Exploratory study of how Cognitive Multisensory Rehabilitation restores parietal operculum connectivity and improves upper limb movements in chronic stroke.

Cognitive Multisensory Rehabilitation (CMR) is a promising therapy for upper limb recovery in stroke, but the brain mechanisms are unknown. We previously demonstrated that the parietal operculum (parts OP1/OP4) is activated with CMR exercises. In this exploratory study, we assessed the baseline difference between OP1/OP4 functional connectivity (FC) at rest in stroke versus healthy adults to then explore whether CMR affects OP1/OP4 connectivity and sensorimotor recovery after stroke. We recruited 8 adults with chronic stroke and left hemiplegia/paresis and 22 healthy adults. Resting-state FC with the OP1/OP4 region-of-interest in the affected hemisphere was analysed before and after 6 weeks of CMR. We evaluated sensorimotor function and activities of daily life pre- and post-CMR, and at 1-year post-CMR. At baseline, we found decreased FC between the right OP1/OP4 and 34 areas distributed across all lobes in stroke versus healthy adults. After CMR, only four areas had decreased FC compared to healthy adults. Compared to baseline (pre-CMR), participants improved on motor function (MESUPES arm p = 0.02; MESUPES hand p = 0.03; MESUPES total score p = 0.006); on stereognosis (p = 0.03); and on the Frenchay Activities Index (p = 0.03) at post-CMR and at 1-year follow-up. These results suggest enhanced sensorimotor recovery post-stroke after CMR. Our results justify larger-scale studies.

A new bedside test of gestures in stroke: the apraxia screen of TULIA (AST).

BACKGROUND: Apraxia in patients with stroke may be overlooked, as clumsiness and deficient gestural communication are often attributed to frequently coexisting sensorimotor deficits and aphasia. Early and reliable detection of apraxia by a bedside test is relevant for functional outcome in patients with stroke. The present study was aimed at constructing a new bedside screening test for apraxia, called the Apraxia Screen of TULIA (AST), based on the comprehensive standardised Test for Upper-Limb Apraxia (TULIA). METHODS: First, an item-reduction analysis of the TULIA (48 gestures) was performed, based on the methods of classical test theory and on a larger sample of patients with stroke (n=133) and matched healthy controls (n=50). Stepwise elimination of items resulted in a set of 12 items, demonstrating high internal consistency (Cronbach alpha=0.92). The six-point scoring method of the TULIA was dichotomised to the score levels pass and fail. In the second part of this study the validity of the AST was assessed prospectively in a new cohort of patients with stroke (n=31) by using the Pearson correlation analysis and binary classification display with the TULIA. RESULTS AND DISCUSSION: Validation of the 12-item AST with the TULIA showed a remarkable diagnostic reliability with high specificity, sensitivity and positive predictive value, for the presence and severity of apraxia. The AST is shown to be a reliable and valid bedside test in patients with stroke, allowing a straightforward assessment of apraxia within a few minutes.

A systematic review of arm activity measures for children with hemiplegic cerebral palsy.

OBJECTIVE: To identify psychometrically sound and clinically feasible assessments of arm activities in children with hemiplegic cerebral palsy for implementation in research and clinical practice. DATA SOURCES: PubMed, CINAHL, Cochrane Library, Web of Science and reference lists of relevant articles were searched. REVIEW METHODS: A systematic search was performed based on the following inclusion criteria: (1) evaluative tools at the activity level according to the International Classification of Functioning, Disability and Health; (2) previously used in studies including children with hemiplegic cerebral palsy aged 2-18 years; (3) at least one aspect of reliability and validity in children with cerebral palsy should be established. Descriptive information, psychometric properties and clinical utility were reviewed. RESULTS: Eighteen assessments were identified of which 11 met the inclusion criteria: eight functional tests and three questionnaires. Five functional tests were condition-specific, three were generic. All functional tests measure different aspects of activity, including unimanual capacity and performance during bimanual tasks. The questionnaires obtain information about the child's abilities at home or school. The reliability and validity have been established, though further use in clinical trials is necessary to determine the responsiveness. CONCLUSIONS: To obtain a complete view of what the child can do and what the child actually does, we advise a capacity-based test (Melbourne Assessment of Unilateral Upper Limb Function), a performance-based test (Assisting Hand Assessment) and a questionnaire (Abilhand-Kids). This will allow outcome differentiation and treatment guidance for the arm in children with cerebral palsy.

Comprehensive assessment of gesture production: a new test of upper limb apraxia (TULIA).

BACKGROUND: Only few standardized apraxia scales are available and they do not cover all domains and semantic features of gesture production. Therefore, the objective of the present study was to evaluate the reliability and validity of a newly developed test of upper limb apraxia (TULIA), which is comprehensive and still short to administer. METHODS: The TULIA consists of 48 items including imitation and pantomime domain of non-symbolic (meaningless), intransitive (communicative) and transitive (tool related) gestures corresponding to 6 subtests. A 6-point scoring method (0-5) was used (score range 0-240). Performance was assessed by blinded raters based on videos in 133 stroke patients, 84 with left hemisphere damage (LHD) and 49 with right hemisphere damage (RHD), as well as 50 healthy subjects (HS). RESULTS: The clinimetric findings demonstrated mostly good to excellent internal consistency, inter- and intra-rater (test-retest) reliability, both at the level of the six subtests and at individual item level. Criterion validity was evaluated by confirming hypotheses based on the literature. Construct validity was demonstrated by a high correlation (r = 0.82) with the De Renzi-test. CONCLUSION: These results show that the TULIA is both a reliable and valid test to systematically assess gesture production. The test can be easily applied and is therefore useful for both research purposes and clinical practice.

Group physiotherapy improves time use by patients with stroke in rehabilitation.

Does feedback about the time use of patients with stroke influence the organisation of services in rehabilitation? An observation was made of the time use by 22 patients with stroke in a specialised rehabilitation unit, feedback was given to the staff, and another observation on 16 patients was made one year later. As a result of the first observation, the physiotherapy staff were urged to organise group sessions for patients with similar levels of disability, allowing practice with a higher patient to staff ratio. During the second observation, patients spent significantly more time on therapy (8%) and with their peers (25%). These results indicate that feedback about patients' time use can substantially influence management and consequently patients' behaviour in rehabilitation.

Time use of stroke patients in an intensive rehabilitation unit: a comparison between a Belgian and a Swiss setting.

PURPOSE: Functional improvement after stroke has been related to the intensity of treatment. The present study was set up to observe how stroke patients spend their time in a rehabilitation unit. METHOD: Behavioural mapping was performed throughout a full working day in a Belgian and Swiss stroke unit. RESULTS: Patients were most frequently involved in therapeutic activities, 28% of the day in Belgium and 45% in Switzerland. Physiotherapy accounted for the majority of the therapy time. The Belgian patients spent 27% of the day in their own room and Swiss patients 49% of the day. The most striking finding was that the Swiss patients spent nearly 1.5 hours per day more in therapy. CONCLUSIONS: Differences between the two settings could only partially be explained by more favourable patient-staff ratios in the Swiss setting. Autonomous practice, group therapy sessions and family involvement have to also be considered.

Predicting motor recovery of the upper limb after stroke rehabilitation: value of a clinical examination.

BACKGROUND AND PURPOSE: Only a few studies have been conducted to predict motor recovery of the arm after stroke. The aims of this study were to identify which clinical variables, assessed at different points in time, were predictive of motor recovery, and to construct useful regression equations. METHOD: One hundred consecutive stroke patients who had an obvious motor deficit of the upper limb were evaluated on entry to the study (two to five weeks post-stroke) and at two, six and 12 months after stroke. The Brunnström-Fugl-Meyer test was used as the outcome measure. Predictors included demographic data, overall disability, clinical neurological features, neuropsychological factors and secondary shoulder complications. RESULTS: In multiple regression analyses, motor performance was invariably retained as the predictive factor with the highest R-square. Other significant predictive variables were overall disability, muscle tone, proprioception and hemi-inattention. Between 53% and 89% of the total amount of variance was accounted for in all selected models. The accuracy of prediction from clinical measurement in the acute phase diminished as the time span of measurement of outcome increased. Similarly, assessment of the variables at two and six months, rather than in the acute stage, resulted in a considerable improvement in the percentage variance explained at 12 months. The highest accuracy was obtained when predictions were made step-by-step in time. CONCLUSIONS: It is possible to predict motor recovery of the upper limb accurately through the use of a few clinical measures. Predictive equations are proposed, the use of which are practicable in both clinical practice and research.