Bilateral versus unilateral upper limb training in (sub)acute stroke: A systematic and meta-analysis

Background

Integrating high dosage bilateral movements to improve upper limb (UL) recovery after stroke is a rehabilitation strategy that could potentially improve bimanual activities.

Objectives

This study aims to compare the effects of bilateral with unilateral UL training on upper limb impairments and functional independence in (sub)acute stroke.

Method

Five electronic databases (PubMed, Scopus, PEDro, ScienceDirect, Web of Science) were systematically searched from inception to June 2023. Randomised controlled trials comparing the effect of bilateral training to unilateral training in stroke survivors (< 6 months poststroke) were included. The treatment effect was computed by the standard mean differences (SMDs).

Results

The review included 14 studies involving 706 participants. Bilateral training yielded a significant improvement on UL impairments measured by FMA-UE compared to unilateral training (SMD = 0.48; 95% CI: 0.08 to 0.88; P = 0.02). In addition, subgroup analysis based on the severity of UL impairments reported significant results in favour of bilateral UL training in improving UL impairments compared to unilateral training in "no motor capacity" patients (SMD = 0.66; 95% CI: 0.16 to 1.15; P = 0.009). Furthermore, a significant difference was observed in favour of bilateral UL training compared to unilateral UL training on daily activities measured by Functional Independence Measure (SMD = 0.45; 0.13 to 0.78; P = 0.006).

Conclusion

Bilateral UL training was superior to unilateral training in improving impairments measured by FMA-UE and functional independence in daily activities measured by Functional Independence Measure in (sub)acute stroke.

Clinical implications

Bilateral upper limb training promotes recovery of impairments and daily activities in (sub)acute phase of stroke.

Auditory attention measured by EEG in neurological populations: systematic review of literature and meta-analysis

Sensorimotor synchronization strategies have been frequently used for gait rehabilitation in different neurological populations. Despite these positive effects on gait, attentional processes required to dynamically attend to the auditory stimuli needs elaboration. Here, we investigate auditory attention in neurological populations compared to healthy controls quantified by EEG recordings. Literature was systematically searched in databases PubMed and Web of Science. Inclusion criteria were investigation of auditory attention quantified by EEG recordings in neurological populations in cross-sectional studies. In total, 35 studies were included, including participants with Parkinson's disease (PD), stroke, Traumatic Brain Injury (TBI), Multiple Sclerosis (MS), Amyotrophic Lateral Sclerosis (ALS). A meta-analysis was performed on P3 amplitude and latency separately to look at the differences between neurological populations and healthy controls in terms of P3 amplitude and latency. Overall, neurological populations showed impairments in auditory processing in terms of magnitude and delay compared to healthy controls. Consideration of individual auditory processes and thereafter selecting and/or designing the auditory structure during sensorimotor synchronization paradigms in neurological physical rehabilitation is recommended.

Physiotherapy practices in acute and sub-acute stroke in a low resource country: A prospective observational study in Benin

BACKGROUND AND OBJECTIVE

Physiotherapy is highly recommended for early recovery from stroke. This study aimed to document physiotherapy practices for people with acute and early sub-acute stroke in Benin.

METHODS

In this prospective observational study, physiotherapists working with acute stroke people documented the content of their treatment from six hospitals in Benin during the first session, at 2-week, and 1-month post-stroke with a standardized physiotherapy documentation form. We used the motricity index (MI) and trunk control test (TCT) to assess impairments, and the 10-meter walk test (10mWT), functional independence measure (FIM), walking, stair climbing, and dressing upper body subscales were used for activity limitations.

RESULTS

Fifteen physiotherapists (60 % male, mean±SD age=31.3±5.8 years) recorded treatment sessions for 77 stroke participants (53.2 % male, mean±SD age=57.7±12.5 years). Physiotherapists focused on conventional physiotherapy approaches, including musculoskeletal (67 % of pre-functional activity time) and neuromuscular (53 % of sitting activity time) interventions. A significant difference was found between the therapy time delivered for people with mild, moderate, and severe stroke (p < 0.001). The MI (p= 0.033) and TCT (p= 0.002) measures showed significant improvement at 2-week and 1-month (p< 0.001) post-stroke, while 10mWT, FIM walking, stair climbing, and dressing upper body items significantly increased at 1-month (p< 0.001) but not at 2-week post-stroke.

CONCLUSION

Physiotherapists working with acute stroke patients in Benin mainly use conventional neuromuscular and musculoskeletal interventions. In contrast, aerobic exercises were rarely employed regardless of stroke severity. Furthermore, our findings showed that the volume of physiotherapy sessions varied by stroke severity.

The Place of Botulinum Toxin in Spastic Hemiplegic Shoulder Pain after Stroke: A Scoping Review

Stroke is a common pathology worldwide, with an age-standardized global rate of new strokes of 150.5 per 100,000 population in 2017. Stroke causes upper motor neuron impairment leading to a spectrum of muscle weakness around the shoulder joint, changes in muscle tone, and subsequent soft tissue changes. Hemiplegic shoulder pain (HSP) is the most common pain condition in stroke patients and one of the four most common medical complications after stroke. The importance of the appropriate positioning and handling of the hemiplegic shoulder for prevention of HSP is therefore of high clinical relevance. Nevertheless, HSP remains a frequent and disabling problem after stroke, with a 1-year prevalence rate up to 39%. Furthermore, the severity of the motor impairment is one of the most important identified risk factors for HSP in literature. Spasticity is one of these motor impairments that is likely to be modifiable. After ruling out or treating other shoulder pathologies, spasticity must be assessed and treated because it could lead to a cascade of unwanted complications, including spastic HSP. In clinical practice, Botulinum toxin A (BTA) is regarded as the first-choice treatment of focal spasticity in the upper limb, as it gives the opportunity to target specifically selected muscles. It thereby provides the possibility of a unique patient tailored focal and reversible treatment for post stroke spasticity. This scoping review aims to summarize the current evidence of BTA treatment for spastic HSP. First, the clinical manifestation and outcome measures of spastic HSP will be addressed, and second the current evidence of BTA treatment of spastic HSP will be reviewed. We also go in-depth into the elements of BTA application that may optimize the therapeutic effect of BTA. Finally, future considerations for the use of BTA for spastic HSP in clinical practice and research settings will be discussed.

Physical Activity Level, Barriers, and Facilitators for Exercise Engagement for Chronic Community-Dwelling Stroke Survivors in Low-Income Settings: A Cross-Sectional Study in Benin

After a stroke incident, physical inactivity is common. People with stroke may perceive several barriers to performing physical activity (PA). This study aimed to document the PA level and understand the barriers and facilitators to engaging in PA for community-dwelling stroke survivors in Benin, a lower middle-income country. A cross-sectional study was conducted in three hospitals in Benin. Levels of PA were recorded by means of the Benin version of the International Physical Activity Questionnaire long form (IPAQ-LF-Benin), which is validated for stroke survivors in Benin. The perceived exercise facilitators and barriers were assessed by the Stroke Exercise Preference Inventory-13 (SEPI-13). A descriptive analysis and associations were performed with a Confidence Interval of 95% and <0.05 level of significance. A total of 87 participants (52 men, mean age of 53 ± 10 years, mean time after a stroke of 11 (IQR: 15) months and an average of 264.5 ± 178.9 m as distance on the 6 min walking test (6MWT) were included. Overall, stroke survivors in Benin reached a total PA of 985.5 (IQR: 2520) metabolic equivalent (METs)-minutes per week and were least active at work, domestic, and leisure domains with 0 MET-minutes per week. The overview of PA level showed that 52.9% of participants performed low PA intensity. However, 41.4% performed moderate PA or walking per day for at least five days per week. Important perceived barriers were lack of information (45.3%), hard-to-start exercise (39.5%), and travelling to places to exercise (29.9%). The preference for exercise was with family or friends, outdoors, for relaxation or enjoyment (90.2%), and receiving feedback (78.3%). Several socio-demographic, clinical, and community factors were significantly associated with moderate or intense PA (p < 0.05) in stroke survivors in this study. Our findings show that the PA level among chronic stroke survivors in Benin is overall too low relative to their walking capacity. Cultural factors in terms of the overprotection of the patients by their entourage and/or the low health literacy of populations to understand the effect of PA on their health may play a role. There is a need for new approaches that consider the individual barriers and facilitators to exercise.

Efficacy and Dose of Rehabilitation Approaches for Severe Upper Limb Impairments and Disability during Early Acute and Subacute Stroke: A Systematic Review

Objective. The purpose of this study was to examine the evidence regarding the efficacy of rehabilitation approaches for improving severe upper limb impairments and activity during acute and early subacute stroke, taking into consideration the dosage of therapy.

Methods. Randomized controlled trials from PubMed, Web of Science, and Scopus databases were searched by 2 independent researchers. Studies were selected if they involved active rehabilitation interventions that were conducted in the acute stage (&lt;7 days after stroke) or the early subacute stage (&gt;7 days–3 months after stroke), with the aim of improving severe upper limb motor impairments and disability. Data were extracted on the basis of the type and effect of rehabilitation interventions, and on the dosage (duration, frequency, session length, episode difficulty, and intensity). Study quality was assessed using the Physiotherapy Evidence Database Scale.

Results. Twenty-three studies (1271 participants) with fair to good methodological quality were included. Only 3 studies were performed in the acute stage. Regardless of the type of intervention, upper limb rehabilitation was found to be beneficial for severe upper limb impairments and disability. Robotic therapy and functional electrical stimulation were identified as the most popular upper limb interventions; however, only a limited number of studies showed their superiority over a dose-matched control intervention for severe upper limb impairments in the subacute stage. A longer rehabilitation session length (&lt;60 minutes) did not seem to have a larger impact on the magnitude of improved upper limb impairments.

Conclusion. Different rehabilitation approaches seem to improve severe upper limb impairments and disability in the subacute stage after stroke; however, they are not distinctly superior to standard care or other interventions provided at the same dosage.

Impact. Robotic therapy and functional electrical stimulation add variety to rehabilitation programs, but their benefit has not been shown to exceed that of standard care. Further research is necessary to identify the impact of dose (eg, intensity) on upper limb motor impairments and function, especially in the acute stage.

Exercise dosage to facilitate the recovery of balance, walking, and quality of life after stroke

Background

Although aerobic training (AT) and resistance training (RT) are recommended after stroke, the optimal dosage of these interventions and their effectiveness on balance, walking capacity, and quality of life (QoL) remain conflicting.

Objectives

Our study aimed to quantify the effects of different modes, dosages and settings of exercise therapy on balance, walking capacity, and QoL in stroke survivors.

Method

PubMed, CINHAL, and Hinari databases were searched for randomised controlled trials (RCTs) evaluating the effects of AT and RT on balance, walking, and QoL in stroke survivors. The treatment effect was computed by the standard mean differences (SMDs).

Results

Twenty-eight trials (n = 1571 participants) were included. Aerobic training and RT interventions were ineffective on balance. Aerobic training interventions were the most effective in improving walking capacity (SMD = 0.37 [0.02, 0.71], p = 0.04). For walking, capacity, a higher dosage (duration ≥ 120 min/week; intensity ≥ 60% heart rate reserve) of AT interventions demonstrated a significantly greater effect (SMD = 0.58 [0.12, 1.04], p = 0.01). Combined AT and RT improved QoL (SMD = 0.56 [0.12, 0.98], p = 0.01). Hospital located rehabilitation setting was effective for improving walking capacity (SMD = 0.57 [0.06, 1.09], p = 0.03) compared with home and/or community and laboratory settings.

Conclusion

Our findings showed that neither AT nor RT have a significant effect on balance. However, AT executed in hospital-located settings with a higher dose is a more effective strategy to facilitate walking capacity in chronic stroke. In contrast, combined AT and RT is beneficial for improving QoL.

Clinical implications

A high dosage of aerobic exercise, duration ≥ 120 min/week; intensity ≥ 60% heart rate reserve is beneficial for improving walking capacity.

Reliability of Upper Limb Pin-Prick Stimulation With Electroencephalography: Evoked Potentials, Spectra and Source Localization

In order for electroencephalography (EEG) with sensory stimuli measures to be used in research and neurological clinical practice, demonstration of reliability is needed. However, this is rarely examined. Here we studied the test-retest reliability of the EEG latency and amplitude of evoked potentials and spectra as well as identifying the sources during pin-prick stimulation. We recorded EEG in 23 healthy older adults who underwent a protocol of pin-prick stimulation on the dominant and non-dominant hand. EEG was recorded in a second session with rest intervals of 1 week. For EEG electrodes Fz, Cz, and Pz peak amplitude, latency and frequency spectra for pin-prick evoked potentials was determined and test-retest reliability was assessed. Substantial reliability ICC scores (0.76-0.79) were identified for evoked potential negative-positive amplitude from the left hand at C4 channel and positive peak latency when stimulating the right hand at Cz channel. Frequency spectra showed consistent increase of low-frequency band activity (< 5 Hz) and also in theta and alpha bands in first 0.25 s. Almost perfect reliability scores were found for activity at both low-frequency and theta bands (ICC scores: 0.81-0.98). Sources were identified in the primary somatosensory and motor cortices in relation to the positive peak using s-LORETA analysis. Measuring the frequency response from the pin-prick evoked potentials may allow the reliable assessment of central somatosensory impairment in the clinical setting.

Interlimb Coordination Performance in Seated Position in Persons With Multiple Sclerosis: Reduced Amplitude Over 6 min and Higher Coordination Variability in Persons With Walking Fatigability

Background: Walking fatigability is prevalent in MS and can be measured by a percentage distance decline during a 6-min walking test. Walking is characterized by an accurate and consistent interlimb antiphase coordination pattern. A decline in coordination each minute during a 6-min walking test is observed in persons with MS (pwMS). Measuring coordination during a 6-min seated coordination task with minimized balance and strength requirements, is assumed to examine a more fundamental interlimb antiphase coordination pattern in pwMS. This research aimed to answer the following research question: How does interlimb antiphase coordination pattern change during a seated coordination task in pwMS with walking fatigability (WF), non-walking fatigability (NWF) and Healthy Controls (HC)?

Methods: Thirty-five pwMS and 13 HC participated. Interlimb coordination was assessed by a seated 6-min coordination task (6MCT) with the instruction to perform antiphase lower leg movements as fast as possible. Outcomes were Phase Coordination Index (PCI) and movement parameters (amplitude, frequency).

Results: Mixed models revealed a significant effect of time for the the variability of generating interlimb movements, with a difference in mean values between WF and HC. A significant group^∗time interaction effect was found for movement amplitude, represented by a significant decrease in movement amplitude in the WF group from minute 1 to the end of the task.

Conclusion: The higher variability in interlimb coordination and decrease in movement amplitude over time during the 6MCT in the WF group could be an indicator of decreased control of fundamental antiphase coordination pattern in pwMS with walking fatigability.

Clinical Trial Registration:www.clinicaltrials.gov, identifier NCT04142853 (registration date: October 29, 2019) and NCT03938558 (registration date: May 6, 2019).

A nation-wide survey exploring the views of current and future use of functional electrical stimulation in spinal cord injury

PURPOSE

Functional electrical stimulation (FES) can be effective in assisting physical and psychosocial difficulties experienced by people with spinal cord injury. Perceived benefits and barriers of the current and future use of FES within the wider spinal cord injury community is currently unknown. The main objective of this research was to explore the spinal cord injury community's views of the use of FES to decrease disability in rehabilitation programmes.

MATERIALS AND METHODS

An online and paper questionnaire was distributed to people with spinal cord injury, health care professionals and researchers working in spinal cord injury settings in the United Kingdom.

RESULTS

A total of 299 participants completed the survey (152 people with spinal cord injury, 141 health care professionals and 6 researchers). Common views between groups identified were: (1) FES can be beneficial in improving physical and psychosocial aspects and that (2) adequate support and training for FES application was provided to users. Barriers to FES use included a lack of staff time and training, financial cost and availability of the equipment. Sixty three percent of non-users felt they would use FES in the future if they had the opportunity.

CONCLUSIONS

Users' views were important in identifying that FES application can be beneficial for people with spinal cord injury but also has some resourceful barriers. In order to increase use, future research should focus on reducing the cost of FES clinical service and also address implementation of awareness and training programmes within spinal units and community rehabilitation settings.IMPLICATIONS FOR REHABILITATIONUsers of functional electrical stimulation think that it is beneficial for improving physical and psychosocial limitations after spinal cord injuryBarriers to FES use include a lack of staff time and training, financial cost and availability of the equipment have been suggested by people with spinal cord injury and health care professionals Education and implementation programs for health care professionals and people with spinal cord injury are now necessary to increase the awareness about functional electrical stimulation applicationReduction of FES cost could also increase its uptake in spinal cord injury clinical services.

Predictors of upper limb spasticity after stroke? A systematic review and meta-analysis

OBJECTIVE

To determine the predictive markers for the occurrence of upper limb spasticity in the first 12 months after stroke.

DATA SOURCES

A systematic review was undertaken of the databases MEDLINE, EMBASE, CINAHL and PEDRO to 31st December 2017.

STUDY SELECTION

Non-experimental or experimental studies that included a control group with spasticity who did not receive an experimental intervention which investigated at least one variable (explanatory variable) measured at baseline against the development (or not) of spasticity at a future time point within 12 months post stroke were selected independently by two reviewers. Eleven papers met the selection criteria.

STUDY APPRAISAL

Data were extracted into tabular format using predefined data fields by two reviewers. Study quality was evaluated using the modified Downs and Black tool. Data were analysed using a meta-analysis or narrative review.

RESULTS

Ten studies, including 856 participants were analysed. The predictive markers of upper limb spasticity at one month post stroke were: motor 11.25 (odds ratio, OR); [95% CI:2.48, 51.04] and sensory impairments 4.91 (OR); [1.24, 19.46]; haemorrhagic stroke 3.70 (OR); [1.05, 12.98] and age 0.01 (OR) [0.00, 69.89]. Only motor impairment was found as a significant predictor at six months post stroke 30.68 (OR); [1.60, 587.06].

LIMITATIONS

Low number of studies exploring biomechanical and neurophysiological in addition to behavioural predictors of spasticity were included.

CONCLUSION AND IMPLICATIONS OF KEY FINDINGS

Using the results, the identified predictive markers have potential to better inform clinical decision-making and to plan specific rehabilitation interventions by physiotherapists for stroke survivors with upper limb spasticity. Systematic Review Registration Number PROSPERO (ID: CRD42016027642).

Does sensorimotor upper limb therapy post stroke alter behavior and brain connectivity differently compared to motor therapy? Protocol of a phase II randomized controlled trial

Background

The role of somatosensory feedback in motor performance has been warranted in the literature. Although sensorimotor deficits are common after stroke, current rehabilitation approaches primarily focus on restoring upper limb motor ability. Evidence for integrative sensorimotor rehabilitation approaches is scarce, as is knowledge about neural correlates of somatosensory impairments after stroke and the effect of rehabilitation on brain connectivity level. Therefore, we aim to investigate changes in sensorimotor function and brain connectivity following a sensorimotor therapy program compared to an attention-matched motor therapy program for the upper limb after stroke.

Methods

An assessor-blinded randomized controlled trial will be conducted. Sixty inpatient rehabilitation patients up to eight weeks after stroke will be included. Patients will be randomized to either an experimental group receiving sensorimotor therapy or a control group receiving attention-matched motor therapy for the upper limb, with both groups receiving conventional therapy. Thus, all patients will receive extra therapy, a total of 16 1-h sessions over four weeks. Patients will be assessed at baseline, after four weeks of training, and after four weeks of follow-up. Primary outcome measure is the Action Research Arm Test. Secondary outcome measures will consist of somatosensory, motor and cognitive assessments, and a standardized resting-state functional magnetic resonance imaging protocol.

Discussion

The integration of sensory and motor rehabilitation into one therapy model might provide the added value of this therapy to improve sensorimotor performance post stroke. Insight in the behavioral and brain connectivity changes post therapy will lead to a better understanding of working mechanisms of therapy and will provide new knowledge for patient-tailored therapy approaches.

Trial registration

ClinicalTrials.gov, NCT03236376. Registered on 8 August 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2609-4) contains supplementary material, which is available to authorized users.

Measurement of motor-evoked potential resting threshold and amplitude of proximal and distal arm muscles in healthy adults. A reliability study

Purpose

Reliability of motor-evoked potential threshold and amplitude measurement of upper limb muscles is important when detecting changes in cortical excitability. The objective of this study was to investigate intra-rater, test–retest reliability and minimal detectable change of resting motor threshold and amplitude of a proximal and distal upper limb muscles, anterior deltoid and distal extensor digitorum communis in healthy adults.

Method

To measure motor-evoked potential responses, transcranial magnetic stimulation was interfaced with electromyography and neuronavigation equipment. Two measurements were conducted on day 1 and a third measurement three days later. Reliability was analysed using intraclass correlation coefficients.

Results

Twenty participants completed the study. Excellent intra-rater (intraclass correlation coefficient = 0.91 (extensor digitorum), 0.94 (anterior deltoid)) and good to excellent test–retest reliability (intraclass correlation coefficient = 0.69 (anterior deltoid), 0.84 (extensor digitorum)) was found for resting motor threshold. Minimal detectable change for resting motor threshold was found at 10.95% (extensor digitorum) and 16.35% (anterior deltoid) between first and third measurements. Motor-evoked potential amplitude of extensor digitorum communis had fair to good intra-rater (intraclass correlation coefficient = 0.50) and test–retest reliability (intraclass correlation coefficient = 0.65).

Conclusions

Our results suggest that resting motor threshold is a reliable neurophysiological measure even for proximal shoulder muscles. Future research should further explore the reliability of motor-evoked potential amplitude before integration into neurological rehabilitation.

Mismatch between observed and perceived upper limb function: an eye-catching phenomenon after stroke

PURPOSE

To investigate the relation between observed and perceived upper limb motor function in patients with chronic stroke.

MATERIAL AND METHODS

We investigated 32 patients at six months after stroke with the Fugl-Meyer Assessment (observed function) and hand subscale of the Stroke Impact Scale (perceived function). Spearman correlation was calculated to relate observed and perceived function. Through cut-off scores, we divided our sample in low (Fugl-Meyer Assessment <31/66) and good observed function, and low (hand subscale of Stroke Impact Scale <61/100) and good perceived function. Scatterplot and hierarchical clustering analysis was conducted to detect distinct groups.

RESULTS

A strong positive relation was found between observed and perceived function (r = 0.84). Three groups could be identified; a "low match group" of patients with low observed and low perceived function (n = 11, 34%), a "good match group" containing patients with good observed and good perceived function (n = 15, 47%), and a "mismatch group" comprising patients with good observed but low perceived function (n = 6, 19%).

CONCLUSIONS

In our chronic sample, one in five patients showed good upper limb observed but low perceived function. Measuring both observed and perceived arm and hand function seems warranted together with considering a differential therapy approach for the distinct groups. Implications for rehabilitation A considerable group of patients in the chronic phase post-stroke have good motor function in their affected upper limb, but nevertheless perceive a restricted ability. In order to identify a mismatch in people with chronic stroke, both observed and perceived upper limb motor function should be assessed. Besides common measurement tools for observed function like the Fugl-Meyer Assessment, perceived function can be evaluated by means of the hand function section of the Stroke Impact Scale. For patients with good observed but low perceived function, an additional rehabilitation strategy should be considered, potentially including awareness of ability and a self-efficacy approach.