Current practice and clinical relevance of somatosensory assessment after stroke

[Psychometric properties of performance outcome tools to assess sensitivity in subjects with stroke sequela: A systematic review]

The objective was to perform a systematic review of those performance outcomes (HRD) tools that assess sensitivity in post-stroke subjects, as well as to know which of all is the most reliable and viable. The design was a systematic review. The following were included: HRD, developed in post-stroke subjects, of any etiology and period of evolution; 18 years of age or older and testing for sensitivity; results on psychometric properties. Excluded: self-reported results, the report of cross-cultural adaptation, designed through computerized means. 19 HRD were acquired. The psychometric properties analyzed were reliability, internal consistency, measurement error, construct validity, content validity, and sensitivity to change, the first being the most studied. Psychometric properties were identified, assessed, compared, and summarized. Of all of them, we recommend the use of the modified Erasmus Nottingham Sensory Assessment, as it presents the best degree of confidence in the evidence.

Limitations in utilization and prioritization of standardized somatosensory assessments after stroke: A cross-sectional survey of neurorehabilitation clinicians

BACKGROUND AND PURPOSE

Somatosensory impairments are common after stroke, but receive limited evaluation and intervention during neurorehabilitation, despite negatively impacting functional movement and recovery.

OBJECTIVES

Our objective was to understand the scope of somatosensory assessments used by clinicians in stroke rehabilitation, and barriers to increasing use in clinical practice.

METHODS

An electronic survey was distributed to clinicians (physical therapists, occupational therapists, physicians, and nurses) who assessed at least one individual with stroke in the past 6 months. The survey included questions on evaluation procedures, type, and use of somatosensory assessments, as well as barriers and facilitators in clinical practice.

RESULTS

Clinicians (N = 431) indicated greater familiarity with non-standardized assessments, and greater utilization compared to standardized assessments (p < 0.0001). Components of tactile sensation were the most commonly assessed modality of somatosensation (25%), while proprioception was rarely assessed (1%). Overall, assessments of motor function were prioritized over assessments of somatosensory function (p < 0.0001).

DISCUSSION

Respondents reported assessing somatosensation less frequently than motor function and demonstrated a reliance on rapid and coarse non-standardized assessments that ineffectively capture multi-modal somatosensory impairments, particularly for proprioceptive deficits common post-stroke. In general, clinicians were not familiar with standardized somatosensory assessments, and this knowledge gap likely contributes to lack of translation of these assessments into practice.

CONCLUSIONS

Clinicians utilize somatosensory assessments that inadequately capture the multi-modal nature of somatosensory impairments in stroke survivors. Addressing barriers to clinical translation has the potential to increase utilization of standardized assessments to improve the characterization of somatosensory deficits that inform clinical decision-making toward enhancing stroke rehabilitation outcomes.

Physiotherapy assessment in people with neurological conditions-Evidence for the most frequently included domains: A mixed-methods systematic review

RATIONALE

There is a lack of consensus in the literature related to what is assessed clinically by physical therapists in people with neurological disorders.

AIMS

This mixed-methods systematic review aimed to identify domains that physiotherapists routinely assess in people with neurological conditions in clinical settings and explored factors influencing assessment domains including country, clinical setting, therapist experience and neurological condition.

METHOD

Five databases were searched from 1946 to 31st January 2023. Studies with any design reporting on domains assessed by a physiotherapist, in people with neurological conditions in any clinical setting, were included. Independent reviewers assessed eligibility and risk of bias using relevant McMaster critical appraisal tools. Data were extracted and synthesised following the Joanna Briggs Institute approach for mixed systematic reviews.

RESULTS

A total of 23 (16 quantitative, 7 qualitative) studies involving 3134 participants were included. The studies were rated as high (n = 14) or medium (n = 9) quality. The domains of function (n = 14); postural alignment and symmetry (n = 11); gait (n = 11); balance (n = 9), and muscle strength (n = 8) were most frequently included in assessments. Five key themes were identified from the qualitative studies: the clinical reasoning process, clinical use of standardised measures, utilisation of the senses, clinician experience and information gathering. There was minimal data on how country, clinical setting, therapist experience and neurological condition influence inclusion of assessed domains.

CONCLUSION

Five domains were most frequently included in assessment: function; postural alignment and symmetry; gait; muscle strength; and balance. This limited number of domains is in stark contrast to the full neurological physiotherapy assessment recommended by expert textbooks. Further research is needed to understand the reasons why this might be so.

Characterizing Touch Discrimination Impairment from Pooled Stroke Samples Using the Tactile Discrimination Test: Updated Criteria for Interpretation and Brief Test Version for Use in Clinical Practice Settings

Somatosensory loss post-stroke is common, with touch sensation characteristically impaired. Yet, quantitative, standardized measures of touch discrimination available for clinical use are currently limited. We aimed to characterize touch impairment and re-establish the criterion of abnormality of the Tactile Discrimination Test (TDT) using pooled data and to determine the sensitivity and specificity of briefer test versions. Baseline data from stroke survivors (n = 207) and older neurologically healthy controls (n = 100) assessed on the TDT was extracted. Scores were re-analyzed to determine an updated criterion of impairment and the ability of brief test versions to detect impairment. Updated scoring using an area score was used to calculate the TDT percent maximum area (PMA) score. Touch impairment was common for the contralesional hand (83%) but also present in the ipsilesional hand (42%). The criterion of abnormality was established as 73.1 PMA across older adults and genders. High sensitivity and specificity were found for briefer versions of the TDT (25 vs. 50 trials; 12 or 15 vs. 25 trials), with sensitivity ranging between 91.8 and 96.4% and specificity between 72.5 and 95.0%. Conclusion: Updated criterion of abnormality and the high sensitivity and specificity of brief test versions support the use of the TDT in clinical practice settings.

Current clinical practice in managing somatosensory impairments and the use of technology in stroke rehabilitation

Stroke-induced somatosensory impairments seem to be clinically overlooked, despite their prevalence and influence on motor recovery post-stroke. Interest in technology has been gaining traction over the past few decades as a promising method to facilitate stroke rehabilitation. This questionnaire-based cross-sectional study aimed to identify current clinical practice and perspectives on the management of somatosensory impairments post-stroke and the use of technology in assessing outcome measures and providing intervention. Participants were 132 physiotherapists and occupational therapists currently working with stroke patients in public hospitals and rehabilitation centres in Singapore. It was found that the majority (64.4%) of the therapists spent no more than half of the time per week on somatosensory interventions. Functional or task-specific training was the primary form of intervention applied to retrain somatosensory functions in stroke survivors. Standardised assessments (43.2%) were used less frequently than non-standardised assessments (97.7%) in clinical practice, with the sensory subscale of the Fugl-Meyer Assessment being the most popular outcome measure, followed by the Nottingham Sensory Assessment. While the adoption of technology for assessment was relatively scarce, most therapists (87.1%) reported that they have integrated technology into intervention. There was a common agreement that proprioception is an essential component in stroke rehabilitation, and that robotic technology combined with conventional therapy is effective in enhancing stroke rehabilitation, particularly for retraining proprioception. Most therapists identified price, technology usability, and lack of available space as some of the biggest barriers to integrating robotic technology in stroke rehabilitation. Standardised assessments and interventions targeting somatosensory functions should be more clearly delineated in clinical guidelines. Although therapists were positive about technology-based rehabilitation, obstacles that make technology integration challenging ought to be addressed.

The Italian version of the Erasmus MC modifications to the Nottingham Sensory Assessment for patients following acquired brain injury: Translation and reliability study

Objective

To develop the Italian version of the Erasmus MC modifications to the Nottingham Sensory Assessment and to investigate its internal consistency, intra- and inter-rater reliability.

Design

Prospective cohort study.

Setting

Rehabilitation department.

Subjects

A total of 34 patients with acquired brain injury.

Main measure

The translation and cultural adaptation process was completed, and the testing procedures of the Italian version of the Erasmus MC modifications to the Nottingham Sensory Assessment were standardized. Internal consistency was evaluated using Cronbach's alpha index; assessment of intra- and inter-rater reliability was carried out using weighted kappa coefficient.

Results

The internal consistency of the tactile sensations and the proprioception items of the Italian version of the Erasmus MC modifications to the Nottingham Sensory Assessment were generally acceptable to excellent with a range of Cronbach's alpha between 0.73 and 0.97. The intra-rater reliability of the tactile sensations and the proprioception items of the Italian version of the Erasmus MC modifications to the Nottingham Sensory Assessment were generally good to excellent with a range of weighted kappa coefficients between 0.47 and 1.00. Likewise, the inter-rater reliabilities of these items were predominantly good to excellent with a range of weighted kappa coefficients between 0.42 and 0.92.

Conclusion

The Italian version of the Erasmus MC modifications to the Nottingham Sensory Assessment is a reliable screening tool to evaluate primary somatosensory impairments in patients with acquired brain injury. Further research is necessary to consolidate these results and establish the validity and responsiveness of the Italian version of the Erasmus MC modifications to the Nottingham Sensory Assessment.

Simple and Reliable Position Sense Assessment under Different External Torques: Toward Developing a Post-stroke Proprioception Evaluation Device

Evaluation of position sense post-stroke is essential for rehabilitation. Position sense may be an output of a process needing position information, external torque, and the sense of effort. Even for healthy individuals, it is unclear whether external torque affects position sense. Thus, evaluation of position sense under different external torques in clinical settings is strongly needed. However, simple devices for measuring position sense under different external torques in clinical settings are lacking. Technologically advanced devices that may evaluate the elbow position sense under different torques were reported to be infeasible clinically because of device complexity and the need for technical experts when analyzing data. To address the unmet need, in this study, a simple and light elbow position sense measurement device was developed that allows clinicians to measure elbow position sense under different external torques in the form of position matching error objectively without any technical difficulties. The feasibility of the device, including intra-session intra-rater reliability and test-retest reliability over two consecutive days, was verified to be clinically applicable using tests with 25 healthy subjects. Thanks to its ease of use, high reliability, and ease of data analysis, it is expected that the device can help to evaluate the position sense post-stroke comprehensively.

Targeting Sensory and Motor Integration for Recovery of Movement After CNS Injury

The central nervous system (CNS) integrates sensory and motor information to acquire skilled movements, known as sensory-motor integration (SMI). The reciprocal interaction of the sensory and motor systems is a prerequisite for learning and performing skilled movement. Injury to various nodes of the sensorimotor network causes impairment in movement execution and learning. Stimulation methods have been developed to directly recruit the sensorimotor system and modulate neural networks to restore movement after CNS injury. Part 1 reviews the main processes and anatomical interactions responsible for SMI in health. Part 2 details the effects of injury on sites critical for SMI, including the spinal cord, cerebellum, and cerebral cortex. Finally, Part 3 reviews the application of activity-dependent plasticity in ways that specifically target integration of sensory and motor systems. Understanding of each of these components is needed to advance strategies targeting SMI to improve rehabilitation in humans after injury.

Factors influencing allied health professionals' implementation of upper limb sensory rehabilitation for stroke survivors: a qualitative study to inform knowledge translation

OBJECTIVES

Somatosensory loss is common after stroke with one-in-two individuals affected. Although clinical practice guidelines recommend providing somatosensory rehabilitation, this impairment often remains unassessed and untreated. To address the gap between guideline recommendations and clinical practice, this study sought to understand the factors influencing delivery of evidence-based upper limb sensory rehabilitation after stroke.

DESIGN

Qualitative study involving focus groups and interviews. Data analysis used an inductive approach (thematic analysis) and deductive analysis using implementation theory (the Theoretical Domains Framework and Normalisation Process Theory).

SETTING

Eight healthcare organisations in metropolitan and regional areas of Victoria and New South Wales, Australia.

PARTICIPANTS

Eighty-seven rehabilitation therapists (79% occupational therapists and 21% physiotherapists) were purposively sampled and participated in a knowledge translation study with staggered recruitment from 2014 to 2018.

RESULTS

Three types of factors influenced therapists' delivery of upper limb somatosensory rehabilitation: individual ('The uncertain, unskilled therapist'), patient ('Patient understanding and priorities') and organisational ('System pressures and resources'). Deductive analysis using implementation theory identified key determinants of practice change, such as opportunities to consolidate new skills, the anticipated benefits of upskilling as a therapy team and the work anticipated by therapists to incorporate a new somatosensory rehabilitation approach.

CONCLUSIONS

Occupational therapists and physiotherapists hold valuable insights towards practice change in somatosensory rehabilitation from the 'frontline'. Therapists experience barriers to change including a lack of knowledge and skills, lack of resources and organisational pressures. Facilitators for change were identified, including social support and therapists' perceived legitimacy in using new somatosensory rehabilitation approaches. Results will inform the design of a tailored implementation strategy to increase the use of evidence-based somatosensory rehabilitation in Australia.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12615000933550).

Validity and Reliability of the Semmes-Weinstein Monofilament Test and the Thumb Localizing Test in Patients With Stroke

Background: Somatosensory impairment is common in patients who have had a stroke and can affect their motor function and activities of daily living (ADL). Therefore, detecting and treating somatosensory impairments properly is considered to be very important, and various examinations have been developed. However, the reliability and validity of few of them have been verified due to differences in the procedure of each examiner or poor quantification by the examination itself.

Objective: We hypothesized that, with fixed procedures two convenient clinical examinations, the Semmes-Weinstein Monofilament Test (SWMT) and the Thumb Localizing Test (TLT), could provide reliable assessments of light touch sensation and proprioception. The purpose of this study was to verify the reliability and validity of these two examinations as indices of somatosensory impairment of the upper extremity (UE) in patients with chronic post-stroke hemiparesis.

Methods: Fifty patients with chronic stroke (median time after onset of stroke, 848 [474–1708] days, mean age 57 [standard deviation 14] years) were enrolled at Keio University Hospital from 2017 to 2018. Examiners learned the original method of the SWMT and the TLT rigorously and shared it with each other. The TLT procedure was partially modified by dividing the location of the patient's thumb into four spaces. Two examiners evaluated the SWMT and the TLT for 2 days, and intra-rater and inter-rater reliabilities were calculated using weighted kappa statistics. In addition to this, the evaluator size score of the SWMT was assessed with Bland-Altman analysis to evaluate systematic bias. The Stroke Impairment Assessment Set (SIAS) sensory items were used to assess validity, and Spearman's rank correlation coefficients were calculated.

Results: Intra/inter-rater agreements of the SWMT grade score were 0.89 (thumb, 95%CI: 0.83–0.95)/ 0.75 (0.60–0.91) and 0.80 (index finger, 0.67–0.93)/0.79 (0.66–0.92), and of the TLT they were 0.83 (navel level proximal space, 0.71–0.95)/ 0.83 (0.73–0.92), 0.90 (navel level distal space, 0.85–0.96)/ 0.80 (0.69–0.90), 0.80 (shoulder level proximal space, 0.68–0.92)/ 0.77 (0.65–0.89), and 0.87 (shoulder level distal space, 0.80–0.93)/ 0.80 (0.68–0.92) (P < 0.001, each item). All of them showed substantial agreement, but the MDC of the SWMT evaluator size was 1.28 to 1.79 in the inter-rater test and 1.94–2.06 in the intra-rater test. The SWMT grade score showed a strong correlation with the SIAS light touch sensation item (r = 0.65, p < 0.001), as did the TLT with the SIAS position sense item (r = −0.70–0.62, p < 0.001 each space).

Conclusions: The reliability and validity of the SWMT and the TLT were verified. These tests can be used as reliable sensory examinations of the UE in patients with chronic stroke, and especially for the SWMT, it is more reliable for screening.

Perspectives and Challenges in Robotic Neurorehabilitation

The development of robotic devices for rehabilitation is a fast-growing field. Nowadays, thanks to novel technologies that have improved robots’ capabilities and offered more cost-effective solutions, robotic devices are increasingly being employed during clinical practice, with the goal of boosting patients’ recovery. Robotic rehabilitation is also widely used in the context of neurological disorders, where it is often provided in a variety of different fashions, depending on the specific function to be restored. Indeed, the effect of robot-aided neurorehabilitation can be maximized when used in combination with a proper training regimen (based on motor control paradigms) or with non-invasive brain machine interfaces. Therapy-induced changes in neural activity and behavioral performance, which may suggest underlying changes in neural plasticity, can be quantified by multimodal assessments of both sensorimotor performance and brain/muscular activity pre/post or during intervention. Here, we provide an overview of the most common robotic devices for upper and lower limb rehabilitation and we describe the aforementioned neurorehabilitation scenarios. We also review assessment techniques for the evaluation of robotic therapy. Additional exploitation of these research areas will highlight the crucial contribution of rehabilitation robotics for promoting recovery and answering questions about reorganization of brain functions in response to disease.

Sensory Function, Measured as Active Discriminative Touch, is Associated With Dexterity after Stroke

BACKGROUND

Reduced dexterity is common after stroke, which can affect the ability to perform upper limb daily activities. To improve upper limb function after stroke, it is important to understand which factors are most associated with dexterity.

OBJECTIVE

To evaluate how several factors are associated with dexterity after stroke.

DESIGN

Cross-sectional study.

SETTING

A university hospital.

PARTICIPANTS

A convenience sample of 75 persons (54 men and 21 women, mean age 66 years) with mild to moderate impairments of the upper limb after stroke.

METHODS

Dexterity and potentially associated factors (age, gender, affected hand, social situation, vocational situation, grip strength, spasticity, sensory function, and pain) were evaluated by linear regression models.

MAIN OUTCOME MEASUREMENTS

Dexterity was measured with the mini Sollerman Hand Function Test, sensory function with both the Fugl-Meyer Assessment of the Upper Extremity (to assess light touch and proprioception) and the Shape Texture Identification Test (to assess active discriminative touch), spasticity with the Modified Ashworth Scale, and grip strength with the Grippit dynamometer.

RESULTS

Active discriminative touch had the strongest association with dexterity, explaining 46% of the variance. When spasticity and grip strength were added, the explained variance increased to 57% in the final multivariate model.

CONCLUSIONS

This study indicates that sensory function in terms of active discriminative touch is a major contributing factor to dexterity in persons with mild to moderate stroke, whereas spasticity and grip strength may be of lesser importance.

LEVEL OF EVIDENCE

III.

Reliability, validity, and clinical feasibility of a rapid and objective assessment of post-stroke deficits in hand proprioception

BACKGROUND

Proprioceptive function can be affected after neurological injuries such as stroke. Severe and persistent proprioceptive impairments may be associated with a poor functional recovery after stroke. To better understand their role in the recovery process, and to improve diagnostics, prognostics, and the design of therapeutic interventions, it is essential to quantify proprioceptive deficits accurately and sensitively. However, current clinical assessments lack sensitivity due to ordinal scales and suffer from poor reliability and ceiling effects. Robotic technology offers new possibilities to address some of these limitations. Nevertheless, it is important to investigate the psychometric and clinimetric properties of technology-assisted assessments.

METHODS

We present an automated robot-assisted assessment of proprioception at the level of the metacarpophalangeal joint, and evaluate its reliability, validity, and clinical feasibility in a study with 23 participants with stroke and an age-matched group of 29 neurologically intact controls. The assessment uses a two-alternative forced choice paradigm and an adaptive sampling procedure to identify objectively the difference threshold of angular joint position.

RESULTS

Results revealed a good reliability (ICC(2,1) = 0.73) for assessing proprioception of the impaired hand of participants with stroke. Assessments showed similar task execution characteristics (e.g., number of trials and duration per trial) between participants with stroke and controls and a short administration time of approximately 12 min. A difference in proprioceptive function could be found between participants with a right hemisphere stroke and control subjects (p<0.001). Furthermore, we observed larger proprioceptive deficits in participants with a right hemisphere stroke compared to a left hemisphere stroke (p=0.028), despite the exclusion of participants with neglect. No meaningful correlation could be established with clinical scales for different modalities of somatosensation. We hypothesize that this is due to their low resolution and ceiling effects.

CONCLUSIONS

This study has demonstrated the assessment's applicability in the impaired population and promising integration into clinical routine. In conclusion, the proposed assessment has the potential to become a powerful tool to investigate proprioceptive deficits in longitudinal studies as well as to inform and adjust sensorimotor rehabilitation to the patient's deficits.

Tactile-STAR: A Novel Tactile STimulator And Recorder System for Evaluating and Improving Tactile Perception

Many neurological diseases impair the motor and somatosensory systems. While several different technologies are used in clinical practice to assess and improve motor functions, somatosensation is evaluated subjectively with qualitative clinical scales. Treatment of somatosensory deficits has received limited attention. To bridge the gap between the assessment and training of motor vs. somatosensory abilities, we designed, developed, and tested a novel, low-cost, two-component (bimanual) mechatronic system targeting tactile somatosensation: the Tactile-STAR-a tactile stimulator and recorder. The stimulator is an actuated pantograph structure driven by two servomotors, with an end-effector covered by a rubber material that can apply two different types of skin stimulation: brush and stretch. The stimulator has a modular design, and can be used to test the tactile perception in different parts of the body such as the hand, arm, leg, big toe, etc. The recorder is a passive pantograph that can measure hand motion using two potentiometers. The recorder can serve multiple purposes: participants can move its handle to match the direction and amplitude of the tactile stimulator, or they can use it as a master manipulator to control the tactile stimulator as a slave. Our ultimate goal is to assess and affect tactile acuity and somatosensory deficits. To demonstrate the feasibility of our novel system, we tested the Tactile-STAR with 16 healthy individuals and with three stroke survivors using the skin-brush stimulation. We verified that the system enables the mapping of tactile perception on the hand in both populations. We also tested the extent to which 30 min of training in healthy individuals led to an improvement of tactile perception. The results provide a first demonstration of the ability of this new system to characterize tactile perception in healthy individuals, as well as a quantification of the magnitude and pattern of tactile impairment in a small cohort of stroke survivors. The finding that short-term training with Tactile-STAR can improve the acuity of tactile perception in healthy individuals suggests that Tactile-STAR may have utility as a therapeutic intervention for somatosensory deficits.

Development of a System Architecture for Evaluation and Training of Proprioceptive Deficits of the Upper Limb

Proprioception plays a fundamental role in maintaining posture and executing movement, and the quantitative evaluation of proprioceptive deficits in poststroke patients is important. But currently it is not widely performed due to the complexity of the evaluation tools required for a reliable assessment. The aims of this pilot study were to (a) develop a system architecture for upper limb evaluation and training of proximal and distal sense of position in the horizontal plane and (b) test the system in healthy and pathological subjects. Two robotic devices for evaluation and training of, respectively, wrist flexion/extension and shoulder-elbow manipulation were employed. The system we developed was applied in a group of 12 healthy subjects and 10 patients after stroke. It was able to quantitatively evaluate upper limb sense of position in the horizontal plane thanks to a set of quantitative parameters assessing position estimation errors, variability, and gain. In addition, it was able to distinguish healthy from pathological conditions. The system could thus be a reliable method to detect changes in the sense of position of patients with sensory deficits after stroke and could enable the implementation of novel training approaches for the recovery of normal proprioception.

Reliable and Rapid Robotic Assessment of Wrist Proprioception Using a Gauge Position Matching Paradigm

Quantitative assessments of position sense are essential for the investigation of proprioception, as well as for diagnosis, prognosis and treatment planning for patients with somatosensory deficits. Despite the development and use of various paradigms and robotic tools, their clinimetric properties are often poorly evaluated and reported. A proper evaluation of the latter is essential to compare results between different studies and to identify the influence of possible confounds on outcome measures. The aim of the present study was to perform a comprehensive evaluation of a rapid robotic assessment of wrist proprioception using a passive gauge position matching task. Thirty-two healthy subjects undertook six test-retests of proprioception of the right wrist on two different days. The constant error (CE) was 0.87°, the absolute error (AE) was 5.87°, the variable error (VE) was 4.59° and the total variability (E) was 6.83° in average for the angles presented in the range from 10° to 30°. The intraclass correlation analysis provided an excellent reliability for CE (0.75), good reliability for AE (0.68) and E (0.68), and fair reliability for VE (0.54). Tripling the assessment length had negligible effects on the reliabilities. Additional analysis revealed significant trends of larger overestimation (constant errors), as well as larger absolute and variable errors with increased flexion angles. No proprioceptive learning occurred, despite increased familiarity with the task, which was reflected in significantly decreased assessment duration by 30%. In conclusion, the proposed automated assessment can provide sensitive and reliable information on proprioceptive function of the wrist with an administration time of around 2.5 min, demonstrating the potential for its application in research or clinical settings. Moreover, this study highlights the importance of reporting the complete set of errors (CE, AE, VE, and E) in a matching experiment for the identification of trends and subsequent interpretation of results.

A cross-sectional observational study comparing foot and ankle characteristics in people with stroke and healthy controls

PURPOSE

The purpose of this study was to explore and compare foot and ankle characteristics in people with stroke and healthy controls; and between stroke fallers and non-fallers.

METHODS

Participants were recruited from community groups and completed standardized tests assessing sensation, foot posture, foot function, ankle dorsiflexion and first metatarsal phalangeal joint range of motion (1st MPJ ROM), hallux valgus presence and severity.

RESULTS

Twenty-three stroke participants (mean age 75.09 ± 7.57 years; 12 fallers) and 16 controls (mean age 73.44 ± 8.35 years) took part. Within the stroke group, reduced 1st MPJ sensation (p = 0.016) and 1st MPJ ROM (p = 0.025) were observed in the affected foot in comparison to the non-affected foot; no other differences were apparent. Pooled data (for both feet) was used to explore between stroke/control (n = 78 feet) and stroke faller/non-faller (n = 46 feet) group differences. In comparison to the control group, stroke participants exhibited reduced sensation of the 1st MPJ (p = 0.020), higher Foot Posture Index scores (indicating greater foot pronation, p = 0.008) and reduced foot function (p = 0.003). Stroke fallers exhibited significantly greater foot pronation in comparison to non-fallers (p = 0.027).

CONCLUSIONS

Results indicated differences in foot and ankle characteristics post stroke in comparison to healthy controls. These changes may negatively impact functional ability and the ability to preserve balance. Further research is warranted to explore the influence of foot problems on balance ability and falls in people with stroke. Implications for Rehabilitation Foot problems are common post stroke. As foot problems have been linked to increased fall risk among the general population we recommend that it would be beneficial to include foot and ankle assessments or a referral to a podiatrist for people with stroke who report foot problems. Further research is needed to explore if we can improve functional performance post stroke and reduce fall risk if treatment or prevention of foot problems can be included in stroke rehabilitation.

Somatosensory deficits after stroke: a scoping review

In the past years, there have been increasing research activities focusing on somatosensory symptoms following stroke. However, as compared to the large number of clinical and neuroimaging studies on motor symptoms, the number of studies tracing somatosensory symptoms after stroke and their recovery is rather small. It is an ongoing discussion, to which extent somatosensory deficits after stroke influence patient's long-term outcome in motor and sensory performance and functional independence in activities of daily living. Modern brain imaging techniques allow for studying the impact of stroke lesion localization and size on acute and persisting clinical impairment. Here, we review the literature on somatosensory symptoms after stroke. We summarize epidemiological information on frequency and characteristics of somatosensory symptoms affecting all parts of the body in the acute and chronic stage of stroke. We further give an overview of brain imaging studies of stroke affecting the somatosensory system. Finally, we identify open questions which need to be addressed in future research and summarize the implications for clinical practice.

Use of a robotic device to measure age-related decline in finger proprioception

Age-related changes in proprioception are known to affect postural stability, yet the extent to which such changes affect the finger joints is poorly understood despite the importance of finger proprioception in the control of skilled hand movement. We quantified age-related changes in finger proprioception in 37 healthy young, middle-aged, and older adults using two robot-based tasks wherein participants' index and middle fingers were moved by an exoskeletal robot. The first task assessed finger position sense by asking participants to indicate when their index and middle fingers were directly overlapped during a passive crisscross movement; the second task assessed finger movement detection by asking participants to indicate the onset of passive finger movement. When these tasks were completed without vision, finger position sense errors were 48 % larger in older adults compared to young participants (p < 0.05); proprioceptive reaction time was 78 % longer in older adults compared to young adults (p < 0.01). When visual feedback was provided in addition to proprioception, these age-related differences were no longer apparent. No difference between dominant and non-dominant hand performance was found for either proprioception task. These findings demonstrate that finger proprioception is impaired in older adults, and visual feedback can be used to compensate for this deficit. The findings also support the feasibility and utility of the FINGER robot as a sensitive tool for detecting age-related decline in proprioception.

Upper extremity proprioception in healthy aging and stroke populations, and the effects of therapist- and robot-based rehabilitation therapies on proprioceptive function

The world’s population is aging, with the number of people ages 65 or older expected to surpass 1.5 billion people, or 16% of the global total. As people age, there are notable declines in proprioception due to changes in the central and peripheral nervous systems. Moreover, the risk of stroke increases with age, with approximately two-thirds of stroke-related hospitalizations occurring in people over the age of 65. In this literature review, we first summarize behavioral studies investigating proprioceptive deficits in normally aging older adults and stroke patients, and discuss the differences in proprioceptive function between these populations. We then provide a state of the art review the literature regarding therapist- and robot-based rehabilitation of the upper extremity proprioceptive dysfunction in stroke populations and discuss avenues of future research.

Relationship between touch sensation of the affected hand and performance of valued activities in individuals with chronic stroke

OBJECTIVE

To investigate the association between touch sensation of the affected hand and performance and satisfaction with performance of valued activities in individuals with chronic stroke.

METHODS

Using a cross-sectional study design, this study correlated factors related to hand sensation and activity performance in individuals with chronic stroke. The Touch Test Evaluators and Canadian Occupational Performance Measure (COPM) were used. Correlations were used to determine the relationships between touch sensation of the affected hand and individuals' performance and satisfaction with performance of valued activities.

RESULTS

There was a good to excellent relationship between sensation and performance and satisfaction with performance of valued activities for individuals with intact touch sensation of the affected hand who scored higher on the COPM. There was little to no relationship between touch sensation of the affected hand and performance of valued activities for individuals with impaired sensation.

CONCLUSION

This is the first study to relate touch sensation of the affected hand and performance and satisfaction with performance of valued activities in individuals with stroke. The findings suggest that rehabilitation therapists need to continue to address sensory function in evaluation and intervention as it relates to performance in valued activities. This study serves as a foundation for future research in sensation and performance of valued activities in individuals with chronic stroke.

Assessment of movement quality in robot- assisted upper limb rehabilitation after stroke: a review

Studies of stroke patients undergoing robot-assisted rehabilitation have revealed various kinematic parameters describing movement quality of the upper limb. However, due to the different level of stroke impairment and different assessment criteria and interventions, the evaluation of the effectiveness of rehabilitation program is undermined. This paper presents a systematic review of kinematic assessments of movement quality of the upper limb and identifies the suitable parameters describing impairments in stroke patients. A total of 41 different clinical and pilot studies on different phases of stroke recovery utilizing kinematic parameters are evaluated. Kinematic parameters describing movement accuracy are mostly reported for chronic patients with statistically significant outcomes and correlate strongly with clinical assessments. Meanwhile, parameters describing feed-forward sensorimotor control are the most frequently reported in studies on sub-acute patients with significant outcomes albeit without correlation to any clinical assessments. However, lack of measures in coordinated movement and proximal component of upper limb enunciate the difficulties to distinguish the exploitation of joint redundancies exhibited by stroke patients in completing the movement. A further study on overall measures of coordinated movement is recommended.

Improvement of hand function using different surfaces and identification of difficult movement post stroke in the Box and Block Test

This study determined the impact of changing block surfaces on hand function, as well as identified particularly time-consuming movement components post stroke, measured by the Box and Block Test (BBT). Eight chronic stroke survivors and eight age- and gender-matched control subjects participated in this study. The BBT score (number of blocks moved) and time for seven movement components were compared for three different block surfaces (wood, paper, and rubber). The rubber blocks improved BBT scores 8% (compared to all other conditions) not only for control subjects but also for the paretic and non-paretic hands of stroke survivors, by reducing movement time for finger closing and contact-to-lift. Modifying daily objects' surfaces with rubber could help stroke survivors' hand function. The paretic hand displayed notably slower movement for contact-to-lift, transport-release, reach before barrier, and reach after barrier suggesting that therapies may focus on goal directed reaching and object grasping/releasing.

Influence of lower extremity sensory function on locomotor adaptation following stroke: a review

Following stroke, people commonly demonstrate locomotor impairments including reduced walking speed and spatiotemporal asymmetry. Rehabilitation programs have been effective in increasing gait speed, but spatiotemporal asymmetry has been more resistant to change. The inability to modify gait patterns for improved symmetry may be related, in part, to impairments in lower extremity sensation. Assessment of lower extremity sensory impairments in people post stroke, including cutaneous and proprioceptive sensation, has been insufficiently studied. Conventional rehabilitation programs, including body weight-supported walking or robotic assistance, that modify sensory feedback intended to alter lower extremity movement patterns have shown limited success in improving gait symmetry. Rehabilitation programs that amplify specific gait asymmetries have demonstrated the potential to ultimately produce more symmetric gait, presumably by allowing individuals post stroke to more readily perceive their gait asymmetry. The effectiveness of such error augmentation paradigms, however, may be influenced by lower extremity sensation and the ability of the central nervous system to be aware of altered lower extremity movement. The purpose of this review is to critically examine the literature on lower extremity sensory function and its influence on gait adaptation in people post stroke.

Differences in somatosensory and motor improvement during temporary functional deafferentation in stroke patients and healthy subjects

Temporary functional deafferentation is of interest to become an additional tool in neurorehabilitative treatments. Temporary functional deafferentation is known to improve sensory and motor outcomes in chronic stroke patients and healthy subjects. The present study soughts to indicate differences in the efficiency of pharmacologically induced temporary functional deafferentation between chronic stroke patients and matched healthy subjects. 46 chronic stroke patients and 20 age- and gender-matched healthy subjects were deafferented on one forearm by an anesthetic cream. Somatosensory performance was assessed using von-Frey Hair testing and Grating orientation task; motor performance was assessed by means of a shape-sorter-drum task. Grating orientation task and shape-sorter-drum task were significantly improved during temporary functional deafferentation in stroke patients but not in healthy subjects. Von-Frey Hair testing revealed no improvement of absolute tactile thresholds during temporary functional deafferentation in both groups. Furthermore, the stroke patients showed deficits at baseline measurement in all assessments except the von-Frey Hair test. Temporary functional deafferentation of a forearm by an anesthetic cream results in improvements of motor performance and somatosensory discrimination in stroke patients but not in healthy subjects. Therefore, it is reasonable to test in a next step whether temporary functional deafferentation might become an additional tool in motor rehabilitation of post stroke patients.

Relationship between somatosensory function and the spinothalamocortical pathway in chronic stroke patients

Diffusion tensor tractography (DTT) allows for identification and evaluation of the spinothalamic tract and its thalamocortical pathway (STP). We attempted to investigate the relationship between tactile sensation and the STP in chronic stroke patients. We measured fractional anisotropy, mean diffusivity, and tract volume of the STP. The tactile sensation score of the affected side in patients with preserved STP integrity was higher compared with that of patients with an interrupted STP. The remaining volume and integrity of the STP in the affected hemisphere were important factors for tactile sensation of the affected side in chronic patients with intracerebral hemorrhage (ICH).

Assessment of upper extremity impairment, function, and activity after stroke: foundations for clinical decision making

The purpose of this review is to provide a comprehensive approach for assessing the upper extremity (UE) after stroke. First, common UE impairments and how to assess them are briefly discussed. Although multiple UE impairments are typically present after stroke, the severity of one's impairment, paresis, is the primary determinant of UE functional loss. Second, UE function is operationally defined and a number of clinical measures are discussed. It is important to consider how impairment and loss of function affect UE activity outside of the clinical environment. Thus, this review also identifies accelerometry as an objective method for assessing UE activity in daily life. Finally, the role that each of these levels of assessment should play in clinical decision making is discussed to optimize the provision of stroke rehabilitation services.

Influence of sensory loss on the perception of verticality in stroke patients

PURPOSE

The aim of this study was to investigate the relationship between somatosensory loss and perception of verticality in stroke patients suffering single-hemisphere lesions.

METHOD

Somatosensory loss was measured using the Rivermead Assessment for Somatosensory Performance (RASP). Perception of verticality was assessed with the Subjective Visual Vertical (SVV) and the Subjective Postural Vertical (SPV) tests. Absolute Values of SVV and SPV were used to analyze the amount of deviation in relation to somatosensory loss.

RESULTS

Thirty-two patients were included in the study (mean age = 45.91 SD = 31.88 years). Analysis showed that somatosensory loss was related to results of the SVV (r = -0.552, p = 0.001, Pearson Rank) and the SPV (r = -0.661, p < 0.001, Spearman Ï). Furthermore, results showed that both joint-related (SVV: r = -0.411, p = 0.019, Pearson Rank; SPV: r = -0.597, p = 0.001, Spearman Ï) and skin-related (SVV: r = -0.595, p < 0.001, Pearson Rank; SPV: r = -0.663, p < 0.001, Spearman Ï) somatosensory information is related to verticality perception.

CONCLUSIONS

This study provides evidence that perception of verticality is related to somatosensory loss, which means that somatosensory loss will lead to a larger amount of deviation of SVV and SPV in relation to the gravitational vector. Furthermore, it is interesting to note that both SVV and SPV are influenced by somatosensory loss.

IMPLICATIONS FOR REHABILITATION

• Somatosensory information is related to both visual and postural aspects of verticality perception. • Both joint- and cutaneous-related modalities of sensory information are related to perception of verticality. • Sensory training could be important in the recovery of verticality perception.

Prediction of discharge walking ability from initial assessment in a stroke inpatient rehabilitation facility population

OBJECTIVES

To (1) determine which clinical assessments at admission to an inpatient rehabilitation facility (IRF) most simply predict discharge walking ability, and (2) identify a clinical decision rule to differentiate household versus community ambulators at discharge from an IRF.

DESIGN

Retrospective cohort study.

SETTING

IRF.

PARTICIPANTS

Two samples of participants (n=110 and 159) admitted with stroke.

INTERVENTIONS

A multiple regression determined which variables obtained at admission (age, time from stroke to assessment, Motricity Index, somatosensation, Modified Ashworth Scale, FIM, Berg Balance Scale, 10-m walk speed) could most simply predict discharge walking ability (10-m walk speed). A logistic regression determined the likelihood of a participant achieving household (<0.4m/s) versus community (≥0.4-0.8m/s; >0.8m/s) ambulation at the time of discharge. Validity of the results was evaluated on a second sample of participants.

MAIN OUTCOME MEASURE

Discharge 10-m walk speed.

RESULTS

Admission Berg Balance Scale and FIM walk item scores explained most of the variance in discharge walk speed. The odds ratio of achieving only household ambulation at discharge was 20 (95% confidence interval [CI], 6-63) for sample 1 and 32 (95% CI, 10-96) for sample 2 when the combination of having a Berg Balance Scale score of ≤20 and a FIM walk item score of 1 or 2 was present.

CONCLUSIONS

A Berg Balance Scale score of ≤20 and a FIM walk item score of 1 or 2 at admission indicates that a person with stroke is highly likely to only achieve household ambulation speeds at discharge from an IRF.

Adult norms of the perceptual threshold of touch (PTT) in the hands and feet in relation to age, gender, and right and left side using transcutaneous electrical nerve stimulation

There is a lack of standardized and quantifiable measures of touch function, for clinical work. Furthermore, it is not possible to make accurate diagnostic judgments of touch function before normative values are estimated. The objectives of this study were to establish adult norms of the perceptual threshold of touch (PTT) for the hands and feet according to age and gender and to determine the effect of right/left side, handedness, height, weight, and body mass index (BMI) on the PTT. The PTT was assessed by using a high-frequency transcutaneous electrical nerve stimulator (Hf/TENS) with self-adhesive skin electrodes in 346 adults. The PTT was identified as the level registered in mA at which the participants perceived a tingling sensation. The PTT for all participants was a median of 3.75 mA (range 2.50-7.25) in the hands and a median of 10.00 (range 5.00-30.00) in the feet. With increasing age an increase of the PTT was found. Men reported higher PTT than women. The right hand had higher PTT than the left. Handedness, height, weight, and BMI did not affect the PTT. Adult norms of the PTT in the hands for age, gender, and right/left side are presented for four age groups. The present study's estimate of the PTT in the hands could be used as adult norms. Adult norms for the feet could not be estimated because the PTT values in the feet showed a great variance.

Measures of sensation in neurological conditions: a systematic review

Objective: To systematically review the psychometric properties and clinical utility of measures of sensation in neurological conditions to inform future research studies and clinical practice.

Data sources: Electronic databases (MEDLINE, CINAHL, EMBASE and AMED) were searched from their inception to December 2010.

Review methods: Search terms were used to identify articles that investigated any sensory measures in neurological conditions. Data about their psychometric properties and clinical utility were extracted and analyzed independently. The strength of the psychometric properties and clinical utility were assessed following recommendations. 1

Results: Sixteen sensory measures were identified. Inter-rater reliability and redundancy of testing protocols are particular issues for this area of assessment. Eleven were rejected because they were not available for a researcher or clinician to use. Of the remaining five measures, the Erasmus MC modifications of the Nottingham Sensory Assessment and the Sensory section of the Fugl–Meyer Assessment showed the best balance of clinical utility and psychometric properties.

Conclusion: Many measures of sensory impairment have been used in research but few have been fully developed to produce robust data and be easy to use. At present, the sensory section of the Fugl–Meyer Assessment and the Erasmus MC modifications of the Nottingham Sensory Assessment show the most effective balance of usability and robustness, when delivered according to the operating instructions.

An initial exploration of the perceptual threshold test using electrical stimulation to measure arm sensation following stroke

Objective: To explore the viability of the perceptual threshold test using electrical stimulation to measure light touch sensation in the hands of stroke survivors.

Design: Descriptive study.

Setting: University research laboratory.

Subjects: Twenty-nine adult community-dwelling chronic stroke survivors.

Main measure(s): Perceptual threshold test using electrical stimulation, stroke rehabilitation assessment of movement, Nottingham sensory assessment for stereognosis, action research arm test, Fugl-Meyer assessment of sensation and motor activity log 14.

Results: Perceptual threshold test using electrical stimulation mean threshold values were 1.23 (0.6) milliamperes (range 0.5–3.5) for the uninvolved side and 1.68 (0.91) milliamperes (range 0.5–4.5) for the involved side. The perceptual threshold test using electrical stimulation demonstrated excellent intra-rater reliability (intraclass correlation coefficient = 0.896 – uninvolved; 0.829 – involved). There was a statistically significant difference between the perceptual threshold test using electrical stimulation mean threshold values for the uninvolved and involved arms ( P = 0.003), but this significance did not hold for subjects who had normal sensation as measured by the Fugl-Meyer assessment of sensation ( P = 0.083). Low to nonexistent correlations were found between the perceptual threshold test using electrical stimulation and other measures of sensation, arm movement, activity and participation.

Conclusions: The perceptual threshold test using electrical stimulation is a reliable and clinically feasible test with the potential to identify sensory capacity in stroke survivors with substantial sensory loss. Electrical sensory thresholds do not reflect overall sensory function or motor capabilities in stroke survivors.

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.

Trials needed to assess knee proprioception following stroke

BACKGROUND AND PURPOSE

This study explores the number of trials required to identify clinically significant impairments in knee joint position sense and movement sense following stroke.

METHOD

Proprioception was assessed in 33 stroke patients aged 37-87 years. Ten trials for each assessment were performed in sitting and supine positions using both verbal response techniques and contralateral limb matching.

RESULTS

Forty-six percent of participants were identified with a proprioceptive deficit. The trial where the first incorrect response occurred varied across individuals and testing positions. Performing only one trial detected proprioceptive impairments in less than 10% patients, and incorrect responses did not always occur in the first 5 trials. In sitting, no participant failed the assessment of knee joint position sense using the verbal response technique after only 6 trials. In supine, no participant failed the assessment of knee movement sense using the verbal response technique after only 6 trials. For the assessment of knee joint position sense in sitting using contralateral limb matching an estimated 9.4% of patients with a deficit would be missed if only 3 trials were used in preference to 5. For assessment of knee joint position sense in sitting, an estimated 18.8% of patients with deficits would be missed if only 3 trials were used rather than 10 trials.

CONCLUSIONS

Clinicians should perform at least 10 trials in either sitting or supine to quantify joint position sense and movement sense at the knee following stroke.

Sensory dysfunction following stroke: incidence, significance, examination, and intervention

Recent studies have provided evidence of the widespread incidence of sensory dysfunction following stroke. The importance of these findings lies in the association between sensory loss poststroke and poorer outcomes in motor capacity, functional abilities, length of inpatient stay, and quality of life. Since literature suggests that clinicians can use information about clients' sensory status to predict rehabilitation outcomes and select appropriate interventions, the accuracy of somatosensory assessment is extremely clinically relevant. However, many of the clinical tests that are commonly used to examine sensation have not been found to be valid or reliable. Emerging evidence supports the efficacy of several interventions that target the sensory systems. This article reviews the incidence, significance, examination, and interventions for sensory dysfunction following stroke and summarizes the important characteristics of interventions directed at somatosensation.

Development of the Hand Active Sensation Test: reliability and validity

OBJECTIVE

To develop and establish the reliability and validity of a new quantitative functional measure of haptic perception in the hand, the Hand Active Sensation Test (HASTe).

DESIGN

Reliability was assessed by test-retest sessions. Validity was assessed via discriminant analysis, concurrent validity with 2-point discrimination and wrist position test, and receiver operating characteristic (ROC) curve construction.

SETTING

Subject preference.

PARTICIPANTS

Heterogeneous sample of 28 stroke survivors and 28 individually matched controls.

INTERVENTION

Subjects used 1 hand to manipulate HASTe objects that vary by weight or texture to complete 18 match-to-sample trials.

MAIN OUTCOME MEASURES

Two-point discrimination threshold, Wrist Position Sense Test (WPST) average error, and HASTe accuracy score.

RESULTS

Test-retest reliability was strong (intraclass correlation coefficient model 3,1 = .77). The HASTe score significantly discriminated the groups (t = 8.3, P < .001) and correlated with 2-point discrimination (r = -.67, P < .001) and WPST (r = -.60, P < .001). ROC curve area was .94 for test 1 and .92 for the average of 2 tests.

CONCLUSIONS

The HASTe is a reliable and valid functional measure of haptic perception, appears to detect impairment of haptic perception even in stroke survivors with no reported sensory deficits, and may provide valuable quantitative clinical data about complex sensory loss and hand function after stroke.

Evaluation of impaired fingertip texture discrimination and wrist position sense in patients affected by stroke: comparison of clinical and new quantitative measures

Discriminative sensory loss is common following stroke but may not be adequately detected by routine clinical measures. Quantitative tests of texture discrimination and limb position sense have been recently developed. These tests provide reliable estimates of discrimination, differentiate impaired performance following stroke, and have standardized criteria of abnormality. The purpose of this study was to compare predictions of impairment based on current clinical measures with predictions based on these quantitative, standardized measures. Thirty-five patients who had strokes were tested on the new quantitative measures and clinical measures of texture discrimination and limb position sense. The findings indicated poor agreement between impairment defined using current clinical measures and statistically abnormal performance on the new quantitative, norm-referenced measures. The findings suggest that the quantitative tests may provide additional assessment information to supplement that of the existing clinical measures of texture discrimination and limb position sense. Further development of these new quantitative measures is indicated.