The effect of eccentric and task oriented upper limb strength training in chronic stroke patients.

Literature has shown that strength training can improve strength without
increasing muscle tone or pain in chronic stroke patients (Ada et al., 2006,
Pak and Patten, 2008, Harris et al., 2009, Borges et al., 2009). Furthermore,
eccentric strength training is proven to be an effective strength training
method in chronic stroke patients (Engardt et al., 1995; Clark et al., 2013).
However, the feasibility of such a program is not known, due to the fact that
the studies used an isokinetic exerciser. Isokinetic exercisers are expensive
machines and only one patient can train at the time. Also, strength training
can improve activities of daily living, although the research is only
implemented for the lower limb. The study of Yang et al. (2006) showed that
task oriented strength training could improve lower extremity muscle strength
in chronic stroke patients and could carry over into improvement in functional
abilities. No literature was found on the effects of a training program for
upper limb combining strength training and task-oriented training. It could be
possible that one needs a certain amount of strength before task oriented
strength training will have a positive effect.
Therefore, a study in which eccentric strength training and task oriented
strength training are investigated will be performed. The two main research
questions are: *Is eccentric strength training of the upper limb an effective
and feasible strength training program to provide to chronic stroke patients?*
and *Can task oriented strength training of the upper limb improve upper limb
function in the ICF activities domain of individuals with chronic stroke?* The
secondary effect that will be studied is the order of eccentric and task
oriented strength training.

The objectives of the study in chronic stroke patients are 1) to determine
whether eccentric strength training is an effective strength training program,
2) whether upper-limb task oriented strength training improves upper limb
function in the International Classification of Functioning, Disability and
Health (ICF) activities domain, 3) whether task oriented strength training is
more effective when preceded by eccentric strength training, 4) whether
eccentric strength training is more effective when preceded by task oriented
strength training, 5) whether eccentric strength training is a feasible
strength training.

The study is a pilot study with a pre-post design similar to a cross-over
design, but without a control intervention. All participants will receive two
different interventions; an eccentric strength training and a task oriented
strength intervention. Both interventions will take four weeks. Half of the
participants will receive the eccentric training first (EST-TOST group), the
other half will receive the task oriented training first (TOST-EST group). The
participants will be allocated to a group randomly. Outcome measures are
upper-limb strength measured with a hand-held dynamometer (HHD), the action
research arm test (ARAT) to measure upper limb function in the ICF activities
domain, and a combination of the intrinsic motivational inventory (IMI) and the
attendance of the participants to measure feasibility. There will be three
measurement moments; baseline, after the first intervention and after the
second intervention. At baseline the strength and upper limb function will be
measured and after the first and second intervention the strength, upper limb
function and feasibility will be measured.

An eight week (three days/week) program consisting of four weeks of upper-limb
eccentric strength training and four weeks of upper-limb task oriented strength
training will be carried out. Both strength interventions will be performed one
day per week at Beatrixoord with a physiotherapist or occupational therapist
and two days per week at home. During the first and second training session at
home one researcher is present to assist the participant with the technical
aspects of the program and possible other problems. If necessary, the
researcher will assist the participant during the other training sessions at
home.
Eccentric training: The participants will receive eccentric strength training
for the upper limb 3 times a week for 30 minutes. The training consists of
exercises for the major wrist-, elbow- and shoulder muscles. In each exercise
the unaffected arm will help the affected arm against resistance, than the
affected side moves slowly with the resistance, without the help of the
unaffected arm. The exercises will start at 60% of one-repetition maximum (1RM)
and repeated ten to fifteen times for one to three times. Every week the
intensity will be increased.
Task oriented strength training: The task oriented strength training will be a
bilateral upper-limb training using a movement-based game controller (Cy Wee
Z), incorporated into a handlebar. The participant will play games on a PC
using the movement-based game controller for 30 minutes. The weight of the
handlebar will be increased over the four week intervention period.

The patient will have to visit Beatrixoord once a week, the total amount of
site visits is eight times for the intervention and three times for the
measurements. Also, the patient has to train twice a week at home, which is a
total amount of sixteen times. There are three measurement moments. During
every measurement moment strength (HHD) and ARAT will be tested. The second
(after four weeks) and third (after eight weeks) measurement moment the IMI
will also have to be filled out. The risks are negligible, because there is a
physiotherapist or occupational therapist who will observe during the
intervention at Beatrixoord. Also, the patient will sit on a chair during the
interventions, reducing the risk of falling. The study is in chronic stroke
patients since it is unknown what the effect is of eccentric strength training
and task oriented strength training on chronic stroke patients and the
influence of natural recovery is ruled out in this population. This can help to
optimize the rehabilitation process of chronic stroke patients.