Upper limb recovery after stroke: The stroke survivors' perspective

Purpose.?This study investigated stroke survivors' perspective of upper limb recovery after stroke. The aim was to determine factors other than medical diagnosis and co-morbidities that contribute to recovery. The objectives were to explore how stroke survivors define recovery, identify factors they believe influence recovery and determine strategies used to maximize upper limb recovery.

Method.?A qualitative study consisting of three focus groups and two in-depth interviews was conducted with stroke survivors (n = 19) and spouses (n = 9) in metropolitan, regional and rural Queensland, Australia. Data were analysed using principles of grounded theory.

Results.?Stroke survivors maximize upper limb recovery by ‘keeping the door open’ a process of continuing to hope for and work towards improvement amidst adjusting to life with stroke. They achieve this by ‘hanging in there’, ‘drawing on support from others’, ‘getting going and keeping going with exercise’, and ‘finding out how to keep moving ahead’.

Conclusions.?This study provides valuable insight into the personal experience of upper limb recovery after stroke. It highlights the need to develop training strategies that match the needs and aspirations of stroke survivors and that place no time limits on recovery. It reinforces the benefits of stroke support groups and advocates their incorporation into stroke recovery services. These findings can be used to guide both the development and evaluation of stroke survivor centred upper limb training programmes.     

Factors contributing to upper limb recovery after stroke: a survey of stroke survivors in Queensland Australia

Purpose. To identify factors which contribute to upper limb recovery, from the perspective of stroke survivors.

Method. A retrospective cross-sectional survey was administered by post to 220 stroke survivors with upper limb impairment who were more than 3 months post-stroke. The content and language for the questionnaire were drawn from a series of focus groups and in-depth interviews with stroke survivors (n = 29). Where possible items or composite scales were replicated or adapted from existing surveys.

Results. Many factors regarding the stroke survivors' commitment to recovery, the type and amount of exercise undertaken and their knowledge of how to progress were associated with self-reported upper limb recovery. The single most important factor was 'use of the arm in everyday tasks', which was independently responsible for more than 12% of the variance in recovery. 'Not enough movement to work with' was the second most important factor, representing the greatest barrier to recovery.

Conclusions. The findings of this survey highlight many practical day to day factors that may contribute to a stroke survivor's ability to advance the recovery of their upper limb. Stroke recovery services can use this information to tailor their services to ensure these practical concerns are addressed.     

Interventions to promote upper limb recovery in stroke survivors with severe paresis: a systematic review

Purpose.?To investigate the effect of interventions that promote upper limb (UL) recovery in stroke survivors with severe paresis.

Methods.?A systematic search of the scientific literature from January 1970 to March 2009 was conducted using CINAHL, Cochrane, PEDro, Pubmed and Web of Science. keywords used included stroke, severe, hemiplegia, UL, task-oriented, robot, non-robot and electrical stimulation. Methodological quality of the studies was assessed using the PEDro rating scale. Studies were grouped into one of three intervention categories: robotic therapy, electrical stimulation or ‘other’ therapy.

Results.?Seventeen randomised controlled trials met the inclusion criteria. A ‘best evidence synthesis’ indicated strong evidence that robotic therapy provides a large beneficial effect and limited evidence that electrical stimulation and ‘other’ interventions provide a large beneficial effect on function. There is no evidence that these interventions influence use of the arm in everyday tasks.

Conclusion.?There are a number of newly developed interventions that enable stroke survivors with severe paresis to actively participate in task-oriented practice to promote UL recovery. While these interventions offer some promise for stroke survivors with severe paresis, ultimately, the effectiveness of these interventions will be dependent on whether they lead to restoration of function to the point at which the stroke survivor can practice everyday tasks.     

Reasons for recovery after stroke: A perspective based on personal experience

Purpose. The purpose of this study was to learn more about individual beliefs and personal strategies used to support the period of recovery after stroke. It sought to identify the factors that were perceived to be enablers as well as challenges to recovery. Personal actions or experiences, which were perceived to be effective in influencing progress, would be identified.

Method. Qualitative in-depth interviews were carried out with 10 participants (mean age 61.8 years). Time following stroke onset ranged between 6 weeks and 13 months. All participants had some residual activity limitation and three participants had varying degrees of aphasia. The interviews were ～60 – 90 minutes and all data was subjected to content analysis.

Results. Analyses of interview data identified two main themes which were perceived to have influenced progress after stroke. The first related to internal factors such as personal control over progress, optimism and fears of dependency and the second included more external factors, such as the influence of therapeutic interactions and success with a specified marker of independence such as dressing, washing and walking.

Conclusion. An important finding of this study was that individuals all identified a number of specific factors which had supported or hindered their own recovery. There were a diversity of both internal/personal and external factors which may not be surprising, given the complexity of stroke, but all participants stressed the importance of both factors. The findings from this study are preliminary and relate only to this particular group of participants, as such they cannot be generalizable to the stroke population as a whole. However, the interaction between the two themes identified requires further exploration, especially in relation to therapy which could have both a positive and negative influence on personal control. There is a clear need to understand how professionals can, in the first place, take time to identify each individual's preferences and personal goals and secondly, make sure that these are fully addressed in a planned treatment programme. This will ensure that progress in individuals after stroke is supported by professionals with a more eclectic, individualized approach.     

Reasons for recovery after stroke: a perspective based on personal experience

Purpose. The purpose of this study was to learn more about individual beliefs and personal strategies used to support the period of recovery after stroke. It sought to identify the factors that were perceived to be enablers as well as challenges to recovery. Personal actions or experiences, which were perceived to be effective in influencing progress, would be identified.

Method. Qualitative in-depth interviews were carried out with 10 participants (mean age 61.8 years). Time following stroke onset ranged between 6 weeks and 13 months. All participants had some residual activity limitation and three participants had varying degrees of aphasia. The interviews were ∼60 - 90 minutes and all data was subjected to content analysis.

Results. Analyses of interview data identified two main themes which were perceived to have influenced progress after stroke. The first related to internal factors such as personal control over progress, optimism and fears of dependency and the second included more external factors, such as the influence of therapeutic interactions and success with a specified marker of independence such as dressing, washing and walking.

Conclusion. An important finding of this study was that individuals all identified a number of specific factors which had supported or hindered their own recovery. There were a diversity of both internal/personal and external factors which may not be surprising, given the complexity of stroke, but all participants stressed the importance of both factors. The findings from this study are preliminary and relate only to this particular group of participants, as such they cannot be generalizable to the stroke population as a whole. However, the interaction between the two themes identified requires further exploration, especially in relation to therapy which could have both a positive and negative influence on personal control. There is a clear need to understand how professionals can, in the first place, take time to identify each individual's preferences and personal goals and secondly, make sure that these are fully addressed in a planned treatment programme. This will ensure that progress in individuals after stroke is supported by professionals with a more eclectic, individualized approach.     

Interventions combined with task-specific training to improve upper limb motor recovery following stroke: a systematic review with meta-analyses

Background: Upper limb (UL) hemiparesis is a common, disabling and persistent problem, and a major contributor to poor well-being and quality of life in persons after stroke. Conventional UL rehabilitation has had limited success. Novel combined interventions are being investigated in an effort to stimulate greater recovery.

Objective: To identify and assess the efficacy of interventions combined with task-specific training aimed at UL motor recovery after stroke.

Methods: A systematic search was undertaken in databases including MEDLINE, MEDLINE In-Process, EMBASE, AMED, CINAHL, OTseeker, and PEDro. Key inclusion criteria were: peer-reviewed articles published in English, adults after stroke, and an intervention combined with task-specific training targeted to improve motor function and/or impairment of the UL following stroke. Findings from included studies were synthesized qualitatively and meta-analyzed where there was sufficient homogeneity.

Results: From 3494 citations identified, 120 papers (72 randomized controlled trials and 4 pseudo-randomized controlled trials) were included. Adjunctive interventions (21 categories) identified included electrical stimulation, transcranial magnetic stimulation, robotic devices, mental practice, action observation, trunk restraint, virtual reality, and resistance training. Of the interventions meta-analyzed, only peripheral nerve stimulation demonstrated small additional benefits over those of task-specific training alone for UL impairment, as measured by the Fugl-Meyer scale (MD 2.69, 95% CI 1.12, 4.26). Several individual studies found benefits for other interventions combined with task-specific training, but further investigations are needed to provide more comprehensive evidence of their efficacy.

Conclusion: To date, there is little evidence that adding another intervention to TST confers additional benefits and therefore there is no evidence to guide rehabilitation professionals. Further research is required as heterogeneity of studies limited ability to conduct meta-analyses.     

Shoulder subluxation after stroke: relationships with pain and motor recovery

Background and Purpose. Glenohumeral subluxation (GHS) is a frequent complication in patients with post‐stroke hemiplegia, but its role in functional recovery is still unclear. The aim of the present investigation was to understand the relationship of GHS with shoulder pain and arm motor recovery. Method. A case–control study design was used. A sample of 107 hemiplegic adults with recent stroke (less than 30 days from onset) was differentiated into two groups according to the presence of GHS. Motor recovery was assessed using the upper extremity part of the Fugl‐Meyer Assessment Scale and the presence of shoulder pain was recorded at admission (T1), at discharge (T2) and at follow‐up, 30–40 days after discharge (T3). Results. GHS was present in 52 patients (48.6%) and correlated significantly to shoulder pain at T1, at T2 and at T3 (p < 0.001). Moreover, GHS at admission accounted for nearly 50% of shoulder pain at T3 (adjusted R² = 0.458; p < 0.001). The presence of GHS was independently associated with the upper extremity score of the Fugl‐Meyer Assessment Scale at follow‐up (adjusted R² = 0.766; p < 0.001). Conclusions. GHS is a factor associated with shoulder pain development and with arm motor recovery and should be treated in the acute stage of hemiplegia. Copyright © 2006 John Wiley & Sons, Ltd.     

Mismatch between observed and perceived upper limb function: an eye-catching phenomenon after stroke

Purpose: To investigate the relation between observed and perceived upper limb motor function in patients with chronic stroke.

Material and methods: We investigated 32 patients at six months after stroke with the Fugl-Meyer Assessment (observed function) and hand subscale of the Stroke Impact Scale (perceived function). Spearman correlation was calculated to relate observed and perceived function. Through cut-off scores, we divided our sample in low (Fugl-Meyer Assessment <31/66) and good observed function, and low (hand subscale of Stroke Impact Scale <61/100) and good perceived function. Scatterplot and hierarchical clustering analysis was conducted to detect distinct groups.

Results: A strong positive relation was found between observed and perceived function (r?=?0.84). Three groups could be identified; a “low match group” of patients with low observed and low perceived function (n?=?11, 34%), a “good match group” containing patients with good observed and good perceived function (n?=?15, 47%), and a “mismatch group” comprising patients with good observed but low perceived function (n?=?6, 19%).

Conclusions: In our chronic sample, one in five patients showed good upper limb observed but low perceived function. Measuring both observed and perceived arm and hand function seems warranted together with considering a differential therapy approach for the distinct groups.

• Implications for rehabilitation

• A considerable group of patients in the chronic phase post-stroke have good motor function in their affected upper limb, but nevertheless perceive a restricted ability.

• In order to identify a mismatch in people with chronic stroke, both observed and perceived upper limb motor function should be assessed.

• Besides common measurement tools for observed function like the Fugl-Meyer Assessment, perceived function can be evaluated by means of the hand function section of the Stroke Impact Scale.

• For patients with good observed but low perceived function, an additional rehabilitation strategy should be considered, potentially including awareness of ability and a self-efficacy approach.

     

Upper limb robot-assisted rehabilitation versus physical therapy on subacute stroke patients: A follow-up study

This study aims to analyse the long-term effects (6 months follow-up) of upper limb Robot-assisted Therapy (RT) compared to Traditional physical Therapy (TT), in subacute stroke patients. Although the literature on upper-limb rehabilitation with robots shows increasing evidence of its effectiveness in stroke survivors, the length of time for which the re-learned motor abilities could be maintained is still understudied. A randomized controlled follow-up study was conducted on 48 subacute stroke patients who performed the upper-limb therapy using a planar end-effector robotic system (Experimental Group-EG) or TT (Control Group-CG). The clinical assessments were collected at T0 (baseline), T1 (end of treatment) and T2 (6 months follow-up): Upper Limb part of Fugl-Meyer assessment (FM-UL), total passive Range Of Motion (pROM), Modified Ashworth Scale Shoulder (MAS-S) and Elbow (MAS-E). At T1, the intra-group analysis showed significant gain of FM-UL in both EG and CG, while significant improvement in MAS-S, MAS-E, and pROM were found in the EG only. At T2, significant increase in MAS-S were revealed only in the CG. In FM-UL, pROM and MAS-E the improvements obtained at the end of treatment seem to be maintained at 6 months follow-up in both groups. The inter-groups analysis of FM-UL values at T1 and T2 demonstrated significant differences in favour of EG. In conclusion, upper limb Robot-assisted Therapy may lead a greater reduction of motor impairment in subacute stroke patients compared to Traditional Therapy. The gains observed at the end of treatment persisted over time. No serious adverse events related to the study occurred.     

虚拟现实技术训练对脑卒中患者上肢功能恢复的影响

目的：探讨虚拟现实技术训练对脑卒中患者上肢功能恢复的影响。方法选取脑卒中患者34例,根据Mini -mize软件随机分为试验组和对照组各17例,均接受为期4周的康复治疗,试验组在此基础上加用虚拟现实技术训练,根据康复治疗前后的Fugl-Meyer上肢运动功能和Barthel指数的评定结果,比较两组患者上肢功能和日常生活能力的改变。结果两组患者治疗后的Fugl-Meyer上肢运动功能和Barthel指数较治疗前均有提高,试验组的功能改善程度明显优于对照组,差异均有统计学意义（ P＜0.05）。结论虚拟现实技术训练对脑卒中患者上肢运动功能和日常生活活动能力有较好的改善。     

Responsiveness and validity of the Motor Activity Log in patients during the subacute phase after stroke

Purpose.?To investigate the responsiveness and cross-sectional and longitudinal validity of the Motor Activity Log (MAL) in the subacute phase after stroke.

Method.?Data were collected pre-intervention, post-intervention, and at 3-month follow-up evaluations from 30 patients with stroke participating in a randomized trial of forced use. Assessments included MAL, the Fugl-Meyer test, the 16-hole peg test, grip strength, the Action Research Arm Test, and the Motor Assessment Scale. Measurements of responsiveness were effect size, standardized response mean (SRM), and responsiveness ratio (RR). Relationships between the MAL and the other measures were determined with Spearman correlations.

Results.?The MAL is responsive to change, with effect size, SRM, and RR?>?1.0 at the 3-month follow-up, and SRM and RR?>?1.0 at post-intervention. Correlations at the separate test occasions between MAL and the other measures were mostly close to 0.50, which shows fair to moderate construct validity. Correlations between changes in MAL and in the other measures were weaker than cross-sectional relationships.

Conclusions.?The MAL is a responsive measure of daily hand use in patients participating in rehabilitation in the subacute phase after stroke. Correlations of construct validity indicate that daily hand use may need to be measured separately from body function and activity capacity, in line with the underlying constructs of International Classification of Functioning, Disability and Health. To strengthen our findings, they should be repeated in larger samples of patients.     

镜像疗法结合肌电生物反馈对脑卒中恢复期患者上肢功能的影响

目的:观察镜像治疗结合肌电生物反馈对脑卒中恢复期患者上肢功能的影响。方法:选取脑卒中上肢功能障碍者60例,随机分为4组,常规组、镜像组、肌电组、联合组各15例。4组患者均接受常规的康复治疗,镜像组在常规治疗的基础上增加镜像治疗,肌电组在常规治疗的基础上增加肌电生物反馈,联合组在常规治疗的基础上增加镜像疗法结合肌电生物反馈。于治疗前后采用Fugl‐Meyer上肢运动功能评定(FMA‐UE)、改良Barthel指数(MBI)及主动腕背伸角度(AROM)进行康复效果评价。结果:治疗8周后,4组患者腕背伸角度及MBI评分均较治疗前都有明显提高(均P<0.05),且联合组高于其余3组(P<0.05)。在FMA‐UE评分方面,治疗8周后仅联合组较治疗前显著提高(均P<0.05),而其余3组较治疗前提高差异无统计学意义。结论:镜像疗法结合肌电生物反馈可以显著改善脑卒中恢复期患者上肢功能,值得推荐。     

上肢运动游戏对轻度认知障碍脑卒中患者功能恢复的效果

目的 观察上肢运动游戏对轻度认知障碍脑卒中患者认知功能、上肢运动功能和日常生活活动能力的影响。方法 选取2020年8月至2021年11月在北京博爱医院住院的脑卒中后轻度认知障碍患者50例，随机分为对照组和试验组各25例，两组均接受常规作业疗法训练，对照组增加功能性作业治疗，试验组增加上肢运动游戏训练，共4周。治疗前后分别采用蒙特利尔认知评估量表(MoCA)、Fugl-Meyer评定量表上肢部分(FMA-UE)和改良Barthel指数(MBI)评估治疗效果。结果 治疗后，两组MoCA总分、FMA-UE评分和MBI评分均较治疗前明显改善(|t|> 3.354,|Z|> 4.379, P <0.01)。对照组MoCA 5个认知维度(除命名和抽象思维外)较治疗前提高(|Z|> 2.000, P <0.05)；试验组MoCA 6个认知维度(除命名外)较治疗前明显提高(|Z|> 2.646, P <0.01)。试验组治疗后MoCA总分及5个维度评分(除命名和抽象思维外)以及FMA-UE评分较对照组改善(|Z|> 1.982, t=3.565, P &...     

引导性上肢协调训练对脑卒中所致单侧空间忽略的疗效观察

目的:观察应用引导性上肢协调训练治疗脑卒中所致单侧空间忽略患者的疗效。方法:脑卒中所致单侧空间忽略(USN)患者150例,随机分为2组各75例,2组患者均给予针对USN的训练,观察组在此基础上加用引导性上肢协调训练器训练。治疗前后进行空间忽略情况评价、改良Barthel指数(MBI)评定日常生活活动能力、简式Fugl-Meyer评分(FMA)评定运动功能。结果:治疗2个月后,2组患者的USN阳性率明显低于治疗前(P0.05),且观察组更低于对照组(P0.05);2组MBI及FMA评分均明显高于治疗前(P0.05),且观察组更高于对照组(P0.05)。结论:在常规康复治疗基础上联合引导性上肢协调训练进行综合治疗能有效改善脑卒中患者的单侧空间忽略,改善患者日常生活能力、提高患侧的运动能力。     

Pre-stroke socioeconomic status predicts upper limb motor recovery after inpatient neurorehabilitation

BackgroundLower socioeconomic status (SES) is associated with higher mortality rates and the likelihood of receiving less evidence-based treatment after stroke. In contrast, little is known about the impact of SES on recovery after discharge from inpatient rehabilitation. The aim of this study was to investigate the influence of SES on long-term recovery after stroke.Patients and methodsIn a prospective, observational, multicentre study, inpatients were recruited towards the end of rehabilitation. The 12-month follow-up focussed on upper limb motor recovery, measured by the Fugl-Meyer score. A clinically relevant improvement of ≥5.25 points was considered recovery. Patient-centric measures such as the Patient-reported Outcomes Measurement Information System-Physical Health (PROMIS-10 PH) provided secondary outcomes. Information on schooling, vocational training, income and occupational status pre-stroke entered a multidimensional SES index. Multivariate logistic regression models calculating odds ratios (ORs) and corresponding confidence intervals (CIs) were applied. SES was added to an initial model including age, sex and baseline neurological deficit. Additional exploratory analyses examined the association between SES and outpatient treatment.ResultsOne hundred and seventy-six patients were enrolled of whom 98 had SES and long-term recovery data. Model comparisons showed the SES-model superior to the initial model (Akaike information criterion (AIC): 123 vs. 120, Pseudo R²: 0.09 vs. 0.13). The likelihood of motor recovery (OR = 17.12, 95%CI = 1.31; 224.18) and PROMIS-10 PH improvement (OR = 20.76, 95%CI = 1.28; 337.11) were significantly increased with higher SES, along with more frequent use of outpatient therapy (p = .02).ConclusionsHigher pre-stroke SES is associated with better long-term recovery after discharge from rehabilitation. Understanding these factors can improve outpatient long-term stroke care and lead to better recovery.

KEY MESSAGE

• Higher pre-stroke socioeconomic status (SES) is associated with better long-term recovery after discharge from rehabilitation both in terms of motor function and self-reported health status.
• Higher SES is associated with significantly higher utilization of outpatient therapies.
• Discharge management of rehabilitation clinics should identify and address socioeconomic factors in order to detect individual needs and to improve outpatient recovery.
• Article registration: clinicaltrials.gov {"type":"clinical-trial","attrs":{"text":"NCT04119479","term_id":"NCT04119479"}}NCT04119479.

     

脑卒中后偏瘫手运动功能恢复的功能性磁共振成像研究

目的：应用功能磁共振成像（fMRI）技术探索脑卒中后运动功能恢复的脑代偿形式和机制。方法：选择25例脑卒中患者作为患者组，其中男16例，女9例；年龄28～75岁，平均54．1岁；进行fMRI检查时间最短为发病2周，最长为60个月。同时选择15例正常人作为对照组进行fMRI检查，其中男11例，女4例，年龄35～69岁，平均48．6岁。结果：对照组双侧手分别运动时，均在对侧SM1区产生激活，12例右手运动时激活同侧SM1区（12／15），6例左手运动时激活同侧SM1区（6／7）。SM1激活区呈斑片状或不规则状高信号。各非主要运动区亦有一定比例的激活。患者组均在对侧SM1区产生激活，同侧SM1区则有22例产生激活，激活体积多数以对侧较大，LI值为正值。右侧患手对侧SM1活平均体积及LI与正常组相近，同侧SM1均激活体积大于正常组，LI小于正常组，差异有统计学意义（P〈0．05）。左侧患手的双侧SM1均激活体积及LI与正常组比较，差异均无统计学意义。PM、SMA、CMA激活的出现率有不同程度增高，以对侧明显。结论：卒中后处于康复进程中者，患手对侧SM1积已恢复到正常水平，同侧SM1有代偿现象。双侧的PM、SMA和CMA也有代偿表现。     

乳腺癌改良根治术后加速康复外科指导功能锻炼对上肢功能的改善效果

目的观察乳腺癌患者改良根治术后加速康复外科(ERAS)指导功能锻炼对上肢功能的恢复效果。方法选取行乳腺癌改良根治术的200例女性乳腺癌患者为研究对象,将其随机分为对照组和实验组,每组100例,分别采用传统功能锻炼和ERAS模式功能锻炼。观察2组术区引流量、住院时间以及患侧上肢水肿情况,比较2组患侧上肢功能恢复效果。结果2组术区引流量比较,差异无统计学意义(P>0.05);实验组住院时间短于对照组,术后2、4周患侧上肢水肿发生率低于对照组,差异均有统计学意义(P<0.05);2组术后4周患侧上肢功能均较术后2周改善,实验组术后2、4周患侧上肢外展、前伸、后伸的活动夹角大于对照组,手指爬墙高度高于对照组,差异均有统计学意义(P<0.05)。结论乳腺癌改良根治术后ERAS功能锻炼能降低患侧上肢水肿发生率,促进功能恢复,缩短住院时间。     

强化训练对脑卒中偏瘫患者上肢运动功能的影响

目的：探讨强化训练对脑卒中偏瘫患者上肢运动功能恢复的影响。方法：62例脑卒中偏瘫患者随机分为治疗组32例，对照组30例，均接受正规的康复治疗。治疗组在康复训练的基础上，增加强化训练。结果：经4个疗程治疗后．2组上肢功能评分及简易手功能检查评分与治疗前比较有一定程度的提高，且治疗组评分明显高于对照组（P〈0.05）。结论：对脑卒中偏瘫患者进行强化训练能明显地提高患者上肢的运动功能。