Stephen D. Bagg

Quantitative Assessment of Limb Position Sense Following Stroke

Background. Impairment of position sense of the upper extremity (UE) may impede activities of daily living and limit motor gains after stroke. Most clinical assessments of position sense rely on categorical or ordinal ratings by clinicians that lack sensitivity to change or the ability to discriminate subtle deficits. Objective. Use robotic technology to develop a reliable, quantitative technique with a continuous scale to assess UE position sense following stroke. Methods. Forty-five patients recruited from an inpatient stroke rehabilitation service and 65 age-matched healthy controls performed an arm position matching task. Each UE was fitted in the exoskeleton of a KINARM device. One UE was passively placed in one of 9 positions, and the subject was told to match his or her position with the other UE. Patients were compared with statistical distributions of control data to identify those with deficits in UE position sense. Test—retest sessions using 2 raters established interrater reliability. Results. Two thirds of left hemiparetic and one third of right hemiparetic patients had deficits in limb position sense. Left-affected stroke subjects demonstrated significantly more trial-to-trial variability than right-affected or control subjects. The robotic assessment technique demonstrated good interrater reliability but limited agreement with the clinical thumb localizing test. Conclusions. Robotic technology can provide a reliable quantitative means to assess deficits in limb position sense following stroke.

Assessment of Upper-Limb Sensorimotor Function of Subacute Stroke Patients Using Visually Guided Reaching

Objective. Using robotic technology, we examined the ability of a visually guided reaching task to assess the sensorimotor function of patients with stroke. Methods. Ninety-one healthy participants and 52 with subacute stroke of mild to moderate severity (26 with left- and 26 with right-affected body sides) performed an unassisted reaching task using the KINARM robot. Each participant was assessed using 12 movement parameters that were grouped into 5 attributes of sensorimotor control. Results. A number of movement parameters individually identified a large number of stroke participants as being different from 95% of the controls—most notably initial direction error, which identified 81% of left-affected patients. We also found interlimb differences in performance between the arms of those with stroke compared with controls. For example, whereas only 31% of left-affected participants showed differences in reaction time with their affected arm, 54% showed abnormal interlimb differences in reaction time. Good interrater reliability (r > 0.7) was observed for 9 of the 12 movement parameters. Finally, many stroke patients deemed impaired on the reaching task had been scored 6 or less on the arm portion of the Chedoke-McMaster Stroke Assessment Scale, but some who scored a normal 7 were also deemed impaired in reaching. Conclusions. Robotic technology using a visually guided reaching task can provide reliable information with greater sensitivity about a patient’s sensorimotor impairments following stroke than a standard clinical assessment scale.

The independence of deficits in position sense and visually guided reaching following stroke

BackgroundSeveral studies have found correlations between proprioception and visuomotor function during stroke recovery, however two more recent studies have found no correlation. Unfortunately, most of the studies to date have been conducted with clinical assessments of sensation that are observer-based and have poor reliability. We have recently developed new tests to assess position sense and motor function using robotic technology. The present study was conducted to reassess the relationship between position sense and upper limb movement following stroke.MethodsWe assessed position sense and motor performance of 100 inpatient stroke rehabilitation subjects and 231 non-disabled controls. All subjects completed quantitative assessments of position sense (arm-position matching task) and motor performance (visually-guided reaching task) using the KINARM robotic device. Subjects also completed clinical assessments including handedness, vision, Purdue Pegboard, Chedoke-McMaster Stroke Assessment-Impairment Inventory and Functional Independence Measure (FIM). Neuroimaging documented lesion localization. Fisher’s exact probability tests were used to determine the relationship between performances on the arm-position matching and visually-guided reaching task. Pearson’s correlations were conducted to determine the relationship between robotically measured parameters and clinical assessments.ResultsPerformance by individual subjects on the matching and reaching tasks was statistically independent (Fisher’s test, P<0.01). However, performance on the matching and reaching tasks both exhibited relationships with abilities in daily activities as measured by the FIM. Performance on the reaching task also displayed strong relationships with other clinical measures of motor impairment.ConclusionsOur data support the concept that position sense deficits are functionally relevant and point to the importance of assessing proprioceptive and motor impairments independently when planning treatment strategies.

The berg balance scale as a predictor of length of stay and discharge destination in an acute stroke rehabilitation setting

OBJECTIVE To examine the utility of the Berg Balance Scale (BBS) in predicting length of stay and discharge destination for patients admitted to a stroke rehabilitation unit. DESIGN Retrospective study. SETTING Regional tertiary inpatient stroke rehabilitation unit. PATIENTS One hundred twenty-eight of 141 patients admitted consecutively between January 1, 1995, and March 31, 1996. MAIN OUTCOME MEASURES Length of stay and discharge destination. RESULTS Admission BBS scores and Functional Independence Measure scores correlated with length of stay (r = -0.6 and -0.5, respectively, controlling for age). Logistic regression revealed that the following were independent predictors of being discharged home rather than to an institution (adjusted odds ratio, 95% confidence interval): admission BBS (1.09, 1.04-1.13), age (.89, .83-.95), and presence of family support (11.7, 3.1-44.3). CONCLUSIONS Measuring the BBS scores of patients upon admission to an acute stroke rehabilitation unit may assist in approximating length of stay and predicting eventual discharge destination.

Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update 2015:

Stroke rehabilitation is a progressive, dynamic, goal-orientated process aimed at enabling a person with impairment to reach their optimal physical, cognitive, emotional, communicative, social and/or functional activity level. After a stroke, patients often continue to require rehabilitation for persistent deficits related to spasticity, upper and lower extremity dysfunction, shoulder and central pain, mobility/gait, dysphagia, vision, and communication. Each year in Canada 62,000 people experience a stroke. Among stroke survivors, over 6500 individuals access in-patient stroke rehabilitation and stay a median of 30 days (inter-quartile range 19 to 45 days). The 2015 update of the Canadian Stroke Best Practice Recommendations: Stroke Rehabilitation Practice Guidelines is a comprehensive summary of current evidence-based recommendations for all members of multidisciplinary teams working in a range of settings, who provide care to patients following stroke. These recommendations have been developed to address both the organization of stroke rehabilitation within a system of care (i.e., Initial Rehabilitation Assessment; Stroke Rehabilitation Units; Stroke Rehabilitation Teams; Delivery; Outpatient and Community-Based Rehabilitation), and specific interventions and management in stroke recovery and direct clinical care (i.e., Upper Extremity Dysfunction; Lower Extremity Dysfunction; Dysphagia and Malnutrition; Visual-Perceptual Deficits; Central Pain; Communication; Life Roles). In addition, stroke happens at any age, and therefore a new section has been added to the 2015 update to highlight components of stroke rehabilitation for children who have experienced a stroke, either prenatally, as a newborn, or during childhood. All recommendations have been assigned a level of evidence which reflects the strength and quality of current research evidence available to support the recommendation. The updated Rehabilitation Clinical Practice Guidelines feature several additions that reflect new research areas and stronger evidence for already existing recommendations. It is anticipated that these guidelines will provide direction and standardization for patients, families/caregiver(s), and clinicians within Canada and internationally.

First Clinical Experience with BION Implants for Therapeutic Electrical Stimulation

The objective of this study was to assess the usability and safety of BION injectable neuromuscular microstimulators for therapeutic electrical stimulation (TES) to treat two conditions involving disuse atrophy: poststroke shoulder subluxation in hemiplegic subjects and knee osteoarthritis. Clinicians were provided with PC‐based software to track implants and to design the exercise programs. Subjects self‐administered TES (3 sessions/day, 10–30 min/session) for 6 or 12 weeks. Outcome measures included subluxation for the shoulder study and knee function and pain for the osteoarthritis study. All subjects were comfortable with the BION equipment and therapy; eight of 10 experimental subjects elected to continue treatment after the study period. Shoulder subluxation was reduced by 55% ± 54%; knee function was enhanced by 65% ± 24%; and knee pain decreased by 78% ± 18%. The devices did not migrate and did not cause inflammation or pain. Thresholds were stable over time. We conclude that the use of BION implants to exercise atrophic muscles was well‐accepted and provided effective rehabilitation in these two clinical conditions.

A Comparison of Studies on the Quality of Life of Primary Caregivers of Stroke Survivors: A Systematic Review of the Literature

Abstract Background and Purpose: Few studies have been conducted on the quality of life (QOL) of primary caregivers of stroke survivors (with and without aphasia), with little consistency in the methods of evaluation. The purpose of this systematic review of the literature was to determine the appropriateness of study designs and instruments used to assess QOL in caregivers of stroke survivors. Method: A comprehensive literature review was conducted to identify peer-reviewed articles of caregiver’s QOL where CINAHL, MEDLINE, and PsycINFO databases were searched. Results: Nine studies that met the inclusion criteria used different QOL instruments and study designs. None of the instruments were specific to caregivers of stroke survivors. Conclusion: Future studies are warranted to assess the quality of life of caregivers of stroke survivors with and without aphasia.

Shoulder Complex Position and Glenohumeral Subluxation in Hemiplegia

OBJECTIVES 1. To determine if scapular and humeral orientation differed between the affected and nonaffected side in two groups of hemiplegic subjects (low tone and high tone). 2. To determine if there was a relationship between these measures and glenohumeral subluxation in either group. DESIGN Retrospective case-comparison study. SUBJECTS, SETTING: Thirty-four hemiplegic subjects, 41 to 89 years of age, participated in the study. Subjects were divided into high-tone (n = 17) and low-tone (n = 17) groups on the basis of Ashworth scoring of muscle tone. OUTCOME MEASURES Linear and angular measures of scapular and humeral orientation were calculated from tridimensional coordinates of bony landmarks collected using an electromagnetic device with subjects in a seated position with arms relaxed by their side. Glenohumeral subluxation was measured from radiographs. RESULTS The scapula was further from the midline and lower on the thorax on the affected side in the low-tone group (p < .05). Glenohumeral subluxation was greater in the low-tone group (p < .05). The scapular abduction angle (ScAb) was significantly greater on the nonaffected in the low-tone group compared with both the affected side in this group and to the nonaffected side in the high-tone group. In the high-tone group, no differences were found between the affected and nonaffected side in either the angular or linear measures. There was no significant correlation between scapular or humeral orientation and glenohumeral subluxation in either group (p > .05). CONCLUSIONS This study provided little evidence of a consistent pattern of alteration in shoulder complex orientation, particularly in subjects with increased muscle tone, and no support for the concept of a relationship between scapular and humeral orientation and glenohumeral subluxation.

A robotic object hitting task to quantify sensorimotor impairments in participants with stroke

BackgroundExisting clinical scores of upper limb function often use observer-based ordinal scales that are subjective and commonly have floor and ceiling effects. The purpose of the present study was to develop an upper limb motor task to assess objectively the ability of participants to select and engage motor actions with both hands.MethodsA bilateral robotic system was used to quantify upper limb sensorimotor function of participants with stroke. Participants performed an object hit task that required them to hit virtual balls moving towards them in the workspace with virtual paddles attached to each hand. Task difficulty was initially low, but increased with time by increasing the speed and number of balls in the workspace. Data were collected from 262 control participants and 154 participants with recent stroke.ResultsControl participants hit ~60 to 90% of the 300 balls with relatively symmetric performance for the two arms. Participants with recent stroke performed the task with most participants hitting fewer balls than 95% of healthy controls (67% of right-affected and 87% of left-affected strokes). Additionally, nearly all participants (97%) identified with visuospatial neglect hit fewer balls than healthy controls. More detailed analyses demonstrated that most participants with stroke displayed asymmetric performance between their affected and non-affected limbs with regards to number of balls hit, workspace area covered by the limb and hand speed. Inter-rater reliability of task parameters was high with half of the correlations above 0.90. Significant correlations were observed between many of the task parameters and the Functional Independence Measure and/or the Behavioural Inattention Test.ConclusionsAs this object hit task requires just over two minutes to complete, it provides an objective and easy approach to quantify upper limb motor function and visuospatial skills following stroke.

Gait Changes Following Botulinum Toxin A Treatment in Stroke

Abstract Purpose: To characterize the effects of botulinum toxin A treatment of spastic plantar flexors in stroke on joint mobility and gait kinematics and kinetics. Method: Nine patients with hemiparetic stroke presenting with ankle hypertonicity participated in this exploratory open-label case series study. Comprehensive gait analysis provided bilateral kinematic and kinetic information for the ankle, knee, and hip joints throughout the stance phase. Data were obtained at baseline, 2 weeks, and 10 weeks post botulinum toxin injection of the spastic plantar flexors. Results: Passive ankle range of motion increased post injection (p < .05). The amount of plantarflexion in late stance was significantly reduced (p < .05) while the maximum dorsiflexion increased in midstance at 10 weeks post treatment. The angular displacement profiles for the knee revealed that patients tended to display less hyperextension following treatment (p = .053). No significant changes in kinetic measures were found; however, case-by-case observations suggested that most patients experienced improvements in positive work production. Conclusions: The findings indicate that botulinum toxin treatment results in improved joint mobility and ankle kinematics and, in some patients, increases in positive work, suggesting better gait performance.