Matching Task Difficulty to Patient Ability During Task Practice Improves Upper Extremity Motor Skill After Stroke

Abstract

Background During upper extremity (UE) stroke rehabilitation it is critical to match patient-ability to task-difficulty to promote neural reorganization and UE skill re-learning. However, there are few methods to do so. A Fugl-Meyer Upper Extremity Assessment (FMA-UE) “keyform,” derived from Rasch Analysis informed and progressed an UE rehabilitation program. Objective Test the feasibility of the keyform method for systematically planning and progressing rehabilitation. We hypothesized that optimally-challenging task-practice will maximize UE motor skill reacquisition. Methods Inclusion criteria: ischemic stroke >3 mo., voluntarily shoulder flexion ≥30° and simultaneous elbow extension ≥20°. The keyform method defined initial targets (goals) and progressed therapy after every 3rd session. Therapy targets were practiced within the context of client-selected functional tasks not in isolation. Feasibility was defined by subject pain/fatigue, UE motor function (Wolf Motor Function Test, WMFT) and movement patterns (kinematics). Assessments were administered pre- and post-treatment and compared with paired t-tests. Task-difficulty and patient-ability measures were calculated with Rasch analysis and compared with paired t-tests (p<0.05). Results Ten subjects (59.70±9.96 yrs., 24.1±30.54 mo. post-stroke) participated in 9 sessions, 200 movement repetitions/session in <2 hrs without pain or fatigue. Subjects gained UE motor function (WMFT: Pre 22.23±24.26 seconds, Post 15.46±22.12 seconds, p=0.01), improved shoulder-elbow coordination (index of curvature: Pre 1.30±0.15, Post 1.21±0.11, p=0.01) and exhibited reduced trunk compensatory movement (trunk displacement: Pre 133.97±74.15 mm, Post 108.08±64.73 mm, p=0.02). Task-difficulty and patient-ability measures were not statistically different throughout the program (Person-ability measures of 1.01±0.05, 1.64±0.45 and 2.22±0.65 logits and item difficulty measures of 0.93±0.37, 1.70±0.20, and 2.06±0.24 logits at the 3 testing time points respectively, p>0.05). Conclusion The FMA-UE keyform is a feasible method to assure that the difficulty of tasks practiced were well matched to initial and evolving levels of UE motor ability.

A Paradigm Shift: Rehabilitation Robotics, Cognitive Skills Training, and Function After Stroke

“…Participants randomized to the robot and task-oriented training (RT-TOT) group received therapist-guided task-oriented training in addition to RT during 20–30 min of each 1-h treatment session. The participant's baseline performance on the FMA was reviewed, and the FMA keyform and patient-targeted treatment activities outlined by Woodbury et al (17) aided the selection of UE tasks with greatest potential for improvement during TOT. While we tracked the number of repetitions performed and/or time that participants engaged in continuous motions (e.g., wiping table) the actual dose of TOT differed among participants, based on their activity tolerance and level of function.…”

“…Participants identify specific, achievable tasks for their HAP based on personal interests. The clinician may use scores from the upper limb subtest of the Fugl-Meyer Assessment (FMA-UE) (16, 17) when providing input to select appropriate tasks based on the participant's current level of function. Due to this participant-centered approach, there are no core tasks included in every HAP, however, similarities do occur across individuals.…”

An exploration of aphasia therapy dosage in the first six months of stroke recovery

“…There is also the possibility that the active ingredients of therapy are not directly observable or so readily measurable. The concept of activity challenge and the level of task difficulty is a parameter in stroke rehabilitation that is receiving increasing attention and will influence the outcome of future study designs (Akizuki & Ohashi, 2015;Woodbury et al, 2016). Therefore, not only should the quantity of therapeutic inputs and client acts be addressed but also the quality of these, such as a measure of task difficulty relative to the individual, with an optimal challenge point identified (Guadagnoli & Lee, 2004).…”

Interpreting Action Research Arm Test Assessment Scores to Plan Treatment

“…Therefore, the keyform allows a clinician to identify appropriately challenging behaviors, represented by items in the transition zone, to target in TSP sessions (Bode, Heinemann, Kozlowski, & Pretz, 2014; Kielhofner et al, 2005; Velozo & Woodbury, 2011; Woodbury, Velozo, Richards, & Duncan, 2013). Rasch keyforms have been used to improve the scoring, interpretation and clinical utility of assessments of vision (Velozo et al, 2013), disorders of consciousness (Pape, Mallinson, & Guernon, 2014), functional independence (Bode et al, 2014), pediatric gross motor function (Avery, Russell, Raina, Walter, & Rosenbaum, 2003), and post-stroke UE impairment (Woodbury et al, 2016). To our knowledge, there is only one UE stroke assessment (Velozo & Woodbury, 2011; Woodbury et al, 2016) with a keyform and there are no keyforms for measuring post-stroke UE function.…”

“…Rasch keyforms have been used to improve the scoring, interpretation and clinical utility of assessments of vision (Velozo et al, 2013), disorders of consciousness (Pape, Mallinson, & Guernon, 2014), functional independence (Bode et al, 2014), pediatric gross motor function (Avery, Russell, Raina, Walter, & Rosenbaum, 2003), and post-stroke UE impairment (Woodbury et al, 2016). To our knowledge, there is only one UE stroke assessment (Velozo & Woodbury, 2011; Woodbury et al, 2016) with a keyform and there are no keyforms for measuring post-stroke UE function. Given the dearth of rehabilitation keyforms, few clinicians are aware that they exist or understand how they are used.…”