Consideration-of-concept of EvolvRehab-Body for upper limb virtual rehabilitation at home for people late after stroke.

OBJECTIVE: EvolvRehab-Body is a non-immersive virtual rehabilitation system that could provide high-dose, exercise-based upper limb therapy after stroke. This consideration-of-concept study investigated: adherence rate to prescribed repetitions; viability of repeated measures in preparation for a dose-articulation study; and preliminary signal of potential benefit. METHODS: Pre-post and repeated measures with people at least six months after stroke. Twelve-week intervention: exercise-based therapy via EvolvRehab-Body. Pre-post-intervention measures: Wolf Motor Function Test (WMFT); hand grip force. Repeated-during-intervention measures: Motricity Index (MI) and Action Research Arm Test (ARAT). ANALYSIS: adherence rate (%) to set repetitions; percentage of total possible measures collected; pre-to-post-intervention change estimated in relation to published minimally detectable changes of WMFT and hand grip force; and slope of plotted data for MI and ARAT (linear regression). RESULTS: Eight of twelve participants completed the 12-week intervention phase. Adherence: 88% (1710-9377 repetitions performed). Viability repeated measures: 88 of 96 (92%) ARAT and MI scores collected. Preliminary signal of potential benefit was observed in five participants but not always for the same measures. Three participants improved WMFT-time (-7.9 to -27.2 s/item), four improved WMFT-function (0.2-1.1 points/item), and nobody changed grip force. Slope of plotted data over the 12-week intervention ranged from: - 1.42 (p = 0.26) to 1.36 (p = 0.24) points-per-week for MI and - 0.30 (p = 0.40) to 1.71 (p < 0.001) points-per-week for ARAT. CONCLUSION: Findings of good adherence rate in home settings and preliminary signal of benefit for some participants gives support to proceed to a dose-articulation study. These findings cannot inform clinical practice. CONTRIBUTION OF THE PAPER.

A rule-based, dose-finding design for use in stroke rehabilitation research: methodological development.

BACKGROUND: Dose-optimisation studies as precursors to clinical trials are rare in stroke rehabilitation. OBJECTIVE: To develop a rule-based, dose-finding design for stroke rehabilitation research. DESIGN: 3+3 rule-based, dose-finding study. Dose escalation/de-escalation was undertaken according to preset rules and a mathematical sequence (modified Fibonacci sequence). The target starting daily dose was 50 repetitions for the first cohort. Adherence was recorded by an electronic counter. At the end of the 2-week training period, the adherence record indicated dose tolerability (adherence to target dose) and the outcome measure indicated dose benefit (10% increase in motor function). The preset increment/decrease and checking rules were then applied to set the dose for the subsequent cohort. The process was repeated until preset stopping rules were met. PARTICIPANTS: Participants had a mean age of 68 (range 48 to 81) years, and were a mean of 70 (range 9 to 289) months post stroke with moderate upper limb paresis. MODEL TASK: A custom-built model of exercise-based training to enhance ability to open the paretic hand. OUTCOME MEASURE: Repetitions per minute of extension/flexion of paretic digits against resistance. ANALYSIS: Usability of the preset rules and whether the maximally tolerated dose was identifiable. RESULTS: Five cohorts of three participants were involved. Discernibly different doses were set for each subsequent cohort (i.e. 50, 100, 167, 251 and 209 repetitions/day). The maximally tolerated dose for the model training task was 209 repetitions/day. CONCLUSIONS: This dose-finding design is a feasible method for use in stroke rehabilitation research.

Functional strength training and movement performance therapy produce analogous improvement in sit-to-stand early after stroke: early-phase randomised controlled trial.

OBJECTIVES: Restoring independence in the sit-to-stand (STS) task is an important objective for stroke rehabilitation. It is not known if a particular intervention, strength training or therapy focused on movement performance is more likely to improve STS recovery. This study aimed to compare STS outcomes from functional strength training, movement performance therapy and conventional therapy. DESIGN: Randomised controlled trial. SETTING: Acute stroke units. PARTICIPANTS: Medically well patients (n=93) with recent (<42 days) stroke. The mean age of patients was 68.8 years, mean time post ictus was 33.5 days, 54 (58%) were male, 20 showed neglect (22%) and 37 (40%) had a left-sided brain lesion. INTERVENTIONS: Six weeks of either conventional therapy, functional strength training or movement performance therapy. Subjects were allocated to groups on a random basis. MAIN OUTCOME MEASURES: STS ability, timing, symmetry, co-ordination, smoothness and knee velocity were measured at baseline, outcome (after 6 weeks of intervention) and follow-up (3 months after outcome). RESULTS: No significant differences were found between the groups. All three groups improved their STS ability, with 88% able to STS at follow-up compared with 56% at baseline. Few differences were noted in quality of movement, with only symmetry when rising showing significantly greater improvement in the movement performance therapy group; this benefit was not evident at follow-up. CONCLUSIONS: Recovery of the STS movement is consistently good during stroke rehabilitation, irrespective of the type of therapy experienced. Changes in quality of movement did not differ according to group allocation, indicating that the type of therapy is less important. Clinical trial registration number NCT00322192.

Electrostimulation for promoting recovery of movement or functional ability after stroke.

BACKGROUND: Electrostimulation might improve motor recovery after stroke by providing neuromuscular re-training. OBJECTIVES: To find if electrostimulation improved functional motor ability, and the ability to undertake activities of daily living. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched August 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), CINAHL (1982 to January 2004), AMED - Allied and Complementary Medicine Database (1985 to January 2004), Physiotherapy Evidence Database (PEDro), REHABDATA and the ISI Science Citation Index (1981 to 2003). We placed a request on the PHYSIO e-mail discussion list and contacted authors of relevant studies to elicit any unpublished or ongoing studies, searched the reference lists of included trials and contacted trialists. SELECTION CRITERIA: Randomised controlled trials of electrostimulation delivered to the peripheral neuromuscular system which was designed to improve voluntary movement control, functional motor ability and activities of daily living. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, assessed trial quality and extracted the data. MAIN RESULTS: Of the 2077 references identified, 24 trials were included in this review. For electrostimulation compared with no treatment this review found that electrostimulation improved some aspects of functional motor ability and some aspects of motor impairment and normality of movement. In addition, there was a significant difference in favour of no treatment compared with electrostimulation for an aspect of functional motor ability. For electrostimulation compared with placebo this review found that electrostimulation improved an aspect of functional motor ability. For electrostimulation compared with conventional physical therapy this review found that electrostimulation improved an aspect of motor impairment. There were no statistically significant differences between electrostimulation and control treatment for all other outcomes. However, these results need to be interpreted with reference to the following: (1) the majority of analyses only contained one trial; (2) variation was found between included trials in time after stroke, level of functional deficit, and dose of electrostimulation; and (3) the possibility of selection and detection bias in the majority of included trials. AUTHORS' CONCLUSIONS: At present, there are insufficient robust data to inform clinical use of electrostimulation for neuromuscular re-training. Research is needed to address specific questions about the type of electrostimulation that might be most effective, in what dose and at what time after stroke.

Development of a schedule of current physiotherapy treatment used to improve movement control and functional use of the lower limb after stroke: a precursor to a clinical trial.

OBJECTIVE: To develop a treatment schedule of physical therapy techniques used to improve movement control and functional use of the paretic lower limb after stroke in U.K. clinical centers to be involved in a subsequent clinical trial of experimental interventions given in addition to routine clinical practice. METHODS: Ten physiotherapists experienced in stroke rehabilitation who worked in or near the clinical centers to be involved in a subsequent clinical trial completed an individual semi-structured interview. The verbatim transcripts were condensed independently by 2 researchers into a draft list of interventions. The researchers then resolved disagreement through discussion and produced a preliminary list of interventions. At a focus group meeting, the participating physiotherapists discussed the preliminary list, refined it to produce a final list, and then transformed it into a draft treatment schedule. The draft treatment schedule was piloted in clinical practice. Refinements were made, and the final treatment schedule was produced. RESULTS: The treatment schedule consists of an A4 recording form with instructions and glossary of terms printed on the back. Each treatment record provides information including duration of treatment, treatment aims, and the 45 specific physical therapy interventions provided in the 11 sections (e.g., "splinting techniques" and "function - in sitting towards standing"). CONCLUSION: A treatment schedule was produced, which can now be used in a subsequent phase II evaluative trial.

Reliability of measurement of tempo-spatial parameters of gait after stroke using GaitMat II.

OBJECTIVE: (1) To find the inter-rater and intra-rater reliability of raters using GaitMat II to measure tempo-spatial gait parameters of stroke patients. (2) To find if reliability is related to abnormality of footprint patterns. DESIGN: A prospective agreement study. SETTING: A movement analysis laboratory. SUBJECTS: Nineteen adults who were at least six months after stroke and able to walk 4 metres with or without assistance participated as subjects in this study. There were five raters. METHODS: Subjects completed at least two walks along GaitMat II. The raw footprint data were analysed independently by each of the five raters. RESULTS: Mean intraclass correlation coefficients (ICCs) for each rater within subject ranged from 0.8398 to 0.9318. However eight of the 17 parameters tested showed significant differences between raters (p = 0.0029 to p < 0.0001). When the most inexperienced rater was excluded, differences between experienced raters (n = 4) was found to be statistically insignificant for all parameters. The association of the mean score and standard deviation of experienced raters was significant for nine parameters (r values 0.5087 to 0.9459), i.e., as walking pattern became more abnormal, variation in scoring between raters increased. CONCLUSIONS: GaitMat II may have acceptable inter-rater reliability if raters have experience of gait analysis but disagreement may increase when stroke patients exhibit more abnormal gait patterns.

A comparison of knee kinematic characteristics of stroke patients and age-matched healthy volunteers.

OBJECTIVE: To investigate which knee kinematic characteristics show the greatest differences between stroke patients with minimal residual disability and age-matched healthy volunteers as a first step towards the development of a sensitive, objective measure of performance of movement for use in the clinical setting. DESIGN: A comparative study. SETTING: A movement analysis laboratory. SUBJECTS: Ten patients between 6 and 12 months post stroke aged between 65 and 74 years and 10 age-matched healthy volunteers. All patients had made a good recovery and were able to complete all of the functional tasks. INTERVENTIONS: Each subject had reflective markers placed on anatomical landmarks and was filmed performing three movement tasks: sit-to-stand, walking, and step on block. MAIN OUTCOME MEASURES: Knee kinematic characteristics involving timing, joint angle and angular velocity at key points during each task. RESULTS: Significant differences were found between patients and volunteers for only some of the timing and joint angle characteristics but for all angular velocity characteristics for which the mean differences ranged from 31.85 degrees/s for sit-to-stand (p = 0.013) to 82.5 degrees/s (p = 0.014) for the swing phase of gait. CONCLUSIONS: These preliminary findings suggest that angular velocity of the knee during functional tasks might have potential as a sensitive, objective measure of performance of movement after stroke for patients with minimal residual disability.

Agreement between physiotherapists on quality of movement rated via videotape.

BACKGROUND: Although achieving quality of movement after stroke is an important aim of physiotherapy it is rarely measured objectively or described explicitly. OBJECTIVE: To test whether physiotherapists agree on a composite measure of quality of movement. SETTING; A movement analysis laboratory SUBJECTS: Ten stroke patients and 10 healthy age-matched volunteers. DESIGN: Prospective correlational. PROCEDURE: All subjects were videofilmed performing three trials of six standardized functional tasks. Two videotapes were made, each with a different randomized order of appearance of the trials. Ten senior physiotherapists independently rated the videotapes twice using a 100-mm visual analogue scale. ANALYSIS: Analysis of variance models were fitted to transformed data. Estimates of components of variance were calculated and presented as a percentage of the total variance for differences, within subjects (intra-subject), between raters (inter-rater) and within raters (intra-rater). An acceptable percentage was set at less than 10%. RESULTS: The percentage of intra-subject variance ranged from 1% (pick up box and walking) to 9% (step on block). The percentage of inter-rater variance ranged from 18% (pick up pencil) to 38% (sit to stand). The percentage of intra-rater variance was less than 1% for all tasks. CONCLUSIONS: Although physiotherapists disagreed with each other on quality of movement they were more consistent in their own scoring.

A hypothesis: self-propulsion in a wheelchair early after stroke might not be harmful.

BACKGROUND: There is often strong clinical resistance to patients self-propelling a wheelchair post stroke as this is believed to produce immediate increases in abnormal posture and movement. Research to support this viewpoint is limited. OBJECTIVE: To begin investigation of the immediate effects of self-propulsion on symmetrical sitting. DESIGN: Replicated single-case studies ABABA. SETTING: Movement analysis laboratory. SUBJECTS: Four patients, a maximum of eight weeks post stroke and six age-matched healthy volunteers. INTERVENTIONS: Subjects sat in the wheelchair during the A phases and self-propelled forwards during the B phases. The Manchester Active Position Seat (consists of 68 force transducers which transmit data at 10 Hz) measured the magnitude of peak force and the position of peak force on both sides of the seat. The mean symmetry index and standard deviation for each study phase were calculated and graphed for each subject. Interpretation was by visual inspection. RESULTS: Only one stroke patient and one volunteer increased asymmetry of magnitude of peak force following the two periods of self-propulsion. Only one of the stroke patients increased asymmetry of position of peak force following self-propulsion compared with three of the healthy volunteers. CONCLUSIONS: These results raise the hypothesis that self-propulsion early post stroke might not produce immediate detrimental effects on seated symmetry.

Measurement of sitting balance using the Manchester Active Position Seat (MAPS): a feasibility study.

BACKGROUND: Evaluation of the effectiveness of therapy to improve sitting balance has been hampered by the limited number of sensitive objective clinical measures. We developed the Manchester Active Position Seat (MAPS) to provide a portable system to track change in the position of centre of force over time. OBJECTIVES: (1) To investigate whether there is correspondence between the measurement of position change by a forceplate and by MAPS. (2) To explore whether and how MAPS measures changes in position when seated healthy adults change posture. DESIGN: A feasibility study. METHODS: (1) An adult subject sat on MAPS placed on top of a forceplate. The x and y coordinates of the centre of pressure recorded from the forceplate and centre of force from MAPS during movement were compared graphically. (2) Four adults sat on MAPS using a standardized starting position and moving into six sets of six standardized target postures in a predetermined randomized order. The absolute shift in centre of force from the starting position was calculated. RESULTS: (1) The pattern of change of position over time was similar for the forceplate and for MAPS although there was a measurement difference, which increased with distance from the centre. (2) The direction of change of position corresponded to the direction of movement to the target postures but the amount of change varied between subjects. CONCLUSIONS: MAPS shows promise as an objective clinical measure of sitting balance, but peripheral accuracy of measurement needs to be improved.

An exploration of the effects of weighted garments on balance and gait of stroke patients with residual disability.

OBJECTIVE: To explore the effects of weighted garments on the balance and gait of stroke patients. DESIGN: A pilot randomized controlled study with blinded measurement. SETTING: Weighted garments were worn by patients living in the community and measurement was made in a hospital-based gait laboratory. SUBJECTS: Twenty-four adults who were at least six months post stroke and were able to walk 10 metres with or without assistance or a walking aid. INTERVENTION: The six-week treatment-phase subjects were given a set of weighted garments which they were shown how to apply and instructed to wear on their paretic side. Subjects randomly allocated to the six-week control phase were not given any weighted garments. MAIN OUTCOME MEASURES: Balance was measured with the Berg Balance Scale. Gait was measured using GaitMat II, an instrumented walkway. Gait parameters of interest were velocity and symmetry of: step length; single support time; double support time; and support base width. Measures were made at baseline before randomization (baseline) and at the end of the six weeks of intervention (outcome). RESULTS: No statistically significant differences were found between the treatment and control groups at outcome for balance (Mann-Whitney U-test; p = 0.74), gait velocity (p = 0.68) or symmetry of gait parameters (p = 0.33 to p = 0.75). CONCLUSIONS: We found no evidence to support the clinical use of these weighted garments for stroke survivors.

Positioning for stroke patients: a survey of physiotherapists' aims and practices.

PURPOSE: The survey was undertaken to identify current physiotherapy practice for positioning patients in the first week following stroke. METHOD: A postal questionnaire comprised of closed questions, was sent to 674 physiotherapists identified as working with patients in the first week following stroke, who were employed in 155 randomly selected NHS Trusts throughout England. RESULTS: Response rate was 73%. Specific positions were recommended during the first week following stroke by 98 % of respondents. The most common aims of positioning were modulation of muscle tone (93%), preventing damage to affected limbs (92%) and supporting and stabilizing body segments (91%). The positions sitting in an armchair, side lying on the non-hemiplegic side and side lying on the hemiplegic side were recommended by 98%, 96% and 92% of respondents respectively. The components of the positions considered as 'most important' varied between positions, proximal components were usually preferred to distal components. CONCLUSION: Positioning is still an important part of physiotherapy practice and therefore requires evaluation. The positions used and the aims of positioning identified by clinicians accord with those in the literature. However, there is a lack of consensus regarding key components of the positions. The positions identified in this study should now be systematically evaluated for their ability to achieve different aims.

Unpacking the black box of nursing and therapy practice for post-stroke shoulder pain: a precursor to evaluation.

OBJECTIVES: To describe current nursing and therapy interventions for the prevention and treatment of post-stroke shoulder pain and to explore the extent of their reported use in England. DESIGN: Semi-structured, the med interviews followed by a postal questionnaire. PARTICIPANTS: Six nurses, five occupational therapists (OTs) and six physiotherapists (PTs) were interviewed. Twelve nurses, 12 OTs and 12 PTs were sent the pilot questionnaire and the main questionnaire was posted to 332 nurses, 332 OTs and 332 PTs. SETTING: NHS Trusts in England which provide acute stroke care/rehabilitation. PROCEDURE: Two researchers independently condensed the transcripts of the interviews into a list of interventions which were then transformed into a pilot postal questionnaire. Following the pilot small changes were made. Participants sent the main questionnaire were given three weeks to return it before being posted a reminder. After a further two weeks a researcher gave a telephone reminder. RESULTS: One hundred and seventy-five different types of interventions were identified. The main questionnaire (57.8% response rate) found that all of the interventions were used by at least one respondent and that only 22.9% of the interventions were used to the same extent by nurses, OTs and PTs. The data also suggest variation in reported use within professions. CONCLUSIONS: This study has found a large number of interventions for post-stroke shoulder pain which are reported to be used. This might reflect different causes of shoulder pain or variation between clinicians. Answers to these questions are expected to guide future evaluative research.

Reliability of a measure of post-stroke shoulder pain in patients with and without aphasia and/or unilateral spatial neglect.

OBJECTIVE: To determine the inter/intra-rater reliability of expert physiotherapists (PTs) measuring post-stroke shoulder pain with 100 mm vertical visual analogue scales (VAS; intensity, frequency and affective response) and a categorical site-of-pain scale. DESIGN: Three PTs independently rated subjects (normal clinical procedure but with a standardized starting position) on three days, at the same time of day, during one week in a randomized order determined by a nested latin square. Reliability for VAS scores was determined with the intraclass correlation coefficient (ICC) and for site-of-pain with the kappa statistic (kappa). Acceptable reliability was set at 0.75. The limits of agreement were also calculated. SETTING: Community. SUBJECTS: Thirty-three patients, mean time post stroke 42 months (range 7-360). RESULTS: Mean inter-rater reliability was 0.79 for intensity, 0.75 for frequency and 0.62 for affective response (ICC). The limits of agreement were wide and rater bias was significant for 6/27 ratings. Mean intra-rater reliability was 0.70 for intensity, 0.77 for frequency and 0.69 for affective response (ICC). For site-of-pain inter-rater reliability ranged from 0.156 (kappa) to 0.385 (kappa) and intrarater reliability ranged from 0.300 (kappa) to 0.559 (kappa). CONCLUSIONS: Although inter-rater reliability was acceptable for intensity and frequency there was a consistently large systematic bias between pairs of raters. Agreement might be improved if a standardized assessment procedure was used and/or if training in pain behaviour interpretation was provided.

The unreliability of clinical measures of muscle tone: implications for stroke therapy.

BACKGROUND: the central tenet of the neurofacilitatory approach to stroke therapy is that muscle tone needs to be normal before normal movement can occur. A reliable clinical measure of the full spectrum of muscle tone is needed to test: (i) the purported relationship between muscle tone, other motor impairments and disability, and (ii) the effectiveness of stroke therapy to restore movement. AIM: the purpose of the study was to test the inter-rater reliability of clinical categorization of muscle tone (spastic/normal/flaccid) and also a visual analogue scale with anchor points of 'lowest tone possible' (score 0) and 'highest tone possible' (score 100). METHODS: four independent raters assessed tone of elbow flexors and knee extensors of 14 stroke rehabilitation inpatients using the categorical scale. Six independent raters assessed tone of elbow flexors and knee extensors of 25 chronic stroke patients and two healthy volunteers using the visual analogue scale. All assessment orders were randomized. RESULTS: both scales were unreliable, with K coefficients for the categorical scale ranging from -0.046 to 0.56 for the categorical scale, and intra-class correlation coefficients for the visual analogue scale of 0.595 for elbow flexors and 0.451 for knee extensors. Assessment order effects for the visual analogue scale were non-significant for elbow flexors (P= 0.545) and knee extensors (P= 0.911). CONCLUSIONS: these results, and those of earlier studies, suggest that clinical measures of muscle tone are consistently unreliable. Systematic investigation of the therapy rationale for planning and evaluating treatment is required before relevant clinical measures can be developed.

The effect of body position on arterial oxygen saturation in acute stroke.

BACKGROUND: Evidence suggests that respiratory function is impaired poststroke. Body position is known to influence respiratory function in normal subjects and those with respiratory pathologies. Its effect on respiratory function after stroke has received little attention. However, one study suggests that some positions used in clinical practice may adversely influence respiratory function. This study therefore aimed to identify resting positions that maintain arterial oxygen saturation (SaO2) at optimal levels, changes in SaO2 during time spent in the test position, and differences in SaO2 among the positions investigated. METHOD: A within-subject, two-center clinical study was made. Patients in the first 72 hours following mild to moderately severe stroke were allocated a randomized sequence of four positions. One hour was spent in each position. SaO2 was recorded each minute by pulse oximetry with a finger probe. Mean values for the hour were calculated. RESULTS: Mean arterial oxygen saturation values for all patients were >90% for the hour spent in each test position for all patients. There were no changes in arterial oxygen saturation across the hour spent in the test positions (repeated-measures analysis of variance). No differences in arterial oxygen saturation were identified among positions (analysis of covariance). DISCUSSION: The saturation levels recorded corresponded to those observed in studies of normal elderly persons. The positions tested may be recommended for use in clinical practice to maintain arterial oxygen saturation in patients in the first 72 hours following mild to moderately severe stroke.

The feasibility of a kinematic measure of lip closure during meaningful speech.

PURPOSE: Assessment of dysarthria has traditionally been based on perceptual methods. The purpose of this study was to examine the feasibility of using 2D kinematic analysis to measure lip closure during normal speech. METHOD: Retroflective markers (4 mm diameter) were placed on the midline of each lip of three healthy male, caucasian volunteers aged 69 years who repeated the sentence 'My mother made me an apple and blackberry pie' six times. Videorecordings were analysed using the Ariel Performance Analysis System to calculate the distance between the lips before, during and after the sentence. RESULTS: The graphs produced from the data objectively measured the distance between the lips and identified the eight bilabial sounds. However, in spite of stringent study criteria to minimize differences linked to age, gender and race, differences were found between participants. CONCLUSION: Kinematic 2D analysis may have potential for the objective measurement of lip closure in dysarthria in the context of meaningful speech. These results justify further pilot work to explore: the possible variability within defined populations; and the usefulness of 2D kinematic analysis in the measurement of disordered lip closure in dysarthria.