Self-Perceived Utilization of the Paretic Arm in Chronic Stroke Requires High Upper Limb Functional Ability

Objective

To explore potential predictors of self-reported paretic arm use at baseline and after task-specific training (TST) in survivors of stroke.

Design

Data were obtained from a randomized controlled trial of somatosensory stimulation and upper limb TST in chronic stroke.

Setting

University laboratory.

Participants

Chronic (≥3mo) survivors of stroke (N=33; mean age, 62y; mean stroke duration, 38mo).

Interventions

Participants received 12 sessions of TST preceded by either active (n=16) or sham (n=17) somatosensory stimulation to all 3 peripheral nerves.

Main Outcome Measures

Demographic and clinical characteristics were entered stepwise into multiple linear regression analyses to determine the factors that best predict baseline Motor Activity Log (MAL) amount of use rating and change 3 months after TST.

Results

The Action Research Arm Test (ARAT) score predicted the amount of use at baseline (R²=.47, P<.001); in using this model, an ARAT score of 54 (maximum of 57) is required to score 2.5 on the MAL (use described as between rarely and sometimes). After TST the change in the ARAT score predicted the change in the amount of use (R²=.31, P=.001). The predictive power of the model for change at 3 months increased if the Fugl-Meyer Assessment wrist component score was added (R²=.41, P=.001).

Conclusions

Utilization of the paretic upper limb in activities of daily living requires high functional ability. The increase in self-reported arm use after TST is dependent on the change in functional ability. These results provide further guidance for rehabilitation decisions.     

Virtual Reality Rehabilitation With Functional Electrical Stimulation Improves Upper Extremity Function in Patients With Chronic Stroke: A Pilot Randomized Controlled Study

Objective

To compare virtual reality (VR) combined with functional electrical stimulation (FES) with cyclic FES for improving upper extremity function and health-related quality of life in patients with chronic stroke.

A 1-Year Follow-Up After Shortened Constraint-Induced Movement Therapy With and Without Mitt Poststroke

Brogårdh C, Lexell J. A 1-year follow-up after shortened constraint-induced movement therapy with and without mitt poststroke.

Objective

To explore the long-term benefits of shortened constraint-induced movement therapy (CIMT) in the subacute phase poststroke.

Design

A 1-year follow-up after shortened CIMT (3h training/d for 2wk) where the participants had been randomized to a mitt group or a nonmitt group.

Setting

A university hospital rehabilitation department.

Participants

Poststroke patients (N=20, 15 men, 5 women; mean age 58.8y; on average 14.8mo poststroke) with mild to moderate impairments of hand function.

Interventions

Not applicable.

Main Outcome Measures

The Sollerman hand function test, the modified Motor Assessment Scale, and the Motor Activity Log test. Assessments were made by blinded observers.

Results

One year after shortened CIMT, participants within both the mitt group and the nonmitt group showed statistically significant improvements in arm and hand motor performance and on self-reported motor ability compared with before and after treatment. No significant differences between the groups were found in any measure at any time.

Conclusions

Shortened CIMT seems to be beneficial up to 1 year after training, but the restraint may not enhance upper motor function. To determine which components of CIMT are most effective, larger randomized studies are needed.     

Kinematics of Pointing Movements Made in a Virtual Versus a Physical 3-Dimensional Environment in Healthy and Stroke Subjects

Knaut LA, Subramanian SK, McFadyen BJ, Bourbonnais D, Levin MF. Kinematics of pointing movements made in a virtual versus a physical 3-dimensional environment in healthy and stroke subjects.

Objective

To compare kinematics of 3-dimensional pointing movements performed in a virtual environment (VE) displayed through a head-mounted display with those made in a physical environment.

Design

Observational study of movement in poststroke and healthy subjects.

Setting

Motion analysis laboratory.

Participants

Adults (n=15; 4 women; 59±15.4y) with chronic poststroke hemiparesis were recruited. Participants had moderate upper-limb impairment with Chedoke-McMaster Arm Scores ranging from 3 to 6 out of 7. Twelve healthy subjects (6 women; 53.3±17.1y) were recruited from the community.

Interventions

Not applicable.

Main Outcome Measures

Arm and trunk kinematics were recorded in similar virtual and physical environments with an Optotrak System (6 markers; 100Hz; 5s). Subjects pointed as quickly and as accurately as possible to 6 targets (12 trials/target in a randomized sequence) placed in arm workspace areas requiring different arm movement patterns and levels of difficulty. Movements were analyzed in terms of performance outcome measures (endpoint precision, trajectory, peak velocity) and arm and trunk movement patterns (elbow and shoulder ranges of motion, elbow/shoulder coordination, trunk displacement, rotation).

Results

For healthy subjects, precision and trajectory straightness were higher in VE when pointing to contralateral targets, and movements were slower for all targets in VE. Stroke participants made less accurate and more curved movements in VE and used less trunk displacement. Elbow/shoulder coordination differed when pointing to the lower ipsilateral target. There were no group-by-environment interactions.

Conclusions

Movements in both environments were sufficiently similar to consider VE a valid environment for clinical interventions and motor control studies.     

Effects of Repetitive Electrical Stimulation to Treat Sensory Loss in Persons Poststroke

Smith PS, Dinse HR, Kalisch T, Johnson M, Walker-Batson D. Effects of repetitive electrical stimulation to treat sensory loss in persons poststroke.

Objective

To explore the effectiveness of repetitive electrical stimulation referred to here as tactile coactivation and to improve sensory discrimination and function in the most involved hand of a person recovering from stroke.

Design

Pre-experimental 1-group (n=4) design with multiple measures.

Setting

Outpatient stroke treatment center.

Participants

Subjects with 6 months or longer poststroke with self-reported sensory loss and a mild motor impairment in the most involved hand.

Intervention

Electrical stimulation (coactivation) of the fingers of the involved hand for 90 minutes 4 days a week for 6 weeks.

Main Outcome Measures

Primary-dependent measures included touch threshold, tactile acuity, haptic object recognition, motor tapping task, pegboard activities, and functional tasks from the Wolf Motor Function Test.

Results

Posttreatment assessments revealed improvements in sensory discrimination and motor task performance in all subjects in varying degrees; these results held 4 weeks posttreatment.

Conclusions

The type of repetitive electrical stimulation or tactile coactivation used in this study has not been explored previously in subjects with sensory loss caused by stroke. The results of this pilot study suggest that coactivation may have the potential to be a useful therapeutic modality for this population.     

Circuit-Based Rehabilitation Improves Gait Endurance but Not Usual Walking Activity in Chronic Stroke: A Randomized Controlled Trial

Mudge S, Barber PA, Stott NS. Circuit-based rehabilitation improves gait endurance but not usual walking activity in chronic stroke: a randomized controlled trial.

Objective

To determine whether circuit-based rehabilitation would increase the amount and rate that individuals with stroke walk in their usual environments.

Design

Single-blind randomized controlled trial.

Setting

Rehabilitation clinic.

Participants

Sixty participants with a residual gait deficit at least 6 months after stroke originally enrolled in the study. Two withdrew in the initial phase, leaving 58 participants (median age, 71.5y; range, 39.0–89.0y) who were randomized to the 2 intervention groups.

Interventions

The exercise group had 12 sessions of clinic-based rehabilitation delivered in a circuit class designed to improve walking. The control group received a comparable duration of group social and educational classes.

Main Outcome Measures

Usual walking performance was assessed using the StepWatch Activity Monitor. Clinical tests were gait speed (timed 10-meter walk) and endurance (six-minute walk test [6MWT]), confidence (Activities-Based Confidence Scale), self-reported mobility (Rivermead Mobility Index [RMI]), and self-reported physical activity (Physical Activity and Disability Scale).

Results

Intention-to-treat analysis revealed that the exercise group showed a significantly greater distance for the 6MWT than the control group immediately after the intervention (P=.030) but that this effect was not retained 3 months later. There were no changes in the StepWatch measures of usual walking performance for either group. The exercise and control groups had significantly different gait speed (P=.038) and scores on the RMI (P=.025) at the 3-month follow-up. These differences represented a greater decline in the control group compared with the exercise group for both outcome measures.

Conclusions

Circuit-based rehabilitation leads to improvements in gait endurance but does not change the amount or rate of walking performance in usual environments. Clinical gains made by the exercise group were lost 3 months later. Future studies should consider whether rehabilitation needs to occur in usual environments to improve walking performance.     

5-Repetition Sit-to-Stand Test in Subjects With Chronic Stroke: Reliability and Validity

Mong Y, Teo TW, Ng SS. 5-repetition sit-to-stand test in subjects with chronic stroke: reliability and validity.

Objectives

To examine the (1) intrarater, interrater, and test-retest reliability of the 5-repetition sit-to-stand test (5-repetition STS test) scores, (2) correlation of 5-repetition STS test scores with lower-limb muscle strength and balance performance, and (3) cut-off scores among the 3 groups of subjects: the young, the healthy elderly, and subjects with stroke.

Design

Cross-sectional study.

Setting

University-based rehabilitation center.

Participants

A convenience sample of 36 subjects: 12 subjects with chronic stroke, 12 healthy elderly subjects, and 12 young subjects.

Interventions

Not applicable.

Main Outcome Measures

5-Repetition STS test time scores; hand-held dynamometer measurements of hip flexors, and knee flexors and extensors; ankle dorsiflexors and plantarflexors muscle strength; Berg Balance Scale (BBS); and limits of stability (LOS) test using dynamic posturography.

Results

Excellent intrarater reliability of intraclass correlation coefficient (ICC) (range, .970-.976), interrater reliability (ICC=.999), and test-retest reliability (ICC range, .989-.999) were found. Five-repetition STS test scores were also found to be significantly associated with the muscle strength of affected and unaffected knee flexors (ρ=-.753 to -.830; P<.00556) of the subjects with stroke. No significant associations were found between 5-repetition STS test and BBS and LOS tests in subjects with stroke. Cut-off scores of 12 seconds were found to be discriminatory between healthy elderly and subjects with stroke at a sensitivity of 83% and specificity of 75%.

Conclusions

The 5-repetition STS test is a reliable measurement tool that correlates with knee flexors muscle strength but not balance ability in subjects with stroke.     

Comparison of the action research arm test and the Fugl-Meyer assessment as measures of upper-extremity motor weakness after stroke

OBJECTIVE: To assess the relative responsiveness of 2 commonly used upper-extremity motor scales, the Action Research Arm Test (ARAT) and the Fugl-Meyer Assessment (FMA), in evaluating recovery of upper-extremity function after an acute stroke in patients undergoing inpatient rehabilitation. DESIGN: Prospective. SETTING: An acute stroke rehabilitation unit. PARTICIPANTS: One hundred four consecutive admissions (43 men, 61 women; mean age +/- standard deviation, 72+/-13y) to a rehabilitation unit 16+/-9 days after acute stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The following assessments were completed within 72 hours of admission and 24 hours before discharge: ARAT, upper-extremity motor domain of the FMA, National Institutes of Health Stroke Scale, FIM instrument total score, and FIM activities of daily living (FIM-ADL) subscore. RESULTS: The Spearman rank correlation statistic indicated that the 2 upper-limb motor scales (ARAT, FMA) correlated highly with one another, both on admission (rho = .77, P < .001) and on discharge (rho = .87, P < .001). The mean change in score from admission to discharge was 10+/-15 for the ARAT and 10+/-13 for the FMA motor score. The responsiveness to change as measured by the standard response mean was .68 for the ARAT and .74 for the FMA motor score. The Spearman rank correlation of each upper-limb motor scale with the FIM-ADL at the time of admission was as follows: ARAT, rho equal to .32 (P < .001) and FMA motor score, rho equal to .54 (P < .001). CONCLUSIONS: Both the FMA motor score and the ARAT were equally sensitive to change during inpatient acute rehabilitation and could be routinely used to measure recovery of upper-extremity motor function.     

Arm motor control as predictor for hypertonia after stroke: a prospective cohort study

de Jong LD, Hoonhorst MH, Stuive I, Dijkstra PU. Arm motor control as predictor for hypertonia after stroke: a prospective cohort study.

Objectives

To analyze the development of hypertonia in the hemiparetic elbow flexors, and to explore the predictive value of arm motor control on hypertonia in a cohort of first-ever stroke survivors in the first 6 months poststroke.

Design

A prospective cohort study.

Setting

A cohort of stroke survivors from a large, university-affilliated hospital in The Netherlands.

Participants

Patients (N=50) with first-time ischemic strokes and initial arm paralysis who were admitted to a stroke unit.

Interventions

Not applicable.

Main Outcome Measures

At 48 hours, 10 to 12 days, 3 and 6 months poststroke, hypertonia and arm motor control were assessed using the Modified Ashworth Scale and the Fugl-Meyer Assessment arm score.

Results

The incidence rate of hypertonia reached its maximum before the third month poststroke (30%). Prevalence was 42% at 3 and 6 months. Participants with poor arm motor control at 48 hours poststroke were 13 times more likely to develop hypertonia in the first 6 months poststroke than those with moderate to good arm motor control. These results were not confounded by the amount of arm function training received.

Conclusions

Hypertonia develops in a large proportion of patients with stroke, predominantly within the first 3 months poststroke. Poor arm motor control is a risk factor for the development of hypertonia.     

Examination of Sustained Gait Speed During Extended Walking in Individuals With Chronic Stroke

Objectives

To determine if individuals with chronic stroke were able to sustain their peak gait speed during the 6-minute walk test (6MWT), and to explore this sustainability across community ambulation potential subgroups.

Design

Prospective cross-sectional study.

Setting

University-based research laboratory, hospitals, and stroke support groups.

Participants

A sample of individuals with chronic stroke (N=48) completed a series of questionnaires and physical outcome measures, including gait mat assessment, during a single visit.

Interventions

Not applicable; 1-time cross-sectional data collection.

Main Outcome Measures

During the 6MWT, we measured peak gait speed and end gait speed to assess sustainability, along with beginning gait speed, total distance walked, and rating of perceived exertion. We also assessed maximum gait speed during the 10-meter walk test (10MWT). Finally, we examined these gait outcomes across the subgroups.

Results

During the 6MWT, peak gait speed declined from .89m/s (SD=.38) to an end speed of .82m/s (SD=.36), whereas perceived exertion increased from 7.7 (SD=2.6) to 11.8 (SD=3.6). This peak gait speed was slower than the 10MWT maximum speed of 1.06m/s (SD=.51), but faster than the 6MWT beginning speed of .81m/s (SD=.34). The unlimited community ambulator subgroup was the primary contributor to sustainability differences.

Conclusions

Predicting community ambulation potential based on the discrete gait speed from the 10MWT and endurance based on the average from the 6MWT might be incomplete if gait speed sustainability is not also assessed.     

Validity, responsiveness, and clinically important difference of the ABILHAND questionnaire in patients with stroke

Wang T, Lin K, Wu C, Chung C, Pei Y, Teng Y. Validity, responsiveness, and clinically important difference of the ABILHAND questionnaire in patients with stroke.

Objective

To investigate the criterion-related validity, responsiveness, and clinically important differences of the ABILHAND questionnaire in patients with stroke.

Design

Validation and clinimetric study.

Setting

Three medical centers.

Participants

Patients with stroke (N=51).

Interventions

A total of 51 patients with stroke received 1 of 3 upper extremity rehabilitation programs for 4 weeks.

Main Outcome Measures

The ABILHAND and the criterion measures, including the Stroke Impact Scale (SIS), FIM, Nottingham Extended Activities of Daily Living (NEADL), and accelerometers, were administered at pretreatment and posttreatment. The score of the ABILHAND, given in logits, was based on the conversion of the ordinal score into a linear measure of ability.

Results

Correlation coefficients (Pearson r) were moderate to large between the ABILHAND and SIS physical domains (.54–.66), fair to moderate between the ABILHAND and FIM-motor and NEADL (.28–.48), and moderate between the ABILHAND and accelerometer data (.45–.54). The responsiveness of the ABILHAND was large (standardized response mean=1.27). The minimal clinically important difference range for the ABILHAND was .26 to .35, and 51.0% of the patients showed a positive change that exceeded the lower bound of a clinically important difference after intervention.

Conclusions

The results support that the ABILHAND is an appropriate outcome measure for assessing upper extremity performance in daily activities in patients with stroke and is sensitive to detect change after rehabilitative interventions. The change score of a patient with stroke on the ABILHAND should reach .26 to .35 logits points to be regarded as a clinically important change.     

Deep Repetitive Transcranial Magnetic Stimulation With H-coil on Lower Limb Motor Function in Chronic Stroke: A Pilot Study

Objectives

To assess the efficacy of high-frequency (20Hz) brain stimulation on lower limb motor function in subjects with chronic (>6mo) subcortical stroke.

Design

Double-blind, placebo-controlled crossover study.

Setting

University hospital.

Participants

Right-handed subjects (N=10) affected by a first-ever subcortical stroke in the territory of the middle cerebral artery were included in this study.

Interventions

Repetitive transcranial magnetic stimulation (rTMS) was delivered with the H-coil, specifically designed to target deeper and larger brains regions. Each subject received both real and sham rTMS in a random sequence. The 2 rTMS cycles (real or sham) were composed of 11 sessions each, administered over 3 weeks and separated by a 4-week washout period.

Main Outcome Measures

Lower limb functions were assessed by the lower limb Fugl-Meyer scale, the 10-m walk test, and the 6-minute walk test before and 1 day after the end of each treatment period, as well as at a 4-week follow-up.

Results

Real rTMS treatment was associated with a significant improvement in lower limb motor function. This effect persisted over time (follow-up) and was significantly greater than that observed with sham stimulation. A significant increase in walking speed was also found after real rTMS, but this effect did not reach statistical significance in comparison with the sham stimulation.

Conclusions

These data demonstrated that 3 weeks of high-frequency deep rTMS could induce long-term improvements in lower limb functions in the chronic poststroke period, lasting at least 1 month after the end of the treatment.     

Attentional focus of feedback for improving performance of reach-to-grasp after stroke: a randomised crossover study

Objective

To investigate whether feedback inducing an external focus (EF) of attention (about movement effects) was more effective for retraining reach-to-grasp after stroke compared with feedback inducing an internal focus (IF) of attention (about body movement). It was predicted that inducing an EF of attention would be more beneficial to motor performance.

Design

Crossover trial where participants were assigned at random to two feedback order groups: IF followed by EF or EF followed by IF.

Setting

Research laboratory.

Participants

Forty-two people with upper limb impairment after stroke.

Intervention

Participants performed three reaching tasks: (A) reaching to grasp a jar; (B) placing a jar forwards on to a table; and (C) placing a jar on to a shelf. Ninety-six reaches were performed in total over one training session.

Main outcome measures

Kinematic measures were collected using motion analysis. Primary outcome measures were movement duration, peak velocity of the wrist, size of peak aperture and peak elbow extension.

Results

Feedback inducing an EF of attention produced shorter movement durations {first feedback order group: IF mean 2.53 seconds [standard deviation (SD) 1.85]; EF mean 2.12 seconds (SD 1.63), mean difference 0.41 seconds; 95% confidence interval -0.68 to 1.5; P = 0.008}, an increased percentage time to peak deceleration (P = 0.01) when performing Task B, and an increased percentage time to peak velocity (P = 0.039) when performing Task A compared with feedback inducing an IF of attention. However, an order effect was present whereby performance was improved if an EF of attention was preceded by an IF of attention.

Conclusions

Feedback inducing an EF of attention may be of some benefit for improving motor performance of reaching in people with stroke in the short term; however, these results should be interpreted with caution. Further research using a randomised design is recommended to enable effects on motor learning to be assessed.