Functional Training for Lower Extremities in Stroke Survivors: A Scoping Review

Engaging in meaningful and repetitive goal-oriented functional tasks can effectively enhance neuroplasticity and facilitate recovery following a stroke. This particular approach has primarily been studied in relation to functional outcomes and has predominantly focused on late subacute and chronic stroke patients. However, there is a lack of information regarding the standardized protocol of lower extremity functional training, its constituent elements, and its impact on motor recovery during the early subacute phase of stroke. The aim of this study was to examine the available evidence related to the intervention protocol of lower extremity functional training in order to identify common training elements and assess their impact on motor and functional outcomes in stroke survivors. A systematic search was conducted on PubMed and Scopus, covering the period from 2000 to 2022. A total of 1786 articles were retrieved and screened based on predefined inclusion criteria. A total of 36 articles were included in this review. The primary findings were classified into categories such as intervention protocols for functional training and their constituent elements, outcome measures utilized, minimal clinically important differences (MCID) reported, and the conclusions drawn by the respective studies. Only a limited quantity of studies reported on the intervention protocol of lower extremity functional training. The majority of these studies focused on the efficacy of functional training for enhancing gait and balance, as evaluated through functional outcome assessments, particularly in the context of chronic stroke patients. In most studies, the evaluation of outcomes was typically based on statistical significance rather than clinical significance. In light of these findings, it is recommended that future studies be conducted during the early subacute phase of stroke to further investigate the impact of functional training on motor outcomes. This will contribute to a broader understanding of the benefits of functional training in facilitating motor recovery in the lower extremities and its clinical significance in stroke survivors.

Effectiveness of Activity-Based Task-Oriented Training on Upper Extremity Recovery for Adults With Stroke: A Systematic Review

IMPORTANCE

Interventions for improving upper extremity (UE) recovery have become a priority in stroke rehabilitation because UE disability can undermine a person's capacity to perform daily activities after stroke. A better understanding of the use of activity-based task-oriented training (TOT) will inform the development of more effective UE interventions in stroke rehabilitation.

OBJECTIVE

To examine the effectiveness of activity-based TOT in improving the UE recovery of adults with stroke.

DATA SOURCES

CINAHL Plus, MEDLINE, and PubMed.

STUDY SELECTION AND DATA COLLECTION

Inclusion criteria included quantitative studies published between June 2012 and December 2022 that reported UE recovery as an outcome, including measurements of motor function, motor performance, and performance of activities of daily living (ADLs); a sample age ≥18 yr, with stroke in all phases; and interventions that incorporated real-world daily activities. We assessed articles for inclusion, quality, and risk of bias following Cochrane methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

FINDINGS

Sixteen studies (692 participants, Level 1-4 evidence) were included. Strong to moderate evidence supported the effectiveness of activity-based TOT in UE motor function, motor performance, and ADL performance for adults with stroke. Strong evidence supported the effectiveness of hospital-based TOT, and moderate evidence supported the effectiveness of home-based TOT.

CONCLUSIONS AND RELEVANCE

The results not only showed the value of activity-based TOT as an effective UE intervention in stroke rehabilitation but also supported the occupational therapy philosophy of using functional and meaningful activities in practice. Further research on home-based TOT is needed. Plain-Language Summary: This systematic review shows the effectiveness and value of using real-life activities in task-oriented training approaches for adult survivors of stroke. The authors found strong evidence for hospital-based task-oriented training interventions and moderate evidence for home-based interventions for improving upper extremity recovery. This review shows the value of upper extremity task-oriented training as an effective intervention in stroke rehabilitation. The review also supports the occupational therapy philosophy of using functional and meaningful activities in practice as well as the profession's use of evidence-based practice in stroke rehabilitation.

Efficacy of telerehabilitation with digital and robotic tools for the continuity of care of people with chronic neurological disorders: The TELENEURO@REHAB protocol for a randomized controlled trial

Context

Chronic Neurological Disorders (CNDs) are among the leading causes of disability worldwide, and their contribution to the overall need for rehabilitation is increasing. Therefore, the identification of new digital solutions to ensure early and continuous care is mandatory.

Objective

This protocol proposes to test the usability, acceptability, safety, and efficacy of Telerehabilitation (TR) protocols with digital and robotic tools in reducing the perceived level of disability in CNDs including Parkinson's Disease (PD), Multiple Sclerosis (MS), and post-stroke patients.

Design Setting and Subjects

This single-blinded, multi-site, randomized, two-treatment arms controlled clinical trial will involve PD (N = 30), MS (N = 30), and post-stroke (N = 30). Each participant will be randomized (1:1) to the experimental group (20 sessions of motor telerehabilitation with digital and robotic tools) or the active control group (20 home-based motor rehabilitation sessions according to the usual care treatment). Primary and secondary outcome measures will be obtained at the baseline (T0), post-intervention (T1, 5 weeks after baseline), and at follow-up (T2, 2 months after treatment).

Main Outcome Measures

a multifaceted evaluation including quality of life, motor, and clinical/functional measures will be conducted at each time-point of assessment. The primary outcome measures will be the change in the perceived level of disability as measured by the World Health Organization Disability Assessment Schedule 2.0.

Conclusion

The implementation of TR protocols will enable a more targeted and effective response to the growing need for rehabilitation linked to CNDs, ensuring accessibility to rehabilitation services from the initial stages of the disease.

Effectiveness of task-specific training using assistive devices and task-specific usual care on upper limb performance after stroke: a systematic review and meta-analysis

PURPOSE

Task-specific rehabilitation is a key indicator for successful rehabilitation to improve the upper limb performance after stroke. Assistive robotic and non-robotic devices are emerging to provide rehabilitation therapy; however, the effectiveness of task-specific training programs using assistive training devices compared with task-specific usual care training has not been summarized yet. Therefore, the effectiveness of task-specific training using assistive arm devices (TST-AAD) compared with task-specific usual care (TSUC) on the upper limb performance of patients with a stroke was investigated. To assess task specificity, a set of criteria was proposed: participation, program, relevant, repeated, randomized, reconstruction and reinforced.

MATERIALS AND METHODS

Out of 855 articles, 17 fulfilled the selection criteria. A meta-analysis was performed on the Fugl-Meyer Assessment scores in the subacute and chronic stages after stroke and during follow-up.

RESULTS AND CONCLUSION

Both TST-AAD and TSUC improved the upper limb performance after stroke. In the sub-acute phase after stroke, TST-AAD was more effective than TSUC in reducing the upper limb impairment, although findings were based on only three studies. In the chronic phase, TST-AAD and TSUC showed similar effectiveness. No differences between the two types of training were found at the follow-up measurements. Future studies should describe training, device usage and criteria of task specificity in a standardized way to ease comparison.Implications for rehabilitationArm or hand function is often undertreated in stroke patients, assistive training devices may be able to improve the upper limb performance.Task-specific training using assistive devices is effective in improving the upper limb performance after stroke.Task-specific training using assistive devices seems to be more effective in reducing impairment compared with task specific usual care in the subacute phase after stroke, but they are equally effective in the chronic phase of stroke.

The effect of local vibration applied to the forearm extensor muscles on hand function and muscle activation in stroke patients: a randomized controlled study

OBJECTIVE

This study aims to reveal the effect of low-frequency local vibration applied to the forearm extensor muscles on stroke patients' muscle activation and hand functions.

METHODS

Twenty-four stroke patients were randomized to the vibration group (n = 12) or control group (n = 12). The vibration was applied at a 30 Hz frequency to the forearm extensor muscles with a local vibration device three days a week after the routine, conventional physical therapy sessions for four weeks. Six vibration sets were applied, including one vibration for one minute and a rest for 2 min. Routine, traditional physical therapy was used for the control group in 60-min sessions for 4 weeks. Patients were assessed for muscle activation with surface electromyography (MVC) and The Wolf Motor Function Test (WMFT), Functional Independent Test (FIM) was applied to all patients before and after treatment.

RESULTS

As a result of our study, MVC measurement, WMFT and FIM scores of the vibration group showed more improvement than the control group. Measurement results of vibration group; While MVC measurement increased from 10.21 to 13.79, WMFT-Functional Ability score increased from 42 to 50, WMFT-Performance Time duration increased from 68.78 to 61.83, and FIM score increased from 74.5 to 83. and the measurement results of the control group; MVC measurement increased from 12.28 to 12.22, WMFT-Functional Ability score increased from 48.5 to 51, WMFT-Performance Time duration increased from 70.39 to 70.61, and FIM score increased from 72.5 to 80.5.

CONCLUSION

It was concluded that low-frequency local vibration applied to the forearm extensor muscles improve forearm extensor muscle activation and hand motor function.

CLINICAL TRIAL REGISTRATION

NCT04562220.

Task-specific training versus usual care to improve upper limb function after stroke: the "Task-AT Home" randomised controlled trial protocol

Background

Sixty percent of people have non-functional arms 6 months after stroke. More effective treatments are needed. Cochrane Reviews show low-quality evidence that task-specific training improves upper limb function. Our feasibility trial showed 56 h of task-specific training over 6 weeks resulted in an increase of a median 6 points on the Action Research Arm test (ARAT), demonstrating the need for more definitive evidence from a larger randomised controlled trial. Task-AT Home is a two-arm, assessor-blinded, multicentre randomised, controlled study, conducted in the home setting.

Aim

The objective is to determine whether task-specific training is a more effective treatment than usual care, for improving upper limb function, amount of upper limb use, and health related quality of life at 6 weeks and 6 months after intervention commencement. Our primary hypothesis is that upper limb function will achieve a ≥ 5 point improvement on the ARAT in the task-specific training group compared to the usual care group, after 6 weeks of intervention.

Methods

Participants living at home, with remaining upper limb deficit, are recruited at 3 months after stroke from sites in NSW and Victoria, Australia. Following baseline assessment, participants are randomised to 6 weeks of either task-specific or usual care intervention, stratified for upper limb function based on the ARAT score. The task-specific group receive 14 h of therapist-led task-specific training plus 42 h of guided self-practice. The primary outcome measure is the ARAT at 6 weeks. Secondary measures include the Motor Activity Log (MAL) at 6 weeks and the ARAT, MAL and EQ5D-5 L at 6 months. Assessments occur at baseline, after 6 weeks of intervention, and at 6 months after intervention commencement. Analysis will be intention to treat using a generalised linear mixed model to report estimated mean differences in scores between the two groups at each timepoint with 95% confidence interval and value of p.

Discussion

If the task-specific home-based training programme is more effective than usual care in improving arm function, implementation of the programme into clinical practice would potentially lead to improvements in upper limb function and quality of life for people with stroke.

Clinical Trial Registration

ANZCTR.org.au/ACTRN12617001631392p.aspx.

Effect of task-based bilateral arm training on upper limb recovery after stroke: A systematic review and meta-analysis

OBJECTIVE

Upper limb recovery is a crucial component of stroke rehabilitation aimed to maximize functional activities and reduce disability. Using both arms post stroke is essential to carry out many functional activities but the evidence on bilateral arm training (BAT) is understudied. To investigate the evidence for efficacy of task-based BAT on upper limb recovery, function, and participation post stroke.

METHODS

We included 13 randomized controlled trials, and methodological quality was assessed using Cochrane risk of bias tool and the PEDro scale. The outcome measures such as Fugl-Meyer Assessment-Upper Extremity (FMA-UE), Action Research Arm Test (ARAT), Wolf Motor Function Test (WMFT), Motor Activity Log (MAL), Box and Block Test (BBT), Modified Barthel Index (MBI), Functional Independence Measure (FIM), and Stroke Impact Scale (SIS) were synthesized and analysed based on ICF.

RESULTS

When comparing BAT with control group, BAT showed improvement in the pooled standard mean difference (SMD) of FMA-UE (SMD= 0.62, 95% confidence interval (CI), 0.12 to 1.12, p = 0.01; I²=83%). The control group showed significant improvement in MAL-QOM (SMD= -0.10, 95%CI, -0.77 to 0.58, p = 0.78; I²=89%). Compared to conventional group, BAT showed a significant improvement in BBT (SMD= 0.52, 95%CI, 0.04 to 1.00, p = 0.03; I²=0%). When compared with BAT, unimanual training yielded a significant improvement (SMD= -0.60, 95%CI, -0.98 to -0.22, p = 0.002; I²=0%) in MAL-QOM. In real-life participation, the control group showed improvement in SIS (SMD= -0.17, 95% (CI), -0.70 to 0.37, p = 0.54; I²=48%) over BAT.

CONCLUSIONS

Task-based BAT appears to improve upper limb motor function post stroke. The benefits of task-based BAT on activity performance and participation in real life are not statistically significant.

Effects of a remote-handling-concept-based task-oriented arm training (ReHab-TOAT) on arm-hand skill performance in chronic stroke: a study protocol for a two-armed randomized controlled trial

BACKGROUND

Improving arm-hand skill performance is a major therapeutic target in stroke rehabilitation and needs intensive and varied training. However, guided treatment time is limited. Technology can assist in the training of patients, offering a higher intensity and more variety in content. A new task-oriented arm training approach was developed, using a 'Remote Handling concept based' device to provide haptic feedback during the performance of daily living activities (ReHab-TOAT). This study aims to investigate the effects of ReHab-TOAT on patients' arm-hand function and arm-hand skill performance, quality of life of both patients in the chronic phase after stroke and their caregivers and the patients' perception regarding the usability of the intervention.

METHODS

A randomized clinical trial was designed. Adult chronic stroke patients suffering from hemiparesis and arm-hand problems, with an Utrechtse Arm-hand Test score of 1-3, will be invited to participate. Participants in the experimental group receive ReHab-TOAT additional to care as usual. ReHab-TOAT contains task-oriented arm training for stroke patients in combination with haptic feedback, generated by a remote handling device. They will train for 4 weeks, 3× per week, 1.5h per day. Participants in the control group will receive no additional therapy apart from care as usual. The Fugl-Meyer Assessment (FMA), measuring participants' motor performance of the affected arm, is used as the primary outcome measure. Secondary outcome measures are arm-hand capacity of the patient (ARAT), perceived arm-hand skill performance (MAL), actual arm-hand skill performance (accelerometry), patients' quality of life (EuoQol-5D) and caregivers' quality of life (CarerQoL). Participants' perception regarding the usability of the intervention, including both the developed approach and technology used, will be evaluated by the System Usability Scale and a questionnaire on the user experience of technology. Measurements will be performed at 1, 2, 3 and 4 weeks pre-intervention (baseline); immediately post-intervention; and 3, 6 and 9 months post-intervention. Statistical analysis includes linear mixed model analysis.

DISCUSSION

This study is designed to investigate the evidence regarding the effects of ReHab-TOAT on patients' performance at different levels of the International Classification of Functioning, disability and health (ICF) model, i.e. a framework measuring functioning and disability in relation to a health condition, and to provide insights on a successful development and research process regarding technology-assisted training in co-creation.

TRIAL REGISTRATION

Netherlands Trial Register NL9541. Registered on June 22, 2021.

Descriptive analysis of post-stroke patients in a neurological physical therapy unit

Introduction

Physical therapy (PT) is the mainstay treatment in functional recovery after suffering a stroke. It is important in the acute phase of hospitalization after a stroke and later in the ambulatory phase.

Patients and methods

The present study aimed to analyze the data provided by the clinical history (CH) of people with stroke (pwS) who received PT treatment in order to establish a "preferential patient profile" (PPP) that may benefit more from an early PT treatment. This was an observational, descriptive, and cross-sectional study. A total of 137 pwS who had been treated with PT were selected. Information provided age, gender, stroke type and localization, and start and end dates of the different PT treatments. A descriptive analysis of the variables was conducted using absolute frequencies and percentages for the qualitative variables. Student's t-test or the Mann-Whitney U-test was used to determine the relationship between the time and variables "stroke type," "outpatient," and "occupational therapy." The Kruskal-Wallis H-test was applied for the "localization" variable.

Results

Of the entire sample, 57.7% were men, 65% had an ischemic stroke, and 48.9% had a stroke on the left side. The patients with hemorrhagic stroke had an increased number of hospital PT sessions (p = 0.01) and were younger (59.58 years) than patients with ischemic stroke (65.90 years) (p = 0.04).

Discussion and conclusion

Our results do not show significant differences between the persons < 65 years and the number of outpatient physiotherapy sessions performed, although the resulting values are close to significance. Our results suggest that the PPP is a young person, with a hemorrhagic and left or bilateral stroke.

Applied strategies of neuroplasticity

Various levels of somatotopic organization are present throughout the human nervous system. However, this organization can change when needed based on environmental demands, a phenomenon known as neuroplasticity. Neuroplasticity can occur when learning a new motor skill, adjusting to life after blindness, or following a stroke. Following an injury, these neuroplastic changes can be adaptive or maladaptive, and often occur regardless of whether rehabilitation occurs or not. But not all movements produce neuroplasticity, nor do all rehabilitation interventions. Here, we focus on research regarding how to maximize adaptive neuroplasticity while also minimizing maladaptive plasticity, known as applied neuroplasticity. Emphasis is placed on research exploring how best to apply neuroplastic principles to training environments and rehabilitation protocols. By studying and applying these principles in research and clinical practice, it is hoped that learning of skills and regaining of function and independence can be optimized.

Bobath therapy is inferior to task-specific training and not superior to other interventions in improving arm activity and arm strength outcomes after stroke: a systematic review

QUESTION

What is the effect of Bobath therapy on arm activity and arm strength compared with a dose-matched comparison intervention or no intervention after stroke?

DESIGN

Systematic review of randomised trials with meta-analysis.

PARTICIPANTS

Adults after stroke.

INTERVENTION

Bobath therapy compared with no intervention or other interventions delivered at the same dose as the Bobath therapy.

OUTCOME MEASURES

Arm activity outcomes and arm strength outcomes. Trial quality was assessed with the PEDro scale.

RESULTS

Thirteen trials were included; all compared Bobath with another intervention, which were categorised as: task-specific training (five trials), arm movements (five trials), robotics (two trials) and mental practice (one trial). The PEDro scale scores ranged from 5 to 8. Pooled data from five trials indicated that Bobath therapy was less effective than task-specific training for improving arm activities (SMD -1.07, 95% CI -1.59 to -0.55). Pooled data from five trials indicated that Bobath therapy was similar to or less effective than arm movements for improving arm activities (SMD -0.18, 95% CI -0.44 to 0.09). One trial indicated that Bobath therapy was less effective than robotics for improving arm activities and one trial indicated similar effects of Bobath therapy and mental practice on arm activities. For strength outcomes, pooled data from two trials indicated a large benefit of task-specific training over Bobath therapy (SMD -1.08); however, this estimate had substantial uncertainty (95% CI -3.17 to 1.01). The pooled data of three trials indicated that Bobath therapy was less effective than task-specific training for improving Fugl-Meyer scores (MD -7.84, 95% CI -12.99 to -2.69). The effects of Bobath therapy relative to other interventions on strength outcomes remained uncertain.

CONCLUSIONS

After stroke, Bobath therapy is less effective than task-specific training and robotics in improving arm activity and less effective than task-specific training on the Fugl-Meyer score.

REGISTRATION

PROSPERO CRD42021251630.

Effects of Combining Cognitive Behavioral Therapy with Bilateral Upper Limb Training in Stroke Patients: A Randomized Controlled Trial

CBT has a beneficial effect on depression and anxiety; however, the number of cases where therapy was used in patients with stroke was rare. In addition, there is still a lack of research on the effects of occupation-based training and the effects of bilateral upper limb training that provides an intervention based on patients' state of hemiplegic upper limb function. This study investigated the effects of combining CBT and occupation-based bilateral upper limb training on the depression, anxiety, upper limb function, and occupational performance. The experimental group was given 30-min cognitive behavioral therapy and occupation-based bilateral upper limb training, while the control group was given 30-min conventional occupational therapy and occupation-based bilateral upper limb training. For both groups, the intervention was given as a 30-min session once a day and five times a week for 4 weeks. Following intervention, the experimental group showed significant within-group variance for automatic thoughts, depression, anxiety, upper limb function, and occupational performance only (p < 0.01). For between-group variance, a significant difference was found for automatic thoughts, depression, anxiety, and occupational performance (p < 0.01), however, not for upper limb function (p > 0.05). In this study, it is meaningful that this author provided good guidelines for therapists and caregivers by organizing and providing actual programs in a very rare situation where cognitive behavioral therapy was applied to stroke patients.

The Effects of Occupation-Based Community Rehabilitation for Improving Activities of Daily Living and Health-Related Quality of Life of People with Disabilities after Stroke Living at Home: A Single Subject Design

Objective

The aim of this study is to investigate the effect of occupation-based community rehabilitation on activity daily of living and health-related quality of life of people with disabilities after stroke at home.

Method

In this study of three people with disabilities after stroke living at home, A-B-A single-subject design was used. The occupation-based community rehabilitation was implemented during the intervention phase. It included task oriented and feedback, related information education, home environment modification, and community resource network. After applying the intervention, changes in activities of daily living and health-related quality of life were evaluated by the Modified Barthel Index (MBI), the EuroQol-5 dimension (EQ-5D), and the Assessment of Motor and Process Skills (AMPS).

Result

After applying the occupation-based community rehabilitation program, all three participants' daily life activities and quality of life improved. In addition, the occupational performance skills in all participants were maintained.

Conclusion

It was confirmed that individual occupational-based community rehabilitation had a positive effect on the activities of daily living and quality of life improvement of the people with disabilities after stroke at home.

Feasibility of an individualised, task-oriented, video-supported home exercise programme for arm function in patients in the subacute phase after stroke: protocol of a randomised controlled pilot study

INTRODUCTION

Stroke rehabilitation guidelines suggest a high-frequency task-oriented training at high intensity. A targeted and self-paced daily training with intermittent supervision is recommended to improve patients' self-management and functional output. So far, there is conflicting evidence concerning the most effective home-training delivery method.

METHODS AND ANALYSIS

The purpose of this pilot study is to compare the feasibility and preliminary effects of task-oriented home-exercises in patients in the subacute stage after stroke. Twenty-four patients will be randomised (1:1) to a Video group (a) or Paper group (b) of an individualised, task-oriented home-training (50 min, 6×/week, for 4 weeks) based on Wulf and Lewthwaite's Optimizing Performance Through Intrinsic Motivation and Attention for Learning theory of motor learning. Patient-relevant goals will be identified using Goal Attainment Scaling and exercises progressively adapted. Semistructured interviews and a logbook will be used to monitor adherence, arm use and acceptability. Primary outcome will be the feasibility of the methods and a full-scale trial employing predefined feasibility criteria (recruitment, retention and adherence rates, patients' satisfaction with the home-exercise programme and their progress, affected hand use and acceptance of the intervention). Assessed at baseline, post intervention and 4-week follow-up, secondary outcomes include self-perceived hand and arm use, actual upper extremity function and dexterity, hand strength, independence in activities of daily living and health-related quality of life. Interview data will be analysed using qualitative content analysis. Medians (ranges) will be reported for ordinal data, means (SD) for continuous and frequency (percentage) for nominal data.

ETHICS AND DISSEMINATION

This study follows the Standard Protocol Items: Recommendations for Interventional Trials-Patient-Reported Outcome (PRO) Extension guideline. Ethical approval was received from the Ethics Committee of the Medical University of Innsbruck, Austria (1304/2020). Written informed consent will be obtained from all participants prior to data collection. Study results will be disseminated to participating patients, patient organisations, via the clinic's homepage, relevant conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

DRKS-ID: DRKS00023395.Study protocol, second revision, 5 December 2021.

Occupational Therapy and the IMPACT Act: Part 2. A Systematic Review of Evidence for Functional Status, Medication Reconciliation, and Skin Integrity Interventions

IMPORTANCE

Interventions that promote function, medication reconciliation, and skin integrity assist occupational therapy practitioners in demonstrating professional value, improving quality, and reducing health care costs.

OBJECTIVE

In this systematic review, we focus on three outcome areas of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014: functional status, medication reconciliation, and skin integrity.

DATA SOURCES

We conducted a search of the literature published between 2009 and 2019 in CINAHL, Cochrane, MEDLINE, PsycINFO, OTseeker, and Scopus. We also hand searched the systematic reviews and meta-analyses in our search results for articles that met our inclusion criteria. Study Selection and Data Collection: This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

FINDINGS

We found 47 articles that address the three outcome areas. Regarding functional status, low strength of evidence is available for cognition and functional mobility interventions to support functional performance, moderate strength of evidence supports interventions for vision, and moderate evidence supports task-oriented and individualized interventions to promote activities of daily living (ADL) outcomes among people with neurological conditions. Strong strength of evidence supports individualized occupational therapy interventions focusing on medication adherence. Low strength of evidence was found for occupational therapy interventions to reduce pressure ulcers and promote skin integrity. Conclusion and Relevance: The evidence supports occupational therapy interventions to improve functional status in ADLs and medication management. Additional research is needed that examines the outcomes of occupational therapy interventions for other areas of function and skin integrity. What This Article Adds: We found evidence to support occupational therapy interventions that align with value-based measures in the three outcome areas of interest. The effectiveness of these interventions highlights the viability of occupational therapy as an essential profession and the worth of occupational therapy to the public, potential clients, and payers.

Comparing the effectiveness of bimanual and unimanual mirror therapy in unilateral neglect after stroke: A pilot study

BACKGROUND

Unilateral neglect in stroke patients is a major obstacle to rehabilitation, which is a great challenge for therapists.

OBJECTIVE

This study aimed to compare the effectiveness of bimanual mirror therapy (BMT) and unimanual mirror therapy (UMT), the two protocols of mirror therapy, for the reduction of the symptoms of unilateral neglect in stroke patients.

METHODS

Twenty-eight individuals were randomly assigned to the UMT or BMT groups. Both groups received mirror therapy for 30 minutes per day, 5 days a week, for a period of 4 weeks. The Star Cancelation Test (SCT), Line Bisection Test (LBT), Picture Scanning test (PST), and Korean Catherine Bergego Scale (K-CBS) were used to measure the change in unilateral neglect, and the Korean version of the Modified Barthel Index (K-MBI) was used to evaluate activities of daily living (ADL).

RESULTS

The results of SCT, LBT, PST, and K-CBS showed significant decreases in unilateral neglect in both groups (p <  0.05). K-MBI improved significantly in both groups (p <  0.05). There were significant differences between the two groups in the unilateral neglect tests (p <  0.05), but no significant difference in ADL evaluation (p >  0.05).

CONCLUSIONS

Mirror therapy protocols can be applied to treat unilateral neglect in stroke patients. However, BMT may be more beneficial for reducing the symptoms of unilateral neglect.

The Bobath Concept (NDT) as rehabilitation in stroke patients: A systematic review

Background and Objectives:

The Bobath approach, also known as neurodevelopmental treatment (NDT), is a widely used concept in the rehabilitation of stroke patients with hemiparesis in many countries. This technique is being used since years all over the world; however, strong evidence of its usefulness is still not present. This review is aimed to find out its effectiveness based on the randomized controlled trials in the rehabilitation of stroke patients with motor disability and to compare it with other therapeutic techniques.

Materials and Methods:

A systematic literature search on PubMed Central, Science-Direct, Cochrane, Scopus, Clinical Trial Database, and Indian Clinical Trial Registry in English till 31^st July 2021 was undertaken. The review is published in Prospective Register of Systematic Reviews (PROSPERO) with registration number “CRD42019125400.” Physiotherapy Evidence-based Database (PEDro) score has been used for the quality assessment of the studies. Randomized clinical trials that studied the comparative effect of the NDT/Bobath concept on motor activity outcomes and cognition/behavior in stroke patients in comparison with other rehabilitative techniques were included.

Results:

No strong documentation describing the effectiveness of this neuro-developmental treatment or its supporting neuro-developmental treatment in comparison with other advanced neuro-physiotherapeutic techniques has been found so as to consider it as the recommended treatment for post-stroke hemiplegia/hemiparesis. Methodological aspects of selected studies for further research are suggested.

Interpretation and Conclusions:

This study is inconclusive in determining the effectiveness of the Bobath approach for the movement rehabilitation of stroke patients. These results are similar to the results of previous reviews done on the same topic.

Probabilistic Model-based Learning Control of a Soft Pneumatic Glove for Hand Rehabilitation

OBJECTIVE

Stroke survivors are usually unable to perform activities of daily living (ADL) independently due to loss of hand functions. Soft pneumatic gloves provide a promising assistance approach for stroke survivors to conduct ADL tasks. However, few studies have explored effective control strategies for the 'human-soft robot' integrated system due to challenges in the nonlinearities of soft robots and uncertainties of human intentions. Therefore, this work aims to develop control approaches for the system to improve stroke survivors hand functions.

METHODS

Firstly, a soft pneumatic glove was utilized to aid with stroke-impaired hands. Secondly, a probabilistic model-based learning control approach was proposed to overcome the challenges. Then a task-oriented intention-driven training modality was designed. Finally, the control performance was evaluated on three able-bodied subjects and three stroke survivors who attended 20-session rehabilitation training.

RESULTS

The proposed approach could enable the soft pneumatic glove to provide adaptive assistance for all participants to accomplish different tasks. The tracking error and muscle co-contraction index showed decreasing trends while the hand gesture index showed an increasing tendency over training sessions. All stroke survivors showed improved hand functions and better muscle coordination after training.

CONCLUSION

This work developed a learning-based soft robotic glove training system and demonstrated its potential in post-stroke hand rehabilitation.

SIGNIFICANCE

This work promotes the application of soft robotic training systems in stroke rehabilitation.

Quantifying upper limb motor impairment in chronic stroke: a physiological profiling approach

Upper limb motor impairments, such as muscle weakness, loss of dexterous movement, and reduced sensation, are common after a stroke. The extent and severity of these impairments differ among individuals, depending on the anatomical location and size of lesions. Identifying impairments specific to the individual is critical to optimize their functional recovery. The upper limb Physiological Profile Assessment (PPA) provides quantitative measures of key physiological domains required for adequate function in the upper limbs. The present study investigates the use of the upper limb PPA in a chronic stroke population. Fifty participants with chronic stroke completed all tests of the upper limb PPA with both their affected and less affected upper limbs. Performance in each test was compared to that of 50 age- and sex-matched control subjects with no history of a stroke. Correlations between test performance and validated measures of stroke, sensorimotor function, and disability were examined. Compared with control subjects, people with stroke demonstrated substantially impaired upper limb PPA performance for both their affected and less affected limbs. Performance in the upper limb PPA was associated with validated measures of sensorimotor function specific to the stroke population (Fugl-Meyer Assessment) and stroke-related disability (Stroke Impact Scale). The upper limb PPA shows good concurrent validity as a means to quantify upper limb function in a chronic stroke population. These tests identify domain-specific deficits and could be further tailored to an individual patient by the clinician to inform rehabilitation and track recovery.NEW & NOTEWORTHY Upper limb motor impairment is a common manifestation after stroke, compromising independence in fundamental daily activities involving the ability to reach, grasp, and manipulate objects. The upper limb Physiological Profile Assessment (PPA) offers a means of quantifying performance of the individual sensorimotor domains that are essential for upper limb function. Establishing individual performance profiles based on age- and sex-based normative scores may facilitate individualized treatment decisions by identifying the stroke patient's specific strengths and limitations.

Analysing the Action Research Arm Test (ARAT): a cautionary tale from the RATULS trial

Many studies of stroke rehabilitation use the Action Research Arm Test (ARAT) as an outcome, which measures upper limb function by scoring the ability to complete functional tasks. This report describes an issue encountered when analysing the ARAT subscales in a trial of upper limb therapies after stroke. The subscales of the ARAT at three months followed a 'U-shaped' distribution, and therefore, comparing means or medians was not appropriate. A simple alternative approach was chosen that dichotomised the subscales. When analysing the ARAT, the shape of the distributions must be checked in order to choose the most appropriate descriptive and inferential statistical techniques. In particular, if the data follows a 'U-shaped' distribution, a simple dichotomising or a more sophisticated approach is needed. These should also be considered for heavily skewed distributions, often arising from substantial floor or ceiling effects. Inappropriate analyses can lead to misleading conclusions.

Zakaria H, M. Ragab W, Al Awaji NN, Y. Elzanaty M, R. Elserougy H. Therapeutic Efficacy of Transcutaneous Electrical Nerve Stimulation Acupoints on Motor and Neural Recovery of the Affected Upper Extremity in Chronic Stroke: A Sham-Controlled Randomized Clinical Trial

Inability to use the affected upper extremity (UE) in daily activities is a common complaint in stroke patients. The somatosensory system (central and peripheral) is essential for brain reorganization and plasticity. Neuromuscular electrical stimulation is considered an effective modality for improving UE function in stroke patients. The aim of the current study was to determine the therapeutic effects of transcutaneous electrical nerve stimulation (TENS) acupoints on cortical activity and the motor function of the affected UE in chronic stroke patients. Forty male and female patients diagnosed with stroke agreed to join the study. They were randomly assigned to group 1 (G1) and group 2 (G2). G1 received task-specific training (TST) and sham electrical stimulation while G2 received TST in addition to TENS acupoints. Session duration was 80 min. Both groups received 18 sessions for 6 successive weeks, 3 sessions per week. Evaluation was carried out before and after completion of the treatment program. Outcome measures used were the Fugl-Meyer Assessment of the upper extremity (FMA-UE) and the box and block test (BBT) as measures of the motor function of the affected UE. Brain activity of the motor area (C3) in the ipsilesional hemisphere was measured using a quantitative electroencephalogram (QEEG). The measured parameter was peak frequency. It was noted that the motor function of the affected UE improved significantly post-treatment in both groups, while no significant change was reported in the FMA-UE and BBT scores post-treatment in either G1 or G2. On the other hand, the activity of the motor area C3 improved significantly in G2 only, post-treatment, while G1 showed no significant improvement. There was also significant improvement in the activity of the motor area (C3) in G2 compared to G1 post-treatment. The results of the current study indicate that TST only or combined with TENS acupoints can be considered an effective method for improving motor function of the affected UE in chronic stroke patients, both being equally effective. However, TST combined with TENS acupoints proved better in improving brain plasticity in chronic stroke patients.

Canadian Platform for Trials in Noninvasive Brain Stimulation (CanStim) Consensus Recommendations for Repetitive Transcranial Magnetic Stimulation in Upper Extremity Motor Stroke Rehabilitation Trials

Objective. To develop consensus recommendations for the use of repetitive transcranial magnetic stimulation (rTMS) as an adjunct intervention for upper extremity motor recovery in stroke rehabilitation clinical trials. Participants. The Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim) convened a multidisciplinary team of clinicians and researchers from institutions across Canada to form the CanStim Consensus Expert Working Group. Consensus Process. Four consensus themes were identified: (1) patient population, (2) rehabilitation interventions, (3) outcome measures, and (4) stimulation parameters. Theme leaders conducted comprehensive evidence reviews for each theme, and during a 2-day Consensus Meeting, the Expert Working Group used a weighted dot-voting consensus procedure to achieve consensus on recommendations for the use of rTMS as an adjunct intervention in motor stroke recovery rehabilitation clinical trials. Results. Based on best available evidence, consensus was achieved for recommendations identifying the target poststroke population, rehabilitation intervention, objective and subjective outcomes, and specific rTMS parameters for rehabilitation trials evaluating the efficacy of rTMS as an adjunct therapy for upper extremity motor stroke recovery. Conclusions. The establishment of the CanStim platform and development of these consensus recommendations is a first step toward the translation of noninvasive brain stimulation technologies from the laboratory to clinic to enhance stroke recovery.

Effect of Task-Specific Training on Trunk Control and Balance in Patients with Subacute Stroke

Objectives

Impairment of static and dynamic posture control is common after stroke. It is found to be a predictor and an essential component for balance, walking ability, and activities of daily living (ADL) outcomes. Studies investigating effect of physical therapy techniques with an aim to improve trunk function after stroke are limited. This study aimed at studying the effect of task-specific training on trunk control and balance in patients with subacute stroke.

Methods

In this randomized controlled trail, thirty-four patients were alienated into two equal groups. The study group (n = 17) received task-specific training, and the control group (n = 17) received conventional physical therapy based on the neurodevelopmental technique. Task-specific training was applied through two phases with criteria of progression based on Chedoke-McMaster Stroke Assessment postural control stages. The interventions were applied in a dosage of 60 min per session, three times a week for ten weeks. Static and dynamic balance were measured by the trunk impairment scale (TIS), postural assessment scale (PAS), and functional reach test (FRT). Laser-guided digital goniometer was used to measure the trunk ranges of motions (ROM) as a secondary outcome.

Results

Significant differences between the baseline and the follow-up measures including TIS, PAS, FRT, and trunk (ROM) were found in both groups (P ≤ 0.05). In-between group comparison also showed significant differences between the results of both groups indicating more improvements among patients representing the study group.

Conclusion

Task-specific training may be effective in improving the static and dynamic postural control and trunk ranges of motion among subacute stroke patients.

Effects of a single mental chronometry training session in subacute stroke patients - a randomized controlled trial

Background

Motor imagery training might be helpful in stroke rehabilitation. This study explored if a single session of motor imagery (MI) training induces performance changes in mental chronometry (MC), motor execution, or changes of motor excitability.

Methods

Subacute stroke patients (n = 33) participated in two training sessions. The order was randomized. One training consisted of a mental chronometry task, the other training was a hand identification task, each lasting 30 min. Before and after the training session, the Box and Block Test (BBT) was fully executed and also performed as a mental version which served as a measure of MC. A subgroup analysis based on the presence of sensory deficits was performed. Patients were allocated to three groups (no sensory deficits, moderate sensory deficits, severe sensory deficits). Motor excitability was measured by transcranial magnetic stimulation (TMS) pre and post training. Amplitudes of motor evoked potentials at rest and during pre-innervation as well as the duration of cortical silent period were measured in the affected and the non-affected hand.

Results

Pre-post differences of MC showed an improved MC after the MI training, whereas MC was worse after the hand identification training. Motor execution of the BBT was significantly improved after mental chronometry training but not after hand identification task training. Patients with severe sensory deficits performed significantly inferior in BBT execution and MC abilities prior to the training session compared to patients without sensory deficits or with moderate sensory deficits. However, pre-post differences of MC were similar in the 3 groups. TMS results were not different between pre and post training but showed significant differences between affected and unaffected side.

Conclusion

Even a single training session can modulate MC abilities and BBT motor execution in a task-specific way. Severe sensory deficits are associated with poorer motor performance and poorer MC ability, but do not have a negative impact on training-associated changes of mental chronometry. Studies with longer treatment periods should explore if the observed changes can further be expanded.

Trial registration

DRKS, DRKS00020355, registered March 9th, 2020, retrospectively registered

Effects of home-based mirror therapy and cognitive therapeutic exercise on the improvement of the upper extremity functions in patients with severe hemiparesis after a stroke: a protocol for a pilot randomised clinical trial

INTRODUCTION

Neuroplasticity is defined as the capacity of the brain to reorganise new neuronal pathways. Mirror therapy (MT) and cognitive therapeutic exercise (CTE) are two neurorehabilitation techniques based on neuroplasticity and designed to improve the motor functions of the affected upper extremity in patients with severe hemiparesis after a stroke. Home-based interventions are an appropriate alternative to promote independence and autonomy. The objective of this study is to evaluate which of these techniques, MT and CTE, combined with task-oriented training, is more effective in functional recovery and movement patterns of the upper extremities in patients with severe hemiparesis after a stroke.

METHODS AND ANALYSIS

This is a home-based, single-blind, controlled, randomised clinical trial with three parallel arms, including 154 patients who had a stroke aged above 18 years. The primary outcome will be the functionality of the affected upper extremity measured using the Fugl-Meyer Assessment. Secondary variables will include cognitive performance, emotional state, quality of life and activities of daily living. During 6 weeks, one of the intervention groups will receive a treatment based on MT and the other one on CTE, both combined with task-oriented training. No additional interventions will be provided to the control group. To assess the progress of patients who had a stroke in the subacute phase, all variables will be evaluated at different visits: initial (just before starting treatment and 4 weeks post-stroke), post-intervention (6 weeks after initial) and follow-up (6 months).

ETHICS AND DISSEMINATION

This protocol has been approved by the Institutional Review Board (CEIm-2.134/2.019) and registered at ClinicalTrials.gov (NCT04163666). The results will be disseminated through open-access peer-reviewed journals, conference presentation, broadcast media and a presentation to stakeholders. These study results will provide relevant and novel information on effective neurorehabilitation strategies and improve the quality of intervention programmes aimed at patients after a stroke.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT04163666).

Effects of Exoskeletal Lower Limb Robot Training on the Activities of Daily Living in Stroke Patients: Retrospective Pre-Post Comparison Using Propensity Score Matched Analysis

PURPOSE

There is limited evidence of gait training using newly developed exoskeletal lower limb robot called Hybrid Assistive Limb (HAL) on the function and ability to perform ADL in stroke patients. In clinical settings, we frequently find it challenging to conduct a randomized controlled trial; thus, a large-scale observational study using propensity score analysis methods is a feasible alternative. The present study aimed to determine whether exoskeletal lower limb robot training improved the ability to perform ADL in stroke patients.

MATERIALS AND METHODS

Acute stroke patients who were admitted to our facility from April 2016 to March 2017 were evaluated in the conventional rehabilitation period (CRP) and those admitted from April 2017 to June 2019 were evaluated in the HAL rehabilitation period (HRP). We started a new gait rehabilitation program using HAL at the midpoint of these two periods. The functional outcomes or ADL ability outcomes of the patients in the CRP and the subsequent HRP were compared using propensity score matched analyses.

RESULTS

Propensity score matching analysis was performed for 108 stroke patients (63 from the CRP and 45 from the HRP), and 36 pairs were matched. The ADL ability, defined by the FIM scores and FIM score change, was significantly higher in patients admitted during the HRP. In addition, more stroke patients obtained practical walking ability during hospitalization in the HRP.

CONCLUSION

Gait training using HAL affects the ADL ability and obtaining of practical walking ability of stroke patients.

Potential benefits of music playing in stroke upper limb motor rehabilitation

Music-based interventions have emerged as a promising tool in stroke motor rehabilitation as they integrate most of the principles of motor training and multimodal stimulation. This paper aims to review the use of music in the rehabilitation of upper extremity motor function after stroke. First, we review the evidence supporting current music-based interventions including Music-supported Therapy, Music glove, group music therapy, Rhythm- and music-based intervention, and Musical sonification. Next, we describe the mechanisms that may be responsible for the effectiveness of these interventions, focusing on motor learning aspects, how multimodal stimulation may boost motor performance, and emotional and motivational aspects related to music. Then, we discuss methodological concerns in music therapy research related to modifications of therapy protocols, evaluation of patients and study designs. Finally, we highlight clinical considerations for the implementation of music-based interventions in clinical settings.

Harnessing smartphone technology and three dimensional printing to create a mobile rehabilitation system, mRehab: assessment of usability and consistency in measurement

BACKGROUND

Residual sensorimotor deficits are common following stroke. While it has been demonstrated that targeted practice can result in improvements in functional mobility years post stroke, there is little to support rehabilitation across the lifespan. The use of technology in home rehabilitation provides an avenue to better support self-management of recovery across the lifespan. We developed a novel mobile technology, capable of quantifying quality of movement with the purpose of providing feedback to augment rehabilitation and improve functional mobility. This mobile rehabilitation system, mRehab, consists of a smartphone embedded in three dimensional printed items representing functional objects found in the home. mRehab allows individuals with motor deficits to practice activities of daily living (ADLs) and receive feedback on their performance. The aim of this study was to assess the usability and consistency of measurement of the mRehab system.

METHODS

To assess usability of the mRehab system, four older adults and four individuals with stroke were recruited to use the system, and complete surveys to discuss their opinions on the user interface of the smartphone app and the design of the 3D printed items. To assess the consistency of measurement by the mRehab system, 12 young adults were recruited and performed mRehab ADLs in three lab sessions within 1 week. Young adults were chosen for their expected high level of consistency in motor performance.

RESULTS

Usability ratings from older adults and individuals with stroke led us to modify the design of the 3D printed items and improve the clarity of the mRehab app. The modified mRehab system was assessed for consistency of measurement and six ADLs resulted in coefficient of variation (CV) below 10%. This is a commonly used CV goal for consistency. Two ADLs ranged between 10 and 15% CV. Only two ADLs demonstrated high CV.

CONCLUSIONS

mRehab is a client-centered technology designed for home rehabilitation that consistently measures performance. Development of the mRehab system provides a support for individuals working on recovering functional upper limb mobility that they can use across their lifespan.

A systematic review of the application and psychometric properties of the graded Wolf Motor Function Test

Introduction

Adapted from the Wolf Motor Function Test, the graded Wolf Motor Function Test is an upper limb activity assessment for use following stroke and brain injury. The aim of this systematic review was to identify and appraise evidence where the test has been used or has undergone psychometric evaluation.

Method

A systematic review of five databases was conducted to identify studies reporting the graded Wolf Motor Function Test using a keyword search. Intervention and clinical measurement studies were eligible for inclusion. Data quality was assessed using the adapted Critical Appraisal Skills Programme questions and the Consensus-based Standards for the Selection of Health Measurement Instruments Risk of Bias checklist.

Results

Twelve studies, of mostly low quality, were included. Studies included one randomised controlled trial, 10 pre- and post-studies and one clinical measurement study. All studies involved participants following stroke. Reliability was the only measurement property assessed in two studies, which were of a ‘doubtful’ and ‘poor’ quality.

Conclusion

Low quality studies impede the ability of clinicians and researchers to best determine the applicability of the graded Wolf Motor Function Test to patient groups and research contexts. Further exploration of the psychometric properties of the graded Wolf Motor Function Test is recommended across stroke populations using rigorous design methods.

Current therapy for the upper limb after stroke: a cross-sectional survey of UK therapists

OBJECTIVES

To survey the reported content, frequency and duration of upper limb treatment provided by occupational and physiotherapists for people after stroke in the UK.

DESIGN

A cross-sectional online survey was used. Description and analysis of the data were based on items from the Template for Intervention Description and Replication (Who, Where, What and How much).

SETTING

The online survey was distributed via professional and social networks to UK-based therapists.

PARTICIPANTS

Respondents were occupational or physiotherapists currently working clinically in the UK with people after stroke. Over the 6 week data collection period, 156 respondents opened the survey, and 154 completed it. Respondents comprised 85 physiotherapists and 69 occupational therapists.

RESULTS

Respondents reported treating the upper limb a median of three times a week (range: 1 to 7) for a mean of 29 min (SD: 18). Most (n=110) stated this was supplemented by rehabilitation assistants, family and/or carers providing additional therapy a median of three times a week (range 1 to 7). Functional training was the most commonly reported treatment for people with mild and moderate upper limb deficits (>40%). There was much less consistency in treatments reported for people with severe upper limb deficits with less than 20% (n=28) reporting the same treatments.

CONCLUSIONS

This study provides a contemporaneous description of reported therapy in the UK for people with upper limb deficits after stroke and a detailed template to inform standard therapy interventions in future research. Several evidence-based therapies were reported to be used by respondents (eg, constraint induced movement therapy), but others were not (eg, mental imagery). The findings also highlight that the current reported provision of upper limb therapy is markedly less than what is likely to be effective. This underlines an urgent need to configure and fund services to empower therapists to deliver greater amounts of evidence-based treatment for people with upper limb deficits after stroke.

Factors influencing the implementation of Home-Based Stroke Rehabilitation: Professionals' perspective

Background

Stroke has a major impact on survivors and their social environment. Care delivery is advocated to become more client-centered and home-based because of their positive impact on client outcomes. The objective of this study was to explore professionals’ perspectives on the provision of Home-Based Stroke Rehabilitation (HBSR) in the Netherlands and on the barriers and facilitators influencing the implementation of HBSR in daily practice.

Methods

Semi-structured focus groups were conducted to explore the perspectives of health and social care professionals involved in stroke rehabilitation. Directed content analysis was performed to analyze the transcripts of recorded conversations.

Results

Fourteen professionals participated in focus groups (n = 12) or, if unable to attend, an interview (n = 2). Participants varied in professional backgrounds and roles in treating Dutch clients post stroke. Barriers and facilitators influencing the implementation of HBSR in daily practice were identified in relation to: the innovation, the user, the organization and the socio-political context. Participants reported that HBSR can be efficient and effective to most clients because it facilitates client- and caregiver-centered rehabilitation within the clients’ own environment. However, barriers in implementing HBSR were perceived in a lack of (structured) inter-professional collaboration and the transparency of expertise of primary care professionals. Also, the current financial structures for HBSR in the Netherlands are viewed as inappropriate.

Discussion

In line with previous studies, we found that HBSR is recognized by professionals as a promising alternative to institution-based rehabilitation for clients with sufficient capabilities (e.g. their own health and informal support).

Conclusion

Multiple factors influencing the implementation of HBSR were identified. Our study suggests that, in order to implement HBSR in daily practice, region specific implementation strategies need to be developed. We recommend developing strategies concerning: organized and coordinated inter-professional collaboration, transparency of the expertise of primary care professionals, and the financial structures of HBSR.

A Touch-Observation and Task-Based Mirror Therapy Protocol to Improve Sensorimotor Control and Functional Capability of Hands for Patients With Peripheral Nerve Injury

IMPORTANCE

To develop a practical program in the early phase after nerve repair for more rapid return of function.

OBJECTIVE

To investigate the effects of touch-observation and task-based mirror therapy on the sensorimotor outcomes of patients with nerve repair.

DESIGN

An assessor-blinded study with a randomized controlled design.

SETTING

University hospital.

PARTICIPANTS

We recruited 12 patients with median or ulnar nerve repair between the level of midpalm and elbow referred by the plastic surgeons.

INTERVENTION

The patients were randomized into touch-observation and task-based mirror therapy or control groups, and both groups received training for 12 wk.

OUTCOMES AND MEASURES

The Semmes-Weinstein monofilament (SWM) test, two-point discrimination test, Purdue Pegboard Test (PPT), Minnesota Manual Dexterity Test (MMDT), and pinch-holding-up activity test were assessed at pretreatment, immediately after treatment, and 12 wk after the last treatment.

RESULTS

The experimental group showed greater improvements in the results of the pinch-holding-up activity test and the PPT Unilateral Pin Insertion, Bilateral Pin Insertion, and Assembly subtests. However, change on the SWM test revealed no significant difference between the two groups.

CONCLUSIONS AND RELEVANCE

Touch-observation and task-based mirror therapy is an effective but low-cost treatment protocol to optimize sensorimotor control and functional capability of the upper limb in patients with peripheral nerve injury.

Differences in muscle activity and fatigue of the upper limb between Task-Specific training and robot assisted training among individuals post stroke

OBJECTIVE

To compare the activity and fatigue of upper extremity muscles, pain levels, subject satisfaction levels, perceived exertion, and number of repetitions in Task-Specific Training (TST) compared with Robot-Assisted Training (RAT) in individuals post-stroke.

METHODS

Twenty sub-acute post stroke subjects (16 men; median (interquartile range) age 64.0 (71.5-57.0) years) received two 30-min treatment sessions, one TST and one RAT. Before each session, the Visual Analogue Scale (VAS) was administered. Activity levels and fatigue of six muscles were monitored using surface electromyography and the number of repetitions was counted. After each session, the subjective assessment questionnaire of treatment, the Borg scale and VAS were administered.

RESULTS

During TST, the Anterior Deltoid, Upper Trapezius and Biceps were more active, while during the RAT, the Triceps was more active. The Triceps activity increased during TST towards the end of the session. The pain levels increased after TST and the number of repetitions was higher compared to RAT. There were no significant differences in muscle fatigue, perceived physical exertion and subject satisfaction levels between both treatment sessions.

CONCLUSION

This is the first study to explore the biomechanics of both treatment methods and might therefore shed light on the mechanisms behind their positive outcomes. Due to the differences in the biomechanics of the treatments, a combination of both treatments may be beneficial to the activation of different muscle groups, thereby contributing to the rehabilitation program post stroke.

Comparison of bilateral and unilateral upper limb training in people with stroke: A systematic review and meta-analysis

Background and objectives

Bilateral upper limb training (BULT) and unilateral upper limb training (UULT) are two effective strategies for the recovery of upper limb motor function after stroke. This meta-analysis aimed to compare the improvements in motor impairment and functional performances of people with stroke after BULT and UULT.

Research design and methods

This systematic review and meta-analysis identified 21 randomized controlled trials (RCTs) met the eligibility criteria from CINAHL, Medline, Embase, Cochrane Library and PubMed. The outcome measures were the Fugl-Meyer Assessment of Upper Extremity (FMA-UE), Wolf Motor Function Test (WMFT), Action Research Arm Test (ARAT) and Box and Block Test (BBT), which are validated measures of upper limb function.

Results

Twenty-one studies involving 842 subjects with stroke were included. Compared with UULT, BULT yielded a significantly greater mean difference (MD) in the FMA-UE (MD = 2.21, 95% Confidence Interval (CI), 0.12 to 4.30, p = 0.04; I² = 86%, p<0.001). However, a comparison of BULT and UULT yielded insignificant mean difference (MD) in terms of the time required to complete the WMFT (MD = 0.44; 95%CI, -2.22 to 3.10, p = 0.75; I² = 55%, p = 0.06) and standard mean difference (SMD) in terms of the functional ability scores on the WMFT, ARAT and BBT (SMD = 0.25; 95%CI, -0.02 to 0.52, p = 0.07; I² = 54%, p = 0.02).

Discussion and implications

Compared to UULT, BULT yielded superior improvements in the improving motor impairment of people with stroke, as measured by the FMA-UE. However, these strategies did not yield significant differences in terms of the functional performance of people with stroke, as measured by the WMFT, ARAT and BBT. More comparative studies of the effects of BULT and UULT are needed to increase the reliability of these conclusions.

"I'm just not a Sudoku person": analysis of stroke survivor, carer, and healthcare professional perspectives for the design of a cognitive rehabilitation intervention

Purpose: Exploring the views of those impacted by stroke is key to the design of an effective and appropriate cognitive rehabilitation intervention for post-stroke cognitive impairment. This qualitative study examined the perspectives and preferences of stroke survivors, carers, and healthcare professionals to inform the design of a cognitive rehabilitation intervention.Design and methods: The research employed a qualitative study design and thematic analysis of data. In-depth semi-structured interviews were conducted with stroke survivors (n = 14), carers (n = 11), and healthcare professionals involved in providing stroke care (n = 19). Interviews were audio-recorded and transcribed. Coding was conducted and themes were developed both inductively and deductively.Results: Themes address five broad areas relevant for the design and implementation of the intervention: (i) activities to include; (ii) when it takes place; (iii) location; (vi) format; (v) who the intervention should include.Conclusions: Qualitative work with stroke survivors, carers and healthcare professionals provided vital information for the intervention design. Issues identified by participants as being key to intervention development included: (i) implications of post-stroke cognitive impairment survivors' confidence; (ii) their individual capacity in terms of fatigue and metacognition; and (iii) practical issues such as intervention location. The inclusion of psychoeducation regarding consequences of stroke was recommended.Implications for rehabilitationStroke survivors, carers, and rehabilitation professionals who provide stroke care can provide valuable insights and ideas to inform the development of a cognitive rehabilitation intervention.A cognitive rehabilitation intervention should be tailored to patient-specified goals, incorporating both group and individualized activities.Information, education, and communication are required to help stroke survivors and carers understand the cognitive, emotional, and behavioral consequences of stroke.Intervention content should be considerate of stroke survivors' capacity in terms of cognitive impairment and fatigue levels.

Effects of task-oriented training on upper extremity functional performance in patients with sub-acute stroke: a randomized controlled trial

[Purpose] The present study aimed to determine the effects of a task-oriented training on paretic upper extremity functional performance in patients with subacute stroke. [Participants and Methods] Twenty-eight subacute stroke sufferers (mean age: 50.07, standard deviation 9.31 years; mean time since stroke 11.11, standard deviation 6.73 weeks) were randomly allocated to task-oriented training (n=14) or conventional exercise program (n=14) group. They were trained as a hospital-based, individualized training 1 hour a session, 5 sessions a week for 4 weeks. Wolf Motor Function Test (primary outcome), motor portion of Fugl-Meyer assessment upper extremity, and hand function domain of Stroke Impact Scale were assessed at baseline, after 2 and 4 weeks of training. [Results] All participants completed their training programs. At all post-training assessments, the task-oriented training group showed significantly more improvements in all outcomes than the conventional exercise program group. No serious adverse effects were observed during or after the training. [Conclusion] Task-oriented training produced statistically significant and clinically meaningful improvements of paretic upper extremity functional performance in patients with subacute stroke. These beneficial effects were observed after 2 weeks (10 hours) of training. Future investigation is warranted to confirm and expand these findings.

Declines in motor transfer following upper extremity task-specific training in older adults

BACKGROUND

Age-related declines in function can limit older adults' independence with activities of daily living (ADLs). While task-specific training maybe a viable approach to improve function, limited clinical resources prevent extensive training on wide ranges of skills and contexts. Thus, training on one task for the benefit of another (i.e., transfer) is important in geriatric physical rehabilitation. The purpose of this study was to test whether motor transfer would occur between two functionally different upper extremity tasks that simulate ADLs in a sample of older adults following task-specific training.

METHODS

Ninety community dwelling adults ages 43 to 94 years old performed two trials of a functional dexterity and functional reaching task at baseline, and were then assigned to one of two groups. The training group completed 3 days of task-specific training (150 trials) on the functional reaching task, whereas the no-training group received no training on either task. Both groups were re-tested on both tasks at the end of Day 3.

RESULTS

No significant interactions were observed between group (training vs. no-training) and time (baseline vs. re-test) on the functional dexterity task (i.e. transfer task), indicating no difference in the average amount of change from baseline to re-test between the groups. However, post hoc bivariate linear regression revealed an effect of age on motor transfer within the training group. For those who trained on the functional reaching task, the amount of transfer to the dexterity task was inversely related to age. There was no significant relationship between age and motor transfer for the no-training group.

DISCUSSION AND CONCLUSIONS

Results of our a priori group analysis suggest that functional reaching training did not, on average, transfer to the dexterity task. However, post hoc regression analysis showed that motor transfer was both experience- and age-dependent, such that motor transfer may decline with advanced age. Future research will consider how functional and cognitive aging influences transfer of motor skills across different activities of daily living.

A systematic review of physical rehabilitation interventions for stroke in low and lower-middle income countries

Purpose: Approximately 70% of strokes occur in low and middle income countries, yet the effectiveness of physical rehabilitation in these contexts remains undetermined. This systematic review identifies and summarises the current evidence supporting physical rehabilitation interventions post-stroke in low and lower-middle income countries.Methods: Five databases were comprehensively searched (April 2017) for randomised controlled trials, clinical controlled trials, and cohort studies testing rehabilitation interventions post-stroke in these countries. The Effective Public Health Practice Project Tool assessed quality of included studies.Results: Sixty-two studies (2115 participants) were included. Interventions addressed upper limb (n = 26), lower limb (n = 22), and other (n = 14) outcomes. Seven studies were rated as strong in quality, 16 moderate and 39 rated as weak. Overall, in addition to usual care, physical rehabilitation interventions improved outcomes for stroke survivors. Best evidence synthesis provides level I (b) evidence supporting constraint induced movement therapy and mirror therapy to improve upper limb functional outcomes. Level I (b) evidence supports multimodal interventions that include lower limb motor imagery to improve gait parameters. Level II (b) evidence supports sit-to-stand training to improve balance outcomes.Conclusions: Exercise-based and brain training interventions improved functional outcomes post-stroke in low and lower-middle income countries. Further high-quality studies including participation outcomes are required.Implications for RehabilitationLow-cost physical rehabilitation interventions requiring minimal resources can improve functional outcomes after stroke in low and lower-middle income countries.Exercise-based interventions can improve upper limb, lower limb, gait, and balance outcomes after stroke.Brain training paradigms such as mirror therapy and motor imagery, when included in therapy packages, can improve upper limb and gait outcomes.The proven efficacy for rehabilitation interventions in improving stroke outcomes in low and lower-middle income countries supports the need to strengthen the rehabilitation workforce in this context.

Practice Variability Combined with Task-Oriented Electromyographic Biofeedback Enhances Strength and Balance in People with Chronic Stroke

Objectives

To investigate the effects of practice variability combined with task-oriented electromyographic biofeedback (EMGBFB) on strength and balance in people with chronic stroke.

Methods

Thirty-three participants were randomly assigned into the constant force EMGBFB tibialis anterior (TA) exercise (constant) group, the variable force EMGBFB tibialis anterior exercise (variable) group, or the upper extremity exercise without EMGBFB (control) group. Subjects in each group received 6 weekly sessions of exercise training (18 sessions, 40 minutes each). Motor outcomes were TA strength, balance (anteroposterior sway amplitude defined by limits of stability test in dynamic posturography), walking speed, Timed Up and Go test (TUGT), and six-minute walk test (6MWT). Data were measured at baseline, 1 day, 2 weeks, and 6 weeks posttraining.

Results

TA strength increased significantly in both the constant and variable groups after training. Balance significantly improved only in the variable group. All participants showed improvements in walking speed, TUGT, and 6MWT.

Conclusions

Task-oriented EMGBFB-assisted TA exercise training improved muscle strength in people with chronic stroke. Practicing to reach varying force levels during EMGBFB-assisted tibialis anterior exercises facilitated improvements in the ability to sway in the anteroposterior direction while standing. Our findings highlight the importance of task-oriented and motor learning principles while using the EMGBFB as an adjunct therapy in stroke rehabilitation. This trial was registered with trial registration number NCT01962662.

The Effects of Task-Oriented Circuit Training Using Rehabilitation Tools on the Upper-Extremity Functions and Daily Activities of Patients with Acute Stroke: A Randomized Controlled Pilot Trial

Objectives

The purpose of this study was to investigate the effect of task-oriented circuit training (TOCT) using the rehabilitation tools for upper extremity function upon the daily life of patients with acute stroke.

Methods

Eighteen patients with acute stroke were randomly allocated into either the experimental group or the control group. The experimental group performed the TOCT program using rehabilitation tools, whilst the control group had neuro-developmental treatment. Both groups received 30 minutes of treatment per session, 5~6 times per week, for 4 weeks. The assessments conducted were the Fugl-Meyer assessment, motor activity log and stroke impact scale to compare the upper extremity function and activities of daily living.

Results

The results showed a significant improvement in the TOCT group compared with the neuro-developmental treatment group in the amount of motor activity use and high stroke impact score, indicating recovery (p < 0.05).

Conclusion

The TOCT program using rehabilitation tools could have a positive impact on acute stroke patients use of their upper extremity.

Rehabilitation Strategies Following Surgical Treatment of Upper Extremity Spasticity

Upper motor neuron injuries that occur in cases such as cerebral palsy, cerebrovascular accidents, and traumatic brain injury often have resulting upper extremity deformity and dysfunction. Multiple surgical options are available to improve upper extremity positioning, and, in some cases, motor control. Postoperative therapeutic management is imperative to assist the patient/caregiver in maximizing potential functional gains. This article provides an overview of postoperative guidelines for commonly performed surgeries to manage upper extremity dysfunction caused by spasticity and discusses acute management as well as therapeutic techniques for functional training and improved motor control.

Effectiveness and Superiority of Rehabilitative Treatments in Enhancing Motor Recovery Within 6 Months Poststroke: A Systemic Review

OBJECTIVE

To investigate the effects of various rehabilitative interventions aimed at enhancing poststroke motor recovery by assessing their effectiveness when compared with no treatment or placebo and their superiority when compared with conventional training program (CTP).

DATA SOURCE

A literature search was based on 19 Cochrane reviews and 26 other reviews. We also updated the searches in PubMed up to September 30, 2017.

STUDY SELECTION

Randomized controlled trials associated with 18 experimented training programs (ETP) were included if they evaluated the effects of the programs on either upper extremity (UE) or lower extremity (LE) motor recovery among adults within 6 months poststroke; included ≥10 participants in each arm; and had an intervention duration of ≥10 consecutive weekdays.

DATA EXTRACTION

Four reviewers evaluated the eligibility and quality of literature. Methodological quality was assessed using the PEDro scale.

DATA SYNTHESIS

Among the 178 included studies, 129 including 7450 participants were analyzed in this meta-analysis. Six ETPs were significantly effective in enhancing UE motor recovery, with the standard mean differences (SMDs) and 95% confidence intervals outlined as follow: constraint-induced movement therapy (0.82, 0.45-1.19), electrostimulation (ES)-motor (0.42, 0.22-0.63), mirror therapy (0.71, 0.22-1.20), mixed approach (0.21, 0.01-0.41), robot-assisted training (0.51, 0.22-0.80), and task-oriented training (0.57, 0.16-0.99). Six ETPs were significantly effective in enhancing LE motor recovery: body-weight-supported treadmill training (0.27, 0.01-0.52), caregiver-mediated training (0.64, 0.20-1.08), ES-motor (0.55, 0.27-0.83), mixed approach (0.35, 0.15-0.54), mirror therapy (0.56, 0.13-1.00), and virtual reality (0.60, 0.15-1.05). However, compared with CTPs, almost none of the ETPs exhibited significant SMDs for superiority.

CONCLUSIONS

Certain experimented interventions were effective in enhancing poststroke motor recovery, but little evidence supported the superiority of experimented interventions over conventional rehabilitation.

Effect of Gravity and Task Specific Training of Elbow Extensors on Upper Extremity Function after Stroke

BACKGROUND

In individuals with hemiparetic stroke, reaching with the paretic arm can be impaired by abnormal muscle coactivation. Prior trails for improving upper extremity functions after stroke have underestimated the role of gravitational force in motor planning and execution.

OBJECTIVE

The aims this trial were to study the effect of gravity as a facilitator for elbow extension and to estimate the immediate and retention effects of task specific training of elbow extensors on upper extremity function after stroke.

METHODS

Twenty-six right handed patients with first ever stroke represented the sample of the study. The participants were randomly assigned into two equal groups. The study group received treatment through two phases. Phase one included training for the elbow extensors in an antigravity position. Phase two included a set of task specific exercise for 16 weeks. The control group received traditional passive stretch and range of motion exercises. Manual dexterity and upper limb function were assessed by Nine-Hole Peg Test and Fugl-Meyer upper extremity. Goniometry was used for measuring elbow extension and forearm supination active ranges of motion.

RESULTS

Significant improvements were observed in Nine-Hole Peg Test, Fugl-Meyer upper extremity, and ranges of motion at postintervention and follow-up compared to preintervention at P≤0.05.

CONCLUSIONS

The results of this study provide an evidence that antigravity positions can be used as a centrally presented facilitator of elbow extension. Additionally, task specific training was effective in improving upper extremity function and elbow extension range of motion.

Effects of a 12-month task-specific balance training on the balance status of stroke survivors with and without cognitive impairments in Selected Hospitals in Nnewi, Anambra State, Nigeria

BACKGROUND

Stroke results in varying levels of physical disabilities that may adversely impact balance with increased tendency to falls. This may intensify with cognitive impairments (CI), and impede functional recovery. Therefore, task-specific balance training (TSBT), which presents versatile task-specific training options that matches varied individual needs, was explored as a beneficial rehabilitation regime for stroke survivors with and without CI. It was hypothesized that there will be no significant difference in the balance control measures in stroke survivors with and without CI after a 12-month TSBT.

OBJECTIVE

To determine if TSBT will have comparable beneficial effects on the balance control status of sub-acute ischemic stroke survivors with CI and without CI.

METHODS

One hundred of 143 available sub-acute first ever ischemic stroke survivors were recruited using convenience sampling technique in a quasi-experimental study. They were later assigned into the cognitive impaired group (CIG) and non-cognitive impaired group (NCIG), respectively, based on the baseline presence or absence of CI, after screening with the mini-mental examination (MMSE) tool. With the help of four trained research assistants, TSBT was applied to each group, thrice times a week, 60 mins per session, for 12 months. Their balance was measured as Bergs Balance scores (BBS) at baseline, 4th, 8th, and 12th month intervals. Data were analyzed statistically using Kruskal Wallis test, and repeated measure ANOVA, at p < 0.05.

RESULTS

There was significant improvement across time points in the balance control of CIG with large effect size of 0.69 after 12 months of TSBT. There was also significant improvement across time points in the balance control of NCIG with large effect size of 0.544 after 12 months of TSBT. There was no significant difference between the improvement in CIG and NCIG after 8th and 12th months of TSBT.

CONCLUSIONS

Within the groups, a 12-month TSBT intervention significantly improved balance control, respectively, but with broader effects in the CIG than NCIG. Importantly, though between-group comparison at baseline revealed significantly impaired balance control in the CIG than NCIG, these differences were not significant at the 8th month and non-existent at the 12th month of TSBT intervention. These results underscore the robustness of TSBT to evenly address specific balance deficits of stroke survivors with and without CI within a long-term rehabilitation plan as was hypothesized.

Mobile Game-based Virtual Reality Program for Upper Extremity Stroke Rehabilitation

Stroke rehabilitation requires repetitive, intensive, goal-oriented therapy. Virtual reality (VR) has the potential to satisfy these requirements. Game-based therapy can promote patients' engagement in rehabilitation therapy as a more interesting and a motivating tool. Mobile devices such as smartphones and tablet PCs can provide personalized home-based therapy with interactive communication between patients and clinicians. In this study, a mobile VR upper extremity rehabilitation program using game applications was developed. The findings from the study show that the mobile game-based VR program effectively promotes upper extremity recovery in patients with stroke. In addition, patients completed two weeks of treatment using the program without adverse effects and were generally satisfied with the program. This mobile game-based VR upper extremity rehabilitation program can substitute for some parts of the conventional therapy that are delivered one-on-one by an occupational therapist. This time-efficient, easy to implement, and clinically effective program would be a good candidate tool for tele-rehabilitation for upper extremity recovery in patients with stroke. Patients and therapists can collaborate remotely through these e-health rehabilitation programs while reducing economic and social costs.

Mirror Therapy and Task-Oriented Training for People With a Paretic Upper Extremity

OBJECTIVE

This study investigates the effect of mirror therapy and task-oriented training on the paretic upper extremity function and occupational performance of people with stroke.

METHOD

This study used a repeated-measures, case-series design in which 4 participants completed a 4-wk intervention consisting of mirror therapy and task-specific training. The intervention was conducted 2×/wk in the clinic and 4×/wk at home.

RESULTS

All participants displayed clinically meaningful improvements in self-identified goals at the end of the intervention and at follow-up. Three participants showed clinically meaningful changes in motor function. Although only 1 participant improved in his reported amount of use, all participants showed clinically meaningful improvements in perceived movement quality at varying points of assessment.

CONCLUSION

Mirror therapy, when used as priming for task-oriented training, can produce clinical improvements in upper extremity function and occupational performance in people with hemiparesis.

Mobile game-based virtual reality rehabilitation program for upper limb dysfunction after ischemic stroke

BACKGROUND

Virtual reality (VR) has the potential to provide intensive, repetitive, and task-oriented training, and game-based therapy can enhance patients' motivation and enjoyment.

OBJECTIVE

The objective of the present study was to develop a mobile game-based upper extremity VR program for patients who have experienced stroke, and to evaluate the feasibility and effectiveness of the program.

METHODS

This randomized, double-blind, controlled trial included 24 patients with ischemic stroke. The intervention group (n = 12) received 30 min of conventional occupational therapy (OT) and 30 min of the mobile upper extremity rehabilitation program using a smartphone and a tablet PC (MoU-Rehab). The controls (n = 12) received conventional OT alone for 1 h per day. Rehabilitation consisted of 10 sessions of therapy, 5 days per week, for 2 weeks. The outcome measures (Fugl-Meyer Assessment of the upper extremity [FMA-UE], Brunnström stage [B-stage] for the arm and the hand, manual muscle testing [MMT], modified Barthel index [MBI], EuroQol-5 Dimension [EQ-5D], and Beck Depression Inventory [BDI]) were assessed at the beginning and end of treatment, and at 1 month. User satisfaction was evaluated by a questionnaire.

RESULTS

A greater improvement in the FMA-UE, B-stage, and MMT was found after treatment with the MoU-Rehab than with conventional therapy. The extent of improvements in the MBI, EQ-5D, and BDI was not significantly different between the two groups. Patients in the experimental group completed the 2-weeks treatment without adverse effects, and they were generally satisfied with MoU-Rehab.

CONCLUSION

This mobile game-based VR rehabilitation program appears to be feasible and effective for promoting upper limb recovery after ischemic stroke.