Hand dominance and side of stroke affect rehabilitation in chronic stroke

Objective: to examine the difference between upper extremity deficits in subjects with left versus right hemispheric lesions at baseline and after bilateral arm training.Design: a one-way ANOVA was used to detect group differences and a least square means analysis used to determine significance in pre-to-post scores for each group.Setting: testing was in the Physical Therapy and Rehabilitation Science Department Research Laboratory, University of Maryland, Baltimore. Training was at the Senior Exercise Rehabilitation Center in the Veterans Administration Hospital, Baltimore.Subjects: twenty-two (11 left hemispheric lesion, 11 right hemispheric lesion) right-handed subjects with chronic stroke.Interventions: a six-week nonprogressive repetitive bilateral arm training with rhythmic auditory cueing (BATRAC).Main measures: Fugl-Meyer Upper Extremity Test, Wolf Motor Arm Test, University of Maryland Arm Questionnaire for Stroke (UMAQS), isometric strength and active and passive range of motion for both sides.Results: no statistical differences were seen at baseline between groups in this sample. Both groups demonstrated improvement after BATRAC in Fugl-Meyer Upper Extremity Test (change scores of those with left lesions = 5.5; right lesions = 3.6) and UMAQS (change scores of those with left lesions = 5 and right lesions = 2.9). Additionally, patients with left hemispheric lesions but not right lesions made improvements in the Wolf Motor Arm Test (time and weight), in strength measures of paretic elbow flexion, shoulder extension, shoulder abduction and nonparetic wrist flexion, wrist extension and shoulder abduction.Conclusions: there were no baseline motor function differences between those with left and right hemispheric lesions in this sample. There was a clear training response advantage for patients with left hemispheric lesions after completing six weeks of bilateral arm training. As a result, treatment approaches for upper extremity hemiparesis may need to be more specifically selected based on side of strok

Fine motor control in adults with and without chronic hemiparesis: baseline comparison to nondisabled adults and effects of bilateral arm training

Objectives: to characterize fine motor control through finger tapping in both arms of 10 patients with chronic stroke, to make baseline comparisons with matched controls, and to examine the responsiveness of deficits seen in stroke patients after 6 weeks of bilateral arm-based training.Design: nonrandomized controlled, cohort before-after trial.Setting: research institution.Participants: ten people from the community with chronic unilateral ischemic stroke and 10 age- and sex-matched healthy controls. Participants with hemiparesis had completed all conventional care and were more than 6 month poststroke. Inclusion criteria were at least 6 months since a unilateral stroke, ability to follow simple instructions and 2-step commands, volitional control of the nonparetic arm, and at least minimal antigravity movement in the shoulder of the paretic arm.Interventions: not applicable.Main outcome measures: measurements included rate and timing consistency of unilateral tapping at a preferred and a maximal rate and the accuracy and stability of interlimb coordination in bilateral simultaneous (inphase) and alternating (antiphase) tapping at a preferred rate.Results: nonparetic finger control was similar to that of the nondisabled participants except under bilateral conditions, where it was less consistent. A subgroup with residual paretic finger function, had slower and less consistent paretic finger tapping, as well as less accurate and more variable interlimb coordination; however, basic bilateral coupling relationships were preserved. Bilateral arm-based training improved bilateral nonparetic consistency but slowed unilateral preferred tapping. Training also improved paretic fine motor control in 2 of 4 participants with mild stroke severity. The 2 responders, with dominant hemisphere lesions, indicated a possible recovery advantage with bilateral training for such lesions.Conclusions: in general, nonparetic finger control for tapping was preserved but paretic finger control was compromised. Disruption of nonparetic control of tapping, particularly consistency of tapping, occurred during bilateral tapping tasks but was responsive to 6 weeks of bilateral arm-based training. Despite the apparent lack of training specificity, the generalizable effects of bilateral arm training to fine motor interlimb coordination may reflect central motor control mechanisms for upper-extremity coordination, which may be accessed and may influence the recovery of arm function after strok

Kinect-based individualized upper extremity rehabilitation is effective and feasible for individuals with stroke using a transition from clinic to home protocol

Purpose: To investigate the effectiveness and feasibility of Kinect-based upper extremity rehabilitation on functional performance in chronic stroke survivors. Methods: This was a single cohort pre-post test study. Participants (N = 10; mean age = 62.5 ± 9.06) engaged in Kinect-based training three times a week for four to five weeks in a university laboratory. To simulate a clinic to home transfer condition, individualized guidance was given to participants at the initial three sessions followed by independent usage. Outcomes included Fugl-Meyer assessment of upper extremity, Wolf Motor Function Test, Stroke Impact Scale, Confidence of Arm and Hand Movement and Active Range of Motion. Participant experience was assessed using a structured questionnaire and a semi-structured interview. Results. Improvement was found in Fugl-Meyer assessment scores (p = 0.001), Wolf Motor Function Test, (p = 0.008), Active Range of Motion (p < 0.05) and Stroke Impact Scale-Hand function (p = 0.016). Clinically important differences were found in Fugl-Meyer assessment scores (Δ = 5.70 ± 3.47) and Wolf Motor Function Test (Δ Time = −4.45 ± 6.02; ∆ Functional Ability Scores = 0.29 ± 0.31). All participants could use the system independently and recognized the importance of exercise individualization by the therapist. Conclusions. The Kinect-based UE rehabilitation provided clinically important functional improvements to our study participants

Exploiting interlimb coupling to improve paretic arm reaching performance in people with chronic stroke

Objective: to determine whether paretic arm reaching performance is improved in bilateral compared with unilateral conditions.Design: cohort study.Setting: university human performance laboratory.Participants: thirty-two subjects with chronic stroke (57±14y; on Fugl-Meyer Assessment arm score, 37±14).Intervention: unilateral and bilateral reaching. Bilateral tasks included varying levels of weight on the nonparetic hand.Main outcome measures: an electromagnetic tracking system recorded hand peak acceleration, velocity, and movement time. A 2-way repeated-measures analysis of variance and Tukey-adjusted pairwise comparisons were used to analyze the results (?=.05).Results: paretic differed significantly from nonparetic peak acceleration and velocity in unilateral reaching but not bilateral reaching. Within limbs, the paretic arm attained a higher peak acceleration (P&lt;.001) and velocity (P=.03) in the bilateral compared with the unilateral task, but movement time was unchanged between tasks. Nonparetic peak acceleration was higher (P=.015), velocity was unchanged, and movement time increased (P=.005) in the bilateral compared with the unilateral task. The addition of a weight to the nonparetic arm during bilateral reaching did not result in further improvement in paretic arm performance.Conclusions: interlimb coupling effects during bilateral reaching are retained even after chronic stroke and can be used to produce an immediate improvement in paretic arm reaching performance<br/

Kinect-based Individualized Upper Extremity Rehabilitation is Effective and Feasible for Individuals with Stroke Using a Transition from Clinic to Home Protocol

[[abstract]]Purpose: To investigate the effectiveness and feasibility of Kinect-based upper extremity rehabilitation on functional performance in chronic stroke survivors. Methods: This was a single cohort pre-post test study. Participants (N = 10; mean age = 62.5 ± 9.06) engaged in Kinect-based training three times a week for four to five weeks in a university laboratory. To simulate a clinic to home transfer condition, individualized guidance was given to participants at the initial three sessions followed by independent usage. Outcomes included Fugl-Meyer assessment of upper extremity, Wolf Motor Function Test, Stroke Impact Scale, Confidence of Arm and Hand Movement and Active Range of Motion. Participant experience was assessed using a structured questionnaire and a semi-structured interview. Results. Improvement was found in Fugl-Meyer assessment scores (p = 0.001), Wolf Motor Function Test, (p = 0.008), Active Range of Motion (p < 0.05) and Stroke Impact Scale-Hand function (p = 0.016). Clinically important differences were found in Fugl-Meyer assessment scores (Δ = 5.70 ± 3.47) and Wolf Motor Function Test (Δ Time = −4.45 ± 6.02; ∆ Functional Ability Scores = 0.29 ± 0.31). All participants could use the system independently and recognized the importance of exercise individualization by the therapist. Conclusions. The Kinect-based UE rehabilitation provided clinically important functional improvements to our study participants

Intracortical inhibition and facilitation with unilateral dominant, unilateral nondominant and bilateral movement tasks in left- and right-handed adults

PurposeTo investigate intracortical inhibition and facilitation in response to unilateral dominant, nondominant and bilateral biceps activation and short-term upper extremity training in right- and left-handed adults.MethodsPaired-pulse transcranial magnetic stimulation was used to measure intracortical excitability in motor dominant and nondominant cortices of 26 nondisabled adults. Neural facilitation and inhibition were measured in each hemisphere during unilateral dominant, nondominant and bilateral arm activation and after training in each condition.ResultsNo differences were seen between right- and left-handed subjects. Intracortical facilitation and decreased inhibition were seen in each hemisphere with unilateral activation/training of contralateral muscles and bilateral muscle activation/training. Persistent intracortical inhibition was seen in each hemisphere with ipsilateral muscle activation/training. Inhibition was greater in the nondominant hemisphere during dominant hemisphere activation (dominant arm contraction).ConclusionStrongly dominant individuals show no difference in intracortical responses given handedness. Intracortical activity with unilateral and bilateral arm activation and short-term training differs based on hemispheric dominance, with the motor dominant hemisphere exerting a larger inhibitory influence over the nondominant hemisphere. Bilateral activation and training have a disinhibitory effect in both dominant and nondominant hemispheres

Compensatory arm reaching strategies after stroke: Induced position analysis

After stroke, movement patterns of the upper limb (UL) during functional arm reaching change to accommodate altered constraints. These compensatory movement control strategies do not, however, have a one-to-one mapping with posttraining outcomes. In this study, we quantify arm movement control strategies in unilateral and bilateral reaching tasks using induced position analysis. In addition, we assess how those strategies are associated with UL residual impairments and with functional improvement after a specific bilateral arm training intervention. Twelve individuals with chronic stroke were measured while reaching to a box as part of their pre- and posttesting assessments. Other measurements included the Fugl-Meyer Upper Extremity Assessment (FM), Modified Wolf Motor Function Test (WT), and the University of Maryland Arm Questionnaire for Stroke (UMAQS). We identified arm control strategies that did not differ between unilateral and bilateral tasks but did differ by FM impairment level and by predicted gains in WT but not UMAQS. Increased shoulder relative to elbow moment contribution was associated with less impairment and greater gains of speed in functional tasks. These results suggest that one goal of training to achieve better outcomes may be to decrease the abnormal coupling of the shoulder and elbo

Temporal coordination of the arms during bilateral simultaneous and sequential movements in patients with chronic hemiparesis

Upper extremity (UE) hemiparesis results in decreased movement speed and impaired coordination leading to functional limitations and disability. The effects of UE hemiparesis on bilateral functional reaching have not been studied even though most activities of daily living are bilateral tasks. We examined the characteristics of bilateral simultaneous (SIM-B) and bilateral sequential paretic-lead (SEQ-P) and nonparetic-lead (SEQ-NP) functional reaching tasks at preferred and fast speeds. Sixteen patients with chronic hemiparesis completed three bilateral reaching tasks as fast as possible. A subset of eight participants attempted to complete the tasks at both preferred and fastest possible speeds. Paretic (P) and nonparetic (NP) arms were not different from each other in movement time (MT) or peak velocity in the SIM-B condition. MT and peak velocity differed between the two arms during both SEQ tasks. P MT was shorter and NP MT longer in the SIM-B task compared to SEQ-P and SEQ-NP. The P arm MT was the shortest when moving with the NP arm in a simultaneous task compared to both P and NP lead sequential movements. Despite hemiparesis, the two arms demonstrate a temporal coupling when moving simultaneously. When attempting to move at fastest speed, P arm MT time is better when reaching before or with the NP arm than when reaching after the NP arm showing coupling to the NP limb and increased speed of movement. These coupling effects support the rationale for bilateral arm training for individuals with UE hemiparesi