Susan Hillier

Does induction of plastic change in motor cortex improve leg function after stroke

Combined peripheral nerve and brain stimulation (“dual stimulation”) induces changes in the excitability of normal motor cortex. The authors sought to establish whether dual stimulation would also induce motor cortex plasticity and associated functional improvements in nine stroke patients with chronic stable hemiparesis. Following 4 weeks of daily dual stimulation, improvements were seen in some neurophysiological and functional measures. This technique may offer therapeutic opportunities in some stroke patients.

Evidence for the retraining of sensation after stroke: a systematic review

Objective: Retraining of sensory function following stroke is frequently overlooked in rehabilitation protocols despite more than 60% of patients presenting with sensory deficits. Methods to train sensory function include both passive and active training protocols. Here we examined the volume and quality of the evidence available for both passive and active sensory training following stroke. In addition, we aimed to quantify the effect of sensory training on impairment and function. Data sources: Databases searched included MEDLINE, AMED, CINAHL, Academic search elite, Scopus and the Cochrane library. Unpublished articles were identified using a search engine. Review methods: Studies utilizing passive or active sensory training paradigms post stroke were identified. Methodological quality was examined using the National Health and Medical Research Council hierarchy of evidence and the McMaster University critical appraisal tool. Results: Fourteen studies met the inclusion criteria; 8 examined passive and 6 active sensory training. Methodological quality scores ranged from 11 to 18.5 (maximum 20). Meta-analysis was performed using three studies examining hand function, demonstrating a moderate effect in favour of passive sensory training. Other studies were unable to be pooled due to heterogeneity of measures or insufficient data. Conclusion: Meta-analyses and single studies offer some support for the effectiveness of passive sensory training in relation to sensory impairment and motor function. However, empirical evidence for active sensory training is limited. Further high-quality studies with greater statistical power and meaningful clinical measures are required in order to accurately determine the effectiveness of sensory retraining following stroke.

Influence of Combined Afferent Stimulation and Task-Specific Training Following Stroke: A Pilot Randomized Controlled Trial

Background. Reorganization of the human motor cortex can be induced by specific patterns of peripheral afferent stimulation. The potential for afferent stimulation to facilitate the functional recovery associated with conventional rehabilitative techniques has not previously been investigated. Objective. The authors sought to determine whether combining appropriate afferent stimulation with task-specific training resulted in greater improvements than training alone in patients with impaired upper limb function in the subacute phase following stroke. Method. Twenty patients with hemiparesis due to stroke were allocated randomly to either a stimulation or control group. All received 9 sessions of task-specific physiotherapy training over 3 weeks. Prior to each training session, associative electrical stimulation of the motor point of 2 hand muscles was given in the stimulation group, whereas the control group received sham stimulation. Changes in dexterity were assessed using a grip-lift task, and standard measures of upper-limb function were made before and following the intervention. Corticospinal excitability was examined using transcranial magnetic stimulation. Results. Both groups showed comparable improvements in functional measures of upper-limb function. Of the 20 patients, only 14 could perform the grip-lift task, which is an objective measure of dexterity. Patients in the stimulation group From the Research Centre for Human Movement Control, School of exhibited significantly greater improvements in this task than the control group. There was no significant change in corticospinal excitability in either group. Conclusion. This pilot study provides preliminary data suggesting that targeted afferent stimulation may facilitate the response to conventional rehabilitation in patients with hemiparesis due to stroke, but these results need to be confirmed in a larger scale study.

The sensitivity of three commonly used outcome measures to detect change amongst patients receiving inpatient rehabilitation following stroke.

Objective: To investigate the sensitivity of three commonly used functional outcome measures to detect change over time in subjects receiving inpatient rehabilitation post stroke. Design: Subjects were assessed within one week of admission and one week of discharge from an inpatient rehabilitation facility. Several parameters of sensitivity were calculated, including floor and ceiling effects, the percentage of subjects showing no change and the effect size of the change between admission and discharge. Setting: The medical rehabilitation ward of an inpatient rehabilitation facility. Subjects: Seventy-eight subjects receiving inpatient rehabilitation following a first or recurrent stroke. Measures: Five-metre walk, comfortable pace (gait speed), the Berg Balance Scale and the Motor Assessment Scale. Results: Sixty-one subjects had complete admission and discharge data. Gait speed and the Berg Balance Scale were both sensitive to change and demonstrated large effect sizes. The Motor Assessment Scale item five also showed a large effect size and was able to detect change amongst lower functioning subjects. The other items of the Motor Assessment Scale were less useful, in particular, the effect sizes for upper extremity change scores were small (d=0.36–0.5) and the majority of subjects (44.3–63.9%) showed no change over time on these measures. Conclusion: Gait speed, the Berg Balance Scale and the Motor Assessment Scale item five were sensitive to change over time in this sample.

FORM: An Australian method for formulating and grading recommendations in evidence-based clinical guidelines

BackgroundClinical practice guidelines are an important element of evidence-based practice. Considering an often complicated body of evidence can be problematic for guideline developers, who in the past may have resorted to using levels of evidence of individual studies as a quasi-indicator for the strength of a recommendation. This paper reports on the production and trial of a methodology and associated processes to assist Australian guideline developers in considering a body of evidence and grading the resulting guideline recommendations.MethodsIn recognition of the complexities of clinical guidelines and the multiple factors that influence choice in health care, a working group of experienced guideline consultants was formed under the auspices of the Australian National Health and Medical Research Council (NHMRC) to produce and pilot a framework to formulate and grade guideline recommendations. Consultation with national and international experts and extensive piloting informed the process.ResultsThe FORM framework consists of five components (evidence base, consistency, clinical impact, generalisability and applicability) which are used by guideline developers to structure their decisions on how to convey the strength of a recommendation through wording and grading via a considered judgement form. In parallel (but separate from the grading process) guideline developers are asked to consider implementation implications for each recommendation.ConclusionsThe framework has now been widely adopted by Australian guideline developers who find it to be a logical and intuitive way to formulate and grade recommendations in clinical practice guidelines.

Impairments in precision grip correlate with functional measures in adult hemiplegia.

OBJECTIVE Analysis of a precision grip-lift task provides measures to assess functional disability of the hand, but the correlation between these measures and accepted tests of motor function in stroke patients has not been established. METHODS Seventeen subacute stroke patients were studied to compare parameters of a precision grip-lift task between the affected and unaffected side, and to correlate them with function. Functional impairment was assessed with the Action Research Arm Test and the Fugl-Meyer assessment, as well as grip strength and maximal finger-tapping speed. The grip force (GF) and load force (LF) were recorded as patients lifted a custom-built manipulandum. All measures were recorded on two separate occasions, at least 1 week apart. RESULTS There was good reproducibility between testing sessions for the grip-lift and functional measures. The affected hand gripped the manipulandum for longer prior to lift-off than the unaffected hand, and the normal close temporal coupling between the rate of change of GF and LF during the lift was disrupted. These two measures correlated more highly with the ARAT than the FMA and, when combined with measures of grip strength and tapping speed, explained 71% of the variance of the ARAT. CONCLUSIONS The grip-lift task is a sensitive measure of impaired dexterity following stroke and provides measures which correlate well with a commonly applied functional assessment scale. SIGNIFICANCE This task may be used clinically to detect changes in the hemiplegic upper limb during rehabilitation and recovery.

Physical Activity Frequency and Risk of Incident Stroke in a National US Study of Blacks and Whites

Background and Purpose— Regular physical activity (PA) is an important recommendation for stroke prevention. We compared the associations of self-reported PA with incident stroke in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. Methods— REGARDS recruited 30 239 US blacks (42%) and whites, aged ≥45 years with follow-up every 6 months for stroke events. Excluding those with prior stroke, analysis involved 27 348 participants who reported their frequency of moderate to vigorous intensity PA at baseline according to 3 categories: none (physical inactivity), 1 to 3×, and ≥4× per week. Stroke and transient ischemic attack cases were identified during an average of 5.7 years of follow-up. Cox proportional hazards models were constructed to examine whether self-reported PA was associated with risk of incident stroke. Results— Physical inactivity was reported by 33% of participants and was associated with a hazard ratio of 1.20 (95% confidence intervals, 1.02–1.42; P=0.035). Adjustment for demographic and socioeconomic factors did not affect hazard ratio, but further adjustment for traditional stroke risk factors (diabetes mellitus, hypertension, body mass index, alcohol use, and smoking) partially attenuated this risk (hazard ratio, 1.14 [0.95–1.37]; P=0.17). There was no significant association between PA frequency and risk of stroke by sex groups, although there was a trend toward increased risk for men reporting PA 0 to 3× a week compared with ≥4× a week. Conclusions— Self-reported low PA frequency is associated with increased risk of incident stroke. Any effect of PA is likely to be mediated through reducing traditional risk factors.

Rehabilitation for community-dwelling people with stroke: home or centre based? A systematic review

Stroke rehabilitation for people living in the community is commonly delivered either in a centre, outpatient or day hospital setting. More recently, services may be offered in the actual home of the person as home-based or domiciliary rehabilitation. There are differing reports of the benefits and barriers of home-based vs. centre-based community rehabilitation. This systematic review sought to pool data from all retrieved studies that compared the functional benefits of home-based vs. centre for community-dwelling people with stroke. A comprehensive search strategy was implemented in all major databases (Cochrane library, Medline, AMED, Embase, Ageline, Cinahl, PEDro) for randomised controlled trials investigating this question in relation to functional benefits as a primary outcome and carer, cost or other benefits as secondary outcomes. There were no language or date limits. Eleven trials were found and results pooled for the Barthel Index, the measure of functional independence used consistently across the majority of retrieved studies. There was a significant effect in favour of home-based rehabilitation at 6 weeks (P = 0·03) and 3–6 months (P = 0·01). The effects were less clear at 6 months, although this was using the less sensitive version of the Barthel Index (P = 0·27 or adjusted P = 0·04). Individual studies reported cost benefits and increased carer satisfaction in favour of home-based rehabilitation. The provision of rehabilitation for people living in the community should trend towards home-based. Further research is required into adverse events and the experiences of all stakeholders.

Assessing proprioception: a systematic review of possibilities

Proprioception is a vital aspect of motor control and when degraded or lost can have a profound impact on function in diverse clinical populations. This systematic review aimed to identify clinically related tools to measure proprioceptive acuity, to classify the construct(s) underpinning the tools, and to report on the clinimetric properties of the tools. We searched key databases with the pertinent search terms, and from an initial list of 935 articles, we identified 57 of relevance. These articles described 32 different tools or methods to quantify proprioception. There was wide variation in methods, the joints able to be tested, and the populations sampled. The predominant construct was active or passive joint position detection, followed by passive motion detection and motion direction discrimination. The clinimetric properties were mostly poorly evaluated or reported. The Rivermead Assessment of Somatosensory Perception was generally considered to be a valid and reliable tool but with low precision; other tools with higher precision are potentially not clinically feasible. Clinicians and clinical researchers can use the summary tables to make more informed decisions about which tool to use to match their predominant requirements. Further discussion and research is needed to produce measures of proprioception that have improved validity and utility.

Consensus on Exercise Reporting Template (CERT): Modified Delphi Study.

Background Exercise interventions are often incompletely described in reports of clinical trials, hampering evaluation of results and replication and implementation into practice. Objective The aim of this study was to develop a standardized method for reporting exercise programs in clinical trials: the Consensus on Exercise Reporting Template (CERT). Design and Methods Using the EQUATOR Networks methodological framework, 137 exercise experts were invited to participate in a Delphi consensus study. A list of 41 items was identified from a meta-epidemiologic study of 73 systematic reviews of exercise. For each item, participants indicated agreement on an 11-point rating scale. Consensus for item inclusion was defined a priori as greater than 70% agreement of respondents rating an item 7 or above. Three sequential rounds of anonymous online questionnaires and a Delphi workshop were used. Results There were 57 (response rate=42%), 54 (response rate=95%), and 49 (response rate=91%) respondents to rounds 1 through 3, respectively, from 11 countries and a range of disciplines. In round 1, 2 items were excluded; 24 items reached consensus for inclusion (8 items accepted in original format), and 16 items were revised in response to participant suggestions. Of 14 items in round 2, 3 were excluded, 11 reached consensus for inclusion (4 items accepted in original format), and 7 were reworded. Sixteen items were included in round 3, and all items reached greater than 70% consensus for inclusion. Limitations The views of included Delphi panelists may differ from those of experts who declined participation and may not fully represent the views of all exercise experts. Conclusions The CERT, a 16-item checklist developed by an international panel of exercise experts, is designed to improve the reporting of exercise programs in all evaluative study designs and contains 7 categories: materials, provider, delivery, location, dosage, tailoring, and compliance. The CERT will encourage transparency, improve trial interpretation and replication, and facilitate implementation of effective exercise interventions into practice.