Constraint-induced movement therapy for motor recovery in chronic stroke patients

Global research hotspots and trends in constraint-induced movement therapy in rehabilitation over the past 30 years: a bibliometric and visualization study

Background

Stroke is a cerebrovascular disease with high prevalence and mortality, and upper limb hemiparesis is a major factor limiting functional recovery in stroke patients. Improvement of motor function in stroke patients through various forms of constraint-induced movement therapy (CITM) has been recognized as safe and effective in recent years. This research field lacks a comprehensive systematic and clear vein combing analysis, analyzing the literature research of CIMT in the field of rehabilitation in the past three decades, summarizing the research hotspots and cutting-edge trends in this field, in an effort to offer ideas and references for subsequent researchers.

Methods

Relevant literature on CIMT in rehabilitation was collected from 1996 to 2024 within the Web of Science database's core dataset by using CiteSpace6.1, VOSviewer1.6.18, R-bibliometrix4.6.1, Pajek5.16, Scimago Graphica 1.0.26 software for visualization and analysis.

Results

There were 970 papers in all United States was ranked first with 401 papers. Alabama Univ was ranked first for institutions with 53 papers. Neurorehabilitation and Neural Repair was ranked first for journals with 78 papers, and Taub E was ranked first for author publications with 64 papers. Research keywords were CIMT, stroke rehabilitation, upper extremity function, lower extremity gait balance, randomized controlled trials, physical therapy techniques (transcranial magnetic stimulation and sensory amplitude electrical stimulation), primary motor cortex plasticity, lateral dominance (spatial behaviors), cerebral vascular accidents, activities of daily living, hand function, disability, functional restoration, bimanual training, aphasia, acquired invalidity, type A Botulinum toxin and joystick riding toys.

Conclusion

The current state of research shows that CIMT still has a vast potential for development in the field of rehabilitation research. The research hotspots are the clinical efficacy of CIMT combined with other therapies (botulinum toxin type A, transcranial direct current stimulation, virtual reality, mirror therapy, robotic-assisted) to enhance the functionality of upper limb hemiparesis in stroke patients, the mechanism of CIMT to improve the plasticity of the motor cortex through electrophysiological and imaging methods, and improvement of lower limb gait balance function in stroke patients and aphasia applications, the optimal intervention time and dose, and exploration of CIMT in new settings such as robot-assisted, telemedicine, and home rehabilitation.

Design and Performance Analysis of a Mecanum-Built Perturbation-Based Balance Training Device

This study proposes a mecanum-built perturbation-based balance training device aimed at improving motor adaptive skills for fall prevention in individuals with neurological disorders or the elderly. Incorporating multidirectional fall simulations in line with modified constraint-induced movement therapy, the device's efficacy was evaluated by measuring the distance traveled and peak acceleration under different static loads (20, 30, and 40 kg) and input accelerations (1, 2, and 3 m/s2). A pilot study with 10 subjects was conducted to assess device performance, utilizing repeated measures analysis of variance and Bonferroni's post hoc analysis. Results indicated a load-dependent reduction in distance traveled, with an average mean difference of 0.74-1.23 cm between the 20 and 40 kg loads for trials of 9 and 18 cm, respectively. Despite varying loads, the device consistently achieved near-anticipated peak accelerations, suggesting its capability to induce effective perturbations. The study also observed a significant lateral movement preference, suggesting adjustments to pulse width modulation and time period may optimize lateral movement performance.

Minimal Clinically Important Difference of Scales Reported in Stroke Trials: A Review

There is a growing awareness of the significance of using minimum clinically important differences (MCIDs) in stroke research. An MCID is the smallest change in an outcome measure that is considered clinically meaningful. This review is the first to provide a comprehensive summary of various scales and patient-reported outcome measures (PROMs) used in stroke research and their MCID values reported in the literature, including a concise overview of the concept of and methods for determining MCIDs in stroke research. Despite the controversies and limitations surrounding the estimation of MCIDs, their importance in modern clinical trials cannot be overstated. Anchor-based and distribution-based methods are recommended for estimating MCIDs, with patient self-evaluation being a crucial component in capturing the patient's perspective on their health. A combination of methods can provide a more comprehensive understanding of the clinical relevance of treatment effects, and incorporating the patient's perspective can enhance the care of stroke patients.

A Cross-Sectional Study on Fall Direction and Lower Limb Loading in Response to a Perturbation on Laterally Inclined Platform

Perturbation-based balance training (PBT) improves reactive stepping in older adults and people with neurological disorders. Slip-induced falls are a threat to older adults, leading to hip fractures. Fall-prone individuals must be trained to regain balance during a fall in the posterolateral direction. This study aims to analyze the characteristics of the reactive step induced by a laterally inclined platform. This cross-sectional study included 46 healthy participants who performed a "lean and release" backward fall using a platform with two inclined angles on each side. Kinovea software was used to analyze the step width. Reactive steps, characterized by crossover or medial foot placement, are preventive measures against posterolateral falls. The first objective was on the narrowed step width that was subjected to analysis using analysis of variance (ANOVA) and Tukey's post hoc assessment, indicating a tendency toward posterolateral falls. As part of our second objective, the inclined platform resulted in uneven loading between the legs, with a preference for the unloaded leg as the reactive leg (p < 0.001), as determined by Fisher's exact test and Cramer's V. These characteristics align closely with those observed in modified constraint-induced movement therapy (mCIMT). The angled platform had a significant effect on selecting the reactive leg, particularly at higher angles (p < 0.001). Thus, the study suggested that the device is capable of inducing posterolateral falls and exhibited mCIMT characteristics.

Enhanced phasic sensory afferents paired with controlled constraint force improve weight shift toward the paretic side in individuals post-stroke

PURPOSE

The goal of this study was to determine whether enhanced phasic sensory afferent input paired with the application of controlled constraint force during walking would improve weight shift toward the paretic side and enhance use of the paretic leg.

METHODS

Fourteen stroke survivors participated in two experimental conditions, sessions that consisted of 1 min treadmill walking without force and stimulation (baseline), 7 min walking with either "constraint force and sensory stimulation (constraint+stim)" or "constraint force only (constraint)" (adaptation), and then 2 min walking without force and stimulation (post-adaptation). Kinematics of the pelvis and legs, and muscle activity of the paretic leg were recorded.

RESULTS

Participants showed greater increases in hip abductor (p < 0.001) and adductor (p = 0.04) muscle activities, weight shift toward the paretic side (p = 0.002), and step length symmetry (p < 0.01) during the late post-adaptation period in the "constraint+stim" condition, compared with the effect of the "constraint" condition. In addition, changes in overground walking speed from baseline to 10 min post treadmill walking was significantly greater for the "constraint force and stimulation" condition than for the "constraint force only" condition (p = 0.04).

CONCLUSION

Enhanced targeted sensory afferent input during locomotor training may facilitate recruitment of targeted muscles of the paretic leg and facilitate use-dependent motor learning of locomotor tasks, which might retain longer and partially transfer from treadmill to overground walking, in stroke survivors.

Gaze-contingent display technology can help to reduce the ipsilesional attention bias in hemispatial neglect following stroke

Background

Hemispatial neglect results from unilateral brain damage and represents a disabling unawareness for objects in the hemispace opposite the brain lesion (contralesional). The patients’ attentional bias for ipsilesional hemispace represents a hallmark of neglect, which results from an imbalanced attentional priority map in the brain. The aim of this study was to investigate whether gaze-contingent display (GCD) technology, reducing the visual salience of objects in ipsilesional hemispace, is able to rebalance this map and increase awareness and exploration of objects in the neglected contralesional hemispace.

Methods

Using remote eye-tracking, we recorded gaze positions in 19 patients with left hemispatial neglect following right-hemisphere stroke and 22 healthy control subjects, while they were watching static naturalistic scenes. There were two task conditions, free viewing (FV) or goal-directed visual search (VS), and four modification conditions including the unmodified original picture, a purely static modification and two differently strong modifications with an additional gaze-contingent mask (GC-LOW, GC-HIGH), that continuously reduced color saturation and contrast of objects in the right hemispace.

Results

The patients’ median gaze position (Center of Fixation) in the original pictures was markedly deviated to the right in both tasks (FV: 6.8° ± 0.8; VS: 5.5° ± 0.7), reflecting the neglect-typical ipsilesional attention bias. GC modification significantly reduced this bias in FV (GC-HIGH: d = − 3.2 ± 0.4°; p < 0.001). Furthermore, in FV and VS, GC modification increased the likelihood to start visual exploration in the (neglected) left hemifield by about 20%. This alleviation of the ipsilesional fixation bias was not associated with an improvement in detecting left-side targets, in contrast, the GC mask even decreased and slowed the detection of right-side targets. Subjectively, patients found the intervention pleasant and most of the patients did not notice any modification.

Conclusions

GCD technology can be used to positively influence visual exploration patterns in patients with hemispatial neglect. Despite an alleviation of the neglect-related ipsilesional fixation bias, a concomitant functional benefit (improved detection of contralesional targets) was not achieved. Future studies may investigate individualized GCD-based modifications as augmented reality applications during the activities of daily living.

The Predictive Role of Hand Section of Fugl–Meyer Assessment and Motor Activity Log in Action Research Arm Test in People With Stroke

Background:

Recent findings of clinical studies have demonstrated a significant positive relationship between Fugl–Meyer Assessment of upper extremity score and the action research arm test (ARAT) score in people with stroke. Although the motor activity log (MAL) can assess the self-perception of motor performance, which can affect the performance of the upper limb, the relationship between MAL score and ARAT score still remains unclear. The objective of this study is to quantify the independent contribution of MAL score and FMA-hand score on the ARAT score in people with stroke.

Methods

This is a cross-sectional study. There were a total of 87 subjects (50 males, 37 females; mean age = 61.12 ± 6.88 years, post-stroke duration=6.31 ± 2.84 years) included in this study. Self-perceived performance in using the paretic limb was measured by MAL, including subscale of the amount of usage (MAL-AOU) and quality of movement (MAL-QOM). Functional performance of the upper limb was measured by action research arm test (ARAT). Upper limb motor control of the hand was measured by hand section of Fugl–Meyer assessment (FMA-hand).

Results

The result showed that MAL-QOM (r = 0.648, p < 0.001), MAL-AOU (r = 0.606, p < 0.001), FMA-hand scores (r = 0.663, p < 0.001), and the use of a walking aid (r = −0.422, p < 0.001) were significantly correlated with the ARAT scores. A total 66.9% of the variance in the ARAT scores was predicted by the final regression model including MAL-QOM, MAL-AOU, FMA-hand scores, and walking aid. The FMA-hand score was the best predictor of ARAT scores, which can predict a 36.4% variance of ARAT scores in people with stroke, which controlled the effect of using a walking aid. After controlling for use of a walking aid and FMA-hand scores, the multiple linear regression modeling showed that MAL-QOM and MAL-AOU scores could also independently predict an additional 10.4% of the variance in ARAT scores.

Conclusion

In addition to the FMA-hand score, the MAL score was significantly correlated with the ARAT score. Improving self-perceived performance should be one goal of rehabilitation in people with stroke. Further work developing and testing techniques to do so is clearly warranted.

Upper extremity self-efficacy correlates with daily hand-use of individuals with high functional capacity post-stroke

PURPOSE

To understand the role of affected upper extremity (UE) self-efficacy for explaining daily-hand-use in individuals post-stroke. Specifically, to describe UE self-efficacy and to assess the associations between UE self-efficacy to UE motor and functional capacity and daily hand-use.

MATERIALS AND METHODS

This cross-sectional study included individuals post-stroke receiving rehabilitation with high UE functional capacity [Action Research Arm Test (ARAT) > 50]. The Rating of Everyday Arm-Use in the Community and Home (REACH) assessed perceived UE daily use and the Confidence in Arm and Hand Movement scale (CAHM) assessed UE self-efficacy. Functional capacity was assessed by the ARAT and the Fugl-Meyer-motor-assessment assessed motor impairment. Correlations between measures were assessed.

RESULTS

Twenty-two individuals, aged 19-80, with high UE functional capacity [median (IQR) ARAT-56.5 (54-57)] and varying UE self-efficacy [median (IQR) CAHM-76.7 (58-84.4)], were included. UE self-efficacy was significantly correlated with the ARAT (r_s = 0.53, p < 0.01) and REACH (r_s = 0.51, p < 0.01) but ARAT was not significantly correlated with REACH.

CONCLUSIONS

UE self-efficacy is correlated with perceived daily hand-use in individuals with high functional capacity. Further research and a deeper understanding of the clinical implications of UE self-efficacy are warranted. UE self-efficacy should perhaps be assessed during rehabilitation. IMPLICATIONS FOR REHABILITATIONIndividuals with stroke with high affected upper extremity functional capacity do not necessarily use this hand for daily living.Upper extremity self-efficacy is correlated with perceived daily hand-use in individuals with high functional capacity; participants with higher upper extremity self-efficacy also reported more daily hand-use.Upper extremity self-efficacy seems to be upper extremity task or situation-specific.Upper extremity self-efficacy should be assessed during rehabilitation and the clinical implications of (low) upper extremity self-efficacy should be further researched.

Activities of Daily Living-based Rehabilitation System for Arm and Hand Motor Function Retraining after Stroke

Most stroke survivors have difficulties completing activities of daily living (ADLs) independently. However, few rehabilitation systems have focused on ADLs-related training for gross and fine motor function together. We propose an ADLs-based serious game rehabilitation system for the training of motor function and coordination of both arm and hand movement where the user performs corresponding ADLs movements to interact with the target in the serious game. A multi-sensor fusion model based on electromyographic (EMG), force myographic (FMG), and inertial sensing was developed to estimate users' natural upper limb movement. Eight healthy subjects and three stroke patients were recruited in an experiment to validate the system's effectiveness. The performance of different sensor and classifier configurations on hand gesture classification against the arm position variations were analyzed, and qualitative patient questionnaires were conducted. Results showed that elbow extension/flexion has a more significant negative influence on EMG-based, FMG-based, and EMG+FMG-based hand gesture recognition than shoulder abduction/adduction does. In addition, there was no significant difference in the negative influence of shoulder abduction/adduction and shoulder flexion/extension on hand gesture recognition. However, there was a significant interaction between sensor configurations and algorithm configurations in both offline and real-time recognition accuracy. The EMG+FMG-combined multi-position classifier model had the best performance against arm position change. In addition, all the stroke patients reported their ADLs-related ability could be restored by using the system. These results demonstrate that the multi-sensor fusion model could estimate hand gestures and gross movement accurately, and the proposed training system has the potential to improve patients' ability to perform ADLs.

Data-Driven Classification of Human Movements in Virtual Reality-Based Serious Games: Preclinical Rehabilitation Study in Citizen Science

BACKGROUND

Sustained engagement is essential for the success of telerehabilitation programs. However, patients' lack of motivation and adherence could undermine these goals. To overcome this challenge, physical exercises have often been gamified. Building on the advantages of serious games, we propose a citizen science-based approach in which patients perform scientific tasks by using interactive interfaces and help advance scientific causes of their choice. This approach capitalizes on human intellect and benevolence while promoting learning. To further enhance engagement, we propose performing citizen science activities in immersive media, such as virtual reality (VR).

OBJECTIVE

This study aims to present a novel methodology to facilitate the remote identification and classification of human movements for the automatic assessment of motor performance in telerehabilitation. The data-driven approach is presented in the context of a citizen science software dedicated to bimanual training in VR. Specifically, users interact with the interface and make contributions to an environmental citizen science project while moving both arms in concert.

METHODS

In all, 9 healthy individuals interacted with the citizen science software by using a commercial VR gaming device. The software included a calibration phase to evaluate the users' range of motion along the 3 anatomical planes of motion and to adapt the sensitivity of the software's response to their movements. During calibration, the time series of the users' movements were recorded by the sensors embedded in the device. We performed principal component analysis to identify salient features of movements and then applied a bagged trees ensemble classifier to classify the movements.

RESULTS

The classification achieved high performance, reaching 99.9% accuracy. Among the movements, elbow flexion was the most accurately classified movement (99.2%), and horizontal shoulder abduction to the right side of the body was the most misclassified movement (98.8%).

CONCLUSIONS

Coordinated bimanual movements in VR can be classified with high accuracy. Our findings lay the foundation for the development of motion analysis algorithms in VR-mediated telerehabilitation.

Contralesional plasticity following constraint-induced movement therapy benefits outcome: contributions of the intact hemisphere to functional recovery

Stroke is a leading cause of death and disability worldwide. A common, chronic deficit after stroke is upper limb impairment, which can be exacerbated by compensatory use of the nonparetic limb. Resulting in learned nonuse of the paretic limb, compensatory reliance on the nonparetic limb can be discouraged with constraint-induced movement therapy (CIMT). CIMT is a rehabilitative strategy that may promote functional recovery of the paretic limb in both acute and chronic stroke patients through intensive practice of the paretic limb combined with binding, or otherwise preventing activation of, the nonparetic limb during daily living exercises. The neural mechanisms that support CIMT have been described in the lesioned hemisphere, but there is a less thorough understanding of the contralesional changes that support improved functional outcome following CIMT. Using both human and non-human animal studies, the current review explores the role of the contralesional hemisphere in functional recovery of stroke as it relates to CIMT. Current findings point to a need for a better understanding of the functional significance of contralesional changes, which may be determined by lesion size, location, and severity as well stroke chronicity.

Modified Constraint-Induced Movement Therapy for persons with unilateral upper extremity amputation: A case report

STUDY DESIGN

Pretest/posttest case series design.

INTRODUCTION

Rates of prosthetic device abandonment are highest among persons with upper extremity (UE) amputation. Modified Constraint-Induced Movement Therapy (mCIMT), which has been extensively studied in patients with chronic, subacute, and acute stroke, is an under-utilized approach to treat persons with UE amputation.

PURPOSE OF THE STUDY

To present an mCIMT intervention for prosthetic device training after a unilateral UE amputation.

METHODS

The two cases from an advanced rehabilitation center herein described followed a standard UE amputation rehabilitation program used in conjunction with a home training program using mCIMT 3 hours a day, 5 days a week, for 3 weeks. Progress was evaluated weekly using the Activities Measure for Upper Limb Amputees (AM-ULA); Disabilities of the Arm, Shoulder, and Hand; Trinity Amputation and Prosthesis Experience Scales-Revised.

RESULTS

Both the cases exhibited an increase in observable and objective functional use with a UE prosthetic device, as indicated by the AM-ULA.

CONCLUSIONS

To our knowledge, this is the first description of mCIMT as part of a unilateral UE amputee rehabilitation program. The AM-ULA results show meaningful change, whereas Disabilities of the Arm, Shoulder, and Hand and Trinity Amputation and Prosthesis Experience Scales-Revised show mixed results.

Longitudinal fMRI measures of cortical reactivation and hand use with and without training after sensory loss in primates

In a series of previous studies, we demonstrated that damage to the dorsal column in the cervical spinal cord deactivates the contralateral somatosensory hand cortex and impairs hand use in a reach-to-grasp task in squirrel monkeys. Nevertheless, considerable cortical reactivation and behavioral recovery occurs over the following weeks to months after lesion. This timeframe may also be a window for targeted therapies to promote cortical reactivation and functional reorganization, aiding in the recovery process. Here we asked if and how task specific training of an impaired hand would improve behavioral recovery and cortical reorganization in predictable ways, and if recovery related cortical changes would be detectable using noninvasive functional magnetic resonance imaging (fMRI). We further asked if invasive neurophysiological mapping reflected fMRI results. A reach-to-grasp task was used to test impairment and recovery of hand use before and after dorsal column lesions (DC-lesion). The activation and organization of the affected primary somatosensory cortex (area 3b) was evaluated with two types of fMRI - either blood oxygenation level dependent (BOLD) or cerebral blood volume (CBV) with a contrast agent of monocrystalline iron oxide nanocolloid (MION) - before and after DC-lesion. At the end of the behavioral and fMRI studies, microelectrode recordings in the somatosensory areas 3a, 3b and 1 were used to characterize neuronal responses and verify the somatotopy of cortical reactivations. Our results indicate that even after nearly complete DC lesions, monkeys had both considerable post-lesion behavioral recovery, as well as cortical reactivation assessed with fMRI followed by extracellular recordings. Generalized linear regression analyses indicate that lesion extent is correlated with the behavioral outcome, as well as with the difference in the percent signal change from pre-lesion peak activation in fMRI. Monkeys showed behavioral recovery and nearly complete cortical reactivation by 9-12 weeks post-lesion (particularly when the DC-lesion was incomplete). Importantly, the specific training group revealed trends for earlier behavioral recovery and had higher magnitude of fMRI responses to digit stimulation by 5-8 weeks post-lesion. Specific kinematic measures of hand movements in the selected retrieval task predicted recovery time and related to lesion characteristics better than overall task performance success. For measures of cortical reactivation, we found that CBV scans provided stronger signals to vibrotactile digit stimulation as compared to BOLD scans, and thereby may be the preferred non-invasive way to study the cortical reactivation process after sensory deprivations from digits. When the reactivation of cortex for each of the digits was considered, the reactivation by digit 2 stimulation as measured with microelectrode maps and fMRI maps was best correlated with overall behavioral recovery.

Robot-Assisted Therapy and Constraint-Induced Movement Therapy for Motor Recovery in Stroke: Results From a Randomized Clinical Trial

Background: Stroke is one of the leading causes of adult disability, and up to 80% of stroke survivors undergo upper extremity motor dysfunction. Constraint-Induced Movement Therapy (CIMT) and Robot-Assisted Therapy (RT) are used for upper limb stroke rehabilitation. Although CIMT and RT are different techniques, both are beneficial; however, their results must be compared. The objective is to establish the difference between RT and CIMT after a rehabilitation program for chronic stroke patients.

Method: This is a randomized clinical trial, registered at ClinicalTrials.gov (ID number NCT02700061), in which patients with stroke received sessions of RT or CIMT protocol, combined with a conventional rehabilitation program for 12 weeks. The primary outcome was measured by Wolf Motor Function Test (WMFT) and Fugl-Meyer Assessment—Upper Limb (FMA-UL). Activities of daily living were also assessed.

Results: Fifty one patients with mild to moderate upper limb impairment were enrolled in this trial, 25 women and 26 men, mean age of 60,02 years old (SD 14,48), with 6 to 36 months after stroke onset. Function significantly improved regardless of the treatment group. However, no statistical difference was found between both groups as p-values of the median change of function measured by WMFT and FMA were 0.293 and 0.187, respectively.

Conclusion: This study showed that Robotic Therapy (RT) was not different from Constraint-Induced Movement Therapy (CIMT) regardless of the analyzed variables. There was an overall upper limb function, motor recovery, functionality, and activities of daily living improvement regardless of the interventions. At last, the combination of both techniques should be considered in future studies.

Robot enhanced stroke therapy optimizes rehabilitation (RESTORE): a pilot study

BACKGROUND

Robotic rehabilitation after stroke provides the potential to increase and carefully control dosage of therapy. Only a small number of studies, however, have examined robotic therapy in the first few weeks post-stroke. In this study we designed robotic upper extremity therapy tasks for the bilateral Kinarm Exoskeleton Lab and piloted them in individuals with subacute stroke. Pilot testing was focused mainly on the feasibility of implementing these new tasks, although we recorded a number of standardized outcome measures before and after training.

METHODS

Our team developed 9 robotic therapy tasks to incorporate feedback, intensity, challenge, and subject engagement as well as addressing both unimanual and bimanual arm activities. Subacute stroke participants were assigned to a robotic therapy (N = 9) or control group (N = 10) in a matched-group manner. The robotic therapy group completed 1-h of robotic therapy per day for 10 days in addition to standard therapy. The control group participated only in standard of care therapy. Clinical and robotic assessments were completed prior to and following the intervention. Clinical assessments included the Fugl-Meyer Assessment of Upper Extremity (FMA UE), Action Research Arm Test (ARAT) and Functional Independence Measure (FIM). Robotic assessments of upper limb sensorimotor function included a Visually Guided Reaching task and an Arm Position Matching task, among others. Paired sample t-tests were used to compare initial and final robotic therapy scores as well as pre- and post-clinical and robotic assessments.

RESULTS

Participants with subacute stroke (39.8 days post-stroke) completed the pilot study. Minimal adverse events occurred during the intervention and adding 1 h of robotic therapy was feasible. Clinical and robotic scores did not significantly differ between groups at baseline. Scores on the FMA UE, ARAT, FIM, and Visually Guided Reaching improved significantly in the robotic therapy group following completion of the robotic intervention. However, only FIM and Arm Position Match improved over the same time in the control group.

CONCLUSIONS

The Kinarm therapy tasks have the potential to improve outcomes in subacute stroke. Future studies are necessary to quantify the benefits of this robot-based therapy in a larger cohort.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04201613, Registered 17 December 2019-Retrospectively Registered, https://clinicaltrials.gov/ct2/show/NCT04201613 .

Canadian Platform for Trials in Noninvasive Brain Stimulation (CanStim) Consensus Recommendations for Repetitive Transcranial Magnetic Stimulation in Upper Extremity Motor Stroke Rehabilitation Trials

Objective. To develop consensus recommendations for the use of repetitive transcranial magnetic stimulation (rTMS) as an adjunct intervention for upper extremity motor recovery in stroke rehabilitation clinical trials. Participants. The Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim) convened a multidisciplinary team of clinicians and researchers from institutions across Canada to form the CanStim Consensus Expert Working Group. Consensus Process. Four consensus themes were identified: (1) patient population, (2) rehabilitation interventions, (3) outcome measures, and (4) stimulation parameters. Theme leaders conducted comprehensive evidence reviews for each theme, and during a 2-day Consensus Meeting, the Expert Working Group used a weighted dot-voting consensus procedure to achieve consensus on recommendations for the use of rTMS as an adjunct intervention in motor stroke recovery rehabilitation clinical trials. Results. Based on best available evidence, consensus was achieved for recommendations identifying the target poststroke population, rehabilitation intervention, objective and subjective outcomes, and specific rTMS parameters for rehabilitation trials evaluating the efficacy of rTMS as an adjunct therapy for upper extremity motor stroke recovery. Conclusions. The establishment of the CanStim platform and development of these consensus recommendations is a first step toward the translation of noninvasive brain stimulation technologies from the laboratory to clinic to enhance stroke recovery.

Relationships between accelerometry and general compensatory movements of the upper limb after stroke

Background

Standardized assessments are used in rehabilitation clinics after stroke to measure restoration versus compensatory movements of the upper limb. Accelerometry is an emerging tool that can bridge the gap between in- and out-of-clinic assessments of the upper limb, but is limited in that it currently does not capture the quality of a person’s movement, an important concept to assess compensation versus restoration. The purpose of this analysis was to characterize how accelerometer variables may reflect upper limb compensatory movement patterns after stroke.

Methods

This study was a secondary analysis of an existing data set from a Phase II, single-blind, randomized, parallel dose–response trial (NCT0114369). Sources of data utilized were: (1) a compensatory movement score derived from video analysis of the Action Research Arm Test (ARAT), and (2) calculated accelerometer variables quantifying time, magnitude and variability of upper limb movement from the same time point during study participation for both in-clinic and out-of-clinic recording periods.

Results

Participants had chronic upper limb paresis of mild to moderate severity. Compensatory movement scores varied across the sample, with a mean of 73.7 ± 33.6 and range from 11.5 to 188. Moderate correlations were observed between the compensatory movement score and each accelerometer variable. Accelerometer variables measured out-of-clinic had stronger relationships with compensatory movements, compared with accelerometer variables in-clinic. Variables quantifying time, magnitude, and variability of upper limb movement out-of-clinic had relationships to the compensatory movement score.

Conclusions

Accelerometry is a tool that, while measuring movement quantity, can also reflect the use of general compensatory movement patterns of the upper limb in persons with chronic stroke. Individuals who move their limbs more in daily life with respect to time and variability tend to move with less movement compensations and more typical movement patterns. Likewise, individuals who move their paretic limbs less and their non-paretic limb more in daily life tend to move with more movement compensations at all joints in the paretic limb and less typical movement patterns.

Predictors of Arm Nonuse in Chronic Stroke: A Preliminary Investigation

Background. Nonuse (NU) after stroke is characterized by failure to use the contralesional arm despite adequate capacity. It has been suggested that NU is a consequence of the greater effort and/or attention required to use the affected limb, but such accounts have not been directly tested, and we have poor understanding of the predictors of NU. Objective. We aimed to provide preliminary evidence regarding demographic, neuropsychological (ie, apraxia, attention/arousal, neglect), and psychological (ie, self-efficacy) factors that may influence NU in chronic stroke. Methods. Twenty chronic stroke survivors with mild to moderate sensory-motor impairment characterized by the Upper-Extremity Fugl-Meyer (UEFM) were assessed for NU with a modified version of the Actual Amount of Use Test (AAUT), which measures the disparity between amount of use in spontaneous versus forced conditions. Participants were also assessed with measures of limb apraxia, spatial neglect, attention/arousal, and self-efficacy. Using stepwise multiple regression, we determined which variables predicted AAUT NU scores. Results. Scores on the UEFM as well as attention/arousal predicted the degree of NU (P < .05). Attention/arousal predicted NU above and beyond UEFM (P < .05). Conclusions. The results are consistent with the importance of attention and engagement necessary to fully incorporate the paretic limb into daily activities. Larger-scale studies that include additional behavioral (eg, sensation, proprioception, spasticity, pain, mental health, motivation) and neuroanatomical measures (eg, lesion volume and white matter connectivity) will be important for future investigations.

Towards the Design of a Ring Sensor-based mHealth System to Achieve Optimal Motor Function in Stroke Survivors

Maximizing the motor practice in stroke survivors' living environments may significantly improve the functional recovery of their stroke-affected upper-limb. A wearable system that can continuously monitor upper-limb performance has been considered as an effective clinical solution for its potential to provide patient-centered, data-driven feedback to improve the motor dosage. Towards that end, we investigate a system leveraging a pair of finger-worn, ring-type accelerometers capable of monitoring both gross-arm and fine-hand movements that are clinically relevant to the performance of daily activities. In this work, we conduct a mixed-methods study to (1) quantitatively evaluate the efficacy of finger-worn accelerometers in measuring clinically relevant information regarding stroke survivors' upper-limb performance, and (2) qualitatively investigate design requirements for the self-monitoring system, based on data collected from 25 stroke survivors and seven occupational therapists. Our quantitative findings demonstrate strong face and convergent validity of the finger-worn accelerometers, and its responsiveness to changes in motor behavior. Our qualitative findings provide a detailed account of the current rehabilitation process while highlighting several challenges that therapists and stroke survivors face. This study offers promising directions for the design of a self-monitoring system that can encourage the affected limb use during stroke survivors' daily living.

Increasing perceived hand size improves motor performance in individuals with stroke: a home-based training study

Background

Increasing perceived hand size with magnifying lenses improves tactile discrimination and induces changes in action performance. We previously demonstrated that motor skills (tested with grip force, finger tapping, and a reach to grasp tasks) improved when actions were performed with magnified compared to normal vision; twenty-eight percent of 25 participants with stroke exhibited significant improvement on a composite measure of motor performance with magnification as compared to a session without magnification.

Methods

To investigate the potential implications of magnification of vision for motor rehabilitation, we recruited individuals with stroke from the original cohort who exhibited an improvement of at least 10% in grip force and/or finger tapping for a home training protocol. Six individuals with stroke completed a two-week home-based training program in which they performed a range of activities while looking at their hand magnified. Motor skills were measured before, immediately after, and two weeks after the training.

Results

Five of the six participants showed an improvement on motor tasks when tested after the training. In two participants the improvement was evident immediately after the training and persisted in time, while it occurred at two-weeks post-training in the other participants. These results suggest that the magnification of vision is a potential tool for the rehabilitation of post-stroke motor deficits.

A novel upper-limb function measure derived from finger-worn sensor data collected in a free-living setting

The use of wrist-worn accelerometers has recently gained tremendous interest among researchers and clinicians as an objective tool to quantify real-world use of the upper limbs during the performance of activities of daily living (ADLs). However, wrist-worn accelerometers have shown a number of limitations that hinder their adoption in the clinic. Among others, the inability of wrist-worn accelerometers to capture hand and finger movements is particularly relevant to monitoring the performance of ADLs. This study investigates the use of finger-worn accelerometers to capture both gross arm and fine hand movements for the assessment of real-world upper-limb use. A system of finger-worn accelerometers was utilized to monitor eighteen neurologically intact young adults while performing nine motor tasks in a laboratory setting. The system was also used to monitor eighteen subjects during the day time of a day in a free-living setting. A novel measure of real-world upper-limb function—comparing the duration of activities of the two limbs—was derived to identify which upper limb subjects predominantly used to perform ADLs. Two validated handedness self-reports, namely the Waterloo Handedness Questionnaire and the Fazio Laterality Inventory, were collected to assess convergent validity. The analysis of the data recorded in the laboratory showed that the proposed measure of upper-limb function is suitable to accurately detect unilateral vs. bilateral use of the upper limbs, including both gross arm movements and fine hand movements. When applied to recordings collected in a free-living setting, the proposed measure showed high correlation with self-reported handedness indices (i.e., ρ = 0.78 with the Waterloo Handedness Questionnaire scores and ρ = 0.77 with the Fazio Laterality Inventory scores). The results herein presented establish face and convergent validity of the proposed measure of real-world upper-limb function derived using data collected by means of finger-worn accelerometers.

Early constraint-induced movement therapy affects behavior and neuronal plasticity in ischemia-injured rat brains

Constraint-induced movement therapy is an effective rehabilitative training technique used to improve the restoration of impaired upper extremity movement after stroke. However, whether constraint-induced movement therapy is more effective than conventional rehabilitation in acute or sub-acute stroke remains controversial. The aim of the present study was to identify the optimal time to start constraint-induced movement therapy after ischemic stroke and to explore the mechanisms by which constraint-induced movement therapy leads to post-stroke recovery. Sixty-four adult male Sprague-Dawley rats were randomly divided into four groups: sham-surgery group, cerebral ischemia/reperfusion group, early constraint-induced movement therapy group, and late constraint-induced movement therapy group. Rat models of left middle cerebral artery occlusion were established according to the Zea Longa line embolism method. Constraint-induced movement therapy was conducted starting on day 1 or day 14 in the early constraint-induced movement therapy and late constraint-induced movement therapy groups, respectively. To explore the effect of each intervention time on neuromotor function, behavioral function was assessed using a balance beam walking test before surgery and at 8 and 21 days after surgery. The expression levels of brain-derived neurotrophic factor, nerve growth factor and Nogo receptor were evaluated using real time-polymerase chain reaction and western blot assay to assess the effect of each intervention time. The results showed that the behavioral score was significantly lower in the early constraint-induced movement therapy group than in the cerebral ischemia/reperfusion and late constraint-induced movement therapy groups at 8 days. At 21 days, the scores had significantly decreased in the early constraint-induced movement therapy and late constraint-induced movement therapy groups. At 8 days, only mild pyknosis appeared in neurons of the ischemic penumbra in the early constraint-induced movement therapy group, which was distinctly better than in the cerebral ischemia/reperfusion group. At 21 days, only a few vacuolated cells were observed and no obvious inflammatory cells were visible in late constraint-induced movement therapy group, which was much better than at 8 days. The mRNA and protein expression levels of brain-derived neurotrophic factor and nerve growth factor were significantly higher, but expression levels of Nogo receptor were significantly lower in the early constraint-induced movement therapy group compared with the cerebral ischemia/reperfusion and late constraint-induced movement therapy groups at 8 days. The changes in expression levels at 21 days were larger but similar in both the early constraint-induced movement therapy and late constraint-induced movement therapy groups. Besides, the protein nerve growth factor level was higher in the late constraint-induced movement therapy group than in the early constraint-induced movement therapy group at 21 days. These results suggest that both early (1 day) and late (14 days) constraint-induced movement therapy induces molecular plasticity and facilitates functional recovery after ischemic stroke, as illustrated by the histology. The mechanism may be associated with downregulation of Nogo receptor expression and upregulation of brain-derived neurotrophic factor and nerve growth factor expression.

A Novel EMG-driven Functional Electrical Stimulator for Post- Stroke Individuals to Practice Activities of Daily Living

Prior research has demonstrated that hand function can be recovered in individuals with mild stroke through an intervention that is both 'intense' and 'functional'. However, in individuals with moderate to severe post stroke hand paresis, current evidence for an effective intervention to regain hand function is almost absent. A possible contributor to such poor recovery in these individuals may be the inability to intensively practice with the paretic hand during activities of daily living (ADLs). Many ADLs require use of the paretic arm and hand. Due to post-stroke abnormal muscle synergies, functional arm movements, such as lifting or reaching, often result in unwanted activity in the wrist/finger flexors. This makes voluntary hand opening more difficult. A possible solution to enable these individuals to practice with their paretic hand in a functional context is using devices to assist hand opening. Unfortunately, most of currently available hand rehabilitation devices do not sufficiently address hand opening with the appearance of abnormal muscle synergies. We, therefore, developed a synergy resistant, electromyographic (EMG)-driven electrical stimulation device that allows for $\mathbf {Re}$liable and $\mathbf {In}$tuitive control of the hand (ReIn-Hand) opening while using the paretic arm during lifting and reaching.

Different weight shift trainings can improve the balance performance of patients with a chronic stroke: A randomized controlled trial

BACKGROUND

Improving balance ability, increasing walking ability, and reducing the occurrence of falls are important objectives in the rehabilitation of stroke patients. Do the posture balance training and the intervention of lateral wedge insoles to improve of balance function and increase walking ability in patients with a chronic stroke?

METHODS

A randomized, controlled trial with concealed allocation, intention-to-treat analysis, and blinded assessors. Participants who had a chronic stroke (onset >6 months) were recruited from the rehabilitation and neurology departments of a hospital in central Taiwan. Subjects were divided into 3 groups: a visual biofeedback balance training group, a lateral wedge group, and a control group; apart from their usual rehabilitation program, and both experimental groups received a 6-week training session program. The primary outcome was the balance computerized adaptive test (balance CAT), and secondary outcome was timed up and go (TUG) test. All subjects were evaluated at the baseline, posttraining (6-week), 1st follow-up (10-week), and 2nd follow-up (18-week).

RESULTS

A total of 56 subjects were participated in this study, including 38 males and 18 females. The mean age of the subjects was 59.1 years old, and the mean time was 43.7 months after the onset of the stroke. This study found the interaction in groups and measurement time points reached statistical significance of the balance CAT and TUG test (F = 5.740, P < .001; F = 2.926, P = .011; respectively). In addition, the performance of both the visual biofeedback training and lateral wedge group was superior to that of the control group.

CONCLUSION

Six-week visual biofeedback training and intervention of 5° lateral wedge insoles can improve the balance ability of patients with a chronic stroke.

TRIAL REGISTRY

http://www.chictr.org.cn, ChiCTR-IPR-15007092.

Feasibility of a smartphone-based balance assessment system for subjects with chronic stroke

BACKGROUND

Stroke is a cerebral artery disease that may lead to long-term disabilities or death. Patients that survive a stroke usually suffer balance impairments, which affect their performance in activities of daily living (ADLs) and quality of life (QoL). In recent years, smartphones have become very popular and have many capabilities. Smartphone built-in sensors have shown their ability and potential in balance performance assessment. However, the feasibility of smartphones on subjects with chronic strokes remains to be proved. Therefore, the purpose of this study is to evaluate the feasibility of a smartphone-based balance assessment system for subjects with chronic stroke.

METHODS

Ten subjects with chronic stroke and thirteen healthy adults were recruited in the study. The smartphone HTC 10 (HTC Corporation, Taiwan) was used to perform the balance assessment, and its built-in accelerometer and gyroscope were used to record data from the subjects. Six postures were tested for thirty seconds each: shoulder-width stance (SWS) with eyes opened (E/O) and eyes closed (E/C), feet-together stance (FTS) with E/O and E/C, and semi-tandem stance (STS) with E/O and E/C. The smartphone was fixed to the back of subjects at the second sacral spine (S2) level. The changes registered in the accelerometer and gyroscope data were used to represent the balance performance, in which higher values indicate more instability. Data was analyzed using the independent t-test with the software SPSS 20, and the statistical significance level was set to α < 0.05.

RESULTS AND DISCUSSION

Significant difference in the acceleration data was found among subjects with chronic stroke and healthy adults under four assessment postures: SWS with E/C (p = 0.048), FTS with E/O (p = 0.027), FTS with E/C (p = 0.000), and STS with E/C (p = 0.048). Furthermore, according to the gyroscope data, there were significant differences in how the two groups performed the postures. The results demonstrate that a smartphone with a built-in accelerometer and gyroscope can be used to classify balance performances between healthy adults and subjects with chronic stroke.

CONCLUSION

This study shows that smartphones are feasible to assess balance for subjects with chronic stroke.

Enabling Stroke Rehabilitation in Home and Community Settings: A Wearable Sensor-Based Approach for Upper-Limb Motor Training

High-dosage motor practice can significantly contribute to achieving functional recovery after a stroke. Performing rehabilitation exercises at home and using, or attempting to use, the stroke-affected upper limb during Activities of Daily Living (ADL) are effective ways to achieve high-dosage motor practice in stroke survivors. This paper presents a novel technological approach that enables 1) detecting goal-directed upper limb movements during the performance of ADL, so that timely feedback can be provided to encourage the use of the affected limb, and 2) assessing the quality of motor performance during in-home rehabilitation exercises so that appropriate feedback can be generated to promote high-quality exercise. The results herein presented show that it is possible to detect 1) goal-directed movements during the performance of ADL with a \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$c$ \end{document}-statistic of 87.0% and 2) poorly performed movements in selected rehabilitation exercises with an \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$F$ \end{document}-score of 84.3%, thus enabling the generation of appropriate feedback. In a survey to gather preliminary data concerning the clinical adequacy of the proposed approach, 91.7% of occupational therapists demonstrated willingness to use it in their practice, and 88.2% of stroke survivors indicated that they would use it if recommended by their therapist.

Training of the impaired forelimb after traumatic brain injury enhances hippocampal neurogenesis in the Emx1 null mice lacking a corpus callosum

Unilateral brain injury is known to disrupt the balance between the two cortices, as evidenced by an abnormally high interhemispheric inhibitory drive from motor cortex M1_intact to M1_lesioned transmitted transcallosally. Our previous work has shown that the deletion of homeobox gene Emx1 not only led to the agenesis of the corpus callosum (cc), but also to reduced hippocampal neurogenesis. The current study sought to determine whether lacking the cc affected the recovery of forelimb function and hippocampal plasticity following training of the affected limb in mice with unilateral traumatic brain injuries (TBI). One week after TBI, produced by a controlled cortical impact to impair the preferred limb, Emx1 wild type (WT) and knock out (KO) mice were subjected to the single-pellet reaching task with the affected limb for 4 weeks. Both TBI and Emx1 deletion had overall adverse effects on the successful rate of reaching. However, TBI significantly affected reaching performance only in the WT mice and not in the KO mice. Both TBI and Emx1 gene deletion also negatively affected hippocampal neurogenesis, demonstrated by a reduction in doublecortin (DCX)-expressing immature neurons, while limb training enhanced DCX expression. However, limb training increased DCX cells in KO mice only in the TBI-treated group, whereas it induced neurogenesis in both WT mice groups regardless of the treatment. Our finding also suggests that limb training enhances neuroplasticity after brain injury at functionally remote regions including the hippocampus, which may have implications for promoting overall recovery of function after TBI.

Comparison of the effects of bilateral and unilateral training after stroke: A meta-analysis

BACKGROUND

The differential effects of bilateral and unilateral training on upper extremity (UE) function remain unclear.

OBJECTIVE

To compare the effectiveness of bilateral and unilateral training on UE function and activities of daily living (ADL) after stroke.

METHODS

Randomized controlled trials (RCTs) were selected for inclusion by two reviewers after searching the following databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and KoreaMed. Methodological qualities were assessed using the PEDro scale. Effect size was estimated by calculating the standardized mean difference (SMD).

RESULTS

Eleven RCTs of sufficient quality were included in our meta-analysis. The effect size on UE capacity was statistically significant in favor of the Constraint-Induced Movement Therapy (CIMT) groups (SMD [fixed], g: - 0.34; 95% CI: - 0.59-0.08; p = 0.01; I2 = 0%). No other SMDs were significant.

CONCLUSION

The CIMT tasks were more effective than bilateral training with regard to increased UE capacity; however, this result should be cautiously interpreted since the evaluation tools were designed for assessment of unilateral UE function, not bilateral UE function. Further, the effect of the CIMT tasks on UE capacity was not translated into ADL. Considering the disadvantages of CIMT such as fatigue, bilateral training may be more appropriate for improving ADL.

Constraint-induced movement therapy: time for a little restraint?

Our aim was to consider some issues surrounding constraint-induced movement therapy (CIMT), and in particular, its theoretical basis, effectiveness, utility and composition. We examined selected articles and related publications concerning CIMT. Considerable evidence from case studies and case series has accumulated but only a limited number of randomized controlled trials (RCTs) exist. The two most positive RCTs represent a combined total of 15 people undergoing CIMT. Other issues include: how analogous deafferentation of an upper limb in monkeys is to cerebral infarcts in humans; teasing out the active components of CIMT; a need for replication by groups not already strongly associated with CIMT; and patient/therapist acceptability. CIMT may hold considerable promise, but independent, large-scale, multicentre RCTs comparing its effectiveness with conventional therapy of equal intensity are required, as is the consideration of some associated issues.

The effect of a task-oriented intervention on arm function in people with stroke: a randomized controlled trial

Objective: To evaluate the efficacy of a task-oriented intervention in enhancing arm function in people with stroke.

Design: Two-centre, observer-blinded, stratified, block-randomized controlled trial.

Setting: General community.

Patients: Ninety-one individuals within one year of a first or recurrent stroke consented to participate between May 2000 and February 2003.

Interventions: The experimental intervention involved practice of functional, unilateral and bilateral tasks that were designed to improve gross and fine manual dexterity whereas the control intervention was composed of walking tasks. Members in both groups participated in three sessions a week for six weeks.

Main outcome measure(s): The primary test of arm function was the Box and Block Test. Secondary tests included the Nine-Hole Peg Test, maximal grip strength, the Test d'Evaluation des Membres supé rieurs des Personnes Agées (TEMPA) and the Stroke Rehabilitation Assessment of Movement.

Results: Results are for the more affected arm. Baseline performance on the Box and Block Test was an average of 26 blocks (standard deviation (SD=16) in the experimental group (n=47) and 26 blocks (Sd=18) in the control group (n=44). These values represent approximately 40% of age-predicted values. Values for the postintervention evaluation were an average of 28 (SD=17) and 28 (SD=19) blocks for the experimental and control group respectively. No meaningful change on other measures of arm function was observed.

Conclusions: A task-oriented intervention did not improve voluntary movement or manual dexterity of the affected arm in people with chronic stroke.

Constraint-induced movement therapy in patients with stroke: a pilot study on effects of small group training and of extended mitt use

Objective: (1) To evaluate constraint-induced movement therapy for chronic stroke patients modified into group practice to limit the demand on therapist resources. (2) To explore whether extended mitt use alone may enhance outcome.

Design: A combined case-control and randomized controlled study with pre- and post-treatment measures by blinded observers.

Setting: A university hospital rehabilitation department.

Participants: Sixteen stroke patients (nine men and seven women; mean age 56.7 years; on average 28.9 months post stroke, five of whom were 6-9 months post stroke) with moderate motor impairments in the contralateral upper limb.

Intervention: Constraint-induced therapy (mitt on the less affected hand 90% of waking hours for 12 days) with 2-3 patients per therapist and 6 h of group training per day. After the training period, the patients were randomized either to using the mitt at home every other day for two-week periods for another three months (in total 21 days) or to no further treatment.

Outcome measures: Modified Motor Assessment Scale, Sollerman Hand Function Test, Two-Point Discrimination test and Motor Activity Log.

Results: The mean motor performance improved significantly after two weeks of constraint-induced group therapy on Motor Assessment Scale (1.44 (95% confidence interval (95% CI) 0.59-2.28) points; P = 0.003) and on Sollerman Hand Function Test (3.81 (95% CI 0.26-7.36) points; P = 0.037) but showed no sensory change in the Two-Point Discrimination Test (P = 0.283). The median difference in self-reported motor ability (Motor Activity Log) also improved (P B=0.001). However, no additional effect was seen from wearing a mitt for another three months.

Conclusion: Constraint-induced group therapy, allowing several patients per therapist, seems to be a feasible alternative to improve upper limb motor function. The restraint alone, extended in time, did not enhance the treatment effect.

The Effect of Constraint-Induced Movement Treatment on Occupational Performance and Satisfaction in Stroke Survivors

Stroke is a leading cause of disability and impaired arm function is a common consequence. Constraint-induced movement treatment is a technique used to increase weak arm use and to decrease motor deficits resulting from stroke. Eleven stroke survivors participated in a constraint-induced movement treatment protocol of 3 ½ hours of treatment per day for 8 days. Participants experienced significantly increased use of the weak arm in daily activities, which was measured by the Motor Activity Log, and a trend toward improved coordination in the weak arm, which was measured by the Wolf Motor Function Test. Participants did not report significant improvements in average performance or satisfaction in self-identified occupational performance problems. When these problems were analyzed individually, no significant differences were seen immediately post-treatment. However, significant improvements were seen for satisfaction at 4 to 6 months post-treatment. The occupational performance problems identified by the participants were equally divided between problems related to hand use and problems not related to hand use. Approximately half of the non-hand use problems involved endurance. Although participants in this study did make improvements in arm use and coordination, they did not identify improvements in average occupational performance or satisfaction as an outcome of constraint-induced movement treatment.

A study of the effect of visual depth information on upper limb movement by use of measurement of smoothness

[Purpose] This study verified that the smoothness of reaching movements is able to quantitatively evaluate the effects of two- and three-dimensional images on movement in healthy people. In addition, clinical data of cerebrovascular accident patients were also analyzed by the same method. [Subjects] Ten healthy adult volunteers and two male patients with previous cerebrovascular accidents participated. [Methods] The subjects were tasked with reaching for objects shown on a display. The target and virtual limb, rendered with computer graphics, were shown on the display. Movements of the virtual limb were synchronized with those of the subject. Healthy subjects reached for targets with their dominant arm, and cerebrovascular accident patients used their paretic arm. A polarized display and polarized glasses were used when the subjects were shown three-dimensional images. In the present study, jerk cost was used to quantify the smoothness of movement. [Results] Six of the 10 healthy subjects had significantly smoother reaching movements when viewing the three-dimensional images. The two cerebrovascular accident patients tended to have smoother movements in response to the three-dimensional images. [Conclusion] Analysis of the smoothness of movement was able to detect the influence of the depth cue in vision on movement quantitatively for the healthy subjects and cerebrovascular accident patients.

Task Selection and Enriched Environments: A Functional Upper Extremity Training Program for Stroke Survivors

Functional tasks using real-life objects in an enriched environment provide a multidimensional approach to treatment. Functional tasks are therapeutic for stroke survivors, because they require the simultaneous use of motor control, cognition, visual perception, sensation, and motor planning. Therapists utilizing functional tasks as treatment modalities must also be multidimensional in their implementation. This article provides a systematic approach to guide therapists in developing a functional upper extremity training program for stroke survivors.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation

BACKGROUND AND PURPOSE

The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA).

METHOD

Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale.

RESULTS

The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation.

DISCUSSION AND CONCLUSION

The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.

Motor Recovery Strategies After Stroke

Impaired motor function after stroke is a major cause of disability in young stroke survivors. The plasticity of the adult human brain provides opportunities to enhance traditional rehabilitation programs for these individuals. Younger stroke patients appear to have a greater ability to recover from stroke and are likely to benefit substantially from treatments that facilitate plasticity-mediated recovery. The use of new exercise treatments, such as constraint-induced movement therapy, robot-aided rehabilitation, and partial body weight supported treadmill training are being studied intensively and are likely to ultimately be incorporated into standard poststroke rehabilitation. Medications to enhance recovery, growth factors, and stem cells will also be components of rehabilitation for the young stroke survivor in the foreseeable future.

Implications of CI therapy for visual deficit training

We address here the question of whether the techniques of Constraint Induced (CI) therapy, a family of treatments that has been employed in the rehabilitation of movement and language after brain damage might apply to the rehabilitation of such visual deficits as unilateral spatial neglect and visual field deficits. CI therapy has been used successfully for the upper and lower extremities after chronic stroke, cerebral palsy (CP), multiple sclerosis (MS), other central nervous system (CNS) degenerative conditions, resection of motor areas of the brain, focal hand dystonia, and aphasia. Treatments making use of similar methods have proven efficacious for amblyopia. The CI therapy approach consists of four major components: intensive training, training by shaping, a "transfer package" to facilitate the transfer of gains from the treatment setting to everyday activities, and strong discouragement of compensatory strategies. CI therapy is said to be effective because it overcomes learned nonuse, a learned inhibition of movement that follows injury to the CNS. In addition, CI therapy produces substantial increases in the gray matter of motor areas on both sides of the brain. We propose here that these mechanisms are examples of more general processes: learned nonuse being considered parallel to sensory nonuse following damage to sensory areas of the brain, with both having in common diminished neural connections (DNCs) in the nervous system as an underlying mechanism. CI therapy would achieve its therapeutic effect by strengthening the DNCs. Use-dependent cortical reorganization is considered to be an example of the more general neuroplastic mechanism of brain structure repurposing. If the mechanisms involved in these broader categories are involved in each of the deficits being considered, then it may be the principles underlying efficacious treatment in each case may be similar. The lessons learned during CI therapy research might then prove useful for the treatment of visual deficits.

Automated assessment of upper extremity movement impairment due to stroke

Current diagnosis and treatment of movement impairment post-stroke is based on the subjective assessment of select movements by a trained clinical specialist. However, modern low-cost motion capture technology allows for the development of automated quantitative assessment of motor impairment. Such outcome measures are crucial for advancing post-stroke treatment methods. We sought to develop an automated method of measuring the quality of movement in clinically-relevant terms from low-cost motion capture. Unconstrained movements of upper extremity were performed by people with chronic hemiparesis and recorded by standard and low-cost motion capture systems. Quantitative scores derived from motion capture were compared to qualitative clinical scores produced by trained human raters. A strong linear relationship was found between qualitative scores and quantitative scores derived from both standard and low-cost motion capture. Performance of the automated scoring algorithm was matched by averaged qualitative scores of three human raters. We conclude that low-cost motion capture combined with an automated scoring algorithm is a feasible method to assess objectively upper-arm impairment post stroke. The application of this technology may not only reduce the cost of assessment of post-stroke movement impairment, but also promote the acceptance of objective impairment measures into routine medical practice.

Video games and rehabilitation: using design principles to enhance engagement in physical therapy

Patient nonadherence with therapy is a major barrier to rehabilitation. Recovery is often limited and requires prolonged, intensive rehabilitation that is time-consuming, expensive, and difficult. We review evidence for the potential use of video games in rehabilitation with respect to the behavioral, physiological, and motivational effects of gameplay. In this Special Interest article, we offer a method to evaluate effects of video game play on motor learning and their potential to increase patient engagement with therapy, particularly commercial games that can be interfaced with adapted control systems. We take the novel approach of integrating research across game design, motor learning, neurophysiology changes, and rehabilitation science to provide criteria by which therapists can assist patients in choosing games appropriate for rehabilitation. Research suggests that video games are beneficial for cognitive and motor skill learning in both rehabilitation science and experimental studies with healthy subjects. Physiological data suggest that gameplay can induce neuroplastic reorganization that leads to long-term retention and transfer of skill; however, more clinical research in this area is needed. There is interdisciplinary evidence suggesting that key factors in game design, including choice, reward, and goals, lead to increased motivation and engagement. We maintain that video game play could be an effective supplement to traditional therapy. Motion controllers can be used to practice rehabilitation-relevant movements, and well-designed game mechanics can augment patient engagement and motivation in rehabilitation. We recommend future research and development exploring rehabilitation-relevant motions to control games and increase time in therapy through gameplay.Video Abstract available (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A61) for more insights from the authors.

The functional significance of cortical reorganization and the parallel development of CI therapy

For the nineteenth and the better part of the twentieth centuries two correlative beliefs were strongly held by almost all neuroscientists and practitioners in the field of neurorehabilitation. The first was that after maturity the adult CNS was hardwired and fixed, and second that in the chronic phase after CNS injury no substantial recovery of function could take place no matter what intervention was employed. However, in the last part of the twentieth century evidence began to accumulate that neither belief was correct. First, in the 1960s and 1970s, in research with primates given a surgical abolition of somatic sensation from a single forelimb, which rendered the extremity useless, it was found that behavioral techniques could convert the limb into an extremity that could be used extensively. Beginning in the late 1980s, the techniques employed with deafferented monkeys were translated into a rehabilitation treatment, termed Constraint Induced Movement therapy or CI therapy, for substantially improving the motor deficit in humans of the upper and lower extremities in the chronic phase after stroke. CI therapy has been applied successfully to other types of damage to the CNS such as traumatic brain injury, cerebral palsy, multiple sclerosis, and spinal cord injury, and it has also been used to improve function in focal hand dystonia and for aphasia after stroke. As this work was proceeding, it was being shown during the 1980s and 1990s that sustained modulation of afferent input could alter the structure of the CNS and that this topographic reorganization could have relevance to the function of the individual. The alteration in these once fundamental beliefs has given rise to important recent developments in neuroscience and neurorehabilitation and holds promise for further increasing our understanding of CNS function and extending the boundaries of what is possible in neurorehabilitation.

Effect of a robotic restraint gait training versus robotic conventional gait training on gait parameters in stroke patients

Kinematic and kinetic gait parameters have never been assessed following robotic-assisted gait training in hemiparetic patients. Previous studies suggest that restraint of the non-paretic lower limb during gait training could be a useful rehabilitation approach for hemiparetic patients. The aim of this study is to compare a new Lokomat(®) asymmetrical restraint paradigm (with a negative kinematic constraint on the non-paretic limb and a positive kinematic constraint on the paretic limb) with a conventional symmetrical Lokomat(®) training in hemiparetic subjects. We hypothesized that hip and knee kinematics on paretic side would be more improved after the asymmetrical Lokomat(®) training than after the conventional training. In a prospective observational controlled study, 26 hemiparetic subjects were randomized to one of the two groups Lokomat(®) experimental gait training (LE) or Lokomat(®) conventional gait training (LC). They were assessed using 3D gait analysis before, immediately after the 20 min of gait training and following a 20-min rest period. There was a greater increase in peak knee flexion on the paretic side following LE than LC (p = 0.04), and each type of training induced different changes in vertical GRF during single-support phase on the paretic side. Several other spatiotemporal, kinematic and kinetic gait parameters were similarly improved after both types of training. Lokomat(®) restrained gait training with a negative kinematic constraint on the non-paretic limb and a positive kinematic constraint on the paretic limb appears to be an effective approach to specifically improve knee flexion in the paretic lower limb in hemiparetic patients. This study also highlights spatiotemporal, kinematic and kinetic improvements after Lokomat(®) training, in hemiparetic subjects, rarely investigated before.

Randomized, Multicenter, Comparative Study of NEURO versus CIMT in Poststroke Patients with Upper Limb Hemiparesis: The NEURO-VERIFY Study

Background

Many poststroke patients suffer functional motor limitation of the affected upper limb, which is associated with diminished health-related quality of life.

Aims

The aim of this study is to conduct a randomized, multicenter, comparative study of low-frequency repetitive transcranial magnetic stimulation combined with intensive occupational therapy, NEURO (NovEl intervention Using Repetitive TMS and intensive Occupational therapy) versus constraint-induced movement therapy in poststroke patients with upper limb hemiparesis.

Methods

In this randomized controlled study of NEURO and constraint-induced movement therapy, 66 poststroke patients with upper limb hemiparesis were randomly assigned at 2:1 ratio to low-frequency repetitive transcranial magnetic stimulation plus occupational therapy (NEURO group) or constraint-induced movement therapy (constraint-induced movement therapy group) for 15 days. Fugl–Meyer Assessment and Wolf Motor Function Test and Functional Ability Score of Wolf Motor Function Test were used for assessment.

Results

No differences in patients' characteristics were found between the two groups at baseline. The Fugl–Meyer Assessment score was significantly higher in both groups after the 15-day treatment compared with the baseline. Changes in Fugl–Meyer Assessment scores and Functional Ability Score of Wolf Motor Function Test were significantly higher in the NEURO group than in the constraint-induced movement therapy group, whereas the decrease in the Wolf Motor Function Test log performance time was comparable between the two groups (changes in Fugl–Meyer Assessment score, NEURO: 5·39 ± 4·28, constraint-induced movement therapy: 3·09 ± 4·50 points; mean ± standard error of the mean; P < 0·05) (changes in Functional Ability Score of Wolf Motor Function Test, NEURO: 3·98 ± 2·99, constraint-induced movement therapy: 2·09 ± 2·96 points; P < 0·05).

Conclusions

The results of the 15-day rehabilitative protocol showed the superiority of NEURO relative to constraint-induced movement therapy; NEURO improved the motion of the whole upper limb and resulted in functional improvement in activities of daily living.