Feasibility and Preliminary Efficacy of Visual Cue Training to Improve Adaptability of Walking after Stroke: Multi-Centre, Single-Blind Randomised Control Pilot Trial.

OBJECTIVES: Given the importance of vision in the control of walking and evidence indicating varied practice of walking improves mobility outcomes, this study sought to examine the feasibility and preliminary efficacy of varied walking practice in response to visual cues, for the rehabilitation of walking following stroke. DESIGN: This 3 arm parallel, multi-centre, assessor blind, randomised control trial was conducted within outpatient neurorehabilitation services. PARTICIPANTS: Community dwelling stroke survivors with walking speed <0.8m/s, lower limb paresis and no severe visual impairments. INTERVENTION: Over-ground visual cue training (O-VCT), Treadmill based visual cue training (T-VCT), and Usual care (UC) delivered by physiotherapists twice weekly for 8 weeks. MAIN OUTCOME MEASURES: Participants were randomised using computer generated random permutated balanced blocks of randomly varying size. Recruitment, retention, adherence, adverse events and mobility and balance were measured before randomisation, post-intervention and at four weeks follow-up. RESULTS: Fifty-six participants participated (18 T-VCT, 19 O-VCT, 19 UC). Thirty-four completed treatment and follow-up assessments. Of the participants that completed, adherence was good with 16 treatments provided over (median of) 8.4, 7.5 and 9 weeks for T-VCT, O-VCT and UC respectively. No adverse events were reported. Post-treatment improvements in walking speed, symmetry, balance and functional mobility were seen in all treatment arms. CONCLUSIONS: Outpatient based treadmill and over-ground walking adaptability practice using visual cues are feasible and may improve mobility and balance. Future studies should continue a carefully phased approach using identified methods to improve retention. TRIAL REGISTRATION: Clinicaltrials.gov NCT01600391.

Recognising neuroplasticity in musculoskeletal rehabilitation: a basis for greater collaboration between musculoskeletal and neurological physiotherapists.

Evidence is emerging for central nervous system (CNS) changes in the presence of musculoskeletal dysfunction and pain. Motor control exercises, and potentially manual therapy, can induce changes in the CNS, yet the focus in musculoskeletal physiotherapy practice is conventionally on movement impairments with less consideration of intervention-induced neuroplastic changes. Studies in healthy individuals and those with neurological dysfunction provide examples of strategies that may also be used to enhance neuroplasticity during the rehabilitation of individuals with musculoskeletal dysfunction, improving the effectiveness of interventions. In this paper, the evidence for neuroplastic changes in patients with musculoskeletal conditions is discussed. The authors compare and contrast neurological and musculoskeletal physiotherapy clinical paradigms in the context of the motor learning principles of experience-dependent plasticity: part and whole practice, repetition, task-specificity and feedback that induces an external focus of attention in the learner. It is proposed that increased collaboration between neurological and musculoskeletal physiotherapists and researchers will facilitate new discoveries on the neurophysiological mechanisms underpinning sensorimotor changes in patients with musculoskeletal dysfunction. This may lead to greater integration of strategies to enhance neuroplasticity in patients treated in musculoskeletal physiotherapy practice.

Interventions for coordination of walking following stroke: systematic review.

Impairments in gait coordination may be a factor in falls and mobility limitations after stroke. Therefore, rehabilitation targeting gait coordination may be an effective way to improve walking post-stroke. This review sought to examine current treatments that target impairments of gait coordination, the theoretical basis on which they are derived and the effects of such interventions. Few high quality RCTs with a low risk of bias specifically targeting and measuring restoration of coordinated gait were found. Consequently, we took a pragmatic approach to describing and quantifying the available evidence and included non-randomised study designs and limited the influence of heterogeneity in experimental design and control comparators by restricting meta-analyses to pre- and post-test comparisons of experimental interventions only. Results show that physiotherapy interventions significantly improved gait function and coordination. Interventions involving repetitive task-specific practice and/or auditory cueing appeared to be the most promising approaches to restore gait coordination. The fact that overall improvements in gait coordination coincided with increased walking speed lends support to the hypothesis that targeting gait coordination gait may be a way of improving overall walking ability post-stroke. However, establishing the mechanism for improved locomotor control requires a better understanding of the nature of both neuroplasticity and coordination deficits in functional tasks after stroke. Future research requires the measurement of impairment, activity and cortical activation in an effort to establish the mechanism by which functional gains are achieved.

Feedback device for improvement of coordination of reach-to-grasp after stroke.

OBJECTIVE: To describe a novel feedback device (Grasp Rehabilitation Accessory for Stroke Patients [GRASP]) that gives feedback on the time lag between the start of hand opening and the start of transport during reach-to-grasp movements, and to report the results of a preliminary series of single case studies to assess the utility of the device for improving the coordination of arm and hand at the beginning of a reach-to-grasp movement. DESIGN: A multiple baseline design across 6 subjects was used, with each subject performing 40 repetitions of reaching to grasp a jar. Two subjects each performed 10, 15, or 20 randomly assigned baseline repetitions. SETTING: Physiotherapy department or at the participant's home. PARTICIPANTS: Participants with middle cerebral artery or parietal stroke (n=6) were consecutively recruited from physiotherapy departments. Additional inclusion criteria were a Rivermead Motor Assessment score of 5 or more and time between start of hand opening and transport of more than 60ms. INTERVENTIONS: During the intervention phase, feedback on time between start of transport and start of grasp was communicated via GRASP. Participants were encouraged to reduce the time. MAIN OUTCOME MEASURE: The outcome measure was the time between start of transport and start of grasp, measured with GRASP. RESULTS: All participants decreased the mean time lag during the intervention phase compared with the baseline phase. Participants 1 to 6 showed decreases of 35, 296, 34, 34, 1212, and 114ms, respectively. Two out of 6 participants demonstrated a significant decrease in time lag in the intervention compared with the baseline phase. CONCLUSIONS: GRASP is potentially beneficial as an adjunct to physiotherapy training of reach-to-grasp coordination after stroke.

Ability to adjust reach extent in the hemiplegic arm.

OBJECTIVE: Insufficient information exists about the ability of hemiparetic patients to adjust reach extent during early recovery from stroke. Further knowledge may suggest guidance for therapy intervention. The objective of this study was to investigate the ability of hemiparetic subjects to adjust reach extent within 6 months after stroke. DESIGN: Repeated-measures design experiment with two factors-group and target position. SETTING: Physiotherapy department. PARTICIPANTS: Nine hemiparetic and nine age- and gender-matched healthy subjects. METHODS: Participants performed 15 reaching movements in the sagittal plane, five to each target of 8, 13 and 18 cm from the starting position. MAIN OUTCOME MEASURES: Motion analysis was used to collect information on the kinematic variables of distance moved, movement duration, peak velocity, average velocity and the timing of peak velocity. These variables were compared between the different target positions and between groups. RESULTS: The stroke group demonstrated a longer movement duration, lower peak and average velocity, and a later time to peak velocity compared with the healthy group. In response to the change in target position, both groups increased peak velocity for each increase in target position with no significant increase in movement duration, and showed a longer deceleration phase for the 18-cm target position. There was no significant difference between scaling of distance moved and peak velocity to target position between the groups. However, stroke subjects tended to overshoot the closer target and undershoot the more distant targets. The mean difference between groups was 12 mm [95% confidence interval (CI): -17 to 50] for the 8-cm position, 5mm (95% CI: -34 to 23) for the 13-cm position, and 9 mm (95% CI: -39 to 22) for the 18-cm position. The difference in peak velocity between each target position was smaller in the stroke subjects compared with the healthy subjects. The mean difference between groups was 103 mm/second (95% CI: -171 to -34) for the 8-cm position, 157 mm/second (95% CI: -231 to -82) for the 13-cm position, and 171 mm/second (95% CI: -262 to -80) for the 18-cm position. CONCLUSIONS: Some aspects of the movement organisation of stroke subjects were similar to that of healthy subjects. However, stroke subjects showed errors in adjusting reach extent and velocity appropriately for different distances.

Use of information feedback and attentional focus of feedback in treating the person with a hemiplegic arm.

BACKGROUND AND PURPOSE: Feedback about motor performance can induce either an internal focus of attention (about body movement) or an external focus of attention (about the effects on the environment) in the learner. The main aim of this pilot study was to examine the attentional focus of feedback given by physiotherapists during treatment of the hemiplegic arm. A second aim was to examine the frequency of feedback about motor performance during treatment. METHOD: A multi-methods design was used (quantitative and qualitative). Eight physiotherapists and eight patients with stroke were recruited from two hospitals. Data were collected by video recordings of treatment, interviews (both therapists and patients) and questionnaire (therapists). Information feedback, instructions and motivational statements were identified from the video recordings. Feedback and instructions were further grouped into internal focus, external focus or mixed focus of attention. Themes were drawn from the interview transcripts. Triangulation was used to provide corroborating information from the different data sets. RESULTS: Two hundred and forty-six of the total 1914 statements identified in the videos were feedback, the rest comprising instructions and statements of motivation. Of the feedback statements, 236 of the total 247 identified had an internal focus. Therapist interviews and questionnaires revealed more external focus communication than actual treatment. CONCLUSIONS: Physiotherapists used instructions and statements of motivation more than feedback and directed the patient's attention more to body movement than movement effects. The outcome of this study may prompt clinicians' to examine the amount and the attentional focus of the feedback they use in their clinical practice, and to consider whether it is a most effective approach in light of current evidence.

Coordination between reaching and grasping in patients with hemiparesis and healthy subjects.

OBJECTIVE: To investigate the coordination of reach-to-grasp components in hemiparetic and healthy subjects. DESIGN: Split-plot repeated-measures design with 3 factors (group, object size, movement speed). SETTING: Movement laboratory. PARTICIPANTS: Twelve hemiparetic and 12 age-matched healthy subjects. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We used motion analysis to collect information on the kinematic variables of movement duration, peak velocity, peak deceleration, and maximum aperture, and the time of peak velocity, peak deceleration, and maximum aperture expressed as a percentage of movement duration during 32 reaching movements by each subject. We examined the coordination between the 2 components in 2 ways. First, we investigated the correlation between time of hand opening and start of hand transport, and between time of maximum aperture and time of peak deceleration. Second, we compared movements at preferred and fast speeds (manipulation of transport component) and to 2 different-sized cups (manipulation of grasp component). RESULTS: Both groups demonstrated a temporal coupling between grasp and transport components at the start of the reach and at the time of maximum aperture. Both groups increased the aperture of grasp for larger cups and increased the maximum grip aperture, and had a shorter deceleration phase for faster movements. The deceleration phase of the hemiparetic patients was longer than that of the healthy subjects, however, and the components were not as tightly coupled. CONCLUSIONS: The hemiparetic patients, who had a moderate amount of functional recovery, were similar to healthy subjects in their ability to control reach-to-grasp components. Their performance was not as skilled, however.

Extrinsic feedback for motor learning after stroke: what is the evidence?

PURPOSE: There is little guidance on using extrinsic feedback to enhance motor learning after stroke. This narrative review synthesises research findings and identifies questions remaining to be answered. METHOD: A summary is given relating to the use of extrinsic feedback in healthy subjects. Then, research concerning content of feedback, feedback scheduling, and attentional focus is discussed in relation to patients with stroke. RESULTS: Though research is scarce, preliminary key findings were as follows: Patients' balance performance can improve from receiving visual feedback about weight distribution during practice; auditory feedback of force production may improve performance of sit-to-stand; providing feedback on less than 100% of trials, and giving summary or average feedback may enhance learning; instructions or feedback inducing an external focus may be more effective than those with an internal focus. Further research is needed concerning the relative benefits of verbal, visual, video and kinematic feedback; reduced feedback frequencies and summary feedback schedules; feedback delays, error estimation, and self-controlled feedback; and attentional focus of feedback. CONCLUSIONS: Although there are some indications that feedback might enhance motor learning after stroke, there are many areas as yet not examined and there is clearly a need for considerable research in this area.

Motor control and the management of musculoskeletal dysfunction.

This paper aims to develop understanding of three important motor control issues--feedforward mechanisms, cortical plasticity and task-specificity and assess the implications for musculoskeletal practice. A model of control for the reach-to-grasp movement illustrates how the central nervous system integrates sensorimotor processes to control complex movements. Feedforward mechanisms, an essential element of motor control, are altered in neurologically intact patients with chronic neck pain and low back pain. In healthy subjects, cortical mapping studies using transcranial magnetic stimulation have demonstrated that neural pathways adapt according to what and how much is practised. Neuroplasticity has also been demonstrated in a number of musculoskeletal conditions, where cortical maps are altered compared to normal. Behavioural and neurophysiological studies indicate that environmental and task constraints such as the goal of the task and an object's shape and size, are determinants of the motor schema for reaching and other movements. Consideration of motor control issues as well as signs and symptoms, may facilitate management of musculoskeletal conditions and improve outcome. Practice of entire everyday tasks at an early stage and systematic variation of the task is recommended. Training should be directed with the aim of re-educating feedforward mechanisms where necessary and the amount of practice should be sufficient to cause changes in cortical activity.