Developing Patient-Centered Preventative Care to Reduce Mobility Disability With Aging: Preferences From a Discrete Choice Experiment.

BACKGROUND AND PURPOSE: Mobility disability is the most prevalent form of disability for older adults in the United States. A physical therapy mobility checkup (MC) under development is a patient-centered preventative physical therapy visit. It includes physical performance testing and education on physical performance as a valuable and modifiable health indicator. The purpose of this study was to identify the proportion of older adults willing to participate in an MC, the age at which they would initiate care, their desired frequency of participation, and the characteristics, or attributes, of the MC they preferred. METHODS: In a cross-sectional study conducted at the Minnesota State Fair, adults older than 55 years answered survey questions about preventative health practices and completed a discrete choice experiment (DCE) to determine their preferences for the MC. Attributes studied in the DCE were visit duration, checkup content, education, and possible outcomes of participating in preventative care for mobility. Descriptive statistics characterized demographic information and survey responses. Conjoint choice modeling estimated the main effect for each DCE attribute. RESULTS AND DISCUSSION: One hundred sixty-six older adults participated in the study. Seventy-eight percent indicated that they would choose an MC if available. Most participants (66%) believed that MCs should occur before 60 years of age and at least annually (68%). A 30-minute visit duration, which accounted for 84% of attribute importance, was preferred. Balance, the preferred content of the MC, accounted for 12% of the attribute importance. Preferences for educational content and possible outcomes of participation with preventative care aimed at preventing mobility loss were not statistically significant. CONCLUSION: Older adults value preventative care for reducing mobility disability. They identified time efficiency and the inclusion of measures to assess balance as priorities for this preventative physical therapy visit.

A cross-sectional methodological study: evaluation of the examiner performance on the Dix-Hallpike test.

PURPOSE: The Dix-Hallpike test is recommended to diagnose Benign Paroxysmal Positional Vertigo (BPPV). This research aimed to quantify the movement of a healthy subject during the Dix-Hallpike test and determine what factors contribute to performance variation from the recommended head position with 20° cervical extension, 45° cervical rotation, and a brisk movement velocity. MATERIALS AND METHODS: Examiners performed the Dix-Hallpike test 10 times. The examinee's movement was recorded with Qualisys and processed with Visual3D. The proportion of variation in test performance within examiners, between examiners, and due to examiner position was calculated. RESULTS: Thirteen participants, 54% male and mean age 40, performed 50 cranial and 77 lateral Dix-Hallpike tests. Head position differed significantly from the recommendations with the cranial tests for extension (mean difference [MD] = 11.6°, p < 0.001) and rotation (MD = 4.8°, p < 0.001) and with lateral tests for extension (MD = 13.3°, p < 0.001). The largest proportion of variation was between examiners (60-91%), followed by within-examiners (3-16%). The examiner position contributed to 20% of the variation in the cervical rotation achieved. Tests lasted, on average, 1.80 s. CONCLUSIONS: Differences within and between examiners visually estimating the Dix-Hallpike test endpoints may impede BPPV diagnosis accuracy.

Vertigo diagnosis with the Dix-Hallpike may be improved by reducing inter-examiner differences with head positioning and velocity.With Dix-Hallpike testing, examiners should consider a cranial orientation relative to the examinee to better achieve the recommended head positioning.The cranial Dix-Hallpike and encouraging briskness as tolerated by the examinee should be emphasized with teaching the maneuver.

Tactile Sensation Improves Following Motor Rehabilitation for Chronic Stroke: The VIGoROUS Randomized Controlled Trial.

Background. Up to 85% of people with chronic stroke experience somatosensory impairment, which contributes to poor sensorimotor control and non-use of the affected limb. Neurophysiological mechanisms suggest motor rehabilitation may improve tactile sense post-stroke, however, somatosensory recovery has rarely been reported in controlled trials. Objective. To compare the effect of four upper limb motor rehabilitation programs on the recovery of tactile sensation in adults with chronic stroke. Methods. Adults with chronic stroke and mild or moderate upper extremity hemiparesis (n = 167) were enrolled in a multi-site randomized controlled trial. Participants completed three weeks of gaming therapy, gaming therapy with additional telerehabilition, Constraint-Induced Movement therapy, or traditional rehabilitation. Here, we report the results of a secondary outcome, tactile sensation, measured with monofilaments, before and after treatment, and 6 months later. Results. A mixed-effects general linear model revealed similar positive change in tactile sensitivity regardless of the type of training. On average, participants were able to detect a stimulus that was 32% and 33% less after training and at 6-month follow-up, respectively. One-third of participants experienced recategorization of their level of somatosensory impairment (e.g., regained protective sensation) following training. Poorer tactile sensation at baseline was associated with greater change. Conclusions. About one-third of individuals with mild/moderate chronic hemiparesis experience sustained improvements in tactile sensation following motor rehabilitation, regardless of the extent of tactile input in the rehabilitation program. Potential for sensory improvement is an additional motivator for those post-stroke. Characteristics of those who improve and mechanisms of improvement are important future questions. Clinicaltrials.gov NCT02631850.

Observational Study of Neuroimaging Biomarkers of Severe Upper Limb Impairment After Stroke.

BACKGROUND AND OBJECTIVES: It is difficult to predict post-stroke outcome for people with severe motor impairment, as both clinical tests and corticospinal tract (CST) microstructure may not reliably indicate severe motor impairment. Here, we test whether imaging biomarkers beyond the CST relate to severe upper limb impairment post-stroke by evaluating white matter microstructure in the corpus callosum (CC). In an international, multisite hypothesis-generating observational study we determined if: a) CST asymmetry index can differentiate between individuals with mild-moderate and severe upper limb impairment; and b) CC biomarkers relate to upper limb impairment within individuals with severe impairment post-stroke. We hypothesised that CST asymmetry index would differentiate between mild-moderate and severe impairment, but CC microstructure would relate to motor outcome for individuals with severe upper limb impairment. METHODS: Seven cohorts with individual diffusion imaging and motor impairment (Fugl Meyer-Upper Limb) data were pooled. Hand-drawn regions-of-interest were used to seed probabilistic tractography for CST (ipsilesional/contralesional) and CC (prefrontal/premotor/motor/sensory/posterior) tracts. Our main imaging measure was mean fractional anisotropy. Linear mixed-effect regression explored relationships between candidate biomarkers and motor impairment, controlling for observations nested within cohorts, as well as age, sex, time post-stroke and lesion volume. RESULTS: Data from 110 individuals (30 mild-moderate, 80 with severe motor impairment) were included. In the full sample, greater CST asymmetry index (i.e., lower fractional anisotropy in the ipsilesional hemisphere, p<.001) and larger lesion volume (p=.139) were negatively related to impairment. In the severe subgroup, CST asymmetry index was not reliably associated with impairment across models. Instead, lesion volume and CC microstructure explained impairment in the severe group beyond CST asymmetry index (p's<.010). CONCLUSIONS: Within a large cohort of individuals with severe upper limb impairment, CC microstructure related to motor outcome post-stroke. Our findings demonstrate that CST microstructure does relate to upper limb outcome across the full range of motor impairment but was not reliably associated within the severe subgroup. Therefore, CC microstructure may provide a promising biomarker for severe upper limb outcome post-stroke, which may advance our ability to predict recovery in people with severe motor impairment after stroke.

A Physical Therapy Mobility Checkup for Older Adults: Feasibility and Participant Preferences From a Discrete Choice Experiment.

PURPOSE: Physical performance measures, like walking speed, identify and predict preclinical mobility disability but are rarely used in routine medical care. A preventive model of care called Mobility Checkup is being designed to reduce mobility disability in older adults. This study had two purposes: 1) determine feasibility and outcomes of the Mobility Checkup, and 2) identify preferences of older adults regarding this model of care using a discrete choice experiment. METHODS: Adults over 55 years of age were recruited from the community. In the study's first phase, participants completed a Mobility Checkup, with feasibility evaluated using 6 criteria. In the second phase, a new sample of older adults (>55 years old) were educated about the Mobility Checkup and then completed a discrete choice experiment to determine their preferences regarding 4 attributes of this care model: cost, visit duration, desired education topic, and style of educational graphic. RESULTS: Each study phase was completed by 31 participants. Of the 6 feasibility criteria, 5 were met. Visit duration exceeded the 60-minute criteria for 13 of the 31 participants. Still, 91% of participants were very satisfied with the Mobility Checkup. Ability to transition positions identified preclinical mobility disability most frequently. A 30-minute visit with no out-of-pocket cost was deemed preferred. CONCLUSIONS: Older adults value knowing what physical performance measurements predict about their general health. Transitions should be evaluated as part of a Mobility Checkup for older adults. Clearly conveyed cost of health care service is important to older adult consumers.

Video game rehabilitation for outpatient stroke (VIGoROUS): A multi-site randomized controlled trial of in-home, self-managed, upper-extremity therapy.

BACKGROUND: Integrating behavioral intervention into motor rehabilitation is essential for improving paretic arm use in daily life. Demands on therapist time limit adoption of behavioral programs like Constraint-Induced Movement (CI) therapy, however. Self-managed motor practice could free therapist time for behavioral intervention, but there remains insufficient evidence of efficacy for a self-management approach. METHODS: This completed, parallel, five-site, pragmatic, single-blind trial established the comparative effectiveness of using in-home gaming self-management as a vehicle to redirect valuable therapist time towards behavioral intervention. Community-dwelling adults with post-stroke (>6 months) mild/moderate upper extremity hemiparesis were randomized to receive one of 4 different interventions over a 3-week period: 5 h of behaviorally-focused intervention plus gaming self-management (Self-Gaming), the same with additional behaviorally-focused telerehabilitation (Tele-Gaming), 5 h of Traditional motor-focused rehabilitation, or 35 h of CI therapy. Primary outcomes assessed everyday arm use (Motor Activity Log Quality of Movement, MAL) and motor speed/function (Wolf Motor Function Test, WMFT) immediately before treatment, immediately after treatment, and 6 months later. Intent-to-treat analyses were implemented with linear mixed-effects models on data gathered from March 15, 2016 to November 21, 2019. ClinicalTrials.gov, NCT02631850. RESULTS: Of 193 enrolled participants, 167 began treatment and were analyzed, 150 (90%) completed treatment, and 115 (69%) completed follow-up. Tele-Gaming and Self-Gaming produced clinically meaningful MAL gains that were 1·0 points (95% CI 0·8 to 1·3) and 0·8 points (95% CI 0·5 to 1·0) larger than Traditional care, respectively. Self-Gaming was less effective than CI therapy (-0·4 points, 95% CI -0·6 to -0·2), whereas Tele-Gaming was not (-0·2 points, 95% CI -0·4 to 0·1). Six-month retention of MAL gains across all groups was 57%. All had similar clinically-meaningful WMFT gains; six-month retention of WMFT gains was 92%. INTERPRETATION: Self-managed motor-gaming with behavioral telehealth visits has outcomes similar to in-clinic CI therapy. It addresses most access barriers, requiring just one-fifth as much therapist time that is redirected towards behavioral interventions that enhance the paretic arm's involvement in daily life. FUNDING: PCORI, NIH.

A Standardized Method for Measurement of Elbow Kinesthesia.

Proprioception is an important component of controlled movement. The threshold to detection of passive movement (TDPM) is a commonly used method for quantifying the proprioceptive submodality of kinesthesia in research settings. The TDPM paradigm has been found to be valid and reliable; however, the equipment and methods used for TDPM vary between studies. In particular, the research laboratory apparatuses for producing passive movement of an extremity are often custom designed by individual laboratories or inaccessible due to high cost. There is a need for a standardized, valid, and reliable method for measuring TDPM using readily available equipment. The purpose of this protocol is to provide a standardized method for measurement of TDPM at the elbow that is economical, easy to administer, and that produces quantitative results for measurement purposes in research-based settings. This method was tested on 20 healthy adults without neurological impairment, and eight adults with chronic stroke. The results obtained suggest this method is a reliable way to quantify elbow TDPM in healthy adults, and provides initial support for validity. Researchers seeking a balance between equipment affordability and measurement precision are most likely to find this protocol of benefit.

The Effect of Priming on Outcomes of Task-Oriented Training for the Upper Extremity in Chronic Stroke: A Systematic Review and Meta-analysis.

Background. Priming results in a type of implicit memory that prepares the brain for a more plastic response, thereby changing behavior. New evidence in neurorehabilitation points to the use of priming interventions to optimize functional gains of the upper extremity in poststroke individuals. Objective. To determine the effects of priming on task-oriented training on upper extremity outcomes (body function and activity) in chronic stroke. Methods. The PubMed, CINAHL, Web of Science, EMBASE, and PEDro databases were searched in October 2019. Outcome data were pooled into categories of measures considering the International Classification Functional (ICF) classifications of body function and activity. Means and standard deviations for each group were used to determine group effect sizes by calculating mean differences (MDs) and 95% confidence intervals via a fixed effects model. Heterogeneity among the included studies for each factor evaluated was measured using the I2 statistic. Results. Thirty-six studies with 814 patients undergoing various types of task-oriented training were included in the analysis. Of these studies, 17 were associated with stimulation priming, 12 with sensory priming, 4 with movement priming, and 3 with action observation priming. Stimulation priming showed moderate-quality evidence of body function. Only the Wolf Motor Function Test (time) in the activity domain showed low-quality evidence. However, gains in motor function and in use of extremity members were measured by the Fugl-Meyer Assessment (UE-FMA). Regarding sensory priming, we found moderate-quality evidence and effect size for UE-FMA, corresponding to the body function domain (MD 4.77, 95% CI 3.25-6.29, Z = 6.15, P < .0001), and for the Action Research Arm Test, corresponding to the activity domain (MD 7.47, 95% CI 4.52-10.42, Z = 4.96, P < .0001). Despite the low-quality evidence, we found an effect size (MD 8.64, 95% CI 10.85-16.43, Z = 2.17, P = .003) in movement priming. Evidence for action observation priming was inconclusive. Conclusion. Combining priming and task-oriented training for the upper extremities of chronic stroke patients can be a promising intervention strategy. Studies that identify which priming techniques combined with task-oriented training for upper extremity function in chronic stroke yield effective outcomes in each ICF domain are needed and may be beneficial for the recovery of upper extremities poststroke.

Correction to: Effect of aerobic exercise prior to modified constraint-induced movement therapy outcomes in individuals with chronic hemiparesis: a study protocol for a randomized clinical trial.

Following publication of the original article [1], the authors reported an error in Table 2 wherein the item numbering in the first column is wrong.

Predicting Improved Daily Use of the More Affected Arm Poststroke Following Constraint-Induced Movement Therapy.

BACKGROUND: Constraint-induced movement therapy (CI therapy) produces, on average, large and clinically meaningful improvements in the daily use of a more affected upper extremity in individuals with hemiparesis. However, individual responses vary widely. OBJECTIVE: The study objective was to investigate the extent to which individual characteristics before treatment predict improved use of the more affected arm following CI therapy. DESIGN: This study was a retrospective analysis of 47 people who had chronic (> 6 months) mild to moderate upper extremity hemiparesis and were consecutively enrolled in 2 CI therapy randomized controlled trials. METHODS: An enhanced probabilistic neural network model predicted whether individuals showed a low, medium, or high response to CI therapy, as measured with the Motor Activity Log, on the basis of the following baseline assessments: Wolf Motor Function Test, Semmes-Weinstein Monofilament Test of touch threshold, Motor Activity Log, and Montreal Cognitive Assessment. Then, a neural dynamic classification algorithm was applied to improve prognostic accuracy using the most accurate combination obtained in the previous step. RESULTS: Motor ability and tactile sense predicted improvement in arm use for daily activities following intensive upper extremity rehabilitation with an accuracy of nearly 100%. Complex patterns of interaction among these predictors were observed. LIMITATIONS: The fact that this study was a retrospective analysis with a moderate sample size was a limitation. CONCLUSIONS: Advanced machine learning/classification algorithms produce more accurate personalized predictions of rehabilitation outcomes than commonly used general linear models.

Effect of aerobic exercise prior to modified constraint-induced movement therapy outcomes in individuals with chronic hemiparesis: a study protocol for a randomized clinical trial.

BACKGROUND: Recovery of upper limb function in individuals after a stroke remains challenging. Modified constraint-induced movement therapy (m-CIMT) has strong evidence for increasing the use and recovery of sensorimotor function of the paretic upper limb. Recent studies have shown that priming with aerobic exercise prior to task-specific training potentiates upper limb recovery in individuals with stroke. This protocol describes a randomized clinical trial designed to determine whether priming with moderate-high intensity aerobic exercise prior to m-CIMT will improve the manual dexterity of the paretic upper limb in individuals with chronic hemiparesis. METHODS: Sixty-two individuals with chronic hemiparesis will be randomized into two groups: Aerobic exercise + m-CIMT or Stretching + m-CIMT. m-CIMT includes 1) restraint of the nonparetic upper limb for 90% of waking hours, 2) intensive task-oriented training of the paretic upper limb for 3 h/day for 10 days and 3) behavior interventions for improving treatment adherence. Aerobic exercise will be conducted on a stationary bicycle at intervals of moderate to high intensity. Participants will be evaluated at baseline, 3, 30, and 90 days postintervention by the following instruments: Motor Activity Log, Nottingham Sensory Assessment, Wolf Motor Function Test, Box and Block Test, Nine-Hole Peg Test, Stroke Specific Quality of Life Scale and three-dimensional kinematics. The data will be tested for normality and homogeneity. Parametric data will be analyzed by two-way ANOVA with repeated measures and Bonferroni's adjustment. For nonparametric data, the Friedman test followed by the Wilcoxon test with Bonferroni's adjustment will be used to compare the ratings for each group. To compare the groups in each assessment, the Mann-Whitney test will be used. DISCUSSION: This study will provide valuable information about the effect of motor priming for fine upper limb skill improvement in people with chronic poststroke hemiparesis, bringing new evidence about the association of two therapies commonly used in clinical practice. TRIAL REGISTRATION: This trial was retrospectively registered (registration number RBR-83pwm3 ) on 07 May 2018.

Improved quality of life following constraint-induced movement therapy is associated with gains in arm use, but not motor improvement.

BACKGROUND: Constraint-induced movement therapy (CI therapy) is one of few treatments for upper extremity (UE) hemiparesis that has been shown to result in motor recovery and improved quality of life in chronic stroke. However, the extent to which treatment-induced improvements in motor function versus daily use of the more affected arm independently contribute to improved quality of life remains largely unexplored. OBJECTIVE: The objective of this study is to identify whether motor function or daily use of a hemiparetic arm has a greater influence on quality of life after CI therapy. METHODS: Two cohorts of participants with chronic stroke received either in-person CI therapy (n = 29) or video-game home-based CI therapy (n = 16). The two cohorts were combined and the motor-related outcomes (Wolf Motor Function Test, Action Research Arm Test, Motor Activity Log [MAL]) and quality of life (Stroke-Specific Quality of Life) were jointly modeled to assess the associations between outcomes. RESULTS: The only outcome associated with improved quality of life was the MAL. Improvements in quality of life were not restricted to motor domains, but generalized to psychosocial domains as well. CONCLUSIONS: Results suggest that improved arm use during everyday activities is integral to maximizing quality of life gains during motor rehabilitation for chronic post-stroke UE hemiparesis. In contrast, gains in motor function were not associated with increases in quality of life. These findings further support the need to implement techniques into clinical practice that promote arm use during daily life if improving quality of life is a main goal of treatment. ClinicalTrials.gov Registration Numbers: NCT01725919 and NCT03005457.

Professional Values Are Implicit in Written Reflections by DPT Students in a Short-Term International Service Learning Course.

International service learning (ISL) courses within physical therapy (PT) education programs are designed, in part, to promote the development of professional values. Assessment of students' professional values, however, is a challenge for educators. METHODS: This study focused on the reflective learning component of an elective 10-day ISL course, evaluated whether PT professional values were manifested in students' written reflections, and characterized the level of student reflections using Bradley's criteria. Twenty-one third-year PT students participated. A qualitative content analysis of each student's written assignments was conducted. RESULTS: Although explicit instruction on PT values was not provided, reflections on professional values were identified in 97% of assignments. All three of Bradley's levels were found in all three written assignments, with the highest proportion of level 2 and 3 reflections being found in unstructured journals. CONCLUSION: Although no instruction specific to PT professional values was provided, values were implicit in student written assignments during this ISL course.

A Simple Non-invasive Method for Temporary Knockdown of Upper Limb Proprioception.

Proprioception may be the least well measured of all contributors to the neural control of movement. New precise, reliable measures of proprioception are needed for clinical diagnosis of impairment, and to measure outcomes of proprioceptive training. The purpose of this simple, non-invasive method is to temporarily knockdown upper limb proprioception in healthy adults, to an extent that would be useful in the development and testing of upper limb proprioception measures. Knockdown models have two main advantages over studying humans with impaired proprioception: participant availability and the ability to control the extent of impairment across participants. Current published methods of temporary proprioception knockdown of the upper limb, such as ischemic nerve blocks and cryotherapy, are invasive, impractical, or uncomfortable for the participant. Here, vibration over the ulnar groove was used to reduce upper limb proprioception. High frequency vibration may reduce proprioceptive acuity by inhibiting pacinian corpuscle-induced input. The effect of vibration used in this protocol was confirmed using two quantitative measures. This method was simple to administer, comfortable for participants, and practical.

In-Home Delivery of Constraint-Induced Movement Therapy via Virtual Reality Gaming.

PURPOSE: People with chronic hemiparesis are frequently dissatisfied with the recovery of their hand and arm, yet many lack access to effective treatments. Constraint-induced movement therapy (CI therapy) effectively increases arm function and spontaneous use in persons with chronic hemiparesis. The purpose of this study was to determine the feasibility and measure safety and outcomes of an in-home model of delivering CI therapy using a custom, avatar-based virtual reality game. METHODS: Seventeen individuals with chronic hemiparesis participated in this pretest/posttest quasi-experimental design study. The 10-day intervention had three components: 1) high-repetition motor practice using virtual reality gaming; 2) constraint of the stronger arm via a padded restraint mitt; and 3) a transfer package to reinforce arm use. Feasibility of the intervention was evaluated through comparison to traditional CI therapy and through participants' subjective responses. The primary outcome measures were the Wolf Motor Function Test (WMFT) and the Motor Activity Log quality of movement scale (MAL-QOM). RESULTS: On average, participants completed 17.2 ± 8 hours and 19,436 repetitions of motor practice. No adverse events were reported. Of 7 feasibility criteria, 4 were met. WMFT rate and MAL-QOM increased, with effect size (Cohen's d) of 1.5 and 1.1, respectively. CONCLUSIONS: This model of delivering CI therapy using a custom, avatar-based virtual reality game was feasible, well received, and showed preliminary evidence of being a safe intervention to use in the home for persons with chronic hemiparesis.

Gross motor ability predicts response to upper extremity rehabilitation in chronic stroke.

The majority of rehabilitation research focuses on the comparative effectiveness of different interventions in groups of patients, while much less is currently known regarding individual factors that predict response to rehabilitation. In a recent article, the authors presented a prognostic model to identify the sensorimotor characteristics predictive of the extent of motor recovery after Constraint-Induced Movement (CI) therapy amongst individuals with chronic mild-to-moderate motor deficit using the enhanced probabilistic neural network (EPNN). This follow-up paper examines which participant characteristics are robust predictors of rehabilitation response irrespective of the training modality. To accomplish this, EPNN was first applied to predict treatment response amongst individuals who received a virtual-reality gaming intervention (utilizing the same enrollment criteria as the prior study). The combinations of predictors that yield high predictive validity for both therapies, using their respective datasets, were then identified. High predictive classification accuracy was achieved for both the gaming (94.7%) and combined datasets (94.5%). Though CI therapy employed primarily fine-motor training tasks and the gaming intervention emphasized gross-motor practice, larger improvements in gross motor function were observed within both datasets. Poorer gross motor ability at pre-treatment predicted better rehabilitation response in both the gaming and combined datasets. The conclusion of this research is that for individuals with chronic mild-to-moderate upper extremity hemiparesis, residual deficits in gross motor function are highly responsive to motor restorative interventions, irrespective of the modality of training.

Video Game Rehabilitation for Outpatient Stroke (VIGoROUS): protocol for a multi-center comparative effectiveness trial of in-home gamified constraint-induced movement therapy for rehabilitation of chronic upper extremity hemiparesis.

BACKGROUND: Constraint-Induced Movement therapy (CI therapy) is shown to reduce disability, increase use of the more affected arm/hand, and promote brain plasticity for individuals with upper extremity hemiparesis post-stroke. Randomized controlled trials consistently demonstrate that CI therapy is superior to other rehabilitation paradigms, yet it is available to only a small minority of the estimated 1.2 million chronic stroke survivors with upper extremity disability. The current study aims to establish the comparative effectiveness of a novel, patient-centered approach to rehabilitation utilizing newly developed, inexpensive, and commercially available gaming technology to disseminate CI therapy to underserved individuals. Video game delivery of CI therapy will be compared against traditional clinic-based CI therapy and standard upper extremity rehabilitation. Additionally, individual factors that differentially influence response to one treatment versus another will be examined. METHODS: This protocol outlines a multi-site, randomized controlled trial with parallel group design. Two hundred twenty four adults with chronic hemiparesis post-stroke will be recruited at four sites. Participants are randomized to one of four study groups: (1) traditional clinic-based CI therapy, (2) therapist-as-consultant video game CI therapy, (3) therapist-as-consultant video game CI therapy with additional therapist contact via telerehabilitation/video consultation, and (4) standard upper extremity rehabilitation. After 6-month follow-up, individuals assigned to the standard upper extremity rehabilitation condition crossover to stand-alone video game CI therapy preceded by a therapist consultation. All interventions are delivered over a period of three weeks. Primary outcome measures include motor improvement as measured by the Wolf Motor Function Test (WMFT), quality of arm use for daily activities as measured by Motor Activity Log (MAL), and quality of life as measured by the Quality of Life in Neurological Disorders (NeuroQOL). DISCUSSION: This multi-site RCT is designed to determine comparative effectiveness of in-home technology-based delivery of CI therapy versus standard upper extremity rehabilitation and in-clinic CI therapy. The study design also enables evaluation of the effect of therapist contact time on treatment outcomes within a therapist-as-consultant model of gaming and technology-based rehabilitation. TRIAL REGISTRATION: Clinicaltrials.gov, NCT02631850 .

Computer-aided prediction of extent of motor recovery following constraint-induced movement therapy in chronic stroke.

Constraint-induced movement therapy (CI therapy) is a well-researched intervention for treatment of upper limb function. Overall, CI therapy yields clinically meaningful improvements in speed of task completion and greatly increases use of the more affected upper extremity for daily activities. However, individual improvements vary widely. It has been suggested that intrinsic feedback from somatosensation may influence motor recovery from CI therapy. To test this hypothesis, an enhanced probabilistic neural network (EPNN) prognostic computational model was developed to identify which baseline characteristics predict extent of motor recovery, as measured by the Wolf Motor Function Test (WMFT). Individual characteristics examined were: proprioceptive function via the brief kinesthesia test, tactile sensation via the Semmes-Weinstein touch monofilaments, motor performance captured via the 15 timed items of the Wolf Motor Function Test, stroke affected side. A highly accurate predictive classification was achieved (100% accuracy of EPNN based on available data), but facets of motor functioning alone were sufficient to predict outcome. Somatosensation, as quantified here, did not play a large role in determining the effectiveness of CI therapy.

The Brief Kinesthesia test is feasible and sensitive: a study in stroke

BACKGROUND: Clinicians lack a quantitative measure of kinesthetic sense, an important contributor to sensorimotor control of the hand and arm. OBJECTIVES: The objective here was to determine the feasibility of administering the Brief Kinesthesia Test (BKT) and begin to validate it by 1) reporting BKT scores from persons with chronic stroke and a healthy comparison group and 2) examining the relationship between the BKT scores and other valid sensory and motor measures. METHOD: Adults with stroke and mild to moderate hemiparesis (N=12) and an age-, gender-, and handedness-matched healthy comparison group (N=12) completed the BKT by reproducing three targeted reaching movements per hand with vision occluded. OTHER MEASURES: the Hand Active Sensation Test (HASTe), Touch-Test(tm) monofilament aesthesiometer, 6-item Wolf Motor Function Test (Wolf), the Motor Activity Log (MAL), and the Box and Blocks Test (BBT). A paired t-test compared BKT scores between groups. Pearson product-moment correlation coefficients assessed the relationship between BKT scores and other measures. RESULTS: Post-stroke participants performed more poorly on the BKT than comparison participants with their contralesional and ipsilesional upper extremity. The mean difference for the contralesional upper extremity was 3.7 cm (SE=1.1, t=3.34; p<0.008). The BKT score for the contralesional limb was strongly correlated with the MAL-how much (r=0.84, p=0.001), the MAL-how well (r=0.76, p=0.007), Wolf (r=0.69, p=0.02), and the BBT (r=0.77, p=0.006). CONCLUSIONS: The BKT was feasible to administer and sensitive to differences in reaching accuracy between persons with stroke and a comparison group. With further refinement, The BKT may become a valuable clinical measure of post-stroke kinesthetic impairment.

The Brief Kinesthesia test is feasible and sensitive: a study in stroke.

BACKGROUND: Clinicians lack a quantitative measure of kinesthetic sense, an important contributor to sensorimotor control of the hand and arm. OBJECTIVES: The objective here was to determine the feasibility of administering the Brief Kinesthesia Test (BKT) and begin to validate it by 1) reporting BKT scores from persons with chronic stroke and a healthy comparison group and 2) examining the relationship between the BKT scores and other valid sensory and motor measures. METHOD: Adults with stroke and mild to moderate hemiparesis (N=12) and an age-, gender-, and handedness-matched healthy comparison group (N=12) completed the BKT by reproducing three targeted reaching movements per hand with vision occluded. OTHER MEASURES: the Hand Active Sensation Test (HASTe), Touch-Test monofilament aesthesiometer, 6-item Wolf Motor Function Test (Wolf), the Motor Activity Log (MAL), and the Box and Blocks Test (BBT). A paired t-test compared BKT scores between groups. Pearson product-moment correlation coefficients assessed the relationship between BKT scores and other measures. RESULTS: Post-stroke participants performed more poorly on the BKT than comparison participants with their contralesional and ipsilesional upper extremity. The mean difference for the contralesional upper extremity was 3.7 cm (SE=1.1, t=3.34; p<0.008). The BKT score for the contralesional limb was strongly correlated with the MAL-how much (r=0.84, p=0.001), the MAL-how well (r=0.76, p=0.007), Wolf (r=0.69, p=0.02), and the BBT (r=0.77, p=0.006). CONCLUSIONS: The BKT was feasible to administer and sensitive to differences in reaching accuracy between persons with stroke and a comparison group. With further refinement, The BKT may become a valuable clinical measure of post-stroke kinesthetic impairment.