A study of prisms and therapy in attention loss after stroke (SPATIAL): A feasibility randomised controlled trial.

OBJECTIVE: Investigate feasibility and acceptability of prism adaptation training for people with inattention (spatial neglect), early after stroke, during usual care. DESIGN: Phase II feasibility randomised controlled trial with 3:1 stratified allocation to standard occupational therapy with or without intervention, and nested process evaluation. SETTING: Ten hospital sites providing in-patient stroke services. PARTICIPANTS: Screened positive for inattention more than one-week post-stroke; informal carers. Occupational therapists participated in qualitative interviews. INTERVENTION: Adjunctive prism adaptation training at the start of standard occupational therapy sessions for three weeks. MAIN MEASURES: Feasibility measures included recruitment and retention rates, intervention fidelity and attrition. Outcomes collected at baseline, 3 weeks and 12 weeks tested measures including Nottingham Extended Activities of Daily Living Scale. Acceptability was explored through qualitative interviews and structured questions. RESULTS: Eighty (31%) patients were eligible, 57 (71%) consented, 54 randomised (40:13, +1 exclusion) and 39 (74%) completed 12-week outcomes. Treatment fidelity was good: participants received median eight intervention sessions (IQR: 5, 12) lasting 4.7 min (IQR: 4.1, 5.0). All six serious adverse events were unrelated. There was no signal that patients allocated to intervention did better than controls. Twenty five of 35 recruited carers provided outcomes with excellent data completeness. Therapists, patients and carers found prism adaptation training acceptable. CONCLUSIONS: It is feasible and acceptable to conduct a high-quality definitive trial of prism adaptation training within occupational therapy early after stroke in usual care setting, but difficult to justify given no sign of benefit over standard occupational therapy. CLINICAL TRIAL REGISTRATION: https://www.isrctn.com/ Ref ISRCTN88395268.

Assessing the impact of upper limb disability following stroke: a qualitative enquiry using internet-based personal accounts of stroke survivors.

PURPOSE: Upper limb disability following stroke may have multiple effects on the individual. Existing assessment instruments tend to focus on impairment and function and may miss other changes that are personally important. This study aimed to identify personally significant impacts of upper limb disability following stroke. METHODS: Accounts by stroke survivors, in the form of web-based diaries (blogs) and stories, were sought using a blog search engine and in stroke-related web-sites. Thematic analysis using the World Health Organisation's International Classification of Functioning Disability and Health (ICF) was used to identify personal impacts of upper limb disability following stroke. RESULTS: Ninety-nine sources from at least four countries were analysed. Many impacts were classifiable using the ICF, but a number of additional themes emerged, including emotional, cognitive and behavioural changes. Blogs and other web-based accounts were easily accessible and rich sources of data, although using them raised several methodological issues, including potential sample bias. CONCLUSIONS: A range of impacts was identified, some of which (such as use of information technology and alienation from the upper limb) are not addressed in current assessment instruments. They should be considered in post-stroke assessments. Blogs may help in the development of more comprehensive assessments. IMPLICATIONS FOR REHABILITATION: A comprehensive assessment of the upper limb following stroke should include the impact of upper limb problems on social participation, as well as associated emotional, cognitive and behavioural changes. Using personalised assessment instruments alongside standardised measures may help ensure that these broader domains are considered in discussions between clinicians and patients. Rehabilitation researchers should investigate whether and how these domains could be addressed and operationalised in standard upper limb assessment instruments.

Task-specific reach-to-grasp training after stroke: development and description of a home-based intervention.

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is to transparently describe the process of developing a complex intervention for people after stroke as part of a feasibility randomised controlled trial. OBJECTIVE: To describe and justify the development of a home-based, task-specific upper limb training intervention to improve reach-to-grasp after stroke and pilot it for feasibility and acceptability prior to a randomized controlled trial. INTERVENTION DESCRIPTION: The intervention is based on intensive practice of whole reach-to-grasp tasks and part-practice of essential reach-to-grasp components. A 'pilot' manual of activities covering the domains of self-care, leisure and productivity was developed for the feasibility study. The intervention comprises 14 hours of therapist-delivered sessions over six weeks, with additional self-practice recommended for 42 hours (i.e. one hour every day). As part of a feasibility randomized controlled trial, 24 people with a wide range of upper limb impairment after stroke experienced the intervention to test adherence and acceptability. The median number of repetitions in one-hour therapist-delivered sessions was 157 (interquartile range IQR 96-211). The amount of self-practice was poorly documented. Where recorded, the median amount of practice was 30 minutes (interquartile range 22-45) per day. Findings demonstrated that the majority of participants found the intensity, content and level of difficulty of the intervention acceptable, and the programme to be beneficial. Comments on the content and presentation of the self-practice material were incorporated in a revised 'final' intervention manual. DISCUSSION: A comprehensive training intervention to improve reach-to-grasp for people living at home after stroke has been described in accordance with the Template for Intervention Description and Replication (TIDieR) reporting guidelines. The intervention has been piloted, and found to be acceptable and feasible in the home setting. TRIAL REGISTRATION: ISRCTN56716589.

Evaluation of a prototype tool for communicating body perception disturbances in complex regional pain syndrome.

Patients with Complex Regional Pain Syndrome (CRPS) experience distressing changes in body perception. However representing body perception is a challenge. A digital media tool for communicating body perception disturbances was developed. A proof of concept study evaluating the acceptability of the application for patients to communicate their body perception is reported in this methods paper. Thirteen CRPS participants admitted to a 2-week inpatient rehabilitation program used the application in a consultation with a research nurse. Audio recordings were made of the process and a structured questionnaire was administered to capture experiences of using the tool. Participants produced powerful images of disturbances in their body perception. All reported the tool acceptable for communicating their body perception. Participants described the positive impact of now seeing an image they had previously only imagined and could now convey to others. The application has provided a novel way for communicating perceptions that are otherwise difficult to convey.

Home-based reach-to-grasp training for people after stroke: study protocol for a feasibility randomized controlled trial.

BACKGROUND: This feasibility study is intended to assess the acceptability of home-based task-specific reach-to-grasp (RTG) training for people with stroke, and to gather data to inform recruitment, retention, and sample size for a definitive randomized controlled trial. METHODS/DESIGN: This is to be a randomized controlled feasibility trial recruiting 50 individuals with upper-limb motor impairment after stroke. Participants will be recruited after discharge from hospital and up to 12 months post-stroke from hospital stroke services and community therapy-provider services. Participants will be assessed at baseline, and then electronically randomized and allocated to group by minimization, based on the time post-stroke and extent of upper-limb impairment. The intervention group will receive 14 training sessions, each 1 hour long, with a physiotherapist over 6 weeks and will be encouraged to practice independently for 1 hour/day to give a total of 56 hours of training time per participant. Participants allocated to the control group will receive arm therapy in accordance with usual care. Participants will be measured at 7 weeks post-randomization, and followed-up at 3 and 6 months post-randomization. Primary outcome measures for assessment of arm function are the Action Research Arm Test (ARAT) and Wolf Motor Function Test (WMFT). Secondary measures are the Motor Activity Log, Stroke Impact Scale, Carer Strain Index, and health and social care resource use. All assessments will be conducted by a trained assessor blinded to treatment allocation. Recruitment, adherence, withdrawals, adverse events (AEs), and completeness of data will be recorded and reported. DISCUSSION: This study will determine the acceptability of the intervention, the characteristics of the population recruited, recruitment and retention rates, descriptive statistics of outcomes, and incidence of AEs. It will provide the information needed for planning a definitive trial to test home-based RTG training. TRIAL REGISTRATION ISRCTN: ISRCTN56716589.

A single blinded randomised controlled pilot trial of prism adaptation for improving self-care in stroke patients with neglect.

Prism adaptation has been shown to alleviate the symptoms of unilateral spatial neglect following stroke in single case and small group studies. The purposes of this single blinded pilot randomised controlled trial were to determine the feasibility of delivering prism adaptation treatment in a clinically valid sample and to assess its impact on self-care. Thirty seven right hemisphere stroke patients with unilateral spatial neglect were randomised into either prism adaptation (using 10 dioptre, 6 degree prisms) or sham treatment (using plain glasses) groups. Treatment was delivered each weekday for two weeks. Pointing accuracy, without vision of the finger, was recorded each day before treatment. Outcome was measured, by blinded assessors, four days and eight weeks after the end of treatment using the Catherine Bergego Scale (CBS) and the conventional neuropsychological tests from the Behavioural Inattention Test (BIT). Thirty four patients received treatment: 16 with prisms, 18 sham. Mean compliance was 99% and 97%, respectively. Over the treatment days only the prism treated group showed increased leftward bias in open loop pointing to targets on a touch screen. However, despite the group level changes in pointing behaviour no overall effect of the treatment on self-care or BIT were found.

Walking and wheelchair navigation in patients with left visual neglect.

Patients with neglect veer to one side when walking or driving a wheelchair, however there is a contradiction in the literature about the direction of this deviation. The study investigated the navigational trajectory of a sample of neglect patients of mixed mobility status in an ecological setting. Fifteen patients with left-sided neglect after right hemisphere stroke were recorded walking or driving a powered wheelchair along a stretch of corridor. Their position in the corridor and the number of collisions was recorded. The results showed that the patients' path was dependent on their mobility status: wheelchair patients with neglect consistently deviated to the left of the centre of the corridor and walking patients with neglect consistently deviated to the right. A further two ambulant patients with neglect were recorded both walking and using the wheelchair to determine whether the differences were task or patient dependent. These two patients also exhibited leftward deviation when driving the wheelchair, but a rightward deviation when walking. These results suggest that the direction of the deviation is task dependent. Further work will be required to identify what features of the two modes of navigation lead to this dissociation.

Sensorimotor integration in Complex Regional Pain Syndrome: a transcranial magnetic stimulation study.

There is evidence that patients with Complex Regional Pain Syndrome (CRPS) have altered central sensorimotor processing. Sensory input can influence motor output either through indirect pathways or through direct connections from the sensory to motor cortex. The purpose of this study was to investigate sensorimotor interaction via direct connections in patients with CRPS and to compare the results with normal subjects'. Direct short-latency sensory-motor interaction was evaluated in eight patients with CRPS1 affecting a hand. Modulation of EMG responses to transcranial magnetic stimulation (TMS) induced by concomitant median nerve stimulation was measured, the so-called, short-latency afferent inhibition (SAI). Results were compared with eight normal subjects who were age and sex matched with the patients. As expected, all the normal subjects' EMG responses to TMS with median nerve stimulation were smaller than responses to TMS alone. In seven of the eight CRPS patients EMG responses to TMS were suppressed when paired with median nerve stimulation. Only one CRPS patient's results showed no suppression of EMG responses. These results suggest that the disease mechanisms of CRPS1 do not typically affect the direct neural circuit between sensory and motor cortex and that normal sensorimotor interaction is occurring via this route.

A pilot randomized controlled trial of a daily muscle stretch regime to prevent contractures in the arm after stroke.

OBJECTIVE: To evaluate the feasibility and effects of daily stretch positioning for prevention of contractures in stroke patients without arm function. DESIGN: Randomized controlled pilot study. SETTING: Stroke rehabilitation ward, U.K. SUBJECTS: Twenty-five subjects drawn from an initial pool of 126 presenting with loss of arm function, all within four weeks of stroke. INTERVENTIONS: In addition to usual care, subjects in the experimental group (n=13) were prescribed two 30-min stretches for wrist and finger flexors and two 30-min stretches targeting shoulder adductors and internal rotators, per day for up to 12 weeks post stroke. Stretches were carried out by therapists and nursing staff. MAIN MEASURES: Passive range of wrist extension and shoulder external rotation to standard force or to pain at four, eight and twelve weeks after stroke. RESULTS: Compliance was variable. Frequency of positioning was fair from four to eight weeks post stroke but declined after that. Mean (SD) frequency of stretch positions completed between four and eight weeks was 36.5 (13.0) for the wrist, 31.2 (14.1) for the shoulder, out of 56 prescribed. There were no significant effects of treatment. By eight weeks post stroke the mean range of wrist extension and shoulder external rotation lost on the affected side in both groups was approximately 30 degrees. CONCLUSIONS: The stretch treatment was not well tolerated over many weeks. Statistical power was low due to the large degree of variability of range of motion and small sample size. The regime tested cannot be recommended as a workable treatment to prevent contractures.

A multiple case design experiment to investigate the performance and neural effects of a programme for training hand function after stroke.

OBJECTIVE: To investigate the effects of task-specific practice on hand function in stroke subjects who were given computer-assisted training and to look for associated changes in corticospinal connectivity. DESIGN: Single case design experiments. SETTING: Subjects' homes. SUBJECTS: Seven chronic stroke subjects with impaired hand function. INTERVENTIONS: Daily intensive practice of fast and accurate force changes in pinch grip and knob turning grip for four weeks. MAIN MEASURES: Pinch and power grip strength and dexterity measured using the Ten-hole Peg Test and a timed nuts and bolts test were recorded twice a week throughout the study. Corticospinal connectivity was assessed by latency of electromyography (EMG) responses to transcranial magnetic stimulation (TMS) recorded during the baseline weeks before the training and again immediately after the training period. RESULTS: Subjects completed between 5760 and 18560 force changes. Clinically relevant improvements in grip strength were evident in only two subjects. None of the subjects showed clinically significant improvement in dexterity measures. Statistical analysis showed that improved performance was related to the training phase in only two subjects. A reduction in latency of EMG responses to TMS was seen in two subjects but could not be attributed to the training phase. CONCLUSIONS: The intensive training did not improve hand function in most subjects. Latencies of EMG responses to TMS were also unable to detect any change.