Estimating the Accuracy of the Chedoke-McMaster Stroke Assessment Predictive Equations for Stroke Rehabilitation

Motor adaptation and immediate retention to overground gait-slip perturbation training in people with chronic stroke: an experimental trial with a comparison group

Background

Perturbation-based training has shown to be effective in reducing fall-risk in people with chronic stroke (PwCS). However, most evidence comes from treadmill-based stance studies, with a lack of research focusing on training overground perturbed walking and exploring the relative contributions of the paretic and non-paretic limbs. This study thus examined whether PwCS could acquire motor adaptation and demonstrate immediate retention of fall-resisting skills following bilateral overground gait-slip perturbation training.

Methods

65 PwCS were randomly assigned to either (i) a training group, that received blocks of eight non-paretic (NP-S1 to NP-S8) and paretic (P-S1 to P-S8) overground slips during walking followed by a mixed block (seven non-paretic and paretic slips each interspersed with unperturbed walking trials) (NP-S9/P-S9 to NP-S15/P-S15) or (ii) a control group, that received a single non-paretic and paretic slip in random order. The assessor and training personnel were not blinded. Immediate retention was tested for the training group after a 30-minute rest break. Primary outcomes included laboratory-induced slip outcomes (falls and balance loss) and center of mass (CoM) state stability. Secondary outcomes to understand kinematic contributors to stability included recovery strategies, limb kinematics, slipping kinematics, and recovery stride length.

Results

PwCS within the training group showed reduced falls (p < 0.01) and improved post-slip stability (p < 0.01) from the first trial to the last trial of both paretic and non-paretic slip blocks (S1 vs. S8). During the mixed block training, there was no further improvement in stability and slipping kinematics (S9 vs. S15) (p > 0.01). On comparing the first and last training trial (S1 vs. S15), post-slip stability improved on both non-paretic and paretic slips, however, pre-slip stability improved only on the non-paretic slip (p < 0.01). On the retention trials, the training group had fewer falls and greater post-slip stability than the control group on both non-paretic and paretic slips (p < 0.01). Post-slip stability on the paretic slip was lower than that on the non-paretic slip for both groups on retention trials (p < 0.01).

Conclusion

PwCS can reduce laboratory-induced slip falls and backward balance loss outcomes by adapting their post-slip CoM state stability after bilateral overground gait-slip perturbation training. Such reactive adaptations were better acquired and retained post-training in PwCS especially on the non-paretic slips than paretic slips, suggesting a need for higher dosage for paretic slips.

Clinical registry number

NCT03205527.

Accelerometer assessed upper limb activity in people with stroke: a validation study considering ambulatory and non-ambulatory activities

PURPOSE

Accelerometry measurements are a promising method to provide quantitative information of upper limb function in daily life post stroke. Our purpose was to investigate i) the validity of accelerometer-based vector magnitude ratios (VMR) to distinguish upper limb function between individuals post-stroke and healthy controls during ambulatory and non-ambulatory activities and, ii) the association between the VMR and clinical assessment of upper limb function for individuals post-stroke.

METHODS

Forty persons with stroke and 32 healthy controls wore wrist and hip accelerometers while performing three upper limb activities in a clinical setting and during three days in daily living. Clinical assessment of upper limb function was assessed with the Chedoke-McMaster Stroke Assessment measure and ABILHand.

RESULTS

In the clinical setting and daily living, the VMR was significantly lower for individuals post-stroke compared to controls during non-ambulatory activities but not during ambulatory activities. There was a moderate to strong association between VMR and clinical assessment of upper limb function during all conditions, except for walking in the clinical setting.

CONCLUSION

The VMR could be used as a sensitive objective marker to measure upper limb function post-stroke during ambulatory and non-ambulatory daily activities.Implications for rehabilitationAccelerometer-based assessment of upper limb function is a sensitive measure of upper limb function post stroke during different activity domains.Accelerometers-based assessment of arm function can detect differences in arm function outside the clinical setting (daily living) over a prolonged period that are not always identified by clinical assessment or perceived ability.

A prospective study to establish the minimal clinically important difference of the Mini-BESTest in individuals with stroke

OBJECTIVE

To determine the minimal clinically important difference of the Mini-BESTest in individuals' post-stroke.

DESIGN

Prospective cohort study.

SETTING

Outpatient stroke rehabilitation.

SUBJECTS

Fifty outpatients with stroke with a mean (SD) age of 60.8 (9.4).

INTERVENTION

Outpatients with stroke were assessed with the Mini-BESTest before and after a course of conventional rehabilitation. Rehabilitation sessions occurred one to two times/week for one hour and treatment duration was 1.3-42 weeks (mean (SD) = 17.4(10.6)).

MAIN MEASURES

We used a combination of anchor- and distribution-based approaches including a global rating of change in balance scale completed by physiotherapists and patients, the minimal detectable change with 95% confidence, and the optimal cut-point from receiver operating characteristic curves.

RESULTS

The average (SD) Mini-BESTest score at admission was 18.2 (6.5) and 22.4 (5.2) at discharge (effect size: 0.7) (P = 0.001). Mean change scores on the Mini-BESTest for patient and physiotherapist ratings of small change were 4.2 and 4.3 points, and 4.7 and 5.3 points for substantial change, respectively. The minimal detectable change with 95% confidence for the Mini-BESTest was 3.2 points. The minimally clinical importance difference was determined to be 4 points for detecting small changes and 5 points for detecting substantial changes.

CONCLUSIONS

A change of 4-5 points on the Mini-BEST is required to be perceptible to clinicians and patients, and beyond measurement error. These values can be used to interpret changes in balance in stroke rehabilitation research and practice.

Psychometric properties of measures of upper limb activity performance in adults with and without spasticity undergoing neurorehabilitation-A systematic review

Introduction

This systematic review appraises the measurement quality of tools which assess activity and/or participation in adults with upper limb spasticity arising from neurological impairment, including methodological quality of the psychometric studies. Differences in the measurement quality of the tools for adults with a neurological impairment, but without upper limb spasticity, is also presented.

Methods

29 measurement tools identified in a published review were appraised in this systematic review. For each identified tool, we searched 3 databases (Medline, Embase, CINAHL) to identify psychometric studies completed with neurorehabilitation samples. Methodological quality of instrument evaluations was assessed with use of the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN) checklist. Synthesis of ratings allowed an overall rating of the psychometric evidence for each measurement tool to be calculated.

Results

149 articles describing the development or evaluation of psychometric properties of 22 activity and/or participation measurement tools were included. Evidence specific to tool use for adults with spasticity was identified within only 15 of the 149 articles and provided evidence for 9 measurement tools only. Overall, COSMIN appraisal highlighted a lack of evidence of measurement quality. Synthesis of ratings demonstrated all measures had psychometric weaknesses or gaps in evidence (particularly for use of tools with adults with spasticity).

Conclusions

The systematic search, appraisal and synthesis revealed that currently there is insufficient measurement quality evidence to recommend one tool over another. Notwithstanding this conclusion, newer tools specifically designed for use with people with neurological conditions who have upper limb spasticity, have emergent measurement properties that warrant further research.

Systematic review registration

PROSPERO CRD42014013190.

Effect of Task-Specific Training on Trunk Control and Balance in Patients with Subacute Stroke

Objectives

Impairment of static and dynamic posture control is common after stroke. It is found to be a predictor and an essential component for balance, walking ability, and activities of daily living (ADL) outcomes. Studies investigating effect of physical therapy techniques with an aim to improve trunk function after stroke are limited. This study aimed at studying the effect of task-specific training on trunk control and balance in patients with subacute stroke.

Methods

In this randomized controlled trail, thirty-four patients were alienated into two equal groups. The study group (n = 17) received task-specific training, and the control group (n = 17) received conventional physical therapy based on the neurodevelopmental technique. Task-specific training was applied through two phases with criteria of progression based on Chedoke-McMaster Stroke Assessment postural control stages. The interventions were applied in a dosage of 60 min per session, three times a week for ten weeks. Static and dynamic balance were measured by the trunk impairment scale (TIS), postural assessment scale (PAS), and functional reach test (FRT). Laser-guided digital goniometer was used to measure the trunk ranges of motions (ROM) as a secondary outcome.

Results

Significant differences between the baseline and the follow-up measures including TIS, PAS, FRT, and trunk (ROM) were found in both groups (P ≤ 0.05). In-between group comparison also showed significant differences between the results of both groups indicating more improvements among patients representing the study group.

Conclusion

Task-specific training may be effective in improving the static and dynamic postural control and trunk ranges of motion among subacute stroke patients.

Estimating the Threshold Value for Change for the Six Dimensions of the Impairment Inventory of the Chedoke-McMaster Stroke Assessment

Purpose: Our purpose was to estimate a threshold value for change for the six dimensions of the Impairment Inventory of the Chedoke-McMaster Stroke Assessment and the confidence in labelling a person as having improved or not. Method: Secondary analysis of two data sets, previously reported by two research teams, consisted of two statistical analyses. The first analysis used a multiple of the standard error of measurement to calculate the threshold value for change for the six dimensions. The second analysis used the diagnostic test method to calculate a threshold improvement value and the confidence a clinician had in labelling a person as having improved or not on the leg, foot, and postural control dimensions. Results: The threshold value for change was determined to be 1 impairment point (i.e., stage) for the arm, hand, leg, foot, and postural control dimensions and 2 impairment points for the shoulder pain dimension. The positive predictive values associated with the leg, foot, and postural control dimensions were 74%, 59%, and 65%, respectively. Conclusions: Clinicians can use a change of 1 impairment point for the arm, hand, leg, foot, and postural control dimensions and a change of 2 impairment points for the shoulder pain dimension to identify true change in a patient's motor recovery.

Stroke-related motor outcome measures: do they quantify the neurophysiological aspects of upper extremity recovery?

Various stroke rehabilitation outcome measures are used in clinical and research practice. Severe upper extremity paresis serves as a challenge for the selection of an appropriate outcome measure. No single measure is universally acceptable and sufficient to record the minute clinically important changes. The objectives of the present review were to explore the stroke-specific upper extremity motor outcome measures and to better understand those measures' ability to quantify upper extremity motor recovery. Seven outcome measures were selected for this review. The criteria used to select outcome measures for this review included performance-based tools that assessed the upper extremity's voluntary motor control and outcome measures which had been used for the past 10 years. A critical review that referred to motor recovery stages and volitional control was performed. The upper extremity components of each measure were compared with the neurophysiological aspects of recovery (Brunnstrom Recovery Stages) and analyzed for their clinical relevance. The concepts of minimal detectable change and minimal clinically important difference were also considered while examining the outcome measures. The findings of this review reveal that there were very few measures available to precisely assess the upper extremity motor components and volitional control. Most of the measures are functional and performance-based. Only Fugl-Meyer Assessment was found to explore the individual joint motor control as per the sequential recovery stages. Further, there is a need to develop stroke-specific upper extremity outcome measures. Scoring criteria of the acceptable measures may be modified to discern precise and progressive, but clinically significant motor changes.