Paretic Arm Use Research Articles

Reaching the cognitive-motor interface: effects of cognitive load on arm choice and motor performance after stroke.

A vexing characteristic of motor disability after stroke is that many individuals fail to use their affected arm effectively despite having the capacity to do so, a phenomenon termed arm nonuse. Based on the hypothesis that nonuse is influenced by the competing cognitive demands of many daily activities, we examined the effects of cognitive load on arm choice and motor performance in individuals with stroke using a novel virtual reality paradigm that mimics the demands of real-life visual search, object selection, and reaching to targets. Twenty individuals with single left or right hemispheric chronic stroke (11 left cerebrovascular accident; 9 right cerebrovascular accident) and 10 age-matched neurotypical participants completed the Virtual Reality Arm Choice task, in which they reached for target objects in an array under varied cognitive demand. To manipulate cognitive demand, we varied the semantic similarity of objects in the reaching space and the presence or absence of a secondary task. The results showed reduced use of the paretic arm under increased demand. Under cognitive load, participants with stroke also showed slower reach initiation, slower movements, increased reach curvature, and increased performance differences between the paretic and non-paretic arms. The arm choice of neurotypical individuals was also modulated under cognitive load. These data indicate that cognitive factors influence arm choice and motor performance in naturalistic reaching tasks in individuals with chronic stroke. Performance decrements under cognitive load may in turn influence reduced paretic arm use during daily activities.

The Perspectives of Individuals with Chronic Stroke on Motor Recovery: A Qualitative Analysis.

The priorities of individuals with chronic stroke are not always reflected in clinical practice. This study provides insight into meaningful factors related to long-term motor recovery in stroke survivors. Thirty individuals with chronic stroke participated in semi-structured interviews about movement, recovery, and barriers to and facilitators of mobility and paretic arm use. The interviews were analyzed using inductive thematic analysis. Three categories, the individual, environment, and task, defined five emergent themes. Individual: (1) mindset is a strong and consistent influencer of daily physical activity and overall recovery; (2) severe physical impairment limits physical activity and recovery, regardless of other factors; and (3) a negative perception of disability impacts mindset and willingness to move in public. Environment: (4) social and physical environments influence physical activity and recovery. Task: (5) participation in meaningful activities increases physical activity and promotes long-term recovery. Strategies to incorporate paretic arm use, exercise, and encouragement from others facilitate physical activity. Insufficient paretic limb function, environmental obstacles, and fear are barriers to physical activity. Neurorehabilitation must address the factors that are meaningful to stroke survivors. Building motor capacity is essential and must be integrated with factors such as a positive mindset and proper environment. Individual differences reinforce the need for personalized care.

Wearable Technology to Capture Arm Use of People With Stroke in Home and Community Settings: Feasibility and Early Insights on Motor Performance.

The objectives of this study were to establish the short-term feasibility and usability of wrist-worn wearable sensors for capturing the arm and hand activity of people with stroke and to explore the association between factors related to the use of the paretic arm and hand. Thirty people with chronic stroke were monitored with wrist-worn wearable sensors for 12hours per day for a 7-day period. Participants also completed standardized assessments to capture stroke severity, arm motor impairments, self-perceived arm use, and self-efficacy. The usability of the wearable sensors was assessed using the adapted System Usability Scale and an exit interview. Associations between motor performance and capacity (arm and hand impairments and activity limitations) were assessed using Spearman correlations. Minimal technical issues or lack of adherence to the wearing schedule occurred, with 87.6% of days procuring valid data from both sensors. The average sensor wear time was 12.6 (standard deviation [SD] = 0.2) hours per day. Three participants experienced discomfort with 1 of the wristbands, and 3 other participants had unrelated adverse events. There were positive self-reported usability scores (mean = 85.4/100) and high user satisfaction. Significant correlations were observed for measures of motor capacity and self-efficacy with paretic arm use in the home and the community (Spearman correlation coefficients = 0.44-0.71). This work demonstrates the feasibility and usability of a consumer-grade wearable sensor for capturing paretic arm activity outside the laboratory. It provides early insight into the everyday arm use of people with stroke and related factors, such as motor capacity and self-efficacy. The integration of wearable technologies into clinical practice offers new possibilities to complement in-person clinical assessments and to better understand how each person is moving outside of therapy and throughout the recovery and reintegration phase. Insight gained from monitoring the arm and hand use of people with stroke in the home and community is the first step toward informing future research with an emphasis on causal mechanisms with clinical relevance.

Relationship Between Body-Specific Attention to a Paretic Limb and Real-World Arm Use in Stroke Patients: A Longitudinal Study.

Learned nonuse is a major problem in upper limb (UL) rehabilitation after stroke. Among the various factors that contribute to learned nonuse, recent studies have focused on body representation of the paretic limb in the brain. We previously developed a method to measure body-specific attention, as a marker of body representation of the paretic limb and revealed a decline in body-specific attention to the paretic limb in chronic stroke patients by a cross-sectional study. However, longitudinal changes in body-specific attention and paretic arm use in daily life (real-world arm use) from the onset to the chronic phase, and their relationship, remain unknown. Here, in a longitudinal, prospective, observational study, we sought to elucidate the longitudinal changes in body-specific attention to the paretic limb and real-world arm use, and their relationship, by using accelerometers and psychophysical methods, respectively, in 25 patients with subacute stroke. Measurements were taken at baseline (TBL), 2 weeks (T2w), 1 month (T1M), 2 months (T2M), and 6 months (T6M) after enrollment. UL function was measured using the Fugl-Meyer Assessment (FMA) and Action Research Arm Test (ARAT). Real-world arm use was measured using accelerometers on both wrists. Body-specific attention was measured using a visual detection task. The UL function and real-world arm use improved up to T6M. Longitudinal changes in body-specific attention were most remarkable at T1M. Changes in body-specific attention up to T1M correlated positively with changes in real-world arm use up to T6M, and from T1M to T6M, and the latter more strongly correlated with changes in real-world arm use. Changes in real-world arm use up to T2M correlated positively with changes in FMA up to T2M and T6M. No correlation was found between body-specific attention and FMA scores. Thus, these results suggest that improved body-specific attention to the paretic limb during the early phase contributes to increasing long-term real-world arm use and that increased real-world use is associated with the recovery of UL function. Our results may contribute to the development of rehabilitation strategies to enhance adaptive changes in body representation in the brain and increase real-world arm use after stroke.

Video game rehabilitation for outpatient stroke (VIGoROUS): A multi-site randomized controlled trial of in-home, self-managed, upper-extremity therapy.

SummaryBackgroundIntegrating behavioral intervention into motor rehabilitation is essential for improving paretic arm use in daily life. Demands on therapist time limit adoption of behavioral programs like Constraint-Induced Movement (CI) therapy, however. Self-managed motor practice could free therapist time for behavioral intervention, but there remains insufficient evidence of efficacy for a self-management approach.MethodsThis completed, parallel, five-site, pragmatic, single-blind trial established the comparative effectiveness of using in-home gaming self-management as a vehicle to redirect valuable therapist time towards behavioral intervention. Community-dwelling adults with post-stroke (>6 months) mild/moderate upper extremity hemiparesis were randomized to receive one of 4 different interventions over a 3-week period: 5 h of behaviorally-focused intervention plus gaming self-management (Self-Gaming), the same with additional behaviorally-focused telerehabilitation (Tele-Gaming), 5 h of Traditional motor-focused rehabilitation, or 35 h of CI therapy. Primary outcomes assessed everyday arm use (Motor Activity Log Quality of Movement, MAL) and motor speed/function (Wolf Motor Function Test, WMFT) immediately before treatment, immediately after treatment, and 6 months later. Intent-to-treat analyses were implemented with linear mixed-effects models on data gathered from March 15, 2016 to November 21, 2019. ClinicalTrials.gov, NCT02631850.ResultsOf 193 enrolled participants, 167 began treatment and were analyzed, 150 (90%) completed treatment, and 115 (69%) completed follow-up. Tele-Gaming and Self-Gaming produced clinically meaningful MAL gains that were 1·0 points (95% CI 0·8 to 1·3) and 0·8 points (95% CI 0·5 to 1·0) larger than Traditional care, respectively. Self-Gaming was less effective than CI therapy (-0·4 points, 95% CI -0·6 to -0·2), whereas Tele-Gaming was not (-0·2 points, 95% CI -0·4 to 0·1). Six-month retention of MAL gains across all groups was 57%. All had similar clinically-meaningful WMFT gains; six-month retention of WMFT gains was 92%.InterpretationSelf-managed motor-gaming with behavioral telehealth visits has outcomes similar to in-clinic CI therapy. It addresses most access barriers, requiring just one-fifth as much therapist time that is redirected towards behavioral interventions that enhance the paretic arm's involvement in daily life.Funding10.13039/100006093PCORI, NIH

Insights Gained From Activity Monitors for Upper Limb Stroke Rehabilitation

<h3>Research Objectives</h3> To determine if measures derived from wrist-worn activity monitors can be used as a proxy for functional arm/hand behaviors of chronic stroke survivors. <h3>Design</h3> Cross-sectional study. <h3>Setting</h3> Laboratory. <h3>Participants</h3> Chronic stroke survivors (n=20; 7 females, age: 58.4 (SD=8.9) years with mild-severe arm motor impairments (Fugl-Meyer Assessment (FMA) score: 39.4 (17.3) [1]). <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> The Chedoke Arm and Hand Activity Inventory-7 (CAHAI), the FMA and the Reaching Performance Scale (RPS) were administered. For the CAHAI, participants were outfitted with two wrist-worn activity monitors (MiGo, Flint Rehabilitation Devices) and video recorded. Each video was annotated to identify movements of each arm and time in active movements. For each arm, time in active movement, movement counts, and percentage of arm use were computed from the MiGo and compared to the video recording metrics [2-3]. <h3>Results</h3> Movement metrics derived from the MiGo were strongly related to metrics from the video annotations (active movement time: r2=0.946; movement counts: r2=0.893). Asymmetries in arm use for bimanual tasks were quantified as a ratio (paretic/total movements) and expressed as a percentage of paretic arm use: 28.6 (12.6)%; and time in active movement for the paretic arm: 37.5 (10.6)% (neurotypical symmetry ratio: ∼50% [4]). Altogether, the relationship between each of the three clinical measures and MiGo metrics (Movement count, Movement time) ranged from moderate to strong (r2=0.539-0.746). <h3>Conclusions</h3> Time in active movements may be a more intuitive outcome than movement count for stroke survivors, and a valid proxy for the more standard movement count metric. Perspectives from users would provide insight about the meaningfulness of each metric for future efforts to effect durable gains in paretic arm use in the natural environment [5]. <h3>Author(s) Disclosures</h3> JR is a full-time employee of Flint Rehabilitation Devices, LLC. DZ is a full-time employee and co-owner of Flint Rehabilitation Devices, LLC.

Whole-Body Movements Increase Arm Use Outcomes of Wrist-Worn Accelerometers in Stroke Patients

Wrist-worn accelerometers are often applied to measure arm use after stroke. They measure arm movements during all activities, including whole-body movements, such as walking. Whole-body movements may influence clinimetric properties of arm use measurements—however, this has not yet been examined. This study investigates to what extent arm use measurements with wrist-worn accelerometers are affected by whole-body movements. Assuming that arm movements during whole-body movements are non-functional, we quantify the effect of whole-body movements by comparing two methods: Arm use measured with wrist-worn accelerometers during all whole-body postures and movements (P&M method), and during sitting/standing only (sit/stand method). We have performed a longitudinal observational cohort study with measurements in 33 stroke patients during weeks 3, 12, and 26 poststroke. The P&M method shows higher daily paretic arm use outcomes than the sit/stand method (p < 0.001), the mean difference increased from 31% at week three to 41% at week 26 (p < 0.001). Differences in daily paretic arm use between methods are strongly related to daily walking time (r = 0.83–0.92). Changes in the difference between methods are strongly related to changes in daily walking time (r = 0.89). We show that not correcting arm use measurements for whole-body movements substantially increases arm use outcomes, thereby threatening the validity of arm use outcomes and measured arm use changes.

Accelerometer Measurements Indicate That Arm Movements of Children With Cerebral Palsy Do Not Increase After Constraint-Induced Movement Therapy (CIMT).

Constraint-induced movement therapy (CIMT) is a common treatment for children with unilateral cerebral palsy (CP). Although clinic-based assessments have demonstrated improvements in arm function after CIMT, whether these changes are translated and sustained outside of a clinic setting remains unclear. Accelerometers were used to quantify arm movement for children with CP 1 wk before, during, and 4 wk or more after CIMT; measurements were compared with those from typically developing (TD) peers. Observational. Tertiary hospital and community. Seven children with CP (5 boys, 2 girls; average [AVE] age ± standard deviation [SD] = 7.4 ± 1.2 yr) and 7 TD peers (2 boys, 5 girls; AVE age ± SD = 7.0 ± 2.3 yr). 30-hr CIMT protocol. Use ratio, magnitude ratio, and bilateral magnitude were calculated from the accelerometer data. Clinical measures were administered before and after CIMT, and parent surveys assessed parent and child perceptions of wearing accelerometers. During CIMT, the frequency and magnitude of paretic arm use among children with CP increased in the clinic and in daily life. After CIMT, although clinical scores showed sustained improvement, the children's accelerometry data reverted to baseline values. Children and parents in both cohorts had positive perceptions of accelerometer use. The lack of sustained improvement in accelerometry metrics after CIMT suggests that therapy gains did not translate to increased movement outside the clinic. Additional therapy may be needed to help transfer gains outside the clinic. Accelerometer measurements were effective at monitoring arm movement outside of the clinic during CIMT and suggested that additional interventions may be needed after CIMT to sustain benefits.

Determining User Intent of Partly Dynamic Shoulder Tasks in Individuals With Chronic Stroke Using Pattern Recognition.

Stroke remains the leading cause of long-term disability in the US. Although therapy can achieve limited improvement of paretic arm use and performance, weakness and abnormal muscle synergies-which cause unintentional elbow, wrist, and finger flexion during shoulder abduction-contribute significantly to limb disuse and compound rehabilitation efforts. Emerging wearable exoskeleton technology could provide powered abduction support for the paretic arm, but requires a clinically feasible, robust control scheme capable of differentiating multiple shoulder degrees-of-freedom. This study examines whether pattern recognition of sensor data can accurately identify user intent for 9 combinations of 1- and 2- degree-of-freedom shoulder tasks. Participants with stroke (n = 12) used their paretic and non-paretic arms, and healthy controls (n = 12) used their dominant arm to complete tasks on a lab-based robot involving combinations of abduction, adduction, and internal and external rotation of the shoulder. We examined the effect of arm (paretic, non-paretic), load level (25% vs 50% maximal voluntary torque), and dataset (electromyography, load cell, or combined) on classifier performance. Results suggest that paretic arm, lower load levels, and using load cell or EMG data alone reduced classifier accuracy. However, this method still shows promise. Further work will examine classifier-user interaction during active control of a robotic device and optimization/minimization of sensors.

Neglect May Not Impact Real-World Paretic Arm Use in the Chronic Stage of Stroke Recovery

Abstract Date Presented 04/05/19 Nonuse of the paretic arm is highly prevalent after stroke. In the chronic stage of stroke, individuals with neglect have similar patterns of paretic arm use as individuals without neglect when matched for paretic arm motor impairment. These findings highlight how critical it is that stroke rehabilitation therapists address paretic arm nonuse in therapy. Primary Author and Speaker: Emily Grattan Additional Authors and Speakers: Michelle Woodbury

Abstract WP152: Exploration of the Factors That Influence Spontaneous Bimanual Arm Use After Stroke: Implications for Clinical Rehabilitation

After a stroke, returning to activities of daily living requires the use of the two hands together for bimanual tasks, such as cutting bread, buttoning a shirt etc. Here, we sought to first, identify spontaneous volitional arm use patterns adopted for two distinct bimanual tasks, and, next, determine if and to what extent the degree of impairment, side of stroke, task demands, self-reported confidence, and single-limb (paretic and non-paretic) measures of functional performance can predict the observed task use patterns. Fifty pre-morbidly right-handed stroke survivors (Upper Extremity Fugl-Meyer, UEFM 42±10, 25 right-hemiparesis, RHP) performed 2 bimanual tasks (letter-envelope and photo-album) without explicit instructions. Arm use patterns were classified by: 1) whether one or both arms were used, and 2) the nature of paretic arm use. Logistic regression and receiver-operator characteristics (AUC) were used to examine the influence of impairment (UEFM, more severe &lt; 41, less severe ≥ 41), side of lesion, task demand, self-reported confidence (CAHM), and single-limb functional performances (paretic and non-paretic log-transformed distal component time-scores of Wolf Motor Function test, ln-WMFT) on bimanual arm use. Those more severely impaired and LHP were less likely to choose a bimanual strategy for either task (β = 14.64, p&lt;0.001). For the photo-album task, probability of bimanual use was greater for RHP than LHP group, especially in less impaired; whereas, for the letter-envelope task, probability of use for RHP &gt; LHP only in the more impaired (β = -1.45, p&lt; 0.001). LHP, but not RHP, who reported greater confidence in the use of the paretic arm were more likely to use a bimanual strategy (ρ &gt; 0.34, p&lt;0.05). Finally, paretic arm ln-WMFT was a fair predictor of use patterns for both LHP (AUC = 0.79) and RHP (AUC = 0.80) groups, while the non-paretic arm time-score was a good predictor of use patterns only for the RHP (AUC = 0.85), but not the LHP group (AUC = 0.55). Taken together, spontaneous bimanual arm use is modified by impairment, task demands, confidence in paretic arm, and non-paretic arm function, but the effect depends on the side of stroke. Thus, consideration of side of lesion is important when developing interventions to improve bimanual arm use.

Adapted Tai Chi Enhances Upper Limb Motor Control in Chronic Stroke Patients: A Pilot Study

Background: Tai Chi has been reported as beneficial for improving balance post stroke, yet no study examined the use of Tai Chi for upper limb rehabilitation. The objective of this study was to evaluate the efficacy and acceptability of Tai Chi for upper limb rehabilitation post stroke. Methods: Twelve chronic stroke survivors with a persistent paretic upper limb underwent 60-min adapted Tai Chi sessions twice a week for eight weeks and a 4-week follow-up. A 10-min Tai Chi home program was recommended for the days without sessions. Session attendance and duration of self-practice at home were recorded. Motor function of the paretic arm (Fugl-Meyer Assessment upper-limb section (FMA-UL)), Wolf Motor Function Test (WMFT) and paretic arm use in daily life(Motor Activity Log (MAL)) were measured at baseline, post-treatment and follow-up. A feedback questionnaire was used to evaluate participants’ perception of the use of Tai Chi at follow-up. Results: Eleven participants completed the 8-week study. Participants with varying profiles including severely impaired upper limb, poor balance, shoulder pain, and severe spasticity, were able to practice an adapted version of Tai Chi. They attended all 16 sessions and practiced Tai Chi at home more than recommended (a total of 16.51 ± 9.21 hours). Participants demonstrated significant improvement over time in the FMA-UL (p=0.009), WMFT functional scale (p=0.003), WMFT performance time (p=0.048) and MAL Amount of Use scale (p=0.02). Moreover, participants confirmed the usefulness and ease of practicing the adapted Tai Chi. Conclusion: Tai Chi was acceptable and found to be effective for upper limb rehabilitation post stroke after adaptation of movements. Further large-scale randomized trials evaluating Tai Chi for upper limb rehabilitation are warranted.

Self-Perceived Utilization of the Paretic Arm in Chronic Stroke Requires High Upper Limb Functional Ability

ObjectiveTo explore potential predictors of self-reported paretic arm use at baseline and after task-specific training (TST) in survivors of stroke. DesignData were obtained from a randomized controlled trial of somatosensory stimulation and upper limb TST in chronic stroke. SettingUniversity laboratory. ParticipantsChronic (≥3mo) survivors of stroke (N=33; mean age, 62y; mean stroke duration, 38mo). InterventionsParticipants received 12 sessions of TST preceded by either active (n=16) or sham (n=17) somatosensory stimulation to all 3 peripheral nerves. Main Outcome MeasuresDemographic and clinical characteristics were entered stepwise into multiple linear regression analyses to determine the factors that best predict baseline Motor Activity Log (MAL) amount of use rating and change 3 months after TST. ResultsThe Action Research Arm Test (ARAT) score predicted the amount of use at baseline (R2=.47, P<.001); in using this model, an ARAT score of 54 (maximum of 57) is required to score 2.5 on the MAL (use described as between rarely and sometimes). After TST the change in the ARAT score predicted the change in the amount of use (R2=.31, P=.001). The predictive power of the model for change at 3 months increased if the Fugl-Meyer Assessment wrist component score was added (R2=.41, P=.001). ConclusionsUtilization of the paretic upper limb in activities of daily living requires high functional ability. The increase in self-reported arm use after TST is dependent on the change in functional ability. These results provide further guidance for rehabilitation decisions.

Discriminant validity of a new measure of self-efficacy for reaching movements after stroke-induced hemiparesis

Study designCase-control study. IntroductionAfter stroke, difficulties in motor control mediate spontaneous paretic arm use in real life. Along with the obvious motor impairments, self-efficacy has been shown to be an important modifier for physical function. However, a self-efficacy measure for arm reaching is lacking. The aim of this study was to develop such a measure and to examine its validity. MethodsFifteen participants with hemiparesis and ten control participants were recruited. A measure of reaching self-efficacy (RSE) was developed using a two-dimensional center-out target array. ResultsFor the control group, RSE was significantly correlated with target distance (r = −0.657) and location (r = −0.545), respectively. Additionally, average RSE was lower for the non-dominant than the dominant hand (p < 0.001). More importantly, for the stroke group, RSE was significantly correlated with target distance (r = −0.603) and location (r = −0.378), respectively. Finally, average RSE was lower for the paretic than the non-paretic hand (p < 0.001). ConclusionsThese results demonstrate robust discriminant validity for this new measure of reaching self-efficacy. Level of evidence3b.

Mean diffusivity as a potential diffusion tensor biomarker of motor rehabilitation after electrical stimulation incorporating task specific exercise in stroke: a pilot study

Changes in diffusion tensor imaging (DTI) values co-occur with neurological and functional changes after stroke. However, quantitative DTI metrics have not been examined in response to participation in targeted rehabilitative interventions in chronic stroke. The primary purpose of this pilot study was to examine whether changes in DTI metrics co-occur with paretic arm movement changes among chronic stroke patients participating in a regimen of electrical stimulation targeting the paretic arm. Three subjects exhibiting stable arm hemiparesis were administered 30-minute (n = 1) or 120-minute (n = 2) therapy sessions emphasizing paretic arm use during valued, functional tasks and incorporating an electrical stimulation device. These sessions occurred every weekday for 8weeks. A fourth subject served as a treatment control, participating in a 30-minute home exercise regimen without electrical stimulation every weekday for 8weeks. DTI and behavioral outcome measures were acquired at baseline and after intervention. DTI data were analyzed using a region of interest (ROI) approach, with ROIs chosen based on tract involvement in sensorimotor function or as control regions. Behavioral outcome measures were the Fugl-Meyer Scale (FM) and the Action Research Arm Test (ARAT). The treatment control subject exhibited gains in pinch and grasp, as shown by a 5-point increase on the ARAT. The subject who participated in 30-minute therapy sessions exhibited no behavioral gains. Subjects participating in 120-minute therapy sessions displayed consistent impairment reductions and distal movement changes. DTI changes were largest in subjects two and three, with mean diffusivity (MD) decreases in the middle cerebellar peduncle and posterior limb of the internal capsule following treatment. No changes in fractional anisotropy (FA) were observed for sensorimotor tracts. Our preliminary results suggest that active rehabilitative therapies augmented by electrical stimulation may induce positive behavioral changes which are underscored by DTI changes indicative of increased white matter tract integrity in regions specific to sensory-motor function.

Greater Activation of Secondary Motor Areas Is Related to Less Arm Use After Stroke

Background. Past studies have identified reorganization of brain activity in relation to motor outcome through standardized laboratory measures, which are quantifiable surrogates for arm use in real life. In contrast, accelerometers can provide a real-life estimate of arm and hand usage. Methods. Ten persons with chronic, subcortical stroke and 10 healthy controls of similar age performed a squeeze motor task at 40% maximum voluntary contraction during functional magnetic resonance imaging (fMRI). Use of the upper extremity was quantified over 3 consecutive days using wrist accelerometers. Correlations were performed between arm use and peak percent signal change (PSC) during grasp force production in 6 regions of interest (ROIs): bilateral primary motor cortex (M1), supplementary motor area (SMA), and premotor cortex (PM). Results. Results demonstrate that in healthy controls, PSC across all ROIs did not show a relationship between arm use and brain activation during force production. In contrast, after stroke, contralesional PM and M1 showed a significant (P ≤ .05) correlation between increasing activation and decreasing paretic arm use, whereas ipsilesional PM showed a significant correlation ( P ≤ .05) between increasing activation and decreasing nonparetic arm use. Conclusions. The results of this pilot study demonstrate a negative relationship between brain activation and actual arm use after stroke. Larger studies using accelerometers that can detect amount and types of movement may offer further insight into brain reorganization and rehabilitation interventions.

Robotic Therapy and Botulinum Toxin Type A

The combined effects of robotic therapy and botulinum toxin type A (BTX-A) on upper-limb movement and function were studied in an 8(1/2)-yr-old child with hemiplegic cerebral palsy. Robotic therapy comprising repetitive, goal-directed reaching tasks was administered two times per week for 8 wks. Clinical measures included the Modified Ashworth Scale, the Quality of Upper Extremity Skills Test, and the Fugl-Meyer Assessment (upper-limb section). Improvements in upper-limb coordination and quality of motor performance were apparent throughout the robotic therapy trial. The observed gains are comparable with those attained from conventional occupational therapy combined with BTX-A. A parent questionnaire indicated that the amount of paretic arm use also improved during daily activities at home. This preliminary study indicates that robotic therapy may be a useful clinical tool when combined with BTX-A injections for improving upper-limb coordination and quality of motor performance in children with cerebral palsy.

Individuals with the Dominant Hand Affected following Stroke Demonstrate Less Impairment Than Those with the Nondominant Hand Affected

Objective. The purpose was to determine if upper extremity impairment and function in individuals with chronic stroke is dependent upon whether the dominant or non-dominant hand is affected. Methods. Ninety-three community-dwelling individuals with stroke. The Modified Ashworth Scale (tone), handheld dynamometry (isometric strength), monofilaments (sensation), Brief Pain Inventory (pain), Chedoke Arm and Hand Activity Inventory Motor Activity Log (paretic arm use), and Reintegration to Normal Living Index (participation) were used to form impairment and function models. Results. Multivariate analysis models (Dominance × Severity) were created for impairment and function variables. There was a significant interaction and main effect of Dominance for the impairment model (P = 0.01) but not the function model (P = 0.75). The dependent variables of tone, grip strength, and pain were all significantly affected by Dominance, indicating less impairment if the dominant hand was affected. All dependent variables except pain were affected by Severity. Conclusion. This study looked at the effect of the dominant hand being affected versus the nondominant in individuals with chronic stroke. Individuals with the dominant hand affected demonstrated less impairment than those with the nondominant hand affected. However, there was no effect of dominance on paretic arm use or performance in activities of daily living. Prospective studies to further explore the issue of hand dominance and poststroke function are suggested.