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. Author manuscript; available in PMC: 2023 Jan 1.
Published in final edited form as: OTJR (Thorofare N J). 2021 Sep 9;42(1):30–39. doi: 10.1177/15394492211042275

Using subthreshold vibratory stimulation during post-stroke rehabilitation therapy: a case series

Amanda A Vatinno 1, Lucion Hall 2, Hannah Cox 3, Alison Fluharty 4, Catilyn Taylor 5, Alexandra Wease 6, Allison Davis 7, Shannon Cain 8, Viswanathan Ramakrishnan 9, Michelle Woodbury 10,11, Na Jin Seo 12,13,14
PMCID: PMC8720500  NIHMSID: NIHMS1761614  PMID: 34496711

Abstract

Background:

Subthreshold vibratory stimulation to the paretic wrist has been shown to prime the sensorimotor cortex and improve 2-week upper extremity (UE) therapy outcomes.

Objective:

To determine feasibility, safety, and preliminary efficacy of the stimulation over a typical 6-week therapy duration.

Methodology:

Four chronic stroke survivors received stimulation during 6-week therapy. Feasibility/safety/efficacy were assessed at baseline, post-therapy, and 1-month follow-up.

Results:

For feasibility, all participants wore the device throughout therapy and perceived the stimulation comfortable/safe. Regarding safety, no serious/moderate intervention-related adverse events occurred. For efficacy, all participants improved in Wolf Motor Function Test and UE use in daily living based on accelerometry and Stroke Impact Scale. Mean improvements at post-therapy/follow-up were greater than the minimal detectable change/clinically important difference and other trials with similar therapy without stimulation.

Conclusion:

The stimulation was feasible/safe for 6-week use. Preliminary efficacy encourages a larger trial to further evaluate the stimulation as a therapy adjunct.

Keywords: Stroke rehabilitation, upper extremity, paresis, subliminal stimulation, physical stimulation, patient safety

Introduction

Stroke is a leading cause of long-term disability in the United States (Virani et al., 2020). Upper extremity (UE) impairment affects 65% of stroke survivors at 6 months post-stroke (Dobkin & Carmichael, 2016). UE impairment limits stroke survivors’ ability to perform functional tasks, thus reducing independence (Stewart & Cramer, 2013). Given limited time and resources allotted for therapy (Lynch et al., 2017). post-stroke treatment must be optimized to maximize recovery.

One approach to enhance motor recovery is using sensory stimulation as a therapy adjunct (Conforto et al., 2018). Sensory stimulation facilitates changes in the primary motor cortex (Baker, 2007; Schabrun et al., 2012) and associated motor output (M. Ridding & J. Rothwell, 1999) via direct neuronal projections from the sensory to motor areas (Chen & Ashby, 1993; Jenner & Stephens, 1982). As such, meta-analysis showed that applying sensory stimulation immediately before therapy enhanced UE motor recovery more than therapy without stimulation (Conforto et al., 2018). However, the existing sensory stimulation method requires patients to remain in a sedentary position for 2 hours during stimulation (Bastos Conforto et al., 2010; Carrico, Chelette, II, et al., 2016; Carrico, Chelette, Westgate, et al., 2016; Celnik et al., 2007; Conforto et al., 2007) and the effect diminishes once the stimulation is removed (Kaelin-Lang et al., 2002; Smith & Brouwer, 2005).

To address these limitations, a novel sensory stimulation was recently developed. Specifically, the new stimulation uses a wearable wristband to apply subthreshold random-frequency vibratory stimulation to the paretic wrist during therapy. Thus, the effect of the stimulation may remain potent during therapy tasks because it is delivered continuously during therapy. In addition, the new stimulation does not interfere with therapy tasks because the device is compact and wearable, and the stimulation is imperceptible. Using this stimulation eliminates the need for patients to receive stimulation in a sedentary position prior to therapy. Therefore, the new stimulation may offer advantages that might promote translation to clinical practice.

Preliminary studies have shown that the new stimulation primes the sensorimotor cortex for the hand (Seo et al., 2015; Seo et al., 2019). Specifically, sensory processing activity in the sensory cortex measured by electroencephalography increased when the stimulation was applied (Seo et al., 2015), explaining enhanced sensation with the stimulation in chronic stroke survivors (Enders et al., 2013). Since sensory input affects motor output (M. C. Ridding & J. C. Rothwell, 1999), the stimulation has also been shown to increase brain activity for grip tasks (Seo et al., 2019), explaining improved grip performance with the stimulation in chronic stroke survivors (Seo et al., 2014). Thus, the new stimulation may have potential to facilitate neural plasticity and recovery of hand function post-stroke. A 2-week pilot randomized controlled study showed that use of this stimulation during task-practice therapy increased UE motor function more than therapy without stimulation (Seo, Woodbury, et al., 2019).

However, use of this stimulation over a longer treatment duration typical in standard rehabilitation, such as 6 weeks, has not been examined. Clinicians and peer scientists have expressed serious concerns that longer exposure to the stimulation may cause patients to become desensitized to UE sensory input and/or dependent on the stimulation, resulting in worse sensory and/or motor function. Thus, it is critical to examine whether patients exhibit deterioration of sensation with safety concerns and a lack of motor improvement after 2 weeks of treatment, possibly resulting in patients’ refusal of the stimulation. Therefore, the purpose of this study was to determine feasibility, safety, and preliminary efficacy of using this stimulation during a typical 6-week therapy duration.

Materials and Methods

Participants

The study protocol was approved by the Institutional Review Board. All participants provided written informed consent. Participants were included if they were adults at least 6-months post-stroke with moderate UE impairment (Fugl-Meyer Assessment Upper Extremity score 19–47) (Woodbury et al., 2013) with the ability to participate in UE therapy. Participants were excluded if they had (1) complete UE deafferentation, (2) UE rigidity, (3) botulinum toxin injection in the paretic UE within 3 months (Setler, 2002) prior to/during enrollment, (4) brainstem stroke, (5) comorbidity, such as orthopedic conditions, peripheral neuropathy of the hand, or compromised skin integrity of the wrist, (6) concurrent UE therapy, or (7) language barrier/cognitive impairment that precluded following 3-step instructions and/or providing consent.

Experimental Design

A single-arm pilot study was conducted. All participants received in-lab task-practice therapy with an occupational therapist while wearing a stimulation device on the paretic wrist (figure 1). Therapy was approximately 2 hours/session, 3 sessions/week for 6 weeks, for a total of 18 sessions, resembling a typical outpatient therapy schedule.

Figure 1.

Figure 1.

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The stimulation device (circled) was worn on the paretic wrist and delivered subthreshold vibration during task-practice therapy addressing upper extremity motor function, such as the ability to use a screwdriver.

Therapy followed a standardized manual. The manual (Seo, Woodbury, et al., 2019) was developed by experienced therapists based on the EXCITE trial (Wolf et al., 2006) manual and Task Specific Practice (Lang & Birkenmeier, 2014). The manual outlined that in each session, participants practice 2 in-hand manipulation tasks and 2 tasks involving reaching to grasp/place objects. The manual contained a list of tasks from which the therapist and participant collaboratively selected as relevant to the participant’s daily living. To standardize therapy dosage, participants completed 300 UE movement repetitions per session (75 per task) according to the manual. The manual also defined a repetition for each task to ensure consistency in counting repetitions. Per manual, tasks were adjusted to achieve a difficulty level that was “just-right” for each participant. The right difficulty level was achieved by changing the weight, size, shape, and location of the object, using adaptive materials (e.g., nonslip mat to prevent items from moving) as needed, and adjusting task complexity, instruction, movement speed, and accuracy. Participants were also encouraged to practice the tasks in-home and use the paretic UE in daily activities.

The stimulation device (figure 1) was composed of a vibrator (C-3 Tactor, EAI, Casselberry, FL) and MP3-playing watch (Amazon). The device delivered random-frequency vibration (with white noise signal low-pass filtered at 500 Hz) to the wrist at 60% of the sensory threshold (i.e., imperceptible to the participant), continuously throughout each therapy session. These vibration parameters were selected because they yielded consistent, reproducible, statistically significant improvement in hand function in previous studies (Enders et al., 2013; Lakshminarayanan et al., 2015; Seo, Woodbury, et al., 2019; Seo et al., 2014; Seo et al., 2015). The participants’ sensory threshold was determined at the beginning of each therapy session by increasing or decreasing the vibration intensity until the participant verbally indicated they could or could not perceive the vibration, respectively (Ehrenstein & Ehrenstein, 1999; Seo, Woodbury, et al., 2019). The stimulation device was not worn outside therapy.

Feasibility

First, the therapist observed whether the participants wore the device and monitored participants’ reactions throughout therapy sessions. Second, participants’ perceived comfort and safety in receiving the stimulation from the device during therapy were obtained on a 7-point Likert scale (1=strongly agree, 4=neutral, 7=strongly disagree) post-intervention. In addition, to determine if the vibration was indeed imperceptible, the therapist asked participants if they felt vibration after each therapy session.

Safety

Adverse events (AEs) were identified according to the criteria/schedule in table 1. AEs were evaluated for severity and relatedness to the intervention following the established definitions (National Cancer Institute, 2017; National Institute of Neurological Disorders and Stroke, 2017). The severity and relatedness categorizations were approved by the Data and Safety Monitoring Board.

Table 1.

Adverse event criteria and assessment time. All criteria are compared to the baseline.

Adverse Event Criteria Time of Assessment
Modified Ashworth scale (spasticity) increase more than 1[47] Assessed weekly
Pain increase more than 2 on a visual analog scale 0–10
Emergence of numbness
Emergence of swelling based on wrist circumference
UE motor function score decrease more than the Minimum Detectable Change (BBT decrease more than 5.5[35] or WMFT time increase more than 4.36 sec[40])
Any other self-reported adverse events
Emergence of skin irritation
Monofilament or two-point discrimination increase by more than 2 levels and by a category on 1st, 2nd, and 5th digit pads Assessed at pre, post, follow-up
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Preliminary Efficacy

The effect of the intervention on motor function was assessed using the Wolf Motor Function Test (WMFT) (Wolf et al., 2001) time and Box and Block Test (BBT) (Chen et al., 2009). Translation of improved motor function to paretic UE use in daily living was assessed using the objective accelerometer measure (Waddell et al., 2017), patient-perceived measure of the Stroke Impact Scale (SIS) hand and activities of daily living (ADL) subscales, and self-reported benefits. For accelerometers, participants wore an ActiGraph GT9X Link (ActiGraph, Pensacola, FL) on the paretic wrist outside therapy for 3 days. The total number of hours per day that the paretic UE was active was computed. For SIS, difficulty in tasks was rated on a 5-point scale (could not do it at all, very difficult, somewhat difficult, a little difficult, not difficult at all). All assessments were administered at baseline, post (within 1-week post-therapy), and 1-month follow-up. Additionally, WMFT and accelerometer were assessed after each week of therapy to examine the trend of change over time.

To ensure reliability, WMFT and BBT were videotaped and scored by blinded raters trained on standard scoring procedures (Mathiowetz et al., 1985; Taub et al., 2011). Videos were coded so raters did not know the time of the assessment (before, when during treatment, or when after treatment). Inter-rater and intra-rater reliabilities were assessed using Spearman correlation using scores from all assessment times and subjects. Interrater reliability was 0.999 for WMFT and 1.0 for BBT. Intra-rater reliability was 1.0 for both WMFT and BBT.

As secondary analysis, changes in UE motor function and use in daily living were examined for individual participants and compared to the minimum detectable change (MDC) and minimal clinically important difference (MCID) to gauge whether they were beyond measurement error and clinically relevant, respectively. In addition, week-to-week changes in WMFT and accelerometer data were visually examined for any trend over time. Furthermore, the changes were compared to other published trials with similar manual therapy but without stimulation. This historical comparison was to gauge if the addition of stimulation to therapy might improve UE outcomes more than therapy without stimulation. Specifically, WMFT, SIS, and accelerometer data were historically compared because those measures were reported in previous trials with similar manual therapy.

Results

Participants

Four participants completed the study. Participants had the mean age of 69 (SD=6) years, mean time post-stroke of 6 (SD=7, range=1.6–16) years, and mean baseline FMUE score of 33 (SD=12, range=22–46).

Feasibility

All participants completed 18 therapy sessions while wearing the stimulation device, with no requests to remove it at any time, as observed by the therapist. Participants perceived that the stimulation was comfortable (median=2, range=1–2 on the 7-point Likert scale) and safe (median=2.5, range=1–4) during therapy. The vibration remained imperceptible, as all participants reported that they did not feel vibration during any therapy session.

Safety

No serious AEs were observed throughout the study. No moderate AEs related to the intervention were observed. Only one participant experienced mild AEs with reasonable possibility of being related to the intervention, which were skin irritation on the paretic elbow during one therapy session and increased Monofilament scores on the 5th digit pad at post and follow-up (3.61) compared to baseline (2.44). All AEs are detailed in supplement 1.

Preliminary Efficacy

Changes in UE Motor Function

All participants improved in WMFT time at post and follow-up compared to baseline (figure 2A). There was a trend of mean improvement in WMFT time of 10 sec (SD=7) at post and 14 sec (SD=11) at follow-up. The mean improvements in WMFT time were beyond MDC (0.7 (Fritz et al., 2009) or 4.36 (Lin et al., 2009) secs). However, mean improvement in BBT did not exceed MDC (5.5 blocks (Chen et al., 2009)) (figure 2B).

Figure 2.

Figure 2.

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Mean and individual scores on the Wolf Motor Function Test time (A), Box and Block Test (B), hours of paretic upper extremity use per day measured by the accelerometer (C) and Stroke Impact Scale - Hand (D) and Activities of Daily Living (ADL) subscales (E). Darker lines represent the mean and lighter lines represent individual participant scores.

Changes in UE Use in Daily Living

All participants moved their paretic UE more in daily living at post and follow-up compared to baseline, as seen by a trend of increased hours of UE use from accelerometers (figure 2C). There was also a trend of increase in SIS-hand for all participants (figure 2D) and SIS-ADL for 3 out of 4 participants (figure 2E) at post and follow-up compared to baseline. The mean increase for SIS-hand was 21 and 18 at post and follow-up, which was above MCID (17.8 (Lin et al., 2010)). For SIS-ADL, the mean increase was 15 and 18 at post and follow-up, which was above MCID at post and follow-up and MDC at follow-up (5.9 (Lin et al., 2010) and 17.3 (Lin et al., 2010), respectively). Furthermore, all participants had self-reported benefits in using the paretic UE in daily living, as summarized in supplement 2.

Week-to-Week Changes

A trend of continuous improvement over the study period was observed for UE motor function measured by WMFT time (figure 3A). A similar trend was observed also for UE use in daily living as measured by the active hours for the paretic UE using the accelerometer (figure 3B).

Figure 3.

Figure 3.

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Week-to-week change in the Wolf Motor Function Test (WMFT) time (A) and hours of paretic upper extremity use per day measured by the accelerometer (B). The mean and standard error of the changes are shown. The Minimum Detectable Change (MDC) for WMFT (Lin et al., 2009) is also shown (A).

Comparison to Other Trials

Mean UE improvements tended to be greater in our study than those in other trials using similar manual therapy without stimulation. Specifically, mean improvement in WMFT time was greater in our study than in other large trials (Lo et al., 2010; Winstein et al., 2016) (figure 4A). In addition, the trend of mean increase in hours of paretic UE use from accelerometers was higher in our study than in another trial (Waddell et al., 2017) at post (24% vs. 4% increase, or 35 vs. 10 min more per day from baseline, only post data available in the other trial (Waddell et al., 2017)). Similarly, the trend of mean increases in SIS-hand and SIS-ADL were higher in our study than in other trials (Birkenmeier et al., 2010; Lang et al., 2016) (figure 4B-C, only post data available for one trial (Lang et al., 2016)).

Figure 4.

Figure 4.

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Comparison to other trials. (A) Change in the Wolf Motor Function Test time compared to other large trials with similar manual therapy of 10 (Winstein et al., 2016) and 12 (Lo et al., 2010) weeks. The mean and standard error (SE) of the change are shown. Minimum detectable change (MDC) (Lin et al., 2009) is also shown. Changes in the Stroke Impact Scale - Hand (B) and Activities of Daily Living (ADL) subscales (C) are compared to other trials with similar manual therapy of 6 (Birkenmeier et al., 2010) and 8 (Lang et al., 2016) weeks. The mean and SE of the change score are shown for the present study. The mean change and SE of the raw score are shown for other trials because SE of the change was not provided. Minimum detectable change (MDC) (Lin et al., 2010) and minimal clinically important difference (MCID) (Lin et al., 2010) are also shown.

Discussion

This study investigated feasibility, safety, and preliminary efficacy of using subthreshold random-frequency vibratory stimulation during 6-week task-practice therapy. This study extends the previous 2-week study (Seo, Woodbury, et al., 2019) in the following ways.

Feasibility/Safety Over a Longer Therapy Duration of 6 Weeks

First, we found that the stimulation was feasible and safe to use over a longer therapy duration of 6 weeks. For safety, the mild skin irritation experienced by one participant likely resulted from the elbow rubbing on an armrest, which could occur during any therapy intervention or in daily living. Increased Monofilament scores may have been influenced by the little to moderate reliability of the test (Bulut et al., 2018), since other sensory measures did not decline for this participant. Specifically, s/he did not develop perceived numbness and had improved two-point discrimination scores from fair (6–8 mm) to normal (5 mm) for all digits at this time. In addition, this person frequently experienced skin irritation prior to the study, which may be related to the change in the Monofilament score. This finding extends previous reports of safety in using this stimulation over 2 (Seo, Woodbury, et al., 2019) and 4 (Seo, Enders, et al., 2019) weeks.

Continuous, Detectable, and Sustained Trend of Improvement in UE Motor Function

Second, this study extends the previous study by showing that continued use of the stimulation during therapy beyond 2 weeks may yield additional UE improvements, as seen by the trend of continuous UE improvement over 6 weeks. This trend of continuous UE improvement without deterioration supports further investigation into using the stimulation over a longer rehabilitation duration.

Specifically, every participant had a trend of improvement in UE motor function as assessed by WMFT time at post and follow-up compared to baseline. Mean improvement in WMFT time was greater than MDC for post and follow-up, suggesting that the improvement was beyond measurement error. Further, mean improvement at post was retained at 1-month follow-up. This finding suggests a trend of detectable and sustained improvement in UE motor function from the 6-week treatment.

While participants in the present study had a trend of improvement in WMFT time, they did not improve on BBT. This finding contrasts the trend found in the previous 2-week study in which improvement was more prominent in BBT than WMFT time (Seo, Woodbury, et al., 2019). These different findings may be explained by different participant characteristics. Specifically, participants in the present study had greater impairment at baseline compared to those in the previous study (WMFT hand-task time mean±SD = 76±48 vs. 14±15 sec, BBT = 9±11 vs. 29±14 for the present study and previous study (Seo, Woodbury, et al., 2019), respectively). It is possible that while our participants were able to improve WMFT time, the improvement was not sufficient to change BBT scores. For example, two participants had WMFT hand-task time of 114 and 115 sec at baseline. While they were able to substantially improve the time to 75 and 86 sec at follow-up, such time is still longer than the 60 sec time limit imposed for BBT. Consequently, their BBT scores remained at 1 from baseline to follow-up.

Trend of Clinically Meaningful/Sustained Impact on UE Use in Daily Living

Third, this study extends the previous study by showing that the trend of improved UE motor function seen in WMFT time translated from the laboratory to UE use in daily living in meaningful ways. Specifically, all participants had a trend of less difficulty using their paretic hand to perform daily tasks at post and follow-up compared to baseline, based on SIS. Mean difficulty level lessened from “very difficult” to “somewhat difficult” for SIS-hand items, such as turning a doorknob and opening a can. Mean difficulty level lessened from “somewhat difficult” to “a little difficult” for SIS-ADL items, such as dressing and bathing oneself. Mean improvements in SIS were greater than MCID, suggesting potential for the intervention to lead to clinically meaningful changes in the participants’ perceived abilities in daily living.

Clinical meaningfulness is further highlighted by participants’ self-reported benefits. All participants reported benefits in a variety of domains, including ADLs (e.g., self-feeding), instrumental ADL (e.g., meal preparation), leisure, and vocation. As a result, participants experienced increased ability to integrate into society and participate within the community, such as dining at restaurants and mini-golfing with family. These perceived improvements in UE use in daily living from SIS and self-reports were consistent with the objective measure using accelerometers, showing that every participant increased the duration of paretic UE use in daily living.

Historical Comparisons

Since this case series study did not include a control group, we performed historical comparison to other trials in the literature. Historical comparisons show a trend of greater mean UE improvements in our study than in other trials with similar manual therapy without stimulation. This comparison suggests a potential that addition of the stimulation might improve UE motor function and use in daily living more than therapy without stimulation. However, due to the small sample size of the present study, this hypothesis should be tested in a larger study.

In the historical comparisons, greater mean improvements were obtained despite no difference and/or inferiority in baseline function, time post-stroke, and intervention length. Specifically, for baseline, our mean WMFT time of 50 (SD=37) sec was within the ranges of the other trials (mean±SD = 74±30 sec (Lo et al., 2010) and 17±19 sec (Winstein et al., 2016)). For UE use in daily living, mean baseline levels were lower in our participants than other trials (51% fewer hours of paretic UE use per day (Waddell et al., 2017); SIS-hand mean±SE = 31±14 for our study vs. 43±6 (Birkenmeier et al., 2010), 47±3 (Lang et al., 2016); SIS-ADL mean±SE = 61±7 for our study vs. 69±4 (Birkenmeier et al., 2010), 63±2 (Lang et al., 2016)). Secondly, our participants were more chronic on average than the other trials (time post-stroke mean±SD (range) = 6.2±6.6 (1.6–16) years for our study vs. 0.1±0.1 years (Winstein et al., 2016), 4.8±4.0 years (Lo et al., 2010), 1 (0.5–18.4) years (Lang et al., 2016; Waddell et al., 2017), and 3.2 (0.5–10) years (Birkenmeier et al., 2010)). Third, our intervention duration was shorter than or equal to the other trials (6 weeks for our study vs. 10 weeks (Winstein et al., 2016), 12 weeks (Lo et al., 2010), 6 weeks (Birkenmeier et al., 2010), and 8 weeks (Lang et al., 2016; Waddell et al., 2017)).

Limitations and Future Direction

Primary limitations are the small sample and lack of control group. While the previous study using the stimulation (Seo, Woodbury, et al., 2019) was a randomized controlled study, the sample was still small. Therefore, a larger randomized controlled trial is needed to determine the safety and efficacy of the stimulation during therapy compared to therapy without stimulation. For intervention duration, since this study shows a trend of continuous improvement over the 6-week intervention period, future studies may investigate at least 6 weeks of intervention to achieve maximal effects while further examining duration effects of the stimulation.

Conclusion

In summary, this study demonstrates that use of the stimulation during 6-week therapy was feasible and safe, and resulted in trends of continuous, detectable, clinically meaningful, and sustained UE improvements, with translation to daily living, that could be greater than therapy alone as seen in historical comparisons. The trends in the present study, together with the previous pilot randomized controlled study (Seo, Woodbury, et al., 2019), collectively suggest a potential that the stimulation may be a promising therapy adjunct to improve post-stroke UE recovery beyond therapy alone. Therapists may consider using the stimulation as an adjunct for rehabilitation therapy to improve UE motor outcomes for stroke survivors, pending evidence from a larger efficacy trial.

Supplementary Material

Supplement 1
Supplement 2

Acknowledgments

The authors would like to thank the Data and Safety Monitoring Board members, Drs. Robert Adams, Craig Velozo, and Caitlyn Meinzer. The authors would also like to thank Dr. Fabrizio Sergi and Andrea Farrens for contributing to the study design.

Funding

This study was possible through funding from NIH/NIGMS U54 GM104941 and P20 GM109040 COBRE for Stroke Recovery, NIH/NICHD R01HD094731, and NIH/NCATS TL1 TR001451 and UL1 TR001450.

Footnotes

Declaration of Interest Statement

N.J. Seo is an inventor of a patent regarding the investigated sensory stimulation. The other authors report no conflicts of interest.

Ethics Approval

The study protocol was approved by the Institutional Review Board at the Medical University of South Carolina (Pro00074041).

Clinical Trial Registration

Clinical trial Identifier: NCT03473808

Contributor Information

Amanda A. Vatinno, Department of Health Sciences and Research, Medical University of South Carolina (MUSC), Charleston, SC.

Lucion Hall, Division of Occupational Therapy, Department of Health Professions, MUSC.

Hannah Cox, Division of Occupational Therapy, Department of Health Professions, MUSC.

Alison Fluharty, Division of Occupational Therapy, Department of Health Professions, MUSC.

Catilyn Taylor, Division of Occupational Therapy, Department of Health Professions, MUSC.

Alexandra Wease, Division of Occupational Therapy, Department of Health Professions, MUSC.

Allison Davis, Division of Occupational Therapy, Department of Health Professions, MUSC.

Shannon Cain, Division of Occupational Therapy, Department of Health Professions, MUSC.

Viswanathan Ramakrishnan, Department of Public Health Sciences, MUSC.

Michelle Woodbury, (1) Division of Occupational Therapy, Department of Health Professions, MUSC; (2) Department of Health Sciences and Research, MUSC.

Na Jin Seo, (1) Division of Occupational Therapy, Department of Health Professions, MUSC; (2) Department of Health Sciences and Research, MUSC; (3) Ralph H. Johnson VA Medical Center.

References

  1. Baker SN (2007). Oscillatory interactions between sensorimotor cortex and the periphery. Current Opinion in Neurobiology, 17(6), 649–655. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bastos Conforto A, Nocelo Ferreiro K, Tomasi C, dos Santos RL, Loureiro Moreira V, Nagahashi Marie SK, Baltieri SC, Scaff M, & Cohen LG (2010). Effects of somatosensory stimulation on motor function after subacute stroke. Neurorehabilitation and Neural Repair, 24(3), 263–272. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Birkenmeier RL, Prager EM, & Lang CE (2010). Translating animal doses of task-specific training to people with chronic stroke in 1-hour therapy sessions: a proof-of-concept study. Neurorehabilitation and Neural Repair, 24(7), 620–635. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Bulut T, Tahta M, Sener U, & Sener M (2018). Inter- and intra-tester reliability of sensibility testing in healthy individuals. J Plast Surg Hand Surg, 52(3), 189–192. [DOI] [PubMed] [Google Scholar]
  5. Carrico C, Chelette KC II, P. M. W., Salmon-Powell E, Nichols L, & Sawaki L (2016). A randomized trial of peripheral nerve stimulation to enhance mondified constraint-induced therapy after stroke. American journal of physical medicine & rehabilitation, 95(6), 397. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Carrico C, Chelette KC, Westgate PM, Powell E, Nichols L, Fleischer A, & Sawaki L (2016). Nerve stimulation enhances task-oriented training in chronic, severe motor deficit after stroke: a randomized trial. Stroke, 47(7), 1879–1884. [DOI] [PubMed] [Google Scholar]
  7. Celnik P, Hummel F, Harris-Love M, Wolk R, & Cohen LG (2007). Somatosensory stimulation enhances the effects of training functional hand tasks in patients with chronic stroke. Archives of Physical Medicine and Rehabilitation, 88(11), 1369–1376. [DOI] [PubMed] [Google Scholar]
  8. Chen HM, Chen CC, Hsueh IP, Huang SL, & Hsieh CL (2009). Test-retest reproducibility and smallest real difference of 5 hand function tests in patients with stroke. Neurorehabilitation and Neural Repair, 23(5), 435–440. [DOI] [PubMed] [Google Scholar]
  9. Chen R, & Ashby P (1993). Reflex responses in upper limb muscles to cutaneous stimuli. The Canadian journal of neurological sciences, 20(4), 271–278. [DOI] [PubMed] [Google Scholar]
  10. Conforto AB, Cohen LG, Dos Santos RL, Scaff M, & Marie SKN (2007). Effects of somatosensory stimulation on motor function in chronic cortico-subcortical strokes. Journal of Neurology, 254(3), 333–339. [DOI] [PubMed] [Google Scholar]
  11. Conforto AB, dos Anjos SM, Bernardo WM, Silva A. A. d., Conti J, Machado AG, & Cohen LG (2018). Repetitive peripheral sensory stimulation and upper limb performance in stroke: a systematic review and meta-analysis. Neurorehabilitation and Neural Repair, 32(10), 863–871. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Dobkin BH, & Carmichael ST (2016). The Specific Requirements of Neural Repair Trials for Stroke. Neurorehabilitation and Neural Repair, 30(5), 470–478. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Ehrenstein WH, & Ehrenstein A (1999). Psychophysical methods. In Modern techniques in neuroscience research (pp. 1211–1241). Springer. [Google Scholar]
  14. Enders LR, Hur P, Johnson MJ, & Seo NJ (2013). Remote vibrotactile noise improves light touch sensation in stroke survivors’ fingertips via stochastic resonance. Journal of Neuroengineering and Rehabilitation, 10, 105. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Fritz SL, Blanton S, Uswatte G, Taub E, & Wolf SL (2009). Minimal detectable change scores for the Wolf Motor Function Test. Neurorehabilitation and Neural Repair, 23(7), 662–667. [DOI] [PubMed] [Google Scholar]
  16. Jenner J, & Stephens J (1982). Cutaneous reflex responses and their central nervous pathways studied in man. The Journal of physiology, 333(1), 405–419. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Kaelin-Lang A, Luft AR, Sawaki L, Burstein AH, Sohn YH, & Cohen LG (2002). Modulation of human corticomotor excitability by somatosensory input. The Journal of physiology, 540(2), 623–633. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Lakshminarayanan K, Lauer AW, Ramakrishnan V, Webster JG, & Seo NJ (2015). Application of vibration to wrist and hand skin affects fingertip tactile sensation. Physiol Rep, 3(7). [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Lang CE, & Birkenmeier RL (2014). Upper-extremity task-specific training after stroke or disability: A manual for occupational therapy and physical therapy. AOTA Press. [Google Scholar]
  20. Lang CE, Strube MJ, Bland MD, Waddell KJ, Cherry-Allen KM, Nudo RJ, Dromerick AW, & Birkenmeier RL (2016). Dose response of task-specific upper limb training in people at least 6-months poststroke: A phase II, single-blind, randomized, controlled trial. Annals of Neurology, 80(3), 342–354. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Lin KC, Fu T, Wu CY, Wang YH, Liu JS, Hsieh CJ, & Lin SF (2010). Minimal detectable change and clinically important difference of the Stroke Impact Scale in stroke patients. Neurorehabilitation and Neural Repair, 24(5), 486–492. [DOI] [PubMed] [Google Scholar]
  22. Lin KC, Hsieh YW, Wu CY, Chen CL, Jang Y, & Liu JS (2009). Minimal detectable change and clinically important difference of the Wolf Motor Function Test in stroke patients. Neurorehabilitation and Neural Repair, 23(5), 429–434. [DOI] [PubMed] [Google Scholar]
  23. Lo AC, Guarino PD, Richards LG, Haselkorn JK, Wittenberg GF, Federman DG, Ringer RJ, Wagner TH, Krebs HI, Volpe BT, Bever CT Jr., Bravata DM, Duncan PW, Corn BH, Maffucci AD, Nadeau SE, Conroy SS, Powell JM, Huang GD, & Peduzzi P (2010). Robot-assisted therapy for long-term upper-limb impairment after stroke. New England Journal of Medicine, 362(19), 1772–1783. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Lynch EA, Cadilhac DA, Luker JA, & Hillier SL (2017). Inequities in access to inpatient rehabilitation after stroke: an international scoping review. Topics in Stroke Rehabilitation, 24(8), 619–626. [DOI] [PubMed] [Google Scholar]
  25. Mathiowetz V, Volland G, Kashman N, & Weber K (1985). Adult norms for the Box and Block Test of manual dexterity. American Journal of Occupational Therapy, 39(6), 386–391. [DOI] [PubMed] [Google Scholar]
  26. National Cancer Institute. (2017). Common terminology criteria for adverse events version 5.0. https://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_50.
  27. National Institute of Neurological Disorders and Stroke. (2017). Adverse event relatedness scale. https://cde.nlm.nih.gov/deView?tinyId=XrsKeH6EJCC
  28. Ridding M, & Rothwell J (1999). Afferent input and cortical organisation: a study with magnetic stimulation. Experimental Brain Research, 126(4), 536–544. [DOI] [PubMed] [Google Scholar]
  29. Ridding MC, & Rothwell JC (1999). Afferent input and cortical organisation: a study with magnetic stimulation. Experimental Brain Research, 126(4), 536–544. [DOI] [PubMed] [Google Scholar]
  30. Schabrun SM, Ridding MC, Galea MP, Hodges PW, & Chipchase LS (2012). Primary sensory and motor cortex excitability are co-modulated in response to peripheral electrical nerve stimulation. PloS One, 7(12). [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Seo Enders, Fortune Cain, Vatinno Schuster, Ramakrishnan, & Feng. (2019). Phase I Safety Trial: Extended Daily Peripheral Sensory Stimulation Using a Wrist-Worn Vibrator in Stroke Survivors. Translational stroke research, 1–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Seo Woodbury, Bonilha Ramakrishnan, Kautz Downey, Dellenbach Lauer, Roark Landers, Phillips, & Vatinno (2019). TheraBracelet Stimulation During Task-Practice Therapy to Improve Upper Extremity Function After Stroke: A Pilot Randomized Controlled Study. Physical Therapy, 99(3), 319–328. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Seo Kosmopoulos, Enders, & Hur (2014). Effect of remote sensory noise on hand function post stroke. Frontiers in Human Neuroscience, 8, 934. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Seo Lakshminarayanan, Bonilha Lauer, & Schmit(2015). Effect of imperceptible vibratory noise applied to wrist skin on fingertip touch evoked potentials-an EEG study. Physiol Rep, 3(11). [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Seo Lakshminarayanan, Lauer Ramakrishnan, Schmit V, Hanlon, George Bonilha, Downey DeVries, & Nagy (2019). Use of imperceptible wrist vibration to modulate sensorimotor cortical activity. Experimental Brain Research, 237(3), 805–816. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Setler PE (2002). Therapeutic use of botulinum toxins: background and history. Clinical Journal of Pain, 18(6 Suppl), S119–124. [DOI] [PubMed] [Google Scholar]
  37. Smith L, & Brouwer B (2005). Effectiveness of muscle vibration in modulating corticospinal excitability. Journal of Rehabilitation Research and Development, 42(6), 787. [DOI] [PubMed] [Google Scholar]
  38. Stewart JC, & Cramer SC (2013). Patient-reported measures provide unique insights into motor function after stroke. Stroke, 44(4), 1111–1116. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Taub E, Morris DM, Crago J, King DK, Bowman M, Bryson C, Bishop S, Pearson S, & Shaw SE (2011). Wolf motor function test manual. Birmingham: University of Alabama, CI Therapy Research Group. [Google Scholar]
  40. Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, & Delling FN (2020). Heart Disease and Stroke Statistics—2020 Update: A Report From the American Heart Association. Circulation, CIR. 0000000000000757. [DOI] [PubMed] [Google Scholar]
  41. Waddell KJ, Strube MJ, Bailey RR, Klaesner JW, Birkenmeier RL, Dromerick AW, & Lang CE (2017). Does Task-Specific Training Improve Upper Limb Performance in Daily Life Poststroke? Neurorehabilitation and Neural Repair, 31(3), 290–300. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Winstein CJ, Wolf SL, Dromerick AW, Lane CJ, Nelsen MA, Lewthwaite R, Cen SY, & Azen SP (2016). Effect of a Task-Oriented Rehabilitation Program on Upper Extremity Recovery Following Motor Stroke: The ICARE Randomized Clinical Trial. JAMA, 315(6), 571–581. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Wolf SL, Catlin PA, Ellis M, Archer AL, Morgan B, & Piacentino A (2001). Assessing Wolf motor function test as outcome measure for research in patients after stroke. Stroke, 32(7), 1635–1639. [DOI] [PubMed] [Google Scholar]
  44. Wolf SL, Winstein CJ, Miller JP, Taub E, Uswatte G, Morris D, Giuliani C, Light KE, Nichols-Larsen D, & Investigators E (2006). Effect of constraint-induced movement therapy on upper extremity function 3-to-9 months after stroke: the EXCITE randomized clinical trial. JAMA, 296(17), 2095–2104. [DOI] [PubMed] [Google Scholar]
  45. Woodbury ML, Velozo CA, Richards LG, & Duncan PW (2013). Rasch analysis staging methodology to classify upper extremity movement impairment after stroke. Archives of Physical Medicine and Rehabilitation, 94(8), 1527–1533. [DOI] [PubMed] [Google Scholar]

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