Posts Tagged HANDS

[ARTICLE] Changes in actual arm-hand use in stroke patients during and after clinical rehabilitation involving a well-defined arm-hand rehabilitation program: A prospective cohort study – Full Text



Improvement of arm-hand function and arm-hand skill performance in stroke patients is reported by many authors. However, therapy content often is poorly described, data on actual arm-hand use are scarce, and, as follow-up time often is very short, little information on patients’ mid- and long-term progression is available. Also, outcome data mainly stem from either a general patient group, unstratified for the severity of arm-hand impairment, or a very specific patient group.


To investigate to what extent the rate of improvement or deterioration of actual arm-hand use differs between stroke patients with either a severely, moderately or mildly affected arm-hand, during and after rehabilitation involving a well-defined rehabilitation program.


Design: single–armed prospective cohort study. Outcome measure: affected arm-hand use during daily tasks (accelerometry), expressed as ‘Intensity-of arm-hand-use’ and ‘Duration-of-arm-hand-use’ during waking hours. Measurement dates: at admission, clinical discharge and 3, 6, 9, and 12 months post-discharge. Statistics: Two-way repeated measures ANOVAs.


Seventy-six patients (63 males); mean age: 57.6 years (sd:10.6); post-stroke time: 29.8 days (sd:20.1) participated. Between baseline and 1-year follow-up, Intensity-of-arm-hand-use on the affected side increased by 51%, 114% and 14% (p < .000) in the mildly, moderately and severely affected patients, respectively. Similarly, Duration-of-arm-hand-use increased by 26%, 220% and 161% (p < .000). Regarding bimanual arm-hand use: Intensity-of-arm-hand-use increased by 44%, 74% and 30% (p < .000), whereas Duration-of-arm-hand-use increased by 10%, 22% and 16% (p < .000).


Stroke survivors with a severely, moderately or mildly affected arm-hand showed different, though (clinically) important, improvements in actual arm-hand use during the rehabilitation phase. Intensity-of-arm-hand-use and Duration-of-arm-hand-use significantly improved in both unimanual and bimanual tasks/skills. These improvements were maintained until at least 1 year post-discharge.



After stroke, the majority of stroke survivors experiences significant arm-hand impairments [12] and a decreased use of the paretic arm and hand in daily life [3]. The actual use of the affected hand in daily life performance depends on the severity of the arm-hand impairment [46] and is associated with perceived limitations in participation [78]. Severity of arm-hand impairment is also associated with a decrease of health-related quality of life [9], restricted social participation [10], and subjective well-being [1112].

Numerous interventions and arm-hand rehabilitation programs have been developed in order to resolve arm-hand impairments in stroke patients [613]. In the Netherlands, a number of stroke units in rehabilitation centres implemented a well-described ‘therapy-as-usual’ arm-hand rehabilitation program, called CARAS (acronym for: Concise Arm and hand Rehabilitation Approach in Stroke)[14], serving a broad spectrum of stroke patients across the full stroke severity range of arm-hand impairments. The arm-hand rehabilitation program has been developed to guide clinicians in systematically designing arm-hand rehabilitation, tailored towards the individual patient’s characteristics while keeping control over the overall heterogeneity of this population typically seen in stroke rehabilitation centres. A vast majority of stroke patients who participated in CARAS improved on arm-hand function (AHF), on arm-hand skilled performance (AHSP) capacity and on (self-) perceived performance, both during and after clinical rehabilitation [15]. The term ‘arm-hand function’ (AHF) refers to the International Classification of Functioning (ICF) [16] ‘body function and structures level’. The term ‘arm-hand skilled performance’ (AHSP) refers to the ICF ‘activity level’, covering capacity as well as both perceived performance and actual arm-hand use [17].

Improved AHF and/or AHSP capacity do not automatically lead to an increase in actual arm-hand use and do not guarantee an increase of performing functional activities in daily life [1820]. Improvements at function level, i.e. regaining selectivity, (grip) strength and/or grip performance, do not automatically lead to improvements experienced in real life task performance of persons in the post-stroke phase who live at home [1821]. Next to outcome measures regarding AHF, AHSP capacity and (self-) perceived AHSP, which are typically measured in controlled conditions, objective assessment of functional activity and actual arm-hand use outside the testing situation is warranted [2223].

Accelerometry can be used to reliably and objectively assess actual arm-hand use during daily task performance [2432]and has been used in several studies to detect arm-hand movements and evaluate arm-hand use in the post-stroke phase [203335]. Previous studies have demonstrated that, in stroke patients, movement counts, as measured with accelerometers, are associated with the use of the affected arm-hand (Motor Activity Log score) [3637] and, at function level, with the Fugl-Meyer Assessment [38]. Next to quantifying paretic arm-hand use, accelerometers have also been used to provide feedback to further enhance the use of the affected hand in home-based situations [39]. Most studies consist of relatively small [27304044] and highly selected study populations [45] with short time intervals between baseline and follow-up measurements. As to our knowledge, only a few studies monitored arm-hand use in stroke patients for a longer period, i.e. between time of discharge to a home situation or till 6 to 12 months after stroke [194446]. However, they used a relatively small study sample and their intervention aimed at arm-hand rehabilitation was undefined. Both studies of Connell et al. and Uswatte et al. describe a well-defined arm hand intervention where accelerometry data were used as an outcome measure [2747]. However, the study population described by Connell et al. consisted of a relative small and a relative mildly impaired group of chronic stroke survivors. The study population described by Uswatte et al. consisted of a large group of sub-acute stroke patients within strict inclusion criteria ranges [37], who, due to significant spontaneous neurologic recovery within this sub-acute phase, had a mildly impaired arm and hand [4849]. This means that the group lacked persons with a moderately to severely affected arm-hand, who are commonly treated in the daily rehabilitation setting.

The course of AHF and AHSP of a broad range of sub-acute stroke patients during and after rehabilitation involving a well-defined arm-hand rehabilitation program (i.e. CARAS) [14] has been reported by Franck et al. [15]. The present paper provides data concerning actual arm-hand use in the same study population, and focuses on two objectives. The first aim is to investigate changes in actual arm-hand use across time, i.e. during and after clinical rehabilitation, within a stroke patient group typically seen in daily medical rehabilitation practice, i.e. covering a broad spectrum of arm-hand problem severity levels, who followed a well-described arm-hand treatment regime. The second aim is to investigate to what extent improvement (or deterioration) regarding the use of the affected arm-hand in daily life situations differs between patient categories, i.e. patients with either a severely, moderately or mildly impaired arm-hand, during and after their rehabilitation, involving a well-defined arm-hand rehabilitation program.[…]

Continue —->  Changes in actual arm-hand use in stroke patients during and after clinical rehabilitation involving a well-defined arm-hand rehabilitation program: A prospective cohort study

Fig 3. Mean values for Intensity-of-arm-hand-use during uptime for subgroups 1, 2 and 3.
T = time; bl = baseline; cd = clinical discharge; m = month; Solid line = subgroup 1; Dotted line = subgroup 2; Dashed line = subgroup 3.

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[Abstract+References] Cortical and functional responses to an early protocol of sensory re-education of the hand using audio–tactile interaction.

Early sensory re-education techniques are important strategies associated with cortical hand area preservation. The aim of this study was to investigate early cortical responses, sensory function outcomes and disability in patients treated with an early protocol of sensory re-education of the hand using an audio-tactile interaction device with a sensor glove model.

After surgical repair of median and/or ulnar nerves, participants received either early sensory re-education twice a week with the sensor glove during three months or no specific sensory training. Both groups underwent standard rehabilitation. Patients were assessed at one, three and six months after surgery on training-related cortical responses by functional magnetic resonance imaging, sensory thresholds, discriminative touch and disability using the Disabilities of the Arm, Shoulder and Hand patient-reported questionnaire.

At six-months, there were no statistically significant differences in sensory function between groups. During functional magnetic resonance imaging, trained patients presented complex cortical responses to auditory stimulation indicating an effective connectivity between the cortical hand map and associative areas.

Training with the sensor glove model seems to provide some type of early cortical audio-tactile interaction in patients with sensory impairment at the hand after nerve injury. Although no differences were observed between groups related to sensory function and disability at the intermediate phase of peripheral reinnervation, this study suggests that an early sensory intervention by sensory substitution could be an option to enhance the response on cortical reorganization after nerve repair in the hand. Longer follow-up and an adequately powered trial is needed to confirm our findings.

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via Cortical and functional responses to an early protocol of sensory re-education of the hand using audio–tactile interactionHand Therapy – Raquel Metzker Mendes, Carlo Rondinoni, Marisa de Cássia Registro Fonseca, Rafael Inácio Barbosa, Carlos Ernesto Garrido Salmón, Cláudio Henrique Barbieri, Nilton Mazzer, 2017

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[ARTICLE] Hybrid Assistive Neuromuscular Dynamic Stimulation Therapy: A New Strategy for Improving Upper Extremity Function in Patients with Hemiparesis following Stroke – Full Text


Hybrid Assistive Neuromuscular Dynamic Stimulation (HANDS) therapy is one of the neurorehabilitation therapeutic approaches that facilitates the use of the paretic upper extremity (UE) in daily life by combining closed-loop electromyography- (EMG-) controlled neuromuscular electrical stimulation (NMES) with a wrist-hand splint. This closed-loop EMG-controlled NMES can change its stimulation intensity in direct proportion to the changes in voluntary generated EMG amplitudes recorded with surface electrodes placed on the target muscle. The stimulation was applied to the paretic finger extensors. Patients wore a wrist-hand splint and carried a portable stimulator in an arm holder for 8 hours during the daytime. The system was active for 8 hours, and patients were instructed to use their paretic hand as much as possible. HANDS therapy was conducted for 3 weeks. The patients were also instructed to practice bimanual activities in their daily lives. Paretic upper extremity motor function improved after 3 weeks of HANDS therapy. Functional improvement of upper extremity motor function and spasticity with HANDS therapy is based on the disinhibition of the affected hemisphere and modulation of reciprocal inhibition. HANDS therapy may offer a promising option for the management of the paretic UE in patients with stroke.

1. Functional Recovery of Upper Extremity Motor Function following Stroke

Stroke is a common health-care problem that causes physical impairment, disability, and problems in social participation. The most common impairment caused by stroke is motor impairment. Motor impairment affects the control of the unilateral upper and lower extremities. Recovery of function in the hemiparetic upper extremity is noted in fewer than 15% of patients after stroke [1].

Patients often compensate for their paretic upper extremity by using their intact upper extremity in the performance of everyday tasks [2]. It is supposed that strong reliance on compensatory overuse of the intact upper extremity inhibits functional recovery of the impaired upper extremity. This may explain the limited improvement of the functional capability of the paretic upper extremity in activities of daily living (ADL).

Principles of motor rehabilitation following stroke have been described as being dose-dependent and task-specific [3]. High-intensity practice and task-specific training are recommended for functional recovery. Several systematic reviews [4, 5] have explored whether high-intensity therapy improves recovery, and the principle that increased intensive training is helpful is widely accepted. Task-specific training is a well-accepted principle in motor rehabilitation. Training should target the goals that are relevant for the needs of the patients and preferably be given in the patient’s own environment.

The goal of upper extremity rehabilitation is to improve the capability of the paretic upper extremity for ADL. Constraint-induced movement therapy (CIMT) has been developed to enhance the forced use of the paretic hand in ADL with reduction of the compensatory overuse of the intact upper extremity. However, to participate in CIMT, the candidates must be able to voluntary extend their fingers and wrist at least 10 degrees, practice for 6 hours daily in a 2-week course, and spend waking hours with their nonparetic hand in a mitt [6].

To counter potential problems inherent in the intensive services needed for CIMT, we developed an alternative therapeutic approach that provides high-intensity training to facilitate the use of the paretic upper extremity in daily living by combining closed-loop electromyography- (EMG-) controlled neuromuscular electrical stimulation (NMES) with a wrist-hand splint for patients with moderate to severe hemiparesis. Fujiwara et al. called this hybrid assistive neuromuscular dynamic stimulation (HANDS) therapy [7].

2. HANDS Therapy

A PubMed literature search was conducted using the MeSH terms stroke, rehabilitation, upper extremity function, and neuromuscular electrical stimulation, and 71 articles were identified. A further search of PubMed with the terms stroke, rehabilitation, upper extremity function, neuromuscular electrical stimulation, and splint identified 4 articles, all regarding HANDS therapy.

HANDS therapy facilitates the use of the paretic upper extremity in daily living by combining closed-loop EMG-controlled NMES with a wrist-hand splint for patients with moderate to severe hemiparesis. This HANDS system is active for 8 hours, and patients are instructed to use their paretic hand as much as possible while wearing the HANDS system. Their nonparetic upper extremity is not restrained. The patients are also instructed to practice bimanual activities in their ADL. All participants in HANDS therapy are admitted, and the length of the intervention is 21 days. They receive 90 minutes of occupational therapy per day, 5 days a week. Each session of occupational therapy consists of gentle stretching exercise of the paretic upper extremity and active muscle reeducation exercise. All participants are instructed how to use their paretic hand in ADL with the HANDS system. Occupational therapists are directed toward participants’ goals and focused on their particular impairments and disabilities; thus, the specific therapy that each patient receives varies [7, 8].

Fujiwara et al. [7, 8] reported the indications for HANDS therapy as follows: () no cognitive deficits; () no pain in the paretic upper extremity; () passive extension range of motion (ROM) greater than 0 degrees of the affected wrist and −10 degrees of the metacarpophalangeal joints; () detectable surface EMG signals in the affected extensor digitorum communis (EDC) or extensor pollicis longus (EPL) when the patient intends to extend their fingers; () ability to raise the paretic hand to the height of the nipple; () scores of Fugl-Meyer test position sense of joints in the glenohumeral joint, elbow, wrist, and thumb of 1 or more; and () the ability to walk without physical assistance in daily life (e.g., including patients who can walk independently with a cane and/or an orthosis). The exclusion criteria were () history of major psychiatric or previous neurological disease, including seizures; () cognitive impairment precluding appropriately giving informed consent or the patient’s Mini Mental Examination Scale score was below 25; () patients with severe pain in the paretic upper extremity; () patients with a pacemaker or other implanted stimulator; and () patients with visuospatial neglect or apraxia.

Previous reports showed that none of the patients experienced any discomfort or significant disability with the HANDS therapy.

2.1. Closed-Loop Electromyography- (EMG-) Controlled Neuromuscular Electrical Stimulation (NMES)

Twenty-nine articles were found in PubMed using the terms stroke, electromyography, neuromuscular electrical stimulation, and upper extremity. Thirteen of 29 articles were on EMG-triggered NMES. Six of 29 articles were on EMG-controlled NMES. Two involved contralaterally controlled electrical stimulation.

EMG-triggered NMES applies preset electrical stimulation when EMG activity reaches a target threshold. The stimulus intensity and duration are determined and not changeable. EMG-controlled NMES applies electrical stimulation during voluntary contraction and changes the stimulation intensity in proportion to the changes in EMG amplitude.

For assistive stimulation, HANDS therapy used closed-loop EMG-controlled NMES, which was developed by Muraoka [9] and commercially available with MURO stimulation (Pacific Supply, Osaka, Japan). This closed-loop EMG-controlled NMES is portable and attaches to the arm (Figure 1). The surface electrodes pick up EMG signals at the target muscle and simultaneously stimulate it in direct proportion to the picked-up EMG signal, with the exception of the 25 ms after delivering each stimulation pulse, in which stimulation artifacts and M wave are observed. The external adjustment unit sets () range of stimulus intensity; () sensitivity of the EMG; () threshold of EMG amplitude that starts stimulation; and () gradient of stimulus intensity change to the change of EMG amplitude. Once these parameters were set with the external adjustment unit, the stimulator memorized these parameters.

Continue —>  Hybrid Assistive Neuromuscular Dynamic Stimulation Therapy: A New Strategy for Improving Upper Extremity Function in Patients with Hemiparesis following Stroke

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