Professor Paulette Van Vliet

Measuring cardiorespiratory fitness (CRF) in the stroke population is challenging. Currently, the recommended method is a graded exercise test (GXT) on an ergometer such as a treadmill or cycle, which may not always be possible. We investigated whether walking tests such as the six-minute walk test (6MWT) and the shuttle walk test (SWT) may be appropriate indicators of CRF in the stroke population. Twenty-three independently ambulant stroke survivors (11 men, age 61.5¿±¿18.4¿years) within one-year post stroke performed the 6MWT, SWT, and cycle GXT, during which peak oxygen consumption (VO2peak) and heart rate (HRpeak) were recorded. There were no differences (p¿>¿0.05) in mean VO2peak among the three tests (min-max: 17.08¿18.09¿mL¿kg-1¿min-1). For individuals, small discrepancies in VO2peak between the 6MWT and other tests were greater with higher fitness levels. HRpeak was significantly (p¿=¿0.005) lower during the 6MWT. Correlations between VO2peak and performance measures within each test were high (6MWT VO2peak and distance: r¿=¿0.78, SWT VO2peak and shuttles: r¿=¿0.73, cycle GXT VO2peak and workload: r¿=¿0.77) suggesting the performance measures may be clinically useful as proxy measures of CRF. Common comorbidities, such as lower-limb joint pain and poor balance, and participant¿s fastest walking speed, should inform the choice of CRF test.

Purpose: The purpose of this systematic scoping review was to (1) identify combined somatosensory and motor training interventions for the upper limb and their training components, and (2) review the efficacy of the combined interventions. Methods: Participants were adults post-stroke with somatosensory and/or movement deficits in the upper limb. All studies with interventions combining somatosensory and motor training and targeting the affected upper limb were included. Outcome measures were assessments of somatosensory and/or motor impairment and upper limb function. Results: Ten studies (n = 219) were included, comprising three randomized controlled trials, two pre-post studies with non-randomized comparison groups, three single-case experimental studies, and two case reports. There was heterogeneity across studies with regards to intervention contents and dosage, participant characteristics, and outcome measures. The interventions included combinations of tactile stimulation/discrimination, proprioceptive stimulation/discrimination, haptic object discrimination/recognition, movement training, and functional training. Only one group study, a non-randomized controlled study with multiple active components and the largest dose of treatment, found significant improvements in fine motor and somatosensory measures. Some improvements were found in case studies. Conclusion: There was little consistency across ¿combined somatosensory and motor training¿ interventions and few have been rigorously tested for efficacy across somatosensory, motor and functional outcomes.

Motor function may be enhanced if aerobic exercise is paired with motor training. One potential mechanism is that aerobic exercise increases levels of brain-derived neurotrophic factor (BDNF), which is important in neuroplasticity and involved in motor learning and motor memory consolidation. This study will examine the feasibility of a parallel-group assessor-blinded randomised controlled trial investigating whether task-specific training preceded by aerobic exercise improves upper limb function more than task-specific training alone, and determine the effect size of changes in primary outcome measures. People with upper limb motor dysfunction after stroke will be allocated to either task-specific training or aerobic exercise and consecutive task-specific training. Both groups will perform 60 hours of task-specific training over 10 weeks, comprised of 3 × 1 hour sessions per week with a therapist and 3 × 1 hours of home-based self-practice per week. The combined intervention group will also perform 30 minutes of aerobic exercise (70¿85%HRmax) immediately prior to the 1 hour of task-specific training with the therapist. Recruitment, adherence, retention, participant acceptability, and adverse events will be recorded. Clinical outcome measures will be performed pre-randomisation at baseline, at completion of the training program, and at 1 and 6 months follow-up. Primary clinical outcome measures will be the Action Research Arm Test (ARAT) and the Wolf Motor Function Test (WMFT). If aerobic exercise prior to task-specific training is acceptable, and a future phase 3 randomised controlled trial seems feasible, it should be pursued to determine the efficacy of this combined intervention for people after stroke.

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is to transparently describe the process of developing a complex intervention for people after stroke as part of a feasibility randomised controlled trial. Objective: To describe and justify the development of a home-based, task-specific upper limb training intervention to improve reach-to-grasp after stroke and pilot it for feasibility and acceptability prior to a randomized controlled trial. Intervention description: The intervention is based on intensive practice of whole reach-to-grasp tasks and part-practice of essential reach-to-grasp components. A 'pilot' manual of activities covering the domains of self-care, leisure and productivity was developed for the feasibility study. The intervention comprises 14 hours of therapist-delivered sessions over six weeks, with additional self-practice recommended for 42 hours (i.e. one hour every day). As part of a feasibility randomized controlled trial, 24 people with a wide range of upper limb impairment after stroke experienced the intervention to test adherence and acceptability. The median number of repetitions in one-hour therapist-delivered sessions was 157 (interquartile range IQR 96-211). The amount of self-practice was poorly documented. Where recorded, the median amount of practice was 30 minutes (interquartile range 22-45) per day. Findings demonstrated that the majority of participants found the intensity, content and level of difficulty of the intervention acceptable, and the programme to be beneficial. Comments on the content and presentation of the self-practice material were incorporated in a revised 'final' intervention manual. Discussion: A comprehensive training intervention to improve reach-to-grasp for people living at home after stroke has been described in accordance with the Template for Intervention Description and Replication (TIDieR) reporting guidelines. The intervention has been piloted, and found to be acceptable and feasible in the home setting. Trial registration: ISRCTN56716589

Background and Purpose: Published reports of intervention in randomized controlled trials are often poorly described. The Template for Intervention Description and Replication (TIDieR) checklist has been recently developed to improve the reporting of interventions. The aim of this article is to describe a therapy intervention used in the stroke rehabilitation trial, "Clinical Efficacy of Functional Strength Training for Upper Limb Motor Recovery Early After Stroke: Neural Correlates and Prognostic Indicators" (FAST-INdICATE), using TIDieR. Methods: The functional strength training intervention used in the FAST-INdICATE trial was described using TIDieR so that intervention can be replicated by both clinicians, who may implement it in practice, and researchers, who may deliver it in future research. The usefulness of TIDieR in the context of a complex stroke rehabilitation intervention was then discussed. Results and Discussion: The TIDieR checklist provided a systematic way of describing a treatment intervention used in a clinical trial of stroke rehabilitation. Clarification is needed regarding several aspects of the TIDieR checklist, including in which section to report about the development of the intervention in pilot studies, results of feasibility studies; overlap between training and procedures for assessing fidelity; and where to publish supplementary material so that it remains in the public domain. Conclusions: TIDieR is a systematic way of reporting the intervention delivered in a clinical trial of a complex intervention such as stroke rehabilitation. This approach may also have value for standardizing intervention in clinical practice.

Transcranial direct current stimulation has been gaining increasing interest as a potential therapeutic treatment in stroke recovery. We performed a systematic review with meta-analysis of randomized controlled trials to collate the available evidence in adults with residual motor impairments as a result of stroke. The primary outcome was change in motor function or impairment as a result of transcranial direct current stimulation, using any reported electrode montage, with or without adjunct physical therapy. The search yielded 15 relevant studies comprising 315 subjects. Compared with sham, cortical stimulation did not produce statistically significant improvements in motor performance when measured immediately after the intervention (anodal stimulation: facilitation of the affected cortex: standardized mean difference=0·05, P=0·71; cathodal stimulation: inhibition of the nonaffected cortex: standardized mean difference=0·39, P=0·08; bihemispheric stimulation: standardized mean difference=0·24, P=0·39). When the data were analyzed according to stroke characteristics, statistically significant improvements were evident for those with chronic stroke (standardized mean difference=0·45, P=0·01) and subjects with mild-to-moderate stroke impairments (standardized mean difference=0·37, P=0·02). Transcranial direct current stimulation is likely to be effective in enhancing motor performance in the short term when applied selectively to patients with stroke. Given the range of stimulation variables and heterogeneous nature of stroke, this modality is still experimental and further research is required to determine its clinical merit in stroke rehabilitation.

Background: The differential contributions of the cerebellum and parietal lobe to coordination between hand transport and hand shaping to an object have not been clearly identified. Objective: To contrast impairments in reach-to-grasp coordination, in response to object location perturbation, in patients with right parietal and cerebellar lesions, in order to further elucidate the role of each area in reach-to-grasp coordination. Method: A two-factor design with one between subject factor (right parietal stroke; cerebellar stroke; controls) and one within subject factor (presence or absence of object location perturbation) examined correction processes used to maintain coordination between transport-to-grasp in the presence of perturbation. Sixteen chronic stroke participants (eight with right parietal lesions and eight with cerebellar lesions) were matched in age (mean = 61 years; standard deviation = 12) and hand dominance with 16 healthy controls. Hand and arm movements were recorded during unperturbed baseline trials (10) and unpredictable trials (60) in which the target was displaced to the left (10) or right (10) or remained fixed (40). Results: Cerebellar patients had a slowed response to perturbation with anticipatory hand opening, an increased number of aperture peaks and disruption to temporal coordination, and greater variability. Parietal participants also exhibited slowed movements, with increased number of aperture peaks, but in addition, increased the number of velocity peaks and had a longer wrist path trajectory due to difficulties planning the new transport goal and thus relying more on feedback control. Conclusion: Patients with parietal or cerebellar lesions showed some similar and some contrasting deficits. The cerebellum was more dominant in controlling temporal coupling between transport and grasp components, and the parietal area was more concerned with using sensation to relate arm and hand state to target position.

Objectives: Given the importance of vision in the control of walking and evidence indicating varied practice of walking improves mobility outcomes, this study sought to examine the feasibility and preliminary efficacy of varied walking practice in response to visual cues, for the rehabilitation of walking following stroke. Design: This 3 arm parallel, multi-centre, assessor blind, randomised control trial was conducted within outpatient neurorehabilitation services Participants: Community dwelling stroke survivors with walking speed <0.8m/s, lower limb paresis and no severe visual impairments Intervention: Over-ground visual cue training (O-VCT), Treadmill based visual cue training (T-VCT), and Usual care (UC) delivered by physiotherapists twice weekly for 8 weeks. Main outcome measures: Participants were randomised using computer generated random permutated balanced blocks of randomly varying size. Recruitment, retention, adherence, adverse events and mobility and balance were measured before randomisation, postintervention and at four weeks follow-up. Results: Fifty-six participants participated (18 T-VCT, 19 O-VCT, 19 UC). Thirty-four completed treatment and follow-up assessments. Of the participants that completed, adherence was good with 16 treatments provided over (median of) 8.4, 7.5 and 9 weeks for T-VCT, O-VCT and UC respectively. No adverse events were reported. Post-treatment improvements in walking speed, symmetry, balance and functional mobility were seen in all treatment arms. Conclusions: Outpatient based treadmill and over-ground walking adaptability practice using visual cues are feasible and may improve mobility and balance. Future studies should continue a carefully phased approach using identified methods to improve retention. Trial Registration: Clinicaltrials.gov NCT01600391. Copyright:

Rationale: Functional strength training in addition to conventional physical therapy could enhance upper limb recovery early after stroke more than movement performance therapy plus conventional physical therapy. Aims: To determine (a) the relative clinical efficacy of conventional physical therapy combined with functional strength training and conventional physical therapy combined with movement performance therapy for upper limb recovery; (b) the neural correlates of response to conventional physical therapy combined with functional strength training and conventional physical therapy combined with movement performance therapy; (c) whether any one or combination of baseline measures predict motor improvement in response to conventional physical therapy combined with functional strength training or conventional physical therapy combined with movement performance therapy. Design: Randomized, controlled, observer-blind trial. Study: The sample will consist of 288 participants with upper limb paresis resulting from a stroke that occurred within the previous 60 days. All will be allocated to conventional physical therapy combined with functional strength training or conventional physical therapy combined with movement performance therapy. Functional strength training and movement performance therapy will be undertaken for up to 1·5h/day, five-days/week for six-weeks. Outcomes and Analysis: Measurements will be undertaken before randomization, six-weeks thereafter, and six-months after stroke. Primary efficacy outcome will be the Action Research Arm Test. Explanatory measurements will include voxel-wise estimates of brain activity during hand movement, brain white matter integrity (fractional anisotropy), and brain-muscle connectivity (e.g. latency of motor evoked potentials). The primary clinical efficacy analysis will compare treatment groups using a multilevel normal linear model adjusting for stratification variables and for which therapist administered the treatment. Effect of conventional physical therapy combined with functional strength training versus conventional physical therapy combined with movement performance therapy will be summarized using the adjusted mean difference and 95% confidence interval. To identify the neural correlates of improvement in both groups, we will investigate associations between change from baseline in clinical outcomes and each explanatory measure. To identify baseline measurements that independently predict motor improvement, we will develop a multiple regression model. © 2013 The Authors. Organization.

Objective: To investigate whether feedback inducing an external focus (EF) of attention (about movement effects) was more effective for retraining reach-to-grasp after stroke compared with feedback inducing an internal focus (IF) of attention (about body movement). It was predicted that inducing an EF of attention would be more beneficial to motor performance. Design: Crossover trial where participants were assigned at random to two feedback order groups: IF followed by EF or EF followed by IF. Setting: Research laboratory. Participants: Forty-two people with upper limb impairment after stroke. Intervention: Participants performed three reaching tasks: (A) reaching to grasp a jar; (B) placing a jar forwards on to a table; and (C) placing a jar on to a shelf. Ninety-six reaches were performed in total over one training session. Main outcome measures: Kinematic measures were collected using motion analysis. Primary outcome measures were movement duration, peak velocity of the wrist, size of peak aperture and peak elbow extension. Results: Feedback inducing an EF of attention produced shorter movement durations {first feedback order group: IF mean 2.53. seconds [standard deviation (SD) 1.85]; EF mean 2.12. seconds (SD 1.63), mean difference 0.41. seconds; 95% confidence interval -0.68 to 1.5; P= 0.008}, an increased percentage time to peak deceleration (P = 0.01) when performing Task B, and an increased percentage time to peak velocity (P = 0.039) when performing Task A compared with feedback inducing an IF of attention. However, an order effect was present whereby performance was improved if an EF of attention was preceded by an IF of attention. Conclusions: Feedback inducing an EF of attention may be of some benefit for improving motor performance of reaching in people with stroke in the short term; however, these results should be interpreted with caution. Further research using a randomised design is recommended to enable effects on motor learning to be assessed. © 2013 Chartered Society of Physiotherapy.

Evidence is emerging for central nervous system (CNS) changes in the presence of musculoskeletal dysfunction and pain. Motor control exercises, and potentially manual therapy, can induce changes in the CNS, yet the focus in musculoskeletal physiotherapy practice is conventionally on movement impairments with less consideration of intervention-induced neuroplastic changes. Studies in healthy individuals and those with neurological dysfunction provide examples of strategies that may also be used to enhance neuroplasticity during the rehabilitation of individuals with musculoskeletal dysfunction, improving the effectiveness of interventions. In this paper, the evidence for neuroplastic changes in patients with musculoskeletal conditions is discussed. The authors compare and contrast neurological and musculoskeletal physiotherapy clinical paradigms in the context of the motor learning principles of experience-dependent plasticity: part and whole practice, repetition, task-specificity and feedback that induces an external focus of attention in the learner. It is proposed that increased collaboration between neurological and musculoskeletal physiotherapists and researchers will facilitate new discoveries on the neurophysiological mechanisms underpinning sensorimotor changes in patients with musculoskeletal dysfunction. This may lead to greater integration of strategies to enhance neuroplasticity in patients treated in musculoskeletal physiotherapy practice.