Determining Levels of Upper Extremity Movement Impairment by Applying a Cluster Analysis to the Fugl-Meyer Assessment of the Upper Extremity in Chronic Stroke.

OBJECTIVE: To quantitatively determine levels of upper extremity movement impairment by using a cluster analysis of the Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) with and without reflex items. DESIGN: Secondary analysis. SETTING: University and research centers. PARTICIPANTS: Individuals (N=247) with chronic stroke (>6mo poststroke). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Cutoff scores defined by FMA-UE total scores of clusters identified by 2 hierarchical cluster analyses performed on the full sample of FMA-UE individual item scores (with and without reflexes). Patterns of motor function defined by aggregate item scores of clusters. RESULTS: FMA-UE scores ranged from 2 to 63 (mean, 26.9±15.7) with reflex items and from 0 to 57 (mean, 22.1±15.3) without reflex items. Three clusters were identified. The distributions of the FMA-UE scores revealed considerable overlap between the clusters; therefore, 4 distinct stroke impairment levels were derived. CONCLUSIONS: For chronic stroke, the cluster analysis of the FMA-UE supports either a 3- or a 4-impairment level classification scheme.

Robot-assisted therapy for long-term upper-limb impairment after stroke.

BACKGROUND: Effective rehabilitative therapies are needed for patients with long-term deficits after stroke. METHODS: In this multicenter, randomized, controlled trial involving 127 patients with moderate-to-severe upper-limb impairment 6 months or more after a stroke, we randomly assigned 49 patients to receive intensive robot-assisted therapy, 50 to receive intensive comparison therapy, and 28 to receive usual care. Therapy consisted of 36 1-hour sessions over a period of 12 weeks. The primary outcome was a change in motor function, as measured on the Fugl-Meyer Assessment of Sensorimotor Recovery after Stroke, at 12 weeks. Secondary outcomes were scores on the Wolf Motor Function Test and the Stroke Impact Scale. Secondary analyses assessed the treatment effect at 36 weeks. RESULTS: At 12 weeks, the mean Fugl-Meyer score for patients receiving robot-assisted therapy was better than that for patients receiving usual care (difference, 2.17 points; 95% confidence interval [CI], -0.23 to 4.58) and worse than that for patients receiving intensive comparison therapy (difference, -0.14 points; 95% CI, -2.94 to 2.65), but the differences were not significant. The results on the Stroke Impact Scale were significantly better for patients receiving robot-assisted therapy than for those receiving usual care (difference, 7.64 points; 95% CI, 2.03 to 13.24). No other treatment comparisons were significant at 12 weeks. Secondary analyses showed that at 36 weeks, robot-assisted therapy significantly improved the Fugl-Meyer score (difference, 2.88 points; 95% CI, 0.57 to 5.18) and the time on the Wolf Motor Function Test (difference, -8.10 seconds; 95% CI, -13.61 to -2.60) as compared with usual care but not with intensive therapy. No serious adverse events were reported. CONCLUSIONS: In patients with long-term upper-limb deficits after stroke, robot-assisted therapy did not significantly improve motor function at 12 weeks, as compared with usual care or intensive therapy. In secondary analyses, robot-assisted therapy improved outcomes over 36 weeks as compared with usual care but not with intensive therapy. (ClinicalTrials.gov number, NCT00372411.)

Novel use of existing technology: A preliminary study of patient portal use for telerehabilitation.

CLINICALTRIALS.GOV IDENTIFIER: NCT02665052. Registered 27 January 2016. https://clinicaltrials.gov/ct2/show/NCT02665052.

Baseline Predictors of Response to Repetitive Task Practice in Chronic Stroke.

BACKGROUND: Repetitive task practice reduces mean upper extremity motor impairment in populations of patients with chronic stroke, but individual response is highly variable. A method to predict meaningful reduction in impairment in response to training based on biomarkers and other data collected prior to an intervention is needed to establish realistic rehabilitation goals and to effectively allocate resources. OBJECTIVES: To identify prognostic factors and better understand the biological substrate for reductions in arm impairment in response to repetitive task practice among patients with chronic (≥6 months) post-stroke hemiparesis. METHODS: The intervention is a form of repetitive task practice using a combination of robot-assisted therapy and functional arm use in real-world tasks. Baseline measures include the Fugl-Meyer Assessment, Wolf Motor Function Test, Action Research Arm Test, Stroke Impact Scale, questionnaires on pain and expectancy, MRI, transcranial magnetic stimulation, kinematics, accelerometry, and genomic testing. RESULTS: Mean increase in FM-UE was 4.6 ± 1.0 SE, median 2.5. Approximately one-third of participants had a clinically meaningful response to the intervention, defined as an increase in FM ≥ 5. The selected logistic regression model had a receiver operating curve with AUC = .988 (Std Error = .011, 95% Wald confidence limits: .967-1) showed little evidence of overfitting. Six variables that predicted response represented impairment, functional, and genomic measures. CONCLUSION: A simple weighted sum of 6 baseline factors can accurately predict clinically meaningful impairment reduction after outpatient intensive practice intervention in chronic stroke. Reduction of impairment may be a critical first step to functional improvement. Further validation and generalization of this model will increase its utility in clinical decision-making.

Effect of gravity on robot-assisted motor training after chronic stroke: a randomized trial.

OBJECTIVES: To determine the efficacy of 2 distinct 6-week robot-assisted reaching programs compared with an intensive conventional arm exercise program (ICAE) for chronic, stroke-related upper-extremity (UE) impairment. To examine whether the addition of robot-assisted training out of the horizontal plane leads to improved outcomes. DESIGN: Randomized controlled trial, single-blinded, with 12-week follow-up. SETTING: Research setting in a large medical center. PARTICIPANTS: Adults (N=62) with chronic, stroke-related arm weakness stratified by impairment severity using baseline UE motor assessments. INTERVENTIONS: Sixty minutes, 3 times a week for 6 weeks of robot-assisted planar reaching (gravity compensated), combined planar with vertical robot-assisted reaching, or intensive conventional arm exercise program. MAIN OUTCOME MEASURE: UE Fugl-Meyer Assessment (FMA) mean change from baseline to final training. RESULTS: All groups showed modest gains in the FMA from baseline to final with no significant between group differences. Most change occurred in the planar robot group (mean change ± SD, 2.94 ± 0.77; 95% confidence interval [CI], 1.40-4.47). Participants with greater motor impairment (n=41) demonstrated a larger difference in response (mean change ± SD, 2.29 ± 0.72; 95% CI, 0.85-3.72) for planar robot-assisted exercise compared with the intensive conventional arm exercise program (mean change ± SD, 0.43 ± 0.72; 95% CI, -1.00 to 1.86). CONCLUSIONS: Chronic UE deficits because of stroke are responsive to intensive motor task training. However, training outside the horizontal plane in a gravity present environment using a combination of vertical with planar robots was not superior to training with the planar robot alone.

Comparing Home Upper Extremity Activity with Clinical Evaluations of Arm Function in Chronic Stroke.

OBJECTIVE: To determine if clinical evaluations of post-stroke arm function correspond to everyday motor performance indexed by arm accelerometers. DESIGN: Cross-sectional study analyzing baseline data from a larger trial (NCT02665052). SETTING: Outpatient research center. PARTICIPANTS: Twenty community-dwelling adults with chronic arm motor deficits (stroke≥6mo). INTERVENTION: 72-hours of home wrist-worn accelerometry during normal routine. MAIN OUTCOME MEASURES: Clinical evaluations included the Fugl-Meyer (FM), Action Research Arm Test (ARAT), Wolf Motor Function Test (WMFT), and two self-assessments: the Motor Activity Log (MAL) and hand motor subscale of the Stroke Impact Scale (SIS). Accelerometer-derived variables included quantifications of movement intensity (magnitude) and duration of arm use. RESULTS: Participants had moderate arm impairment (FM 36.1 ± 9.4). The accelerometer-derived mean magnitude ratio correlated significantly with the FM (ρ = 0.60, p < 0.01), WMFT functional score (ρ = 0.59, p < 0.01), and ARAT (ρ = 0.50, p < 0.05). The hours of use ratio correlated with the MAL amount of use (ρ = 0.58, p < 0.01) and quality of movement (ρ = 0.61, p < 0.01). Total paretic hours did not correlate with the FM, WMFT or ARAT, and intensity variables did not correlate with the MAL or SIS. CONCLUSIONS: Participants with higher baseline function had greater intensity of paretic arm movement at home; similarly, those who perceived they had less disability used their paretic arm more relative to their non-paretic arm. However, some participants with higher clinical scores did not exhibit greater arm use in everyday life, possibly due to neglect and learned non-use. Therefore, individualized home accelerometry profiles could provide valuable insight to better tailor post-stroke rehabilitation.

Robot-Assisted Arm Training in Chronic Stroke: Addition of Transition-to-Task Practice.

Background. Robot-assisted therapy provides high-intensity arm rehabilitation that can significantly reduce stroke-related upper extremity (UE) deficits. Motor improvement has been shown at the joints trained, but generalization to real-world function has not been profound. Objective. To investigate the efficacy of robot-assisted therapy combined with therapist-assisted task training versus robot-assisted therapy alone on motor outcomes and use in participants with moderate to severe chronic stroke-related arm disability. Methods. This was a single-blind randomized controlled trial of two 12-week robot-assisted interventions; 45 participants were stratified by Fugl-Meyer (FMA) impairment (mean 21 ± 1.36) to 60 minutes of robot therapy (RT; n = 22) or 45 minutes of RT combined with 15 minutes therapist-assisted transition-to-task training (TTT; n = 23). The primary outcome was the mean FMA change at week 12 using a linear mixed-model analysis. A subanalysis included the Wolf Motor Function Test (WMFT) and Stroke Impact Scale (SIS), with significance P <.05. Results. There was no significant 12-week difference in FMA change between groups, and mean FMA gains were 2.87 ± 0.70 and 4.81 ± 0.68 for RT and TTT, respectively. TTT had greater 12-week secondary outcome improvements in the log WMFT (-0.52 ± 0.06 vs -0.18 ± 0.06; P = .01) and SIS hand (20.52 ± 2.94 vs 8.27 ± 3.03; P = .03). Conclusion. Chronic UE motor deficits are responsive to intensive robot-assisted therapy of 45 or 60 minutes per session duration. The replacement of part of the robotic training with nonrobotic tasks did not reduce treatment effect and may benefit stroke-affected hand use and motor task performance.

Methods for an Investigation of Neurophysiological and Kinematic Predictors of Response to Upper Extremity Repetitive Task Practice in Chronic Stroke.

OBJECTIVE: To demonstrate the feasibility of algorithmic prediction using a model of baseline arm movement, genetic factors, demographic characteristics, and multimodal assessment of the structure and function of motor pathways. To identify prognostic factors and the biological substrate for reductions in arm impairment in response to repetitive task practice. DESIGN: This prospective single-group interventional study seeks to predict response to a repetitive task practice program using an intent-to-treat paradigm. Response is measured as a change of ≥5 points on the Upper Extremity Fugl-Meyer from baseline to final evaluation (at the end of training). SETTING: General community. PARTICIPANTS: Anticipated enrollment of community-dwelling adults with chronic stroke (N = 96; onset≥6mo) and moderate to severe residual hemiparesis of the upper limb as defined by a score of 10-45 points on the Upper Extremity Fugl-Meyer. INTERVENTION: The intervention is a form of repetitive task practice using a combination of robot-assisted therapy coupled with functional arm use in real-world tasks administered over 12 weeks. MAIN OUTCOME MEASURES: Upper Extremity Fugl-Meyer Assessment (primary outcome), Wolf Motor Function Test, Action Research Arm Test, Stroke Impact Scale, questionnaires on pain and expectancy, magnetic resonance imaging, transcranial magnetic stimulation, arm kinematics, accelerometry, and a saliva sample for genetic testing. RESULTS: Methods for this trial are outlined, and an illustration of interindividual variability is provided by example of 2 participants who present similarly at baseline but achieve markedly different outcomes. CONCLUSION: This article presents the design, methodology, and rationale of an ongoing study to develop a predictive model of response to a standardized therapy for stroke survivors with chronic hemiparesis. Applying concepts from precision medicine to neurorehabilitation is practicable and needed to establish realistic rehabilitation goals and to effectively allocate resources.

Self-directed exercise in multiple sclerosis: Evaluation of a home automated tele-management system.

Introduction Physical rehabilitation is one of the few non-pharmaceutical therapies for maintaining or improving walking ability for patients with multiple sclerosis. However, travel distance to rehabilitation clinics, neurological disability and insurance coverage often limit access to specialised rehabilitation services. To address these issues, we utilised a web-based system to support a home-based self-directed exercise programme. Methods Patients ( n = 24) were randomised to either routine home rehabilitation or to the multiple sclerosis home automated tele-management system for a six-month period. The study group had a mean age of 50.4 years, 56% of patients were male, and 67% had progressive multiple sclerosis with an overall mean Patient Determined Disease Steps score of 4.4 (cane or crutch required for walking). Key outcomes included the timed 25-foot-walk, six-minute-walk and the Berg Balance Scale. Results There was no statistically significant difference in the change of the primary walking outcome measure, timed 25-foot-walk, at six months between the home automated tele-management intervention and control groups ( p = 0.44). Similarly, change scores for the six-minute-walk were not significantly different between the home automated tele-management or control groups at six months. Discussion Maintaining overall gait abilities in this group of predominantly progressive multiple sclerosis patients is notable. Exercise adherence was positively associated with higher multiple sclerosis disability and self-reported walking ability. Study engagement and participation in routine home-based exercise for the entire study period was challenging. Further research using clinical video telerehabilitation techniques that optimise patient involvement warrants further study.

A Clinically Relevant Method of Analyzing Continuous Change in Robotic Upper Extremity Chronic Stroke Rehabilitation.

BACKGROUND: Robots designed for rehabilitation of the upper extremity after stroke facilitate high rates of repetition during practice of movements and record precise kinematic data, providing a method to investigate motor recovery profiles over time. OBJECTIVE: To determine how motor recovery profiles during robotic interventions provide insight into improving clinical gains. METHODS: A convenience sample (n = 22), from a larger randomized control trial, was taken of chronic stroke participants completing 12 sessions of arm therapy. One group received 60 minutes of robotic therapy (Robot only) and the other group received 45 minutes on the robot plus 15 minutes of translation-to-task practice (Robot + TTT). Movement time was assessed using the robot without powered assistance. Analyses (ANOVA, random coefficient modeling [RCM] with 2-term exponential function) were completed to investigate changes across the intervention, between sessions, and within a session. RESULTS: Significant improvement (P < .05) in movement time across the intervention (pre vs post) was similar between the groups but there were group differences for changes between and within sessions (P < .05). The 2-term exponential function revealed a fast and slow component of learning that described performance across consecutive blocks. The RCM identified individuals who were above or below the marginal model. CONCLUSIONS: The expanded analyses indicated that changes across time can occur in different ways but achieve similar goals and may be influenced by individual factors such as initial movement time. These findings will guide decisions regarding treatment planning based on rates of motor relearning during upper extremity stroke robotic interventions.