Looking in the Rear View Mirror When Conversing With Back Seat Drivers: The EXCITE Trial Revisited

Reaching a Tipping Point for Neurorehabilitation Research: Obstacles and Opportunities in Trial Design, Description, and Pooled Analysis

The record-breaking pace of COVID-19 vaccine development and implementation depended heavily on collaboration among academic, government, and commercial stakeholders, especially through data-sharing and robust multicenter trials. Collaborative efforts have not been as fruitful in fields such as neurorehabilitation, where non-pharmacological interventions play a much larger role. Barriers to translating scientific advancements into clinical practice in neurorehabilitation include pervasively small study sizes, exacerbated by limited funding for non-pharmacological multicenter clinical trials; difficulty standardizing—and adequately describing—non-pharmacological interventions; and a lack of incentives for individual patient-level data-sharing. These barriers prevent reliable meta-analysis of non-pharmacological clinical studies in neurorehabilitation. This point-of-view will highlight these challenges as well as suggest practical steps that may be taken to improve the neurorehabilitation pipeline between evidence and implementation.

Scientific basis and active ingredients of current therapeutic interventions for stroke rehabilitation

Background: Despite tremendous advances in the treatment and management of stroke, restoring motor and functional outcomes after stroke continues to be a major clinical challenge. Given the wide range of approaches used in motor rehabilitation, several commentaries have highlighted the lack of a clear scientific basis for different interventions as one critical factor that has led to suboptimal study outcomes. Objective: To understand the content of current therapeutic interventions in terms of their active ingredients. Methods: We conducted an analysis of randomized controlled trials in stroke rehabilitation over a 2-year period from 2019-2020. Results: There were three primary findings: (i) consistent with prior reports, most studies did not provide an explicit rationale for why the treatment would be expected to work, (ii) most therapeutic interventions mentioned multiple active ingredients and there was not a close correspondence between the active ingredients mentioned versus the active ingredients measured in the study, and (iii) multimodal approaches that involved more than one therapeutic approach tended to be combined in an ad-hoc fashion, indicating the lack of a targeted approach. Conclusion: These results highlight the need for strengthening cross-disciplinary connections between basic science and clinical studies, and the need for structured development and testing of therapeutic approaches to find more effective treatment interventions.

Clinical Case Reporting in the Peer-Reviewed Physical Therapy Literature: Time to Move Toward Functioning

Physical therapists increasingly are contributing clinical case reports to the health literature, which form the basis for higher quality evidence that has been incorporated into clinical practice guidelines. Yet, few resources exist to assist physical therapists with the basic mechanics and quality standards of producing a clinical case report. This situation is further complicated by the absence of uniform standards for quality in case reporting. The importance of including a concise yet comprehensive description of patient functioning in all physical therapy case reports suggest the potential appropriateness of basing quality guidelines on the World Health Organization's International Classification of Functioning Disability and Health (ICF) model. The purpose of this paper is to assist physical therapists in creating high-quality clinical case reports for the peer-reviewed literature using the ICF model as a guiding framework. Along these lines, current recommendations related to the basic mechanics of writing a successful clinical case report are reviewed, as well and a proposal for uniform clinical case reporting requirements is introduced with the aim to improve the quality and feasibility of clinical case reporting in physical therapy that are informed by the ICF model.

Clinical trials in neurorehabilitation

The clinical trial is essential to testing efficacy and effectiveness of therapeutic interventions. Neurorehabilitation presents unique challenges in the execution of clinical trials due to the complexity of both human interface with complex interventions and clinical/research staff interaction. Attention to key elements, recruitment, retention, treatment fidelity, and control intervention selection, contributes to successful conduct of a trial. Alternatives to the randomized controlled trial and outcome measure selection are important considerations contributing to the merit of the trial. While clinical trial outcomes contribute to the scientific evidence, their true value and impact comes in the next step, translation to clinical practice and the improvement of patient outcomes and qualify of life. Translation of evidence into practice may best be achieved via partnerships of scientists, clinicians, and administrators resulting in a dynamic interface between science and practice, the laboratory, and the clinic.

Constraint-Induced Movement Therapy (CIMT): Current Perspectives and Future Directions

Constraint-induced movement therapy (CIMT) has gained considerable popularity as a treatment technique for upper extremity rehabilitation among patients with mild-to-moderate stroke. While substantial evidence has emerged to support its applicability, issues remain unanswered regarding the best and most practical approach. Following the establishment of what can be called the "signature" CIMT approach characterized by intense clinic/laboratory-based practice, several distributed forms of training, collectively known as modified constraint therapy (mCIMT), have emerged. There is a need to examine the strengths and limitations of such approaches, and based upon such information, develop the components of a study that would compare the signature approach to the best elements of mCIMT, referred to here as "alternative" CIMT. Based upon a PEDro review of literature, limitations in mCIMT studies for meeting criteria were identified and discussed. A suggestion for a "first effort" at a comparative study that would both address such limitations while taking practical considerations into account is provided.

The EXCITE stroke trial: comparing early and delayed constraint-induced movement therapy

BACKGROUND AND PURPOSE

Although constraint-induced movement therapy (CIMT) has been shown to improve upper extremity function in stroke survivors at both early and late stages after stroke, the comparison between participants within the same cohort but receiving the intervention at different time points has not been undertaken. Therefore, the purpose of this study was to compare functional improvements between stroke participants randomized to receive this intervention within 3 to 9 months (early group) to participants randomized on recruitment to receive the identical intervention 15 to 21 months after stroke (delayed group).

METHODS

Two weeks of CIMT was delivered to participants immediately after randomization (early group) or 1 year later (delayed group). Evaluators blinded to group designation administered primary (Wolf Motor Function Test, Motor Activity Log) and secondary (Stroke Impact Scale) outcome measures among the 106 early participants and 86 delayed participants before delivery of CIMT, 2 weeks thereafter, and 4, 8, and 12 months later.

RESULTS

Although both groups showed significant improvements from pretreatment to 12 months after treatment, the earlier CIMT group showed greater improvement than the delayed CIMT group in Wolf Motor Function Test Performance Time and the Motor Activity Log (P<0.0001), as well as in Stroke Impact Scale Hand and Activities domains (P<0.0009 and 0.0214, respectively). Early and delayed group comparison of scores on these measures 24 months after enrollment showed no statistically significant differences between groups.

CONCLUSIONS

CIMT can be delivered to eligible patients 3 to 9 months or 15 to 21 months after stroke. Both patient groups achieved approximately the same level of significant arm motor function 24 months after enrollment. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00057018.

Sensor-based arm skill training in chronic stroke patients: results on treatment outcome, patient motivation, and system usability

As stroke incidence increases, therapists' time is under pressure. Technology-supported rehabilitation may offer new opportunities. The objective of this study was to evaluate patient motivation for and the feasibility and effects of a new technology-supported task-oriented arm training regime (T-TOAT). Nine chronic stroke patients performed T-TOAT (2 x 30 min/day, four days/week) during eight weeks. A system including movement tracking sensors, exercise board, and software-based toolkit was used for skill training. Measures were recorded at baseline, after four and eight weeks of training, and six months posttraining. T-TOAT improved arm-hand performance significantly on Fugl-Meyer, Action Research Arm Test, and Motor Activity Log. Training effects lasted at least six months posttraining. Health-related-quality-of-life had improved significantly after eight weeks of T-TOAT with regard to perceived physical health, but not to perceived mental health (SF-36). None of the EuroQol-5D components showed significant differences before and after training. Participants were intrinsically motivated and felt competent to use the system. Furthermore, system usability was rated very good. However, exercise challenge as perceived by participants decreased significantly over eight weeks of training. The results of this study indicate that T-TOAT is feasible. Despite the small number of stroke patients tested, significant and clinically relevant improvements in skilled arm-hand performance were found.

Rehabilitation of reaching and grasping function in severe hemiplegic patients using functional electrical stimulation therapy

OBJECTIVE

The aim of this study was to establish the efficacy of a therapeutic intervention based on functional electrical stimulation (FES) therapy to improve reaching and grasping function after severe hemiplegia due to stroke.

METHODS

A total of 21 subjects with acute stroke were randomized into 2 groups, FES plus conventional occupational and physiotherapy (FES group) or only conventional therapy (control group) 5 days a week for 12 to 16 weeks. A third group of 7 subjects with chronic hemiplegia (at least 5 months poststroke) received only FES therapy (chronic group) and pre-post training changes were compared. FES was applied to proximal and then distal muscle groups during specific motor tasks. At baseline and at the end of treatment, grasping function was assessed using the Rehabilitation Engineering Laboratory Hand Function Test, along with more standard measures of rehabilitation outcome.

RESULTS

The FES group improved significantly more than the control group in terms of object manipulation, palmar grip torque, pinch grip pulling force, Barthel Index, Upper Extremity Fugl-Meyer scores, and Upper Extremity Chedoke-McMaster Stages of Motor Recovery. The chronic stroke subjects demonstrated improvements in most categories, but the changes were not statistically significant.

CONCLUSIONS

FES therapy with upper extremity training may be an efficacious intervention in the rehabilitation of reaching and grasping function during acute stroke rehabilitation.

Progressive Staging of Pilot Studies to Improve Phase III Trials for Motor Interventions

Based on the suboptimal research pathways that finally led to multicenter randomized clinical trials (MRCTs) of treadmill training with partial body weight support and of robotic assistive devices, strategically planned successive stages are proposed for pilot studies of novel rehabilitation interventions. Stage 1, consideration-of-concept studies, drawn from animal experiments, theories, and observations, delineate the experimental intervention in a small convenience sample of participants, so the results must be interpreted with caution. Stage 2, development-of-concept pilots, should optimize the components of the intervention, settle on most appropriate outcome measures, and examine dose-response effects. A well-designed study that reveals no efficacy should be published to counterweight the confirmation bias of positive trials. Stage 3, demonstration-of-concept pilots, can build out from what has been learned to test at least 15 participants in each arm, using random assignment and blinded outcome measures. A control group should receive an active practice intervention aimed at the same primary outcome. A third arm could receive a substantially larger dose of the experimental therapy or a combinational intervention. If only 1 site performed this trial, a different investigative group should aim to reproduce positive outcomes based on the optimal dose of motor training. Stage 3 studies ought to suggest an effect size of 0.4 or higher, so that approximately 50 participants in each arm will be the number required to test for efficacy in a stage 4, proof-of-concept MRCT. By developing a consensus around acceptable and necessary practices for each stage, similar to CONSORT recommendations for the publication of phase III clinical trials, better quality pilot studies may move quickly into better designed and more successful MRCTs of experimental interventions.

Can the Wolf Motor Function Test be streamlined?

BACKGROUND

To assess upper extremity (UE) capabilities following stroke, the Wolf Motor Function Test (WMFT) measures time to complete 15 UE tasks and 2 strength tasks, but takes 30 to 45 minutes for the clinician to complete.

OBJECTIVE

In an effort to streamline the WMFT, this study evaluated the association between the magnitude of improvement on any timed task of the WMFT and the change score on all other tasks among participants in the Extremity Constraint Induced Therapy Evaluation (EXCITE) trial.

METHODS

This association was evaluated using regression methods according to chronicity and controlling for key covariates (functional level, gender, concordance) for log mean WMFT scores.

RESULTS

After controlling for covariates, 6 tasks (hand to table [front], hand to box [front], reach and retrieve, lift can, lift pencil, and fold towel) influenced the overall WMFT score for survivors meeting EXCITE criteria and treated within 3 to 9 months poststroke. Six different tasks (extend elbow weight, hand to box [front], lift can, lift pencil, turn key in lock, and fold towel) influenced the overall WMFT score for those receiving constraint-induced movement therapy (CIMT) 1 year later. The importance of certain tasks relative to others may best represent overall UE function, but this streamlining enables the clinician to prioritize these tasks in the evaluation.

CONCLUSIONS

The delineation of those tasks depends on the time poststroke from enrollment to CIMT. This study demonstrates that the WMFT can be streamlined from 17 to 6 tasks.

Motor improvement and corticospinal modulation induced by hybrid assistive neuromuscular dynamic stimulation (HANDS) therapy in patients with chronic stroke

BACKGROUND AND OBJECTIVE

We devised a therapeutic approach to facilitate the use of the hemiparetic upper extremity (UE) in daily life by combining integrated volitional control electrical stimulation with a wrist splint, called hybrid assistive neuromuscular dynamic stimulation (HANDS).

METHODS

Twenty patients with chronic hemiparetic stroke (median 17.5 months) had moderate to severe UE weakness. Before and immediately after completing 3 weeks of training in 40-minute sessions, 5 days per week over 3 weeks and wearing the system for 8 hours each day, clinical measures of motor impairment, spasticity, and UE functional scores, as well as neurophysiological measures including electromyography activity, reciprocal inhibition, and intracortical inhibition were assessed. A follow-up clinical assessment was performed 3 months later.

RESULTS

UE motor function, spasticity, and functional scores improved after the intervention. Neurophysiologically, the intervention induced restoration of presynaptic and long loop inhibitory connections as well as disynaptic reciprocal inhibition. Paired pulse transcranial magnetic stimulation study indicated disinhibition of the short intracortical inhibition in the affected hemisphere. The follow-up assessment showed that improved UE functions were maintained at 3 months.

CONCLUSION

The combination of hand splint and volitional and electrically induced muscle contraction can induce corticospinal plasticity and may offer a promising option for the management of the paretic UE in patients with stroke. A larger sample size with randomized controls is needed to demonstrate effectiveness.

Potential predictors of motor and functional outcomes after distributed constraint-induced therapy for patients with stroke

BACKGROUND

Selection of patients who are most and least likely to benefit from constraint-induced therapy (CIT) for the upper extremity is uncertain.

OBJECTIVE

This study investigated demographic and clinical characteristics that may predict outcomes for a distributed form of CIT.

METHODS

A group of 57 patients were treated with distributed CIT, and 7 potential predictors were identified, including age, sex, side of stroke, time since stroke, spasticity, neurologic status, and movement performance of the distal part of the upper extremity. Treatment outcome was assessed in terms of motor performance, perceived functional ability of the affected hand, and functional performance of daily activities, measured by Fugl-Meyer Assessment (FMA), Motor Activity Log (MAL), and Functional Independence Measure (FIM), respectively.

RESULTS

Motor ability of the distal part of the upper extremity and time since stroke were significantly predictive of outcomes on the FMA (adjusted R(2) = 0.18, P = .002) and the MAL subtest quality of movement (adjusted R( 2) = 0.43, P < .0001). Motor ability and age were significant predictors of amount of use measured by the MAL (adjusted R(2) = 0.20, P = .001). None of the variables exhibited a predictive relationship with the FIM.

CONCLUSIONS

The best predictor for motor outcomes after distributed CIT was greater motor ability of the distal part of the upper extremity, which is consistent with the presence of residual motor pathways that may respond to training. The FMA may be of value in stratifying patients for their likelihood to benefit from distributed CIT protocols.

Effects of Trunk Restraint Combined With Intensive Task Practice on Poststroke Upper Extremity Reach and Function: A Pilot Study

Background. Poststroke reaching is characterized by excessive trunk motion and abnormal shoulder—elbow coordination. Little attention is typically given to arm—trunk kinematics during task practice. Preventing compensatory trunk motion during short-term practice immediately improves kinematics, but effects of longer-term practice are unknown. Objective. This study compared the effects of intensive task practice with and without trunk restraint on poststroke reaching kinematics and function. Methods. A total of 11 individuals with chronic stroke, baseline Fugl-Meyer Upper Extremity Assessment scores 26 to 54, were randomized to 2 constraint-therapy intervention groups. All participants wore a mitt on the unaffected hand for 90% of waking hours over 14 days and participated in 10 days/6 hours/day of supervised progressive task practice. During supervised sessions, one group trained with a trunk restraint (preventing anterior trunk motion) and one group did not. Tasks for the trunk-restraint group were located to afford repeated use of a shoulder flexion—elbow extension reaching pattern. Outcome measures included kinematics of unrestrained targeted reaching and tests of functional arm ability. Results. Posttraining, the trunk-restraint group demonstrated straighter reach trajectories ( P = .000) and less trunk displacement ( P = .001). The trunk-restraint group gained shoulder flexion ( P = .006) and elbow extension ( P = .022) voluntary ranges of motion, the nonrestraint group did not. Posttraining angle—angle plots illustrated that individuals from the trunk-restraint group transitioned from elbow flexion to elbow extension during mid-reach; individuals in the nonrestraint group retained pretraining movement strategies. Both groups gained functional arm ability ( P < .05 all tests). Conclusion. Intensive task practice structured to prevent compensatory trunk movements and promote shoulder flexion—elbow extension coordination may reinforce development of “normal” reaching kinematics.

Training and exercise to drive poststroke recovery

To make practical recommendations regarding therapeutic strategies for the rehabilitation of patients with hemiparetic stroke, it is important to have a general understanding of the fundamental mechanisms underlying the neuroplasticity that is induced by skills training and by exercise programs designed to increase muscle strength and cardiovascular fitness. Recent clinical trials have provided insights into methods that promote adaptations within the nervous system that correlate with improved walking and upper extremity function, and that can be instigated at any time after stroke onset. Data obtained to date indicate that patients who have mild to moderate levels of impairment and disability can benefit from interventions that depend on repetitive task-oriented practice at the intensity and duration necessary to reach a plateau in a reacquired skill. Studies are underway to lessen the consequences of more-severe motor deficits by drawing on medications that augment plasticity, biological interventions that promote neural repair, and strategies that employ electrical stimulation and robotics.