I have zero finger individuation. So what is the protocol to get to the starting point of this rehab?
Pushing the Rehabilitation Boundaries: Hand Motor Impairment Can Be Reduced in Chronic Stroke
Abstract
Background.
Stroke is one of the most common causes of physical disability
worldwide. The majority of survivors experience impairment of movement,
often with lasting deficits affecting hand dexterity. To date,
conventional rehabilitation primarily focuses on training compensatory
maneuvers emphasizing goal completion rather than targeting reduction of
motor impairment.
Objective.
We aim to determine whether finger
dexterity impairment can be reduced in chronic stroke when training on a
task focused on moving fingers against abnormal synergies without
allowing for compensatory maneuvers.
Methods.
We recruited 18
chronic stroke patients with significant hand motor impairment. First,
participants underwent baseline assessments of hand function,
impairment, and finger individuation. Then, participants trained for 5
consecutive days, 3 to 4 h/d, on a multifinger piano-chord-like task
that cannot be performed by compensatory actions of other body parts
(e.g., arm). Participants had to learn to simultaneously coordinate and
synchronize multiple fingers to break unwanted flexor synergies. To test
generalization, we assessed performance in trained and nontrained
chords and clinical measures in both the paretic and the nonparetic
hands. To evaluate retention, we repeated the assessments 1 day, 1 week,
and 6 months post-training.
Results.
Our results showed that
finger impairment assessed by the individuation task was reduced after
training. The reduction of impairment was accompanied by improvements in
clinical hand function, including precision pinch. Notably, the effects
were maintained for 6 months following training.
Conclusion.
Our
findings provide preliminary evidence that chronic stroke patient can
reduce hand impairment when training against abnormal flexor synergies, a
change that was associated with meaningful clinical benefits.
Introduction
Stroke is one of the leading causes of death and disability globally,1,2 resulting in a wide range of physical, emotional, and cognitive consequences.3
Among the most common physical sequela of stroke are hemiparesis and
spasticity, two forms of motor impairment that affect daily living and
overall quality of life in approximately 80% of survivors.3
Hand impairment, in particular, is often present in the chronic stage
after stroke, frequently manifesting itself as both a decrease in finger
strength, loss of dexterity (negative signs), and abnormal hand flexion
synergy, characterized by a pattern of involuntary motor activation
resulting in finger and hand flexion (positive signs).4,5
Indeed, one of the most prominent deficits in hand dexterity is
increased finger enslaving, or unintended force produced by the
uninstructed fingers. This hand function abnormality is thought to be a
direct result of lesions to the motor cortex and corticospinal tract,5,6,7,8,9 as these are known to be critical for the control of independent finger movements (i.e., finger individuation).5,10-13
Previously,
we have shown that stroke patients recover both finger individuation
and strength relying on separable recovery processes.5
Recovery asymptotes after the first 3 to 6 months, although typically
remains far from the level of performance of healthy individuals,
especially for the individuation component. Over the past few years,
different training and rehabilitation strategies have assessed the
effect of finger and hand training as well as virtual reality
environments in chronic stroke patients in an attempt to improve
deficits in dexterous movement.14-20
Some of these works reported positive gains in clinical measures of
hand dexterity. However, these studies cannot distinguish between
compensatory maneuvers versus true impairment reduction as the mechanism
underlying clinical benefits. Specifically, these studies did not fully
assess force control in the finger individuation tasks,14,18-20 used gross measures of hand dexterity and did not report a detailed individuation metric,14,16
and/or did not report post-training long-term retention of clinical
outcomes or retention of improvement in finger individuation.14,18,20 In the present study, we use a direct and quantitative measure of finger dexterity5.
The
goal of this study was to discern whether true hand motor impairment
can be reduced in the chronic phase after stroke following personalized
multidimensional training targeting finger dexterity that minimizes the
use of compensatory maneuvers to facilitate performance. To this end, we
modified a previously published piano-chord-like task13,21
to train finger dexterity by asking participants to practice in an
intense manner against their baseline flexion synergy. Task difficulty
during practice was adjusted for each participant based on baseline
ability, controlling for individual differences in initial weakness and
performance. Participants cannot perform this task by recruiting actions
beyond their fingers. We tested both the short- and long-term retention
of trained and nontrained hand-chord postures. We quantified hand
dexterity by measuring finger individuation and also gauged the impact
of the training on clinical outcome measures of impairment, activity,
and participation. We hypothesized that intensive training focused on
moving fingers against abnormal synergies while minimizing compensatory
movements, would improve the ability of patients with chronic stroke to
individuate their fingers and perform functional tasks better.
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