Determinants of Different Aspects of Upper-Limb Activity after Stroke.

We examined factors associated with different aspects of upper-limb (UL) activity in chronic stroke to better understand and improve UL activity in daily life. Three different aspects of UL activity were represented by four sensor measures: (1) contribution to activity according to activity ratio and magnitude ratio, (2) intensity of activity according to bilateral magnitude, and (3) variability of activity according to variation ratio. We combined data from a Belgian and Danish patient cohort (n = 126) and developed four models to determine associated factors for each sensor measure. Results from standard multiple regression show that motor impairment (Fugl−Meyer assessment) accounted for the largest part of the explained variance in all sensor measures (18−61%), with less motor impairment resulting in higher UL activity values (p < 0.001). Higher activity ratio, magnitude ratio, and variation ratio were further explained by having the dominant hand affected (p < 0.007). Bilateral magnitude had the lowest explained variance (adjusted R2 = 0.376), and higher values were further associated with being young and female. As motor impairment and biological aspects accounted for only one- to two-thirds of the variance in UL activity, rehabilitation including behavioral strategies might be important to increase the different aspects of UL activity.

Prediction of Upper Limb use Three Months after Stroke: A Prospective Longitudinal Study.

BACKGROUND: A major goal of upper limb (UL) rehabilitation after stroke is to facilitate the use of the paretic arm in daily life activities. PURPOSE: To examine if UL impairment two weeks after stroke can predict real-life UL use at three months. Furthermore, to identify additional factors which contribute to future UL use, and characteristics of patients who do not achieve normal UL use. METHODS: This study included patients with stroke ≥ 18 years. UL impairment was assessed by Fugl-Meyer upper extremity motor assessment (FM). Use ratio between affected and unaffected UL was assessed with accelerometers at three months after stroke. The association between FM score and UL use ratio was investigated with linear regression models and adjusted for secondary variables. Non-normal use was examined by a logistic regression. RESULTS: Eighty-seven patients were included. FM score two weeks after stroke predicted 38% of the variance in UL use ratio three months after stroke. A multivariate regression model predicted 55%, and the significant predictors were FM, motor-evoked potential (MEP) status, and neglect. Non-normal use could be predicted with a high accuracy based on MEP and/or neglect. In a logistic regression sensitivity for prediction of non-normal use was 0.93 and specificity was 0.75. CONCLUSION: Better baseline capacity of the paretic UL predicted increased use of the arm and hand in daily life. Non-normal UL use could be predicted reliably based on the absence of MEPs and/or presence of neglect.

Cross-cultural adaptation of the Functional Ambulation Categories (FAC) in Danish patients with acquired brain injury.

PURPOSE: The Functional Ambulation Categories (FAC) is a measurement tool used to classify walking ability according to the amount of physical support required. In this study, the FAC is translated into Danish and the reliability and validity of the FAC are established in a population of patients with acquired brain injury (ABI). METHODS: The study took place in a neuro-rehabilitation setting. The translation process followed an accepted forward-backward translation method in six steps. For the assessment of clinometric properties a cross-sectional study design was applied. Interrater reliability was assessed with weighted Cohen's kappa. Construct validity of the FAC was assessed with Spearman's rho by correlating the FAC to walking velocity assessed with the 10-meter walk test and to the number of daily steps assessed with accelerometers. RESULTS: The FAC was successfully translated into Danish. For the assessment of clinometric properties, 53 patients were included. Almost perfect interrater reliability was found (κ = 0.92, p < 0.0001). Construct validity was high between FAC and walking velocity (r2 = 0.87, p < 0.0001) and moderate between FAC and the number of daily steps (r2 = 0.62, p < 0.0001). CONCLUSION: The Danish version of the FAC was found reliable and valid for use in-patients with ABI.

A systematic review on functional electrical stimulation based rehabilitation systems for upper limb post-stroke recovery.

Background: Stroke is one of the most common neurological conditions that often leads to upper limb motor impairments, significantly affecting individuals' quality of life. Rehabilitation strategies are crucial in facilitating post-stroke recovery and improving functional independence. Functional Electrical Stimulation (FES) systems have emerged as promising upper limb rehabilitation tools, offering innovative neuromuscular reeducation approaches. Objective: The main objective of this paper is to provide a comprehensive systematic review of the start-of-the-art functional electrical stimulation (FES) systems for upper limb neurorehabilitation in post-stroke therapy. More specifically, this paper aims to review different types of FES systems, their feasibility testing, or randomized control trials (RCT) studies. Methods: The FES systems classification is based on the involvement of patient feedback within the FES control, which mainly includes "Open-Loop FES Systems" (manually controlled) and "Closed-Loop FES Systems" (brain-computer interface-BCI and electromyography-EMG controlled). Thus, valuable insights are presented into the technological advantages and effectiveness of Manual FES, EEG-FES, and EMG-FES systems. Results and discussion: The review analyzed 25 studies and found that the use of FES-based rehabilitation systems resulted in favorable outcomes for the stroke recovery of upper limb functional movements, as measured by the FMA (Fugl-Meyer Assessment) (Manually controlled FES: mean difference = 5.6, 95% CI (3.77, 7.5), P < 0.001; BCI-controlled FES: mean difference = 5.37, 95% CI (4.2, 6.6), P < 0.001; EMG-controlled FES: mean difference = 14.14, 95% CI (11.72, 16.6), P < 0.001) and ARAT (Action Research Arm Test) (EMG-controlled FES: mean difference = 11.9, 95% CI (8.8, 14.9), P < 0.001) scores. Furthermore, the shortcomings, clinical considerations, comparison to non-FES systems, design improvements, and possible future implications are also discussed for improving stroke rehabilitation systems and advancing post-stroke recovery. Thus, summarizing the existing literature, this review paper can help researchers identify areas for further investigation. This can lead to formulating research questions and developing new studies aimed at improving FES systems and their outcomes in upper limb rehabilitation.

Is modified constraint-induced movement therapy more effective than bimanual training in improving arm motor function in the subacute phase post stroke? A randomized controlled trial.

OBJECTIVE: To compare the effect of modified constraint-induced movement therapy (mCIMT) to bimanual task-related training for patients in the subacute phase post stroke. DESIGN: A single-blinded randomized controlled trial. SETTINGS: Inpatient and outpatient rehabilitation clinics and the patient's home. SUBJECTS: Thirty patients in the subacute phase post stroke (2-16 weeks) were randomized to modified constraint-induced movement therapy with an emphasis on unimanual tasks, or bimanual task-related training, emphasizing bimanual tasks. All trained with a therapist 4 hours a week for four weeks, followed by a 2-3 hours daily self-training program. Patients in the modified constraint-induced movement therapy group were supposed to wear a restraining mitt on the unaffected hand for 4 hours a day for four weeks. MAIN MEASURES: Blinded assessments at pre and post treatment and after three months with Action Research Arm Test as a primary outcome measure, Nine-Hole Peg Test and Motor Activity Log. RESULTS: Power calculations suggested an inclusion of 60 patients, but due to recruitment difficulties the trial was stopped after an interim analysis at 30 patients. There was no difference in change (P > 0.05) between the groups on any of the measures, neither at post treatment nor at follow-up assessments. From pre-intervention to follow-up assessment the modified constraint-induced movement therapy group obtained a mean change score of 17.77 (14.66) on Action Research Arm Test, the bimanual group 15.47 (13.59). CONCLUSION: Bimanual training was as effective as modified constraint-induced movement therapy in improving arm motor function. Wearing a mitt seems unnecessary for most patients in the subacute phase post stroke when focused affected arm training is provided.

Recovery of upper extremity motor function post stroke with regard to eligibility for constraint-induced movement therapy.

PURPOSE: To examine eligibility for modalities such as constraint-induced movement therapy (CIMT) and modified CIMT (mCIMT) in the subacute phase after stroke and to define the share of patients who should be offered this treatment. METHODS: A prospective, repeated-measures design was used. A total of 100 consecutive patients with arm paresis 1 to 2 weeks post stroke were screened. Eligible for CIMT were patients who were cognitively intact, medically stable, and able to extend the wrist and 3 fingers 10° as a lower limit. The active range of motion was registered, and motor function was assessed by the Action Research Arm Test (ARAT) and the Nine Hole Peg Test at 1 to 2 weeks, 4 weeks, and 3 months post stroke. RESULTS: From 100 patients, 54 were excluded from motor assessment, mostly due to cognitive impairments. Of the remaining 46 patients, 21 (46%) were eligible according to motor function of the hand at 1 to 2 weeks post stroke, whereas in the other patients motor function was either too good or too poor. The share of patients eligible declined to 31% after 4 weeks and 15% after 3 months. Within 3 months, 60% reached reasonable dexterity, expressed by an ARAT score ≯ 51, all receiving standard rehabilitation. CONCLUSION: Results indicate that eligibility for CIMT or mCIMT should not be considered before 4 weeks post stroke because much improvement in arm function was shown to occur during the first month post stroke with standard rehabilitation.

Exploring physiotherapists' and occupational therapists' perceptions of the upper limb prediction algorithm PREP2 after stroke in a rehabilitation setting: a qualitative study.

OBJECTIVE: To explore how physiotherapists (PTs) and occupational therapists (OTs) perceive upper limb (UL) prediction algorithms in a stroke rehabilitation setting and identify potential barriers to and facilitators of their implementation. DESIGN: This was a qualitative study. SETTING: The study took place at a neurorehabilitation centre. PARTICIPANTS: Three to six PTs and OTs. METHODS: We conducted four focus group interviews in order to explore therapists' perceptions of UL prediction algorithms, in particular the Predict Recovery Potential algorithm (PREP2). The Consolidated Framework for advancing Implementation Research was used to develop the interview guide. Data were analysed using a thematic content analysis. Meaning units were identified and subthemes formed. Information gained from all interviews was synthesised, and four main themes emerged. RESULTS: The four main themes were current practice, perceived benefits, barriers and preconditions for implementation. The participants knew of UL prediction algorithms. However, only a few had a profound knowledge and few were using the Shoulder Abduction Finger Extension test, a core component of the PREP2 algorithm, in their current practice. PREP2 was considered a potentially helpful tool when planning treatment and setting goals. A main barrier was concern about the accuracy of the algorithm. Furthermore, participants dreaded potential dilemmas arising from having to confront the patients with their prognosis. Preconditions for implementation included tailoring the implementation to a specific unit, sufficient time for acquiring new skills and an organisation supporting implementation. CONCLUSION: In the present study, experienced neurological therapists were sceptical towards prediction algorithms due to the lack of precision of the algorithms and concerns about ethical dilemmas. However, the PREP2 algorithm was regarded as potentially useful.

Accuracy of the Upper Limb Prediction Algorithm PREP2 Applied 2 Weeks Poststroke: A Prospective Longitudinal Study.

BACKGROUND: The Predict Recovery Potential algorithm (PREP2) was developed to predict upper limb (UL) function early after stroke. However, assessment in the acute phase is not always possible. OBJECTIVE: To assess the prognostic accuracy of the PREP2 when applied in a subacute neurorehabilitation setting. METHODS: This prospective longitudinal study included patients ≥18 years old with UL impairment following stroke. Patients were assessed in accordance with the PREP2 approach. However, 2 main components, the shoulder abduction finger extension (SAFE) score and motor-evoked potentials (MEPs) were obtained 2 weeks poststroke. UL function at 3 months was predicted in 1 of 4 categories and compared with the actual outcome at 3 months as assessed by the Action Research Arm Test. The prediction accuracy of the PREP2 was quantified using the correct classification rate (CCR). RESULTS: Ninety-one patients were included. Overall CCR of the PREP2 was 60% (95% CI 50%-71%). Within the 4 categories, CCR ranged from the lowest value at 33% (95% CI 4%-85%) for the category Limited to the highest value at 78% (95% CI 43%-95%) for the category Poor. In the present study, the overall CCR was significantly lower (P < .001) than the 75% reported by the PREP2 developers. CONCLUSIONS: The low overall CCR makes PREP2 obtained 2 weeks poststroke unsuited for clinical implementation. However, PREP2 may be used to predict either excellent UL function in already well-recovered patients or poor UL function in patients with persistent severe UL paresis.