Evolution and prediction of mismatch between observed and perceived upper limb function after stroke: a prospective, longitudinal, observational cohort study.

BACKGROUND: A previously shown 'mismatch' group of patients with good observed upper limb (UL) motor function but low perceived UL activity at six months post stroke tends to use the affected UL less in daily life than would be expected based on clinical tests, and this mismatch may also be present at 12 months. We aimed to confirm this group in another cohort, to investigate the evolution of this group from six to 12 months, and to determine factors on admission to inpatient rehabilitation and at 6 months that can discriminate between mismatch and good match groups at 12 months. METHODS: Persons after stroke were recruited on rehabilitation admission and re-assessed at six and 12 months. Observed UL function was measured with the upper extremity subscale of the Fugl-Meyer Assessment (FMA-UE) and perceived UL activity by the hand subscale of the Stroke Impact Scale 3.0 (SIS-Hand). We defined mismatch as good observed UL function (FMA-UE > 50/66) but low perceived activity (SIS-Hand≤75/100). Potential discriminators at admission and 6 months (demographic characteristics, stroke characteristics, UL somatosensory function, cognitive deficits, mental function and activity) were statistically compared for match and mismatch groups at 12 months. RESULTS: We included 60 participants (female: 42%) with mean (SD) age of 65 (12) years. We confirmed a mismatch group of 11 (18%) patients at 6 months, which increased to 14 (23%) patients at 12 months. In the mismatch group compared to the good match group at 12 months, patients had a higher stroke severity and more somatosensory impairments on admission and at 6 months. CONCLUSIONS: We confirmed a group of patients with good observed UL function but low perceived activity both at six and at 12 months post stroke. Assessment of stroke severity and somatosensory impairments on admission into rehabilitation could determine mismatch at 12 months and might warrant intervention. However, large differences in clinical outcomes between patients in the mismatch group indicate the importance of tailoring training to the individual needs.

Brain connectivity alterations after additional sensorimotor or motor therapy for the upper limb in the early-phase post stroke: a randomized controlled trial.

Somatosensory function plays an important role for upper limb motor learning. However, knowledge about underlying mechanisms of sensorimotor therapy is lacking. We aim to investigate differences in therapy-induced resting-state functional connectivity changes between additional sensorimotor compared with motor therapy in the early-phase post stroke. Thirty first-stroke patients with a sensorimotor impairment were included for an assessor-blinded multi-centre randomized controlled trial within 8 weeks post stroke [13 (43%) females; mean age: 67 ± 13 years; mean time post stroke: 43 ± 13 days]. Patients were randomly assigned to additional sensorimotor (n = 18) or motor (n = 12) therapy, receiving 16 h of additional therapy within 4 weeks. Sensorimotor evaluations and resting-state functional magnetic resonance imaging were performed at baseline (T1), post-intervention (T2) and after 4 weeks follow-up (T3). Resting-state functional magnetic resonance imaging was also performed in an age-matched healthy control group (n = 19) to identify patterns of aberrant connectivity in stroke patients between hemispheres, or within ipsilesional and contralesional hemispheres. Mixed model analysis investigated session and treatment effects between stroke therapy groups. Non-parametric partial correlations were used to investigate brain-behaviour associations with age and frame-wise displacement as nuisance regressors. Connections within the contralesional hemisphere that showed hypo-connectivity in subacute stroke patients (compared with healthy controls) showed a trend towards a more pronounced pre-to-post normalization (less hypo-connectivity) in the motor therapy group, compared with the sensorimotor therapy group (mean estimated difference = -0.155 ± 0.061; P = 0.02). Further, the motor therapy group also tended to show a further pre-to-post increase in functional connectivity strength among connections that already showed hyper-connectivity in the stroke patients at baseline versus healthy controls (mean estimated difference = -0.144 ± 0.072; P = 0.06). Notably, these observed increases in hyper-connectivity of the contralesional hemisphere were positively associated with improvements in functional activity (r = 0.48), providing indications that these patterns of hyper-connectivity are compensatory in nature. The sensorimotor and motor therapy group showed no significant differences in terms of pre-to-post changes in inter-hemispheric connectivity or ipsilesional intrahemispheric connectivity. While effects are only tentative within this preliminary sample, results suggest a possible stronger normalization of hypo-connectivity and a stronger pre-to-post increase in compensatory hyper-connectivity of the contralesional hemisphere after motor therapy compared with sensorimotor therapy. Future studies with larger patient samples are however recommended to confirm these trend-based preliminary findings.

Sensorimotor vs. Motor Upper Limb Therapy for Patients With Motor and Somatosensory Deficits: A Randomized Controlled Trial in the Early Rehabilitation Phase After Stroke.

Background: Somatosensory function plays an important role in motor learning. More than half of the stroke patients have somatosensory impairments in the upper limb, which could hamper recovery. Question: Is sensorimotor upper limb (UL) therapy of more benefit for motor and somatosensory outcome than motor therapy? Design: Randomized assessor- blinded multicenter controlled trial with block randomization stratified for neglect, severity of motor impairment, and type of stroke. Participants: 40 first-ever stroke patients with UL sensorimotor impairments admitted to the rehabilitation center. Intervention: Both groups received 16 h of additional therapy over 4 weeks consisting of sensorimotor (N = 22) or motor (N = 18) UL therapy. Outcome measures: Action Research Arm test (ARAT) as primary outcome, and other motor and somatosensory measures were assessed at baseline, post-intervention and after 4 weeks follow-up. Results: No significant between-group differences were found for change scores in ARAT or any somatosensory measure between the three time points. For UL impairment (Fugl-Meyer assessment), a significant greater improvement was found for the motor group compared to the sensorimotor group from baseline to post-intervention [mean (SD) improvement 14.65 (2.19) vs. 5.99 (2.06); p = 0.01] and from baseline to follow-up [17.38 (2.37) vs. 6.75 (2.29); p = 0.003]. Conclusion: UL motor therapy may improve motor impairment more than UL sensorimotor therapy in patients with sensorimotor impairments in the early rehabilitation phase post stroke. For these patients, integrated sensorimotor therapy may not improve somatosensory function and may be less effective for motor recovery. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03236376.

Psychometric properties of the Flemish version of the life balance inventory: a patient-reported outcome measure in the chronic stage after stroke.

Purpose: To investigate test-retest reliability, measurement error, and convergent validity of the Flemish version of the Life Balance Inventory (Fl-LBI) in chronic community-dwelling stroke survivors.Methods: Stroke survivors living at home (>6 months post-stroke) were recruited. The Fl-LBI was administered twice (1st home-visit, 2nd postal), with a 1-week time interval.Results: Thirty-two stroke-survivors participated: median age 61 years (IQR: 54-67), median time since stroke 571 days (IQR: 433-734). Median total Fl-LBI score was 2.47(IQR: 2.18-2.80) out of 3 on the first occasion (n = 32) and 2.55(IQR: 2.35-2.77) on the second occasion (n = 29), 91% retention rate. The intraclass correlation coefficient [95% confidence interval] for total Fl-LBI score was 0.88 [0.77-0.94] and for subscale scores >0.74 [0.48-0.94] indicating moderate to good test-retest reliability. Standard error of measurement was 0.14 out of 3(7%) and minimal detectable difference 0.39(20%). Agreement for activity category scores ranged from moderate to excellent. Construct validity was supported by moderate associations between Fl-LBI and participation (rs = 0.46); mobility (rs = 0.36) and emotion (rs = 0.37) subscales of the Stroke Impact Scale.Conclusion: In a pilot sample, the FL-LBI has satisfactory test-retest reliability, acceptable measurement error and minimal detectable difference and acceptable convergent validity. It can be used in clinical practice and research to assess life balance in chronic community-dwelling stroke survivors.Implications for rehabilitationLife balance can be a useful concept in stroke rehabilitation; it corresponds to individuals' perception of having a satisfying activity pattern tailored to their life circumstances.The Flemish version of the Life Balance Inventory can be used to evaluate life balance in community-dwelling chronic stroke.Satisfactory test-retest reliability and acceptable measurement error and minimal detectable difference were demonstrated in a pilot sample for the Flemish version of the Life Balance Inventory.

Mismatch between observed and perceived upper limb function: an eye-catching phenomenon after stroke.

PURPOSE: To investigate the relation between observed and perceived upper limb motor function in patients with chronic stroke. MATERIAL AND METHODS: We investigated 32 patients at six months after stroke with the Fugl-Meyer Assessment (observed function) and hand subscale of the Stroke Impact Scale (perceived function). Spearman correlation was calculated to relate observed and perceived function. Through cut-off scores, we divided our sample in low (Fugl-Meyer Assessment <31/66) and good observed function, and low (hand subscale of Stroke Impact Scale <61/100) and good perceived function. Scatterplot and hierarchical clustering analysis was conducted to detect distinct groups. RESULTS: A strong positive relation was found between observed and perceived function (r = 0.84). Three groups could be identified; a "low match group" of patients with low observed and low perceived function (n = 11, 34%), a "good match group" containing patients with good observed and good perceived function (n = 15, 47%), and a "mismatch group" comprising patients with good observed but low perceived function (n = 6, 19%). CONCLUSIONS: In our chronic sample, one in five patients showed good upper limb observed but low perceived function. Measuring both observed and perceived arm and hand function seems warranted together with considering a differential therapy approach for the distinct groups. Implications for rehabilitation A considerable group of patients in the chronic phase post-stroke have good motor function in their affected upper limb, but nevertheless perceive a restricted ability. In order to identify a mismatch in people with chronic stroke, both observed and perceived upper limb motor function should be assessed. Besides common measurement tools for observed function like the Fugl-Meyer Assessment, perceived function can be evaluated by means of the hand function section of the Stroke Impact Scale. For patients with good observed but low perceived function, an additional rehabilitation strategy should be considered, potentially including awareness of ability and a self-efficacy approach.

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.

Does sensorimotor upper limb therapy post stroke alter behavior and brain connectivity differently compared to motor therapy? Protocol of a phase II randomized controlled trial.

BACKGROUND: The role of somatosensory feedback in motor performance has been warranted in the literature. Although sensorimotor deficits are common after stroke, current rehabilitation approaches primarily focus on restoring upper limb motor ability. Evidence for integrative sensorimotor rehabilitation approaches is scarce, as is knowledge about neural correlates of somatosensory impairments after stroke and the effect of rehabilitation on brain connectivity level. Therefore, we aim to investigate changes in sensorimotor function and brain connectivity following a sensorimotor therapy program compared to an attention-matched motor therapy program for the upper limb after stroke. METHODS: An assessor-blinded randomized controlled trial will be conducted. Sixty inpatient rehabilitation patients up to eight weeks after stroke will be included. Patients will be randomized to either an experimental group receiving sensorimotor therapy or a control group receiving attention-matched motor therapy for the upper limb, with both groups receiving conventional therapy. Thus, all patients will receive extra therapy, a total of 16 1-h sessions over four weeks. Patients will be assessed at baseline, after four weeks of training, and after four weeks of follow-up. Primary outcome measure is the Action Research Arm Test. Secondary outcome measures will consist of somatosensory, motor and cognitive assessments, and a standardized resting-state functional magnetic resonance imaging protocol. DISCUSSION: The integration of sensory and motor rehabilitation into one therapy model might provide the added value of this therapy to improve sensorimotor performance post stroke. Insight in the behavioral and brain connectivity changes post therapy will lead to a better understanding of working mechanisms of therapy and will provide new knowledge for patient-tailored therapy approaches. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03236376 . Registered on 8 August 2017.

Association between site of lesion and driving performance after ischemic stroke.

BACKGROUND: Stroke presents with heterogeneous recovery periods, severity, and manifestation of deficits, all of which may adversely impact fitness-to-drive. Little is known about the association between site of lesion and driving performance after stroke. OBJECTIVE: To investigate the association between site of stroke lesion and driving performance. METHOD: Seventy-three participants (age = 56 ± 11 years; 66 men) underwent a detailed battery of visual, cognitive, and on-road tests to determine fitness-to-drive at about 10 months after ischemic stroke. Associations between stroke location and driving performance were calculated using rank biserial (r rb) correlation coefficients. Correlations were considered weak below 0.10, moderate between 0.10 and 0.49, and strong above 0.50. Wilcoxon rank sum tests were employed to discern differences in on-road driving performance between participants whose performance was of concern to the driving assessor and those who exhibited no major difficulties on the road. RESULTS: In all, 28 (38%) out of the 73 participants exhibited major difficulties on the road. Those who showed difficulties on the road performed worse in all driving skills (P < 0.05). Correlation analysis showed moderate to strong correlations between site of lesion and performance in several visual, cognitive and on-road tests. Lesions in the parietal lobe showed correlations ranging between 0.23 and 0.25 with driving skills including vehicle control and speed adaptations. Lesions in the occipital lobes correlated strongly with visual field (r rb = 0.53) and moderately with visual neglect (r rb = 0.28). CONCLUSIONS: Our results suggest that cortical lesions in the parietal and occipital lobes are associated with driving deficits after stroke. Further advances in our understanding of the neural correlates of driving performance may provide prognostic markers of fitness-to-drive and lead to early, targeted rehabilitation.