Michelle L. Woodbury

Effects of trunk restraint combined with intensive task practice on poststroke upper extremity reach and function: a pilot study.

Background. Poststroke reaching is characterized by excessive trunk motion and abnormal shoulder—elbow coordination. Little attention is typically given to arm—trunk kinematics during task practice. Preventing compensatory trunk motion during short-term practice immediately improves kinematics, but effects of longer-term practice are unknown. Objective. This study compared the effects of intensive task practice with and without trunk restraint on poststroke reaching kinematics and function. Methods. A total of 11 individuals with chronic stroke, baseline Fugl-Meyer Upper Extremity Assessment scores 26 to 54, were randomized to 2 constraint-therapy intervention groups. All participants wore a mitt on the unaffected hand for 90% of waking hours over 14 days and participated in 10 days/6 hours/day of supervised progressive task practice. During supervised sessions, one group trained with a trunk restraint (preventing anterior trunk motion) and one group did not. Tasks for the trunk-restraint group were located to afford repeated use of a shoulder flexion—elbow extension reaching pattern. Outcome measures included kinematics of unrestrained targeted reaching and tests of functional arm ability. Results. Posttraining, the trunk-restraint group demonstrated straighter reach trajectories (P = .000) and less trunk displacement (P = .001). The trunk-restraint group gained shoulder flexion (P = .006) and elbow extension (P = .022) voluntary ranges of motion, the nonrestraint group did not. Posttraining angle—angle plots illustrated that individuals from the trunk-restraint group transitioned from elbow flexion to elbow extension during mid-reach; individuals in the nonrestraint group retained pretraining movement strategies. Both groups gained functional arm ability (P < .05 all tests). Conclusion. Intensive task practice structured to prevent compensatory trunk movements and promote shoulder flexion—elbow extension coordination may reinforce development of “normal” reaching kinematics.

Bilateral Arm Training With Rhythmic Auditory Cueing in Chronic Stroke: Not Always Efficacious

Objective. Bilateral arm training with rhythmic auditory cueing (BATRAC) has been reported to be efficacious in promoting upper-extremity (UE) recovery in chronic stroke. We tested a modified form of BATRAC (modBATRAC) in a new group of participants with a condensed treatment regime to determine whether we could replicate these reported results. Methods. Fourteen subjects with chronic stroke completed 2 weeks of 2.25 hours per session, 4 sessions per week of modBATRAC. Results. No significant changes were observed in UE Fugl-Meyer or Wolf Motor Function Test scores. Subjects did report increased paretic UE use on the Motor Activity Log (mean change, 0.50; SD = 0.70). Conclusions. The results of this study offer only partial support for the efficacy of modBATRAC. As in previous trials, modBATRAC facilitated increased use of the paretic arm, but unlike previous trials, it did not increase motor performance. These differences may reflect a more temporally condensed training schedule and less impaired patients.

Longitudinal Stability of the Fugl-Meyer Assessment of the Upper Extremity

OBJECTIVE To investigate the longitudinal stability of the Fugl-Meyer Assessment (FMA) of the upper-extremity item difficulties by using Rasch analysis. DESIGN Secondary analysis of existing data from a cohort longitudinal study of stroke recovery. SETTING University research center. PARTICIPANTS A total of 377 people, ages 69.2+/-11.2 years, to whom the assessment was administered at 2 weeks and 6 months poststroke. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Differential item function analysis performed by using the Winsteps software program examined whether the item difficulty hierarchical order of a modified 30-item FMA for the upper extremity (reflex items removed) was invariant across 2 testing occasions. RESULTS Only 2 items (shoulder flexion to 180 degrees, movement with normal speed) showed large differences in test-retest item difficulty calibration. Item instability had no practical consequences on the longitudinal measurement of person ability. CONCLUSIONS The 30-item assessment shows a longitudinally stable item difficulty order and is valid for measuring volitional arm motor ability over time.

Measurement structure of the Wolf Motor Function Test: implications for motor control theory.

Background. Tools chosen to measure poststroke upper-extremity rehabilitation outcomes must match contemporary theoretical expectations of motor deficit and recovery because an assessment’s theoretical underpinning forms the conceptual basis for interpreting its score. Objective. The purpose of this study was to investigate the theoretical framework of the Wolf Motor Function Test (WMFT) by (1) determining whether all items measured a single underlying trait and (2) examining the congruency between the hypothesized and the empirically determined item difficulty orders. Methods. Confirmatory factor analysis (CFA) and Rasch analysis were applied to existing WMFT Functional Ability Rating Scale data from 189 participants in the EXCITE (Extremity Constraint-Induced Therapy Evaluation) trial. Fit of a 1-factor CFA model (all items) was compared with the fit of a 2-factor CFA model (factors defined according to item object-grasp requirements) with fit indices, model comparison test, and interfactor correlations. Results. One item was missing sufficient data and therefore removed from analysis. CFA fit indices and the model-comparison test suggested that both models fit equally well. The 2-factor model yielded a strong interfactor correlation, and 13 of 14 items fit the Rasch model. The Rasch item difficulty order was consistent with the hypothesized item difficulty order. Conclusion. The results suggest that WMFT items measure a single construct. Furthermore, the results depict an item difficulty hierarchy that may advance the theoretical discussion of the person ability versus task difficulty interaction during stroke recovery.

Promoting neuroplasticity and recovery after stroke: future directions for rehabilitation clinical trials.

PURPOSE OF REVIEW The purpose is to establish a theoretical framework by which new interventions for poststroke rehabilitation may be developed incorporating knowledge of neuroplasticity and the critical ingredients of rehabilitation. RECENT FINDINGS Large phase III randomized controlled trials (RCTs) are rare in neurorehabilitation, and the results of those that have been completed are perplexing because the experimental and control treatments were not different when matched for activity level. In addition, the outcome measures used to define treatment effects reflected behavioral endpoints, but did not reveal how neuroplastic mechanisms or other mechanistic factors may have contributed to the treatment response. Knowledge of both the neurophysiologic basis of recovery and key elements of interventions that drive motor learning, such as intensity and task progression, are critical for optimizing future poststroke motor rehabilitation clinical trials. SUMMARY Future neurorehabilitation RCTs require a better understanding of the interaction of interventions and neurophysiological recovery in order to target interventions at specific neurophysiologic substrates, develop a more clear understanding of the impact of intervention parameters (e.g. dose, intensity), and advance discussions regarding optimal ways to partner medical and rehabilitation interventions in order to improve outcomes.

Rasch Analysis Staging Methodology to Classify Upper Extremity Movement Impairment After Stroke

OBJECTIVES To define Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) cutoff scores that demarcate 1 level of upper extremity (UE) impairment from another, and describe motor behaviors for each category in terms of expected FMA-UE item performance. DESIGN Analysis of existing FMA-UE data. SETTING University research laboratory. PARTICIPANTS Persons (N=512) 0 to 145 days poststroke, 42 to 90 years of age. INTERVENTION Not applicable. MAIN OUTCOME MEASURES An item response Rasch analysis staging method was used to calculate cutoff scores, which were defined as the Rasch-Andrich threshold values of 2 criterion FMA-UE items derived from an analysis of this sample. The analysis enabled conversion of cutoff scores, in logit units, to FMA-UE points assessed on 30 FMA-UE voluntary movement items (60 possible points). RESULTS The boundary between severe and moderate impairment was defined as -1.59 ± .27 logits or 19 ± 2 points; and between moderate and mild impairment was defined as 2.44 ± .27 logits or 47 ± 2 points. A description of expected performance in each impairment level shows that patients with severe impairment exhibited some distal movements, and patients with mild impairment had difficulties with some proximal movements. CONCLUSIONS The cutoff scores, which link to a description of specific movements a patient can, can partially, and cannot perform, may enable formation of heterogeneous patient groups, advance efforts to identify specific movement therapy targets, and define treatment response in terms of specific movement that changed or did not change with therapy.

Advancing measurement of locomotor rehabilitation outcomes to optimize interventions and differentiate between recovery versus compensation.

Progress in locomotor rehabilitation has created an increasing need to understand the factors that contribute to motor behavior, to determine whether these factors are modifiable, and if so, to determine how best to modify them in a way that promotes improved function. Currently available clinical measures do not have the capacity to distinguish between neuromotor recovery and compensation for impaired underlying body structure/functions. This Special Interest article examines the state of outcomes measurement in physical therapy in regard to locomotor rehabilitation, and suggests approaches that may improve assessment of recovery and clinical decision-making capabilities. We examine historical approaches to measurement of locomotor rehabilitation outcomes, including rating scales, timed movement tasks, and laboratory-based outcome measures, and we discuss the emerging use of portable technology to assess walking in a free-living environment. The ability to accurately measure outcomes of rehabilitation, both in and away from the clinical/laboratory setting, allows assessment of skill acquisition, retention, and long-term carryover in a variety of environments. Accurate measurement allows behavioral changes to be observed, and assessments to be made, regarding an individuals ability to adapt during interventions and to incorporate new skills into real-world behaviors. The result of such an approach to assessment may be that interventions truly translate from clinical/laboratory to real-world environments. Future locomotor measurement tools must be based on a theoretical framework that can guide their use to accurately quantify treatment effects and provide a basis upon which to develop and refine therapeutic interventions.

Response to Intensive Upper Extremity Therapy by Individuals with Ataxia from Stroke

Abstract Objective: This study investigated whether or not individuals with ataxia from stroke improve their upper extremity motor function with intense motor practice. Method: Three individuals with ataxia from chronic stroke completed modified constraint-induced movement therapy (CIMT) protocols. Stroke Participants 1 and 2 completed 60 hours and Stroke Participant 3 completed 30 hours of graded task practice while being asked to wear a mitt on the nonparetic arm for 90% of waking hours. Outcome measures were the upper extremity subscale of the Fugl-Meyer Motor Assessment, Wolf Motor Function Test, Motor Activity Log, and kinematics of reaching. Results: All stroke participants improved on either the Fugl-Meyer or the Wolf tests and increased their daily use of the paretic upper extremity. Participants 1 and 2 also improved on all kinematic measures: maximum velocity and time to maximum velocity increased, while index of curvature, number of peaks in the velocity profile, and trunk movement decreased. Participant 3 improved on some kinematic measures (smoother velocity profile, increased time to maximum velocity, decreased number of peaks in the velocity profile) but not all (decreased maximum velocity, increased index of curvature). Conclusion: Individuals with ataxia from stroke can improve their motor function with intense motor practice.

Virtual reality video games to promote movement recovery in stroke rehabilitation: a guide for clinicians.

After stroke, people often have difficulty moving one arm and hand, but movement can improve with considerable practice. Arm movements may need to be repeated upwards of 2500 times for a person to approach his/her peak level of motor function. Video-gaming technology can effectively deliver engaging, high-repetition movement practice. Use of video games for rehabilitation can be as effective as more conventional approaches.

Development of an item bank for a computerised adaptive test of upper-extremity function.

Purpose. The purpose of this study was to determine the psychometric characteristics of an upper-extremity item bank as a precursor to developing a computer adaptive patient reported outcome instrument. The Activity dimension of the World Health Organizations International Classification of Functioning, Disability and Health (ICF) provided the conceptual framework for the items. Method. Factor and Rasch analyses were used to evaluate the psychometric properties of the item bank, including: monotonicity, local independence, dimensionality, item difficulty hierarchy and match between sample ability and item difficulty. Results. Monotonicity of the rating scale was supported. Nine item pairs were locally dependent, and thus one item from each pair was removed from subsequent analyses. There was evidence for two unidimensional constructs; gross upper-extremity and fine hand. Both constructs showed good internal consistency and person separation. In general, the order of item difficulty within each construct replicated the hypothesised item difficulty order. The fine hand construct had a ceiling effect. Conclusions. The above study of our newly developed upper-extremity item bank empirically verified the intended item difficulty order, identified separate constructs (i.e. gross upper-extremity and fine hand) and provided insights into eliminating the ceiling effect of one of the constructs. These findings are critical precursors to the development of upper-extremity components of the ICF Activity Measure, an ICF-based, CAT located on the web at: www.icfmeasure.phhp.ufl.edu.