Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations.
Both action observation and repetitive-task practice are efficacious interventions for poststroke upper limb hemiplegia individually, yet these interventions have not been combined before. A feasibility study was completed to determine preliminary evidence of the response to intervention and whether a Phase III study should be completed to test efficacy of the combined intervention. The functional impact of improving poststroke upper limb performance could benefit millions of stroke survivors.
Primary Author and Speaker: Christine Griffin
Contributing Authors: Marcia Bockbrader, Erinn Hade, Anne Kloos, John A. Buford
PURPOSE: With 7.0 million people in the United States having experienced a stroke, stroke is one of the leading causes of serious long term-disability amongst Americans (Virani et al., 2020). Hemiplegia of the upper limb (UL) impedes performance and independence in activities of daily living (ADL). An intervention that has been supported to increase the performance of the hemiplegic UL is action observation (AO), which is performing a functional task after watching a video depicting the physical performance of the same task (Borges et al., 2018). Repetitive Task Practice (RTP) is the performance of goal-directed, functional, task-specific activities that are completed with intensive repetitions and high effort with the hemiplegic UL (Wolf et al., 2002), and has shown to be effective in UL stroke rehabilitation (Arya et al., 2012). While both AO and RTP are efficacious interventions for post-stroke UL hemiplegia individually, these interventions have not been combined before. The combination of AO providing visual motor learning for functional tasks prior to the intense physical performance during RTP could potentially increase performance of the hemiplegic UL. This synergistic combination of AO and RTP seems promising, and requires scientific investigation into the feasibility of completing a study with chronic moderately impaired stroke survivors. The purpose of this study is to determine the feasibility of the response to intervention through detecting changes in UL outcomes in the AO + RTP practice schedule compared to placebo + RTP in the chronic, moderately impaired stroke survivor
DESIGN: A feasibility randomized controlled single-blinded, parallel-group pilot study was completed with 15 chronic moderately impaired stroke survivors. Subjects were randomized to AO + RTP group, or in the control condition of Placebo Video + RTP, and completed an intervention for 1 hour, 3 times per week, for 8 weeks (total of 24 sessions), and a daily 30 minute Home Exercise Program.
METHOD: The outcome measures of the Upper Extremity Fugl Meyer (UEFM) and Arm Motor Ability Test (AMAT) were completed at pretest (Pre), post intervention (Post 1), and 1 month post intervention (Post 2). A quantitative survey of the subject's perception of the intervention (i.e., helpful, meaningful, or beneficial) on a 5 point Likert scale was completed at Post 2. A linear regression model that estimated the difference in the change from Pre to Post 2 was utilized, and frequencies for the quantitative survey were calculated for each question and group assignment.
RESULTS: There was significant evidence of a larger improvement in the AO + RTP group at Post 2, with the difference in the average change in UEFM was 8.2 (90% CI 4.0 - 12.4, p-value = 0.006), and change in the AMAT Total Functional Ability of 8.3 (90% CI 2.2 - 14.5, p-value = 0.034). Overall, both the AO + RTP and Placebo + RTP groups reported they were satisfied with and enjoyed the intervention, it was beneficial and meaningful, the task learned were helpful, the videos helped them perform the tasks, and they improved over the course of the study. This would mean that there was no resentment of the subjects in the Placebo + RTP group receiving a placebo assignment.
CONCLUSION: In this small feasibility pilot study of moderately impaired stroke survivors, there was a significant response of change on the UEFM and AMAT for the combination of AO + RTP on the hemiplegic UL.
IMPACT STATEMENT: This significant response would indicate that a larger Phase III RCT should be completed to determine efficacy for AO + RTP. The functional impact of improving UL performance in ADL and IADL tasks through AO + RTP would benefit millions of stroke survivors, and decreased the impact of disability.
References
Arya, K. N., Verma, R., Garg, R. K., Sharma, V. P., Agarwal, M., & Aggarwal, G. G. (2012). Meaningful Task-Specific Training (MTST) for Stroke Rehabilitation: A Randomized Controlled Trial. Topics in Stroke Rehabilitation, 19(3), 193–211. https://doi.org/10.1310/tsr1903-193
Borges, L. R., Fernandes, A. B., Melo, L. P., Guerra, R. O., & Campos, T. F. (2018). Action observation for upper limb rehabilitation after stroke. Cochrane Database of Systematic Reviews, 10. https://doi.org/10.1002/14651858.CD011887.pub2
Virani, S. S., Alonso, A., Benjamin, E. J., Bittencourt, M. S., Callaway, C. W., Carson, A. P., Chamberlain, A. M., Chang, A. R., Cheng, S., Delling, F. N., Djousse, L., Elkind, M. S. V., Ferguson, J. F., Fornage, M., Khan, S. S., Kissela, B. M., Knutson, K. L., Kwan, T. W., Lackland, D. T.; On behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. (2020). Heart Disease and Stroke Statistics-2020 Update: A Report.
Wolf, S. L., Blanton, S., Baer, H., Breshears, J., & Butler, A. J. (2002). Repetitive Task Practice: A Critical Review Of Constraint-Induced Movement Therapy In Stroke. The Neurologist, 8(6), 325–338. https://doi.org/10.1097/01.nrl.0000031014.85777.76
