Arm and leg impairments and disabilities after stroke rehabilitation: relation to handicap

Concurrent validity of walking speed measured by a wearable sensor and a stopwatch during the 10-meter walk test in individuals with stroke

BACKGROUND

Walking speed is often measured with a stopwatch throughout stroke recovery. Wearable sensors also have been used recently to measure walking speed and provide information about spatiotemporal characteristics of walking.

RESEARCH QUESTION

Do walking speeds measured with stopwatch and APDM wearable sensors have concurrent validity?

METHODS

Individuals with chronic stroke (n = 62) performed the 10-meter walk test at comfortable and maximal speeds. Walking speeds were measured with a stopwatch and APDM Opal wireless wearable sensors (3-unit). Tests of concurrent validity between stopwatch and APDM (Bland-Altman plots, systematic and proportional bias, and intraclass correlations) and test-retest reliability between trials (intraclass correlations, standard error of measurement, and minimal detectable change) were performed.

RESULTS

Walking speeds measured with APDM were ∼0.07 m/s slower than those measured with stopwatch (systematic bias; t ≥ 13.1, p < 0.001). Intraclass correlations ranged from poor to excellent. There were greater differences in walking speeds between APDM and stopwatch for individuals with faster walking speeds (proportional bias). Test-retest reliability was excellent for both APDM and stopwatch (intraclass correlation≥0.94). Standard error of measurement ranged from 0.04 to 0.07 m/s and minimal detectable change ranged from 0.10 to 0.19 m/s.

SIGNIFICANCE

It may be inappropriate to use walking speed measurements from APDM sensors and stopwatch interchangeably in individuals with chronic stroke. Differences in walking speeds may reflect stopwatch error or the derivation of walking speed from wearable sensors. Test-retest reliability was excellent for both stopwatch and APDM, but minimal detectable change values were large. Large changes in walking speed may be required to be confident that the change is a true and clinically meaningful change and not measurement error. The validity and reliability of measuring walking speed with wearable sensors in individuals with chronic stroke has important implications for determining community ambulation, assessing improvements after rehabilitation, and developing exercise prescriptions.

Responsiveness of the Reaching Performance Scale for Stroke

OBJECTIVE

The objective of the study was to estimate the internal and external responsiveness of the Reaching Performance Scale for Stroke (RPSS) in individuals with stroke.

DESIGN

Retrospective analysis of data from 4 randomized controlled trials.

SETTING

Recruitment locations spanning rehabilitation centers and hospitals in Canada, Italy, Argentina, Peru, and Thailand.

PARTICIPANTS

Data from 567 participants (acute to chronic stroke; N=567) were available.

INTERVENTIONS

All 4 studies involved training using virtual reality for upper limb rehabilitation.

MAIN OUTCOME MEASURES

RPSS and upper extremity Fugl-Meyer Assessment (FMA-UE) scores. Responsiveness was quantified for all data and across different stages of stroke. Internal responsiveness of the RPSS was quantified as effect-sizes calculated using post and preintervention change data. External responsiveness was quantified using orthogonal regressions between FMA-UE and RPSS scores. The area under the Receiver Operating Characteristic curve (AUC) was quantified based on the ability of RPSS scores to detect change above FMA-UE minimal clinically important different values across different stages of stroke.

RESULTS

The RPSS had high internal responsiveness overall and across the acute or subacute and chronic stages of stroke. For external responsiveness, orthogonal regression analyses indicated that change in FMA-UE scores had positive moderate correlations with both RPSS Close and Far Target scores for all data and across the acute or subacute and chronic stages of stroke (0.6

CONCLUSIONS

In addition to being reliable and valid, the RPSS is also responsive. Along with the FMA-UE, using RPSS scores can help present a more comprehensive picture of motor compensations to characterize poststroke upper limb motor improvement.

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Key Words

• Movement quality
• cerebrovascular accident
• compensation
• outcomes
• reaching
• restitution or true recovery
• upper limb

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MESH Headings

• Humans
• Disability Evaluation
• Recovery of Function
• Retrospective Studies
• Stroke
• Stroke Rehabilitation
• Upper Extremity
• Randomized Controlled Trials as Topic

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Affiliation(s)

Sandeep K Subramanian Departments of Physical Therapy, Physician Assistant Studies and Rehabilitation Medicine, University of Texas Health San Antonio, San Antonio, TX
Gita Margolese School of Physical and Occupational Therapy, McGill University, Montreal, Canada; Centre for Interdisciplinary Research in Rehabilitation, Montreal, Canada
Andrea Turolla Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; Laboratory of Rehabilitation Technologies, Hospital San Camillo IRCCS, Venice, Italy
Gustavo Saposnik Stroke Outcomes and Decision Neuroscience Unit, Unity Health Toronto, University of Toronto, Toronto, Canada
Mindy F Levin School of Physical and Occupational Therapy, McGill University, Montreal, Canada; Centre for Interdisciplinary Research in Rehabilitation, Montreal, Canada.

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Contralaterally EMG-triggered functional electrical stimulation during serious gaming for upper limb stroke rehabilitation: a feasibility study

Introduction

Virtual Reality/serious games (SG) and functional electrical stimulation (FES) therapies are used in upper limb stroke rehabilitation. A combination of both approaches seems to be beneficial for therapy success. The feasibility of a combination of SG and contralaterally EMG-triggered FES (SG+FES) was investigated as well as the characteristics of responders to such a therapy.

Materials and methods

In a randomized crossover trial, patients performed two gaming conditions: SG alone and SG+FES. Feasibility of the therapy system was assessed using the Intrinsic Motivation Inventory (IMI), the Nasa Task Load Index, and the System Usability Scale (SUS). Gaming parameters, fatigue level and a technical documentation was implemented for further information.

Results

In total, 18 patients after stroke (62.1 ± 14.1 years) with a unilateral paresis of the upper limb (MRC ≤4) were analyzed in this study. Both conditions were perceived as feasible. Comparing the IMI scores between conditions, perceived competence was significantly increased (z = -2.88, p = 0.004) and pressure/tension during training (z = -2.13, p = 0.034) was decreased during SG+FES. Furthermore, the task load was rated significantly lower for the SG+FES condition (z = -3.14, p = 0.002), especially the physical demand (z = -3.08, p = 0.002), while the performance was rated better (z = -2.59, p = 0.010). Responses to the SUS and the perceived level of fatigue did not differ between conditions (SUS: z = -0.79, p = 0.431; fatigue: z = 1.57, p = 0.115). For patients with mild to moderate impairments (MRC 3-4) the combined therapy provided no or little gaming benefit. The additional use of contralaterally controlled FES (ccFES), however, enabled severely impaired patients (MRC 0-1) to play the SG.

Discussion

The combination of SG with ccFES is feasible and well-accepted among patients after stroke. It seems that the additional use of ccFES may be more beneficial for severely impaired patients as it enables the execution of the serious game. These findings provide valuable implications for the development of rehabilitation systems by combining different therapeutic interventions to increase patients' benefit and proposes system modifications for home use.

Clinical trial registration

https://drks.de/search/en, DRKS00025761.

Using immersive virtual reality to remotely examine performance differences between dominant and non-dominant hands

Circle drawing may be a useful task to study upper-limb function in patient populations. However, previous studies rely on expensive and bulky robotics to measure performance. For clinics or hospitals with limited budgets and space, this may be unfeasible. Virtual reality (VR) provides a portable and low-cost tool with integrated motion capture. It offers potentially a more feasible medium by which to assess upper-limb motor function. Prior to use with patient populations, it is important to validate and test the capabilities of VR with healthy users. This study examined whether a VR-based circle drawing task, completed remotely using participant's own devices, could capture differences between movement kinematics of the dominant and non-dominant hands in healthy individuals. Participants (n = 47) traced the outline of a circle presented on their VR head-mounted displays with each hand, while the positions of the hand-held controllers were continuously recorded. Although there were no differences observed in the size or roundness of circles drawn with each hand, consistent with prior literature our results did show that the circles drawn with the dominant hand were completed faster than those with the non-dominant hand. This provides preliminary evidence that a VR-based circle drawing task may be a feasible method for detecting subtle differences in function in clinical populations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10055-023-00794-z.

Prediction of Factors Affecting Mobility in Patients with Stroke and Finding the Mediation Effect of Balance on Mobility: A Cross-Sectional Study

(1) Background: Regaining mobility after stroke is essential to facilitate patient independency in activities of daily living. Predicting post-stroke mobility is clinically important and plays a significant part in rehabilitation programs. The purpose of this study is to find the factors affecting mobility in patients with stroke and to analyze the mediation effect of balance on mobility. (2) Methods: This cross-sectional study included forty-one patients with stroke averaging an age of 57.2 ± 88.6. The Rivermead Mobility Index (RMI) was used for measuring the mobility, Timed Up and Go (TUG) to measure the walking speed, Berg Balance Scale (BBS) to assess the balance and a handheld dynamometer (HHD) was used for measuring the isometric strength of the ankle and knee. (3) Results: In regression analysis balance (β=0.58;&nbsp;p≤&nbsp;0.0001) and walking speed (β=-0.27;&nbsp;p=0.04) were the significant factors predicting mobility. (4) Conclusions: Balance and gait speed were the factors that influenced mobility in stroke patients, indicating the utility of measuring these aspects in order to provide appropriate rehabilitation programs.

Telerehabilitation for lower extremity recovery poststroke: a systematic review and meta-analysis protocol

INTRODUCTION

Approximately 30% of individuals with stroke report unmet lower extremity recovery needs after formal hospital-based rehabilitation programmes have ended. Telerehabilitation can mitigate issues surrounding accessibility of rehabilitation services by providing ongoing support to promote recovery, however, no review exists that is specific to telerehabilitation for lower extremity recovery. This paper describes the protocol of a systematic review and meta-analysis that aims to describe and evaluate the effectiveness of lower extremity-focused telerehabilitation interventions on clinical outcomes poststroke.

METHODS AND ANALYSIS

A systematic review of relevant electronic databases (MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, Google Scholar, PEDro, PubMed and Cochrane Library) between inception and February 2022 will be undertaken to identify eligible interventional studies published in English that compared telerehabilitation focusing on lower extremity recovery to another intervention or usual care for individuals living in the community with stroke. Clinical outcomes examined will include those related to physical function and impairment, activities and participation that are typically assessed in clinical practice and research. Two reviewers will independently screen results, identify studies to be included for review, extract data and assess risk of bias. Meta-analyses will be performed if sufficient data exist. Sensitivity analyses will be performed by removing studies with low methodological quality, and subgroup analyses will be performed if data allow by stratifying papers based on salient demographic or stroke factors and comparing results. The reporting of the review will follow the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The quality of evidence regarding various outcomes for telerehabilitation for lower extremity recovery poststroke will be assessed according to the Grading of Recommendation, Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

No ethical approval or informed consent is needed for this systematic review. The findings of this review will be disseminated via peer-reviewed publications and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42021246886.

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.

Whole-Body Movements Increase Arm Use Outcomes of Wrist-Worn Accelerometers in Stroke Patients

Wrist-worn accelerometers are often applied to measure arm use after stroke. They measure arm movements during all activities, including whole-body movements, such as walking. Whole-body movements may influence clinimetric properties of arm use measurements—however, this has not yet been examined. This study investigates to what extent arm use measurements with wrist-worn accelerometers are affected by whole-body movements. Assuming that arm movements during whole-body movements are non-functional, we quantify the effect of whole-body movements by comparing two methods: Arm use measured with wrist-worn accelerometers during all whole-body postures and movements (P&M method), and during sitting/standing only (sit/stand method). We have performed a longitudinal observational cohort study with measurements in 33 stroke patients during weeks 3, 12, and 26 poststroke. The P&M method shows higher daily paretic arm use outcomes than the sit/stand method (p < 0.001), the mean difference increased from 31% at week three to 41% at week 26 (p < 0.001). Differences in daily paretic arm use between methods are strongly related to daily walking time (r = 0.83–0.92). Changes in the difference between methods are strongly related to changes in daily walking time (r = 0.89). We show that not correcting arm use measurements for whole-body movements substantially increases arm use outcomes, thereby threatening the validity of arm use outcomes and measured arm use changes.

Motor evoked potential latency and duration from tibialis anterior in individuals with chronic stroke

Ipsilateral motor pathways from the contralesional hemisphere to the paretic limbs may be upregulated to compensate for impaired function after stroke. Onset latency and duration of motor evoked potentials (MEPs) evoked by transcranial magnetic stimulation (TMS) provide insight into compensatory pathways but have been understudied in the lower limb. This study assessed MEP onset latency and duration in the lower limb after stroke, and compared ipsilateral and contralateral MEPs in the paretic and non-paretic limb. We hypothesized that: (1) onset latency would be longer for ipsilateral than contralateral MEPs and longer for the paretic than the non-paretic limb, and (2) duration would be shorter for ipsilateral than contralateral MEPs and longer for the paretic than the non-paretic limb. Data were collected as a part of a pre-test of a randomized controlled trial. TMS was applied to the ipsilateral and contralateral hemisphere of the paretic and non-paretic limb. MEP onset latency and duration were calculated from the tibialis anterior. Thirty-five participants with chronic stroke were included in the final analysis. Onset latency was longer in the paretic than the non-paretic limb (~ 6.0 ms) and longer after ipsilateral than contralateral stimulation (~ 1.8 ms). Duration was longer in the paretic than the non-paretic limb (~ 9.2 ms) and longer after contralateral than ipsilateral stimulation (~ 5.2 ms). Ipsilateral MEPs may be elicited through ipsilateral pathways with fewer fibers with a higher activation threshold and/or greater spinal branching. MEPs from the paretic limb may reflect slower central motor conduction, peripheral changes, or changes in motor pathway.

Ipsilateral Motor Pathways and Transcallosal Inhibition During Lower Limb Movement After Stroke

BACKGROUND

Stroke rehabilitation may be improved with a better understanding of the contribution of ipsilateral motor pathways to the paretic limb and alterations in transcallosal inhibition. Few studies have evaluated these factors during dynamic, bilateral lower limb movements, and it is unclear whether they relate to functional outcomes.

OBJECTIVE

Determine if lower limb ipsilateral excitability and transcallosal inhibition after stroke depend on target limb, task, or number of limbs involved, and whether these factors are related to clinical measures.

METHODS

In 29 individuals with stroke, ipsilateral and contralateral responses to transcranial magnetic stimulation were measured in the paretic and nonparetic tibialis anterior during dynamic (unilateral or bilateral ankle dorsiflexion/plantarflexion) and isometric (unilateral dorsiflexion) conditions. Relative ipsilateral excitability and transcallosal inhibition were assessed. Fugl-Meyer, ankle movement accuracy, and walking characteristics were assessed.

RESULTS

Relative ipsilateral excitability was greater during dynamic than isometric conditions in the paretic limb (P ≤ .02) and greater in the paretic than the nonparetic limb during dynamic conditions (P ≤ .004). Transcallosal inhibition was greater in the ipsilesional than contralesional hemisphere (P = .002) and during dynamic than isometric conditions (P = .03). Greater ipsilesional transcallosal inhibition was correlated with better ankle movement accuracy (R² = 0.18, P = .04). Greater contralateral excitability to the nonparetic limb was correlated with improved walking symmetry (R² = 0.19, P = .03).

CONCLUSIONS

Ipsilateral pathways have increased excitability to the paretic limb, particularly during dynamic tasks. Transcallosal inhibition is greater in the ipsilesional than contralesional hemisphere and during dynamic than isometric tasks. Ipsilateral pathways and transcallosal inhibition may influence walking asymmetry and ankle movement accuracy.

Kinematic Measures of Bimanual Performance are Associated With Callosum White Matter Change in People With Chronic Stroke

Objectives

To investigate the relationship between bimanual performance deficits measured using kinematics and callosum (CC) white matter changes that occur in people with chronic stroke.

Design

Cross-sectional, observational study of participants with chronic stroke and age-matched controls.

Setting

Recruitment and assessments occurred at a stroke recovery research center. Behavioral assessments were performed in a controlled laboratory setting. Magnetic resonance imaging scans were performed at the Center for Biomedical Imaging.

Participants

Individuals were enrolled and completed the study (N=39; 21 participants with chronic stroke; 18 age-matched controls with at least 2 stroke risk factors).

Main Outcome Measures

Diffusion imaging metrics were obtained for each individual’s CC and corticospinal tract (CST), including mean kurtosis (MK) and fractional anisotropy (FA). A battery of motor assessments, including bimanual kinematics, were collected from individuals while performing bimanual reaching.

Results

Participants with stroke had lower FA and MK in the CST of the lesioned hemisphere when compared with the non-lesioned hemisphere. The FA and MK values in the CST were correlated with measures of unimanual hand performance. In addition, participants with stroke had significantly lower FA and MK in the CC than matched controls. CC diffusion metrics positively correlated with hand asymmetry and trunk displacement during bimanual performance, even when correcting for age and lesion volume.

Conclusions

These data confirm previous studies that linked CST integrity to unimanual performance and provide new data demonstrating a link between CC integrity and both bimanual motor deficits and compensatory movements.

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Fractional anisotropy and mean kurtosis in the corpus callosum are lower in participants with stroke.

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Hand position symmetry and trunk displacement are disrupted during bimanual tasks.

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Corpus callosum white matter correlated with bimanual kinematics in participants with stroke.

Evaluation of upper limb function with digitizing tablet-based tests: reliability and discriminative validity in healthy persons and patients with neurological disorders

PURPOSE

To evaluate discriminative validity, relative reliability and absolute reliability of four tablet-based tests for the evaluation of upper limb motor function in healthy persons and patients with neurological disorders.

METHODS

Cross-sectional study in 54 participants: 29 patients with upper limb movement impairment due to a neurological condition recruited from an inpatient rehabilitation centre and 25 healthy persons. Accuracy, speed and path length were analysed for four tablet-based tests: "Spiral drawings," "Tapping," "Follow the dot" and "Trace a star." The area under the receiver operating characteristic curve (AUC) was used to evaluate discriminative validity. Relative reliability was analysed with the intra-class correlation coefficient (ICC), and absolute reliability by limits of agreement (LoA) and minimal detectable difference (MDD).

RESULTS

All four tests showed excellent discriminative validity for the parameter accuracy (AUC 0.93-0.98). Tapping was the best test for discriminating patients from healthy persons. Test-retest reliability was good for accuracy in all tests (ICC = 0.76-0.88), but poor to moderate for speed and path length (ICC = 0.20-0.69). The MDD varied between 14% and 38%. Performance on the four tablet-based tests was stable between sessions, indicating that there was no learning effect.

CONCLUSION

The parameter accuracy showed excellent discriminative validity and reliability in all four tablet-based tests. Discriminative validity was excellent for all three parameters in the Tapping test. In the other tasks speed showed good to poor reliability, while the reliability of path-length was poor in all tasks. Results were comparable for the dominant and non-dominant hand. Tablet-based tests have the advantage that patients can use them for self-monitoring of upper limb motor function.Implications for rehabilitationFour tablet-based tests for the assessment of upper limb motor function in patients with upper limb neurological dysfunction were evaluated: "Spiral drawings", "Tapping", "Follow the dot" and "Trace a star". The parameter accuracy in these four tests had excellent discriminative validity and good reliability.Patients can perform the tests independently at home for self-monitoring of progress. This may increase patients' motivation to exercise at home.The results can be sent to physicians, enabling the earlier detection of deterioration, which may require medical attention.

Evaluation of Predictive Factors Influencing Community Reintegration in Adult Patients with Stroke

Objectives

Patients with stroke are faced with gait, balance, and fall difficulties which could impact on their community reintegration. In Nigeria, community reintegration after stroke has been understudied. The objective of this study was to evaluate the predictors of community reintegration in adult patients with stroke.

Materials and Methods

Participants were 91 adult patients with stroke. Gait variables, balance self-efficacy, community balance/mobility, and fall self-efficacy were assessed using Rivermead Mobility Index, Activities-specific Balance Confidence Scale, Community Balance and Mobility Scale, and Falls Efficacy Scale-International respectively. Reintegration to Normal Living Index was used to assess satisfaction with community reintegration. Pearson Product-Moment Correlation Coefficient was used to determine the relationship between community reintegration and gait spatiotemporal variables, balance performance, and risk of fall. Multiple regression analysis was used to determine predictors of community reintegration (P ≤ 0.05).

Results

There was significant positive relationship between community reintegration and cadence (r = 0.250, P = 0.017), functional mobility (r = 0.503, P = 0.001), balance self-efficacy (r = 0.608, P = 0.001), community balance/mobility (r = 0.586, P = 0.001), and duration of stroke (r = 0.220, P = 0.036). Stride time (r = -0.282, P = 0.073) and fall self-efficacy (r = 0.566, P = 0.001) were negatively correlated with community reintegration. Duration of stroke, balance self-efficacy, community balance/mobility, and fall self-efficacy (52.7% of the variance) were the significant predictors of community reintegration.

Conclusion

Community reintegration is influenced by cadence, functional mobility, balance self-efficacy, community balance/mobility, and duration of stroke. Hence, improving balance and mobility during rehabilitation is important in enhancing community reintegration in patients with stroke.

Feasibility of incorporating functionally relevant virtual rehabilitation in sub-acute stroke care: perception of patients and clinicians

PURPOSE

To determine user satisfaction and safety of incorporating a low-cost virtual rehabilitation intervention as an adjunctive therapeutic option for cognitive-motor upper limb rehabilitation in individuals with sub-acute stroke.

METHODS

A low-cost upper limb virtual rehabilitation application incorporating realistic functionally-relevant unimanual and bimanual tasks, specifically designed for cognitive-motor rehabilitation was developed for patients with sub-acute stroke. Clinicians and individuals with stroke interacted with the intervention for 15-20 or 20-45 minutes, respectively. The study had a mixed-methods convergent parallel design that included a focus group interview with clinicians working in a stroke program and semi-structured interviews and standardized assessments (Borg Perceived Exertion Scale, Short Feedback Questionnaire) for participants with sub-acute stroke undergoing rehabilitation. The occurrence of adverse events was also noted.

RESULTS

Three main themes emerged from the clinician focus group and patient interviews: Perceived usefulness in rehabilitation, satisfaction with the virtual reality intervention and aspects to improve. All clinicians and the majority of participants with stroke were highly satisfied with the intervention and perceived its usefulness to decrease arm motor impairment during functional tasks. No participants experienced major adverse events.

CONCLUSIONS

Incorporation of this type of functional activity game-based virtual reality intervention in the sub-acute phase of rehabilitation represents a way to transfer skills learned early in the clinical setting to real world situations. This type of intervention may lead to better integration of the upper limb into everyday activities. Implications for Rehabilitation • Use of a cognitive-motor low-cost virtual reality intervention designed to remediate arm motor impairments in sub-acute stroke is feasible, safe and perceived as useful by therapists and patients for stroke rehabilitation.    • Input from end-users (therapists and individuals with stroke) is critical for the development and implementation of a virtual reality intervention.

Community mobility after stroke: a systematic review

Background Stroke is the leading cause of severe disability and many survivors report long-term physical or cognitive impairments that may impact their ability to achieve community mobility (CM).

PURPOSE

To determine the extent to which people with chronic stroke achieve CM compared to age-matched norms or non-neurologically impaired controls. Methods The StrokEDGE outcome measures were searched to identify validated tools that included >25% of items addressing CM. MEDLINE, CINAHL, Google Scholar, PubMed, PEDro and the Cochrane databases were searched from 2001 to 2015 with the identified outcome measures cross-referenced against search terms related to stroke and CM.

INCLUSION CRITERIA

utilized a validated CM outcome measure, chronic (>3 months post) stroke survivors, and randomized controlled trial, observational or cohort study design. One reviewer screened the studies and performed data extraction and three performed quality appraisal. Fourteen studies met all inclusion criteria. Results Stroke survivors have impaired CM as demonstrated by 30-83% of normative or non-stroke subject CM scores. As time post-stroke increased, CM improved only slightly. Factors found to correlate with the CM were age, education, general well-being, emotional state, motor function and coordination, independence in activities of daily living, balance, endurance and driving status. Limitations of this review include a relatively high functioning cohort, no meta-analysis and reliance on outcome measures not specifically designed to measure CM. Conclusion Survivors of stroke may experience a significant decrease in CM compared to people without neurological injury. Rehabilitation addressing motor function, coordination, independence in activities of daily living, balance and endurance may be important for achieving higher levels of CM. Outcome measures directly addressing CM are needed.

Comparison of the effects of bilateral and unilateral training after stroke: A meta-analysis

BACKGROUND

The differential effects of bilateral and unilateral training on upper extremity (UE) function remain unclear.

OBJECTIVE

To compare the effectiveness of bilateral and unilateral training on UE function and activities of daily living (ADL) after stroke.

METHODS

Randomized controlled trials (RCTs) were selected for inclusion by two reviewers after searching the following databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and KoreaMed. Methodological qualities were assessed using the PEDro scale. Effect size was estimated by calculating the standardized mean difference (SMD).

RESULTS

Eleven RCTs of sufficient quality were included in our meta-analysis. The effect size on UE capacity was statistically significant in favor of the Constraint-Induced Movement Therapy (CIMT) groups (SMD [fixed], g: - 0.34; 95% CI: - 0.59-0.08; p = 0.01; I2 = 0%). No other SMDs were significant.

CONCLUSION

The CIMT tasks were more effective than bilateral training with regard to increased UE capacity; however, this result should be cautiously interpreted since the evaluation tools were designed for assessment of unilateral UE function, not bilateral UE function. Further, the effect of the CIMT tasks on UE capacity was not translated into ADL. Considering the disadvantages of CIMT such as fatigue, bilateral training may be more appropriate for improving ADL.

Hand Passive Mobilization Performed with Robotic Assistance: Acute Effects on Upper Limb Perfusion and Spasticity in Stroke Survivors

This single arm pre-post study aimed at evaluating the acute effects induced by a single session of robot-assisted passive hand mobilization on local perfusion and upper limb (UL) function in poststroke hemiparetic participants. Twenty-three patients with subacute or chronic stroke received 20 min passive mobilization of the paretic hand with robotic assistance. Near-infrared spectroscopy (NIRS) was used to detect changes in forearm tissue perfusion. Muscle tone of the paretic UL was assessed by the Modified Ashworth Scale (MAS). Symptoms concerning UL heaviness, joint stiffness, and pain were evaluated as secondary outcomes by self-reporting. Significant (p = 0.014) improvements were found in forearm perfusion when all fingers were mobilized simultaneously. After the intervention, MAS scores decreased globally, being the changes statistically significant for the wrist (from 1.6 ± 1.0 to 1.1 ± 1.0; p = 0.001) and fingers (from 1.2 ± 1.1 to 0.7 ± 0.9; p = 0.004). Subjects reported decreased UL heaviness and stiffness after treatment, especially for the hand, as well as diminished pain when present. This study supports novel evidence that hand robotic assistance promotes local UL circulation changes, may help in the management of spasticity, and acutely alleviates reported symptoms of heaviness, stiffness, and pain in subjects with poststroke hemiparesis. This opens new scenarios for the implications in everyday clinical practice. Clinical Trial Registration Number is NCT03243123.

The influence of NDT-Bobath and PNF methods on the field support and total path length measure foot pressure (COP) in patients after stroke

In stroke patients, the NDT - (Bobath - Neurodevelopmental Treatment) and PNF (Proprioceptive Neuromuscular Facilitation) methods are used to achieve the main objective of rehabilitation, which aims at the restoration of maximum patient independence in the shortest possible period of time (especially the balance of the body). The aim of the study is to evaluate the effect of the NDT-Bobath and PNF methods on the field support and total path length measure foot pressure (COP) in patients after stroke. The study included 72 patients aged from 20 to 69 years after ischemic stroke with Hemiparesis. The patients were divided into 4 groups by a simple randomization. The criteria for this division were: the body side (right or left) affected by paresis and the applied rehabilitation methods. All the patients were applied the recommended kinesitherapeutic method (randomized), 35 therapy sessions, every day for a period of six weeks. Before initiation of therapy and after 6 weeks was measured the total area of the support and path length (COP (Center Of Pressure) measure foot pressure) using stabilometer platform - alpha. The results were statistically analyzed. After treatment studied traits decreased in all groups. The greatest improvement was obtained in groups with NDT-Bobath therapy. NDT-Bobath method for improving the balance of the body is a more effective method of treatment in comparison with of the PNF method. In stroke patients, the effectiveness of NDT-Bobath method does not depend on hand paresis.

Impairment-oriented training or Bobath therapy for severe arm paresis after stroke: a single-blind, multicentre randomized controlled trial

Objective: To study the effects of augmented exercise therapy time for arm rehabilitation as either Bobath therapy or the impairment-oriented training (Arm BASIS training) in stroke patients with arm severe paresis.

Design: Single blind, multicentre randomized control trial.

Setting: Three inpatient neurorehabilitation centres.

Subjects: Sixty-two anterior circulation ischaemic stroke patients.

Interventions: Random assignment to three group: (A) no augmented exercise therapy time, (B) augmented exercise therapy time as Bobath therapy and (C) augmented exercise therapy time as Arm BASIS training.

Main measures: Main outcome measure: Fugl-Meyer arm motor score. Secondary measure: Action Research Arm Test (ARA). Ancillary measures: Fugl-Meyer arm sensation and joint motion/pain scores and the Ashworth Scale (elbow flexors).

Results: An overall effect of augmented exercise therapy time on Fugl-Meyer scores after four weeks was not corroborated (mean and 95% confidence interval (CI) of change scores: no augmented exercise therapy time ( n = 20) 8.8, 5.2–12.3; augmented exercise therapy time ( n = 40) 9.9, 6.8-13.9; p = 0.2657). The group who received the augmented exercise therapy time as Arm BASIS training ( n = 20) had, however, higher gains than the group receiving the augmented exercise therapy time as Bobath therapy ( n = 20) (mean and 95% CI of change scores: Bobath 7.2, 2.6-11.8; BASIS 12.6, 8.4 - 16.8; p = 0.0432). Passive joint motion/pain deteriorated less in the group who received BASIS training (mean and 95% CI of change scores: Bobath -3.2, -5.2 to -1.1; BASIS 0.1, -1.8-2.0; p = 0.0090). ARA, Fugl-Meyer arm sensation, and Ashworth Scale scores were not differentially affected.

Conclusions: The augmented exercise therapy time as Arm BASIS training enhanced selective motor control. Type of training was more relevant for recovery of motor control than therapeutic time spent.

Reproducibility and validity of the Dutch Life Habits Questionnaire (LIFE-H 3.0) in older adults

Objective: To examine the reproducibility, the discriminant and convergent validity and feasibility of the Dutch translation of the self-administered Life Habits Questionnaire (LIFE-H).

Design: Three cross-sectional community-based studies on clinimetric properties of a measurement instrument.

Subjects: Older adults (n = 85) with functional limitations due to various chronic illnesses and healthy older adults (n = 40).

Measurement protocol: Participants of the reproducibility study (n = 35) filled out the LIFE-H twice in a two-week time period. In the discriminant validity study (n = 120), LIFE-H scores of healthy and ill subjects were compared. In the convergent validity study (n = 63), correlations were examined between LIFE-H, the Impact on Participation and Autonomy questionnaire and the London Handicap Scale.

Results: The test—retest reliability showed a satisfactory intraclass correlation coefficient for the total overall score (0.80) but not for the categories scores. The discriminant validity study showed significant differences between the healthy and ill subjects for the 10 separate categories (P < 0.01) and the total score (P < 0.001). The correlations between the LIFE-H categories and total scores and the Impact on Participation and Autonomy Questionnaire (0.80—0.82) and London Handicap Scale (0.89—0.92) were strong. Feasibility testing showed that the subjects experienced difficulties due to the long and fairly complex instructions and structure of the LIFE-H.

Conclusions: The clinimetric properties of the LIFE-H were moderate to good. The validity of LIFE-H was as good as the validity of the Impact on Autonomy and Participation and the London Handicap Scale, but the latter questionnaires were shorter and much easier to administer.

The effect of exercise of the affected foot in stroke patients-a randomized controlled pilot trial

Objective: To evaluate the effect of treatment with a portable device called Stimulo on range of motion, muscle strength and spasticity in the ankle joint and its effect on walking ability, balance, activities of daily living (ADL) and health-related quality of life in stroke patients.

Design: A randomized controlled pilot study.

Setting: A research centre.

Subjects: Ambulatory or partly ambulatory chronic stroke patients with remaining spasticity and/or decreased range of motion in the hemiparetic leg/ankle.

Interventions: Standardized and individualized programme including active and passive range of motion of the ankle with a portable device (Stimulo), performed three times a week for 30 min, over a six-week period.

Main measures: Range of motion, muscle strength, spasticity, gait variables, balance, ADL and health-related quality of life.

Results: Eighteen subjects were included in the study with a mean age of 75 years. The compliance rate was 94-99%. There were no significant differences between the groups.

Conclusion: The study showed no significant effect of an ankle-exercise intervention programme with Stimulo. Further studies with a larger sample size are of importance before any further conclusions can be drawn.

Post-Stroke Walking Behaviors Consistent with Altered Ground Reaction Force Direction Control Advise New Approaches to Research and Therapy

Recovery of walking after stroke requires an understanding of how motor control deficits lead to gait impairment. Traditional therapy focuses on removing specific observable gait behaviors that deviate from unimpaired walking; however, those behaviors may be effective compensations for underlying problematic motor control deficits rather than direct effects of the stroke. Neurological deficits caused by stroke are not well understood, and thus, efficient interventions for gait rehabilitation likely remain unrealized. Our laboratory has previously characterized a post-stroke control deficit that yields a specific difference in direction of the ground reaction force (F, limb endpoint force) exerted with the hemiplegic limb of study participants pushing on both stationary and moving pedals while seated. That task was not dependent on F to retain upright posture, and thus, the task did not constrain F direction. Rather, the F direction was the product of neural preference. It is not known if this specific muscle coordination deficit causes the observed walking deviations, but if present during walking, the deficit would prevent upright posture unless counteracted by compensatory behaviors. Compensations are presented that mechanically counteract the F misdirection to allow upright posture. Those compensations are similar to behaviors observed in stroke patients. Based on that alignment between predictions of this theory and clinical observations, we theorize that post-stroke gait results from the attempt to compensate for the underlying F misdirection deficit. Limb endpoint force direction has been shown to be trainable in the paretic upper limb, making it a feasible goal in the lower limb. If this F misdirection theory is valid, these ideas have tremendous promise for advancing the field of post-stroke gait rehabilitation.

Assessment of grip strength with the modified sphygmomanometer test: association between upper limb global strength and motor function

BACKGROUND

Grip strength, commonly evaluated with the handgrip dynamometer, is a good indicator of upper limb (UL) function in stroke subjects and may reflect the global strength deficits of the whole paretic UL. The Modified Sphygmomanometer Test (MST) also provides objective and adequate measures at low-cost.

OBJECTIVE

To assess whether grip strength values obtained by using the MST and those obtained by using a handgrip dynamometer would present similar correlations with the global strength and motor function of the paretic UL in subjects with stroke, both in the subacute and chronic phases.

METHOD

Measures of grip strength (MST and handgrip dynamometer), UL global strength (MST and hand-held dynamometer), and UL motor function (Fugl-Meyer motor assessment scale) were obtained with 33 subacute and 44 chronic stroke subjects. Pearson and Spearman correlation coefficients were calculated and Stepwise multiple regression analyses were performed to investigate predictor variables of grip strength (α=0.05).

RESULTS

Significant correlations of similar magnitude were found between measures of global strength of the paretic UL and grip strength assessed with both the MST (0.66≤r≤0.78) and handgrip dynamometer (0.66≤r≤0.78) and between UL motor function and grip strength assessed with both the MST (0.50≤rs≤0.51) and hand-held dynamometer (0.50≤rs≤0.63) in subacute and chronic stroke subjects. Only global strength remained as a significant predictor variable of grip strength for the MST (0.43≤R2≤0.61) and for the handgrip dynamometer (0.44≤R2≤0.61) for both stroke subgroups.

CONCLUSION

Grip strength assessed with the MST could be used to report paretic UL global strength.

Stroke rehabilitation: clinical picture, assessment, and therapeutic challenge

This chapter reviews the evolution of stroke rehabilitation in the last 20 years. It begins by describing the different types of stroke that can occur in adults, their potential consequences on a person's capacity to function in daily life and statistics on the number of strokes and their burden on families and the economy. The assessment of stroke severity, recovery of function over time, and the impact of initial stroke severity and age on potential recovery are then addressed as well as the concept of rehabilitation to enhance recovery. Fueled by the synthesis of an ever-increasing research knowledge base and the creation of stroke rehabilitation recommendations for optimal delivery of rehabilitation services and of therapeutic interventions, stroke rehabilitation has changed dramatically. Examples of improvements in stroke rehabilitation in Canada are given with emphasis on the "best practices" inspired stroke rehabilitation continuum recently recommended for the Province of Quebec. The need for an improved community-based rehabilitation approach that includes regular follow-ups and community-based programs promoting reintegration is emphasized. The importance of knowledge translation strategies to promote the uptake of best-practice recommendations is illustrated by describing the activities of the Sensorimotor Rehabilitation Research Team. Over the past 3 years, the researchers of this team and clinicians in three rehabilitation centers, two in Montreal and one in Quebec City, have collaborated to adopt standardized assessment tools, create a common stroke registry, a best-practice recommended approach to interventions and the participation of clinicians in the research process.

Use of a robotic device for the rehabilitation of severe upper limb paresis in subacute stroke: exploration of patient/robot interactions and the motor recovery process

This pioneering observational study explored the interaction between subacute stroke inpatients and a rehabilitation robot during upper limb training. 25 stroke survivors (age 55 ± 17 years; time since stroke, 52 ± 21 days) with severe upper limb paresis carried out 16 sessions of robot-assisted shoulder/elbow training (InMotion 2.0, IMT, Inc., MA, USA) combined with standard therapy. The values of 3 patient/robot interaction parameters (a guidance parameter: Stiffness, a velocity-related parameter: Slottime, and Robotic Power) were compared between sessions 1 (S1), 4 (S4), 8 (S8), 12 (S12), and 16 (S16). Pre/post Fugl-Meyer Assessment (FMA) scores were compared in 18 patients. Correlations between interaction parameters and clinical and kinematic outcome measures were evaluated. Slottime decreased at S8 (P = 0.003), while Guidance decreased at S12 (P = 0.008). Robotic Power tended to decrease until S16. FMA scores improved from S1 to S16 (+49%, P = 0.002). Changes in FMA score were correlated with the Stiffness parameter (R = 0.4, P = 0.003). Slottime was correlated with movement velocity. This novel approach demonstrated that a robotic device is a useful and reliable tool for the quantification of interaction parameters. Moreover, changes in these parameters were correlated with clinical and kinematic changes. These results suggested that robot-based recordings can provide new insights into the motor recovery process.

Trajectory of Motor Performance Over Twelve Months in Nigerian Stroke Survivors

Objective: Submissions on recovery of post-stroke motor performance vary, especially in relation to increasing time after stroke. This study examined the trajectory of motor performance over the first 12 months after stroke.

Methods: Consecutive first-incidence stroke survivors (N = 83) were recruited within 1 month of onset from a tertiary health institution in Nigeria. Simplified Fugl Meyer scale (S-FM) was used to assess motor performance at monthly intervals. Changes in overall motor performance, and differences between the affected upper and lower extremities, were examined using Friedman's ANOVA and paired t-tests, respectively.

Results: Significant improvement in motor performance was observed across 12 months (p < .001), with the proportion of stroke survivors with severe impairment at onset (53.3%) decreasing to 20% by 12 months. Lower extremity motor performance scores were significantly higher than for the upper extremity from 1 to 12 months (p <.01 at 3, 4, 5, 6 and 12 months; and p < .05 at the remaining months).

Conclusions: The potential for long-term improvement in motor performance after stroke was observed, suggesting that this can be harnessed by long-term rehabilitation efforts. The comparatively poorer outcome in the upper extremity indicates the need for extra rehabilitation strategies to enhance upper-extremity motor recovery in the first year of stroke.

Social Participation after Stroke: One-Year Follow-Up of Stroke Survivors in Nigeria

Background. Stroke may negatively affect social participation in survivors. Aims. This study assessed the pattern of social participation in a sample of Nigerian stroke survivors across the first 12 months after stroke. Methods. Stroke survivors were consecutively recruited while on admission at a tertiary health institution. The London handicap scale was used to assess social participation at 1, 3, 6, 9, and 12 months at the homes of the stroke survivors. Overall and domain-specific patterns of social participation were examined independently and also in relation to initial stroke severity. Results. Overall social participation significantly improved over 12 months (), while significant improvements were observed only in the mobility, physical independence, and work and leisure domains at P equals 0.04, 0.04, and 0.05, respectively. In spite of the improvement in the work and leisure domain, the domain recorded the lowest level of participation. Social participation also differed by initial stroke severity with severe stroke survivors having the lowest level of participation across 12 months after stroke. Conclusions. The poor outcome in the work and leisure domain of social participation and in individuals with initial severe stroke has implications for planning and provision of appropriate long-term stroke rehabilitation.

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.

A Review of Measures to Evaluate Participation Outcomes Post-Stroke

Background:

Stroke is one of the most common disabling conditions of adulthood. Participation problems are extremely common post-stroke. Occupational therapists, by virtue of their commitment to enabling occupation, are in a strong position to help stroke survivors improve their participation. To demonstrate effectiveness, occupational therapists must be able to provide evidence of post-treatment changes in participation.

Objective:

The objective of this paper was to identify participation measures that have been developed for, or tested with, individuals who have experienced a stroke and to review them for use as occupational therapy outcome measures.

Method:

A literature review was carried out to locate relevant tools. These tools were then rated for psychometric and clinical properties that are critical for clinical outcome measurement. In addition, the theoretical fit of each evaluation with occupational therapy's commitment to client-centredness was considered.

Results:

Ten evaluations were identified and rated. These ratings were designed to assist occupational therapists to choose a participation measure for their practice.

Conclusion:

Selection and use of such a measure will help occupational therapists to document its effectiveness in improving participation among stroke survivors.

Effects of intensity of arm training on hemiplegic upper extremity motor recovery in stroke patients: a randomized controlled trial

OBJECTIVE

To investigate the effects of different intensities of arm rehabilitation training on the functional recovery of hemiplegic upper extremity.

DESIGN

A randomized controlled trial.

INTERVENTIONS

Thirty-two stroke patients meeting the enrolment criteria were randomly divided into three groups: group A (n = 11), group B (n = 10) and group C (n = 11). Each group received arm training for 1 hour, 2 hours and 3 hours a day respectively, 5 days per week, for a period of six weeks.

MAIN MEASURES

Motor function was assessed by Fugl-Meyer Assessment, Action Research Arm Test and Barthel Index, carried out before treatment, two weeks, four weeks and six weeks after treatment.

RESULTS

When comparing the three groups, the Fugl-Meyer Assessment improvement was more significant in group C (20.50 ± 7.84) than that in group A (11.90 ± 6.52 ) and group B (13.80 ± 6.41) after four weeks of treatment (P < 0.05). The Action Research Arm Test score improvement was more significant in group C (7.30 ± 2.95) than in group A (3.30 ± 2.91 ) (P < 0.05). After six weeks of treatment, the Fugl-Meyer Assessment and Action Research Arm Test score improvements were more significant in group C (24.50 ± 7.96, 10.90 ± 3.60) and group B (19.70 ± 7.09, 8.70 ± 4.62) than in group A (13.00 ± 6.38, 5.30 ± 3.40) (P < 0.05). There were no significant differences of Barthel Index among the three groups (P > 0.05). In each group, Fugl-Meyer Assessment, Action Research Arm Test and Barthel Index scores increased significantly after six weeks of treatment (P < 0.05).

CONCLUSIONS

An increase in the intensity of arm training might improve the motor function of the arm after stroke.

Upper extremity function in stroke subjects: relationships between the international classification of functioning, disability, and health domains

Upper limb (UL) impairments are the most common disabling deficits after stroke and have complex relationships with activity and participation domains. However, relatively few studies have applied the ICF model to identify the contributions of specific UL impairments, such as muscular weakness, pain, and sensory loss, as predictors of activity and participation. The purposes of this predictive study were to evaluate the relationships between UL variables related to body functions/structures, activity, and participation domains and to determine which would best explain activity and participation with 55 subjects with chronic stroke. Body functions/structures were assessed by measures of grip, pinch, and UL strength, finger tactile sensations, shoulder pain, and cognition (MMSE); activity domain by measures of observed performance (BBT, NHPT, and TEMPA); and participation by measures of quality of life (SSQOL). Upper-limb and grip strength were related to all activity measures (0.52 <r < 0.82, p < .0001). Shoulder pain (r = -.39,p < .001) was the variable which was mostly related to participation. Grip strength alone accounted for 62%, 54%, and 36% of the variance in the activity measures (respectively TEMPA, BBT and NHPT). Shoulder pain accounted for 30% of the participation measure. Strength deficits and shoulder pain of the paretic UL demonstrated to be important targets for clinical interventions to improve activity and participation with chronic stroke subjects.

LEVEL OF EVIDENCE

2c.

Feasibility of the adaptive and automatic presentation of tasks (ADAPT) system for rehabilitation of upper extremity function post-stroke

BACKGROUND

Current guidelines for rehabilitation of arm and hand function after stroke recommend that motor training focus on realistic tasks that require reaching and manipulation and engage the patient intensively, actively, and adaptively. Here, we investigated the feasibility of a novel robotic task-practice system, ADAPT, designed in accordance with such guidelines. At each trial, ADAPT selects a functional task according to a training schedule and with difficulty based on previous performance. Once the task is selected, the robot picks up and presents the corresponding tool, simulates the dynamics of the tasks, and the patient interacts with the tool to perform the task.

METHODS

Five participants with chronic stroke with mild to moderate impairments (> 9 months post-stroke; Fugl-Meyer arm score 49.2 ± 5.6) practiced four functional tasks (selected out of six in a pre-test) with ADAPT for about one and half hour and 144 trials in a pseudo-random schedule of 3-trial blocks per task.

RESULTS

No adverse events occurred and ADAPT successfully presented the six functional tasks without human intervention for a total of 900 trials. Qualitative analysis of trajectories showed that ADAPT simulated the desired task dynamics adequately, and participants reported good, although not excellent, task fidelity. During training, the adaptive difficulty algorithm progressively increased task difficulty leading towards an optimal challenge point based on performance; difficulty was then continuously adjusted to keep performance around the challenge point. Furthermore, the time to complete all trained tasks decreased significantly from pretest to one-hour post-test. Finally, post-training questionnaires demonstrated positive patient acceptance of ADAPT.

CONCLUSIONS

ADAPT successfully provided adaptive progressive training for multiple functional tasks based on participant's performance. Our encouraging results establish the feasibility of ADAPT; its efficacy will next be tested in a clinical trial.

Step Test scores are related to measures of activity and participation in the first 6 months after stroke

BACKGROUND

The Step Test (ST) is a measure of dynamic standing balance and paretic-lower-extremity motor control in patients with stroke. Little is known about the extent to which impairments assessed by the ST relate to activity and participation during stroke recovery.

OBJECTIVE

The purpose of this study was to determine relationships between ST scores and measures of activity and participation during the first 6 months after stroke.

DESIGN

This was a prospective cohort study.

METHODS

Thirty-three individuals (18 men, 15 women) with a diagnosis of a single, unilateral stroke participated in the study. Participants were tested one time per month from 1 to 6 months poststroke. The ST was considered an impairment-level measure. Self-selected gait speed and the Medical

OUTCOMES

Study 36-Item Short-Form Health Survey (SF-36) Physical Function Index (PFI) were used to assess physical function. Three domains (mobility, basic and instrumental activities of daily living, participation) of the Stroke Impact Scale were used to assess self-reported disability. Regression analyses were conducted to examine the bivariate associations between ST scores and each physical function and disability measure at each time point (1-6 months).

RESULTS

The ST scores were positively associated with both physical function measures. The associations were stronger for self-selected gait speeds (R(2)=.60-.79) than for the PFI scores (R(2)=.32-.60). During the first 6 months after stroke, each additional step with the paretic lower extremity on the ST corresponded to a 0.07-m/s to 0.09-m/s increase in gait speed, and each additional step with the nonparetic lower extremity was associated with a 0.07-m/s to 0.08-m/s gait speed increase. The impairment-disability associations were weaker than the impairment-physical function associations.

LIMITATIONS

Limitations of the study include a relatively small sample size and lack of examiner blinding with regard to participant characteristics.

CONCLUSIONS

Impairments in balance and paretic-lower-extremity motor control, as measured by the ST, relate to physical function and disability during the first 6 months following stroke.

Best Conventional Therapy Versus Modular Impairment-Oriented Training for Arm Paresis After Stroke: A Single-Blind, Multicenter Randomized Controlled Trial

Background. The study investigated whether passive splinting or active motor training as either individualized best conventional therapy or as standardized impairment-oriented training (IOT) would be superior in promoting motor recovery in subacute stroke patients with mildly or severely paretic arms. Methods. A total of 148 anterior circulation ischemic stroke patients were randomly assigned to 45 minutes of additional daily arm therapy over 3 to 4 weeks as either ( a) passive therapy with inflatable splints or active arm motor therapy as either ( b) individualized best conventional therapy (CONV) or ( c) standardized IOT, that is Arm BASIS training for severe paresis or Arm Ability training for mild paresis. Main outcome measures included the following: Fugl-Meyer arm motor score (severely paretic arms) and the TEMPA time scores (mildly affected arms). Pre—post (immediate effects) and pre—4 weeks follow-up analyses (long-term effects) were performed. Results. Overall improvements were documented (mean baseline and change scores efficacy: Fugl-Meyer, arm motor scores, 24.4, +9.1 points; TEMPA, 119, −26.6 seconds; P < .0001), but with no differential effects between splint therapy and the combined active motor rehabilitation groups. Both efficacy and effectiveness analyses indicated, however, bigger immediate motor improvements after IOT as compared with best conventional therapy (Fugl-Meyer, arm motor scores: IOT +12.3, CONV +9.2 points; TEMPA: IOT −31.1 seconds, CONV −20.5 seconds; P = .0363); for mildly affected patients long-term effects could also be substantiated. Conclusions. Specificity of active training seemed more important for motor recovery than intensity (therapy time). The comprehensive modular IOT approach promoted motor recovery in patients with either severe or mild arm paresis.

Combat casualty hand burns: evaluating impairment and disability during recovery

This study evaluated the use of the American Medical Association (AMA) impairment guides and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire in U.S. military casualties recovering from burn injury to the hand. Study sample included patients with burns to at least one hand and complete evaluations of impairment and disability upon discharge from the hospital and at a follow-up visit less than four months later. AMA and DASH scores were calculated for each visit and standardized response means (SRMs) were calculated to indicate responsiveness. Correlation between impairment and disability was assessed at discharge and follow-up and scores were examined for ability to discriminate between casualties returned to duty (RTD) and casualties not returned to duty (N-RTD). Both outcome instruments revealed a statistically significant change in scores between visits (p<0.001) with corresponding SRM indexes greater than 0.8 (large effect). There was a moderate correlation (r=0.50) between impairment and disability at discharge and a moderately high correlation (r=0.74) at follow-up. Both AMA and DASH scores clearly discriminated between casualties RTD (AMA 10+/-10 and DASH 12+/-12) and casualties N-RTD (AMA 39+/-19 and DASH 41+/-17) with improved accuracy at follow-up visit. The AMA and DASH can provide a comprehensive assessment of impairment and disability and may be used to detect changes in patient health status over time while clearly discriminating between RTD and N-RTD in combat casualties recovering from burn injury to the hand(s).

Maladaptive effects of learning with the less-affected forelimb after focal cortical infarcts in rats

It is common following stroke to focus early rehabilitation efforts on developing compensatory use of the less-affected body side. Here we used a rat model of focal cortical infarct to examine how motor skill acquisition with the less-affected ("intact") forelimb influences sensorimotor function of the infarct-impaired forelimb and neural activity in peri-infarct cortex. Rats proficient in skilled reaching with one forelimb were given focal ischemic lesions in the contralateral sensorimotor cortex (SMC). Recovery in this forelimb was tested following a period of reach training focused on the intact forelimb or control procedures. Quantitative measures of the cumulatively expressed transcription factor, FosB/DeltaFosB, were used to assay intact forelimb training effects on neuronal activity in remaining SMC of the infarcted hemisphere. Intact forelimb training worsened behavioral recovery in the impaired forelimb following unilateral focal ischemia. Furthermore, it decreased neuronal FosB/DeltaFosB expression in layer II/III of peri-infarct SMC. These effects were not found in sham-operated rats trained sequentially with both forelimbs or in animals receiving bilateral forelimb training after unilateral infarcts. Thus, focused use of the intact forelimb has detrimental effects on recovery of impaired forelimb function following a focal ischemic injury and this is linked to reduced neuronal activation in remaining cortex. These results suggest that peri-infarct cortex becomes vulnerable to early post-stroke experience with the less-affected forelimb and that this experience may drive neural plasticity here in a direction that is maladaptive for functional outcome.

Determinants of satisfaction with community reintegration in older adults with chronic stroke: role of balance self-efficacy

BACKGROUND AND PURPOSE

Many people with stroke have a low level of satisfaction with community reintegration. Although previous studies focused on the effect of physical factors on community reintegration, the effect of psychological factors, such as balance self-efficacy, has been ignored. The purpose of this study was to determine the contribution of balance self-efficacy to satisfaction with community reintegration in older adults with chronic stroke.

SUBJECTS

A sample of 63 community-dwelling older adults (50 years of age or older) with chronic stroke (onset of 1 year or more) participated in this study.

METHODS

This study involved a secondary analysis of data collected from a stroke exercise clinical trial. Satisfaction with community reintegration was measured with the Reintegration to Normal Living (RNL) Index, and balance self-efficacy was measured with the Activities-specific Balance Confidence (ABC) Scale.

RESULTS

Bivariate correlation analyses showed that the RNL Index scores were moderately correlated with the ABC Scale scores. In a multiple regression analysis, after adjusting for age, sex, depression, and other impairments after stroke, balance self-efficacy remained independently associated with the RNL Index scores, accounting for 6.5% of the variance in the RNL Index scores.

DISCUSSION AND CONCLUSION

Balance self-efficacy is an independent predictor of satisfaction with community reintegration in older adults with chronic stroke. Improving balance self-efficacy may be instrumental in enhancing community reintegration in this population.

Paretic upper-limb strength best explains arm activity in people with stroke

BACKGROUND AND PURPOSE

The purpose of this study was to determine the relationship among variables of upper-limb impairment, upper-limb performance in activities of daily living (activity), and engagement in life events and roles (participation) in people with chronic stroke.

SUBJECTS

The subjects were 93 community-dwelling individuals with stroke (> or =1 year).

METHODS

This study, which was conducted in a tertiary rehabilitation center, used a cross-sectional design. The main measures of impairment were the Modified Ashworth Scale, handheld dynamometry, sensory testing (monofilaments), and the Brief Pain Inventory. The main measures of activity were the Chedoke Arm and Hand Activity Inventory (CAHAI) and the Motor Activity Log (MAL). The main measure of participation was the Reintegration to Normal Living (RNL) Index.

RESULTS

Paretic upper-limb strength (force-generating capacity) (r=.89, P<.01), grip strength (r=.69, P<.01), and tone (resistance to passive movement) (r=-.80, P<.01) were the impairment variables that were most strongly related to activity. Tone (r=-.23, P<.05) and CAHAI scores (r=.22, P<.05) had a significant, but weak, relationship to participation. Upper-limb strength accounted for 87% of the variance of the CAHAI scores and 78% of the variance of the MAL scores. In the participation models, tone and CAHAI scores accounted for 5% of the variance of the RNL Index scores.

DISCUSSION AND CONCLUSION

Paretic upper-limb strength had the strongest relationship with variables of activity and best explained upper-limb performance in activities of daily living. Grip strength, tone, and sensation also were factors of upper-limb performance in activities of daily living. Increased tone and upper-limb performance in activities of daily living had a weak relationship with participation.

Developing empirical models to enhance stroke rehabilitation

PURPOSE

Models identifying functional indicators most strongly associated with favourable and unfavourable outcomes may bolster evidence to improve stroke rehabilitation assessment and intervention. This study examined the feasibility of decision analysis methods for developing data-driven models that examined associations between specific functional indicators and global disability.

METHOD

Data were derived from functional assessment of 67 participants 3 months following stroke. Decision analysis methods were used to examine specific activity and body function indicators associated with global disability, and the degree of limitation or impairment that contributed to favourable and unfavourable outcomes, in 2 models. The feasibility of decision analysis methods was evaluated.

RESULTS

Of the 26 activity indicators, dressing was most strongly associated with global disability, followed by bill mailing, shopping and sweeping. Of 15 body function indicators, facial weakness and mental functions were most strongly associated with global disability. The misclassification risk estimates were fair for the two models.

CONCLUSIONS

Findings suggest that decision analysis methods show promise for developing models examining associations between specific functional indicators and disability. Further study with these methods may identify specific priorities for functional assessment and intervention in stroke rehabilitation.

Individuals with the dominant hand affected following stroke demonstrate less impairment than those with the nondominant hand affected

OBJECTIVE

The purpose was to determine if upper extremity impairment and function in individuals with chronic stroke is dependent upon whether the dominant or non-dominant hand is affected.

METHODS

Ninety-three community-dwelling individuals with stroke. The Modified Ashworth Scale (tone), handheld dynamometry (isometric strength), monofilaments (sensation), Brief Pain Inventory (pain), Chedoke Arm and Hand Activity Inventory Motor Activity Log (paretic arm use), and Reintegration to Normal Living Index (participation) were used to form impairment and function models.

RESULTS

Multivariate analysis models (Dominance x Severity) were created for impairment and function variables. There was a significant interaction and main effect of Dominance for the impairment model (P = 0.01) but not the function model (P = 0.75). The dependent variables of tone, grip strength, and pain were all significantly affected by Dominance, indicating less impairment if the dominant hand was affected. All dependent variables except pain were affected by Severity.

CONCLUSION

This study looked at the effect of the dominant hand being affected versus the nondominant in individuals with chronic stroke. Individuals with the dominant hand affected demonstrated less impairment than those with the nondominant hand affected. However, there was no effect of dominance on paretic arm use or performance in activities of daily living. Prospective studies to further explore the issue of hand dominance and poststroke function are suggested.

Adjustment to severe disability: constructing and examining a cognitive and occupational performance model

Ninety adults with severe physical disabilities were tested with respect to their adjustment to severe disabilities in their adapted computerized work environment 1 year following occupational therapy consultation. The research goal was to examine a model that incorporates variables from the cognitive coping model (self-esteem, appraisal and social support) and variables from the occupational performance model (engagement in activities, involvement in work/study, time of typing performance and environmental adaptations). Findings showed goodness of fit between the observed and the proposed research models, although few changes in positions and relations were found. Self-esteem and time of performance were found to be core variables connecting cognitive and functional variables. Age and activities of daily living were the only background variables that contributed to the model. Research and rehabilitation clinical implications are discussed.

Predictors of long-term participation after stroke

PURPOSE

(1) To explore factors that predict long-term participation after stroke (2-4 years after discharge from rehabilitation), and (2) to determine factors that predict both short- and long-term participation.

METHODS

Biopsychosocial data of people who had had a stroke were measured at discharge from an intensive rehabilitation unit using valid instruments. Six months later (n=102) as well as 2-4 years later (n=66), social participation of the survivors was measured in their living environments. Participation was estimated with the Assessment of Life Habits (LIFE-H), which includes 12 categories of daily activities and social roles.

RESULTS

From multivariate regression analyses, the best predictors of long-term participation after stroke appear to be age, comorbidity, motor coordination, upper extremity ability and affect. Age, comorbidity, affect and lower extremity coordination are the best predictors of participation after stroke at both measurement times.

CONCLUSIONS

With the exception of age, these factors may be positively modified and thus warrant special attention in rehabilitation interventions.