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

Kinematic analysis of movement patterns during a reach-and-grasp task in stroke patients

Background

This study aimed to evaluate the kinematic movement patterns during a reach-and-grasp task in post-stroke patients according to the upper extremity impairment severity.

Methods

Subacute stroke patients (n = 46) and healthy controls (n = 20) were enrolled in this study. Spatiotemporal and kinematic data were obtained through 3D motion analysis during the reach-and-grasp task. Stroke patients were grouped using the Fugl-Meyer Assessment (FMA) scale, and a comparison of the groups was performed.

Results

The severe group showed a significantly longer movement time, lower peak velocity, and higher number of movement units than the mild group during the reach-and-grasp task (p < 0.05). Characteristic compensatory movement patterns, such as shoulder abduction, thoracic posterior tilting, and upward and external rotation were significantly greater during the forward transporting phase in the severe group than in the mild group (p < 0.05). The FMA score was significantly associated with the movement time during the forward transporting phase, number of movement units during the reaching phase, range of shoulder abduction-adduction and wrist flexion-extension movements during the reaching phase, and range of thoracic internal-external rotation during the backward transporting phase (p < 0.05).

Conclusion

Post-stroke patients have unique spatiotemporal and kinematic movement patterns during a reach-and grasp-task according to the impairment severity.

Validity and Reliability of Kinect v2 for Quantifying Upper Body Kinematics during Seated Reaching

Kinematic analysis of the upper limbs is a good way to assess and monitor recovery in individuals with stroke, but it remains little used in clinical routine due to its low feasibility. The aim of this study is to assess the validity and reliability of the Kinect v2 for the analysis of upper limb reaching kinematics. Twenty-six healthy participants performed seated hand-reaching tasks while holding a dumbbell to induce behaviour similar to that of stroke survivors. With the Kinect v2 and with the VICON, 3D upper limb and trunk motions were simultaneously recorded. The Kinect assesses trunk compensations, hand range of motion, movement time and mean velocity with a moderate to excellent reliability. In contrast, elbow and shoulder range of motion, time to peak velocity and path length ratio have a poor to moderate reliability. Finally, instantaneous hand and elbow tracking are not precise enough to reliably assess the number of velocity peaks and the peak hand velocity. Thanks to its ease of use and markerless properties, the Kinect can be used in clinical routine for semi-automated quantitative diagnostics guiding individualised rehabilitation of the upper limb. However, engineers and therapists must bear in mind the tracking limitations of the Kinect.

Predictors of Clinically Important Improvements in Motor Function and Daily Use of Affected Arm after a Botulinum Toxin A Injection in Patients with Chronic Stroke

Identifying patients who can gain minimal clinically important difference (MCID) in active motor function in the affected upper extremity (UE) after a botulinum toxin A (BoNT-A) injection for post-stroke spasticity is important. Eighty-eight participants received a BoNT-A injection in the affected UE. Two outcome measures, Fugl–Meyer Assessment Upper Extremity (FMA-UE) and Motor Activity Log (MAL), were assessed at pre-injection and after 24 rehabilitation sessions. We defined favorable response as an FMA-UE change score ≥5 or MAL change score ≥0.5.Statistical analysis revealed that the time since stroke less than 36 months (odds ratio (OR) = 4.902 (1.219–13.732); p = 0.023) was a significant predictor of gaining MCID in the FMA-UE. Medical Research Council scale -proximal UE (OR = 1.930 (1.004–3.710); p = 0.049) and post-injection duration (OR = 1.039 (1.006–1.074); p =0.021) were two significant predictors of MAL amount of use. The time since stroke less than 36 months (OR = 3.759 (1.149–12.292); p = 0.028), naivety to BoNT-A (OR = 3.322 (1.091–10.118); p = 0.035), and education years (OR = 1.282 (1.050–1.565); p = 0.015) were significant predictors of MAL quality of movement. The findings of our study can help optimize BoNT-A treatment planning.

Postural Difference between the Interventions Reflecting the Concept of Mirror Therapy in Healthy Subjects

(1) Background: Mirror therapy is one of the promising interventions for the upper limb rehabilitation of stroke patients. Postural asymmetry during mirror therapy was pointed out as a possibility to influence stroke patients’ rehabilitation negatively. However, it is still difficult to find studies on the postural changes in mirror therapy concept interventions. This study compared three methods of postural differences as follows: traditional mirror therapy (mirror); displaying the real-time movement of the unaffected side on the screen above the affected side (screen); and playing a pre-recorded movement of the unaffected side on a tablet placed on a movable box where the affected hand is put inside (movable). (2) Methods: to observe a kinematic difference, we recruited 16 healthy volunteers to go through three different interventions (mirror, screen, movable). The motion capture system made observations on the postures before and during interventions, then compared and analyzed. (3) Results: while using the mirror, the sitting posture was observed to become asymmetric, and the following unique posture was observed where the target hand went further from the trunk while performing tasks. In addition, the shoulder of the target side came forward, and the difference between both elbow flexion angles was also observed. On the other hand, the screen or movable device did not cause a significant change in the sitting posture, and no additional postural differences were observed either. (4) Conclusions: mirror therapy showed a tendency to cause lateral flexion opposite the target hand, thus, creating additional postural change. However, developed methods controlled spine tilt, and enabled the keeping of the midline while sitting during the intervention.

Detailed characterization of physiological EMG activations and directional tuning of upper-limb and trunk muscles in point-to-point reaching movements

In recent years, several studies have investigated upper-limb motion in a variety of scenarios including motor control, physiology, rehabilitation and industry. Such applications assess people’s kinematics and muscular performances, focusing on typical movements that simulate daily-life tasks. However, often only a limited interpretation of the EMG patterns is provided. In fact, rarely the assessments separate phasic (movement-related) and tonic (postural) EMG components, as well as the EMG in the acceleration and deceleration phases. With this paper, we provide a comprehensive and detailed characterization of the activity of upper-limb and trunk muscles in healthy people point-to-point upper limb movements. Our analysis includes in-depth muscle activation magnitude assessment, separation of phasic (movement-related) and tonic (postural) EMG activations, directional tuning, distinction between activations in the acceleration and deceleration phases. Results from our study highlight a predominant postural activity with respect to movement related muscular activity. The analysis based on the acceleration phase sheds light on finer motor control strategies, highlighting the role of each muscle in the acceleration and deceleration phase. The results of this study are applicable to several research fields, including physiology, rehabilitation, design of robots and assistive solutions, exoskeletons.

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Upper-limb motion is assessed with kinematics and EMG in many scenarios: motor control, physiology, rehabilitation, industry

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Separation of phasic (movement-related) and tonic (postural) EMG, and of acceleration and deceleration phases

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Comprehensive and detailed characterization of the EMG of upper-limb and trunk muscles in point-to-point upper limb movements

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EMG magnitude assessment, phasic and tonic EMG activations, directional tuning, acceleration and deceleration phases

Manual Dexterity Is Associated With Use of the Paretic Upper Extremity in Community-Dwelling Individuals With Stroke

BACKGROUND AND PURPOSE

Regarding people with stroke, simple outcome measures in clinical settings capable of representing the actual use of the upper extremity (UE) would be useful to rehabilitation professionals for the purposes of goal setting. This study seeks to describe the relative levels of paretic UE use, investigate the association between manual dexterity and task-related UE use, and to establish the manual dexterity cutoff points that correspond to relative levels of paretic UE use.

METHODS

Forty-six adults with chronic hemiparesis participated in this cross-sectional study. Behavioral mapping was employed to ascertain the actual amount of UE use by the identifying the unimanual and bimanual activities performed in the participants' homes within a 4-hour period. Participants were classified into 4 levels of paretic UE integration into activities considering the data from the behavioral mapping (activity, hand function, and type of grasp). The Box and Block Test (BBT) and the Nine Hole Peg Test (NHPT) were used to evaluate dexterity. The Spearman test was used to evaluate the correlations. In analyzing the receiver operating characteristic curve, we applied the Youden index to determine the cutoff points.

RESULTS

Participants with full/almost full (n = 11), partial (n = 12), and limited (n = 12) integration of the paretic UE into activities and with little/no use (n = 11) were identified. Unimanual and total paretic UE activities were found to have a high correlation with the BBT scores. The boundaries between the integration levels were between full/almost full and partial integration, BBT greater than 30 blocks or NHPT of 41 seconds and less; between partial and limited, BBT greater than 16 blocks; and between limited and little/no use, BBT greater than 3 blocks. Both tests show good accuracy (≥0.81).

DISCUSSION AND CONCLUSIONS

The BBT presents a positive high correlation with paretic UE use at home and was shown to be better able to identify "limited" and "partial" integration of the paretic UE. Both tests can identify when the paretic UE is fully/almost fully integrated into activities at home.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A354).

Can kinematic parameters of 3D reach-to-target movements be used as a proxy for clinical outcome measures in chronic stroke rehabilitation? An exploratory study

BACKGROUND

Despite numerous trials investigating robot-assisted therapy (RT) effects on upper-extremity (UE) function after stroke, few have explored the relationship between three-dimensional (3D) reach-to-target kinematics and clinical outcomes. The objectives of this study were to 1) investigate the correlation between kinematic parameters of 3D reach-to-target movements and UE clinical outcome measures, and 2) examine the degree to which differences in kinematic parameters across individuals can account for differences in clinical outcomes in response to RT.

METHODS

Ten chronic stroke survivors participated in a pilot RT intervention (eighteen 1-h sessions) integrating cognitive skills training and a home-action program. Clinical outcome measures and kinematic parameters of 3D reach-to-target movements were collected pre- and post-intervention. The correlation between clinical outcomes and kinematic parameters was investigated both cross-sectionally and longitudinally (i.e., changes in response to the intervention). Changes in clinical outcomes and kinematic parameters were tested for significance in both group and subject-by-subject analyses. Potential associations between individual differences in kinematic parameters and differences in clinical outcomes were examined.

RESULTS

Moderate-to-strong correlation was found between clinical measures and specific kinematic parameters when examined cross-sectionally. Weaker correlation coefficients were found longitudinally. Group analyses revealed significant changes in clinical outcome measures in response to the intervention; no significant group changes were observed in kinematic parameters. Subject-by-subject analyses revealed changes with moderate-to-large effect size in the kinematics of 3D reach-to-target movements pre- vs. post-intervention. Changes in clinical outcomes and kinematic parameters varied widely across participants.

CONCLUSIONS

Large variability was observed across subjects in response to the intervention. The correlation between changes in kinematic parameters and clinical outcomes in response to the intervention was variable and not strong across parameters, suggesting no consistent change in UE motor strategies across participants. These results highlight the need to investigate the response to interventions at the individual level. This would enable the identification of clusters of individuals with common patterns of change in response to an intervention, providing an opportunity to use cluster-specific kinematic parameters as a proxy of clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02747433 . Registered on April 21st, 2016.

The Effects of Upper Limb Motor Recovery on Submovement Characteristics among the Patients with Stroke: A Meta-Analysis

OBJECTIVE

To evaluate the evidence related to the effect of upper limb motor recovery on submovement characteristics, including duration, amplitude, overlap, interpeak distance, and the number of submovements in stroke patients using a meta-analysis.

TYPE OF STUDY

Meta-analysis.

LITERATURE SURVEY

The literature search was restricted to articles written in English published from inception to October 2018 in Web of Science, PubMed, Science Direct, IEEE Explore, MEDLINE, CDSR, Scopus, Compendex, Wiley Online Library, Springer Link, and REHABDATA.

METHODOLOGY

Studies were included if they encompassed adult participants with a clinical diagnosis of stroke who underwent upper limb rehabilitation and if they assessed and reported submovement characteristics as the outcome measures in pre- and posttreatment stages. Changes in submovement characteristics between pre- and postinterventions were compared using the standardized mean difference (SMD). Finally, a test for heterogeneity and publication bias was implemented for all meta-analyses.

SYNTHESIS

Among the 188 retrieved articles, seven of them (one randomized controlled trial, six pre-post) involving 259 patients were selected for meta-analysis. Based on the results, the overall observed changes in all meta-analyses were statistically significant. In total, submovement amplitude (SMD 0.624, 95% confidence interval [CI] [0.356, 0.893]), duration (SMD 0.61, 95% CI [0.332, 0.888]), and overlap (SMD 0.928, 95% CI [0.768, 1.088]) increased whereas interpeak distance (SMD -0.278, 95% CI [-0.42, -0.137]), and the total number of submovements (SMD -0.804, 95% CI [-1.069, -0.538]) decreased.

CONCLUSIONS

The submovements appeared to become longer, fewer, and more overlapped with motor recovery. Based on the results, the ability of the neural system to blend submovements increased in both acute/subacute and chronic patients during recovery. Therefore, assessing the submovements during recovery can be a new quantitative measure of motor improvement, providing another means of comparing rehabilitation interventions and individualizing therapy for stroke patients.

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.

Strong relations of elbow excursion and grip strength with post-stroke arm function and activities: Should we aim for this in technology-supported training?

Objective

To investigate the relationships between an extensive set of objective movement execution kinematics of the upper extremity and clinical outcome measures in chronic stroke patients: at baseline and after technology-supported training at home.

Methods

Twenty mildly to severely affected chronic stroke patients participated in the baseline evaluation, 15 were re-evaluated after six weeks of intensive technology-supported or conventional arm/hand training at home. Grip strength, 3D motion analysis of a reach and grasp task, and clinical scales (Fugl-Meyer assessment (FM), Action Research Arm Test (ARAT) and Motor Activity Log (MAL)) were assessed pre- and post-training.

Results

Most movement execution parameters showed moderate-to-strong relationships with FM and ARAT, and to a smaller degree with MAL. Elbow excursion explained the largest amount of variance in FM and ARAT, together with grip strength. The only strong association after training was found between changes in ARAT and improvements in hand opening (conventional) or grip strength (technology-supported).

Conclusions

Elbow excursion and grip strength showed strongest association with post-stroke arm function and activities. Improved functional ability after training at home was associated with increased hand function. Addressing both reaching and hand function are indicated as valuable targets for (technological) treatment applications to stimulate functional improvements after stroke.

Upper Limb Coordination in Individuals With Stroke: Poorly Defined and Poorly Quantified

Background. The identification of deficits in interjoint coordination is important in order to better focus upper limb rehabilitative treatment after stroke. The majority of standardized clinical measures characterize endpoint performance, such as accuracy, speed, and smoothness, based on the assumption that endpoint performance reflects interjoint coordination, without measuring the underlying temporal and spatial sequences of joint recruitment directly. However, this assumption is questioned since improvements of endpoint performance can be achieved through different degrees of restitution or compensation of upper limb motor impairments based on the available kinematic redundancy of the system. Confusion about adequate measurement may stem from a lack a definition of interjoint coordination during reaching. Methods and Results. We suggest an operational definition of interjoint coordination during reaching as a goal-oriented process in which joint degrees of freedom are organized in both spatial and temporal domains such that the endpoint reaches a desired location in a context-dependent manner. Conclusions. In this point-of-view article, we consider how current approaches to laboratory and clinical measures of coordination comply with our definition. We propose future study directions and specific research strategies to develop clinical measures of interjoint coordination with better construct and content validity than those currently in use.

Developing the Observatory Test of Capacity, Performance, and Developmental Disregard (OTCPDD) for Children with Cerebral Palsy

PURPOSE

The purpose of this study was to develop a reliable and valid instrument, named the Observatory Test of Capacity, Performance, and Developmental Disregard (OTCPDD), for measuring the amount and quality of use of affected upper limb functions in the daily routines of children with CP.

METHODS

Forty-eight participants (24 children with CP and 24 matched typically developing children) were recruited. The OTCPDD was administered twice (the spontaneous use condition first, followed by the forced use condition) on children with CP. Their parents were asked to complete the Pediatric Motor Activity Log-Revised (PMAL-R). The internal consistency, the intrarater and interrater reliabilities, and the convergent and discriminate validities were measured.

RESULTS

The internal consistency (Cronbach's alpha) and the intrarater and interrater reliabilities were higher than 0.9 for all of the OTCPDD scores. The convergent validity was confirmed by significant correlations between the OTCPDD and the PMAL-R. For the discriminant validity, significant differences (p<0.05) were found between children with CP and typically developing children.

CONCLUSIONS

The results support that the OTCPDD is a reliable and valid observation-based assessment. The OTCPDD, which uses bimanual daily living activities, is able to represent the children's general affected hand functions (including capacity, performance, and developmental disregard) in their daily routines.