Corina Schuster

Efficacy of motor imagery in post-stroke rehabilitation: a systematic review

BackgroundEvaluation of how Motor Imagery and conventional therapy (physiotherapy or occupational therapy) compare to conventional therapy only in their effects on clinically relevant outcomes during rehabilitation of persons with stroke.DesignSystematic review of the literatureMethodsWe conducted an electronic database search in seven databases in August 2005 and also hand-searched the bibliographies of studies that we selected for the review.Two reviewers independently screened and selected all randomized controlled trials that compare the effects of conventional therapy plus Motor Imagery to those of only conventional therapy on stroke patients.The outcome measurements were: Fugl-Meyer Stroke Assessment upper extremity score (66 points) and Action Research Arm Test upper extremity score (57 points).Due to the high variability in the outcomes, we could not pool the data statistically.ResultsWe identified four randomized controlled trials from Asia and North America. The quality of the included studies was poor to moderate. Two different Motor imagery techniques were used (three studies used audiotapes and one study had occupational therapists apply the intervention). Two studies found significant effects of Motor Imagery in the Fugl-Meyer Stroke Assessment: Differences between groups amounted to 11.0 (1.0 to 21.0) and 3.2 (-4 to 10.3) respectively and in the Action Research Arm Test 6.1 (-6.2 to 18.4) and 15.8 (0.5 to 31.0) respectively. One study did not find a significant effect in the Fugl-Meyer Stroke Assessment and Color trail Test (p = 0.28) but in the task-related outcomes (p > 0.001).ConclusionCurrent evidence suggests that Motor imagery provides additional benefits to conventional physiotherapy or occupational therapy. However, larger and methodologically sounder studies should be conducted to assess the benefits of Motor imagery.

Best practice for motor imagery: a systematic literature review on motor imagery training elements in five different disciplines

BackgroundThe literature suggests a beneficial effect of motor imagery (MI) if combined with physical practice, but detailed descriptions of MI training session (MITS) elements and temporal parameters are lacking. The aim of this review was to identify the characteristics of a successful MITS and compare these for different disciplines, MI session types, task focus, age, gender and MI modification during intervention.MethodsAn extended systematic literature search using 24 databases was performed for five disciplines: Education, Medicine, Music, Psychology and Sports. References that described an MI intervention that focused on motor skills, performance or strength improvement were included. Information describing 17 MITS elements was extracted based on the PETTLEP (physical, environment, timing, task, learning, emotion, perspective) approach. Seven elements describing the MITS temporal parameters were calculated: study duration, intervention duration, MITS duration, total MITS count, MITS per week, MI trials per MITS and total MI training time.ResultsBoth independent reviewers found 96% congruity, which was tested on a random sample of 20% of all references. After selection, 133 studies reporting 141 MI interventions were included. The locations of the MITS and position of the participants during MI were task-specific. Participants received acoustic detailed MI instructions, which were mostly standardised and live. During MI practice, participants kept their eyes closed. MI training was performed from an internal perspective with a kinaesthetic mode. Changes in MI content, duration and dosage were reported in 31 MI interventions. Familiarisation sessions before the start of the MI intervention were mentioned in 17 reports. MI interventions focused with decreasing relevance on motor-, cognitive- and strength-focused tasks. Average study intervention lasted 34 days, with participants practicing MI on average three times per week for 17 minutes, with 34 MI trials. Average total MI time was 178 minutes including 13 MITS. Reporting rate varied between 25.5% and 95.5%.ConclusionsMITS elements of successful interventions were individual, supervised and non-directed sessions, added after physical practice. Successful design characteristics were dominant in the Psychology literature, in interventions focusing on motor and strength-related tasks, in interventions with participants aged 20 to 29 years old, and in MI interventions including participants of both genders. Systematic searching of the MI literature was constrained by the lack of a defined MeSH term.

Interactive visuo-motor therapy system for stroke rehabilitation

We present a virtual reality (VR)-based motor neurorehabilitation system for stroke patients with upper limb paresis. It is based on two hypotheses: (1) observed actions correlated with self-generated or intended actions engage cortical motor observation, planning and execution areas (“mirror neurons”); (2) activation in damaged parts of motor cortex can be enhanced by viewing mirrored movements of non-paretic limbs. We postulate that our approach, applied during the acute post-stroke phase, facilitates motor re-learning and improves functional recovery. The patient controls a first-person view of virtual arms in tasks varying from simple (hitting objects) to complex (grasping and moving objects). The therapist adjusts weighting factors in the non-paretic limb to move the paretic virtual limb, thereby stimulating the mirror neuron system and optimizing patient motivation through graded task success. We present the system’s neuroscientific background, technical details and preliminary results.

Sensing muscle activities with body-worn sensors

We demonstrate that simple, unobtrusive sensors attached to the lower arm can be used to capture muscle activations during specific hand and arm activities such as grasping. Specifically, we investigate the use of force sensitive resistors and fabric stretch sensors, that can both be easily integrated into clothing. We use the above sensors to detect the contractions of arm muscles. We present and compare the signals that both sensors produce for a set of typical hand actions. We finally argue that they can provide important information for activity recognition

Motor Training of Upper Extremity With Functional Electrical Stimulation in Early Stroke Rehabilitation

Background. Functional electrical stimulation (FES) allows active exercises in stroke patients with upper extremity paralysis. Objective. To investigate the effect of motor training with FES on motor recovery in acute and subacute stroke patients with severe to complete arm and/or hand paralysis. Methods. For this pilot study, 23 acute and subacute stroke patients were randomly assigned to the intervention (n = 12) and control group (n = 11). Distributed over 4 weeks, FES training replaced 12 conventional training sessions in the intervention group. An Extended Barthel Index (EBI) subscore assessed the performance of activities of daily living (ADL). The Chedoke McMaster Stroke Assessment (CMSA) measured hand and arm function and shoulder pain. The Modified Ashworth Scale (MAS) assessed resistance to passive movement. Unblinded assessments were performed prior to and following the end of the training period. Results. The EBI subscore and CMSA arm score improved significantly in both groups. The CMSA hand function improved significantly in the FES group. Resistance to passive movement of finger and wrist flexors increased significantly in the FES group. Shoulder pain did not change significantly. None of the outcome measures, however, demonstrated significant gain differences between the groups. Conclusions. We did not find clear evidence for superiority or inferiority of FES. Our findings, and those of similar trials, suggest that the number of sessions should be at least doubled to test for superiority of FES in these highly impaired patients and approximately 50 participants would have to be assigned to each therapeutic intervention to find significant differences.

Dexamphetamine improves upper extremity outcome during rehabilitation after stroke: a pilot randomized controlled trial.

Background. For early inpatient stroke rehabilitation, the effectiveness of amphetamine combined with physiotherapy varies across studies. Objective. To investigate whether the recovery of activities of daily living (ADL, primary outcome) and motor function (secondary outcome) can be improved by dexamphetamine added to physiotherapy. Methods. In a double-blind, placebo-controlled trial, 16 patients, from 918 who were screened, were randomized to the experimental group (EG, dexamphetamine + physiotherapy) or control group (CG, placebo + physiotherapy). Both groups received multidisciplinary inpatient rehabilitation. Dexamphetamine (10 mg oral) or placebo was administered 2 days per week before physiotherapy. ADL and motor function were measured using the Chedoke–McMaster Stroke Assessment (CMSA) twice during baseline, every week during the 5-week treatment period, and at follow-up 1 week, 6 months, and 12 months after intervention. Results. The majority of ineligible patients had too little paresis, were on anticoagulants, or had a stroke >60 days prior to entry. Participants (EG, n = 7, age 70.3 ± 10 years, 5 women, 37.9 ± 9 days after stroke; CG, n = 9, age 65.2 ± 17 years, 3 women, 40.3 ± 9 days after stroke) did not differ at baseline except for the leg subscale. Analysis of variance from baseline to 1 week follow-up revealed significant improvements in favor of EG for subscales ADL (P = .023) and arm function (P = .020) at end of treatment. No adverse events were detected. Conclusion. In this small trial that was based on prior positive trials, significant gains in ADL and arm function suggest that the dose and timing of dexamphetamine can augment physiotherapy. Effect size calculation suggests inclusion of at least 25 patients per group in future studies (ClinicalTrials.gov number: NCT00572767).

A distinct pattern of myofascial findings in patients after whiplash injury

OBJECTIVE To identify objective clinical examinations for the diagnosis of whiplash syndrome, whereby we focused on trigger points. DESIGN A cross-sectional study with 1 measurement point. SETTING A quiet treatment room in a rehabilitation center. PARTICIPANTS Patients (n=124) and healthy subjects (n=24) participated in this study. Among the patient group were patients with whiplash-associated disorders (n=47), fibromyalgia (n=21), nontraumatic chronic cervical syndrome (n=17), and endogenous depression (n=15). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Each patient and control subject had a manual examination for trigger points of the semispinalis capitis, trapezius pars descendens, levator scapulae, scalenus medius, sternocleidomastoideus, and masseter muscles bilaterally. RESULTS Forty (85.1%) of the patients with whiplash had positive trigger points in the semispinalis capitis muscle. The patients with whiplash had a significantly higher prevalence of positive trigger points in the semispinalis capitis muscle than any of the control groups (P<.05). For the other examined muscles, the prevalence of trigger points in the patients with whiplash did not differ significantly from the patients with fibromyalgia or nontraumatic chronic cervical syndrome. It did differ from the patients with endogenous depression and the healthy controls. CONCLUSIONS Patients with whiplash showed a distinct pattern of trigger point distribution that differed significantly from other patient groups and healthy subjects. The semispinalis capitis muscle was more frequently affected by trigger points in patients with whiplash, whereas other neck and shoulder muscles and the masseter muscle did not differentiate between patients with whiplash and patients with nontraumatic chronic cervical syndrome or fibromyalgia.

Objectively-assessed outcome measures: a translation and cross-cultural adaptation procedure applied to the Chedoke McMaster Arm and Hand Activity Inventory (CAHAI)

BackgroundStandardised translation and cross-cultural adaptation (TCCA) procedures are vital to describe language translation, cultural adaptation, and to evaluate quality factors of transformed outcome measures. No TCCA procedure for objectively-assessed outcome (OAO) measures exists. Furthermore, no official German version of the Canadian Chedoke Arm and Hand Activity Inventory (CAHAI) is available.MethodsAn eight-step for TCCA procedure for OAO was developed (TCCA-OAO) based on the existing TCCA procedure for patient-reported outcomes. The TCCA-OAO procedure was applied to develop a German version of the CAHAI (CAHAI-G). Inter-rater reliability of the CAHAI-G was determined through video rating of CAHAI-G. Validity evaluation of the CAHAI-G was assessed using the Chedoke-McMaster Stroke Assessment (CMSA). All ratings were performed by trained, independent raters. In a cross-sectional study, patients were tested within 31 hours after the initial CAHAI-G scoring, for their motor function level using the subscales for arm and hand of the CMSA. Inpatients and outpatients of the occupational therapy department who experienced a cerebrovascular accident or an intracerebral haemorrhage were included.ResultsPerformance of 23 patients (mean age 69.4, SD 12.9; six females; mean time since stroke onset: 1.5 years, SD 2.5 years) have been assessed. A high inter-rater reliability was calculated with ICCs for 4 CAHAI-G versions (13, 9, 8, 7 items) ranging between r = 0.96 and r = 0.99 (p < 0.001). Correlation between the CAHAI-G and CMSA subscales for hand and arm was r = 0.74 (p < 0.001) and r = 0.67 (p < 0.001) respectively. Internal consistency of the CAHAI-G for all four versions ranged between α = 0.974 and α = 0.979.ConclusionsThe TCCA-OAO procedure was validated regarding its feasibility and applicability for objectively-assessed outcome measures. The resulting German CAHAI can be used as a valid and reliable assessment for bilateral upper limb performance in ADL in patients after stroke.

New Technologies and Concepts for Rehabilitation in the Acute Phase of Stroke: A Collaborative Matrix

The process of developing a successful stroke rehabilitation methodology requires four key components: a good understanding of the pathophysiological mechanisms underlying this brain disease, clear neuroscientific hypotheses to guide therapy, adequate clinical assessments of its efficacy on multiple timescales, and a systematic approach to the application of modern technologies to assist in the everyday work of therapists. Achieving this goal requires collaboration between neuroscientists, technologists and clinicians to develop well-founded systems and clinical protocols that are able to provide quantitatively validated improvements in patient rehabilitation outcomes. In this article we present three new applications of complementary technologies developed in an interdisciplinary matrix for acute-phase upper limb stroke rehabilitation – functional electrical stimulation, arm robot-assisted therapy and virtual reality-based cognitive therapy. We also outline the neuroscientific basis of our approach, present our detailed clinical assessment protocol and provide preliminary results from patient testing of each of the three systems showing their viability for patient use.

Two assessments to evaluate imagery ability: translation, test-retest reliability and concurrent validity of the German KVIQ and Imaprax

BackgroundA combination of physical practice and motor imagery (MI) can improve motor function. It is essential to assess MI vividness in patients with sensorimotor impairments before implementing MI interventions. The studys aims were to translate the Canadian Kinaesthetic and Visual Imagery Questionnaire (KVIQ) and the French Imaprax, and to examine reliability and validity of the German versions.MethodsQuestionnaires were translated according to guidelines. With examiner’s help patients (diagnosis: stroke: subacute/chronic, brain tumour, Multiple Sclerosis, Parkinson’s disease) were tested twice within seven days (T0, T1). KVIQ-G: Patients were shown a movement by the examiner, before executing and imagining the movement. They rated vividness of the image and intensity of the sensations on a five-point Likert-scale. Imaprax required a 3-step procedure: imagination of one of six gestures; evaluation of gesture understanding, vividness, and imagery perspective. Questionnaire data were analysed overall and for each group. Reliability parameters were calculated: intraclass correlation coefficient (ICC), Cronbachs alpha, standard error of measurement, minimal detectable change. Validity parameters included Spearmans rank correlation coefficient and factor analysis of the KVIQ-G-20.ResultsPatients (N = 73, 28 females, age: 63 ± 13) showed the following at T0: KVIQ-G-20vis 41.7 ± 9, KVIQ-G-10vis 21.1 ± 5. ICC for KVIQ-G-20vis and KVIQ-G-10vis was 0.77; KVIQ-G-20kin 36.4 ± 12, KVIQ-G-10kin 18.3 ± 6. ICCs for KVIQ-G-20kin and KVIQ-G-10kin were 0.83/0.85; Imapraxvis 32.7 ± 4 and ICC 0.51. Internal consistency was estimated for KVIQ-G-20 αvis = 0.94/αkin = 0.92, KVIQ-G-10 αvis = 0.88/αkin = 0.96, Imaprax-G αvis = 0.70. Validity testing was performed with 19 of 73 patients, who chose an internal perspective: rs = 0.36 (p = 0.13). Factor analysis revealed two factors correlating with r = 0.36. Both explain 69.7% of total variance.ConclusionsKVIQ-G and Imaprax-G are reliable instruments to assess MI in patients with sensorimotor impairments confirmed by a KVIQ-G-factor analysis. KVIQ-G visual values were higher than kinaesthetic values. Patients with Multiple Sclerosis showed the lowest, subacute stroke patients the highest values. Hemiparetic patients scored lower in both KVIQ-G subscales on affected side compared to non-affected side. It is suggested to administer the Imaprax-G before the KVIQ-G to test patient’s ability to distinguish between external and internal MI perspective. Duration of both questionnaires lead to an educational effect. Imaprax validity testing should be repeated.