A randomized controlled pilot study to obtain the best estimate of the size of the effect of a thermoplastic resting splint on spasticity in the stroke-affected wrist and fingers.

OBJECTIVE: To obtain the best estimate of the size of the effect of a thermoplastic resting splint on spasticity in the stroke-affected upper limb. DESIGN: A randomized controlled intervention involving 14 adults affected by stroke,allocated to two groups. SETTING: Inpatient and outpatient rehabilitation departments. INTERVENTION: Following one week of baseline when neither group wore a splint, group 1 continued without a splint for week 2 and then wore a splint during week 3. Group 2 wore a splint during weeks 2 and 3. Both groups then wore a splint through weeks 4-7. MAIN MEASURES: A computerized torque apparatus was used to measure resistance at the wrist in newtons at every one-degree angle through the range of extension. Amount and rate of change in resistance was compared between the groups to obtain the best estimate of the size of the effect of splinting. RESULTS: Effect sizes were small and failed to reach the suggested smallest clinically worthwhile effect size for amount and rate of change in resistance in the short term. However, the average estimated size of the effect for rate of change with longer term splinting exceeded the smallest clinically worthwhile effect. CONCLUSIONS: These findings and the fact that confidence intervals overlapped the smallest clinically worthwhile size of the effect for amount and rate of change in both short and long term suggest that a study with a larger sample is warranted.

Training symmetry of weight distribution after stroke: a randomized controlled pilot study comparing task-related reach, Bobath and feedback training approaches.

OBJECTIVE: To determine (1) the most effective of three treatment approaches to retrain seated weight distribution long-term after stroke and (2) whether improvements could be generalized to weight distribution in standing. SETTING: Inpatient rehabilitation unit. DESIGN: Forty asymmetrical acute stroke subjects were randomly allocated to one of four groups in this pilot study. Changes in weight distribution were compared between the 10 subjects of each of three treatment groups (task-specific reach, Bobath, or Balance Performance Monitor [BPM] feedback training) and a no specific treatment control group. One week of measurement only was followed by two weeks of daily training sessions with the treatment to which the subject was randomly allocated. Measurements were performed using the BPM daily before treatment sessions, two weeks after cessation of treatment and 12 weeks post study. Weight distribution was calculated in terms of mean balance (percentage of total body weight) or the mean of 300 balance points over a 30-s data run. RESULTS: In the short term, the Bobath approach was the most effective treatment for retraining sitting symmetry after stroke (p = 0.004). Training with the BPM and no training were also significant (p = 0.038 and p = 0.035 respectively) and task-specific reach training failed to reach significance (p = 0.26). At 12 weeks post study 83% of the BPM training group, 38% of the task-specific reach group, 29% of the Bobath group and 0% of the untrained group were found to be distributing their weight to both sides. Some generalization of symmetry training in sitting to standing was noted in the BPM training group which appeared to persist long term. CONCLUSIONS: Results should be treated with caution due to the small group sizes. However, these preliminary findings suggest that it might be possible to restore postural symmetry in sitting in the early stages of rehabilitation with therapy that focuses on creating an awareness of body position.

Responses of the densely hemiplegic upper extremity to bilateral training.

OBJECTIVE: Recovery of movement in the densely hemiplegic upper extremity remains a problem after stroke. This study aimed to determine whether movement recovery could be improved in the hemiplegic arm with bilateral isokinematic training. METHODS: Within and between groups, planned comparisons investigated the effects of bilateral training on attempts at two movements by subjects with acute and chronic problems with one and two bilateral practice phases. Electromyographic (EMG) activity of middle deltoid and extensor carpi radialis longus in the hemiplegic arm was recorded during unilateral and bilateral isometric shoulder abduction and wrist extension. RESULTS: Small increases in muscle activity were demonstrated by both experimental and control subjects during most bilateral practices in both actions. However, these increases were not significantly different from the previous unilateral trial, and the bilateral effect failed to generalize to subsequent trials. Previous studies with less densely hemiplegic subjects had demonstrated generalization of improvements in movement patterns with bilateral training to unimanual actions of the densely hemiplegic arm. CONCLUSIONS: Extensive lesions may limit brain reorganization and recover of dense hemiplegia after stroke. Nonetheless, on the basis of findings from other studies in which functional improvements occurred in both acute and chronic severely stroke-affected subjects, outcome forecasting for the hemiplegic upper extremity should only eventuate after provision of practice under optimal learning conditions.

Can simultaneous bilateral movement involve the undamaged hemisphere in reconstruction of neural networks damaged by stroke?

Normalization of upper limb movement remains a difficult problem for a significant subpopulation of hemiplegic stroke patients. Clinical observations prompted investigation of a novel approach using simultaneous identical bilateral movements performed independently. We briefly report 12 controlled single-case experiments using multiple-baseline designs across three separate grasp/reach activities. Unilateral performance tests with the hemiplegic arm using the bilaterally trained actions demonstrated clinically and statistically significant improvements in movement patterns. These improvements were specific to the trained movement and well maintained. Using recent literature we develop a theoretical model proposing that bilateral simultaneous movement promotes interhemispheric disinhibition likely to allow reorganization by sharing of normal movement commands from the undamaged hemisphere. Disinhibition may also encourage recruitment of undamaged neurones to construct new task-relevant neural networks. The potential contribution of spared ipsilateral pathways in the damaged hemisphere, indirect corticospinal pathways and ipsilateral pathways from the undamaged hemisphere is discussed.