Factors Influencing Real-World Use of the More-Affected Upper Limb After Stroke: A Scoping Review.

IMPORTANCE: Current interventions are limited in improving use of the more-affected upper limb in real-world daily occupations and functional independence poststroke. A comprehensive understanding of the factors influencing real-world upper limb use is required to develop interventions to improve functional independence poststroke. OBJECTIVE: To systematically review the factors that influence real-world use of the more-affected upper limb poststroke. DATA SOURCES: We searched MEDLINE, Embase, PsycINFO, and the Physiotherapy Evidence Database for English-language articles from 2012 to 2023. STUDY SELECTION AND DATA COLLECTION: Of 774 studies, we included 33 studies that had participants at least age 18 yr who exhibited upper limb impairments poststroke, objectively measured real-world upper limb use using a movement sensor, and measured factors affecting upper limb use. Two reviewers independently screened the abstracts. FINDINGS: The results were categorized by International Classification of Functioning, Disability and Health domains. Prominent factors were upper limb impairment; motor ability; functional independence; task type; hand dominance; stroke-related factors, including time since stroke; and perception of use of the more-affected upper limb. CONCLUSIONS AND RELEVANCE: Existing interventions primarily focus on upper limb impairments and motor ability. Our findings suggest that interventions should also incorporate other factors: task type (unilateral vs. bilateral), hand dominance, self-efficacy, and perception of more-affected limb use as active ingredients in improving real-world use of the more-affected upper limb poststroke. We also provide recommendations to use behavioral activation theory in designing an occupation-focused intervention to augment self-efficacy and confidence in use of the more-affected upper limb in daily occupations. Plain-Language Summary: In order to develop interventions to improve functional independence poststroke, occupational therapy practitioners must have a comprehensive understanding of the factors that influence real-world more-affected upper limb use. The study findings provide a set of distinct factors that practitioners can target separately or in combination to improve real-world use of the more-affected upper limb poststroke.

Transcranial random noise stimulation to augment hand function in individuals with moderate-to-severe stroke: A pilot randomized clinical trial.

Background: Interventions to recover upper extremity (UE) function after moderate-to-severe stroke are limited. Transcranial random noise stimulation (tRNS) is an emerging non-invasive technique to improve neuronal plasticity and may potentially augment functional outcomes when combined with existing interventions, such as functional electrical stimulation (FES). Objective: The objective of this study was to investigate the feasibility and preliminary efficacy of combined tRNS and FES-facilitated task practice to improve UE impairment and function after moderate-to-severe stroke. Methods: Fourteen individuals with UE weakness were randomized into one of two groups: 1) tRNS with FES-facilitated task practice, or 2) sham-tRNS with FES-facilitated task practice. Both groups involved 18 intervention sessions (3 per week for 6 weeks). tRNS was delivered at 2 mA current between 100-500 Hz for the first 30 minutes of FES-facilitated task practice. We evaluated the number of sessions completed, adverse effects, participant satisfaction, and intervention fidelity between the two therapists. UE impairment (Fugl-Meyer Upper Extremity, FMUE), function (Wolf Motor Function Test, WMFT), participation (Stroke Impact Scale hand score, SIS-H), and grip strength were assessed at baseline, within 1 week and 3 months after completing the intervention. Results: All participants completed the 18 intervention sessions. Participants reported minimal adverse effects (mild tingling in head). The two trained therapists demonstrated 93% adherence and 96% competency with the intervention protocol. FMUE and SIS-H improved significantly more in the tRNS group than in the sham-tRNS group at both timepoints (p≤0.05), and the differences observed exceeded the clinically meaningful differences for these scores. The WMFT and paretic hand grip strength improved in both groups after the intervention (p≤0.05), with no significant between group differences. Conclusion: Our findings show for the first time that combining tRNS and FES-facilitated task practice is a feasible and promising approach to improve UE impairment and function after moderate-to-severe stroke.