Efficacy and Dose of Rehabilitation Approaches for Severe Upper Limb Impairments and Disability During Early Acute and Subacute Stroke: A Systematic Review.

OBJECTIVE: The purpose of this study was to examine the evidence of the efficacy of rehabilitation approaches for improving severe upper limb impairments and disability during acute and early subacute stroke, taking into consideration the dosage of therapy. METHODS: Randomized controlled trials from PubMed, Web of Science, and Scopus databases were searched by 2 independent researchers. Studies were selected if they involved active rehabilitation interventions that were conducted in the acute stage (<7 days after stroke) or the early subacute stage (>7 days-3 months after stroke), with the aim of improving severe upper limb motor impairments and disability. Data were extracted on the basis of the type and effect of rehabilitation interventions and on the dosage (duration, frequency, session length, episode difficulty, and intensity). Study quality was assessed using the Physiotherapy Evidence Database Scale. RESULTS: Twenty-three studies (1271 participants) with fair to good methodological quality were included. Only 3 studies were performed in the acute stage. Regardless of the type of intervention, upper limb rehabilitation was found to be beneficial for severe upper limb impairments and disability. Robotic therapy and functional electrical stimulation were identified as the most popular upper limb interventions; however, only a limited number of studies showed their superiority over a dose-matched control intervention for severe upper limb impairments in the subacute stage. A longer rehabilitation session length (<60 minutes) did not seem to have a larger impact on the magnitude of improved upper limb impairments. CONCLUSION: Different rehabilitation approaches seem to improve severe upper limb impairments and disability in the subacute stage after stroke; however, they are not distinctly superior to standard care or other interventions provided at the same dosage. IMPACT: Robotic therapy and functional electrical stimulation add variety to rehabilitation programs, but their benefit has not been shown to exceed that of standard care. Further research is necessary to identify the impact of dosage parameters (eg, intensity) on severe upper limb motor impairments and function, especially in the acute stage.

Effect of Transcranial Direct Current Stimulation Combined with Rehabilitation on Arm and Hand Function in Stroke Patients: A Systematic Review and Meta-Analysis.

Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation technique that may enhance motor recovery after stroke. We performed a systematic review and meta-analysis to assess the efficacy of tDCS combined with rehabilitation on arm and hand function after stroke. Electronic databases were searched from their inception to September 2021. We performed a systematic review of selected randomized controlled trials, and methodological qualities were measured using the PEDro (Physiotherapy Evidence Database) scale. We calculated the standardized mean difference for effect size using the Comprehensive Meta-Analysis 3.0 software. We selected 28 studies for the systematic review and 20 studies for the meta-analysis. The overall effect size was 0.480 (95% CI [0.307; 0.653], p < 0.05), indicating a moderate effect size of tDCS combined with rehabilitation for upper extremity function in stroke survivors. The tDCS with occupational therapy/physical therapy (0.696; 95% CI [0.390; 1.003], p < 0.05) or virtual reality therapy (0.510; 95% CI [0.111; 0.909], p < 0.05) was also significantly more effective than other treatments. This meta-analysis of 20 randomized controlled trials provides further evidence that tDCS combined with rehabilitation, especially occupational therapy/physical therapy and virtual reality therapy, may benefit upper extremity function of the paretic upper limb in stroke patients.

A Framework for Sensor-Based Assessment of Upper-Limb Functioning in Hemiparesis.

The ultimate goal of any upper-limb neurorehabilitation procedure is to improve upper-limb functioning in daily life. While clinic-based assessments provide an assessment of what a patient can do, they do not completely reflect what a patient does in his/her daily life. The use of compensatory strategies such as the use of the less affected upper-limb or excessive use of trunk in daily life is a common behavioral pattern seen in patients with hemiparesis. To this end, there has been an increasing interest in the use of wearable sensors to objectively assess upper-limb functioning. This paper presents a framework for assessing upper-limb functioning using sensors by providing: (a) a set of definitions of important constructs associated with upper-limb functioning; (b) different visualization methods for evaluating upper-limb functioning; and (c) two new measures for quantifying how much an upper-limb is used and the relative bias in their use. The demonstration of some of these components is presented using data collected from inertial measurement units from a previous study. The proposed framework can help guide the future technical and clinical work in this area to realize valid, objective, and robust tools for assessing upper-limb functioning. This will in turn drive the refinement and standardization of the assessment of upper-limb functioning.

Five Features to Look for in Early-Phase Clinical Intervention Studies.

Neurorehabilitation relies on core principles of neuroplasticity to activate and engage latent neural connections, promote detour circuits, and reverse impairments. Clinical interventions incorporating these principles have been shown to promote recovery and demote compensation. However, many clinicians struggle to find interventions centered on these principles in our nascent, rapidly growing body of literature. Not to mention the immense pressure from regulatory bodies and organizational balance sheets that further discourage time-intensive recovery-promoting interventions, incentivizing clinicians to prioritize practical constraints over sound clinical decision making. Modern neurorehabilitation practices that result from these pressures favor strategies that encourage compensation over those that promote recovery. To narrow the gap between the busy clinician and the cutting-edge motor recovery literature, we distilled 5 features found in early-phase clinical intervention studies-ones that value the more enduring biological recovery processes over the more immediate compensatory remedies. Filtering emerging literature through this lens and routinely integrating promising research into daily practice can break down practical barriers for effective clinical translation and ultimately promote durable long-term outcomes. This perspective is meant to serve a new generation of mechanistically minded and caring clinicians, students, activists, and research trainees, who are poised to not only advance rehabilitation science, but also erect evidence-based policy changes to accelerate recovery-based stroke care.

German version of the Chedoke McMaster arm and hand activity inventory (CAHAI-G): intra-rater reliability and responsiveness.

BACKGROUND: The English version of the Chedoke Arm and Hand Activity Inventory is a validated, upper-limb measure with the purpose of assessing functional recovery of the arm and hand after a stroke. A German translation and cross-cultural adaptation was recently produced and demonstrated high validity, inter-rater reliability and internal consistency. As a follow-up, the present study evaluated the intra-rater reliability and responsiveness of the CAHAI-G for the long and all shortened versions. METHODS: The CAHAI-G and the Action Research Arm Test were assessed on three different measurement events: upon entry (ME1), two to 3 days after entry (ME2), and after three to 4 weeks (ME3). For the intra-rater reliability analysis, the ME1 CAHAI assessments were recorded on video and rated by three therapists to obtain the intraclass coefficients (ICC). The data of all three MEs were analysed in a group of stroke inpatients for the evaluation of responsiveness. To test for responsiveness, the CAHAI-G change data were compared to concurrent instruments: The Global Rating of Change-questionnaire and the Global Rating of Concept-questionnaire. Both served as external criteria. For all CAHAI-G versions (7, 8, 9 or 13 items), the same analysis procedures for the evaluation of the responsiveness parameter were performed. RESULTS: In total, 27 patients (9 females, age 63 ± 13.7) were enrolled in the study. The ICCs for the intra-rater reliability were calculated to be between 0.988 and 0.998 for all CAHAI versions. Responsiveness parameters were as follows from CAHAI-G 7 to 13: Minimal Detectable Change (MDC90) 5.3, 6.0, 6.1, 8.2; Pearson's correlation coefficients CAHAI-Gs with ARAT 0.365, 0.409*, 0.500**, 0.597**. The Area und Under the Curve and the Minimal Clinical Important Difference values for all CAHAI-G versions and the three external criteria ranged between 0.483 to 0.603 and 2.5 to 9.0, respectively. CONCLUSION: In addition to the high validity, inter-rater reliability and internal consistency, the CAHAI-G revealed high intra-rater reliability. The data also suggest an adequate responsiveness of the CAHAI-G versions 9 and 13.

Mouse Arm and hand movements in grooming are reaching movements: Evolution of reaching, handedness, and the thumbnail.

Grooming in the mouse features hand licking and symmetric and asymmetric arm and hand "strokes" over the face and body to maintain pelage. Grooming is syntactically organized but the structure of individualized movements of the arm, hand, and tongue have not been examined. Here spontaneous and water-induced grooming was video recorded in free-moving and head-fixed mice and subject to frame-by-frame video inspection and kinematic analysis using Physics Tracker. All groom arm and hand movements had a structure similar to that described for reach-to-eat movements. The movement included the hand lifting from the floor to supinate with the digits flexing and closed to a collect position, an aim position directed to a groom target, an advance to the target during which the fingers extend and open and the hand pronates, a grasp of a target on the snout, nose, or vibrissae, and a withdraw to the mouth where licking occurs, or a return to the starting position. This structure was present in individual unilateral forelimb groom strokes, in bilateral symmetric, or asymmetric groom strokes, and comprised the individuated components of a sequence of groom movements. Reach-to-groom movements could feature an ulnar adduction that positions the ulnar portion of the hand including and the thumb across the eye and nose, a movement that aids Hardarian fluid spreading. It is proposed that the mouse thumb nail is an anatomical feature that minimizes damage to the eye or nose that might be incurred by a claw. This analysis of the reach-to-groom movement provides insights into the flexibility of hand use in adaptive behavior, the evolution of skilled reaching movements, the neural control of reaching movements and the presence of the thumb nail in the mouse.

Are changes in upper extremity use during sub-acute rehabilitation after stroke associated with physical, cognitive, and social activities? An observational cohort pilot study.

OBJECTIVES: To investigate how changes in physical, social, and cognitive activity levels are associated with the use of the affected upper extremity at different time points during inpatient rehabilitation after stroke. METHODS: In an observational longitudinal cohort pilot study activity of 14 patients with subacute stroke was registered 2-4 times during their inpatient rehabilitation from 2 p.m. to 8 p.m. At the same time, patients wore accelerometers on both wrists to register amount of use and use ratio of the affected to the unaffected upper extremity. Before and after the observation period, patients were assessed with action research arm test, Box and Blocks Test, and Functional Independence Measure. Linear regression models were used to examine the influence of different categories of activities and motor function levels on affected upper extremity use. RESULTS: Increasing physical activity levels during rehabilitation and improvement in upper extremity motor function were associated with increased use of the affected upper extremity. Cognitive and social activity levels did not change and were not associated with affected upper extremity use. CONCLUSION: Our findings suggest that the use of the affected upper extremity and a general increase in activity are associated. Facilitating both general physical activity and specific upper extremity use at a rehabilitation ward may benefit overall recovery.

Been there, done that, so what's next for arm and hand rehabilitation in stroke?

BACKGROUND: The extraordinary advances in technology such as body-worn sensors, health information technologies, technological advances in neuroimaging, and computational approaches to predictive modelling using biomarkers offers considerable promise to literally transform our thinking, our approach to the problem, and the design of future clinical trials about arm and hand rehabilitation after stroke. OBJECTIVE: To provide a focused review that considers the past, present and future of arm and hand rehabilitation in stroke. METHOD: We organized this perspective into three parts: 1) Past- we summarize the past decade of the clinical trial enterprise in neurorehabilitation, 2) Present- we provide a brief review of three research areas where mechanistic studies that rely on uniquely human neural circuits provide a basis for promising intervention tools, and 3) Future-we highlight three unique research domains that are likely to provide the biggest impact on the future of post-stroke arm and hand recovery. RESULTS: The past has not been a complete failure- in particular, the EXCITE RCT put arm and hand rehabilitation on the map. Unfortunately, the majority of clinical trials that followed were based on an immature science of neurorehabilitation. We got drawn in by the seductive preclinical animal model work which suggested that dose and intensity of task-oriented training was the most important ingredient for fostering recovery in humans. While dose, and intensity are clearly important, they are of little value unless the stroke survivor is engaged, motivated, and the neural infrastructure provides enough resource to allow the recovery process. Recently, we noticed an increase in mechanistic and theory-driven studies, findings from which will not only advance our understanding of critical brain-behavior mechanisms, but will provide a more mature science moving into the future. CONCLUSIONS: The good news is that there is evidence that we learned from the past and have invented a future that appears to be much more exciting and promising than the past.

Validity and responsiveness of the German version of the Motor Activity Log for the assessment of self-perceived arm use in hemiplegia after stroke.

BACKGROUND: Rehabilitation of patients after stroke requires valid and responsive assessments for arm and hand function to determine the effectiveness of rehabilitative interventions. The Motor Activity Log (MAL) aims to assess self-perceived arm and hand use after stroke. Its clinimetric properties are incomplete and contradictory. OBJECTIVE: To investigate internal consistency, concurrent validity and responsiveness of the German MAL-30 in patients after stroke with minimal to moderate arm and hand function. METHODS: 42 patients were included in this longitudinal prospective cohort study. Internal consistency was determined in a complete-case analysis with Cronbach's α. Concurrent validity was assessed with Spearman' rho by comparing the German MAL-30 with Wolf Motor Function Test, Chedoke McMaster Stroke Assessment, isometric elbow, shoulder and grip strength at baseline, post-treatment and 6 month follow-up. Responsiveness was determined separately for lower and higher arm and hand function by calculating the standardized response mean. RESULTS: Internal consistency was excellent (Cronbach's α = 0.94-0.99), concurrent validity good to excellent (Spearman's rho = 0.64-0.99). Responsiveness was high for both functional levels from baseline to discharge (SRM = 0.93-1.43) and to follow-up (SRM = 0.95-1.34). CONCLUSION: The German MAL-30 is a valid and responsive assessment for self-perceived arm and hand use after stroke even when function is low.