Archive for category Paretic Hand
[ARTICLE] Brain regions important for recovery after severe post-stroke upper limb paresis – Full Text
Background The ability to predict outcome after stroke is clinically important for planning treatment and for stratification in restorative clinical trials. In relation to the upper limbs, the main predictor of outcome is initial severity, with patients who present with mild to moderate impairment regaining about 70% of their initial impairment by 3 months post-stroke. However, in those with severe presentations, this proportional recovery applies in only about half, with the other half experiencing poor recovery. The reasons for this failure to recover are not established although the extent of corticospinal tract damage is suggested to be a contributory factor. In this study, we investigated 30 patients with chronic stroke who had presented with severe upper limb impairment and asked whether it was possible to differentiate those with a subsequent good or poor recovery of the upper limb based solely on a T1-weighted structural brain scan.
Methods A support vector machine approach using voxel-wise lesion likelihood values was used to show that it was possible to classify patients as good or poor recoverers with variable accuracy depending on which brain regions were used to perform the classification.
Results While considering damage within a corticospinal tract mask resulted in 73% classification accuracy, using other (non-corticospinal tract) motor areas provided 87% accuracy, and combining both resulted in 90% accuracy.
Conclusion This proof of concept approach highlights the relative importance of different anatomical structures in supporting post-stroke upper limb motor recovery and points towards methodologies that might be used to stratify patients in future restorative clinical trials.
Stroke is one of the the most common causes of physical disability worldwide and about 80% of stroke survivors experience impairment of movement on one side of the body.1 Hand and arm impairment in particular is often persistent, disabling and a major contributor to reduced quality of life.2 The main predictor of long-term outcome of upper limb function is the level of initial impairment.3 This can be quantified as the proportional recovery rule which states that by 3 months, patients with stroke will recover about 70% of the initial upper limb motor impairment that has been observed on day 3 post-stroke.4–6 The prediction works extremely well for those presenting with mild to moderate upper limb impairment, but in only about half of those with initially severe upper limb impairment.4–6 In the other half, patients do worse than predicted, that is, there is a failure of proportional recovery. A key question then is, what is the difference between patients with stroke matched for initial severity who go on and have different recovery trajectories? The answer to this will point to the factors that are important for the dynamic process of recovery independent from the causes of initial impairment.
One possibility is the anatomy of the damage may be different in each group. A number of recent studies have proposed that the corticospinal tract (CST) plays a decisive role in this categorical difference7–11 as cortical reorganisation for improved motor function ultimately requires access for cortical motor areas to muscles. However, CST lesion load correlates with initial motor impairment,12 which is the major predictor of long-term outcome. It is therefore reasonable to ask how much CST lesion load can improve prediction of long-term outcome over and above initial severity. Furthermore, most of the patients involved in these studies had suffered from subcortical stroke and recent work has suggested that taking account of cortical damage after stroke can improve prediction of the motor clinical consequences.13 14
In this study, we investigated 30 patients with chronic stroke with a range of lesion locations (cortical and/or subcortical involvement) known to have presented with severe initial upper limb impairment but who had gone on to have quite different recovery trajectories. We applied a support vector machine approach to data representing lesion likelihood derived from structural T1-weighted MRI to answer the following questions. First, how accurately can patients with stroke with severe initial upper limb impairment be classified as having either good or poor recovery using only data extracted from whole brain structural MRI? Second, which brain regions contribute most to the classification? The results have the potential to transform how prediction of long-term upper limb outcome after stroke is achieved in routine clinical practice in future. The ability to easily and accurately predict outcome with standard clinical neuroimaging would have important implications for planning of treatment but also for stratification in future trials of restorative therapies.15[…]
[ARTICLE] Does non-invasive brain stimulation modify hand dexterity? Protocol for a systematic review and meta-analysis – Full Text
Introduction Dexterity is described as coordinated hand and finger movement for precision tasks. It is essential for day-to-day activities like computer use, writing or buttoning a shirt. Integrity of brain motor networks is crucial to properly execute these fine hand tasks. When these networks are damaged, interventions to enhance recovery are frequently accompanied by unwanted side effects or limited in their effect. Non-invasive brain stimulation (NIBS) are postulated to target affected motor areas and improve hand motor function with few side effects. However, the results across studies vary, and the current literature does not allow us to draw clear conclusions on the use of NIBS to promote hand function recovery. Therefore, we developed a protocol for a systematic review and meta-analysis on the effects of different NIBS technologies on dexterity in diverse populations. This study will potentially help future evidence-based research and guidelines that use these NIBS technologies for recovering hand dexterity.
Methods and analysis This protocol will compare the effects of active versus sham NIBS on precise hand activity. Records will be obtained by searching relevant databases. Included articles will be randomised clinical trials in adults, testing the therapeutic effects of NIBS on continuous dexterity data. Records will be studied for risk of bias. Narrative and quantitative synthesis will be done.
Strengths and limitations of this study
This is a novel systematic review and meta-analysis focusing specifically on dexterity.
We use continuous data not dependent on the evaluator or participant.
This work will potentially help future evidence-based research and guidelines to refine non-invasive brain stimulation.
The hand’s somatotopy is extensively represented in the human motor cortex.1 2 Phylogenetically, this relates to the development of corticomotoneuronal cells that specialise in creating patterns of muscle activity that synergises into highly skilled movements.3 This organised hand-and-finger movement to use objects during a specific task is known as dexterity.4 Evolutionary, dexterity played a pivotal role in human survival and is fundamental to actives of daily living, and hence quality of life.5 6
This precision motor movement relies on integration of information from the cerebral cortex, the spinal cord, several neuromusculoskeletal systems and the external world to coordinate finger force control, finger independence, timing and sequence performance.7 During these tasks, multivoxel pattern decoding shows bilateral primary motor cortex activation (M1), which was responsible for muscle recruitment timing and hand movement coordination.8 9 This is related to motor cortex connectivity through the corpus callosum, to motor regions of the cerebellum and white matter integrity.10–15 Adequate motor output translates into successfully executed tasks, like picking up objects, turning over cards, manipulating cutlery, writing, using computer–hand interfaces like smartphones, playing an instrument and performing many other similarly precise skills.16
These motor tasks are negatively impacted when motor output networks are affected, as seen in stroke or Parkinson’s disease.17 18 Therapeutic interventions that restore these damaged motor networks can be vital to restore fine motor movement after injury occurs. Pharmaceutical approaches often lead to adverse effects such as dyskinesias in Parkinson’s disease. Moreover, even after intensive rehabilitation programmes, only about 5%–20% of patients with stroke fully recover their motor function.19–21 Non-invasive brain stimulation (NIBS) techniques, like transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS), are proposed adjuvant or stand-alone interventions to target these affected areas and improve fine motor function.22 23 Briefly, these NIBS interventions are shown to influence the nervous system’s excitability and modulate long-term plasticity, which may be beneficial to the brain’s recovery of functions after injury.24–27
Fine hand motor ability is not studied as much in previous reviews of NIBS. Specifically, one narrative review focuses on rTMS in affected hand recovery poststroke; however, it does not consider the implications of varying International Classification of Functioning, Disability and Health (ICF) domains, data types and rater dependent outcomes, and its interpretability is limited without quantitative synthesis.28–31 The overarching conclusion was supportive of rTMS for paretic hand recovery, though with limited data to support its regular use, and a pressing need to study individualised patient parameters.28 One meta-analysis had positive and significant results when specifically studying the effects of rTMS on finger coordination and hand function after stroke.32 However, while various meta-analysis, and another systematic review, studied upper-limb movement after NIBS in distinct populations, they did not focus on precise hand function, pooled upper-limb outcomes with hand outcomes and presented mixed results.33–38
Motivated by this gap in the evidence for NIBS in dexterity, we will do a systematic review and meta-analysis of the literature on these brain stimulation technologies using outcomes that focus exactly on manual dexterity. These outcomes will be continuous and not dependent on the participant’s or rater’s observation (ie, they will be measured in seconds, or number of blocks/pegs placed, and not by an individual’s interpretation). They will be comprised of multiple domains as defined by the ICF, providing an appreciation of function rather than only condition or disease.29–31 By focusing on the ICF model, we will be able to study dexterity across a larger sample of studies, NIBS techniques and conditions in order to provide a better understanding of brain stimulation efficacy on hand function in various populations.[…]
Prospective, repeated-measures study.
Understanding individual hand function can assist therapists with the process of determining relevant treatment approaches and realistic therapeutic outcomes. At this point in time, a composite test that assesses both unilateral and bimanual hand function in relation to a functional activity is not available.
Purpose of the Study
To establish the reliability and validity of the suitcase packing activity (SPA).
An expert panel established face and content validity. Eighty healthy, English-speaking volunteers aged between 18 and 45 years were randomly assigned to either 1 or 2 sessions (test-retest reliability). Relative agreement between 2 examiners using an intraclass correlation coefficient (ICC)3,1 determined interrater reliability. Test-retest reliability was determined by using a repeated-measures analysis of variance and an ICC3,2. Concurrent validity was evaluated against 2 well-established hand evaluations using separate tests of correlational coefficients.
Face and content validity were established across 4 focus groups. Our results demonstrate good to excellent interrater reliability (ICC3,1 ≥ 0.93) and good to excellent test-retest reliability (ICC3,2 ≥ 0.83). SPA scores were moderately correlated with the 2-hand evaluations.
Through evaluating hand function during participation in a goal-directed activity (eg, packing a suitcase), the SPA exhibits promise in usefulness as a future viable outcome measure that can be used to assess functional abilities following a hand injury.
The SPA is a valid and reliable tool for assessing bimanual and unilateral hand function in healthy subjects.
[ARTICLE] Home-based neurologic music therapy for arm hemiparesis following stroke: results from a pilot, feasibility randomized controlled trial – Full Text
A total of 80% of stroke cases result in hemiparesis,1 and half this number experience persistent lack of arm function.2 Effective interventions are lacking, and evidence to support those that are accessible is insufficient.3 A clear need has been identified for long-term support in the community for people with stroke, but services are limited and few studies have examined home-based interventions and provided sufficient detail of the protocols used.4
Music interventions may be beneficial for improving arm function following stroke,5,6 and a strong rhythmic stimulus embedded within music may enhance motor performance more than the use of a rhythmic stimulus alone without music.7 More research is needed to establish the effects of music interventions on arm function, and with the majority of rehabilitation being delivered in patients’ homes it is useful to determine the feasibility of home-based treatment delivery and research. This article reports on the feasibility of conducting a randomized controlled trial where a music intervention, for which there was a clear protocol based on published guidelines,8,9 was delivered in a variety of home environments.[…]
Continue —> Home-based neurologic music therapy for arm hemiparesis following stroke: results from a pilot, feasibility randomized controlled trialClinical Rehabilitation – Alexander J Street, Wendy L Magee, Andrew Bateman, Michael Parker, Helen Odell-Miller, Jorg Fachner, 2017
[ARTICLE] Robotic-assisted serious game for motor and cognitive post-stroke rehabilitation – Full Text PDF
Stroke is a major cause of long-term disability that can cause motor and cognitive impairments. New technologies such as robotic devices and serious games are increasingly being developed to improve post-stroke rehabilitation. The aim of the present project was to develop a ROBiGAME serious game to simultaneously improve motor and cognitive deficits (in particular hemiparesis and hemineglect). In this context, the difficulty level of the game was adapted to each patient’s performance, and this individualized adaptation was addressed as the main challenge of the game development. The game was implemented on the REAplan end-effector rehabilitation robot, which was used in continuous interaction with the game. A preliminary feasibility study of a target pointing game was run in order to validate the game features and parameters. Results showed that the game was perceived as enjoyable, and that patients reported a desire to play the game again. Most of the targets included in the game design were realistic, and they were well perceived by the patients. Results also suggested that the cognitive help strategy could include one visual prompting cue, possibly combined with an auditory cue. It was observed that the motor assistance provided by the robot was well adapted for each patient’s impairments, but the study results led to a suggestion that the triggering conditions should be reviewed. Patients and therapists reported the desire to receive more feedback on the patient’s performances. Nevertheless, more patients and therapists are needed to play the game in order to give further and more comprehensive feedback that will allow for improvements of the serious game. Future steps also include the validation of the motivation assessment module that is currently under development.
[Abstract] A Randomized Trial on the Effects of Attentional Focus on Motor Training of the Upper Extremity Using Robotics with Individuals after Chronic Stroke
Source: A Randomized Trial on the Effects of Attentional Focus on Motor Training of the Upper Extremity Using Robotics with Individuals after Chronic Stroke – Archives of Physical Medicine and Rehabilitation
[Abstract] Effects of Transcranial direct current stimulation with sensory modulation on stroke motor rehabilitation: A randomized controlled trial
[Abstract] The Effect of Modified Constraint-Induced Movement Therapy on Spasticity and Motor Function of the Affected Arm in Patients with Chronic Stroke
Purpose: The purpose of this study was to explore the effect of modified constraint-induced movement therapy (CIMT) in a real-world clinical setting on spasticity and functional use of the affected arm and hand in patients with spastic chronic hemiplegia.
Method: A prospective consecutive quasi-experimental study design was used. Twenty patients with spastic hemiplegia (aged 22–67 years) were tested before and after 2-week modified CIMT in an outpatient rehabilitation clinic and at 6 months. The Modified Ashworth Scale (MAS), active range of motion (AROM), grip strength, Motor Activity Log (MAL), Sollerman hand function test, and Box and Block Test (BBT) were used as outcome measures.
Results: Reductions (p<0.05–0.001) in spasticity (MAS) were seen both after the 2-week training period and at 6-month follow-up. Improvements were also seen in AROM (median change of elbow extension 5°, dorsiflexion of hand 10°), grip strength (20 Newton), and functional use after the 2-week training period (MAL: 1 point; Sollerman test: 8 points; BBT: 4 blocks). The improvements persisted at 6-month follow-up, except for scores on the Sollerman hand function test, which improved further.
Conclusion: Our study suggests that modified CIMT in an outpatient clinic may reduce spasticity and increase functional use of the affected arm in spastic chronic hemiplegia, with improvements persisting at 6 months.
[Abstract] Hand therapy interventions, outcomes, and diagnoses evaluated over the last 10 years: A mapping review linking research to practice
Although published literature and evidence to support medical practice is becoming more abundant, it is not known how well available evidence supports the full spectrum of hand therapy practice.
Purpose of the Study
The aim of this mapping review was to identify strengths and/or gaps in the available literature as compared with the hand therapy scope of practice to guide future research.
A systematic search and screening was conducted to identify evidence published from 2006 to 2015. Descriptive data from 191 studies were extracted, and the diagnoses, interventions, and outcomes used in the literature were compared with the hand therapy scope of practice.
Osteoarthritis, tendon surgeries, and carpal tunnel syndrome were most frequently studied. Exercise, education, and orthotic interventions were most common, each used in more than 100 studies; only 12 studies used activity-based interventions. Primary outcome measures included range of motion, pain/symptoms, strength, and functional status.
Abundant high-quality research exists for a portion of the hand therapy scope of practice; however, there is a paucity of evidence for numerous diagnoses and interventions.
More evidence is needed for complex diagnoses and activity-based interventions as well as behavioral and quality-of-care outcomes.
[ARTICLE] Changes in arm-hand function and arm-hand skill performance in patients after stroke during and after rehabilitation – Full Text
Arm-hand rehabilitation programs applied in stroke rehabilitation frequently target specific populations and thus are less applicable in heterogeneous patient populations. Besides, changes in arm-hand function (AHF) and arm-hand skill performance (AHSP) during and after a specific and well-described rehabilitation treatment are often not well evaluated.
This single-armed prospective cohort study featured three subgroups of stroke patients with either a severely, moderately or mildly impaired AHF. Rehabilitation treatment consisted of a Concise_Arm_and_hand_ Rehabilitation_Approach_in_Stroke (CARAS). Measurements at function and activity level were performed at admission, clinical discharge, 3, 6, 9 and 12 months after clinical discharge.
Eighty-nine stroke patients (M/F:63/23; mean age:57.6yr (+/-10.6); post-stroke time:29.8 days (+/-20.1)) participated. All patients improved on AHF and arm-hand capacity during and after rehabilitation, except on grip strength in the severely affected subgroup. Largest gains occurred in patients with a moderately affected AHF. As to self-perceived AHSP, on average, all subgroups improved over time. A small percentage of patients declined regarding self-perceived AHSP post-rehabilitation.
A majority of stroke patients across the whole arm-hand impairment severity spectrum significantly improved on AHF, arm-hand capacity and self-perceived AHSP. These were maintained up to one year post-rehabilitation. Results may serve as a control condition in future studies.
One of the most common deficits following stroke is a persistent impairment of the arm and hand due to a hemiparesis, which has a significant impact on performance in daily life activities . Recovery of arm-hand function and skills is a major rehabilitation and health care challenge. Motor rehabilitation approaches for arm-hand performance after stroke has been changing substantially over the last decades. However, an integral arm-hand skill training approach, accommodating both the heterogeneity of the patient population and its associated patterns and levels of recovery directly post-stroke seems to be absent. A large number of well-explored and well-investigated examples of training approaches in specific (sub) populations have been identified  like, for instance, task-oriented training , mental practice  and constraint-induced movement therapy (CIMT) . In task-oriented approaches specific functional, skill-related tasks are trained. This is done preferably by using real-life objects , thereby teaching patients to solve specific problems related to, e.g., anticipatory motor adjustments or cognitive processing by using efficient goal-oriented movement strategies [7, 8].
Existing task-oriented arm-hand programs (e.g. [9–16]) are valuable contributions to rehabilitation practice and may offer a stable point of departure for clinicians to select the most appropriate therapy for a particular patient.
However, several aspects make it difficult for clinicians to choose the most appropriate arm-hand therapy intervention(s) for a particular patient: 1) Most studies or programs target specific populations (in particular those with some preservation of wrist and/or finger extension) and thus are less applicable for patients with a more severely affected arm-hand as seen in the heterogeneous populations of many rehabilitation centres . 2) Programs are focused on either the arm or the hand alone. 3) Most of the current studies in research projects feature strictly protocolled interventions, which cannot be easily adopted in the clinicians’ daily practice. 4) The lack of information about the proportional improvement or deterioration to be expected in stroke survivors in the sub-acute phase after stroke may lead to difficulties for clinicians to make decisions about arm-hand treatment objectives and concomitant prognostics regarding arm-hand skill performance.
In order to overcome these four drawbacks a Concise Arm and hand Rehabilitation Approach in Stroke (acronym: CARAS)  was developed in order to guide clinicians, during their daily practice, in systematically designing a patient’s optimal arm-hand rehabilitation program. CARAS is based on four constructs: a) stratification of the patient population is based on the severity of arm–hand impairment for which the Utrechtse Arm-hand Test (UAT) is used , b) clear focus on the individual’s rehabilitation goals and concomitant potential rehabilitation treatment outcomes, c) principles of self-efficacy, and d) possibility to systematically incorporate (new) technology and new evidence-based training elements swiftly. CARAS has proven to be feasible in a number of stroke units of rehabilitation centres throughout the Netherlands.
In the present study, the term ‘arm–hand function’ (AHF) refers to the ICF ‘body function and structures level’. The term ‘arm-hand skilled performance’ (AHSP) refers to the ICF activity level, covering both capacity and performance .
The present paper focusses on two aspects.
Firstly, during rehabilitation AHF and AHSP may improve to a certain level. However, once a stroke patient has left the rehabilitation program, his arm-hand capacity and performance may deteriorate . Whereas stroke patients with mild to moderate initial impairments show an almost fixed amount of recovery after stroke, ranging up to 70% [22, 23], stroke patients with a more severely affected arm-hand, i.e. absence of finger extension combined with large motor impairments, strongly lag behind this recovery percentage. Four years after stroke, 67% of stroke survivors still experience non-use or disuse of the moderately or severely affected arm–hand .
However, it is neither well understood at what rate such deterioration (or improvement) occurs, nor in which patient categories, i.e. patients with a certain level of arm-hand severity, this is most prominent. Answers to these questions are essential for the development of more adequate, personalised and cost-effective interventions that may augment and/or maintain arm-hand skill performance (AHSP) levels in stroke patients living in their home environment.
Secondly, the risk of losing the opportunity to clearly define ‘therapy-as-usual’ (TAU) is becoming a problem in AHSP research in stroke patients. In the myriad of studies evaluating newly developed training protocols aimed at improving AHF and/or AHSP, each of these new training approaches is contrasted to some kind of TAU, the latter of which may vary widely between clinics and institutes. Even worse, often TAU is not clearly defined at all.
As the implementation of many of the tested experimental treatments progresses, the concept of ‘therapy-as-usual’ inevitably will be lost.
The aim of the present study was to evaluate the course AHF and AHSP take in a broad range of sub-acute stroke patients during and after rehabilitation involving a therapy-as-usual (i.e. CARAS) .
Three subgroups, i.e. a subgroup of patients with a severely affected arm-hand, a subgroup of patients with a moderately affected arm-hand and a subgroup of patients with a mildly affected arm-hand, were formed.
The research questions were:
- To what extent do arm-hand function and arm-hand skill performance in stroke patients change during and after their rehabilitation involving therapy-as-usual?
- To what extent does the rate of improvement or deterioration (over time) of arm-hand function and arm-hand skill performance differ between three subgroups of stroke patients, i.e. patients with either a severely, moderately or mildly affected functional arm-hand, during and after their rehabilitation involving CARAS?[…]