Bench and cross-sectional study.
Impairments in dexterity after stroke are commonly assessed by the Nine Hole Peg Test (NHPT), where the only outcome variable is the time taken to complete the test. We aimed to kinematically quantify and to compare the motor performance of the NHPT in persons post-stroke and controls (discriminant validity), to compare kinematics to clinical assessments of upper extremity function (convergent validity), and to establish the within-session reliability.
The NHPT was modified and standardized (S-NHPT) by 1) replacing the original peg container with an additional identical nine hole pegboard, 2) adding a specific order of which peg to pick, and 3) specifying to insert the peg taken from the original pegboard into the corresponding hole of the target pegboard. Eight optical cameras registered upper body kinematics of 30 persons post-stroke and 41 controls during the S-NHPT. Four sequential phases of the task were identified and analyzed for kinematic group differences. Clinical assessments were performed.
The stroke group performed the S-NHPT slower (total movement time; mean diff 9.8 s, SE diff 1.4), less smoothly (number of movement units; mean diff 0.4, SE diff 0.1) and less efficiently (path ratio; mean diff 0.05, SE diff 0.02), and used increased scapular/trunk movements (acromion displacement; mean diff 15.7 mm, SE diff 3.5) than controls (P < 0.000, r ≥ 0.32), indicating discriminant validity. The stroke group also spent a significantly longer time grasping and releasing pegs relative to the transfer phases of the task compared to controls. Within the stroke group, kinematics correlated with time to complete the S-NHPT and the Fugl-Meyer Assessment (rs 0.38–0.70), suggesting convergent validity. Within-session reliability for the S-NHPT was generally high to very high for both groups (ICCs 0.71–0.94).
The S-NHPT shows adequate discriminant validity, convergent validity and within-session reliability. Standardization of the test facilitates kinematic analysis of movement performance, which in turn enables identification of differences in movement control between persons post-stroke and controls that may otherwise not be captured through the traditional time-based NHPT. Future research should ascertain further psychometric properties, e.g. sensitivity, of the S-NHPT.
Impaired upper limb dexterity is evident as in many as 45–70% of the stroke victims one year post-stroke [1, 2]. Such impairment is often evaluated in clinics by performance of the Nine Hole Peg Test (NHPT) , which is a frequently used dexterity task in many clinical populations [4, 5, 6, 7]. The NHPT equipment consists of a container with nine small pegs and a target pegboard with nine holes. Performance of the NHPT requires the pegs to be picked up from the container one-by-one unimanually and transferred and inserted into the holes of the pegboard until it is filled, upon which the pegs are returned unimanually to the container. The test is performed as quickly as possible and the only outcome variable is the total time to complete the task. Consequently, motor performance is currently not analyzed during the NHPT despite potentially providing valuable information relating to upper limb dexterity, especially among persons with a neurological dysfunction.
Among persons with stroke, the NHPT is considered reliable , valid [7, 9, 10], and sensitive to change [7, 10, 11]. Nevertheless, and despite overall good test-retest reliability post-stroke, low test-retest reliability has been found in persons post-stroke who have spasticity in the affected hand . Further, the measurement errors are large; the minimal detectable change of the NHPT is estimated to 33 s for an individual post-stroke, and even doubled in the presence of spasticity . The measurement properties of computer-assisted assessments of NHPT in virtual environments have been investigated with promising results [12, 13]. However, high intra-subject variation indicates that haptic and virtual reality technologies are more demanding for a stroke population and for instance require more practice trials prior to the actual test than when performing a conventional NHPT.
Advantages of the NHPT include the simple, cheap and easily portable equipment as well as the test being easy to administer and time-efficient [7, 10]. There are, however, some drawbacks when testing persons post-stroke. First, the outcome score of the test is based solely on the time for task accomplishment . Hence, a time reduction of the NHPT in rehabilitation of a person post-stroke may represent either a true motor recovery (i.e. performing movement patterns in a similar way as before the stroke) or compensation (performing different movement patterns than prior to the stroke) . Compensatory strategies are common during upper limb tasks post-stroke, and thus plausible in a fine manipulative task like the NHPT. Secondly, the current NHPT test procedure may provide unreliable results for repeated measures or group comparisons as there is no standardized procedure with regard to the order in which the pegs are inserted into the target holes. To increase the stringency of the NHPT, we modified and standardized the test, which we henceforth refer to as the Standardized Nine Hole Peg test (S-NHPT). The experimental setup with two pegboards was in analogy with that of a study exploring three different methods of completing the NHPT, focusing on comparisons to tests in a virtual setting . However, we have standardized the experimental setup even further by stipulating the order in which the pegs should be transferred.
Kinematic assessments may detect changes in movement performance that are not captured by only considering the time taken to complete the NHPT , and provide objective measures that may be more sensitive and not vulnerable to ceiling effects . Recent research calls for parameters indicating quality of movements in persons post-stroke by means of kinematic analysis in order to better understand motor recovery [14, 15, 17]. However, a test of fine upper limb fine dexterity like the NHPT has not been investigated. Our modifications and standardization enabled our first aim to kinematically characterize S-NHPT performance in a group of persons post-stroke and compare it to that of a non-disabled control group (discriminant validity). A second aim was to determine the convergent validity of the S-NHPT by comparing kinematics (movement time, peak speed, number of movement units, reach-grasp ratio, path ratio, acromion vertical displacement and trunk displacement) to the total movement time and to other clinical assessments (the Fugl-Meyer Assessment, the Stroke Impact Scale and grip strength). A third aim was to establish the within-session reliability of the S-NHPT, i.e., the consistency of the hand trajectories during the nine pick-up and transfer movements of the test.[…]
Bench and cross-sectional study.
Information obtained from dexterity tests is an important component of a comprehensive examination of the hand.
To analyze and compare finger interdependencies during the performance of the Purdue Pegboard Test (PBT) and comparative daily tasks.
A method based on the optoelectronic kinematic analysis of the precision grip style and on the calculation of cross-correlation coefficients between relevant joint angles, which provided measures of the degree of finger coordination, was conducted on 10 healthy participants performing the PBT and 2 comparative daily living tasks.
Daily tasks showed identifiable interdependencies patterns between the metacarpophalangeal joints of the fingers involved in the grip. Tasks related to activities of daily living resulted in significantly higher cross-correlation coefficients across subjects and movements during the formation and manipulation phases of the tasks (0.7-0.9), whereas the release stage produced significantly lower movement correlation values (0.3-0.7). Contrarily, the formation and manipulation stages of the PBT showed low finger correlation across most subjects (0.2-0.6), whereas the release stage resulted in the highest values for all relevant movements (0.65-0.9).
Interdependencies patterns were consistent for the activities of daily living but differ from the patterns observed from the PBT.
The PBT does not compare well with the whole range of finger movements that account for hand performance during daily tasks.
Rationale: Spasticity is a major complication after stroke, and botulinumtoxin A (BoNT-A) injection is commonly used to manage focal spasticity. However, it is uncertain whether BoNT-A can improve voluntary motor control or activities of daily living function of paretic upper limbs. This study investigated whether BoNT-A injection combined with robot-assisted upper limb therapy improves voluntary motor control or functions of upper limbs after stroke.
Patient concerns: Two subacute stroke patients were transferred to the Department of Rehabilitation.
Diagnoses: Patients demonstrated spasticity in the upper extremity on the affected side.
Interventions: BoNT-A was injected into the paretic muscles of the shoulder, arm, and forearm of the 2 patients at the subacute stage. Conventional rehabilitation therapy and robot-assisted upper limb training were performed during the rehabilitation period.
Outcomes: Manual dexterity, grip strength, muscle tone, and activities of daily living function were improved after multidisciplinary rehabilitation treatment.
Lessons: BoNT-A injection in combination with multidisciplinary rehabilitation treatment, including robot-assisted arm training, should be recommended for subacute spastic stroke patients to enhance appropriate motor recovery.
Upper limb spasticity is a common complication following stroke, occurring in 20% to 40% of stroke survivors. As upper limb spasticity, joint contractures, and pain limit the voluntary motor control of the arm and hand, the functions of which are essential for the activity of daily living (ADL), ADL dependencies, including hygiene, dressing, and positioning, can be exacerbated.
Injection of botulinumtoxin A (BoNT-A), which is commonly used in the management of focal spasticity in the chronic phase of stroke, reduces muscle tone and passive range of motion. However, it is unclear whether BoNT-A can improve voluntary motor control or ADL functions of upper limbs.
Recently, task-specific high-intensity training with a multidisciplinary team approach has become an important concept in stroke rehabilitation therapy, and robot-assisted arm training (RAT) has been shown to allow well tolerated and intensive task-specific repetitive training of the paretic arm. However, multidisciplinary rehabilitation therapies using RAT in combination with BoNT-A injection have rarely been applied to subacute poststroke spasticity. Thus, we report on 2 cases showing the beneficial effects of RAT in combination with BoNT-A injection on upper limb spasticity in the subacute phase of stroke. […]
Objective: The purpose of this study was to evaluate the Role of Practice and Mental Imagery on Hand function improvement in stroke survivors
Method: We conducted systematic review of the previous studies and searched electronic databases for the years 1995 to 2016, studies were selected according to inclusion criteria, and critical appraisal was done for each study and summarized the use of mental practice for the improvement in hand function in stroke survivors.
Results: Studies differed in the various aspects like intervention protocols, outcome measures, design, and patient’s characteristics. The total number of practice hours to see the potential benefits from mental practice varied widely. Results suggest that mental practice has potential to improve the upper extremity function in stroke survivors.
Conclusion: Although the benefits of mental practice to improve upper extremity function looks promising, general guidelines for the clinical use of mental practice is difficult to make. Future research should explore the dosage, factors affecting the use of Mental Practice, effects of Mental Therapy alone without in combination with other interventions.
Up to 85% stroke survivors experience hemi paresis resulting in impaired movement of the arm, and hand as reported by Nakayama et al. Loss of arm function adversely affects quality of life and functional motor recovery in affected upper extremity.
Sensorimotor deficits in the upper limb, such as weakness, decreased speed of movement, decreased angular excursion and impaired temporal coordination of the joints impaired upper-limb and trunk coordination.
Treatment interventions such as materials-based occupations constraint-induced movement therapy modified constraint-induced movement therapy and task-related or task-specific training are common training methods for remediating impairments and restoring function in the upper limb.
For the improvement of upper and lower functions, physical therapy provides training for functional improvement and fine motor. For most patients such rehabilitation training has many constraints of time, place and expense, accordingly in recent studies, clinical methods such as mental practice for improvement of the upper and lower functions have been suggested.
Mental practice is a training method during which a person cognitively rehearses a physical skill using motor imagery in the absence of overt, physical movements for the purpose of enhancing motor skill performance. For example, a review of the duration of mental movements found temporal equivalence for reaching; grasping; writing; and cyclical activities, such as walking and running.
Evidence for the idea that motor imagery training could enhance the recovery of hand function comes from several lines of research: the sports literature; neurophysiologic evidence; health psychology research; as well as preliminary findings using motor imagery techniques in stroke patients.
Much interest has been raised by the potential of Motor Practice of Motor task, also called “Motor Imagery” as a neuro rehabilitation technique to enhance Motor Recovery following Stroke.
Mental Practice is a training method during which a person cognitively rehearsals a physical skill using Motor Imagery in the absence of Physical movements for the purpose of enhancing Motor skill performance.
The merits of this intervention are that the patient concentration and motivation can be enhanced without regard to time and place and the training is possible without expensive equipment.
Researchers have speculated about its utility in neurorehabilitation. In fact, several review articles examining the impact of mental practice have been published. Two reviews examined stroke outcomes in general and did not limit their review to upper-extremity–focused outcomes. Both articles included studies that were published in 2005 or earlier.
Previous reviews, however, did not attempt to rate the studies reviewed in terms of the level of evidence. Thus, in this review, we determined whether mental practice is an effective intervention strategy to remediate impairments and improve upper-limb function after stroke by examining and rating the current evidence. […]
[Purpose] The aim of this study was to investigate the effects of repeated vibratory stimulation to muscles related to hand functions on dexterity, strength, and sensory function in patients with chronic stroke.
[Subjects and Methods] A total of 10 stroke patients with hemiplegia participated in this study. They were divided into two groups: a) Experimental and b) Control, with five randomly selected subjects for each group. The experimental group received vibratory stimulation, while the control group received the traditional physical therapy. Both interventions were performed for 30 minutes each session, three times a week for four weeks.
[Results] There was a significant within-group improvement in the box and block test results in both groups for dexterity. Grip strength improved in both groups but the improvement was not statistically significant.
[Conclusion] The vibratory stimulation activated the biceps brachii and flexor carpi radialis, which increased dexterity to grasp and lift the box and block from the surface. Therefore, repeated vibratory stimulation to muscles related to hand functions improved hand dexterity equality to the traditional physical therapy in patients with chronic stroke.
The aim of this study was to examine the effect of the side of brain lesion on the ipsilesional hand function of stroke survivors.
Twenty-four chronic stroke survivors, equally allocated in 2 groups according to the side of brain lesion (right or left), and 12 sex- and age-matched healthy controls performed the Jebsen-Taylor Hand Function Test (JTHFT), the Nine-Hole Peg Test (9HPT), the maximum power grip strength (PwGSmax) test, and the maximum pinch grip strength (PnGSmax) test. Only the ipsilesional hand of the stroke survivors and both hands (left and right) of the controls were assessed.
PwGS max and PnGS max were similar among all tested groups. Performances in JTHFT and 9HPT were affected by the brain injury. Individuals with left brain damage showed better performance in 9HPT than individuals with right brain damage, but performance in JTHFT was similar.
Individuals after a brain injury have the capacity to produce maximum strength preserved when using their ipsilesional hand. However, the dexterity of their hands and digits is affected, in particular for stroke individuals with right brain lesion.
According to a clinical trial, a new form of electrical stimulation therapy can help rewire the brain and restore some dexterity to a hand that’s been paralyzed by stroke. In the experimental therapy, patients use their good hand to help their brain regain control over the paralyzed hand. A sensored glove, worn on the patient’s good hand, sends signals to electric stimulators attached to the paralyzed hand. The inert muscles are then prompted to mirror the movements of the functioning hand while patients think about opening both hands at the same time,
Research is still underway, but so far almost all patients who received the new therapy have felt an improvement.
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Department of Health Sciences, Physiotherapy, Lund University
Date of issue 2016-10-08
Author(s) Elisabeth Ekstrand
Disability of the upper extremity is common after stroke. To be able to evaluate recovery and effects of interventions there is a need for stable and precise outcome measures. In order to design and target efficient rehabilitation interventions it is important to know which factors that affect the ability to perform daily hand activities. At the time when the studies in this thesis were planned there was limited knowledge of the psychometric properties of outcome measures for persons with mild to moderate impairments of the upper extremity after stroke. There was also a lack of knowledge of which daily hand activities these persons perceive difficult to perform and which factors are associated with the performance.
The overall aim of this thesis was to evaluate the psychometric properties of outcome measures for upper extremity after stroke, and to describe which daily hand activities persons with mild to moderate impairments in upper extremity after stroke perceive difficult to perform and identify associated factors with their performance.
In paper I – IV, between 43 and 45 participants were included. Muscle strength in the upper extremity, somatosensation (active touch), dexterity and self-perceived ability to perform daily hand activities were assessed twice, one to two weeks apart. In paper V, 75 participants were included and the evaluated measures of the upper extremity were used together with other stroke specific outcomes to cover important aspects of functioning and disability according to the International Classification of Functioning, Disability and Health (ICF). Test-retest analyses for continuous data were made with the Intraclass Correlation Coefficient (ICC), the Change in Mean, the Standard Error of Measurement (SEM) and the Smallest Real Difference (SRD) (Paper I, III and IV). For ordinal data the Kappa coefficient and the Elisabeth Svensson rank-invariant method were used (Paper II and III). For analyses of convergent validity the Spearman’s correlation coefficient (rho) was calculated (Paper III). The ability to perform daily hand activities and the associations with potential factors were evaluated by univariate and multivariate linear regression models (Study V).
The results showed that outcome measures for isometric and isokinetic muscle strength, active touch, dexterity and self-perceived daily hand activities have high test-retest agreements and can be recommended for persons with mild to moderate impairments in the upper extremity after stroke (Paper I to IV). Isometric strength measurements had lower measurement errors than isokinetic measurements and might be preferred (Paper I). The outcomes of dexterity showed learning effects (Paper III) and the ratings of perceived daily hand activities (Paper IV) had relatively high random measurement errors which must be taken into account when recovery and effects of interventions are evaluated. The three evaluated dexterity measures were partly related and can complement each other (Paper IV). Daily hand activities that require bimanual dexterity were perceived most difficult to perform, and dexterity and participation were the strongest contributing factors for performing daily hand activities after stroke (Paper V).
In conclusion, this thesis has shown that outcome measures assessing functioning and disability of upper extremity after stroke are reliable and can be used in clinical settings and research. To increase the ability to perform daily hand activities, dexterity and perceived participation, in particular, should be considered in the assessments, goal-settings and rehabilitation after stroke.
Despite that disability of the upper extremity is common after stroke, there is limited knowledge how it influences self-perceived ability to perform daily hand activities. The aim of this study was to describe which daily hand activities that persons with mild to moderate impairments of the upper extremity after stroke perceive difficult to perform and to evaluate how several potential factors are associated with the self-perceived performance.
Seventy-five persons (72 % male) with mild to moderate impairments of the upper extremity after stroke (4 to 116 months) participated. Self-perceived ability to perform daily hand activities was rated with the ABILHAND Questionnaire. The perceived ability to perform daily hand activities and the potentially associated factors (age, gender, social and vocational situation, affected hand, upper extremity pain, spasticity, grip strength, somatosensation of the hand, manual dexterity, perceived participation and life satisfaction) were evaluated by linear regression models.
The activities that were perceived difficult or impossible for a majority of the participants were bimanual tasks that required fine manual dexterity of the more affected hand. The factor that had the strongest association with perceived ability to perform daily hand activities was dexterity (p < 0.001), which together with perceived participation (p = 0.002) explained 48 % of the variance in the final multivariate model.
Persons with mild to moderate impairments of the upper extremity after stroke perceive that bimanual activities requiring fine manual dexterity are the most difficult to perform. Dexterity and perceived participation are factors specifically important to consider in the rehabilitation of the upper extremity after stroke in order to improve the ability to use the hands in daily life.
Disability of the upper extremity is common after stroke and almost 50 % of those affected have remaining impairments more than three months post-stroke [1, 2]. The impairments often lead to difficulties in performing daily hand activities , especially those that require the use of both hands, i.e., bimanual activities . The ability to perform bimanual activities is therefore an important goal in stroke rehabilitation, regardless of which hand that is affected .
The ability to perform daily activities can be objectively assessed by observations of different tasks in a standardized environment or by patient-reported questionnaires. The advantage of using questionnaires is that they often provide a better understanding of an individual’s self-reported everyday difficulties and thereby enable clinicians to design more individually targeted rehabilitation interventions . One questionnaire that is recommended for persons with disability of the upper extremity after stroke is the ABILHAND Questionnaire [4, 7, 8]. It assesses self-perceived ability to perform daily bimanual activities. Previous studies have focused on evaluating the psychometric properties of the ABILHAND [4, 8], but no study has thoroughly described which activities persons in a stable phase post stroke perceive difficult to perform.
In order to improve functioning of the upper extremity after stroke, it is important to understand which factors affect self-perceived ability to perform daily hand activities. Previous studies have shown that single factors, such as motor function, muscle strength, spasticity, somatosensation, dexterity, perceived participation and life satisfaction are moderately to strongly associated with the perceived ability [4, 9, 10, 11, 12, 13, 14, 15, 16, 17]. However, as several factors simultaneously may influence the ability to perform daily hand activities there is a need to understand how these factors are associated with the performance. To the best of our knowledge, only one study  has evaluated this association in persons in a stable phase after stroke. In that study by Harris and Eng , muscle strength, spasticity, somatosensation and pain were included in multivariate analyses and the authors found that muscle strength in the upper extremity and spasticity were the strongest contributing factors to the perceived ability to use the hands in daily activities. However, dexterity was omitted as a potentially associated factor in the analysis, which was addressed as a limitation of the study. In other studies, gender, dominance of the affected upper extremity, and social and vocational situations have been shown to be important factors for overall functioning after stroke [18, 19, 20, 21]. However, it is unclear how these factors are associated with the self-perceived ability.
Taken together, despite that disability of the upper extremity is common after stroke there is limited knowledge of which daily activities that are perceived difficult to perform and which factors that affect the self-perceived performance. The majority of previous studies have evaluated how single or few factors are associated with perceived daily hand activities. Thus, there is a need for more studies that take several factors into account simultaneously.
The aim of this study was to evaluate a) which daily activities persons with mild to moderate impairments of the upper extremity after stroke perceive difficult to perform and b) how several factors (age, gender, social and vocational situation, affected hand, upper extremity pain, spasticity, grip strength, somatosensation, manual dexterity, perceived participation and life satisfaction) are associated with the self-perceived performance.
A new electrical stimulation remedy helped stroke survivors with hand weakness improve hand dexterity greater than an existing stimulation approach, in line with new studies in the American Heart Association’s journal Stroke.
Approximately 800,000 people within the United States of America have strokes every year, according to the American Heart Association. Stroke generally results in some paralysis or partial paralysis on one side of the body that can result in survivors having difficulties in executing function. A common remedy in stroke rehabilitation uses low tiers of electrical current to stimulate the paralyzed muscle groups to open the hand, enhance muscle power and likely repair hand function. Stimulation intensity, cycle timing, and repetitions are set by a therapist.
In the new experimental therapy discovered by researchers at the MetroHealth System, Case Western Reserve University and the Cleveland Functional Electrical Stimulation Center, sufferers manage the stimulation to their vulnerable hand by wearing a glove with sensors on the opposite, unaffected hand. When the affected person opens their unaffected hand, they receive a corresponding amount of stimulation that opens their susceptible stroke-affected hand. This places the affected person in control of their hand and permits them to participate in therapy with the help of electrical stimulation.
According to Jayme S. Knutson, Ph.D., senior author of the study and an assistant professor of Physical Medicine and Rehabilitation at Case Western Reserve University School of Medicine in Cleveland, Ohio, Based on positive findings from our previous studies, we sought to determine if the new glove-controlled hand stimulation therapy could be more effective than the common therapy in improving hand dexterity in patients who are more than six months past their stroke.
Researchers enrolled 80 stroke survivors. For 12 weeks, half of the survivors received remedy using the new glove, and the remainder received the common remedy. Both groups used an electrical stimulator on their own at home for 10 hours every week, plus three hours per week training hand tasks with an occupational therapist in the lab. Hand feature was measured earlier and after remedy with a standard dexterity test that measured the number of blocks members can pick out up, elevate over a barrier and launch in some other place on a desk within a 60 second duration. They determined that sufferers who acquired the new therapy had extra improvement at the dexterity test (4.6 blocks) than the common institution (1.8 blocks). Patients who had greater improvements in hand dexterity following the new therapy have been much less than two years post-stroke and had at least a few finger movements when they started the study. These sufferers saw a development of 9.6 blocks on the dexterity test, compared to 4.1 blocks in the common group.
Sufferers without a finger movement additionally noticed upgrades in arm movement after the new remedy. At the end of treatment, 97 percent of the subjects who obtained the new therapy agreed that they might use their hand greatly than on the start of the study.
Due to the fact that the therapy is new and this was a single-site study, researchers do not know if similar outcomes may also be seen in other rehab centers. They plan to perform a multi-site study to verify their consequences, as well as measure quality of life enhancements for sufferers. And whilst the researchers speculate that the new remedy can be converting neural connections within the brain that manage hand dexterity, extra research is yet to prove what consequences it is able to have on the central nervous system.
The study additionally demonstrates that stroke sufferers can correctly use technology for self-administered therapy at home. According to Knutson, Home-based therapy is becoming increasingly important to offset increasing healthcare costs and to meet the need for high doses of therapy that are critical for attaining the best outcomes. The more therapy a patient can get the better potential outcome they will get.