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

Motor cortex excitability in stroke before and after constraint-induced movement therapy

OBJECTIVE

To investigate motor cortex excitability in stroke patients and explore excitability changes induced by an intense physiotherapy.

METHODS

We studied 12 chronic stroke patients (6 cortical, 6 subcortical lesions) before and after participation in 12 days of constraint-induced movement therapy. Transcranial magnetic stimulation was applied to test intracortical inhibition (ICI), intracortical facilitation, silent periods, amplitudes of motor evoked potentials, and motor thresholds. Motor function was assessed by the Motor Activity Log, the Wolf Motor Function Test, and the Modified Ashworth Scale for spasticity.

RESULTS

Motor evoked potential amplitudes and motor thresholds were inversely correlated, indicating that both parameters reflect the function of corticospinal pathways. Before therapy, a motor cortex disinhibition was found in the affected hemisphere. This disinhibition was stronger in patients with cortical lesions. The amount of disinhibition was correlated with the degree of spasticity. After therapy, ICI changes were more pronounced in the affected hemisphere compared with the unaffected side. Both ICI decreases and increases were observed. Motor function tests indicated an improvement in all patients.

CONCLUSIONS

Motor cortical disinhibition is present in chronic stroke patients. Therapy-associated changes of motor cortex excitability mainly occur in the lesioned hemisphere by up-regulation or down-regulation of ICI. We replicate that constraint-induced movement therapy improves motor functions in the chronic stage after stroke.

Constraint-based Therapies as a Proposed Model for Cognitive Rehabilitation

This article proposes that constraint-induced therapy represents a theoretical model of rehabilitation emerging from basic research with implications for cognitive remediation attempts. It provides an overview of current work on constraint-induced therapies with a focus on the most widely used of these techniques, constraint-induced movement therapy (CIMT). An example from recent research in the cognitive sciences demonstrates how underlying principles of the CIMT could be used to guide rehabilitative efforts for cognitive dysfunction. Limitations and obstacles of applying such an approach are discussed.

A community-based upper-extremity group exercise program improves motor function and performance of functional activities in chronic stroke: a randomized controlled trial

OBJECTIVE

To assess the effects of a community-based exercise program on motor recovery and functional abilities of the paretic upper extremity in persons with chronic stroke.

DESIGN

Randomized controlled trial.

SETTING

Rehabilitation research laboratory and a community hall.

PARTICIPANTS

A sample of 63 people (> or =50y) with chronic deficits resulting from stroke (onset > or =1y).

INTERVENTIONS

The arm group underwent an exercise program designed to improve upper-extremity function (1h/session, 3 sessions/wk for 19wk). The leg group underwent a lower-extremity exercise program.

MAIN OUTCOME MEASURES

The Wolf Motor Function Test (WMFT), Fugl-Meyer Assessment (FMA), hand-held dynamometry (grip strength), and the Motor Activity Log.

RESULTS

Multivariate analysis showed a significant group by time interaction (Wilks lambda=.726, P=.017), indicating that overall, the arm group had significantly more improvement than the leg group. Post hoc analysis demonstrated that gains in WMFT (functional ability) (P=.001) and FMA (P=.001) scores were significantly higher in the arm group. The amount of improvement was comparable to other novel treatment approaches such as constraint-induced movement therapy or robot-aided exercise training previously reported in chronic stroke. Participants with moderate arm impairment benefited more from the program.

CONCLUSIONS

The pilot study showed that a community-based exercise program can improve upper-extremity function in persons with chronic stroke. This outcome justifies a larger clinical trial to further assess efficacy and cost effectiveness.

Opening the black box of post-stroke rehabilitation: stroke rehabilitation patients, processes, and outcomes

DeJong G, Horn SD, Conroy B, Nichols D, Healton EB. Opening the black box of post-stroke rehabilitation: stroke rehabilitation patients, processes, and outcomes. This article introduces the journal's supplement devoted to the methods and findings of the 7-site Post-Stroke Rehabilitation Outcomes Project (PSROP), a study designed to provide a very granular in-depth understanding of stroke rehabilitation practice and how practice is related to outcomes. The article summarizes current knowledge about the effectiveness of post-stroke rehabilitation, outlines where the PSROP fits into the broader traditions of stroke rehabilitation outcomes research, underscores the study's methodologic innovations, and summarizes the scope of the articles that follow.

Home-based electromyography-triggered stimulation in chronic stroke

OBJECTIVES

(1) To determine the feasibility of a home-based electromyography-triggered neuromuscular stimulation (ETMS) programme; and (2) to determine ETMS efficacy in increasing affected wrist extension and reducing affected arm impairment.

DESIGN

Randomized, controlled, pre-post, cross-over design.

SETTING

Outpatient rehabilitation hospital.

PATIENTS

Twelve chronic stroke patients with palpable muscle contraction in their affected wrist extensors but no movement (7 males; mean age = 59.75 years, age range 44-75 years; mean time since stroke = 52.75 months, range 13-131 months).

INTERVENTION

Subjects were randomly assigned to receive either: (a) ETMS use twice every weekday in 35-min increments during an eight-week period followed by an eight-week home exercise programme (ETMS/home exercise programme) (n=8); or (b) an eight-week home exercise programme followed by use of ETMS twice every weekday in 35-min increments during an eight-week period (home exercise programme) (n=4).

MAIN OUTCOME MEASURES

The Fugl-Meyer, Action Research Arm Test and goniometry.

RESULTS

After home exercise programme participation, subjects showed nominal or no changes on any of the outcome measures. After ETMS, patients showed modest impairment reductions, as shown by the Fugl-Meyer, and no Action Research Arm Test changes. However, both groups showed a 21 degree increase in active affected wrist extension after ETMS use.

CONCLUSION

ETMS use is feasible in the home environment. Neither participation in a traditional home exercise programme nor ETMS use conveyed changes on the Fugl-Meyer or Action Research Arm Test. However, ETMS use increased active affected limb extension. This new movement may provide a potential pathway for subjects to participate in other interventions, such as modified constraint induced therapy.

The effectiveness of constraint-induced therapy as a stroke intervention: a meta-analysis

Stroke is one of the most disabling conditions affecting adults today. Much research has been performed on rehabilitation interventions targeting hemiparesis after stroke. Constraint-induced therapy is a treatment technique that focuses on restraining the unaffected upper extremity while forcing use of the affected extremity to promote purposeful movement. This study presents a meta-analysis of applicable current literature on this treatment approach. It is concluded that constraint-induced therapy may be an effective treatment option for hemiparesis experienced after stroke.

Back From the Brink: Electromyography-Triggered Stimulation Combined With Modified Constraint-Induced Movement Therapy in Chronic Stroke

OBJECTIVE

To determine the efficacy of a regimen that combines electromyography-triggered neuromuscular stimulation (ETMS) with modified constraint-induced movement therapy (mCIMT) in patients with chronic stroke.

DESIGN

Pre-post, case series.

SETTING

Outpatient rehabilitation hospital.

PARTICIPANTS

Six subjects who had had a stroke more [corrected] than 1 year before the study and who had upper-limb hemiparesis. All subjects were only able to activate the affected wrist extensors.

INTERVENTION

Subjects underwent ETMS twice every weekday in 35-minute increments during an 8-week period. One week after they completed the ETMS regimen, and after the outcome measures were readministered, subjects participated in mCIMT, which consisted of structured therapy sessions that emphasized use of the more affected arm in valued activities. The sessions were held 3 times a week for 10 weeks. The less affected arms were also restrained 5 days a week for 5 hours.

MAIN OUTCOME MEASURES

The Fugl-Meyer Assessment (FMA) of motor recovery, Action Research Arm Test (ARAT), and goniometry.

RESULTS

Subjects had nominal changes on the ARAT (mean change, 0.3), and no functional changes after ETMS. However, they had a mean increase of 21.5 degrees in affected wrist extension and an improved ability to perform the wrist items of the FMA (reflected by a mean increase of 4.1 points on the FMA), which qualified them for mCIMT. After mCIMT, subjects had a 15.5-point change on the FMA, an 11.4-point change on the ARAT, and a new ability to perform valued activities.

CONCLUSIONS

ETMS alone does not result in functional changes. However, it may elicit sufficient active affected wrist and finger extension increases to permit possible participation in mCIMT, which can result in marked functional gains. This study is among the first to show improved function in stroke patients who initially had little hand motor control, and it is among the first to effectively combine 2 singularly efficacious regimens.

Individual factors in constraint-induced movement therapy after stroke

OBJECTIVES

Constraint-induced movement therapy (CIMT) has been shown to be effective in chronic stroke patients. It is worthwhile to investigate the influence of individual factors for two reasons: to find out whether they influence outcome and to see whether they support the theory underlying CIMT.

METHODS

A group of 26 patients were treated with CIMT and followed over 6 months. In total, 14 individual factors were identified. Patients were assessed with 6 tests, including 2 commonly used after stroke (Frenchay Arm Test, 9 Hole Peg Test).

RESULTS

There were individual differences, but as a group, patients improved after therapy. There were no individual factors that influenced improvement in more than one test.

CONCLUSIONS

CIMT is an effective therapy in patients with moderate impairment after stroke, also in tests commonly used in stroke rehabilitation. Factors that could have expected to make a difference on the basis of the theory behind CIMT (e.g., time since stroke, previous therapy, sensory deficit) did not influence results. Patients with hemorrhagic lesions and those with a high level of performance (Motor Activity Log > 2.5) profit as well. Pairwise therapy is as effective as individual therapy.

Combined use of a cytoprotectant and rehabilitation therapy after severe intracerebral hemorrhage in rats

After moderate intracerebral hemorrhage (ICH), both hypothermia (HYPO) and constraint-induced movement therapy (CIMT) improve recovery and reduce the volume of brain injury. We tested the hypothesis that more severe ICH requires both cytoprotection and rehabilitation to significantly improve recovery. Rats were subjected to a unilateral striatal ICH via collagenase infusion. Rats remained normothermic or were subjected to mild HYPO ( approximately 2 days) starting 12 h later. Fourteen days after ICH, half of the rats received CIMT (7 days of restraint of the less affected limb plus daily exercises); the remainder were untreated. Walking, limb use and skilled reaching were assessed up to 60 days, at which time animals were euthanized and the volume of tissue lost was determined. The HYPO treatment alone did not improve outcome, whereas CIMT alone provided significant benefit on the limb use asymmetry test. In the staircase test, the greatest benefit was achieved with the combination of HYPO and CIMT treatments. The volume of tissue lost after ICH was similar among groups arguing against cytoprotection as a mechanism of functional recovery. Finally, these findings suggest that, at least under the present circumstances (e.g., severe striatal ICH), CIMT provides superior benefit to HYPO and that combination therapy will sometimes further improve recovery.

Experimental results using force-feedback cueing in robot-assisted stroke therapy

Stroke is the leading cause of disability among adults in the United States. Behaviors such as learned nonuse hinder hemiplegic stroke survivors from the full use of both arms in activities of daily living. Active force-feedback cues, designed to restrain the use of the less-affected arm, were embedded into a meaningful driving simulation environment to create robot-assisted therapy device, driver's simulation environment for arm therapy (SEAT). The study hypothesized that force-feedback control mode could "motivate" stroke survivors to increase the productive use of their impaired arm throughout a bilateral steering task, by providing motivating feedback and reinforcement cues to reduce the overuse of the less-affected arm. Experimental results demonstrate that the force cues counteracted the tendency of hemiplegic subjects to produce counter-productive torques only during bilateral steering tasks (p < 0.05) that required the movement of their impaired arm in steering directions up and against gravity. Impaired arm activity was quantified in terms of torques due to the measured tangential forces on the split-steering wheel of driver's SEAT during bilateral steering. Results were verified using surface electromyograms recorded from key muscles in the impaired arm.

Muscle strength is a determinant of bone mineral content in the hemiparetic upper extremity: implications for stroke rehabilitation

Individuals with stroke have a high incidence of bone fractures and approximately 30% of these fractures occur in the upper extremity. The high risk of falls and the decline in bone and muscle health make the chronic stroke population particularly prone to upper extremity fractures. This was the first study to investigate the bone mineral content (BMC), bone mineral density (BMD), and soft tissue composition of the upper extremities and their relationship to stroke-related impairments in ambulatory individuals with chronic stroke (onset >1 year). Dual-energy X-ray absorptiometry (DXA) was used to acquire total body scans on 56 (22 women) community-dwelling individuals (>or=50 years of age) with chronic stroke. BMC (g) and BMD (g/cm2), lean mass (g), and fat mass (g) for each arm were derived from the total body scans. The paretic upper extremity was evaluated for muscle strength (hand-held dynamometry), impairment of motor function (Fugl-Meyer motor assessment), spasticity (Modified Ashworth Scale), and amount of use of the paretic arm in daily activities (Motor Activity Log). Results showed that the paretic arm had significantly lower BMC (13.8%, P<0.001), BMD (4.5%, P<0.001), and lean mass (9.0%, P<0.001) but higher fat mass (6.3%, P=0.028) than the non-paretic arm. Multiple regression analysis showed that lean mass in the paretic arm, height, and muscle strength were significant predictors (R2=0.810, P<0.001) of the paretic arm BMC. Height, muscle strength, and gender were significant predictors (R2=0.822, P<0.001) of lean mass in the paretic arm. These results highlight the potential of muscle strengthening to promote bone health of the paretic arm in individuals with chronic stroke.

Évolution des concepts en rééducation du patient hémiplégique

INTRODUCTION

The author attempts to show the evolution of the ideas guiding the rehabilitation treatment of motricity disorders after a vascular or traumatic brain lesion.

METHOD

Expert opinion based on an uncomprehensive review of the literature, from the databases Reedoc and Medline and from the Institut Lionnois library in Nancy and the Charcot library in Paris.

RESULTS AND DISCUSSION

Many theories and techniques have been proposed. The modern history of this rehabilitation treatment has been marked by a period that stressed control of the abnormal motricity characterizing central motor disorders, sometimes too exclusively. The development of evidence-based medicine in the 1980s undermined certain dogmas. At the same time, the advent of cerebral imaging technology confirmed clinical observations and hypotheses concerning cerebral plasticity. Today, the rehabilitation treatment of these motor disorders uses notions of learning; the diversity and complementarity of the exercises, which must be task-oriented; relative earliness and intensity of therapy; close interactions between sensitivity and motricity; and different concepts as mental imagery, the perception of verticality, or muscle strengthening.

CONCLUSION

To its well-known preventive and palliative roles, rehabilitation treatment has now added a curative role. All the concepts applied today are not new, but the spirit of their application is new. Because we are sure that neurological recovery can be improved, no idea can be rejected at the outset; its effect must be demonstrated. Among the numerous ideas presently proposed, future studies will define the best ones, for the most suitable patient, at the best time.

Client-Centered Occupational Therapy Using Constraint-Induced Therapy

Constraint-induced therapy (CIT) is a rehabilitation intervention designed to promote increased use of a weak or paralyzed arm, most commonly in patients who sustained a stroke. CIT involves constraining the unaffected arm in a sling or mitt, forcing the use of the weaker or paralyzed arm in daily activities. The aim of this study was to determine whether immobilizing the uninvolved arm of persons who experienced a stroke while participating in meaningful activities of daily living would increase their satisfaction and performance in life roles. Nine clients participated in a pilot study consisting of 2 weeks of individualized occupation-based CIT. This pilot study combined therapy in the clinic with therapy in the individual's home environment and incorporated meaningful daily activities chosen by the client into treatment. Results revealed a significant change in reported satisfaction and performance postintervention; however, a decline in satisfaction at follow-up despite continued motor improvement. Even though voluntary movements demonstrated improvement, participants were not satisfied with their performance in functional goal-related activities in their natural environment. Motor improvement can be repeated; however, at follow-up, participants were not satisfied with the improvement in meaningful activities that they identified. This may have to do with participants wanting or expecting their affected upper extremity to function better despite the deficits. It is also possible that participants expected their function to improve at the rate that it did during treatment. Further investigation using meaningful activity is needed to identify integration of the affected upper extremity into individuals' own environments and determine how it affects overall life roles and satisfaction over time.

Effects of mental practice on affected limb use and function in chronic stroke

OBJECTIVE

To determine the efficacy of a mental practice (MP) protocol in increasing the function and use of the more affected limb in stroke patients.

DESIGN

Randomized, controlled, multiple baseline, pre-post, case series.

SETTING

Outpatient rehabilitation hospital.

PARTICIPANTS

Eleven patients who had a stroke more than 1 year before study entry (9 men; mean age, 62.3+/-5.1 y; range, 53-71 y; mean time since stroke, 23.8 mo; range, 15-48 mo; 10 strokes exhibiting upper-limb hemiparesis on the dominant side) and who exhibited affected arm hemiparesis and nonuse.

INTERVENTION

All patients received 30-minute therapy sessions 2 days a week for 6 weeks. The sessions emphasized activities of daily living (ADLs): 6 subjects randomly assigned to the MP condition concurrently received sessions requiring daily MP of the ADLs; 5 subjects (control group) received an intervention consisting of relaxation techniques.

MAIN OUTCOME MEASURES

The Motor Activity Log and Action Research Arm (ARA) test.

RESULTS

Affected limb use as rated by MP patients and their caregivers increased (1.55, 1.66, respectively), as did patient and caregiver ratings of quality of movement (2.33, 2.15, respectively) and ARA scores (10.7). In contrast, the controls showed nominal increases in the amount they used their affected limb and in limb function. A Wilcoxon test on the ARA scores revealed significantly ( P =.004) greater changes in the MP group's scores.

CONCLUSIONS

Participation in an MP protocol may increase a stroke patient's use of his/her more affected limb. Data further support that the protocol resulted in correlative, MP-induced, motor function improvements. The mechanisms whereby MP increases affected arm use are unknown. Perhaps using the more affected limb becomes more salient through MP, or perhaps motor schema are altered during MP to integrate limb use.

Constraint-induced movement therapy following stroke: A systematic review of randomised controlled trials

This systematic review investigated the effects on function, quality of life, health care costs, and patient/carer satisfaction of constraint-induced movement therapy (CIMT) for upper limb hemiparesis following stroke. A comprehensive search of the complete holdings of MEDLINE, CINAHL, EMBASE, Cochrane Library, PEDro and OTseeker to March 2005 was conducted. Fourteen eligible randomised controlled trials were identified and relevant data extracted by two independent reviewers. Effect sizes were calculated and results were pooled where possible. Method quality of the trials, assessed using the PEDro scale, had a mean score of five (range three to seven). Thirteen trials compared CIMT to an alternative treatment and/or a control group. One trial compared two CIMT protocols. Acute, subacute, and chronic conditions were studied. Effect sizes could be estimated for nine trials. Results were significant and in favour of CIMT in eight of these for at least one measure of upper limb function. The pooled standardised mean difference could be calculated for five outcome measures producing moderate to large effect sizes, only one of which attained statistical significance. Results indicate that CIMT may improve upper limb function following stroke for some patients when compared to alternative or no treatment. Rigorous evaluation of constraint-induced movement therapy using well-designed and adequately powered trials is required to evaluate the efficacy of different protocols on different stroke populations and to assess impact on quality of life, cost and patient/carer satisfaction.

Strategies for stroke rehabilitation

Rehabilitation after hemiplegic stroke has typically relied on the training of patients in compensatory strategies. The translation of neuroscientific research into care has led to new approaches and renewed promise for better outcomes. Improved motor control can progress with task-specific training incorporating increased use of proximal and distal movements during intensive practice of real-world activities. Functional gains are incorrectly said to plateau by 3-6 months. Many patients retain latent sensorimotor function that can be realised any time after stroke with a pulse of goal-directed therapy. The amount of practice probably best determines gains for a given level of residual movement ability. Clinicians should encourage patients to build greater strength, speed, endurance, and precision of multijoint movements on tasks that increase independence and enrich daily activity. Imaging tools may help clinicians determine the capacity of residual networks to respond to a therapeutic approach and help establish optimal dose-response curves for training. Promising adjunct approaches include practice with robotic devices or in a virtual environment, electrical stimulation to increase cortical excitability during training, and drugs to optimise molecular mechanisms for learning. Biological strategies for neural repair may augment rehabilitation in the next decade.

Reconsidering the motor recovery plateau in stroke rehabilitation11No 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

Termination of motor rehabilitation is often recommended as patients with cerebrovascular accident (CVA) become more chronic and/or when they fail to respond positively to motor rehabilitation (commonly termed a "plateau"). Managed-care programs frequently reinforce this practice by restricting care to patients responding to therapy and/or to the most acute patients. When neuromuscular adaptation occurs in exercise, rather than terminating the current regimen, a variety of techniques (eg, modifying intensity, attempting different modalities) are used to facilitate neuromuscular adaptations. After presenting the concepts of the motor recovery plateau and adaptation, we similarly posit that patients with CVA adapt to therapeutic exercise but that this is not indicative of a diminished capacity for motor improvement. Instead, like traditional exercise circumstances, adaptive states can be overcome by modifying regimen aspects (eg, intensity, introducing new exercises). Findings suggesting that patients with chronic CVA can benefit from motor rehabilitation programs that apply novel or different parameters and modalities. The objectives of this commentary are to (1) to encourage practitioners to reconsider the notion of the motor recovery plateau, (2) to reconsider chronic CVA patients' ability to recover motor function, and (3) to use different modalities when accommodation is exhibited.