Rebecca L. Birkenmeier

Very Early Constraint-Induced Movement during Stroke Rehabilitation (VECTORS): A single-center RCT

Background: Constraint-induced movement therapy (CIMT) is among the most developed training approaches for motor restoration of the upper extremity (UE). Methods: Very Early Constraint-Induced Movement during Stroke Rehabilitation (VECTORS) was a single-blind phase II trial of CIMT during acute inpatient rehabilitation comparing traditional UE therapy with dose-matched and high-intensity CIMT protocols. Participants were adaptively randomized on rehabilitation admission, and received 2 weeks of study-related treatments. The primary endpoint was the total Action Research Arm Test (ARAT) score on the more affected side at 90 days after stroke onset. A mixed model analysis was performed. Results: A total of 52 participants (mean age 63.9 ± 14 years) were randomized 9.65 ± 4.5 days after onset. Mean NIHSS was 5.3 ± 1.8; mean total ARAT score was 22.5 ± 15.6; 77% had ischemic stroke. Groups were equivalent at baseline on all randomization variables. As expected, all groups improved with time on the total ARAT score. There was a significant time x group interaction (F = 3.1, p < 0.01), such that the high intensity CIT group had significantly less improvement at day 90. No significant differences were found between the dose-matched CIMT and control groups at day 90. MRI of a subsample showed no evidence of activity-dependent lesion enlargement. Conclusion: Constraint-induced movement therapy (CIMT) was equally as effective but not superior to an equal dose of traditional therapy during inpatient stroke rehabilitation. Higher intensity CIMT resulted in less motor improvement at 90 days, indicating an inverse dose-response relationship. Motor intervention trials should control for dose, and higher doses of motor training cannot be assumed to be more beneficial, particularly early after stroke.

Estimating Minimal Clinically Important Differences of Upper-Extremity Measures Early After Stroke

OBJECTIVE To estimate minimal clinically important difference (MCID) values of several upper-extremity measures early after stroke. DESIGN Data in this report were collected during the Very Early Constraint-induced Therapy for Recovery of Stroke trial, an acute, single-blind randomized controlled trial of constraint-induced movement therapy. Subjects were tested at the prerandomization baseline assessment (average days poststroke, 9.5d) and the first posttreatment assessment (average days poststroke, 25.9d). At each time point, the affected upper extremity was evaluated with a battery of 6 tests. At the second assessment, subjects were also asked to provide a global rating of perceived changes in their affected upper extremity. Anchor-based MCID values were calculated separately for the affected dominant upper extremities and the affected nondominant upper extremities for each of the 6 tests. SETTING Inpatient rehabilitation hospital. PARTICIPANTS Fifty-two people with hemiparesis poststroke. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Estimated MCID values for grip strength, composite upper-extremity strength, Action Research Arm Test (ARAT), Wolf Motor Function Test (WMFT), Motor Activity Log (MAL), and duration of upper-extremity use as measured with accelerometry. RESULTS MCID values for grip strength were 5.0 and 6.2 kg for the affected dominant and nondominant sides, respectively. MCID values for the ARAT were 12 and 17 points, for the WMFT function score were 1.0 and 1.2 points, and for the MAL quality of movement score were 1.0 and 1.1 points for the 2 sides, respectively. MCID values were indeterminate for the dominant (composite strength), the nondominant (WMFT time score), and both affected sides (duration of use) for the other measures. CONCLUSIONS Our data provide some of the first estimates of MCID values for upper-extremity standardized measures early after stroke. Future studies with larger sample sizes are needed to refine these estimates and to determine whether MCID values are modified by time poststroke.

Translating Animal Doses of Task-Specific Training to People With Chronic Stroke in 1-Hour Therapy Sessions: A Proof-of-Concept Study:

Objective. The purposes of this study were to (1) examine the feasibility of translating high-repetition doses of upper-extremity (UE) task-specific training to people with stroke within the confines of the current outpatient delivery system of 1-hour therapy sessions and (2) to gather preliminary data regarding the potential benefit of this intensity of training. Methods. A total of 15 patients with chronic (>6 months) UE paresis caused by stroke underwent 3 weeks of baseline assessments followed by 6 weeks of the high-repetition intervention (3 sessions/wk for 6 weeks). During each 1-hour session, participants were challenged to complete 300 or more repetitions of UE functional task training (3 tasks × 100 repetitions). Assessments during and after the intervention were used to measure feasibility and potential benefit. Results. For the 13 participants completing the intervention, the average number of repetitions per session was 322. The percentage of sessions attended was 97%. Participant ratings of pain and fatigue were low. Action Research Arm test scores improved an average of 8 points during the intervention and were maintained at the 1-month follow-up. Secondary measures of activity and participation increased, but the measure of impairment did not. Conclusions. It is feasible to deliver hundreds of repetitions of task-specific training to people with stroke in 1-hour therapy sessions. Preliminary outcome data suggest that this intervention may be beneficial for some people with stroke.

Assessment of upper extremity impairment, function, and activity after stroke: Foundations for clinical decision making

The purpose of this review is to provide a comprehensive approach for assessing the upper extremity (UE) after stroke. First, common UE impairments and how to assess them are briefly discussed. Although multiple UE impairments are typically present after stroke, the severity of ones impairment, paresis, is the primary determinant of UE functional loss. Second, UE function is operationally defined and a number of clinical measures are discussed. It is important to consider how impairment and loss of function affect UE activity outside of the clinical environment. Thus, this review also identifies accelerometry as an objective method for assessing UE activity in daily life. Finally, the role that each of these levels of assessment should play in clinical decision making is discussed to optimize the provision of stroke rehabilitation services.

Relationships between upper-limb functional limitation and self-reported disability 3 months after stroke

This study explored relationships between upper-limb (UL) functional limitations and self-reported disability in stroke patients with relatively pure motor hemiparesis who were enrolled in an acute rehabilitation treatment trial. All participants were enrolled in the VECTORS (Very Early Constraint Treatment for Recovery from Stroke) study. VECTORS is a single-center pilot clinical trial of early application of constraint-induced movement therapy (CIMT). All 39 subjects who completed 90 days of VECTORS were included in this analysis. Trained study personnel who were blinded to the treatment type performed all evaluations. Data in this article examine relationships between assessments performed 90 days after stroke. Functional limitation measures included the Action Research Arm (ARA) test and Wolf Motor Function Test (WMFT), and self-reported disability measures included the Functional Independence Measure (FIM) and Motor Activity Log (MAL) (by telephone). Mean plus or minus standard deviation time from stroke onset to randomization was 9.4 plus or minus 4.3 days, and median time to follow-up was 99 days (range 68-178). Subjects with perfect or near-perfect scores on the ARA test or WMFT reported residual disability on the FIM and MAL. Quality of movement on the WMFT (functional ability score) was not strongly associated with self-reported frequency, and speed of movement on the WMFT (timed score) was not associated with self-reported frequency (MAL amount of use). In this early UL intervention trial, we found that perceived disability measures captured information that was not assessed by functional limitation and impairment scales. Our results indicate that excellent motor recovery as measured by functional limitation and impairment scales did not equal restoration of everyday productive UL use and speed of task completion did not translate to actual use. Our results confirm the need for a measurement strategy that is sensitive to change, assesses a broad performance range, and detects meaningful clinical improvements in early rehabilitation intervention trials.

Dose‐response of task‐specific upper limb training in people at least 6 months post stroke: A Phase II, single‐blind, randomized, controlled trial

The objectives of this work were to (1) determine whether higher doses of motor therapy in chronic poststroke hemiparesis result in better outcomes, compared to lower doses, and (2) evaluate potential modifiers of the dose‐response relationship.

Dose and timing in neurorehabilitation: Prescribing motor therapy after stroke

PURPOSE OF REVIEW Prescribing the most appropriate dose of motor therapy for individual patients is a challenge because minimal data are available and a large number of factors are unknown. This review explores the concept of dose and reviews the most recent findings in the field of neurorehabilitation, with a focus on relearning motor skills after stroke. RECENT FINDINGS Appropriate dosing involves the prescription of a specific amount of an active ingredient, at a specific frequency and duration. Dosing parameters, particularly amount, are not well defined or quantified in most studies. Compiling data across studies indicates a positive, moderate dose-response relationship, indicating that more movement practice results in better outcomes. This relationship is confounded by time after stroke, however, wherein longer durations of scheduled therapy may not be beneficial in the first few hours, days, and/or weeks. SUMMARY These findings suggest that substantially more movement practice may be necessary to achieve better outcomes for people living with the disabling consequences of stroke. Preclinical investigations are needed to elucidate many of the unknowns and allow for a more biologically driven rehabilitation prescription process. Likewise, clinical investigations are needed to determine the dose-response relationships and examine the potential dose-timing interaction in humans.

Feasibility of high-repetition, task-specific training for individuals with upper-extremity paresis.

OBJECTIVE. We investigated the feasibility of delivering an individualized, progressive, high-repetition upper-extremity (UE) task-specific training protocol for people with stroke in the inpatient rehabilitation setting. METHOD. Fifteen patients with UE paresis participated in this study. Task-specific UE training was scheduled for 60 min/day, 4 days/wk, during occupational therapy for the duration of a participants inpatient stay. During each session, participants were challenged to complete ≥300 repetitions of various tasks. RESULTS. Participants averaged 289 repetitions/session, spending 47 of 60 min in active training. Participants improved on impairment and activity level outcome measures. CONCLUSION. People with stroke in an inpatient setting can achieve hundreds of repetitions of task-specific training in 1-hr sessions. As expected, all participants improved on functional outcome measures. Future studies are needed to determine whether this high-repetition training program results in better outcomes than current UE interventions.

An Evaluation of the Wolf Motor Function Test in Motor Trials Early After Stroke

OBJECTIVE To examine the internal consistency, validity, responsiveness, and advantages of the Wolf Motor Function Test (WMFT) and compare these results to the Action Research Arm Test (ARAT) in participants with mild to moderate hemiparesis within the first few months after stroke. DESIGN Data were collected as part of the Very Early Constraint-Induced Therapy for Recovery from Stroke (VECTORS) trial, an acute, single-blind randomized controlled trial of constraint-induced movement therapy. Subjects were studied at baseline (day 0), after treatment (day 14), and after 90 days (day 90) poststroke. SETTING Inpatient rehabilitation hospital; follow-up 3 months poststroke. PARTICIPANTS Hemiparetic subjects (N=51) enrolled in the VECTORS trial. INTERVENTION None. MAIN OUTCOME MEASURES At each time point, subjects were tested on (1) the WMFT and ARAT, (2) clinical measures of sensorimotor impairments, (3) reach and grasp movements performed in the kinematics laboratory, and (4) clinical measures of disability. Blinded raters performed all evaluations. Analyses at each time point included calculating effect size as indicators of responsiveness, and correlation analyses to examine relationships between WMFT scores and other measures. RESULTS The WMFT is internally consistent, valid, and responsive in the early stages of stroke recovery. Sensorimotor and kinematic measures of reach and grasp support the construct validity of the WMFT. CONCLUSIONS In an acute stroke population, the WMFT has acceptable reliability, validity, and responsiveness to change over time. However, when compared with the ARAT, the higher training and testing burdens may not be offset by the relatively small psychometric advantages.

Real-world affected upper limb activity in chronic stroke: an examination of potential modifying factors

Abstract Background: Despite improvement in motor function after intervention, adults with chronic stroke experience disability in everyday activity. Factors other than motor function may influence affected upper limb (UL) activity. Objective: To characterize affected UL activity and examine potential modifying factors of affected UL activity in community-dwelling adults with chronic stroke. Methods: Forty-six adults with chronic stroke wore accelerometers on both ULs for 25 hours and provided information about potential modifying factors [time spent in sedentary activity, cognitive impairment, depressive symptomatology, number of comorbidities, motor dysfunction of the affected UL, age, activities of daily living (ADL) status, and living arrangement]. Accelerometry was used to quantify duration of affected and unaffected UL activity. The ratio of affected-to-unaffected UL activity was also calculated. Associations within and between accelerometry-derived variables and potential modifying factors were examined. Results: Mean hours of affected and unaffected UL activity were 5.0 ± 2.2 and 7.6 ± 2.1 hours respectively. The ratio of affected-to-unaffected UL activity was 0.64 ± 0.19, and hours of affected and unaffected UL activity were strongly correlated (r = 0.78). Increased severity of motor dysfunction and dependence in ADLs were associated with decreased affected UL activity. No other factors were associated with affected UL activity. Conclusions: Severity of motor dysfunction and ADL status should be taken into consideration when setting goals for UL activity in people with chronic stroke. Given the strong, positive correlation between affected and unaffected UL activity, encouragement to increase activity of the unaffected UL may increase affected UL activity.