Home-based therapy programmes for upper limb functional recovery following stroke

Background: With an increased focus on home-based stroke services and the undertaking of programmes, targeted at upper limb recovery within clinical practice, a systematic review of home-based therapy programmes for individuals with upper limb impairment following stroke was required. Objectives: To determine the effects of home-based therapy programmes for upper limb recovery in patients with upper limb impairment following stroke. Search methods: We searched the Cochrane Stroke Group's Specialised Trials Register (May 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), MEDLINE (1950 to May 2011), EMBASE (1980 to May 2011), AMED (1985 to May 2011) and six additional databases. We also searched reference lists and trials registers. Selection criteria: Randomised controlled trials (RCTs) in adults after stroke, where the intervention was a home-based therapy programme targeted at the upper limb, compared with placebo, or no intervention or usual care. Primary outcomes were performance in activities of daily living (ADL) and functional movement of the upper limb. Secondary outcomes were performance in extended ADL and motor impairment of the arm. Data collection and analysis: Two review authors independently screened abstracts, extracted data and appraised trials. We undertook assessment of risk of bias in terms of method of randomisation and allocation concealment (selection bias), blinding of outcome assessment (detection bias), whether all the randomised patients were accounted for in the analysis (attrition bias) and the presence of selective outcome reporting. Main results: We included four studies with 166 participants. No studies compared the effects of home-based upper limb therapy programmes with placebo or no intervention. Three studies compared the effects of home-based upper limb therapy programmes with usual care. Primary outcomes: we found no statistically significant result for performance of ADL (mean difference (MD) 2.85; 95% confidence interval (CI) -1.43 to 7.14) or functional movement of the upper limb (MD 2.25; 95% CI -0.24 to 4.73)). Secondary outcomes: no statistically significant results for extended ADL (MD 0.83; 95% CI -0.51 to 2.17)) or upper limb motor impairment (MD 1.46; 95% CI -0.58 to 3.51). One study compared the effects of a home-based upper limb programme with the same upper limb programme based in hospital, measuring upper limb motor impairment only; we found no statistically significant difference between groups (MD 0.60; 95% CI -8.94 to 10.14). Authors' conclusions: There is insufficient good quality evidence to make recommendations about the relative effect of home-based therapy programmes compared with placebo, no intervention or usual care

Stimulator Listrik Guna Menjaga Kemampuan Kontraksi Otot Ekstremitas Atas

The cause of slow development of physiotherapy in after stroke patients is caused by muscle contraction was not optimal again. In previous research, have successfully designed and tested a non-clinical electrical stimulator in order to maintain the ability of lower limb muscle contractions. This research design a four channel electrical stimulator in order to maintain the ability for muscle contractions of the upper limb of stroke patients so they do not experience muscle degeneration. Electrical stimulator used in previous studies should be retested if all the parameters used in upper limb muscles in accordance with the amount required by upper limb muscles. After being tested on normal subjects, obtained voltage parameters should be adjusted and has a maximum stimulation of 70 V

Modulation of Stretch Reflexes of the Finger Flexors by Sensory Feedback from the Proximal Upper Limb Poststroke

Neural coupling of proximal and distal upper limb segments may have functional implications in the recovery of hemiparesis after stroke. The goal of the present study was to investigate whether the stretch reflex response magnitude of spastic finger flexor muscles poststroke is influenced by sensory input from the shoulder and the elbow and whether reflex coupling of muscles throughout the upper limb is altered in spastic stroke survivors. Through imposed extension of the metacarpophalangeal (MCP) joints, stretch of the relaxed finger flexors of the four fingers was imposed in 10 relaxed stroke subjects under different conditions of proximal sensory input, namely static arm posture (3 different shoulder/elbow postures) and electrical stimulation (surface stimulation of biceps brachii or triceps brachii, or none). Fast (300°/s) imposed stretch elicited stretch reflex flexion torque at the MCP joints and reflex electromyographic (EMG) activity in flexor digitorum superficialis. Both measures were greatest in an arm posture of 90° of elbow flexion and neutral shoulder position. Biceps stimulation resulted in greater MCP stretch reflex flexion torque. Fast imposed stretch also elicited reflex EMG activity in nonstretched heteronymous upper limb muscles, both proximal and distal. These results suggest that in the spastic hemiparetic upper limb poststroke, sensorimotor coupling of proximal and distal upper limb segments is involved in both the increased stretch reflex response of the finger flexors and an increased reflex coupling of heteronymous muscles. Both phenomena may be mediated through changes poststroke in the spinal reflex circuits and/or in the descending influence of supraspinal pathways

Movement kinematics and proprioception in post-stroke spasticity: assessment using the Kinarm robotic exoskeleton

Background Motor impairment after stroke interferes with performance of everyday activities. Upper limb spasticity may further disrupt the movement patterns that enable optimal function; however, the specific features of these altered movement patterns, which differentiate individuals with and without spasticity, have not been fully identified. This study aimed to characterize the kinematic and proprioceptive deficits of individuals with upper limb spasticity after stroke using the Kinarm robotic exoskeleton. Methods Upper limb function was characterized using two tasks: Visually Guided Reaching, in which participants moved the limb from a central target to 1 of 4 or 1 of 8 outer targets when cued (measuring reaching function) and Arm Position Matching, in which participants moved the less-affected arm to mirror match the position of the affected arm (measuring proprioception), which was passively moved to 1 of 4 or 1 of 9 different positions. Comparisons were made between individuals with (n = 35) and without (n = 35) upper limb post-stroke spasticity. Results Statistically significant differences in affected limb performance between groups were observed in reaching-specific measures characterizing movement time and movement speed, as well as an overall metric for the Visually Guided Reaching task. While both groups demonstrated deficits in proprioception compared to normative values, no differences were observed between groups. Modified Ashworth Scale score was significantly correlated with these same measures. Conclusions The findings indicate that individuals with spasticity experience greater deficits in temporal features of movement while reaching, but not in proprioception in comparison to individuals with post-stroke motor impairment without spasticity. Temporal features of movement can be potential targets for rehabilitation in individuals with upper limb spasticity after stroke.York University Librarie

Unilateral versus bilateral upper limb training after stroke: The upper limb training after stroke clinical trial

This article is available open access through the publisher’s website at the link below. Copyright © 2013 American Heart Association, Inc.Background and Purpose — Unilateral and bilateral training protocols for upper limb rehabilitation after stroke represent conceptually contrasting approaches with the same ultimate goal. In a randomized controlled trial, we compared the merits of modified constraint-induced movement therapy, modified bilateral arm training with rhythmic auditory cueing, and a dose-matched conventional treatment. Modified constraint-induced movement therapy and modified bilateral arm training with rhythmic auditory cueing targeted wrist and finger extensors, given their importance for functional recovery. We hypothesized that modified constraint-induced movement therapy and modified bilateral arm training with rhythmic auditory cueing are superior to dose-matched conventional treatment. Methods — Sixty patients, between 1 to 6 months after stroke, were randomized over 3 intervention groups. The primary outcome measure was the Action Research Arm test, which was conducted before, directly after, and 6 weeks after intervention. Results — Although all groups demonstrated significant improvement on the Action Research Arm test after intervention, which persisted at 6 weeks follow-up, no significant differences in change scores on the Action Research Arm test were found between groups postintervention and at follow-up. Conclusions — Modified constraint-induced movement therapy and modified bilateral arm training with rhythmic auditory cueing are not superior to dose-matched conventional treatment or each other in improving upper limb motor function 1 to 6 months after stroke. Clinical Trial Registration — URL: http://www.trialregister.nl. Unique identifier: NTR1665

Mirror therapy and self-care autonomy after stroke: an intervention program

Background: In patients with middle cerebral artery (MCA) stroke, changes in upper limb function lead to dependence on others for self-care. In the process of recovering autonomy/independence, there is evidence on the effectiveness of sensory stimulation techniques in the motor recovery after stroke. Objective: To assess the effect of mirror therapy on the self-care autonomy of patients with hemiplegia/hemiparesis due to MCA stroke. Methodology: Cross-sectional and quasi-experimental study with a quantitative approach, a before-and-after design, and a non-equivalent control group. A nonprobability sample of 30 participants was selected. Results: Gains in grip strength, joint range of motion, and manual dexterity of the upper limb were more significant in the experimental group but without statistically significant differences between groups. Conclusion: Despite the more significant evolution of the experimental group, mirror therapy was not effective in the motor recovery of the upper limb. Further studies are needed in this area using randomized designs, larger samples, and focused on self-care

Effect of Sensory Feedback from the Proximal Upper Limb on Voluntary Isometric Finger Flexion and Extension in Hemiparetic Stroke Subjects

This study investigated the potential influence of proximal sensory feedback on voluntary distal motor activity in the paretic upper limb of hemiparetic stroke survivors and the potential effect of voluntary distal motor activity on proximal muscle activity. Ten stroke subjects and 10 neurologically intact control subjects performed maximum voluntary isometric flexion and extension, respectively, at the metacarpophalangeal (MCP) joints of the fingers in two static arm postures and under three conditions of electrical stimulation of the arm. The tasks were quantified in terms of maximum MCP torque [MCP flexion (MCPflex) or MCP extension (MCPext)] and activity of targeted (flexor digitorum superficialis or extensor digitorum communis) and nontargeted upper limb muscles. From a previous study on the MCP stretch reflex poststroke, we expected stroke subjects to exhibit a modulation of voluntary MCP torque production by arm posture and electrical stimulation and increased nontargeted muscle activity. Posture 1 (flexed elbow, neutral shoulder) led to greater MCPflex in stroke subjects than posture 2 (extended elbow, flexed shoulder). Electrical stimulation did not influence MCPflex or MCPext in either subject group. In stroke subjects, posture 1 led to greater nontargeted upper limb flexor activity during MCPflex and to greater elbow flexor and extensor activity during MCPext. Stroke subjects exhibited greater elbow flexor activity during MCPflex and greater elbow flexor and extensor activity during MCPext than control subjects. The results suggest that static arm posture can modulate voluntary distal motor activity and accompanying muscle activity in the paretic upper limb poststroke

Exploring the Complexities of Real World Upper Limb Performance after Stroke

Stroke is the leading cause of long-term disability in the United States. Hemiparesis, or weakness on one side of the body, is a common impairment following a stroke. Approximately 80% of individuals with stroke will experience upper limb paresis, with only a small percentage regaining full functional use of their paretic upper limb. Individuals report ongoing difficulties with incorporating their paretic upper limb into routine activities after a stroke. Rehabilitation interventions often try to increase real world upper limb use by improving what an individual is capable of doing (i.e. capacity) in the rehabilitation clinic. Both clinicians and researchers assume that improving in-clinic capacity translates to increased use (i.e. performance) in daily life. For this dissertation, we explicitly tested the assumption that improved upper limb capacity translates to increased upper limb performance, or use, in daily life. Additionally, we explored known factors that influence human behavior (e.g. confidence, motivation) as they relate to upper limb performance, or use, in adults with stroke. Using sensors (i.e. wrist-worn accelerometers), we tested the assumption that improved in-clinic upper limb capacity translates to increased upper limb performance, or use, in daily life in adults with chronic (≥ 6 months) upper limb paresis post-stroke. Testing this common assumption provided important insights into the efficacy of an in-clinic intervention for improving upper limb use in the free-living environment. Many personal, environmental, biological, and psychosocial factors influence human behavior and the activities individuals choose to engage in throughout their day. There is a growing emphasis on the potentially powerful role self-efficacy and other psychosocial factors may play in the stroke recovery process. Currently, there are limited data on how psychosocial factors, specifically related to the upper limb, evolve over the critical period of motor recovery (\u3c 6 months post-stroke). Here, we quantified the natural time course of belief further improvement of the paretic upper limb is possible, confidence, and motivation to use the paretic upper limb in daily life, as well as self-reported barriers to upper limb recovery. These data provide a more robust understanding of how psychosocial factors evolve as overall recovery improves. Additionally, these data provide important information about potential mechanisms for action for future upper limb interventions. The final project of this dissertation maps the natural trajectory of upper limb performance over the first 12 weeks post-stroke. Presently, no studies have examined the natural trajectory of sensor-measured upper limb performance over the same period of time when majority of upper limb motor recovery occurs. We sought to characterize the relationship between upper limb performance and psychosocial factors by testing belief, confidence, and motivation as potential moderators of upper limb performance in daily life. The reported findings show that in-clinic improvements in upper limb capacity do not directly translate to increased upper limb performance, or use, in daily life in the chronic phase of stroke recovery. Indeed, improving what someone is capable of doing does not indicate their behavior will change in daily life. These results help distinguish between upper limb capacity and upper limb performance. While conceptually similar, they are distinct constructs. Belief, confidence, and motivation to use the paretic upper limb in daily life are remarkably high early, and remain high over the first 24 weeks (6 months) post-stroke. Upper limb performance in daily life does improve early (\u3c12 weeks) after stroke. This change, however, is not moderated by belief, confidence, and motivation. Together, this dissertation provides multi-dimensional information related to upper limb performance after stroke. These results will lead to a more integrated approach for optimizing upper limb performance outcomes, a top priority for people post-stroke

Simultaneous bilaternal training for improving arm function after stroke

Background Simultaneous bilateral training, the completion of identical activities with both arms simultaneously, is one intervention to improve arm function and reduce impairment. Objectives To determine the effects of simultaneous bilateral training for improving arm function after stroke. Search strategy We searched the Cochrane Stroke Trials Register (last searched August 2009) and 10 electronic bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2009), MEDLINE, EMBASE, CINAHL and AMED (August 2009). We also searched reference lists and trials registers. Selection criteria Randomised trials in adults after stroke, where the intervention was simultaneous bilateral training compared to placebo or no intervention, usual care or other upper limb (arm) interventions. Primary outcomes were performance in activities of daily living (ADL) and functional movement of the upper limb. Secondary outcomes were performance in extended activities of daily living and motor impairment of the arm. Data collection and analysis Two authors independently screened abstracts, extracted data and appraised trials. Assessment of methodological quality was undertaken for allocation concealment, blinding of outcome assessor, intention-to-treat, baseline similarity and loss to follow up. Main results We included 18 studies involving 549 relevant participants, of which 14 (421 participants) were included in the analysis (one within both comparisons). Four of the 14 studies compared the effects of bilateral training with usual care. Primary outcomes: results were not statistically significant for performance in ADL (standardised mean difference (SMD) 0.25, 95% confidence interval (CI) -0.14 to 0.63); functional movement of the arm (SMD -0.07, 95% CI -0.42 to 0.28) or hand (SMD -0.04, 95% CI -0.50 to 0.42). Secondary outcomes: no statistically significant results. Eleven of the 14 studies compared the effects of bilateral training with other specific upper limb (arm) interventions. Primary outcomes: no statistically significant results for performance of ADL (SMD -0.25, 95% CI -0.57 to 0.08); functional movement of the arm (SMD -0.20, 95% CI -0.49 to 0.09) or hand (SMD -0.21, 95% CI -0.51 to 0.09). Secondary outcomes: one study reported a statistically significant result in favour of another upper limb intervention for performance in extended ADL. No statistically significant differences were found for motor impairment outcomes. Authors' conclusions There is insufficient good quality evidence to make recommendations about the relative effect of simultaneous bilateral training compared to placebo, no intervention or usual care. We identified evidence that suggests that bilateral training may be no more (or less) effective than usual care or other upper limb interventions for performance in ADL, functional movement of the upper limb or motor impairment outcome