Does the application of constraint-induced movement therapy during acute rehabilitation reduce arm impairment after ischemic stroke?

Participant perception of recovery as criterion to establish importance of improvement for constraint-induced movement therapy outcome measures: a preliminary study

BACKGROUND AND PURPOSE

Changes in function following constraint-induced movement therapy (CIMT) are characterized primarily by improvements in performance; however, the importance of these outcome measures to the participant may be unclear. The primary purpose of this study was to determine whether either change scores or raw follow-up scores for the Motor Activity Log amount scale (MALa) and the Wolf Motor Function Test (WMFT) predicted participants' self-reports of recovery of upper-extremity function at 4 to 6 months after starting CIMT.

SUBJECTS AND METHODS

This study was a secondary analysis of a cohort of subjects (N=46) who participated in CIMT trials.

SUBJECTS

completed measures at baseline and 4 to 6 months later. Hierarchical regression models determined whether change scores or raw follow-up scores of CIMT outcome measures were predictive of perceived recovery. Receiver operating characteristic (ROC) curves determined cutoff scores for measures that significantly contributed to participants' reports of perceived recovery.

RESULTS

The regression models indicated that raw follow-up MALa scores (beta=0.80, P=.024) and WMFT scores (beta=-0.37, P=.03) contributed to perceived recovery. Proposed cutoff scores for the MALa scores were less than 1.15 (negative likelihood ratio [LR]=0.17) for predicting less than 50% recovery and greater than 2.50 (positive LR=2.75) for predicting 50% or greater recovery. Proposed cutoff scores for follow-up WMFT scores were greater than 34.0 seconds (negative LR=0.24) for predicting less than 50% recovery and less than 11.0 seconds (positive LR=5.96) for predicting 50% or greater recovery.

DISCUSSION AND CONCLUSION

Raw follow-up scores for the MALa and WMFT were better predictors of self-report of recovery in comparison with change scores. These data also serve as a starting point for developing cutoff scores that accurately predict self-report of recovery.

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.

Pathophysiology of stroke rehabilitation: the natural course of clinical recovery, use-dependent plasticity and rehabilitative outcome

Even though the disruption of motor activity and function caused by stroke is at times severe, recovery is often highly dynamic. Recuperation reflects the ability of the neuronal network to adapt. Next to an unmasking of latent network representations, other adaptive processes, such as excitatory metabolic stress, an imbalance in activating and inhibiting transmission, leading to salient hyperexcitability, or the consolidation of novel connections, prime the plastic capabilities of the system. Rehabilitative interventions may modulate mechanisms of neurofunctional plasticity and influence the natural course after stroke, both positively, but potentially also acting detrimentally. Though routine rehabilitative procedures are an integral part of stroke care, evidence as to their effectiveness remains equivocal. The present review describes the natural course of motor recovery, focusing on ischemic stroke, and discusses use- and training-dependent adaptive effects. It complements a prior article which highlighted the pathophysiology of plasticity. Though the interaction between rehabilitation and plasticity remains elusive, an attempt is made to clarify how and to what extent rehabilitative therapy shapes motor recovery.

Functional Imaging of Intervention Effects in Stroke Motor Rehabilitation

OBJECTIVE

To assess intervention-specific effects on cortical reorganization after stroke as shown by available functional neuroimaging studies.

DATA SOURCES

We searched Medline for clinical trials that contained the terms stroke, reorganization, and recovery, as well as either positron-emission tomography and PET, near-infrared spectroscopy and NIRS, single-photon emission tomography and SPECT, or functional magnetic resonance imaging and functional MRI; we reviewed primary and secondary references.

STUDY SELECTION

Articles that reported neuroimaging findings as a result of a specific treatment involving more than 1 subject were included.

DATA EXTRACTION

We included clinical trials that contained the terms stroke, reorganization, and recovery, as well as functional neuroimaging data findings as a result of a specific treatment involving more than 1 subject.

DATA SYNTHESIS

Included studies differed clearly from one another with regard to patient characteristics, intervention protocol, and outcome measures. Most studies used functional magnetic resonance imaging and a motor paradigm. Studies were limited in size.

CONCLUSIONS

Despite the methodologic differences, several common features can be identified based on the reviewed studies. Clinical improvements occurred even late after injury, after subjects were deemed to have reached a recovery plateau. This clinical improvement was accompanied by cortical reorganization that depended on the type of intervention as well as other factors. This review also suggests direction for future research studies.

Measurement of Upper-Extremity Function Early After Stroke: Properties of the Action Research Arm Test

OBJECTIVE

To examine the responsiveness and validity of the Action Research Arm Test (ARAT) in a population of subjects with mild-to-moderate hemiparesis within the first few months after stroke.

DESIGN

Data were collected as part of the Very Early Constraint-Induced Therapy for Recovery from Stroke trial, an acute, single-blind randomized controlled trial of constraint-induced movement therapy. Subjects were studied at baseline (day 0), after treatment (day 14), and after 90 days (day 90) poststroke.

SETTING

Inpatient rehabilitation hospital; follow-up 3 months poststroke.

PARTICIPANTS

Fifty hemiparetic subjects.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

At each time point, subjects were tested on: (1) the ARAT, (2) clinical measures of sensorimotor impairments, (3) in the kinematics laboratory where they performed reach and grasp movements, and (4) clinical measures of disability. Blinded raters performed all evaluations. Analyses at each time point included calculating effect size as indicators of responsiveness, and correlation and regression analyses to examine relationships between ARAT scores and other measures.

RESULTS

The ARAT is responsive to change, with effect sizes greater than 1.0 and responsiveness ratios of 7.0 at 3 months poststroke. ARAT scores were related to sensorimotor impairment measures, 3-dimensional kinematic measures of movement performance, and disability measures at all 3 time points.

CONCLUSIONS

The ARAT is a responsive and valid measure of upper-extremity functional limitation and therefore may be an appropriate measure for use in acute upper-extremity rehabilitation trials.

Imaging motor recovery after stroke

Most patients show improvement in the weeks or months after a stroke. Recovery is incomplete, however, leaving most with significant impairment and disability. Because the brain does not grow back to an appreciable extent, this recovery occurs on the basis of change in function of surviving tissues. Brain mapping studies have characterized a number of processes and principles relevant to recovery from stroke in humans. The findings have potential application to improving therapeutics that aim to restore function after stroke.

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.

Recovery of hand function through mental practice: a study protocol

BACKGROUND

The study aims to assess the therapeutic benefits of motor imagery training in stroke patients with persistent motor weakness. There is evidence to suggest that mental rehearsal of movement can produce effects normally attributed to practising the actual movements. Imagining hand movements could stimulate the redistribution of brain activity, which accompanies recovery of hand function, thus resulting in a reduced motor deficit.

METHODS/DESIGN

A multi-centre randomised controlled trial recruiting individuals between one and six months post-stroke (n = 135). Patients are assessed before and after a four-week evaluation period. In this trial, 45 patients daily mentally rehearse movements with their affected arm under close supervision. Their recovery is compared to 45 patients who perform closely supervised non-motor mental rehearsal, and 45 patients who are not engaged in a training program. Motor imagery training effectiveness is evaluated using outcome measures of motor function, psychological processes, and level of disability.

DISCUSSION

The idea of enhancing motor recovery through the use of motor imagery rehabilitation techniques is important with potential implications for clinical practice. The techniques evaluated as part of this randomised controlled trial are informed by the current understanding in cognitive neuroscience and the trial is both of scientific and applied interest.

Effects of constraint-induced movement therapy in adolescents with hemiplegic cerebral palsy: a day camp model

This study examined whether restraining the dominant hand during an intensive training period could provide a means by which to improve adolescents' hemiplegic hand function. Nine adolescents with hemiplegic CP between the ages of 13 and 18 years were enrolled at a two-week day camp, of 7 hours/day. They were restricted in the use of their dominant hand in various daily and recreational activities by wearing a glove-like splint. The basis for intervention was built upon the adolescents' own motivation, and the activities were chosen to be challenging and specifically to provide opportunities for repetition. The treatment approach used was an adapted model of Constraint Induced Movement Therapy. Assessments took place before and after intervention as well as at a 5-month follow-up. The results revealed that hand function did improve and was sustained at follow-up for dexterity, coordination and precision, and manipulative abilities. The performance of tasks that had been trained specifically showed major improvements.

Pain, fatigue, and intensity of practice in people with stroke who are receiving constraint-induced movement therapy

BACKGROUND AND PURPOSE

There is little available information about changes in pain and fatigue status among people receiving constraint-induced movement therapy (CI therapy). This study examined such changes.

SUBJECTS

All participants were a subset of individuals with stroke enrolled in the Extremity Constraint-Induced Therapy Evaluation (EXCITE) trial and received 2 weeks of CI therapy either 3 to 9 months after stroke (subacute therapy group, n=18) or 1 year later (chronic therapy group, n=14).

METHODS

Pain, fatigue, and intensity of therapy were evaluated. The Wolf Motor Function Test (WMFT) and the pain scale of the Fugl-Meyer Assessment for the upper extremity were administered before and after training. Single-item measures for pain and fatigue were administered twice daily during therapy.

RESULTS

All participants reported low mean pain (X=2.0, SD=0.93) and fatigue (X=2.7, SD=1.23) scores. Generally, differences between the subacute and the chronic therapy groups for pain, fatigue, intensity, and WMFT change scores were nonsignificant.

DISCUSSION AND CONCLUSION

For selected patients with stroke, the intensive practice associated with CI therapy may be administered without exacerbation of pain or fatigue, even early during the recovery process.

Motor Imagery

Background and Purpose— Understanding brain plasticity after stroke is important in developing rehabilitation strategies. Active movement therapies show considerable promise but depend on motor performance, excluding many otherwise eligible patients. Motor imagery is widely used in sport to improve performance, which raises the possibility of applying it both as a rehabilitation method and to access the motor network independently of recovery. Specifically, whether the primary motor cortex (M1), considered a prime target of poststroke rehabilitation, is involved in motor imagery is unresolved.

Summary of Review— We review methodological considerations when applying motor imagery to healthy subjects and in patients with stroke, which may disrupt the motor imagery network. We then review firstly the motor imagery training literature focusing on upper-limb recovery, and secondly the functional imaging literature in healthy subjects and in patients with stroke.

Conclusions— The review highlights the difficulty in addressing cognitive screening and compliance in motor imagery studies, particularly with regards to patients with stroke. Despite this, the literature suggests the encouraging effect of motor imagery training on motor recovery after stroke. Based on the available literature in healthy volunteers, robust activation of the nonprimary motor structures, but only weak and inconsistent activation of M1, occurs during motor imagery. In patients with stroke, the cortical activation patterns are essentially unexplored as is the underlying mechanism of motor imagery training. Provided appropriate methodology is implemented, motor imagery may provide a valuable tool to access the motor network and improve outcome after stroke.

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.

Motor learning: its relevance to stroke recovery and neurorehabilitation

PURPOSE OF REVIEW

Much of neurorehabilitation rests on the assumption that patients can improve with practice. This review will focus on arm movements and address the following questions: (i) What is motor learning? (ii) Do patients with hemiparesis have a learning deficit? (iii) Is recovery after injury a form of motor learning? (iv) Are approaches based on motor learning principles useful for rehabilitation?

RECENT FINDINGS

Motor learning can be broken into kinematic and dynamic components. Studies in healthy subjects suggest that retention of motor learning is best accomplished with variable training schedules. Animal models and functional imaging in humans show that the mature brain can undergo plastic changes during both learning and recovery. Quantitative motor control approaches allow differentiation between compensation and true recovery, although both improve with practice. Several promising new rehabilitation approaches are based on theories of motor learning. These include impairment oriented-training (IOT), constraint-induced movement therapy (CIMT), electromyogram (EMG)-triggered neuromuscular stimulation, robotic interactive therapy and virtual reality (VR).

SUMMARY

Motor learning mechanisms are operative during spontaneous stroke recovery and interact with rehabilitative training. For optimal results, rehabilitation techniques should be geared towards patients' specific motor deficits and possibly combined, for example, CIMT with VR. Two critical questions that should always be asked of a rehabilitation technique are whether gains persist for a significant period after training and whether they generalize to untrained tasks.

Two different reorganization patterns after rehabilitative therapy: an exploratory study with fMRI and TMS

We used two complementary methods to investigate cortical reorganization in chronic stroke patients during treatment with a defined motor rehabilitation program. BOLD ("blood oxygenation level dependent") sensitive functional magnetic resonance imaging (fMRI) and intracortical inhibition (ICI) and facilitation (ICF) measured with transcranial magnetic stimulation (TMS) via paired pulse stimulation were used to investigate cortical reorganization before and after "constraint-induced movement therapy" (CI). The motor hand function improved in all subjects after CI. BOLD signal intensity changes within affected primary sensorimotor cortex (SMC) before and after CI showed a close correlation with ICI (r = 0.93) and ICF (r = 0.76) difference before and after therapy. Difference in number of voxels and ICI difference before and after CI also showed a close correlation (r = 0.92) in the affected SMC over the time period of training. A single subject analysis revealed that patients with intact hand area of M1 ("the hand knob") and its descending motor fibers (these patients revealed normal motor evoked potentials [MEP] from the affected hand) showed decreasing ipsilesional SMC activation which was paralleled by an increase in intracortical excitability. This pattern putatively reflects increasing synaptic efficiency. When M1 or its descending pyramidal tract was lesioned (MEP from the affected hand was pathologic) ipsilesional SMC activation increased, accompanied by decreased intracortical excitability. We suggest that an increase in synaptic efficiency is not possible here, which leads to reorganization with extension, shift and recruitment of additional cortical areas of the sensorimotor network. The inverse dynamic process between both complementary methods (activation in fMRI and intracortical excitability determined by TMS) over the time period of CI illustrates the value of combining methods for understanding brain reorganization.

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.

New perspectives on improving upper extremity function after spinal cord injury

Injury to the cervical spinal cord adversely affects arm and hand function to varying degrees depending on the level and severity of injury. These impairments typically result in reduced independence in the performance of activities of daily living and limit participation in recreational activities. There is evidence to suggest individuals with incomplete spinal cord injury may benefit from intensive rehabilitation interventions aimed at improving hand and arm function. Massed practice (repetitive activity-based training) and somatosensory stimulation (prolonged peripheral nerve electrical stimulation at submotor threshold intensity) are 2 interventions that have been shown to improve strength and function in individuals with stroke, presumably by changing cortical excitability. These techniques, however, had not previously been investigated in individuals with spinal cord injury (SCI). In this article the stroke and SCI literature supporting the use of massed practice and somatosensory stimulation as a potential rehabilitative tool to promote recovery of function in individuals with incomplete cervical spinal cord injury (SCI) is reviewed. Recently published research using these novel techniques in which a combination of massed practice and somatosensory stimulation resulted in increased pinch grip strength and upper extremity function in individuals with incomplete cervical SCI when compared to subjects participating in massed practice alone is presented.

Functional reorganization and recovery after constraint-induced movement therapy in subacute stroke: case reports

Preliminary assessments of the feasibility, safety, and effects on neuronal reorganization measured with transcranial magnetic stimulation (TMS) from Constraint-Induced Movement Therapy (CIMT) of the upper extremity were made in eight cases of subacute stroke. Within fourteen days of their stroke, patients were randomly assigned to two weeks of CIMT or traditional therapy. Baseline motor performance and cortical/subcortical representation for movement with TMS were assessed before treatment. Post-treatment assessments were made at the end of treatment and at three months after the stroke. The TMS mapping showed a larger motor representation in the lesioned hemisphere of the CIMT patients as compared to the controls at the three-month follow-up assessment. The enlarged motor representation in the lesioned hemisphere for hand movement correlated with improved motor function of the affected hand, suggesting a link between movement representation size as measured with TMS and functionality. These results suggest that TMS can be safely and effectively used to assess brain function in subacute stroke and further suggest that CIMT may enhance cortical/subcortical motor reorganization and accelerate motor recovery when started within the first two weeks after stroke.

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.

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.

Robotics and other devices in the treatment of patients recovering from stroke

Stroke is the leading cause of permanent disability in the United States despite advances in prevention and novel interventional treatments. Randomized controlled studies have demonstrated the effectiveness of specialized post-stroke rehabilitation units, but administrative orders have severely limited the length of stay, so novel approaches to the treatment of recovery need to be tested in outpatients. Although the mechanisms of stroke recovery depend on multiple factors, a number of techniques that concentrate on enhanced exercise of the paralyzed limb have demonstrated effectiveness in reducing the motor impairment. For example, interactive robotic devices are new tools for therapists to deliver enhanced sensorimotor training for the paralyzed upper limb, which can potentially improve patient outcome and increase patient productivity. New data support the idea that for some post-stroke patients and for some aspects of training-induced recovery, timing of the training may be less important than the quality and intensity of the training. The positive outcome that resulted in the interactive robotic trials contrasts with the failure to find a beneficial result in trials that used a noninteractive device that delivered continuous passive motion only. New pilot data from novel devices to move the wrist demonstrate benefit and suggest that successive improvement of the function of the arm progressing to the distal muscles may eventually lead to significant disability reduction. These data from robotic trials continue to contribute to the emerging scientific basis of neuro-rehabilitation.

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.

Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care: executive summary

BACKGROUND

A panel of experts developed stroke rehabilitation guidelines for the Veterans Health Administration and Department of Defense Medical Systems.

METHODS

Starting from previously established guidelines, the panel evaluated published literature through 2002, using criteria developed by the US Preventive Services Task Force. Recommendations were based on evidence from randomized clinical trials, uncontrolled studies, or consensus expert opinion if definitive data were lacking.

RESULTS

Recommendations with Level I evidence include the delivery of poststroke care in a multidisciplinary rehabilitation setting or stroke unit, early patient assessment via the NIH Stroke Scale, early initiation of rehabilitation therapies, swallow screening testing for dysphagia, an active secondary stroke prevention program, and proactive prevention of venous thrombi. Standardized assessment tools should be used to develop a comprehensive treatment plan appropriate to each patient's deficits and needs. Medical therapy for depression or emotional lability is strongly recommended. A speech and language pathologist should evaluate communication and related cognitive disorders and provide treatment when indicated. The patient, caregiver, and family are essential members of the rehabilitation team and should be involved in all phases of the rehabilitation process. These recommendations are available in their entirety at http://stroke.ahajournals.org/cgi/content/full/36/9/e100. Evidence tables for each of the recommendations are also in the full document.

CONCLUSIONS

These recommendations should be equally applicable to stroke patients receiving rehabilitation in all medical system settings and are not based on clinical problems or resources unique to the Federal Medical System.

Constraint-Induced Movement Therapy After Stroke: Efficacy for Patients With Minimal Upper-Extremity Motor Ability

OBJECTIVE

To examine the effects of constraint-induced movement therapy (CIMT) on chronic moderate-to-severe upper-extremity motor impairment after stroke.

DESIGN

Within-subjects design; pre- and posttesting as well as 1-month follow-up.

SETTING

Outpatient clinic within a rehabilitation hospital.

PARTICIPANTS

Twenty participants, each greater than 12 months poststroke.

INTERVENTION

Three weeks of CIMT including restraint of the nonparetic upper extremity and 6 hours of training a day.

MAIN OUTCOME MEASURES

Fugl-Meyer Assessment (FMA), Graded Wolf Motor Function Test (GWMFT), and Motor Activity Log (MAL).

RESULTS

There was a statistically significant effect of treatment on upper-extremity motor impairment as assessed by the FMA, the MAL, and the functional ability scale of the GWMFT. There was a trend toward an effect of CIMT on mean speed of performance on the GWMFT. Post hoc analysis showed significant differences between motor impairment scores between pretreatment and posttreatment assessments, and improvements in motor impairment scores remained stable 1 month after completion of formal treatment. Improvements appeared to be mostly in the use of the involved upper extremity for bimanual activities.

CONCLUSIONS

CIMT conferred significant changes in objective measures in subjects with chronic moderate-to-severe impairments after stroke. Additional studies of long-term benefits of this treatment on poststroke motor impairments and related functional disabilities are warranted.

Contemporary linkages between EMG, kinetics and stroke rehabilitation

EMG and kinetic measures have been primary tools in the study of movement and have provided the foundation for much of the work presented in this journal. Recently, novel ways of combining these tools have provided opportunities to examine elements of motor learning and brain plasticity. This presentation reviews the quantification of EMG within the context of transcranial magnetic stimulation. This vehicle permits acquisition of measures that are fundamental to examining prospects for cortical reorganization among patients with stroke and employs a therapeutic approach called "constraint induced therapy" as a model to demonstrate the interpretation of changes in EMG measures among patients with stroke. Moreover, interfacing novel uses of kinetic measurements during functional task performances is highlighted to illustrate how EMG and kinetics can provide further insight into mechanisms related to reacquisition of movement and concomitant changes in plasticity. Clinicians and researchers interested in expanding their use of these measurement tools are encouraged to learn more about application possibilities.

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.

Immediate constraint-induced movement therapy causes local hyperthermia that exacerbates cerebral cortical injury in rats

Constraint-induced movement therapy (CIMT), which involves restraint of the nonimpaired arm coupled with physiotherapy for the impaired arm, lessens impairment and disability in stroke patients. Surprisingly, immediate ipsilateral forelimb immobilization exacerbates brain injury in rats. We tested whether immediate ipsilateral restraint for 7 days aggravates injury after a devascularization lesion in rats. Furthermore, we hypothesized that ipsilateral restraint aggravates injury by causing hyperthermia. In experiment 1, each rat received two lesions, one in the motor cortex and one in the visual cortex. Ipsilateral restraint increased only the motor cortex lesion. In additional rats, no differences in core temperature occurred after ipsilateral or contralateral restraint. Thus, ipsilateral restraint does not aggravate injury by a systemic side effect. In experiment 2, we hypothesized that ipsilateral restraint causes hyperthermia in the region surrounding the initial cortical lesion. Brain temperature, measured via telemetry, was significantly higher (approximately 1 degrees C for 24 h) with ipsilateral restraint. A third experiment similarly found that ipsilateral restraint aggravates injury and causes local cortical hyperthermia and that contralateral restraint with externally induced mild hyperthermia aggravates injury. In conclusion, immediate ipsilateral restraint aggravates injury apparently by localized events that include hyperthermia. Caution must be exercised in applying early CIMT to humans, as hyperthermia is detrimental.

Clinical practice. Rehabilitation after stroke

A 66-year-old man was suddenly unable to speak, follow directions, or move his right arm and leg. He received tissue plasminogen activator within 90 minutes. Four days later, his speech was limited to effortful answers of yes or no. He could not walk or use his right arm, and self-care tasks required maximal assistance. What advice would you offer him and his family regarding rehabilitation for his disabilities?

The impact of physical therapy on functional outcomes after stroke: what's the evidence?

OBJECTIVE

To determine the evidence for physical therapy interventions aimed at improving functional outcome after stroke.

METHODS

MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, DARE, PEDro, EMBASE and DocOnline were searched for controlled studies. Physical therapy was divided into 10 intervention categories, which were analysed separately. If statistical pooling (weighted summary effect sizes) was not possible due to lack of comparability between interventions, patient characteristics and measures of outcome, a best-research synthesis was performed. This best-research synthesis was based on methodological quality (PEDro score).

RESULTS

In total, 151 studies were included in this systematic review; 123 were randomized controlled trials (RCTs) and 28 controlled clinical trials (CCTs). Methodological quality of all RCTs had a median of 5 points on the 10-point PEDro scale (range 2-8 points). Based on high-quality RCTs strong evidence was found in favour of task-oriented exercise training to restore balance and gait, and for strengthening the lower paretic limb. Summary effect sizes (SES) for functional outcomes ranged from 0.13 (95% Cl 0.03-0.23) for effects of high intensity of exercise training to 0.92 (95% Cl 0.54-1.29) for improving symmetry when moving from sitting to standing. Strong evidence was also found for therapies that were focused on functional training of the upper limb such as constraint-induced movement therapy (SES 0.46; 95% Cl 0.07-0.91), treadmill training with or without body weight support, respectively 0.70 (95% Cl 0.29-1.10) and 1.09 (95% Cl 0.56-1.61), aerobics (SES 0.39; 95% Cl 0.05-0.74), external auditory rhythms during gait (SES 0.91; 95% Cl 0.40-1.42) and neuromuscular stimulation for glenohumeral subluxation (SES 1.41; 95% Cl 0.76-2.06). No or insufficient evidence in terms of functional outcome was found for: traditional neurological treatment approaches; exercises for the upper limb; biofeedback; functional and neuromuscular electrical stimulation aimed at improving dexterity or gait performance; orthotics and assistive devices; and physical therapy interventions for reducing hemiplegic shoulder pain and hand oedema.

CONCLUSIONS

This review showed small to large effect sizes for task-oriented exercise training, in particular when applied intensively and early after stroke onset. In almost all high-quality RCTs, effects were mainly restricted to tasks directly trained in the exercise programme.

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.

Neurobiology of rehabilitation

Rehabilitation aims to lessen the physical and cognitive impairments and disabilities of patients with stroke, multiple sclerosis, spinal cord or brain injury, and other neurologic diseases. Conventional approaches beyond compensatory adjustments to disability may be augmented by applying some of the myriad experimental results about mechanisms of intrinsic biological changes after injury and the effects of extrinsic manipulations on spared neuronal assemblies. The organization and inherent adaptability of the anatomical nodes within distributed pathways of the central nervous system offer a flexible substrate for treatment strategies that drive activity-dependent plasticity. Opportunities for a new generation of approaches are manifested by rodent and non-human primate studies that reveal morphologic and physiologic adaptations induced by injury, by learning-associated practice, by the effects of pharmacologic neuromodulators, by the behavioral and molecular bases for enhancing activity-dependent synaptic plasticity, and by cell replacement, gene therapy, and regenerative biologic strategies. Techniques such as functional magnetic resonance imaging and transcranial magnetic stimulation will help determine the most optimal physiologic effects of interventions in patients as the cortical representations for skilled movements and cognitive processes are modified by the combination of conventional and biologic therapies. As clinicians digest the finer details of the neurobiology of rehabilitation, they will translate laboratory data into controlled clinical trials. By determining how much they can influence neural reorganization, clinicians will extend the opportunities for neurorestoration.

Robotics and other devices in the treatment of patients recovering from stroke

Stroke is the leading cause of permanent disability in the United States despite advances in prevention and novel interventional treatments. Randomized controlled studies have demonstrated the effectiveness of specialized post-stroke rehabilitation units, but administrative orders have severely limited the length of stay, so novel approaches to the treatment of recovery need to be tested in outpatients. Although the mechanisms of stroke recovery depend on multiple factors, a number of techniques that concentrate on enhanced exercise of the paralyzed limb have demonstrated effectiveness in reducing the motor impairment. For example, interactive robotic devices are new tools for therapists to deliver enhanced sensorimotor training for the paralyzed upper limb, which can potentially improve patient outcome and increase their productivity. New data support the idea that for some post-stroke patients and for some aspects of training-induced recovery, timing of the training may be less important than the quality and intensity of the training. The positive outcome that resulted in the interactive robotic trials contrasts with the failure to find a beneficial result in trials that used a noninteractive device that delivered continuous passive motion only. New pilot data from novel devices to move the wrist demonstrate benefit and suggest that successive improvement of the function of the arm progressing to the distal muscles may eventually lead to significant disability reduction. These data from robotic trials continue to contribute to the emerging scientific basis of neuro-rehabilitation.

Constraint-Induced Movement Therapy

Constraint-induced movement therapy improves outcome after chronic stroke, conforms experimental observations of neuronal plasticity, and proves the efficacy of intensive occupational therapy. More acutely instituted constraint-induced movement therapy has both practical and theoretic risks and benefits that deserve further careful evaluation.

Can forced-use therapy be clinically applied after stroke? an exploratory randomized controlled trial11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To determine the efficacy, safety, and compliance with forced-use therapy (FUT) applied without additional "shaping" therapy during the rehabilitation phase of stroke.

DESIGN

Prospective, randomized controlled trial.

SETTING

Tertiary mixed rehabilitation center.

PARTICIPANTS

Consecutive sample of 30 inpatients or outpatients with first stroke showing minimal movement of the arm and hand. Subjects who scored below 26 on the Mini-Mental State Examination were excluded. Seven subjects either did not provide consent or withdrew from the study. The remaining subjects were randomized into the control group (n=13) and the FUT group (n=10).

INTERVENTION

FUT involved wearing a thick constraint mitten on the sound arm for as many as 6 hours a day.

MAIN OUTCOME MEASURES

The Chedoke McMaster Impairment Inventory for arm, hand, postural control, and shoulder pain; Action Research Arm Test; grip strength; and FIM instrument.

RESULTS

FUT subjects experienced 20% more recovery of the arm than did control subjects and more recovery of postural control (P=.04). Men benefited most from the program, and there was a tendency for FUT subjects to have more shoulder pain. Compliance was related to cognitive status.

CONCLUSIONS

FUT, without shaping therapy, appears to augment arm recovery, but a larger sample is required to confirm these findings. The FUT mitten was safe and well tolerated; however, more research is needed to determine the relation between FUT and hemiplegic shoulder pain.

Comparison of Two Techniques of Robot-Aided Upper Limb Exercise Training After Stroke

OBJECTIVE

This study examined whether incorporating progressive resistive training into robot-aided exercise training provides incremental benefits over active-assisted robot-aided exercise for the upper limb after stroke.

DESIGN

A total of 47 individuals at least 1 yr poststroke were enrolled in this 6-wk training protocol. Paretic upper limb motor abilities were evaluated using clinical measures and a robot-based assessment to determine eligibility for robot-aided progressive resistive training at study entry. Subjects capable of participating in resistance training were randomized to receive either active-assisted robot-aided exercises or robot-aided progressive resistance training. Subjects who were incapable of participating in resistance training underwent active-assisted robotic therapy and were again screened for eligibility after 3 wks of robotic therapy. Those subjects capable of participating in resistance training at 3 wks were then randomized to receive either robot-aided resistance training or to continue with robot-aided active-assisted training.

RESULTS

One subject withdrew due to unrelated medical issues, and data for the remaining 46 subjects were analyzed. Subjects in all groups showed improvement in measures of motor control (mean increase in Fugl-Meyer of 3.3; 95% confidence interval, 2.2-4.4) and maximal force (mean increase in maximal force of 3.5 N, P = 0.027) over the course of robot-aided exercise training. No differences in outcome measures were observed between the resistance training groups and the matched active-assisted training groups. Subjects' ability to perform the robotic task at the time of group assignment predicted the magnitude of the gain in motor control.

CONCLUSION

The incorporation of robot-aided progressive resistance exercises into a program of robot-aided exercise did not favorably or negatively affect the gains in motor control or strength associated with this training, though interpretation of these results is limited by sample size. Individuals with better motor control at baseline experienced greater increases in motor control with robotic training.

Loss of strength contributes more to physical disability after stroke than loss of dexterity

OBJECTIVE

The major contributors to physical disability after stroke are considered to be the negative impairments of loss of dexterity (defined here as loss of the ability to co-ordinate muscle activity in the performance of any motor task) and loss of strength. The aims of this study were: (1) to determine the relative contributions of strength and dexterity to function during recovery after stroke; and (2) to determine the predictive value of initial strength, dexterity and function on long-term function after stroke.

DESIGN

A longitudinal descriptive study.

SETTING

The inpatient and outpatient rehabilitation departments of two metropolitan hospitals.

SUBJECTS

Twenty-two patients undergoing rehabilitation after acute stroke participated.

MAIN OUTCOME MEASURES

Strength and dexterity of the elbow flexors and extensors were measured, along with arm function, at 3, 5, 7, 9, 11, 15, 19, 23 and 27 weeks after stroke.

RESULTS

Standard multiple linear regression analysis demonstrated that strength and dexterity in total contributed significantly to function at all times (r2 = 0.66-0.82, p < 0.0001). Furthermore, strength always made an additional separate contribution to function (r2 = 0.05-0.26, p < 0.05). Function at week 3 was the best clinical predictor of function at week 27 (r2 = 0.55, p < 0.001).

CONCLUSIONS

Loss of strength is a more significant contributor than loss of dexterity to physical disability after stroke. This suggests that, where significant weakness is present, exercise designed to increase strength will be required to decrease disability.

[Evidence-based arm rehabilitation--a systematic review of the literature]

Based on a systematic MEDLINE search and informal sources, 40 references were identified that evaluate training therapy or neuromuscular electric stimulation for arm paresis after stroke and describe either a systematic review, meta-analysis, randomised controlled trial, or controlled cohort study. The evidence was grouped into three areas of interest: comparison of physiotherapy schools, effects of intensity of training, and efficacy of specific arm rehabilitation techniques. The only physiotherapy school with evidence of superior efficacy was the task-oriented 'motor relearning programme'. Higher intensities of motor rehabilitation can accelerate motor recovery. Various training techniques with demonstrated efficacy are available for specific patient subgroups: arm ability training for mildly affected patients with reduced efficiency of motor control, constrained-induced movement therapy for patients with partial functional deficits and learned nonuse of the affected arm, and repetitive sensorimotor training techniques, EMG-biofeedback, functional electrical stimulation, and robot-assisted training for patients with severe arm paresis.

A randomized controlled comparison of upper-extremity rehabilitation strategies in acute stroke: a pilot study of immediate and long-term outcomes

OBJECTIVE

To evaluate the immediate and long-term effects of 2 upper-extremity rehabilitation approaches for stroke compared with standard care in participants stratified by stroke severity.

DESIGN

Nonblinded, randomized controlled trial (baseline, postintervention, 9mo) design.

SETTING

Inpatient rehabilitation hospital and outpatient clinic.

PARTICIPANTS

Sixty-four patients with recent stroke admitted for inpatient rehabilitation were randomized within severity strata (Orpington Prognostic Scale) into 1 of 3 intervention groups. Forty-four patients completed the 9-month follow-up.

INTERVENTIONS

Standard care (SC), functional task practice (FT), and strength training (ST). The FT and ST groups received 20 additional hours of upper-extremity therapy beyond standard care distributed over a 4- to 6-week period.

MAIN OUTCOME MEASURES

Performance measures of impairment (Fugl-Meyer Assessment), strength (isometric torque), and function (Functional Test of the Hemiparetic Upper Extremity [FTHUE]).

RESULTS

Compared with SC participants, those in the FT and ST groups had significantly greater increases in Fugl-Meyer motor scores (P=.04) and isometric torque (P=.02) posttreatment. Treatment benefit was primarily in the less severe participants, where improvement in FT and ST group Fugl-Meyer motor scores more than doubled that of the SC group. Similar results were found for the FTHEU and isometric torque. During the long term, at 9 months, the less severe FT group continued to make gains in isometric muscle torque, significantly exceeding those of the ST group (P<.05).

CONCLUSIONS

Task specificity and stroke severity are important factors for rehabilitation of arm use in acute stroke. Twenty hours of upper extremity-specific therapy over 4 to 6 weeks significantly affected functional outcomes. The immediate benefits of a functional task approach were similar to those of a resistance-strength approach, however, the former was more beneficial in the long-term.

Motor enrichment and the induction of plasticity before or after brain injury

Voluntary exercise, treadmill activity, skills training, and forced limb use have been utilized in animal studies to promote brain plasticity and functional change. Motor enrichment may prime the brain to respond more adaptively to injury, in part by upregulating trophic factors such as GDNF, FGF-2, or BDNF. Discontinuation of exercise in advance of brain injury may cause levels of trophic factor expression to plummet below baseline, which may leave the brain more vulnerable to degeneration. Underfeeding and motor enrichment induce remarkably similar molecular and cellular changes that could underlie their beneficial effects in the aged or injured brain. Exercise begun before focal ischemic injury increases BDNF and other defenses against cell death and can maintain or expand motor representations defined by cortical microstimulation. Interfering with BDNF synthesis causes the motor representations to recede or disappear. Injury to the brain, even in sedentary rats, causes a small, gradual increase in astrocytic expression of neurotrophic factors in both local and remote brain regions. The neurotrophic factors may inoculate those areas against further damage and enable brain repair and use-dependent synaptogenesis associated with recovery of function or compensatory motor learning. Plasticity mechanisms are particularly active during time-windows early after focal cortical damage or exposure to dopamine neurotoxins. Motor and cognitive impairments may contribute to self-imposed behavioral impoverishment, leading to a reduced plasticity. For slow degenerative models, early forced forelimb use or exercise has been shown to halt cell loss, whereas delayed rehabilitation training is ineffective and disuse is prodegenerative. However, it is possible that, in the chronic stages after brain injury, a regimen of exercise would reactivate mechanisms of plasticity and thus enhance rehabilitation targeting residual functional deficits.

Quality of the stroke rehabilitation research

The Stroke Rehabilitation Evidence-Based Review revealed a wide range of quality scores across primary studies. The aim of this section is to determine what differences there are across studies and to provide a detailed examination of methodological issues in the stroke rehabilitation literature. Methodology of each article was assessed using the Physiotherapy Evidence Database (PEDro) quality scale. Mean PEDro scores and percentage of studies meeting individual PEDro criteria were determined for all studies, for therapy-based studies only, and for drug-based studies only. It was noted that the stroke rehabilitation literature lacked rigor in the area of concealed allocation, blinding of the assessor, and intention-to-treat analysis. Investigation of the methodological quality of stroke rehabilitation literature emphasizes the need for improved treatment protocols, taking into account previous deficits, during research.

An evidence-based review of stroke rehabilitation

A comprehensive evidence-based review of stroke rehabilitation was created to be an up-to-date review of the current evidence in stroke rehabilitation and to provide specific conclusions based on evidence that could be used to help direct stroke care at the bedside and at home. A literature search using multiple data-bases was used to identify all trials from 1968 to 2001. Methodological quality of the individual randomized controlled trials was assessed using the Physiotherapy Evidence Database (PEDro) quality assessment scale. A five-stage level-of-evidence approach was used to determine the best practice in stroke rehabilitation. Over 403 treatment-based articles investigating of various areas of stroke rehabilitation were identified. This included 272 randomized controlled trials.

Stroke

The search for evidence-based treatments has resulted in an exciting new era for neurorehabilitation intervention strategies for stroke. Although stroke rehabilitation research poses many methodologic challenges, evaluation of stroke rehabilitation interventions is clearly moving beyond descriptive and observational studies toward well designed randomized clinical trials. The goals of this article are to summarize issues of trial design for stroke rehabilitation, to discuss promising stroke rehabilitation treatments currently undergoing rigorous evaluation, and to present treatments that may be candidates for randomized clinical trials in the future on the basis of promising preliminary data. Several examples of new developments in neuroscience research that are leading to possible rehabilitation interventions will be discussed. New modalities to evaluate the response of neural networks to rehabilitation interventions are also reviewed.

Arm reaching improvements with short-term practice depend on the severity of the motor deficit in stroke

The effects of short-term, constant practice on the kinematics of a multi-joint pointing movement were studied in the hemiparetic arm of 20 chronic patients with unilateral left cerebro-vascular accident (CVA) and in 10 age- and sex-matched healthy individuals. Practice consisted of a single session of 70 pointing movements made with the right arm. Movements were made from a target located beside the body to one in the contralateral workspace, in front of the body. Vision of the final hand position was allowed after every 5th trial. At the beginning of practice, stroke patients made slower, less precise and more segmented movements, characterised by smaller active ranges of elbow and shoulder motion, disrupted elbow-shoulder coordination, as well as greater trunk movement compared with healthy subjects. With practice, healthy subjects and some patients made faster and more precise movements. These tendencies were revealed only after many repetitions (up to 55 for those with severe hemiparesis), whereas changes in healthy individuals occurred after fewer trials (approximately 20). In addition, the patients decreased movement segmentation with practice. In healthy subjects, faster movement times may be attributed to better shoulder/elbow movement timing in the first half of the reach, whereas improvement of precision was not correlated with any changes in the movement variables. In patients, improvements were accomplished differently depending on arm motor severity. For some patients with mild-to-moderate clinical symptoms, practice resulted in better timing of shoulder/elbow movements with less trunk rotation in middle to late reach. Patients with more severe impairment also improved shoulder/elbow movement timing in mid-reach but used more compensatory trunk rotation. The results suggest that even one session of repetitive practice of a multi-joint pointing task leads to improvements in movement performance-based outcome measures, but the mechanisms of improvement may vary with the individual's level of motor impairment.

Does an early increased-intensity interdisciplinary upper limb therapy programme following acute stroke improve outcome?

OBJECTIVE

To determine whether an early increased-intensity upper limb therapy programme following acute stroke improves outcome.

DESIGN

A randomized controlled trial.

SETTING

A stroke unit which provides acute care and rehabilitation for all stroke admissions.

SUBJECTS

One hundred and twenty-three patients who had had a stroke causing upper limb impairment within the previous 10 days.

INTERVENTION

The intervention group received stroke unit care plus enhanced upper limb rehabilitation provided jointly by a physiotherapist and occupational therapist, commencing within 10 days of stroke, and available up to 30 minutes/day, five days/week for six weeks. The control group received stroke unit care.

MAIN OUTCOME MEASURES

The primary outcome measure was the Action Research Arm Test (ARAT) three months after stroke.

SECONDARY OUTCOME MEASURES

Motricity Index; Frenchay Arm Test; upper limb pain; Barthel ADL Index; Nottingham E-ADL Scale; and costs to health and social services at three and six months after stroke.

RESULTS

There were no differences in outcomes between the intervention and control groups three and six months after stroke. During the intervention period the intervention group received a median of 29 minutes of enhanced upper limb therapy per working day as inpatients. The total amount of inpatient physiotherapy and occupational therapy received by the intervention group was a median of 52 minutes per working day during the intervention period and 38 minutes per working day for the control group (p = 0.001). There were no differences in service costs.

CONCLUSIONS

An early increased-intensity interdisciplinary upper limb therapy programme jointly provided by a physiotherapist and occupational therapist did not improve outcome after stroke. The actual difference in the amount of therapy received by intervention and control groups was less than planned due to a competitive therapy bias.

Constraint-induced movement therapy and rehabilitation exercises lessen motor deficits and volume of brain injury after striatal hemorrhagic stroke in rats

BACKGROUND AND PURPOSE

Constraint-induced movement therapy (CIMT) promotes motor recovery after occlusive stroke in humans, but its efficacy after intracerebral hemorrhage (ICH) has not been investigated clinically or in the laboratory. In this study we tested whether CIMT and a rehabilitation exercise program would lessen motor deficits after ICH in rats.

METHODS

Rats were subjected to striatal ICH (via infusion of collagenase) or sham stroke. Seven days later, treatment began with CIMT (8 h/d of ipsilateral forelimb restraint), rehabilitation exercises (eg, reaching, walking; 1 h/d), or both for 7 days. Some rats were not treated. Motor deficits were assessed up to the 60-day survival time, after which the volume of tissue lost was determined.

RESULTS

Untreated ICH rats made more limb slips traversing a horizontal ladder and showed an asymmetry toward less use of the contralateral paw in the cylinder test of limb use asymmetry (day 28). These rats were also significantly less successful in the Montoya staircase test (days 55 to 59) of skilled reaching. Neither therapy alone provided much benefit. However, the combination of daily exercises and CIMT substantially and persistently improved recovery. Unexpectedly, this group had a statistically smaller volume of tissue lost than untreated ICH rats.

CONCLUSIONS

The combination of focused rehabilitation exercises and CIMT effectively promotes functional recovery after ICH, while either therapy alone is less effective. This therapy may work in part by reducing the volume of tissue lost, likely through reducing atrophy while promoting remodeling.

Improved motor recovery after stroke and massive cortical reorganization following Constraint-Induced Movement therapy

Constraint-Induced Movement therapy (CI therapy) has been demonstrated to improve motor function and upper extremity (UE) use of persons with hemiparesis resulting from chronic stroke through two separate but linked mechanisms, overcoming learned nonuse, and facilitating use-dependent cortical reorganization. The principles of CI therapy and adaptations of the basic techniques have been used successfully with diagnostic categories other than stroke that involve disability greater than what is warranted by the organic condition of the individual. Because neuroimaging and transcranial magnetic stimulation studies indicate that many of these conditions involve abnormalities of cortical organization, CI therapy might therefore be viewed as a technique that achieves clinical efficacy by correcting disorders of brain plasticity. CI therapy constitutes a new approach to neurorehabilitation and, with continued investigation, elaboration, and application to clinical settings, it seems to hold considerable promise.