Paulette van Vliet

Transcranial direct current stimulation (tDCS): does it have merit in stroke rehabilitation? A systematic review.

Transcranial direct current stimulation has been gaining increasing interest as a potential therapeutic treatment in stroke recovery. We performed a systematic review with meta-analysis of randomized controlled trials to collate the available evidence in adults with residual motor impairments as a result of stroke. The primary outcome was change in motor function or impairment as a result of transcranial direct current stimulation, using any reported electrode montage, with or without adjunct physical therapy. The search yielded 15 relevant studies comprising 315 subjects. Compared with sham, cortical stimulation did not produce statistically significant improvements in motor performance when measured immediately after the intervention (anodal stimulation: facilitation of the affected cortex: standardized mean difference = 0·05, P = 0·71; cathodal stimulation: inhibition of the nonaffected cortex: standardized mean difference = 0·39, P = 0·08; bihemispheric stimulation: standardized mean difference = 0·24, P = 0·39). When the data were analyzed according to stroke characteristics, statistically significant improvements were evident for those with chronic stroke (standardized mean difference = 0·45, P = 0·01) and subjects with mild-to-moderate stroke impairments (standardized mean difference = 0·37, P = 0·02). Transcranial direct current stimulation is likely to be effective in enhancing motor performance in the short term when applied selectively to patients with stroke. Given the range of stimulation variables and heterogeneous nature of stroke, this modality is still experimental and further research is required to determine its clinical merit in stroke rehabilitation.

Interventions for coordination of walking following stroke: Systematic review

Impairments in gait coordination may be a factor in falls and mobility limitations after stroke. Therefore, rehabilitation targeting gait coordination may be an effective way to improve walking post-stroke. This review sought to examine current treatments that target impairments of gait coordination, the theoretical basis on which they are derived and the effects of such interventions. Few high quality RCTs with a low risk of bias specifically targeting and measuring restoration of coordinated gait were found. Consequently, we took a pragmatic approach to describing and quantifying the available evidence and included non-randomised study designs and limited the influence of heterogeneity in experimental design and control comparators by restricting meta-analyses to pre- and post-test comparisons of experimental interventions only. Results show that physiotherapy interventions significantly improved gait function and coordination. Interventions involving repetitive task-specific practice and/or auditory cueing appeared to be the most promising approaches to restore gait coordination. The fact that overall improvements in gait coordination coincided with increased walking speed lends support to the hypothesis that targeting gait coordination gait may be a way of improving overall walking ability post-stroke. However, establishing the mechanism for improved locomotor control requires a better understanding of the nature of both neuroplasticity and coordination deficits in functional tasks after stroke. Future research requires the measurement of impairment, activity and cortical activation in an effort to establish the mechanism by which functional gains are achieved.

Kinematics of turning 180 degrees during the timed up and go in stroke survivors with and without falls history

Background. Community-dwelling, chronic stroke survivors are at risk of falling during turning and are more likely to sustain a hip fracture when they fall. Objective. This study quantifies kinematic differences between stroke survivors (mean ± SD: 38.3 ± 31.3 months poststroke, 59.9 ± 10.1 years of age), with (n = 9) and without a falls history (n = 9), and age-matched healthy counterparts (n = 18) in turning coordination during the 180° turn around in the Timed “Up & Go„ (TUG) test. Methods. Full-body kinematics were recorded while participants performed the 180° turn around in the TUG. Dependent measures were time to turn, number of steps to turn, and measures of axial segment coordination. Result. Although participants who had a stroke and falls history took significantly longer to turn (mean ± SD: 4.4 ± 1.7 seconds) than age-matched controls (2.5 ± 0.6 seconds), no kinematic differences were found in performance or in the axial segment coordination during turning that could contribute to falls history or falls risk. Conclusions. These results indicate incidences of falls during turning following stroke may not be due to impaired movement patterns but due to the many other factors that are associated with falls, such as deficits in cognitive processes—attention or central integration—and/or sensory deficits.

Comparison of the content of two physiotherapy approaches for stroke

Objective: To identify similarities and differences between a Bobath-based (BB) and a movement science-based (MSB) approach. Design: Direct observation by a trained observer was used to record behaviours during treatments. Setting: An acute stroke ward. Subjects: Twenty-two stroke patients. Interventions: Behaviours were recorded during 12 treatment sessions by three therapists, for each treatment approach. Physical and communication behaviours were recorded in pre-defined categories. The equipment used was recorded and a semi-structured interview conducted with the therapist after treatment to identify follow-up actions by the therapist. Main outcome measures: Frequency of occurrence of each category was compared between the approaches. Results: Treatment in the BB group contained more social conversation (p = 0.004), and more use of physiotherapy equipment (p = 0.02) and a physiotherapy assistant (p = 0.01). In the MSB group there was more detailed feedback given to the patient (p = 0.002) more use of everyday objects in training (p = 0.001), therapists more frequently listed specific components as the patients main problems (p = 0.003) and relatives were involved more in positioning to stretch muscles (p = 0.03). Training walking was given more emphasis in the BB group and training of sit-to-stand in the MSB group. Conclusions: The study indicates that there are differences in content between the Bobath-based and movement science-based approaches to treatment.

Recognising neuroplasticity in musculoskeletal rehabilitation: A basis for greater collaboration between musculoskeletal and neurological physiotherapists

Evidence is emerging for central nervous system (CNS) changes in the presence of musculoskeletal dysfunction and pain. Motor control exercises, and potentially manual therapy, can induce changes in the CNS, yet the focus in musculoskeletal physiotherapy practice is conventionally on movement impairments with less consideration of intervention-induced neuroplastic changes. Studies in healthy individuals and those with neurological dysfunction provide examples of strategies that may also be used to enhance neuroplasticity during the rehabilitation of individuals with musculoskeletal dysfunction, improving the effectiveness of interventions. In this paper, the evidence for neuroplastic changes in patients with musculoskeletal conditions is discussed. The authors compare and contrast neurological and musculoskeletal physiotherapy clinical paradigms in the context of the motor learning principles of experience-dependent plasticity: part and whole practice, repetition, task-specificity and feedback that induces an external focus of attention in the learner. It is proposed that increased collaboration between neurological and musculoskeletal physiotherapists and researchers will facilitate new discoveries on the neurophysiological mechanisms underpinning sensorimotor changes in patients with musculoskeletal dysfunction. This may lead to greater integration of strategies to enhance neuroplasticity in patients treated in musculoskeletal physiotherapy practice.

Stroke-related differences in axial body segment coordination during preplanned and reactive changes in walking direction

This study quantitatively describes differences between participants with hemiparetic stroke and age-matched healthy participants in axial body segment and gait kinematics during a direction change task. Participants were required to change walking direction by 45°, either to their left or right, at the midpoint of a 6-m path. Participants were visually cued either at the start of the walk (pre-planned) or one stride before they reached the turn point (reactive). The sequence and inter-segmental timing of axial orientation onset was preserved in participants with stroke. Analysis of a subgroup of stroke survivors indicated that participants with lesions affecting the basal ganglia (BG) took significantly longer time than control participants to initiate the reorientation synergy when making turns to their non-paretic side. We hypothesize that these differences are a product of asymmetrical activity of dopaminergic pathways in the brain resulting from compromised BG function.

Home-based reach-to-grasp training for people after stroke: study protocol for a feasibility randomized controlled trial

BackgroundThis feasibility study is intended to assess the acceptability of home-based task-specific reach-to-grasp (RTG) training for people with stroke, and to gather data to inform recruitment, retention, and sample size for a definitive randomized controlled trial.Methods/designThis is to be a randomized controlled feasibility trial recruiting 50 individuals with upper-limb motor impairment after stroke. Participants will be recruited after discharge from hospital and up to 12 months post-stroke from hospital stroke services and community therapy-provider services. Participants will be assessed at baseline, and then electronically randomized and allocated to group by minimization, based on the time post-stroke and extent of upper-limb impairment. The intervention group will receive 14 training sessions, each 1 hour long, with a physiotherapist over 6 weeks and will be encouraged to practice independently for 1 hour/day to give a total of 56 hours of training time per participant. Participants allocated to the control group will receive arm therapy in accordance with usual care. Participants will be measured at 7 weeks post-randomization, and followed-up at 3 and 6 months post-randomization. Primary outcome measures for assessment of arm function are the Action Research Arm Test (ARAT) and Wolf Motor Function Test (WMFT). Secondary measures are the Motor Activity Log, Stroke Impact Scale, Carer Strain Index, and health and social care resource use. All assessments will be conducted by a trained assessor blinded to treatment allocation. Recruitment, adherence, withdrawals, adverse events (AEs), and completeness of data will be recorded and reported.DiscussionThis study will determine the acceptability of the intervention, the characteristics of the population recruited, recruitment and retention rates, descriptive statistics of outcomes, and incidence of AEs. It will provide the information needed for planning a definitive trial to test home-based RTG training.Trial registrationISRCTN: ISRCTN56716589

Interventions for improving coordination of reach to grasp following stroke: a systematic review.

BACKGROUND Stroke is associated with disruption to efficient and accurate reach to grasp function. Information about treatments for upper limb coordination deficits and their effectiveness may contribute to improved recovery of upper limb function after stroke. AIMS To identify all existing interventions targeted at coordination of arm and hand segments for reach to grasp following stroke. To determine the effectiveness of current treatments for improving coordination of reach to grasp after stroke. SEARCH STRATEGY The search included The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); MEDLINE; EMBASE; CINAHL; AMED; ProQuest Dissertations and Theses (International) and ISI Proceedings (Conference) databases. A grey literature search included Mednar, Dissertation International, Conference Proceedings, National Institute of Health Clinical Trials and the National Institute of Clinical Studies. We also explored Physiotherapy Evidence Database, Chartered Society of Physiotherapy Research and REHABDATA therapy databases. Finally, the reference lists of identified articles were examined for additional studies. The search spanned from 1950 to April 2010 and was limited to English language papers only. METHODS OF THE REVIEW Studies were included with a specific design objective related to coordination of the hand and arm during reach to grasp and involving participants with a clinical diagnosis of stroke. The review was inclusive with regard to study design. To determine effectiveness of interventions we analysed studies with coordination measures that exist within impairment measurement scales or specific kinematic measures of coordination. The methodological quality of the studies was assessed by two independent authors using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Comparable Cohort/Case Control and the JBI Critical Appraisal Checklist for Experimental Studies together with additional questions from Downs and Black. Two review authors independently extracted data from the studies using standardised JBI-MAStARI data extraction forms. Pooling of results was not appropriate so the findings were summarised in tables and in narrative form. RESULTS One randomised controlled trial, two case-control studies and four experimental studies without controls were included in this review. The review has identified three categories of potential intervention for improving hand and arm coordination after stroke; functional therapy, biofeedback or electrical stimulation and robot or computerised training. In view of the limited availability of good quality evidence and lack of empirical data, this review does not draw a definitive conclusion for the second question regarding the effectiveness of interventions aimed at improving hand and arm coordination after stroke. Improvements in hand and arm coordination during reach to grasp were reported in four studies, whereas one study found no benefit. Two studies did not report specific effects of interventions for hand and arm coordination after stroke. CONCLUSIONS IMPLICATIONS FOR PRACTICE There is currently insufficient evidence to provide strong recommendations about the effect of interventions for improving hand and arm coordination during reach to grasp after stroke. IMPLICATIONS FOR RESEARCH Randomised controlled trials of sufficient power with standardised outcome measures are needed to enable meta-analysis comparison in the future. Such studies should include both functional performance and detailed kinematic measures of hand and arm coordination.

Neuroscience Findings on Coordination of Reaching to Grasp an Object: Implications for Research

Background. Knowledge of how damage to brain regions and pathways affects central nervous system control of coordination of reach-to-grasp (RTG) following stroke may not be sufficiently used in existing treatment interventions or in research that assesses their effectiveness. Objective. To review current knowledge of motor control of coordination of RTG and discuss the extent to which this information is being used in research evaluating treatment interventions. Method. This review (1) summarizes the current knowledge of motor control of RTG coordination in healthy individuals, including speculative models and structures of the brain identified as being involved; (2) summarizes evidence of RTG coordination deficits in people with stroke; (3) evaluates current interventions directed at retraining coordination of RTG, including a review of the extent to which these interventions are based on putative neurobiological mechanisms and reports on their effectiveness; and (4) recommends directions for research on treatment interventions for coordination of RTG. Results. Functional task-specific therapy, electrical stimulation, and robot or computerized training were identified as treatments targeted at improving coordination of RTG. However, none of the studies reporting the effect of these interventions related results to individual brain regions affected, and neurobiological mechanisms underlying improved performance were only minimally discussed. Conclusions. Research on treatment interventions for coordination of RTG needs to combine measures of interruption to brain networks and how remaining intact neural tissue and networks respond to therapy with measures of spatiotemporal motor control and upper-limb function to gain a fuller understanding of treatment effects and their mechanisms.

Ability to adjust reach extent in the hemiplegic arm

OBJECTIVE Insufficient information exists about the ability of hemiparetic patients to adjust reach extent during early recovery from stroke. Further knowledge may suggest guidance for therapy intervention. The objective of this study was to investigate the ability of hemiparetic subjects to adjust reach extent within 6 months after stroke. DESIGN Repeated-measures design experiment with two factors-group and target position. SETTING Physiotherapy department. PARTICIPANTS Nine hemiparetic and nine age- and gender-matched healthy subjects. METHODS Participants performed 15 reaching movements in the sagittal plane, five to each target of 8, 13 and 18 cm from the starting position. MAIN OUTCOME MEASURES Motion analysis was used to collect information on the kinematic variables of distance moved, movement duration, peak velocity, average velocity and the timing of peak velocity. These variables were compared between the different target positions and between groups. RESULTS The stroke group demonstrated a longer movement duration, lower peak and average velocity, and a later time to peak velocity compared with the healthy group. In response to the change in target position, both groups increased peak velocity for each increase in target position with no significant increase in movement duration, and showed a longer deceleration phase for the 18-cm target position. There was no significant difference between scaling of distance moved and peak velocity to target position between the groups. However, stroke subjects tended to overshoot the closer target and undershoot the more distant targets. The mean difference between groups was 12 mm [95% confidence interval (CI): -17 to 50] for the 8-cm position, 5mm (95% CI: -34 to 23) for the 13-cm position, and 9 mm (95% CI: -39 to 22) for the 18-cm position. The difference in peak velocity between each target position was smaller in the stroke subjects compared with the healthy subjects. The mean difference between groups was 103 mm/second (95% CI: -171 to -34) for the 8-cm position, 157 mm/second (95% CI: -231 to -82) for the 13-cm position, and 171 mm/second (95% CI: -262 to -80) for the 18-cm position. CONCLUSIONS Some aspects of the movement organisation of stroke subjects were similar to that of healthy subjects. However, stroke subjects showed errors in adjusting reach extent and velocity appropriately for different distances.