CRITICALLY APPRAISED PAPER (CAP)

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1 CRITICALLY APPRAISED PAPER (CAP) Friedman, N., Chan, V., Reinkensmeyer, A. N., Beroukhim, A., Zambrano, G. J., Bachman, M., & Reinkensmeyer, D. J. (2014). Retraining and assessing hand movement after stroke using the MusicGlove: Comparison with conventional hand therapy and isometric grip training. Journal of Neuroengineering and Rehabilitation, 11(1), CLINICAL BOTTOM LINE: This study compared the MusicGlove (MG) with IsoTrainer (IT) and conventional tabletop (CT) exercise in promoting functional activity among stroke patients. The MG is a dynamic activity in which patients touch their thumb to their fingers after playing the Frets on Fire video game, while wearing a glove that records their responses and provides feedback. The IT also followed the Frets on Fire video game and provided feedback, but it is an isometric activity. The CT consisted of exercises without the Frets on Fire video game. Each participant with hemiparesis participated in six 1-hr treatment sessions with each intervention, and they received each of the three interventions in random order. Only two of the six outcome measures showed a significant difference between the MG and tabletop exercises. These comparisons offer some evidence that the MG improves hand dexterity and speed of movement. A significant linear relationship was demonstrated in this study between the MG Frets on Fire score and Box and Blocks Test scores. This indicates that the MG Frets on Fire score could possibly provide a valid evaluation of coordination. Although it was not a stated goal of the study, the results suggest that clients preferred the purposeful activity of the MG over rote exercise of the CT exercise. The evidence presented in this study suggests the MG may be a meaningful leisure activity that promotes recovery of hand dexterity and speed of movement among patients who have suffered a stroke. RESEARCH OBJECTIVE(S) List study objectives. To investigate the efficacy of the MG as a tool to promote hand function through the coordination of finger and thumb movement among patients who have suffered a stroke To compare the effectiveness of the MG with the IT and CT To determine whether a correlation exists between the MG score and the primary outcome of Box and Blocks Test score DESIGN TYPE AND LEVEL OF EVIDENCE:

2 Level I: Within-subject study design; randomly assigned order of interventions SAMPLE SELECTION How were subjects recruited and selected to participate? Please describe. Participants were stroke survivors ranging in age between 19 and 80 years old and were selected from hospitals and support groups in the Orange County area of California, along with people in the University of California, Irvine, database who completed previous stroke studies. Inclusion Criteria Participants included in the study had suffered a single ischemic or hemorrhagic stroke at least 6 months before the study. All participants scored between 34 and 62 on the Fugl Meyer Assessment s Upper Extremity Impairment test and between 1 and 55 on the Box and Blocks Test. Exclusion Criteria Severe pain, tone, or loss of sensation in the affected upper extremity, as well as severe comorbidity, cognitive dysfunction, severe neglect, apraxia, or participation in other upper extremity studies SAMPLE CHARACTERISTICS N= (Number of participants taking part in the study): 12 #/ (%) Male: 7/(58%) #/ (%) Female: 5/(42%) Ethnicity: NR Disease/disability diagnosis: Single ischemic or hemorrhagic stroke with upper extremity deficit INTERVENTION(S) AND CONTROL GROUPS Add groups if necessary Group 1: MG group Brief description of the intervention MG is a music video game similar to Guitar Hero that involves finger and thumb coordination. The glove has sensors on the tip of the thumb and the index, long, ring, and small fingers as well as the radial aspect of the index finger; these sensors send a signal when touched together. With video as the guide, the intervention involved tapping the specific sensors of the digits to the thumb sensor in functional patterns, such as pincer or key pinch, within a specific time. The sensors were connected by USB to the Frets on Fire game. After using a tutorial song as practice, the participant played the dexterity assessment song for 1 min 10 s, using 42 notes, and the speed assessment song for 1 min 50 s, using 81 notes. Participants then played about 45 min of 12 songs. The assessments were repeated for a total of 1,420 movements per session. The score was recorded at the end of each song and reflected the percentage of total correct

3 How many participants in the group? Where did the intervention take place? Who Delivered? How often? For how long? Group 2: IT group Brief description of the intervention How many participants in the group? Where did the intervention take place? Who Delivered? How often? For how long? taps as well as the percentage for each digit. 12: each participant participated in all three interventions Clinic Physical therapist 45-min sessions three times per week 2 weeks IT is a device the authors developed to evaluate isometric hand training. Flexiforce sensors were located on opposite sides of the acrylic boards. With the thumb and one digit on the opposing sensors, the user squeezed with 10 N of force. This stimulus was sent to the same Frets on Fire game that the MG used. This device removed the dynamic nature of the MG activity, making the activity isometric. 12: each participant participated in all three interventions Clinic Physical therapist 45-min sessions three times per week 2 weeks Group 3: CT exercise group Brief description of the intervention CT exercises included passive range of motion, active range of motion, isometric strengthening, and functional gripping practice for the hand for 45 min. The number of repetitions was not controlled during the session. If participants finished all of the exercises within the 45 min, they began the exercises again. For the passive range of motion exercises, the participants used their unaffected hand to manipulate their affected hand, which made up 15% 20% of their exercises. The focus was on individual metacarpophalangeal, interphalangeal, and distal interphalangeal flexion, as well as composite flexion of the distal two joints and then all three joints. During the active range of motion exercises, participants used their wrist and hand without the help of their unaffected hand. They performed the isometric strengthening exercises using the unaffected

4 hand as oppositional force. The functional grip focused on touching the thumb to the tip of each finger; practicing pincer grasp, power grasp, and thumb opposition; picking up coins; and picking up a pencil. How many participants in the group? Where did the intervention take place? Who Delivered? How often? For how long? 12: each participant participated in all three interventions Clinic Physical therapist 45-min sessions three times per week 2 weeks Intervention Biases: Check yes, no, or NR and explain, if needed. Contamination: YES Comment: There could have been contamination between interventions because of the within-subject crossover design. There was no washout period between interventions. Co-intervention: NO Timing: NO Site: NO Comment: Comment: Comment: All interventions were held at the Sue and Bill Gross Stem Cell Research Center at the University of California, Irvine. Use of different therapists to provide intervention: Comment: NO MEASURES AND OUTCOMES Complete for each measure relevant to occupational therapy:

5 Measure 1: Box and Blocks Test Name/type of What outcome was Box and Blocks Test Grasp, transport, and gross dexterity YES NO Measure 2: Fugl Meyer Assessment Name/type of Arm Motor section of Fugl Meyer Assessment What outcome was Motor function of hemiparetic arm Measure 3: Wolf Motor Function Test Name/type of Wolf Motor Function Test score and time What outcome was Performance of functional activities with the arm Measure 4: Action Research Arm Test Name/type of Action Research Arm Test What outcome was Motor function

6 Measure 5: Nine-Hole Peg Test (NHPT) Name/type of What outcome was Measure 6: Dexterity test Name/type of What outcome was Measure 7: Speed test Name/type of What outcome was NHPT Dexterity and fine motor control Dexterity test Three notes played 42 times using the MG for 1 minute 26 seconds, used in an unpredictable sequence and continuously sped up during the test. Score equaled percentage of correct notes. Response to an unpredictable sequence Beginning and end of each of the six MG training sessions (this measure was not used for the other interventions) 81 total notes played in a predictable sequence with all finger thumb pairs with the MG for 1 min 50 s, continuously sped up during the test. Score equaled percentage of correct notes tapped. Ability to play a predicted sequence of notes, testing all finger thumb pairs Beginning and end of each of the six MG training sessions (this measure was not used for the other interventions) Measurement Biases Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain. YES Comment: The occupational therapist who administered the assessments was blinded. Recall or memory bias. Check yes, no, or NR, and if yes, explain. Comment:

7 NO Others (list and explain): RESULTS List key findings based on study objectives Include statistical significance where appropriate (p<0.05) Include effect size if reported The study used the Box and Blocks Test as the primary outcome measure. There was significant improvement among participants who used the MG, in comparison with CT, on the Box and Blocks Test as well as the NHPT assessment. Those were the only two comparisons that showed significant results. The Arm Motor score of the Fugl Meyer Assessment and the Action Research Arm Test did not show significant differences in the use of the three treatments. The table below shows a comparison of the MG, IT, and CT results for each outcome measure. Outcome measure MG vs. CT (p) MG vs. IT (p) IT vs. CT (p) Box and Blocks Test (blocks/min) Arm Motor section of Fugl Meyer Assessment (out of 66) Wolf Motor Function Test score Wolf Motor Function Test time (seconds) Action Research Arm Test NHPT (pegs/min) p <.0166 was considered a significant difference between treatments. There was a significant linear relationship between the scores of the gold-standard Box and Blocks Test and the MG s Frets on Fire game in both the MG dexterity test and the speed test. The following table shows the significance value and effect size of the speed and dexterity tests that were administered at the beginning and end of every MG session. Test p R 2 Dexterity: Day 1 start Dexterity: Day 1 end Dexterity: Day 6 start Dexterity: Day 6 end < Speed: Day 1 start Speed: Day 1 end Speed: Day 6 start < Speed: Day 6 end < Was this study adequately powered (large enough to show a difference)? Check yes, no, or NR, and if no, explain. Comment: The authors characterized the sample size as small and limited.

8 NO No power analysis was done. Were appropriate analytic methods used? Check yes, no, or NR, and if no, explain. YES Comment: Were statistics appropriately reported (in written or table format)? Check yes or no, and if no, explain. YES Comment: Was the percent/number of subjects/participants who dropped out of the study reported? YES Limitations: What are the overall study limitations? Only 12 participants were observed in this study, and the age range was from 19 to 80. This is a small population for a large demographic. Outliers could easily have skewed the results. This suggests that the study was not adequately powered. There is also some concern about the carryover effects from condition to condition. CONCLUSIONS State the authors conclusions related to the research objectives. The authors concluded that there was significant evidence to support the use of MG; however, the Box and Blocks Test and NHPT were the only outcome measures that showed significant differences when the MG was compared with CT. The study does demonstrate that patients found the MG to be more satisfying and motivational to use; however, that question was not included in the purpose of the study. The most significant evidence presented in this study supports a strong correlation between the scores on the MG and the Box and Blocks Test. This work is based on the evidence-based literature review completed by Gena Andreasen, MOTS, and Michael Borst, OTD, OTR, CHT, faculty advisor, Concordia University Wisconsin. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, and M. Westmorland, McMaster University. Used with permission.