Effects of Sensory Cueing on Voluntary Arm Use for Patients With Chronic Stroke: A Preliminary Study

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ORIGINAL ARTICLE

Effects of Sensory Cueing on Voluntary Arm Use for Patients With Chronic Stroke: A Preliminary Study Kenneth N. Fong, PhD, OTR, Pinky C. Lo, BSc, Yoyo S. Yu, BSc, Connie K. Cheuk, BSc, Toto H. Tsang, BSc, Ash S. Po, BSc, Chetwyn C. Chan, PhD ABSTRACT. Fong KN, Lo PC, Yu YS, Cheuk CK, Tsang TH, Po AS, Chan CC. Effects of sensory cueing on voluntary arm use for patients with chronic stroke: a preliminary study. Arch Phys Med Rehabil 2011;92:15-23. Objective: To investigate the effect of a 2-week program of sensory cueing in which vibration induces the use of the paretic upper extremity in participants with chronic stroke in the community. Design: A single-group longitudinal study. Setting: Self-help organizations. Participants: A convenience sample of 16 community residents (N⫽16) with chronic unilateral stroke and mild to moderate upper-extremity impairment stratified by the severity of their paretic arm function, measured by using the Functional Test for the Hemiplegic Upper Extremity (FTHUE). Interventions: Participants engaged in repetitive upperextremity task practice for 2 weeks while wearing an ambulatory sensory cueing device on their affected hand for 3 hours a day. Main Outcome Measures: Evaluations were conducted on the 3 occasions of pretest (1 day before training), posttest (immediately after training), and follow-up test (2 weeks after training) by using the following behavioral measures of paretic upper-extremity performance: the Action Research Arm Test (ARAT), the Box and Block Test, the Fugl-Meyer Assessment (FMA), the FTHUE, power and pinch grips, the Motor Activity Log assessment of arm use, and kinematic data obtained from the device. Results: Significant differences were found in ARAT and FMA scores among the pretest, posttest, and follow-up evaluations. The lower functioning group achieved a more significant increase in overall upper-extremity score than in the hand score for the FMA. Conclusion: A combination of sensory cueing and movement-based strategies is useful and feasible in improving paretic upper-extremity performance in participants with chronic stroke; however, additional studies with a larger sample size and longer treatment period in a randomized controlled trial would be beneficial. Key Words: Chronic stroke; Learned nonuse; Paretic upper extremity; Rehabilitation; Sensory cueing; Voluntary arm use. © 2011 by the American Congress of Rehabilitation Medicine

TROKE IS THE MOST significant cause of severe disabilS ity and results in many chronically disabled patients in the population. Functional recovery of the paretic upper extremity 1

after stroke often is slower than that of the lower extremity and is 1 of the greatest challenges faced by rehabilitation professionals.2 More than 60% of patients with chronic stroke have motor dysfunction in their upper extremities, with only 5% showing complete functional recovery.3 One of the biggest problems arising in upper-extremity rehabilitation after stroke is “learned nonuse,” in which some of the patient’s motor impairment is caused by the learned suppression of movement rather than brain cell damage.4 One of the main advances made in recent years has been the introduction of CIMT to overcome the learned nonuse of the paretic limbs in daily living activities in the home.5 CIMT involves restraint of the unaffected limb in either a mitt or sling for 90% of waking hours over a number of weeks and training of the paretic limb during the treatment period,6 or its modified version, involving different levels of intensity through variation in the duration and frequency of sessions and in total treatment duration.7-10 It now is clear that the phenomenon underlying CIMT is that it repeatedly induces the use of the paretic arm in task-specific functions and involves the upper extremities in intensive practice, even where they reach a performance plateau.11-13 Although CIMT is highly efficacious for stroke survivors who show some voluntary wrist and finger extension,5 it may not be so in patients with chronic stroke with moderate to severe impairment or poorer functioning of the affected upper extremity.14,15 CIMT also may be difficult to carry out because of safety concerns, especially for patients who have difficulty with balance and therefore may be at risk for falling when the less-affected arm is restrained.9,13 It also is awkward for patients to walk outdoors with a limb restrained in a mitt. Other effective treatments that use different theoretical approaches have been used to tackle upper-extremity impairment, including neurofacilitation techniques, repetitive bilateral arm training, and robot-aided exercise training. However, these approaches may require a number of costly therapy hours and expensive equipment. An effective self-administered home exercise program recently has been developed for upper-extremity recovery in patients with stroke, but it still requires staff to teach and monitor closely and the patient has to be very

List of Abbreviations From the Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong. Supported in part by the Hong Kong Polytechnic University, Hong Kong (internal research grant nos. 934E and A-SA60). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Reprint requests to Kenneth N.K. Fong, PhD, OTR, Dept of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong, e-mail: [email protected]. 0003-9993/11/9201-00725$36.00/0 doi:10.1016/j.apmr.2010.09.014

AOU ARAT BBT CIMT FMA FTHUE MAL QOM

amount of use Action Research Arm Test Box and Block Test constraint-induced movement therapy Fugl-Meyer Assessment Functional Test for the Hemiplegic Upper Extremity Motor Activity Log quality of movement

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SENSORY CUEING FOR LEARNED NONUSE, Fong

motivated to continue with the treatment at home for 3 months.16 Previous findings have reported the use of an external limb activation device that is strapped to the hemiplegic arm and provides an auditory alert signal to alleviate the problem of unilateral neglect in stroke patients.17-20 In a previous study, we explored the effects of using external sensory signals on a device to provide a sensory cue to the paretic upper extremity of subacute patients poststroke with unilateral neglect. We found that when the patient is appropriately trained, use of external signals promotes the patient’s awareness of their hemiplegic field and improves the initiation of movements and learned use of the paretic limb for daily functions.21 In the study reported here, we sought to substantiate an innovative treatment that involves promoting the awareness of and overcoming learned nonuse of the paretic upper extremity in patients with chronic stroke by activating the affected limb through a sensory cue emitted by a portable wristwatch device strapped to the forearm. We taught participants how to carry out upper-limb movement tasks for the paretic limb according to a protocol we designed by reference to the main therapeutic factor of awareness resulting from sensory cueing. This treatment would save the cost of intensive training involving supervised therapy and its results would represent a significant contribution to both the use of cost-effective strategies and treatment of learned nonuse to promote paretic upper-extremity function in the field of stroke rehabilitation. We hypothesized that a 2-week program of sensory cueing in which vibration induces the use of the paretic upper extremity and an ambulatory wristwatch device is used to remind patients to move would promote recovery of the paretic upper extremity in participants with chronic stroke. METHODS Participants A single-group longitudinal design was adopted for this study. A convenience sample of 16 community residents with chronic unilateral stroke from 3 self-help groups for stroke survivors in Hong Kong was recruited for the study from September 2008 to August 2009. Inclusion criteria were as follows: (1) first-time ischemic or hemorrhagic stroke; (2) stroke with unilateral hemispherical involvement; (3) aged 18 years or older; (4) chronic stroke (ie, stroke onset) more than 6 months before the study; (5) moderate to mild unilateral upperlimb paresis determined by using the FTHUE22,23 (FTHUE level ⱖ 3), with volitional elbow flexion/extension to initiate forearm pronation/supination and flexion/extension of the wrist; (6) able to understand verbal instructions and follow 1-step commands; (7) no excessive spasticity, defined as a score higher than 3 on the Modified Ashworth Scale24; (9) no excessive pain or swelling over the paretic upper extremity; (10) no prior participation in experimental or drug studies; and (11) able to understand the meaning of the study and give informed consent to participate. Potential participants were excluded if they (1) scored less than 22 on the Mini-Mental State Examination25; (2) showed inadequate balance, indicated by inability to stand for at least 2 minutes with or without upper-extremity support; or (3) showed unilateral neglect, assessed by using the letter cancellation and line bisection subtests of the Behavioral Inattention Test.26,27 The choice of a poststroke period of 6 months or more as an inclusion criterion for chronic stroke reflected the probability that any spontaneous recovery would have slowed down by the time of the study, thus enabling more brain reorganization in response to the therapeutic intervention under study. To investigate which level of Arch Phys Med Rehabil Vol 92, January 2011

severity of paretic upper-extremity functional impairment would benefit most from the treatment, participants were stratified further into 2 groups for additional analysis according to whether their upper-extremity impairment was moderate or mild. Group 1, the lower functioning group, included 8 participants with moderate impairment to a paretic upper extremity (ie, FTHUE levels of 3– 4) who were able to show a mass flexion pattern in the shoulder of 30° to 60° and at the elbow of 60° to 100°, gross grasp of 3 to 5 pounds, and mild lateral pinch. Group 2, the higher functioning group, included 8 participants with mild upper-extremity paresis (ie, FTHUE level ⱖ 5) who were able to show a beginning ability to combine components of strong mass flexion and strong mass extension patterns and were able to perform some release of the hand, as well as isolated control of all upper-extremity musculature with fair strength. Written and informed consent was obtained from all participants before the study started. The study was carried out in accordance with the principles of the Declaration of Helsinki. Ethical approval was sought and obtained from the Hong Kong Polytechnic University (Reference: HSEAR20080829001). Sensory Cueing Device The only piece of equipment used for sensory cueing was the sensory cueing wristwatch (SCW-V2),a which is designed to provide pertinent electronic sensory signals to patients with hemiplegia to increase their awareness of the paretic limb (fig 1). The SCW-V2 is small, lightweight (78g), user friendly, and easy to secure comfortably to the wrist by using nonallergenic neoprene straps with a Velcro closure. It can be set to emit a sensory signal in the form of a vibration cue (196Hz, similar to the vibration mode of a mobile telephone). This signal occurs within a predetermined variable (or random) time that ranges from a few seconds to several minutes. Built into the device is an acknowledgement button that is used to stop the signal and that will be activated continuously as long as the button is not pressed. This means that a wearer who wants to stop the cues must press the button as soon as possible. The SCW-V2 has a built-in logger to detect the amount of upper-extremity movement in the X, Y, and Z directions and the speed at which the signal is switched off, which indicates reaction time to the cue. Movement acceleration is sampled at a range of 1 to 10Hz and summed as a raw count over a user-specified epoch period that varies from 1 second to 60 minutes. The device, which is

Fig 1. View of the device from above to show the acknowledgement button and how it is worn on the wrist.

SENSORY CUEING FOR LEARNED NONUSE, Fong

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Table 1: Customary Upper-Limb Movement Tasks Corresponding FTHUE Levels

Principles of Movement

Examples of Tasks Recommended*

3

1. Range of motion exercise 2. Limb segments working together as functional synergy

4

1. Individual limb segments control training 2. Grasp and release training

5

1. Finger coordination training 2. Coordinating mild grasp and release in shoulder, elbow, and wrist control training

6

1. 2. 3. 4. 1. 2.

Elbow flexion and extension with cylindrical grasp Full fist and finger extension with forearm pronation and stretching of hand and fingers afterward Touch ear with shoulder abduction and elbow flexion Wrist flexion and extension with elbow support on table or forearm supported by sound side Grasp and release (with soft ball) Wrist circumduction with fingers in prayer position Wrist flexion and extension in open hand with forearm supported by sound side at 90° Elbow flexion and extension Touch ear with forearm flexion and supination Touch lumbar spine region Shoulder horizontal abduction and adduction Wrist flexion and extension with forearm supported by sound hand or table at 90° Finger opposition Elbow flexion and extension Finger opposition Clipping clothes pegs Small ball shifting in hand Coin shifting using radial 3 fingers Finger opposition in a fast manner Pen shifting using fingers Card translation between fingers

7

Fine motor skills training Individual finger movement Grasp and release training Endurance training Finger motor skills training Endurance, speed, and coordination in arm use

*Exercises are repeated 5 times for each item.

operated by a rechargeable battery, has a recording capacity of up to 72 continuous hours of use. All the raw data can be retrieved and read on a computer. In this study, the device was set to vibrate at 5-minute intervals with a 5-second on/off vibration pattern. Acceleration was sampled at 10Hz, and a 2-second recording epoch time was used. Procedure Participants were instructed to wear the device on the affected hand daily for 3 consecutive waking hours during the daytime (other than while bathing) during a 2-week period including 2 weekends while engaging in repetitive standardized task practice with the same hand without a therapist present. Because this study investigated whether sensory cueing induced the use of the paretic upper extremity, the reason participants were asked to wear the device for 2 weeks was to match the treatment duration used in the Extremity Constraint Induced Therapy Evaluation randomized trial,5 which requires that the less-impaired upper extremity be restrained by placing the hand in a mitt for most waking hours over a 2-week period. All participants took part in a 1-hour testing and learning session at their community center to learn how to operate the ambulatory device. Participants were instructed to perform 3 sets of standardized tasks 5 times each time a vibratory cue was emitted from the device at a fixed interval of 5 minutes. Tasks were tailored for participants according to the severity of their specific upper-limb impairment (FTHUE levels 3–7), as specified by a trained occupational therapist. The standardized tasks were repetitive and discrete movements carried out through functional activities, including strengthening tasks (making a fist), range-of-motion tasks (active flexion/extension of the shoulder/ elbow/wrist), and fine motor tasks, such as thumb-to-finger opposition, abduction and adduction of the fingers, and translation and

shifting of easily available objects (eg, a pen or coin) in the hand (table 1). The investigators selected the tasks based on the upper-extremity recovery sequence principle in the FTHUE.22,23 A behavioral contract was signed to ensure compliance in using the device and due regard for safety while it was being worn. Participants also were encouraged to practice safe daily living tasks involving the paretic limb as much as possible at home each day while the device was being worn for the 3-hour period (fig 2). These home assignments were discussed with participants in the first session and documented in a diary. Home assignments were important because they would enable participants to generalize the skills they had learned to real-life activities. To monitor participant compliance in using the ambulatory device and download data from the device, the investigators made telephone calls to each participant every 2 days during the wearing period and visited each participant at the community center every 4 days to download the data from the device and collect feedback, including any reports of discomfort. Participant adherence to the components of the treatment was monitored through the movement data captured by the accelerometer built into the device, which could be downloaded to a computer regularly. In addition, the investigators also used verbal feedback during the visit to reinforce to participants the attainment of target movements in the standardized tasks. A money coupon (HK$50) was given to each participant as an incentive when the follow-up assessment had been completed. Measurements First, information was collected for participants’ demographic characteristics, medical history, functional levels (rated by using the FTHUE), and self-perceived percentage of loss in light touch sensation on the paretic upper extremity. Seven Arch Phys Med Rehabil Vol 92, January 2011

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dated locally by adding some cultural-related items, such as using chopsticks, and was found to have good validity and reliability.22 This tool had been used for paretic upper-extremity studies recently.11,37,38 The MAL is a reliable self-assessment questionnaire capturing QOM and AOU in 30 real-life activites of daily living.35 A local version was developed for use in paretic upper extremities.34 Secondary outcomes included the kinematic data recorded by the built-in accelerometer in the cueing device.39 These data included mean movement acceleration in the X, Y, and Z directions during the 3-hour wearing period, average total number of movements a day, and mean ⫾ SD response time for pressing the acknowledgement button on the device to stop the cue. All these scales have shown good reliability and validity in the local cultural context.2,22,34 Behavioral measures were evaluated both the day before and the day after training was delivered. To ensure the reliability of assessment results, each assessment was conducted by the same rater (ie, 1 person conducted the same assessment on each participant in the pretest, posttest, and follow-up evaluations) who was not the therapist who worked with the participant in training. All raters were trained to administer these assessments properly. The estimated time required to complete all measurements for each participant was about one-half hour. Pretest, posttest, and follow-up assessments were conducted at the laboratory or community center.

Fig 2. Participants were encouraged to practice daily living tasks that involved the paretic limb.

primary outcome measures were administered at baseline (1 day before intervention), postintervention (immediately after training), and in the 2-week follow-up on completion of training. Secondary outcomes (kinematic data captured by the sensory device) were recorded on days 1 and 14 of the training period. The primary outcome measures included the following: (1) the ARAT28,29; (2) the BBT30,31; (3) the FMA32,33; (4) the FTHUE22; (5) the MAL, a self-assessment questionnaire that captures QOM and AOU in 30 real-life daily tasks34-36; and (6) the power and pinch grips of the affected hand, assessed by using the Jamar dynamometer.b The ARAT contains 19 items grouped in 4 subtests: grasp, grip, pinch, and gross movement. Ratings are made according to the QOM along a 4-point scale from 0 (no movement) to 3 (normal movement).28 The BBT is a quick and simple test measuring unilateral gross manual dexterity.31 It can be used with a wide range of populations, including patients with stroke. The upper-extremity motor subscore of the FMA is a measure of the synergistic pattern of and ability to make arm movements and consists of a 3-point scale with a total maximum score of 66.32 The total score can be divided further into upper-extremity and hand subscores. The FTHUE was developed originally according to Brunnstrom’s developmental stages of stoke recovery in a hierarchy of 7 functional difficulty levels.23 The local version has been valiArch Phys Med Rehabil Vol 92, January 2011

Statistical Analysis We performed data analysis using SPSS.c Baseline data, including demographic data and baseline scores for the instruments, were calculated according to descriptive statistics that were appropriate for SPSS. Nonparametric tests were chosen because of the small sample size. Friedman test was used to evaluate any significant difference between the hand function and arm use of participants before and immediately after training and at within-group follow-up sessions after training. A separate analysis using Wilcoxon signed-rank test was used to evaluate any significant difference in the kinematic data captured: accelerations of the X, Y and Z axes, average number of movements, and mean response time of participants between days 1 and 14 of the training period. Wilcoxon signed-rank test also was used for post hoc analysis in which the measurements obtained for each variable on the 3 occasions (ie, before and immediately after training and at follow-up) were compared to determine where any significant differences lay. The level of significance was set at Pⱕ.005 for the Friedman test after Bonferroni adjustment (0.05/n; n⫽number of tests) and at Pⱕ.017 (0.05/n; n⫽number of comparisons) according to the Bonferroni method for post hoc analysis in primary outcome measures. The level of significance was set at Pⱕ.01 (0.05/n; n⫽number of tests) in pre/post comparison of accelerometry values. Friedman and Wilcoxon signed-rank tests were used later for separate analysis when patients were stratified into those with moderate (the lower functioning group) and mild impairments (the higher functioning group) according to the severity of their paretic arm functional impairment. The purpose was to test whether sensory cueing had different effects on lower or higher upper-extremity functioning groups. RESULTS Demographic characteristics of participants are listed in table 2. Table 3 lists results of the behavioral outcome measures at the pretest, posttest, and 2-week follow-up evaluations. Table 4 lists results of the kinematic measures between days 1 and 14.

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SENSORY CUEING FOR LEARNED NONUSE, Fong Table 2: Baseline Demographics of Study Participants Characteristics

Sex (men/women) Age (y) Onset to treatment (mo) Type of stroke Hemorrhagic Ischemic Right-hand dominance Hemiparetic side (left/right) FTHUE level 3 4 5 6 7 MAS score 0 1 2 3 Self-perceived % loss in light touch sensation 0 10 20 30 40 50 60 70 80 90 100 BIT score Letter cancellation Line bisection

All (N⫽16)

11 (69.0)/5 (31.0) 57.6⫾9.0 57.9 (23.8) 7 (43.7) 9 (56.3) 10 (62.5) 6 (37.5)/10 (62.5)

Lower Functioning Group (n⫽8)

Higher Functioning Group (n⫽8)

4 (50.0)/4 (50.0) 60.6⫾8.5 66.3 (30.7)

7 (87.5)/1 (12.5) 54.5⫾8.9 49.5 (10.6)

4 (50.0) 4 (50.0) 4 (40.0) 4 (50.0)/4 (50.0)

3 (37.5) 5 (62.5) 6 (60.0) 2 (25.0)/6 (75.0)

4 (25.0) 4 (25.0) 1 (6.2) 6 (37.5) 1 (6.2)

4 (50.0) 4 (50.0) 0 (0) 0 (0) 0 (0)

0 (0) 0 (0) 1 (12.5) 6 (75.0) 1 (12.5)

2 (12.5) 7 (43.7) 4 (25.0) 3 (18.8)

0 (0) 3 (37.5) 2 (25.0) 3 (37.5)

2 (25.0) 4 (50.0) 2 (25.0) 0 (0)

5 (31.2) 0 (0) 1 (6.2) 1 (6.2) 4 (25.0) 2 (12.5) 1 (6.2) 1 (6.2) 0 (0) 0 (0) 1 (6.2)

2 (25.0) 0 (0) 1 (12.5) 0 (0) 1 (12.5) 1 (12.5) 1 (12.5) 1 (12.5) 0 (0) 0 (0) 1 (12.5)

3 (37.5) 0 (0) 0 (0) 1 (12.5) 3 (37.5) 1 (12.5) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

37.7⫾2.7 8.8⫾0.4

37.9⫾1.9 8.8⫾0.7

37.5⫾3.2 8.4⫾0.7

NOTE. Values expressed as n (%) or mean ⫾ SD. Abbreviations: BIT, Behavioral Inattention Test; MAS, Modified Ashworth Scale; self-perceived % loss in light touch sensation, the loss the person feels in his/her light touch sensation in comparison to the nonaffected side according to a Likert scale from 0 to 10.

Effects on Upper-Extremity Functions There was a significant increase in ARAT scores between the pretest and posttest and follow-up evaluations (P⫽.003). The mean gain in the total score was 4.81 points from pretest to follow-up (see table 3). Post hoc analysis showed that the ARAT score differed significantly between pre- and posttest, but not between posttest and follow-up. There was a significant improvement in the hand subscore and total FMA score (P⬍.001). Further post hoc investigation of these mean FMA scores showed significant differences between pretest and follow-up and between posttest and follow-up (see table 3). From pretest to follow-up, mean total FMA scores increased by 5.37 points. Although there was no significant improvement in the upper-extremity FMA subscore, when the 16 participants were stratified into higher and lower functioning groups, there was a significant difference between pretest and follow-up for (1) total FMA scores of participants in group 1, the lower functioning group (P⫽.004), with a gain of 6.87 points; and (2) the hand subscore for those in group 2, the higher functioning group (P⫽.001), with a gain of 2.75 points (table 5). There were no significant differences in the power and pinch grips, BBT, FTHUE, and Modified Ashworth Scale scores (see table 3) before and after treatment and at follow-up.

Effects on Actual Arm Use Actual arm use was determined by using both AOU and QOM in the MAL based on the primary outcome measures and kinematic data recorded by the built-in logger in the cueing device. No significant increases in AOU and QOM in the MAL were found in any participants (see tables 3 and 5). Nevertheless, mean scores for AOU and QOM had increased by .39 and .37 by the 2-week follow-up, respectively. Although overall differences in AOU and QOM were not significant on any occasion, the QOM of group 1 (mean gain, .39) increased more than that of group 2 (mean gain, .27), whereas the AOU of group 2 (mean gain, .43) increased more than that of group 1 (mean gain, .36) (see table 5). Mean response time for pressing the switch to stop the cue emitted by the wristwatch device improved significantly (P⫽.01). Apart from this, there were no significant differences in mean accelerations of any of the axes or in the average number of movements between days 1 and 14 (see table 4). DISCUSSION The main results of this study showed that the treatment involving a 2-week program of sensory cueing to activate the paretic upper extremity by using an ambulatory device tied to Arch Phys Med Rehabil Vol 92, January 2011

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SENSORY CUEING FOR LEARNED NONUSE, Fong Table 3: Differences in Primary Outcome Measures at Pretest, Posttest, and Follow-up Outcome Measures

Pretest

Posttest

Follow-up

␹2

P

ARAT BBT FMA Upper Extremity Hand Total FTHUE MAL AOU QOM Grip Power Pinch

36.00⫾20.07 20.50⫾17.15

39.81⫾18.67 23.44⫾19.52

40.81⫾18.63 24.50⫾19.84

11.85 7.85

.003† .020

27.69⫾7.13 16.06⫾9.62 43.88⫾16.12 4.75⫾1.39

29.38⫾6.31 17.62⫾9.42 47.12⫾14.70 5.00⫾1.27

29.94⫾6.23 19.31⫾9.08 49.25⫾14.67 5.00⫾1.27

8.00 21.97 18.66 8.00

.018 .000† .000† .018

1.71⫾1.49 1.83⫾1.61

1.98⫾1.51 1.89⫾1.48

2.10⫾1.45 2.20⫾1.49

9.10 7.31

.011 .026

12.04⫾10.00 4.03⫾2.36

12.22⫾8.91 4.22⫾2.45

13.76⫾11.40 4.61⫾2.49

4.51 4.63

.105 .099

Multiple Comparisons*‡

1–2

1–3; 2–3 1–3; 2–3

NOTE. N⫽16. Values shown as mean ⫾ SD. Pretest indicates 1 day before intervention; posttest, 1 day after intervention; and follow-up, 2 weeks after intervention. ABBREVIATION: ND, not done. *Wilcoxon signed-rank test with Pⱕ.017. † Pⱕ.005. ‡ Post hoc analysis had not been carried about for no significant within group differences across all measurement occasions.

the limb promoted paretic upper-extremity recovery and awareness of the paretic upper limbs in patients with chronic stroke. ARAT, FMA, and reaction time scores showed statistically significant improvements within groups across the tests conducted at the 3 times. In this study, we found that participants’ hand performance improved significantly after 2 weeks of wearing the new ambulatory sensory cueing device and performing upper-limb activation tasks prescribed according to their hand performance, measured by using the FTHUE, with specific improvement in the hand in the higher functioning group and overall improvement in both the hand and upper extremity in the lower functioning group. FMA results were divided into upperextremity and hand subscores and total score for analysis, with improvements in only the hand subscore and total score found to be statistically significant. Results showed that hand performance, in terms of the movement and stability of the wrist, grip and pinch, coordination, and speed, improved to a remarkable extent during the study period. These findings are understandable because we recruited participants with only moderate to mild unilateral upper-limb paresis (ie, FTHUE level ⱖ 3) who had already achieved some degree of beginning voluntary motion of the shoulder and elbow. According to a previous study,40 clinical experiences of therapists and neurologists with the FMA scale showed that a 10-point increase in FMA motor

Table 4: Differences in Accelerometry Values on Days 1 and 14 of the Training Period Outcome Measures

Day 1

Accelerations X axis 3.70⫾1.40 Y axis 4.21⫾1.00 Z axis 3.48⫾0.88 Mean no. of movements 993.94⫾480.79 Mean response time 18.03⫾47.83

Day 14

z

3.99⫾1.32 3.98⫾1.17 3.34⫾0.89

⫺0.19 ⫺2.07 ⫺0.98

.243 .836 .326

960.81⫾366.72

⫺0.42

.679

4.17⫾5.60

⫺2.53

.010*

NOTE. N⫽16. Values shown as mean ⫾ SD. *Pⱕ.01.

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P

score represented a clinically relevant improvement. In this study, 3 participants showed an FMA motor score gain greater than 10 between the pretest and follow-up results, and 5 participants had an FMA score gain greater than 7. These results are consistent with the improvement seen in the ARAT, a test consisting of 19 arm motor function tasks that are more distally sensitive to therapy-related gains after stroke. The power and pinch grips and accelerometry data for participants showed no significant improvement after the course of treatment. Strengthening and speed elements generally were not addressed by the upper-limb movement tasks included in the program because most participants sought improvement in the quality of hand performance rather than in grip and pinch strengths or speed of movement. No significantly different treatment effects were observed between the higher and lower functioning participants, other than the significant increase measured in hand scores, such as wrist/finger movement, of participants in the higher functioning group between pretest and follow-up. The treatment was useful in improving functioning of the upper extremity as a whole in the lower level group between pretest and follow-up. Participants’ arm use was measured by using the MAL and kinematic data collected by the accelerometer built into the device. No significant differences were found in overall measures, including AOU and QOM in the MAL and acceleration and number of movements recorded by the SCW-V2. The absence of changes in accelerometry data did not suggest an actual increase in amount of movement in the upper extremity as cued practice was undertaken over time. Participants wore the device and practiced the same repetitive tasks continuously for 3 hours and were encouraged to use the device to practice daily living tasks involving the paretic limb as much as possible, but the limited improvement observed in arm use in both groups suggests that performing these tasks within the dosing parameters used in this study may not translate into increased arm use in daily life. However, 1 limitation of this study relates to the use of accelerometry values because they might not have a genuine connection with the performance of functional activities, especially in patients with paresis in their nondominant arm.35 It was noted that the improvement in arm use in the lower functioning group measured by using the MAL almost reached the conservative .005 cutoff point for signifi-

1, 3

Higher Functioning Group

.122 .095 3.47 0.83

.029 .010 2.77 0.75

.008 .011 .004† .050 1.04 13.56 5.81 2.00

.027 .311 4.91 5.79

4.21 4.71 21.00⫾11.74 6.15⫾2.63 6.53⫾4.60 3.08⫾0.96 17.90⫾8.32 5.61⫾2.66 19.36⫾8.79 5.50⫾2.36 4.71⫾3.16 2.55⫾1.17

6.54⫾5.19 2.83⫾1.16

7.10 9.17 3.18⫾1.20 3.25⫾1.35 1.03⫾0.64 1.07⫾0.47 3.12⫾1.22 3.04⫾1.17 2.75⫾1.32 2.98⫾1.47 0.67⫾0.73 0.68⫾0.60

0.84⫾0.68 0.72⫾0.52

9.54 8.97 10.83 6.00 34.12⫾1.96 27.25⫾2.12 61.38⫾3.34 6.17⫾0.75 25.75⫾6.27 11.38⫾5.32 37.12⫾10.67 3.88⫾0.35 33.62⫾2.39 25.88⫾1.96 59.50⫾2.62 6.12⫾0.64 33.00⫾3.74 24.50⫾3.12 57.50⫾5.88 6.00⫾0.54 22.38⫾5.50 7.62⫾5.10 30.25⫾9.91 3.50⫾0.54

25.12⫾6.19 9.38⫾5.53 34.75⫾10.31 3.88⫾0.35

7.20 2.33 55.12⫾2.80 40.25⫾15.40 26.50⫾16.35 8.75⫾6.27 55.12⫾2.60 39.12⫾13.58 24.50⫾14.27 7.75⫾8.33 53.25⫾5.42 35.25⫾10.08 18.75⫾12.75 5.75⫾5.63

Outcome Measures

ARAT BBT FMA Upper extremity Hand Total FTHUE MAL AOU QOM Grip Power Pinch

NOTE. Values shown as mean ⫾ SD. Pretest indicates 1 day before intervention; posttest, 1 day after intervention; and follow-up, 2 weeks after intervention. *Wilcoxon signed-rank test with Pⱕ.017. Pⱕ.005. ‡ Post hoc analysis had not been carried about for no significant within group differences across all measurement occasions. †

.177 .661

.250 .687

.593 .001† .012 .368

.086 .055

1, 3

Lower Functioning Group Higher Functioning Group

P Lower Functioning Group Higher Functioning Group

␹2 Lower Functioning Group Higher Functioning Group (n⫽8) Lower Functioning Group (n⫽8) Higher Functioning Group (n⫽8) Lower Functioning Group (n⫽8) Higher Functioning Group (n⫽8) Lower Functioning Group (n⫽8)

Follow-up Posttest Pretest

Table 5: Results of the Friedman Test on Outcome Measures at Pretest, Posttest, and Follow-up in Subgroups

Multiple Comparisons*‡

SENSORY CUEING FOR LEARNED NONUSE, Fong

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cance (P⫽.029 and P⫽.01) (see table 5). This finding implies that the treatment may be more beneficial to patients with moderate upper-extremity impairments. The intervention examined in this study is a top-down treatment in which the patient’s mind is the controller. We hypothesized that the external signals emitted from the sensory device would improve patients’ awareness of their paretic limbs and thus increase the extent to which they initiated movements in these limbs by reminding them to engage in repetitive standardized task practice and participate in real-life activities. Previous studies have suggested that the primary motor cortex, adjacent premotor cortex, supplementary motor area, cingulated motor area, and cerebellum are physiologically and anatomically altered in response to contralesional upper-extremity motor impairment in patients after stroke or brain injury,12,41-43 and that lesions to these areas affect the initiation of movement with the impaired hand and coordination of different limb movements in response to different types of sensory feedback through the corticospinal fibers.44 Sensory feedback is modulated by attention, cognition, and emotional influences.45 For example, we are constantly bombarded with sensory stimuli from the environment, but we attend to sensory cues only when we choose to do so (eg, answering our mobile telephone). Therefore, results of this study may support the view that by priming the motor system with sensory stimulation and using movement-based strategies, it might be possible to modulate the attention system and thus activate the ipsilesional primary motor cortex to achieve better recovery of motor function. Our study finding of a significant pre-/posttest decrease in response time for pressing the switch on the device to stop the cue might show an increased level of attention. In preparing for this study, we developed a model for paretic upper-extremity recovery in patients with chronic stroke that is useful, safe, cost-effective, and easy to implement. This approach is safer than and has an advantage over CIMT because it leaves participants with both hands free to protect themselves when they lose their balance while walking. There also is no need to restrain the less-affected hand in either a mitt or sling, which looks very odd in the outdoor environment, during the treatment period. Moreover, the less-affected hand is free to be used in bimanual tasks that are essential to daily life (eg, wringing a towel in a grooming task). It is impossible to carry out such bilateral hand activities when undergoing CIMT.43 Moreover, very few patients with stroke qualify for CIMT because of their poor motor function and the strict inclusion and exclusion criteria, and CIMT imposes substantial demands on therapist and rehabilitation resources.46,47 Furthermore, our intervention techniques are different from those examined in studies of repetitive task-oriented practice or self-administered homework exercise programs for the upper extremities because we adhered to the principle of minimal contact time with the therapist by using our ambulatory device as a reminder.16,48 Most of the therapist time in our study was spent capturing data from the device and providing verbal feedback to participants during visits to the community center. Study Limitations This study was subject to several limitations. Location of stroke was not known. Also, no control group was included in the study, and other factors, such the maturation effect and possible rater bias in assessment, may have affected results. Replication of this study with a larger sample size, longer treatment period, and use of a placebo group in a randomized controlled trial would be beneficial. A study of the long-term effects of this treatment also should be conducted by extending the follow-up period. Different protocols, including alternative Arch Phys Med Rehabil Vol 92, January 2011

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SENSORY CUEING FOR LEARNED NONUSE, Fong

wearing regimens for the sensory device and different upperlimb activation tasks, should be considered to maximize treatment effects and induce changes in response to feedback received from participants. CONCLUSION The study reported here indicates that a top-down course of treatment incorporating sensory cueing and limb activation is useful in improving the paretic upper-extremity performance of patients with chronic stroke. Although our study was of a preliminary nature, findings suggest that use of an ambulatory sensory cueing device to remind patients to move is a useful treatment method for promoting arm use in patients with chronic stroke. The estimated cost of a single device is similar to the cost of a few hourly sessions of supervised therapy. This new training mode thus is highly beneficial to the advancement of stroke rehabilitation knowledge. Furthermore, if its objectives are achieved, this treatment method represents a costeffective way of meeting the needs of survivors of chronic stroke. Acknowledgment: We thank the Self Help Group for the Brain Damaged, Neuro United, and the Hong Kong Stroke Association. We also thank Mr Yuen Siu Lam for coordinating data collection. References 1. Hong Kong Hospital Authority Statistics and Research Section. Hospital Authority statistical report 2007-2008, Hong Kong. Available at: http://www.ha.org.hk/haho/ho/hacp/0708_Full_ report_07_08.pdf. Accessed October 2, 2009. 2. Fong KNK, Chan CCH, Au DKS. Relationship of motor and cognitive performance to functional performance in stroke rehabilitation. Brain Inj 2001;15:443-53. 3. Dobkin BH. Clinical practice. Rehabilitation after stroke. N Engl J Med 2005;352:1677-84. 4. Taub E, Uswatte G, Mark VW, Morris DM. The learned nonuse phenomenon: implications for rehabilitation. Eur Medicophys 2006;42:241-56. 5. Wolf SL, Winstein CJ, Miller JP, et al. Effect of constraintinduced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. JAMA 2006;296:2095-104. 6. Taub E, Miller NE, Novack TA, et al. Techniques to improve chronic motor deficit after stroke. Arch Phys Med Rehabil 1993; 74:347-54. 7. Page SJ, Sisto S, Johnston MV, Levine P. Modified constraintinduced therapy after subacute stroke: a preliminary study. Neurorehabil Neural Repair 2002;16:290-5. 8. Page SJ, Sisto S, Levine P, Johnston MV, Hughes M. Modified constraint induced therapy: a randomized feasibility and efficacy study. J Rehabil Res Dev 2001;38:583-90. 9. Page SJ, Sisto S, Levine P, McGrath RE. Efficacy of modified constraint-induced movement therapy in chronic stroke: a singleblinded randomized controlled trial. Arch Phys Med Rehabil 2004;85:14-8. 10. Wu CY, Chen CL, Tsai WC, Lin KC, Chou SH. A randomized controlled trial of modified constraint-induced movement therapy for elderly stroke survivors: changes in motor impairment, daily functioning, and quality of life. Arch Phys Med Rehabil 2007;88: 273-8. 11. Leung DPK, Ng AKY, Fong KNK. Effect of group treatment of the modified constraint induced movement therapy (mCIMT) for clients with chronic stroke in a community setting in Hong Kong. Hum Movement Sci 2009;28:798-808. 12. Nudo RJ. Adaptive plasticity in motor cortex: implications for rehabilitation after brain injury. J Rehabil Med 2003;(Suppl 41): 7-10. Arch Phys Med Rehabil Vol 92, January 2011

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32. Duncan PW, Propst M, Nelson SG. Reliability of the Fugl-Meyer Assessment of sensorimotor recovery following cerebrovascular accident. Phys Ther 1983;63:1606-10. 33. Fugl-Meyer AR, Jaasko L. Post-stroke hemiplegia and ADL performance. Scand J Rehabil Med 1980;7:140-52. 34. Ng AKY, Leung DPK, Fong KNK. Clinical utility of the Action Research Arm Test, Wolf Motor Function Test and the Motor Activity Log of hemiparetic upper extremity functions after stroke: a pilot study. Hong Kong J Occup Ther 2008;18:20-7. 35. Uswatte G, Taub E, Morris D, Light K, Thompson PA. The Motor Activity Log-28: assessing daily use of the hemiparetic arm after stroke. Neurology 2006;67:1189-94. 36. Van der Lee JH, Beckerman H, Knol DL, De Vet HCW, Bouter LM. Clinical properties of the Motor Activity Log for the assessment of arm use in hemiparetic patients. Stroke 2004;35:1410-4. 37. Myint JMWW, Yuen GFC, Yu TKK, et al. A study of constraintinduced movement therapy in subacute stroke patients in Hong Kong. Clin Rehabil 2008;22:112-24. 38. Chan MK, Tong RK, Chung KY. Bilateral upper limb training with functional electric stimulation in patients with chronic stroke. Neurorehabil Neural Repair 2009;23:357-65. 39. Uswatte G, Giuliani C, Winstein C, Zeringue A, Hobbs L, Wolf SL. Validity of accelerometry for monitoring real-world arm activity in patients with subacute stroke: evidence from the extremity constraint-induced therapy evaluation trial. Arch Phys Med Rehabil 2006;87:1304-45. 40. Gladstone DJ, Danells CJ, Black SE. The Fugl-Meyer Assessment of motor recovery after stroke: a critical review of its measurement properties. Neurorehabil Neural Repair 2002;16:232-40.

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41. Frost SB, Barbay S, Friel KM, Plautz EJ, Nudo RJ. Reorganization of remote cortical regions after ischemic brain injury: a potential substrate for stroke recovery. J Neurophysiol 2003;89: 3205-14. 42. Miyai I, Suzuki T, Kang J, Kubota K, Volpe BT. Middle cerebral artery stroke that includes the premotor cortex reduces mobility outcome. Stroke 1999;30:1380-3. 43. Wolf SL. Revisiting constraint-induced movement therapy: are we too smitten with the mitten? Is all nonuse “learned”? And other quandaries. Phys Ther 2007;87:1212-23. 44. Gilman S, Newman SW. Manter and Gatz’s clinical neuroanatomy and neurophysiology. 9th ed. Philadelphia: F.A. Davis Co; 1992. 45. Dubner R, Ren K. Endogenous mechanisms of sensory modulation. Pain 1999;82(Suppl 1):S45-53. 46. Dobkin BH. Interpreting the randomized clinical trial of constraint-induced movement therapy. Arch Neurol 2007;64:336-8. 47. Grotta JC, Noser EA, Ro T, et al. Constraint-induced movement therapy. Stroke 2004;35:2699-701. 48. Winstein CJ, Rose DK, Tan SM, Lewthwaite R, Chui HC, Azen SP. A randomized controlled comparison of upper-extremity rehabilitation strategies in acute stroke: a pilot study of immediate and long-term outcomes. Arch Phys Med Rehabil 2004;85:620-8. Suppliers a. PolyU Technology & Consultancy Co Ltd, QR603, The Hong Kong Polytechnic University, Hung Hom, Hong Kong. b. Hydraulic hand dynamometer, Saehan Corp., Masan, Korea. c. SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.

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