The Effect of Self-directed Exercise Using a Task Board on Pain and Function in the Upper Extremities of Stroke Patients

The effect and mechanism of exercise for post-stroke pain

One of the common negative effects of a stroke that seriously lowers patients' quality of life is post-stroke pain (PSP). Thus, exercise in PSP management has become a hot research topic. The main advantages of exercise therapy are affordability and ease of acceptance by patients compared to other treatment methods. Therefore, this article reviews the effectiveness and possible mechanisms of exercise interventions for PSP. Exercise training for patients with PSP not only improves physical function but also effectively reduces pain intensity and attenuates the behavioral response to pain. In addition, exercise therapy can improve brain function and modulate levels of pro-inflammatory and neurotrophic factors to exert specific analgesic effects. Potential mechanisms for exercise intervention include modulation of synaptic plasticity in the anterior cingulate gyrus, modulation of endogenous opioids in vivo, reversal of brain-derived neurotrophic factor overexpression, inhibition of purinergic receptor (P2X4R, P2X7R) expression, and inhibition of microglia activation. However, current research on exercise for PSP remains limited, and the sustainable benefits of exercise interventions for PSP need to be further investigated.

A Comparative Study on the Effect of Task Specific Training on Right Versus Left Chronic Stroke Patients

Functional impairment of the upper limb (UL) after stroke is a great problem. Finding methods that can improve UL function after stroke is a major concern to all medical service providers. This study was intended to compare the effect of upper limb task specific training (TST) on brain excitability of the affected hemisphere and motor function improvements in patients with left and right stroke. Forty male patients with mild impairment of UL functions were divided into two equal groups; G1 consisted of patients with left hemisphere affection (right side stroke) while G2 consisted of patients with right hemisphere affection (left side stroke). All patients received TST for the affected UL for one hour, three sessions per week for six consecutive weeks. Evaluation was performed twice, pre-, and post-treatment. Outcome measures used were Wolf Motor Function Test (WMFT) and Box and Block Test (BBT) as measures of UL motor function and Quantitative Electroencephalogram (QEEG) of motor and sensory areas of the affected hemisphere as a measure of brain reorganization post-stroke. Both groups showed improvement in motor function of the affected UL measured by WMFT and BBT with reported significant difference between them. G1 showed greater improvement in motor function of the affected UL post-treatment compared to G2. Additionally, there was a significant increase in peak frequency of motor and sensory areas with higher and significant excitability in G1 only. These findings imply that brain reorganization in the left hemisphere responded more to TST compared to the right hemisphere. Based on findings of the current study, we can recommend adding TST to the physical therapy program in stroke patients with left hemisphere lesions.

Influence of task-oriented circuit training on upper limb function among rural community-dwelling survivors of stroke

Background

Task-oriented circuit training using a Multi-Activities workstation emphasises goal-oriented tasks practiced in a circuit or series in order to learn a new skill. It can be used for upper limb rehabilitation among stroke patients in a community setting, but there is currently very little evidence available regarding its use in this patient group and setting. This study aimed to explore the influence of task-oriented circuit training using a Multi-Activities workstation on upper limb function among community-dwelling individuals with chronic stroke.

Methods

A pre-test–post-test study was conducted involving 17 community-dwelling individuals with chronic stroke who were attending a stroke rehabilitation centre. Six weeks of task-oriented circuit training was given using a Multi-Activities workstation aimed to improve strength, range of motion and dexterity. Streamlined Wolf Motor Function Test and Chedoke Arm and Hand Activity Inventory were used to measure outcomes. Wilcoxon signed-rank test was used for data analysis.

Results

A total of 12 sessions of task-oriented circuit training using Multi-Activities workstations did not result in any statistically significant differences in outcome measures.

Conclusions

Task-oriented circuit training using the Multi-Activities workstation did not improve upper limb function in community-dwelling individuals with chronic stroke.

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

Background

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

Methods

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

Results

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

Conclusion

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

Self-directed therapy programmes for arm rehabilitation after stroke: a systematic review

AIM

To investigate the effectiveness of self-directed arm interventions in adult stroke survivors.

METHODS

A systematic review of Medline, EMBASE, CINAHL, SCOPUS and IEEE Xplore up to February 2018 was carried out. Studies of stroke arm interventions were included where more than 50% of the time spent in therapy was initiated and carried out by the participant. Quality of the evidence was assessed using the Cochrane risk of bias tool.

RESULTS

A total of 40 studies ( n = 1172 participants) were included (19 randomized controlled trials (RCTs) and 21 before-after studies). Studies were grouped according to no technology or the main additional technology used (no technology n = 5; interactive gaming n = 6; electrical stimulation n = 11; constraint-induced movement therapy n = 6; robotic and dynamic orthotic devices n = 8; mirror therapy n = 1; telerehabilitation n = 2; wearable devices n = 1). A beneficial effect on arm function was found for self-directed interventions using constraint-induced movement therapy ( n = 105; standardized mean difference (SMD) 0.39, 95% confidence interval (CI) -0.00 to 0.78) and electrical stimulation ( n = 94; SMD 0.50, 95% CI 0.08-0.91). Constraint-induced movement therapy and therapy programmes without technology improved independence in activities of daily living. Sensitivity analysis demonstrated arm function benefit for patients >12 months poststroke ( n = 145; SMD 0.52, 95% CI 0.21-0.82) but not at 0-3, 3-6 or 6-12 months.

CONCLUSION

Self-directed interventions can enhance arm recovery after stroke but the effect varies according to the approach used and timing. There were benefits identified from self-directed delivery of constraint-induced movement therapy, electrical stimulation and therapy programmes that increase practice without using additional technology.

The effects of training using EMG biofeedback on stroke patients upper extremity functions

[Purpose] While electromyography (EMG) biofeedback has been recently used in diverse therapeutic interventions for stroke patients, research on its effects has been lacking. Most existing studies are confined to functions of the lower extremities, and research on upper extremity functional recovery using EMG biofeedback training is limited. Therefore, this study examined the effects of training using EMG biofeedback on stroke patients' upper extremity functions. [Subjects and Methods] The subjects of this study included 30 hemiplegia patients whose disease duration was longer than six months. They were randomly divided into a control group (n=15) receiving traditional rehabilitation therapy and an experimental group (n=15) receiving both traditional rehabilitation therapy and training using EMG biofeedback. The program lasted for a total of four weeks. In order to examine the subjects' functional recovery, the author measured their upper limb function using the Fugl-Meyer Assessment and Manual Function Test, and activities of daily living using the Functional Independence Measure before and after training. [Results] A comparison of the study groups revealed that those in the experimental group experienced greater improvement in upper extremity function after training in all tests compared to the control group; however, there was no significant difference in terms of the activities of daily living between the two groups. The results of this study were as follows. [Conclusion] Thus, stroke patients receiving intensive EMG biofeedback showed more significant upper extremity functional recovery than those who only received traditional rehabilitation therapy.

The effect of Monkey Chair and Band exercise system on shoulder range of motion and pain in post-stroke patients with hemiplegia

[Purpose] A simple rehabilitation device system for strengthening upper limb muscles in hemiplegic patients was developed. This system, which stimulates active exercise while accounting for intensity, time, and frequency, was examined in the present pilot study. [Subjects and Methods] Patients had shoulder pain and limited shoulder movement. Changes in range of motion (ROM) and scores of a visual analog scale (VAS) for pain were evaluated in the experimental and control groups every four weeks for twelve weeks. The modified motor assessment scale (MMAS) was used before and after experiments. [Results] Significant differences between experimental times in ROM for shoulder flexion, abduction, and adduction on the paralyzed side were observed in the experimental group at every time point. Pain VAS scores in the experimental group improved progressively and significantly with time, indicating a consistently increasing effect of exercise. There were significant differences between the MMAS scores before and after completion of the program in the experimental group. [Conclusion] Muscle strengthening is important in hemiplegic patients, and active exercise was more efficient than passive exercise in this regard. Rehabilitation with the Monkey Chair and Band system may represent an efficient and important tool in upper limb training and comprehensive modern rehabilitation therapy.

Sonification of Arm Movements in Stroke Rehabilitation - A Novel Approach in Neurologic Music Therapy

Gross motor impairments are common after stroke, but efficient and motivating therapies for these impairments are scarce. We present an innovative musical sonification therapy, especially designed to retrain patients’ gross motor functions. Sonification should motivate patients and provide additional sensory input informing about relative limb position. Twenty-five stroke patients were included in a clinical pre–post study and took part in the sonification training. The patients’ upper extremity functions, their psychological states, and their arm movement smoothness were assessed pre and post training. Patients were randomly assigned to either of two groups. Both groups received an average of 10 days (M = 9.88; SD = 2.03; 30 min/day) of musical sonification therapy [music group (MG)] or a sham sonification movement training [control group (CG)], respectively. The only difference between the two protocols was that in the CG no sound was played back during training. In the beginning, patients explored the acoustic effects of their arm movements in space. At the end of the training, the patients played simple melodies by coordinated arm movements. The 15 patients in the MG showed significantly reduced joint pain (F = 19.96, p < 0.001) in the Fugl–Meyer assessment after training. They also reported a trend to have improved hand function in the stroke impact scale as compared to the CG. Movement smoothness at day 1, day 5, and the last day of the intervention was compared in MG patients and found to be significantly better after the therapy. Taken together, musical sonification may be a promising therapy for motor impairments after stroke, but further research is required since estimated effect sizes point to moderate treatment outcomes.

Pain syndromes in hemiplegic patients and their effects on rehabilitation results

[Purpose] The aim of this study was to determine the frequency, type, and location of pain in hemiplegic patients and the effects on rehabilitation results in our inpatient rehabilitation unit. [Subjects and Methods] Patients rehabilitated between January 2010 and July 2012 were investigated retrospectively. Properties of pain were recorded. Pre- and post-rehabilitation motor evaluation and achievement in daily activities were considered, and differences in scores between groups classified as with and without pain were examined. [Results] The number of patients included in the study was 156. The mean age was 64.28 ± 12.45 years, the mean disease duration was 11.10 months, and the gender distribution was 75 males (48%) and 81 females (52%). Fortysix (29.5%) patients had pain complaints. The nociceptive pain ratio was 86.7%, and the neuropathic pain ratio was 13.3%. Pain was mostly localized at the shoulder joint, with the proportion being 86.9%. In the pain group, statistically significant improvement was found in pain scores after the treatment. There was no significant difference between groups in the pre- and post-rehabilitation Brunnstrom motor evaluation and functional independence measurement scores. [Conclusion] Nociceptive pain is more common than neuropathic pain in patients with hemiplegia, and the shoulder joint is the most frequent location of nociceptive pain.

The antalgic effects of non-invasive physical modalities on central post-stroke pain: a systematic review

[Purpose] This study systematically reviewed the antalgic effects of non-invasive physical modalities (NIPMs) on central post-stroke pain (CPSP). [Subjects and Methods] Clinical studies were sought on September 2015 in 10 electronic databases, including Medline and Scopus. The searching strings were “central pain and stroke” and “treatment, and physical or non-pharmacological”. The inclusion and exclusion criteria were set for screening the clinical articles by two reviewers. Pain scores on visual analog scale in an article were used as the outcome measure for resulting judgment. The NIPMs intervention summarized from the eligible articles was rated from Levels A to C according to Evidence Classification Scheme for Therapeutic Interventions. [Results] Over 1200 articles were identified in the initial searches and 85 studies were retrieved. Sixteen studies were eligible and judged. Caloric vestibular stimulation (n=3), heterotopic noxious conditioning stimulation (n=1), and transcutaneous electrical stimulation (n=1) were rated below Level C. Transcranial direct current stimulation (TDCS; n=2) and transcranial magnetic stimulation (TMS; n=9) were rated as Level B. [Conclusion] The findings suggest that TMS and TDCS were better than other treatments for CPSP relief but the studies were of insufficient quality.

Medical complications experienced by first-time ischemic stroke patients during inpatient, tertiary level stroke rehabilitation

[Purpose] The aim of this study was to assess the medical complications in first-time ischemic stroke patients, to identify the factors related to occurrence of complications. [Subjects and Methods] First-time ischemic stroke patients (n=81) admitted to a tertiary level inpatient rehabilitation center during a 5 year period were included in the study. The attending physiatrist noted the presence of specific medical complications and complications that required transfer to the acute care facility from patient records. The Oxfordshire Community Stroke Project classification was used to define the clinical subtypes of the ischemic stroke patients. The Charlson comorbidity index was used to evaluate co-morbid conditions. Functional disability was assessed using the Functional Independence Measure at admission and discharge. [Results] We found that 88.9% of the patients had at least one complication. The five most common complications were urinary tract infection (48.1%), shoulder pain (37.0%), insomnia (37.0%), depression (32.1%), and musculoskeletal pain other than shoulder pain (32.1%) and 11.1% of patients were transferred to acute care facility during rehabilitation period. Functional Independence Measure scores both at admission and discharge were significantly lower in patients with at least one complication than in patients with no complications. [Conclusion] Medical complications are common among patients undergoing stroke rehabilitation. Close interdisciplinary collaboration between physiatrists and other medical specialities is necessary for optimal management.

Effect of spatial target reaching training based on visual biofeedback on the upper extremity function of hemiplegic stroke patients

[Purpose] The aim of this study was to determine the effect of spatial target reaching training (TRT) based on visual biofeedback (VB) on the upper extremity (UE) function of hemiplegic subjects. [Subjects and Methods] Forty subjects between six and eighteen months post-stroke were enrolled in this study. They were randomly allocated to an experimental group (EG, n=20) and a control group (CG, n=20). All subjects received an hour of routine therapy for stroke three times a week for four weeks. Subjects in EG received additional spatial TRT based on VB using a 2-dimensional motion capture analysis system. Both groups were tested at pre and post-intervention. The motor function of each subject's UE was assessed using the Fugl-Meyer (FM) test of UE and the Wolf Motor Function Test (WMFT). The reaching speed, angle and maximum reach distance were recorded using the motion capture analysis system. The experimental data were analyzed using the paired and independent t-tests. [Results] The mean change scores of the FM Test of UE and WMFT show there was significantly more improvement at post-intervention in EG than in CG. Also, the speed and angle reached showed significantly more increase in the EG compared with the CG. [Conclusions] The findings indicate that UE motor recovery of hemiplegic stroke patients can be enhanced through the use of TRT based on VB.