Ching-yi Wu

A kinematic study of contextual effects on reaching performance in persons with and without stroke: influences of object availability.

OBJECTIVE To examine the effects of context on reaching performance in neurologically impaired and intact populations. Context was varied by the presence or absence of objects used to complete a task. DESIGN A counterbalanced repeated-measures design. SETTING A motor control laboratory in a university setting. PARTICIPANTS Fourteen persons with stroke and 25 neurologically intact adults. INTERVENTIONS Each participant was tested under two conditions: the presence of the object, in which the participant reached forward with the impaired arm (or corresponding arm) to scoop coins off the table into the other hand; and the absence of the object, in which the participant reached forward to the place where the coins would be placed in the condition of object present. MAIN OUTCOME MEASURES Kinematic Variables of movement time, total displacement, peak velocity, percentage of reach where peak velocity occurs, and movement units (derived from acceleration data) for reaching tasks. RESULTS The condition of using real objects elicited kinematically better performance of reaching movements than the condition of performing movements without relevant objects present. Better performance was reflected by shorter movement time, less total displacement, higher peak velocity, greater percentage of reach where peak velocity occurs, and fewer movement units. CONCLUSION The results of this study showed that the condition of object present elicited better performance of movements represented by kinematic variables than the condition of object absent. The clinical implication is that the use of real and functional objects might be an effective way of facilitating efficient, smooth, and coordinated movement with the impaired arm in persons with stroke. This study, however, should be replicated and extended to confirm the validity of its findings and to allow for generalization in various functional activities.

Responsiveness and Validity of Three Outcome Measures of Motor Function After Stroke Rehabilitation

Background and Purpose— This study investigated and compared the responsiveness and validity of the Fugl-Meyer Assessment (FMA), the Action Research Arm Test (ARAT), and the Wolf Motor Function Test (WMFT) for patients after stroke rehabilitation. Methods— A total of 57 patients with stroke received 1 of 3 rehabilitation treatments for 3 weeks. At pretreatment and posttreatment, the 3 outcome measures, as well as the Functional Independence Measure (FIM) as the external criterion, were administered. The standardized response mean (SRM) and the Wilcoxon signed rank test were used to examine the responsiveness. Construct validity and predictive validity were examined by the Spearman correlation coefficient (&rgr;). Results— The responsiveness of the FMA, ARAT, and WMFT functional ability scores was large (SRM=0.95–1.42), whereas the WMFT performance time score was small (SRM=0.38). The responsiveness of the FMA was significantly larger than those of the ARAT and the WMFT-TIME, but not the WMFT functional ability scores. With respect to construct validity, correlations between the FMA and other measures were relatively high (&rgr;=0.42–0.76). The FMA and the WMFT performance time scores at pretreatment had moderate predictive validity with the FIM scores at posttreatment (&rgr;=0.42–0.47). In addition, the ARAT and the WMFT functional ability scores revealed a low predictive validity with the FIM (&rgr;=0.17–0.26). Conclusions— The results support the FMA and the WMFT-FAS are suitable to detect changes over time for patients after stroke rehabilitation. While simultaneously considering the responsiveness and validity attributes, the FMA may be a relatively sound measure of motor function for stroke patients based on our results. Further research based on a larger sample is needed to replicate the findings.

Effects of Constraint-Induced Therapy Versus Bilateral Arm Training on Motor Performance, Daily Functions, and Quality of Life in Stroke Survivors

Background and Objective. This study investigated the relative effects of distributed constraint-induced therapy (CIT) and bilateral arm training (BAT) on motor performance, daily function, functional use of the affected arm, and quality of life in patients with hemiparetic stroke. Methods. A total of 60 patients were randomized to distributed CIT, BAT, or a control intervention of less specific but active therapy. Each group received intensive training for 2 hours/day, 5 days/week, for 3 weeks. Pretreatment and posttreatment measures included the Fugl—Meyer Assessment (FMA), Functional Independence Measure (FIM), Motor Activity Log (MAL), and Stroke Impact Scale (SIS). The proximal and distal scores of FMA were used to examine separate upper limb (UL) elements of movement. Results . The distributed CIT and BAT groups showed better performance in the overall and the distal part score of the FMA than the control group. The BAT group exhibited greater gains in the proximal part score of the FMA than the distributed CIT and control groups. Enhanced performance was found for the distributed CIT group in the MAL, the subtest of locomotion in the FIM, and certain domains of the SIS (eg, ADL/IADL). Conclusion. BAT may uniquely improve proximal UL motor impairment. In contrast, distributed CIT may produce greater functional gains for the affected UL in subjects with mild to moderate chronic hemiparesis.

Effects of modified constraint-induced movement therapy on reach-to-grasp movements and functional performance after chronic stroke: a randomized controlled study

Objective: To evaluate changes in (1) motor control characteristics of the hemiparetic hand during the performance of a functional reach-to-grasp task and (2) functional performance of daily activities in patients with stroke treated with modified constraint-induced movement therapy. Design: Two-group randomized controlled trial with pretreatment and posttreatment measures. Setting: Rehabilitation clinics. Subjects: Thirty-two chronic stroke patients (21 men, 11 women; mean age=57.9 years, range=43—81 years) 13—26 months (mean 16.3 months) after onset of a first-ever cerebrovascular accident. Intervention: Thirty-two patients were randomized to receive modified constraint-induced movement therapy (restraint of the unaffected limb combined with intensive training of the affected limb) or traditional rehabilitation for three weeks. Main measures: Kinematic analysis was used to assess motor control characteristics as patients reached to grasp a beverage can. Functional outcomes were evaluated using the Motor Activity Log and Functional Independence Measure. Results: There were moderate and significant effects of modified constraint-induced movement therapy on some aspects of motor control of reach-to-grasp and on functional ability. The modified constraint-induced movement therapy group preplanned reaching and grasping (P=0.018) more efficiently and depended more on the feedforward control of reaching (P=0.046) than did the traditional rehabilitation group. The modified constraint-induced movement therapy group also showed significantly improved functional performance on the Motor Activity Log (P<0.0001) and the Functional Independence Measure (P=0.016). Conclusions: In addition to improving functional use of the affected arm and daily functioning, modified constraint-induced movement therapy improved motor control strategy during goal-directed reaching, a possible mechanism for the improved movement performance of stroke patients undergoing this therapy.

Gait performance with compensatory adaptations in stroke patients with different degrees of motor recovery.

Chen CL, Chen HC, Tang SFT, Wu CY, Cheng PT, Hong WH: Gait performance with compensatory adaptations in stroke patients with different degrees of motor recovery. Am J Phys Med Rehabil 2003;82:925–935. ObjectiveGait patterns vary among stroke patients. This study attempted to discover gait performance with compensatory adaptations in stroke patients with different degrees of motor recovery. DesignData were gathered from 35 stroke patients and 15 healthy subjects. Gait performance and motor recovery were assessed 6 mos after stroke. Stroke patients further were divided into poor and good groups. The walking velocity was correlated with Brunnström’s stages, and the temporal stride and motion variables of the two groups were compared. ResultsWalking velocity was positively correlated with the Brunnström’s stages of the proximal lower limb. The poor group displayed slower walking velocity and shorter single-support time compared with the good group. Both groups displayed low maximum excursion of hip extension and ankle plantarflexion during the stance phase and low maximum excursion of hip and knee flexion and ankle dorsiflexion during the swing phase. Moreover, both groups displayed excessive pelvic tilts during the stance and swing phases. However, the poor group displayed different pelvic motion and timing sequences to each peak joint angle from normal subjects and the good group. Peak hip and knee angles of the affected limb during the stance phase occurred almost simultaneously in this group. ConclusionsSelective control of the proximal lower limb may be the main determinant of walking velocity. The compensatory adaptations were similar, except for pelvic motion, in stroke patients with different levels of motor recovery, whereas the poor group walked with synergistic mass patterns and reduced stability.

Randomized Trial of Distributed Constraint-Induced Therapy Versus Bilateral Arm Training for the Rehabilitation of Upper-Limb Motor Control and Function After Stroke

Background and Objective. This study compared the efficacy of distributed constraint-induced therapy (dCIT), bilateral arm training (BAT), and control treatment (CT) on motor control and functional performance of the upper limb in stroke patients. Methods. A total of 66 patients with mean stroke onset of 16.20 months and mild to moderate motor impairment were randomized to dCIT, BAT, or CT groups. Each group received treatment for 2 h/d and 5 d/wk for 3 weeks. Pretreatment and posttreatment measures included reaching kinematic variables in unilateral and bilateral tasks, the Wolf Motor Function Test (WMFT), and the Motor Activity Log (MAL). Results. The dCIT and BAT groups had smoother reaching trajectories in the unilateral and bilateral tasks than the CT group. The BAT group, but not the dCIT group, generated greater force at movement initiation than the CT group during the unilateral and bilateral tasks. The dCIT patients had decreased WMFT time and higher functional ability scores than the CT patients. MAL results pointed to better performance in the amount and quality of use of the affected arm than BAT and CT patients. Conclusions. BAT and dCIT exhibited similar beneficial effects on movement smoothness but differential effects on force at movement initiation and functional performance. Therefore, BAT is a better option if improvement of force generation is the treatment goal, and dCIT is more appropriate for improving functional ability and use of the affected arm in daily life. These findings may assist in the planning of individually tailored rehabilitation therapies.

Constraint-induced therapy versus dose-matched control intervention to improve motor ability, basic/extended daily functions, and quality of life in stroke.

Background. Trials of constraint-induced movement therapy (CIT) to improve upper extremity function after stroke have usually not included an actively treated control group. Objective. This study compared a modified CIT intervention with a dose-matched control intervention that included restraint of the less affected hand and assessed for differences in motor and functional performance and health-related quality of life. Methods. This 2-group randomized controlled trial, using pretreatment and posttreatment measures, enrolled 32 patients within 6 to 40 months after onset of a first stroke (mean age, 55.7 years). They received either CIT (restraint of the less affected limb combined with intensive training of the affected limb for 2 hours daily 5 days per week for 3 weeks and restraint of the less affected hand for 5 hours outside of the rehabilitation training) or a conventional intervention with hand restraint for the same duration. Outcome measures were the Fugl-Meyer Assessment, Functional Independence Measure, Motor Activity Log, Nottingham Extended Activities of Daily Living Scale, and Stroke Impact Scale. Results. Compared with the control group, the CIT group exhibited significantly better performance in motor function, level of functional independence, mobility of extended activities during daily life, and health-related quality of life after treatment. Conclusions. The robust effects of this form of CIT were demonstrated in various aspects of outcome, including motor function, basic and extended functional ability, and quality of life.

Effects of robot-assisted upper limb rehabilitation on daily function and real-world arm activity in patients with chronic stroke: a randomized controlled trial

Objective: To compare the outcome of robot-assisted therapy with dose-matched active control therapy by using accelerometers to study functional recovery in chronic stroke patients. Design: Prospective, randomized, controlled trial. Setting: Stroke units in three medical centres. Subjects: Twenty patients post stroke for a mean of 22 months. Intervention: Robot-assisted therapy (n = 10) or dose-matched active control therapy (n = 10). All patients received either of these two therapies for 90–105 minutes each day, 5 days per week, for four weeks. Main measures: Outcome measures included arm activity ratio (the ratio of mean activity between the impaired and unimpaired arm) and scores on the Fugl-Meyer Assessment Scale, Functional Independence Measure, Motor Activity Log and ABILHAND questionnaire. Results: The robot-assisted therapy group significantly increased motor function, hemiplegic arm activity and bilateral arm coordination (Fugl-Meyer Assessment Scale: 51.20 ± 8.82, P = 0.002; mean arm activity ratio: 0.76 ± 0.10, P = 0.026; ABILHAND questionnaire: 1.24 ± 0.28, P = 0.043) compared with the dose-matched active control group (Fugl-Meyer Assessment Scale: 40.90 ± 13.14; mean arm movement ratio: 0.69 ± 0.11; ABILHAND questionnaire: 0.95 ± 0.43). Conclusions: Symmetrical and bilateral robotic practice, combined with functional task training, can significantly improve motor function, arm activity, and self-perceived bilateral arm ability in patients late after stroke.

Minimal detectable change and clinically important difference of the Stroke Impact Scale in stroke patients.

Objectives. The purpose of this study was to establish the minimal detectable change (MDC) and clinically important differences (CIDs) of the physical domains of the Stroke Impact Scale (SIS) and to assess the proportions of patients’ change scores exceeding the MDC and CIDs after stroke rehabilitation. Methods. Seventy-four patients received 1 of 3 treatments for 3 weeks and underwent clinical assessment before and after treatment. The MDC was calculated from the standard error of measurement to indicate a real change with 95% confidence for individual patients (MDC95). Anchor-based and distribution-based approaches were adopted to triangulate the ranges of minimal CIDs. The percentage of patients exceeding MDC95 and minimal CIDs were also calculated. Results. The MDC95 of the strength, activities of daily living/instrumental activities of daily living, mobility, and hand function subscales were 24.0, 17.3, 15.1, and 25.9, respectively. The respective minimal CIDs for these 4 subscales were 9.2, 5.9, 4.5, and 17.8 points, respectively, and the MDC95 and CID proportions were 14% to 43%, 16% to 49%, 10% to 50%, and 23% to 64%, respectively. Conclusions . The change score of an individual patient has to reach 24.0, 17.3, 15.1, and 25.9 on the 4 subscales to indicate a true change. The mean change scores of a stroke group on the 4 subscales should reach 9.2, 5.9, 4.5, and 17.8 points to be regarded as clinically important changes. Future research with larger sample sizes is warranted to validate these estimates.

Influence of heel height and shoe insert on comfort perception and biomechanical performance of young female adults during walking

Background: The possible negative effects of high-heeled shoes on subjective comfort perception and objective biomechanical assessment have been noted. Although shoe inserts have been widely applied in footwear to increase comfort and to reduce the frequency of movement-related injury, no study has attempted to identify insert effectiveness in high heels. The purpose of this study was to determine the effects of heel height and shoe inserts on comfort and biomechanics as represented by plantar pressure and ground reaction force (GRF). Methods: Twenty young female adults performed the test conditions formed by the cross-matching of shoe inserts (shoe without insert and shoe with total contact insert [TCI]) and heel height (a flat, a low heel [3.8 cm] and a high heel [7.6 cm]). Two-way analyses of variance for repeated measures design were used to test condition effects on comfort rating, plantar pressure, and GRF during gait. To determine the biomechanical variables that can predict comfort, a multiple linear regression with stepwise method was done. Results: The results showed that discomfort increased with heel height. In high heels, the plantar pressure in the heel and midfoot shifted to the medial forefoot, and the vertical and anteroposterior GRF increased. Use of the TCI reduced the peak pressure in the medial forefoot. Interestingly, the effectiveness of the TCI was greater in the higher heels than in the lower heels and in flat heels. The peak pressure in the medial forefoot, impact force, and the first peak vertical GRF could explain 75.6% of the variance of comfort in high-heeled gait. Conclusions: These findings suggest that higher heels result in decreased comfort, which can be reflected by both the subjective rating scale and biomechanical variables. Use of a TCI altered the biomechanics and therefore improved the comfort in high-heeled shoes.