Objective 1) Determine if higher doses of motor therapy in chronic post-stroke hemiparesis result in better outcomes compared to lower doses, and 2) Evaluate potential modifiers of the dose-response relationship. Methods Eighty-five adults with UE paresis ≥ 6 months after stroke were randomized to one of four dose groups in this single-blind, parallel, RCT. The dosing parameter manipulated was amount of task-specific training, as indexed by the number of task repetitions. Groups received 3200, 6400, 9600, or Individualized Maximum (IM) repetitions, during 1 hr sessions, 4 days/week for 8 weeks. The intervention was an individualized, progressive task-specific upper limb training program designed to improve upper limb functional motor capacity. The primary outcome was the slope of the Action Research Arm Test (ARAT) during the intervention. Effects of dose and potential modifiers of the dose-response relationship were evaluated with hierarchical linear models. Results ARAT scores for the 3200, 9600, and IM groups improved over time as indicated by slopes (ΔARAT/wk, mean ± SEs) of 0.40 ± 0.15, 0.31 ± 0.16, and 0.66 ± 0.14, respectively (p < 0.05). The slope of the 6400 group was smaller (−0.05 ± 0.15) and significantly different from the 3200 and IM groups (p < 0.001). Initial motor capacity, neglect, and other tested characteristics did not modify the dose-response relationship. Interpretation Overall, treatment effects were small. There was no evidence of a dose-response effect of task-specific training on functional capacity in people with long-standing upper limb paresis post stroke.

Background A common assumption is that changes in upper limb (UL) capacity, or what an individual is capable of doing, translate to improved UL performance in daily life, or what an individual actually does. This assumption should be explicitly tested for individuals with UL paresis post-stroke. Objective To examine changes in UL performance after an intensive, individualized, progressive, task-specific UL intervention for individuals at least 6 months post-stroke. Methods Secondary analysis on 78 individuals with UL paresis who participated in a Phase II, single-blind, randomized parallel dose-response trial. Participants were enrolled in a task-specific intervention for 8 weeks. Participants were randomized into 1 of 4 treatment groups with each group completing different amounts of UL movement practice. UL performance was assessed with bilateral, wrist-worn accelerometers once a week for 24 hours throughout the duration of the study. The six accelerometer variables were tested for change and the influence of potential modifiers using hierarchical linear modeling. Results No changes in UL performance were found on any of the 6 accelerometer variables used to quantify UL performance. Neither changes in UL capacity nor the overall amount of movement practice influenced changes in UL performance. Stroke chronicity, baseline UL capacity, concordance, and ADL status significantly increased the baseline starting points but did not influence the rate of change (slopes) for participants. Conclusions Improved motor capacity resulting from an intensive outpatient UL intervention does not appear to translate to increased UL performance outside the clinic.

Objectives The primary purpose of this study was to determine if acceleration metrics derived from monitoring outside of treatment are responsive to change in upper extremity (UE) function. The secondary purposes were two-fold: The first was to compare metric values during task-specific training and while in the free-living environment. The second was to establish metric associations with an in-clinic measure of movement capabilities. Design Before-After Observational Study Setting Inpatient Hospital (primary purpose); Outpatient Hospital (secondary purpose) Participants Individuals (n=8) with UE hemiparesis < 30 days post stroke (primary purpose); Individuals (n=27) with UE hemiparesis ≥ 6 months post stroke (secondary purpose). Methods The inpatient sample was evaluated for UE movement capabilities and monitored with wrist-worn accelerometers for 22 hours outside of treatment before and after multiple sessions of task-specific training. The outpatient sample was evaluated for UE movement capabilities and monitored during a single session of task-specific training and the subsequent 22 hours outside of clinical settings. Main Outcome Measures Action Research Arm Test and acceleration metrics quantified from accelerometer recordings. Results Five metrics improved in the inpatient sample, along with UE function as measured on the ARAT: use ratio, magnitude ratio, variation ratio, median paretic UE acceleration magnitude, and paretic UE acceleration variability. Metric values were greater during task-specific training than in the free-living environment, and each metric was strongly associated with ARAT score. Conclusions Multiple metrics that characterize different aspects of UE movement are responsive to change in function. Metric values are different during training than in the free-living environment, providing further evidence that what the paretic UE does in the clinic may not generalize to what it does in everyday life.

OBJECTIVE. We investigated the feasibility of delivering an individualized, progressive, high-repetition upper-extremity (UE) task-specific training protocol for people with stroke in the inpatient rehabilitation setting. METHOD. Fifteen patients with UE paresis participated in this study. Task-specific UE training was scheduled for 60 min/day, 4 days/wk, during occupational therapy for the duration of a participant's inpatient stay. During each session, participants were challenged to complete ≥300 repetitions of various tasks. RESULTS. Participants averaged 289 repetitions/session, spending 47 of 60 min in active training. Participants improved on impairment and activity level outcome measures. CONCLUSION. People with stroke in an inpatient setting can achieve hundreds of repetitions of task-specific training in 1-hr sessions. As expected, all participants improved on functional outcome measures. Future studies are needed to determine whether this high-repetition training program results in better outcomes than current UE interventions.

A key reason for referral to rehabilitation services after stroke and other neurological conditions is to improve one's ability to function in daily life. It has become important to measure a person's activities in daily life, and not just measure their capacity for activity in the structured environment of a clinic or laboratory. A wearable sensor that is now enabling measurement of daily movement is the accelerometer. Accelerometers are commercially-available devices resembling large wrist watches that can be worn throughout the day. Data from accelerometers can quantify how the limbs are engaged to perform activities in peoples' homes and communities. This report describes a methodology to collect accelerometry data and turn it into clinically-relevant information. First, data are collected by having the participant wear two accelerometers (one on each wrist) for 24 h or longer. The accelerometry data are then downloaded and processed to produce four different variables that describe key aspects of upper limb activity in daily life: hours of use, use ratio, magnitude ratio, and the bilateral magnitude. Density plots can be constructed that visually represent the data from the 24 h wearing period. The variables and their resultant density plots are highly consistent in neurologically-intact, community-dwelling adults. This striking consistency makes them a useful tool for determining if upper limb daily performance is different from normal. This methodology is appropriate for research studies investigating upper limb dysfunction and interventions designed to improve upper limb performance in daily life in people with stroke and other patient populations. Because of its relative simplicity, it may not be long before it is also incorporated in clinical neurorehabilitation practice.