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Handlery K1, Lockhart O1, Foster Lewis A1, Kolar M1, Blanck E2, Fritz S1, Stewart J1
1University of South Carolina, Exercise Science, Columbia, United States, 2University of South Carolina School of Medicine, Columbia, United States
Background: Stroke may result in a variety of upper extremity (UE) impairments resulting in loss of function. Task-oriented training (ToT) can improve arm function post-stroke, however, principles describing a standardized approach to individualization of ToT are lacking.
Purpose: To define and apply principles of individualization during the implementation of a standardized approach to UE ToT in individuals with chronic stroke.
Methods: S1 (47 years old, 11 months post right hemisphere subcortical stroke) presented with severe motor impairment (Upper Extremity Fugl-Meyer (UEFM) motor score 21/66, Action Research Arm Test (ARAT) 10/57, Box and Blocks Test (B&B) 3, UE Modified Ashworth 11/20). S2 (61 years old, 40 months post left hemisphere cortical/subcortical stroke) presented with moderate motor impairment and apraxia (UEFM 29/66, ARAT 30/57, B&B 17, UE Modified Ashworth 7/20, Test for Upper Limb Apraxia 129/240). S3 (61 years old, 12 months post left pontine stroke) presented with mild motor impairment (UEFM 52/66, ARAT 55/57, B&B 45). Participants completed 14-15 sessions (90 minutes per day, 5 days/week) of UE ToT that aimed to maximize the number of movement repetitions per day. Individualized training was provided through the application of principles that guided task selection, minimized compensations, directed feedback schedules, and graded tasks to maintain an optimal level of challenge. Tasks were categorized in two domains to determine the content of training across sessions: Arm Domain (unimanual, bimanual) and Task Domain (proximal, gross grasp, fine motor, distal object manipulation).
Results: S1 performed an average of 181 repetitions/session and spent the greatest percentage of time performing unimanual (71%) and proximal (44%) tasks. S2 averaged 173 repetitions/session and spent the greatest time performing unimanual (75%) and fine motor tasks (37%). S3 performed an average of 233 repetitions/session and spent similar time performing unimanual (58%) and bimanual (42%) tasks; S3 also performed the greatest percentage of distal object manipulation tasks (49%). All participants demonstrated improvements in arm function as measured by changes in the ARAT: S1 (change from pre-post, pre-follow-up: 8, 10); S2 (4, 3); S3 (1, 2) and B&B: S1 (2, 8); S2 (5, 2); S3 (6, 2). All participants also reported improvements in hand function as measured by the Stroke Impact Scale Hand Domain: S1 (change from pre-post, pre-follow-up: 27.50, 17.50), S2 (15.00, 25.00) and S3 (10.00, 10.00); and Confidence in Arm and Hand Movements: S1 (26.25, 15.25), S2 (36.38, 22.38) and S3 (3.38, 4.38).
Conclusion(s): Our approach to defining challenge (repetitions, Arm Domain, Task Domain) during a standardized approach to ToT differentiated between individuals based on their clinical presentation. The participant with the most motor ability (S3) completed the highest number of repetitions and the most distal object manipulation tasks while the participants with the least motor ability (S1) completed less repetitions and more unimanual and proximal tasks; training content for S2 was impacted by the presence of apraxia.
Implications: Utilizing standardized principles to determine the content of training may be useful in defining individualization during ToT and assist with structuring practice to optimize gains based on level of UE function.
Keywords: Stroke, task-oriented training, upper extremity
Funding acknowledgements: American Heart Association Grant 15SDG24970011
Purpose: To define and apply principles of individualization during the implementation of a standardized approach to UE ToT in individuals with chronic stroke.
Methods: S1 (47 years old, 11 months post right hemisphere subcortical stroke) presented with severe motor impairment (Upper Extremity Fugl-Meyer (UEFM) motor score 21/66, Action Research Arm Test (ARAT) 10/57, Box and Blocks Test (B&B) 3, UE Modified Ashworth 11/20). S2 (61 years old, 40 months post left hemisphere cortical/subcortical stroke) presented with moderate motor impairment and apraxia (UEFM 29/66, ARAT 30/57, B&B 17, UE Modified Ashworth 7/20, Test for Upper Limb Apraxia 129/240). S3 (61 years old, 12 months post left pontine stroke) presented with mild motor impairment (UEFM 52/66, ARAT 55/57, B&B 45). Participants completed 14-15 sessions (90 minutes per day, 5 days/week) of UE ToT that aimed to maximize the number of movement repetitions per day. Individualized training was provided through the application of principles that guided task selection, minimized compensations, directed feedback schedules, and graded tasks to maintain an optimal level of challenge. Tasks were categorized in two domains to determine the content of training across sessions: Arm Domain (unimanual, bimanual) and Task Domain (proximal, gross grasp, fine motor, distal object manipulation).
Results: S1 performed an average of 181 repetitions/session and spent the greatest percentage of time performing unimanual (71%) and proximal (44%) tasks. S2 averaged 173 repetitions/session and spent the greatest time performing unimanual (75%) and fine motor tasks (37%). S3 performed an average of 233 repetitions/session and spent similar time performing unimanual (58%) and bimanual (42%) tasks; S3 also performed the greatest percentage of distal object manipulation tasks (49%). All participants demonstrated improvements in arm function as measured by changes in the ARAT: S1 (change from pre-post, pre-follow-up: 8, 10); S2 (4, 3); S3 (1, 2) and B&B: S1 (2, 8); S2 (5, 2); S3 (6, 2). All participants also reported improvements in hand function as measured by the Stroke Impact Scale Hand Domain: S1 (change from pre-post, pre-follow-up: 27.50, 17.50), S2 (15.00, 25.00) and S3 (10.00, 10.00); and Confidence in Arm and Hand Movements: S1 (26.25, 15.25), S2 (36.38, 22.38) and S3 (3.38, 4.38).
Conclusion(s): Our approach to defining challenge (repetitions, Arm Domain, Task Domain) during a standardized approach to ToT differentiated between individuals based on their clinical presentation. The participant with the most motor ability (S3) completed the highest number of repetitions and the most distal object manipulation tasks while the participants with the least motor ability (S1) completed less repetitions and more unimanual and proximal tasks; training content for S2 was impacted by the presence of apraxia.
Implications: Utilizing standardized principles to determine the content of training may be useful in defining individualization during ToT and assist with structuring practice to optimize gains based on level of UE function.
Keywords: Stroke, task-oriented training, upper extremity
Funding acknowledgements: American Heart Association Grant 15SDG24970011
Topic: Neurology: stroke; Disability & rehabilitation
Ethics approval required: Yes
Institution: University of South Carolina
Ethics committee: University of South Carolina Institutional Review Board
Ethics number: Pro00032516
All authors, affiliations and abstracts have been published as submitted.
