Susan M. Hunter

Hand function and stroke

Stroke is particularly prevalent in older people and the effects of stroke can be profound. Not only are the abilities to stand, balance and walk affected, but also the ability to use the upper limb and hand in its diversity of functions in everyday life. Loss of independence of upper limb function contributes enormously to functional disability, affecting quality of life and independence in ‘basic’ (washing, grooming, feeding, dressing, etc.) and ‘instrumental’ activities (shopping, home/financial management, etc.) of daily living. A larger proportion of stroke patients with initial severe upper limb paresis are discharged to institutionalized care (63%) than are discharged home (37%).

Dose–Response Study of Mobilisation and Tactile Stimulation Therapy for the Upper Extremity Early After Stroke A Phase I Trial

Background. Physical therapy doses may need to be higher than provided in current clinical practice, especially for patients with severe paresis. The authors aimed to find the most effective and feasible dose of Mobilisation and Tactile Stimulation (MTS), which includes joint and soft-tissue mobilization and passive or active-assisted movement to enhance voluntary muscle contraction. Methods. This 2-center, randomized, controlled, observer-blinded feasibility trial compared conventional rehabilitation but no extra therapy (group 1) with conventional therapy plus 1 of 3 daily doses of MTS, up to 30 (group 2), 60 (group 3), or 120 (group 4) minutes for 14 days. The 76 participants had substantial paresis (Motricity Index [MI] < 61) a mean of 30 days (standard deviation [SD] = 20 days) after anterior circulation stroke. MTS was delivered using a standardized schedule of techniques (eg, sensory input, active-assisted movement). The primary outcome was the Motricity Index (MI) and secondary outcome was the Action Research Arm Test (ARAT) tested on day 16. Adverse events were monitored daily. Results. No difference was found in the change in control group MI compared with each of the 3 intervention groups (P = .593) or in the ARAT. Mean actual daily treatment time for all MTS groups was less than expected. The attrition rate was 1.3%. No adverse events related to overuse occurred. Conclusion. The authors were not able to deliver a maximum dose of 120 minutes of daily therapy each day. The mean daily dose of MTS feasible for subsequent evaluation is between 37 and 66 minutes.

Effects of mobilization and tactile stimulation on recovery of the hemiplegic upper limb: a series of replicated single-system studies.

OBJECTIVE To explore the effects on motor function and impairment of mobilization and tactile stimulation for the paretic arm and hand after stroke. DESIGN Replicated single-system series, ABA design. SETTING The stroke rehabilitation ward of a community hospital in the United Kingdom. PARTICIPANTS Consecutive sample, men and women (N=6) with stroke (left or right), within 3 months of onset. INTERVENTION Sixty minutes of daily mobilization and tactile stimulation to the paretic arm and hand for 6 weeks in addition to the usual rehabilitation program. MAIN OUTCOME MEASURES Focal disability (Action Research Arm Test [ARAT]) and motor impairment (Motricity Index arm section). RESULTS All participants showed visual change in 1 or more of trend, level, or slope between baseline and intervention phases for both the ARAT and the Motricity Index. The visual analysis was confirmed through statistical testing (c statistic and/or Mann-Whitney U test) for 5 of 6 participants (statistical analysis was precluded for 1 participant). No further improvements were made on intervention withdrawal. CONCLUSIONS This study shows proof of concept for using mobilization and tactile stimulation to improve motor recovery after severe paresis, justifying conducting dose-finding studies as a precursor to multicenter phase III clinical trials.

Using the TIDieR Checklist to Standardize the Description of a Functional Strength Training Intervention for the Upper Limb After Stroke.

Background and Purpose: Published reports of intervention in randomized controlled trials are often poorly described. The Template for Intervention Description and Replication (TIDieR) checklist has been recently developed to improve the reporting of interventions. The aim of this article is to describe a therapy intervention used in the stroke rehabilitation trial, “Clinical Efficacy of Functional Strength Training for Upper Limb Motor Recovery Early After Stroke: Neural Correlates and Prognostic Indicators” (FAST-INdICATE), using TIDieR. Methods: The functional strength training intervention used in the FAST-INdICATE trial was described using TIDieR so that intervention can be replicated by both clinicians, who may implement it in practice, and researchers, who may deliver it in future research. The usefulness of TIDieR in the context of a complex stroke rehabilitation intervention was then discussed. Results and Discussion: The TIDieR checklist provided a systematic way of describing a treatment intervention used in a clinical trial of stroke rehabilitation. Clarification is needed regarding several aspects of the TIDieR checklist, including in which section to report about the development of the intervention in pilot studies, results of feasibility studies; overlap between training and procedures for assessing fidelity; and where to publish supplementary material so that it remains in the public domain. Conclusions: TIDieR is a systematic way of reporting the intervention delivered in a clinical trial of a complex intervention such as stroke rehabilitation. This approach may also have value for standardizing intervention in clinical practice. Video abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A131).

FAST INdiCATE Trial protocol. Clinical efficacy of functional strength training for upper limb motor recovery early after stroke: Neural correlates and prognostic indicators

Rationale Functional strength training in addition to conventional physical therapy could enhance upper limb recovery early after stroke more than movement performance therapy plus conventional physical therapy. Aims To determine (a) the relative clinical efficacy of conventional physical therapy combined with functional strength training and conventional physical therapy combined with movement performance therapy for upper limb recovery; (b) the neural correlates of response to conventional physical therapy combined with functional strength training and conventional physical therapy combined with movement performance therapy; (c) whether any one or combination of baseline measures predict motor improvement in response to conventional physical therapy combined with functional strength training or conventional physical therapy combined with movement performance therapy. Design Randomized, controlled, observer-blind trial. Study The sample will consist of 288 participants with upper limb paresis resulting from a stroke that occurred within the previous 60 days. All will be allocated to conventional physical therapy combined with functional strength training or conventional physical therapy combined with movement performance therapy. Functional strength training and movement performance therapy will be undertaken for up to 1·5 h/day, five-days/week for six-weeks. Outcomes and Analysis Measurements will be undertaken before randomization, six-weeks thereafter, and six-months after stroke. Primary efficacy outcome will be the Action Research Arm Test. Explanatory measurements will include voxel-wise estimates of brain activity during hand movement, brain white matter integrity (fractional anisotropy), and brain–muscle connectivity (e.g. latency of motor evoked potentials). The primary clinical efficacy analysis will compare treatment groups using a multilevel normal linear model adjusting for stratification variables and for which therapist administered the treatment. Effect of conventional physical therapy combined with functional strength training versus conventional physical therapy combined with movement performance therapy will be summarized using the adjusted mean difference and 95% confidence interval. To identify the neural correlates of improvement in both groups, we will investigate associations between change from baseline in clinical outcomes and each explanatory measure. To identify baseline measurements that independently predict motor improvement, we will develop a multiple regression model.

Development of the Occupational Therapy Stroke Arm and Hand Record: An Upper Limb Treatment Schedule

Introduction: This study aimed to develop a comprehensive occupational therapy treatment schedule of upper limb interventions for stroke survivors with reduced upper limb function. Method: In a three-phased qualitative consensus study, 12 occupational therapists from acute and community settings in North West England contributed to interviews and subsequently group discussions to design and pilot a treatment schedule. Interview data were analysed using thematic analysis; the themes were used to develop a framework for the schedule that was supported by and reflected the International Classification of Functioning, Disability and Health framework. A draft schedule was the subject of a focus group and the resultant schedule was piloted in clinical practice by eight local occupational therapists working in neurological rehabilitation. Findings: Consensus was reached on three themes summarizing aspects of function: interventions that address preparation for activity, functional skills (that is, an aspect of function), and function. Three additional themes summarized other aspects of therapy: advice and education, practice outside therapy sessions, and psychosocial interventions. These themes became the main headings of the treatment schedule. The Occupational Therapy Stroke Arm and Hand Record treatment schedule was piloted and found to be comprehensive and potentially beneficial to clinical practice. Conclusion: The Occupational Therapy Stroke Arm and Hand Record treatment schedule provides a tool for use in stroke research and clinical practice.

Abstract TP352: Dysphagia Screening: The Quest for a Validated Tool

Background: Patients with stroke and other comorbidities are at risk for dysphagia and aspiration. Aspiration pneumonia is associated with high morbidity and mortality rates. Get with the Guideline...

Functional Strength Training and Movement Performance Therapy for Upper Limb Recovery Early Poststroke-Efficacy, Neural Correlates, Predictive Markers, and Cost-Effectiveness: FAST-INdiCATE Trial

Background Variation in physiological deficits underlying upper limb paresis after stroke could influence how people recover and to which physical therapy they best respond. Objectives To determine whether functional strength training (FST) improves upper limb recovery more than movement performance therapy (MPT). To identify: (a) neural correlates of response and (b) whether pre-intervention neural characteristics predict response. Design Explanatory investigations within a randomised, controlled, observer-blind, and multicentre trial. Randomisation was computer-generated and concealed by an independent facility until baseline measures were completed. Primary time point was outcome, after the 6-week intervention phase. Follow-up was at 6 months after stroke. Participants With some voluntary muscle contraction in the paretic upper limb, not full dexterity, when recruited up to 60 days after an anterior cerebral circulation territory stroke. Interventions Conventional physical therapy (CPT) plus either MPT or FST for up to 90 min-a-day, 5 days-a-week for 6 weeks. FST was “hands-off” progressive resistive exercise cemented into functional task training. MPT was “hands-on” sensory/facilitation techniques for smooth and accurate movement. Outcomes The primary efficacy measure was the Action Research Arm Test (ARAT). Neural measures: fractional anisotropy (FA) corpus callosum midline; asymmetry of corticospinal tracts FA; and resting motor threshold (RMT) of motor-evoked potentials. Analysis Covariance models tested ARAT change from baseline. At outcome: correlation coefficients assessed relationship between change in ARAT and neural measures; an interaction term assessed whether baseline neural characteristics predicted response. Results 288 Participants had: mean age of 72.2 (SD 12.5) years and mean ARAT 25.5 (18.2). For 240 participants with ARAT at baseline and outcome the mean change was 9.70 (11.72) for FST + CPT and 7.90 (9.18) for MPT + CPT, which did not differ statistically (p = 0.298). Correlations between ARAT change scores and baseline neural values were between 0.199, p = 0.320 for MPT + CPT RMT (n = 27) and −0.147, p = 0.385 for asymmetry of corticospinal tracts FA (n = 37). Interaction effects between neural values and ARAT change between baseline and outcome were not statistically significant. Conclusions There was no significant difference in upper limb improvement between FST and MPT. Baseline neural measures did not correlate with upper limb recovery or predict therapy response. Trial registration Current Controlled Trials: ISRCT 19090862, http://www.controlled-trials.com

Hands-On Therapy Interventions for Upper Limb Motor Dysfunction After Stroke

Recent studies have attempted to disaggregate therapeutic intervention packages. However, what is commonly referred to as the “black box” of therapy has yet to be comprehensively unpacked. It remains unclear how much therapy should be provided, who should provide it, and which patients should be targeted to maximize functional outcomes. This review seeks to assess the effectiveness of specific therapeutic interventions in the rehabilitation of the paretic upper limb poststroke. In particular, it aims to identify whether or not specific hands-on therapeutic interventions enhance motor activity and function. We searched the trials registers of the Cochrane Stroke Group (March 2010), the Cochrane Complementary Medicine Field (March 2010), and the Cochrane Rehabilitation and Related Therapies Field (March 2010); MEDLINE (1966 to March …

Providing acute stroke rehabilitation in the home: Views from a stroke early supported discharge team

Internal capsular genu infarcts infrequently cause cognitive impairment and behavioral changes, and little is known about the underlying mechanism. Using diffusion-tensor imaging (DTI) and the fractional anisotropy (FA) index in the region of interest (ROI) and ipsilesional frontal cortex, we evaluated two patients with internal capsular genu infarction who presented with frontal dysfunction and cognitive impairment. The reported findings help to elucidate the mechanism underlying cognitive deterioration in internal capsular genu infarction. J Korean Neurol Assoc 28(2):104-107, 2010