Henk A. M. Seelen

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.

Disuse and deconditioning in chronic low back pain: Concepts and hypotheses on contributing mechanisms

For years enhancement of a patients level of physical fitness has been an important goal in rehabilitation treatment in chronic low back pain (CLBP), based on the hypothesis that physical deconditioning contributes to the chronicity of low back pain. However, whether this hypothesis in CLBP holds is not clear. In this paper, possible mechanisms that contribute to the development of physical deconditioning in CLBP, such as avoidance behaviour and suppressive behaviour, are discussed. The presence of both deconditioning‐related physiological changes, such as muscle atrophy, changes in metabolism, osteoporosis and obesity as well as deconditioning related functional changes, such as a decrease in cardiovascular capacity, a decrease in muscle strength and impaired motor control in patients with CLBP are discussed. Results of studies on the level of physical activities in daily life (PAL) and the level of physical fitness in patients with CLBP compared to healthy controls were reviewed. In studies on PAL results that were either lower or comparable to healthy subjects were found. The presence of disuse (i.e., a decrease in the level of physical activities in daily life) in patients with CLBP was not confirmed. The inconclusive findings in the papers reviewed may partly be explained by different measurement methods used in research on PAL in chronic pain. The level of physical fitness of CLBP patients also appeared to be lower or comparable to the fitness level of healthy persons. A discriminating factor between fit and unfit patients with back pain may be the fact that fit persons more frequently are still employed, and as such may be involved more in physical activity. Lastly some suggestions are made for further research in the field of disuse and deconditioning in CLBP.

Fear of movement/(re)injury and muscular reactivity in chronic low back pain patients : an experimental investigation

This experiment was set up to test the hypothesis that confrontation with feared movements would lead to symptom-specific muscular reactivity in chronic low back pain patients who report high fear of movement/(re)injury. Thirty-one chronic low back pain patients were asked to watch a neutral nature documentary, followed by a fear-eliciting video-presentation, while surface electromyography (EMG) recordings were made from the lower paraspinal and the tibialis anterior muscles. It was further hypothesized that negative affectivity (NA) would moderate the effects of fear on symptom-specific muscular reactivity, as well as the effects of muscular reactivity on pain report. The results were partly as predicted. Unexpectedly, paraspinal EMG-readings decreased during video-exposure but this decrement tended to be less in fearful patients than in the non-fearful patients. Negative affectivity did not moderate this effect, but moderated the effect of pain-related fear on muscular reactivity of lower leg muscles. In addition, NA directly predicted muscular reactivity in the right tibialis anterior muscle. As predicted, there was a significant covariation between left paralumbar muscular activity and pain report. This association was moderated by NA, but in the opposite direction. The findings extend the symptom-specificity model of psychophysiological reactivity, and support the idea that pain-related fear perpetuates pain and pain disability through muscular reactivity.

Disuse and physical deconditioning in the first year after the onset of back pain

Abstract For years, physical deconditioning has been thought to be both a cause and a result of back pain. As a consequence physical reconditioning has been proposed as treatment‐goal in patients with chronic low back pain (LBP). However, it is still unclear whether a patient’s physical fitness level really decreases after pain‐onset. The objectives of the present study were, firstly, to test the assumption that long‐term non‐specific LBP leads to a decrease of the level of physical activity (disuse), secondly, to evaluate any development of physical deconditioning as a result of disuse in CLBP, and thirdly, to evaluate predictors for disuse in CLBP. A longitudinal cohort study over one year including 124 patients with sub‐acute LBP (i.e., 4–7 weeks after pain onset) was performed. Main outcome measures were change in physical activity level (PAL) and physical fitness (measured by changes in body weight, body fat and muscle strength) over one year. Hypothesized predictors for disuse were: pain catastrophizing; fear of movement; depression; physical activity decline; the perceived level of disability and PAL prior to pain. Results showed that only in a subgroup of patients a PAL‐decrease had occurred after the onset of pain, whereas no signs of physical deconditioning were found. Negative affect and the patients’ perceived physical activity decline in the subacute phase predicted a decreased level of PAL over one year. Based on these results, we conclude that as to the assumption that patients with CLBP suffer from disuse and physical deconditioning empirical evidence is still lacking.

Fear of injury and physical deconditioning in patients with chronic low back pain

OBJECTIVES To test the assumption that fear of injury leads to disability and physical deconditioning in patients with chronic low back pain (CLBP) and to evaluate the relation between disability and physical deconditioning. DESIGN Survey in a cross-sectional design. SETTING A rehabilitation center in the Netherlands. PARTICIPANTS Forty patients with nonspecific CLBP. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Fear of injury was measured with the Tampa Scale of Kinesiophobia. Physical fitness was expressed in aerobic fitness measured as predicted maximum oxygen consumption derived in a submaximal exercise test according the protocol of Siconolfi. Disability was measured with the Roland Disability Questionnaire. The association between fear of injury and physical fitness or disability was examined with correlational and multiple linear regression analyses. RESULTS Fear of injury correlated significantly with disability (r=.44), but did not correlate significantly with aerobic fitness. There was no statistically significant association between disability and aerobic fitness. Multiple regression analysis revealed that aerobic fitness was predicted by gender only. CONCLUSIONS Fear of injury appears to be more strongly associated with perceived disability than with aerobic fitness. The assumption that fear of injury leads to physical deconditioning was not confirmed in this sample of patients with CLBP.

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.

Decline in physical activity, disability and pain-related fear in sub-acute low back pain

Aim of investigation: To evaluate whether a perceived decline in the level of physical activity after the onset of pain (PAD) is more appropriate in the explanation of disability as compared to the actual level of physical activity (PAL) in patients with sub‐acute back pain.

Do depression and pain intensity interfere with physical activity in daily life in patients with Chronic Low Back Pain

&NA; Patients with chronic pain may have difficulties estimating their own physical activity level in daily life. Pain‐related factors such as depression and pain intensity may affect a patients’ ability to estimate their own daily life activity level. This study evaluates whether patients with Chronic Low Back Pain (CLBP) who are more depressed and/or report more pain indeed have a lower objectively assessed daily life activity level or whether they only perceive their activity level as lower. Patients with CLBP were included in a cross‐sectional study. During 14 days physical activity in daily life was measured, with both an electronic diary and an accelerometer. Multilevel analyses were performed to evaluate whether a higher level of depression and/or pain intensity was associated with a lower objectively assessed activity level or the discrepancy between the self‐reported and objectively assessed daily life activity levels. Results, based on 66 patients with CLBP (mean RDQ score 11.8), showed that the objectively assessed daily life activity level is not associated with depression or pain intensity. There was a moderate association between the self‐reported and objectively assessed activity levels (&bgr; = 0.39, p < 0.01). The discrepancy between the two was significantly and negatively related to depression (&bgr; = −0.19, p = 0.01), indicating that patients who had higher levels of depression judged their own activity level to be relatively low compared to their objectively assessed activity level. Pain intensity was not associated with the perception of a patients activity level (&bgr; = 0.12, ns).

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.

Assessment of Arm Activity Using Triaxial Accelerometry in Patients With a Stroke

OBJECTIVE To study the validity of accelerometry in the assessment of arm activity of patients with impaired arm function after stroke. DESIGN Cross-sectional concurrent validity study. SETTING Rehabilitation center. PARTICIPANTS Patients (N=45) at different stages after stroke. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES All patients wore 2 triaxial accelerometers around their wrists during 3 consecutive days. Arm activity was assessed, based on unilateral (activity of the affected arm) and bilateral accelerometry (ratio between the activity of the affected and nonaffected arm). The Motor Activity Log-26 (MAL-26) Amount of Use (AOU) scale was used as the main external criterion to test the concurrent validity of arm accelerometry. In addition, the MAL-26 Quality of Movement (QOM) scale and the Stroke Impact Scale (SIS) subscale Hand Function were used. To test the divergent validity, the SIS subscale Mobility was used. Spearman correlation coefficients were calculated. In an additional regression analysis, the hypothesized confounding influence of spasm, therapy intensity, and interobserver differences was studied. RESULTS Both unilateral (ρ=.58, P<.001) and bilateral (ρ=.60, P<.001) accelerometry were significantly related to the MAL-AOU scale. Associations of both unilateral and bilateral accelerometry with the MAL-QOM and SIS subscale Hand Function corroborated these findings. The SIS subscale Mobility was not significantly associated with unilateral accelerometry (ρ=.41, P=.01) or bilateral accelerometry (ρ=.23, P=.11). None of the hypothesized confounders influenced these associations significantly. CONCLUSIONS Based on the results, both the concurrent and divergent validity of unilateral and bilateral arm accelerometry for measuring arm activity after stroke are good.