Scale (MAS) scores, accelerometer data, Box and Block Test (BBT) scores, and kinematic parameters.

RESULTS

BBT scores were predictive of FMA (29%) and MAL (9%-15%) improvements. Reduced shoulder flexion synergy, as measured by less shoulder abduction during forward reach, and MAS-distal were predictive of WMFT-function improvements. MAS-distal was predictive of SIS-physical improvements. Demographic variables did not predict outcomes.

CONCLUSION

Manual dexterity was a valuable predictor of motor impairment and daily function after RT. Outcomes at different levels may have different predictors.

Post-stroke spasticity: predictors of early development and considerations for therapeutic intervention

OBJECTIVE

The complexities of post-stroke spasticity (PSS), and the resultant difficulties in treating the disability, present a significant challenge to patients, stroke rehabilitation teams, and caregivers. Reducing the severity of spasticity and its long-term complications may be facilitated by early intervention, making identification of stroke patients at high risk for developing spasticity essential. Factors that predict which patients are at risk for the development of PSS are identified. TYPE: Systematic search and review

LITERATURE SURVEY

A PubMed search of the following terms was conducted: predictors OR risk factors AND stroke AND spasticity. Studies discussing predictors of early PSS development and factors predictive of motor/functional outcomes and recovery were selected and reviewed in detail.

SYNTHESIS

Several predictors of PSS have been proposed, based on studies conducted in patients within 6 months after stroke, including development of increased muscle tone, greater severity of paresis, hemihypesthesia, and low Barthel Index score. Predictors identified in later stages post-stroke (within 12 months) have also proved useful for clinicians, as has the consideration of predictors of motor and functional outcomes and recovery; yet there is a need for additional studies in this area. An understanding of these and other potential predictive factors--such as motor impairment, neurologic and sensory deficit, lesion volume and location, and associated diseases--has not progressed to the same extent and warrants further investigation.

CONCLUSION

The studies discussed in this review support the notion that early identification of factors predictive of PSS should significantly affect the course of intervention, help target individuals who would benefit most from specific types and intensities of therapy, and possibly provide better motor and functional outcomes.

A follow-up study on the relationship among participation, activity and motor function in survivors of stroke following constraint-induced therapy

PURPOSE

The aim of this follow-up study was to examine the relationships among motor function, activity and participation following constraint-induced therapy (CIT).

METHODS

In this correlational study, 12 individuals who had previously participated in CIT completed the Fugl Meyer Assessment for the Upper Extremity and Wolf Motor Function Test (motor assessments), the Motor Activity Log (activity measure) and the Daily Experiences of Pleasure, Productivity and Restoration Profile (participation measure). Motor and activity changes over time were assessed using repeated measures ANOVA and Friedman's tests. Spearman's correlations were used to examine the associations between the participation measure and motor and activity measures were analyzed using Spearman's correlations.

RESULTS

No statistically significant correlations were found among motor and activity scores and the amount of time spent in activity categories (e.g. self-care, leisure). Yet, moderate to strong correlations were found between motor assessments and time spent with others versus alone.

CONCLUSION

The lack of significant correlations between motor, activity and participation measures challenges assumptions that improved motor abilities will translate to greater participation. Correlations found between motor and activity measures and the context of participation suggests participation post-stroke is complex, and survivors of stroke may benefit from rehabilitation practices that encompass more than motor therapy.

Corticospinal excitability as a predictor of functional gains at the affected upper limb following robotic training in chronic stroke survivors

BACKGROUND

Robotic training can help improve function of a paretic limb following a stroke, but individuals respond differently to the training. A predictor of functional gains might improve the ability to select those individuals more likely to benefit from robot-based therapy. Studies evaluating predictors of functional improvement after a robotic training are scarce. One study has found that white matter tract integrity predicts functional gains following a robotic training of the hand and wrist. Objective. To determine the predictive ability of behavioral and brain measures in order to improve selection of individuals for robotic training.

METHODS

Twenty subjects with chronic stroke participated in an 8-week course of robotic exoskeletal training for the arm. Before training, a clinical evaluation, functional magnetic resonance imaging (fMRI), diffusion tensor imaging, and transcranial magnetic stimulation (TMS) were each measured as predictors. Final functional gain was defined as change in the Box and Block Test (BBT). Measures significant in bivariate analysis were fed into a multivariate linear regression model.

RESULTS

Training was associated with an average gain of 6 ± 5 blocks on the BBT (P < .0001). Bivariate analysis revealed that lower baseline motor-evoked potential (MEP) amplitude on TMS, and lower laterality M1 index on fMRI each significantly correlated with greater BBT change. In the multivariate linear regression analysis, baseline MEP magnitude was the only measure that remained significant.

CONCLUSION

Subjects with lower baseline MEP magnitude benefited the most from robotic training of the affected arm. These subjects might have reserve remaining for the training to boost corticospinal excitability, translating into functional gains.

Self-perceived utilization of the paretic arm in chronic stroke requires high upper limb functional ability

Objective

To explore potential predictors of self-reported paretic arm use at baseline and after task-specific training (TST) in survivors of stroke.

Design

Data were obtained from a randomized controlled trial of somatosensory stimulation and upper limb TST in chronic stroke.

Setting

University laboratory.

Participants

Chronic (≥3mo) survivors of stroke (N=33; mean age, 62y; mean stroke duration, 38mo).

Interventions

Participants received 12 sessions of TST preceded by either active (n=16) or sham (n=17) somatosensory stimulation to all 3 peripheral nerves.

Main Outcome Measures

Demographic and clinical characteristics were entered stepwise into multiple linear regression analyses to determine the factors that best predict baseline Motor Activity Log (MAL) amount of use rating and change 3 months after TST.

Results

The Action Research Arm Test (ARAT) score predicted the amount of use at baseline (R²=.47, P<.001); in using this model, an ARAT score of 54 (maximum of 57) is required to score 2.5 on the MAL (use described as between rarely and sometimes). After TST the change in the ARAT score predicted the change in the amount of use (R²=.31, P=.001). The predictive power of the model for change at 3 months increased if the Fugl-Meyer Assessment wrist component score was added (R²=.41, P=.001).

Conclusions

Utilization of the paretic upper limb in activities of daily living requires high functional ability. The increase in self-reported arm use after TST is dependent on the change in functional ability. These results provide further guidance for rehabilitation decisions.

Predicting clinically significant changes in motor and functional outcomes after robot-assisted stroke rehabilitation

OBJECTIVE

To investigate the predictors of minimal clinically important changes on outcome measures after robot-assisted therapy (RT).

DESIGN

Observational cohort study.

SETTING

Outpatient rehabilitation clinics.

PARTICIPANTS

A cohort of outpatients with stroke (N=55).

INTERVENTIONS

Patients with stroke received RT for 90 to 105min/d, 5d/wk, for 4 weeks.

MAIN OUTCOME MEASURES

Outcome measures, including the Fugl-Meyer Assessment (FMA) and Motor Activity Log (MAL), were measured before and after the intervention. Potential predictors include age, sex, side of lesion, time since stroke onset, finger extension, Box and Block Test (BBT) score, and FMA distal score.

RESULTS

Statistical analysis showed that the BBT score (odds ratio[OR]=1.06; P=.04) was a significant predictor of clinically important changes in the FMA. Being a woman (OR=3.9; P=.05) and BBT score (OR=1.07; P=.02) were the 2 significant predictors of clinically significant changes in the MAL amount of use subscale. The BBT score was the significant predictor of an increased probability of achieving clinically important changes in the MAL quality of movement subscale (OR=1.07; P=.02). The R(2) values for the 3 logistic regression models were low (.114-.272).

CONCLUSIONS

The results revealed that patients with stroke who had greater manual dexterity measured by the BBT appear to have a higher probability of achieving clinically significant motor and functional outcomes after RT. Further studies are needed to evaluate other potential predictors to improve the models and validate the findings.

Constraint-Induced Movement Therapy Compared to Dose-Matched Interventions for Upper-Limb Dysfunction in Adult Survivors of Stroke: A Systematic Review with Meta-analysis

PURPOSE

To summarize the existing literature examining constraint-induced movement therapy (CIMT), relative to dose-matched control interventions, for upper-limb (UL) dysfunction in adult survivors of stroke.

METHODS

CINAHL, Cochrane Library, Embase, NARIC/CIRRIE-Rehabdata, PEDro, PubMed, Scopus, and Web of Science were searched from their inception to February 2011. Trial quality was described using the PEDro scale. The findings were summarized with meta-analysis.

RESULTS

For the 22 trials identified, the mean (SD) PEDro score was 6.4 (1.2). Meta-analysis showed CIMT to be superior to dose-matched interventions based on indicators of UL motor capacity (15 trials, n=432; standardized mean difference [SMD]=0.47, 95% CI, 0.27-0.66) and UL ability (14 trials, n=352; SMD=0.80, 95% CI, 0.57-1.02); Functional Independence Measure scores (6 trials, n=182; mean difference [MD]=5.05, 95% CI, 2.23-7.87); and Motor Activity Log scores (Amount of Use: 12 trials, n=318; MD=1.05, 95% CI, 0.85-1.24; Quality of Movement: 11 trials, n=330; MD=0.89, 95% CI, 0.69-1.08).

CONCLUSIONS

Compared to control interventions of equal duration and dose, CIMT produced greater improvements in a variety of indicators of UL function in adult survivors of a stroke with residual movement of their upper limb.

Efficacy of Pharmacopuncture for Treating Children with Physical Disabilities in Uzbekistan

Objective:

This research was performed to investigate the efficacy of complex rehabilitation combined with pharmacopuncture treatment for the children with neuromotor system diseases.

Methods:

Fifty (50) patients aged from 5 to 15 yr old were compared. Twenty (20) patients received conventional treatments and complex rehabilitation as a control group, and fifty (50) patients received complex rehabilitation with pharmacopuncture. At their first visits, the patients had checkups and neurological scales, and after 10 days of pharmacopuncture treatments and 55 days of rehabilitation, they also took neurological scales. We studied the pre and post effects of the treatment group.

Results:

The number of patients with ankle joint disorder and contracture, knee joint contracture, steppage, horsey hoof, shoulder weakness and contracture, radio-carpal joint disorder and contracture, arm hypotrophia, arm atrophia, leg hypotrophia and total atrophia decreased after treatments.

Conclusion:

This study showed the efficacy of pharmacopuncture combined with complex rehabilitation for the treatment of neuromotor system diseases.

A standardized approach to the Fugl-Meyer assessment and its implications for clinical trials

BACKGROUND

Standardizing scoring reduces variability and increases accuracy. A detailed scoring and training method for the Fugl-Meyer motor assessment (FMA) is described and assessed, and implications for clinical trials considered.

METHODS

A standardized FMA scoring approach and training materials were assembled, including a manual, scoring sheets, and instructional video plus patient videos. Performance of this approach was evaluated for the upper extremity portion.

RESULTS

Inter- and intrarater reliability in 31 patients were excellent (intraclass correlation coefficient = 0.98-0.99), validity was excellent (r = 0.74-0.93, P < .0001), and minimal detectable change was low (3.2 points). Training required 1.5 hours and significantly reduced error and variance among 50 students, with arm FMA scores deviating from the answer key by 3.8 ± 6.2 points pretraining versus 0.9 ± 4.9 points posttraining. The current approach was implemented without incident into training for a phase II trial. Among 66 patients treated with robotic therapy, change in FMA was smaller (P ≤ .01) at the high and low ends of baseline FMA scores.

CONCLUSIONS

Training with the current method improved accuracy, and reduced variance, of FMA scoring; the 20% FMA variance reduction with training would decrease sample size requirements from 137 to 88 in a theoretical trial aiming to detect a 7-point FMA difference. Minimal detectable change was much smaller than FMA minimal clinically important difference. The variation in FMA gains in relation to baseline FMA suggests that future trials consider a sliding outcome approach when FMA is an outcome measure. The current training approach may be useful for assessing motor outcomes in restorative stroke trials.

Determinants of change in stroke-specific quality of life after distributed constraint-induced therapy

OBJECTIVE

We identified the predictive factors of change in quality of life (QOL) after a distributed form of constraint-induced therapy (dCIT) among stroke survivors.

METHOD

Seventy-four participants were treated with dCIT. We identified eight potential determinants of change: age, gender, side of lesion, time since stroke, cognitive status, motor impairment of the upper extremity, activities of daily living (ADLs), and instrumental ADLs (IADLs). The Stroke-Specific Quality of Life Scale (SS-QOL) was used to assess QOL.

RESULTS

Right-sided lesion and onset >17 mo earlier determined greater improvement in the SS-QOL Energy domain. Onset >10 mo earlier, poorer IADL performance, and age >68 yr predicted improvement in the Family Role, Mobility, and Mood domains, respectively.

CONCLUSION

Side of lesion, time since stroke, IADL performance, and age were the most important determinants of QOL in patients receiving stroke motor rehabilitation.

Randomized controlled trial of surface peroneal nerve stimulation for motor relearning in lower limb hemiparesis

OBJECTIVE

To compare the motor relearning effect of a surface peroneal nerve stimulator (PNS) versus usual care on lower limb motor impairment, activity limitation, and quality of life among chronic stroke survivors.

DESIGN

Single-blinded randomized controlled trial.

SETTING

Teaching hospital of academic medical center.

PARTICIPANTS

Chronic stroke survivors (N=110; >12wk poststroke) with unilateral hemiparesis and dorsiflexion strength of ≤4/5 on the Medical Research Council scale.

INTERVENTIONS

Subjects were stratified by motor impairment level and then randomly assigned to ambulation training with either a surface PNS device or usual care (ankle-foot orthosis or no device) intervention. Subjects were treated for 12 weeks and followed up for 6 months posttreatment.

MAIN OUTCOME MEASURES

Lower limb portion of the Fugl-Meyer (FM) Assessment (motor impairment), the modified Emory Functional Ambulation Profile (mEFAP) performed without a device (functional ambulation), and the Stroke Specific Quality of Life (SSQOL) scale.

RESULTS

There was no significant treatment group main effect or treatment group by time interaction effect on FM, mEFAP, or SSQOL raw scores (P>.05). The time effect was significant for the 3 raw scores (P<.05). However, when comparing average change scores from baseline (t1) to end of treatment (t2, 12wk), and at 12 weeks (t3) and 24 weeks (t4) after end of treatment, significant differences were noted only for the mEFAP and SSQOL scores. The change in the average scores for both mEFAP and SSQOL occurred between t1 and t2, followed by relative stability thereafter.

CONCLUSIONS

There was no evidence of a motor relearning effect on lower limb motor impairment in either the PNS or usual-care groups. However, both the PNS and usual-care groups demonstrated significant improvements in functional mobility and quality of life during the treatment period, which were maintained at 6-month follow-up.

Dose-response relationship of robot-assisted stroke motor rehabilitation: the impact of initial motor status

BACKGROUND AND PURPOSE

The increasing availability of robot-assisted therapy (RT), which provides quantifiable, reproducible, interactive, and intensive practice, holds promise for stroke rehabilitation, but data on its dose-response relation are scanty. This study used 2 different intensities of RT to examine the treatment effects of RT and the effect on outcomes of the severity of initial motor deficits.

METHODS

Fifty-four patients with stroke were randomized to a 4-week intervention of higher-intensity RT, lower-intensity RT, or control treatment. The primary outcome, the Fugl-Meyer Assessment, was administered at baseline, midterm, and posttreatment. Secondary outcomes included the Medical Research Council scale, the Motor Activity Log, and the physical domains of the Stroke Impact Scale.

RESULTS

The higher-intensity RT group showed significantly greater improvements on the Fugl-Meyer Assessment than the lower-intensity RT and control treatment groups at midterm (P=0.003 and P=0.02) and at posttreatment (P=0.04 and P=0.02). Within-group gains on the secondary outcomes were significant, but the differences among the 3 groups did not reach significance. Recovery rates of the higher-intensity RT group were higher than those of the lower-intensity RT group, particularly on the Fugl-Meyer Assessment. Scatterplots with curve fitting showed that patients with moderate motor deficits gained more improvements than those with severe or mild deficits after the higher-intensity RT.

CONCLUSIONS

This study demonstrated the higher treatment intensity provided by RT was associated with better motor outcome for patients with stroke, which may shape further stroke rehabilitation. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique identifier: NCT00917605.

The promise of mHealth: daily activity monitoring and outcome assessments by wearable sensors

Mobile health tools that enable clinicians and researchers to monitor the type, quantity, and quality of everyday activities of patients and trial participants have long been needed to improve daily care, design more clinically meaningful randomized trials of interventions, and establish cost-effective, evidence-based practices. Inexpensive, unobtrusive wireless sensors, including accelerometers, gyroscopes, and pressure-sensitive textiles, combined with Internet-based communications and machine-learning algorithms trained to recognize upper- and lower-extremity movements, have begun to fulfill this need. Continuous data from ankle triaxial accelerometers, for example, can be transmitted from the home and community via WiFi or a smartphone to a remote data analysis server. Reports can include the walking speed and duration of every bout of ambulation, spatiotemporal symmetries between the legs, and the type, duration, and energy used during exercise. For daily care, this readily accessible flow of real-world information allows clinicians to monitor the amount and quality of exercise for risk factor management and compliance in the practice of skills. Feedback may motivate better self-management as well as serve home-based rehabilitation efforts. Monitoring patients with chronic diseases and after hospitalization or the start of new medications for a decline in daily activity may help detect medical complications before rehospitalization becomes necessary. For clinical trials, repeated laboratory-quality assessments of key activities in the community, rather than by clinic testing, self-report, and ordinal scales, may reduce the cost and burden of travel, improve recruitment and retention, and capture more reliable, valid, and responsive ratio-scaled outcome measures that are not mere surrogates for changes in daily impairment, disability, and functioning.

Differential Effects of Power Training Versus Functional Task Practice on Compensation and Restoration of Arm Function After Stroke

Background. Improved upper-extremity (UE) movement with stroke rehabilitation may involve restoration of more normal or development of compensatory movement patterns. Objective. The authors investigated the differential effects of functional task practice (FTP) and dynamic resistance training (POWER) on clinical function and reaching kinematics in an effort to distinguish between mechanisms of gains. Methods. A total of 14 hemiparetic individuals were randomly assigned to 10 weeks of either FTP or POWER and then crossed over to 10 weeks of the alternate treatment. Treatment order A was FTP followed by POWER, whereas treatment order B was POWER followed by FTP. Evaluation before and after each treatment block included a battery of clinical evaluations and kinematics of paretic UE functional reach to grasp. Results. Both FTP and POWER improved movement accuracy, as revealed by a shift toward normal, including fewer submovements and reduced reach-path ratio. However, active range of motion revealed differential treatment effects. Shoulder flexion and elbow extension decreased with FTP and were associated with increased trunk displacement. In contrast, shoulder flexion and elbow extension excursion increased with POWER and were associated with significantly reduced trunk displacement. Treatment order B (POWER followed by FTP) revealed greater overall improvements. Conclusion. FTP increases compensatory movement patterns to improve UE function. POWER leads to more normal movement patterns. POWER prior to FTP may enhance the benefits of repetitive task practice.

The EXCITE Trial: analysis of "noncompleted" Wolf Motor Function Test items

OBJECTIVE

This is the first study to examine Wolf Motor Function Test (WMFT) tasks among EXCITE Trial participants that could not be completed at baseline or 2 weeks later.

METHODS

Data were collected from participants who received constraint-induced movement therapy (CIMT) immediately at the time of randomization (CIMT-I, n = 106) and from those for whom there was a delay of 1 year in receiving this intervention (CIMT-D, n = 116). Data were collected at baseline and at a 2-week time point, during which the CIMT-I group received the CIMT intervention and the CIMT-D group did not. Generalized estimating equation (GEE) analyses were used to examine repeated binary data and count values. Group and visit interactions were assessed, adjusting for functional level, affected side, dominant side, age, and gender covariates.

RESULTS

In CIMT-I participants, there was an increase in the proportion of completed tasks at posttest compared with CIMT-D participants, particularly with respect to those tasks requiring dexterity with small objects and total incompletes (P < .0033). Compared with baseline, 120 tasks governing distal limb use for CIMT-I and 58 tasks dispersed across the WMFT for CIMT-D could be completed after 2 weeks. Common movement components that may have contributed to incomplete tasks include shoulder stabilization and flexion, elbow flexion and extension, wrist pronation, supination and ulnar deviation, and pincer grip.

CONCLUSION

CIMT training should emphasize therapy for those specific movement components in patients who meet the EXCITE criteria for baseline motor control.

Predictors of upper limb recovery after stroke: a systematic review and meta-analysis

OBJECTIVE

To systematically review and summarize the current available literature on prognostic variables relating to upper limb recovery following stroke. To identify which, if any variables predict upper limb recovery following stroke.

DATA SOURCES

We completed searches in MEDLINE, EMBASE, AMED, CINAHL and Cochrane CENTRAL databases. Searches were completed in November 2010.

REVIEW METHODS

Studies were included if predictor variables were measured at baseline and linked to an outcome of upper limb recovery at a future time point. Exclusion criteria included predictor variables relating to response to treatment and outcome measurements of very specific upper limb impairments such as spasticity or pain. Two independent reviewers completed data extraction and assessed study quality.

RESULTS

Fifty-eight studies met the inclusion criteria. Predictor variables which have been considered within these studies include; age, sex, lesion site, initial motor impairment, motor-evoked potentials and somatosensory-evoked potentials. Initial measures of upper limb impairment and function were found to be the most significant predictors of upper limb recovery; odds ratio 14.84 (95% confidence intervals (CI) 9.08-24.25) and 38.62 (95% CI 8.40-177.53), respectively.

CONCLUSIONS

Interpretation of these results is complicated by methodological factors including variations in study populations, upper limb motor outcome scales, timing of baseline and outcome assessments and predictors selected. The most important predictive factors for upper limb recovery following stroke appears to the initial severity of motor impairment or function.

Measurement structure of the Wolf Motor Function Test: implications for motor control theory

BACKGROUND

Tools chosen to measure poststroke upper-extremity rehabilitation outcomes must match contemporary theoretical expectations of motor deficit and recovery because an assessment's theoretical underpinning forms the conceptual basis for interpreting its score.

OBJECTIVE

The purpose of this study was to investigate the theoretical framework of the Wolf Motor Function Test (WMFT) by (1) determining whether all items measured a single underlying trait and (2) examining the congruency between the hypothesized and the empirically determined item difficulty orders.

METHODS

Confirmatory factor analysis (CFA) and Rasch analysis were applied to existing WMFT Functional Ability Rating Scale data from 189 participants in the EXCITE (Extremity Constraint-Induced Therapy Evaluation) trial. Fit of a 1-factor CFA model (all items) was compared with the fit of a 2-factor CFA model (factors defined according to item object-grasp requirements) with fit indices, model comparison test, and interfactor correlations.

RESULTS

One item was missing sufficient data and therefore removed from analysis. CFA fit indices and the model-comparison test suggested that both models fit equally well. The 2-factor model yielded a strong interfactor correlation, and 13 of 14 items fit the Rasch model. The Rasch item difficulty order was consistent with the hypothesized item difficulty order.

CONCLUSION

The results suggest that WMFT items measure a single construct. Furthermore, the results depict an item difficulty hierarchy that may advance the theoretical discussion of the person ability versus task difficulty interaction during stroke recovery.

Predictors of response to treadmill exercise in stroke survivors

BACKGROUND

Aerobic treadmill exercise (T-EX) therapy has been shown to benefit walking and cardiorespiratory fitness in stroke survivors with chronic gait impairment even long after their stroke. The response, however, varies between individuals.

OBJECTIVE

The purpose of this post hoc analysis of 2 randomized controlled T-EX trials was to identify predictors for therapy response.

METHODS

In all, 52 participants received T-EX for 3 (Germany) or 6 (United States) months. Improvements in overground walking velocity (10 m/6-min walk) and fitness (peak VO(2)) were indicators of therapy response. Lesion location and volume were measured on T1-weighted magnetic resonance scans.

RESULTS

T-EX significantly improved gait and fitness, with gains in 10-m walk tests ranging between +113% and -25% and peak VO(2) between -12% and 88%. Baseline walking impairments or fitness deficits were not predictive of therapy response; 10-m walk velocity improved more in those with subcortical rather than cortical lesions and in patients with smaller lesions. Improvements in 6-minute walk velocity were greater in those with more recent strokes and left-sided lesions. No variable other than training intensity, which was different between trials, predicted fitness gains.

CONCLUSIONS

Despite proving overall effectiveness, the response to T-EX varies markedly between individuals. Whereas intensity of aerobic training seems to be an important predictor of gains in cardiovascular fitness, lesion size and location as well as interval between stroke onset and therapy delivery likely affect therapy response. These findings may be used to guide the timing of training and identify subgroups of patients for whom training modalities could be optimized.

Predictors of change in quality of life after distributed constraint-induced therapy in patients with chronic stroke

BACKGROUND

There are no reports of predictive models or predictors for quality of life (QoL) after constraint-induced therapy (CIT).

OBJECTIVE

This investigation identified predictors of change in stroke-related QoL after distributed CIT using the Chi-squared Automatic Interaction Detector (CHAID) method.

METHODS

A total of 58 patients with chronic stroke were treated with CIT for 2 hours daily for 3 weeks. The 7 potential predictors were age, gender, side of lesion, time since stroke, cognitive status, motor impairment of upper extremity, and activities of daily living (ADL). QoL was measured by the Stroke Impact Scale (SIS). CHAID analysis was used to examine for associations between the 7 predictors and each SIS domain. The validity of each model generated by the analysis was evaluated.

RESULTS

Daily functional performance as measured by the Functional Independence Measure (FIM) was found to determine SIS outcomes, including overall score (P = .006) and the ADL/instrumental ADL (IADL) domain (P = .004). None of the potential predictors emerged as significant predictors of the strength, memory, emotion, communication, mobility, hand function, and participation domains of SIS. The misclassification risk estimates were small, indicating good validity for the CHAID models.

CONCLUSIONS

The functional independence score of the FIM can predict the overall SIS score as well as the ADL/IADL domain of the SIS in chronic stroke patients who receive CIT, but larger databases are needed to confirm this. CHAID analysis was a useful approach for an exploratory study.

6-Hz primed low-frequency rTMS to contralesional M1 in two cases with middle cerebral artery stroke

This case study contrasted two subjects with stroke who received 6-Hz primed low-frequency repetitive transcranial magnetic stimulation (rTMS) to the contralesional primary motor area (M1) to disinhibit ipsilesional M1. Functional magnetic resonance imaging (fMRI) showed that the intervention disrupted cortical activation at contralesional M1. Subject 1 showed decreased intracortical inhibition and increased intracortical facilitation following intervention during paired-pulse TMS testing of ipsilesional M1. Subject 2, whose precentral knob was totally obliterated and who did not show an ipsilesional motor evoked potential at pretest, still did not show any at posttest; however, her fMRI did show a large increase in peri-infarct zone cortical activation. Behavioral results were mixed, indicating the need for accompanying behavioral training to capitalize on the brain organization changes induced with rTMS.