Strategies for increasing the intensity of upper limb task-specific practice after acquired brain impairment: A secondary analysis from a randomised controlled trial

Abstract

Introduction

Patients with acquired brain impairments require intensive, task-specific training to maximise upper limb recovery. Current evidence suggests, however, that they rarely achieve this. The purpose of this study was to describe the amount of practice that can be achieved by patients with acquired brain impairment during intensive upper limb treatment within a public hospital, and to examine the strategies used by therapists to maximise practice.

Method

A secondary analysis was conducted using data from a previously published randomised trial. The training received by 20 people with acquired brain impairment over the 6-week trial period was recorded. The strategies used by therapists to maximise practice were also noted.

Results

Over the 6-week period, 45 hours of upper limb training was provided. The median (interquartile range) amount of actual practice achieved by patients was 59 (54–63) minutes per day, with a median (interquartile range) of 186 (50–330) repetitions of active movement. Patients’ practice was maximised through the use of task-specific feedback, practice books, counters, environmental cues and stopwatches. In addition, therapists provided coaching as well as ensuring tasks were goal-oriented, measurable and patient-driven.

Conclusion

Described strategies enabled patients with acquired brain impairment to practise upper limb tasks at intensities greater than currently reported in the literature.

Keywords

Stroke exercise training arm hand extremity shoulder

Get full access to this article

View all access options for this article.

References

Ada

Foongchomcheay

(2002) Efficacy of electrical stimulation in preventing or reducing subluxation of the shoulder after stroke: A meta-analysis. Australian Journal of Physiotherapy 48(4): 257–267.

Ada

Goddard

McCully

(2005) Thirty minutes of positioning reduces the development of shoulder external rotation contractures after stroke: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation 86(2): 230–234.

Bernhardt

Dewey

Thrift

(2004) Inactive and alone: Physical activity within the first 14 days of acute stroke unit care. Stroke 35(4): 1005–1009.

Carr

Shepherd

(2003) Stroke Rehabilitation – Guidelines for Exercise and Training to Optimise Motor Skill, Edinburgh: Butterworth Heinemann.

Carr

Shepherd

(2010) Neurological Rehabilitation: Optimizing Motor Performance, Edinburgh: Churchill Livingstone.

Cooke

Mares

Clark

(2010) The effects of increased dose of exercise-based therapies to enhance motor recovery after stroke: A systematic review and meta-analysis. BMC Medicine 8: 60. DOI:10.1186/1741-7015-8-60.

Dean

Richards

Malouin

(2000) Task-related circuit training improves performance of locomotor tasks in chronic stroke: A randomized, controlled pilot trial. Archives of Physical Medicine and Rehabilitation 81(4): 409–417.

Ericsson

(2004) Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic Medicine 79(10 Suppl.): S70–S81.

French

Thomas

Leathley

(2007) Repetitive task training for improving functional ability after stroke. Cochrane Database of Systematic Reviews 2007(4): CD006073.

10.

Hakkennes

Keating

(2005) Constraint-induced movement therapy following stroke: A systematic review of randomised controlled trials. Australian Journal of Physiotherapy 51(5): 221–231.

11.

Harris

Eng

Miller

(2009) A self-administered graded repetitive arm supplementary program (GRASP) improves arm function during inpatient stroke rehabilitation: A multi-site randomized controlled trial. Stroke 40(6): 2123–2128.

12.

Horsley

Herbert

Ada

(2007) Four weeks of daily stretch has little or no effect on wrist contracture after stroke: A randomised controlled trial. [Erratum appears in Australian Journal of Physiotherapy (2008) 54(1): 38]. Australian Journal of Physiotherapy 53(4): 239–245.

13.

Kilduski

Rice

(2003) Qualitative and quantitative knowledge of results: Effects on motor learning. American Journal of Occupational Therapy 57(3): 329–336.

14.

Kleim

Barbay

Nudo

(1998) Functional reorganization of the rat motor cortex following motor skill learning. Journal of Neurophysiology 80(6): 3321–3325.

15.

Kwah

Harvey

Diong

(2013) Models containing age and NIHSS predict recovery of ambulation and upper limb function six months after stroke: An observational study. Journal of Physiotherapy 59(3): 189–197.

16.

Kwakkel

(2006) Impact of intensity of practice after stroke: Issues for consideration. Disability and Rehabilitation 28(13–14): 823–830.

17.

Kwakkel

Kollen

(2013) Predicting activities after stroke: What is clinically relevant? International Journal of Stroke 8(1): 25–32.

18.

Kwakkel

Kollen

Van der Grond

(2003) Probability of regaining dexterity in the flaccid upper limb: Impact of severity of paresis and time since onset in acute stroke. Stroke 34(9): 2181–2186.

19.

Lang

MacDonald

Reisman

(2009) Observation of amounts of movement practice provided during stroke rehabilitation. Archives of Physical Medicine and Rehabilitation 90(10): 1692–1698.

20.

Laver

George

Thomas

(2011) Virtual reality for stroke rehabilitation. Cochrane Database of Systematic Reviews 7(9): CD008349.

21.

Lyle

(1981) A performance test for assessment of upper limb function in physical rehabilitation treatment and research. International Journal of Rehabilitation Research 4(4): 483–492.

22.

McClellan

Ada

(2004) A six-week, resource-efficient mobility program after discharge from rehabilitation improves standing in people affected by stroke: Placebo-controlled, randomised trial. Australian Journal of Physiotherapy 50(3): 163–167.

23.

McCluskey

Lannin

Schurr

(2009) Optimising motor performance following brain impairment. In: Curtin

Molineux

Supyk-Mellson

(eds) Occupational Therapy and Physical Dysfunction: Enabling Occupation, 6th edn. Edinburgh: Churchill Livingstone, pp. 579–606.

24.

Morris

Uswatte

Crago

(2001) The reliability of the Wolf motor function test for assessing upper extremity function after stroke. Archives of Physical Medicine and Rehabilitation 82: 750–755.

25.

Nudo

Milliken

Jenkins

(1996) Use-dependent alterations of movement representations in primary motor cortex of adult squirrel monkeys. Journal of Neuroscience 16(2): 785–807.

26.

Parry

Lincoln

Vass

(1999) Effect of severity of arm impairment on response to additional physiotherapy early after stroke. Clinical Rehabilitation 13(3): 187–198.

27.

Rose

Paris

Crews

(2011) Feasibility and effectiveness of circuit training in acute stroke rehabilitation. Neurorehabilitation and Neural Repair 25(2): 140–148.

28.

Ross

Harvey

Lannin

(2009) Do people with acquired brain impairment benefit from additional therapy specifically directed at the hand? A randomized controlled trial. Clinical Rehabilitation 23(6): 492–503.

29.

Scrivener

Sherrington

Schurr

(2012) Exercise dose and mobility outcome in a comprehensive stroke unit: Description and prediction from a prospective cohort study. Journal of Rehabilitation Medicine 44(10): 824–829.

30.

Sirtori

Corbetta

Moja

(2009) Constraint-induced movement therapy for upper extremities in stroke patients. Cochrane Database of Systematic Reviews 2009(4): CD004433.

31.

Van der Lee

Beckerman

Lankhorst

(2001a) The responsiveness of the action research arm test and the Fugl-Meyer assessment scale in chronic stroke patients. Journal of Rehabilitation Medicine 33(3): 110–113.

32.

Van der Lee

De Groot

Beckerman

(2001b) The intra- and interrater reliability of the action research arm test: A practical test of upper extremity function in patients with stroke. Archives of Physical Medicine and Rehabilitation 82(1): 14–19.

33.

Van Peppen

Kwakkel

Wood-Dauphinee

(2004) The impact of physical therapy on functional outcomes after stroke: What’s the evidence? Clinical Rehabilitation 18(8): 833–862.

34.

Wolf

Catlin

Ellis

(2001) Assessing Wolf motor function test as outcome measure for research in patients after stroke. Stroke 32(7): 1635–1639.