Six hours in the laboratory: a quantification of practice time during constraint-induced therapy (CIT)

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.

Constraint-induced movement therapy protocols using the number of repetitions of task practice: a systematic review of feasibility and effects

BACKGROUND

High repetitions of task practice is required for the recovery of the motor function during constraint-induced movement therapy (CIMT). This can be achieved into ways: when the task practice is measured in hours of practice or when the number of repetitions is counted. However, it has been argued that using hours of task practice as a measure of practice does not provide a clear instruction on the dose of practice.

AIM

The aim of this study is to determine the feasibility and effects of the CIMT protocol that uses the number of repetitions of task practice.

MATERIALS/METHOD

The study was a systematic review registered in PROSPERO (CRD42020142140). Five databases, PubMED, CENTRAL, PEDro, OTSeeker and Web of Science, were searched. Studies of any designs in adults with stroke were included if they used the number of repetitions of task practice as a measure of dose. The methodological quality of the included studies was assessed using Modified McMaster critical review form. The results were analysed using qualitative synthesis.

RESULTS

Eight studies (n = 205) were included in the study. The number of task repetitions in the studies ranges between 45 and 1280 per day. The results showed that CIMT protocol using the number of repetitions of task practice was feasible and improved outcomes such as motor function, quality of life, functional mobility and spasticity.

CONCLUSION

The number of repetitions of task practice as a measure of CIMT dose can be used in place of the existing protocol that uses the number of hours of task practice.

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.

Comparing Two Different Modes of Task Practice during Lower Limb Constraint-Induced Movement Therapy in People with Stroke: A Randomized Clinical Trial

Background

Constraint-induced movement therapy (CIMT) is used for the rehabilitation of motor function after stroke.

Objectives

The aim of this study was to compare the effects of lower limb CIMT that uses number of repetition of tasks with the one that uses number of hours of practice.

Method

The study was a randomized clinical trial approved by the Ethics Committee of Kano State Ministry of Health. Fifty-eight people with stroke participated in the study. Groups 1 and 2 performed daily 600 repetitions and 3 hours of task practice, respectively, 5 times weekly for 4 weeks. Motor impairment (primary outcome), balance, functional mobility, knee extensor spasticity, walking speed and endurance, and exertion before and after commencement of activities were assessed at baseline and postintervention. The data was analyzed using Friedmann and Mann-Whitney U tests.

Result

The results showed that there was only significant difference (p < 0.05) in knee extensor spasticity (group 1 (median = 0(0), mean rank = 27.50); group 2 (median = 0(0), mean rank = 31.64)), exertion before commencement of activities (group 1 (median = 0(0.5), mean rank = 21.90); group 2 (median = 1(0.5), mean rank = 37.64)), and exertion after commencement of activities (group 1 (median = 1(1), mean rank = 20.07); group 2 (median = 1(0), mean rank = 39.61) postintervention in favour of the experimental group (group 1)).

Conclusion

The group 1 protocol is more effective at improving outcomes after stroke.

Effects of Number of Repetitions and Number of Hours of Shaping Practice during Constraint-Induced Movement Therapy: A Randomized Controlled Trial

Background

Constraint-induced movement therapy (CIMT) is effective in improving motor outcomes after stroke. However, its existing protocols are resource-intensive and difficult to implement. The aim of this study is to design an easier CIMT protocol using number of repetitions of shaping practice.

Method

The study design was randomized controlled trial. Participants within 4 weeks after stroke were recruited at Murtala Muhammad Specialist Hospital. They were randomly assigned to groups A, B, C, and D. Group A received 3 hours of traditional therapy. Groups B, C, and D received modified CIMT consisting of 3 hours of shaping practice per session, 300 repetitions of shaping practice in 3 sessions, and 600 repetitions of shaping practice in 3 sessions per day, respectively, and constraint for 90% of the waking hours. All treatment protocols were administered 5 times per week for 4 weeks. The primary outcome was measured using upper limb Fugl-Meyer assessment, while the secondary outcome was measured using motor activity log, Wolf Motor Function Test, and upper limb self-efficacy test at baseline, 2 weeks, and 4 weeks after intervention.

Result

There were 48 participants 4 weeks after intervention. The result showed that there was no significant difference between groups at baseline (p > 0.05). Within-group improvements attained minimal clinically important difference (MCID) in modified CIMT and 300 repetitions and 600 repetitions groups.

Conclusion

Number of repetitions of shaping practice significantly improved motor function, real-world arm use, and upper limb self-efficacy after stroke. Therefore, it seems to be a simple alternative for the use of number of hours.

Trial Registration

This trial is registered with Pan African Clinical Trial Registry (registration number: PACTR201610001828172) (date of registration: 21/10/2016).

Task-specific reach-to-grasp training after stroke: development and description of a home-based intervention

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is to transparently describe the process of developing a complex intervention for people after stroke as part of a feasibility randomised controlled trial.

Objective:

To describe and justify the development of a home-based, task-specific upper limb training intervention to improve reach-to-grasp after stroke and pilot it for feasibility and acceptability prior to a randomized controlled trial.

Intervention description:

The intervention is based on intensive practice of whole reach-to-grasp tasks and part-practice of essential reach-to-grasp components. A ‘pilot’ manual of activities covering the domains of self-care, leisure and productivity was developed for the feasibility study. The intervention comprises 14 hours of therapist-delivered sessions over six weeks, with additional self-practice recommended for 42 hours (i.e. one hour every day). As part of a feasibility randomized controlled trial, 24 people with a wide range of upper limb impairment after stroke experienced the intervention to test adherence and acceptability. The median number of repetitions in one-hour therapist-delivered sessions was 157 (interquartile range IQR 96–211). The amount of self-practice was poorly documented. Where recorded, the median amount of practice was 30 minutes (interquartile range 22–45) per day. Findings demonstrated that the majority of participants found the intensity, content and level of difficulty of the intervention acceptable, and the programme to be beneficial. Comments on the content and presentation of the self-practice material were incorporated in a revised ‘final’ intervention manual.

Discussion:

A comprehensive training intervention to improve reach-to-grasp for people living at home after stroke has been described in accordance with the Template for Intervention Description and Replication (TIDieR) reporting guidelines. The intervention has been piloted, and found to be acceptable and feasible in the home setting.

Trial registration:

ISRCTN56716589

Occupational Therapists’ Opinions of Two Pediatric Constraint-Induced Movement Therapy Protocols

OBJECTIVE. We sought to determine occupational therapists’ opinions of two pediatric constraint-induced movement therapy (pCIMT) protocols.

METHOD. A total of 272 therapists in pediatric rehabilitation clinics completed an electronic survey to determine their opinions of two published pCIMT protocols. In Protocol A, restraint is worn 24 hr/day on the nonparetic upper extremity (UE), and in-clinic, therapist-supervised practice sessions occur 7 days/wk for 6 hr/day over 3 wk. In Protocol B, restraint is worn 2 hr/day on the nonparetic UE, and in-clinic, therapist-supervised practice sessions occur 1 day/wk for 2 hr/day over 8 wk.

RESULTS. The majority of participants reported moderate to high concerns about every facet of Protocol A. Conversely, &gt;50% of participants reported low or no concerns about five of seven facets of Protocol B.

CONCLUSION. This study adds to a growing body of evidence suggesting that therapists strongly prefer low-duration pCIMT protocols.

It takes two: noninvasive brain stimulation combined with neurorehabilitation

The goal of postacute neurorehabilitation is to maximize patient function, ideally by using surviving brain and central nervous system tissue when possible. However, the structures incorporated into neurorehabilitative approaches often differ from this target, which may explain why the efficacy of conventional clinical treatments targeting neurologic impairment varies widely. Noninvasive brain stimulation (eg, transcranial magnetic stimulation [TMS], transcranial direct current stimulation [tDCS]) offers the possibility of directly targeting brain structures to facilitate or inhibit their activity to steer neural plasticity in recovery and measure neuronal output and interactions for evaluating progress. The latest advances as stereotactic navigation and electric field modeling are enabling more precise targeting of patient's residual structures in diagnosis and therapy. Given its promise, this supplement illustrates the wide-ranging significance of TMS and tDCS in neurorehabilitation, including in stroke, pediatrics, traumatic brain injury, focal hand dystonia, neuropathic pain, and spinal cord injury. TMS and tDCS are still not widely used and remain poorly understood in neurorehabilitation. Therefore, the present supplement includes articles that highlight ready clinical application of these technologies, including their comparative diagnostic capabilities relative to neuroimaging, their therapeutic benefit, their optimal delivery, the stratification of likely responders, and the variable benefits associated with their clinical use because of interactions between pathophysiology and the innate reorganization of the patient's brain. Overall, the supplement concludes that whether provided in isolation or in combination, noninvasive brain stimulation and neurorehabilitation are synergistic in the potential to transform clinical practice.

The home stroke rehabilitation and monitoring system trial: a randomized controlled trial

RATIONALE

Because many individuals poststroke lack access to the quality and intensity of rehabilitation to improve upper extremity motor function, a home-based robotic-assisted upper extremity rehabilitation device is being paired with an individualized home exercise program.

AIMS/HYPOTHESIS

The primary aim of this project is to determine the effectiveness of robotic-assisted home therapy compared with a home exercise program on upper extremity motor recovery and health-related quality of life for stroke survivors in rural and underserved locations. The secondary aim is to explore whether initial degree of motor function of the upper limb may be a factor in predicting the extent to which patients with stroke may be responsive to a home therapy approach. We hypothesize that the home exercise program intervention, when enhanced with robotic-assisted therapy, will result in significantly better outcomes in motor function and quality of life.

DESIGN

A total of 96 participants within six-months of a single, unilateral ischemic, or hemorrhagic stroke will be recruited in this prospective, single-blind, multisite randomized clinical trial.

STUDY OUTCOMES

The primary outcome is the change in upper extremity function using the Action Research Arm Test. Secondary outcomes include changes in: upper extremity function (Wolf Motor Function Test), upper extremity impairment (upper extremity portion of the Fugl-Meyer Test), self-reported quality of life (Stroke Impact Scale), and affect (Centers for Epidemiologic Studies Depression Scale).

DISCUSSION

Similar or greater improvements in upper extremity function using the combined robotic home exercise program intervention compared with home exercise program alone will be interpreted as evidence that supports the introduction of in-home technology to augment the recovery of function poststroke.

Protocol development, treatment fidelity, adherence to treatment, and quality control

Occupational therapy leaders have emphasized the importance of intervention effectiveness research. The CONSORT and TREND checklists have been suggested as useful tools for reporting the results of randomized and nonrandomized studies, respectively. Despite such recommendations, research protocols and reports continue to underutilize the available tools, a situation reflecting limited resources for and experience with the conduct of effectiveness research. To address this issue, and using the CONSORT statement to structure the analysis, this article discusses strategies for optimization of protocol development, treatment fidelity, adherence to treatment, and quality control. We recommend several approaches to increase the quality of research throughout these various processes. Examples of implementation from our laboratory provide evidence of the utility of these strategies.

The EXCITE Trial: analysis of "noncompleted" Wolf Motor Function Test items

OBJECTIVE

This is the first study to examine Wolf Motor Function Test (WMFT) tasks among EXCITE Trial participants that could not be completed at baseline or 2 weeks later.

METHODS

Data were collected from participants who received constraint-induced movement therapy (CIMT) immediately at the time of randomization (CIMT-I, n = 106) and from those for whom there was a delay of 1 year in receiving this intervention (CIMT-D, n = 116). Data were collected at baseline and at a 2-week time point, during which the CIMT-I group received the CIMT intervention and the CIMT-D group did not. Generalized estimating equation (GEE) analyses were used to examine repeated binary data and count values. Group and visit interactions were assessed, adjusting for functional level, affected side, dominant side, age, and gender covariates.

RESULTS

In CIMT-I participants, there was an increase in the proportion of completed tasks at posttest compared with CIMT-D participants, particularly with respect to those tasks requiring dexterity with small objects and total incompletes (P < .0033). Compared with baseline, 120 tasks governing distal limb use for CIMT-I and 58 tasks dispersed across the WMFT for CIMT-D could be completed after 2 weeks. Common movement components that may have contributed to incomplete tasks include shoulder stabilization and flexion, elbow flexion and extension, wrist pronation, supination and ulnar deviation, and pincer grip.

CONCLUSION

CIMT training should emphasize therapy for those specific movement components in patients who meet the EXCITE criteria for baseline motor control.

Affected Upper-Extremity Movement Ability Is Retained 3 Months After Modified Constraint-Induced Therapy

The practicality and patient compliance of constraint-induced movement therapy limit its application in many clinical environments. For more than a decade, the principal investigator's laboratory has shown efficacy of an outpatient, modified constraint-induced therapy (mCIT). The current study examined whether participants administered mCIT retained motor changes 3 mo after intervention. The upper-extremity section of the Fugl-Meyer Impairment Scale (FM) and the Action Research Arm Test (ARA) were administered directly after mCIT intervention. Thirteen patients poststroke were tracked prospectively from directly after intervention concluded to 3 mo after intervention, at which time the FM and ARA were readministered. Three months after intervention, 25 of the 26 scores on the FM and ARA increased between the time after intervention and 3 months after intervention, reflecting continued increases in affected extremity movement ability. It is believed that the continued motor changes were caused by the comparatively larger number of extremity-use opportunities during the 10-wk mCIT intervention period. These opportunities encourage habitual extremity use even after the intervention period has concluded, leading to the changes observed.

Quality-of-life change associated with robotic-assisted therapy to improve hand motor function in patients with subacute stroke: a randomized clinical trial

BACKGROUND

At 6 months poststroke, most patients cannot incorporate their affected hand into daily activities, which in turn is likely to reduce their perceived quality of life.

OBJECTIVE

This preliminary study explored change in patient-reported, health-related quality of life associated with robotic-assisted therapy combined with reduced therapist-supervised training.

DESIGN AND SETTING

A single-blind, multi-site, randomized clinical trial was conducted.

PARTICIPANTS

Seventeen individuals who were 3 to 9 months poststroke participated.

INTERVENTION

Sixty hours of therapist-supervised repetitive task practice (RTP) was compared with 30 hours of RTP combined with 30 hours of robotic-assisted therapy.

MEASUREMENTS

Participants completed the Stroke Impact Scale (SIS) at baseline, immediately postintervention, and 2 months postintervention. Change in SIS score domains was assessed in a mixed model analysis.

RESULTS

The combined therapy group had a greater increase in rating of mood from preintervention to postintervention, and the RTP-only group had a greater increase in rating of social participation from preintervention to follow-up. Both groups had statistically significant improvement in activities of daily living and instrumental activities of daily living scores from preintervention to postintervention. Both groups reported significant improvement in hand function postintervention and at follow-up, and the magnitude of these changes suggested clinical significance. The combined therapy group had significant improvements in stroke recovery rating postintervention and at follow-up, which appeared clinically significant; this also was true for stroke recovery rating from preintervention to follow-up in the RTP-only group. LIMITATIONS OUTCOMES: of 30 hours of RTP in the absence of robotic-assisted therapy remain unknown.

CONCLUSION

Robotic-assisted therapy may be an effective alternative or adjunct to the delivery of intensive task practice interventions to enhance hand function recovery in patients with stroke.