The Adult Assisting Hand Assessment Stroke: Psychometric Properties of an Observation-Based Bimanual Upper Limb Performance Measurement.

OBJECTIVE: To investigate interrater and intrarater reliability, measurement error, and convergent and discriminative validity of the Adult Assisting Hand Assessment Stroke (Ad-AHA Stroke). DESIGN: Cross-sectional observational study. SETTING: A total of 7 stroke rehabilitation centers. PARTICIPANTS: Stroke survivors (reliability sample: n=30; validity sample: N=118) were included (median age 67y; interquartile range [IQR], 59-76); median time poststroke 81 days (IQR 57-117). INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Ad-AHA Stroke, Action Research Arm Test (ARAT), upper extremity Fugl-Meyer Assessment (UE-FMA). The Ad-AHA Stroke is an observation-based instrument assessing the effectiveness of the spontaneous use of the affected hand when performing bimanual activities in adults poststroke. Reliability of Ad-AHA Stroke was examined using intraclass correlation coefficients (ICCs), Bland-Altman plots, and weighted kappa statistics for reliability on item level. SEM was calculated based on Ad-AHA units. Convergent validity was assessed by calculating Spearman rank correlation coefficients between Ad-AHA Stroke and ARA test and UE-FMA. Comparison of Ad-AHA Stroke scores between subgroups of patients according to hand dominance, neglect, and age evaluated discriminative validity. RESULTS: Intrarater and interrater agreement showed an ICC of 0.99 (95% confidence interval, 0.99-0.99), an SEM of 2.15 and 1.64 out of 100, respectively, and weighted kappa for item scores were all above 0.79. The relation between Ad-AHA and other clinical assessments was strong (ρ=0.9). Patients with neglect had significantly lower Ad-AHA scores compared to patients without neglect (P=.004). CONCLUSIONS: The Ad-AHA Stroke captures actual bimanual performance. Therefore, it provides an additional aspect of upper limb assessment with good to excellent reliability and low SEM for patients with subacute stroke. High convergent validity with the ARA test and UE-FMA and discriminative validity were supported.

The impact of robot-mediated adaptive I-TRAVLE training on impaired upper limb function in chronic stroke and multiple sclerosis.

PURPOSE: The current study aimed to investigate proof-of-concept efficacy of an individualized, robot-mediated training regime for people with MS (pwMS) and stroke patients. METHOD: Thirteen pwMS and 14 chronic stroke patients performed 36 (stroke) or 40 (pwMS) training sessions with the I-TRAVLE system. Evaluation of upper limb function was performed at baseline, after training and at 3 months follow-up. Clinical outcome measures consisted of active range of motion (ROM), Motricity Index, Jamar handgrip strength, perceived fatigue and strength, Wolf Motor Function Test (WFMT) and ABILHAND. Robot-generated outcome measures consisted of movement velocity, ROM and actual covered distance compared to straight-line distance. RESULTS: In pwMS, significant improvements were found after training in active shoulder ROM, handgrip strength, perceived strength and WMFT activities. No significant change in clinical outcome was found in stroke patients, except for perceived strength. Significant improvement in speed and movement duration was found after training in both groups. At follow-up, clinical outcome deteriorated in pwMS and was maintained in stroke patients. CONCLUSIONS: Robot-mediated training resulted in improved movement coordination in both groups, as well as clinical improvement in pwMS. Absence of functional improvements in stroke patients may relate to severe upper limb dysfunction at baseline. Implications for Rehabilitation Robot-mediated training improved strength, active range of motion and upper limb capacity in pwMS. Robot-mediated therapy allows for adapted training difficulty.

Somatosensory Impairments in the Upper Limb Poststroke: Distribution and Association With Motor Function and Visuospatial Neglect.

BACKGROUND: A thorough understanding of the presence of different upper-limb somatosensory deficits poststroke and the relation with motor performance remains unclear. Additionally, knowledge about the relation between somatosensory deficits and visuospatial neglect is limited. OBJECTIVE: To investigate the distribution of upper-limb somatosensory impairments and the association with unimanual and bimanual motor outcomes and visuospatial neglect. METHODS: A cross-sectional observational study was conducted, including 122 patients within 6 months after stroke (median = 82 days; interquartile range = 57-133 days). Somatosensory measurement included the Erasmus MC modification of the (revised) Nottingham Sensory Assessment (Em-NSA), Perceptual Threshold of Touch (PTT), thumb finding test, 2-point discrimination, and stereognosis subscale of the NSA. Upper-limb motor assessment comprised the Fugl-Meyer assessment, motricity index, Action Research Arm Test, and Adult-Assisting Hand Assessment Stroke. Screening for visuospatial neglect was performed using the Star Cancellation Test. RESULTS: Upper-limb somatosensory impairments were common, with prevalence rates ranging from 21% to 54%. Low to moderate Spearman ρ correlations were found between somatosensory and motor deficits (r = 0.22-0.61), with the strongest associations for PTT (r = 0.56-0.61) and stereognosis (r = 0.51-0.60). Visuospatial neglect was present in 27 patients (22%). Between-group analysis revealed somatosensory deficits that occurred significantly more often and more severely in patients with visuospatial neglect (P < .05). Results showed consistently stronger correlations between motor and somatosensory deficits in patients with visuospatial neglect (r = 0.44-0.78) compared with patients without neglect (r = 0.08-0.59). CONCLUSIONS: Somatosensory impairments are common in subacute patients poststroke and are related to motor outcome. Visuospatial neglect was associated with more severe upper-limb somatosensory impairments.

Robot-supported upper limb training in a virtual learning environment : a pilot randomized controlled trial in persons with MS.

BACKGROUND: Despite the functional impact of upper limb dysfunction in multiple sclerosis (MS), effects of intensive exercise programs and specifically robot-supported training have been rarely investigated in persons with advanced MS. AIM: To investigate the effects of additional robot-supported upper limb training in persons with MS compared to conventional treatment only. METHODS: Seventeen persons with MS (pwMS) (median Expanded Disability Status Scale of 8, range 3.5-8.5) were included in a pilot RCT comparing the effects of additional robot-supported training to conventional treatment only. Additional training consisted of 3 weekly sessions of 30 min interacting with the HapticMaster robot within an individualised virtual learning environment (I-TRAVLE). Clinical measures at body function (Hand grip strength, Motricity Index, Fugl-Meyer) and activity (Action Research Arm test, Motor Activity Log) level were administered before and after an intervention period of 8 weeks. The intervention group were also evaluated on robot-mediated movement tasks in three dimensions, providing active range of motion, movement duration and speed and hand-path ratio as indication of movement efficiency in the spatial domain. Non-parametric statistics were applied. RESULTS: PwMS commented favourably on the robot-supported virtual learning environment and reported functional training effects in daily life. Movement tasks in three dimensions, measured with the robot, were performed in less time and for the transporting and reaching movement tasks more efficiently. There were however no significant changes for any clinical measure in neither intervention nor control group although observational analyses of the included cases indicated large improvements on the Fugl-Meyer in persons with more marked upper limb dysfunction. CONCLUSION: Robot-supported training lead to more efficient movement execution which was however, on group level, not reflected by significant changes on standard clinical tests. Persons with more marked upper limb dysfunction may benefit most from additional robot-supported training, but larger studies are needed. TRIAL REGISTRATION: This trial is registered within the registry Clinical Trials GOV ( NCT02257606 ).

Responsiveness and clinically meaningful improvement, according to disability level, of five walking measures after rehabilitation in multiple sclerosis: a European multicenter study.

BACKGROUND: Evaluation of treatment effects on walking requires appropriate and responsive outcome measures. OBJECTIVES: To determine responsiveness of 5 walking measures and provide reference values for clinically meaningful improvements, according to disability level, in persons with multiple sclerosis (pwMS). METHODS: Walking tests were measured pre- and postrehabilitation in 290 pwMS from 17 European centers. Combined anchor- and distribution-based methods determined responsiveness of objective short and long walking capacity tests (Timed 25-Foot Walk [T25FW] and 2- and 6-Minute Walk Tests [2MWT and 6MWT] and of the patient-reported Multiple Sclerosis Walking Scale-12 [MSWS-12]). A global rating of change scale, from patients' and therapists' perspective, was used as external criteria to determine the area under the receiver operating characteristic curve (AUC), minimally important change (MIC), and smallest real change (SRC). Patients were stratified into disability subgroups (Expanded Disability Status Scale score ≤4 [n = 98], >4 [n = 186]). RESULTS: MSWS-12, 2MWT, and 6MWT were more responsive (AUC 0.64-0.73) than T25FW (0.50-0.63), especially in moderate to severely disabled pwMS. Clinically meaningful changes (MICs) from patient and therapist perspective were -10.4 and -11.4 for MSWS-12 (P < .01), 9.6 m and 6.8 m for 2MWT (P < .05), and 21.6 m (P < .05) and 9.1 m (P = .3) for 6MWT. In subgroups, MIC was significant from patient perspective for 2MWT (10.8 m) and from therapist perspective for MSWS-12 (-10.7) in mildly disabled pwMS. In moderate to severely disabled pwMS, MIC was significant for MSWS-12 (-14.1 and -11.9). CONCLUSIONS: Long walking tests and patient-reported MSWS-12 were more appropriate than short walking tests in detecting clinically meaningful improvement after physical rehabilitation, particularly the MSWS-12 for moderate to severely disabled pwMS.