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.

Characterizing Touch Discrimination Impairment from Pooled Stroke Samples Using the Tactile Discrimination Test: Updated Criteria for Interpretation and Brief Test Version for Use in Clinical Practice Settings.

Somatosensory loss post-stroke is common, with touch sensation characteristically impaired. Yet, quantitative, standardized measures of touch discrimination available for clinical use are currently limited. We aimed to characterize touch impairment and re-establish the criterion of abnormality of the Tactile Discrimination Test (TDT) using pooled data and to determine the sensitivity and specificity of briefer test versions. Baseline data from stroke survivors (n = 207) and older neurologically healthy controls (n = 100) assessed on the TDT was extracted. Scores were re-analyzed to determine an updated criterion of impairment and the ability of brief test versions to detect impairment. Updated scoring using an area score was used to calculate the TDT percent maximum area (PMA) score. Touch impairment was common for the contralesional hand (83%) but also present in the ipsilesional hand (42%). The criterion of abnormality was established as 73.1 PMA across older adults and genders. High sensitivity and specificity were found for briefer versions of the TDT (25 vs. 50 trials; 12 or 15 vs. 25 trials), with sensitivity ranging between 91.8 and 96.4% and specificity between 72.5 and 95.0%. Conclusion: Updated criterion of abnormality and the high sensitivity and specificity of brief test versions support the use of the TDT in clinical practice settings.

Calibration of Impairment Severity to Enable Comparison across Somatosensory Domains.

Comparison across somatosensory domains, important for clinical and scientific goals, requires prior calibration of impairment severity. Provided test score distributions are comparable across domains, valid comparisons of impairment can be made by reference to score locations in the corresponding distributions (percentile rank or standardized scores). However, this is often not the case. Test score distributions for tactile texture discrimination (n = 174), wrist joint proprioception (n = 112), and haptic object identification (n = 98) obtained from pooled samples of stroke survivors in rehabilitation settings were investigated. The distributions showed substantially different forms, undermining comparative calibration via percentile rank or standardized scores. An alternative approach is to establish comparable locations in the psychophysical score ranges spanning performance from just noticeably impaired to maximally impaired. Several simulation studies and a theoretical analysis were conducted to establish the score distributions expected from completely insensate responders for each domain. Estimates of extreme impairment values suggested by theory, simulation and observed samples were consistent. Using these estimates and previously discovered values for impairment thresholds in each test domain, comparable ranges of impairment from just noticeable to extreme impairment were found. These ranges enable the normalization of the three test scales for comparison in clinical and research settings.

Measures of Maximal Tactile Pressures during a Sustained Grasp Task Using a TactArray Device Have Satisfactory Reliability and Concurrent Validity in People with Stroke.

Sensor-based devices can record pressure or force over time during grasping and therefore offer a more comprehensive approach to quantifying grip strength during sustained contractions. The objectives of this study were to investigate the reliability and concurrent validity of measures of maximal tactile pressures and forces during a sustained grasp task using a TactArray device in people with stroke. Participants with stroke (n = 11) performed three trials of sustained maximal grasp over 8 s. Both hands were tested in within- and between-day sessions, with and without vision. Measures of maximal tactile pressures and forces were measured for the complete (8 s) grasp duration and plateau phase (5 s). Tactile measures are reported using the highest value among three trials, the mean of two trials, and the mean of three trials. Reliability was determined using changes in mean, coefficients of variation, and intraclass correlation coefficients (ICCs). Pearson correlation coefficients were used to evaluate concurrent validity. This study found that measures of reliability assessed by changes in means were good, coefficients of variation were good to acceptable, and ICCs were very good for maximal tactile pressures using the average pressure of the mean of three trials over 8 s in the affected hand with and without vision for within-day sessions and without vision for between-day sessions. In the less affected hand, changes in mean were very good, coefficients of variations were acceptable, and ICCs were good to very good for maximal tactile pressures using the average pressure of the mean of three trials over 8 s and 5 s, respectively, in between-day sessions with and without vision. Maximal tactile pressures had moderate correlations with grip strength. The TactArray device demonstrates satisfactory reliability and concurrent validity for measures of maximal tactile pressures in people with stroke.

Pre-existing Comorbidity Burden and Patient Perceived Stroke Impact.

BACKGROUND: Pre-existing comorbidities can compromise recovery post-stroke. However, the association between comorbidity burden and patient-rated perceived impact has not been systematically investigated. To date, only observer-rated outcome measures of function, disability, and dependence have been used, despite the complexity of the impact of stroke on an individual. AIM: Our aim was to explore the association between comorbidity burden and patient-rated perceived impact and overall recovery, within the first-year post-stroke, after adjusting for stroke severity, age, and sex. METHODS: The sample comprised 177 stroke survivors from 18 hospitals throughout Australia and New Zealand. Comorbidity burden was calculated using the Charlson Comorbidity Index. Perceived impact and recovery were measured by the Stroke Impact Scale index and Stroke Impact Scale overall recovery scale. Quantile regression models were applied to investigate the association between comorbidity burden and perceived impact and recovery. RESULTS: Significant negative associations between the Charlson Comorbidity Index and the Stroke Impact Scale index were found at three months. At the .25 quantile, a one-point increase on the Charlson Comorbidity Index was associated with 6.80-points decrease on the Stroke Impact Scale index (95%CI: -11.26, -2.34; p = .003). At the median and .75 quantile, a one-point increase on the Charlson Comorbidity Index was associated, respectively, with 3.58-points decrease (95%CI: -5.62, -1.54; p = .001) and 1.76-points decrease (95%CI: -2.80, -0.73; p = .001) on the Stroke Impact Scale index. At 12 months, at the .25 and .75 quantiles, a one-point increase on the Charlson Comorbidity Index was associated, respectively, with 6.47-points decrease (95%CI: -11.05, -1.89; p = .006) and 1.26-points decrease (95%CI: -2.11, -0.42; p = .004) on the Stroke Impact Scale index. For the Stroke Impact Scale overall recovery measure, significant negative associations were found only at the median at three months and at the .75 quantile at 12 months. CONCLUSION: Comorbidity burden is independently associated with patient-rated perceived impact within the first-year post-stroke. The addition of patient-rated impact measures in personalized rehabilitation may enhance the use of conventional observer-rated outcome measures.

The Functional Tactile Object Recognition Test: A Unidimensional Measure With Excellent Internal Consistency for Haptic Sensing of Real Objects After Stroke.

INTRODUCTION: Our hands, with their exquisite sensors, work in concert with our sensing brain to extract sensory attributes of objects as we engage in daily activities. One in two people with stroke experience impaired body sensation, with negative impact on hand use and return to previous valued activities. Valid, quantitative tools are critical to measure somatosensory impairment after stroke. The functional Tactile Object Recognition Test (fTORT) is a quantitative measure of tactile (haptic) object recognition designed to test one's ability to recognize everyday objects across seven sensory attributes using 14 object sets. However, to date, knowledge of the nature of object recognition errors is limited, and the internal consistency of performance across item scores and dimensionality of the measure have not been established. OBJECTIVES: To describe the original development and construction of the test, characterize the distribution and nature of performance errors after stroke, and to evaluate the internal consistency of item scores and dimensionality of the fTORT. METHOD: Data from existing cohorts of stroke survivors (n = 115) who were assessed on the fTORT quantitative measure of sensory performance were extracted and pooled. Item and scale analyses were conducted on the raw item data. The distribution and type of errors were characterized. RESULTS: The 14 item sets of the fTORT form a well-behaved unidimensional scale and demonstrate excellent internal consistency (Cronbach alpha of 0.93). Deletion of any item failed to improve the Cronbach score. Most items displayed a bimodal score distribution, with function and attribute errors (score 0) or correct response (score 3) being most common. A smaller proportion of one- or two-attribute errors occurred. The total score range differentiated performance over a wide range of object recognition impairment. CONCLUSION: Unidimensional scale and similar factor loadings across all items support simple addition of the 14 item scores on the fTORT. Therapists can use the fTORT to quantify impaired tactile object recognition in people with stroke based on the current set of items. New insights on the nature of haptic object recognition impairment after stroke are revealed.

Measures of maximal tactile pressures of a sustained grasp task using a TactArray device have satisfactory reliability and validity in healthy people.

Objective: To investigate the reliability and the concurrent validity of maximal tactile pressures and forces of a sustained grasp task using a TactArray device in healthy adults.Methods: Healthy participants (n = 18, mean age: 62.2 ± 9.9 years) performed three repeat trials of sustained maximal grasp over 8 seconds. Both hands were tested in within-day and between-day sessions, with vision and without vision. Measures of maximal tactile pressures and forces were measured for the complete grasp duration (8s) and for the plateau phase (5s). Measures of maximal tactile pressures and forces were reported using the highest value among three repeat trials, the mean of two repeat trials, and the mean of three repeat trials. Reliability was determined using changes in mean, coefficients of variation and intraclass correlation coefficients (ICCs). Pearson correlation coefficients were used to evaluate concurrent validity.Results: Changes in mean were very good, coefficients of variation were good to acceptable and ICCs were very good to good for maximal tactile pressures using the highest value among three repeat trials and the mean of three repeat trials for the complete grasp duration (8s) and for the plateau phase (5s) in the dominant hand with and without vision and in the non-dominant hand without vision for within-day and between-day sessions. Maximal tactile pressures had moderate to large correlations with grip strength.Conclusion: The TactArray device demonstrates satisfactory reliability for maximal tactile pressures during a sustained grasp for within-day and between-day testing sessions in both hands. Validity was satisfactory with grip strength in both hands.

Comparing Participation Outcome Over Time Across International Stroke Cohorts: Outcomes and Methods.

OBJECTIVE: To enable a direct comparison of participation levels in the first year post-stroke, assessed by different outcome measures internationally. DESIGN: Two prospective stroke cohort studies following persons from stroke onset to 12 months post-stroke. SETTING: Community. PARTICIPANTS: Persons with stroke (N=495), not living at a nursing home, from Australia STroke imAging pRevention and Treatment-Prediction and Prevention to Achieve optimal Recovery Endpoints after stroke (START-PrePARE; n=100) and the Netherlands (Restore4stroke; n=395). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Activity Card Sort-Australia and Utrecht Scale for Evaluation of Rehabilitation-Participation. Activity domains were matched across measures to find common denominators and original scoring methods were recoded, hereby enabling a direct comparison of retained activities. RESULTS: Ninety-one (START-PrePARE) and 218 (Restore4stroke) persons with stroke were included for analyses. No major differences in background characteristics were observed between the cohorts; the Dutch cohort suffered from slightly more severe stroke. A higher level of participation was observed (radar charts) in the first months post-stroke for the Australian cohort than in the Dutch cohort, especially for unpaid work (P<.003). At 12 months post-stroke, participation levels were similar, without significant differences in retained activities using the defined common denominators (P>.003). CONCLUSIONS: An international comparison of actual activities that persons re-engage in in the first year post-stroke was achieved using a new method and recoding of data. High levels of participation were observed in both cohorts. Unpaid work showed different frequencies at 2-3 months, contributing to different trajectories over time across cultures. Important insights were gained. Although valuable information is inevitably lost with recoding, the approach may assist future studies on the harmonization of data across cohorts, particularly for 1 of the key outcomes of stroke: participation.

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.

Effects of Somatosensory Impairment on Participation After Stroke.

OBJECTIVE: Our objective was to determine the effect of loss of body sensation on activity participation in stroke survivors. METHOD: Participants (N = 268) were assessed at hospital admission for somatosensory and motor impairment using the National Institutes of Health Stroke Scale. Participation was assessed using the Activity Card Sort (ACS) in the postacute phase. Between-group differences in activity participation were analyzed for participants with and without somatosensory impairment and with or without paresis. RESULTS: Somatosensory impairment was experienced in 33.6% of the sample and paresis in 42.9%. ACS profiles were obtained at a median of 222 days poststroke. Somatosensory loss alone (z = 1.96, p = .048) and paresis in upper and lower limbs without sensory loss (z = 4.62, p < .001) influenced activity participation. CONCLUSION: Somatosensory impairment is associated with reduced activity participation; however, paresis of upper and lower limbs can mask the contribution of sensory loss.

Change in Functional Arm Use Is Associated With Somatosensory Skills After Sensory Retraining Poststroke.

OBJECTIVE: We investigated changes in functional arm use after retraining for stroke-related somatosensory loss and identified whether such changes are associated with somatosensory discrimination skills. METHOD: Data were pooled (N = 80) from two randomized controlled trials of somatosensory retraining. We used the Motor Activity Log to measure perceived amount of arm use in daily activities and the Action Research Arm Test to measure performance capacity. Somatosensory discrimination skills were measured using standardized modality-specific measures. RESULTS: Participants' arm use improved after somatosensory retraining (z = -6.80, p < .01). Change in arm use was weakly associated with somatosensation (tactile, ß = 0.31, p < .01; proprioception, ß = -0.17, p > .05; object recognition, ß = 0.13, p < .05). CONCLUSION: Change in daily arm use was related to a small amount of variance in somatosensory outcomes. Stroke survivors' functional arm use can increase after somatosensory retraining, with change varying among survivors.

An fMRI study of training voluntary smooth circular eye movements.

Despite a large number of recent studies, the promise of fMRI methods to produce valuable insights into motor skill learning has been restricted to sequence learning paradigms, or manual training paradigms where a relatively advanced capacity for sensory-motor integration and effector coordination already exists. We therefore obtained fMRIs from 16 healthy adults trained in a new paradigm that demanded voluntary smooth circular eye movements without a moving target. This aimed to monitor neural activation during two possible motor learning processes: (a) the smooth pursuit control system develops a new perceptual-motor relationship and successfully becomes involved in voluntary action in which it is not normally involved or (b) the saccadic system normally used for voluntary eye movement and which only exhibits linear action skill develops new dynamic coordinative control capable of smooth circular movement. Participants were able to improve within half an hour, typically demonstrating saccadic movement with progressively reduced amplitudes, which better approximated smooth circular movement. Activity in the inferior premotor cortex was significantly modulated and decreased during the progress of learning. In contrast, activations in dorsal premotor and parietal cortex along the intraparietal sulcus, the supplementary eye field and the anterior cerebellum did not change during training. Thus, the decrease of activity in inferior premotor cortex was critically related to the learning progress in visuospatial eye movement control.

The Right Supramarginal Gyrus Is Important for Proprioception in Healthy and Stroke-Affected Participants: A Functional MRI Study.

Human proprioception is essential for motor control, yet its central processing is still debated. Previous studies of passive movements and illusory vibration have reported inconsistent activation patterns related to proprioception, particularly in high-order sensorimotor cortices. We investigated brain activation specific to proprioception, its laterality, and changes following stroke. Twelve healthy and three stroke-affected individuals with proprioceptive deficits participated. Proprioception was assessed clinically with the Wrist Position Sense Test, and participants underwent functional magnetic resonance imaging scanning. An event-related study design was used, where each proprioceptive stimulus of passive wrist movement was followed by a motor response of mirror -copying with the other wrist. Left (LWP) and right (RWP) wrist proprioception were tested separately. Laterality indices (LIs) were calculated for the main cortical regions activated during proprioception. We found proprioception-related brain activation in high-order sensorimotor cortices in healthy participants especially in the supramarginal gyrus (SMG LWP z = 4.51, RWP z = 4.24) and the dorsal premotor cortex (PMd LWP z = 4.10, RWP z = 3.93). Right hemispheric dominance was observed in the SMG (LI LWP mean 0.41, SD 0.22; RWP 0.29, SD 0.20), and to a lesser degree in the PMd (LI LWP 0.34, SD 0.17; RWP 0.13, SD 0.25). In stroke-affected participants, the main difference in proprioception-related brain activation was reduced laterality in the right SMG. Our findings indicate that the SMG and PMd play a key role in proprioception probably due to their role in spatial processing and motor control, respectively. The findings from stroke--affected individuals suggest that decreased right SMG function may be associated with decreased proprioception. We recommend that clinicians pay particular attention to the assessment and rehabilitation of proprioception following right hemispheric lesions.

Intensive therapy following upper limb botulinum toxin A injection in young children with unilateral cerebral palsy: a randomized trial.

AIM: Botulinum toxin A (BoNT-A) combined with occupational therapy is effective in improving upper limb outcomes in children with unilateral cerebral palsy (CP). It is now essential to identify the most effective therapies following BoNT-A. Given the added burden for children and families, the aim of this study was to explore whether modified constraint-induced movement therapy (mCIMT) leads to sufficiently superior gains compared with bimanual occupational therapy (BOT) in young children with unilateral CP following BoNT-A injections. METHOD: In this randomized, controlled, evaluator-blinded trial, 34 children (20 males, 14 females; mean age 3y, SD 1y 4mo, range 18mo-6y) with unilateral CP were randomized using concealed allocation to one of two 8-week interventions. The experimental group (n=17) received BoNT-A and mCIMT. The comparison group (n=17) received BoNT-A and BOT. Participants were recruited from a physical rehabilitation clinic and randomized between August 2003 and May 2009. Primary outcome was measured using the Assisting Hand Assessment at 3 months. Secondary outcomes were measured at 3 months and 6 months using the Quality of Upper Extremity Skills Test, the Pediatric Evaluation of Disability Inventory, Canadian Occupational Performance Measure, and the Goal Attainment Scale. RESULTS: There were no clinically important differences between groups at baseline. Immediately following intervention, there was no evidence of a superior effect for BoNT-A + mCIMT as determined by the Assisting Hand Assessment (estimated mean difference [EMD] 0.81, upper 95% confidence limit 3.6; p=0.32) or secondary outcomes. However, both groups showed improvement over time (BoNT-A + mCIMT: EMD 2.7, 95% confidence interval [CI] 0.7-5.2; BONT-A + BOT: EMD 4.7, 95% CI 2.1-8.6). Follow-up at 6 months also demonstrated no superior effect for BoNT-A + mCIMT. INTERPRETATION: Following upper limb injection of BoNT-A, there was no evidence that mCIMT, despite the significantly increased intensity of the home programme, produced a superior effect across a range of outcomes compared with a structured programme of BOT in young children with unilateral CP.

Stress reactivity and the Hemodynamic Profile-Compensation Deficit (HP-CD) Model of blood pressure regulation.

Considering the central role of the concept of blood pressure reactivity to explanations of the influence of life stress in the pathogenesis of cardiovascular disease, it is important that the underlying psychophysiological determinants of blood pressure change are elucidated. Empirical evidence is reviewed concerning the utility of the Hemodynamic Profile-Compensation Deficit (HP-CD) Model (Gregg et al., 2002), which draws on physiological theory that explains blood pressure regulation as a dynamic compensatory relation between cardiac output and total peripheral resistance. Core constructs and quantitative features of the Model are explained, accompanied by a focussed review of the Model's application in reactivity studies of stress, lifestyle behaviours, laboratory-to-field generalisability, and personality differences. Although the available studies are relatively few in number, evidence of the Model's utility is promising. Application of the Model in further research could help to elucidate cardiovascular pathogenesis in ways not achievable through the study of blood pressure reactivity alone.

Translating CBT for voices into a program for carers: a pilot study.

BACKGROUND: The treatment of persisting psychotic symptoms with cognitive behavioural therapy (CBTp) is now established as an evidence-based treatment; however its availability remains limited. We piloted a novel CBTp skills-based group training program for carers. The aim was to reduce service users' auditory hallucinations severity through carers' use of basic CBTp methods in their regular interactions. METHOD: Eight carer-service user dyads and one carer-carer-service user triad participated. Carers attended the 10-week (25-hour) program, and completed measures of subjective burden and expressed emotion (EE) over a 30-week period that included a baseline phase prior to the training and implementation phase. Service users completed weekly interviews assessing voice symptomatology. Analyses were conducted for each dyad using time-series methods. RESULTS: The training program was rated highly. Improvements in symptoms and carer burden ranged from none to clinically significant across different dyads. Carer implementation of strategies was related to reduced symptoms in one dyad; reductions in EE were related to symptom improvements in two dyads. CONCLUSIONS: There may be benefits in training carers in behavioural and cognitive management of persisting hallucinations. Possible mechanisms for improvements in voice symptomatology include reduction in carers' EE, and carer implementation of strategies taught.

Frequency of discriminative sensory loss in the hand after stroke in a rehabilitation setting.

OBJECTIVE: Somatosensory loss following stroke is common, with negative consequences for functional outcome. However, existing studies typically do not include quantitative measures of discriminative sensibility. The aim of this study was to quantify the proportion of stroke patients presenting with discriminative sensory loss of the hand in the post-acute rehabilitation phase. DESIGN: Prospective cohort study of stroke survivors presenting for rehabilitation. PATIENTS: Fifty-one consecutive patients admitted to a metropolitan rehabilitation centre over a continuous 12-month period who met selection criteria. METHODS: Quantitative measures of touch discrimination and limb position sense, with high re-test reliability, good discriminative test properties and objective criteria of abnormality, were employed. Both upper limbs were tested, in counterbalanced order. RESULTS: Impaired touch discrimination was identified in the hand contralateral to the lesion in 47% of patients, and in the ipsilesional hand in 16%. Forty-nine percent showed impaired limb position sense in the contralesional limb and 20% in the ipsilesional limb. Sixty-seven percent demonstrated impairment of at least one modality in the contralesional limb. Ipsilesional impairment was less severe. CONCLUSION: Discriminative sensory impairment was quantified in the contralesional hand in approximately half of stroke patients presenting for rehabilitation. A clinically significant number also experienced impairment in the ipsilesional "unaffected" hand.

SENSe: Study of the Effectiveness of Neurorehabilitation on Sensation: a randomized controlled trial.

BACKGROUND: Sensory loss is common after stroke, with negative impact on exploration of the immediate environment, hand function, and return to daily activities. OBJECTIVE: To compare the effectiveness of a perceptual-learning based sensory discrimination program versus non-specific exposure to sensory stimuli via passive movements and grasping of common objects. METHODS: The authors conducted a randomized parallel-group controlled trial, with blinding of subjects, clinical assessors, and data analysts. Fifty subjects with impaired texture discrimination, limb position sense, and/or tactile object recognition (>6 weeks, median 48 weeks poststroke) were randomized to receive somatosensory discrimination training (n = 25) or repeated exposure to sensory stimuli (n = 25) in 60-minute sessions for a total of 10 hours. The primary outcome was change in a composite standardized somatosensory deficit (SSD) index following intervention. Follow-up was at 6 weeks and 6 months posttraining. RESULTS: Between-group comparisons revealed a significantly greater improvement in sensory capacity following sensory discrimination training, t(47) = 2.75, P = .004, 1-tailed; mean between-group change = 11.1 SSD; confidence interval 3.0 to 19.2. Improvements were maintained at 6 weeks and 6 months. CONCLUSION: Sensory discrimination training can achieve significant improvements in functional sensory discrimination capacity after stroke. The clinically oriented training achieved transfer of training effects to novel stimuli. Our findings provide support for introducing SENSe discrimination training in rehabilitation of sensory deficits after stroke.