A Systematic Review of Voluntary Arm Recovery in Hemiparetic Stroke: Critical Predictors for Meaningful Outcomes Using the International Classification of Functioning, Disability, and Health

Dose and Content of Training Provided to Stroke Survivors with Severe Upper Limb Disability Undertaking Inpatient Rehabilitation: An Observational Study

Background: To retrain upper limb function after stroke, a high dose of activity-related therapy is recommended. However, observational studies indicate that the dose undertaken is minimal. While it is speculated that those with severe disability will perform less therapy, this remains to be explored.

Objective: Quantify the dose and content of upper limb therapy performed by stroke survivors with severe upper limb disability during routine inpatient rehabilitation.

Methods: Therapy provided by physiotherapists and occupational therapists to 32 stroke survivors receiving inpatient rehabilitation over 20 weekdays was recorded. Dose of individual and group therapy was analysed by discipline and severity of upper and lower limb disability. Dose and content of individual therapy was also analysed by functional domain.

Results: On average, 46 minutes of individual and 11 minutes of group upper limb therapy were provided per participant, per day. Occupational therapists provided a higher dose of both individual and group therapy compared to physiotherapists (p < 0.0005). Findings suggest that greater residual upper and lower limb movement can lead to provision of a higher dose of activity-related therapy. Within individual therapy, a higher dose (29 versus 17 minutes, p < 0.002) and greater number (1218 versus 549) of impairment- than activity-related interventions were administered.

Conclusions: The dose of activity-related upper limb therapy provided to stroke survivors with severe disability was limited. There is a need to identify interventions and models of service delivery that can increase the intensity and appropriateness of therapy that stroke survivors with severe disability undertake during inpatient rehabilitation.

Compensatory arm reaching strategies after stroke: induced position analysis

After stroke, movement patterns of the upper limb (UL) during functional arm reaching change to accommodate altered constraints. These compensatory movement control strategies do not, however, have a one-to-one mapping with posttraining outcomes. In this study, we quantify arm movement control strategies in unilateral and bilateral reaching tasks using induced position analysis. In addition, we assess how those strategies are associated with UL residual impairments and with functional improvement after a specific bilateral arm training intervention. Twelve individuals with chronic stroke were measured while reaching to a box as part of their pre- and posttesting assessments. Other measurements included the Fugl-Meyer Upper Extremity Assessment (FM), Modified Wolf Motor Function Test (WT), and the University of Maryland Arm Questionnaire for Stroke (UMAQS). We identified arm control strategies that did not differ between unilateral and bilateral tasks but did differ by FM impairment level and by predicted gains in WT but not UMAQS. Increased shoulder relative to elbow moment contribution was associated with less impairment and greater gains of speed in functional tasks. These results suggest that one goal of training to achieve better outcomes may be to decrease the abnormal coupling of the shoulder and elbow.

Models containing age and NIHSS predict recovery of ambulation and upper limb function six months after stroke: an observational study

QUESTIONS

What is the incidence of recovery of ambulation and upper limb function six months after stroke? Can measures such as age and the National Institutes of Health Stroke Scale (NIHSS) be used to develop models to predict the recovery of ambulation and upper limb function?

DESIGN

Prospective cohort study.

PARTICIPANTS

Consecutive sample of 200 people with stroke admitted to a Sydney Hospital.

OUTCOME MEASURES

Ambulation was measured with item 5 of the Motor Assessment Scale (MAS); patients scoring ≥3 could ambulate independently. Upper limb function was measured with items 7 and 8 of the MAS; patients scoring ≥5 could move a cup across the table and feed themselves with a spoonful of liquid with the hemiplegic arm.

RESULTS

Of the 114 stroke survivors who were unable to ambulate initially, 80 (70%) achieved independent ambulation at six months. Of the 51 stroke survivors who could not move a cup across the table initially, 21 (41%) achieved the upper limb task at six months. Of the 56 stroke survivors who were unable to feed themselves initially, 25 (45%) could feed themselves at six months. Models containing age and severity of stroke (measured with NIHSS) predicted recovery of ambulation and ability to move a cup across the table, whilst a model containing severity of stroke predicted ability to feed oneself. All prediction models showed good discrimination (AUC 0.73 to 0.84).

CONCLUSION

More than two-thirds of people after stroke recovered independent ambulation and less than half recovered upper limb function at six months. Models using age and NIHSS can predict independent ambulation and upper limb function but these prediction models now require external validation before use in clinical practice.

Observation-to-Imitate Plus Practice Could Add Little to Physical Therapy Benefits Within 31 Days of Stroke

Background and Purpose. Observation of action with intention-to-imitate (OTI) might enhance motor recovery. This early phase trial investigated whether OTI followed by physical practice (OTI + PP) enhanced the benefits of conventional physical therapy (CPT) on upper limb recovery early after stroke. Methods. Participants were 3 to 31 days poststroke. They had substantial paresis and ability to imitate action with their ipsilesional arm. After baseline measures, participants were randomized to either OTI + PP in addition to CPT or to CPT only. Outcome measures were made after 15 days of treatment. The measurement battery was the Motricity Index (MI) and the Action Research Arm Test (ARAT). Change, baseline to outcome, was examined using the Wilcoxon test for within group and Mann–Whitney U test for between groups. Results. Sixty-five of 570 stroke survivors were eligible, 55 were able to imitate, 37 gave informed consent, 7 were transferred out of area before baseline, and 29 were randomized. Outcome measures were completed with 13 CPT participants and 9 OTI + PP participants. Both groups showed statistically significant improvements for the MI (CPT median change 8, P = .003; OTI + PP median change 10, P = .012) but the median (95% confidence interval [CI]) between-group difference was 0.0 (−11, 16), P = 1.000. For the ARAT, only the CPT group showed a statistically significant improvement (median 9, P = .006). The median (95% CI) between-group difference of 1.0 (−18, 23) was not statistically significant ( P = .815). Conclusions. These findings suggest that OTI + PP might add little to the benefits of CPT early after stroke.

A randomized controlled trial of Cognitive Sensory Motor Training Therapy on the recovery of arm function in acute stroke patients

OBJECTIVE

The aim of this study was to evaluate the effectiveness of Cognitive Sensory Motor Training Therapy (Perfetti's method) vis-à-vis conventional occupational therapy in the recovery of arm function after acute stroke.

DESIGN

Prospective randomized controlled trial.

SETTING

Two rehabilitation centers in Bangkok, Thailand.

SUBJECTS

Forty first-time acute stroke patients without severe cognitive or language impairment.

INTERVENTION

All subjects were randomly divided into two groups; one was treated using Perfetti's method and the other using conventional occupational therapy. Each group underwent therapy for 30 minutes, five times a week for four weeks.

MAIN MEASURES

The primary variable was arm function as assessed by the Action Research Arm Test; secondary variables were the extended Barthel Index and the box and block test score.

RESULTS

The intention-to-treat analysis revealed no statistically significant differences between the two groups at the end of treatment for any variable.

CONCLUSIONS

There was no evidence of a difference between Cognitive Sensory Motor Training Therapy of Perfetti's method and conventional occupational therapy with respect to the restoration of hand and arm function after a stroke.

Predictors of upper limb recovery after stroke: a systematic review and meta-analysis

OBJECTIVE

To systematically review and summarize the current available literature on prognostic variables relating to upper limb recovery following stroke. To identify which, if any variables predict upper limb recovery following stroke.

DATA SOURCES

We completed searches in MEDLINE, EMBASE, AMED, CINAHL and Cochrane CENTRAL databases. Searches were completed in November 2010.

REVIEW METHODS

Studies were included if predictor variables were measured at baseline and linked to an outcome of upper limb recovery at a future time point. Exclusion criteria included predictor variables relating to response to treatment and outcome measurements of very specific upper limb impairments such as spasticity or pain. Two independent reviewers completed data extraction and assessed study quality.

RESULTS

Fifty-eight studies met the inclusion criteria. Predictor variables which have been considered within these studies include; age, sex, lesion site, initial motor impairment, motor-evoked potentials and somatosensory-evoked potentials. Initial measures of upper limb impairment and function were found to be the most significant predictors of upper limb recovery; odds ratio 14.84 (95% confidence intervals (CI) 9.08-24.25) and 38.62 (95% CI 8.40-177.53), respectively.

CONCLUSIONS

Interpretation of these results is complicated by methodological factors including variations in study populations, upper limb motor outcome scales, timing of baseline and outcome assessments and predictors selected. The most important predictive factors for upper limb recovery following stroke appears to the initial severity of motor impairment or function.

Measurement properties of the Motor Evaluation Scale for Upper Extremity in Stroke patients (MESUPES)

PURPOSE

To investigate inter-rater reliability of the Motor Evaluation Scale for Upper Extremity in Stroke patients (MESUPES), to provide estimates of the minimal detectable change (MDC) of the MESUPES and to investigate concurrent validity in relation to the arm scores of the Modified Motor Assessment Scale (M MAS).

METHODS

Forty-two stroke patients (mean age 56 ± 12 years) were independently assessed within a 48-hours window by two raters in different pairs (total available raters = 4).

RESULTS

Weighted κ analysis indicated good to very good agreement at item level (range 0.63-0.96). The relative and absolute reliability of the total score of MESUPES (maximum 58) was high according to the intraclass correlation coefficients (ICC = 0.98) and the standard error of measurement (SEM = 2.68). The MDC for three levels of confidence was calculated: A score change of 8, 7 and 5 is necessary for a MDC to have confidence of 95%, 90% and 80%, respectively, of a genuine change. Correlation between the MESUPES and M MAS was high (r(s) = 0.87).

CONCLUSIONS

The MESUPES shows high inter-rater reliability, and our study provides useful estimates of MDC for different levels of certainty. Additional research to confirm concurrent validity and to examine other psychometric properties of the MESUPES such as sensitivity is needed.

Current trends in stroke rehabilitation. A review with focus on brain plasticity

Current understanding of brain plasticity has lead to new approaches in ischemic stroke rehabilitation. Stroke units that combine good medical and nursing care with task-oriented intense training in an environment that provides confidence, stimulation and motivation significantly improve outcome. Repetitive trans-cranial magnetic stimulation (rTMS), and trans-cranial direct current stimulation (tDCS) are applied in rehabilitation of motor function. The long-term effect, optimal way of stimulation and possibly efficacy in cognitive rehabilitation need evaluation. Methods based on multisensory integration of motor, cognitive, and perceptual processes including action observation, mental training, and virtual reality are being tested. Different approaches of intensive aphasia training are described. Recent data on intensive melodic intonation therapy indicate that even patients with very severe non-fluent aphasia can regain speech through homotopic white matter tract plasticity. Music therapy is applied in motor and cognitive rehabilitation. To avoid the confounding effect of spontaneous improvement, most trials are preformed ≥3 months post stroke. Randomized controlled trials starting earlier after strokes are needed. More attention should be given to stroke heterogeneity, cognitive rehabilitation, and social adjustment and to genetic differences, including the role of BDNF polymorphism in brain plasticity.

Systematic literature review on ICF from 2001 to 2009: its use, implementation and operationalisation

PURPOSE

To present a systematic literature review on the state of the art of the utilisation of the International Classification of Functioning, Disability and Health (ICF) since its release in 2001.

METHOD

The search was conducted through EMBASE, MEDLINE and PsychInfo covering the period between 2001 and December 2009. Papers were included if ICF was mentioned in title or abstract. Papers focussing on the ICF-CY and clinical research on children and youth only were excluded. Papers were assigned to six different groups covering the wide scenario of ICF application.

RESULTS

A total of 672 papers, coming from 34 countries and 211 different journals, were included in the analysis. The majority of publications (30.8%) were conceptual papers or papers reporting clinical and rehabilitation studies (25.9%). One-third of the papers were published in 2008 and 2009.

CONCLUSIONS

The ICF contributed to the development of research on functioning and on disability in clinical, rehabilitation as well as in several other contexts, such as disability eligibility and employment. Diffusion of ICF research and use in a great variety of fields and scientific journals is a proof that a cultural change and a new conceptualisation of functioning and disability is happening.

Predictors of response to treadmill exercise in stroke survivors

BACKGROUND

Aerobic treadmill exercise (T-EX) therapy has been shown to benefit walking and cardiorespiratory fitness in stroke survivors with chronic gait impairment even long after their stroke. The response, however, varies between individuals.

OBJECTIVE

The purpose of this post hoc analysis of 2 randomized controlled T-EX trials was to identify predictors for therapy response.

METHODS

In all, 52 participants received T-EX for 3 (Germany) or 6 (United States) months. Improvements in overground walking velocity (10 m/6-min walk) and fitness (peak VO(2)) were indicators of therapy response. Lesion location and volume were measured on T1-weighted magnetic resonance scans.

RESULTS

T-EX significantly improved gait and fitness, with gains in 10-m walk tests ranging between +113% and -25% and peak VO(2) between -12% and 88%. Baseline walking impairments or fitness deficits were not predictive of therapy response; 10-m walk velocity improved more in those with subcortical rather than cortical lesions and in patients with smaller lesions. Improvements in 6-minute walk velocity were greater in those with more recent strokes and left-sided lesions. No variable other than training intensity, which was different between trials, predicted fitness gains.

CONCLUSIONS

Despite proving overall effectiveness, the response to T-EX varies markedly between individuals. Whereas intensity of aerobic training seems to be an important predictor of gains in cardiovascular fitness, lesion size and location as well as interval between stroke onset and therapy delivery likely affect therapy response. These findings may be used to guide the timing of training and identify subgroups of patients for whom training modalities could be optimized.