Feasibility of High-Repetition, Task-Specific Training for Individuals With Upper-Extremity Paresis

Participants

We recruited a convenience sample of inpatients with poststroke unilateral paresis at an IRF. We selected the inclusion criteria on the basis of Birkenmeier et al.’s (2010) study examining the feasibility of this intervention in the outpatient setting. Inclusion criteria were as follows: Patient (1) meets ICD–9 criteria of unilateral stroke with residual UE paresis; (2) has a Motricity Index (Collin & Wade, 1990) score between 42 and 93 points; (3) has cognitive ability to follow commands, as indicated by a score of 0 to 1 on the Commands item of the National Institutes of Health Stroke Scale (NIHSS; Brott, et al., 1989); and (4) is at least age 18 yr. Participants were excluded if they (1) had severe neglect, as indicated by a score of 2 on the NIHSS Extinction and Inattention subtest, and (2) had a history of stroke more than 1 wk before the current index stroke located on or affecting the same side of the body.

The planned number of participants to recruit was 6–15; this number was considered sufficient to examine feasibility in the IRF environment and was similar to prior feasibility studies (Birkenmeier et al., 2010; Combs, Kelly, Barton, Ivaska, & Nowak, 2010; Page, Levine, & Leonard, 2005; Page, Levine, Sisto, & Johnston, 2001). Recruitment occurred through informing inpatient staff occupational therapists about the study and the criteria for participation. During the recruitment period (November 2012 to April 2013), 123 people with stroke were admitted. Staff occupational therapists referred 22 patients to the study during that time, and 15 were enrolled. Of the 15 patients enrolled, 3 failed their initial screen and were rescreened within 7 days for later enrollment. We closely monitored individuals who failed their initial screen because changes in the motor system can occur at a fast rate during the early phase of stroke rehabilitation. As increased UE movement emerged, participants were then rescreened and enrolled as appropriate.

Measures

Feasibility measures were taken during all sessions by the treating therapist. Outcome measures were administered by trained assessors at the time points shown in Figure 1. Because all participants received the intervention, the assessors could not be blinded. The primary assessor did not deliver treatment. All assessment sessions were video recorded and periodically reviewed by the research team to ensure accurate scoring.

Intervention

The intervention was an individually tailored UE training protocol (Birkenmeier et al., 2010) provided 60 min/day, 4 days/wk during occupational therapy for the duration of the IRF admission. All treating therapists were trained in the protocol and monitored to ensure fidelity. In this IRF, patients receive 6 days/wk of occupational therapy services. On the remaining 2 days, participants received interventions related to ADLs to ensure that basic self-care deficits were being addressed. ADL tasks, however, were regularly incorporated into task-specific training sessions. Participants were encouraged to incorporate the paretic UE into functional activity outside of the intervention hour but not in a repetitive manner. For example, participants were encouraged to use the paretic hand to assist with prepping a toothbrush with toothpaste or to answer a cell phone.

Treatment activities were individualized, graded, and progressed for each participant. At enrollment, the treating occupational therapist and the participants discussed their meaningful activities to generate an occupational profile (American Occupational Therapy Association, 2008). They selected three activities to be used during the treatment sessions. If communication was a challenge (e.g., aphasia), the occupational therapist obtained an occupational profile from family members or friends. The goal for each treatment session was to achieve ≥300 repetitions in 1 hr through supervised, massed practice of the three selected activities (≥100 repetitions per activity).

Following the principle of shaping (Taub et al., 1994, 2013; Uswatte, Taub, Morris, Barman, & Crago, 2006), we graded and progressed activities to challenge each person without over- or underwhelming their motor capabilities, using established grading criteria (Birkenmeier et al., 2010). Examples of increasing task difficulty include increasing the height or distance to reach or place an item, increasing the weight or size of items, and changing the physical position of the participant (e.g., standing vs. sitting). Given the acuity of illness in the IRF, participants were provided rest breaks on request.

Feasibility Data

No participants were withdrawn or dropped out during the intervention. Individual examples of the number of repetitions and time in active practice across sessions are shown in Figure 2. These individual examples were selected to highlight participants who performed at and below the study means and also to illustrate the medical complexities and barriers to service delivery often found in an IRF. One participant (#8) increased the number of repetitions over the first few sessions, achieving an average of 302 after the first two sessions (Figure 2A). The number of minutes of active practice started higher and was reduced slightly as the intervention progressed. Another participant (#15) achieved fewer repetitions per session (average of 183 after the first two sessions) but spent nearly the whole hour in active practice (Figure 2B). Another participant’s (#10) treatment was disrupted by a hospital acquired infection (C. difficile; Figure 2C). In many sessions, this participant (#10) achieved a high number of repetitions and spent a substantial amount of the hour in active practice. In other sessions, his treatment was limited by toileting needs, fatigue, and frustration.

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Figure 2.

Individual examples of number of repetitions achieved and time spent in active practice per session over the course of the intervention.

The average number of repetitions achieved per session was 289 ± 35, 95% confidence interval (CI) [280, 299]. The total repetitions achieved across the intervention ranged from 1,207 to 5,963, with an average of 2,956 ± 1,197. Time spent in active task practice per session was 47 ± 3.7 min, 95% CI [46.1, 48.0]. Effort to achieve the desired number of repetitions was high, as indicated by an average fatigue score of 6.5 ± 1.2, 95% CI [6.2, 6.8] on the 0–10 point scale. Pain scores at the beginning of each session were 1.6 ± 1.6, 95% CI [1.2, 2.1] and after each session were 2.7 ± 2.7, 95% CI [2.0, 3.4]. The average change in pain per session was 1.1 points (different pre- and postsession, p = .02).

The number of sessions attempted was 11.5 ± 5.3, 95% CI [10.2, 12.9], and the number of sessions attended was 10.9 ± 4.9, 95% CI [9.7, 12.2], indicating that participants did not often miss scheduled sessions. The highest number of sessions attempted and attended was 24 (Participant 13), whereas the lowest number of both attempted and attended sessions was four (Participant 5).

Feasibility

The finding of feasibility without detracting from ADL retraining is important to clinicians trying to implement higher doses of therapy within the IRF setting and for clinical scientists wanting to study the potential benefits of higher doses. We do not know whether the higher doses achieved were optimal; the target of 300 repetitions was somewhat arbitrary. No data are available on the optimal dose of task-specific training needed to promote motor recovery for UE paresis, although a trial is under way ({"type":"clinical-trial","attrs":{"text":"NCT01146379","term_id":"NCT01146379"}}NCT01146379).

As anticipated, reports of fatigue were high. The substantial effort expended, however, did not limit overall participation, as indicated by a long duration of time spent in task practice and nearly identical values for the average number of sessions attempted and the average number of sessions attended for each participant.

Pain scores changed significantly from pre- to postintervention. Participants reported more pain at the end than at the beginning of sessions. The magnitude of the scores was, however, relatively low. Even by the end of sessions, the pain scores were mild (<3/10) and substantially lower than pain values reported in the hemiparetic shoulder pain literature (Castiglione, Bagnato, Boccagni, Romano, & Galardi, 2011; Ratmansky, Defrin, & Soroker, 2012). Pain did not limit participation, evidenced by the similar number of sessions attempted and attended. By visual inspection, individual participant pain scores showed that pain reports had returned to baseline before the next scheduled session.

We acknowledge Marghuretta Bland, Jill Seelbach, and Brittany Hill for their ongoing contributions to data acquisition and processing. We also acknowledge Caitlin Doman and Kathleen Froehlich for their involvement in data acquisition and administering outcome measures for this study. Support for this project comes from a National Institutes of Health grant no. R01 HD068290 to Catherine Lang and from a grant from the Buchanan Family Fellowship to Kimberly Waddell.