The Brief Kinesthesia test is feasible and sensitive: a study in stroke

Impaired proprioception and magnified scaling of proprioceptive error responses in chronic stroke

BACKGROUND

Previous work has shown that ~ 50-60% of individuals have impaired proprioception after stroke. Typically, these studies have identified proprioceptive impairments using a narrow range of reference movements. While this has been important for identifying the prevalence of proprioceptive impairments, it is unknown whether these error responses are consistent for a broad range of reference movements. The objective of this study was to characterize proprioceptive accuracy as function of movement speed and distance in stroke.

METHODS

Stroke (N = 25) and controls (N = 21) completed a robotic proprioception test that varied movement speed and distance. Participants mirror-matched various reference movement speeds (0.1-0.4 m/s) and distances (7.5-17.5 cm). Spatial and temporal parameters known to quantify proprioception were used to determine group differences in proprioceptive accuracy, and whether patterns of proprioceptive error were consistent across testing conditions within and across groups.

RESULTS

Overall, we found that stroke participants had impaired proprioception compared to controls. Proprioceptive errors related to tested reference movement scaled similarly to controls, but some errors showed amplified scaling (e.g., significantly overshooting or undershooting reference speed). Further, interaction effects were present for speed and distance reference combinations at the extremes of the testing distribution.

CONCLUSIONS

We found that stroke participants have impaired proprioception and that some proprioceptive errors were dependent on characteristics of the movement (e.g., speed) and that reference movements at the extremes of the testing distribution resulted in significantly larger proprioceptive errors for the stroke group. Understanding how sensory information is utilized across a broad spectrum of movements after stroke may aid design of rehabilitation programs.

Does idiopathic carpal tunnel syndrome deteriorate proprioception of the hand? A case-control study

OBJECTIVES

This study aims to investigate the deterioration in kinesthetic kinesthesia (KKS) and visual kinesthesia (VKS) of the hand as a component of proprioception in patients with idiopathic carpal tunnel syndrome (CTS).

PATIENTS AND METHODS

This study included a total of 90 hands of 60 patients (9 males, 51 females; mean age: 47.6±9.4 years; range, 28 to 60 years) who were diagnosed with CTS and 25 hands of 25 healthy individuals (8 males, 17 females; mean age: 42.6±14.4 years; range, 20 to 60 years) as the controls between January 2019 and January 2021. The KKS and VKS scores were compared between the groups. Clinical parameters such as pain levels, hand grip strength (HGS) values, and two-point discrimination (2PD) test scores were compared between the patients with and without KKS or VKS deficits. The association between the severity of electromyographic findings and KKS or VKS deficits was examined.

RESULTS

The mean VKS score of the CTS group was 22.9±1.6 and the KKS score was 20.8±3.4, which was significantly lower than that of the control group (p=0.002 and p<0.001, respectively). The CTS patients performed less accurate repetitions in visually cued (60%) and kinesthetically cued (40%) positions than the control group (100% both). There were significantly more patients with VKS and KKS deficits in the moderate or severe CTS groups than in the mild CTS group (p<0.001 and p=0.007, respectively), and KKS or VKS deficits were significantly associated with the impaired HGS (p=0.042 and p=0.048, respectively) and functional status (p=0.020 and p=0.016, respectively) accompanied by the increased symptom severity (p=0.010 and p=0.002, respectively).

CONCLUSION

Our study results suggest that idiopathic CTS is associated with impaired proprioception and kinesthetic sense of the hand. In addition, idiopathic CTS is related to impaired hand function and severe symptoms. Screening kinesthetic sense in patients with idiopathic CTS prior to decompression surgery or postoperative hand therapy is helpful to set realistic goals and achieve superior clinical outcomes.

Where Are We on Proprioception Assessment Tests Among Poststroke Individuals? A Systematic Review of Psychometric Properties

BACKGROUND AND PURPOSE

Proprioception is often impaired in poststroke individuals. This is a significant issue since altered proprioception is associated with poorer physical function outcomes poststroke. However, there is limited consensus on the best tools for assessing proprioception and support for their widespread use by clinicians. The objective is to appraise the psychometric properties of each test used to assess proprioception in poststroke individuals.

METHODS

A systematic search was performed according to PRISMA guidelines using the databases MEDLINE, Cochrane Library, PEDro, DiTa, and BioMedicalCentral for articles published up to January 2021.

RESULTS

Sixteen studies of low methodological quality were included. Sixteen different proprioception assessment tests were extracted. The proprioception portion of the Fugl-Meyer Assessment Scale was found to be the most valid and reliable tool for screening patients in clinical settings. Although no real gold standard exists, the technological devices demonstrated better responsiveness and measurement accuracy than clinical tests. Technological devices might be more appropriate for assessing proprioception recovery or better suited for research purposes.

DISCUSSION AND CONCLUSIONS

This review revealed low-quality articles and a paucity of tests with good psychometric properties available to clinicians to properly screen and assess all subcomponents of proprioception. In perspective, technological devices, such as robotic orthoses or muscle vibration, may provide the best potential for assessing the different subcomponents of proprioception. Further studies should be conducted to develop and investigate such approaches.Video, Supplemental Digital Content 1, available at:http://links.lww.com/JNPT/A388.

Correlation Between Proprioceptive Impairment and Motor Deficits After Stroke: A Meta-Analysis Review

Introduction: Proprioceptive impairment is a common symptom after stroke. Clarifying how proprioception correlates with motor function after stroke may be helpful in optimizing proprioception-augmented movement training. Previous studies have shown inconsistent findings. A meta-analysis is an optimal method to explore the correlation and identify the factors contributing to these inconsistencies.

Objective: To explore the correlation between proprioception and motor function after stroke through a meta-analysis, taking into account characteristics of the measurements used in these studies.

Methods: We searched multiple databases until November 2021 for eligible studies that measured both proprioception and motor functions in persons with stroke and reported their correlation or data for correlation analysis. A meta-analysis of the correlations was performed. The subgroup analysis and meta-regression were further conducted to investigate potential factors contributing to the heterogeneity of correlation strength, based on the participants' characteristics, proprioception, and motor function measures.

Results: In total, 28 studies comprising of 1,829 participants with stroke were included in the meta-analysis. The overall correlation between proprioception and motor function was significant (r = 0.267, p < 0.05), but there was heterogeneity across studies (I² = 45%, p < 0.05). The results of the subgroup analysis showed proprioception of the axial segment in weight-bearing conditions (r = 0.443, p < 0.05) and upper limb without weight-bearing (r = 0.292, p < 0.05) had a stronger correlation with motor function than proprioception of the lower limb without weight-bearing. The proprioception measured through ipsilateral matching (r = 0.412, p < 0.05) showed a stronger correlation with motor function than through contralateral matching. The International Classification of Functioning, Disability, and Health (ICF) domains of motor function, movement function (r = 0.338, p < 0.05), activity performance (r = 0.239, p < 0.05), and independence (r = 0.319, p < 0.05) showed a stronger correlation with proprioception than with other domains.

Conclusion: There is a significant correlation between proprioception and motor dysfunction after stroke. The proprioception measured in the axial segment under weight-bearing conditions or measured with ipsilateral matching, and motor function, specifically in the ICF domains of movement function, activity performance, and independence showed a positive contribution to the association between proprioception and motor function. The correlation does not imply causation and might be underestimated by attributes of current tests for proprioception and motor function. Further studies are needed to clarify the cause-effect relationship.

In-Home Delivery of Constraint-Induced Movement Therapy via Virtual Reality Gaming

Purpose

People with chronic hemiparesis are frequently dissatisfied with the recovery of their hand and arm, yet many lack access to effective treatments. Constraint-induced movement therapy (CI therapy) effectively increases arm function and spontaneous use in persons with chronic hemiparesis. The purpose of this study was to determine the feasibility and measure safety and outcomes of an in-home model of delivering CI therapy using a custom, avatar-based virtual reality game.

Methods

Seventeen individuals with chronic hemiparesis participated in this pretest/posttest quasi-experimental design study. The 10-day intervention had three components: 1) high-repetition motor practice using virtual reality gaming; 2) constraint of the stronger arm via a padded restraint mitt; and 3) a transfer package to reinforce arm use. Feasibility of the intervention was evaluated through comparison to traditional CI therapy and through participants' subjective responses. The primary outcome measures were the Wolf Motor Function Test (WMFT) and the Motor Activity Log quality of movement scale (MAL-QOM).

Results

On average, participants completed 17.2 ± 8 hours and 19,436 repetitions of motor practice. No adverse events were reported. Of 7 feasibility criteria, 4 were met. WMFT rate and MAL-QOM increased, with effect size (Cohen's d) of 1.5 and 1.1, respectively.

Conclusions

This model of delivering CI therapy using a custom, avatar-based virtual reality game was feasible, well received, and showed preliminary evidence of being a safe intervention to use in the home for persons with chronic hemiparesis.

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

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

Video Game Rehabilitation for Outpatient Stroke (VIGoROUS): protocol for a multi-center comparative effectiveness trial of in-home gamified constraint-induced movement therapy for rehabilitation of chronic upper extremity hemiparesis

Background

Constraint-Induced Movement therapy (CI therapy) is shown to reduce disability, increase use of the more affected arm/hand, and promote brain plasticity for individuals with upper extremity hemiparesis post-stroke. Randomized controlled trials consistently demonstrate that CI therapy is superior to other rehabilitation paradigms, yet it is available to only a small minority of the estimated 1.2 million chronic stroke survivors with upper extremity disability. The current study aims to establish the comparative effectiveness of a novel, patient-centered approach to rehabilitation utilizing newly developed, inexpensive, and commercially available gaming technology to disseminate CI therapy to underserved individuals. Video game delivery of CI therapy will be compared against traditional clinic-based CI therapy and standard upper extremity rehabilitation. Additionally, individual factors that differentially influence response to one treatment versus another will be examined.

Methods

This protocol outlines a multi-site, randomized controlled trial with parallel group design. Two hundred twenty four adults with chronic hemiparesis post-stroke will be recruited at four sites. Participants are randomized to one of four study groups: (1) traditional clinic-based CI therapy, (2) therapist-as-consultant video game CI therapy, (3) therapist-as-consultant video game CI therapy with additional therapist contact via telerehabilitation/video consultation, and (4) standard upper extremity rehabilitation. After 6-month follow-up, individuals assigned to the standard upper extremity rehabilitation condition crossover to stand-alone video game CI therapy preceded by a therapist consultation. All interventions are delivered over a period of three weeks. Primary outcome measures include motor improvement as measured by the Wolf Motor Function Test (WMFT), quality of arm use for daily activities as measured by Motor Activity Log (MAL), and quality of life as measured by the Quality of Life in Neurological Disorders (NeuroQOL).

Discussion

This multi-site RCT is designed to determine comparative effectiveness of in-home technology-based delivery of CI therapy versus standard upper extremity rehabilitation and in-clinic CI therapy. The study design also enables evaluation of the effect of therapist contact time on treatment outcomes within a therapist-as-consultant model of gaming and technology-based rehabilitation.

Trial registration

Clinicaltrials.gov, NCT02631850.