Christine T. Shiner

Two Common Tests of Dexterity Can Stratify Upper Limb Motor Function After Stroke

Background. Neurological deficits after a stroke are commonly classified according to motor function for clinical decision making regarding discharge and rehabilitation. Participants in clinical stroke studies are also stratified by motor function to avoid a sampling bias. Objective. This post hoc analysis examined a suite of upper limb functional assessment tools to test the hypothesis that motor function of survivors of stroke can be stratified using 2 simple tests of manual dexterity despite the heterogeneity of the population. Methods. The functional ability of the more affected hand and arm was assessed for 67 hemiparetic patients, aged 18 to 83 years (mean ± standard deviation, 59.8 ± 14.0 years), at 1 to 264 months after a stroke (23.6 ± 39.6 months) using the Wolf Motor Function Test (WMFT), upper limb motor Fugl-Meyer Assessment (F-M), Box and Block Test (BBT), grooved pegboard test, and wrist range of motion. We tested the strength of our proposed stratification scheme with a hypothesis-driven hierarchical cluster analysis using standardized raw scores and dichotomous BBT and grooved pegboard test values. Results. The most salient discriminator between low and higher motor function was the ability to move >1 block on the BBT. Within the higher function group, the ability to place all 25 pegs on the grooved pegboard test discriminated between moderate and high motor function. The derived scheme was congruent with clinical observations. The WMFT timed tasks, F-M scores, and range of motion did not discriminate functional groups. Conclusions. Two simple unambiguous and objective tests of gross (BBT) and fine (grooved pegboard test) manual dexterity discriminated 3 groups of motor function ability for a heterogeneous group of patients after stroke.

The efficacy of Wii-based Movement Therapy for upper limb rehabilitation in the chronic poststroke period: a randomized controlled trial.

Background More effective and efficient rehabilitation is urgently needed to address the prevalence of unmet rehabilitation needs after stroke. This study compared the efficacy of two poststroke upper limb therapy protocols. Aims and/or hypothesis We tested the hypothesis that Wii-based movement therapy would be as effective as modified constraint-induced movement therapy for post-stroke upper-limb motor rehabilitation. Methods Forty-one patients, 2–46 months poststroke, completed a 14-day program of Wii-based Movement Therapy or modified Constraint-induced Movement Therapy in a dose-matched, assessor-blinded randomized controlled trial, conducted in a research institute or patients homes. Primary outcome measures were the Wolf Motor Function Test timed-tasks and Motor Activity Log Quality of Movement scale. Patients were assessed at prebaseline (14 days pretherapy), baseline, post-therapy, and six-month follow-up. Data were analyzed using linear mixed models and repeated measures analysis of variance. Results There were no differences between groups for either primary outcome at any time point. Motor function was stable between prebaseline and baseline (P > 0·05), improved with therapy (P < 0·001); and improvements were maintained at six-months (P > 0·05). Wolf Motor Function Test timed-tasks log times improved from 2·1 ± 0·22 to 1·7 ± 0·22 s after Wii-based Movement Therapy, and 2·6 ± 0·23 to 2·3 ± 0·24 s after modified Constraint-induced Movement Therapy. Motor Activity Log Quality of Movement scale scores improved from 67·7 ± 6·07 to 102·4 ± 6·48 after Wii-based Movement Therapy and 64·1 ± 7·30 to 93·0 ± 5·95 after modified Constraint-induced Movement Therapy (mean ± standard error of the mean). Patient preference, acceptance, and continued engagement were higher for Wii-based Movement Therapy than modified Constraint-induced Movement Therapy. Conclusions This study demonstrates that Wii-based Movement Therapy is an effective upper limb rehabilitation poststroke with high patient compliance. It is as effective as modified Constraint-induced Movement Therapy for improving more affected upper limb movement and increased independence in activities of daily living.

Bilateral priming before wii-based movement therapy enhances upper limb rehabilitation and its retention after stroke: a case-controlled study.

Background. Motor deficits after a stroke are thought to be compounded by the development of asymmetric interhemispheric inhibition. Bilateral priming was developed to rebalance this asymmetry and thus improve therapy efficacy. Objective. This study investigated the effect of bilateral priming before Wii-based Movement Therapy to improve rehabilitation after stroke. Methods. Ten patients who had suffered a stroke (age, 23-77 years; 3-123 months after stroke) underwent a 14-day program of Wii-based Movement Therapy for upper limb rehabilitation. Formal Wii-based Movement Therapy sessions were immediately preceded by 15 minutes of bilateral priming, whereby active flexion-extension of the less affected wrist drove mirror-symmetric passive movements of the more affected wrist through a custom device. Functional movement was assessed at weeks 0 (before therapy), 3 (after therapy), and 28 (follow-up) using the Wolf Motor Function Test (WMFT), upper limb Fugl-Meyer Assessment (FMA), upper limb range of motion, and Motor Activity Log (MAL). Case-matched controls were patients who had suffered a stroke who received Wii-based Movement Therapy but not bilateral priming. Results. Upper limb functional ability improved for both groups on all measures tested. Posttherapy improvement on the FMA for primed patients was twice that of the unprimed patients (37.3% vs 14.6%, respectively) and was significantly better maintained at 28 weeks (P = .02). Improvements on the WMFT and MAL were similar for both groups, but the pattern of change in range of motion was strikingly different. Conclusions. Bilateral priming before Wii-based Movement Therapy led to a greater magnitude and retention of improvement compared to control, especially measured with the FMA. These data suggest that bilateral priming can enhance the efficacy of Wii-based Movement Therapy, particularly for patients with low motor function after a stroke.

BDNF Genotype Interacts with Motor Function to Influence Rehabilitation Responsiveness Poststroke

Background Persistent motor impairment is common but highly heterogeneous poststroke. Genetic polymorphisms, including those identified on the brain-derived neurotrophic factor (BDNF) and apolipoprotein E (APOE) genes, may contribute to this variability by limiting the capacity for use-dependent neuroplasticity, and hence rehabilitation responsiveness. Objective To determine whether BDNF and APOE genotypes influence motor improvement facilitated by poststroke upper-limb rehabilitation. Methods BDNF-Val66Met and APOE isoform genotypes were determined using leukocyte DNA for 55 community-dwelling patients 2–123 months poststroke. All patients completed a dose-matched upper-limb rehabilitation program of either Wii-based Movement Therapy or Constraint-induced Movement Therapy. Upper-limb motor function was assessed pre- and post-therapy using a suite of functional measures. Results Motor function improved for all patients post-therapy, with no difference between therapy groups. In the pooled data, there was no significant effect of BDNF or APOE genotype on motor function at baseline, or following the intervention. However, a significant interaction between the level of residual motor function and BDNF genotype was identified (p = 0.029), whereby post-therapy improvement was significantly less for Met allele carriers with moderate and high, but not low motor function. There was no significant association between APOE genotype and therapy outcomes. Conclusion This study identified a novel interaction between the BDNF-Val66Met polymorphism, motor-function status, and the magnitude of improvement with rehabilitation in chronic stroke. This polymorphism does not preclude, but may reduce, the magnitude of motor improvement with therapy, particularly for patients with higher, but not lower residual motor function. BDNF genotype should be considered in the design and interpretation of clinical trials.

Wii-based Movement Therapy benefits stroke patients with low and very low movement ability

Purpose – Stroke patients with low and very low functional movement are not usually considered suitable for rehabilitation. Without therapy the more-affected side will not improve and may lose any residual function. Poor movement ability reduces independence and limits the social engagement of such patients. The purpose of this paper was to investigate whether Wii-based Movement Therapy was suitable and beneficial for stroke patients with low and very low movement ability. Design/methodology/approach – In total, 13 patients aged 22-77 years and three months to 21 years post-stroke completed the standardised 14-day protocol of Wii-based Movement Therapy. Therapy is a structured and targeted programme, tailored to the individual needs and deficits of each patient. Functional ability was assessed using a suite of tools. Increased use of the more-affected hand and arm in everyday life was assessed using the Quality of Movement subscale of the Motor Activity Log. Findings – Functional movement of the more-affe...

Comparison of Three Tools to Measure Improvements in Upper-Limb Function With Poststroke Therapy

Background. Functional ability is regularly monitored poststroke to assess improvement and the efficacy of clinical trials. The balance between implementation times and sensitivity has led to multidomain tools that aim to assess upper-limb function comprehensively. Objective. This study implemented 3 common multidomain tools to investigate their suitability across a broad spectrum of movement ability after stroke. Methods. Forty-nine hemiparetic patients (18 females), aged 22 to 83 years and 24.7 ± 39.2 months poststroke, were assessed before and after a 14-day upper-limb rehabilitation program of Wii-based Movement Therapy. Assessments included the upper-limb motor subscale of the Fugl-Meyer Assessment (F-M), the Wolf Motor Function Test (WMFT), and the Motor Assessment Scale (MAS) upper-limb sections 6 to 8. The MAS was analyzed both with and without the hierarchical system. Patients were stratified with low, moderate, or high motor-function. Results. Upper-limb function improved significantly for the pooled cohort for all assessments (P < .001), although ceiling effects were evident for the F-M, floor effects for the WMFT, and both floor and ceiling effects for MAS. When analyzed by stratified subgroup these improvements were significant for all groups with the F-M, for the moderate and high motor-function groups with both the WMFT and the MAS scored without hierarchical system, but only for the high motor-function group with the hierarchically scored MAS. Conclusion. These results suggest that no single test is suitable for measuring function and improvement across the spectrum of poststroke upper-limb dysfunction and that assessment tool selection should be based on the level of residual motor-function of individual patients.

A Longitudinal Electromyography Study of Complex Movements in Poststroke Therapy. 2: Changes in Coordinated Muscle Activation

Fine motor control is achieved through the coordinated activation of groups of muscles, or “muscle synergies.” Muscle synergies change after stroke as a consequence of the motor deficit. We investigated the pattern and longitudinal changes in upper limb muscle synergies during therapy in a largely unconstrained movement in patients with a broad spectrum of poststroke residual voluntary motor capacity. Electromyography (EMG) was recorded using wireless telemetry from 6 muscles acting on the more-affected upper body in 24 stroke patients at early and late therapy during formal Wii-based Movement Therapy (WMT) sessions, and in a subset of 13 patients at 6-month follow-up. Patients were classified with low, moderate, or high motor-function. The Wii-baseball swing was analyzed using a non-negative matrix factorization (NMF) algorithm to extract muscle synergies from EMG recordings based on the temporal activation of each synergy and the contribution of each muscle to a synergy. Motor-function was clinically assessed immediately pre- and post-therapy and at 6-month follow-up using the Wolf Motor Function Test, upper limb motor Fugl-Meyer Assessment, and Motor Activity Log Quality of Movement scale. Clinical assessments and game performance demonstrated improved motor-function for all patients at post-therapy (p < 0.01), and these improvements were sustained at 6-month follow-up (p > 0.05). NMF analysis revealed fewer muscle synergies (mean ± SE) for patients with low motor-function (3.38 ± 0.2) than those with high motor-function (4.00 ± 0.3) at early therapy (p = 0.036) with an association trend between the number of synergies and the level of motor-function. By late therapy, there was no significant change between groups, although there was a pattern of increase for those with low motor-function over time. The variability accounted for demonstrated differences with motor-function level (p < 0.05) but not time. Cluster analysis of the pooled synergies highlighted the therapy-induced change in muscle activation. Muscle synergies could be identified for all patients during therapy activities. These results show less complexity and more co-activation in the muscle activation for patients with low motor-function as a higher number of muscle synergies reflects greater movement complexity and task-related phasic muscle activation. The increased number of synergies and changes within synergies by late-therapy suggests improved motor control and movement quality with more distinct phases of movement.

Cardiovascular fitness is improved post-stroke with upper-limb Wii-based Movement Therapy but not dose-matched constraint therapy

Introduction: Post-stroke cardiovascular fitness is typically half that of healthy age-matched people. Cardiovascular deconditioning is a risk factor for recurrent stroke that may be overlooked during routine rehabilitation. This study investigated the cardiovascular responses of two upper limb rehabilitation protocols. Methods: Forty-six stroke patients completed a dose-matched program of Wii-based Movement Therapy (WMT) or modified Constraint-induced Movement Therapy (mCIMT). Heart rate and stepping were recorded during early (day 2)- and late (day 12–14)-therapy. Pre- and post-therapy motor assessments included the Wolf Motor Function Test and 6-min walk. Results: Upper limb motor function improved for both groups after therapy (WMT p = 0.003, mCIMT p = 0.04). Relative peak heart rate increased from early- to late-therapy WMT by 33% (p < 0.001) and heart rate recovery (HRR) time was 40% faster (p = 0.04). Peak heart rate was higher and HRR faster during mCIMT than WMT, but neither measure changed during mCIMT. Stepping increased by 88% during Wii-tennis (p < 0.001) and 21% during Wii-boxing (p = 0.045) while mCIMT activities were predominantly sedentary. Six-min walk distances increased by 8% (p = 0.001) and 4% (p = 0.02) for WMT and mCIMT, respectively. Discussion: Cardiovascular benefits were evident after WMT as both a cardiovascular challenge and improved cardiovascular fitness. The peak heart rate gradient across WMT activities suggests this therapy can be further individualized to address cardiovascular needs. The mCIMT data suggest a cardiovascular stress response. Conclusions: This is the first study to demonstrate a cardiovascular benefit during specifically targeted upper limb rehabilitation. Thus, WMT not only improves upper limb motor function but also improves cardiovascular fitness.

Cortical beta oscillations and motor thresholds differ across the spectrum of post-stroke motor impairment, a preliminary MEG and TMS study

BACKGROUND Cortical oscillatory activity in the beta frequency band (13-30Hz) is associated with voluntary movement and may be altered in motor disorders such as stroke. METHODS We used a multimodal case-series approach to investigate movement-related beta oscillations, cortical excitability and upper-limb motor-function in 10 chronic stroke-patients across a broad range of motor-impairment. Assessments included: (i) whole-head magnetoencephalography (MEG) during a voluntary motor task; (ii) resting and active motor-thresholds to transcranial magnetic stimulation (TMS); and (iii) assessments of upper-limb motor-function. RESULTS MEG revealed distinct patterns of movement-related beta oscillations according to motor-function. An elongated event-related desynchronisation (ERD) was correlated with poorer motor-function (p=0.004) whereas an elongated event-related resynchronisation (ERS) was correlated with higher motor function and lower TMS motor thresholds on the more-affected side (p=0.014 and p<0.001, respectively). Oscillation amplitude and laterality were also correlated with motor-function, where a stronger ERD/ERS and a greater relative contribution from the ipsilesional hemisphere were correlated with better motor-function (p=0.016, p=0.025). Unlike TMS responses and motor-function, the temporal profile of beta oscillations was largely symmetrical for movements of the more- and less-affected hands. CONCLUSIONS Beta ERD/ERS patterns differ across the post-stroke motor impairment spectrum, and are bilaterally similar after stroke. Both the amplitude and duration of beta oscillations relate to post-stroke motor-function. SIGNIFICANCE The contralesional hemisphere is not unaffected post-stroke. Caution is needed when generalising imaging and neurophysiological findings from patients with moderate to high motor ability to the more heterogeneous general stroke population and particularly those with low levels of residual voluntary motor-function.

Targeted upper-limb Wii-based Movement Therapy also improves lower-limb muscle activation and functional movement in chronic stroke

Abstract Purpose: Post-stroke hemiparesis may manifest as asymmetric gait, poor balance, and inefficient movement patterns. We investigated improvements in lower-limb muscle activation and function during Wii-based Movement Therapy (WMT), a rehabilitation program specifically targeting upper-limb motor-function. Methods: Electromyography (EMG) was recorded bilaterally from tibialis anterior (TA) in 20 stroke patients during a 14-day WMT program. EMG amplitude and burst duration were analyzed during stereotypical movement sequences of WMT activities. Functional movement ability was assessed pre- and post-therapy including 6-min walk test (6MWT), stair-climbing speed, and Wolf Motor Function Test timed-tasks. Results: TA EMG burst duration during Wii-golf increased by 30% on the more-affected side (p = 0.04) and decreased by 28% on the less-affected side. Patients who did not step during Wii-tennis had a 16% decrease in more-affected TA burst sum (p = 0.047) resulting in more symmetrical activation ratio at late-therapy, with the ratio changing from 3.24 ± 2.25 to 0.99 ± 0.11 (p = 0.047). Six-minute walk and stair-climbing speed improved (p = 0.005 and 0.03, respectively), as did upper-limb movement (p ≤ 0.001). Conclusion: This study provides physiological evidence for lower-limb improvements with WMT. Different patterns of muscle activation changes were evident across the WMT activities. Despite the relatively good pre-therapy lower-limb function, muscle activation and symmetry improved significantly with upper-limb WMT. Implications for rehabilitation WMT is an upper-limb neurorehabilitation program that also improves lower-limb motor-function. We report a shift towards more symmetrical muscle activation of tibialis anterior on the more- and less-affected sides that were reflected in increased distance walked during the 6MWT. The use of standing during therapy not only improves lower-limb function but also permits larger and more powerful upper-limb movements. Targeted upper-limb rehabilitation can also significantly improve mobility and balance, whether dynamic or static, that should reduce the risk of falls post-stroke.