Rinske Nijland

Presence of Finger Extension and Shoulder Abduction Within 72 Hours After Stroke Predicts Functional Recovery Early Prediction of Functional Outcome After Stroke: The EPOS Cohort Study

Background and Purpose— The aim of the present study was to determine if outcome in terms of upper limb function at 6 months after stroke can be predicted in hospital stroke units using clinical parameters measured within 72 hours after stroke. In addition, the effect of the timing of assessment after stroke on the accuracy of prediction was investigated by measurements on days 5 and 9. Methods— Candidate determinants were measured in 188 stroke patients within 72 hours and at 5 and 9 days after stroke. Logistic regression analysis was used for model development to predict upper limb function at 6 months measured with the action research arm test (ARAT). Results— Patients with an upper limb motor deficit who exhibit some voluntary extension of the fingers and some abduction of the hemiplegic shoulder on day 2 have a probability of 0.98 to regain some dexterity at 6 months, whereas the probability was 0.25 for those without this voluntary motor activity. Sixty percent of patients with some early finger extension achieved full recovery at 6 months in terms of action research arm test score. Retesting the model on days 5 and 9 resulted in a gradual decline in probability from 0.25 to 0.14 for those without voluntary motor activity of shoulder abduction and finger extension, whereas the probability remained 0.98 for those with this motor activity. Conclusions— Based on 2 simple bedside tests, finger extension and shoulder abduction, functional recovery of the hemiplegic arm at 6 months can be predicted early in a hospital stroke unit within 72 hours after stroke onset.

Predictive value of the NIHSS for ADL outcome after ischemic hemispheric stroke: Does timing of early assessment matter?

BACKGROUND AND PURPOSE Early prediction of future functional abilities is important for stroke management. The objective of the present study was to investigate the predictive value of the 13-item National Institutes of Health Stroke Scale (NIHSS), measured within 72 h after stroke, for the outcome in terms of activities of daily living (ADL) 6 months post stroke. The second aim was to examine if the timing of NIHSS assessment during the first days post stroke affects the accuracy of predicting ADL outcome 6 months post stroke. METHODS Baseline characteristics including neurological deficits were measured in 188 stroke patients, using the 13-item NIHSS, within 72 h and at 5 and 9 days after a first-ever ischemic hemispheric stroke. Outcome in terms of ADL dependency was measured with the Barthel Index (BI) at 6 months post stroke. The area under the curve (AUC) from the receiver operating characteristic (ROC) was used to determine the discriminative properties of the NIHSS at days 2, 5 and 9 for outcome of the BI. In addition, at optimal cut-off odds ratio (OR), sensitivity, specificity, positive (PPV) and negative predicted values (NPV) for the different moments of NIHSS assessment post stroke were calculated. RESULTS One hundred and fifty-nine of the 188 patients were assessed at a mean of 2.2 (1.3), 5.4 (1.4) and 9.0 (1.8) days after stroke. Significant Spearman rank correlation coefficients were found between BI at 6 months and NIHSS scores on days 2 (r(s)=0.549, p<0.001), 5 (r(s)=0.592, p<0.001) and 9 (r(s)=0.567, p<0.001). The AUC ranged from 0.789 (95%CI, 0.715-0.864) for measurements on day 2 to 0.804 (95%CI, 0.733-0.874) and 0.808 (95%CI, 0.739-0.877) for days 5 and 9, respectively. Odds ratios ranged from 0.143 (95%CI, 0.069-0.295) for assessment on day 2 to a maximum of 0.148 (95%CI, 0.073-0.301) for day 5. The NPV gradually increased from 0.610 (95%CI, 0.536-0.672) for assessment on day 2 to 0.679 (95%CI, 0.578-0.765) for day 9, whereas PPV declined from 0.810 (95%CI, 0.747-0.875) for assessment on day 2 to 0.767 (95%CI, 0.712-0.814) for day 9. The overall accuracy of predictions increased from 71.7% for assessment on day 2 to 73.6% for day 9. CONCLUSIONS When measured within 9 days, the 13-item NIHSS is highly associated with final outcome in terms of BI at 6 months post stroke. The moment of assessment beyond 2 days post stroke does not significantly affect the accuracy of prediction of ADL dependency at 6 months. The NIHSS can therefore be used at acute hospital stroke units for early rehabilitation management during the first 9 days post stroke, as the accuracy of prediction remained about 72%, irrespective of the moment of assessment.

Understanding Adaptive Motor Control of the Paretic Upper Limb Early Poststroke: The EXPLICIT-stroke Program

Background. During upper limb motor recovery after stroke, the greatest improvements occur typically in the first 5 weeks poststroke. It is unclear what patients learn during this early phase of recovery. Objective. To investigate the hypothesis that, early poststroke, patients learn to master the degrees of freedom in the paretic upper limb as reflected by dissociated shoulder and elbow movements during reach-to-grasp. Methods. Thirty-one patients with a first-ever ischemic stroke were included. Repeated 3-dimensional kinematic measurements were conducted at 14, 25, 38, 57, 92, and 189 days poststroke. Trunk, shoulder, elbow, and wrist rotations were measured during a reach-to-grasp task. Using principal component analysis the longitudinal changes in dissociated upper limb movements during reach-to-grasp were investigated. Twelve healthy subjects were included for comparison. Results. The main coordination pattern during reach-to-grasp in patients with stroke and healthy subjects consisted mostly of horizontal shoulder adduction and elbow extension. The standard deviation of this main pattern increased over time, with the largest increase in the first 5 weeks poststroke (F = 5.5, P < .001), but remained smaller than in healthy individuals. The standard deviation increased by 0.46° per day between 14 and 38 days and tapered off to 0.05° per day between 38 and 189 days poststroke. Conclusions. Our results suggest that restitution of motor control by dissociation of shoulder and elbow movements occurs mainly early poststroke. However, compared with healthy adults, most patients did not achieve fully dissociated upper limb movements at 26 weeks poststroke, suggesting that upper limb motor control after stroke remains adaptive.

Effects of Unilateral Upper Limb Training in Two Distinct Prognostic Groups Early After Stroke: The EXPLICIT-Stroke Randomized Clinical Trial

Background and Objective. Favorable prognosis of the upper limb depends on preservation or return of voluntary finger extension (FE) early after stroke. The present study aimed to determine the effects of modified constraint-induced movement therapy (mCIMT) and electromyography-triggered neuromuscular stimulation (EMG-NMS) on upper limb capacity early poststroke. Methods. A total of 159 ischemic stroke patients were included: 58 patients with a favorable prognosis (>10° of FE) were randomly allocated to 3 weeks of mCIMT or usual care only; 101 patients with an unfavorable prognosis were allocated to 3-week EMG-NMS or usual care only. Both interventions started within 14 days poststroke, lasted up until 5 weeks, focused at preservation or return of FE. Results. Upper limb capacity was measured with the Action Research Arm Test (ARAT), assessed weekly within the first 5 weeks poststroke and at postassessments at 8, 12, and 26 weeks. Clinically relevant differences in ARAT in favor of mCIMT were found after 5, 8, and 12 weeks poststroke (respectively, 6, 7, and 7 points; P < .05), but not after 26 weeks. We did not find statistically significant differences between mCIMT and usual care on impairment measures, such as the Fugl-Meyer assessment of the arm (FMA-UE). EMG-NMS did not result in significant differences. Conclusions. Three weeks of early mCIMT is superior to usual care in terms of regaining upper limb capacity in patients with a favorable prognosis; 3 weeks of EMG-NMS in patients with an unfavorable prognosis is not beneficial. Despite meaningful improvements in upper limb capacity, no evidence was found that the time-dependent neurological improvements early poststroke are significantly influenced by either mCIMT or EMG-NMS.

Assessing Longitudinal Change in Coordination of the Paretic Upper Limb Using On-Site 3-Dimensional Kinematic Measurements

Background and Purpose It is largely unknown how adaptive motor control of the paretic upper limb contributes to functional recovery after stroke. This paucity of knowledge emphasizes the need for longitudinal 3-dimensional (3D) kinematic studies with frequent measurements to establish changes in coordination after stroke. A portable 3D kinematic setup would facilitate the frequent follow-up of people poststroke. This case report shows how longitudinal kinematic changes of the upper limb can be measured at a patients home using a portable 3D kinematic system in the first 6 months poststroke. Case Description The outcomes of the upper-limb section of the Fugl-Meyer Motor Assessment (FMA), the Action Research Arm Test (ARAT), and 3D kinematic analyses were obtained from a 41-year-old man with a left hemispheric stroke. Three-dimensional kinematic data of the paretic upper limb were collected during a reach-to-grasp task using a portable motion tracker in 5 measurements during the first 6 months after stroke. Data from an individual who was healthy were used for comparison. Outcomes The FMA and ARAT scores showed nonlinear recovery profiles, accompanied by significant changes in kinematic outcomes over time poststroke. Specifically, elbow extension increased, forward trunk motion decreased, peak hand speed increased, peak hand opening increased, and peak hand opening occurred sooner after peak hand speed. Discussion This case report illustrates the feasibility of frequently repeated, on-site 3D kinematic measurements of the paretic upper limb. Early after stroke, task performance was mainly driven by adaptive motor control, whereas adaptations were mostly reduced at 26 weeks poststroke. The presented approach allows the investigation of what is changing in coordination and how these changes are related to the nonlinear pattern of improvements in body functions and activities after stroke.

How Do Fugl-Meyer Arm Motor Scores Relate to Dexterity According to the Action Research Arm Test at 6 Months Poststroke?

OBJECTIVE To determine the optimal cutoff scores for the Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) with regard to predicting no, poor, limited, notable, or full upper-limb capacity according to frequently used cutoff points for the Action Research Arm Test (ARAT) at 6 months poststroke. DESIGN Prospective. SETTING Rehabilitation center. PARTICIPANTS Patients (N=460) with a first-ever ischemic stroke at 6 months poststroke. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Based on the ARAT classification of poor to full upper-limb capacity, receiver operating characteristic curves were used to calculate the area under the curve, optimal cutoff points for the FMA-UE were determined, and a weighted kappa was used to assess the agreement. RESULTS FMA-UE scores of 0 through 22 represent no upper-limb capacity (ARAT 0-10); scores of 23 through 31 represent poor capacity (ARAT 11-21); scores of 32 through 47 represent limited capacity (ARAT 22-42); scores of 48 through 52 represent notable capacity (ARAT 43-54); and scores of 53 through 66 represent full upper-limb capacity (ARAT 55-57). Overall, areas under the curve ranged from .916 (95% confidence interval [CI], .890-.943) to .988 (95% CI, .978-.998; P<.001). CONCLUSIONS There is considerable overlap in the area under the curve between the ARAT and FMA-UE. FMA-UE scores >31 points correspond to no to poor arm-hand capacity (ie, ≤21 points) on the ARAT, whereas FMA-UE scores >31 correspond to limited to full arm-hand capacity (ie, ≥22 points) on the ARAT.

Caregiver-mediated exercises with e-health support for early supported discharge after stroke (CARE4STROKE): study protocol for a randomized controlled trial

BackgroundSeveral systematic reviews have shown that additional exercise therapy has a positive effect on functional outcome after stroke. However, there is an urgent need for resource-efficient methods to augment rehabilitation services without increasing health care costs. Asking informal caregivers to do exercises with their loved ones, combined with e-health services may be a cost-effective method to promote early supported discharge with increased functional outcome.The primary aim of the CARE4STROKE study is to evaluate the effects and cost-effectiveness of a caregiver-mediated exercises program combined with e-health services after stroke in terms of self-reported mobility and length of stay.MethodsAn observer-blinded randomized controlled trial, in which 66 stroke-patients admitted to a hospital stroke unit, rehabilitation center or nursing home are randomly assigned to either 8 weeks of the CARE4STROKE program in addition to usual care (i.e., experimental group) or 8 weeks of usual care alone (i.e., control group). The CARE4STROKE program is compiled in consultation with a trained physical therapist. A tablet computer is used to present video-based exercises for gait and gait-related activities in which a caregiver acts as an exercise coach.Primary outcomes are the mobility domain of the Stroke Impact Scale and length of stay. Secondary outcomes are the other domains of the Stroke Impact Scale, motor impairment, strength, walking ability, balance, mobility, (Extended) Activities of Daily Living, psychosocial functioning, self-efficacy, fatigue, health-related quality of life of the patient as well as the experienced strain, psychosocial functioning and quality of life of the caregiver. An economic evaluation will be conducted from the societal and health care perspective.DiscussionThe main aspects of the CARE4STROKE program are 1) increasing intensity of training by doing exercises with a caregiver in addition to usual care and 2) e-health support. We hypothesize this program leads to better functional outcome and early supported discharge, resulting in reduced costs.Trial registrationThe study is registered in the Dutch trial register as NTR4300, registered 2 December 2013.

When Does Return of Voluntary Finger Extension Occur Post-Stroke? A Prospective Cohort Study

Objectives Patients without voluntary finger extension early post-stroke are suggested to have a poor prognosis for regaining upper limb capacity at 6 months. Despite this poor prognosis, a number of patients do regain upper limb capacity. We aimed to determine the time window for return of voluntary finger extension during motor recovery and identify clinical characteristics of patients who, despite an initially poor prognosis, show upper limb capacity at 6 months post-stroke. Methods Survival analysis was used to assess the time window for return of voluntary finger extension (Fugl-Meyer Assessment hand sub item finger extension≥1). A cut-off of ≥10 points on the Action Research Arm Test was used to define return of some upper limb capacity (i.e. ability to pick up a small object). Probabilities for regaining upper limb capacity at 6 months post-stroke were determined with multivariable logistic regression analysis using patient characteristics. Results 45 of the 100 patients without voluntary finger extension at 8 ± 4 days post-stroke achieved an Action Research Arm Test score of ≥10 points at 6 months. The median time for regaining voluntary finger extension for these recoverers was 4 weeks (lower and upper percentile respectively 2 and 8 weeks). The median time to return of VFE was not reached for the whole group (N = 100). Patients who had moderate to good lower limb function (Motricity Index leg≥35 points), no visuospatial neglect (single-letter cancellation test asymmetry between the contralesional and ipsilesional sides of <2 omissions) and sufficient somatosensory function (Erasmus MC modified Nottingham Sensory Assessment≥33 points) had a 0.94 probability of regaining upper limb capacity at 6 months post-stroke. Conclusions We recommend weekly monitoring of voluntary finger extension within the first 4 weeks post-stroke and preferably up to 8 weeks. Patients with paresis mainly restricted to the upper limb, no visuospatial neglect and sufficient somatosensory function are likely to show at least some return of upper limb capacity at 6 months post-stroke.

Stroke Impact Scale

Description: Several outcome measures are available to assess the physical impact of stroke; however, the types of problems experienced by stroke patients are multidimensional. The Stroke Impact Scale (SIS) is a disease-specific, self-report questionnaire that evaluates disability and health-related quality of life after stroke. The SIS was developed in collaboration with stroke patients, informal caregivers and experienced healthcare professionals, ensuring that all aspects of stroke that may influence health-related quality of life were incorporated. The first published SIS included 64 items, but Rasch Analysis identified five redundant items that were subsequently removed, creating the current SIS 3.0. The SIS 3.0 takes approximately 15 to 20 minutes to administer and requires no formal training. It assesses self-reported impact of stroke in eight domains: strength, memory and thinking, emotion, communication, (instrumental) activities of daily living (ADL/IADL), mobility, hand function and participation. In addition, a visual analogue scale ranging from 0 to 100 measures general perceived recovery since the onset of stroke. Domain scores range from 0 to 100 and are calculated using the following equation:

Description of the CARE4STROKE programme : A caregiver-mediated exercises intervention with e-health support for stroke patients

Background Intensity of practice and task and context specificity are key factors for improving functional outcome in stroke survivors. Novel methods are needed to augment intensity of practice with minimal use of resources and costs. Caregiver‐mediated exercises (CMEs) focused on mobility, in which a caregiver acts as an exercise coach and can increase the intensity of practice. There is preliminary evidence that CME can improve functional outcome, reduce length of stay, and allow early supported discharge, without an increase in caregiver burden. In the CARE4STROKE programme (C4S), CME therapy and e‐health support are combined to promote a smoother transition from the inpatient setting to the home environment, with active rehabilitation continuing in the community. The objective of this paper is to describe the content of the C4S intervention in detail and explain implementation of this intervention in practice using the Template for Intervention Description and Replication checklist. Methods Content, timing and intensity of the programme, participant screening and selection, and intervention procedures were described using the Template for Intervention Description and Replication checklist. Mobility exercises and use of a video application on tablet/smartphone are explained. The role of the caregiver as provider of the intervention is illustrated. Discussion C4S prescribes an additional exercise dose of 1,200 min and may be a promising novel and effective method to augment the pallet of therapeutic options for stroke rehabilitation. Important aspects for successful implementation are availability and suitability of a caregiver. Suggestions for additional use of e‐health technology are described. Implications for physiotherapy practice The presented description of C4S gives physical therapists practical guidelines to facilitate implementation of the CME intervention.