| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Case Reports |
K Dunning, PT, PhD, is Assistant Professor, Department of Rehabilitation Sciences, College of Allied Health Sciences, University of Cincinnati Academic Medical Center, 3202 Eden Ave, Cincinnati, OH 45220-0394 (USA), and Director of Clinical Research, Drake Center, Cincinnati, Ohio
A Berberich, BS, is a graduate student in the Health Promotion and Education Program, College of Education, Criminal Justice, and Human Services, University of Cincinnati, Cincinnati, Ohio. She was an undergraduate health science student in the Department of Rehabilitation Sciences, College of Allied Health Sciences, University of Cincinnati Academic Medical Center at the time of this research
B Albers, BS, is a Doctor of Physical Therapy student in the Department of Rehabilitation Sciences, University of Cincinnati. She was an undergraduate health science student in the Department of Rehabilitation Sciences, College of Allied Health Sciences, University of Cincinnati Academic Medical Center at the time of this research
K Mortellite, BS, is a Doctor of Physical Therapy student in the Doctor of Physical Therapy Division, Department of Family and Community Medicine, School of Medicine, Duke University, Durham, NC. She was an undergraduate health science student in the Department of Rehabilitation Sciences, College of Allied Health Sciences, University of Cincinnati Academic Medical Center at the time of this research
PG Levine, PTA, BA, is Principal Research Assistant, Department of Rehabilitation Sciences, College of Allied Health Sciences, University of Cincinnati Academic Medical Center, and Co-Director, Neuromotor Recovery and Rehabilitation Laboratory, Drake Center
VA Hill Hermann, OT, MS, is Research Occupational Therapist, Neuromotor Recovery and Rehabilitation Laboratory, Drake Center
SJ Page, PhD, is Associate Professor of Rehabilitation Sciences, Physical Medicine and Rehabilitation, and Neurosciences, University of Cincinnati Academic Medical Center, and Director, Neuromotor Recovery and Rehabilitation Laboratory, Drake Center
Address all correspondence to Dr Dunning at: kari.dunning{at}uc.edu
Submitted March 19, 2007;
Accepted October 19, 2007
 | Abstract |
|---|
Case Description: A 63-year-old man with hemiparesis caused by an ischemic stroke 7 years before the intervention described here received task-specific training incorporating an electrical stimulation neuroprosthesis 3 hours per day, 5 days per week, for 4 weeks. Testing was conducted before and after the intervention and again 6 weeks later with stroke-specific outcome measures.
Outcomes: Increases in function and quality of life were observed after the intervention.
Discussion: An intervention incorporating task-specific training with functional electrical stimulation appears to have increased function and quality of life in a person with chronic stroke. This type of intervention might provide a pathway by which people with similar impairments would become eligible for more advanced treatment regimens, such as modified constraint-induced therapy.
| Introduction |
|---|
 TopAbstract Introduction Case DescriptionOutcomesDiscussionConclusionReferences |
|---|
Recent data suggested that surface neuromuscular electrical stimulation (NMES), administered twice per weekday over an 8-week period, increases active wrist extension in people with stroke and initially exhibiting flaccid wrists and fingers.11 Although there were no increases in function as a result of NMES, gains in active range of motion (AROM) were sufficient for patients to then participate in modified CIT, and functional movement was restored.12 Clinically, these findings suggest that a therapist should send a patient with no active wrist or finger movement home with an NMES unit for a time before initiating task-specific treatments.
The limitations of conventional surface NMES include difficulty with consistent, reproducible electrode placement with repeated treatments. In addition, for a patient with no wrist or finger AROM, NMES does not provide support of the wrist into extension to facilitate the optimum reach, grasp, and release movement necessary to perform a number of task-specific activities. Functional electrical stimulation (FES) delivered through a neuroprosthesis has the potential to overcome these limitations. In a previous study with an FES neuroprosthesis and task-specific activities, functional improvements were shown for people with acute or chronic stroke and initially demonstrating at least 10 degrees of AROM extension in the wrist and at least 2 fingers.13 That study concluded that future studies should evaluate "chronic post stroke hemiplegia subjects and ... patients with a major disability."13(p755) A new, noninvasive neuroprosthesis has provided synchronized, precise, and reliable activation of affected arm flexor and extensor muscles during the performance of activities of daily living (ADL). Limited studies with this device have shown increased wrist passive range of motion (PROM), decreased spasticity (as measured with the Ashworth scale), and increased function in people with chronic stroke and with some initial wrist or finger AROM.14–16
Given the aforementioned effect of surface stimulation in flaccid stroke,11,12 we wondered whether intensive, task-specific, repetitive ADL training with the neuroprosthesis might increase function in a patient with no active movement in the wrist or fingers. Clinically, such training might facilitate a faster recovery (as opposed to sending the patient home with an NMES unit before working on task-specific activities). Therefore, we evaluated how a combination of FES (with a neuroprosthesis) and task-specific training would affect function and quality of life in a person who had sustained a stroke several years before the implementation of this therapy and who exhibited no wrist or finger AROM.
| Case Description |
|---|
|
TopAbstractIntroductionCase DescriptionOutcomesDiscussionConclusionReferences |
|---|
25 (out of 30) on the Modified Mini-Mental State Examination,17 (4) age of more than 35 years but less than 85 years, (5) occurrence of only one stroke, and (6) discharge from all forms of physical rehabilitation. The following characteristics were avoided in the selection of the patient: (1) participation in any experimental rehabilitation or drug studies; (2) pregnancy; (3) uncontrolled seizure disorders; (4) excessive spasticity at the affected elbow, wrist, or fingers, defined as a score of 3 on the Modified Ashworth Spasticity Scale18; and (5) excessive pain in the affected arm, as measured by a score of 4 on a 10-point visual analog scale. A volunteer contacted us in response to an announcement made at a local stroke support group with these criteria in mind. Before being screened and receiving the intervention, the patient signed an informed consent form approved by the local institutional review board. He was a 63-year-old white man who had had an ischemic stroke 7 years earlier and who exhibited right-arm hemiparesis. He was right-hand dominant but reported not using his right hand since the stroke. After his stroke, he received 10 weeks of inpatient rehabilitation followed by 3 months of outpatient speech therapy. After discharge, he received speech therapy for an additional 3 months. He had not received any additional therapy since completing his speech therapy. At the start of our treatment program, he was taking medications for high blood pressure and high cholesterol, and he had a history of angina. He lived alone and received help with household chores from a friend. Because of his affected arm impairment, he did not cook and ate out at every meal. He did not actively use his hand for any activities. He ambulated independently without an ankle-foot orthosis or an assistive device. He exhibited expressive aphasia. His goal was to return to his prestroke function, although he admitted he did not expect this would happen. His goals were to make a sandwich so that he could eat lunch at home, iron his shirts, eat finger food, use his computer, and write with his right hand. He was selected for the intervention because he met our criteria described above and was motivated and willing to follow through with the intervention guidelines.
At the time of screening, the patient's scores on the Modified Ashworth Spasticity Scale were 1 (elbow), 1+ (wrist), 2 (fingers), and 0 (thumb). The patient had never been administered antispasticity medications. The Modified Mini-Mental State Examination score was 30 out of 30. Before the intervention, a licensed and board-certified neurological clinical specialist (physical therapist) evaluated the patient to assess upper extremity sensation, range of motion (ROM), and strength (force-generating capacity). There was no indication of upper-limb contractures, and PROM was normal, without pain. The patient's unaffected (left) upper extremity exhibited normal ROM and strength. He was able to actively flex and abduct his right shoulder 80 degrees but not without elbow flexion, indicating flexor synergy. Wrist flexion and extension were present at trace levels, and there was no active movement of the fingers.
Apparatus
The patient used the Bioness H-200 system* (Fig. 1) as part of a structured task-specific program. The Bioness H-200 is a microprocessor-based, US Food and Drug Administration-approved NMES device. It comprises 3 sizes of a forearm-hand molded orthosis and contains an array of 5 surface electrodes ranging in size from 2x2 to 6x4 cm. The electrodes are positioned over the extensor digitorum, extensor pollicis brevis, flexor digitorum superficialis, flexor pollicis longus, and thenar muscles. Electrode positioning within the orthosis is custom determined for each patient to optimize the contraction of the wrist and finger flexor and extensor muscles. Once the optimal position is determined, the 5 electrodes are secured within the orthosis. This individualized electrode positioning makes it very easy for the patient to receive a consistent level of stimulation every day.
|
Outcome Measures
The upper-extremity subscale of the Fugl-Meyer Scale (FM)19 was used to determine whether changes occurred in affected arm impairment. The FM assesses several dimensions of impairment, including ROM, pain, sensation, and movement. Items are scored on a 3-point ordinal scale (0=cannot perform, 2=can perform fully), and item scores are summed to provide a maximum score of 66. The FM, as assessed using Pearson product moment correlation coefficients or Spearman rank-order correlation coefficients, offers good test-retest reliability (total=.98–.99, subtests=.87–1.00) and construct validity.20,21 The FM has been used extensively in studies measuring recovery and is recommended for "trials designed to evaluate changes in motor impairment following stroke."22(p239)
The Action Research Arm Test (ARAT)23 was used to determine whether fine motor skill changes occurred in the affected hand and fingers. The ARAT is a 19-item test divided into 4 categories (grasp, grip, pinch, and gross movement). Each item is graded on a 4-point ordinal scale (0=can perform no part of the test, 1=performs test partially, 2=completes test but takes an abnormally long time or has great difficulty, and 3=performs test normally), for a possible total score of 57. The test is hierarchical in that if a patient is able to perform the most difficult skill in each category, he or she will be able to perform the other items in that category and, thus, they need not be tested. The ARAT has high intrarater reliability (r=.99) and retest reliability (r=.98) and validity.24
The Arm Motor Activity Test (AMAT)25 was used to determine whether changes occurred in the ability to perform valued ADL with the affected arm. The AMAT is a 13-item test in which ADL are rated according to a functional ability scale that examines affected limb use (0=does not perform with affected arm, 5=uses arm at a level comparable to that on unaffected side) and a quality-of-movement scale (0=no movement initiated, 5=normal movement). The ADL, which are further subdivided into subactivities to be rated, include the use of a knife and fork, eating with a spoon, combing hair, and tying shoelaces. The AMAT is a valid, stable, and reliable scale and correlates positively with other stroke-specific functional scales.25
The Motor Activity Log (MAL)26 was used to determine whether changes occurred in the use of the affected limb. The MAL is a semistructured interview measuring how patients use their affected limbs for ADL. The patient rated how much and how well he used the affected arm for 30 ADL during the preceding week with a 6-point "amount" scale and a 6-point "how well" scale. In order to further determine effect on independence in daily activities, the "how well" scale was categorized into dependent (0–2) and independent (3–5) functions.
The Stroke Impact Scale 2.0 (SIS)27 was used to measure changes in stroke-specific quality of life. This scale is a 64-item self-report measure assessing 8 domains (strength, hand function, basic and instrumental ADL, mobility, communication, emotion, memory and thinking, and social participation). In a previous study,27 the SIS domains were examined by comparing the SIS with existing stroke measures and by comparing differences in SIS scores across Rankin Scale levels. As determined with these techniques, each domain met or approached the standard of an alpha coefficient of .9 for comparing the same patients across time.27 The intraclass correlation coefficients for test-retest reliability ranged from .70 to .92.27
The Box and Block Test was used to measure disability. This test is a timed grasp and release test in which patients are seated in front of a box with a large partition separating it into 2 equal squares. Colored blocks are situated on one side of the partition, and patients are asked to move as many blocks as possible from one side to the other with the affected hand. This test has been found to be both valid and reliable.28
Preintervention Testing and Intervention
One week after the patient signed the approved consent form and 2 weeks before the intervention, preintervention testing was performed with the above-described outcome measures. All measures were administered by a rater who was unaware of the type, duration, or nature of the intervention that the patient was to receive. After preintervention testing was complete, the patient was oriented to the electrical stimulation device during a 1-hour education session with a therapist member of the research team. After demonstrating safe and correct use, the patient took the device home for 1 week. During this 1-week ramp-up period, the device was used every day, beginning with 10 minutes, until the patient was able to use the device for a full 30 minutes on the seventh and final day.
Based on the task-specific, affected arm training protocol described by Dettmers and colleagues,29 our task-specific, repetitive training regimen was administered 3 hours per day, 5 days per week (weekdays), for a total of 20 weekdays. With the use of this treatment schedule for people with chronic stroke and with at least 20 degrees of wrist extension AROM and 10 degrees of finger extension, Dettmers et al29 reported improved function, strength, and spasticity. Our sessions were conducted in a private therapy room, were supervised by a physical therapist, and began with approximately 15 minutes of stretching and stability exercises (based on the initial physical therapy evaluation). The remaining session time consisted of repeated practice of functional task-specific activities as shown in Table 1. Specific tasks were determined by the patient's motivation and feedback throughout the intervention.
|
|
| Outcomes |
|---|
|
TopAbstractIntroductionCase DescriptionOutcomesDiscussionConclusionReferences |
|---|
Before the intervention, the patient scored 27 on the FM (Tab. 2), 16 on the ARAT (Tab. 3), and 2.07 on the AMAT functional ability scale and was able to transfer 12 blocks in the Box and Block Test. The SIS scores are shown in Table 4. The MAL median "amount" scale score was 0.34; the patient indicated that he did not use his right arm at all (score of 0 on the "how well" scale) for 26 of the 30 functional tasks on the MAL.
|
|
|
Throughout the intervention, the patient reported improvements in his ability to perform ADL, including being able to eat finger foods, make sandwiches, and iron shirts. The structured interview revealed that the patient could not perform ADL with his right hand before the intervention; after the intervention, he reported improvements in holding onto a steering wheel, carrying his lunch tray with both hands, and using his hand to stabilize (eg, removing a straw). He reported that he enjoyed the treatment and believed that he could have continued to improve with more sessions. He said that he did not like the functional tasks initially, but then he understood that he could reach and grasp with the help of the electrical stimulation unit. He had no problems with frequency and duration, but did state that it was helpful to have a therapist watching him daily and providing feedback and motivation. He added that he would do another 4 weeks of the intervention if his hand would continue to improve.
| Discussion |
|---|
|
TopAbstractIntroductionCase DescriptionOutcomesDiscussionConclusionReferences |
|---|
There have been limited studies on people with chronic stroke and with no active wrist or finger movement. Gabr et al11 conducted a crossover randomized controlled trial of 12 people with chronic stroke and with trace wrist movement at baseline. Patients receiving home-based electrical stimulation 2 times per day for 8 weeks while practicing extension exercises showed increased wrist extension AROM (an average of 21°) but no functional increases (ARAT). Gains were not retained after the crossover to 8 weeks of a home exercise program. Santos et al30 conducted a crossover randomized controlled trial of 8 people with stroke and with little or no wrist movement. These 8 people received 30-minute daily sessions of NMES 5 times per week for 2 weeks. After 10 sessions of NMES incorporating grasping and releasing a tennis ball, patients demonstrated significantly increased scores on the FM, Jebsen Hand Function Test, and Box and Block Test. No carryover effects were seen at 10 days after treatment, with all outcome measures returning to baseline or lower values.
Unlike the above protocols, our intervention incorporated task-specific activities based on the patient's goals as well as a longer-duration regimen. Although we did not use AROM as an outcome measure, the patient in our case description gained enough wrist active extension to be eligible for constraint-induced therapy, similar to the results reported by Gabr et al.11 Also as in the above-described studies,11,30 the patient in our case description did not retain increases in FM or Box and Block Test scores. However, not only were increases in the AMAT, MAL, and SIS scores retained, but the SIS and AMAT scores continued to increase up to 6 weeks after the intervention. Although the above-described studies did not use the SIS or MAL, precluding direct comparisons of findings, our findings suggest that the duration of our protocol, the use of a neuroprosthesis to administer the FES, or the emphasis on patient-motivated, task-specific activities allowed functional carryover beyond the intervention. Apart from duration and frequency, it is interesting to consider whether the observed effects were attributable to the FES, to the repetitive, task-specific protocol, or to the combination. We believe that they were attributable to the combination. In the study of Gabr et al,11 in which only NMES was provided to people with flaccid wrists or fingers, increased wrist extension AROM, but no change in function, was observed. Although we cannot determine whether task-specific activities alone would have resulted in changes, this is a moot point, because the patient in our case description was unable to perform task-specific activities without the FES neuroprosthesis (because of decreased active wrist and finger movement) at the beginning of the intervention.
Because this appears to be the first report of the effects of the use of an FES neuroprosthesis on quality of life for a person with chronic stroke, a discussion of SIS changes is warranted. The majority of SIS scores improved with treatment and continued to improve for up to 6 weeks; these included hand function, ADL, mobility, and emotion scores (Tab. 4). Interestingly, the only SIS score that did not improve was strength, because of a decrease in self-assessed leg and foot/ankle strength during the intervention. This decrease in leg and foot/ankle strength may have been relative to the patient's self-reported improvement in hand function and grip. Hand function improved in several areas, including carrying heavy objects, turning a door knob, and picking up a dime. Opening a jar and tying shoelaces did not improve, and these findings were validated by no improvement for these ARAT tasks. Improvement in mobility included improved balance, faster walking, climbing stairs, and getting in and out of a car. These findings agree with the patient's reports of improved gait and balance during the intervention. Although several emotion scores increased, the greatest change was observed in "feeling that you have nothing to look forward to" (changed from "all of the time" to "a little of the time") and "feeling that life is worth living" (changed from "a little of the time" to "most of the time"). These findings are consistent with the patient's reports that the intervention gave the patient hope. The decrease observed for social participation was attributable to a "limit in work and social activities," perhaps because of the intense 4-week treatment schedule, because this rating increased to the baseline value at 6 weeks after the intervention.
It is possible that the attention from the therapist (both during treatment and at the follow-up evaluation) was a catalyst in improving some of the quality-of-life components. We believe that this possibility is unlikely, however, for 2 reasons. The 6-week follow-up evaluation was conducted in the same way and by the same therapist as the baseline and postintervention evaluations. In addition, the SIS is self-administered, further decreasing the effect that a testing therapist may have on the outcome. If the attention given by the treating therapist had affected the SIS, then we would have expected the SIS scores to return to baseline values at the 6-week follow-up; this was not the case. Immediately after treatment, the score on one item of the SIS decreased (as described above).
Interestingly, the patient reported improved gait and balance during the intervention; as mentioned above, these findings were reflected in the SIS scores. One possible explanation is that improved arm function resulted in improved gait (eg, arm swing and balance). Alternatively, it is possible that the improvements were attributable to increased activity (eg, transportation and walking needed to attend daily laboratory sessions). This possibility was less likely for our patient because he ambulated very actively in the community before the intervention and stated that he ate out every day.
The improvements observed in the patient in this case description may have been attributable to cortical reorganization, as previous studies reported cortical reorganization with short periods of task-specific training.4–7 The improvements also may have been attributable to increased wrist and finger strength, ROM, and control. During the third week of treatment, the patient gained enough wrist and finger control to start practicing functional tasks not involving heavy lifting (eg, making a sandwich) without the neuroprosthesis for short periods of time. Future work with other patients will examine these possibilities in more detail, and neuroimaging will be applied to examine hypothesized mechanisms.
| Conclusion |
|---|
|
TopAbstractIntroductionCase DescriptionOutcomesDiscussionConclusionReferences |
|---|
| Footnotes |
|---|
* Bioness Inc, 25134 Rye Canyon Loop, Suite 300, Santa Clarita, CA 91355. 
| References |
|---|
|
TopAbstractIntroductionCase DescriptionOutcomesDiscussionConclusionReferences |
|---|
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
 |
|
  S. J. Page, S. M. Harnish, M. Lamy, J. C. Eliassen, and J. P. Szaflarski Affected Arm Use and Cortical Change in Stroke Patients Exhibiting Minimal Hand Movement Neurorehabil Neural Repair, February 1, 2010; 24(2): 195 - 203. [Abstract] [PDF]
|
|
|
|
 |
|
 D. Broetz, S. R Soekadar, and N. Birbaumer On "A four-week, task-specific neuroprosthesis program..." Dunning K, et al. Phys Ther. 2008;88:397-405. Physical Therapy, August 1, 2008; 88(8): 970 - 970. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
