Efficacy of modified constraint-induced movement therapy in chronic stroke: a single-blinded randomized controlled trial 11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated

Comparison of Constraint-Induced Movement Therapy and Bilateral Treatment of Equal Intensity in People With Chronic Upper-Extremity Dysfunction After Cerebrovascular Accident

OBJECTIVE. We compared the effectiveness of constraint-induced movement therapy (CIMT) with bilateral treatment of equal intensity for chronic upper-extremity (UE) dysfunction caused by cerebrovascular accident (CVA).

DESIGN. We conducted a 2-group, randomized intervention trial with stratification by severity of UE dysfunction. Twelve community-dwelling adults were provided with 6 hr of occupational therapy for 10 days plus additional home practice. Six participants wore a mitt on the unimpaired UE, and 6 participants were intrusively and repetitively cued to use both UEs. The Wolf Motor Function Test (WMFT) and the Canadian Occupational Performance Measure (COPM) were administered before and after treatment and at 6-mo follow-up.

RESULTS. Significant improvements were found in WMFT and COPM scores across time in both groups. No significant between-group differences were found on the WMFT.

CONCLUSION. High-intensity occupational therapy using a CIMT or a bilateral approach can improve UE function in people with chronic UE dysfunction after CVA. Treatment intensity rather than restraint may be the critical therapeutic factor.

Robot-assisted therapy for long-term upper-limb impairment after stroke

BACKGROUND

Effective rehabilitative therapies are needed for patients with long-term deficits after stroke.

METHODS

In this multicenter, randomized, controlled trial involving 127 patients with moderate-to-severe upper-limb impairment 6 months or more after a stroke, we randomly assigned 49 patients to receive intensive robot-assisted therapy, 50 to receive intensive comparison therapy, and 28 to receive usual care. Therapy consisted of 36 1-hour sessions over a period of 12 weeks. The primary outcome was a change in motor function, as measured on the Fugl-Meyer Assessment of Sensorimotor Recovery after Stroke, at 12 weeks. Secondary outcomes were scores on the Wolf Motor Function Test and the Stroke Impact Scale. Secondary analyses assessed the treatment effect at 36 weeks.

RESULTS

At 12 weeks, the mean Fugl-Meyer score for patients receiving robot-assisted therapy was better than that for patients receiving usual care (difference, 2.17 points; 95% confidence interval [CI], -0.23 to 4.58) and worse than that for patients receiving intensive comparison therapy (difference, -0.14 points; 95% CI, -2.94 to 2.65), but the differences were not significant. The results on the Stroke Impact Scale were significantly better for patients receiving robot-assisted therapy than for those receiving usual care (difference, 7.64 points; 95% CI, 2.03 to 13.24). No other treatment comparisons were significant at 12 weeks. Secondary analyses showed that at 36 weeks, robot-assisted therapy significantly improved the Fugl-Meyer score (difference, 2.88 points; 95% CI, 0.57 to 5.18) and the time on the Wolf Motor Function Test (difference, -8.10 seconds; 95% CI, -13.61 to -2.60) as compared with usual care but not with intensive therapy. No serious adverse events were reported.

CONCLUSIONS

In patients with long-term upper-limb deficits after stroke, robot-assisted therapy did not significantly improve motor function at 12 weeks, as compared with usual care or intensive therapy. In secondary analyses, robot-assisted therapy improved outcomes over 36 weeks as compared with usual care but not with intensive therapy. (ClinicalTrials.gov number, NCT00372411.)

Translating animal doses of task-specific training to people with chronic stroke in 1-hour therapy sessions: a proof-of-concept study

OBJECTIVE

The purposes of this study were to (1) examine the feasibility of translating high-repetition doses of upper-extremity (UE) task-specific training to people with stroke within the confines of the current outpatient delivery system of 1-hour therapy sessions and (2) to gather preliminary data regarding the potential benefit of this intensity of training.

METHODS

A total of 15 patients with chronic (>6 months) UE paresis caused by stroke underwent 3 weeks of baseline assessments followed by 6 weeks of the high-repetition intervention (3 sessions/wk for 6 weeks). During each 1-hour session, participants were challenged to complete 300 or more repetitions of UE functional task training (3 tasks x 100 repetitions). Assessments during and after the intervention were used to measure feasibility and potential benefit.

RESULTS

For the 13 participants completing the intervention, the average number of repetitions per session was 322. The percentage of sessions attended was 97%. Participant ratings of pain and fatigue were low. Action Research Arm test scores improved an average of 8 points during the intervention and were maintained at the 1-month follow-up. Secondary measures of activity and participation increased, but the measure of impairment did not.

CONCLUSIONS

It is feasible to deliver hundreds of repetitions of task-specific training to people with stroke in 1-hour therapy sessions. Preliminary outcome data suggest that this intervention may be beneficial for some people with stroke.

Defining and measuring residual deficits of the upper extremity following stroke: a new perspective

PURPOSE

To propose and test a new measure to quantify residual deficits (Rd) following stroke and provide preliminary evidence supporting its usefulness.

METHODS

Patients (N = 46) were stratified based on projected rate of upper extremity recovery and were randomly assigned to task-oriented (control) or task-oriented plus functional electrical stimulation (FES) training groups. All performed the Box & Blocks and the Jebsen-Taylor light object lift tests with the nonparetic and paretic upper extremities. A modified Fugl-Meyer test was performed on the paretic upper extremity. The calculation Rd = 100 - (paretic/nonparetic x 100) was made for each subgroup: task-specific training alone (control subgroup) or task-specific training plus functional electrical stimulation (FES subgroup). Data from each of these two groups were analyzed separately.

RESULTS

Intrasession and between-sessions tests of the nonparetic or paretic extremity yielded interclass correlation (ICC) values between 0.77 and 0.99. After training for 12 weeks, the Rd of the paretic upper extremity of patients who used the FES was significantly less compared to the control group (p < .05). The deficits of patients with slow recovery profile were as expected much greater.

CONCLUSIONS

Rd is a valid, highly reproducible, and dimensionless outcome measure. It should permit objective comparison of effectiveness between and within various rehabilitative intervention options regardless of the outcome measure(s) used.

Group Constraint-Induced Movement Therapy: Motor and Functional Outcomes in Individuals with Stroke

Background

Strokes frequently cause limitations of the upper extremity and in performance of activities of daily living (ADL). Constraint-induced movement therapy (CIMT) is designed to enhance the use of the hemiplegic arm.

Purpose

To assess the effects of group CIMT on upper-extremity motor function and performance level of motor and process skills for instrumental activities in daily living (IADL) in community-dwelling individuals whose stroke occurred at least six months earlier.

Methods

Eight adults with stroke participated in this study. Group-based CIMT was administered for two weeks, five times per week, with two-hour intensive daily training.

Findings

The Fugl-Meyer Assessment (FMA) score and the Assessment of Motor and Process Skills (AMPS) scores improved after intervention.

Implications

The results of this study suggest that relatively brief group-based CIMT may be an effective intervention for improving motor function of the affected upper-limb and the level of IADL in individuals who have had stroke.

Design and Usability of a Home Telerehabilitation System to Train Hand Recovery Following Stroke

Current theories of stroke rehabilitation point toward paradigms of intense concentrated use of the afflicted limb as a means for motor program reorganization and partial function restoration. A home-based system for stroke rehabilitation that trains recovery of hand function by a treatment of concentrated movement was developed and tested. A wearable goniometer measured finger and wrist motions in both hands. An interface box transmitted sensor measurements in real-time to a laptop computer. Stroke patients used joint motion to control the screen cursor in a one-dimensional tracking task for several hours a day over the course of 10–14 days to complete a treatment of 1800 tracking trials. A telemonitoring component enabled a therapist to check in with the patient by video phone to monitor progress, to motivate the patient, and to upload tracking data to a central file server. The system was designed for use at home by patients with no computer skills. The system was placed in the homes of 20 subjects with chronic stroke and impaired finger motion, ranging from 2–305 mi away from the clinic, plus one that was a distance of 1057 miles. Fifteen subjects installed the system at home themselves after instruction in the clinic, while nine required a home visit to install. Three required follow-up visits to fix equipment. A post-treatment telephone survey was conducted to assess ease of use and most responded that the system was easy to use. Functional improvements were seen in the subjects enrolled in the formal treatment study, although the treatment period was too short to trigger cortical reorganization. We conclude that the system is feasible for home use and that tracking training has promise as a treatment paradigm.

Effect of small group treatment of the modified constraint induced movement therapy for clients with chronic stroke in a community setting

This study investigated the effects of the group treatment component of the modified constraint induced movement therapy (mCIMT) protocol for clients with chronic stroke in a community setting. A within-subjects longitudinal study was conducted to which eight participants with chronic stroke being treated in a community setting in Hong Kong were recruited. Ten 3-h group sessions were conducted on two occasions within a four-week period, with four participants per group. Participants' less-affected hands were restrained in a mitt, with a target of wearing it for 4h per weekday. Laboratory based tests and the Motor Activity Log (MAL) were used repeatedly to measure participants' hemiparetic upper extremity functions and the use of the limb in real-life on four measurement occasions: at baseline (four weeks before training), pre-test (one day before training), post-test (one day after training), and follow-up (four weeks after training). The Wilcoxon signed-rank test showed participants' baselines were stable four weeks before the intervention. The Friedman test found significant differences between pre-test, post-test and follow-up in the Box and Block Test (BBT), the total score, grasp and pinch subscores of the Action Research Arm Test (ARAT), and the Hong Kong Version of the Functional Test for the Hemiplegic Upper Extremity (FTHUE-HK), the Wolf Motor Function Test (WMFT), and the MAL. All these gains were maintained during the 1-month follow-up. The small group treatment component of the mCIMT was found to be effective, feasible, and capable of improving both motor performance and functional use of the affected upper extremity for patients with chronic stroke in a community setting.

Constraint-induced movement therapy for upper extremities in stroke patients

BACKGROUND

In stroke patients, upper limb paresis affects many activities of daily life. Reducing disability is therefore a major aim of rehabilitation programmes for hemiparetic patients. Constraint-induced movement therapy (CIMT) is a current approach to stroke rehabilitation that implies the forced use and the massed practice of the affected arm by restraining the unaffected arm.

OBJECTIVES

To assess the efficacy of CIMT, modified CIMT (mCIMT), or forced use (FU) for arm management in hemiparetic patients.

SEARCH STRATEGY

We searched the Cochrane Stroke Group trials register (last searched June 2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2008), MEDLINE (1966 to June 2008), EMBASE (1980 to June 2008), CINAHL (1982 to June 2008), and the Physiotherapy Evidence Database (PEDro) (June 2008).

SELECTION CRITERIA

Randomised control trials (RCTs) and quasi-RCTs (qRCTs) comparing CIMT, mCIMT or FU with other rehabilitative techniques, or none.

DATA COLLECTION AND ANALYSIS

Two review authors independently classified the identified trials according to the inclusion and exclusion criteria, assessed methodological quality and extracted data. The primary outcome was disability.

MAIN RESULTS

We included 19 studies involving 619 participants. The trials included participants who had some residual motor power of the paretic arm, the potential for further motor recovery and with limited pain or spasticity, but tended to use the limb little if at all. Only five studies had adequate allocation concealment. The majority of studies were underpowered (median number of included patients was 15) and we cannot rule out small-trial bias. Six trials (184 patients) assessed disability immediately after the intervention, indicating a significant standard mean difference (SMD) of 0.36, 95% confidence interval (CI) 0.06 to 0.65. For the most frequently reported outcome, arm motor function (11 studies involving 373 patients), the SMD was 0.72 (95% CI 0.32 to 1.12). There were only two studies that explored disability improvement after a few months of follow up and found no significant difference, SMD -0.07 (95% CI -0.53 to 0.40).

AUTHORS' CONCLUSIONS

CIMT is a multifaceted intervention: the restriction to the normal limb is accompanied by a certain amount of exercise of the appropriate quality. It is associated with a moderate reduction in disability assessed at the end of the treatment period. However, for disability measured some months after the end of treatment, there was no evidence of persisting benefit. Further randomised trials, with larger sample sizes and longer follow up, are justified.

Combined Botulinum Toxin Type A With Modified Constraint-Induced Movement Therapy for Chronic Stroke Patients With Upper Extremity Spasticity: A Randomized Controlled Study

Background and objective . Botulinum toxin type A (BtxA) injection and modified constraint-induced movement therapy (mCIMT) are both promising approaches to enhance recovery after stroke. The combined application of these 2 promising modalities has rarely been studied. The aim was to investigate whether combined BtxA and mCIMT would improve spasticity and upper extremity motor function more than BtxA plus conventional rehabilitation in chronic stroke patients with upper extremity spasticity. Methods. In a prospective, randomized controlled, observer-blinded trial with 6-month follow-up, 32 patients (≥1 year after stroke) with ability to actively extend >10° at metacarpophalangeal and interphalangeal joints and 20° at wrist of the affected upper limb were randomized to receive BtxA + mCIMT (combination group) or BtxA + conventional rehabilitation (control group) for 2 hours/day, 3 days/week for 3 months.The primary outcome assessed spasticity on the Modified Ashworth Scale. Secondary outcomes assessed real-world arm function (Motor Activity Log), laboratory motor activity (Action Research Arm Test), and patients’ global satisfaction. Results. A total of 32 stroke patients were recruited, and 29 completed the study. Spasticity significantly improved in all subjects at 4 weeks and 3 months postinjection without between-group differences.The combination group showed significantly greater improvements in elbow, wrist, and finger spasticity ( P = .019, P = .019, and P < .001, respectively), affected upper extremity real-world arm function ( P < .001) and laboratory motor activity ( P < .001) than the control group at 6-month postinjection. Patients reported considerable satisfaction and no serious adverse events occurred. Conclusions. Combining BtxA and mCIMT is an effective and safe intervention for improving spasticity and motor function in chronic stroke patients. The results are promising enough to justify further studies. We recommend future research to address the likely need for including rehabilitation with BtxA to improve function in patients with poststroke spasticity.

Motor recovery after stroke: a systematic review

Loss of functional movement is a common consequence of stroke for which a wide range of interventions has been developed. In this Review, we aimed to provide an overview of the available evidence on interventions for motor recovery after stroke through the evaluation of systematic reviews, supplemented by recent randomised controlled trials. Most trials were small and had some design limitations. Improvements in recovery of arm function were seen for constraint-induced movement therapy, electromyographic biofeedback, mental practice with motor imagery, and robotics. Improvements in transfer ability or balance were seen with repetitive task training, biofeedback, and training with a moving platform. Physical fitness training, high-intensity therapy (usually physiotherapy), and repetitive task training improved walking speed. Although the existing evidence is limited by poor trial designs, some treatments do show promise for improving motor recovery, particularly those that have focused on high-intensity and repetitive task-specific practice.

The effects of repeated rehabilitation "tune-ups" on functional recovery after focal ischemia in rats

BACKGROUND

For most stroke survivors, rehabilitation therapy is the only treatment option available. The beneficial effects of early rehabilitation on neuroplasticity and functional recovery have been modeled in experimental stroke using a combination of enriched environment and rehabilitation. However, the impact of a secondary intervention, such as a periodic return to therapy, remains unclear.

OBJECTIVE

This study examines whether a return to enriched rehabilitation (ie, "tune-up") can further promote functional recovery or produce beneficial changes in brain plasticity in the chronic phase of stroke recovery.

METHODS

Rats were exposed to focal ischemia (endothelin-1 applied to forelimb sensorimotor cortex and dorsolateral striatum) and allowed to recover either in standard housing or in a combination of enriched environment and rehabilitative reaching for 9 weeks. Animals were then exposed to rotating periods of standard housing (5 weeks) and intensive "tune-up" therapy consisting of various sensorimotor/cognitive activities (2 weeks). Functional recovery was assessed using the Montoya staircase, beam-traversing, and cylinder tests, and Golgi-Cox analysis was used to examine dendritic complexity in the contralesional forelimb motor cortex.

RESULTS

Although early enriched rehabilitation significantly improved sensorimotor function in both the beam and staircase tests, "tune-up" therapy had no effect on recovery. Golgi-Cox analysis revealed no effect of treatment on dendritic complexity.

CONCLUSIONS

This study reaffirms the benefits of early rehabilitation for functional recovery after stroke. However, "tune-up" therapy provided no benefit in ischemic animals regardless of earlier rehabilitation experience. It is possible that alternative approaches in the chronic phase may prove more effective.

Constraint-induced therapy for moderate chronic upper extremity impairment after stroke

PRIMARY OBJECTIVE

To explore the effectiveness of constraint-induced therapy (CIT) in the treatment of individuals with moderate chronic upper extremity paresis.

RESEARCH DESIGN

Multiple case reports, pre-post-treatment comparisons as well as long-term follow-ups at 1 and 6 months after intervention.

METHODS AND PROCEDURES

Seven subjects, each greater than 12 months post-stroke, participated in an intensive 3 weeks CIT programme. The Wolf Motor Function Test (WMFT), Motor Activity Log (MAL) and Fugl-Meyer Evaluation (FM) were used to measure outcomes.

MAIN OUTCOMES AND RESULTS

Subjects exhibited notable improvements in mean WMFT scores (0.25 point increase post-treatment, 0.38 point increase at 1-month follow-up, 0.44 point increase at 6-month follow-up). Similarly, improvements were seen for mean MAL (1.71 points for AS, 1.77 points for HW) and FM scores (6 points FM-UE, 6 points FM-TOT) post-treatment. Additional improvements were seen at some follow-up assessments.

CONCLUSIONS

Subjects demonstrated gains in objective measures, however, did not regain normal functional ability of their paretic upper extremities. Further investigation of the effects of CIT in this population, as well the functional significance of the objective measures used is warranted.

Recovery of thumb and finger extension and its relation to grasp performance after stroke

This study investigated how the ability to extend the fingers and thumb recovers early after stroke and how the ability to extend all of the digits affects grasping performance. We studied 24 hemiparetic patients at 3 and 13 wk post stroke. At each visit, we tested the subjects' ability to actively extend all five digits of their contralesional, affected hand against gravity and to perform a grasp movement with the same hand. Three-dimensional motion analysis captured: 1) maximal voluntary extension excursion of each digit and 2) grasp performance variables of movement time, peak aperture, peak aperture rate, and aperture path ratio. We found that finger and thumb extension improved from 3 to 13 wk, with average improvements ranging from 12 to 19 degrees across the five digits. Grasp performance improved on two of the four variables measured. Peak apertures and peak aperture rates improved from 3 to 13 wk, but self-selected movement time and aperture path ratio did not. Stepwise multiple regression models showed that the majority of variance in grasp performance at 13 wk could be predicted by the ability to extend the index or middle finger at 3 wk, plus the change in the ability to extend the index finger from 3 to 13 wk. R2 values ranged from 0.55 to 0.89. Our data indicate that the amount of recovery in finger and thumb extension and grasping is small from 3 to 13 wk post stroke. In people with relatively pure motor hemiparesis, one important factor underlying deficits in hand shaping during grasping is the inability to extend the fingers and thumb. Without sufficient volitional control of finger and thumb extension, successful grasping of objects will not occur.

What is the long-term benefit of constraint-induced movement therapy? A four-year follow-up

Objective: To evaluate the long-term benefits of constraint-induced movement therapy in chronic stroke.

Design: A four-year follow-up after constraint-induced group therapy assessing arm and hand function and self-reported daily hand use.

Subjects: Fourteen post-stroke individuals (six women and eight men; mean age 59.6 ± 12.7 years, range 23—75 years) with mild to moderate impairments of hand function.

Outcome measures: The Sollerman hand function test and the Motor Activity Log test.

Results: Four years after constraint-induced group therapy the participants had maintained their hand function, as measured by the Sollerman hand function test. The self-reported use and quality of movements of the more affected hand, as measured by the Motor Activity Log test, had decreased compared to post-treatment and three months follow-up (P<0.01), but was still significantly higher than pre-treatment (P<0.05).

Conclusion: There seems to be a long-term benefit of constraint-induced group therapy. Hand function was maintained over time and daily hand use had increased compared to pre-treatment. To provide guidelines about the clinical use of constraint-induced movement therapy further, larger and controlled studies are needed.

Modified constraint-induced therapy combined with mental practice: thinking through better motor outcomes

BACKGROUND AND PURPOSE

Modified constraint-induced therapy (mCIT) is an outpatient therapy encouraging repetitive, task-specific practice with the affected arm. mCIT has shown efficacy in all stages poststroke. Given its efficacy when combined with other therapy regimens, the current study examined the efficacy of mental practice when combined with mCIT versus mCIT only using randomized, controlled methods.

METHOD

Ten patients with chronic stroke (7 males; mean age, 61.4+/-3.02 years; age range, 48 to 79 years; mean time since stroke, 28.5 months; range, 13 to 42 months) exhibiting stable, affected arm motor deficits were administered mCIT, consisting of: (1) structured therapy emphasizing affected arm use in functional activities 3 days/week for 10 weeks; and (2) less affected arm restraint 5 days/week for 5 hours. Both of these components were administered during a 10-week period. Subjects randomly assigned to the mCIT+mental practice experimental condition also received 30-minute mental practice sessions provided directly after therapy sessions. These mental practice sessions required daily cognitive rehearsal of the activities of daily living practiced during mCIT clinical sessions.

RESULTS

No pre-existing differences were found between groups on any demographic variable or movement scale. All subjects exhibited marked reductions in affected arm impairment and functional limitation. However, subjects in the mCIT+mental practice group exhibited significantly larger changes on both movement measures after intervention: Action Research Arm Test, +15.4-point change versus +8.4-point change for mCIT only subjects (P<0.001); Fugl-Meyer, +7.8-point change versus +4.1-point change for the mCIT only subjects (P=0.01). These changes were sustained 3 months after intervention.

CONCLUSIONS

mCIT remains a promising motor intervention. However, its efficacy appears to be enhanced by use of mental practice provided directly after mCIT clinical sessions.

Effect of a gravity-compensating orthosis on reaching after stroke: evaluation of the Therapy Assistant WREX

DESIGN

Within-subjects repeated-measures design evaluating reaching with and without the Therapy Assistant Wilmington Robotic Exoskeleton (WREX).

SETTING

Laboratory.

PARTICIPANTS

Stroke survivors (N=10) with chronic upper-extremity hemiparesis.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Arm movement kinematics (Optotrak Certus motion detection system), muscle activity for biceps, triceps, anterior deltoid, and brachioradialis muscles (bipolar surface electromyography).

RESULTS

Significant improvements of reaching distance occurred for all subjects across all targets (P<.001) when using the Therapy Assistant WREX. While the self-selected peak speed of hand movement during the reach decreased significantly with the Therapy Assistant WREX (P<.001), use of the Therapy Assistant WREX led to improved quality of movement as signified by a decrease in jerk (P<.001) and a shift in the timing of the peak speed to an earlier point in the movement (P<.001). Electromyographic muscle activity analysis showed that use of the Therapy Assistant WREX led to a reduction in biceps activity across all targets during the reach (P<.05), in conjunction with a marginally significant reduction in activity of the anterior deltoid (P<.055). No changes were observed in triceps (P=.47) or brachioradialis activity (P=.28).

CONCLUSIONS

By reducing requirements for shoulder activation, the Therapy Assistant WREX improved reaching performance among stroke survivors compared with free reaching, thereby potentially facilitating practice of functional tasks.

Repeat therapy for chronic motor stroke: a pilot study for feasibility and efficacy

BACKGROUND

. Therapeutic interventions improve outcomes in the acute and chronic phase after motor stroke, but a significant amount of this improvement is usually lost after more than 1 year. Patients might profit from a second course of intensive physiotherapy, but this has not been investigated.

OBJECTIVE

. The feasibility and effect of a second phase of physiotherapy was examined 2 years after the first one.

METHODS

. A total of 12 patients with chronic stroke were instructed to wear a constraining splint on the affected elbow and hand while awake for 4 weeks and practice individually tailored tasks 2 hours per day. Motor tests for assessment included the Motor Activity Log, Wolf Motor Function Test, and 9-Hole Peg Test.

RESULTS

. In the 11 patients who were available for postintervention assessment, the deterioration in the amount and quality of movement that had occurred since the first therapy was largely recouped. Patients who wore the constraint more than 80% of waking hours during the second therapy showed a clear secondary improvement in all tests, in some surpassing the level reached after the first therapy.

CONCLUSIONS

. A repeated bout of home-based CIMT 2 years after initial training is feasible with relatively little time and effort provided by a therapist and can lead to further improvement.

Group exercise can improve participants' mobility in an outpatient rehabilitation setting: a randomized controlled trial

Objective: To establish the effects of group exercise on mobility and strength.

Design: Randomized controlled trial.

Setting: Two public hospital outpatient rehabilitation services.

Participants: One hundred and seventy-three people (mean age 74.9 years, SD 10.8) with impaired mobility were randomized and 159 people (92%) completed the trial.

Interventions: Five-week, twice-weekly `circuit-style' group exercise programme run by a physiotherapist (n = 85) and a no-intervention waiting list control group (n = 88).

Main outcome measures: Three aspects of mobility: balance while standing and stepping (Step Test, semi-tandem and tandem stance times); sit-to-stand ability (rate and minimum height) and gait (6-metre and 6-minute walk tests). Lower limb muscle strength (knee flexion and extension).

Results: At retest, exercise participants had improved significantly more than their control counterparts on measures of balance while stepping, sit to stand and gait. Exercise participants averaged 1.6 more steps on the 15-second Step Test (95% confidence interval (CI) 0.5 to 2.8, P=0.005), walked an average of 0.12 m/s faster (95% CI 0.05 to 0.2, P=0.002) and took 2.5 fewer steps in 6 metres (95% CI —4.2 to —0.8, P=0.004). Exercise participants also averaged 0.04 more sit-to-stands/second, (95% CI 0.003 to 0.08, P=0.037) and walked an average of 30.9 metres further in 6 minutes (95% CI 9.4 to 52.4, P=0.005). There were no clinically important or statistically significant between-group differences at retest for the measures of strength (knee extension and flexion), balance while standing or minimal sit-to-stand height.

Conclusion: This short-duration circuit class programme improved mobility, but not strength.

Short- and long-term outcome of constraint-induced movement therapy after stroke: a randomized controlled feasibility trial

Objective: Constraint-induced movement therapy (CIMT) is a method to improve motor function in the upper extremity following stroke. The aim of this trial was to determine the effect and feasibility of CIMT compared with traditional rehabilitation in short and long term.

Design: A randomized controlled trial.

Setting: An inpatient rehabilitation clinic.

Subjects: Thirty patients with unilateral hand impairment after stroke.

Intervention: Six hours arm therapy for 10 consecutive weekdays, while

using a restraining mitten on the unaffected hand.

Main measures: The patients were assessed at baseline, post-treatment and at six-month follow-up using the Wolf Motor Function Test as primary outcome measure and the Motor Activity Log, Functional Independence Measure and Stroke Impact Scale as secondary measurements.

Results: The CIMT group (n=18) showed a statistically significant shorter performance time (4.76 seconds versus 7.61 seconds, P= 0.030) and greater functional ability (3.85 versus 3.47, P= 0.037) than the control group (n=12) on the Wolf Motor Function Test at post-treatment assessment. There was a non-significant trend toward greater amount of use (2.47 versus 1.97, P= 0.097) and better quality of movement (2.45 versus 2.12, P=0.105) in the CIMT group according to the Motor Activity Log. No such differences were seen on Functional Independence Measure at the same time. At six-month follow-up the CIMT group maintained their improvement, but as the control group improved even more, there were no significant differences between the groups on any measurements.

Conclusions: CIMT seems to be an effective and feasible method to improve motor function in the short term, but no long-term effect was found.

Therapy-based rehabilitation services for patients living at home more than one year after stroke

BACKGROUND

Current practice of rehabilitation intervention mainly concentrates on the first six months of stroke. At present, there is no agreed consensus about the benefits of such a service more than one year after stroke.

OBJECTIVES

To ascertain whether therapy-based rehabilitation services can influence outcome one year or more after stroke.

SEARCH STRATEGY

We searched the trials registers of the following Cochrane Review Groups: Stroke Group (last searched September 2007), Effective Practice and Organisation of Care Group (last searched October 2006) and Dementia and Cognitive Improvement Group (last searched October 2006). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2006), MEDLINE (1966 to October 2006), EMBASE (1980 to October 2006), CINAHL (1982 to October 2006), AMED (1985 to October 2006), PEDro (1952 to October 2006), British Nursing Index (1993 to October 2006), DARE (1994 to October 2006), HMIC (1979 to October 2006) and NHS EED (1991 to October 2006). We also searched dissertation databases and ongoing trials and research registers, scanned reference lists and contacted researchers and experts in the field.

SELECTION CRITERIA

All randomised controlled trials of community-based stroke patients, in which at least 75% were recruited one year after stroke and received a therapy-based rehabilitation intervention that was compared with conventional care.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials and extracted data on a number of pre-specified outcomes. The primary outcomes were the proportion of participants who had deteriorated or were dependent in personal activities of daily living at the end of scheduled follow up.

MAIN RESULTS

We identified five trials of 487 participants that were eligible for the review. Overall, there was inconclusive evidence as to whether therapy-based rehabilitation intervention one year after stroke was able to influence any relevant patient or carer outcome. Trials varied in design, type of interventions provided, quality, and outcomes assessed.

AUTHORS' CONCLUSIONS

This review highlights the dearth of evidence investigating long-term therapy-based rehabilitation interventions for patients with stroke.

A four-week, task-specific neuroprosthesis program for a person with no active wrist or finger movement because of chronic stroke

BACKGROUND AND PURPOSE

This case report describes a task-specific training protocol incorporating functional electrical stimulation for a person who had chronic stroke and who initially exhibited no active wrist or finger movement.

CASE DESCRIPTION

A 63-year-old man with hemiparesis caused by an ischemic stroke 7 years before the intervention described here received task-specific training incorporating an electrical stimulation neuroprosthesis 3 hours per day, 5 days per week, for 4 weeks. Testing was conducted before and after the intervention and again 6 weeks later with stroke-specific outcome measures.

OUTCOMES

Increases in function and quality of life were observed after the intervention.

DISCUSSION

An intervention incorporating task-specific training with functional electrical stimulation appears to have increased function and quality of life in a person with chronic stroke. This type of intervention might provide a pathway by which people with similar impairments would become eligible for more advanced treatment regimens, such as modified constraint-induced therapy.

Modified constraint-induced therapy in chronic stroke: results of a single-blinded randomized controlled trial

BACKGROUND AND PURPOSE

This single-blinded randomized controlled trial compared the efficacy of a reimbursable, outpatient, modified constraint-induced therapy (mCIT) protocol (half-hour therapy sessions occurring 3 days per week in which subjects used the more affected arm combined with less affected arm restriction 5 days per week for 5 hours; both of these regimens were administered during a 10-week period) with that of a time-matched exercise program for the more affected arm or a no-treatment control regimen.

SUBJECTS

Thirty-five subjects with chronic stroke participated in the study.

METHODS

The Action Research Arm Test (ARAT), Fugl-Meyer Assessment of Motor Recovery After Stroke (FM), and Motor Activity Log (MAL) were administered to the subjects.

RESULTS

After intervention, significant differences were observed on the ARAT and MAL Amount of Use and Quality of Movement scales, all in favor of the mCIT group.

DISCUSSION AND CONCLUSION

The data affirm previous findings suggesting that this reimbursable, outpatient protocol increases more affected arm use and function. Magnitude of changes was consistent with those reported in more intense protocols, such as constraint-induced therapy.

A study of constraint-induced movement therapy in subacute stroke patients in Hong Kong

Objective: To investigate the beneficial effect of constraint-induced movement therapy in improving the function of hemiplegic upper extremity in the early subacute stroke patients.

Design: A prospective, single-blinded, randomized controlled study comparing the effectiveness of constraint-induced movement therapy or control treatment at post intervention and 12 weeks follow-up.

Subjects: The inclusion criteria were 2—16 weeks after stroke, hemiparesis of the affected limb, minimal function of ≥20 degrees wrist extension and ≥10 degrees extension of all digits and Mini-Mental State Examination score ≥17.

Interventions: The intervention group underwent a programme of 10 days upper extremity training (4 hours per day) with the unaffected limb being restrained in

a shoulder sling and the control group received an equivalent duration of conventional rehabilitation therapy.

Main measures: Functional level for hemiparetic upper extremity, Motor Activity Log, Action Research Arm Test and modified Barthel Index.

Results: There were 23 and 20 subjects respectively in the constraint-induced movement therapy and control groups. Significant improvements were seen at post intervention and 12 weeks after constraint-induced movement therapy in functional level for hemiparetic upper extremity (P= 0.001), and in the `amount of use' (P= 0.001) and `how well' (P= 0.021) subscales of the Motor Activity Log. The total Action Research Arm Test score, grasp (P= 0.004), grip (P= 0.004), pinch (P= 0.032) and gross (P= 0.006) components showed significant improvement over the control group at post intervention. The grip component (P=0.019) and the total Action Research Arm Test score (P= 0.009) were superior to the control group at 12 weeks.

Conclusion: Significant improvement in hand function could be achieved with constraint-induced movement therapy in subacute stroke patients, which was maintained up to 12 week follow-up.

Six hours in the laboratory: a quantification of practice time during constraint-induced therapy (CIT)

OBJECTIVE

To quantify supervised in-laboratory time and practice intensity during the signature protocol specified as 6 hours/day over 10 days for the EXtremity Constraint-Induced Therapy Evaluation (EXCITE) randomized clinical trial.

DESIGN

Retrospective analysis of constraint-induced movement therapy training documentation acquired at the University of Southern California site from EXCITE (n = 38). Training documentation was reviewed and analysed to determine average and between-subject variability of supervised in-laboratory time and actual task-specific practice time for concurrence with the specified constraint-induced movement therapy protocol.

SETTING

Motor Behavior and Neurorehabilitation Laboratory, Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA.

SUBJECTS

Data from 38 participants (35 met inclusion criteria) who, upon enrolment in the EXCITE trial, were between 3 and 10 months post stroke and between 47 and 81 years of age.

RESULTS

The training records revealed an average of 64 hours (SD = 2.6) supervised in-laboratory time for 35 participants across 10 days of training. More importantly, the average time on task-specific practice was 3.95 hours per day (SD = 5.7) representing 62% of the in-laboratory time. Supervised in-laboratory time for10 training days was consistent across the sample as was total practice time for days 2-10, with a substantially lower practice time on the initial training day.

CONCLUSIONS

Participants tolerated an intense task-specific practice schedule that consisted of approximately two-thirds of the specified minimum 6 hour in-laboratory time and was distributed evenly between adaptive task practice (shaping) and task practice components.

Constraint-induced movement therapy for a child with hemiparesis: a case report

This case report describes the outcomes of a method of constraint-induced movement therapy (CIMT) incorporated into a home program using a minimally restrictive constraint over an 18-month period. The movement of the uninvolved hand and wrist of a 13-month-old child with hemiparesis was constrained with a soft removable mitt. Caregivers performed CIMT in 2 intense periods and weaning periods, and a home exercise period. Two independent raters performed video analysis of the quantity and quality of upper extremity. All measures showed improvement. Reaches with the involved upper extremity increased from 8.9% to 41.0%. Use of advanced grasp patterns increased from 3.3% to 76.1%. Successful release of objects improved from 0% to 73.0%. Caregivers reported functional improvements and strong positive feedback regarding success, ease, and satisfaction with CIMT. This case demonstrates positive outcomes using a clinically feasible method of CIMT with far reaching implications on function.

The stroke rehabilitation paradigm

The matrix of stroke rehabilitation is evolving as we look outside the box of traditional therapy type, timing, and intensity of rehabilitation techniques. For inpatient wards, the goal of medical stability and prompt resolution of complications to maximize participation in therapy remains paramount. In the current medical model, we focus on teaching compensatory strategies and rarely on restorative approaches because of time and financial limitations. Researchers aim to identify new technologic and molecular approaches to improve functional outcomes and more accurately predict disability. This article examines different concepts surrounding the comprehensive rehabilitation paradigm of stroke survivors.

Revisiting constraint-induced movement therapy: are we too smitten with the mitten? Is all nonuse "learned"? and other quandaries

Constraint-induced movement therapy (CIMT) has gained considerable popularity as a valuable treatment for a hemiparetic upper extremity. This approach is compatible with the emerging notion that task-oriented or functionally oriented retraining of the impaired limb provides evidence to support its utility. This article first provides a historical perspective on the development of CIMT. An overview model of how learned nonuse of the hemiparetic limb occurs and can be overcome with CIMT is discussed, and then a more detailed model that incorporates critical issues requiring considerably more basic and applied scientific exploration is described. Among the issues considered are the extent to which hemiparetic limb nonuse and subsequent modes of delivery to overcome it are governed by structure-function deficits rather than being attributable primarily to behavioral phenomena; the relative importance of the intensity of training; the need to better balance unimanual and bimanual upper-extremity task practice; the role of psychosocial and cultural factors in fostering patient compliance; the optimization of modes of delivery; and the reevaluation of the constellation of components contributing to successful outcomes with this treatment. Finally, the strengths, uncertainties, and limitations associated with CIMT are examined.

Modified constraint-induced therapy extension: using remote technologies to improve function

OBJECTIVE

To determine efficacy of a modified constraint-induced therapy extension (mCITE) protocol, in which persons with stroke participated in therapy sessions via the Internet.

DESIGN

Pre-post, single-blinded case series.

SETTING

Outpatient clinic.

PARTICIPANTS

Four people with stroke who experienced stroke more than 1 year prior to study entry exhibiting upper-limb hemiparesis and nonuse.

INTERVENTION

Subjects participated in online, 30-minute therapy sessions, 3 times a week for 10 weeks using personal computer-based cameras and free network meeting software. During the same period, subjects' less affected hands and wrists were restrained every weekday for 5 hours. Patients completed online logs to document restraint use and activities practiced at home.

MAIN OUTCOME MEASURES

The Motor Activity Log (MAL) and Wolf Motor Function Test (WMFT). We also used a structured interview to ask patients about their satisfaction with the protocol.

RESULTS

After intervention, subjects exhibited marked improvements in more affected arm use (+2.7, +2.06, +1.7, +2,83, respectively), quality of movement (+2.1, +2.1, +2.03, +1.9, respectively), as measured by the MAL, and speed increases while performing WMFT tasks. Subjects' mCITE satisfaction and adherence were high, and motor changes translated to ability to perform valued activities.

CONCLUSIONS

A home-based, modified constraint-induced movement therapy program is feasible and appears to increase more affected arm use and function using commercially available, inexpensive technologies.

Kinematic and Clinical Analyses of Upper-Extremity Movements After Constraint-Induced Movement Therapy in Patients With Stroke: A Randomized Controlled Trial

OBJECTIVE

To study the effects of constraint-induced movement therapy (CIMT) relative to traditional intervention on motor-control strategies for upper-arm reaching and motor performance at the impairment and functional levels in stroke patients.

DESIGN

Two-group randomized controlled trial (RCT); pretreatment and posttreatment measures.

SETTING

Rehabilitation clinics.

PARTICIPANTS

Forty-seven stroke patients (mean age, 55y) 3 weeks to 37 months postonset of a first-ever cerebrovascular accident.

INTERVENTIONS

Forty-seven patients received either CIMT (restraint of the less affected hand combined with intensive training of the more affected upper extremity) or traditional intervention (control treatment) during the study. The treatment intensity was matched between the 2 groups (2h/d, 5d/wk for 3wk).

MAIN OUTCOME MEASURES

Outcomes were evaluated using (1) kinematic variables of reaching movement used to describe the control strategies for reaching, (2) the Fugl-Meyer Assessment (FMA) of motor-impairment severity, and (3) the Motor Activity Log (MAL) evaluating the functional ability of the upper extremity.

RESULTS

After treatment, the CIMT group showed better strategies of reaching control than the control group (P<.03). The CIMT group also showed less motor impairment on the FMA (P=.019) and higher functional ability on the MAL (P<.001).

CONCLUSIONS

This study is the first RCT to show differences in motor-control strategies as measured by kinematic variables after CIMT versus traditional intervention. In addition to improving motor performance at the impairment and functional levels, CIMT conferred therapeutic benefits on control strategies determined by kinematic analysis.

Modified constraint-induced therapy in patients with chronic stroke exhibiting minimal movement ability in the affected arm

BACKGROUND AND PURPOSE

The purpose of this study was to determine the efficacy of a reimbursable, outpatient modified constraint-induced therapy (mCIT) protocol administered to subjects with chronic stroke who initially exhibited minimal movement ability in their affected wrists and fingers.

SUBJECTS

The subjects were 4 individuals who had experienced a stroke more than 1 year prior to study entry (mean age [+/-SD]=60.25+/-1.98 years, mean time since stroke=37.5+/-23.2 months).

METHOD

A multiple-baseline, preintervention-postintervention, single-blinded case series design was used. The intervention consisted of structured, 1/2-hour therapy sessions emphasizing affected arm use in valued activities, occurring 3 times per week for 10 weeks. Subjects' less affected arms also were restrained 5 days per week for 5 hours per day during the same 10-week period. The main outcome measures were the Action Research Arm Test (ARAT), the Motor Activity Log (MAL), and the Fugl-Meyer Assessment of Motor Recovery (FM).

RESULTS

The subjects exhibited improvements in use of the more affected arm (+1.9, +1.8, +1.7, and +2.3 for subjects 1 through 4, respectively) and in quality of movement (+1.5, +2.1, +1.63, and +1.9 for subjects 1 through 4, respectively), as measured by the MAL. They also exhibited reduced impairment, as measured by the FM (+5.0, +6.5, +5.5, and +5.0 for subjects 1 through 4, respectively), and increased fine motor skill movement, as measured by the ARAT (+7.5, +7.0, +7.0, and +5.5 for subjects 1 through 4, respectively).

DISCUSSION AND CONCLUSION

The findings demonstrated that mCIT participation was efficacious because it led to increased use of the affected arm and of function and to increased ability to perform valued activities. The subjects reported some new ability to perform some valued activities. These outcomes are significant because few therapies are believed to effectively increase use of the affected arm and function in this population.

Limited dose response to constraint-induced movement therapy in patients with chronic stroke

OBJECTIVE

To compare outcomes in motor skill, perceived amount of use and ability of the paretic arm in daily activities between traditional Constraint-Induced Movement Therapy, consisting of 6 hours of in-clinic, therapist-guided task practice, and a shortened Constraint-Induced Movement Therapy, consisting of 1 hour of in clinic, therapist-guided task practice coupled with 5 hours of unsupervised practice at home.

DESIGN

A secondary analysis of two previous randomized, controlled, double-blind, parallel group studies.

SETTING

A research clinic.

PARTICIPANTS

Thirty-nine individuals with hemiparesis from a chronic unilateral stroke who were able to extend the wrist 10 degrees and the fingers and thumb 10 degrees from a flexed position and were participants in one of the two studies examining the efficacy of adding neuroplasticity adjuvants to Constraint-Induced Movement Therapy.

MAIN OUTCOME MEASURES

The Wolf Motor Function Test was used to assess motor skill and the Motor Activity Log amount of use and quality of movement scales were used to assess perceived amount of use and ability respectively.

INTERVENTIONS

Constraint-Induced Movement Therapy plus donepezil in the CIMT-6 study (the traditional 6 hours of in-clinic task practice) and Constraint-Induced Movement Therapy plus repetitive transcranial magnetic stimulation in the CIMT-1 study (1 hour of in-clinic task practice).

RESULTS

Motor skill gains after two weeks of therapy were equivalent for both groups (n=39; mean difference=2.81, P>0.22), but gains were not maintained six months later with either intervention protocol. Despite this, participants in the CIMT-6 group reported greater use (mean difference=1.52, P<0.001) and movement quality (mean difference=0.95, P<0.004) than those with less therapist-guided practice. Both groups had regressed somewhat in use and ability at the six-month follow-up.

CONCLUSION

These results suggest that 6 hours of therapist-guided practice may not be necessary to facilitate motor skill gains, but may influence patterns of use.

Reliability of intracortical and corticomotor excitability estimates obtained from the upper extremities in chronic stroke

We estimated the trial-to-trial variability and the test-retest reliability of several intracortical and corticomotor excitability parameters for the upper extremity in chronic stroke patients. Nine patients with hemiparesis of the upper extremity were enrolled 8-17 months after a unilateral stroke. Transcranial magnetic stimulation was used to obtain repeated measures over a two week interval of motor evoked potential (MEP) recruitment curves and cortical silent periods in the first dorsal interosseus muscle of each hand. Five trials would have provided accurate estimates of the MEP amplitude and silent period duration for the unlesioned side in all patients, but 25% of the datasets from the lesioned side provided poor estimates of MEP amplitude even with 10 trials. Intraclass correlations were >0.70 for all parameters obtained from the lesioned side and for the MEP amplitude, slope of the recruitment curve, silent period, and silent period slope from the unlesioned side. MEP amplitude varied across sessions within subject by 20% on both sides, whereas other parameters showed less variability on the unlesioned side relative to the lesioned side. The Fugl-Meyer upper extremity motor score and the time to complete the 6 fine-motor items from the Wolf Motor Function Test (WMFT) were also found to be highly reliable over this interval. We conclude that the functional and most of the excitability parameters are reliable across time in patients with variable lesions due to stroke. Due to high intrasubject variability, the use of some excitability parameters as indicators of functional neuroplasticity in response to treatment may be limited to interventions with large effect sizes.

Cerebral palsy: new approaches to therapy

Cerebral palsy is the most common developmental disorder causing a physical disability arising from an injury to the central nervous system. The majority of pediatric neurologists remain minimally involved in the rehabilitation of these children. Recent advances in basic and clinical neuroscience give hope that effective rehabilitation strategies, based on motor learning science, can be developed for these children. The aim of this review is to alert pediatric neurologists to these advances.

Using Kinematic Analysis to Evaluate Constraint-Induced Movement Therapy in Chronic Stroke Patients

Objective. This preliminary study aims to verify if the method of kinematic analysis proposed here may be suitable for evaluating the effects of constraint-induced movement therapy (CIMT) in chronic stroke patients and may be of help in the study of the mechanisms underlying functional improvement following CIMT. Methods. Clinical and kinematic data were collected from a group of chronic stroke patients and from an age-matched healthy control group. Affected and less affected upper-limb kinematics related to hand-to-mouth and reaching movements were acquired before and immediately after 2 weeks of CIMT. Healthy subjects were submitted to kinematic analysis of the nondominant side and reevaluated after 2 weeks. Results. The clinical results were consistent with those reported in the literature and showed motor function improvement of the hemiparetic limb after CIMT. Kinematic data of the healthy control group showed high test-retest reliability. Statistically significant differences between the affected limb and both the less affected limb and the healthy subjects' nondominant limb were observed. After CIMT, kinematic data showed improvement in the speed of movement and in measures related to the capacity for coordination. Conclusions. The method of kinematic analysis was sensitive for an assessment of motor recovery induced by CIMT. The kinematic results suggest that the increase in the use of the paretic limb in activities of daily living after the intervention is not only attributable to the patient's increased attention to it and better hand dexterity, but it is also a consequence of the improved speed of movement and better coordination between shoulder and elbow joints.

Quantifying kinematics of purposeful movements to real, imagined, or absent functional objects: implications for modelling trajectories for robot-assisted ADL tasks

BACKGROUND

Robotic therapy is at the forefront of stroke rehabilitation. The Activities of Daily Living Exercise Robot (ADLER) was developed to improve carryover of gains after training by combining the benefits of Activities of Daily Living (ADL) training (motivation and functional task practice with real objects), with the benefits of robot mediated therapy (repeatability and reliability). In combining these two therapy techniques, we seek to develop a new model for trajectory generation that will support functional movements to real objects during robot training. We studied natural movements to real objects and report on how initial reaching movements are affected by real objects and how these movements deviate from the straight line paths predicted by the minimum jerk model, typically used to generate trajectories in robot training environments. We highlight key issues that to be considered in modelling natural trajectories.

METHODS

Movement data was collected as eight normal subjects completed ADLs such as drinking and eating. Three conditions were considered: object absent, imagined, and present. This data was compared to predicted trajectories generated from implementing the minimum jerk model. The deviations in both the plane of the table (XY) and the sagittal plane of torso (XZ) were examined for both reaches to a cup and to a spoon. Velocity profiles and curvature were also quantified for all trajectories.

RESULTS

We hypothesized that movements performed with functional task constraints and objects would deviate from the minimum jerk trajectory model more than those performed under imaginary or object absent conditions. Trajectory deviations from the predicted minimum jerk model for these reaches were shown to depend on three variables: object presence, object orientation, and plane of movement. When subjects completed the cup reach their movements were more curved than for the spoon reach. The object present condition for the cup reach showed more curvature than in the object imagined and absent conditions. Curvature in the XZ plane of movement was greater than curvature in the XY plane for all movements.

CONCLUSION

The implemented minimum jerk trajectory model was not adequate for generating functional trajectories for these ADLs. The deviations caused by object affordance and functional task constraints must be accounted for in order to allow subjects to perform functional task training in robotic therapy environments. The major differences that we have highlighted include trajectory dependence on: object presence, object orientation, and the plane of movement. With the ability to practice ADLs on the ADLER environment we hope to provide patients with a therapy paradigm that will produce optimal results and recovery.

Influence of Combined Afferent Stimulation and Task-Specific Training Following Stroke: A Pilot Randomized Controlled Trial

Background. Reorganization of the human motor cortex can be induced by specific patterns of peripheral afferent stimulation. The potential for afferent stimulation to facilitate the functional recovery associated with conventional rehabilitative techniques has not previously been investigated. Objective. The authors sought to determine whether combining appropriate afferent stimulation with task-specific training resulted in greater improvements than training alone in patients with impaired upper limb function in the subacute phase following stroke. Method. Twenty patients with hemiparesis due to stroke were allocated randomly to either a stimulation or control group. All received 9 sessions of task-specific physiotherapy training over 3 weeks. Prior to each training session, associative electrical stimulation of the motor point of 2 hand muscles was given in the stimulation group, whereas the control group received sham stimulation. Changes in dexterity were assessed using a grip-lift task, and standard measures of upper-limb function were made before and following the intervention. Corticospinal excitability was examined using transcranial magnetic stimulation. Results. Both groups showed comparable improvements in functional measures of upper-limb function. Of the 20 patients, only 14 could perform the grip-lift task, which is an objective measure of dexterity. Patients in the stimulation group From the Research Centre for Human Movement Control, School of exhibited significantly greater improvements in this task than the control group. There was no significant change in corticospinal excitability in either group. Conclusion. This pilot study provides preliminary data suggesting that targeted afferent stimulation may facilitate the response to conventional rehabilitation in patients with hemiparesis due to stroke, but these results need to be confirmed in a larger scale study.

Confounders in rehabilitation trials of task-oriented training: lessons from the designs of the EXCITE and SCILT multicenter trials

Two multicenter randomized clinical trials (MRCT), the Extremity Constraint Induced Therapy Evaluation (EXCITE) to improve upper extremity function after stroke and the Spinal Cord Injury Locomotor Trial (SCILT) to enable functional walking after incomplete spinal cord injury, demonstrate that complex, task-oriented physical therapies can be studied using a scientific methodology during inpatient or outpatient rehabilitation. In the past, a new therapy's benefit may have been overestimated by comparing it to no treatment or to a conventional treatment at a low intensity of practice. Sample sizes were often too small and may have failed to detect the efficacy of a new intervention. In addition, whereas statistical significance in outcomes has been critical to understanding whether one treatment is better than another, the clinical significance of outcomes must also impact the interpretation of the results of a trial. MRCT designs will continue to improve through attention to the limitations of preclinical animal models that offer a conceptual basis for the treatment, [corrected] from enrichment strategies at every phase of trial development, [corrected] from more vigorous dose-response studies using adaptive methods, [corrected] by capturing interim measures of behavior and functional neurophysiologic adaptations during the treatment phase, [corrected] by aiming for a clinically meaningful control intervention, [corrected] and by including ratio or interval outcome measures when feasible that capture a target of the intervention in relation to gains in daily functioning and quality of life.

Functional Electrical Stimulation Enhancement of Upper Extremity Functional Recovery During Stroke Rehabilitation: A Pilot Study

Objective. To test if functional electrical stimulation (FES) can enhance the recovery of upper extremity function during early stroke rehabilitation. Methods. Open-label block-randomized trial, begun during inpatient rehabilitation and continued at the patients' home. Patients were assigned to either FES combined with task-specific upper extremity rehabilitation (n = 7) or a control group that received task-specific therapy alone (n = 8) over 12 weeks. Outcome measures . Hand function (Box & Blocks, B&B; Jebsen-Taylor light object lift, J-T) and motor control (modified Fugl-Meyer, mF-M) were video-recorded for both upper extremities at baseline, 4, 8, and 12 weeks. Results. B&B mean score at 12 weeks favored ( P = .049) the FES group (42.3 ± 16.6 blocks) over the control group (26.3 ± 11.0 blocks). The FES group J-T task was 6.7 ± 2.9 seconds and faster ( P = .049) than the 11.8 ± 5.4 seconds of the control group. Mean mF-M score of the FES group at 12 weeks was 49.3 ± 5.1 points out of 54, compared to the control group that scored 40.6 ± 8.2 points ( P = .042). All patients regained hand function. Conclusion. Upper extremity task-oriented training that begins soon after stroke that incorporates FES may improve upper extremity functional use in patients with mild/moderate paresis more than task-oriented training without FES.

Progress in clinical neurosciences: stroke recovery and rehabilitation

BACKGROUND

Recent literature has provided new insights into the role of rehabilitation in neurological recovery post-stroke. The present review combines results of animal and clinical research to provide a summary of published information regarding the mechanisms of neural recovery and impact of rehabilitation.

METHODS

Plasticity of the uninjured and post-stroke brain is examined to provide a background for the examination of brain reorganization and recovery following stroke.

SUMMARY AND CONCLUSIONS

Recent research has confirmed many of the basic underpinnings of rehabilitation and provided new insight into the role of rehabilitation in neurological recovery. Recovery post stroke is dependent upon cortical reorganization, and therefore, upon the presence of intact cortex, especially in areas adjacent to the infarct. Exposure to stimulating and complex environments and involvement in tasks or activities that are meaningful to the individual with stroke serves to increase cortical reorganization and enhance functional recovery. Additional factors associated with neurological recovery include size of stroke lesion, and the timing and intensity of therapy.

Activity-based therapies

Therapeutic activity is a mainstay of clinical neurorehabilitation, but is typically unstructured and directed at compensation rather than restoration of central nervous system function. Newer activity-based therapies (ABTs) are in early stages of development and testing. The ABTs attempt to restore function via standardized therapeutic activity based on principles of experimental psychology, exercise physiology, and neuroscience. Three of the best developed ABTs are constraint-induced therapy, robotic therapy directed at the hemiplegic arm, and treadmill training techniques aimed at improving gait in persons with stroke and spinal cord injury. These treatments appear effective in improving arm function and gait, but they have not yet been clearly demonstrated to be more effective than equal amounts of traditional techniques. Resistance training is clearly demonstrated to improve strength in persons with stroke and brain injury, and most studies show that it does not increase hypertonia. Clinical trials of ABTs face several methodological challenges. These challenges include defining dosage, standardizing treatment parameters across subjects and within treatment sessions, and determining what constitutes clinically significant treatment effects. The long-term goal is to develop prescriptive ABT, where specific activities are proven to treat specific motor system disorders. Activity-based therapies are not a cure, but are likely to play an important role in future treatment cocktails for stroke and spinal cord injury.

A pilot study of use-dependent learning in the context of Constraint Induced Language Therapy

This investigation reports the results of a pilot study concerning the application of principles of use-dependent learning developed in the motor rehabilitation literature as Constraint Induced Therapy to language rehabilitation in a group of individuals with chronic aphasia. We compared treatment that required forced use of the language modality, Constraint Induced Language Therapy, (CILT) to treatment allowing all modes of communication. Both treatments were administrated intensively in a massed practice paradigm, using the same therapeutic stimuli and tasks. Results suggest that whereas both interventions yielded positive outcomes, CILT participants showed more consistent improvement on standard aphasia measures and clinician judgments of narrative discourse. These findings suggest that CILT intervention may be a viable approach to aphasia rehabilitation.

Application of combined botulinum toxin type A and modified constraint-induced movement therapy for an individual with chronic upper-extremity spasticity after stroke

BACKGROUND AND PURPOSE

Constraint-induced movement therapy (CIMT) is a promising intervention for retraining upper-extremity function after a stroke. The purpose of this case report is to describe the use of a combination of botulinum toxin type A (BtxA) and a modified CIMT program for a patient with severe spasticity who was unable to use his right upper extremity.

CASE DESCRIPTION

The 52-year-old patient, who had a stroke 4 years ago, did not meet the minimum motor criteria for CIMT benefit. After receiving BtxA injections targeting the elbow, wrist, and finger flexors, he completed a 4-week program of modified CIMT followed by a 5-month home exercise program.

OUTCOMES

The patient exhibited improvement in muscle tone (the velocity-dependent resistance to stretch that muscle exhibits) and in scores on several upper-extremity function tests (Modified Ashworth Scale, Motor Activity Log, Wolf Motor Function Test, Action Research Arm Test, and Fugl-Meyer Assessment of Motor Recovery). He also reported making much progress in the functional use of the involved upper extremity.

DISCUSSION

In a patient with severe flexor spasticity and nonuse of the dominant upper extremity after a stroke, a combined treatment of BtxA and modified CIMT may have resulted in improved upper-extremity use.