Post-stroke rehabilitation in the peri-pandemic COVID-19 era

The coronavirus disease 2019 (COVID-19), which arose in late 2019, caused extensive destruction, impacting a substantial proportion of the worldwide population and leading to millions of deaths. Although COVID-19 is mainly linked to respiratory and pulmonary complications, it has the potential to affect neurologic structures as well. Neurological involvement may manifest as minimal and reversible; however, a notable proportion of cases have exhibited pronounced neurological consequences, such as strokes. Endothelial inflammation, hypercoagulation, renin-angiotensin-aldosterone system alterations, and cardiogenic embolism are the pathophysiological mechanisms of stroke under COVID-19 circumstances. Physical activity and exercise have improved several aspects of post-stroke recovery, including cardiovascular health, walking capacity, and upper limb strength. They are commonly used to assist stroke survivors in overcoming their motor restrictions. Furthermore, stroke rehabilitation can incorporate a range of specific techniques, including body-weight-supported treadmill applications, constraint-induced movement therapy, robotic rehabilitation interventions, transcranial direct current stimulation, transcranial magnetic stimulation, and prism adaptation training. Under pandemic conditions, there were several barriers to neurological rehabilitation. The most significant of these were individual's fear of infection, which caused them to postpone their rehabilitation applications and rehabilitation areas being converted into COVID-19 units. The primary emphasis had turned to COVID-19 treatment. Several valuable data and views were gained in reorganizing rehabilitation during the pandemic, contributing to establishing future views in this regard.

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.

An Exploration of the Effectiveness of Different Intensity Protocols of Modified Constraint-Induced Therapy in Stroke: A Systematic Review

Purpose

To examine the effectiveness of different modified Constraint-Inuced Therapy (mCIMT) protocol intensities on upper extremity motor function in adults with hemiplegia.

Methods

A search was conducted in PubMed, Scopus, EBSCO, and Cochrane Library for articles published between April 2010 and December 2021. Only randomized controlled trials (RCTs) were included. Studies were excluded if they used a sample of less than five, mCIMT in combination with other therapy, and/or if they were not written in English. Methodologic quality was assessed using the Cochrane collaboration risk of bias tool-2.

Results

Thirty-six RCTs with a total of 721 participants were included. Most researchers followed a moderate to low protocol intensity in terms of total treatment time and moderate to high intensity with regard to restriction time. Almost all of the upper limb motor function measures showed statistically significant improvements (p < .05) after mCIMT, irrespective of the protocol's intensity, but there was lack of high-quality studies. Statistically significant improvements did not always translate to clinical importance.

Conclusions

Low-intensity CIMT protocols may result in comparable improvements to more intensive ones but caution has to be taken when drawing conclusions due to high risk of bias studies.

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.

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

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

Proprioceptive based training or modified constraint-induced movement therapy on upper extremity motor functions in chronic stroke patients: A randomized controlled study

BACKGROUND: The Modified Constraint-Induced Movement Therapy (mCIMT) method is a unilateral training that respectively avoids and activates less affected and affected sides of upper extremities; however, the selected options are not typically ideal. Proprioceptive based training (PT) includes bilateral training methods and influencing proprioceptive receptors. OBJECTIVE: The primary purpose was to determine if conventional therapy and PT or conventional therapy and mCIMT therapy show similar improvement in patients with chronic stroke. The secondary purpose was to investigate the effectiveness of conventional therapy and PT or mCIMT therapy in patients with chronic stroke and to compare which of the two interventions is more effective. METHODS: Forty patients with chronic stroke were randomly allocated to only conventional therapy (PTR, n = 14), conventional therapy plus proprioception training (PTR-PT, n = 13), and mCIMT (PTR-mCIMT, n = 13) groups. Evaluations were assessed before and 6 weeks after treatment. RESULTS: Intragroup evaluations revealeda significant improvement in the all scores in the PTR-PT and PTR-mCMIT groups (p = 0.006 < 0.001). Intergroup comparisons demonstrated that the PTR-mCIMT group had a significant improvement in spasticity and motor function scores compared to the PTR (p < 0.001) and the PTR-PT groups (p = 0.006–0.015). CONCLUSIONS: PT and mCMIT applied in addition to conventional therapy in patients with chronic stroke were more effective than only conventional therapy. Additionally, mCMIT showed greater improvement in spasticity and motor function scales than PT.

Revisiting dose and intensity of training: Opportunities to enhance recovery following stroke

PURPOSE

Stroke is a global leading cause of adult disability with survivors often enduring persistent impairments and loss of function. Both intensity and dosage of training appear to be important factors to help restore behavior. However, current practice fails to achieve sufficient intensity and dose of training to promote meaningful recovery. The purpose of this review is to propose therapeutic solutions that can help achieve a higher dose and/or intensity of therapy. Raising awareness of these intensive, high-dose, treatment strategies might encourage clinicians to re-evaluate current practice and optimize delivery of stroke rehabilitation for maximal recovery.

METHODS

Literature that tested and evaluated solutions to increase dose or intensity of training was reviewed. For each therapeutic strategy, we outline evidence of clinical benefit, supporting neurophysiological data (where available) and discuss feasibility of clinical implementation.

RESULTS

Possible therapeutic solutions included constraint induced movement therapy, robotics, circuit therapy, bursts of training, gaming technologies, goal-oriented instructions, and cardiovascular exercise.

CONCLUSION

Our view is that clinicians should evaluate current practice to determine how intensive high-dose training can be implemented to promote greater recovery after stroke.

The role of brain oscillations in post-stroke motor recovery: An overview

Stroke is the second cause of disability and death worldwide, highly impacting patient’s quality of life. Several changes in brain architecture and function led by stroke can be disclosed by neurophysiological techniques. Specifically, electroencephalogram (EEG) can disclose brain oscillatory rhythms, which can be considered as a possible outcome measure for stroke recovery, and potentially shaped by neuromodulation techniques. We performed a review of randomized controlled trials on the role of brain oscillations in patients with post-stroke searching the following databases: Pubmed, Scopus, and the Web of Science, from 2012 to 2022. Thirteen studies involving 346 patients in total were included. Patients in the control groups received various treatments (sham or different stimulation modalities) in different post-stroke phases. This review describes the state of the art in the existing randomized controlled trials evaluating post-stroke motor function recovery after conventional rehabilitation treatment associated with neuromodulation techniques. Moreover, the role of brain pattern rhythms to modulate cortical excitability has been analyzed. To date, neuromodulation approaches could be considered a valid tool to improve stroke rehabilitation outcomes, despite more high-quality, and homogeneous randomized clinical trials are needed to determine to which extent motor functional impairment after stroke can be improved by neuromodulation approaches and which one could provide better functional outcomes. However, the high reproducibility of brain oscillatory rhythms could be considered a promising predictive outcome measure applicable to evaluate patients with stroke recovery after rehabilitation.

A Literature Review of High-Tech Physiotherapy Interventions in the Elderly with Neurological Disorders

Neurological physiotherapy adopts a problem-based approach for each patient as determined by a thorough evaluation of the patient’s physical and mental well-being. Τhis work aims to provide a literature review of physical therapy interventions in the elderly with neurological diseases (NDs) and discuss physiotherapy procedures and methods that utilize cutting-edge technologies for which clinical studies are available. Hence, the review focuses on acute NDs (stroke), deteriorating NDs (Parkinson’s disease), and age-related cognitive impairment. The most used physiotherapy procedures on which clinical data are available are balance and gait training (robot-assisted or not), occupational therapy, classical physiotherapy, walking and treadmill training, and upper limb robot-assisted therapy. Respectively, the most often-used equipment are types of treadmills, robotic-assisted equipment (Lokomat^® and Gait Trainer GT1), and portable walkway systems (GAITRite^®), along with state-of-the-art technologies of virtual reality, virtual assistants, and smartphones. The findings of this work summarize the core standard tools and procedures, but more importantly, provide a glimpse of the new era in physiotherapy with the utilization of innovative equipment tools for advanced patient monitoring and empowerment.

BCI-FES With Multimodal Feedback for Motor Recovery Poststroke

An increasing number of research teams are investigating the efficacy of brain-computer interface (BCI)-mediated interventions for promoting motor recovery following stroke. A growing body of evidence suggests that of the various BCI designs, most effective are those that deliver functional electrical stimulation (FES) of upper extremity (UE) muscles contingent on movement intent. More specifically, BCI-FES interventions utilize algorithms that isolate motor signals-user-generated intent-to-move neural activity recorded from cerebral cortical motor areas-to drive electrical stimulation of individual muscles or muscle synergies. BCI-FES interventions aim to recover sensorimotor function of an impaired extremity by facilitating and/or inducing long-term motor learning-related neuroplastic changes in appropriate control circuitry. We developed a non-invasive, electroencephalogram (EEG)-based BCI-FES system that delivers closed-loop neural activity-triggered electrical stimulation of targeted distal muscles while providing the user with multimodal sensory feedback. This BCI-FES system consists of three components: (1) EEG acquisition and signal processing to extract real-time volitional and task-dependent neural command signals from cerebral cortical motor areas, (2) FES of muscles of the impaired hand contingent on the motor cortical neural command signals, and (3) multimodal sensory feedback associated with performance of the behavioral task, including visual information, linked activation of somatosensory afferents through intact sensorimotor circuits, and electro-tactile stimulation of the tongue. In this report, we describe device parameters and intervention protocols of our BCI-FES system which, combined with standard physical rehabilitation approaches, has proven efficacious in treating UE motor impairment in stroke survivors, regardless of level of impairment and chronicity.

Effect of novel training to normalize altered finger force direction post-stroke: study protocol for a double-blind randomized controlled trial

BACKGROUND

Functional task performance requires proper control of both movement and force generation in three-dimensional space, especially for the hand. Control of force in three dimensions, however, is not explicitly treated in current physical rehabilitation. To address this gap in treatment, we have developed a tool to provide visual feedback on three-dimensional finger force. Our objective is to examine the effectiveness of training with this tool to restore hand function in stroke survivors.

METHODS

Double-blind randomized controlled trial. All participants undergo 18 1-h training sessions to practice generating volitional finger force of various target directions and magnitudes. The experimental group receives feedback on both force direction and magnitude, while the control group receives feedback on force magnitude only. The primary outcome is hand function as measured by the Action Research Arm Test. Other outcomes include the Box and Block Test, Stroke Impact Scale, ability to direct finger force, muscle activation pattern, and qualitative interviews.

DISCUSSION

The protocol for this clinical trial is described in detail. The results of this study will reveal whether explicit training of finger force direction in stroke survivors leads to improved motor control of the hand. This study will also improve the understanding of neuromuscular mechanisms underlying the recovery of hand function.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03995069 . Registered on June 21, 2019.

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

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.

Exploration of barriers and enablers for evidence-based interventions for upper limb rehabilitation following a stroke: Use of Constraint Induced Movement Therapy and Robot Assisted Therapy in NHS Scotland

Introduction

The routine use of evidence-based upper limb rehabilitation interventions after stroke has the potential to improve function and increase independence. Two such interventions are Constraint Induced Movement Therapy and Robot Assisted Therapy. Despite evidence to support both interventions, their use within the National Health Service appears, anecdotally, to be low. We sought to understand user perceptions in order to explain low uptake in clinical practice.

Methods

A combination of a cross-sectional online survey with therapists and semi-structured interviews with stroke patients was used to explore uptake and user opinions on the benefits, enablers and barriers to each intervention.

Findings

The therapists surveyed reported low use of Constraint Induced Movement Therapy and Robot Assisted Therapy in clinical practice within the Scottish National Health Service. Barriers identified by therapists were inadequate staffing, and a lack of training and resources. Interviews with stroke patients identified themes that may help us to understand the acceptability of each intervention, such as the impact of motivation.

Conclusion

Barriers to the uptake of Constraint Induced Movement Therapy and Robot Assisted Therapy within the clinical setting were found to be similar. Further qualitative research should be completed in order to help us understand the role patient motivation plays in uptake.

Early non-invasive brain stimulation with modified constraint-induced movement therapy for motor and functional upper limb recovery in stroke patients: Study protocol

Introduction

Upper limb motor impairment after a stroke is an important sequela. Constraint-induced movement therapy is a rehabilitation approach that has strong evidence. The incorporation of transcranial direct-current stimulation has been proposed; however, there is a lack of studies that confirm its benefits. The principal aim is to compare the effectiveness of 7 days of active versus sham bi-hemispheric transcranial direct-current stimulation, combined with modified constraint-induced movement therapy, for motor and functional recovery of the hemiparetic upper limb in subacute stroke patients.

Method/design

Randomized, double blind, sham-controlled, parallel group clinical trial in two stroke units. Participants: adults over 18 years, at least 2 days post unihemispheric stroke event, with hemiparesis, and without severe pain, aphasia or cognitive impairment. Intervention: Patients will receive 7 days of continuous therapy and be assigned to one of the treatment groups: active bi-hemispheric transcranial direct-current stimulation or sham bi-hemispheric transcranial direct-current stimulation. Measurement: Evaluations will take place at days 0, 5, 7 and 10, and at 3rd months. The Fugl-Meyer Assessment – Upper Extremity, Wolf Motor Function Test, Functional Independence Measure and Stroke Impact Scale are considered.

Discussion

Modified constraint-induced movement therapy plus transcranial direct-current stimulation in subacute stroke patients with hemiparesis could maximize motor and functional recovery. Trial registration: ClinicalTrials.gov identifier NCT03452254.

Effectiveness of rehabilitation interventions to improve paretic propulsion in individuals with stroke - A systematic review

BACKGROUND

Stroke survivors often show reduced walking velocity and gait asymmetry. These gait abnormalities are associated with reduced propulsion of the paretic leg. This review aimed to provide an overview of the potential effectiveness of post-stroke rehabilitation interventions to improve paretic propulsion, ankle kinetics and walking velocity.

METHODS

A systematic search was performed in Pubmed, Web of Science, Embase, and Pedro. Studies were eligible if they reported changes in propulsion measures (impulse, peak value and symmetry ratios) or ankle kinetics (moment and power) following intervention in stroke survivors (group size ≥10). Study selection, data extraction and quality assessment were performed independently by two authors.

FINDINGS

A total of 28 studies were included, of which 25 studies applied exercise interventions, two studies focused on surgical interventions, and one on non-invasive brain stimulation. The number of high-quality trials was limited (N = 6; score Downs and Black scale ≥19). Propulsion measures were the primary outcome in eight studies. In general, mixed results were reported with 14 interventions yielding improvements in propulsion and ankle kinetics. In contrast, gains in walking velocity were observed in the vast majority of studies (N = 20 out of 23).

INTERPRETATION

Interventions that yielded gains in propulsion appeared to have in common that they challenged and/or enabled the utilization of latent propulsive capacity of the paretic leg during walking. Walking speed generally increased, regardless of the observed change in propulsion, suggesting the use of compensatory mechanisms. Findings should, however, be interpreted with some caution, as the evidence base for this emerging focus of rehabilitation is limited.

Is there a dose-dependent effect of modified constraint-induced movement therapy in patients with hemiplegia?

BACKGROUND

Impairment of upper extremity function is a common sequelae of stroke. It has been reported that modified constraint-induced movement therapy (mCIMT) could prove to be effective.

OBJECTIVE

To investigate the relationship between the intensity of rehabilitation such as treatment and constraining time, and the functional outcome for the paretic upper extremity in stroke patients through mCIMT.

METHODS

We conducted an observational prospective study of 31 patients with hemiplegia and subacute or chronic stroke. The mCIMT was performed for two weeks. Rehabilitation time and constraining time were variable among patients. The rehabilitation time included an individualized task-oriented program and conventional occupation treatment with an individualized therapist. The constraining time, with mit or splint, was also asked to self-record individually. The outcome was evaluated on the more affected side by the Wolf Motor Function Test, Fugl-Meyer Assessment, Motor Activity Log 14, and Functional Independence Measure for self-care tasks after the therapy.

RESULTS

All participants after the modified constraint-induced movement therapy program for two weeks improved on the evaluated outcome measures (P < 0.05). No significant correlation was found between the dose-dependent treatment or constraining time and outcomes. Comparisons improvement with subgroups based on the duration from onset, constraining component, dominant hand consistent with lesion side of stroke, and initial medical research council score for muscle strength, also showed no significant differences.

CONCLUSIONS

This is the first study on the effects of intensity of mCIMT with respect to time-dosage. Although all patients in this study showed improved functional status, no significant correlation between dose-dependent rehabilitation or constraining time and outcomes was seen.

Ipsilesional Mu Rhythm Desynchronization and Changes in Motor Behavior Following Post Stroke BCI Intervention for Motor Rehabilitation

Loss of motor function is a common deficit following stroke insult and often manifests as persistent upper extremity (UE) disability which can affect a survivor's ability to participate in activities of daily living. Recent research suggests the use of brain-computer interface (BCI) devices might improve UE function in stroke survivors at various times since stroke. This randomized crossover-controlled trial examines whether intervention with this BCI device design attenuates the effects of hemiparesis, encourages reorganization of motor related brain signals (EEG measured sensorimotor rhythm desynchronization), and improves movement, as measured by the Action Research Arm Test (ARAT). A sample of 21 stroke survivors, presenting with varied times since stroke and levels of UE impairment, received a maximum of 18-30 h of intervention with a novel electroencephalogram-based BCI-driven functional electrical stimulator (EEG-BCI-FES) device. Driven by spectral power recordings from contralateral EEG electrodes during cued attempted grasping of the hand, the user's input to the EEG-BCI-FES device modulates horizontal movement of a virtual cursor and also facilitates concurrent stimulation of the impaired UE. Outcome measures of function and capacity were assessed at baseline, mid-therapy, and at completion of therapy while EEG was recorded only during intervention sessions. A significant increase in r-squared values [reflecting Mu rhythm (8-12 Hz) desynchronization as the result of attempted movements of the impaired hand] presented post-therapy compared to baseline. These findings suggest that intervention corresponds with greater desynchronization of Mu rhythm in the ipsilesional hemisphere during attempted movements of the impaired hand and this change is related to changes in behavior as a result of the intervention. BCI intervention may be an effective way of addressing the recovery of a stroke impaired UE and studying neuromechanical coupling with motor outputs. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT02098265.

Effects of modified constraint-induced movement therapy in the recovery of upper extremity function affected by a stroke: a single-blind randomized parallel trial-comparing group versus individual intervention

An extensive corpus of literature supports the positive impact of constraint-induced movement therapy (CIMT) on neuroplasticity and the recovery of function. However, its clinical applicability is limited by the time of intervention and individual modality. We propose to assess the efficacy of modified CIMT protocols through a group therapy intervention. To determine the effectiveness of a group therapy, compared with individual modified CIMT, in increasing the use and functionality of movement of a paretic upper limb. The study was a single-blind, randomized parallel trial. Thirty-six patients who had had a stroke more than 6 months previously were divided randomly into two intervention groups. The independent variable was the implementation of group or individual modalities for 3 h for 10 consecutive days and the dependent variables were evaluated by the Motor Activity Log and Action Research Arm Test, at baseline (preintervention evaluation), end (postintervention evaluation), and 6 months after intervention (follow-up). By controlling the preintervention evaluations, analyses of covariance indicated that both dependent variables presented significant differences in favor of the group therapy at both the postintervention evaluation and the follow-up evaluations. Both types of intervention generated increases in the function and use of the upper extremity, with these increases being higher in the group therapy. The effects of the group therapy modality were maintained 6 months after the intervention ended.

Exploring the parameters of intensity, frequency, and duration within the constraint induced movement therapy published research: A content analysis

BACKGROUND

Neurological rehabilitation specialists must determine appropriate dosage, consisting of frequency, intensity, and duration of specified treatments.

OBJECTIVE

The objective of this study was to perform a content analysis of the current literature related to dosage (duration, frequency and intensity) for constraint-induced movement therapy (CIMT) in the adult population.

METHODS

A content analysis was conducted which yielded 62 scholarly articles.

RESULTS

The frequency of CIMT ranged from 1 to 7 days per week with the average frequency being 4.98 days. The duration of CIMT, ranged from 2 to 10 weeks with the average duration 3.14 weeks. All three components of dosage were reported collectively in outcomes studies conducted in inpatient settings and rehabilitation clinics.

CONCLUSIONS

The findings provide a groundwork for evidence based practice for clinician in the application of CIMT dosage with consideration of settings and CIMT components.

Short-term Efficacy of Hand-Arm Bimanual Intensive Training on Upper Arm Function in Acute Stroke Patients: A Randomized Controlled Trial

Background

Rehabilitation training during the acute phase of stroke (<48 h) markedly improves impaired upper-limb movement. Hand-arm bimanual intensive training (HABIT) represents an intervention that promotes improvements in upper extremity function in children with cerebral palsy. This study repurposed HABIT in acute stroke patients and assessed recovery of upper extremity function when compared with a conventional rehabilitation program (CRP).

Methods

In a randomized trial, 128 patients with acute stroke were assigned to the HABIT or the CRP groups. The primary endpoint was clinical motor functional assessment that was guided by the Fugl-Meyer motor assessment (FMA) and outcomes of the action research arm test (ARAT). The secondary endpoint was an improved neurophysiological evaluation according to the motor-evoked potential amplitude (AMP), resting motion threshold (RMT), and central motor conduction time (CMCT) scores over the 2-week course of therapy. In both groups, scores were evaluated at baseline, 1 week from commencing therapy, and post-therapy.

Results

After 2 weeks, the HABIT group showed improved scores as compared the CRP group for FMA (51.7 ± 6.44 vs. 43.5 ± 5.6, P < 0.001), ARAT (34.5 ± 6.2 vs. 33.3 ± 6.3, P = 0.022), and AMP (1.1 ± 0.1 vs. 1.0 ± 0.1, P < 0.001). However, CMCT (8.6 ± 1.0 vs. 9.1 ± 0.6, P = 0.054) and RMT (55.3 ± 4.2 vs. 57.5 ± 4.1, P = 0.088) were similar when comparing between groups.

Conclusion

HABIT significantly improved motor functional and neuro-physiological outcomes in patients with acute stroke, which suggested that HABIT might represent an improved therapeutic strategy as compared CRP.

Interventions to Improve Movement and Functional Outcomes in Adult Stroke Rehabilitation: Review and Evidence Summary

Background

Patients who have had a stroke may not be familiar with the terminology nor have the resources to efficiently search for evidence-based rehabilitation therapies to restore movement and functional outcomes. Recognizing that a thorough systematic review on this topic is beyond the scope of this article, we conducted a rapid review evidence summary to determine the level of evidence for common rehabilitation interventions to improve movement/motor and functional outcomes in adults who have had a stroke.

Objective

The objective of this study was to find evidence for common rehabilitation interventions to improve movement/motor and functional outcomes in adults who have had a stroke.

Methods

Medline Complete, PubMed, CINAHL Complete, Cochrane Database, Rehabilitation and Sports Medicine Source, Dissertation Abstracts International, and National Guideline Clearinghouse, from 1996 to April of 2016, were searched. From 348 articles, 173 met the following inclusion criteria: (1) published systematic reviews or meta-analyses, (2) outcomes target functional movement or motor skills of the upper and lower limbs, (3) non-pharmacological interventions that are commonly delivered to post-stroke population (acute and chronic), (4) human studies, and (5) English. Evidence tables were created to analyze the findings of systematic reviews and meta-analyses by category of interventions and outcomes.

Results

This rapid review found that the following interventions possess credible evidence to improve functional movement of persons with stroke: cardiorespiratory training, therapeutic exercise (ie, strengthening), task-oriented training (task-specific training), constraint-induced movement therapy (CIMT), mental practice, and mirror therapy. Neuromuscular electrical stimulation (NMES) (ie, functional electrical stimulation) shows promise as an intervention for stroke survivors.

Conclusions

Most commonly delivered therapeutic interventions to improve motor recovery after a stroke possess moderate quality evidence and are effective. Future research recommendations, such as optimal timing and dosage, would help rehabilitation professionals tailor interventions to achieve the best outcomes for stroke survivors.

[The optimization of restoration approaches of advanced hand activity using the sensorial glove and the mCIMT method]

AIM

To reason the choice of methods of restoration of advanced hand activity depending on severity of motor disturbance in the top extremity.

MATERIAL AND METHODS

Eighty-eight patients were randomized into 3 groups: 1) the mCIMT group, 2) the 'touch glove' group, 3) the control group. For assessment of physical activity of the top extremity Fugl-Meyer Assessment Upper Extremity, Nine-Hole Peg Test, Motor Assessment Scale were used. Assessment of non-use phenomenon was carried out with the Motor Activity Log scale.

RESULTS AND CONCLUSION

At a stage of severe motor dysfunction, there was a restoration of proximal departments of a hand in all groups, neither method was superior to the other. In case of moderate severity of motor deficiency of the upper extremity the most effective was the method based on the principle of biological feedback - 'a touch glove'. In the group with mild severity of motor dysfunction, the best recovery was achieved in the mCIMT group.

Early versus late-applied constraint-induced movement therapy: A multisite, randomized controlled trial with a 12-month follow-up

BACKGROUND AND PURPOSE

A direct comparison between the effects of constraint-induced movement therapy (CIMT) applied early after stroke and that of CIMT applied in the chronic phase has not been conducted. This study aimed to compare the long-term effects of CIMT applied 6 months after stroke with the results of CIMT applied within 28 days post-stroke.

METHODS

This study was a single-blinded, multicentre, randomized controlled trial with a crossover design. Forty-seven patients received CIMT either early (within 28 days) or 6 months after stroke. Both groups received standard rehabilitation and were tested at 5 time points. The primary outcome measure was Wolf Motor Function Test (WMFT); the secondary measures were Nine-Hole Peg Test (NHPT), the Fugl-Meyer Assessment (FMA) of the upper extremity, Stroke Impact Scale, and Modified Rankin Scale (MRS).

RESULTS

Compared with baseline data, both groups showed significant improvements in the primary and secondary outcome measures after 12 months. No significant differences between the 2 treatment groups were found before and after the delayed intervention group received CIMT at 6 months and during the 12-month follow-up. Both groups recovered considerably and showed only minor impairment (median FMA score of 64) after 6 months. The early intervention group showed an initially faster recovery curve of WMFT, NHPT, and MRS scores.

DISCUSSION

In contrast to most CIMT studies, our study could not find an effect of CIMT applied 6 months after stroke. Our results indicate that commencing CIMT early is as good as delayed intervention in the long term, specifically in this group of patients who might have reached a ceiling effect during the first 6 months after stroke. Nevertheless, the early CIMT intervention group showed a faster recovery curve than the delayed intervention group, which can be a clinically important finding for patients in the acute phase.

Constraint-induced movement therapy as a rehabilitation intervention for upper extremity in stroke patients: systematic review and meta-analysis

Constraint-induced movement therapy (CIMT) is a neurorehabilitation technique designed to improve upper extremity motor functions after stroke. This review aimed to investigate evidence of the effect of CIMT on upper extremity in stroke patients and to identify optimal methods to apply CIMT. Four databases (MEDLINE, EMBASE, CINHAL, and PEDro) and reference lists of relevant articles and reviews were searched. Randomized clinical trials that studied the effect of CIMT on upper extremity outcomes in stroke patients compared with other rehabilitative techniques, usual care, or no intervention were included. Methodological quality was assessed using the PEDro score. The following data were extracted for each trial: patients' characteristics, sample size, eligibility criteria, protocols of CIMT and control groups, outcome measurements, and the PEDro score. A total of 38 trials were identified according to the inclusion criteria. The trials included were heterogeneous in CIMT protocols, time since stroke, and duration and frequency of treatment. The pooled meta-analysis of 36 trials found a heterogeneous significant effect of CIMT on upper extremity. There was no significant effect of CIMT at different durations of follow-up. The majority of included articles did not fulfill powered sample size and quality criteria. The effect of CIMT changed in terms of sample size and quality features of the articles included. These meta-analysis findings indicate that evidence for the superiority of CIMT in comparison with other rehabilitative interventions is weak. Information on the optimal dose of CIMT and optimal time to start CIMT is still limited.

Sequencing bilateral robot-assisted arm therapy and constraint-induced therapy improves reach to press and trunk kinematics in patients with stroke

BACKGROUND

The combination of robot-assisted therapy (RT) and a modified form of constraint-induced therapy (mCIT) shows promise for improving motor function of patients with stroke. However, whether the changes of motor control strategies are concomitant with the improvements in motor function after combination of RT and mCIT (RT + mCIT) is unclear. This study investigated the effects of the sequential combination of RT + mCIT compared with RT alone on the strategies of motor control measured by kinematic analysis and on motor function and daily performance measured by clinical scales.

METHODS

The study enrolled 34 patients with chronic stroke. The data were derived from part of a single-blinded randomized controlled trial. Participants in the RT + mCIT and RT groups received 20 therapy sessions (90 to 105 min/day, 5 days for 4 weeks). Patients in the RT + mCIT group received 10 RT sessions for first 2 weeks and 10 mCIT sessions for the next 2 weeks. The Bi-Manu-Track was used in RT sessions to provide bilateral practice of wrist and forearm movements. The primary outcome was kinematic variables in a task of reaching to press a desk bell. Secondary outcomes included scores on the Wolf Motor Function Test, Functional Independence Measure, and Nottingham Extended Activities of Daily Living. All outcome measures were administered before and after intervention.

RESULTS

RT + mCIT and RT demonstrated different benefits on motor control strategies. RT + mCIT uniquely improved motor control strategies by reducing shoulder abduction, increasing elbow extension, and decreasing trunk compensatory movement during the reaching task. Motor function and quality of the affected limb was improved, and patients achieved greater independence in instrumental activities of daily living. Force generation at movement initiation was improved in the patients who received RT.

CONCLUSION

A combination of RT and mCIT could be an effective approach to improve stroke rehabilitation outcomes, achieving better motor control strategies, motor function, and functional independence of instrumental activities of daily living.

TRIAL REGISTRATION

ClinicalTrials.gov. NCT01727648.

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.