Repeated measurements of arm joint passive range of motion after stroke: interobserver reliability and sources of variation

Speed-dependent changes in the arm swing during independent walking in individuals after stroke

BACKGROUND

Increasing one's walking speed is an important goal in post-stroke gait rehabilitation. Insufficient arm swing in people post-stroke might limit their ability to propel the body forward and increase walking speed.

PURPOSE

To investigate the speed-dependent changes (and their contributing factors) in the arm swing of persons post-stroke.

MATERIAL AND METHODS

Twenty-five persons post-stroke (53±12.1 years; 40.72±43.0 months post-stroke) walked on a treadmill at comfortable (0.83m/s) and fast (1.01m/s) speed. Shoulder and elbow kinematics were compared between conditions using Statistical Parametric Mapping (SPM) analysis, and discrete parameters using a Wilcoxon signed-rank test or an independent sample t-test. The relations between speed-dependent changes in shoulder and elbow range of motion and clinical and gait parameters were assessed using Spearman correlation coefficients.

RESULTS

The non-paretic arm showed expected speed-dependent kinematic adaptations with increases in active range of motion for shoulder flexion (p<0.001), extension (p<0.05), abduction (p = 0.001), rotation (p = 0.004) and elbow flexion (p<0.001). The paretic arm only showed an increase in shoulder abduction and elbow flexion (both p<0.001). Persons post-stroke with a more impaired arm swing coordination pattern only showed speed-dependent adaptations for elbow flexion (p<0.001) at the paretic side during fast walking. In contrast, persons post-stroke with a normal arm swing coordination pattern presented with increases in active range of motion of the shoulder abduction and elbow flexion (both p<0.001) at the paretic side when walking fast. More upper limb impairment (r = -0.521, p<0.01) and a wider step width (r = 0.534, p<0.01) were related to a larger increase in mean elbow flexion during faster walking.

CONCLUSIONS

Persons post-stroke show different changes in arm swing kinematics at the paretic compared to the non-paretic side when increasing walking speed. The changes are related to the impairment level and stability during walking, indicating that therapeutic interventions aiming to increase walking speed by improving arm swing might need to target these factors.

Assistive technologies, including orthotic devices, for the management of contractures in adults after a stroke

BACKGROUND

Contractures (reduced range of motion and increased stiffness of a joint) are a frequent complication of stroke. Contractures can interfere with function and cause cosmetic and hygiene problems. Preventing and managing contractures might improve rehabilitation and recovery after stroke.

OBJECTIVES

To assess the effects of assistive technologies for the management of contractures in adults after a stroke.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases, and three trials registers in May 2022. We also searched for reference lists of relevant studies, contacted experts in the field, and ran forward citation searches.

SELECTION CRITERIA

Randomised controlled studies (RCTs) that used electrical, mechanical, or electromechanical devices to manage contractures in adults with stroke were eligible for inclusion in this review. We planned to include studies that compared assistive technologies against no treatment, routine therapy, or another assistive technology.

DATA COLLECTION AND ANALYSIS

Three review authors (working in pairs) selected all studies, extracted data, and assessed risk of bias. The primary outcomes were passive joint range of motion (PROM) with and without standardised force, and indirect measures of PROM. The secondary outcomes included hygiene. We also wanted to evaluate the adverse effects of assistive technology. Effects were expressed as mean differences (MDs) or standardised mean differences (SMDs) with 95% confidence intervals (CIs).

MAIN RESULTS

Seven studies fulfilled the inclusion criteria. Five of these were meta-analysed; they included 252 adults treated in acute and subacute rehabilitation settings. All studies compared assistive technology with routine therapy; one study also compared assistive technology with no treatment, but we were unable to obtain separate data for stroke participants. The assistive technologies used in the studies were electrical stimulation, splinting, positioning using a hinged board, and active repetitive motor training using a non-robotic device with electrical stimulation. Only one study applied stretching to end range. Treatment duration ranged from four to 12 weeks. The overall risk of bias was high for all studies. We are uncertain whether: • electrical stimulation to wrist extensors improves passive range of wrist extension (MD -7.30°, 95% CI -18.26° to 3.66°; 1 study, 81 participants; very low-certainty evidence); • a non-robotic device with electrical stimulation to shoulder flexors improves passive range of shoulder flexion (MD -9.00°, 95% CI -25.71° to 7.71°; 1 study; 50 participants; very low-certainty evidence); • assistive technology improves passive range of wrist extension with standardised force (SMD -0.05, 95% CI -0.39 to 0.29; four studies, 145 participants; very low-certainty evidence): • a non-robotic device with electrical stimulation to elbow extensors improves passive range of elbow extension (MD 0.41°, 95% CI -0.15° to 0.97°; 1 study, 50 participants; very low-certainty evidence). One study reported the adverse outcome of pain when using a hinged board to apply stretch to wrist and finger flexors, and another study reported skin breakdown when using a thumb splint. No studies reported hygiene or indirect measures of PROM.

AUTHORS' CONCLUSIONS

Only seven small RCTs met the eligibility criteria of this review, and all provided very low-certainty evidence. Consequently, we cannot draw firm conclusions on the effects of assistive technology compared with routine therapy or no therapy. It was also difficult to confirm whether there is a risk of harm associated with treatment using assistive technology. Future studies should apply adequate treatment intensity (i.e. magnitude and the duration of stretch) and use valid and reliable outcome measures. Such studies might better identify the role of assistive technology in the management of contractures in adults after a stroke.

Dry needling combined with exercise therapy: Effects on wrist flexors spasticity in post-stroke patients - A randomized controlled trial

BACKGROUND

The positive contribution of dry needling (DN) in conjunction with exercise therapy for patients with stroke and spasticity remains uncertain.

OBJECTIVE

To examine the effects of DN combined with exercise therapy on wrist flexor spasticity and motor function in patients with stroke.

METHODS

Twenty-four participants with stroke were randomly assigned to either the DN and exercise therapy group or the DN alone group. Assessments were conducted at baseline, after the 4th treatment session, and 3 weeks post-treatment.

RESULTS

A significant Group×Time interaction was observed for wrist active range of motion (ROM) (P = 0.046), favoring the DN with exercise therapy group (∼10° at baseline, ∼15° immediately after the 4th session, and 15.4° at follow-up). The improvements in spasticity, passive ROM, and H-reflex latency were sustained during follow-up. However, there were no significant between-group differences in any outcome at any measurement time point.

CONCLUSION

The combined DN and exercise therapy did not exhibit superiority over DN alone concerning spasticity severity and motor function. However, it demonstrated additional advantages, particularly in improving motor neuron excitability and wrist passive extension.

Validity and reliability of a smartphone inclinometer app for measuring passive upper limb range of motion in a stroke population

Purpose: To demonstrate the validity and reliability of a smartphone app to measure ROM after stroke.Materials and methods: Twenty-one stroke survivors with a diagnosis of stroke that affected the motor cortex or subcortical motor pathways and were hospital inpatients at one of two metropolitan hospitals were recruited. A within-session test-retest design was used to compare ROM measurements taken using the GetMyROM app for iPhone to those taken by a digital inclinometer. Torque-controlled passive elbow and wrist extension were collected and statistical analysis of concurrent validity and test-retest reliability performed.Results: GetMyROM app was valid when compared to the digital inclinometer for measuring passive ROM of the elbow (r = .98, p = .0001, ICC  =  0.97) and wrist (r = .97, p = .0001, ICC  =  0.96) in individuals with acute stroke. Both the GetMyROM app and inclinometer demonstrated excellent test-retest reliability: ICC values are 0.84 to 0.93, and standard error of measurement between 6° to 10°.Conclusion: The GetMyROM app may be implemented in a clinical setting similar to that where the study was conducted, enabling rehabilitation physicians and therapists to use a smartphone to take precise measurements of ROM in daily clinical practice.Implications for rehabilitationApproximately half of all stroke survivors experience reduced passive upper limb range of movement.Accurate measurement of passive upper limb range of movement using validated assessments and/or instruments is paramount.This study demonstrates that the GetMyROM app is valid and reliable compared to the gold standard comparison (digital inclinometer), and is therefore appropriate to use in clinical settings to take precise measurements.

Passive range of motion in patients with adhesive shoulder capsulitis, an intertester reliability study over eight weeks

BACKGROUND

Measuring range of motion (ROM) in the shoulder joint is important for the diagnosis and monitoring of change over time. To what degree passive ROM can be trusted as a reliable outcome measure was examined as part of an on-going randomized controlled trial for patients with shoulder capsulitis. The aim of this study was to examine intertester reliability of passive ROM in the shoulder joint over a period of eight weeks in patients with adhesive capsulitis stage II.

METHODS

Fifty patients with a clinical diagnosis of adhesive shoulder capsulitis were examined by two independent testers. A predefined protocol was used for measuring passive range of motion with an inclinometer, a plurimeter, in both affected and non-affected shoulders three times; at the start of the study and after 4 and 8 weeks.

RESULTS

Very good to excellent intertester agreements were found for most parameters for the affected arm at all three test points. The intraclass correlation coefficient (ICC 2.1) values ranged from 0.76 to 0.98, i.e. from very reliable to excellent. The measurement error was in general small for the affected arm (5°-7°). ICCs were slightly lower for the non-affected arm at 8 weeks, but with acceptable measurement errors.

CONCLUSIONS

Intertester reliability between two testers was very good at three visits over a time period of eight weeks using a plurimeter to measure passive range of motion in patients with adhesive shoulder capsulitis. This method can reliably determine passive range of motion in this patient population and be a reliable outcome measure.

Bilateral priming before wii-based movement therapy enhances upper limb rehabilitation and its retention after stroke: a case-controlled study

BACKGROUND

Motor deficits after a stroke are thought to be compounded by the development of asymmetric interhemispheric inhibition. Bilateral priming was developed to rebalance this asymmetry and thus improve therapy efficacy.

OBJECTIVE

This study investigated the effect of bilateral priming before Wii-based Movement Therapy to improve rehabilitation after stroke.

METHODS

Ten patients who had suffered a stroke (age, 23-77 years; 3-123 months after stroke) underwent a 14-day program of Wii-based Movement Therapy for upper limb rehabilitation. Formal Wii-based Movement Therapy sessions were immediately preceded by 15 minutes of bilateral priming, whereby active flexion-extension of the less affected wrist drove mirror-symmetric passive movements of the more affected wrist through a custom device. Functional movement was assessed at weeks 0 (before therapy), 3 (after therapy), and 28 (follow-up) using the Wolf Motor Function Test (WMFT), upper limb Fugl-Meyer Assessment (FMA), upper limb range of motion, and Motor Activity Log (MAL). Case-matched controls were patients who had suffered a stroke who received Wii-based Movement Therapy but not bilateral priming.

RESULTS

Upper limb functional ability improved for both groups on all measures tested. Posttherapy improvement on the FMA for primed patients was twice that of the unprimed patients (37.3% vs 14.6%, respectively) and was significantly better maintained at 28 weeks (P = .02). Improvements on the WMFT and MAL were similar for both groups, but the pattern of change in range of motion was strikingly different.

CONCLUSIONS

Bilateral priming before Wii-based Movement Therapy led to a greater magnitude and retention of improvement compared to control, especially measured with the FMA. These data suggest that bilateral priming can enhance the efficacy of Wii-based Movement Therapy, particularly for patients with low motor function after a stroke.

Combined arm stretch positioning and neuromuscular electrical stimulation during rehabilitation does not improve range of motion, shoulder pain or function in patients after stroke: a randomised trial

QUESTION

Does static stretch positioning combined with simultaneous neuromuscular electrical stimulation (NMES) in the subacute phase after stroke have beneficial effects on basic arm body functions and activities?

DESIGN

Multicentre randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis.

PARTICIPANTS

Forty-six people in the subacute phase after stroke with severe arm motor deficits (initial Fugl-Meyer Assessment arm score ≤ 18).

INTERVENTION

In addition to conventional stroke rehabilitation, participants in the experimental group received arm stretch positioning combined with motor amplitude NMES for two 45-minute sessions a day, five days a week, for eight weeks. Control participants received sham arm positioning (ie, no stretch) and sham NMES (ie, transcutaneous electrical nerve stimulation with no motor effect) to the forearm only, at a similar frequency and duration.

OUTCOME MEASURES

The primary outcome measures were passive range of arm motion and the presence of pain in the hemiplegic shoulder. Secondary outcome measures were severity of shoulder pain, restrictions in performance of activities of daily living, hypertonia, spasticity, motor control and shoulder subluxation. Outcomes were assessed at baseline, mid-treatment, at the end of the treatment period (8 weeks) and at follow-up (20 weeks).

RESULTS

Multilevel regression analysis showed no significant group effects nor significant time × group interactions on any of the passive range of arm motions. The relative risk of shoulder pain in the experimental group was non-significant at 1.44 (95% CI 0.80 to 2.62).

CONCLUSION

In people with poor arm motor control in the subacute phase after stroke, static stretch positioning combined with simultaneous NMES has no statistically significant effects on range of motion, shoulder pain, basic arm function, or activities of daily living.

TRIAL REGISTRATION

NTR1748.