Annick Timmermans

Technology-assisted training of arm-hand skills in stroke: concepts on reacquisition of motor control and therapist guidelines for rehabilitation technology design

BackgroundIt is the purpose of this article to identify and review criteria that rehabilitation technology should meet in order to offer arm-hand training to stroke patients, based on recent principles of motor learning.MethodsA literature search was conducted in PubMed, MEDLINE, CINAHL, and EMBASE (1997–2007).ResultsOne hundred and eighty seven scientific papers/book references were identified as being relevant. Rehabilitation approaches for upper limb training after stroke show to have shifted in the last decade from being analytical towards being focussed on environmentally contextual skill training (task-oriented training). Training programmes for enhancing motor skills use patient and goal-tailored exercise schedules and individual feedback on exercise performance. Therapist criteria for upper limb rehabilitation technology are suggested which are used to evaluate the strengths and weaknesses of a number of current technological systems.ConclusionThis review shows that technology for supporting upper limb training after stroke needs to align with the evolution in rehabilitation training approaches of the last decade. A major challenge for related technological developments is to provide engaging patient-tailored task oriented arm-hand training in natural environments with patient-tailored feedback to support (re) learning of motor skills.

Influence of Task-Oriented Training Content on Skilled Arm-Hand Performance in Stroke: A Systematic Review

Objective. This review evaluates the underlying training components currently used in task-oriented training and assesses the effects of these components on skilled arm—hand performance in patients after a stroke. Methods. A computerized systematic literature search in 5 databases (PubMed, CINAHL, EMBASE, PEDro, and Cochrane) identified randomized clinical trials, published through March 2009, evaluating the effects of task-oriented training. Relevant article references listed in publications included were also screened. The methodological quality of the selected studies was assessed with the Van Tulder Checklist. For each functional outcome measure used, the effect size (bias corrected Hedges’s g) was calculated. Results. The intervention results in 528 patients (16 studies) were studied. From these, 15 components were identified to characterize task-oriented training. An average of 7.8 (standard deviation = 2.1) components were used in the included trials. There was no correlation between the number of task-oriented training components used in a study and the treatment effect size. “Distributed practice” and “feedback” were associated with the largest postintervention effect sizes. “Random practice” and “use of clear functional goals” were associated with the largest follow-up effect sizes. Conclusion. The task-oriented training was operationalized with 15 components. The number of components used in an intervention aimed at improving arm—hand performance after stroke was not associated with the posttreatment effect size. Certain components, which optimize storage of learned motor performance in the long-term memory, occurred more in studies with larger treatment effects.

Valid and reliable instruments for arm-hand assessment at ICF activity level in persons with hemiplegia: a systematic review

BackgroundLoss of arm-hand performance due to a hemiparesis as a result of stroke or cerebral palsy (CP), leads to large problems in daily life of these patients. Assessment of arm-hand performance is important in both clinical practice and research. To gain more insight in e.g. effectiveness of common therapies for different patient populations with similar clinical characteristics, consensus regarding the choice and use of outcome measures is paramount. To guide this choice, an overview of available instruments is necessary. The aim of this systematic review is to identify, evaluate and categorize instruments, reported to be valid and reliable, assessing arm-hand performance at the ICF activity level in patients with stroke or cerebral palsy.MethodsA systematic literature search was performed to identify articles containing instruments assessing arm-hand skilled performance in patients with stroke or cerebral palsy. Instruments were identified and divided into the categories capacity, perceived performance and actual performance. A second search was performed to obtain information on their content and psychometrics.ResultsRegarding capacity, perceived performance and actual performance, 18, 9 and 3 instruments were included respectively. Only 3 of all included instruments were used and tested in both patient populations. The content of the instruments differed widely regarding the ICF levels measured, assessment of the amount of use versus the quality of use, the inclusion of unimanual and/or bimanual tasks and the inclusion of basic and/or extended tasks.ConclusionsAlthough many instruments assess capacity and perceived performance, a dearth exists of instruments assessing actual performance. In addition, instruments appropriate for more than one patient population are sparse. For actual performance, new instruments have to be developed, with specific focus on the usability in different patient populations and the assessment of quality of use as well as amount of use. Also, consensus about the choice and use of instruments within and across populations is needed.

Arm and hand skills: Training preferences after stroke

Purpose. An increasing demand for training after stroke has brought about the need to develop rehabilitation technology. This article reports an inquiry into skill preferences of persons after stroke regarding arm–hand training and examines the relationship between the use of the affected arm and the patients training preference. Method. Data collection involved a semi-structured interview of 20 persons in the subacute and 20 persons in the chronic stage after stroke, based on an adaptation of the motor activity log. Results. Subacute and chronic patients after stroke agreed on seven out of 10 most preferred training skills. Patient preferences related mostly to ‘manipulation in combination with positioning’ and ‘manipulation’. Eight motivation aspects for skill training were identified as being important. A positive correlation was found between skill preference scores and use of the impaired arm (r = 0.64) (p < 0.001). Conclusions. This study has resulted in an inventory of skills that persons after stroke prefer to train on. This list can be used for implementation of exercises in rehabilitation technology. Motivation for skill training pertains to optimising participation level, rather than function or activity level. This study suggests that client-centred assessment is advocated to set therapy goals that match patient training preferences.

Effects of task-oriented robot training on arm function, activity, and quality of life in chronic stroke patients: a randomized controlled trial

BackgroundOver fifty percent of stroke patients experience chronic arm hand performance problems, compromising independence in daily life activities and quality of life. Task-oriented training may improve arm hand performance after stroke, whereby augmented therapy may lead to a better treatment outcome. Technology-supported training holds opportunities for increasing training intensity. However, the effects of robot-supported task-oriented training with real life objects in stroke patients are not known to date. The aim of the present study was to investigate the effectiveness and added value of the Haptic Master robot combined with task-oriented arm hand training in chronic stroke patients.MethodsIn a single-blind randomized controlled trial, 22 chronic stroke patients were randomly allocated to receive either task-oriented robot-assisted arm-hand training (experimental group) or task-oriented non-robotic arm-hand training (control group). For training, the T-TOAT (Technology-supported Task-Oriented Arm Training) method was applied. Training was provided during 8xa0weeks, 4 times/week, 2× 30xa0min/day.ResultsA significant improvement after training on the Action Research Arm Test (ARAT) was demonstrated in the experimental group (pu2009=u20090.008). Results were maintained until 6xa0months after cessation of the training. On the perceived performance measure (Motor Activity Log (MAL)), both, the experimental and control group improved significantly after training (control group pu2009=u20090.008; experimental group pu2009=u20090.013). The improvements on MAL in both groups were maintained until 6xa0months after cessation of the training. With regard to quality of life, only in the control group a significant improvement after training was found (EuroQol-5D pu2009=u20090.015, SF-36 physical pu2009=u20090.01). However, the improvement on SF-36 in the control group was not maintained (pu2009=u20090.012). No between-group differences could be demonstrated on any of the outcome measures.ConclusionArm hand performance improved in chronic stroke patients, after eight weeks of task oriented training. The use of a Haptic Master robot in support of task-oriented arm training did not show additional value over the video-instructed task-oriented exercises in highly functional stroke patients.Clinical trial registration informationCurrent Controlled Trials ISRCTN82787126

Motor training programs of arm and hand in patients with MS according to different levels of the ICF: a systematic review

BackgroundThe upper extremity plays an important role in daily functioning of patients with Multiple Sclerosis (MS) and strongly influences their quality of life. However, an explicit overview of arm-hand training programs is lacking. The present review aims to investigate the training components and the outcome of motor training programs for arm and hand in MS.MethodsA computerized systematic literature search in 5 databases (PubMed, CINAHL, EMBASE, PEDro and Cochrane) was performed using the following Mesh terms: Multiple Sclerosis, Rehabilitation, Physical Education and Training, Exercise, Patient-Centered Care, Upper Extremity, Activities of Daily Living, Motor Skills, Motor Activity, Intervention Studies and Clinical Trial. The methodological quality of the selected articles was scored with the Van Tulder Checklist. A descriptive analyses was performed using the PICO principle, including scoring of training components with the calculation of Hedges’g effect sizes.ResultsEleven studies were eligible (mean Van Tulder-scoreu2009=u200910.82(SD2.96)). Most studies reported a specific improvement in arm hand performance at the ICF level that was trained at. The mean number of training components was 5.5(SD2.8) and a significant correlation (ru2009=u20090.67; pu2009<u20090.05) between the number of training components and effect sizes was found. The components ‘client-centered’ and ‘functional movement’ were most frequently used, whereas ‘distribution based practice’, ‘feedback’ and ‘random practice’ were never used. The component ‘exercise progression’ was only used in studies with single ICF body function training, with the exception of 1 study with activity level training. Studies including the component ‘client-centred’ demonstrated moderate to high effect sizes.ConclusionMotor training programs (both at the ICF body function and activity level) have shown to improve arm and hand performance in MS in which the value of the training specificity was emphasized. To optimize upper extremity training in MS the component ‘client-centred’ and ‘exercise progression’ may be important. Furthermore, given the importance attributed to the components ‘distribution based practice’, ‘feedback’ and ‘random practice’ in previous research in stroke patients, the use of these components in arm hand training should be explored in future research.

Effect of Mental Practice on the Improvement of Function and Daily Activity Performance of the Upper Extremity in Patients With Subacute Stroke: A Randomized Clinical Trial

OBJECTIVESnMore than 50% of patients with upper limb paresis after stroke face long-term impaired arm function and ensuing disability in daily life. This study aims to evaluate the effectiveness of a task-oriented mental practice (MP) approach as an addition to regular arm-hand therapy in patients with subacute stroke.nnnMETHODSnA multicenter, prospective, single-blind, randomized clinical trial was performed. Patients trained for 6 weeks, at least 3 times per day. In the experimental group, patients performed video-instructed MP. In the control group, patients performed neurodevelopmental therapy-based exercise therapy. The primary outcome measures are Fugl-Meyer test, Frenchay arm test, Wolf motor function test, and accelerometry.nnnRESULTSnThe patients did improve over time on Fugl-Meyer test and Wolf motor function test in both the control and the experimental group. A significant improvement on the Frenchay arm test was found after training (which was maintained at 12-month follow-up) only in the experimental group. However, no difference in training effects between groups was demonstrated.nnnCONCLUSIONSnTraining effects were demonstrated after MP training in patients with subacute stroke. However, the results of this study do not corroborate the hypothesis that the use of MP in addition to therapy as usual in patients with subacute stroke has an additional effect over neurodevelopmental therapy in addition to therapy as usual.

T-TOAT: A method of task-oriented arm training for stroke patients suitable for implementation of exercises in rehabilitation technology

Task-oriented training improves skilled arm-hand performance after stroke. Exercises for skill training are however not easy to implement in rehabilitation technology, especially for complex skills that involve object manipulation. In this paper, a skill training method, suitable for technology-supported training of arm-hand performance after stroke is presented. A sensor-based and robotic system in which the training method is used, are described.

Us'em: The user-centered design of a device for motivating stroke patients to use their impaired arm-hand in daily life activities

Stroke leaves the majority of its survivors with an impairment of the upper extremity that affects their ability to live independently and their quality of life. Rehabilitation research shows that practice of everyday life activities in a natural context may sustain or even improve arm-hand performance, even during chronic stages after stroke. Based on this insight we designed, developed and evaluated Usem; this consists of two watch-like accelerometry devices that provide feedback to stroke patients regarding the usage of their impaired versus their non-affected upper extremity. System usability and treatment credibility/expectancy were evaluated positively by therapists and patients.

Accelerometry Measuring the Outcome of Robot-Supported Upper Limb Training in Chronic Stroke: A Randomized Controlled Trial

Purpose This study aims to assess the extent to which accelerometers can be used to determine the effect of robot-supported task-oriented arm-hand training, relative to task-oriented arm-hand training alone, on the actual amount of arm-hand use of chronic stroke patients in their home situation. Methods This single-blind randomized controlled trial included 16 chronic stroke patients, randomly allocated using blocked randomization (nu200a=u200a2) to receive task-oriented robot-supported arm-hand training or task-oriented (unsupported) arm-hand training. Training lasted 8 weeks, 4 times/week, 2×30 min/day using the (T-)TOAT ((Technology-supported)-Task-Oriented-Arm-Training) method. The actual amount of arm-hand use, was assessed at baseline, after 8 weeks training and 6 months after training cessation. Duration of use and intensity of use of the affected arm-hand during unimanual and bimanual activities were calculated. Results Duration and intensity of use of the affected arm-hand did not change significantly during and after training, with or without robot-support (i.e. duration of use of unimanual use of the affected arm-hand: median difference of −0.17% in the robot-group and −0.08% in the control group between baseline and after training cessation; intensity of the affected arm-hand: median difference of 3.95% in the robot-group and 3.32% in the control group between baseline and after training cessation). No significant between-group differences were found. Conclusions Accelerometer data did not show significant changes in actual amount of arm-hand use after task-oriented training, with or without robot-support. Next to the amount of use, discrimination between activities performed and information about quality of use of the affected arm-hand are essential to determine actual arm-hand performance. Trial Registration Controlled-trials.com ISRCTN82787126