Upper-extremity Impairment Research Articles

Longitudinal analysis of the recovery of trunk control and upper extremity following stroke: An individual growth curve approach

ABSTRACT Background and Purpose Trunk control is thought to contribute to upper extremity function. It is unclear whether recovery of trunk control has an impact on the recovery of the upper extremity in people with stroke. This longitudinal study monitored the recovery of trunk control and upper extremity in the first 6 months following stroke. Methods Forty-five participants with stroke were assessed monthly for 6 months following stroke. Trunk control was assessed using the Trunk Impairment Scale (TIS); upper extremity impairment and function were assessed with the Fugl-Meyer (FMA) and Streamlined Wolf Motor Function Test (SWMFT) respectively. The SWMFT included the performance time (SWMFT-Time) and functional ability scale (SWMFT-FAS). The individual growth curve modeling was used to analyze the longitudinal data. Results The recovery curve of TIS, FMA, SWMFT-Time and SWMFT-FAS followed a quadratic trend, with the rate of recovery decreasing from the first to sixth month. As TIS score improved over time, FMA, SWMFT-Time and SWMFT-FAS improved in parallel with the TIS score. TIS at each time point was found to be a significant predictor of FMA, SWMFT-Time and SWMFT-FAS at 6 months post stroke. Conclusion Our work has provided, for the first time, substantial evidence that the pattern of recovery of trunk control is similar to that of the recovery of upper extremity following stroke. In addition, this study provides evidence on which to design a prospective study to evaluate whether improvement in trunk control early post-stroke results in better long-term upper extremity function.

Do somatosensory deficits predict efficacy of neurorehabilitation using neuromuscular electrical stimulation for moderate to severe motor paralysis of the upper limb in chronic stroke?

Background:Various neurorehabilitation programs have been developed to promote recovery from motor impairment of upper extremities. However, the response of patients with chronic-phase stroke varies greatly. Prediction of the treatment response is important to provide appropriate and efficient rehabilitation. This study aimed to clarify whether clinical assessments, such as motor impairments and somatosensory deficits, before treatment could predict the treatment response in neurorehabilitation.Methods:The data from patients who underwent neurorehabilitation using closed-loop electromyography (EMG)-controlled neuromuscular electrical stimulation were retrospectively analyzed. A total of 66 patients with chronic-phase stroke with moderate to severe paralysis were included. The changes from baseline in the Fugl-Meyer Assessment–Upper Extremity (FMA-UE) and the Motor Activity Log-14 (MAL-14) of amount of use (AOU) and quality of movement (QOM) were used to assess treatment response, and multivariate logistic regression analysis was performed using the extracted candidate predictors, such as baseline clinical assessments, to identify predictors of FMA-UE and MAL-14 improvement.Results:FMA-UE and MAL-14 scores improved significantly after the intervention (FMA-UE p < 0.01, AOU p < 0.01, QOM p < 0.01). On multivariate logistic regression analysis, tactile sensory (p = 0.043) and hand function (p = 0.030) were both identified as significant predictors of FMA-UE improvement, tactile sensory (p = 0.047) was a significant predictor of AOU improvement, and hand function (p = 0.026) was a significant predictor of QOM improvement. The regression equations explained 71.2% of the variance in the improvement of FMA-UE, 69.7% of AOU, and 69.7% of QOM.Conclusion:Both motor and tactile sensory impairments predict improvement in motor function, tactile sensory impairment predicts improvement in the amount of paralytic hand use, and motor impairment predicts improvement in the quality of paralytic hand use following neurorehabilitation treatment in patients with moderate to severe paralysis in chronic-phase stroke. These findings may help select the appropriate treatment for patients with more severe paralysis and to maximize the treatment effect.

Usability, functionality, and efficacy of a custom myoelectric elbow-wrist-hand orthosis to assist elbow function in individuals with stroke.

IntroductionAfter stroke, upper limb impairment affects independent performance of activities of daily living. We evaluated the usability, functionality, and efficacy of a myoelectric elbow-wrist-hand orthosis to provide support, limit unsafe motion, and enhance the functional motion of paralyzed or weak upper limbs.MethodsIndividuals with stroke participated in a single-session study to evaluate the device. Ability to activate the device was tested in supported and unsupported shoulder position, as well as the elbow range of motion, ability to maintain elbow position, and ability to lift and hold a range of weights while using the device.ResultsNo adverse events were reported. 71% of users were able to operate the device in all three active myoelectric activation modes (Biceps, Triceps, Dual) during testing. Users were able to hold a range of wrist weights (0.5–2 lbs) for 10–120 seconds, with the largest percentage of participants able to hold weights with the device in Biceps Mode.ConclusionsThe myoelectric elbow-wrist-hand orthosis improved range of motion during use and was efficacious at remediating upper extremity impairment after stroke. All users could operate the device in at least one mode, and most could lift and hold weights representative of some everyday objects using the device.

Hand Focused Upper Extremity Rehabilitation in the Subacute Phase Post-stroke Using Interactive Virtual Environments.

Introduction: Innovative motor therapies have attempted to reduce upper extremity impairment after stroke but have not made substantial improvement as over 50% of people post-stroke continue to have sensorimotor deficits affecting their self-care and participation in daily activities. Intervention studies have focused on the role of increased dosing, however recent studies have indicated that timing of rehabilitation interventions may be as important as dosing and importantly, that dosing and timing interact in mediating effectiveness. This study is designed to empirically test dosing and timing.Methods and Analysis: In this single-blinded, interventional study, subjects will be stratified on two dimensions, impairment level (Fugl-Meyer Upper Extremity Assessment (FM) and presence or absence of Motor Evoked Potentials (MEPs) as follows; (1) Severe, FM score 10–19, MEP+, (2) Severe, FM score 10–19, MEP–, (3) Moderate, FM score 20–49, MEP+, (4) Moderate, FM score 20–49, MEP–. Subjects not eligible for TMS will be assigned to either group 2 (if severe) or group 3 (if moderate). Stratified block randomization will then be used to achieve a balanced assignment. Early Robotic/VR Therapy (EVR) experimental group will receive in-patient usual care therapy plus an extra 10 h of intensive upper extremity therapy focusing on the hand using robotically facilitated rehabilitation interventions presented in virtual environments and initiated 5–30 days post-stroke. Delayed Robotic/VR Therapy (DVR) experimental group will receive the same intervention but initiated 30–60 days post-stroke. Dose-matched usual care group (DMUC) will receive an extra 10 h of usual care initiated 5–30 days post-stroke. Usual Care Group (UC) will receive the usual amount of physical/occupational therapy.Outcomes: There are clinical, neurophysiological, and kinematic/kinetic measures, plus measures of daily arm use and quality of life. Primary outcome is the Action Research Arm Test (ARAT) measured at 4 months post-stroke.Discussion: Outcome measures will be assessed to determine whether there is an early time period in which rehabilitation will be most effective, and whether there is a difference in the recapture of premorbid patterns of movement vs. the development of an efficient, but compensatory movement strategy.Ethical Considerations: The IRBs of New Jersey Institute of Technology, Rutgers University, Northeastern University, and Kessler Foundation reviewed and approved all study protocols. Study was registered in https://ClinicalTrials.gov (NCT03569059) prior to recruitment. Dissemination will include submission to peer-reviewed journals and professional presentations.

Using Transcranial Direct Current Stimulation to Augment the Effect of Motor Imagery-Assisted Brain-Computer Interface Training in Chronic Stroke Patients—Cortical Reorganization Considerations

Introduction: Transcranial direct current stimulation (tDCS) has been shown to modulate cortical plasticity, enhance motor learning and post-stroke upper extremity motor recovery. It has also been demonstrated to facilitate activation of brain-computer interface (BCI) in stroke patients. We had previously demonstrated that BCI-assisted motor imagery (MI-BCI) can improve upper extremity impairment in chronic stroke participants. This study was carried out to investigate the effects of priming with tDCS prior to MI-BCI training in chronic stroke patients with moderate to severe upper extremity paresis and to investigate the cortical activity changes associated with training.Methods: This is a double-blinded randomized clinical trial. Participants were randomized to receive 10 sessions of 20-min 1 mA tDCS or sham-tDCS before MI-BCI, with the anode applied to the ipsilesional, and the cathode to the contralesional primary motor cortex (M1). Upper extremity sub-scale of the Fugl-Meyer Assessment (UE-FM) and corticospinal excitability measured by transcranial magnetic stimulation (TMS) were assessed before, after and 4 weeks after intervention.Results: Ten participants received real tDCS and nine received sham tDCS. UE-FM improved significantly in both groups after intervention. Of those with unrecordable motor evoked potential (MEP-) to the ipsilesional M1, significant improvement in UE-FM was found in the real-tDCS group, but not in the sham group. Resting motor threshold (RMT) of ipsilesional M1 decreased significantly after intervention in the real-tDCS group. Short intra-cortical inhibition (SICI) in the contralesional M1 was reduced significantly following intervention in the sham group. Correlation was found between baseline UE-FM score and changes in the contralesional SICI for all, as well as between changes in UE-FM and changes in contralesional RMT in the MEP- group.Conclusion: MI-BCI improved the motor function of the stroke-affected arm in chronic stroke patients with moderate to severe impairment. tDCS did not confer overall additional benefit although there was a trend toward greater benefit. Cortical activity changes in the contralesional M1 associated with functional improvement suggests a possible role for the contralesional M1 in stroke recovery in more severely affected patients. This has important implications in designing neuromodulatory interventions for future studies and tailoring treatment.Clinical Trial Registration: The study was registered at https://clinicaltrials.gov (NCT01897025).

Kinematic and Somatosensory Gains in Infants with Cerebral Palsy After a Multi-Component Upper-Extremity Intervention: A Randomized Controlled Trial.

Upper extremity (UE) impairments in infants with cerebral palsy (CP) result from reduced quality of motor experiences and "noisy" sensory inputs. We hypothesized that a neuroscience-based multi-component intervention would improve somatosensory processing and motor measures of more-affected (UEs) in infants with CP and asymmetric UE neurologic impairments, while remaining safe for less-affected UEs. Our randomized controlled trial compared infants (6-24months) with CP receiving intervention (N = 37) versus a waitlisted group (N = 36). Treatment effects tested a direct measurement of reach smoothness (3D-kinematics), a measure of unimanual fine motor function (Bayley unimanual fine motor raw scores), and EEG measures of cortical somatosensory processing. The four-week therapist-directed, parent-administered intervention included daily (1) bimanual play; (2) less-affected UE wearing soft-constraint (6h/day, electronically-monitored); (3) reach training on more-affected UE; (4) graduated motor-sensory training; and (5) parent education. Waitlist infants received only bimanual play. Effectiveness and safety were tested; z-scores from 54 posttest-matched typically-developing infants provided benchmarks for treatment effects. Intervention and waitlist infants had no pretest differences. Median weekly constraint wear was 38h; parent-treatment fidelity averaged > 92%. On the more affected side, the intervention significantly increased smoothness of reach (Cohen's d = - 0.90; p < .001) and unimanual fine motor skill (d = 0.35; p = .004). Using unadjusted p values, intervention improved somatosensory processing (d = 0.53; p = .04). All intervention effects referenced well to typically developing children. Safety of the intervention was demonstrated through positive- or non-effects on measurements involving the constrained, less-affected UE and gross motor function; unexpected treatment effects on reach smoothness occurred in less-affected UEs (d = - 0.85; p = .01). This large clinical trial demonstrated intervention effectiveness and safety for developing sensory and motor systems with improvements in reach smoothness, and developmental abilities.Clinical Trail Registration: ClinicalTrials.gov NCT02567630, registered October 5, 2015.

A hybrid model of modified constraint induced movement therapy to improve upper extremity performance in children with unilateral upper extremity paresis: Retrospective case series

Introduction The study aims were to assess impact of an intensive camp-based intervention using a hybrid model of modified constraint induced movement therapy with bimanual therapy in children with upper extremity impairment, and to see if improvements persisted over time. Method Twenty subjects participated. Eight subjects attended camp 2 years in a row, and 12 subjects attended camp only 1 year. The Assisting Hand Assessment and Children’s Hand-use Experience Questionnaire were administered before and after camp. Assisting Hand Assessment and Children’s Hand-use Experience Questionnaire scores were compared between assessments using linear mixed effects models, adjusting for covariates (age and Manual Ability Classification System level) and the repeated measures within subjects. Results Assisting Hand Assessment score improved during the intervention phase for subjects at all Manual Ability Classification System levels ( p ≤ 0.0001). Improvement was maintained long-term at 1 year post. Children’s Hand-use Experience Questionnaire scores for grasp efficacy and time taken were significantly improved during intervention but not maintained at 1 year post. The feeling bothered dimension showed no significant change over time. Conclusion A hybrid model of modified constraint induced movement therapy and bimanual therapy was effective in improving bimanual function for children with varying levels of neurologic hemiparesis, with changes maintained long-term.

Development of Self-Adaptable Mechanism to Compensate Angle-Dependent Flexor Tone of the Elbow Joint Post-stroke: A Pilot Study.

Upper extremity impairments are common among stroke survivors. Robotic devices enable a high-dose of repetitive training for patients, but most systems are confined to the laboratory settings due to their complexity and power requirements. Previously we developed a passive elbow device that can counteract the angle-dependent tone of flexor muscles with hypertonia, but its efficacy was found limited as the increase in passive assistance during elbow extension was found not sufficient to provide assistance to those with more severe impairments. Therefore, in this study, we developed a 'self-adaptable' passive device that adjusts its assistance level based on the movements of patients. In addition to the morphological design to adjust moment arms of the elastic components, we incorporated a self-adaptation mechanism, in which the lengths of the elastic bands were adjusted by a pair of miniature linear motors based on the joint position feedback signals. The capacity of the device was then tested in a pilot testing with two healthy subjects, for whom angle-dependent flexion torque was implemented to simulate flexor hypertonia. The additional adjustment of passive component lengths was found to further increase the elbow extension assistance as the elbow joint extended. The proposed self-adapting mechanism, which does not require any complex control input from the experimenters, can be incorporated with the existing passive device to improve its functional efficacy in home-based training.

Effect of Cognitive Behavioral Therapy on Functional Outcomes in Patients with Stroke

Upper extremity impairment is a common motor deϑicit after a stroke, and 30– 60% of stroke sufferers have disability and inability to use their affected upper extremity in their daily lives. Stroke survivors with cognitive dysfunctions are most likely to be dependent in activities of daily living. Further deterioration is possible as a result of limitation in activities. Psychiatric problems are also common among stroke survivors. This may delay recovery process and further impair cognitive function due to adaptations to unhealthy lifestyles or noncompliance to rehabilitation. Cognitive behavioral training (CBT) increase blood supply to 20% of different brain areas, and facilitation of internancial neurons activity. Cognitive behavioral training (CBT) act as Incentive therapy focuses on active participation, self-esteem, motivational features such as score keeping, and competition. The ultimate objective of physiotherapy is for patients to return to full independence and their former occupations.The purpose of this study was to investigate the effect of cognitive behavioral training on functional outcomes in stroke patients.Forty stroke patients from both sexes participated in this study 20 patients for each group. Random distribution for patients to 2 groups; Group (A) exposed cognitive behavioral therapy for 60 min and selected physical therapy program for 30 min, every other day for 24 sessions, total duration of session (90 min). Control group (B) received the same selected physical therapy program for 60 min, every other day for 24 sessions total duration of session (60 min). Changing in affected upper extremity motor impairment were measured (Dash scale, Wolf scale and Jammar hand dynamometer). The result of our study was improvement of motor functions were signiϑicantly greater in the study group than the control group (p=0.0001).

Effect of Hand Rehabilitation on Hand Grip Strength and Manual Dexterity in Patients with Diabetic Hand Syndrome

Background- In patients with diabetes upper extremity impairments are common. Diabetes patient are more prone to diabetic hand. Aim- To study the effect of hand exercises on hand grip strength and manual dexterity in patients with Diabetic hand .Objectives- To study the effect of hand exercises on hand grip strength in patients with Diabetic hand using Modified sphygmomanometer test. To study the effect of hand exercises dexterity in patients with Diabetic hand using grip ability scale. To study the effect of hand function in patients with Diabetic hand using Michigan hand outcomes questionnaire (MHQ) and Duruoz Hand Index. Setting and design – In this study 15 individual participated having diabetic hand which was selected randomly. Modified sphygmomanometer test was performed on patient to check grip strength. Grip ability scale was performed on patient to check manual dexterity. Hand function was check using Michigan hand outcomes questionnaire (MHQ) and Duruoz Hand Index. The effect of hand exercise on hand grip strength and manual dexterity in patients with diabetic hand was analysied. Result- Total 15 individual participated with age mean 58±13.519 and duration of diabetes with mean 11±6.448. Modified sphygmomanometer test result improved from 28.13±3.044 to 32.47±2.875(p=0.001). Grip ability test result improved from 23.13±3.523 to 18.67±1.345(p=0.001). Michigan hand outcome questionnaire result improved from 53.29±10.19 to 71.34±5.036(p=0.001). Duruoz Hand Index result improved from 31.67±11.2 to13.47±4.596(0.001).Conclusion- There is significant effect of hand exercises on hand grip strength and manual dexterity in patient with diabetic hand.

Upper limb kinematics during the first year after stroke: the stroke arm longitudinal study at the University of Gothenburg (SALGOT)

BackgroundReduction of compensation and improved movement quality indicate recovery after stroke. Since clinical measures alone are often inadequate to distinguish between behavioral recovery and compensation, kinematic analysis of functional tasks has been recommended.ObjectiveTo quantify longitudinal changes and residual deficits in movement performance and quality during the first year after stroke using kinematic analysis of drinking task.MethodsA total of 56 participants with first ever stroke causing upper extremity impairment were extracted from a non-selected stroke unit cohort (Stroke Arm Longitudinal Study at the University of Gothenburg-SALGOT). Participants needed to able to perform the drinking task with the more-affected arm at least on 2 occasions out of 6 (3 days, 10 days, 4 weeks, and 3, 6, and 12 months) during the first year to be included. A cohort of 60 healthy individuals was used as reference. Longitudinal changes were analyzed using linear mixed models.ResultsMovement time, number of movement units, peak angular velocity of the elbow, peak hand velocity, and trunk displacement improved significantly over the first 3 months with a peak at 6 months. Movement time and peak hand velocity reached levels comparable to healthy at 3 months, but number of movement units, peak elbow angular velocity, trunk displacement, and arm abduction remained different from healthy over the first year after stroke.ConclusionsEven when the recovery patterns of kinematics follow the known nonlinear pattern, not all kinematic measures reach the levels in par with healthy controls at one year post stroke. Since the number of movement units, peak angular velocity, trunk displacement, and arm abduction remained impaired over the first year, they might be the most suited measures to distinguish behavioral recovery from compensation strategies.Trial registrationClinicalTrials: NCT01115348. 4 May 2010. Retrospectively registered.

Mental practice for treating upper extremity deficits in individuals with hemiparesis after stroke.

Stroke is caused by the interruption of blood flow to the brain (ischemic stroke) or the rupture of blood vessels within the brain (hemorrhagic stroke) and may lead to changes in perception, cognition, mood, speech, health-related quality of life, and function, such as difficulty walking and using the arm. Activity limitations (decreased function) of the upper extremity are a common finding for individuals living with stroke. Mental practice (MP) is a training method that uses cognitive rehearsal of activities to improve performance of those activities. To determine whether MP improves outcomes of upper extremity rehabilitation for individuals living with the effects of stroke. In particular, we sought to (1) determine the effects of MP on upper extremity activity, upper extremity impairment, activities of daily living, health-related quality of life, economic costs, and adverse effects; and (2) explore whether effects differed according to (a) the time post stroke at which MP was delivered, (b) the dose of MP provided, or (c) the type of comparison performed. We last searched the Cochrane Stroke Group Trials Register on September 17, 2019. On September 3, 2019, we searched the Cochrane Central Register of Controlled Trials (the Cochrane Library), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Scopus, Web of Science, the Physiotherapy Evidence Database (PEDro), and REHABDATA. On October 2, 2019, we searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We reviewed the reference lists of included studies. We included randomized controlled trials (RCTs) of adult participants with stroke who had deficits in upper extremity function (called upper extremity activity). Two review authors screened titles and abstracts of the citations produced by the literature search and excluded obviously irrelevant studies. We obtained the full text of all remaining studies, and both review authors then independently selected trials for inclusion. We combined studies when the review produced a minimum of two trials employing a particular intervention strategy and a common outcome. We considered the primary outcome to be the ability of the arm to be used for appropriate tasks, called upper extremity activity. Secondary outcomes included upper extremity impairment (such as quality of movement, range of motion, tone, presence of synergistic movement), activities of daily living (ADLs), health-related quality of life (HRQL), economic costs, and adverse events. We assessed risk of bias in the included studies and applied GRADE to assess the certainty of the evidence. We completed subgroup analyses for time since stroke, dosage of MP, type of comparison, and type of arm activity outcome measure. We included 25 studies involving 676 participants from nine countries. For the comparison of MP in addition to other treatment versus the other treatment, MP in combination with other treatment appears more effective in improving upper extremity activity than the other treatment without MP (standardized mean difference [SMD] 0.66, 95% confidence interval [CI] 0.39 to 0.94; I² = 39%; 15 studies; 397 participants); the GRADE certainty of evidence score was moderate based on risk of bias for the upper extremity activity outcome. For upper extremity impairment, results were as follows: SMD 0.59, 95% CI 0.30 to 0.87; I² = 43%; 15 studies; 397 participants, with a GRADE score of moderate, based on risk of bias. For ADLs, results were as follows: SMD 0.08, 95% CI -0.24 to 0.39; I² = 0%; 4 studies; 157 participants; the GRADE score was low due to risk of bias and small sample size. For the comparison of MP versus conventional treatment, the only outcome with available data to combine (3 studies; 50 participants) was upper extremity impairment (SMD 0.34, 95% CI -0.33 to 1.00; I² = 21%); GRADE for the impairment outcome in this comparison was low due to risk of bias and small sample size. Subgroup analyses of time post stroke, dosage of MP, or comparison type for the MP in combination with other rehabilitation treatment versus the other treatment comparison showed no differences. The secondary outcome of health-related quality of life was reported in only one study, and no study noted the outcomes of economic costs and adverse events. Moderate-certainty evidence shows that MP in addition to other treatment versus the other treatment appears to be beneficial in improving upper extremity activity. Moderate-certainty evidence also shows that MP in addition to other treatment versus the other treatment appears to be beneficial in improving upper extremity impairment after stroke. Low-certainty evidence suggests that ADLs may not be improved with MP in addition to other treatment versus the other treatment. Low-certainty evidence also suggests that MP versus conventional treatment may not improve upper extremity impairment. Further study is required to evaluate effects of MP on time post stroke, the volume of MP required to affect outcomes, and whether improvement is maintained over the long term.

Optimization of Upper Extremity Rehabilitation by Combining Telerehabilitation With an Exergame in People With Chronic Stroke: Protocol for a Mixed Methods Study.

BackgroundExergames have the potential to provide an accessible, remote approach for poststroke upper extremity (UE) rehabilitation. However, the use of exergames without any follow-up by a health professional could lead to compensatory movements during the exercises, inadequate choice of difficulty level, exercises not being completed, and lack of motivation to pursue exercise programs, thereby decreasing their benefits. Combining telerehabilitation with exergames could allow continuous adjustment of the exercises and monitoring of the participant’s completion and adherence. At present, there is limited evidence regarding the feasibility or efficacy of combining telerehabilitation and exergames for stroke rehabilitation.ObjectiveThis study aims to (1) determine the preliminary efficacy of using telerehabilitation combined with exergames on UE motor recovery, function, quality of life, and motivation in participants with chronic stroke, compared with conventional therapy (the graded repetitive arm supplementary program; GRASP); (2) examine the feasibility of using the technology with participants diagnosed with stroke at home; and (3) identify the obstacles and facilitators for its use by participants diagnosed with stroke and stroke therapists and understand the shared decision-making process.MethodsA mixed methods study protocol is proposed, including a randomized, blinded feasibility trial with an embedded multiple case study. The intervention consists of the provision of a remote rehabilitation program, during which participants will use the Jintronix exergame for UE training and the Reacts Application to conduct videoconferenced sessions with the therapists (physical or occupational therapists). We plan to recruit 52 participants diagnosed with stroke, randomly assigned to a control group (n=26; 2-month on-paper home exercise program: the GRASP with no supervision) and an experimental group (n=26; 2-month home program using the technology). The primary outcome is the Fugl-Meyer UE Assessment, a performance-based measure of UE impairment. The secondary outcomes are self-reported questionnaires and include the Motor Activity Log-28 (quality and frequency of use of the UE), Stroke Impact Scale-16 (the quality of life), and Treatment Self-Regulation Questionnaire (motivation). Feasibility data include process, resources, management, and scientific outcomes. Qualitative data will be collected by interviews with both participants and therapists.ResultsAt present, data collection was ongoing with one participant who had completed the exergame- telerehabilitation based intervention. We expect to collect preliminary efficacy data of this technology on the functional and motor recovery of the UE, following a stroke; collect feasibility data with users at home (adherence, safety, and technical difficulties); and identify the obstacles and facilitators for the technology use and understand the shared decision-making process.ConclusionsThis paper describes the protocol underlying the study of a telerehabilitation-exergame technology to contribute to understanding its feasibility and preliminary efficacy for UE stroke rehabilitation.Trial RegistrationClinicalTrials.gov NCT03759106; http://clinicaltrials.gov/show/NCT03759106.International Registered Report Identifier (IRRID)DERR1-10.2196/14629

A Reaching Performance Scale for 2 Wolf Motor Function Test Items

ObjectiveTo adapt the Reaching Performance Scale for Stroke (RPSS) for the Wolf Motor Function Test (WMFT) “Lift Can” (Can) and “Hand to Box” (Box) items. DesignRetrospective analysis of video-recorded WMFT assessment performed by 3 raters on 2 occasions. SettingNot applicable. ParticipantsParticipants (N=29) with mild to moderate upper extremity impairment less than 3 months after stroke. InterventionsNot applicable. Main Outcome MeasuresInter- and intra-rater agreement, concurrent validity of WMFT-RPSS. ResultsMean ± SD inter-rater Gwet’s agreement coefficient (AC2) was 0.61±0.05 for Can WMFT-RPSS and 0.56 (0.03) for Box. Mean ± SD intra-rater AC2 for Can was 0.63±0.05 and 0.70±0.04 for Box. WMFT-RPSS Can and Box scores correlated with log mean WMFT time (C, -0.73; B, -0.48), Functional Ability Scale (C, 0.87; B, 0.62), Upper Extremity Fugl-Meyer Motor Score (C, 0.69; B, 0.51), and item movement rate (C, 0.74; B, 0.71) (P<.05 for all). Mean ± SD WMFT-RPSS score across the 29 participants was 12.7±3.5 for Can (max score, 19) and 11.4±3.0 for Box (max score, 16). ConclusionsWMFT-RPSS demonstrated moderate intra-rater and weak-to-moderate inter-rater agreement for individuals with mild-moderate impairment. For construct validity, Can and Box WMFT-RPSS were significantly correlated with 4 standardized measures. Average WMFT-RPSS scores revealed that some participants may have relied on compensatory movements to complete the task, a revelation not discernable from movement rate alone. The WMFT-RPSS is potentially useful as a valid and reliable tool to examine longitudinal changes in movement quality after stroke.

Longitudinal changes of self-perceived manual ability the first year after stroke: a cohort study

BackgroundRecovery patterns of motor function and activity capacity of the upper extremity after stroke have been described, but less is known about longitudinal changes of perceived manual activity performance. The aim of this study was to investigate longitudinal changes of self-perceived manual ability at several timepoints from onset until 12 months post-stroke in a cohort of consecutively recruited individuals with mild, moderate and severe stroke.MethodsThe study included 106 participants from a non-selected cohort with first-ever mild, moderate or severe stroke and impaired upper extremity function (Stroke Arm Longitudinal Study at the University of Gothenburg, SALGOT). Self-perceived manual ability was assessed with the ABILHAND Questionnaire at 3 and 10 days, 4 weeks, 3, 6 and 12 months after stroke. Longitudinal change was assessed by linear mixed models (fixed and random effects) and adjusted models were built by adding effects of cofactors age, gender, stroke severity, living condition and affected hand.ResultsSelf-perceived manual ability increased over time the first year after stroke for the total group and the subgroups. The final adjusted model for the total group included fix-effects of time (expected mean change 0.24 logits per month) adjusted by age (− 0.06 per year) and stroke severity (− 0.19 per NIHSS-score). In addition to significant effect of time, the adjusted models for moderate stroke subgroup included fixed effect of age, and for mild and severe subgroups there was an interaction effect between time and age. Further analyses between time-points showed that no significant change of self-perceived manual ability was detected beyond 3 months post-stroke.ConclusionsSelf-perceived manual ability increased over time the first year after stroke, and this change was to some degree modulated by age and stroke severity at onset. Most of the improvements occurred early, predominantly within the first three months after stroke.

Smartphone-based remote assessment of upper extremity function for multiple sclerosis using the Draw a Shape Test

Objective: Smartphone devices may enable out-of-clinic assessments in chronic neurological diseases. We describe the Draw a Shape (DaS) Test, a smartphone-based and remotely administered test of Upper Extremity (UE) function developed for people with multiple sclerosis (PwMS). This work introduces DaS-related features that characterise UE function and impairment, and aims to demonstrate how multivariate modelling of these metrics can reliably predict the 9-Hole Peg Test (9HPT), a clinician-administered UE assessment in PwMS. Approach: The DaS Test instructed PwMS and healthy controls (HC) to trace predefined shapes on a smartphone screen. A total of 93 subjects (HC, n = 22; PwMS, n = 71) contributed both dominant and non-dominant handed DaS tests. PwMS subjects were characterised as those with normal (nPwMS, n = 50) and abnormal UE function (aPwMS, n = 21) with respect to their average 9HPT time (≤ or > 22.7 (s), respectively). L1-regularization techniques, combined with linear least squares (OLS, IRLS), or non-linear support vector (SVR) or random forest (RFR) regression were investigated as functions to map relevant DaS features to 9HPT times. Main results: It was observed that average non-dominant handed 9HPT times were more accurately predicted by DaS features (r2 = 0.41, 0.05; MAE: 2.08 ± 0.34 (s)) than average dominant handed 9HPTs (r2 = 0.39, 0.05; MAE: 2.32 ± 0.43 (s)), using simple linear IRLS ( 0.01). Moreover, it was found that the Mean absolute error (MAE) in predicted 9HPTs was comparable to the variability of actual 9HPT times within HC, nPwMS and aPwMS groups respectively. The 9HPT however exhibited large heteroscedasticity resulting in less stable predictions of longer 9HPT times. Significance: This study demonstrates the potential of the smartphone-based DaS Test to reliably predict 9HPT times and remotely monitor UE function in PwMS.

Designing Occupational Therapy Home Programs for People With Aphasia: Aphasia-Friendly Modifications

Purpose The purpose of this article is to describe aphasia-friendly modification for occupational therapy assessments and home programs aimed at addressing upper extremity impairments for people post stroke. Method This article examines a case study example from a larger study (Wallace, Donoso Brown, Saylor, &amp; Lapp, 2018 ) that implemented aphasia-friendly material modifications into an occupational therapy home program. The participant was a 74-year-old man who survived a left hemisphere cerebrovascular attack 6 years prior to the study. The participant experienced upper extremity hemiparesis and aphasia post stroke and was appropriate for an occupational therapy home exercise program with aphasia-friendly modifications to facilitate comprehension of the home program. Aphasia-friendly modifications (e.g., gestures and visual aids) were made to assessments to support comprehension and participation. To support reading comprehension deficits during completion of the home program, the program materials had aphasia-friendly modifications, such as modified text, supportive images, and reduced cognitive load of exercises. Finally, research team members used supported conversational techniques during all study procedures. Results At the end of the home program, an interview with the participant revealed several outcomes regarding the home program and the aphasia-friendly modifications. The participant reported pictures and reduced text to be beneficial in understanding the instructions. He also indicated that he enjoyed completing the exercises independently (i.e., outside of a therapy office). The participant's motor function demonstrated changes in a positive direction, although not greater than the minimally detectable change for performance-based measures. Conclusions Aphasia-friendly modifications (e.g., modifying text, adding supportive images, and using gestures) were found to be supportive of participation in assessments for and creation of an upper extremity home program. Speech-language pathologists can support the participation of people with aphasia through interprofessional collaboration and consideration of environmental adaptations.

Factors associated with depressive symptoms of carepartners of stroke survivors after discharge from rehabilitation therapy

ABSTRACT Background: The long-term consequences of stroke affect both the carepartner (CP) and stroke survivor (SS). Understanding the effects of informal caregiving that may influence the ability of the family to carry over therapeutic activities in the home environment is critical for family-centered care. Objective: This study examined the relationship of CP and SS factors associated with CP depressive symptoms to gain insights into CP needs that may occur after formal rehabilitation therapy has ended for SS with upper extremity deficits. Methods: This correlational study used baseline data of 32 dyads of family CP and SS with upper extremity impairment who had completed rehabilitation therapy and were enrolled in a pilot study of a web-based CP-integrated rehabilitation program. Data using standard questionnaires for CP factors and SS memory and behavior problems and an objective assessment of SS upper extremity function were obtained. Data analysis included descriptive statistics and Pearson product moment correlations. Results: CPs were female (62.5%), White (61.29%), and spouses (68.75%). CPs reported mild-moderate depressive symptoms (M = 9.5 ± 8.3), and a majority had some degree of family conflict. Higher CP depressive symptoms were related to worse life changes (r = −0.41, p =.02), greater fatigue (r = 0.50, p =.004), less effective family functioning (r = 0.46, p =.01), less autonomy support to SS (r = −0.42, p =.02), and more SS memory and behavior problems (r = 0.45, p =.01). Only CP fatigue was related to SS upper extremity function. Conclusions: Negative impacts of caregiving were found in this group of relatively high physically functioning SS which may hinder CP from providing optimal support for SS. Addressing CP needs including education regarding depression, fatigue, SS memory, and behavior problems, and family functioning while SS is receiving rehabilitation therapy may be important considerations to help facilitate the CP to support the SS in carrying over therapeutic activities in the home environment.

Clinical Examination and Self-Reported Upper Extremity Impairments in Patients with Long-Standing Type 1 Diabetes Mellitus.

Aim The aims of the current study were (1) to determine the prevalence of upper extremity impairments (UEIs) in patients with type 1 diabetes by clinical investigation; (2) to investigate if self-reported impairments were concordant with clinical findings and if key questions could be identified; and (3) to investigate if answers to our self-reported questionnaire regarding UEIs are reliable. Methods Patients with type 1 diabetes were invited to participate in a cross-sectional study of clinical and self-reported (12 items) UEIs in adjunction to ordinary scheduled clinical visit. Before the visit, a questionnaire on UEIs was filled in twice (test-retest) followed by clinical testing at the planned visit. Results In total, 69 patients aged 45 ± 14 years and with diabetes duration 26 ± 15 were included in the study. In the clinical examination, two-thirds (65%) of the patients showed one or more UEI, with failure to perform hand against back as the most common clinical finding (40%) followed by positive Phalen's test (27%), Tinel's test (26%), and Prayer's sign (24%). UEIs observed by clinical examination were often bilateral, and multiple impairments often coexisted. Self-reported shoulder stiffness was associated with impaired shoulder mobility and with Prayer's sign. Self-reported reduced hand strength was associated to lower grip force, Prayer's sign, trigger finger, fibrosis string structures, and reduced thenar strength as well as reduced shoulder mobility. In addition, self-reporting previous surgery of carpal tunnel and trigger finger was associated with several clinical UEIs including shoulder, hand, and finger. The test-retest of the questionnaire showed a high agreement of 80-98% for reported shoulder, hand, and finger impairments. Conclusion UEIs are common in type 1 diabetes. Self-reported shoulder stiffness and reduced hand strength might be used to capture patients with UEIs in need of clinical investigation and enhanced preventive and therapeutic strategies, as well as rehabilitative interventions.

8 Degrees of freedom human lower extremity kinematic and dynamic model development and control for exoskeleton robot based physical therapy

The World Health Organization reports that approximately 15% of the world’s population is disabled. Physiotherapy helps promote functional recovery in upper and lower extremity impairment. An exoskeleton robot-based exercise tool for neurorehabilitation is an appealing solution to treat many disabled people. Knowledge of anatomical characteristics and anthropometrical properties are equally important for mechanical design, as well as modeling, and control of exoskeleton robots. However, most of the anthropometrical data is not readily available from a single source. Additionally, eight degrees of freedom human lower extremity kinematic and dynamic models are also not available. This paper presents dynamic modeling and simulation of the human lower extremity (HLE). A comprehensive review of HLE anatomical characteristics, degrees of freedom, and range of motion of various joints are presented. The Lagrange energy method is used for developing the dynamic model. The developed model includes both linear and rotational displacements of the knee joint. The dynamic simulation uses a sliding mode controller. Simulation results show the performance of the controller, joint torque, and power requirements for tracking specified trajectories. It is also shown that sliding mode control (SMC) is a robust control scheme that works effectively even in the presence of external disturbances and parameter variations. The simulation results indicate that SMC is a suitable choice for controlling a physical exoskeleton robot.