Modified constraint-induced therapy in patients with chronic stroke exhibiting minimal movement ability in the affected arm

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Association between oral health status and oral food intake level in subacute stroke patients admitted to a convalescent rehabilitation unit

BACKGROUND

Stroke patients often suffer from dysphagia during their recovery. We hypothesised that subacute stroke patients with dysphagia had more deteriorated oral health status including muscle strength and motor function.

OBJECTIVE

Quantitatively investigate oral health status and identify associations with oral feeding status in stroke patients admitted to a convalescent rehabilitation unit.

METHODS

We prospectively recruited 187 stroke patients admitted to a convalescent rehabilitation unit. Oral feeding status was examined using the Functional Oral Intake Scale (FOIS), and the cohort was divided into three groups based on FOIS score as non-oral feeding (FOIS-123; 22 patients), dysphagic diet (FOIS-45; 74 patients), and regular diet (FOIS-67; 91 patients) groups. Activities of daily living (ADL) were assessed with the Functional Independence Measure (FIM). Oral health status was measured quantitatively in six oral function parameters and Oral Health Assessment Tool (OHAT), and differences according to the FOIS, age and FIM were statistically tested.

RESULTS

In bivariate analysis, two parameters, tongue pressure and tongue-lip motor functions were significantly higher in the regular diet group than in the other groups (P < .01). Gross OHAT score was also significantly better in the regular diet group than in the other groups (P < .01). These significant associations mostly remained in the multiple model after adjusting for age and FIM.

CONCLUSION

This study suggests that, amongst oral health status, tongue strength and motor function, as well as OHAT score, may have strong associations with oral feeding status in subacute stroke patients at convalescent rehabilitation units regardless of ADL levels.

Effect of home-based rehabilitation of purposeful activity-based electrical stimulation therapy for chronic stroke survivors: a crossover randomized controlled trial

Background:

In this trial we combined the effect of purposeful activity and electrical stimulation therapy (PA-EST) to promote transition of severely hemiparetic upper limb to auxiliary upper limb in chronic stroke survivors in a single-case study.

Objective:

The purpose of this study was to examine the effect of PA-EST on the upper limb motor function in a crossover randomized controlled trial.

Methods:

The study included eight stroke survivors (age: 63.1±10.9 years) who were receiving home-based visiting occupational therapy. The average time since stroke onset was 8.8±5.6 years. All participants had severely hemiparetic upper limb, with the Fugl–Meyer Assessment upper extremity (FMA-U) score of 21.3±8.5. Participants were randomly assigned to group A or B. Group A received PA-EST for 3 months (phase 1), followed by standard stretching and exercise for 3 months (phase 2), whereas group B had the inverse order of treatments. To avoid carry-over effect, 1-month washout period was provided between the phase 1 and 2. Two-way analysis of variance (ANOVA) with repeated measures was used for the analysis. The primary outcome was FMA-U, and the secondary outcomes were, Motor Activity Log (MAL; amount of use [AOU] and quality of movement [QOM]), and Goal attainment scale-light (GAS-light).

Results:

Repeated measures-ANOVA revealed a significant interaction between type of intervention and time for FMA-U (F = 16.303, P = 0.005), MAL AOU (F = 7.966, P = 0.026) and QOM (F = 6.408, P = 0.039), and GAS-light (F = 6.905, P = 0.034), where PA-EST was associated with significantly improved motor function and goal achievement compared with standard stretching.

Conclusions:

The PA-EST may have greater effects than stretch/exercise in the recovery of hand function as reflected in FMA-U, MAL, and GAS-light. Our results suggest that PA-EST is an important and useful home-based rehabilitation program for promoting the use of the severely hemiparetic upper limb in chronic stroke survivors.

Prevalence, Effect on Functional Outcome, and Treatment of Sleep-Disordered Breathing in Patients With Subacute Stroke

STUDY OBJECTIVES

We aimed to elucidate the prevalence of sleep-disordered breathing (SDB), effect of SDB severity on the functional outcome, and feasibility of continuous positive airway pressure (CPAP) therapy in patients with subacute stroke.

METHODS

We recruited 433 consecutive patients (mean age: 66.5 years, 271 men) admitted to our rehabilitation wards for subacute stroke (8 to 90 days after onset) from August 2011-November 2013, who had undergone at least one successful sleep study within 4 weeks after admission to the wards. We investigated the prevalence of SDB, defined as a respiratory event index (REI) ≥ 5 events/h; the relationship between SDB severity and the functional outcome at discharge; and the number of patients receiving and adhering to CPAP therapy.

RESULTS

REIs ≥ 5 and ≥ 15 events/h were observed for 87.3% (n = 378) and 46.4% (n = 201) of patients, respectively. The Functional Independence Measure score at discharge was significantly lower for patients with REI ≥ 15 events/h than for those with REI < 15 events/h. However, REI was not an independent factor for functional outcome after adjustment for potential confounders, irrespective of stroke types. CPAP therapy was administered to 41 patients (9.5%). During the mean follow-up period of 21.6 months, 20 patients (48.8%) dropped out from the CPAP therapy. Among the 23 patients who continued CPAP therapy until discharge, 17 (74%) continued its use throughout the follow-up period or discontinued therapy because of improvement.

CONCLUSIONS

SDB prevalence was high in patients with subacute stroke at admission. However, SDB severity was not significantly related to functional outcome at discharge. Although the overall adherence was not good, relatively good adherence to CPAP therapy after discharge was observed when CPAP was successfully introduced during hospitalization.

Effect of segmental muscle vibration on upper extremity functional ability poststroke: A randomized controlled trial

BACKGROUND

Upper extremity functional impairments are common consequences of stroke. Therefore, continuous investigation of effective interventions for upper extremity functions after stroke is a necessity. Segmental muscle vibration (SMV) is one of the interventions that incorporate sensory stimulation to improve motor cortical excitability. The aim of this study was to investigate the influence of 5-minute SMV application along with supervised physical therapy (SPT) on improving activities of daily living and motor recovery on the hemiparetic upper extremity in patients with stroke.

METHODS

A sample of 37 patients poststroke (29 males) was randomly allocated to either SPT control group (n = 18) or SPT and SMV (SPT-SMV) experimental group (n = 19). All patients received 3 sessions per week of SPT for 8 weeks. The SPT-SMV experimental group received SMV at the end of each SPT session. Outcome measures used were Barthel index (BI), modified Ashworth scale, manual muscle testing, and goniometry for range of motion (ROM) assessment.

RESULTS

Thirty-four patients completed the study. Patients in both groups improved significantly after treatment in BI, elbow ROM, and elbow muscles strength. However, muscle tone in elbow joint of the hemiplegic upper extremity improved significantly after SMV only in the experimental group (SPT-SMV).

CONCLUSION

The SPT intervention can improve functional outcomes of upper extremity in people after stroke. However, using SMV may have superior effect on improving muscle tone after stroke.

Thoughts About the Negative Results of Clinical Trials in Rehabilitation Medicine

The last decade has witnessed an increase in the number of moderate to large-scale nonpharmacologic stroke recovery trials. While a majority, having tested the superiority of a particular evidence-based intervention, returned negative findings, the rehabilitation research community has gained an important perspective for future efforts. We offer our interpretation first, on why most of the past decade’s trials failed in the sense of not supporting the primary superiority hypothesis, and, second, we provide our perspective on how to solve this problem and thereby inform the next generation of neurorehabilitation clinical trials. The first large-scale randomized controlled trial (RCT) ever conducted in neurorehabilitation was the Extremity Constraint Induced Movement Therapy Evaluation (EXCITE) trial. The majority of stroke recovery trials that followed were based on a prevailing, but as yet immature science of brain-behavior mechanisms for recovery and limited practical know-how about how to select the most meaningful outcomes. The research community had been seduced by a set of preclinical studies, ignited by the 1990’s revolution in neuroscience and an oversimplified premise that high doses of task-oriented training was the most important ingredient to foster recovery. Here, we highlight recent qualitative and quantitative evidence, both mechanistic and theory-driven, that integrates crucial social and personal factors to inform a more mature science better suited for the next generation of recovery-supportive rehabilitation clinical trials.

The ATTEND trial: An alternative explanation with implications for future recovery and rehabilitation clinical trials

Over the past decade, ATTEND is one of only a handful of moderate to large-scale nonpharmacologic stroke recovery trials with a focus on rehabilitation. While unique in some respects, its test of superiority for the experimental intervention returned negative/neutral results, with no differences in outcome between the experimental intervention and an appropriate control group – a result not uncommon to the majority of moderate to large stroke rehabilitation intervention trials (i.e. six out of eight conducted in the past decade). The authors offer a number of potential explanations for the negative outcome, all of which have merit. We choose not to dwell on these possibilities, but rather offer a radically different explanation, one which has implications for future rehabilitation clinical trials. Our premise is that the process of neurorehabilitation is complex and multifaceted, but most importantly, for success, it requires a genuine collaboration between the patient and the clinician or caregiver to effect optimal recovery. This collaborative relationship must be defined by the unique perspective of each patient. By doing so, we acknowledge the importance of the individual patient’s values, goals, perspectives, and capacity. Rehabilitation scientists can design what arguably is a scientifically sound intervention that is evidence-based and even with preliminary data supporting its efficacy, but if the patient does not value the target outcome, does not fully engage in the therapy, or does not expect the intervention to succeed, the likelihood of success is poor. We offer this opinion, not to be critical, but to suggest a paradigm shift in the way in which we conduct stroke recovery and rehabilitation trials.

Tailoring Brain Stimulation to the Nature of Rehabilitative Therapies in Stroke: A Conceptual Framework Based on their Unique Mechanisms of Recovery

Despite showing early promise, several recent clinical trials of noninvasive brain stimulation (NIBS) failed to augment rehabilitative outcomes of the paretic upper limb. This article addresses why pairing NIBS with unilateral approaches is weakly generalizable to patients in all ranges of impairments. The article also addresses whether alternate therapies are better suited for the more impaired patients, where they may be more feasible and offer neurophysiologic advantages not offered with unilateral therapies. The article concludes by providing insight on how to create NIBS paradigms that are tailored to distinctly augment the effects of therapies across patients with varying degrees of impairment.

Translating the science into practice: shaping rehabilitation practice to enhance recovery after brain damage

The revolution in neuroscience provided strong evidence for learning-dependent neuroplasticity and presaged the role of motor learning as essential for restorative therapies after stroke and other disabling neurological conditions. The scientific basis of motor learning has continued to evolve from a dominance of cognitive or information processing perspectives to a blend with neural science and contemporary social-cognitive-psychological science, which includes the neural and psychological underpinnings of motivation. This transformation and integration across traditionally separate domains is timely now that clinician scientists are developing novel, evidence-based therapies to maximize motor recovery in the place of suboptimal solutions. We will review recent evidence pertaining to therapeutic approaches that spring from an integrated framework of learning-dependent neuroplasticity along with the growing awareness of protocols that directly address the patient's fundamental psychological needs. Of importance, there is mounting evidence that when the individual's needs are considered in the context of instructions or expectations, the learning/rehabilitation process is accelerated.

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.

Use of computer games as an intervention for stroke

Current rehabilitation for persons with hemiparesis after stroke requires high numbers of repetitions to be in accordance with contemporary motor learning principles. The motivational characteristics of computer games can be harnessed to create engaging interventions for persons with hemiparesis after stroke that incorporate this high number of repetitions. The purpose of this case report was to test the feasibility of using computer games as a 6-week home therapy intervention to improve upper extremity function for a person with stroke. One person with left upper extremity hemiparesis after stroke participated in a 6-week home therapy computer game intervention. The games were customized to her preferences and abilities and modified weekly. Her performance was tracked and analyzed. Data from pre-, mid-, and postintervention testing using standard upper extremity measures and the Reaching Performance Scale (RPS) were analyzed. After 3 weeks, the participant demonstrated increased upper extremity range of motion at the shoulder and decreased compensatory trunk movements during reaching tasks. After 6 weeks, she showed functional gains in activities of daily living (ADLs) and instrumental ADLs despite no further improvements on the RPS. Results indicate that computer games have the potential to be a useful intervention for people with stroke. Future work will add additional support to quantify the effectiveness of the games as a home therapy intervention for persons with stroke.

Chronic stroke recovery after combined BCI training and physiotherapy: a case report

A case of partial recovery after stroke and its associated brain reorganization in a chronic patient after combined brain computer interface (BCI) training and physiotherapy is presented. A multimodal neuroimaging approach based on fMRI and diffusion tensor imaging was used to investigate plasticity of the brain motor system in parallel with longitudinal clinical assessments. A convergent association between functional and structural data in the ipsilesional premotor areas was observed. As a proof of concept investigation, these results encourage further research on a specific role of BCI on brain plasticity and recovery after stroke.

Predictors of change in quality of life after distributed constraint-induced therapy in patients with chronic stroke

BACKGROUND

There are no reports of predictive models or predictors for quality of life (QoL) after constraint-induced therapy (CIT).

OBJECTIVE

This investigation identified predictors of change in stroke-related QoL after distributed CIT using the Chi-squared Automatic Interaction Detector (CHAID) method.

METHODS

A total of 58 patients with chronic stroke were treated with CIT for 2 hours daily for 3 weeks. The 7 potential predictors were age, gender, side of lesion, time since stroke, cognitive status, motor impairment of upper extremity, and activities of daily living (ADL). QoL was measured by the Stroke Impact Scale (SIS). CHAID analysis was used to examine for associations between the 7 predictors and each SIS domain. The validity of each model generated by the analysis was evaluated.

RESULTS

Daily functional performance as measured by the Functional Independence Measure (FIM) was found to determine SIS outcomes, including overall score (P = .006) and the ADL/instrumental ADL (IADL) domain (P = .004). None of the potential predictors emerged as significant predictors of the strength, memory, emotion, communication, mobility, hand function, and participation domains of SIS. The misclassification risk estimates were small, indicating good validity for the CHAID models.

CONCLUSIONS

The functional independence score of the FIM can predict the overall SIS score as well as the ADL/IADL domain of the SIS in chronic stroke patients who receive CIT, but larger databases are needed to confirm this. CHAID analysis was a useful approach for an exploratory study.

Affected arm use and cortical change in stroke patients exhibiting minimal hand movement

BACKGROUND AND PURPOSE

Conventional electrical stimulation modalities are limited by their lack of opportunities for motor learning and, consequently, their impact on function. Other rehabilitative regimens necessitate affected hand and wrist movement for patients to be included, making them implausible for most patients. In light of these challenges, the current study examined the efficacy of a repetitive task-specific training (RTP) regimen using an electrical stimulation neuroprosthesis in stroke patients exhibiting no affected wrist or hand movement.

METHOD

Eight chronic stroke patients (mean = 46.5 months) with moderately affected arm motor deficits participated in 30-minute therapy sessions occurring every weekday for 8 weeks. During the sessions, they wore the neuroprosthesis to enable performance of valued activities identified largely by the patients. To ensure transfer to their real-world environments, most sessions were home based, with the patients coming to the clinic for "tune-up" sessions (eg, adjusting the stimulation parameters, exercises, and/or fit of the device) twice every other week (a total of 8 clinical visits). Outcomes were evaluated using the Action Research Arm Test (ARAT) and the upper extremity section of the Fugl-Meyer Assessment (FM), the amount of use scale of the Motor Activity Log (MAL), and high-field functional magnetic resonance imaging (fMRI).

RESULTS

Before the intervention, patients exhibited stable motor deficits. After the intervention, they exhibited ARAT and FM score increases (+2.85 and +2.2, respectively). Postintervention fMRI revealed significant increases in cortical activation, possibly brought about by markedly increased affected arm use patterns on the MAL (+0.97).

CONCLUSIONS

An affected arm RTP program incorporating NEURSTIM appears to increase affected arm use and elicit neural changes in more impaired patients. These factors may conspire to produce motor changes, although motor changes are smaller in this population than with less impaired patients. The program may act as a "bridge" to other promising regimens.

Meaningful gait speed improvement during the first 60 days poststroke: minimal clinically important difference

BACKGROUND

When people with stroke recover gait speed, they report improved function and reduced disability. However, the minimal amount of change in gait speed that is clinically meaningful and associated with an important difference in function for people poststroke has not been determined.

OBJECTIVE

The purpose of this study was to determine the minimal clinically important difference (MCID) for comfortable gait speed (CGS) associated with an improvement in the modified Rankin Scale (mRS) score for people between 20 to 60 days poststroke.

DESIGN

This was a prospective, longitudinal, cohort study.

METHODS

The participants in this study were 283 people with first-time stroke prospectively enrolled in the ongoing Locomotor Experience Applied Post Stroke (LEAPS) multi-site randomized clinical trial. Comfortable gait speed was measured and mRS scores were obtained at 20 and 60 days poststroke. Improvement of >or=1 on the mRS was used to detect meaningful change in disability level.

RESULTS

Mean (SD) CGS was 0.18 (0.16) m/s at 20 days and 0.39 (0.22) m/s at 60 days poststroke. Among all participants, 47.3% experienced an improvement in disability level >or=1. The MCID was estimated as an improvement in CGS of 0.16 m/s anchored to the mRS.

LIMITATIONS

Because the mRS is not a gait-specific measure of disability, the estimated MCID for CGS was only 73.9% sensitive and 57.0% specific for detecting improvement in mRS scores.

CONCLUSIONS

We estimate that the MCID for gait speed among patients with subacute stroke and severe gait speed impairments is 0.16 m/s. Patients with subacute stroke who increase gait speed >or=0.16 m/s are more likely to experience a meaningful improvement in disability level than those who do not. Clinicians can use this reference value to develop goals and interpret progress in patients with subacute stroke.

Constraint-induced movement therapy for upper extremities in stroke patients

BACKGROUND

In stroke patients, upper limb paresis affects many activities of daily life. Reducing disability is therefore a major aim of rehabilitation programmes for hemiparetic patients. Constraint-induced movement therapy (CIMT) is a current approach to stroke rehabilitation that implies the forced use and the massed practice of the affected arm by restraining the unaffected arm.

OBJECTIVES

To assess the efficacy of CIMT, modified CIMT (mCIMT), or forced use (FU) for arm management in hemiparetic patients.

SEARCH STRATEGY

We searched the Cochrane Stroke Group trials register (last searched June 2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2008), MEDLINE (1966 to June 2008), EMBASE (1980 to June 2008), CINAHL (1982 to June 2008), and the Physiotherapy Evidence Database (PEDro) (June 2008).

SELECTION CRITERIA

Randomised control trials (RCTs) and quasi-RCTs (qRCTs) comparing CIMT, mCIMT or FU with other rehabilitative techniques, or none.

DATA COLLECTION AND ANALYSIS

Two review authors independently classified the identified trials according to the inclusion and exclusion criteria, assessed methodological quality and extracted data. The primary outcome was disability.

MAIN RESULTS

We included 19 studies involving 619 participants. The trials included participants who had some residual motor power of the paretic arm, the potential for further motor recovery and with limited pain or spasticity, but tended to use the limb little if at all. Only five studies had adequate allocation concealment. The majority of studies were underpowered (median number of included patients was 15) and we cannot rule out small-trial bias. Six trials (184 patients) assessed disability immediately after the intervention, indicating a significant standard mean difference (SMD) of 0.36, 95% confidence interval (CI) 0.06 to 0.65. For the most frequently reported outcome, arm motor function (11 studies involving 373 patients), the SMD was 0.72 (95% CI 0.32 to 1.12). There were only two studies that explored disability improvement after a few months of follow up and found no significant difference, SMD -0.07 (95% CI -0.53 to 0.40).

AUTHORS' CONCLUSIONS

CIMT is a multifaceted intervention: the restriction to the normal limb is accompanied by a certain amount of exercise of the appropriate quality. It is associated with a moderate reduction in disability assessed at the end of the treatment period. However, for disability measured some months after the end of treatment, there was no evidence of persisting benefit. Further randomised trials, with larger sample sizes and longer follow up, are justified.

Task-oriented training in rehabilitation after stroke: systematic review

AIM

This paper is a report of a review conducted to provide an overview of the evidence in the literature on task-oriented training of stroke survivors and its relevance in daily nursing practice.

BACKGROUND

Stroke is the second leading cause of death and one of the leading causes of adult disability in the Western world. The use of neurodevelopmental treatment in the daily nursing care of stroke survivors does not improve clinical outcomes. Nurses are therefore exploring other forms of rehabilitation intervention, including task-oriented rehabilitation. Despite the growing number of studies showing evidence on task-oriented interventions, recommendations for daily nursing practice are lacking.

DATA SOURCES

A range of databases was searched to identify papers addressing task-oriented training in stroke rehabilitation, including Medline, CINAHL, Embase and the Cochrane Library of systematic reviews. Papers published in English between January 1996 and September 2007 were included. There were 42 papers in the final dataset, including nine systematic reviews.

REVIEW METHODS

The selected randomized controlled trials and systematic reviews were assessed for quality. Important characteristics and outcomes were extracted and summarized.

RESULTS

Studies of task-related training showed benefits for functional outcome compared with traditional therapies. Active use of task-oriented training with stroke survivors will lead to improvements in functional outcomes and overall health-related quality of life.

CONCLUSION

Generally, task-oriented rehabilitation proved to be more effective. Many interventions are feasible for nurses and can be performed in a ward or at home. Nurses can and should play an important role in creating opportunities to practise meaningful functional tasks outside of regular therapy sessions.

Activity-based electrical stimulation training in a stroke patient with minimal movement in the paretic upper extremity

BACKGROUND

Existing task-specific practice interventions do not increase movement in stroke patients exhibiting minimal distal movement in the paretic upper extremity. Although often used, an important limitation of conventional electrical stimulation is that it does not involve task-specific practice.

OBJECTIVE

To determine the impact of an activity-specific electrical stimulation program on paretic limb impairment, functional limitation, and ability to perform valued activities in a subacute stroke patient exhibiting minimal paretic wrist and hand movement.

METHOD

A female subject exhibiting trace paretic hand and finger movement was administered, 9 months after stroke, the upper extremity section of the Fugl-Meyer Impairment Scale (FM), the Action Research Arm Test (ARAT), and the Arm Motor Ability Test (AMAT). She then engaged in paretic upper extremity, task-specific training incorporating an electrical stimulation neuroprosthesis. Training occurred 3 hours per day, 5 days per week for 3 weeks. The FM, ARAT, and AMAT were again administered.

RESULTS

After intervention, she exhibited reduced impairment (evidenced by an FM score change of 22 to 29), decreased functional limitation (evidenced by an ARAT score change of 4 to 10), and increased ability and speed in performing valued AMAT activities. She also reported using the paretic hand and fingers more and new abilities to perform valued activities such as playing piano.

CONCLUSION

Although conventional paretic upper extremity training strategies are ineffective in patients at this level, electrical stimulation training incorporating a neuroprosthesis appears promising.

Constraint-Induced Therapy Versus Dose-Matched Control Intervention to Improve Motor Ability, Basic/Extended Daily Functions, and Quality of Life in Stroke

Background. Trials of constraint-induced movement therapy (CIT) to improve upper extremity function after stroke have usually not included an actively treated control group. Objective. This study compared a modified CIT intervention with a dose-matched control intervention that included restraint of the less affected hand and assessed for differences in motor and functional performance and health-related quality of life. Methods. This 2-group randomized controlled trial, using pretreatment and posttreatment measures, enrolled 32 patients within 6 to 40 months after onset of a first stroke (mean age, 55.7 years). They received either CIT (restraint of the less affected limb combined with intensive training of the affected limb for 2 hours daily 5 days per week for 3 weeks and restraint of the less affected hand for 5 hours outside of the rehabilitation training) or a conventional intervention with hand restraint for the same duration. Outcome measures were the Fugl-Meyer Assessment, Functional Independence Measure, Motor Activity Log, Nottingham Extended Activities of Daily Living Scale, and Stroke Impact Scale. Results. Compared with the control group, the CIT group exhibited significantly better performance in motor function, level of functional independence, mobility of extended activities during daily life, and health-related quality of life after treatment. Conclusions. The robust effects of this form of CIT were demonstrated in various aspects of outcome, including motor function, basic and extended functional ability, and quality of life.