SENSory re-learning of the UPPer limb (SENSUPP) after stroke: development and description of a novel intervention using the TIDieR checklist

Exploring factors influencing the consistent adoption of a post-stroke upper extremity outcome measure using Normalisation Process Theory

BACKGROUND

Stroke rehabilitation guidelines recommend using outcome measures like the Fugl-Meyer Assessment for Upper Extremity (FMA-UE) to assess post-stroke upper extremity function. However, integrating such outcome measures into routine clinical practice remains challenging, highlighting the need to understand factors affecting their implementation in evolving healthcare models.

OBJECTIVE

Our study aimed to identify the barriers and facilitators to sustain the routine use of the FMA-UE among hospital-based occupational therapists (OTs) using a theory-driven approach.

METHODS

Employing a mixed-method sequential exploratory study design rooted in Normalisation Process Theory (NPT), we gathered quantitative data through a validated survey followed by qualitative insights analysed with directed content analysis from focus group discussions involving occupational therapists from four hospitals.

RESULTS

Survey findings (n = 34) revealed barriers primarily associated with NPT constructs of collective action and coherence. Facilitators were linked to the cognitive participation construct. Key barriers identified in focus groups included insufficient coaching, competing priorities, and perceived limited value of the FMA-UE. Facilitators included legitimation of therapists' role in outcome measurements and an open learning culture.

CONCLUSIONS

Through a theory-based approach, we identified barriers and facilitators to sustain the routine of the FMA-UE. Our findings offer insights for designing implementation strategies to embed the FMA-UE into routine practice, supporting its sustained use in stroke rehabilitation.

Feasibility and efficacy of an early sensory-motor rehabilitation program on hand function in patients with stroke: a pilot, single-subject experimental design

OBJECTIVE

Hand and upper limb functional impairments following stroke lead to limitations in performing activities of daily living. We aimed to investigate feasibility and efficacy of an early sensory-motor rehabilitation program on hand and upper limb function in patients with acute stroke.

DESIGN

A pilot, single-subject experimental, A-B-A study.

SETTING

Stroke unit of an educational hospital and an outpatient occupational therapy clinic.

PARTICIPANTS

A convenience sample including five people with acute stroke.

PROCEDURES

Participants received 3 h of an intensive hand and upper limb sensory and motor rehabilitation program, 5 days per week for 3 months (15-min mental imagery, 15-min action observation, 30-min mirror therapy, 1.5-h constraint-induced movement therapy, and 30-min bilateral arm training). Activities were chosen based on the task-oriented occupational therapy approach.

OUTCOME MEASURES

An assessor blinded to intervention program measured sensory and motor functions using action research arm test, box and block test, Semmes-Weinstein monofilaments, and upper extremity section of Fugl-Meyer assessment.

RESULTS

Assessment data points in intervention and follow-up phases compared to baseline were in higher levels, sloped upwardly, and increased significantly for all participants in all outcome measures.

CONCLUSIONS

The present pilot study showed that a package of nowadays evidence-based rehabilitation methods including mental imagery, action observation, mirror therapy, modified constraint-induced movement therapy, bilateral arm training, and task-oriented occupational therapy approach is able to improve sensory and motor functions of the hand and upper limb in patients with acute stroke.

NeuroRehabilitation OnLine: Description of a regional multidisciplinary group telerehabilitation innovation for stroke and neurological conditions using the Template for Intervention Description and Replication checklist

Background

Providing recommended amounts of rehabilitation for stroke and neurological patients is challenging. Telerehabilitation is viable for delivering rehabilitation and an acceptable adjunct to in-person therapy. NeuroRehabilitation OnLine (NROL) was developed as a pilot and subsequently operationalised as a regional innovation embedded across four National Health Service (NHS) Trusts.

Objective

To describe the NROL innovation to assist future implementation and replication efforts.

Methods

The Template for Intervention Description and Replication (TIDieR) checklist, with guidance from the TIDieR-Telehealth extension, was used to describe NROL. The description was developed collaboratively by clinical academics, therapists, managers and researchers. Updated Consolidated Framework for Implementation Research domains were used to describe the context in which the innovation was delivered.

Results

NROL delivers online group-based real-time neurorehabilitation with technology assistance. It incorporates multidisciplinary targeted therapy and peer support to complement existing therapy. Procedures, materials and structure are detailed to demonstrate how NROL is embedded within a healthcare system. NROL uses existing NHS therapy workforce alongside dedicated NROL roles, including an essential technology support role. Selection of NROL groups is dependent on patient needs. The NROL innovation is tailored over time in response to feedback. NROL described here is successfully integrated within a regional stroke and neurorehabilitation network, aligns with local and national strategies and capitalises on an existing clinical-academic partnership.

Conclusion

This comprehensive description of a regional NROL innovation, and clarification of core components, should facilitate other healthcare settings to adapt and implement NROL for their context. Continuous evaluation alongside implementation will ensure maximal impact for neurorehabilitation.

Efficacy and feasibility of SENSory relearning of the UPPer limb (SENSUPP) in people with chronic stroke: A pilot randomized controlled trial

BACKGROUND

Sensorimotor impairments of the upper limb (UL) are common after stroke, but there is a lack of evidence-based interventions to improve functioning of UL.

OBJECTIVE

To evaluate (1) the efficacy of sensory relearning and task-specific training compared to task-specific training only, and (2) the feasibility of the training in chronic stroke.

DESIGN

A pilot randomized controlled trial.

SETTING

University hospital outpatient clinic.

PARTICIPANTS

Twenty-seven participants (median age; 62 years, 20 men) were randomized to an intervention group (IG; n = 15) or to a control group (CG; n = 12).

INTERVENTION

Both groups received training twice weekly in 2.5-hour sessions for 5 weeks. The training in the IG consisted of sensory relearning, task-specific training, and home training. The training in the CG consisted of task-specific training.

MAIN OUTCOME MEASURES

Primary outcome was sensory function (touch thresholds, touch discrimination, light touch, and proprioception). Secondary outcomes were dexterity, ability to use the hand in daily activities, and perceived participation. A blinded assessor conducted the assessments at baseline (T1), post intervention (T2), and at 3-month follow-up (T3). Nonparametric analyses and effect-size calculations (r) were performed. Feasibility was evaluated by a questionnaire.

RESULTS

After the training, only touch thresholds improved significantly from T1 to T2 (p = .007, r = 0.61) in the IG compared to the CG. Within the IG, significant improvements were found from T1 to T2 regarding use of the hand in daily activities (p = .001, r = 0.96) and movement quality (p = .004, r = 0.85) and from T1 to T3 regarding satisfaction with performance in meaningful activities (p = .004, r = 0.94). The CG significantly improved the performance of using the hand in meaningful activities from T1 to T2 (p = .017, r = 0.86). The training was well tolerated by the participants and performed without any adverse events.

CONCLUSIONS

Combined sensory relearning and task-specific training may be a promising and feasible intervention to improve UL sensorimotor function after stroke.

Enhancing touch sensibility by sensory retraining in a sensory discrimination task via haptic rendering

Stroke survivors are commonly affected by somatosensory impairment, hampering their ability to interpret somatosensory information. Somatosensory information has been shown to critically support movement execution in healthy individuals and stroke survivors. Despite the detrimental effect of somatosensory impairments on performing activities of daily living, somatosensory training—in stark contrast to motor training—does not represent standard care in neurorehabilitation. Reasons for the neglected somatosensory treatment are the lack of high-quality research demonstrating the benefits of somatosensory interventions on stroke recovery, the unavailability of reliable quantitative assessments of sensorimotor deficits, and the labor-intensive nature of somatosensory training that relies on therapists guiding the hands of patients with motor impairments. To address this clinical need, we developed a virtual reality-based robotic texture discrimination task to assess and train touch sensibility. Our system incorporates the possibility to robotically guide the participants' hands during texture exploration (i.e., passive touch) and no-guided free texture exploration (i.e., active touch). We ran a 3-day experiment with thirty-six healthy participants who were asked to discriminate the odd texture among three visually identical textures –haptically rendered with the robotic device– following the method of constant stimuli. All participants trained with the passive and active conditions in randomized order on different days. We investigated the reliability of our system using the Intraclass Correlation Coefficient (ICC). We also evaluated the enhancement of participants' touch sensibility via somatosensory retraining and compared whether this enhancement differed between training with active vs. passive conditions. Our results showed that participants significantly improved their task performance after training. Moreover, we found that training effects were not significantly different between active and passive conditions, yet, passive exploration seemed to increase participants' perceived competence. The reliability of our system ranged from poor (in active condition) to moderate and good (in passive condition), probably due to the dependence of the ICC on the between-subject variability, which in a healthy population is usually small. Together, our virtual reality-based robotic haptic system may be a key asset for evaluating and retraining sensory loss with minimal supervision, especially for brain-injured patients who require guidance to move their hands.

Experiences of SENSory Relearning of the UPPer Limb (SENSUPP) after Stroke and Perceived Effects: A Qualitative Study

Recently, it was shown that sensory relearning of the upper limb (SENSUPP) is a promising intervention to improve sensorimotor function after stroke. There is limited knowledge, however, of how participants perceive the training. Here, we explored how persons with sensory impairments in the upper limb experienced the SENSUPP protocol (combined sensory- and motor training and home exercises for 5 weeks) and its effect. Fifteen persons (mean age 59 years; 10 men; >6 months post-stroke) were individually interviewed, and data were analyzed with qualitative content analysis. An overall theme ‘Sensory relearning was meaningful and led to improved ability to perform daily hand activities’ and two categories with six subcategories emerged. The outpatient training was perceived as meaningful, although the exercises were demanding and required concentration. Support from the therapist was helpful and training in small groups appreciated. The home training was challenging due to lack of support, time, and motivation. Small improvements in sensory function were perceived, whereas increased movement control and ability in performing daily hand activities were reported. In conclusion, the SENSUPP protocol is meaningful and beneficial in improving the functioning of the UL in chronic stroke. Improving compliance to the home training, regular follow-ups, and an exercise diary are recommended.