Comparison of tendon and muscle belly vibratory stimulation in the treatment of post-stroke upper extremity spasticity: a retrospective observational pilot study.

Previous studies have reported the effects of vibratory stimulation (VS) therapy in reducing upper extremity spasticity after stroke. However, the effective location of the VS in patients with stroke remains unclear. This study aimed to determine the VS location that is most effective in reducing post-stroke finger and wrist flexor spasticity. We enrolled 27 consecutive patients with stroke and upper extremity spasticity in this retrospective observational study. The participants received stretching, tendon vibration, and muscle belly vibration for 5 min over a period of 3 days. To evaluate spasticity, we assessed the Modified Ashworth Scale score before and immediately after each treatment and immediately after voluntary finger flexion. Participants who received tendon vibration showed greater improvement in flexor tone in the fingers than participants who received stretching and muscle belly vibration (P < 0.05 and < 0.001, respectively). Participants who underwent VS showed no significant improvement in the wrist flexor tone compared to those who underwent stretching. Our results suggest that the tendon may be the most effective location for treating spasticity of the finger flexor muscles and that VS may not significantly improve spasticity of the wrist flexors more than stretching.

Development of the Japanese version of the awareness questionnaire for assessment of self-awareness after acquired brain injury: reliability and validity.

BACKGROUND: The evaluation of impaired self-awareness (ISA) after brain injury is not widespread in Japan, and there is a lack of Japanese assessments of self-awareness. OBJECTIVES: To translate the original version of the Awareness Questionnaire (AQ), an instrument for assessing ISA, into Japanese using a validated method and examine its reliability and validity in inpatients with stroke. METHODS: This cross-sectional, prospective study enrolled 130 participants. The double-translation process was used to develop the Japanese version of the AQ. RESULTS: Data were collected from 120 patients. High intra-rater reliability was observed for the patient (Cronbach's α = 0.824) and clinician samples (Cronbach's α = 0.933). High intra- and inter-rater reliability were found for all AQ items [interclass coefficient (ICC) (1, 1) = 0.828, ICC (2, 1) = 0.852, ICC (3, 1) = 0.848]; however, the sub-item analysis revealed only moderate reliability. Validity assessment revealed a low but significant positive correlation (r = 0.209; p < 0.05) between the Japanese version of the AQ and the Japanese version of the Self-Regulation Skills Interview and a low but significant negative correlation (r = 0.197; p < 0.05) between the Japanese version of the AQ and the Mini-Mental State Examination. CONCLUSIONS: The Japanese version of the AQ was developed and applied to stroke patients, but the concept of post-stroke ISA may differ from ISA after traumatic brain injury, highlighting the need for a stroke-specific version of the AQ.

Characteristics of goal-setting tools in adult rehabilitation: A scoping review.

OBJECTIVES: This scoping review aims to map the literature on goal-setting tools in adult rehabilitation, exploring their characteristics, target users and supporting evidence to inform practice and future research in this area. METHODS: We completed a comprehensive search of four databases to identify relevant articles on tools for goal setting in rehabilitation. We followed Arkey and O'Malley's scoping review process to guide article selection, data extraction and data analysis. RESULTS: We identified a total of 165 studies that reported on 55 different goal-setting tools, including tools for goal selection and goal documentation (n = 31), goal setting and intervention planning (n = 15), and for measuring the quality of the goal-setting process (n = 9). Over half of the tools were primarily designed for use in rehabilitation of physical disabilities (n = 32). Some tools fell under multiple sub-categories based on their characteristics as follows: 22 framework tools, 12 interview tools, 9 outcome measurement tools for goal achievement, 6 outcome measurement tools for goal quality and 25 documentation tools. The majority of goal-setting instruments targeted goals at the level of activity and participation (n = 51) and aimed to facilitate a client-centred or shared decision-making approach to rehabilitation planning (n = 46). CONCLUSIONS: This study provides a comprehensive overview of existing goal-setting tools, highlighting their characteristics, target users and identified needs. These findings can enhance practitioners' awareness of the range of goal-setting tools available and can enable more effective utilization of these tools in clinical practice. Further research should investigate how clinicians can combine multiple tools to deliver goal setting.

Therapeutic effect of adjuvant therapy added to constraint-induced movement therapy in patients with subacute to chronic stroke: a systematic review and meta-analysis.

PURPOSE: This review investigated the effectiveness of adjuvant therapy combined with constraint-induced movement therapy (CIMT) in improving the paretic upper limb functionality in adults with stroke sequelae during the subacute to chronic rehabilitation phase. MATERIALS AND METHODS: In this systematic review and meta-analysis of randomized controlled trials (RCT), electronic databases, including PubMed, Web of Science, CINAHL, and MEDLINE, were searched. We included RCTs that investigated the outcomes of adjuvant therapy (i.e. other therapies) added to CIMT compared with CIMT alone. Key trial findings were qualitatively synthesized and analyzed. This meta-analysis examined variables, such as mean scores and standard deviations, using the following outcome measures: Fugl-Meyer Assessment (FMA) upper limb items, Action Research Arm Test (ARAT), Amount of Use (AOU) of Motor Activity Log (MAL), and Quality of Movement (QOM) of MAL. RESULTS: Eighteen eligible RCTs were included in the analysis. Adding CIMT to adjunctive therapy significantly improved FMA compared with CIMT alone (mean difference [MD] 4.02, 95% confidence interval [CI] 2.60-5.44; I2 = 85%; 15 studies; 330 participants). Similarly, the ARAT and MAL-AOU scores improved significantly. CONCLUSIONS: CIMT combined with several adjunctive therapies effectively improved upper limb function.

In recent years, clinical trials combining other therapies with Constraint-induced movement therapy (CIMT) have become increasingly common.This study shows that combining CIMT with adjuvant therapy improves upper limb function.Different protocols of the CIMT in each study could be factor that impacted the results of Motor Activity Log.In clinical practice, the findings of this study into their treatment protocols to improve patient outcomes and ensure the effective application of evidence-based rehabilitation strategies.

Development of a program to determine optimal settings for robot-assisted rehabilitation of the post-stroke paretic upper extremity: a simulation study.

Robot-assisted therapy can effectively treat upper extremity (UE) paralysis in patients who experience a stroke. Presently, UE, as a training item, is selected according to the severity of the paralysis based on a clinician's experience. The possibility of objectively selecting robot-assisted training items based on the severity of paralysis was simulated using the two-parameter logistic model item response theory (2PLM-IRT). Sample data were generated using the Monte Carlo method with 300 random cases. This simulation analyzed sample data (categorical data with three difficulty values of 0, 1, and 2 [0: too easy, 1: adequate, and 2: too difficult]) with 71 items per case. First, the most appropriate method was selected to ensure the local independence of the sample data necessary to use 2PLM-IRT. The method was to exclude items with low response probability (maximum response probability) within a pair in the Quality of Compensatory Movement Score (QCM) 1-point item difficulty curve, items with low item information content within a pair in the QCM 1-point item difficulty curve, and items with low item discrimination. Second, 300 cases were analyzed to determine the most appropriate model (one-parameter or two-parameter item response therapy) to be used and the most favored method to establish local independence. We also examined whether robotic training items could be selected according to the severity of paralysis based on the ability of a person (θ) in the sample data as calculated by 2PLM-IRT. Excluding items with low response probability (maximum response probability) in a pair in the categorical data 1-point item difficulty curve was effective in ensuring local independence. Additionally, to ensure local independence, the number of items should be reduced to 61 from 71, indicating that the 2PLM-IRT was an appropriate model. The ability of a person (θ) calculated by 2PLM-IRT suggested that seven training items could be estimated from 300 cases according to severity. This simulation made it possible to objectively estimate the training items according to the severity of paralysis in a sample of approximately 300 cases using this model.

Attempt to Make the Upper-Limb Item of Objective Fugl-Meyer Assessment Using 9-Axis Motion Sensors.

The Fugl-Meyer Assessment (FMA) has been used as a functional assessment of upper-limb function in stroke patients. This study aimed to create a more objective and standardized evaluation based on an FMA of the upper-limb items. A total of 30 first-ever stroke patients (65.3 ± 10.3 years old) and 15 healthy participants (35.4 ± 13.4 years old) admitted to Itami Kousei Neurosurgical Hospital were included. A nine-axis motion sensor was attached to the participants, and the joint angles of 17 upper-limb items (excluding fingers) and 23 FMA upper-limb items (excluding reflexes and fingers) were measured. From the measurement results, we analyzed the time-series data of each movement and obtained the correlation between the joint angles of each part. Discriminant analysis showed that 17 and 6 items had a concordance rate of ≥80% (80.0~95.6%) and <80% (64.4~75.6%), respectively. In the multiple regression analysis of continuous variables of FMA, a good regression model was obtained to predict the FMA with three to five joint angles. The discriminant analysis for 17 evaluation items suggests the possibility of roughly calculating FMA scores from joint angles.

The Conceptual Analysis of Collaboration in the Occupational Therapy by Combining the Scoping Review Methodology.

BACKGROUND: Collaboration is an important concept in goal-setting in occupational therapy. However, this concept is not stable due to various definitions. The purpose of this study was to clarify the concept of collaboration in occupational therapy. METHOD: A scoping review was used to search for all articles related to occupational therapy and collaboration. PubMed, Web of Science, CINAHL, and OT Seeker searches were conducted using predetermined keywords. Three examiners independently reviewed and assessed the quality of each study using Walker and Avant's concept analysis method. RESULTS: Results of the database searches yielded 1873 studies, 585 of which were deemed eligible to include in this review. Results showed five attributes ("active participation for the common objective", "existence of something to share", "matured communication and interaction", "relationship founded on the respect and trust" and "complementing each other") and two antecedents and several consequences. CONCLUSIONS: Our findings may contribute to collaborative goal-setting and occupational therapy.

Structural validity and internal consistency of a hypothesized factor structure of the Fugl-Meyer Assessment of the upper extremity.

BACKGROUND: Many studies have confirmed the psychometric properties of Fugl-Meyer Assessment of the upper extremity (FMA-UE). Although several modified versions of the FMA-UE form exist, their structural validity has not been fully established. OBJECTIVES: To assess the structural validity and internal consistency of the original, short, and hypothesized FMA-UE forms. METHODS: In this cross-sectional, multicenter, observational study, the factor structure was assessed using confirmatory factor analysis (CFA) to evaluate the adequate model of each hypothetical FMA-UE form (original, 30-item, 27-item, and 6-item forms). The internal consistency of each FMA-UE form and subscale was assessed using Cronbach's alpha after factor structure evaluation. RESULTS: We recruited 363 patients with first-episode stroke (median age = 70.0, median days = 75.0). The results of the original form models were not estimated by CFA. Of all FMA-UE forms, the 30-item form lacked three reflex items (4-factor, 30-item model) and the 27-item form lacked three reflex and three coordination items (3-factor, 27-item, second-order model); these forms demonstrated an adequate model fitness (root mean square error of approximation = 0.056/0.059, comparative fit index = 0.995/0.996, Tucker-Lewis index = 0.995/0.995). The 6-item form demonstrated a poor model fit. All FMA-UE forms and subscales showed a high internal consistency (Cronbach's alpha>0.91). CONCLUSIONS: Both 30- and 27-item FMA-UE forms showed a good factor structure; therefore, these forms are eligible for use in clinical practice. However, future studies should define the factor structure of the 6-item form.

Factors associated with prognosis of upper limb function in branch atheromatous disease.

BACKGROUND: Branch atheromatous disease (BAD) is often associated with corticospinal tract injury, and some patients develop early neurological deterioration (END) in the acute phase. This study investigated the progress of upper limb prognosis after BAD in the acute phases and examined the factors related to the prognosis of upper limb function. PROCEDURES: 108 subjects diagnosed with BAD were included. Then subjects were classified into two groups: those with good recovery of upper limb function and those with poor recovery of upper limb function. Univariate and multivariate analyses were performed with the objective variable being good or poor upper limb function. The following factors were used as explanatory variables: age, the volume of infarction, initial Fugl-Meyer assessment (FMA) upper limb score, and presence of END. MAIN FINDINGS: The univariate analysis showed significant differences in age and volume of infarction (p < 0.05). Multivariate analysis showed the following finding: age;(OR 0.977,95%CI 0.917-0.997,p = 0.0061; volume of infarction;(OR 0.645,95%CI 0.461-0.902,p = 0.0104). A significant difference was found in the age and volume of the infarct. CONCLUSION: This study finding suggests that age and volume of infarction are associated with the prognosis of upper extremity paralysis in BAD.

Impact of the robotic-assistance level on upper extremity function in stroke patients receiving adjunct robotic rehabilitation: sub-analysis of a randomized clinical trial.

BACKGROUND: Robotic therapy has been demonstrated to be effective in treating upper extremity (UE) paresis in stroke survivors. However, it remains unclear whether the level of assistance provided by robotics in UE training could affect the improvement in UE function in stroke survivors. We aimed to exploratorily investigate the impact of robotic assistance level and modes of adjustment on functional improvement in a stroke-affected UE. METHODS: We analyzed the data of 30 subacute stroke survivors with mild-to-severe UE hemiplegia who were randomly assigned to the robotic therapy (using ReoGo System) group in our previous randomized clinical trial. A cluster analysis based on the training results (the percentage of each stroke patient's five assistance modes of robotics used during the training) was performed. The patients were divided into two groups: high and low robotic assistance groups. Additionally, the two groups were sub-categorized into the following classes based on the severity of UE functional impairment: moderate-to-mild [Fugl-Meyer Assessment (FMA) score ≥ 30] and severe-to-moderate class (FMA < 30). The outcomes were assessed using FMA, FMA-proximal, performance-time in the Wolf motor function test (WMFT), and functional assessment scale (FAS) in WMFT. The outcomes of each class in the two groups were analyzed. A two-way analysis of variance (ANOVA) was conducted with robot assistance level and severity of UE function as explanatory factors and the change in each outcome pre- and post-intervention as the objective factor. RESULTS: Overall, significant differences of the group × severity interaction were found in most of the outcomes, including FMA-proximal (p = 0.038, η2 = 0.13), WMFT-PT (p = 0.021, η2 = 0.17), and WMFT-FAS (p = 0.045, η2 = 0.14). However, only the FMA score appeared not to be significantly different in each group (p = 0.103, η2 = 0.09). CONCLUSION: An optimal amount of robotic assistance is a key to maximize improvement in post-stroke UE paralysis. Furthermore, severity of UE paralysis is an important consideration when deciding the amount of assistance in robotic therapy. Trial registration Trial enrollment was done at UMIN (UMIN 000001619, registration date was January 1, 2009).

Dimensionality and item-difficulty hierarchy of the Fugl-Meyer assessment of the upper extremity among Japanese patients who have experienced stroke.

BACKGROUND: The Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) has been used in many clinical studies and in stroke rehabilitation. In studies evaluating psychometric properties, confirmatory factor analysis (CFA) indicated that the FMA-UE is a multidimensional tool. Item Response Theory One-Parameter Logistic (IRT1PL) supports that item-difficulty hierarchy can be used as a treatment index of upper extremity function for stroke recovery. However, studies on the psychometric properties of the FMA-UE in Asian populations are lacking. OBJECTIVES: To investigate the dimensionality and item-difficulty hierarchy of the FMA-UE for stroke rehabilitation in Japanese patients. METHODS: This was a cross-sectional study. The participants comprised 268 individuals admitted for de novo stroke (median age, 70.0 years; median days since stroke onset, 78.5) in 22 hospitals in Japan. The dimensionality of the FMA-UE was evaluated using CFA of selected items. The item-difficulty hierarchy of the FMA-UE using the appropriately selected model was demonstrated using IRT1PL analysis after confirming dimensionality. RESULTS: Two reflex items were removed by utilizing the floor and ceiling effects. The 31- and 30-item FMA-UE exhibited a good model fit of the unidimensionality in the CFA. The 30-item FMA-UE was found to be a good model by model comparison (the 31-item vs. the 30-item). The item-difficulty hierarchy of the 30-item FMA-UE was found not to be consistent with the expected item order. CONCLUSIONS: This study provides evidence that the FMA-UE has multidimensionality and the 30-item FMA-UE is a valid instrument for measuring upper-extremity impairment after stroke.

The Occupational Experience Helps to Express the Clients' Occupational Needs in Goal Setting: A Retrospective Study in Subacute Care Setting.

This study investigates whether reflection on occupational experience during assessment and intervention would help clients express their occupational needs in goal setting. Sixty-two participants who were not able to express their occupational needs in the initial assessment process were either allocated to the occupational experience group who undertook occupation-based assessment and intervention, or the physical training group who engaged in physical training only. The ratio of participants who expressed their occupational needs in each group was 67% (30/45) and 12% (2/17) respectively. Reflection on occupational experience during assessment and intervention to help clients express their occupational needs would have significant implications for practice, as it may encourage clients to reflect on their performance more easily.

Effects of mechanical thrombectomy for post-stroke patients with upper limb hemiparesis: Use of Propensity Score Matching.

BACKGROUND: Mechanical Thrombectomy (MT) is a recommended approach for post-cerebral ischemia in acute settings. Although a large amount of evidence suggests the use of MT, existing evidence has primarily focused on assessing lower limb performance or gait performance as an outcome measure. METHODS: This study was to investigate whether MT would be an effective approach for improving upper limb performance in post-stroke patients.This case control was divided into two groups: 154 patients as a control group only given conventional rehabilitation; and 25 patients as an intervention group given MT and conventional rehabilitation. Outcome variables were measured by calculating the change of Fugl-Meyer Assessment score at the last intervention compared with the beginning of the intervention. RESULT: By comparing the FMA scores after, the propensity matching compared between before receiving therapy intervention and after, the intervention group showed as follows: 30.4 ± 26.4-44.3 ± 25.4, p = 0.0019, r = 0.59. The control group showed as follows: 39.9 ± 24.1-49.1 ± 21.3, p = 0.002, r = 0.69. Lastly, a comparison of the intervention group with the control group about their FMA score change indicates as follows: intervention group: 13.9 ± 19.4, control group 9.2 ± 10.0, p = 0.2967, r = 0.15. CONCLUSION: This study indicated that there was no significant difference between MT and a conventional approach for improving UE function. However, this is the first study to investigate the course of recovery of UE function in the acute phase after MT, and this finding supports the need for further research.

Effects of collaborative consultation using iPad application in school-based occupational therapy: A single-arm pre-post pilot study.

INTRODUCTION: This pilot study examined the effect of collaborative consultation with teachers in school-based occupational therapy (SBOT) using iPad application for goal-setting-Aid for Decision-Making in Occupation Choice for School (ADOC-S). METHOD: A single arm pre-post intervention design was conducted at four preschools in Japan. The participants were 10 preschool teachers (10.5 ± 0.4 years of teaching), and 10 children (3.8 ± 0.4 years old; five boys). The teachers received three collaborative consultations (1 hr for each) from one occupational therapist. Firstly, the occupational therapist conducted an observational assessment of the child's school life, then the teacher and occupational therapist identified occupation-based goals for each child using the ADOC-S. Secondly, the teacher and the occupational therapist developed the graded goals using the Goal Attainment Scale (GAS) and discussed the daily intervention plan for the teachers to conduct. Thirdly, the occupational therapist followed up on the intervention process using GAS. The subjective outcome was measured at 10 point-satisfaction and performance score in each goal using Canadian Occupational Performance Measure (COPM). The observed outcome was measured using GAS and Strengths and Difficulties Questionnaire (SDQ). RESULTS: All the participants including teachers and children successfully underwent the intervention process. Significant improvement was found pre-post and effect size (ES) was large on the COPM (ES; r = .85-.94), GAS (ES; r = .98-.99) and SDQ (ES; r = .64). All goals (30/30) exceeded expectations of GAS from zero to +2. CONCLUSION: Although there are some limitations and considerations which need to be resolved for future studies, our results suggest that ADOC-S would help build a rapport with a teacher in SBOT settings, and this collaborative consultation would facilitate a positive outcome.

Switching on Endogenous Metal Binding Proteins in Parkinson's Disease.

The formation of cytotoxic intracellular protein aggregates is a pathological signature of multiple neurodegenerative diseases. The principle aggregating protein in Parkinson's disease (PD) and atypical Parkinson's diseases is α-synuclein (α-syn), which occurs in neural cytoplasmic inclusions. Several factors have been found to trigger α-syn aggregation, including raised calcium, iron, and copper. Transcriptional inducers have been explored to upregulate expression of endogenous metal-binding proteins as a potential neuroprotective strategy. The vitamin-D analogue, calcipotriol, induced increased expression of the neuronal vitamin D-dependent calcium-binding protein, calbindin-D28k, and this significantly decreased the occurrence of α-syn aggregates in cells with transiently raised intracellular free Ca, thereby increasing viability. More recently, the induction of endogenous expression of the Zn and Cu binding protein, metallothionein, by the glucocorticoid analogue, dexamethasone, gave a specific reduction in Cu-dependent α-syn aggregates. Fe accumulation has long been associated with PD. Intracellularly, Fe is regulated by interactions between the Fe storage protein ferritin and Fe transporters, such as poly(C)-binding protein 1. Analysis of the transcriptional regulation of Fe binding proteins may reveal potential inducers that could modulate Fe homoeostasis in disease. The current review highlights recent studies that suggest that transcriptional inducers may have potential as novel mechanism-based drugs against metal overload in PD.

Metallothionein, Copper and Alpha-Synuclein in Alpha-Synucleinopathies.

Metallothioneins (MTs) are proteins that function by metal exchange to regulate the bioavailability of metals, such as zinc and copper. Copper functions in the brain to regulate mitochondria, neurotransmitter production, and cell signaling. Inappropriate copper binding can result in loss of protein function and Cu(I)/(II) redox cycling can generate reactive oxygen species. Copper accumulates in the brain with aging and has been shown to bind alpha-synuclein and initiate its aggregation, the primary aetiological factor in Parkinson's disease (PD), and other alpha-synucleinopathies. In PD, total tissue copper is decreased, including neuromelanin-bound copper and there is a reduction in copper transporter CTR-1. Conversely cerebrospinal fluid (CSF) copper is increased. MT-1/2 expression is increased in activated astrocytes in alpha-synucleinopathies, yet expression of the neuronal MT-3 isoform may be reduced. MTs have been implicated in inflammatory states to perform one-way exchange of copper, releasing free zinc and recent studies have found copper bound to alpha-synuclein is transferred to the MT-3 isoform in vitro and MT-3 is found bound to pathological alpha-synuclein aggregates in the alpha-synucleinopathy, multiple systems atrophy. Moreover, both MT and alpha-synuclein can be released and taken up by neural cells via specific receptors and so may interact both intra- and extra-cellularly. Here, we critically review the role of MTs in copper dyshomeostasis and alpha-synuclein aggregation, and their potential as biomarkers and therapeutic targets.