Clinical and biomechanical factors associated with falls and rheumatoid arthritis: baseline cohort with longitudinal nested case-control study.

OBJECTIVE: To identify the clinical and biomechanical characteristics associated with falls in people with RA. METHODS: A total of 436 people ≥60 years of age with RA completed a 1 year prospective survey of falls in the UK. At baseline, questionnaires recorded data including personal and medical history, pain and fatigue scores, health-related quality of life (HRQoL), physical activity and medication history. The occurrence of falls wasmonitored prospectively over 12 months by monthly self-reporting. A nested sample of 30 fallers (defined as the report of one or more falls in 12 months) and 30 non-fallers was evaluated to assess joint range of motion (ROM), muscle strength and gait parameters. Multivariate regression analyses were undertaken to determine variables associated with falling. RESULTS: Compared with non-fallers (n = 236), fallers (n = 200) were older (P = 0.05), less likely to be married (P = 0.03), had higher pain scores (P < 0.01), experienced more frequent dizziness (P < 0.01), were frequently taking psychotropic medications (P = 0.02) and reported lower HRQoL (P = 0.02). Among those who underwent gait laboratory assessments, compared with non-fallers, fallers showed a greater anteroposterior (AP; P = 0.03) and medial-lateral (ML) sway range (P = 0.02) and reduced isokinetic peak torque and isometric strength at 60° knee flexion (P = 0.03). Fallers also showed shorter stride length (P = 0.04), shorter double support time (P = 0.04) and reduced percentage time in swing phase (P = 0.02) and in knee range of motion through the gait cycle (P < 0.01). CONCLUSION: People with RA have distinct clinical and biomechanical characteristics that place them at increased risk of falling. Assessment for these factors may be important to offer more targeted rehabilitation interventions.

Does stroke location predict walk speed response to gait rehabilitation?

OBJECTIVES: Recovery of independent ambulation after stroke is a major goal. However, which rehabilitation regimen best benefits each individual is unknown and decisions are currently made on a subjective basis. Predictors of response to specific therapies would guide the type of therapy most appropriate for each patient. Although lesion topography is a strong predictor of upper limb response, walking involves more distributed functions. Earlier studies that assessed the cortico-spinal tract (CST) were negative, suggesting other structures may be important. EXPERIMENTAL DESIGN: The relationship between lesion topography and response of walking speed to standard rehabilitation was assessed in 50 adult-onset patients using both volumetric measurement of CST lesion load and voxel-based lesion-symptom mapping (VLSM) to assess non-CST structures. Two functional mobility scales, the functional ambulation category (FAC) and the modified rivermead mobility index (MRMI) were also administered. Performance measures were obtained both at entry into the study (3-42 days post-stroke) and at the end of a 6-week course of therapy. Baseline score, age, time since stroke onset and white matter hyperintensities score were included as nuisance covariates in regression models. PRINCIPAL OBSERVATIONS: CST damage independently predicted response to therapy for FAC and MRMI, but not for walk speed. However, using VLSM the latter was predicted by damage to the putamen, insula, external capsule and neighbouring white matter. CONCLUSIONS: Walk speed response to rehabilitation was affected by damage involving the putamen and neighbouring structures but not the CST, while the latter had modest but significant impact on everyday functions of general mobility and gait. Hum Brain Mapp 37:689-703, 2016. © 2015 Wiley Periodicals, Inc.

Physical rehabilitation approaches for the recovery of function and mobility following stroke.

BACKGROUND: Various approaches to physical rehabilitation may be used after stroke, and considerable controversy and debate surround the effectiveness of relative approaches. Some physiotherapists base their treatments on a single approach; others use a mixture of components from several different approaches. OBJECTIVES: To determine whether physical rehabilitation approaches are effective in recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.For the previous versions of this review, the objective was to explore the effect of 'physiotherapy treatment approaches' based on historical classifications of orthopaedic, neurophysiological or motor learning principles, or on a mixture of these treatment principles. For this update of the review, the objective was to explore the effects of approaches that incorporate individual treatment components, categorised as functional task training, musculoskeletal intervention (active), musculoskeletal intervention (passive), neurophysiological intervention, cardiopulmonary intervention, assistive device or modality.In addition, we sought to explore the impact of time after stroke, geographical location of the study, dose of the intervention, provider of the intervention and treatment components included within an intervention. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (last searched December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 12, 2012), MEDLINE (1966 to December 2012), EMBASE (1980 to December 2012), AMED (1985 to December 2012) and CINAHL (1982 to December 2012). We searched reference lists and contacted experts and researchers who have an interest in stroke rehabilitation. SELECTION CRITERIA: Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke. Outcomes included measures of independence in activities of daily living (ADL), motor function, balance, gait velocity and length of stay. We included trials comparing physical rehabilitation approaches versus no treatment, usual care or attention control and those comparing different physical rehabilitation approaches. DATA COLLECTION AND ANALYSIS: Two review authors independently categorised identified trials according to the selection criteria, documented their methodological quality and extracted the data. MAIN RESULTS: We included a total of 96 studies (10,401 participants) in this review. More than half of the studies (50/96) were carried out in China. Generally the studies were heterogeneous, and many were poorly reported.Physical rehabilitation was found to have a beneficial effect, as compared with no treatment, on functional recovery after stroke (27 studies, 3423 participants; standardised mean difference (SMD) 0.78, 95% confidence interval (CI) 0.58 to 0.97, for Independence in ADL scales), and this effect was noted to persist beyond the length of the intervention period (nine studies, 540 participants; SMD 0.58, 95% CI 0.11 to 1.04). Subgroup analysis revealed a significant difference based on dose of intervention (P value < 0.0001, for independence in ADL), indicating that a dose of 30 to 60 minutes per day delivered five to seven days per week is effective. This evidence principally arises from studies carried out in China. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.003, for independence in ADL).We found physical rehabilitation to be more effective than usual care or attention control in improving motor function (12 studies, 887 participants; SMD 0.37, 95% CI 0.20 to 0.55), balance (five studies, 246 participants; SMD 0.31, 95% CI 0.05 to 0.56) and gait velocity (14 studies, 1126 participants; SMD 0.46, 95% CI 0.32 to 0.60). Subgroup analysis demonstrated a significant difference based on dose of intervention (P value 0.02 for motor function), indicating that a dose of 30 to 60 minutes delivered five to seven days a week provides significant benefit. Subgroup analyses also suggest significant benefit associated with a shorter time since stroke (P value 0.05, for independence in ADL).No one physical rehabilitation approach was more (or less) effective than any other approach in improving independence in ADL (eight studies, 491 participants; test for subgroup differences: P value 0.71) or motor function (nine studies, 546 participants; test for subgroup differences: P value 0.41). These findings are supported by subgroup analyses carried out for comparisons of intervention versus no treatment or usual care, which identified no significant effects of different treatment components or categories of interventions. AUTHORS' CONCLUSIONS: Physical rehabilitation, comprising a selection of components from different approaches, is effective for recovery of function and mobility after stroke. Evidence related to dose of physical therapy is limited by substantial heterogeneity and does not support robust conclusions. No one approach to physical rehabilitation is any more (or less) effective in promoting recovery of function and mobility after stroke. Therefore, evidence indicates that physical rehabilitation should not be limited to compartmentalised, named approaches, but rather should comprise clearly defined, well-described, evidenced-based physical treatments, regardless of historical or philosophical origin.

The test-retest reliability of non-navigated transcranial magnetic stimulation (TMS) measures of corticospinal pathway excitability early after stroke.

PURPOSE: Motor evoked potential (MEP) characteristics are potential biomarkers of whether rehabilitation interventions drive motor recovery after stroke. The test-retest reliability of Transcranial Magnetic Stimulation (TMS) measurements in sub-acute stroke remains unclear. This study aims to determine the test-retest reliability of upper limb MEP measures elicited by non-neuronavigated transcranial magnetic stimulation in sub-acute-stroke. METHODS: In two identical data collection sessions, 1-3 days apart, TMS measures assessed: motor threshold (MT), amplitude, latency (MEP-L), silent period (SP), recruitment curve slope in the biceps brachii (BB), extensor carpi radialis (ECR), and abductor pollicis brevis (APB) muscles of paretic and non-paretic upper limbs. Test-retest reliability was calculated using the intra-class correlation coefficient (ICC) and 95% confidence intervals (CI). Acceptable reliability was set at a lower 95% CI of 0.70 or above. The limits of agreement (LOA) and smallest detectable change (SDC) were calculated. RESULTS: 30 participants with sub-acute stroke were included (av 36 days post stroke) reliability was variable between poor to good for the different MEP characteristics. The SDC values differed across muscles and MEP characteristics in both paretic and less paretic limbs. CONCLUSIONS: The present findings indicate there is limited evidence for acceptable test-retest reliability of non-navigated TMS outcomes when using the appropriate 95% CI for ICC, SDC and LOA values. CLINICAL TRIAL REGISTRATION: Current Controlled Trials: ISCRT 19090862, http://www.controlled-trials.com.

This study identified that Non-navigated Transcranial Magnetic Stimulation (TMS) demonstrates low reliability of TMS measures in upper limb with variation between muscles and measures in sub-acute strokeWhen using non-navigated TMS to explore corticospinal pathway excitability the individual target muscle and TMS measure should be taken into considerationNon-navigated TMS may be more useful in exploring group differences rather than individual differences in corticospinal pathway excitabilityNon-navigated TMS could provide a means of measuring recovery in clinical practice and could inform the development of more effective interventions but this needs further development before it can be used as a clinical recovery biomarker.

Maximum tolerable daily dose of mirror movement therapy ankle exercises after stroke: an early phase dose screening study.

BACKGROUND: Mirror movement therapy may reduce lower limb motor impairment after stroke. The dose is unknown. OBJECTIVE: identify the maximum tolerable dose a day (MTD) of lower limb mirror movement therapy DESIGN: 3 + 3 cohort rule-based, dose escalation/de-escalation study. After undertaking baseline measures participants performed mirror movement therapy for 14 consecutive days. Participants then undertook outcome measures. Cohort One trained for 15 minutes daily. Subsequent cohorts exercised at a dose set according to pre-set rules and the modified Fibonacci sequence. The study stopped when the difference between set doses for consecutive cohorts was 10% or less. SETTING: Participants' homes (intervention) and a movement analysis laboratory (measures). PARTICIPANTS: Adults discharged from statutory stroke rehabilitation services. INTERVENTION: Mirror movement therapy ankle exercises. OUTCOME MEASURES: Motricity Index (primary) and bilateral time symmetry from movement onset to peak activation of Tibialis Anterior muscles during standardised sit-to-stand (secondary). RESULTS: Five cohorts of three participants were included (n = 15). Mean (SD) age and time after stroke were 61 (9) years and 35 (42) months respectively. Set daily doses for the five cohorts were: 15, 30, 50, 40 then 35 minutes. The set dose for a subsequent cohort (six) would have been 38 minutes thus the difference from cohort five would have been three minutes i.e., 9% different. Therefore, the study stopped CONCLUSION: The identified MTD of lower limb mirror therapy was 35 minutes daily when frequency was set at seven days a week and duration as two weeks. CLINICAL TRIAL REGISTRATION NUMBER: NCT04339803 (ClinicalTrials.gov) CONTRIBUTION OF THE PAPER: This early phase study found that the maximum tolerable dose per day (MTD) of mirror movement therapy ankle exercises was 35 minutes when frequency was set at seven days a week and duration as two weeks. The optimal therapeutic dose will therefore be somewhere in the range of 15 (starting dose) to 35 minutes per day. Further dose articulation studies are required to identify the optimal therapeutic dose before use of findings in clinical practice. This study is the first step in that research process.

Neurophysiological changes accompanying reduction in upper limb motor impairments in response to exercise-based virtual rehabilitation after stroke: systematic review.

BACKGROUND: Virtual reality-augmented therapist-delivered exercise-based training has promise for enhancing upper limb motor recovery after stroke. However, the neurophysiological mechanisms are unclear. OBJECTIVE: To find if neurophysiological changes are correlated with or accompany a reduction in motor impairment in response to virtual reality-aided exercise-based training. DATA SOURCES: Databases searched from inception to August 2020: MEDLINE, AMED, EMBASE, PUBMED, COCHRANE, CINHAL, PROQUEST and OPEN GREY. ELIGIBILITY CRITERIA: Studies that investigated virtual reality-augmented exercise-based training for the upper limb in adults with stroke, and, measured motor impairment and neurophysiological outcomes. Studies that combined VR with another technology were excluded. DATA EXTRACTION AND SYNTHESIS: Using pre-prepared proformas, three reviewers independently: identified eligible studies, assessed potential risk-of-bias, and extracted data. A critical narrative synthesis was conducted. A meta-analysis was not possible because of heterogeneity in participants, interventions and outcome measures. RESULTS: Of 1387 records identified, four studies were eligible and included in the review. Overall, included studies were assessed as having high potential risk-of-bias. The VR equipment, and control interventions varied between studies. Two studies measured motor impairment with the Fugl-Meyer Assessment but there was no commonality in the use of neurophysiological measures. One study found improvement in neurophysiological measures only. The other three studies found a reduction in motor impairment and changes in neurophysiological outcomes, but did not calculate correlation coefficients. CONCLUSION: There is insufficient evidence to identify the neurophysiological changes that are correlated with, or accompany, reduction in upper limb motor impairment in response to virtual reality-augmented exercise-based training after stroke. Systematic Review Registration Number PROSPERO 2017 CRD42017071312.

User perspectives on the design and setup of lower limb mirror therapy equipment after stroke: a technical report.

OBJECTIVES: To co-design lower limb mirror therapy (MT) equipment and setup by working directly with stroke survivors and physiotherapists. DESIGN: Co-design approach through focus groups. PARTICIPANTS: Twenty-six participants. Sixteen stroke survivors and ten physiotherapists. DATA COLLECTION AND ANALYSIS: Data were collected in an iterative process through two sets of focus groups. Firstly, prototype one of the MT equipment was presented to the participants. They were encouraged to use and comment on it. Then, the key requirements for ankle exercise with MT were presented, and participants discussed whether the prototype one was able to deliver these requirements. These findings informed iterations to the device, and a second prototype was produced and discussed in the second set of focus groups. The final prototype was then produced based on the participants' feedback. All focus groups were audio-recorded, followed by verbatim transcriptions and thematic analysis. RESULTS: Main characteristics required of the lower limb MT device were found to be: the ability to produce MT ankle exercise from an upright sitting posture, an adjustable angle between 5 to 15 degree from the midline to allow clear lower limb reflection during seated exercise, and a lightweight device to enable easy use for stroke survivors. CONCLUSION: This work produced an iteratively co-design lower limb MT to be used with stroke survivors.

Sensory Stimulation of the Foot and Ankle Early Post-stroke: A Pilot and Feasibility Study.

Background: Somatosensory stimulation of the lower extremity could improve motor recovery and walking post-stroke. This pilot study investigated the feasibility of a subsequent randomized controlled trial (RCT) to determine whether task-specific gait training is more effective following either (a) intensive hands-on somatosensory stimulation or (b) wearing textured insoles. Objectives: Determine recruitment and attrition rates, adherence to intervention, acceptability and viability of interventions and outcome measures, and estimate variance of outcome data to inform sample size for a subsequent RCT. Methods: Design: randomized, single-blinded, mixed-methods pilot study. Setting: In-patient rehabilitation ward and community. Participants: n = 34, 18+years, 42-112 days following anterior or posterior circulation stroke, able to follow simple commands, able to walk independently pre-stroke, and providing informed consent. Intervention: Twenty 30-min sessions of task-specific gait training (TSGT) (delivered over 6 weeks) in addition to either: (a) 30-60 min mobilization and tactile stimulation (MTS); or (b) unlimited textured insole (TI) wearing. Outcomes: Ankle range of movement (electrogoniometer), touch-pressure sensory thresholds (Semmes Weinstein Monofilaments), motor impairment (Lower Extremity Motricity Index), walking ability and speed (Functional Ambulation Category, 5-m walk test, pressure insoles) and function (modified Rivermead Mobility Index), measured before randomization, post-intervention, and 1-month thereafter (follow-up). Adherence to allocated intervention and actual dose delivered (fidelity) were documented in case report forms and daily diaries. Focus groups further explored acceptability of interventions and study experience. Analysis: Recruitment, attrition, and dose adherence rates were calculated as percentages of possible totals. Thematic analysis of daily diaries and focus group data was undertaken. Standard deviations of outcome measures were calculated and used to inform a sample size calculation. Results: Recruitment, attrition, and adherence rates were 48.57, 5.88, and 96.88%, respectively. Focus groups, daily-diaries and case report forms indicated acceptability of interventions and outcome measures to participants. The 5-m walk was selected as primary outcome measure for a future trial [mean (SD) at end of intervention: 16.86 (11.24) MTS group and 21.56 (13.57) TI group]; sample size calculation indicated 60 participants are required per group. Conclusion: Recruitment, attrition and adherence rates and acceptability of interventions and outcomes justify a subsequent powered RCT of MTS+TSGT compared with TI+TSGT.

The effects of increased dose of exercise-based therapies to enhance motor recovery after stroke: a systematic review and meta-analysis.

BACKGROUND: Exercise-based therapy is known to enhance motor recovery after stroke but the most appropriate amount, i.e. the dose, of therapy is unknown. To determine the strength of current evidence for provision of a higher dose of the same types of exercise-based therapy to enhance motor recovery after stroke. METHODS: An electronic search of: MEDLINE, EMBASE, CINHAL, AMED, and CENTRAL was undertaken. Two independent reviewers selected studies using predetermined inclusion criteria: randomised or quasi randomised controlled trials with or without blinding of assessors; adults, 18+ years, with a clinical diagnosis of stroke; experimental and control group interventions identical except for dose; exercise-based interventions investigated; and outcome measures of motor impairment, movement control or functional activity. Two reviewers independently extracted outcome and follow-up data. Effect sizes and 95% confidence intervals were interpreted with reference to risk of bias in included studies. RESULTS: 9 papers reporting 7 studies were included. Only 3 of the 7 included studies had all design elements assessed as low risk of bias. Intensity of the control intervention ranged from a mean of 9 to 28 hours over a maximum of 20 weeks. Experimental groups received between 14 and 92 hours of therapy over a maximum of 20 weeks. The included studies were heterogeneous with respect to types of therapy, outcome measures and time-points for outcome and follow-up. Consequently, most effect sizes relate to one study only. Single study effect sizes suggest a trend for better recovery with increased dose at the end of therapy but this trend was less evident at follow-up Meta-analysis was possible at outcome for: hand-grip strength, -10.1 [-19.1,-1.2] (2 studies, 97 participants); Action Research Arm Test (ARAT), 0.1 [-5.7,6.0] (3 studies, 126 participants); and comfortable walking speed, 0.3 [0.1,0.5] (2 studies, 58 participants). At follow-up, between 12 and 26 weeks after start of therapy, meta-analysis findings were: Motricity Arm, 10.7 [1.7,19.8] (2 studies, 83 participants); ARAT, 2.2 [-6.0,10.4] (2 studies, 83 participants); Rivermead Mobility, 1.0 [-0.6, 2.5] (2 studies, 83 participants); and comfortable walking speed, 0.2 [0.0,0.4] (2 studies, 60 participants). CONCLUSIONS: Current evidence provides some, but limited, support for the hypothesis that a higher dose of the same type of exercised-based therapy enhances motor recovery after stroke. Prospective dose-finding studies are required.

Identification of neuromuscular targets for restoration of walking ability after stroke: Precursor to precision rehabilitation.

OBJECTIVES: Restoration of walking is a priority for stroke survivors and key target for physical therapies. Upright pedalling (UP) can provide functional walking-like activity using a variety of muscle synergies; it is unclear which synergies might be most useful for recovery of walking. Objectives here were as follows: to examine whether neuromuscular measures derived during UP might identify targets for walking rehabilitation after stroke and to determine test-retest repeatability and concurrent validity of the measures. DESIGN: This was a prospective correlational study. SETTING: The study was carried out in a movement science laboratory. PARTICIPANTS: The participants were 18 adults with stroke (StrS) and 10 healthy older adults (HOA). INTERVENTION/MEASUREMENT: StrS and HOA took part in two identical measurement sessions. During UP, surface electromyography and kinematic data were recorded and then processed to derive three measures: reciprocal activity of quadriceps and hamstrings; percentage muscle activity "on" according to crank angle; and smoothness of movement. RESULTS: HOA and StrS demonstrated differences in reciprocal muscle activity (p = .044) and quadriceps activity according to crank angle (p = .034) but pedalled similarly smoothly (p = .367). For muscle activation according to crank angle in StrS, intraclass correlation coefficients (95% confidence interval) showing acceptable repeatability were 0.46 [0.32, 0.58] affected quadriceps; 0.43 [0.28, 0.56] affected hamstrings; and 0.67 [0.56, 0.75] unaffected quadriceps. CONCLUSION: Muscle activation according to crank angle is a promising measure of lower limb impairment during functional activity after stroke; subsequent investigation should determine magnitude of variance between testing sessions. Reciprocal activity of quadriceps and hamstrings muscles and quadriceps activity according to crank angle are both potential targets for physical therapies to improve motor recovery. Further investigations are warranted.

Stroke survivors' recommendations for the visual representation of movement analysis measures: a technical report.

BACKGROUND: Stroke survivors do not have routine access to objective feedback on their movement performance. OBJECTIVE: To devise visual representation of objective measures of movement performance that are understandable by and meaningful to stroke survivors. DESIGN: Co-production through interviews and generative discussion. PARTICIPANTS: Eight people, mean age 65 years, who were at least one year after stroke with low, medium or high functional ability. All provided informed consent. DATA COLLECTION: Participants performed standardised upper and lower limb functional tasks. Their movement was measured using the Vicon motion analysis system and surface electromyography. Participants returned six months later when they were shown anonymised visual representations of the movement tasks. Nobody saw their own data. Visual representations were provided of people with low, medium and high functional ability. A generative discussion elicited participants' views on how the measures should be presented visually to maximise understandability and meaningfulness. FINDINGS: Participants' understanding of the visual presentation of movement analysis was enhanced with the addition of everyday symbols such as a stick-figure and a brief explanation from a physiotherapist/researcher. Meaningfulness was seen in terms of motivation to participate in and ownership of their rehabilitation. IMPLICATIONS: These findings justify further development of objective measures of movement performance for use in routine clinical practice.

Motor imagery after subcortical stroke: a functional magnetic resonance imaging study.

BACKGROUND AND PURPOSE: In recovered subcortical stroke, the pattern of motor network activation during motor execution can appear normal or not, depending on the task. Whether this applies to other aspects of motor function is unknown. We used functional MRI to assess motor imagery (MI), a promising new approach to improve motor function after stroke, and contrasted it to motor execution. METHODS: Twenty well-recovered patients with hemiparetic subcortical stroke (14 males; mean age, 66.5 years) and 17 aged-matched control subjects were studied. Extensive behavioral screening excluded 8 patients and 4 control subjects due to impaired MI abilities. Subjects performed MI and motor execution of a paced finger-thumb opposition sequence using a functional MRI paradigm that monitored compliance. Activation within the primary motor cortex (BA4a and 4p), dorsal premotor, and supplementary motor areas was examined. RESULTS: The pattern of activation during affected-hand motor execution was not different from control subjects. Affected-hand MI activation was also largely similar to control subjects, including involvement of BA4, but with important differences: (1) unlike control subjects and the nonaffected hand, activation in BA4a and dorsal premotor was not lower during MI as compared with motor execution; (2) the hemispheric balance of BA4p activation was significantly less lateralized than control subjects; and (3) ipsilesional BA4p activation positively correlated with motor performance. CONCLUSIONS: In well-recovered subcortical stroke, the motor system, including ipsilesional BA4, is activated during MI despite the lesion. It, however, remains disorganized in proportion to residual motor impairment. Thus, components of movement upstream from execution appear differentially affected after stroke and could be targeted by rehabilitation in more severely affected patients.

Neuromechanical Differences Between Successful and Failed Sit-to-Stand Movements and Response to Rehabilitation Early After Stroke.

BACKGROUND: Recovery of the sit-to-stand (StS) movement early after stroke could be improved by targeting physical therapy at the underlying movement deficits in those people likely to respond. AIM: To compare the movement characteristics of successful and failed StS movements in people early after stroke and identify which characteristics change in people recovering their ability to perform this movement independently following rehabilitation. METHODS: Muscle activity and kinematic (including center of mass, CoM) data were recorded from 91 participants (mean 35 days after stroke) performing the StS movement before (baseline), immediately after (outcome), and 3 months after (follow-up) rehabilitation. Three subgroups (never-able [n = 19], always-able [n = 51], and able-after-baseline [n = 21]) were compared at baseline with the able-after-baseline subgroup compared before and after rehabilitation. RESULTS: The subgroups differed at baseline for quadriceps onset time ( P = .009) and forward body position when quadriceps peaked ( P = .038). Following rehabilitation, the able-after-baseline subgroup increased their forward position ( P < .001), decreased the time difference between bilateral quadriceps peaks ( P < .001) and between quadriceps and hamstrings peaks on the nonhemiplegic side ( P = .007). An improved performance in the always-able subgroup was associated with a number of baseline factors, including forward positioning ( P = .002) and time difference between peak activity of bilateral quadriceps ( P = .001). CONCLUSIONS: This neuromechanical study of StS before and after rehabilitation in a sample of people early after stroke identified the importance of temporal coupling between forward trunk movement and quadriceps and hamstrings' activity. These findings advance the science of stroke rehabilitation by providing evidence-based therapy targets to promote recovery of the StS movement.

Evidence-based practice 'on-the-go': using ViaTherapy as a tool to enhance clinical decision making in upper limb rehabilitation after stroke, a quality improvement initiative.

Recovery of upper limb function after stroke is currently sub-optimal, despite good quality evidence showing that interventions enabling repetitive practice of task-specific activity are effective in improving function. Therapists need to access and engage with such evidence to optimise outcomes with people with stroke, but this is challenging in fast-paced stroke rehabilitation services. This quality improvement project aimed to investigate acceptability and service impact of a new, international tool for accessing evidence on upper limb rehabilitation after stroke-'ViaTherapy'-in a team of community rehabilitation therapists. Semi-structured interviews were undertaken at baseline to determine confidence in, and barriers to, evidence-based practice (EBP) to support clinical decision making. Reported barriers included time, lack of access to evidence and a research-practice disconnect. The clinicians then integrated use of 'ViaTherapy' into their practice for 4 weeks. Follow-up interviews explored the accessibility of the tool in community rehabilitation practice, and its impact on clinician confidence, treatment planning and provision. Clinicians found the tool, used predominantly in mobile device app format, to be concise and simple to use, providing evidence 'on-the-go'. Confidence in accessing and using EBP grew by 22% from baseline. Clinicans reported changes in intensity of delivery of interventions, as rapid access to recommended doses via the tool was available. Following this work, the participating health and social care service provider changed provision of therapists' technology to enable use of apps. Barriers to use of EBP in stroke rehabilitation persist; the baseline situation here supported the need for more accessible means of integrating best evidence into clinical processes. This quality improvement project successfully integrated ViaTherapy into clinical practice, and found that the tool has potential to underpin positive changes in upper limb therapy service delivery after stroke, by increasing accessibility to, use of and confidence in EBP. Definitive evaluation is now indicated.

Informing dose-finding studies of repetitive transcranial magnetic stimulation to enhance motor function: a qualitative systematic review.

OBJECTIVE: Repetitive transcranial magnetic stimulation (rTMS) of the lesioned hemisphere might enhance motor recovery after stroke, but the appropriate dose (parameters of rTMS) remains uncertain. The present review collates evidence of the effect of rTMS on corticospinal pathway excitability and motor function in healthy adults and in people after stroke. METHODS: The authors searched MEDLINE and EMBASE (1996 to April 2007), their own collection of peer-reviewed articles, and the reference lists of included studies. They included healthy adults or people with stroke who received rTMS to the primary motor cortex to facilitate or inhibit contralateral corticospinal excitability or movement control. FINDINGS: Of the 625 references identified, 37 studies were included with 455 healthy adults (34 studies) and 69 people with stroke (3 studies). For healthy adults, the effects of rTMS on corticospinal pathway excitability varied within each frequency, for example, 1 Hz rTMS was found to facilitate, inhibit, and have no effect on amplitude of motor-evoked potentials (MEPs). After stroke there was a trend for recovery of MEPs (ie, presence of MEPs) after 10 daily sessions of 3 Hz rTMS (one study). Motor function in healthy adults might be adversely affected by 1 Hz rTMS (two studies), whereas combined frequency rTMS was found to have no effect (one study). INTERPRETATION: There is as yet insufficient published evidence to guide the dose of rTMS to the lesioned hemisphere after stroke to improve recovery of a paretic limb. Moreover, it is apparent that there is variability in response to rTMS in healthy adults. Dose-finding studies in groups of well-characterized stroke patients are needed.

Effects of mobilization and tactile stimulation on recovery of the hemiplegic upper limb: a series of replicated single-system studies.

OBJECTIVE: To explore the effects on motor function and impairment of mobilization and tactile stimulation for the paretic arm and hand after stroke. DESIGN: Replicated single-system series, ABA design. SETTING: The stroke rehabilitation ward of a community hospital in the United Kingdom. PARTICIPANTS: Consecutive sample, men and women (N=6) with stroke (left or right), within 3 months of onset. INTERVENTION: Sixty minutes of daily mobilization and tactile stimulation to the paretic arm and hand for 6 weeks in addition to the usual rehabilitation program. MAIN OUTCOME MEASURES: Focal disability (Action Research Arm Test [ARAT]) and motor impairment (Motricity Index arm section). RESULTS: All participants showed visual change in 1 or more of trend, level, or slope between baseline and intervention phases for both the ARAT and the Motricity Index. The visual analysis was confirmed through statistical testing (c statistic and/or Mann-Whitney U test) for 5 of 6 participants (statistical analysis was precluded for 1 participant). No further improvements were made on intervention withdrawal. CONCLUSIONS: This study shows proof of concept for using mobilization and tactile stimulation to improve motor recovery after severe paresis, justifying conducting dose-finding studies as a precursor to multicenter phase III clinical trials.

Kinematic Components of the Reach-to-Target Movement After Stroke for Focused Rehabilitation Interventions: Systematic Review and Meta-Analysis.

Background: Better upper limb recovery after stroke could be achieved through tailoring rehabilitation interventions directly at movement deficits. Aim: To identify potential; targets for therapy by synthesizing findings of differences in kinematics and muscle activity between stroke survivors and healthy adults performing reach-to-target tasks. Methods: A systematic review with identification of studies, data extraction, and potential risk of bias was completed independently by two reviewers. Online databases were searched from their inception to November 2017 to find studies of reach-to-target in people-with-stroke and healthy adults. Potential risk-of-bias was assessed using the Down's and Black Tool. Synthesis was undertaken via: (a) meta-analysis of kinematic characteristics utilizing the standardized mean difference (SMD) [95% confidence intervals]; and (b), narrative synthesis of muscle activation. Results: Forty-six studies met the review criteria but 14 had insufficient data for extraction. Consequently, 32 studies were included in the meta-analysis. Potential risk-of-bias was low for one study, unclear for 30, and high for one. Reach-to-target was investigated with 618 people-with-stroke and 429 healthy adults. The meta-analysis found, in all areas of workspace, that people-with-stroke had: greater movement times (seconds) e.g., SMD 2.57 [0.89, 4.25]; lower peak velocity (millimeters/second) e.g., SMD -1.76 [-2.29, -1.24]; greater trunk displacement (millimeters) e.g. SMD 1.42 [0.90, 1.93]; a more curved reach-path-ratio e.g., SMD 0.77 [0.32, 1.22] and reduced movement smoothness e.g., SMD 0.92 [0.32, 1.52]. In the ipsilateral and contralateral workspace, people-with-stroke exhibited: larger errors in target accuracy e.g., SMD 0.70 [0.39, 1.01]. In contralateral workspace, stroke survivors had: reduced elbow extension and shoulder flexion (degrees) e.g., elbow extension SMD -1.10 [-1.62, -0.58] and reduced shoulder flexion SMD -1.91 [-1.96, -0.42]. Narrative synthesis of muscle activation found that people-with-stroke, compared with healthy adults, exhibited: delayed muscle activation; reduced coherence between muscle pairs; and use of a greater percentage of muscle power. Conclusions: This first-ever meta-analysis of the kinematic differences between people with stroke and healthy adults performing reach-to-target found statistically significant differences for 21 of the 26 comparisons. The differences identified and values provided are potential foci for tailored rehabilitation interventions to improve upper limb recovery after stroke.

Getting a kinematic handle on reach-to-grasp: a meta-analysis.

BACKGROUND AND OBJECTIVES: Reach-to-grasp is an essential everyday activity that is often impaired after stroke. The objectives of this review are: (1) identify differences in the kinematic characteristics of reach-to-grasp between individuals with and without stroke, and (2) determine the influence of object location on kinematics. DATA SOURCES: MEDLINE, AMED, and Embase databases. ELIGIBILITY CRITERIA: Studies investigating individuals with stroke and neurologically intact control participants completing reach-to-grasp (paretic upper limb) of an object assessed via kinematic assessment (motion analysis). REVIEW METHODS: Following Cochrane Collaboration guidelines a meta-analysis comparing kinematic characteristics of reach-to-grasp between individuals with and without stroke. Potential risk of bias was assessed using the Down's and Black Tool. Data were synthesised by calculating the standardised mean difference (SMD) in kinematic characteristics between adults with and without stroke. RESULTS: Twenty-nine studies met the review criteria, mainly of observational design; 460 individuals with stroke and 324 control participants. Kinematic differences in reach-to-grasp were identified in the central and ipsilateral workspace for example, individuals with stroke exhibited significantly lower peak velocity SMD -1.48 (95% CI -1.94, -1.02), and greater trunk displacement SMD 1.55 (95% CI 0.85, 2.25) than control participants. Included studies were assessed as demonstrating unclear or high potential risk-of-bias. CONCLUSIONS: Differences in kinematic characteristics between individuals with and without stroke were identified which may be different reaching in the ipsilateral and central workspace. Suggesting, that object location may influence some kinematic characteristics and not others which may be pertinent when re-training reach-to-grasp. PROSPERO: CRD42014009479.