Method for enhancing real-world use of a more affected arm in chronic stroke: transfer package of constraint-induced movement therapy

Portable robots for upper-limb rehabilitation after stroke: a systematic review and meta-analysis

BACKGROUND

Robot-assisted upper-limb rehabilitation has been studied for many years, with many randomised controlled trials (RCTs) investigating the effects of robotic-assisted training on affected limbs. The current trend directs towards end-effector devices. However, most studies have focused on the effectiveness of rehabilitation devices, but studies on device sizes are relatively few.

GOAL

Systematically review the effect of a portable rehabilitation robot (PRR) on the rehabilitation effectiveness of paralysed upper limbs compared with non-robotic therapy.

METHODS

A meta-analysis was conducted on literature that included the Fugl-Meyer Assessment (FMA) obtained from the PubMed and Web of Science (WoS) electronic databases until June 2023.

RESULTS

A total of 9 studies, which included RCTs, were completed and a meta-analysis was conducted on 8 of them. The analysis involved 295 patients. The influence on upper-limb function before and after treatment in a clinical environment is analysed by comparing the experimental group using the portable upper-limb rehabilitation robot with the control group using conventional therapy. The result shows that portable robots prove to be effective (FMA: SMD = 0.696, 95% = 0.099 to.293, p < 0.05).

DISCUSSION

Both robot-assisted and conventional rehabilitation effects are comparable. In some studies, PRR performs better than conventional rehabilitation, but conventional treatments are still irreplaceable. Smaller size with better portability has its advantages, and portable upper-limb rehabilitation robots are feasible in clinical rehabilitation.

CONCLUSION

Although portable upper-limb rehabilitation robots are clinically beneficial, few studies have focused on portability. Further research should focus on modular design so that rehabilitation robots can be decomposed, which benefits remote rehabilitation and household applications.

Long COVID Brain Fog Treatment: Findings from a Pilot Randomized Controlled Trial of Constraint-Induced Cognitive Therapy

Purpose

Long COVID brain fog is often disabling. Yet, no empirically-supported treatments exist. This study's objectives were to evaluate feasibility and efficacy, provisionally, of a new rehabilitation approach, Constraint-Induced Cognitive Therapy (CICT), for post-COVID-19 cognitive sequelae.

Design

Sixteen community-residents ≥ 3-months post-COVID-19 infection with mild cognitive impairment and dysfunction in instrumental activities of daily living (IADL) were enrolled. Participants were randomized to Immediate-CICT or treatment-as-usual (TAU) with crossover to CICT. CICT combined behavior change techniques modified from Constraint-Induced Movement Therapy with Speed of Processing Training, a computerized cognitive-training program. CICT was deemed feasible if (a) ≥80% of participants completed treatment, (b) the same found treatment highly satisfying and at most moderately difficult, and (c) <2 study-related, serious adverse-events occurred. The primary outcome was IADL performance in daily life (Canadian Occupational Performance Measure). Employment status and brain fog (Mental Clutter Scale) were also assessed.

Results

Fourteen completed Immediate-CICT (n=7) or TAU (n=7); two withdrew from TAU before their second testing session. Completers were [M (SD)]: 10 (7) months post-COVID; 51 (13) years old; 10 females, 4 males; 1 African American, 13 European American. All the feasibility benchmarks were met. Immediate-CICT, relative to TAU, produced very large improvements in IADL performance (M=3.7 points, p<.001, d=2.6) and brain fog (M=-4 points, p<.001, d=-2.9). Four of five non-retired Immediate-CICT participants returned-to-work post-treatment; no TAU participants did, p=.048.

Conclusions

CICT has promise for reducing brain fog, improving IADL, and promoting returning-to-work in adults with Long COVID. Findings warrant a large-scale RCT with an active-comparison group.

Effectiveness of constraint-induced movement therapy (CIMT)-Telerehabilitation compared to traditional CIMT on upper extremity dysfunction of adult chronic stroke patients-A systematic review and meta-analysis

BACKGROUND/OBJECTIVE

Constraint-induced movement therapy (CIMT), a therapy that encourages the use of the affected upper limb through intensive functional tasks, effectively promotes upper limb function in patients with chronic stroke. This study determined the effectiveness of CIMT using telerehabilitation compared with traditional CIMT in improving mild to moderate upper limb motor function in adult patients with chronic stroke.

METHODS

Eligible studies were identified by searching electronic databases and scanning the reference lists of articles. Review Manager 5.4 was used to determine the pooled mean effect size of the standardized mean difference and 95% confidence interval for the group comparison. Visual heterogeneity, I2 statistic, and chi-square test were used to measure the heterogeneity between the included studies. We evaluated the quality of evidence using GRADEpro GDT, software for creating evidence summaries and healthcare recommendations.

RESULTS

Two randomized controlled trials were included in this review. A total of 109 participants (70 male, 39 female) were evaluated. The time since the stroke was ≥6 months in one study and ≥1 year in another study. Improvements in upper limb motor function while performing functional movements were measured using the Wolf Motor Function Test. The evidence for the effectiveness of CIMT using telerehabilitation compared with traditional CIMT in improving the upper extremity function in patients with chronic stroke is of moderate quality. This suggests no significant difference between the groups (mean difference [95% CI]: -0.04 [-0.42, 0.33]).

CONCLUSIONS

CIMT using telerehabilitation is not superior to traditional CIMT in improving patients' upper extremity motor function with chronic stroke. CIMT using telerehabilitation may improve access to treatment, minimize SARS-CoV-2 risk, and reduce travel in patients with chronic stroke.

Improvement of gait and balance function in chronic post-stroke patients induced by Lower Extremity - Constraint Induced Movement Therapy: a randomized controlled clinical trial

OBJECTIVE

To evaluate the effects of Lower Extremity - Constraint Induced Movement Therapy on gait function and balance in chronic hemiparetic patients.

METHODS

Randomized, controlled, single-blinded study. We recruited chronic post stroke patients and allocated them to Lower Extremity - Constraint Induced Movement Tharapy (LE-CIMT) or Control Group. The LE-CIMT group received this protocol 2.5 hour/day for 15 followed days, including: 1) intensive supervised training, 2) use of shaping as a strategy for motor training, and 3) application of a transfer package. The control group received conventional physiotherapy for 2.5 hours/day for 15 followed days. Outcomes were assessed at baseline, after the interventions, and after 6 months, through 6-minute walk test and Mini-Balance Evaluation Systems Test; 10-meter walk test, Timed Up and Go, 3-D gait analysis, and Lower Extremity - Motor Activity Log.

RESULTS

LE-CIMT was superior on the Assistance and confidence subscale of Lower Extremity - Motor Activity Log, Mini-BESTest and 6-minute walk test. The effect size for all outcomes was small when comparing both groups. LE-CIMT showed clinically significant differences in daily activities, balance, and gait capacity, with no clinically significant difference for spatiotemporal parameters.

CONCLUSION

The LE-CIMT protocol had positive outcomes on balance, performance, and confidence perception.

Effect of a restrictive orthosis on the paralyzed hand in combination with constraint-induced movement therapy in a patient with chronic stroke: a case report

PURPOSE

Many studies have reported the effects of constraint-induced movement therapy (CIMT) with an orthosis on the residual function of the impaired side of post-stroke patients. We encountered a case with left hemiparesis whose functioning of the impaired hand improved by CIMT with an orthosis not to assist as in the past but to restrict the residual function of the paralyzed fingers.

METHODS

The patient was a 46-year-old woman with left hemiparesis due to cerebral infarction 18 months ago. The patient had resumed work but would easily tire while typing the keyboard. We found that the extrinsic hand muscles were more engaged in compensatory movements than the intrinsic muscles. Therefore, we designed an orthosis that would extend and fixation the distal interphalangeal joint and proximal interphalangeal joint muscles to promote the engagement of the intrinsic muscles and restrict the compensatory movements of the extrinsic muscles.

RESULTS

The orthosis was used for 8 h/day for 2 weeks; CIMT were performed. Left hemiplegia improved from CIMT and the patient was able to handle the same amount of work as that before onset.

CONCLUSION

Restrictive orthosis on the paralyzed hand in combination with CIMT was found to be a beneficial rehabilitation approach.

Dose Response to Upper Extremity Stroke Rehabilitation Varies by Individual: Early Indicators of Treatment Response

BACKGROUND

Dose response has remained a priority area in motor rehabilitation research for decades, prompting several large randomized trials and meta-analyses. These between-subjects comparisons have revealed equivocal relationships between the duration of motor practice and rehabilitation response. Prior reliance on time-consuming clinical assessments made it infeasible to capture within-subjects dose response, as tracking the dose-response trajectory of an individual requires dozens of repeated administrations.

METHODS

This secondary observational cohort analysis of existing data from the gaming arms of the VIGoROUS multisite trial (Video Game Rehabilitation for Outpatient Stroke) describes the rehabilitation dose response of 80 participants with mild-moderate chronic stroke. The 3-dimensional joint position data were captured via the Kinect v2 optical sensor as participants completed a prescribed 15 hours of in-home unsupervised game-based motor practice. Kinematic dose response trajectories were fitted from hundreds to thousands of in-game repetitions for 4 separate upper extremity movements for each participant.

RESULTS

Of 75 participants with sufficient data for dose-response analysis, 85% showed improved motor capacity for at least 1 movement. Dose response was bimodal; 42% required <5 hours of motor practice before reaching a plateau in movement kinematics, whereas 55% required >10 and 34% required >30 hours. We could predict with 93% accuracy whether or not an individual would ultimately respond to game-based motor practice within 5 hours of gameplay.

CONCLUSIONS

Dose response varies considerably between individuals. About half of chronic stroke patients benefit from higher doses of motor practice than the current standard of care. Individualized dose-response data from motion capture rehabilitation gaming can guide clinical decision-making early on in treatment.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02631850.

Combined repetitive facilitative exercise under continuous neuromuscular electrical stimulation and task-oriented training for hemiplegic upper extremity during convalescent phase after stroke: before-and-after feasibility trial

Introduction

Whereas repetitive facilitative exercise (RFE) affects primarily recovery of motor impairment after stroke, task-oriented training (TOT) focuses on facilitating daily use of the affected upper extremity. However, feasibility of combined RFE and TOT has not been reported. We originated "task-oriented RFE," as a new combination therapy for patients with hemiplegic upper extremity after subacute stroke, to examine its feasibility in convalescent rehabilitation wards.

Methods

This is a before-and-after pilot study. Eight patients with hemiplegic upper extremity after subacute stroke received the task-oriented RFE program for 6 weeks at 80 min per day (20-60 min of TOT applied after 60-20 min of RFE under continuous neuromuscular electrical stimulation) in a convalescent rehabilitation ward. In the current program, we introduced the Aid for Decision-making in Occupation Choice (ADOC) iPad application as a goal-setting method for determining tasks. Feasibility was assessed with adherence to the protocol, adverse events in response to the intervention, and preliminary efficacy. Motor functions, amount of use and quality of movement in the hemiparetic upper extremity, and satisfaction of the patients were evaluated with Fugl-Meyer Assessment (FMA), the Action Research Arm Test (ARAT), the motor activity log (MAL) for the amount of use (AOU) and quality of movement (QOM) of the paralyzed hand, and ADOC.

Results

All participants accomplished the program, which was implemented as originally planned; neither nonattendance nor an adverse event occurred during the study. Favorable outcomes were obtained with all measures; mean changes in FMA, ARAT in the dominant hand, MAL-AOU, and MAL-QOM were greater than minimal clinically important differences. Mean changes in ADOC were greater than the minimal detectable change.

Discussion

The task-oriented RFE program was safe, well-tolerated, beneficial, and feasible within 80 min a day of occupational therapy, which means also within the procedural constraints of the Japanese health insurance system during the convalescent phase. Future studies are warranted to examine whether combined RFE and TOT enhances the efficacies of each program alone.

The feasibility of the adapted H-GRASP program for perceived and actual daily-life upper limb activity in the chronic phase post-stroke

(Purpose: Assessing feasibility and initial impact of the Home-Graded Repetitive Arm Supplementary Program combined with in-home accelerometer-based feedback (AH-GRASP) on perceived and actual daily-life upper limb (UL) activity in stroke survivors during the chronic phase with good UL motor function but low perceived daily-life activity. Material and methods: A 4-week intervention program (4 contact hours, 48 h self-practice) encompassing task-oriented training, behavioral techniques, phone-based support, monitoring, and weekly feedback sessions using wrist-worn accelerometery was implemented using a pre-post double baseline repeated measures design. Feasibility, clinical assessments, patient-reported outcomes, and accelerometer data were investigated. Results: Of the 34 individuals approached, nineteen were included (recruitment rate 56%). Two dropped out, one due to increased UL pain (retention rate 89%). Seven (41%) achieved the prescribed exercise target (120 min/day, six days/week). Positive patient experiences and improvements in UL capacity, self-efficacy, and contribution of the affected UL to overall activity (p < 0.05, small to large effect sizes) were observed. Additionally, seven participants (41%) surpassed the minimal clinically important difference in perceived UL activity.Conclusions: A home-based UL exercise program with accelerometer-based feedback holds promise for enhancing perceived and actual daily-life UL activity for our subgroup of chronic stroke survivors.

Wearable Sensor to Monitor Quality of Upper Limb Task Practice for Stroke Survivors at Home

Many stroke survivors experience persistent upper extremity impairment that limits performance in activities of daily living. Upper limb recovery requires high repetitions of task-specific practice. Stroke survivors are often prescribed task practices at home to supplement rehabilitation therapy. A poor quality of task practices, such as the use of compensatory movement patterns, results in maladaptive neuroplasticity and suboptimal motor recovery. There currently lacks a tool for the remote monitoring of movement quality of stroke survivors' task practices at home. The objective of this study was to evaluate the feasibility of classifying movement quality at home using a wearable IMU. Nineteen stroke survivors wore an IMU sensor on the paretic wrist and performed four functional upper limb tasks in the lab and later at home while videorecording themselves. The lab data served as reference data to classify home movement quality using dynamic time warping. Incorrect and correct movement quality was labeled by a therapist. The home task practice movement quality was classified with an accuracy of 92% and F1 score of 0.95 for all tasks combined. Movement types contributing to misclassification were further investigated. The results support the feasibility of a home movement quality monitoring system to assist with upper limb rehabilitation post stroke.

Unlocking the restraint-Development of a behaviour change intervention to increase the provision of modified constraint-induced movement therapy in stroke rehabilitation

BACKGROUND

Strong evidence supports the provision of modified constraint-induced movement therapy (mCIMT) to improve upper limb function after stroke. A service audit identified that very few patients received mCIMT in a large subacute, early-supported discharge rehabilitation service. A behaviour change intervention was developed to increase the provision of mCIMT following an unsuccessful 'education only' attempt. This paper aims to systematically document the steps undertaken and to provide practical guidance to clinicians and rehabilitation services to implement this complex, yet effective, rehabilitation intervention.

METHODS

This clinician behaviour change intervention was developed over five stages and led by a working group of neurological experts (n = 3). Data collection methods included informal discussions with clinicians and an online survey (n = 35). The staged process included reflection on why the first attempt did not improve the provision of mCIMT (stage 1), mapping barriers and enablers to the Theoretical Domains Framework (TDF) and behaviour change wheel (BCW) to guide the behaviour change techniques (stages 2 and 3), developing a suitable mCIMT protocol (stage 4), and delivering the behaviour change intervention (stage 5).

RESULTS

Reflection among the working group identified the need for upskilling in mCIMT delivery and the use of a behaviour change framework to guide the implementation program. Key determinants of behaviour change operated within the TDF domains of knowledge, skills, environmental context and resources, social role and identity, and social influences. Following the development of a context-specific mCIMT protocol, the BCW guided the behaviour change intervention, which included education, training, persuasion, environmental restructuring, and modelling.

CONCLUSION

This paper provides an example of using the TDF and BCW to support the implementation of mCIMT in a large early-supported discharge service. It outlines the suite of behaviour change techniques used to influence clinician behaviour. The success of this behaviour change intervention will be explored in future research.

Therapeutic effect of adjuvant therapy added to constraint-induced movement therapy in patients with subacute to chronic stroke: a systematic review and meta-analysis

PURPOSE

This review investigated the effectiveness of adjuvant therapy combined with constraint-induced movement therapy (CIMT) in improving the paretic upper limb functionality in adults with stroke sequelae during the subacute to chronic rehabilitation phase.

MATERIALS AND METHODS

In this systematic review and meta-analysis of randomized controlled trials (RCT), electronic databases, including PubMed, Web of Science, CINAHL, and MEDLINE, were searched. We included RCTs that investigated the outcomes of adjuvant therapy (i.e. other therapies) added to CIMT compared with CIMT alone. Key trial findings were qualitatively synthesized and analyzed. This meta-analysis examined variables, such as mean scores and standard deviations, using the following outcome measures: Fugl-Meyer Assessment (FMA) upper limb items, Action Research Arm Test (ARAT), Amount of Use (AOU) of Motor Activity Log (MAL), and Quality of Movement (QOM) of MAL.

RESULTS

Eighteen eligible RCTs were included in the analysis. Adding CIMT to adjunctive therapy significantly improved FMA compared with CIMT alone (mean difference [MD] 4.02, 95% confidence interval [CI] 2.60-5.44; I2 = 85%; 15 studies; 330 participants). Similarly, the ARAT and MAL-AOU scores improved significantly.

CONCLUSIONS

CIMT combined with several adjunctive therapies effectively improved upper limb function.

Delivering constraint-induced movement therapy in stroke rehabilitation requires informed stakeholders, sufficient resources and organisational buy-in: a mixed-methods systematic review

OBJECTIVE

To summarise and synthesise the qualitative literature relating to constraint-induced movement therapy (CIMT) among stroke survivors, carers, therapists and rehabilitation service managers.

DESIGN

Systematic review of qualitative studies. Quantitative studies using survey data were also included if they investigated perceptions and/or experiences related to CIMT.

DATA SOURCES

Cochrane Library, Medline, JBI, Emcare, Embase, PsycInfo, CINAHL, PEDro, OT Seeker and NICE from inception to January 2022.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data from the included studies and assessed comprehensiveness of reporting using established tools. Thematic synthesis was undertaken to synthesise findings for studies using focus groups and interviews. A summary of themes from quantitative studies using survey data was compiled to complement the qualitative synthesis.

RESULTS

Searches yielded 1,450 titles after removal of duplicates; 60 full-text articles were assessed for eligibility and 14 studies were included (1,570 total participants). Thematic synthesis identified nine descriptive themes from which four analytical themes were developed: CIMT is challenging but support at all levels helps; therapists need the know-how, resources and staffing; CIMT is different to other interventions, and there are positives and negatives to this; and functional outcomes do not always meet high expectations. Quantitative survey themes included: knowledge, skills and confidence in delivering CIMT programs; patient factors; and institutional factors.

CONCLUSIONS

This review identified several determinants of implementation related to CIMT. Rehabilitation therapists need to develop their knowledge and skills to deliver CIMT, engage with organisational leaders, and develop CIMT protocols to fit the local clinical context in order to sustainably deliver CIMT in stroke rehabilitation services. Stroke survivors and carers require improved education to increase their engagement and participation. After addressing these determinants, future research should evaluate population-level outcomes and policy-level implementation in establishing CIMT as global standard rehabilitation practice.

REGISTRATION

CRD42021237757.

Shoulder complex and trunk coordination of individuals with severe hemiparesis following a constraint-induced movement therapy protocol: A case series

INTRODUCTION

Constraint Induced Movement Therapy (CIMT) has been shown to be an effective rehabilitation technique in individuals with mild and moderate upper limb (UL) hemiparesis. The aim was to evaluate the effect the CIMT for improving paretic UL use and interjoint coordination with individuals in severe hemiparesis.

METHODS

Six individuals with severe chronic hemiparesis (mean age = 55 ± 16 years) received a UL CIMT intervention for 2 weeks. UL clinical assessments were conducted five times: two assessments at pre-intervention and then, one assessment at post-intervention and 1- and 3-month follow-up using the Graded Motor Activity Log GMAL) and the Graded Wolf Motor Function Test (GWMFT). Scapula, humerus and trunk coordination variability were assessed using the 3-D kinematics during arm elevation, combing hair, turning on the switch and grasp a washcloth. A paired t-test was used to check differences between coordination variability and a one-way ANOVA repeated measures was used to check differences between GMAL and GWMFT scores.

RESULTS

There were no differences in GMAL and GWMFT between the patient screening and the baseline data collection (p > 0.05). GMAL scores increased at post-intervention and at follow-ups (p < 0.02). GWMFT performance time score decreased at post-intervention and at 1-month follow-up (p < 0.04). Improvements in kinematic variability of the paretic UL at pre and post-intervention were observed in all tasks, except in the activity of turn on the light switch.

CONCLUSION

Following the CIMT protocol, improvements in GMAL and GWMFT scores may reflect improvements in paretic UL performance, in real-life environment. Improvements in kinematic variability may reflect an improving of UL interjoint coordination for individuals with chronic severe hemiparesis.

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.

Can specific virtual reality combined with conventional rehabilitation improve poststroke hand motor function? A randomized clinical trial

TRIAL OBJECTIVE

To verify whether conventional rehabilitation combined with specific virtual reality is more effective than conventional therapy alone in restoring hand motor function and muscle tone after stroke.

TRIAL DESIGN

This prospective single-blind randomized controlled trial compared conventional rehabilitation based on physiotherapy and occupational therapy (control group) with the combination of conventional rehabilitation and specific virtual reality technology (experimental group). Participants were allocated to these groups in a ratio of 1:1. The conventional rehabilitation therapists were blinded to the study, but neither the participants nor the therapist who applied the virtual reality-based therapy could be blinded to the intervention.

PARTICIPANTS

Forty-six patients (43 of whom completed the intervention period and follow-up evaluation) were recruited from the Neurology and Rehabilitation units of the Hospital General Universitario of Talavera de la Reina, Spain.

INTERVENTION

Each participant completed 15 treatment sessions lasting 150 min/session; the sessions took place five consecutive days/week over the course of three weeks. The experimental group received conventional upper-limb strength and motor training (100 min/session) combined with specific virtual reality technology devices (50 min/session); the control group received only conventional training (150 min/session).

RESULTS

As measured by the Ashworth Scale, a decrease in wrist muscle tone was observed in both groups (control and experimental), with a notably larger decrease in the experimental group (baseline mean/postintervention mean: 1.22/0.39; difference between baseline and follow-up: 0.78; 95% confidence interval: 0.38-1.18; effect size = 0.206). Fugl-Meyer Assessment scores were observed to increase in both groups, with a notably larger increase in the experimental group (total motor function: effect size = 0.300; mean: - 35.5; 95% confidence interval: - 38.9 to - 32.0; wrist: effect size = 0.290; mean: - 5.6; 95% confidence interval: - 6.4 to - 4.8; hand: effect size = 0.299; mean: - -8.9; 95% confidence interval: - 10.1 to - 7.6). On the Action Research Arm Test, the experimental group quadrupled its score after the combined intervention (effect size = 0.321; mean: - 32.8; 95% confidence interval: - 40.1 to - 25.5).

CONCLUSION

The outcomes of the study suggest that conventional rehabilitation combined with a specific virtual reality technology system can be more effective than conventional programs alone in improving hand motor function and voluntary movement and in normalizing muscle tone in subacute stroke patients. With combined treatment, hand and wrist functionality and motion increase; resistance to movement (spasticity) decreases and remains at a reduced level.

TRIALS REGISTRY

International Clinical Trials Registry Platform: ISRCTN27760662 (15/06/2020; retrospectively registered).

Effect of Self-Directed Home Therapy Adherence Combined with TheraBracelet on Poststroke Hand Recovery: A Pilot Study

Hand impairment is a common consequence of stroke, resulting in long-term disability and reduced quality of life. Recovery may be augmented through self-directed therapy activities at home, complemented by the use of rehabilitation devices such as peripheral sensory stimulation. The objective of this study was to determine the effect of adherence to self-directed therapy and the use of TheraBracelet (subsensory random-frequency vibratory stimulation) on hand function for stroke survivors. In a double-blind, randomized controlled pilot trial, 12 chronic stroke survivors were assigned to a treatment or control group (n = 6/group). All participants were instructed to perform 200 repetitions of therapeutic hand tasks 5 days/week while wearing a wrist-worn device 8 hours/day for 4 weeks. The treatment group received TheraBracelet vibration from the device, while the control group received no vibration. Home task repetition adherence and device wear logs, as well as hand function assessment (Stroke Impact Scale Hand domain), were obtained weekly. Repetition adherence was comparable between groups but varied among participants. Participants wore the device to a greater extent than adhering to completing repetitions. A linear mixed model analysis showed a significant interaction between repetition and group (p = 0.01), with greater adherence resulting in greater hand function change for the treatment group (r = 0.94; R ² = 0.88), but not for the control group. Secondary analysis revealed that repetition adherence was greater for those with lower motor capacity and greater self-efficacy at baseline. This pilot study suggests that adherence to self-directed therapy at home combined with subsensory stimulation may affect recovery outcomes in stroke survivors. This trial is registered with NCT04026399.

Effects of constraint-induced movement therapy on activity and participation after a stroke: Systematic review and meta-analysis

Introduction

Hemiparesis is the main sensorimotor deficit after stroke. It can result in limitations in Activities of Daily Living (ADL) and social participation. Hemiparesis can be treated with behavioral techniques of intensive use of the affected arm, such as constraint-induced movement therapy (CIMT), however, it remains unclear whether motor improvement can lead to increases in the domains of activity and participation.

Objective

Identify whether CIMT is superior to usual techniques to enhance activity and participation outcomes in stroke survivors.

Methods

A systematic review with meta-analysis was conducted, based on the PRISMA guidelines. Search databases were: PubMed, LILACS, Embase, SciELO, Cochrane Library, Scopus, Medline, and Web of Science, with no language restriction. Meta-analysis was performed with Review Manager (version 5.3), significance level p ≤ 0.05.

Results

A total of 21 articles were included for analysis. Superior effects were observed on motor function and performance in activities of daily living of individuals treated with CIMT. The outcomes measures utilized were: Fugl-Meyer Assessment (p = 0.00001); Wolf motor function test (p = 0.01); Modified Barthel Index (p = 0.00001); Motor Activity log (MAL) Amount of use (AOU) (p = 0.01); MAL Quality of movement (QOM) (p = 0.00001); Action Research Arm Test-ARAT (p = 0.00001); and FIM (p = 0.0007).

Conclusion

Our results show that CIMT results in more significant gains in the functional use of the upper limb in ADL and functional independence, demonstrating superior activity and participation results in stroke survivors when compared to conventional therapies.

Remote constraint induced therapy of the upper extremity (ReCITE): A feasibility study protocol

Background

Difficulty using the upper extremity in everyday activities is common after stroke. Constraint-induced movement therapy (CIMT) has been shown to be effective in both sub-acute and chronic phases of stroke recovery and is recommended in clinical practice guidelines for stroke internationally. Despite reports of equivalence of outcome when stroke rehabilitation interventions are delivered using telehealth, there has been limited evaluation of CIMT when using this mode of delivery. ReCITE will (a) evaluate the feasibility and acceptability of CIMT when delivered via telehealth to stroke survivors (TeleCIMT) and (b) explore therapists' experiences and use of an online support package inclusive of training, mentoring and resources to support TeleCIMT delivery in clinical practice.

Methods

A prospective single-group, single blinded, study design with embedded process evaluation will be conducted. The study will be conducted at three outpatient services in Sydney, Australia. A multi-faceted therapist support package, informed by the Capabilities, Opportunity, Motivation- Behaviour model (COM-B), will be used to support occupational therapists to implement TeleCIMT as part of routine care to stroke survivors. Each service will recruit 10 stroke survivor participants (n = 30) with mild to moderate upper extremity impairment. Upper extremity and quality of life outcomes of stroke survivor participants will be collected at baseline, post-intervention and at a 4 week follow-up appointment. Feasibility of TeleCIMT will be evaluated by assessing the number of stroke participants who complete 80% of intensive arm practice prescribed during their 3 week program (i.e., at least 24 h of intensive arm practice). Acceptability will be investigated through qualitative interviews and surveys with stroke survivors, supporter surveys and therapist focus groups. Qualitative interviews with therapists will provide additional data to explore their experiences and use of the online support package.

Discussion

The COVID-19 pandemic resulted in a rapid transition to delivering telehealth. The proposed study will investigate the feasibility and acceptability of delivering a complex intervention via telehealth to stroke survivors at home, and the support that therapists and patients require for delivery. The findings of the study will be used to inform whether a larger, randomized controlled trial is feasible.

Mediating Effect of Upper Limb Use on the Relationship Between Upper Limb Performance and Activities of Daily Living: A Longitudinal Mediation Analysis

INTRODUCTION

Upper limb performance, frequency of upper limb use, and psychological factors are associated with activities of daily living (ADLs) after stroke. We performed a mediation analysis to investigate how the frequency of upper limb use and some psychological factors mediate the relationship between upper limb performance and ADLs.

METHODS

Twenty-two patients with stroke were included in this longitudinal study. We utilized the frequency of upper limb use outcome measures (amount of use and quality of motion of the motor activity log), psychological factors outcome measures (General Self-Efficacy Scale), upper limb performance outcome measures (Fugl-Meyer Assessment (FMA)), and ADLs outcome measure (Functional Independence Measure (FIM) motor subscale (M)). Mediation analysis with a bootstrap sampling procedure was used to assess the indirect effects.

RESULTS

Mediation analysis showed that the FMA, as measured by the FIM (M), had significant indirect effects on the amount of use (95% bootstrapped confidence interval (CI): 0.36-2.42) and quality of motion (95% bootstrapped CI: 0.06-1.88). The relationship between upper limb performance and ADLs was mediated by the frequency of upper limb use.

CONCLUSION

Our findings suggest that improving the frequency of upper limb use may accelerate post-stroke recovery.

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.

The Mechanism and Clinical Application of Constraint-Induced Movement Therapy in Stroke Rehabilitation

Constraint-induced movement therapy (CIMT) has been widely applied in stroke rehabilitation, and most relevant studies have shown that CIMT helps improve patients' motor function. In practice, however, principal issues include inconsistent immobilization durations and methods, while incidental issues include a narrow application scope and an emotional impact. Although many studies have explored the possible internal mechanisms of CIMT, a mainstream understanding has not been established.

Tactile Sensation Improves Following Motor Rehabilitation for Chronic Stroke: The VIGoROUS Randomized Controlled Trial

Background. Up to 85% of people with chronic stroke experience somatosensory impairment, which contributes to poor sensorimotor control and non-use of the affected limb. Neurophysiological mechanisms suggest motor rehabilitation may improve tactile sense post-stroke, however, somatosensory recovery has rarely been reported in controlled trials. Objective. To compare the effect of four upper limb motor rehabilitation programs on the recovery of tactile sensation in adults with chronic stroke. Methods. Adults with chronic stroke and mild or moderate upper extremity hemiparesis (n = 167) were enrolled in a multi-site randomized controlled trial. Participants completed three weeks of gaming therapy, gaming therapy with additional telerehabilition, Constraint-Induced Movement therapy, or traditional rehabilitation. Here, we report the results of a secondary outcome, tactile sensation, measured with monofilaments, before and after treatment, and 6 months later. Results. A mixed-effects general linear model revealed similar positive change in tactile sensitivity regardless of the type of training. On average, participants were able to detect a stimulus that was 32% and 33% less after training and at 6-month follow-up, respectively. One-third of participants experienced recategorization of their level of somatosensory impairment (e.g., regained protective sensation) following training. Poorer tactile sensation at baseline was associated with greater change. Conclusions. About one-third of individuals with mild/moderate chronic hemiparesis experience sustained improvements in tactile sensation following motor rehabilitation, regardless of the extent of tactile input in the rehabilitation program. Potential for sensory improvement is an additional motivator for those post-stroke. Characteristics of those who improve and mechanisms of improvement are important future questions. Clinicaltrials.gov NCT02631850.

Retrospective Analysis of Task-Specific Effects on Brain Activity After Stroke: A Pilot Study

Background

Evidence supports cortical reorganization in sensorimotor areas induced by constraint-induced movement therapy (CIMT). However, only a few studies examined the neural plastic changes as a function of task specificity. This retrospective analysis aims to evaluate the functional brain activation changes during a precision and a power grasp task in chronic stroke survivors who received 2-weeks of CIMT compared to a no-treatment control group.

Methods

Fourteen chronic stroke survivors, randomized to CIMT (n = 8) or non-CIMT (n = 6), underwent functional MRI (fMRI) before and after a 2-week period. Two behavioral measures, the 6-item Wolf Motor Function Test (WMFT-6) and the Motor Activity Log (MAL), and fMRI brain scans were collected before and after a 2-week period. During scan runs, participants performed two different grasp tasks (precision, power). Pre to post changes in laterality index (LI) were compared by group and task for two predetermined motor regions of interest: dorsal premotor cortex (PMd) and primary motor cortex (MI).

Results

In contrast to the control group, the CIMT group showed significant improvements in the WMFT-6. For the MAL, both groups showed a trend toward greater improvements from baseline. Two weeks of CIMT resulted in a relative increase in activity in a key region of the motor network, PMd of the lesioned hemisphere, under precision grasp task conditions compared to the non-treatment control group. No changes in LI were observed in MI for either task or group.

Conclusion

These findings provide preliminary evidence for task-specific effects of CIMT in the promotion of recovery-supportive cortical reorganization in chronic stroke survivors.

Concomitant sensory stimulation during therapy to enhance hand functional recovery post stroke

Background

Post-stroke hand impairment is prevalent and persistent even after a full course of rehabilitation. Hand diminishes stroke survivors’ abilities for activities of daily living and independence. One way to improve treatment efficacy is to augment therapy with peripheral sensory stimulation. Recently, a novel sensory stimulation, TheraBracelet, has been developed in which imperceptible vibration is applied during task practice through a wrist-worn device. The objective of this trial is to determine if combining TheraBracelet with hand task practice is superior to hand task practice alone.

Methods

A double-blind randomized controlled trial will be used. Chronic stroke survivors will undergo a standardized hand task practice therapy program (3 days/week for 6 weeks) while wearing a device on the paretic wrist. The device will deliver TheraBracelet vibration for the treatment group and no vibration for the control group. The primary outcome is hand function measured by the Wolf Motor Function Test. Other outcomes include the Box and Block Test, Action Research Arm Test, upper extremity use in daily living, biomechanical measure of the sensorimotor grip control, and EEG-based neural communication.

Discussion

This research will determine clinical utility of TheraBracelet to guide future translation. The TheraBracelet stimulation is delivered via a wrist-worn device, does not interfere with hand motion, and can be easily integrated into clinical practice. Enhancing hand function should substantially increase stroke survivors' independence and quality of life and reduce caregiver burden.

Trial registration

NCT04569123. Registered on September 29, 2020

Robot-Assisted Training as Self-Training for Upper-Limb Hemiplegia in Chronic Stroke: A Randomized Controlled Trial

BACKGROUND

This study aimed to examine whether robotic self-training improved upper-extremity function versus conventional self-training in mild-to-moderate hemiplegic chronic stroke patients.

METHODS

Study design was a multi-center, prospective, randomized, parallel-group study comparing three therapist-guided interventions (1-hour sessions, 3×/wk, 10 weeks). We identified 161 prospective patients with chronic, poststroke, upper-limb hemiplegia treated at participating rehabilitation centers. Patients were enrolled between November 29, 2016, and November 12, 2018 in Japan. A blinded web-based allocation system was used to randomly assign 129 qualifying patients into 3 groups: (1) conventional self-training plus conventional therapy (control, N=42); (2) robotic self-training (ReoGo-J) plus conventional therapy (robotic therapy [RT], N=44); or (3) robotic self-training plus constraint-induced movement therapy (N=43).

PRIMARY OUTCOME

Fugl-Meyer Assessment for upper-extremity.

SECONDARY OUTCOMES

Motor Activity Log-14 amount of use and quality of movement; Fugl-Meyer Assessment shoulder/elbow/forearm, wrist, finger, and coordination scores; Action Research Arm Test Score; Motricity Index; Modified Ashworth Scale; shoulder, elbow, forearm, wrist, and finger range of motion; and Stroke Impact Scale (the assessors were blinded). Safety outcomes were adverse events.

RESULTS

Safety was assessed in 127 patients. An intention-to-treat full analysis set (N=121), and a per-protocol set (N=115) of patients who attended 80% of sessions were assessed. One severe adverse event was recorded, unrelated to the robotic device. No significant differences in Fugl-Meyer Assessment for upper-extremity scores were observed between groups (RT versus control: -1.04 [95% CI, -2.79 to 0.71], P=0.40; RT versus movement therapy: -0.33 [95% CI, -2.02 to 1.36], P=0.90). The RT in the per-protocol set improved significantly in the Fugl-Meyer Assessment for upper-extremity shoulder/elbow/forearm score (RT versus control: -1.46 [95% CI, -2.63 to -0.29]; P=0.037).

CONCLUSIONS

Robotic self-training did not improve upper-limb function versus usual self-training, but may be effective combined with conventional therapy in some populations (per-protocol set).

REGISTRATION

URL: https://www.umin.ac.jp/ctr; Unique identifier: UMIN000022509.

Functional neurological disorder: Extending the diagnosis to other disorders, and proposing an alternate disease term—Attentionally-modifiable disorder

BACKGROUND: The term “functional neurological disorder,” or “FND,” applies to disorders whose occurrence of neurological symptoms fluctuate with the patient’s attention to them. However, many other disorders that are not called “FND” nonetheless can also follow this pattern. Consequently, guidelines are unclear for diagnosing “FND.” OBJECTIVE: To review the neurological conditions that follow this pattern, but which have not so far been termed “FND,” to understand their overlap with conditions that have been termed “FND,” and to discuss the rationale for why FND has not been diagnosed for them. METHOD: A systematic review of the PubMed literature registry using the terms “fluctuation,” “inconsistency,” or “attention” did not yield much in the way of these candidate disorders. Consequently, this review instead relied on the author’s personal library of peer-reviewed studies of disorders that have resembled FND but which were not termed this way, due to his longstanding interest in this problem. Consequently, this approach was not systematic and was subjective regarding disease inclusion. RESULTS: This review identified numerous, diverse conditions that generally involve fluctuating neurological symptoms that can vary with the person’s attention to them, but which have not been called “FND.” The literature was unclear for reasons for not referring to “FND” in these instances. CONCLUSION: Most likely because of historical biases, the use of the term “FND” has been unnecessarily restricted. Because at its core FND is an attentionally-influenced disorder that can respond well to behavioral treatments, the field of neurological rehabilitation could benefit by extending the range of conditions that could be considered as “FND” and referred for similar behavioral treatments. Because the term “FND” has been viewed unfavorably by some patients and clinical practitioners and whose treatment is not implied, the alternative term attentionally-modifiable disorder is proposed.

Determinants of Different Aspects of Upper-Limb Activity after Stroke

We examined factors associated with different aspects of upper-limb (UL) activity in chronic stroke to better understand and improve UL activity in daily life. Three different aspects of UL activity were represented by four sensor measures: (1) contribution to activity according to activity ratio and magnitude ratio, (2) intensity of activity according to bilateral magnitude, and (3) variability of activity according to variation ratio. We combined data from a Belgian and Danish patient cohort (n = 126) and developed four models to determine associated factors for each sensor measure. Results from standard multiple regression show that motor impairment (Fugl−Meyer assessment) accounted for the largest part of the explained variance in all sensor measures (18−61%), with less motor impairment resulting in higher UL activity values (p < 0.001). Higher activity ratio, magnitude ratio, and variation ratio were further explained by having the dominant hand affected (p < 0.007). Bilateral magnitude had the lowest explained variance (adjusted R2 = 0.376), and higher values were further associated with being young and female. As motor impairment and biological aspects accounted for only one- to two-thirds of the variance in UL activity, rehabilitation including behavioral strategies might be important to increase the different aspects of UL activity.

Predictors of high dose of massed practice following stroke

Objective

The aim of this study is to determine the factors that affect patients' ability to carry out high dose of massed practice.

Methods

Patients with stroke were included in the study if they had no severe impairment in motor and cognitive functions. Dose of massed practice, motor function, perceived amount and quality of use of the arm in the real world, wrist and elbow flexors spasticity, dominant hand stroke, presence of shoulder pain, and central post-stroke pain were assessed on the first day. Dose of massed practice was assessed again on the second day. The data were analyzed using descriptive statistics and linear multiple regression.

Results

Only motor function (β = -0.310, r = 0.787, P < 0.001), perceived amount of use (β = 0.300, r = 0.823; 95% CI = 0.34-107.224, P = 0.049), severity of shoulder pain (β = -0.155, r = -0.472, P = 0.019), wrist flexors spasticity (β = -0.154, r = -0.421, P = 0.002), age (β = -0.129, r = -0.366, P = 0.018), dominant hand stroke (β = -0.091, r = -0.075, P = 0.041), and sex (β = -0.090, r = -0.161, P = 0.036) significantly influenced patients' ability to carry out high dose of massed practice.

Conclusion

Many factors affect patients' ability to carry out high dose of massed practice. Understanding these factors can help in designing appropriate rehabilitation.

Video game rehabilitation for outpatient stroke (VIGoROUS): A multi-site randomized controlled trial of in-home, self-managed, upper-extremity therapy

BACKGROUND

Integrating behavioral intervention into motor rehabilitation is essential for improving paretic arm use in daily life. Demands on therapist time limit adoption of behavioral programs like Constraint-Induced Movement (CI) therapy, however. Self-managed motor practice could free therapist time for behavioral intervention, but there remains insufficient evidence of efficacy for a self-management approach.

METHODS

This completed, parallel, five-site, pragmatic, single-blind trial established the comparative effectiveness of using in-home gaming self-management as a vehicle to redirect valuable therapist time towards behavioral intervention. Community-dwelling adults with post-stroke (>6 months) mild/moderate upper extremity hemiparesis were randomized to receive one of 4 different interventions over a 3-week period: 5 h of behaviorally-focused intervention plus gaming self-management (Self-Gaming), the same with additional behaviorally-focused telerehabilitation (Tele-Gaming), 5 h of Traditional motor-focused rehabilitation, or 35 h of CI therapy. Primary outcomes assessed everyday arm use (Motor Activity Log Quality of Movement, MAL) and motor speed/function (Wolf Motor Function Test, WMFT) immediately before treatment, immediately after treatment, and 6 months later. Intent-to-treat analyses were implemented with linear mixed-effects models on data gathered from March 15, 2016 to November 21, 2019. ClinicalTrials.gov, NCT02631850.

RESULTS

Of 193 enrolled participants, 167 began treatment and were analyzed, 150 (90%) completed treatment, and 115 (69%) completed follow-up. Tele-Gaming and Self-Gaming produced clinically meaningful MAL gains that were 1·0 points (95% CI 0·8 to 1·3) and 0·8 points (95% CI 0·5 to 1·0) larger than Traditional care, respectively. Self-Gaming was less effective than CI therapy (-0·4 points, 95% CI -0·6 to -0·2), whereas Tele-Gaming was not (-0·2 points, 95% CI -0·4 to 0·1). Six-month retention of MAL gains across all groups was 57%. All had similar clinically-meaningful WMFT gains; six-month retention of WMFT gains was 92%.

INTERPRETATION

Self-managed motor-gaming with behavioral telehealth visits has outcomes similar to in-clinic CI therapy. It addresses most access barriers, requiring just one-fifth as much therapist time that is redirected towards behavioral interventions that enhance the paretic arm's involvement in daily life.

FUNDING

PCORI, NIH.

Home-Based Therapy After Stroke Using the Hand Spring Operated Movement Enhancer (HandSOME II)

We have developed a passive and lightweight wearable hand exoskeleton (HandSOME II) that improves range of motion and functional task practice in laboratory testing. For this longitudinal study, we recruited 15 individuals with chronic stroke and asked them to use the device at home for 1.5 h per weekday for 8 weeks. Subjects visited the clinic once per week to report progress and troubleshoot problems. Subjects were then given the HandSOME II for the next 3 months, and asked to continue to use it, but without any scheduled contact with the project team. Clinical evaluations and biomechanical testing was performed before and after the 8 week intervention and at the 3 month followup. EEG measures were taken before and after the 8 weeks of training to examine any recovery associated brain reorganization. Ten subjects completed the study. After 8 weeks of training, functional ability (Action Research Arm Test), flexor tone (Modified Ashworth Test), and real world use of the impaired limb (Motor Activity Log) improved significantly (p < 0.05). Gains in real world use were retained at the 3-month followup (p = 0.005). At both post-training and followup time points, biomechanical testing found significant gains in finger ROM and hand displacement in a reaching task (p < 0.05). Baseline functional connectivity correlated with gains in motor function, while changes in EEG functional connectivity paralleled changes in motor recovery. HandSOME II is a low-cost, home-based intervention that elicits brain plasticity and can improve functional motor outcomes in the chronic stroke population.

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.

Perspectives From Persons With Multiple Sclerosis for a Comprehensive Real-World Change Therapy for Mobility

Objective

To assess the personal perspectives of persons with multiple sclerosis (MS) on the acceptability of a novel physical therapy program that is designed to transfer gains from the clinic to their real-world lower extremity (LE) use, termed LE constraint-induced therapy (CIT). The program includes several behavior change techniques (prescribed home exercises, daily structured therapist interviews and problem solving for LE activities, keeping an activity diary) and a concentrated physical treatment schedule.

Design

Anonymous internet survey.

Setting

Participants accessed the survey from computers in the community.

Participants

Five hundred adults (N=500) were recruited from an MS support organization's registry for having indicated from mild to total limb spasticity because they were anticipated to have markedly impaired LE use in the community.

Interventions

Not applicable.

Main Outcome Measures

Participants were offered the options on a nonnumerical Likert scale of “Very likely,” “Likely,” “Neutral,” “Unlikely,” or “Very unlikely” to indicate their personal acceptability for each of 5 different key treatment procedures after these were explained. Totals for each option within each key procedure were analyzed for their acceptability.

Results

Of the 281 persons who responded, 90% expressed interest in participating in LE CIT. A large majority of persons who completed the survey selected either “Very likely” or “Likely” for each key procedure (median=88%, range=65%-90%, P<.01). This indicated strong acceptance for the procedures of LE CIT. In addition, more respondents who already had had previous physical therapy accepted LE CIT than did respondents who had not had physical therapy (P<.01).

Conclusions

The results suggest there is strong acceptance of CIT for mobility with preliminary evidence of benefiting community LE use for persons with MS. The results support further clinical trials of LE CIT for persons with MS.

Enhanced error facilitates motor learning in weight shift and increases use of the paretic leg during walking at chronic stage after stroke

The purpose of this study was to determine whether the application of lateral pelvis pulling force toward the non-paretic side during the stance phase of the paretic leg would enhance forced use of the paretic leg and increase weight shift toward the paretic side in stroke survivors. Eleven chronic stroke survivors participated in two experimental sessions, which consisted of (1) treadmill walking with the application of "pelvis resistance" or "pelvis assistance" and (2) overground walking. During the treadmill walking, the laterally pulling force was applied during the stance phase of the paretic leg toward the non-paretic side for the "pelvis resistance" condition or toward the paretic side for the "pelvis assistance" condition during the stance phase of the paretic leg. After force release, the "pelvis resistance" condition exhibited greater enhancement in muscle activation of hip ABD, ADD, and SOL and greater improvement in lateral weight shift toward the paretic side, compared with the effect of the "pelvis assistance" condition (P < 0.03). This improved lateral weight shift was associated with the enhanced muscle activation of hip ABD and ADD (R² = 0.67, P = 0.01). The pelvis resistance condition also improved overground walking speed and stance phase symmetry when measured 10 min after the treadmill walking (P = 0.004). In conclusion, applying pelvis resistance forces to increase error signals may facilitate motor learning of weight shift toward the paretic side and enhance use of the paretic leg in chronic stroke survivors. Results from this study may be utilized to develop an intervention approach to improve walking in stroke survivors.

Daily Life Upper Limb Activity for Patients with Match and Mismatch between Observed Function and Perceived Activity in the Chronic Phase Post Stroke

We investigated actual daily life upper limb (UL) activity in relation to observed UL motor function and perceived UL activity in chronic stroke in order to better understand and improve UL activity in daily life. In 60 patients, we collected (1) observed UL motor function (Fugl-Meyer Assessment (FMA-UE)), (2) perceived UL activity (hand subscale of the Stroke Impact Scale (SIS-Hand)), and (3) daily life UL activity (bilateral wrist-worn accelerometers for 72 h) data. Data were compared between two groups of interest, namely (1) good observed (FMA-UE >50) function and good perceived (SIS-Hand >75) activity (good match, n = 16) and (2) good observed function but low perceived (SIS-Hand ≤75) activity (mismatch, n = 15) with Mann-Whitney U analysis. The mismatch group only differed from the good match group in perceived UL activity (median (Q1-Q3) = 50 (30-70) versus 93 (85-100); p < 0.001). Despite similar observed UL motor function and other clinical characteristics, the affected UL in the mismatch group was less active in daily life compared to the good match group (p = 0.013), and the contribution of the affected UL compared to the unaffected UL for each second of activity (magnitude ratio) was lower (p = 0.022). We conclude that people with chronic stroke with low perceived UL activity indeed tend to use their affected UL less in daily life despite good observed UL motor function.

Tele-rehabilitation of upper-extremity hemiparesis after stroke: Proof-of-concept randomized controlled trial of in-home Constraint-Induced Movement therapy

BACKGROUND

Although Constraint-Induced Movement therapy (CIMT) has been deemed efficacious for adults with persistent, mild-to-moderate, post-stroke upper-extremity hemiparesis, CIMT is not available on a widespread clinical basis. Impediments include its cost and travel to multiple therapy appointments. To overcome these barriers, we developed an automated, tele-health form of CIMT.

OBJECTIVE

Determine whether in-home, tele-health CIMT has outcomes as good as in-clinic, face-to-face CIMT in adults ≥1-year post-stroke with mild-to-moderate upper-extremity hemiparesis.

METHODS

Twenty-four stroke patients with chronic upper-arm extremity hemiparesis were randomly assigned to tele-health CIMT (Tele-AutoCITE) or in-lab CIMT. All received 35 hours of treatment. In the tele-health group, an automated, upper-extremity workstation with built-in sensors and video cameras was set-up in participants' homes. Internet-based audio-visual and data links permitted supervision of treatment by a trainer in the lab.

RESULTS

Ten patients in each group completed treatment. All twenty, on average, showed very large improvements immediately afterwards in everyday use of the more-affected arm (mean change on Motor Activity Log Arm Use scale = 2.5 points, p < 0.001, d' = 3.1). After one-year, a large improvement from baseline was still present (mean change = 1.8, p < 0.001, d' = 2). Post-treatment outcomes in the tele-health group were not inferior to those in the in-lab group. Neither were participants' perceptions of satisfaction with and difficulty of the interventions. Although everyday arm use was similar in the two groups after one-year (mean difference = -0.1, 95% CI = -1.3-1.0), reductions in the precision of the estimates of this parameter due to drop-out over follow-up did not permit ruling out that the tele-health group had an inferior long-term outcome.

CONCLUSIONS

This proof-of-concept study suggests that Tele-AutoCITE produces immediate benefits that are equivalent to those after in-lab CIMT in stroke survivors with chronic upper-arm extremity hemiparesis. Cost savings possible with this tele-health approach remain to be evaluated.

Acceptability of constraint induced movement therapy: influence of perceived difficulty and expected treatment outcome

BACKGROUND

Constraint-Induced Movement (CI) Therapy has evidence of efficaciously rehabilitating upper-extremity hemiparesis after stroke. Yet, it is not widely used in the United States. One barrier appears to be the perception of its difficulty among stroke care consumers, as reported by two published studies in which the participants had little or no apparent direct exposure to CI Therapy.

OBJECTIVES

Assess the perception of difficulty of CI Therapy by individuals with chronic stroke who have actually undergone CI Therapy.

METHODS

A secondary analysis was conducted of data from two randomized controlled trials of CI Therapy. Participants had chronic, mild-to-moderate upper-extremity hemiparesis after stroke. The Motor Activity Log and Wolf Motor Function Test were used to measure motor function of the more-affected arm. A Patient Opinion Survey assessed participants' perception of difficulty and satisfaction with treatment.

RESULTS

The participants (N = 40) showed large improvements in motor function of their more-affected arm after treatment, p's <001. CI Therapy was perceived to be of only moderate difficulty by participants before treatment (mean = 4.4 out of 7). Perception of its difficulty decreased afterward (mean = 3.7, p = .002). Moreover, participants were highly satisfied with their outcomes (mean = 6.3 out of 7). Satisfaction was positively related to the improvements in more-affected arm use in everyday life, ΔR² = .3, p < .001.

CONCLUSIONS

Chronic stroke survivors who have actually had CI Therapy perceive it to be of only moderate difficulty and are highly satisfied. Negative views about its acceptability warrant reconsideration.

A Comparative Efficacy Study of Robotic Priming of Bilateral Approach in Stroke Rehabilitation

Background: Stroke survivors can remain impaired in body functions, activity, and participation. A novel rehabilitation regimen is required to obtain scientific evidence and to help clinicians determine effective interventions for stroke. Mirror therapy (MT) and bilateral upper limb training (BULT) are based on the tenet of bilateral movement practice; however, the additional effect of bilateral robotic priming combined with these two therapies is unclear. Objectives: This study examined the effects of two hybrid therapies, robotic priming combined with MT and robotic priming combined with BULT, in stroke survivors. Methodology: The study randomized 31 participants to groups that received robotic priming combined with MT (n = 15) or robotic priming combined with BULT (n = 16). Outcome measures included the Fugl-Meyer Assessment (FMA), the revised Nottingham Sensory Assessment (rNSA), the Chedoke Arm and Hand Activity Inventory (CAHAI), and accelerometer data. Results: Both groups showed statistically significant within-group improvements in most outcome measures. Significant between-group differences and medium-to-large effect sizes were found in favor of the group that received robotic priming combined with MT based on the FMA distal part subscale scores, FMA total scores, and accelerometer data. Conclusion: Robotic priming combined with MT may have beneficial effects for patients in the improvements of overall and distal arm motor impairment as well as affected arm use in real life. Additional follow-up, a larger sample size, and consideration of the effect of lesion location or different levels of cognitive impairment are warranted to validate our findings in future studies. Clinical trial registration: www.ClinicalTrials.gov, identifier NCT03773653.

Quantification of the relative arm use in patients with hemiparesis using inertial measurement units

Introduction

Accelerometry-based activity counting for measuring arm use is prone to overestimation due to non-functional movements. In this paper, we used an inertial measurement unit (IMU)-based gross movement (GM) score to quantify arm use.

Methods

In this two-part study, we first characterized the GM by comparing it to annotated video recordings of 5 hemiparetic patients and 10 control subjects performing a set of activities. In the second part, we tracked the arm use of 5 patients and 5 controls using two wrist-worn IMUs for 7 and 3 days, respectively. The IMU data was used to develop quantitative measures (total and relative arm use) and a visualization method for arm use.

Results

From the characterization study, we found that GM detects functional activities with 50–60% accuracy and eliminates non-functional activities with >90% accuracy. Continuous monitoring of arm use showed that the arm use was biased towards the dominant limb and less paretic limb for controls and patients, respectively.

Conclusions

The gross movement score has good specificity but low sensitivity in identifying functional activity. The at-home study showed that it is feasible to use two IMU-watches to monitor relative arm use and provided design considerations for improving the assessment method.

Clinical trial registry number: CTRI/2018/09/015648

The feasibility and efficacy of a serial reaction time task that measures motor learning of anticipatory stepping

BACKGROUND

Motor learning has been investigated using various paradigms, including serial reaction time tasks (SRTT) that examine upper extremity reaching and pointing while seated. Few studies have used a stepping SRTT, which could offer additional insights into motor learning involving postural demands. For a task to measure motor learning, naïve participants must demonstrate a) improved performance with task practice, and b) a dose-response relationship to learning the task.

RESEARCH QUESTION

Is a stepping SRTT feasible and efficacious for measuring motor learning?

METHODS

In this prospective study, 20 participants stood on an instrumented mat and were presented with stimuli on a computer screen. They stepped to the corresponding positions on the mat as quickly as possible. Presented stimuli included random sequences and a blinded imbedded repeating sequence. Three days after completing the randomly assigned practice dose [high dose group (n = 10) performed 4320 steps; low dose group (n = 10) performed 144 steps], a retention test of 72 steps was performed. Feasibility was measured as the proportion of participants who completed the assigned practice dose without adverse events. Efficacy was measured as within-group performance improvement on the random sequences and on the repeating sequence (paired t-tests), as well as a dose-response relationship to learning both types of sequences (independent t-tests).

RESULTS

All participants (mean age 26.8 years) completed all practice sessions without adverse events, indicating feasibility. High dose practice resulted in performance improvement while low dose did not; a dose-response relationship was found, with high dose practice resulting in greater learning of the task than low dose practice, indicating efficacy.

SIGNIFICANCE

This stepping SRTT is a feasible and efficacious way to measure motor learning, which could provide critical insights into anticipatory stepping, postural control, and fall risk. Future research is needed to determine feasibility, efficacy, and optimal practice dosages for older and impaired populations.

Constraint Induced Movement Therapy Increases Functionality and Quality of Life after Stroke

This blind randomized clinical trial evaluated the effect of CIMT on the functionality and quality of life (QOL) of chronic hemiparetics. Thirty volunteers were divided into two groups: Control (CG) and CIMT (CIMTG); evaluated before and after 12 and 24 intervention sessions. The scales used were: adapted Fugl-Meyer Motor Assessment (FMA), Modified Ashworth, Stroke Specific Quality Of Life (SS-QOL) and the Functional Reach Test (FRT). The scores for all FMA variables in the CIMTG increased until the 24th session, differing from the pre-treatment. In the CG, the scores increased for pain, coordination/ speed and sensitivity. In the FRT there was an increase in the scores in both groups; after the 12th and 24th sessions, the result of the CIMTG was superior to the CG. For the SS-QOL in the CIMTG, the general score and most of the variables increased, as well as in the CG. Muscle tone in CIMTG was lower compared to CG after 24 sessions. Both protocols used in the study were effective, the CIMT protocol showed benefits in recovering the functionality of the paretic upper limb, in the functional range and in reducing muscle tone, with a consequent improvement in quality of life.

Retention of Physical Gains in the Community Following Physical Training for Multiple Sclerosis: A Systematic Review and Implications

Multiple sclerosis (MS) is a progressive neurological illness whose typically young adult onset results in a nearly entire lifetime of worsening disability. But despite being an unrelenting neurodegenerative disease, numerous clinical trials over the past 40 years for MS have vigorously attempted to improve or at least stabilize declining physical function. Although the vast majority of the studies assessed training effects only within controlled laboratory or clinic settings, in recent years a growing interest has emerged to test whether newer therapies can instead benefit real-life activities in the community. Nonetheless, comparatively little attention has been paid to whether the training gains can be retained for meaningful periods. This review discusses the comparative success of various physical training methods to benefit within-community activities in MS, and whether the gains can be retained long afterward. This review will suggest future research directions toward establishing efficacious treatments that can allow persons with MS to reclaim their physical abilities and maximize functionality for meaningful periods.

Group-based constraint-induced movement therapy in the rehabilitation of chronic poststroke patients

BACKGROUND

This study aimed to describe the effects of a 90-minute group-based constraint-induced movement therapy protocol (CIMT) on upper extremity (UE) rehabilitation in poststroke patients.

METHOD

The study was a case series clinical study with 6 patients with chronic stroke admitted to the institutional integrated clinic. Ten 90-minute CIMT sessions were administered, based on the principles of the original therapy. On completion of the protocol, participants underwent group care once a week, for 1 hour a day. For comparison purposes, the Wolf Motor Function Test (WMFT), Motor Activity Log (MAL), and Canadian Occupational Performance Measure (COPM) were applied on admission, shortly after completing the protocol, and 3 months after completion. In addition, the MAL and shaping tasks were applied daily.

RESULTS

There was a statistically significant difference only in the MAL Amount of Use Scale applied daily between the 2nd (3.56) and 9th (3.31) and 2nd and 10th days (4.49) (P = .004), with a moderate effect size (d' = 0.46), and in the average value of shaping repetitions between the 1st (16.10) and 2nd (6.00) and 1st and 10th tasks (7.00) (P = .014), with a moderate effect size (d' = 0.35).

CONCLUSION

The 90-minute CIMT protocol resulted in significant improvements in use of the more affected arm in activities of daily living during the 2-week protocol. Additional research with a larger sample and a control group is needed to confirm its effectiveness.

Implementation and sustainability of upper limb constraint-induced movement therapy programs for adults with neurological conditions: an international qualitative study

Purpose

Constraint-induced movement therapy (CIMT) is an effective intervention for arm recovery following acquired brain injury; however, there is an evidence-practice gap between research and CIMT use in practice. The aim of this study was to identify individual, organisational and social factors enabling implementation and sustained delivery of CIMT programs internationally.

Design/methodology/approach

Descriptive qualitative design. Purposive sampling was used to recruit occupational therapists and physiotherapists with previous experience delivering CIMT. Semi- structured interviews were conducted, using an interview schedule informed by the Theoretical Domains Framework (TDF) to explore individual factors (such as knowledge, skills and beliefs), organisational factors (such as organisational culture and resources) and social factors (such as leadership) influencing CIMT implementation. Interviews were audio-recorded, transcribed and managed using NVivo. The TDF guided data analysis and identification of key influences on CIMT implementation and sustainability.

Findings

Eleven participants (n = 7 [63.6%] occupational therapists and n = 4 [36.4%] physiotherapists) were interviewed from six countries, working across public (n = 6, 54.6%) and private health (n = 5, 45.5%). Six key domains influenced CIMT implementation and sustainability. Clinicians needed knowledge and opportunities to apply their skills, and confidence in their ability to implement CIMT. Within their workplace, supportive social influences (including broader team support), the environmental context (including organisational culture and resources) and reinforcement from seeing positive outcomes contributed to implementation and sustainability. Other important influences included community demand and tailoring of programs to meet individual needs.

Originality/value

This is the first study to examine therapists' experiences of CIMT implementation and sustainability across multiple countries. Factors related to capacity building, social and organisational support and resources enabled CIMT program implementation and ongoing sustainability. These findings can be used to design behaviour change interventions to support CIMT use in practice.

Voluntary exercise ameliorates the good limb training effect in a mouse model of stroke

Stroke is the leading cause of long-term disability in the United States, making research on rehabilitation imperative. Stroke rehabilitation typically focuses on recovery of the impaired limb, although this process is tedious. Compensatory use of the intact limb after stroke is more efficient, but it is known to negatively impact the impaired limb. Exercise may help with this problem; research has shown that exercise promotes neuronal growth and prevents cell death. This study used a mouse model to investigate if post-stroke exercise could prevent deterioration of the function of the impaired limb despite compensatory training of the intact limb. Results showed that mice that exercised, in combination with intact limb training, demonstrated improved functional outcome compared to mice that received no training or compensatory limb training only. These findings suggest that exercise can prevent the deterioration of impaired limb functional outcome that is typically seen with intact limb use.

Reliability and Validity of the Lower Extremity Motor Activity Log for Measuring Real-World Leg Use in Adults With Multiple Sclerosis

OBJECTIVES

To determine the test-retest reliability and validity of the Lower Extremity Motor Activity Log (LE-MAL) for assessing LE use in the community in adults with multiple sclerosis (MS).

DESIGN

Prospective analysis of measures conducted by trained examiners.

SETTING

Participants were evaluated by telephone on several measures of LE use.

PARTICIPANTS

Adults with MS (N=43).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The LE-MAL has 3 subscales (Assistance, Functional Performance, and Confidence). It was administered twice, at least 2 weeks apart. The Multiple Sclerosis Walking Scale (MSWS-12), Patient Determined Disease Steps (PDDS), and Mobility Scale were only administered during the first call.

RESULTS

The test-retest reliability of the composite and the 3 subscale LE-MAL scores were high (intraclass correlation, >0.94). The composite and subscale LE-MAL scores were strongly correlated with the MSWS-12, PDDS, and Mobility Scale scores (r=-0.56 to -0.77; P<.001).

CONCLUSION

This initial study suggests that the LE-MAL reliably and validly measures LE use in the community in adults with MS.

Clinical Application of Virtual Reality for Upper Limb Motor Rehabilitation in Stroke: Review of Technologies and Clinical Evidence

Neurorehabilitation for stroke is important for upper limb motor recovery. Conventional rehabilitation such as occupational therapy has been used, but novel technologies are expected to open new opportunities for better recovery. Virtual reality (VR) is a technology with a set of informatics that provides interactive environments to patients. VR can enhance neuroplasticity and recovery after a stroke by providing more intensive, repetitive, and engaging training due to several advantages, including: (1) tasks with various difficulty levels for rehabilitation, (2) augmented real-time feedback, (3) more immersive and engaging experiences, (4) more standardized rehabilitation, and (5) safe simulation of real-world activities of daily living. In this comprehensive narrative review of the application of VR in motor rehabilitation after stroke, mainly for the upper limbs, we cover: (1) the technologies used in VR rehabilitation, including sensors; (2) the clinical application of and evidence for VR in stroke rehabilitation; and (3) considerations for VR application in stroke rehabilitation. Meta-analyses for upper limb VR rehabilitation after stroke were identified by an online search of Ovid-MEDLINE, Ovid-EMBASE, the Cochrane Library, and KoreaMed. We expect that this review will provide insights into successful clinical applications or trials of VR for motor rehabilitation after stroke.

Protocol for a Randomized Controlled Trial of CI Therapy for Rehabilitation of Upper Extremity Motor Deficit: The Bringing Rehabilitation to American Veterans Everywhere Project

Constraint-induced movement therapy (CI therapy) has been shown to reduce disability for individuals with upper extremity (UE) hemiparesis following different neurologic injuries. This article describes the study design and methodological considerations of the Bringing Rehabilitation to American Veterans Everywhere (BRAVE) Project, a randomized controlled trial of CI therapy to improve the motor deficit of participants with chronic and subacute traumatic brain injury. Our CI therapy protocol comprises 4 major components: (1) intensive training of the more-affected UE for target of 3 hour/day for 10 consecutive weekdays, (2) a behavioral technique termed shaping during training, (3) a "transfer package," 0.5 hour/day, of behavioral techniques to transfer therapeutic gains from the treatment setting to the life situation, and (4) prolonged restraint of use of the UE not being trained. The primary endpoint is posttreatment change on the Motor Activity Log, which assesses the use of the more-affected arm outside the laboratory in everyday life situations. Data from a number of secondary outcome measures are also being collected and can be categorized as physical, genomic, biologic, fitness, cognitive/behavioral, quality of life, and neuroimaging measures.

EEG Changes in Time and Time-Frequency Domain During Movement Preparation and Execution in Stroke Patients

This study investigated electroencephalogram (EEG) changes during movement preparation and execution in stroke patients. EEG-based event-related potential (ERP) technology was used to measure brain activity changes. Seventeen stroke patients participated in this study and completed ERP tests that were designed to measure EEG changes during unilateral upper limb movements in preparation and execution stages, with Instruction Response Movement (IRM) and Cued Instruction Response Movement (CIRM) paradigms. EEG data were analyzed using motor potential (MP) in the time domain and the mu-rhythm and beta frequency band response mean value (R-means) in the time-frequency domain. In IRM, the MP amplitude at Cz was higher during hemiplegic arm movement than during unaffected arm movement. MP latency was shorter at Cz and the contralesional motor cortex during hemiplegic arm movement in CIRM compared to IRM. No significant differences were found in R-means among locations, between movement sides in both ERP tests. This study presents the brain activity changes in the time and time-frequency domains in stroke patients during movement preparation and execution and supports the contralesional compensation and adjacent-region compensation mechanism of post-stroke brain reconstruction. These findings may contribute to future rehabilitation research about neuroplasticity and technology development such as the brain-computer interface.