Quantifying Quality of Reaching Movements Longitudinally Post-Stroke: A Systematic Review.

BACKGROUND: Disambiguation of behavioral restitution from compensation is important to better understand recovery of upper limb motor control post-stroke and subsequently design better interventions. Measuring quality of movement (QoM) during standardized performance assays and functional tasks using kinematic and kinetic metrics potentially allows for this disambiguation. OBJECTIVES: To identify longitudinal studies that used kinematic and/or kinetic metrics to investigate post-stroke recovery of reaching and assess whether these studies distinguish behavioral restitution from compensation. METHODS: A systematic literature search was conducted using the databases PubMed, Embase, Scopus, and Wiley/Cochrane Library up to July 1st, 2020. Studies were identified if they performed longitudinal kinematic and/or kinetic measurements during reaching, starting within the first 6 months post-stroke. RESULTS: Thirty-two longitudinal studies were identified, which reported a total of forty-six different kinematic metrics. Although the majority investigated improvements in kinetics or kinematics to quantify recovery of QoM, none of these studies explicitly addressed the distinction between behavioral restitution and compensation. One study obtained kinematic metrics for both performance assays and a functional task. CONCLUSIONS: Despite the growing number of kinematic and kinetic studies on post-stroke recovery, longitudinal studies that explicitly seek to delineate between behavioral restitution and compensation are still lacking in the literature. To rectify this situation, future studies should measure kinematics and/or kinetics during performance assays to isolate restitution and during a standardized functional task to determine the contributions of restitution and compensation.

How does upper extremity Fugl-Meyer motor score relate to resting-state EEG in chronic stroke? A power spectral density analysis.

OBJECTIVE: We investigated the potential added value of high-density resting-state EEG by addressing differences with healthy individuals and associations with Fugl-Meyer motor assessment of the upper extremity (FM-UE) scores in chronic stroke. METHODS: Twenty-one chronic stroke survivors with initial upper limb paresis and eleven matched controls were included. Group differences regarding resting-state EEG parameters (Delta Alpha ratio (DAR) and pairwise-derived Brain Symmetry Index (BSI)) and associations with FM-UE were investigated, as well as lateralization of BSI and the value of different frequency bands. RESULTS: Chronic stroke survivors showed higher BSI compared to controls (p < 0.001), most pronounced in delta and theta frequency bands (p < 0.0001; p < 0.001). In the delta and theta band, BSI was significantly negatively associated with FM-UE (both p = 0.008) corrected for confounding factors. DAR showed no differences between groups nor association with FM-UE. Directional BSI showed increased power in the affected versus the unaffected hemisphere. CONCLUSIONS: Asymmetry in spectral power between hemispheres was present in chronic stroke, most pronounced in low frequencies and related to upper extremity motor function deficit. SIGNIFICANCE: BSI is related to motor impairment and higher in chronic stroke patients compared to healthy controls, suggesting that BSI may be a marker of selective motor control.

Standardized Measurement of Quality of Upper Limb Movement After Stroke: Consensus-Based Core Recommendations From the Second Stroke Recovery and Rehabilitation Roundtable.

The second Stroke Recovery and Rehabilitation Roundtable "metrics" task force developed consensus around the recognized need to add kinematic and kinetic movement quantification to its core recommendations for standardized measurements of sensorimotor recovery in stroke trials. Specifically, we focused on measurement of the quality of upper limb movement. We agreed that the recommended protocols for measurement should be conceptually rigorous, reliable, valid and responsive to change. The recommended measurement protocols include four performance assays (i.e. 2D planar reaching, finger individuation, grip strength, and precision grip at body function level) and one functional task (3D drinking task at activity level) that address body function and activity respectively. This document describes the criteria for assessment and makes recommendations about the type of technology that should be used for reliable and valid movement capture. Standardization of kinematic measurement protocols will allow pooling of participant data across sites, thereby increasing sample size aiding meta-analyses of published trials, more detailed exploration of recovery profiles, the generation of new research questions with testable hypotheses, and development of new treatment approaches focused on impairment. We urge the clinical and research community to consider adopting these recommendations.

Sensor assisted self-management in Parkinson's disease: A feasibility study of ambulatory posture detection and feedback to treat stooped posture.

INTRODUCTION: A stooped posture is one of the characteristic motor symptoms of patients with Parkinson's disease, and has been linked to impairments in daily activities and quality of life. We aimed to test the efficacy, safety, practical utility and user-friendliness of a posture correction and vibrotactile trunk angle feedback device (the UpRight) in the home setting of patients with Parkinson's disease with a stooped posture. It was hypothesized that ambulatory use of the UpRight would be safe, feasible and result in a less stooped posture, i.e. a lower trunk angle during daily activities. METHODS: 15 patients wore the UpRight during a baseline period of 1 week (no feedback), followed by an intervention period of 1 week (feedback). RESULTS: We found a significant decrease (average -5,4°) in trunk angle from baseline period to intervention period without the occurrence of adverse events. In addition, patients found the device usable and beneficial to posture. CONCLUSION: Use of the feedback and correction device has a positive effect on ambulatory trunk angles. The device appears to be both safe and useful for self-management of stooped posture in patients with Parkinson's Disease.

Impact of physical therapy for Parkinson's disease: a critical review of the literature.

A systematic review of the literature found 23 randomized clinical trials reflecting specific core areas of physical therapy (PT), that is, transfer, posture, balance, reaching and grasping, gait, and physical condition. All studies were of moderate methodological quality. Important limitations of the studies were: (1) insufficient statistical power (type II error); (2) poor methodological quality due to inadequate randomization and blinding procedures; (3) insufficient contrast in dosage and treatment between experimental and control groups; and (4) lack of appropriate measurement instruments able to identify clinically meaningful changes according to the International Classification of Functioning (ICF). In the last 5 years, the methodological quality of RCTs has shown substantial improvement. Most high-quality studies investigated the effects of exercise therapy, including the use of external rhythms to improve gait and gait-related activities. The results of these trials suggest that the effects of PT are task- and context-specific. This indicates that the tasks that are trained tend not to generalize to related activities that are not directly trained in the rehabilitation programme itself, and suggests that future programmes should train meaningful tasks preferably in patients' home environment. In addition, the decline in treatment effects after an intervention has ended suggests the need for permanent treatment of patients with PD, i.e. chronic treatment for this chronic disease. Future studies should aim to develop responsive measurement instruments able to monitor meaningful changes in activities, as well as better understanding of insufficiently understood symptoms such as freezing, rigidity and bradykinesia and greater insight into neurophysiological mechanisms underlying training-induced changes in activities such as improved gait performance by rhythmic cueing.

Postural control of the trunk during unstable sitting in Parkinson's disease.

Postural instability and falls, both common in Parkinson's disease (PD), have been related to altered trunk control. In this study, we investigated dynamic trunk control with subjects balancing on a seat mounted on a hemisphere, for up to 15s in five trials. We compared eight PD patients with a fall-history, eight without a fall-history, and eight matched healthy subjects. The number of trials completed without balance loss and the time to balance loss were significantly lower in PD patients as compared to healthy controls, whereas the PD patients with a fall-history did not perform significantly less than the patients without a fall-history. Multivariate analysis of variance showed significant effects of group on movements of the center of pressure (CoP) under the seat with the largest amplitudes among the PD fallers and the smallest amplitudes among the healthy controls. Univariate analyses revealed that this effect was mainly based on a significantly larger root mean square CoP displacement in the medio-lateral direction, with significant post hoc differences between all three groups. Trunk angular deviations were significantly smaller among PD patients than controls. Finally, both CoP movements and trunk movements had a significantly lower frequency content and were thus slower in PD patients than in controls, except for anterior-posterior CoP movements. The results show that trunk control is affected in PD and suggest that these changes may be related to postural instability and fall risk.

Measuring gait and gait-related activities in Parkinson's patients own home environment: a reliability, responsiveness and feasibility study.

The aim of this study was to assess reliability, responsiveness and feasibility of gait and gait related tests in the home of patients with Parkinson's disease (PD). The Unified Parkinson's Disease Rating Scale, a timed walking test, the Timed Get Up and Go test the Berg Balance Scale and the Functional Reach test were applied by three independent observers on 26 PD patients. Moderate to high Intraclass Correlation Coefficients were found, ranging from 0.74 to 0.88 and 0.64 to 0.87 for the intra- and inter-observer reliability, respectively. All test showed Reliable Change Indexes under 11% and the whole test battery was applicable within 30 min.

Age-related changes in upper body adaptation to walking speed in human locomotion.

Assessments of changes in gait stability due to aging and disease are predominantly based on lower extremity kinematic and kinetic data. These gait changes are also often based on comparisons at preferred speed only. The purpose of this experiment was to: (1) examine age-related changes in range of motion and coordination of segments of the upper body during locomotion; and (2) investigate the effects of a systematic walking velocity manipulation on rotational motion and coordination. Participants (n=30) walked on a motor driven treadmill at speeds ranging from 0.2 to 1.8m/s and were divided into three groups with mean ages of 23.3, 49.3 and 72.6 years, respectively. Seven high-speed infrared cameras were used to record three-dimensional kinematics of the pelvis, trunk and head. Dependent variables were amplitude of segmental and joint rotations, as well as relative phase to assess coordination between segments. Although no differences in stride parameters were found between the groups, age-related changes in movement amplitude in response to speed manipulations were observed for all segments and joints. Pelvic rotations in sagittal, frontal and transverse planes of motion were systematically reduced with age. Older individuals showed reduced trunk flexion-extension in the sagittal plane and increased trunk axial rotation in the transverse plane. Coordination analysis showed reduced compensatory movement between pelvis and trunk in older individuals. These findings support the importance of systematic manipulation of walking velocity and three-dimensional upper body kinematics in assessing age-related changes in locomotor stability and adaptability.

Postural orientation: age-related changes in variability and time-to-boundary.

The relation between age-specific postural instability and the detection of stability boundaries was examined. Balance control was investigated under different visual conditions (eyes open/closed) and postural orientations (forward/backward lean) while standing on a force platform. Dependent variables included center of pressure variability and the time-to-contact of the center of pressure with the stability boundaries around the feet (i.e., time-to-boundary). While leaning maximally, older individuals (ages 55-69) showed increased center of pressure variability compared to no lean, while younger subjects (ages 24-38) showed a decrease. These significant differences were found only in anterior-posterior direction. No significant age-specific differences were found between eyes open and eyes closed conditions. Time-to-boundary analysis revealed reduced spatio-temporal stability margins in older individuals in both anterior-posterior and medio-lateral directions. Time-to-boundary variability, however, was not significantly different between the groups in both medio-lateral and anterior-posterior direction. These results show the importance of boundary relevant center of pressure measures in the study of postural control, especially concerning the lateral instability often observed in older adults.

Rehabilitation, exercise therapy and music in patients with Parkinson's disease: a meta-analysis of the effects of music-based movement therapy on walking ability, balance and quality of life.

Recent evidence suggests that music-based movement (MbM) therapy may be a promising intervention to improve gait and gait-related activities in Parkinson's disease (PD) patients, because it naturally combines cognitive movement strategies, cueing techniques, balance exercises and physical activity while focussing on the enjoyment of moving on music instead of the current mobility limitations of the patient. A meta-analysis of RCTs on the efficacy of MbM-therapy, including individual rhythmic music training and partnered dance classes, was performed. Identified studies (K = 6) were evaluated on methodological quality, and summary effect sizes (SES) were calculated. Studies were generally small (total N= 168). Significant homogeneous SESs were found for the Berg Balance Scale, Timed Up and Go test and stride length (SESs: 4.1,2.2,0.11; P-values <0.01; I(2) 0,0,7%, respectively). A sensitivity analysis on type of MbM-therapy (dance- or gait-related interventions) revealed a significant improvement in walking velocity for gait-related MbM-therapy, but not for dance-related MbM-therapy. No significant effects were found for UPDRS-motor score, Freezing of Gait and Quality of Life. Overall, MbM-therapy appears promising for the improvement of gait and gait-related activities in PD. Future studies should incorporate larger groups and focus on long-term compliance and follow-up.

Is accurate prediction of gait in nonambulatory stroke patients possible within 72 hours poststroke? The EPOS study.

BACKGROUND: Early prognosis, adequate goal setting, and referral are important for stroke management. OBJECTIVE: To investigate if independent gait 6 months poststroke can be accurately predicted within the first 72 hours poststroke, based on simple clinical bedside tests. Reassessment on days 5 and 9 was used to check whether accuracy changed over time. METHODS: In 154 first-ever ischemic stroke patients unable to walk independently, 19 demographic and clinical variables were assessed within 72 hours and again on days 5 and 9 poststroke. Multivariable logistic modeling was applied to identify early prognostic factors for regaining independent gait, defined as ≥4 points on the Functional Ambulation Categories. RESULTS: Multivariable modeling showed that patients with an independent sitting balance (Trunk Control Test-sitting; 30 seconds) and strength of the hemiparetic leg (Motricity Index leg; eg, visible contraction for all 3 items, or movement against resistance but weaker for 1 item) on day 2 poststroke had a 98% probability of achieving independent gait at 6 months. Absence of these features in the first 72 hours was associated with a probability of 27%, declining to 10% by day 9. CONCLUSIONS: Accurate prediction of independent gait performance can be made soon after stroke, using 2 simple bedside tests: "sitting balance" and "strength of the hemiparetic leg." This knowledge is useful for making early clinical decisions regarding treatment goals and discharge planning at hospital stroke units.

Measuring fatigue in patients with multiple sclerosis: reproducibility, responsiveness and concurrent validity of three Dutch self-report questionnaires.

PURPOSE: To determine the reproducibility, responsiveness and concurrent validity of Dutch versions of the Fatigue Severity Scale (FSS), Modified Fatigue Impact Scale (MFIS), and Checklist Individual Strength (CIS20R) in patients with multiple sclerosis (MS). METHOD: Forthy-three ambulatory patients with MS (mean age 48.7 years; SD 7 years; 30 women; median Expanded Disability Status Scale score 3.5) completed the questionnaires twice within 1 week. The Intraclass Correlation Coefficients (ICCs), Bland and Altman analysis, the smallest detectable change (SDC) and the minimal detectable change (MDC) were calculated. Concurrent validity was determined by Pearson's correlation coefficients. RESULTS: ICCs ranged from 0.76 (FSS), to 0.85 (MFIS) to 0.81 (CIS20R). Bland and Altman analysis showed no significant systematic differences between assessments. MDCs were 20.7% (FSS), 19.23% (MFIS), and 17.7% (CIS20R). Pearson correlation coefficients were r = 0.66 (FSS-MFIS), r = 0.54 (MFIS-CIS20R) and r = 0.42 (CIS20R-FSS). CONCLUSION: Despite good test-retest reliability of FSS, MFIS and the CIS20R, the present study shows that fatigue questionnaires are not very responsive for change in patients with MS. This finding suggests that future trials should monitor profiles of fatigue by repeated measurements rather than pre-post assessments alone. The moderate associations suggest that the three questionnaires largely measure different aspects of perceived fatigue.