Text

theses

Background
Stroke is a leading cause of long-term disability in adults. Functional use of the upper limb, specifically the hand, is essential for independent living. Despite important research efforts, many individuals do not regain long-term upper limb function after sustaining a stroke. Collectively, the work presented here addresses key issues in stroke rehabilition for the upper limb - namely, evaluation of a novel training protocol for persons with severe impairment, determining the effects of a higher dose of upper limb training initiated in the acute and early sub-acute period post-stroke, and assessing the validity and effectiveness of two influential prediction models for stroke.

Methods
All studies were initiated within the first month post-stroke to take advantage of the unique neuroplasticity occurring at that time and were conducted on an inpatient rehabilitation unit. The first study was a longitudinal study which included five individuals with severe hand paresis post-stroke. This study evaluated the feasibility and outcomes of a priming method that utilized mirror visual feedback and contralateral passive range of motion combined with a force modulation task in persons with severe hand impairment. The outcomes included the Upper Extremity Fugl-Meyer Assessment (UEFMA), the Action Research Arm test (ARAT), maximum pinch force, and bilateral maps of cortical reorganization via Transcranial Magnetic Stimulation (TMS). The second study was a non-randomized, two armed intervention study that evaluated the benefits of eight additional hours of intensive upper limb training with individuals with moderate arm paresis. There were seven subjects in the Virtual Reality(VR)/robotic treatment group, and six in the control group. Outcomes included the Wolf Motor Function Test, the UEFMA, wrist AROM, and maximum pinch force, as well as bilateral maps of cortical organization using TMS. Lastly, the third study evaluated the validity and methodology of two influential prediction models for stroke – the Proportional Recovery Rule and the Predicted Recovery Potential (PREP2) algorithm.

Results
For the first study, results showed feasibility of performing this training so early after stroke, as well as clinically significant long-term gains on all clinical measures in this group. However, without a control group it was not possible to determine how much of these gains were from the additional training or from biological recovery combined with the usual care they were concurrently receiving. The second study showed the feasibility of performing intense hand focused upper limb training and multiple clinical and neurophysiologic tests within the first month post-stroke. Importantly, it also showed that an extra eight hours of intensive VR/robotic based upper limb training led to significantly greater gains in long-term impairment compared to usual care. For the third study, trends showed that additional training initiated within one month post lesion may allow for greater than predicted proportional recovery in persons with functional Corticospinal Tracts. The study results also showed that further evaluation of the method used to determine the presence of motor evoked potentials (an indicator of Corticospinal tract function) for the PREP2 algorithm is justified.

Conclusion
Although preliminary in nature, the results presented here may be useful for future development of effective upper limb training protocols for rehabilitation in the acute and early sub-acute periods for persons at all levels of impairment post-stroke.

ETD_10399

Ph.D.

Includes bibliographical references

doi:10.7282/t3-6r8n-5423

ETD doctoral

The author owns the copyright to this work.