A Network of Sites and Upskilled Therapists to Deliver Best-Practice Stroke Rehabilitation of the Arm: Protocol for a Knowledge Translation Study.

Implementation of evidence-informed rehabilitation of the upper limb is variable, and outcomes for stroke survivors are often suboptimal. We established a national partnership of clinicians, survivors of stroke, researchers, healthcare organizations, and policy makers to facilitate change. The objectives of this study are to increase access to best-evidence rehabilitation of the upper limb and improve outcomes for stroke survivors. This prospective pragmatic, knowledge translation study involves four new specialist therapy centers to deliver best-evidence upper-limb sensory rehabilitation (known as SENSe therapy) for survivors of stroke in the community. A knowledge-transfer intervention will be used to upskill therapists and guide implementation. Specialist centers will deliver SENSe therapy, an effective and recommended therapy, to stroke survivors in the community. Outcomes include number of successful deliveries of SENSe therapy by credentialled therapists; improved somatosensory function for stroke survivors; improved performance in self-selected activities, arm use, and quality of life; treatment fidelity and confidence to deliver therapy; and for future implementation, expert therapist effect and cost-effectiveness. In summary, we will determine the effect of a national partnership to increase access to evidence-based upper-limb sensory rehabilitation following stroke. If effective, this knowledge-transfer intervention could be used to optimize the delivery of other complex, evidence-based rehabilitation interventions.

Effects of Upper Limb Exercise or Training on Hand Dexterity and Function in People With Parkinson Disease: A Systematic Review and Meta-analysis.

OBJECTIVE: This systematic review investigated the effects of exercise and training on hand dexterity and function outcomes in people with Parkinson disease (PD). DATA SOURCES: We searched 5 databases (MEDLINE Ovid, CINAHL, PEDro, PubMed, Cochrane Database) from inception to October 2022. STUDY SELECTION: Included studies were randomized controlled trials delivering upper limb exercise or training interventions to people with PD and evaluating 1 or more upper limb activity outcomes. Two independent reviewers screened 668 articles for inclusion. DATA EXTRACTION: Two reviewers independently extracted data relating to study participants, intervention characteristics, and key outcomes. Cochrane Risk of Bias and GRADE tools assessed methodological quality of included studies, and strength of evidence for 3 outcomes: hand dexterity, self-reported hand function, and handwriting performance. Meta-analyses synthesized results for within-hand dexterity and self-reported function. RESULTS: Eighteen randomized controlled trials (n=704) with low to unclear risk of bias were identified. Experimental interventions varied considerably in their approach and treatment dose, and 3 studies focused on training handwriting. Meta-analysis showed moderate quality evidence of a small positive effect on within-hand dexterity (SMD=0.26; 95% CI 0.07, 0.44). Very low-quality evidence pointed toward a nonsignificant effect on self-reported hand function (SMD=0.67; 95% CI -0.40, 1.75). A narrative review of handwriting interventions showed low quality evidence for improved performance after training. CONCLUSIONS: There is moderate certainty of evidence supporting the use of exercise and training to address dexterity problems, but evidence remains unclear for self-reported hand function and handwriting. Our findings suggest that training could employ task-related approaches. Future research should interrogate aspects of clinical practice such as optimal dose and key ingredients for effective interventions.

The stroke exercise preference inventory is feasible to use in a community rehabilitation setting.

Exploring exercise preferences may help people to adhere to exercise programs by promoting customized programs to suit the person's choices and concerns. We investigated if the Stroke Exercise Preference Inventory, a questionnaire designed to explore stroke survivors' preferences for exercise and potential barriers, was feasible to use, and whether it assisted physiotherapists to design ongoing exercise programs in a mixed diagnostic convenience sample attending community rehabilitation. Physiotherapy staff interviewed 42 participants, and sought feedback about the questionnaire. Participant responses for exercise preferences and perceived barriers were then summarized. The questionnaire was quick to administer, readily understood, and considered relevant to consider when discussing options for exercise. Clinicians reported the questionnaire was useful for 48% (20/42) of participants, as it engaged the participant, clarified their preferences and allowed problem solving of potential barriers to exercise. Participants expressed strong preferences to be challenged, and to receive supervision and support. Preferences regarding environmental and social context of exercise varied widely. Difficulty getting started was the most common barrier reported. The Stroke Exercise Preference Inventory was feasible to use with a mixed diagnostic group during community rehabilitation, and provides structure to explore preferences and barriers to exercise. It remains to be tested whether use of the questionnaire promotes adherence to exercise programs.

Experiences of Upper Limb Somatosensory Retraining in Persons With Stroke: An Interpretative Phenomenological Analysis.

PURPOSE: The aim of this study was to explore experiences of upper limb somatosensory discrimination retraining in persons with stroke. METHODS: A qualitative methodology was used within the context of a randomized control trial of somatosensory retraining: the CoNNECT trial. Participants in the CoNNECT trial completed a treatment program, known as SENSe therapy, to retrain upper limb somatosensory discrimination and recognition skills, and use of these skills in personally valued activities. Eight participants were interviewed on their experience of this therapy. Data were analyzed using Interpretative Phenomenological Analysis (IPA). RESULTS: Five themes represented participants' experiences of upper limb somatosensory retraining after stroke: (1) loss of sensation and desire to reclaim normality; (2) harnessing positivity in the therapeutic relationship and specialized therapy; (3) facing cognitive and emotional challenges; (4) distinct awareness of gains and differences in bodily sensations; and (5) improved functioning: control and choice in daily performance. Persons with stroke experienced somatosensory retraining as a valuable treatment that provided them with sensory and functional gains. CONCLUSION: Upper limb somatosensory retraining is a treatment that persons with stroke perceived as challenging and rewarding. People who have experienced stroke believed that somatosensory retraining therapy assisted them to improve their sensation, functional arm use, as well as daily performance and participation in life.

The effectiveness of somatosensory retraining for improving sensory function in the arm following stroke: a systematic review.

OBJECTIVE: The aim of this study was to evaluate if somatosensory retraining programmes assist people to improve somatosensory discrimination skills and arm functioning after stroke. DATA SOURCES: Nine databases were systematically searched: Medline, Cumulative Index to Nursing and Allied Health Literature, PsychInfo, Embase, Amed, Web of Science, Physiotherapy Evidence Database, OT seeker, and Cochrane Library. REVIEW METHODS: Studies were included for review if they involved (1) adult participants who had somatosensory impairment in the arm after stroke, (2) a programme targeted at retraining somatosensation, (3) a primary measure of somatosensory discrimination skills in the arm, and (4) an intervention study design (e.g. randomized or non-randomized control designs). RESULTS: A total of 6779 articles were screened. Five group trials and five single case experimental designs were included ( N = 199 stroke survivors). Six studies focused exclusively on retraining somatosensation and four studies focused on somatosensation and motor retraining. Standardized somatosensory measures were typically used for tactile, proprioception, and haptic object recognition modalities. Sensory intervention effect sizes ranged from 0.3 to 2.2, with an average effect size of 0.85 across somatosensory modalities. A majority of effect sizes for proprioception and tactile somatosensory domains were greater than 0.5, and all but one of the intervention effect sizes were larger than the control effect sizes, at least as point estimates. Six studies measured motor and/or functional arm outcomes ( n = 89 participants), with narrative analysis suggesting a trend towards improvement in arm use after somatosensory retraining. CONCLUSION: Somatosensory retraining may assist people to regain somatosensory discrimination skills in the arm after stroke.

Initial severity of somatosensory impairment influences response to upper limb sensory retraining post-stroke.

BACKGROUND: Somatosensory loss occurs often following stroke. A proportional recovery model is proposed for spontaneous motor recovery, with implication for treatment planning. It is currently unknown if initial severity of sensory impairment influences stroke survivors' response to treatment to improve sensation. OBJECTIVE: To examine if initial (pre-treatment) severity of upper limb somatosensory impairment is related to sensation outcomes following treatment. METHODS: Regression analysis was used to investigate the relationship between initial and post-treatment sensation performance. Data were pooled from two randomized controlled trials of somatosensory discrimination retraining (N = 80). Upper limb somatosensation was measured using standardized tests of sensory discrimination: Fabric Matching Test, Wrist Position Sense Test, and functional Tactile Object Recognition Test. RESULTS: Post-treatment somatosensory improvement patterns were proportional to the extent of initial pre-treatment somatosensory impairment (Texture discrimination: B = 0.74, 95% CIs [0.52, 0.96]; Proprioception: B = 0.35, 95% CIs [0.24, 0.47]; Object recognition: B = 0.85, 95% CIs [0.75, 0.95]). CONCLUSIONS: The effect of somatosensory retraining on post-treatment sensation was proportional to the extent of upper limb initial somatosensory impairment. Findings suggest sensory retraining can benefit stroke survivors of varying severity of sensory impairment, including those with more severe somatosensory loss.

A Phase 1 exercise dose escalation study for stroke survivors with impaired walking.

BACKGROUND: Targeted exercise and increased practice can improve the mobility of stroke survivors. However, many stroke survivors continue to have reduced physical work capacity and impaired walking, and experience frequent falls after participating in physical rehabilitation programs. AIM: In this Phase 1 study, we used a dose escalation method, common in pharmaceutical trials, to determine the maximum tolerable dose of multimodal exercise in community-dwelling stroke survivors with mobility impairment. METHODS: Stroke survivors 14-59 months poststroke participated in a 12-week (36 sessions) multimodal exercise program implemented using a cumulative 3 + 3 dose escalation design (featuring increasing doses in successive cohorts of three participants), with set dose-limiting tolerance criteria. The exercise intervention included challenging balance activities, strength, and endurance training. The program was individualized and focused on task-specific requirements for walking in the community. RESULTS: Six survivors participated before escalation was ceased. Four participants were able to tolerate up to 10·5 h/week of exercise, which included 283 min of endurance, 182 min of task practice, 138 min of strengthening, and 28 min resting. The program led to increased walking distance (Six-Minute Walk Test) and faster mobility (4 Square Step Test, Timed Up and Go Test), with pre-postimprovements averaging 23-41%. CONCLUSIONS: This is the first multimodal exercise dose escalation study in stroke. The maximal dose of exercise identified was dramatically higher than the dose typically delivered to stroke survivors in current trials. We now plan to confirm safety and feasibility of this program in a larger Phase II trial.

Over-ground walking on level and sloped surfaces in people with stroke compared to healthy matched adults.

PURPOSE: To investigate the basic spatio-temporal gait characteristics of people with stroke whilst walking on sloped and level terrain, and to compare this performance to healthy matched adults. METHOD: Fifteen community dwelling people with stroke who walked with a hemiplegic gait and a reference group of 15 adults without impairments matched for sex, age and height participated in this descriptive, observational study. Basic gait spatio-temporal measures were recorded at self-selected speed across a GAITRite mat placed on level, uphill and downhill (ramp gradient 1:14 or 4.1°) surfaces. Measures recorded were gait speed, cadence, step length, support base, single and double limb support duration and step length symmetry. Group and walking condition effects were assessed by two separate 2-way (group × slope) repeated measures multivariate analysis of variance. RESULTS: The stroke group walked slower (p < 0.001) than the reference group for all conditions. Within-group analyses found the stroke group decreased their speed and step length when walking downhill compared to level and uphill walking (p < 0.001). In contrast, the reference group maintained speed across all walking conditions. CONCLUSIONS: The findings suggest that walking on slopes affects gait speed in people with stroke and this may have implications when walking in the community. IMPLICATIONS FOR REHABILITATION: • Although a high percentage of people achieve walking independence following a stroke, few achieve independent community mobility. • Walking on slopes is an important aspect of community mobility. • When walking down a standard gradient ramp, people with stroke reduced their speed and step length, relative to level over-ground and uphill walking. • It is recommended that attention be directed to assessment and treatment of walking on slopes as part of stroke rehabilitation, as this may have implications when walking in the community.

Changes in balance and walking from stroke rehabilitation to the community: a follow-up observational study.

OBJECTIVES: To investigate (1) whether clinical test scores at discharge predict falls or limited community mobility after discharge from inpatient stroke rehabilitation; and (2) how walking and dynamic standing balance change after discharge. DESIGN: Follow-up observational study between 6 and 36 months after discharge. SETTING: Rehabilitation setting. PARTICIPANTS: Community-dwelling stroke survivors (N=30) who could walk unassisted when discharged from inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Six-minute walk test (6MWT), Four Square Step Test (FSST), Step Test (ST), Environmental Analysis of Mobility Questionnaire (EAMQ), Falls Efficacy Scale-International (FES-I), and self-reported falls. RESULTS: Follow-up occurred at a median of 14.5 months postdischarge. Significant improvements occurred between discharge and follow-up for the 6MWT (mean difference [MD]=110.1m; 95% confidence interval [CI], 70.8-149.4; P<.001), ST (MD=1.8 steps; 95% CI, 0.3-3.4; P=.03), and FSST (MD=4.3s; 95% CI, -10.3 to 1.6; P=.05). Despite this, 40% of participants reported falling. The group who fell had lower clinical test scores at discharge and follow-up than nonfallers. Specific cutoff scores for the clinical tests accurately classified falls history in 70% to 78% of participants. The cutoff scores were <250m for the 6MWT, <10 steps on the ST, and a failure or ≥15 seconds to complete the FSST. Participants performing under the cutoff scores reported lower levels of community mobility (EAMQ, P<.04). Concern about falling was only higher for those classified at risk by the FSST (FES-I, P=.008). CONCLUSIONS: The FSST, ST, and 6MWT scores at discharge had good falls prediction. People classified at risk of falls avoided more tasks in their home and community than those not classified at risk.

The test-retest reliability and responsiveness to change for the Hand Function Survey during stroke rehabilitation.

BACKGROUND/AIM: The Hand Function Survey (HFS) is a questionnaire designed to measure self-reported ability to use the affected hand during 13 everyday tasks in people with stroke. The HFS appears practical for clinical use and has established psychometric properties. This study aimed to investigate test-retest reliability and responsiveness to change for the HFS during stroke rehabilitation. METHODS: Twenty-two people with a first episode stroke, and without severe cognitive and language difficulties, participated. Participants were assessed on three occasions: baseline, 48 hours later and at follow-up (four to six weeks later) using two tests of upper extremity function, the HFS and the Action Research Arm Test (ARAT). Test-retest reliability of the HFS between baseline and 48 hours was examined using tests of agreement (Lin's Concordance and Cohen's Kappa). Responsive to change for the HFS was investigated by comparing the difference between baseline and follow-up scores. The level of agreement between the change observed for the ARAT and HFS was analysed. RESULTS: Strong agreement (Rho_c = 0.99; Κ(w) =0.97) was observed between the test-retest HFS scores. Significant improvement between baseline and follow-up occurred for both the HFS and ARAT. A moderate agreement was found between change observed for the HFS and ARAT (Rho_c=0.62; Κ(w) =0.65). CONCLUSION: The HFS was found to be a reliable and responsive self-report test of hand function during stroke rehabilitation. The HFS could be used in conjunction with other clinical tests of hand function during the rehabilitation of people with stroke without severe cognitive and language difficulties.

Reduced active control and passive range at the shoulder increase risk of shoulder pain during inpatient rehabilitation post-stroke: an observational study.

QUESTION: What factors at admission are associated with shoulder pain during stroke rehabilitation? DESIGN: Retrospective audit of medical histories and logistic regression. PARTICIPANTS: 94 people with primary diagnosis of stroke attending inpatient rehabilitation. OUTCOME MEASURES: Predictors were a battery of impairments, stroke-related factors, and patient characteristics. The outcome of interest was shoulder pain. RESULTS: Shoulder pain was present in 23% of patients at admission, and in a total of 35% of patients during inpatient stay. Patients with pain differed significantly (p = 0.04) from those without pain for several factors including age, longer time until rehabilitation admission, impaired movement of the arm (Motor Assessment Scale items), reduced passive range of movement, subluxation, and altered tone and sensation. No differences were found for many factors including neglect, cognitive impairment, side of stroke, and body weight. Logistic regression exploring the association between four predictors (shoulder range, Motor Assessment Scale items, subluxation, and altered sensation) and shoulder pain (outcome of interest) found that shoulder pain was reliably associated with two factors: reduced passive shoulder range (OR 14%, 95% CI 3 to 64), and Motor Assessment Scale Upper Arm item score (OR 64%, 95% CI 43 to 96). The model accurately classified 85% of patients. CONCLUSION: Shoulder pain is common and occurs early after stroke. Reduced active control and passive range at the shoulder appear to be risk factors for shoulder pain during inpatient rehabilitation post-stroke.

The Four Square Step Test is a feasible and valid clinical test of dynamic standing balance for use in ambulant people poststroke.

OBJECTIVE: To examine if the Four Square Step Test (FSST), a previously reported clinical test of dynamic standing balance, which involves stepping over obstacles and turning, was a feasible and valid test, and sensitive to change during stroke rehabilitation. DESIGN: Prospective observational cohort study over a 4-week duration. SETTING: Rehabilitation hospital. PARTICIPANTS: People with stroke (N=37) who could walk at least 50m with minimal assistance were recruited consecutively when attending physical therapy during rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Dynamic standing balance was examined at 2 weekly intervals using 2 clinical tests: the FSST and the Step Test. Falls events were monitored using a falls diary and by an audit of medical histories. RESULTS: Strong agreement was observed between performance scores for the FSST and Step Test obtained within the same testing session (intraclass correlation coefficient(3,k), .94-.99). A moderate to strong inverse relationship (Spearman rho=-.73 to -.86) was observed between the FSST and Step Test scores at each assessment. Scores from both tests revealed significant improvements in dynamic balance across the 4-week period (P<.001-.010). Five of the participants reported falls during the study. These 5 people had low scores for both clinical tests and difficulty clearing their foot when stepping over objects in the FSST. CONCLUSIONS: The FSST is a feasible and valid test of dynamic standing balance that is sensitive to change during stroke rehabilitation.

Clinical measures of handgrip limitation relate to impaired pinch grip force control after stroke.

This study examined whether clinical measures of handgrip limitation relate to laboratory measures of grip force impairment during a pinch grip, lift, and hold task post-stroke. Handgrip ability in 45 people with stroke who had residual grip ability was examined relative to 45 age-matched healthy adults. The clinical tests included items from a) the Jebsen Taylor Hand Function Test; b) the Motor Assessment Scale; c) the Functional Independence Measure (FIM); and d) a custom-designed survey about hand-use in daily life. The laboratory test was summarized by principal components: 1) Pre-Lift Delay and 2) Grip Force Dyscontrol. For the stroke group, a moderate to strong correlation was found between Pre-Lift Delay and each clinical measure of handgrip limitation (rs=0.70-0.85) except the FIM (rs=0.38-0.49). In contrast, Grip Force Dyscontrol was not associated with handgrip limitation on any of the clinical tests (rs=-0.08 to 0.18).

Impaired discrimination of surface friction contributes to pinch grip deficit after stroke.

BACKGROUND: Impaired sensation and force production could both contribute to handgrip limitation after stroke. Clinically, training is usually directed to motor impairment rather than sensory impairment despite the prevalence of sensory deficit and the importance of sensory input for grip control. OBJECTIVE: The aim of this study was to investigate if sensory deficits contribute to pinch grip dysfunction beyond that attributable to motor deficits poststroke. METHODS: The study enlisted 45 stroke participants and 45 healthy controls matched for age, gender, and hand dominance. Ability to differentiate surface friction (Friction Discrimination Test [FDT]), match object weight (Weight Matching Test [WMT]), produce grip force to track a visual target (Visually Guided Pinch Test [VGPT]), and perform a Pinch-Grip Lift-and-Hold Test (PGLHT) was quantified relative to normative performance, as defined by matched controls. The relationship between sensory ability (FDT, WMT) and altered PGLHT performance adjusted for motor ability (VGPT) after stroke was then examined using multivariate regression. RESULTS: Deficits in FDT, WMT, and VGPT ability were present in at least half of the stroke sample and were largely independent across the variables. Poorer friction discrimination was significantly associated with longer latencies of grip-lift (r = .34; P = .03) and grip force dysregulation (r= .34; P= .03) after the impact of VGPT was statistically removed from PGLHT ability. However, performance on WMT did not relate to either PGLHT deficit. CONCLUSION: The findings indicate that impaired friction discrimination ability contributes to altered timing and force adjustment during PGLHT poststroke.

Grip force regulation during pinch grip lifts under somatosensory guidance: comparison between people with stroke and healthy controls.

OBJECTIVES: To compare the timing and grip force application in a pinch grip task performed under somatosensory guidance in stroke and matched controls and to identify characteristics of impaired grip force regulation after stroke. DESIGN: Matched-pairs control group. SETTING: University research laboratory. PARTICIPANTS: Forty-five people with stroke who could pick up a pen lid using a pinch grip and actively participated in rehabilitation and 45 adults without neurologic conditions or musculoskeletal or skin impairments affecting the hand, matched for age, sex, and hand dominance. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Timing and magnitude of grip forces applied during pinch grip lift and hold. RESULTS: Prolonged time to grip and lift objects, and excessive grip force prior to commencing the lift occurred in approximately half of the contralesional (involved) hands of people with stroke. Fluctuating irregular forces and reduced adaptation of the grip safety margin were also observed. Excessive safety margins were not predominant after stroke. Extreme slowing and disorganized sequencing of the grip and lifting forces and difficulty maintaining a stable grip characterized severe dysfunction. CONCLUSIONS: Delayed grip formulation and variable grip force application are key characteristics of grip dysfunction after stroke.