Between commitment and avoidance - working age stroke survivors' perceptions of physical activity and sedentary behaviour: a qualitative study.

BACKGROUND: It is critical for stroke survivors in working age to develop skills and confidence for long-term self-management of physical activity and exercise training to maintain a healthy lifestyle and decrease the risk of recurrent stroke and other cardiovascular diseases. Still, knowledge is scarce about concerns and experiences of physical activity and sedentary behaviour after stroke in working age, and further qualitative studies are required. The aim of this study was to explore and describe perceptions of physical activity and sedentary behaviour in stroke survivors under 65 years who are living with disability. METHODS: A qualitative design with individual semi-structured interviews was selected to generate rich data. Ten informants aged 36-61 years were interviewed 0.5-25 years after their stroke. The interviews were analysed with qualitative content analysis, with an inductive and interpretive approach. RESULTS: A two-sided contradictory relationship to physical activity and sedentary behaviour was identified. The overarching theme found was "Physical activity and sedentary behaviour - between commitment and avoidance", comprising three main themes; "Physical activity - medicine for body and mind", "Physical activity reminds of limitations", and "Sedentary behaviour - risk, rest, and alternative". The informants perceived physical activity as medicine, important for both physical and mental functioning, but also as a constant reminder of having a body that no longer functions as it used to. These mixed perceptions and feelings influenced the informants' behaviours related to physical activity and sedentary behaviour, and both commitment and avoidance were clear strategies. CONCLUSIONS: Working age stroke survivors expressed a clear positive perception of the importance of physical activity for health. However, physical activity was also described as a strong reminder of limitations which paradoxically could lead to sedentary behaviour. To support a physically active lifestyle post stroke, effective interventions as well as health promotion, counselling and patient education are imperative. These should be delivered by appropriately skilled health care professionals.

Changes in the Neural and Non-neural Related Properties of the Spastic Wrist Flexors After Treatment With Botulinum Toxin A in Post-stroke Subjects: An Optimization Study.

Quantifying neural and non-neural contributions to the joint resistance in spasticity is essential for a better evaluation of different intervention strategies such as botulinum toxin A (BoTN-A). However, direct measurement of muscle mechanical properties and spasticity-related parameters in humans is extremely challenging. The aim of this study was to use a previously developed musculoskeletal model and optimization scheme to evaluate the changes of neural and non-neural related properties of the spastic wrist flexors during passive wrist extension after BoTN-A injection. Data of joint angle and resistant torque were collected from 21 chronic stroke patients before, and 4 and 12 weeks post BoTN-A injection using NeuroFlexor, which is a motorized force measurement device to passively stretch wrist flexors. The model was optimized by tuning the passive and stretch-related parameters to fit the measured torque in each participant. It was found that stroke survivors exhibited decreased neural components at 4 weeks post BoNT-A injection, which returned to baseline levels after 12 weeks. The decreased neural component was mainly due to the increased motoneuron pool threshold, which is interpreted as a net excitatory and inhibitory inputs to the motoneuron pool. Though the linear stiffness and viscosity properties of wrist flexors were similar before and after treatment, increased exponential stiffness was observed over time which may indicate a decreased range of motion of the wrist joint. Using a combination of modeling and experimental measurement, valuable insights into the treatment responses, i.e., transmission of motoneurons, are provided by investigating potential parameter changes along the stretch reflex pathway in persons with chronic stroke.

Exercise stress testing after stroke or transient ischemic attack: a scoping review.

OBJECTIVE: To provide insight into exercise stress testing after stroke or transient ischemic attack (TIA) in terms of feasibility, safety, and protocols used. DATA SOURCES: PubMed, Embase, CINAHL, and Web of Science were searched for relevant studies published from inception to March 2014, and reference lists were hand searched. STUDY SELECTION: To be included in the review, the articles needed to include participants diagnosed with stroke or TIA and have any form of test to assess exercise capacity. DATA EXTRACTION: The scoping review methodology does not include critical appraisal of the literature but was chosen to reflect all aspects of exercise stress testing after stroke or TIA. Two reviewers performed screening for eligible studies independently, and 1 reviewer extracted the data. DATA SYNTHESIS: We found a total of 112 studies involving 5008 participants describing symptom-limited (n=103), submaximal (n=9), and field (n=6) exercise stress test protocols. Some of the studies reported on data from >1 protocol. Metabolic analysis was included in 87% of the studies involving symptom-limited tests, 40% of submaximal studies, and 29% of field tests. Monitoring of blood pressure, perceived exertion, and electrocardiographic responses was done in 54%, 42%, and 95% of all studies, respectively. A mere 10% of all studies reported on electrocardiographic abnormalities detected during testing. No serious adverse events were reported. CONCLUSIONS: Symptom-limited exercise stress testing appears to be safe in patients with stroke or TIA and provides a more valid measure of exercise capacity than submaximal and field tests. The level of disability may compromise feasibility, and test modality should be chosen carefully to optimize test results.

Assessment of spasticity after stroke using clinical measures: a systematic review.

PURPOSE: To identify and appraise the literature on clinical measures of spasticity that has been investigated in people after stroke. METHODS: The literature search involved four databases (PubMed, CINAHL, Embase and The Cochrane Library) up to February 2014. The selected studies included those that aimed to measure spasticity using a clinical assessment tool among adult patients post-stroke. Two independent raters reviewed the included articles using a critical appraisal scale and a structured data extraction form. RESULTS: A total of 40 studies examining 15 spasticity assessment tools in patients post-stroke were reviewed. None of the reviewed measurement tools demonstrated satisfactory results for all psychometric properties evaluated, and the majority lacked evidence concerning validity and absolute reliability. CONCLUSION: This systematic review found limited evidence to support the use of most of clinical measures of spasticity for people post-stroke. Future research examining the application and psychometric properties of these measures is warranted. Implications for Rehabilitation There is a need for objective clinical tools for measuring spasticity that are clinically feasible and easily interpreted by clinicians. This review identified various clinical measures of spasticity that have been investigated in people after stroke. Insufficient evidence of psychometric properties precludes recommending one tool over the others. Future research should focus on investigating the psychometric properties of clinical measures of spasticity.

Sensitivity of the NeuroFlexor method to measure change in spasticity after treatment with botulinum toxin A in wrist and finger muscles.

OBJECTIVE: The NeuroFlexor objectively quantifies the neural, elastic and viscous components of passive movement resistance in wrist and finger flexor muscles. In this study we investigated the sensitivity of the NeuroFlexor to changes in spasticity induced by treatment with botulinum toxin type A (BoNT-A). DESIGN: Prospective observational design. SUBJECTS: A convenience sample of 22 adults with post-stroke upper limb spasticity scheduled for botulinum toxin treatment. METHODS: BoNT-A was given according to individual treatment plans. NeuroFlexor assessments were made before treatment and 4 and 12 weeks after. RESULTS: At group level, spasticity decreased significantly at 4 weeks (expected time of maximum effect) (p = 0.04). At 12 weeks, spasticity had rebounded and no longer differed significantly from baseline (p = 0.64), i.e. in line with the pharmacodynamics of BoNT-A. At the individual level, 7 participants showed a reduction in spasticity greater than the measurement error. The reduction was dose-dependent (r(20) = 0.66, p < 0.001), and largest in participants with the highest dose. CONCLUSION: At the group level, the sensitivity of NeuroFlexor is good enough to detect reduction in spasticity after treatment with BoNT-A. Further work is needed to establish the sensitivity of NeuroFlexor on an individual level.

Test-retest and inter-rater reliability of a method to measure wrist and finger spasticity.

OBJECTIVE: To describe the reliability of an instrument (Neuro- Flexor) designed to be used in the clinic for quantification of the relative contribution of spasticity, elasticity and viscosity to resistance during passive wrist movements. DESIGN: A test-retest and inter-rater reliability study. SUBJECTS: A convenience sample of 34 adults with chronic stroke with spasticity in the hand, and a reference group of 10 healthy persons. METHODS: Two raters assessed the participants with the NeuroFlexor. Elastic, viscous and neural components of passive movement resistance were quantified at the wrist. Test-retest and inter-rater intraclass correlation coefficient (ICC2.1) were calculated for each component for both raters and two sessions. Degree of measurement error was evaluated using the coefficient of variation and the repeatability coefficient. RESULTS: Reliability was high for the neural component (test-retest: 0.90-0.96; inter-rater: 0.90-0.94), fair to good for the elastic component (test-retest: 0.79-0.88; inter-rater: 0.76-0.76), and fair to high for the viscous component (test-retest: 0.88-0.90; inter-rater: 0.75-0.80). Based on test-retest data, the coefficients of variation for the neural, elastic and viscous components were 25%, 26% and 16%, respectively, and the repeatability coefficients were 1.798, 1.897 and 1.404, respectively. CONCLUSION: The NeuroFlexor instrument is a reliable measure of spasticity and of muscle elasticity and viscosity in individuals with wrist and finger muscle resistance to passive stretch after stroke.

Validation of a new biomechanical model to measure muscle tone in spastic muscles.

BACKGROUND: There is no easy and reliable method to measure spasticity, although it is a common and important symptom after a brain injury. OBJECTIVE: The aim of this study was to develop and validate a new method to measure spasticity that can be easily used in clinical practice. METHODS: A biomechanical model was created to estimate the components of the force resisting passive hand extension, namely (a) inertia (IC), (b) elasticity (EC), (c) viscosity (VC), and (d) neural components (NC). The model was validated in chronic stroke patients with varying degree of hand spasticity. Electromyography (EMG) was recorded to measure the muscle activity induced by the passive stretch. RESULTS: The model was validated in 3 ways: (a) NC was reduced after an ischemic nerve block, (b) NC correlated with the integrated EMG across subjects and in the same subject during the ischemic nerve block, and (c) NC was velocity dependent. In addition, the total resisting force and NC correlated with the modified Ashworth score. According to the model, the neural and nonneural components varied between patients. In most of the patients, but not in all, the NC dominated. CONCLUSIONS: The results suggest that the model allows valid measurement of spasticity in the upper extremity of chronic stroke patients and that it can be used to separate the neural component induced by the stretch reflex from resistance caused by altered muscle properties.

Cortical activity in relation to velocity dependent movement resistance in the flexor muscles of the hand after stroke.

BACKGROUND: The role of spinal networks in spasticity is well investigated, but little is known about possible cortical contributions to hypertonicity across a joint. OBJECTIVE: The authors hypothesized that there are cortical activation correlates to spasticity in stroke patients with increased muscle tone of the wrist flexors. METHODS: Stroke patients and controls were scanned using event-related functional magnetic resonance imaging (fMRI) during slow and fast passive movements of the hand with simultaneous recording of passive movement resistance (PMR). RESULTS: Control participants had velocity-dependent activity (greater for slow than fast movements) of 2 types, in areas that were also more active in passive movement than rest (eg, relative increase in activation in contralateral S1 and M1 was greater for slow than fast) and in areas that were also more active in rest than passive movement (eg, relative decrease in activation in occipital areas and ipsilateral precentral gyrus was greater for fast than slow). In the patient group, with large interindividual variation of spasticity, we found an association between PMR and the velocity-dependent activity in ipsilateral S1 (area 3b) extending into M1 (area 4a), contralateral cingulate cortex, supplementary motor area (SMA), Brodmann Area 45 (BA 45), and cerebellum. Post hoc testing also revealed a similar correlation in S1 and M1 bilaterally in controls and showed that patients activated ipsilateral S1 and M1 more than controls in the velocity-dependent condition. CONCLUSIONS: The findings suggest the possibility of ipsilateral sensory and motor cortical involvement in spasticity after stroke, which warrant further investigation.