Very Early Constraint-Induced Movement during Stroke Rehabilitation (VECTORS): A single-center RCT

Error augmentation enhancing arm recovery in individuals with chronic stroke: a randomized crossover design

BACKGROUND

Neurorehabilitation studies suggest that manipulation of error signals during practice can stimulate improvement in coordination after stroke.

OBJECTIVE

To test visual display and robotic technology that delivers augmented error signals during training, in participants with stroke.

METHODS

A total of 26 participants with chronic hemiparesis were trained with haptic (via robot-rendered forces) and graphic (via a virtual environment) distortions to amplify upper-extremity (UE) tracking error. In a randomized crossover design, the intervention was compared with an equivalent amount of practice without error augmentation (EA). Interventions involved three 45-minute sessions per week for 2 weeks, then 1 week of no treatment, and then 2 additional weeks of the alternate treatment. A therapist provided a visual cursor using a tracking device, and participants were instructed to match it with their hand. Haptic and visual EA was used with blinding of participant, therapist, technician-operator, and evaluator. Clinical measures of impairment were obtained at the beginning and end of each 2-week treatment phase as well as at 1 week and at 45 days after the last treatment.

RESULTS

Outcomes showed a small, but significant benefit to EA training over simple repetitive practice, with a mean 2-week improvement in Fugl-Meyer UE motor score of 2.08 and Wolf Motor Function Test of timed tasks of 1.48 s.

CONCLUSIONS

This interactive technology may improve UE motor recovery of stroke-related hemiparesis.

FAST INdiCATE Trial protocol. Clinical efficacy of functional strength training for upper limb motor recovery early after stroke: neural correlates and prognostic indicators

RATIONALE

Functional strength training in addition to conventional physical therapy could enhance upper limb recovery early after stroke more than movement performance therapy plus conventional physical therapy.

AIMS

To determine (a) the relative clinical efficacy of conventional physical therapy combined with functional strength training and conventional physical therapy combined with movement performance therapy for upper limb recovery; (b) the neural correlates of response to conventional physical therapy combined with functional strength training and conventional physical therapy combined with movement performance therapy; (c) whether any one or combination of baseline measures predict motor improvement in response to conventional physical therapy combined with functional strength training or conventional physical therapy combined with movement performance therapy.

DESIGN

Randomized, controlled, observer-blind trial.

STUDY

The sample will consist of 288 participants with upper limb paresis resulting from a stroke that occurred within the previous 60 days. All will be allocated to conventional physical therapy combined with functional strength training or conventional physical therapy combined with movement performance therapy. Functional strength training and movement performance therapy will be undertaken for up to 1·5 h/day, five-days/week for six-weeks.

OUTCOMES AND ANALYSIS

Measurements will be undertaken before randomization, six-weeks thereafter, and six-months after stroke. Primary efficacy outcome will be the Action Research Arm Test. Explanatory measurements will include voxel-wise estimates of brain activity during hand movement, brain white matter integrity (fractional anisotropy), and brain-muscle connectivity (e.g. latency of motor evoked potentials). The primary clinical efficacy analysis will compare treatment groups using a multilevel normal linear model adjusting for stratification variables and for which therapist administered the treatment. Effect of conventional physical therapy combined with functional strength training versus conventional physical therapy combined with movement performance therapy will be summarized using the adjusted mean difference and 95% confidence interval. To identify the neural correlates of improvement in both groups, we will investigate associations between change from baseline in clinical outcomes and each explanatory measure. To identify baseline measurements that independently predict motor improvement, we will develop a multiple regression model.

Stroke: More than a ‘Brain Attack’

Stroke is a life-altering event that potentially affects stroke survivors, their families, healthcare resources, and society in general. Stroke has often been described as ‘brain attack’, denoting emergency emphasis on the vascular pathology. Consequently, many national and provincial stroke strategies have emphasized vascular care through primary prevention strategies and thrombolysis. Despite being important initiatives, this has resulted in a stroke system that emphasizes the frontloading of stroke care, focusing on the vascular pathology. The advent of thrombolysis therapy has benefited a small proportion of patients while a vast majority are still affected by stroke-related impairments. Management of the vascular elements of stroke is important; however, the impact of rehabilitation on stroke recovery has been relatively undervalued. Stroke care is in need of a revolution toward a more comprehensive and balanced approach. It is anticipated that the major focus of stroke care will include promoting recovery, in line with the growing evidence on stroke rehabilitation interventions. A paradigm shift is necessary to ensure that comprehensive and balanced stroke care which incorporates rehabilitation is taken into account, leading to a stroke care system where patient needs are managed both as a ‘brain attack’ and an ‘injured brain’.

[Stroke and neuroplasticity]

Characteristics of stroke development and processes of restoration of brain function in post stroke period are considered. The dynamics of neuroplasticity and ambiguity of the involvement of the opposite brain hemisphere in the restoration is highlighted. Special attention is drawn to the time from stroke onset and activation of different brain regions in post stroke period. The importance of neurorehabilitation in these patients is emphasized.

Discriminant validity of a new measure of self-efficacy for reaching movements after stroke-induced hemiparesis

STUDY DESIGN

Case-control study.

INTRODUCTION

After stroke, difficulties in motor control mediate spontaneous paretic arm use in real life. Along with the obvious motor impairments, self-efficacy has been shown to be an important modifier for physical function. However, a self-efficacy measure for arm reaching is lacking. The aim of this study was to develop such a measure and to examine its validity.

METHODS

Fifteen participants with hemiparesis and ten control participants were recruited. A measure of reaching self-efficacy (RSE) was developed using a two-dimensional center-out target array.

RESULTS

For the control group, RSE was significantly correlated with target distance (r = -0.657) and location (r = -0.545), respectively. Additionally, average RSE was lower for the non-dominant than the dominant hand (p < 0.001). More importantly, for the stroke group, RSE was significantly correlated with target distance (r = -0.603) and location (r = -0.378), respectively. Finally, average RSE was lower for the paretic than the non-paretic hand (p < 0.001).

CONCLUSIONS

These results demonstrate robust discriminant validity for this new measure of reaching self-efficacy.

LEVEL OF EVIDENCE

3b.

Effect of early and late rehabilitation onset in a chronic rat model of ischemic stroke- assessment of motor cortex signaling and gait functionality over time

The aim of the present study was to investigate the effects of ischemic stroke and onset of subsequent rehabilitation of gait function in rats. Nine male Sprague-Dawley rats were instrumented with a 16-channel intracortical (IC) electrode array. An ischemic stroke was induced within the hindlimb area of the left motor cortex. The rehabilitation consisted of a repetitive training paradigm over 28 days, initiated on day one ("Early-onset", 5 rats) and on day seven, ("Late-onset", 4 rats). Data were obtained from IC microstimulation tests, treadmill walking tests, and beam walking tests. Results revealed an expansion of the hindlimb representation within the motor cortex area and an increased amount of cortical firing rate modulation for the "Early-onset" group but not for the "Late-onset" group. Kinematic data revealed a significant change for both intervention groups. However, this difference was larger for the "Early-onset" group. Results from the beam walking test showed functional performance deficits following stroke which returned to pre-stroke level after the rehabilitative training. The results from the present study indicate the existence of a critical time period following stroke where onset of rehabilitative training may be more effective and related to a higher degree of true recovery.

Longitudinal Cortical Volume Changes Correlate With Motor Recovery in Patients After Acute Local Subcortical Infarction

Background and Purpose—

Secondary changes in the volume of motor-related cortical regions and the relationship with functional recovery during the acute stage after cerebral infarction have not been determined. In the present study, we quantified changes in gray matter (GM) volume in motor-related cortical regions and analyzed their correlations to clinical scores in patients with focal cerebral infarct.

Methods—

Fifteen patients with acute subcortical infarct underwent longitudinal high-resolution structural MRI and clinical assessment 3 times during a 12-week period (weeks 1, 4, and 12). Fourteen age- and sex-matched controls underwent MRI examination. Voxel-based morphometry was used to quantify changes in global GM volume; in addition, relationships between GM volume changes in volumes of interest and clinical scores were analyzed.

Results—

In patients with cerebral infarction, GM volumes detected by voxel-based morphometry both decreased and increased significantly in diffuse cortical regions during the observation period ( P <0.001). GM volumes within volumes of interest decreased significantly in the ipsilateral supplementary motor area and contralateral insula, but they increased in the contralateral supplementary motor area over time (all P <0.017). The changes of GM volumes in the ipsilesional and contralesional supplementary motor area correlated with the changes in the Fugl–Meyer scale scores (ipsilesional, r s =0.52; P =0.048; contralesional, r s =0.74; P =0.002) and Barthel Index (ipsilesional, r s =0.56; P =0.030; contralesional, r s =0.65; P =0.009).

Conclusions—

These results suggest that secondary GM changes occur in diffuse areas and structural changes in some specific motor-related cortex may inhibit or promote functional recovery after an acute subcortical cerebral infarct.

The epigenetics of stroke recovery and rehabilitation: from polycomb to histone deacetylases

Classical de-afferentation studies, as well as experience-dependent visual plasticity paradigms, have confirmed that both the developing and adult nervous system are capable of unexpected levels of plasticity. This capacity is underscored by the significant spontaneous recovery that can occur in patients with mild-to-moderate impairment following stroke. An evolving model is that an interaction of biological and environmental factors during all epochs post-stroke influences the extent and quality of this plasticity. Here, we discuss data that have implicated specific epigenetic proteins as integrators of environmental influences in 3 aspects of stroke recovery: spontaneous impairment reduction in humans; peri-infarct rewiring in animals as a paradigm for developing therapeutically-driven impairment reduction beyond natural spontaneous recovery; and, finally, classical hippocampal learning and memory paradigms that are theoretically important in skill acquisition for both impairment reduction and compensatory strategies in the rehabilitation setting. Our discussion focuses primarily on B lymphoma Mo-MLV1 insertion region proteins of the polycomb repressive complex, alpha thalassemia/mental retardation syndrome X-linked chromatin remodeling factors, and the best known and most dynamic gene repressors, histone deacetylases. We will highlight exciting current data associated with these proteins and provide promising speculation about how they can be manipulated by drugs, biologics, or noninvasive stimulation for stroke recovery.

Constraint-Induced Movement Therapy Compared to Dose-Matched Interventions for Upper-Limb Dysfunction in Adult Survivors of Stroke: A Systematic Review with Meta-analysis

PURPOSE

To summarize the existing literature examining constraint-induced movement therapy (CIMT), relative to dose-matched control interventions, for upper-limb (UL) dysfunction in adult survivors of stroke.

METHODS

CINAHL, Cochrane Library, Embase, NARIC/CIRRIE-Rehabdata, PEDro, PubMed, Scopus, and Web of Science were searched from their inception to February 2011. Trial quality was described using the PEDro scale. The findings were summarized with meta-analysis.

RESULTS

For the 22 trials identified, the mean (SD) PEDro score was 6.4 (1.2). Meta-analysis showed CIMT to be superior to dose-matched interventions based on indicators of UL motor capacity (15 trials, n=432; standardized mean difference [SMD]=0.47, 95% CI, 0.27-0.66) and UL ability (14 trials, n=352; SMD=0.80, 95% CI, 0.57-1.02); Functional Independence Measure scores (6 trials, n=182; mean difference [MD]=5.05, 95% CI, 2.23-7.87); and Motor Activity Log scores (Amount of Use: 12 trials, n=318; MD=1.05, 95% CI, 0.85-1.24; Quality of Movement: 11 trials, n=330; MD=0.89, 95% CI, 0.69-1.08).

CONCLUSIONS

Compared to control interventions of equal duration and dose, CIMT produced greater improvements in a variety of indicators of UL function in adult survivors of a stroke with residual movement of their upper limb.

Attentional resource allocation during a cued saccade task

Attentional selection of sensory information and motor output is critical for successful interaction with one's surroundings. However, organization of attentional processes involved in selection of salient visual information, decision making, and movement planning has not yet been fully elucidated. We hypothesized that attentional processes involved in these tasks can function independently and draw from separate resources. If true, challenging the capacity limit of one attentional process would not affect performance of others. Healthy participants performed a cued saccade task in which target cues were embedded in a central stream of letters in a Rapid Serial Visual Presentation (RSVP). Participants performed saccades as quickly and as accurately as possible to a peripheral target location based on cue presentation within the central letter stream. To challenge visual attention, we parametrically varied the duration at which each letter of the RSVP was presented (50-200ms). In a separate experiment we challenged motor attention by increasing the number of possible saccade trajectories (1-6 peripheral targets). As expected, increasing attentional load in one domain of the task negatively affected performance in that domain, while performance in other domains was unaffected. We interpret our results as support for the independent allocation of attentional resources, at least in the early stages of processing, required across components of a cued saccade task. Deciphering the contributions of attention during visuomotor tasks is a critical step to understanding how humans process information necessary to successfully interact with the environment.

The effect of altering a single component of a rehabilitation programme on the functional recovery of stroke patients: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of altering a single component of a rehabilitation programme (e.g. adding bilateral practice alone) on functional recovery after stroke, defined using a measure of activity.

DATA SOURCES

A search was conducted of Medline/Pubmed, CINAHL and Web of Science.

REVIEW METHODS

Two reviewers independently assessed eligibility. Randomized controlled trials were included if all participants received the same base intervention, and the experimental group experienced alteration of a single component of the training programme. This could be manipulation of an intrinsic component of training (e.g. intensity) or the addition of a discretionary component (e.g. augmented feedback). One reviewer extracted the data and another independently checked a subsample (20%). Quality was appraised according to the PEDro scale.

RESULTS

Thirty-six studies (n = 1724 participants) were included. These evaluated nine training components: mechanical degrees of freedom, intensity of practice, load, practice schedule, augmented feedback, bilateral movements, constraint of the unimpaired limb, mental practice and mirrored-visual feedback. Manipulation of the mechanical degrees of freedom of the trunk during reaching and the addition of mental practice during upper limb training were the only single components found to independently enhance recovery of function after stroke.

CONCLUSION

This review provides limited evidence to support the supposition that altering a single component of a rehabilitation programme realises greater functional recovery for stroke survivors. Further investigations are required to determine the most effective single components of rehabilitation programmes, and the combinations that may enhance functional recovery.

Management of patients with stroke: is it time to expand treatment options?

Approximately 700,000 people in the United States have an ischemic stroke annually. Substantial research has tested therapies for the very early treatment of ischemic stroke but, to date, only intravenous thrombolysis and intra-arterial measures to restore perfusion have shown success. Despite a 15-year effort to increase the use of these therapies, only approximately 5% of patients with stroke are currently being treated. Although most patients with stroke have some neurological recovery, more than half of stroke survivors have residual impairments that lead to disability or long-term institutionalized care. Laboratory research has demonstrated several mechanisms that help the brain to recover after a stroke. New pharmacological and cell-based approaches that are known to promote brain plasticity are emerging from laboratory studies and may soon expand the window for stroke treatment to restore function. It is time to build on this knowledge and to translate the understanding of recovery after stroke into the clinical setting. Measures that might augment recovery should become a major focus of clinical research in stroke in the 21st century.

Early exercise protects the blood-brain barrier from ischemic brain injury via the regulation of MMP-9 and occludin in rats

Early exercise within 24 h after stroke can reduce neurological deficits after ischemic brain injury. However, the mechanisms underlying this neuroprotection remain poorly understood. Ischemic brain injury disrupts the blood-brain barrier (BBB) and then triggers a cascade of events, leading to secondary brain injury and poor long-term outcomes. This study verified the hypothesis that early exercise protected the BBB after ischemia. Adult rats were randomly assigned to sham, early exercise (EE) or non-exercise (NE) groups. The EE and NE groups were subjected to ischemia induced by middle cerebral artery occlusion (MCAO). The EE group ran on a treadmill beginning 24 h after ischemia, 30 min per day for three days. After three-days’ exercise, EB extravasation and electron microscopy were used to evaluate the integrity of the BBB. Neurological deficits, cerebral infarct volume and the expression of MMP-9, the tissue inhibitors of metalloproteinase-1 (TIMP-1), and occludin were determined. The data indicated that early exercise significantly inhibited the ischemia-induced reduction of occludin, and an increase in MMP-9 promoted TIMP-1 expression (p < 0.01), attenuated the BBB disruption (p < 0.05) and neurological deficits (p < 0.01) and diminished the infarct volume (p < 0.01). Our results suggest that the neuroprotection conferred by early exercise was likely achieved by improving the function of the BBB via the regulation of MMP-9 and occludin.

Rehabilitation with poststroke motor recovery: a review with a focus on neural plasticity

Motor recovery after stroke is related to neural plasticity, which involves developing new neuronal interconnections, acquiring new functions, and compensating for impairment. However, neural plasticity is impaired in the stroke-affected hemisphere. Therefore, it is important that motor recovery therapies facilitate neural plasticity to compensate for functional loss. Stroke rehabilitation programs should include meaningful, repetitive, intensive, and task-specific movement training in an enriched environment to promote neural plasticity and motor recovery. Various novel stroke rehabilitation techniques for motor recovery have been developed based on basic science and clinical studies of neural plasticity. However, the effectiveness of rehabilitative interventions among patients with stroke varies widely because the mechanisms underlying motor recovery are heterogeneous. Neurophysiological and neuroimaging studies have been developed to evaluate the heterogeneity of mechanisms underlying motor recovery for effective rehabilitation interventions after stroke. Here, we review novel stroke rehabilitation techniques associated with neural plasticity and discuss individualized strategies to identify appropriate therapeutic goals, prevent maladaptive plasticity, and maximize functional gain in patients with stroke.

The EXCITE Trial: reacquiring upper-extremity task performance with early versus late delivery of constraint therapy

OBJECTIVE

This study examines performance of Wolf Motor Function Test (WMFT) tasks in terms of the ability of EXCITE trial participants (who had suffered a stroke 3-9 months before recruitment) to complete the task within the timed interval.

METHODS

Data were collected from participants who received constraint-induced movement therapy (CIMT) 3 to 9 months poststroke (CIMT-I, n = 106) or 15 to 21 months poststroke (CIMT-D, n = 116). Performance on the 15 timed WMFT tasks was converted into binary values, and changes in completion of the tasks were analyzed with generalized estimating equation methods, under the assumption of a binomial or Poisson process for completion.

RESULTS

During CIMT, the CIMT-I group showed significant within-group improvements in 3 fine-movement tasks and in total noncompleted tasks (noncompletes), whereas the CIMT-D group did not (P ≤ .0036). CIMT-I improvement was significantly greater than CIMT-D improvement for the lifting pencil task and total noncompletes. During the year following CIMT, neither group showed significant changes in completion of WMFT tasks. Over all time intervals, only the CIMT-I group displayed significant improvement in several tasks and total noncompletes. Between groups, there were significant and almost-significant differences between the improvements of the 2 groups in 3 tasks requiring fine distal movement.

CONCLUSION

Receiving CIMT earlier appears to improve reacquisition and retention of WMFT tasks, especially those requiring fine motor skills. Combined with earlier findings, these results indicate that improvements in existing motor abilities are possible with both immediate and delayed CIMT, but early CIMT is necessary for significant reacquisition of tasks.

Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE): a randomized controlled trial protocol

BACKGROUND

Residual disability after stroke is substantial; 65% of patients at 6 months are unable to incorporate the impaired upper extremity into daily activities. Task-oriented training programs are rapidly being adopted into clinical practice. In the absence of any consensus on the essential elements or dose of task-specific training, an urgent need exists for a well-designed trial to determine the effectiveness of a specific multidimensional task-based program governed by a comprehensive set of evidence-based principles. The Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) Stroke Initiative is a parallel group, three-arm, single blind, superiority randomized controlled trial of a theoretically-defensible, upper extremity rehabilitation program provided in the outpatient setting.The primary objective of ICARE is to determine if there is a greater improvement in arm and hand recovery one year after randomization in participants receiving a structured training program termed Accelerated Skill Acquisition Program (ASAP), compared to participants receiving usual and customary therapy of an equivalent dose (DEUCC). Two secondary objectives are to compare ASAP to a true (active monitoring only) usual and customary (UCC) therapy group and to compare DEUCC and UCC.

METHODS/DESIGN

Following baseline assessment, participants are randomized by site, stratified for stroke duration and motor severity. 360 adults will be randomized, 14 to 106 days following ischemic or hemorrhagic stroke onset, with mild to moderate upper extremity impairment, recruited at sites in Atlanta, Los Angeles and Washington, D.C. The Wolf Motor Function Test (WMFT) time score is the primary outcome at 1 year post-randomization. The Stroke Impact Scale (SIS) hand domain is a secondary outcome measure.The design includes concealed allocation during recruitment, screening and baseline, blinded outcome assessment and intention to treat analyses. Our primary hypothesis is that the improvement in log-transformed WMFT time will be greater for the ASAP than the DEUCC group. This pre-planned hypothesis will be tested at a significance level of 0.05.

DISCUSSION

ICARE will test whether ASAP is superior to the same number of hours of usual therapy. Pre-specified secondary analyses will test whether 30 hours of usual therapy is superior to current usual and customary therapy not controlled for dose.

TRIAL REGISTRATION

www.ClinicalTrials.gov Identifier: NCT00871715

Systematic review and meta-analysis of constraint-induced movement therapy in the hemiparetic upper extremity more than six months post stroke

OBJECTIVE

To conduct a systematic review and meta-analysis of the available evidence on the effectiveness of constraint-induced movement therapy (CIMT) in the hemiparetic upper extremity (UE) among individuals who were more than 6 months post stroke.

METHODS

A literature search of multiple databases (PubMed, CINAHL, and EMBASE) was conducted to identify articles published in the English language up to and including July 2012. Studies were included for review if (1) ≥50% of the sample had sustained a stroke, (2) the research design was a randomized controlled trial (RCT), (3) the mean time since stroke was ≥6 months for both the treated and control groups, (4) the treatment group received CIMT, (5) the control group received a form of traditional rehabilitation, and (6) functional improvement was assessed both pre and posttreatment. Methodological quality was assessed using the PEDro tool with a score out of 10.

RESULTS

Sixteen RCTs (PEDro scores 4-8) met inclusion criteria and included a pooled sample size of 572 individuals with a mean age of 58.2 years (range, 30-87). The meta-analysis revealed a significant treatment effect on the amount of use and quality of movements subscales of the Motor Activity Log ( P < .001, for both), Fugl-Meyer Assessment ( P = .014), and Action Research Arm Test ( P = .001); however, there was no significant treatment effect demonstrated by the Wolf Motor Function Test ( P = .120) or FIM ( P = .070).

CONCLUSIONS

CIMT to improve UE function is an appropriate and beneficial therapy for individuals who have sustained a stroke more than 6 months previously.

Assessment of upper extremity impairment, function, and activity after stroke: foundations for clinical decision making

The purpose of this review is to provide a comprehensive approach for assessing the upper extremity (UE) after stroke. First, common UE impairments and how to assess them are briefly discussed. Although multiple UE impairments are typically present after stroke, the severity of one's impairment, paresis, is the primary determinant of UE functional loss. Second, UE function is operationally defined and a number of clinical measures are discussed. It is important to consider how impairment and loss of function affect UE activity outside of the clinical environment. Thus, this review also identifies accelerometry as an objective method for assessing UE activity in daily life. Finally, the role that each of these levels of assessment should play in clinical decision making is discussed to optimize the provision of stroke rehabilitation services.

Constraint-induced movement therapy: a method for harnessing neuroplasticity to treat motor disorders

Constraint-Induced Movement therapy or CI therapy is an approach to physical rehabilitation elaborated from basic neuroscience and behavioral research with primates. The application of the CI therapy protocol to humans began with the upper extremity after stroke and was then modified and extended to cerebral palsy in young children, traumatic brain injury, and multiple sclerosis. A form of CI therapy was developed for the lower extremities and has been used effectively after stroke, spinal cord injury, fractured hip, multiple sclerosis, and cerebral palsy. Adaptations of the CI therapy paradigm have also been developed for aphasia, focal hand dystonia in musicians, and phantom limb pain. Human and animal studies using a variety of methods provide evidence that CI therapy produces marked neuroplastic changes in the structure and function of the CNS. Moreover, these changes appear to be important for the intervention's therapeutic effect.

When does Stroke Rehabilitation End?

This article examines key evidence on intervention effectiveness late poststroke; provides discussion on how this evidence impacts stroke rehabilitation at a clinical and national level; and explores strategies that should improve the way in which chronic stroke is addressed internationally.

When Should Rehabilitation Begin after Stroke?

Early rehabilitation is widely regarded as an important feature of effective stroke care. But what is ‘early’, and what kinds of therapies should, or can, we begin soon after stroke onset? In this commentary, some of the barriers and drivers for early rehabilitation research and practice are explored.

Functional recovery following stroke: capturing changes in upper-extremity function

BACKGROUND AND PURPOSE

Augmenting changes in recovery is core to the rehabilitation process following a stroke. Hence it is essential that outcome measures are able to detect change as it occurs, a property known as responsiveness. This article critically reviewed the responsiveness of functional outcome measures following stroke, specifically examining tools that captured upper-extremity (UE) functional recovery.

METHODS

A systematic search of the literature was undertaken to identify articles providing responsiveness data for 3 types of change (observed, detectable, and important).

RESULTS

Data from 68 articles for 14 UE functional outcome measures were retrieved. Larger percentage changes were required to be considered important when obtained through anchor-based methods (eg, based on patient opinion or comparative measure) compared with distribution methods (eg, statistical estimates). Larger percentage changes were required to surpass the measurement error for patient-perceived functional measures (eg, Motor Activity Log) compared with laboratory-based performance measures (eg, Action Research Arm Test). The majority of rehabilitation interventions have similar effect sizes on patient-perceived UE function and laboratory-based UE function.

CONCLUSIONS

The magnitude of important change or change that surpasses measurement error can vary substantially depending on the method of calculation. Rehabilitation treatments can affect patient perceptions of functional change as effectively as laboratory-based functional measures; however, larger sample sizes may be required to account for the larger measurement error associated with patient-perceived functional measures.

Influence of constraint-induced movement therapy upon evoked potentials in rats with cerebral infarction

Constraint-induced movement therapy (CIMT) is an effective treatment promoting motor recovery of upper extremity function in stroke patients. The objective of the present study was to determine the effect of CIMT on the evoked potentials in rats with focal cerebral cortical ischemia induced by endothelin-1 (ET-1). Thirty rats were randomly assigned to the sham, infarct or CIMT groups. ET-1 was injected stereotaxically into the forelimb area of the cerebral cortex in the dominant hemisphere. Custom-made constraint jackets were applied to limit movement of the unaffected forelimb in the CIMT group. Motor and sensory function of the forelimb was evaluated by a pellet retrieval task and forearm asymmetry test. Electrophysiologic changes were evaluated by motor-evoked potentials (MEPs) and somatosensory-evoked potentials (SEPs). The location and extent of cerebral ischemia were confirmed and compared histologically. The CIMT group showed better recovery in the pellet retrieval task. Forelimb use was more symmetrical in the CIMT group. The waveform of the SEP was reversed and delayed in the infarct group, but it was preserved in the CIMT group with amplitude decrease only. The estimated volume of infarction was smaller in the CIMT group, although statistically not significant. The results demonstrate that CIMT can promote recovery of motor function in focal cerebral cortical infarcts, and that recovery may be related to reorganization of the cerebral neuronal network in the somatosensory pathway.

Observation-to-Imitate Plus Practice Could Add Little to Physical Therapy Benefits Within 31 Days of Stroke

Background and Purpose. Observation of action with intention-to-imitate (OTI) might enhance motor recovery. This early phase trial investigated whether OTI followed by physical practice (OTI + PP) enhanced the benefits of conventional physical therapy (CPT) on upper limb recovery early after stroke. Methods. Participants were 3 to 31 days poststroke. They had substantial paresis and ability to imitate action with their ipsilesional arm. After baseline measures, participants were randomized to either OTI + PP in addition to CPT or to CPT only. Outcome measures were made after 15 days of treatment. The measurement battery was the Motricity Index (MI) and the Action Research Arm Test (ARAT). Change, baseline to outcome, was examined using the Wilcoxon test for within group and Mann–Whitney U test for between groups. Results. Sixty-five of 570 stroke survivors were eligible, 55 were able to imitate, 37 gave informed consent, 7 were transferred out of area before baseline, and 29 were randomized. Outcome measures were completed with 13 CPT participants and 9 OTI + PP participants. Both groups showed statistically significant improvements for the MI (CPT median change 8, P = .003; OTI + PP median change 10, P = .012) but the median (95% confidence interval [CI]) between-group difference was 0.0 (−11, 16), P = 1.000. For the ARAT, only the CPT group showed a statistically significant improvement (median 9, P = .006). The median (95% CI) between-group difference of 1.0 (−18, 23) was not statistically significant ( P = .815). Conclusions. These findings suggest that OTI + PP might add little to the benefits of CPT early after stroke.

Improvement after constraint-induced movement therapy: recovery of normal motor control or task-specific compensation?

BACKGROUND

Constraint-induced movement therapy (CIMT) has proven effective in increasing functional use of the affected arm in patients with chronic stroke. The mechanism of CIMT is not well understood.

OBJECTIVE

To demonstrate, in a proof-of-concept study, the feasibility of using kinematic measures in conjunction with clinical outcome measures to better understand the mechanism of recovery in chronic stroke patients with mild to moderate motor impairments who undergo CIMT.

METHODS

A total of 10 patients with chronic stroke were enrolled in a modified CIMT protocol over 2 weeks. Treatment response was assessed with the Action Research Arm Test (ARAT), the Upper-Extremity Fugl-Meyer score (FM-UE), and kinematic analysis of visually guided arm and wrist movements. All assessments were performed twice before the therapeutic intervention and once afterward.

RESULTS

There was a clinically meaningful improvement in ARAT from the second pre-CIMT session to the post-CIMT session compared with the change between the 2 pre-CIMT sessions. In contrast, FM-UE and kinematic measures showed no meaningful improvements.

CONCLUSIONS

Functional improvement in the affected arm after CIMT in patients with chronic stroke appears to be mediated through compensatory strategies rather than a decrease in impairment or return to more normal motor control. We suggest that future large-scale studies of new interventions for neurorehabilitation track performance using kinematic analyses as well as clinical scales.

Modified constraint-induced movement therapy improved upper limb function in subacute poststroke patients: a small-scale clinical trial

BACKGROUND

Constraint-induced movement therapy (CIMT) has been advocated as a means of facilitating motor function in poststroke patients; however, the evidence for its efficacy is controversial.

OBJECTIVE

To evaluate the effect of modified CIMT on improving paretic arm function in poststroke patients during a subacute rehabilitation period.

METHODS

A single-blinded randomized controlled trial was conducted at the Loewenstein Rehabilitation Hospital, Israel. Twenty-eight subacute stroke patients with arm paresis after a first ischemic stroke in the middle cerebral artery area were randomized into a modified CIMT or control group by a 1:2 ratio. The modified CIMT group received 1-hour daily physical rehabilitation sessions for 2 weeks. The unaffected arm was restrained during the sessions. Subjects were encouraged to wear a restrictive mitten up to 4 hours a day. The control group received similar intensive regular rehabilitation. Three upper limb function tests, developed for this study, were used as outcome measures. The subjects were asked to perform the following tasks, with the affected hand for 30 seconds: (1) transfer pegs from a saucer to a pegboard; (2) grasp, carry, and release a hard rubber ball; and (3) "eating," using a spoon to remove the jelly from the plate, bring it towards the mouth, and then place it on another plate. The number of repetitions in each test was recorded as an outcome.

RESULTS

The modified CIMT group showed significantly higher changes in all 3 tests compared to the standard rehabilitation group.

CONCLUSION

Our study provides additional support for the use of modified CIMT during a subacute rehabilitation period of poststroke patients. CIMT may facilitate functional improvement of a plegic hand.

Therapy incorporating a dynamic wrist-hand orthosis versus manual assistance in chronic stroke: a pilot study

BACKGROUND AND PURPOSE

The purpose of this study was to compare the effect of therapy using a wrist-hand orthosis (WHO) versus manual-assisted therapy (MAT) for individuals with chronic, moderate-to-severe hemiparesis. The relationship between the repetitions during therapy and functional change was also examined.

METHODS

Nineteen participants were randomly assigned to either the WHO group (n = 10) or the MAT group (n = 9). The WHO group performed therapy while wearing a dynamic WHO (SaeboFlex), the MAT group performed therapy with manual assistance of a therapist. Both groups participated in 1 hour of therapy per week for 6 weeks and were prescribed exercises to perform at home 4 days per week. Pre- and posttraining assessments included grip strength, the Action Research Arm Test (ARAT), Box and Blocks (B&B) test, and Stroke Impact Scale (SIS).

RESULTS

There were no significant between-group differences for any of the measures. Within-group differences showed that the WHO group had a significant improvement in the ARAT score (mean = 2.2; P = 0.04). The MAT group had a significant improvement on the percent recovery on the SIS (mean = 9.3%; P = 0.03) and approached a significant improvement on the ARAT (mean = 1.4; P = 0.08). When analyzing all participants together, the relationship between the number of exercise repetitions and functional improvement was moderate for the ARAT and the B&B test (r = 0.55, P = 0.02, and r = 0.30, P = 0.10, respectively).

DISCUSSION AND CONCLUSIONS

Small improvements in function and perception of recovery were observed in both groups, with no definite advantage of the WHO. This study adds to the evidence that individuals with chronic stroke can improve arm use with therapy incorporating functional hand training, and that there is a relationship between amount of change and amount of practice.

Exploring the efficacy of constraint in animal models of stroke: meta-analysis and systematic review of the current evidence

BACKGROUND

Constraint-induced movement therapy (CIMT) is used to counteract learned nonuse observed following stroke in humans and has been shown to improve function. Variations of CIMT used in animal models of stroke have the potential to inform and improve our understanding of this intervention.

OBJECTIVE

To conduct a systematic review of studies investigating constraint in experimental stroke. The authors aimed to assess the quality and establish the efficacy of constraint on neurobehavior, cognitive function, infarct size, and stress and mortality and to determine the optimal dose or time to administration.

METHODS

Systematic review with meta-analysis was used. Data were analyzed using DerSimonian and Laird weighted-mean-difference random effects meta-analysis.

RESULTS

The quality scores of the 8 articles (15 studies) included were moderate (median 5/10; interquartile range, 4.8-6.0). There was a trend for animals with constraint to have worse neurobehavioral scores (-10% worse; 95% confidence interval [CI] = -20 to 0; P = .06). Infarct volumes were not significantly different between groups (-3% larger with constraint; 95% CI = -15 to 9; P = .63). Cognitive function was significantly better after constraint, although this estimate was based on only 28 animals from 2 studies. Insufficient data prevented analysis of the effect of constraint on stress and mortality.

CONCLUSIONS

This meta-analysis showed no benefit of constraint on neurobehavioral scores, which is at odds with some human studies. Animal models may help us efficiently explore the biological basis of rehabilitation interventions; however, review of the data in this study raise uncertainty about its effectiveness in humans.

Reduced-intensity modified constraint-induced movement therapy versus conventional therapy for upper extremity rehabilitation after stroke: a multicenter trial

BACKGROUND

Constraint-induced movement therapy (CIMT) is a rehabilitation approach for arm paresis consisting of an intensive schedule of treatment (6 h/d). The high demand of resources for CIMT is a critical issue for its implementation in the Italian health system.

OBJECTIVE

To compare the effects of a reduced-intensity modified CIMT (mCIMT) program that included splinting the unaffected arm for 12 hours daily with the effects of a conventional rehabilitation program for arm paresis in patients with stroke.

METHODS

Sixty-six participants with hemiparesis (3-24 months poststroke) who could extend the wrist and several fingers at least 10° were randomly assigned to mCIMT or conventional rehabilitation. Each group underwent 10 (2 h/d) treatment sessions (5 d/wk for 2 weeks). Patients were assessed with the Wolf Motor Function Test (WMFT-FA and WMFT-T), the Motor Activity Log (MAL-AOU and MAL-QOM), and the Ashworth Scale before and after treatment and 3 months later.

RESULTS

Between-groups analysis showed that the mCIMT group overall had greater improvement than the control group in terms of the WMFT-FA (P = .010), MAL-AOU (P < .001), and MAL-QOM (P < .001). Differences between groups were significant both after treatment (P < .01) and at the 3-month follow-up (P < .01), although 40% of participants did not complete the 3-month assessment. Furthermore, the mCIMT group showed a greater decrease of Ashworth Scale score than the control group at 3 months (P = .021).

CONCLUSION

Two hours of CIMT may be more effective than conventional rehabilitation in improving motor function and use of the paretic arm in patients with chronic stroke.

Effects of sling and voluntary constraint during constraint-induced movement therapy for the arm after stroke: a randomized, prospective, single-centre, blinded observer rated study

OBJECTIVE

To determine whether a combination of constraint-induced movement therapy and physiotherapy in stroke patients using different constraint regimens (sling versus voluntary constraint) changes or reduces motor deficits, the amount of functional use of the arm and whether the effects of treatment continue after 12 months.

DESIGN

Forty-seven stroke patients were stratified and randomly divided into intensive physiotherapy programmes focused on regaining arm functions.

SETTING

Neurorehabilitation Unit of IInd Department of Neurology at Institute of Psychiatry and Neurology in Warsaw.

SUBJECT

Patients were randomly allocated to: the sling-constraint group (n = 24) or to the voluntary-constraint group (n = 23).

INTERVENTIONS

Massed practice with the paretic arm (5 hours/day for 15 consecutive working days). Sling-constraint group had their arm immobilized in a hemi-sling during therapy. In addition, individual, 1-hour physiotherapy sessions were conducted in both groups.

MAIN MEASURES

Rivermead Motor Assessment (RMA) Arm scale, (0-15), Motor Activity Log - Quality of Movement (MAL-QOM) (0-5 for 30 daily tasks).

RESULTS

There was no significant difference between groups after therapy (MAL-QOM mean change for sling group 0.78, SD = 0.46 and for voluntary-constraint group 0.84, SD = 0.48; P = 0.687). All treated patients retained mean gains in real-world arm use (MAL-QOM) mean scores after 12 months follow-up compared with posttreatment values but there was no significant difference between groups (comparison of estimated mean change of MAL-QOM stated 0.23. 95% confidence interval = -0.04-0.50).

CONCLUSION

Voluntary activity constraint in the intact arm is equivalent to sling, standard constraint during massed practice of paretic arm.

Barriers to the implementation of constraint-induced movement therapy into practice

BACKGROUND AND PURPOSE

Constraint-induced movement therapy (CIMT) has been studied for many years in the treatment of the hemiplegic upper extremity (UE). However, there has been limited adoption of the protocol in daily practice.

METHODS

In this article, we review the CIMT literature specifically for meta-analysis, randomized controlled trials (RCTs), recent case reports, case series, and pilot studies of CIMT in the adult poststroke population to identify barriers to implementation.

RESULTS

The following barriers have been identified: (a) limited generalizability, (b) resource intensity, (c) therapist factors, (d) patient factors, and (e) uncertainty regarding the emerging debate that the gains seen may be a result of intense, task-specific therapy focused on the use of the more affected UE and not specific to the protocol.

CONCLUSIONS

CIMT has positive outcomes in the treatment of a select group of stroke survivors. Many national guidelines of stroke rehabilitation recommend that CIMT be used when appropriate, however adoption into practice has been limited. The issue of generalizability is being addressed by expanding protocol application to other populations. Resource intensity, with respect to cost and therapist time, is a major concern and has lead to the development of novel modes of service delivery. The benefit seen with CIMT may actually be the result of exposure to intense, task-specific therapy with a focus on the use of the more affected UE, but more research into this area is needed.

Constraint-induced therapy with trunk restraint for improving functional outcomes and trunk-arm control after stroke: a randomized controlled trial

BACKGROUND

Studies have suggested that constraint-induced therapy combined with trunk restraint (CIT-TR) improves arm movement and reduces trunk compensation. Whether participants who receive CIT-TR can translate the benefits to real-life circumstances awaits further investigation.

OBJECTIVE

The effects of distributed CIT-TR (dCIT-TR) on motor function, daily function, quality of life (QOL), and arm-trunk control were investigated.

DESIGN

The study was a single-blind, randomized controlled trial.

SETTING

The study took place at 4 hospitals.

PARTICIPANTS

Participants were 57 people who had had a stroke 6 to 55 months earlier.

INTERVENTION

Participants received a dose-matched intervention (2 hours per day, 5 days per week, for 3 weeks) of dCIT-TR, distributed constraint-induced therapy (dCIT), or control therapy.

MEASUREMENTS

The Action Research Arm Test (ARAT), Motor Activity Log, Frenchay Activities Index (FAI), and Stroke Impact Scale (SIS) were used to evaluate motor function, daily function, and QOL. Data for reaching kinematics were recorded.

RESULTS

Participants receiving dCIT-TR and dCIT exhibited higher overall scores on the ARAT, FAI, and hand function domain of the SIS and better quality of movement and larger amount of use (of the affected arm) on the Motor Activity Log than participants in the control group. Participants receiving dCIT-TR further demonstrated greater improvements on the ARAT grip subscale and FAI outdoor activities scale than participants receiving dCIT or participants in the control group. However, participants receiving dCIT showed greater improvements on the strength domain of the SIS after training than participants receiving dCIT-TR or participants in the control group. Limitations Research with a larger sample size is needed.

CONCLUSIONS

Participants who received dCIT-TR were able to translate gains in arm-trunk control into functional performance and QOL, specifically in grip function and outdoor activities. A long-term study to examine the recovery course for force output may be needed to evaluate people's perception of less improvement in strength after dCIT-TR.

Getting neurorehabilitation right: what can be learned from animal models?

Animal models suggest that a month of heightened plasticity occurs in the brain after stroke, accompanied by most of the recovery from impairment. This period of peri-infarct and remote plasticity is associated with changes in excitatory/inhibitory balance and the spatial extent and activation of cortical maps and structural remodeling. The best time for experience and training to improve outcome is unclear. In animal models, very early (<5 days from onset) and intense training may lead to increased histological damage. Conversely, late rehabilitation (>30 days) is much less effective both in terms of outcome and morphological changes associated with plasticity. In clinical practice, rehabilitation after disabling stroke involves a relatively brief period of inpatient therapy that does not come close to matching intensity levels investigated in animal models and includes the training of compensatory strategies that have minimal impact on impairment. Current rehabilitation treatments have a disappointingly modest effect on impairment early or late after stroke. Translation from animal models will require the following: (1) substantial increases in the intensity and dosage of treatments offered in the first month after stroke with an emphasis on impairment; (2) combinational approaches such as noninvasive brain stimulation with robotics, based on current understanding of motor learning and brain plasticity; and (3) research that emphasizes mechanistic phase II studies over premature phase III clinical trials.

Motor Activity Log-Brazil: reliability and relationships with motor impairments in individuals with chronic stroke

The Motor Activity Log (MAL) assesses the spontaneous use of the most affected upper limb with the amount of use (AOU) and quality of movement (QOM) scales during daily activities in real environments in individuals with chronic stroke. Objectives: This study translated the testing manual into Portuguese and assessed the inter-rater and test-retest reliabilities of the MAL, based upon the Brazilian manual version. Methods: The inter-rater reliability was evaluated by comparing the results of two examiners, and the test-retest reliability was tested by comparing the results of two evaluations, repeated one-week apart with 30 individuals with chronic hemiparesis (55.8±15.1 years). Results: The intra-class correlation coefficients (ICCs) for the total scores were adequate for both the inter-rater (0.98 for the AOU and 0.91 for QOM) and test-retest reliabilities (0.99 for both scales). Conclusions: The results suggested that the MAL was reliable to evaluate the spontaneous use of the most affected upper limb after stroke.

Constraint-induced movement therapy for the upper paretic limb in acute or sub-acute stroke: a systematic review

Constraint-induced movement therapy is a commonly used intervention to improve upper limb function after stroke. However, the effectiveness of constraint-induced movement therapy and its optimal dosage during acute or sub-acute stroke is still under debate. To examine the literature on the effects of constraint-induced movement therapy in acute or sub-acute stroke. A literature search was performed to identify randomized, controlled trials; studies with the same outcome measure were pooled by calculating the mean difference. Separate quantitative analyses for high-intensity and low-intensity constraint-induced movement therapy were applied when possible. Five randomized, controlled trials were included, comprising 106 participants. The meta-analysis demonstrated significant mean differences in favor of constraint-induced movement therapy for the Fugl-Meyer arm, the Action Research Arm Test, the Motor Activity Log, Quality of Movement and the Grooved Pegboard Test. Nonsignificant mean difference in favor of constraint-induced movement therapy were found for the Motor Activity Log, Amount of Use. Separate analyses for high-intensity and low-intensity constraint-induced movement therapy resulted in significant favorable mean differences for low-intensity constraint-induced movement therapy for all outcome measures, in contrast to high-intensity constraint-induced movement therapy. This meta-analysis demonstrates a trend toward positive effects of high-intensity and low-intensity constraint-induced movement therapy in acute or sub-acute stroke, but also suggests that low-intensity constraint-induced movement therapy may be more beneficial during this period than high-intensity constraint-induced movement therapy. However, these results were based on a small number of studies. Therefore, more trials are needed applying different doses of therapy early after stroke and a better understanding is needed about the different time windows in which underlying mechanisms of recovery operate.

Bobath Concept versus constraint-induced movement therapy to improve arm functional recovery in stroke patients: a randomized controlled trial

OBJECTIVE

To compare the effects of the Bobath Concept and constraint-induced movement therapy on arm functional recovery among stroke patients with a high level of function on the affected side.

DESIGN

A single-blinded, randomized controlled trial.

SETTING

Outpatient physiotherapy department of a stroke unit.

SUBJECTS

A total of 24 patients were randomized to constraint-induced movement therapy or Bobath Concept group.

INTERVENTION

The Bobath Concept group was treated for 1 hour whereas the constraint-induced movement therapy group received training for 3 hours per day during 10 consecutive weekdays.

MAIN MEASURES

Main measures were the Motor Activity Log-28, the Wolf Motor Function Test, the Motor Evaluation Scale for Arm in Stroke Patients and the Functional Independence Measure.

RESULTS

The two groups were found to be homogeneous based on demographic variables and baseline measurements. Significant improvements were seen after treatment only in the 'Amount of use' and 'Quality of movement' subscales of the Motor Activity Log-28 in the constraint-induced movement therapy group over the the Bobath Concept group (P = 0.003; P = 0.01 respectively). There were no significant differences in Wolf Motor Function Test 'Functional ability' (P = 0.137) and 'Performance time' (P = 0.922), Motor Evaluation Scale for Arm in Stroke Patients (P = 0.947) and Functional Independence Measure scores (P = 0.259) between the two intervention groups.

CONCLUSIONS

Constraint-induced movement therapy and the Bobath Concept have similar efficiencies in improving functional ability, speed and quality of movement in the paretic arm among stroke patients with a high level of function. Constraint-induced movement therapy seems to be slightly more efficient than the Bobath Concept in improving the amount and quality of affected arm use.