Recovery Of Upper Extremity Motor Function Research Articles

A novel fully immersive virtual reality environment for upper extremity rehabilitation in patients with stroke.

Given the rising incidence of stroke, several technology-driven methods for rehabilitation have recently been developed. Virtual reality (VR) is a promising therapeutic technology among them. We recently developed a neuroscientifically grounded VR system to aid recovery of motor function poststroke. The developed system provides unilateral and bilateral upper extremity (UE) training in a fully immersive virtual environment that may stimulate and activate mirror neurons (MNs) in the brain necessary for UE rehabilitation. Twenty-three participants were randomized to a VR group (n=12) to receive VR intervention (8 h within 2 weeks) plus 8-h occupational therapy (OT) or a control group (n=11) to receive time-matched OT alone. Treatment effects on motor recovery and cortical reorganization were investigated using the Barthel Index (BI), Fugl-Meyer Upper Extremity (FM-UE), and resting-state fMRI. Both groups significantly improved BI (P < 0.05), reflecting the recovery of UE motor function. The VR group revealed significant improvements on FM-UE scores (P < 0.05) than the control group. Neural activity increased after the intervention, particularly in the brain areas implicating MNs, such as in the primary motor cortex. Overall, results suggested that using a neuroscientifically grounded VR system might offer additional benefits for UE rehabilitation in patients receiving OT.

Generalizability of the Maximum Proportional Recovery Rule to Visuospatial Neglect Early Poststroke

Background and objective. Proportional recovery of upper-extremity motor function and aphasia after stroke may suggest common mechanisms for spontaneous neurobiological recovery. This study aimed to investigate if the proportional recovery rule also applies to visuospatial neglect (VSN) in right-hemispheric first-ever ischemic stroke patients and explored the possible common underlying mechanisms. Methods. Patients with upper-limb paresis and VSN were included. Recovery defined as the change in Letter Cancellation Test (LCT) score at ~8 days and 6 months poststroke. Potential recovery defined as LCTmax-LCTinitial = 20 − LCTinitial. Hierarchical clustering separated fitters and nonfitters of the prediction rule. A cutoff value on LCTmax-LCTinitial was determined. The change in LCT and Fugl-Meyer Assessment Upper Extremity was expressed as a percentage of the total possible score to investigate the communality of proportional recovery. Results. Out of 90 patients, 80 displayed proportional recovery of VSN (ie, “fitters,” 0.97; 95% CI = 0.82-1.12). All patients who did not follow the prediction rule for VSN (ie, ”nonfitters”) had ≥15 missing O’s at baseline and failed to show proportional recovery of the upper limb. Conclusions. This study shows that the proportional recovery rule also applies to patients with VSN poststroke. Patients who fail to show proportional recovery of VSN are the same patients who fail to show proportional recovery of the upper limb. These findings support the idea of common intrahemispheric mechanisms underlying spontaneous neurobiological recovery in the first months poststroke. Future studies should investigate the prognostic clinical and neurobiological markers of these subgroups.

Concurrent neuromechanical and functional gains following upper-extremity power training post-stroke.

BackgroundRepetitive task practice is argued to drive neural plasticity following stroke. However, current evidence reveals that hemiparetic weakness impairs the capacity to perform, and practice, movements appropriately. Here we investigated how power training (i.e., high-intensity, dynamic resistance training) affects recovery of upper-extremity motor function post-stroke. We hypothesized that power training, as a component of upper-extremity rehabilitation, would promote greater functional gains than functional task practice without deleterious consequences.MethodNineteen chronic hemiparetic individuals were studied using a crossover design. All participants received both functional task practice (FTP) and HYBRID (combined FTP and power training) in random order. Blinded evaluations performed at baseline, following each intervention block and 6-months post-intervention included: Wolf Motor Function Test (WMFT-FAS, Primary Outcome), upper-extremity Fugl-Meyer Motor Assessment, Ashworth Scale, and Functional Independence Measure. Neuromechanical function was evaluated using isometric and dynamic joint torques and concurrent agonist EMG. Biceps stretch reflex responses were evaluated using passive elbow stretches ranging from 60 to 180º/s and determining: EMG onset position threshold, burst duration, burst intensity and passive torque at each speed.ResultsPrimary outcome: Improvements in WMFT-FAS were significantly greater following HYBRID vs. FTP (p = .049), regardless of treatment order. These functional improvements were retained 6-months post-intervention (p = .03).Secondary outcomes: A greater proportion of participants achieved minimally important differences (MID) following HYBRID vs. FTP (p = .03). MIDs were retained 6-months post-intervention. Ashworth scores were unchanged (p > .05).Increased maximal isometric joint torque, agonist EMG and peak power were significantly greater following HYBRID vs. FTP (p < .05) and effects were retained 6-months post-intervention (p’s < .05). EMG position threshold and burst duration were significantly reduced at fast speeds (≥120º/s) (p’s < 0.05) and passive torque was reduced post-washout (p < .05) following HYBRID.ConclusionsFunctional and neuromechanical gains were greater following HYBRID vs. FPT. Improved stretch reflex modulation and increased neuromuscular activation indicate potent neural adaptations. Importantly, no deleterious consequences, including exacerbation of spasticity or musculoskeletal complaints, were associated with HYBRID. These results contribute to an evolving body of contemporary evidence regarding the efficacy of high-intensity training in neurorehabilitation and the physiological mechanisms that mediate neural recovery.

Combined Functional Task Practice and Dynamic High Intensity Resistance Training Promotes Recovery of Upper-extremity Motor Function in Post-stroke Hemiparesis

Weakness is a significant impairment in persons with post-stroke hemiparesis, yet traditional clinical perspectives caution against strengthening in neurological populations. Significant correlations between weakness and functional movement have been demonstrated, however, a clear relationship between increased strength and functional improvement has been elusive. This case study describes a combined program of dynamic, high-intensity resistance training and functional task practice for the upper-extremity in adult hemiparesis. The patient was a 65-year-old, right hand dominant woman who presented to the Neural Control of Movement Laboratory at the Palo Alto VA Rehabilitation Research and Development Center 16 weeks following clipping of an unruptured aneurysm with consequent dense right hemiparesis. She received 7 weeks of acute rehabilitation according to CARF guidelines (ie, at least 3 hours of two or more disciplines, 6 days per week). Her baseline research evaluation revealed significant upperextremity deficits at the ICF body structure/function level including: weakness, shoulder pain, mild resistance to passive movement, and need for moderate to maximal assistance in many activities of daily living including bathing and dressing. The Stroke Impact Scale score reporting her perspective indicated she had recovered from her stroke only 50%. The hybrid resistance training-functional task practice intervention, detailed in this report, was delivered 3 times per week for 6 weeks with each session lasting 75:00. The subject revealed marked improvements in isometric and dynamic force production in 5 key upper-extremity actions: elbow flexion, elbow extension, shoulder flexion, shoulder abduction, and shoulder external rotation. Strength gains were accompanied by increased EMG activation immediately postintervention and by a combination of increased activation and apparent hypertrophic effects at 6 month follow up. Marked improvements were noted in all clinical and functional measures and in an elbow trajectorytracking task which served as a surrogate measure of motor control. Improvements in strength and positive outcome effects at the physiological, clinical, and functional levels were observed in this subject following the experimental hybrid upper-extremity rehabilitation intervention described. Importantly, no deleterious effects were observed including exacerbation of spasticity or musculoskeletal compromise. Observations of improved EMG activation in this case study suggest that improvements in motor activation underlie these strength gains and can likely be attributed to working at a high intensity level.

Comparison of the Action Research Arm Test and the Fugl-Meyer Assessment as Measures of Upper-Extremity Motor Weakness After Stroke

Rabadi MH, Rabadi FM. Comparison of the Action Research Arm Test and the Fugl-Meyer Assessment as measures of upper-extremity motor weakness after stroke. Objective To assess the relative responsiveness of 2 commonly used upper-extremity motor scales, the Action Research Arm Test (ARAT) and the Fugl-Meyer Assessment (FMA), in evaluating recovery of upper-extremity function after an acute stroke in patients undergoing inpatient rehabilitation. Design Prospective. Setting An acute stroke rehabilitation unit. Participants One hundred four consecutive admissions (43 men, 61 women; mean age ± standard deviation, 72±13y) to a rehabilitation unit 16±9 days after acute stroke. Interventions Not applicable. Main Outcome Measures The following assessments were completed within 72 hours of admission and 24 hours before discharge: ARAT, upper-extremity motor domain of the FMA, National Institutes of Health Stroke Scale, FIM instrument total score, and FIM activities of daily living (FIM-ADL) subscore. Results The Spearman rank correlation statistic indicated that the 2 upper-limb motor scales (ARAT, FMA) correlated highly with one another, both on admission (ρ=.77, P<.001) and on discharge (ρ=.87, P<.001). The mean change in score from admission to discharge was 10±15 for the ARAT and 10±13 for the FMA motor score. The responsiveness to change as measured by the standard response mean was .68 for the ARAT and .74 for the FMA motor score. The Spearman rank correlation of each upper-limb motor scale with the FIM-ADL at the time of admission was as follows: ARAT, ρ equal to .32 ( P<.001) and FMA motor score, ρ equal to .54 ( P<.001). Conclusions Both the FMA motor score and the ARAT were equally sensitive to change during inpatient acute rehabilitation and could be routinely used to measure recovery of upper-extremity motor function.