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

Upper limb motor function in hemiparesis: concurrent validity of the Arm Motor Ability test

OBJECTIVE

To evaluate the concurrent validity of the Arm Motor Ability Test (AMAT) using the Fugl-Meyer Assessment (FMA) as the criterion measure of poststroke upper limb motor impairment.

DESIGN

Upper limb motor impairment and arm ability of 30 chronic stroke survivors were assessed with the FMA and AMAT, respectively. Spearman's correlation coefficients were generated relating the components of FMA and AMAT. Scatterplots were generated to provide qualitative assessments of the relationship between FMA and AMAT. Bar graphs of FMA and AMAT normalized to their maximum scores were generated to compare the levels of motor status measured by each instrument.

RESULTS

All components of AMAT correlated highly with FMA total (r = 0.92-0.94; P < 0.001). AMAT functional ability and AMAT quality of movement were linearly related with FMA total. However, AMAT time of performance exhibited significant ceiling and floor effects with respect to FMA. Normalized AMAT scores were generally lower than normalized FMA scores (P < 0.001), with the greatest difference in scores observed in subjects with more severe motor impairments.

CONCLUSION

This study demonstrates a high degree of concurrent criterion validity of the AMAT. However, AMAT tends to underestimate the arm motor status of those with more severe motor impairments.

Motor Restoration and Spasticity Management after Stroke

The treatment of stroke does not end after a 3-hour time window. Several randomized, controlled studies of focused stroke rehabilitation units showed that these units reduce disability, with treatment effects persisting for years. Although the exact reasons for the superiority of these specialized units remain uncertain, presumably some portion is related to the quality and types of therapies provided to the patients. Advances in the understanding of the brain's ability to react to injury have led to the current testing of treatments based on the neuroscience of recovery rather than simply the clinician's guess about what effective treatments might be. This chapter will provide an overview of the treatments directed towards the restoration of motor function and towards ameliorating spasticity after stroke. The data supporting the use of emerging therapies of constraint induced movement treatment and robotic treatment will be discussed.

Repetitive task practice: a critical review of constraint-induced movement therapy in stroke

BACKGROUND

Constraint-induced (CI) movement therapy (also called forced use by some investigators and clinicians) has gained increasing popularity as a treatment mode for restoring function in the upper extremities of patients with stroke. The purpose of this article is to review the concept of constraint-induced movement therapy and provide a critical analysis of the existing data.

REVIEW SUMMARY

The evidence to date offers encouragement for the application of this procedure for patients who have some movement recovery out of synergy. Success may be contingent on patient cooperation and intense repetitive use with applications of retraining through practice and shaping. The extent to which each of the latter elements influences the magnitude of recovery is still unclear. However, task novelty and challenge seem important to recovery of function. There are several methods used to map cortical changes after stroke. At this time, transcranial magnetic stimulation is the primary vehicle used to assess motor cortical reorganization after CI therapy in humans.

CONCLUSIONS

Accumulating data indicate that the size of a cortical area representative of a muscle does expand and its center of gravity does change with CI therapy.

Constraint-induced therapy for a child with hemiplegic cerebral palsy: a case report

A 12-year-old boy with hemiplegic cerebral palsy (CP) presented with decreased function in his left upper extremity. He was treated with a 3-week protocol of constraint-induced therapy (CIT) consisting of six 2-hour sessions of physical and occupational therapy, plus home practice. Improvements in upper-extremity function were found in the mean and median time for completion of the Wolf Motor Function Test immediately posttreatment and at 8-month follow-up. Also, improvements in functional use of the arm were documented with the Assessment of Motor and Process Skills and by patient self-report of use of the upper extremity at home. The results suggest that CIT may be useful in the treatment of upper-extremity dysfunction in hemiplegic CP. Larger, experimentally controlled investigations of the efficacy of CIT and the mechanism of recovery in patients with CP are warranted. The effects of the duration and intensity of CIT protocols need additional study to increase its clinical application.

Assessing the motor status score: a scale for the evaluation of upper limb motor outcomes in patients after stroke

The Motor Status Scale (MSS) measures shoulder, elbow (maximum score = 40), wrist, hand, and finger movements (maximum score = 42), and expands the measurement of upper extremity impairment and disability provided by the Fugl-Meyer (FM) score. This work examines the interrater reliability and criterion validity of the MSS performed in patients admitted to a rehabilitation hospital 21 +/- 4 days after stroke. Using the MSS and the FM, 7 occupational therapists masked to each other's judgments, evaluated 12 consecutive patients with stroke. Two therapists evaluated 6 additional patients on consecutive days. Intraclass correlation coefficients were significant for each group of raters for the shoulder/elbow and for the wrist/band (P < 0.0001); test-retest measures were also significant for the shoulder/elbow (Pearson correlation coefficient r = 0.99, P < 0.004) and for the wrist/hand (Pearson correlation coefficient r = 0.99, P < 0.003). The internal item consistency for the overall MSS was significant (Cronbach alpha = 0.98, P < 0.0001). Finally the correlation between the MSS and the FM (R2 = 0.964) was significant (P < 0.0001). The MSS affords a reliable and valid assessment of upper limb impairment and disability following stroke.

Modified constraint-induced therapy after subacute stroke: a preliminary study

OBJECTIVE

To determine the efficacy of a modified constraint-induced therapy (mCIT) administered to patients with subacute stroke.

DESIGN

Prospective, multiple-baseline, before-after, randomized clinical trial.

SETTING

Subacute outpatient clinic.

SUBJECTS

Fourteen patients with subacute stroke who exhibited learned nonuse and stable motor deficits in their affected upper limbs.

INTERVENTION

Four patients participated in half-hour, structured physical and occupational therapy sessions that emphasized affected arm use in valued functional activities, 3 times per week for 10 weeks. Their less affected upper limbs were restrained 5 days per week during 5 hours identified as times of frequent use (mCIT). Five patients received regular therapy (TR) with similar therapeutic contact time to mCIT and 5 patients received no therapy (CON).

MAIN OUTCOME MEASURES

The Fugl-Meyer Assessment of Motor Recovery (Fugl), Action Research Arm (ARA) test, and Motor Activity Log (MAL).

RESULTS

After intervention, Fugl, ARA, and MAL scores remained virtually the same for TR and CON groups; scores improved by 11.4 and 11.5points, respectively, on the Fugl and ARA for the mCIT group. Amount and quality of arm use, as measured by the MAL, also improvedfor mCIT patients (2.49 and 0.47, respectively).

CONCLUSIONS

mCIT may be an efficacious method of improving affected arm function and use in stroke patients exhibiting learned nonuse.

New developments in stroke rehabilitation

There is increasing evidence that environmental and neuropharmacologic treatments enhance stroke recovery. Functional magnetic resonance imaging and transcranial magnetic stimulation have significantly broadened our understanding of the neuroanatomic relationships involved in recovery from brain injury due to stroke. These tools have also demonstrated the role for pharmacologic enhancement of cortical plasticity coupled with behavioral interventions. Robot-assisted therapy and partial body weight-supported treadmill gait training have demonstrated the role for technologic intervention in the modern neuro-rehabilitation setting. Current research using hemi-field ocular prisms and patching techniques suggest a role in the rehabilitation of hemianopsia and visual neglect. Finally, many advances have been made in the understanding of common stroke complications, such as depression, dysphagia, venous thromboembolic disease, incontinence, and spasticity.

Robotics in the rehabilitation treatment of patients with stroke

Stroke is the leading cause of permanent disability despite continued advances in prevention and novel interventional treatments. Post-stroke neuro-rehabilitation programs teach compensatory strategies that alter the degree of permanent disability. Robotic devices are new tools for therapists to deliver enhanced sensorimotor training and concentrate on impairment reduction. Results from several groups have registered success in reducing impairment and increasing motor power with task-specific exercise delivered by the robotic devices. Enhancing the rehabilitation experience with task-specific repetitive exercise marks a different approach to the patient with stroke. The clinical challenge will be to streamline, adapt, and expand the robot protocols to accommodate healthcare economies, to determine which patients sustain the greatest benefit, and to explore the relationship between impairment reduction and disability level. With these new tools, therapists will measure aspects of outcome objectively and contribute to the emerging scientific basis of neuro-rehabilitation.

New treatments in neurorehabilitation founded on basic research

Recent discoveries about how the central nervous system responds to injury and how patients reacquire lost behaviours by training have yielded promising new therapies for neurorehabilitation. Until recently, this field had been largely static, but the current melding of basic behavioural science with neuroscience promises entirely new approaches to improving behavioural, perceptual and cognitive capabilities after neurological damage. Studies of phenomena such as cortical reorganization after a lesion, central nervous system repair, and the substantial enhancement of extremity use and linguistic function by behavioural therapy, support this emerging view. The ongoing changes in rehabilitation strategies might well amount to an impending paradigm shift in this field.

Constraint-induced therapy for stroke: more of the same or something completely different?

The term "constraint-induced therapy" is used to denote a "family of treatment modalities" in which the common feature is discouraging the use of the unaffected or less affected arm, combined with intensive training of the paretic arm. A systematic literature search revealed only three randomized controlled studies on the effectiveness of constraint-induced therapy. The results of several systematic reviews on exercise therapy in stroke rehabilitation indicate that more intensive (i.e. more time spent in) training may be beneficial. Therefore, it is not unlikely that any (as yet unproved) effect of constraint-induced techniques is the result of more training, and the answer to the question in the title of this review seems to be "More of the same".

Is robot-aided sensorimotor training in stroke rehabilitation a realistic option?

Stroke is the leading cause of disability, despite continued advances in prevention and treatment techniques based on novel delivery of new fibrinolytic drugs. Improved medical treatment of the complications caused by acute stroke has contributed to decreased mortality, but 90% of the survivors have significant neurological deficits. Reducing the degree of permanent disability remains the goal of poststroke neuro-rehabilitation programs, and new approaches to impairment reduction through managing sensorimotor experience may contribute further to altering disability. Recent reports from a number of laboratories using enhanced sensorimotor training protocols, particularly those with robotic devices, have indicated modest success in reducing impairment and increasing motor power in the exercised limb of patients with stroke when compared with control individuals. Whether arming the therapist with new tools, especially robotic devices, to treat impairment is a realistic approach to modern interdisciplinary rehabilitation raises questions regarding the added value of impairment reduction, and under what conditions should scientific and clinical development of robotic studies continue.

Palliative treatment for stroke

Despite continued advances in prevention and treatment, stroke remains the leading cause of neurologic disability. This article reviews the broad spectrum of palliative efforts underway to treat the impairment and disability that results from stroke. Emphasis is placed on the importance of symptom control, increasing compensation, and enhancing residual and recovering function in patients with stroke. New approaches to impairment reduction have produced encouraging results, but disability reduction remains the cornerstone of care.