Upper Limb Motor Improvement after TBI: Systematic Review of Interventions

AbstractTraumatic Brain Injury (TBI) is a leading cause of adult morbidity and mortality. Individuals sustaining a TBI have impairments in both cognitive and motor domains. Motor improvements post-TBI are attributable to adaptive neuroplasticity and motor learning. Majority of the studies focus on remediation of balance and mobility impairments. There is limited understanding on the use of interventions for upper limb (UL) motor improvements in this population. We examined the evidence regarding the effectiveness of different interventions to augment UL motor improvement after a TBI. We systematically reviewed the literature published in English from 1990-2020. The modified Down’s and Black checklist helped assess study quality (total score:28). Studies were classified as excellent:24-28, good:19-23, fair:14-18 and poor:≤13 in quality. Effect sizes helped quantify intervention effectiveness. Twenty-three studies were retrieved. Study quality was excellent (n=1), good (n=4) or fair (n=19). Interventions used included strategies to decrease spasticity [Botulinum toxin provision (n=2), serial casting, soft splinting, tizanidine and acupuncture (n=1 each)], constraint induced movement therapy (n=4), virtual reality gaming (n=5), noninvasive stimulation (n=3), arm motor ability training (n=1), stem-cell transplant (n=1); task-oriented training (n=2) and augmented feedback (n=1). Motor impairment outcomes included Fugl-Meyer Assessment, Modified Ashworth Scale and kinematic outcomes (error and movement straightness). Activity limitation outcomes included Wolf Motor Function Test and Motor Activity Log. Effect sizes for majority of the interventions ranged from medium (0.5-0.79) to large (≥0.8). Only ten studies included retention testing. Results suggest that using these interventions can reduce UL motor impairment and improve activity performance after a TBI.

Download Full-text

Upper Limb Motor Improvement after Traumatic Brain Injury: Systematic Review of Interventions

Neurorehabilitation and Neural Repair ◽

10.1177/15459683211056662 ◽

2021 ◽

pp. 154596832110566

Author(s):

Sandeep K. Subramanian ◽

Melinda K. Fountain ◽

Ashley F. Hood ◽

Monica Verduzco-Gutierrez

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Upper Limb ◽

Muscle Tone ◽

Motor Impairment ◽

Preliminary Evidence ◽

Effect Sizes ◽

Cell Transplant ◽

Study Quality ◽

Motor Improvement

Background Traumatic brain injury (TBI) is a leading cause of adult morbidity and mortality. Individuals with TBI have impairments in both cognitive and motor domains. Motor improvements post-TBI are attributable to adaptive neuroplasticity and motor learning. Majority of the studies focus on remediation of balance and mobility issues. There is limited understanding on the use of interventions for upper limb (UL) motor improvements in this population. Objective We examined the evidence regarding the effectiveness of different interventions to augment UL motor improvement after a TBI. Methods We systematically examined the evidence published in English from 1990–2020. The modified Downs and Black checklist helped assess study quality (total score: 28). Studies were classified as excellent: 24–28, good: 19–23, fair: 14–18, and poor: ≤13 in quality. Effect sizes helped quantify intervention effectiveness. Results Twenty-three studies were retrieved. Study quality was excellent (n = 1), good (n = 5) or fair (n = 17). Interventions used included strategies to decrease muscle tone (n = 6), constraint induced movement therapy (n = 4), virtual reality gaming (n = 5), non-invasive stimulation (n = 3), arm motor ability training (n = 1), stem cell transplant (n = 1), task-oriented training (n = 2), and feedback provision (n = 1). Motor impairment outcomes included Fugl-Meyer Assessment, Modified Ashworth Scale, and kinematic outcomes (error and movement straightness). Activity limitation outcomes included Wolf Motor Function Test and Motor Activity Log (MAL). Effect sizes for majority of the interventions ranged from medium (.5-.79) to large (≥.8). Only ten studies included retention testing. Conclusion There is preliminary evidence that using some interventions may enhance UL motor improvement after a TBI. Answers to emergent questions can help select the most appropriate interventions in this population.

Download Full-text

Interhemispheric Pathways Are Important for Motor Outcome in Individuals with Chronic and Severe Upper Limb Impairment Post Stroke

Neural Plasticity ◽

10.1155/2017/4281532 ◽

2017 ◽

Vol 2017 ◽

pp. 1-12 ◽

Cited By ~ 7

Author(s):

Kathryn S. Hayward ◽

Jason L. Neva ◽

Cameron S. Mang ◽

Sue Peters ◽

Katie P. Wadden ◽

...

Keyword(s):

Corpus Callosum ◽

Upper Limb ◽

Motor Impairment ◽

Post Stroke ◽

Significant Difference ◽

Motor Outcome ◽

Wolf Motor Function Test ◽

Severe Group ◽

And Function ◽

Motor Outcomes

Background. Severity of arm impairment alone does not explain motor outcomes in people with severe impairment post stroke.Objective. Define the contribution of brain biomarkers to upper limb motor outcomes in people with severe arm impairment post stroke.Methods. Paretic arm impairment (Fugl-Meyer upper limb, FM-UL) and function (Wolf Motor Function Test rate, WMFT-rate) were measured in 15 individuals with severe (FM-UL ≤ 30/66) and 14 with mild–moderate (FM-UL > 40/66) impairment. Transcranial magnetic stimulation and diffusion weight imaging indexed structure and function of the corticospinal tract and corpus callosum. Separate models of the relationship between possible biomarkers and motor outcomes at a single chronic (≥6 months) time point post stroke were performed.Results. Age (ΔR20.365,p=0.017) and ipsilesional-transcallosal inhibition (ΔR20.182,p=0.048) explained a 54.7% (p=0.009) variance in paretic WMFT-rate. Prefrontal corpus callous fractional anisotropy (PF-CC FA) alone explained 49.3% (p=0.007) variance in FM-UL outcome. The same models did not explain significant variance in mild–moderate stroke. In the severe group, k-means cluster analysis of PF-CC FA distinguished two subgroups, separated by a clinically meaningful and significant difference in motor impairment (p=0.049) and function (p=0.006) outcomes.Conclusion. Corpus callosum function and structure were identified as possible biomarkers of motor outcome in people with chronic and severe arm impairment.

Download Full-text

Abstract P218: Effects of Bilateral Transcutaneous Electrical Nerve Stimulation Combined With Task-Oriented Training on the Recovery of Upper Limb Motor Impairment in People With Chronic Stroke

Stroke ◽

10.1161/str.52.suppl_1.p218 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Peiming CHEN ◽

Tai-Wa Liu ◽

Claudia K.Y Lai ◽

Raymond C.K Chung ◽

Shamay S.M Ng

Keyword(s):

Placebo Group ◽

Upper Limb ◽

Active Treatment ◽

Nerve Stimulation ◽

Transcutaneous Electrical Nerve Stimulation ◽

Motor Impairment ◽

Control Group ◽

Electrical Nerve Stimulation ◽

Task Oriented ◽

And Control

Background: Transcutaneous electrical nerve stimulation(TENS) is an effective physiological intervention for people with stroke which aims at reducing muscle spasticity, enhancing muscle strength, and improving motor control and function. In view of the potentials to enhance greater cortical activation of the lesion side by eliciting spare neural pathways through bilateral intervention, this study examined whether the combined use of bilateral TENS (Bi-TENS) and task-oriented training (TOT) was superior to unilateral TENS(Uni-TENS)+TOT, placebo-TENS+TOT and no active treatment to improve the motor impairment of upper limb function in people with stroke. Method: There were 120 subjects with stroke(44 females, mean age=61.52±6.73 years, post-stroke duration=6.04±3.12years) being randomly allocated into 4 groups, including the Bi-group (n=30), Uni-group (n=30), placebo group (n=30) and control group (n=30). Subjects in the Bi-group, Uni-group and placebo group got 60 minutes TENS and TOT simultaneously per time for 20 times(3 times per week for 7 weeks). In the Bi-group, TENS stimulated the radial and median nerves of the bilateral upper limbs. In the Uni-group, TENS and placebo-TENS stimulated the affected and unaffected side, respectively. In the placebo group, placebo-TENS were placed on bilateral sides. In the control group, subjects did not receive any active treatment. Level of motor impairment was assessed by the Fugl-Meyer Assessment of Upper Extremity (FMA-UE). Result: The Bi-group had a significant greater improvement in FMA-UE than the Uni-group(mean change=2.02, p=0.005), placebo group (mean change=2.49, p=0.001) and control group(mean change=3.08, p<0.001) at post-intervention. The Bi-group(mean change=3.25, p<0.001) and Uni-group(mean change=1.23, p=0.015) showed a significant within-group improvement in FMA-UE since 10 sessions of treatment. No significant change was found in the placebo and control groups. Conclusion: Bi-TENS is superior to Uni-TENS, placebo-TENS and no active treatment in augmenting the recovery of upper limb motor impairment in people with chronic stroke. Author Disclosures: The authors received research support from the Health and Medical Research Fund12131821 from the Food and Health Bureau, HKSAR.

Download Full-text

Safety, Feasibility, and Acceptability of a New Virtual Rehabilitation Platform: A Supervised Pilot Study

Rehabilitation Process and Outcome ◽

10.1177/11795727211033279 ◽

2021 ◽

Vol 10 ◽

pp. 117957272110332

Author(s):

Ana María Escalante-Gonzalbo ◽

Yoás Saimon Ramírez-Graullera ◽

Herminia Pasantes ◽

José Jonathan Aguilar-Chalé ◽

Gloria Ixchel Sánchez-Castillo ◽

...

Keyword(s):

Pilot Study ◽

Motor Function ◽

Upper Limb ◽

Virtual Rehabilitation ◽

Function Test ◽

Wolf Motor Function Test ◽

Significant Impairment ◽

Task Oriented ◽

Movement Sensors ◽

Significant Motor

Purpose: Stroke is the leading cause of disability in adults worldwide, with hemiparesis being the most prevalent consequence. The use of video games and movement sensors could contribute to improving patients’ chances of recovery. We performed a supervised pilot study to validate the safety, feasibility, and acceptability of a new virtual rehabilitation platform in patients with chronic post-stroke upper limb hemiparesis. Methods: The participants (n = 9) participated in 40 rehabilitation sessions, twice a week, for a period of 20 weeks. Their experiences with the platform were documented using a Likert-scale survey. Changes in motor function were evaluated using the Chedoke Arm and Hand Activity Inventory (CAHAI) and the Wolf Motor Function Test (WMFT). Results and conclusions: All participants expressed that they enjoyed the experience and felt comfortable using the platform. Preliminary results showed significant motor recovery ( P = .0039) according to the WMFT scores. Patients with significant impairment showed no improvement in upper limb task-oriented motor function after therapy. The new platform is safe and well-accepted by patients. The improvement in motor function observed in some of the participants should be attributed to the therapy since spontaneous functional recovery is not expected in chronic stroke patients.

Download Full-text

Revisiting Poststroke Upper Limb Stratification: Resilience in a Larger Cohort

Neurorehabilitation and Neural Repair ◽

10.1177/1545968321992048 ◽

2021 ◽

pp. 154596832199204

Author(s):

Benjamin J. Varley ◽

Christine T. Shiner ◽

Liam Johnson ◽

Penelope A. McNulty ◽

Angelica G. Thompson-Butel

Keyword(s):

Clinical Practice ◽

Motor Function ◽

Upper Limb ◽

Hierarchical Cluster ◽

Community Dwelling ◽

Stratification Method ◽

Wolf Motor Function Test ◽

Block Test ◽

Time Restriction ◽

Post Hoc

Background Upper limb (UL) impairment in stroke survivors is both multifactorial and heterogeneous. Stratification of motor function helps identify the most sensitive and appropriate assessments, which in turn aids the design of effective and individualized rehabilitation strategies. We previously developed a stratification method combining the Grooved Pegboard Test (GPT) and Box and Block Test (BBT) to stratify poststroke UL motor function. Objective To investigate the resilience of the stratification method in a larger cohort and establish its appropriateness for clinical practice by investigating limitations of the GPT completion time. Methods Post hoc analysis of motor function for 96 community-dwelling participants with stroke (n = 68 male, 28 female, age 60.8 ± 14 years, 24.4 ± 36.6 months poststroke) was performed using the Wolf Motor Function Test (WMFT), Fugl-Meyer Assessment (F-M), BBT, and GPT. Hypothesis-free and hypothesis-based hierarchical cluster analyses were conducted to determine the resilience of the stratification method. Results The hypothesis-based analysis identified the same functional groupings as the hypothesis-free analysis: low (n = 32), moderate (n = 26), and high motor function (n = 38), with 3 exceptions. Thirty-three of the 38 participants with fine manual dexterity completed the GPT in ≤5 minutes. The remaining 5 participants took 6 to 25 minutes to place all 25 pegs but used alternative movement strategies to complete the test. The GPT time restriction changed the functional profile of the moderate and high motor function groups leading to more misclassifications. Conclusion The stratification method unambiguously classifies participants by UL motor function. While the inclusion of a 5-minute cutoff time for the GPT is preferred for clinical practice, it is not recommended for stratification purposes.

Download Full-text

Sequentially applied myoelectrically controlled FES in a task-oriented approach and robotic therapy for the recovery of upper limb in post-stroke patients: A randomized controlled pilot study

Technology and Health Care ◽

10.3233/thc-202371 ◽

2020 ◽

pp. 1-11

Author(s):

Gloria Perini ◽

Rita Bertoni ◽

Rune Thorsen ◽

Ilaria Carpinella ◽

Tiziana Lencioni ◽

...

Keyword(s):

Upper Limb ◽

Standard Care ◽

Experimental Treatment ◽

Stroke Patients ◽

Rehabilitation Care ◽

Post Stroke ◽

Robotic Therapy ◽

Arm Rehabilitation ◽

Point Increase ◽

Task Oriented

BACKGROUND: Functional recovery of the plegic upper limb in post-stroke patients may be enhanced by sequentially applying a myoelectrically controlled FES (MeCFES), which allows the patient to voluntarily control the muscle contraction during a functional movement and robotic therapy which allows many repetitions of movements. OBJECTIVE: Evaluate the efficacy of MeCFES followed by robotic therapy compared to standard care arm rehabilitation for post-stroke patients. METHODS: Eighteen stroke subjects (onset ⩾ 3 months, age 60.1 ± 15.5) were recruited and randomized to receive an experimental combination of MeCFES during task-oriented reaching followed by robot therapy (MRG) or same intensity conventional rehabilitation care (CG) aimed at the recovery of the upper limb (20 sessions/45 minutes). Change was evaluated through Fugl-Meyer upperextremity (FMA-UE), Reaching Performance Scale and Box and Block Test. RESULTS: The experimental treatment resulted in higher improvement on the FMA-UE compared with CG (P= 0.04), with a 10 point increase following intervention. Effect sizes were moderate in favor of the MRG group on FMA-UE, FMA-UE proximal and RPS (0.37–0.56). CONCLUSIONS: Preliminary findings indicate that a combination of MeCFES and robotic treatment may be more effective than standard care for recovery of the plegic arm in persons > 3 months after stroke. The mix of motor learning techniques may be important for successful rehabilitation of arm function.

Download Full-text

Sensory-Based Priming for Upper Extremity Hemiparesis After Stroke: A Scoping Review

OTJR Occupation Participation and Health ◽

10.1177/15394492211032606 ◽

2021 ◽

pp. 153944922110326

Author(s):

Mary E. Stoykov ◽

Courtney Heidle ◽

Shamshir Kang ◽

Lisa Lodesky ◽

Lindsay E. Maccary ◽

...

Keyword(s):

Electrical Stimulation ◽

Motor Skills ◽

Upper Limb ◽

Scoping Review ◽

Web Of Science ◽

Motor Impairment ◽

Cochrane Collaboration ◽

Prisma Statement ◽

Meta Analyses ◽

The Cochrane Collaboration

Sensory priming is a technique to facilitate neuroplasticity and improve motor skills after injury. Common sensory priming modalities include peripheral nerve stimulation/somatosensory electrical stimulation (PNS/SES), transient functional deafferentation (TFD), and vibration. The aim of this study was to determine whether sensory priming with a motor intervention results in improved upper limb motor impairment or function after stroke. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and EMBASE were the databases used to search the literature in July 2020. This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and recommendations for the Cochrane collaboration. In total, 30 studies were included in the analysis: three studies examined TFD, 16 examined PNS/SES, 10 studied vibration, and one combined the three stimulation techniques. Most studies reported significant improvements for participants receiving sensory priming. Given the low risk, it may be advantageous to use sensory-based priming prior to or concurrent with upper limb training after stroke.

Download Full-text

Effect of post-stroke spasticity on voluntary movement of the upper limb

Journal of NeuroEngineering and Rehabilitation ◽

10.1186/s12984-021-00876-6 ◽

2021 ◽

Vol 18 (1) ◽

Author(s):

Hadar Lackritz ◽

Yisrael Parmet ◽

Silvi Frenkel-Toledo ◽

Melanie C. Baniña ◽

Nachum Soroker ◽

...

Keyword(s):

Upper Limb ◽

Target Location ◽

Distance Measure ◽

Movement Time ◽

Motor Impairment ◽

Reach To Grasp ◽

Motion Patterns ◽

Post Stroke ◽

The Impact ◽

Elbow Motion

Abstract Background Hemiparesis following stroke is often accompanied by spasticity. Spasticity is one factor among the multiple components of the upper motor neuron syndrome that contributes to movement impairment. However, the specific contribution of spasticity is difficult to isolate and quantify. We propose a new method of quantification and evaluation of the impact of spasticity on the quality of movement following stroke. Methods Spasticity was assessed using the Tonic Stretch Reflex Threshold (TSRT). TSRT was analyzed in relation to stochastic models of motion to quantify the deviation of the hemiparetic upper limb motion from the normal motion patterns during a reaching task. Specifically, we assessed the impact of spasticity in the elbow flexors on reaching motion patterns using two distinct measures of the ‘distance’ between pathological and normal movement, (a) the bidirectional Kullback–Liebler divergence (BKLD) and (b) Hellinger’s distance (HD). These measures differ in their sensitivity to different confounding variables. Motor impairment was assessed clinically by the Fugl-Meyer assessment scale for the upper extremity (FMA-UE). Forty-two first-event stroke patients in the subacute phase and 13 healthy controls of similar age participated in the study. Elbow motion was analyzed in the context of repeated reach-to-grasp movements towards four differently located targets. Log-BKLD and HD along with movement time, final elbow extension angle, mean elbow velocity, peak elbow velocity, and the number of velocity peaks of the elbow motion were computed. Results Upper limb kinematics in patients with lower FMA-UE scores (greater impairment) showed greater deviation from normality when the distance between impaired and normal elbow motion was analyzed either with the BKLD or HD measures. The severity of spasticity, reflected by the TSRT, was related to the distance between impaired and normal elbow motion analyzed with either distance measure. Mean elbow velocity differed between targets, however HD was not sensitive to target location. This may point at effects of spasticity on motion quality that go beyond effects on velocity. Conclusions The two methods for analyzing pathological movement post-stroke provide new options for studying the relationship between spasticity and movement quality under different spatiotemporal constraints.

Download Full-text