Constraint-Induced Movement Therapy for Lower Extremity Function: Describing the LE-CIMT Protocol

Positive effects of lower extremity constraint-induced movement therapy on balance, leg strength and dual-task ability in stroke patients: a longitudinal cohort study

OBJECTIVE

To investigate whether high-intensity lower extremity constraint-induced movement therapy can improve balance, leg strength, and dual-task ability.

DESIGN

A longitudinal cohort study in a real-world outpatient clinic.

PATIENTS

147 community-dwelling participants in the subacute and chronic poststroke phases.

METHODS

Participants received lower extremity constraint-induced movement therapy for 6 hours/day during 2 consecutive weeks, including balance, strength, and functional training. The Berg Balance Scale (BBS), Single-Leg-Stance (SLS) bilaterally, one Repetition Maximum (1RM) in a leg press, symmetry of leg strength (Diff-1RM), Timed Up and Go (TUG), and the TUG Manual test were assessed before, after, and 3 months after lower extremity constraint-induced movement therapy.

RESULTS

Compared with preintervention data, statistically significant improvements after lower extremity constraint-induced movement therapy (p < 0.001) were demonstrated for balance with an absolute value in BBS at 1.9 points (effect size 0.38) and SLS at 2.4 s (effect size 0.24), and for leg strength at 10.2 kg (effect size 0.54) for the affected leg. Diff 1RM decreased significantly at 5.8 kg (effect size 0.39) and improvements on dual-task ability at 2.7 s were significant (effect size 0.14). The effects persisted at the 3-month follow-up.

CONCLUSIONS

High-intensity lower extremity constraint-induced movement therapy may be a feasible treatment option for middle-aged stroke patients to affect balance, leg strength, and dual-task ability positively in an out-patient clinical setting.

Predictive value of early serum ACSL4 and ASITN/SIR grade for motor function recovery in patients with post-ischemic stroke lower limb neurological sequelae after modified constraint-induced movement therapy

BACKGROUND

Ischemic stroke accounts for over 85 % of all stroke types. Acyl-CoA synthetase long chain family member 4 (ACSL4) is considered to promote myocardial and cerebral ischaemia/ reperfusion. However, up to now, no study focused on the role of ACSL4 in patients with post-stroke lower limb neurological sequelae.

OBJECTIVE

The present study aimed to investigate the predictive value of ACSL4 and collateral circulation for lower limb neurological sequelae of ischemic stroke patients after modified constraint-induced movement therapy (mCIMT).

METHODS

This is a prospective cohort study which included 99 ischemic stroke patients with lower limb neurological sequelae who were admitted to our hospital during January 2021 to December 2022. All patients received mCIMT after the admission. Collateral circulation was evaluated by digital subtraction angiography (DSA) and graded by the American Society of Interventional and Therapeutic Neuroradiology/ Society of Interventional Radiology (ASITN/SIR) grading system. Enzyme linked immunosorbent assay (ELISA) was used to detect serum ACSL4. Basic characteristics were collected and lower limb motor function was measured by Fugl-Meyer score (FMS), modified Ashworth score (MAS) and Brunnstrom stage, as well as timed up and go (TUG) test, ten-Meter walk test (10MWT), and six-minute walk test (6MWT) before and after treatment.

RESULTS

Serum ACSL4 and percentage of patients with ASITN/SIR 0-1 decreased significantly after treatment compared with the values before treatment. Patients with higher baseline serum ACSL4 values at admission showed significantly lower FMS scores, higher TUG and 10MWT, as well as lower 6MWT. Patients with ASITN/SIR grade 0-1 at admission only showed significantly higher TUG and 10MWT, as well as lower 6MWT. Receiver operating characteristic (ROC) curves showed ACSL4 and ASITN/SIR grade could be used to predict the prognosis. Logistic regression found only national institutes of health stroke scores (NIHSS) was the independent risk factor for post-treatment motor impairment after mCIMT.

CONCLUSION

Higher levels of ACSL4 and ASITN/SIR 0-1 are associated with poor recovery of motor functions of patients with post-stroke sequelae after mCIMT.

Effect of insole on postural control and gait of stroke patients: a systematic review and meta-analysis

This systematic review aims to examine the evidence of adding postural insole to traditional physical therapy to improve weight distribution, gait, mobility, balance, and postural control in stroke survivors. Five databases were searched to retrieve all related randomized controlled trials examining the effect of insole on stroke patients. Two independent authors checked the potential articles against eligibility criteria according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A meta-analysis was conducted for available outcomes and the statistical heterogeneity was examined using the I2 test. Of 762 articles, only 15 with 448 patients were included after they met the inclusion criteria with most of them including participants exceeding 6 months of stroke incidence. When insole was used as compelled body weight shifting method, pooled statistical analysis revealed significant improvement in gait velocity [standardized mean difference (SMD) = 0.67; 95% confidence interval (CI): 0.31, 1.02; P  = 0.0003], cadence (SMD = 0.67; 95% CI: 0.16, 1.18; P  = 0.01] and stride length (SMD = 1.11; 95% CI: 0.57, 1.65; P  < 0.0001), while no significant effect on step length (SMD = 0.48; 95% CI: -0.37, 1.33; P  = 0.27). Pooled statistical analysis of balance outcomes revealed significant improvement in weight-bearing symmetry balance (SMD = 0.82; 95% CI: 0.25, 1.39; P  = 0.005) and long-term improvement in Berg Balance Scale (SMD = 1.19; 95% CI: 0.19, 2.20; P  = 0.02), while no difference was observed in balance confidence (SMD = 0.44; 95% CI: -0.15, 1.04; P  = 0.14) and sensorimotor functions (SMD = 0.36; 95% CI -0.39, 1.11; P  = 0.35). Insoles significantly improved spatiotemporal gait parameters, gait symmetry, and static balance compared with traditional physical therapy alone.

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.

PedBotLab: A Novel Video Game-Based Robotic Ankle Platform Created for Therapeutic Exercise for Children With Neurological Impairments

AIMS

Assess the potential benefits of using PedBotLab, a clinic based robotic ankle platform with integrated video game software, to improve ankle active and passive range of motion, strength, selective motor control, gait efficiency, and balance.

METHODS

Ten participants with static neurological injuries and independent ambulation participated in a 10-week pilot study (Pro00013680) to assess feasibility and efficacy of PedBotLab as a therapeutic device twice weekly. Isometric ankle strength, passive and active ankle range of motion, plantarflexor spasticity, selective motor control of the lower extremity, balance, and gait speed were measured pre- and post-trial.

RESULTS

Statistically significant improvements were seen in flexibility, active range of motion, and strength in multiple planes of ankle motion. Ankle dorsiflexion with knee flexion and knee extension demonstrated statistically significant results in all outcome measures. No significant changes were observed in gait speed outcomes.

CONCLUSIONS

The use of PedbotLab can lead to improvements in ankle strength, flexibility, and active range of motion for children with static neurological injuries. Future studies aim to evaluate the effect on gait quality and work toward developing a home-based device.

One-year retention of gait speed improvement in stroke survivors after treatment with a wearable home-use gait device

Background

Gait impairments after stroke are associated with numerous physical and psychological consequences. Treatment with the iStride® gait device has been shown to facilitate improvements to gait function, including gait speed, for chronic stroke survivors with hemiparesis. This study examines the long-term gait speed changes up to 12 months after treatment with the gait device.

Methods

Eighteen individuals at least one-year post-stroke completed a target of 12, 30-minute treatment sessions with the gait device in their home environment. Gait speed was measured at baseline and five follow-up sessions after the treatment period: one  week, one  month, three months, six months, and 12 months. Gait speed changes were analyzed using repeated-measures ANOVA from baseline to each follow-up time frame. Additional analysis included comparison to the minimal clinically important difference (MCID), evaluation of gait speed classification changes, and review of subjective questionnaires.

Results

Participants retained an average gait speed improvement >0.21 m/s compared to baseline at all post-treatment time frames. Additionally, 94% of participants improved their gait speed beyond the MCID during one or more post-treatment measurements, and 88% subjectively reported a gait speed improvement.

Conclusion

Treatment with the gait device may result in meaningful, long-term gait speed improvement for chronic stroke survivors with hemiparetic gait impairments.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT03649217, identifier NCT03649217.

Overground walking with a constraint force on the nonparetic leg during swing improves weight shift toward the paretic side in people after stroke

Targeting enhancing the use of the paretic leg during locomotor practice might improve motor function of the paretic leg. The purpose of this study was to determine whether application of constraint force to the nonparetic leg in the posterior direction during overground walking would enhance the use of the paretic leg in people with chronic stroke. Fifteen individuals after stroke participated in two experimental conditions, i.e., overground walking with a constraint force applied to the nonparetic leg and overground walking only. Each participant was tested in the following procedures that consisted of overground walking with either constraint force or no constraint force, instrumented split-belt treadmill walking, and pressure-sensitive gait mat walking before and after the overground walking. Overground walking practice with constraint force resulted in greater enhancement in lateral weight shift toward the paretic side (P < 0.01), muscle activity of the paretic hip abductors (P = 0.04), and propulsion force of the paretic leg (P = 0.05) compared with the results of the no-constraint condition. Overground walking practice with constraint force tended to induce greater increase in self-selected overground walking speed (P = 0.06) compared with the effect of the no-constraint condition. The increase in propulsion force from the paretic leg was positively correlated with the increase in self-selected walking speed (r = 0.6, P = 0.03). Overground walking with constraint force applied to the nonparetic leg during swing phase of gait may enhance use of the paretic leg, improve weight shifting toward the paretic side and propulsion of the paretic leg, and consequently increase walking speed.NEW & NOTEWORTHY Application of constraint force to the nonparetic leg during overground walking induced improved lateral weight shifts toward the paretic leg and enhanced muscle activity of the paretic leg during walking. In addition, one session of overground walking with constraint force might induce an increase in propulsive force of the paretic leg and an increase in self-selected overground walking speed, which might be partially due to the improvement in motor control of the paretic leg.

Effects of a treatment program based on constraint-induced movement therapy for the lower extremities on gait and balance in chronic stroke: a 6-month follow-up pilot study

Constraint-induced movement therapy (CIMT) for the lower extremities CIMT (LE-CIMT) has been shown feasible and promising but the long-term outcomes remain uncertain. In this pilot study, we recruited eight participants with chronic stroke from our facility for persons with disabilities to determine changes in gait and balance throughout an extended treatment program based on the principles of LE-CIMT. The program consisted of a run-in phase (3 weeks), LE-CIMT phase (3 weeks), and maintenance phase (6 months). In the LE-CIMT phase (3.5 h/day, 5 days/week, 3 weeks), the participants received task-oriented training (3 h) and transfer package training (30 min). The maintenance phase (30 min/day, 2-3 times/week, 6 months) included a transfer package and conventional training. The assessments were performed in the beginning and after each phase using the Fugl-Meyer Assessment, 6-min walk test (6MWT), Berg Balance Scale (BBS), and 10-m walk test from which walking speed, cadence, and stride length were derived. Overall, 6MWT, BBS, walking speed, and cadence improved significantly over time (analysis of variance P  < 0.001). When comparing the results from before to after the LE-CIMT phase, 6MWT, BBS, walking speed, and cadence improved significantly ( P  = 0.002 to 0.022). At the end of the 6-month maintenance phase, further improvements relative to the after LE-CIMT phase were found for 6MWT, walking speed, and cadence ( P  = 0.002 to 0.034). These pilot results suggest that an extended treatment program based on the principles of LE-CIMT can improve balance and more so walking in the chronic phase of stroke.

Progress in the clinical application of constraint-induced therapy following stroke since 2014

Stroke is a group of cerebrovascular diseases with high prevalence and mortality rate. Stroke can induce many impairments, including motor and cognitive dysfunction, aphasia/dysarthria, dysphagia, and mood disorders, which may reduce the quality of life among the patients. Constraint-induced therapy has been proven to be an effective treatment method for stroke rehabilitation. It has been widely used in the recovery of limb motor dysfunction, aphasia, and other impairment like unilateral neglect after stroke. In recent years, constraint-induced therapy can also combine with telehealth and home rehabilitation. In addition, constraint-induced therapy produces significant neuroplastic changes in the central nervous system. Functional magnetic resonance imaging, diffusion tensor imaging, and other imaging/electrophysiology methods have been used to clarify the mechanism and neuroplasticity. However, constraint-induced therapy has some limitations. It can only be used under certain conditions, and the treatment time and effectiveness are controversial. Further research is needed to clarify the mechanism and effectiveness of CI therapy.

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.

Shaping Exploration: How Does the Constraint-Induced Movement Therapy Helps Patients Finding a New Movement Solution

Despite the relative success of constraint-induced movement therapy in the recovery of injury-/trauma-related populations, the mechanisms by which it promotes its results are still unknown. From a dynamical systems approach, we investigated whether the induced exploratory patterns within and between trials during an exercise in Shaping (the therapy's practice) could shed light on this process. We analyzed data from four chronic spinal-cord injury patients during a task of placing and removing their feet from a step. We assessed the within and between trial dynamics through recurrent quantification analyses and task-space analyses, respectively. From our results, individuals found movement patterns directed to modulate foot height (to accomplish the task). Additionally, when the task was manipulated (increasing step height), individuals increased coupling and coupling variability in the ankle, hip, and knee over trials. This pattern of findings is in consonance with the idea of Shaping inducing exploration of different movements. Such exploration might be an important factor affording the positive changes observed in the literature.

Effect of constraint-induced movement therapy on lower extremity motor dysfunction in post-stroke patients: A systematic review and meta-analysis

Objective

Constraint-induced movement therapy (CIMT) is a common treatment for upper extremity motor dysfunction after a stroke. However, whether it can effectively improve lower extremity motor function in stroke patients remains controversial. This systematic review comprehensively studies the current evidence and evaluates the effectiveness of CIMT in the treatment of post-stroke lower extremity motor dysfunction.

Methods

We comprehensively searched randomized controlled trials related to this study in eight electronic databases (PubMed, Embase, The Cochrane Library, Web of Science, CBM, CNKI, WAN FANG, and VIP). We evaluated CIMT effectiveness against post-stroke lower extremity motor dysfunction based on the mean difference and corresponding 95% confidence interval (95% CI). We assessed methodological quality based on the Cochrane Bias Risk Assessment Tool. After extracting the general information, mean, and standard deviation of the included studies, we conducted a meta-analysis using RevMan 5.3 and Stata 16.0. The primary indicator was the Fugl-Meyer Assessment scale on lower limbs (FMA-L). The secondary indicators were the Berg balance scale (BBS), 10-meter walk test (10MWT), gait speed (GS), 6-min walk test (6MWT), functional ambulation category scale (FAC), timed up and go test (TUGT), Brunnstrom stage of lower limb function, weight-bearing, modified Barthel index (MBI), functional independence measure (FIM), stroke-specific quality of life questionnaire (SSQOL), World Health Organization quality of life assessment (WHOQOL), and National Institute of Health stroke scale (NIHSS).

Results

We initially identified 343 relevant studies. Among them, 34 (totaling 2,008 patients) met the inclusion criteria. We found that patients treated with CIMT had significantly better primary indicator (FMA-L) scores than those not treated with CIMT. The mean differences were 3.46 (95% CI 2.74–4.17, P &lt; 0.01, I2 = 40%) between CIMT-treated and conventional physiotherapy-treated patients, 3.83 (95% CI 2.89–4.77, P &lt; 0.01, I2 = 54%) between patients treated with CIMT plus conventional physiotherapy and patients treated only with conventional physiotherapy, and 3.50 (95% CI 1.08–5.92, P &lt; 0.01) between patients treated with CIMT plus western medicine therapy and those treated only with western medicine therapy. The secondary indicators followed the same trend. The subgroup analysis showed that lower extremity CIMT with device seemed to yield a higher mean difference in FMA-L scores than lower extremity CIMT without device (4.52, 95% CI = 3.65–5.38, P &lt; 0.01 and 3.37, 95% CI = 2.95–3.79, P &lt; 0.01, respectively).

Conclusion

CIMT effectively improves lower extremity motor dysfunction in post-stroke patients; however, the eligible studies were highly heterogeneous.

Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=277466.

Impact of Constraint-Induced Movement Therapy (CIMT) on Functional Ambulation in Stroke Patients-A Systematic Review and Meta-Analysis

Constraint-induced movement therapy (CIMT) has been delivered in the stroke population to improve lower-extremity functions. However, its efficacy on prime components of functional ambulation, such as gait speed, balance, and cardiovascular outcomes, is ambiguous. The present review aims to delineate the effect of various lower-extremity CIMT (LECIMT) protocols on gait speed, balance, and cardiovascular outcomes. Material and methods: The databases used to collect relevant articles were EBSCO, PubMed, PEDro, Science Direct, Scopus, MEDLINE, CINAHL, and Web of Science. For this analysis, clinical trials involving stroke populations in different stages of recovery, >18 years old, and treated with LECIMT were considered. Only ten studies were included in this review, as they fulfilled the inclusion criteria. The effect of CIMT on gait speed and balance outcomes was accomplished using a random or fixed-effect model. CIMT, when compared to controlled interventions, showed superior or similar effects. The effect of LECIMT on gait speed and balance were non-significant, with mean differences (SMDs) of 0.13 and 4.94 and at 95% confidence intervals (Cis) of (-0.18-0.44) and (-2.48-12.37), respectively. In this meta-analysis, we observed that despite the fact that several trials claimed the efficacy of LECIMT in improving lower-extremity functions, gait speed and balance did not demonstrate a significant effect size favoring LECIMT. Therefore, CIMT treatment protocols should consider the patient's functional requirements, cardinal principles of CIMT, and cardiorespiratory parameters.

Rehabilitation on a treadmill induces plastic changes in the dendritic spines of spinal motoneurons associated with improved execution after a pharmacological injury to the motor cortex in rats

Lesions to the corticospinal tract result in several neurological symptoms and several rehabilitation protocols have proven useful in attempts to direct underlying plastic phenomena. However, the effects that such protocols may exert on the dendritic spines of motoneurons to enhance accuracy during rehabilitation are unknown. Thirty three female Sprague-Dawley adult rats were injected stereotaxically at the primary motor cerebral cortex (Fr1) with saline (CTL), or kainic acid (INJ), or kainic acid and further rehabilitation on a treadmill 16 days after lesion (INJ+RB). Motor performance was evaluated with the the Basso, Beatie and Bresnahan (BBB) locomotion scale and in the Rotarod. Spine density was quantified in a primary dendrite of motoneurons in Lamina IX in the ventral horn of the thoracolumbar spinal cord as well as spine morphology. AMPA, BDNF, PSD-95 and synaptophysin expression was evaluated by Western blot. INJ+RB group showed higher scores in motor performance. Animals from the INJ+RB group showed more thin, mushroom, stubby and wide spines than the CTL group, while the content of AMPA, BDNF, PSD-95 and Synaptophysin was not different between the groups INJ+RB and CTL. AMPA and synaptophysin content was greater in INJ group than in CTL and INJ+RB groups. The increase in the proportion of each type of spine observed in INJ+RB group suggest spinogenesis and a greater capability to integrate the afferent information to motoneurons under relatively stable molecular conditions at the synaptic level.

Changes in postural sway during upright stance after short-term lower limb physical inactivity: A prospective study

Previous studies have reported that motor behavior is affected by short-term physical inactivity using cast immobilization; however, the effects of inactivity on postural sway are not well-understood. This study aimed to investigate the effects of short-term lower limb disuse on postural sway in the upright position after cast removal. Twenty-two healthy young adults were enrolled, and each participant’s lower limb on one side was fixed with a soft bandage and medical splint made from metal and soft urethane for 10 h. Fluctuations in the center of pressure (COP) were measured before and after immobilization; the total trajectory length, mean velocity, COP root mean square (RMS) area, mean medial-lateral (M-L) COP, and mean anterior-posterior (A-P) COP were selected as evaluation parameters. Compared with the postural sway before cast application, we noted an increase and shift (from the fixed to the nonfixed side) in the postural sway after cast removal. Our results therefore suggest that short-term disuse may cause acute changes in COP movements during quiet standing. Moreover, patients may maintain their standing posture by adopting a compensatory strategy involving lateral control, similar to individuals with stroke and patients who have undergone total knee arthroplasty.

Effects of constraint-induced movement therapy for the lower extremity among individuals post-stroke: A randomized controlled clinical trial

BACKGROUND: Stroke often leads to lower extremity impairments that significantly hinders functional recovery. OBJECTIVE: To investigate the effectiveness of constraint-induced movement therapy for the lower extremity (CIMT-LE) for improving balance and ambulation among people post-stroke. METHODS: A randomized controlled, single-blinded clinical trial was conducted. Participants were recruited and randomized into one of two groups: CIMT-LE group and control. Outcome measures were the Fugl-Meyer assessment of lower extremity, Berg balance scale, ten-meter walk test and six-minute walk test. Outcome measures were collected at baseline, following the conclusion of the therapeutic programs and after three months. RESULTS: 38 participants were enrolled in the study (19 in each group). No significant differences were found between groups at baseline. At the conclusion of therapeutic programs, both groups showed significant changes compared to baseline. However, changes seen in the CIMT-LE were clinically significant. Further, at three months following the conclusion of the program, the recorded improvements were retained by participants. CONCLUSION: A CIMT-LE program compared to an intensity-matched conventional program yielded significant clinical improvements among people post-stroke. These improvements were seen in lower extremity motor recovery, postural balance and gait speed. Furthermore, these improvements were retained three months following the conclusion of the therapeutic program.

Self-reported use of the paretic lower extremity of people with stroke: A reliability and validity study of the Lower-Extremity Motor Activity Log (LE-MAL) - Brazil

BACKGROUND

Most measures to assess the lower extremity (LE) after a neurological injury assess the lower limb motor capacity in the laboratory or clinical settings as the lower-extremity motor subscale of Fugl Meyer Assessment (FMA-LE). The LE Motor Activity Log (LE-MAL) measures the use of paretic LE in real-life conditions, which for many researchers and stakeholders is considered an important goal of rehabilitation.

OBJECTIVE

Investigate the reliability, validity, floor, and ceiling effects of the Brazilian version of the LE-MAL.

METHODS

Cross-sectional study to examine the reliability and validity of LE-MAL in patients with chronic stroke. The translation and adaptation of LE-MAL was carried out for the Brazilian version. After this stage, to ensure the inter-rater reliability two raters (LCF, DBM) applied the translated version of LE-MAL in the 21 selected participants. Subsequently, the concurrent validity was calculated by the correlation with the FMA-LE.

RESULTS

The translation and retro-translation of the LE-MAL was approved to the Brazilian context. A floor effect was not observed, and there was no ceiling effect for the LE-MAL total scores. The Inter-rater reliability ranged between 0.80 and 0.86. The Bland-Altman analysis showed difference of LE-MAL scores ranged from 0.8 to 1.6. The Cronbach's alpha coefficients for LE-MAL and subscales were high ranging between 0.86 and 0.80. There was a significant moderate correlation between the LE-MAL and FMA-LE (Pearson correlation 0.55 (p = .009)).

CONCLUSION

The Brazilian version LE-MAL is valid and reliable to assess real-world use of the paretic LE of individuals with chronic stroke.

Effectiveness of Constraint-Induced Movement Therapy (CIMT) on Balance and Functional Mobility in the Stroke Population: A Systematic Review and Meta-Analysis

Constraint-induced movement therapy (CIMT) is one of the most popular treatments for enhancing upper and lower extremity motor activities and participation in patients following a stroke. However, the effect of CIMT on balance is unclear and needs further clarification. The aim of this research was to estimate the effect of CIMT on balance and functional mobility in patients after stroke. After reviewing 161 studies from search engines including Google Scholar, EBSCO, PubMed, PEDro, Science Direct, Scopus, and Web of Science, we included eight randomized controlled trials (RCT) in this study. The methodological quality of the included RCTs was verified using PEDro scoring. This systematic review showed positive effects of CIMT on balance in three studies and similar effects in five studies when compared to the control interventions such as neuro developmental treatment, modified forced-use therapy and conventional physical therapy. Furthermore, a meta-analysis indicated a statistically significant effect size by a standardized mean difference of 0.51 (P = 0.01), showing that the groups who received CIMT had improved more than the control groups. However, the meta-analysis results for functional mobility were statistically insignificant, with an effect size of −4.18 (P = 0.16), indicating that the functional mobility improvements in the investigated groups were not greater than the control group. This study’s findings demonstrated the superior effects of CIMT on balance; however, the effect size analysis of functional mobility was statistically insignificant. These findings indicate that CIMT interventions can improve balance-related motor function better than neuro developmental treatment, modified forced-use therapy and conventional physical therapy in patients after a stroke.

EMG-Triggered Pedaling Training on Muscle Activation, Gait, and Motor Function for Stroke Patients

This study aimed to determine the effects of electromyography (EMG)-triggered pedaling training to improve motor functions in the lower extremities, muscle activation, gait, postural balance, and activities of daily living in stroke patients. Subjects were randomly allocated to two groups: the EMG-triggered pedaling training group (EMG-PTG, n = 21) and the traditional pedaling training group (TPTG, n = 20). Both groups trained five times per week for four weeks, with 50 min per session. Lower extremity motor function was assessed using the Fugl–Meyer Assessment (FMA). Muscle activation of the four muscles of the lower extremities was assessed using eight-channel electromyography, while gait ability was assessed using GaitRite. Postural balance was assessed using the Berg balance scale (BBS), the timed up and go (TUG), and functional reach tests (FRT). Daily activities were assessed using the Modified Barthel Index (MBI). For lower extremity motor function, gait ability, balance ability, and activities of daily living, the EMG-PTG showed significant improvement compared to TPTG (p < 0.05). These results suggest that EMG-triggered pedaling training effectively improves lower extremity motor function, muscle activation, gait, postural balance, and activities of daily living in stroke patients.

Plasticity in Cervical Motor Circuits following Spinal Cord Injury and Rehabilitation

Simple Summary

Spinal cord injury results in a decreased quality of life and impacts hundreds of thousands of people in the US alone. This review discusses the underlying cellular mechanisms of injury and the concurrent therapeutic hurdles that impede recovery. It then describes the phenomena of neural plasticity—the nervous system’s ability to change. The primary focus of the review is on the impact of cervical spinal cord injury on control of the upper limbs. The neural plasticity that occurs without intervention is discussed, which shows new connections growing around the injury site and the involvement of compensatory movements. Rehabilitation-driven neural plasticity is shown to have the ability to guide connections to create more normal functions. Various novel stimulation and recording technologies are outlined for their role in further improving rehabilitative outcomes and gains in independence. Finally, the importance of sensory input, an often-overlooked aspect of motor control, is shown in driving neural plasticity. Overall, this review seeks to delineate the historical and contemporary research into neural plasticity following injury and rehabilitation to guide future studies.

Abstract

Neuroplasticity is a robust mechanism by which the central nervous system attempts to adapt to a structural or chemical disruption of functional connections between neurons. Mechanical damage from spinal cord injury potentiates via neuroinflammation and can cause aberrant changes in neural circuitry known as maladaptive plasticity. Together, these alterations greatly diminish function and quality of life. This review discusses contemporary efforts to harness neuroplasticity through rehabilitation and neuromodulation to restore function with a focus on motor recovery following cervical spinal cord injury. Background information on the general mechanisms of plasticity and long-term potentiation of the nervous system, most well studied in the learning and memory fields, will be reviewed. Spontaneous plasticity of the nervous system, both maladaptive and during natural recovery following spinal cord injury is outlined to provide a baseline from which rehabilitation builds. Previous research has focused on the impact of descending motor commands in driving spinal plasticity. However, this review focuses on the influence of physical therapy and primary afferent input and interneuron modulation in driving plasticity within the spinal cord. Finally, future directions into previously untargeted primary afferent populations are presented.

Effects of lower extremity constraint-induced movement therapy on gait and balance of chronic hemiparetic patients after stroke: description of a study protocol for a randomized controlled clinical trial

BACKGROUND

Protocols involving intensive practice have shown positive outcomes. Constraint induced movement therapy (CIT) appears to be one of the best options for better outcomes in upper limb rehabilitation, but we still have little data about lower extremity constraint-induced movement therapy (LE-CIT) and its effects on gait and balance.

OBJECTIVE

To evaluate the effects of an LE-CIT protocol on gait functionality and balance in chronic hemiparetic patients following a stroke.

METHODS

The study adopts a randomized, controlled, single-blinded study design. Forty-two patients, who suffered a stroke, who were in the chronic phase of recovery (>6 months), with gait disability (no community gait), and who were able to walk at least 10 m with or without the advice or support of 1 person, will be randomly allocated to 2 groups: the LE-CIT group or the control group (intensive conventional therapy). People will be excluded if they have speech deficits that render them unable to understand and/or answer properly to evaluation scales and exercises selected for the protocol and/or if they have suffered any clinical event between the screening and the beginning of the protocol. Outcome will be assessed at baseline (T0), immediately after the intervention (T1), and after 6 months (T2). The outcome measures chosen for this trial are as follows: 6-min walk test (6minWT), 10-m walk test (10mWT), timed up and go (TUG), 3-D gait analysis (3DGA), Mini Balance Evaluation Systems Test (Mini-BESTest), and as a secondary measure, Lower Extremity Motor Activity Log will be evaluated (LE-MAL). The participants in both groups will receive 15 consecutive days of daily exercise. The participants in the LE-CIT group will be submitted to this protocol 2.5 h/day for 15 consecutive days. It will include (1) intensive supervised training, (2) use of shaping as strategy for motor training, and (3) application of a transfer package (plus 30 min). The control group will receive conventional physiotherapy for 2.5 h/day over 15 consecutive days (the same period as the CIT intervention). Repeated measures analyses will be made to compare differences and define clinically relevant changes between groups.

RESULTS

Data collection is currently on-going and results are expected in 2021.

DISCUSSION

LE-CIT seems to be a good protocol for inclusion into stroke survivors' rehabilitation as it has all the components needed for positive results, as well as intensity and transference of gains to daily life activities.

TRIAL REGISTRATION

www.ensaiosclinicos.gov.br RBR-467cv6 . Registered on 10 October 2017. "Effects of Lower Extremities - Constraint Induced Therapy on gait and balance function in chronic hemipretic post-stroke patients".

Increased motor variability facilitates motor learning in weight shift toward the paretic side during walking in individuals post-stroke

The purpose of this study was to determine whether applying "varied" versus constant pelvis assistance force mediolaterally toward the paretic side of stroke survivors during walking would result in short-term improvement in weight shift toward the paretic side. Twelve individuals post-stroke (60.4 ± 6.2 years; gait speed: 0.53 ± 0.19 m/s) were tested under two conditions (varied vs. constant). Each condition was conducted in a single separate session, which consisted of (a) treadmill walking with no assistance force for 1 min (baseline), pelvis assistance toward the paretic side for 9 min (adaptation), and then no force for additional 1 min (post-adaptation), and (b) overground walking. In the "varied" condition, the magnitude of force was randomly changed across steps between 30% and 100% of the predetermined amount. In the abrupt condition, the magnitude of force was kept constant at 100% of the predetermined amount. Participants exhibited greater improvements in weight shift toward the paretic side (p < 0.01) and in muscle activity of plantar flexors and hip adductors of the paretic leg (p = 0.02) from baseline to late post-adaptation period for the varied condition than for the constant condition. Motor variability of the peak pelvis displacement at baseline was correlated with improvement in weight shift toward the paretic side after training for the varied (R²  = 0.64, p = 0.01) and the constant condition (R²  = 0.39, p = 0.03). These findings suggest that increased motor variability, induced by applying the varied pelvis assistance, may facilitate motor learning in weight shift and gait symmetry during walking in individuals post-stroke.

Effects of Lower Limb Constraint Induced Movement Therapy in People With Stroke: A Systematic Review and Meta-Analysis

Background: Constraint induced movement therapy (CIMT) is effective at improving upper limb outcomes after stroke.

Aim: The aim of this study was to carry out a systematic review and meta-analysis of the effects of lower limb CIMT studies of any design in people with stroke.

Materials/ Method: PubMED, PEDro, OTSeeker, CENTRAL, and Web of Science were searched from their earliest dates to February 2021. Lower limbs CIMT studies that measured outcomes at baseline and post-intervention were selected. Sample size, mean, and standard deviation on the outcomes of interest and the protocols of both the experimental and control groups were extracted. McMaster Critical Review Form was used to assess the methodological quality of the studies.

Result: Sixteen studies with different designs were included in this review. The result showed that lower limb CIMT improves functional, physiological and person's reported outcomes including motor function, balance, mobility, gait speed, oxygen uptake, exertion before and after commencement of activities, knee extensor spasticity, weight bearing, lower limb kinematics and quality of life in people with stroke post intervention. However, there were only significant differences in quality of life in favor of CIMT post-intervention [mean difference (MD) = 16.20, 95% CI = 3.30–29.10, p = 0.01]; and at follow-up [mean difference (MD) = 14.10, 95% CI = 2.07–26.13, p = 0.02] between CIMT and the control group. Even for the quality of life, there was significant heterogeneity in the studies post intervention (I² = 84%, p = 0.01).

Conclusion: Lower limb CIMT improves motor function, balance, functional mobility, gait speed, oxygen uptake, weigh bearing, lower limb kinematics, and quality of life. However, it is only superior to the control at improving quality of life after stroke based on the current literature.

Axonal remodeling of the corticospinal tract during neurological recovery after stroke

Stroke remains the leading cause of long-term disability. Hemiparesis is one of the most common post-stroke motor deficits and is largely attributed to loss or disruption of the motor signals from the affected motor cortex. As the only direct descending motor pathway, the corticospinal tract (CST) is the primary pathway to innervate spinal motor neurons, and thus, forms the neuroanatomical basis to control the peripheral muscles for voluntary movements. Here, we review evidence from both experimental animals and stroke patients, regarding CST axonal damage, functional contribution of CST axonal integrity and remodeling to neurological recovery, and therapeutic approaches aimed to enhance CST axonal remodeling after stroke. The new insights gleaned from preclinical and clinical studies may encourage the development of more rational therapeutics with a strategy targeted to promote axonal rewiring for corticospinal innervation, which will significantly impact the current clinical needs of subacute and chronic stroke treatment.