Revisiting constraint-induced movement therapy: are we too smitten with the mitten? Is all nonuse "learned"? and other quandaries

An analysis of clinical outcomes and essential parameters for designing effective games for upper limb rehabilitation: A scoping review

Background and Aims

Upper limb disabilities are one of the most common disabilities among different groups of people who always need rehabilitation. One of the important methods in helping to carry out efficient rehabilitation processes and exercises is the use of games. The aim of this study is to identify the parameters necessary to design a successful rehabilitation game and the outcomes of using these games in upper limb disabilities rehabilitation.

Methods

This scoping review was conducted by searching the Web of Science, PubMed, and Scopus. The eligibility criteria were: any form of game-based upper limb rehabilitation, published in a peer-reviewed journal, published in English, and not include articles that did not focus upper limb disabilities rehabilitation games, review, meta-analysis, or conference papers. Analysis of collected data was done using descriptive statistics (frequency and percentage).

Results

The search strategy retrieved 537 relevant articles. Finally, after removing irrelevant and repetitive articles, 21 articles were included in this study. Among the six categories of diseases or complications of upper limb disabilities, games were mostly designed for stroke patients. Smart wearables, robots and telerehabilitation were three technologies that were used for rehabilitation along with games. Sports and shooters were the most used games for upper limb disability rehabilitation. Among 99 necessary parameters for designing and implementing a successful rehabilitation game in ten categories. "Increasing the patient's motivation to perform rehabilitation exercises", "Game difficulty levels", "Enjoying and the attractiveness of the game for patients", and "Providing positive or negative audiovisual feedback" were the most important parameters. "Improvement in musculoskeletal performance" and "Increasing users' enjoyment/joy of therapeutic exercises and their motivation to perform these exercises" were the most important positive outcomes, and "Mild discomfort such as nausea and dizziness when using games" was the only negative outcome.

Conclusions

The successful design of a game according to the parameters identified in the present study can lead to an increase in the positive outcomes of using games in the rehabilitation of disabilities. The study results indicate that upper limb therapeutic exercise augmented with virtual reality games may be highly effective in enhancing motor rehabilitation outcomes.

Predicting Arm Nonuse in Individuals with Good Arm Motor Function after Stroke Rehabilitation: A Machine Learning Study

Many stroke survivors demonstrate arm nonuse despite good arm motor function. This retrospective secondary analysis aims to identify predictors of arm nonusers with good arm motor function after stroke rehabilitation. A total of 78 participants were categorized into 2 groups using the Fugl-Meyer Assessment Upper Extremity Scale (FMA-UE) and the Motor Activity Log Amount of Use (MAL-AOU). Group 1 comprised participants with good motor function (FMA-UE ≥ 31) and low daily upper limb use (MAL-AOU ≤ 2.5), and group 2 comprised all other participants. Feature selection analysis was performed on 20 potential predictors to identify the 5 most important predictors for group membership. Predictive models were built with the five most important predictors using four algorithms. The most important predictors were preintervention scores on the FMA-UE, MAL-Quality of Movement, Wolf Motor Function Test-Quality, MAL-AOU, and Stroke Self-Efficacy Questionnaire. Predictive models classified the participants with accuracies ranging from 0.75 to 0.94 and areas under the receiver operating characteristic curve ranging from 0.77 to 0.97. The result indicates that measures of arm motor function, arm use in activities of daily living, and self-efficacy could predict postintervention arm nonuse despite good arm motor function in stroke. These assessments should be prioritized in the evaluation process to facilitate the design of individualized stroke rehabilitation programs to reduce arm nonuse.

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.

Falls in people post-Guillain-Barré syndrome in the United Kingdom: A national cross-sectional survey of community based adults

Guillain-Barré syndrome (GBS) has several enduring effects that can lead to further harm and/or lower quality of life. These effects include falling and body pain, neither of which have been fully explored. This study aims to examine the risk factors associated with falling and potential causes of body pain in a post-GBS population. A cross-sectional survey of 216 participants was conducted using an electronic questionnaire that included. Self-report measures for: overall health, balance, anxiety and depression levels, body pain and demographics related to GBS experience and falls. A large proportion of individuals post-GBS experience ongoing problems beyond those expected with ageing. Comparative tests indicated that people reporting falls in the previous 12 months had: poorer levels of mobility, poorer F-scores, higher levels of body pain, poorer balance, poorer anxiety and depression scores and higher levels of fatigue. Gender did not appear to contribute to falls. Injuries following falls were associated with a lack of physiotherapy postdischarge and time since GBS. In a regression analysis of the identified and expected key variables, age and body pain statistically predicted falls. In over a quarter of cases reported here, respondents did not receive community physiotherapy following hospital discharge. In the midst and aftermath of COVID-19, provision of rehabilitation needs to be recalibrated, not just for COVID patients, but the wider community with ongoing needs. Issues around well-being and quality of life in the post-GBS community also need further consideration.

Remedial Training of the Less-Impaired Arm in Chronic Stroke Survivors With Moderate to Severe Upper-Extremity Paresis Improves Functional Independence: A Pilot Study

The ipsilesional arm of stroke patients often has functionally limiting deficits in motor control and dexterity that depend on the side of the brain that is lesioned and that increase with the severity of paretic arm impairment. However, remediation of the ipsilesional arm has yet to be integrated into the usual standard of care for upper limb rehabilitation in stroke, largely due to a lack of translational research examining the effects of ipsilesional-arm intervention. We now ask whether ipsilesional-arm training, tailored to the hemisphere-specific nature of ipsilesional-arm motor deficits in participants with moderate to severe contralesional paresis, improves ipsilesional arm performance and generalizes to improve functional independence. We assessed the effects of this intervention on ipsilesional arm unilateral performance [Jebsen–Taylor Hand Function Test (JHFT)], ipsilesional grip strength, contralesional arm impairment level [Fugl–Meyer Assessment (FM)], and functional independence [Functional independence measure (FIM)] (N = 13). Intervention occurred over a 3 week period for 1.5 h/session, three times each week. All sessions included virtual reality tasks that targeted the specific motor control deficits associated with either left or right hemisphere damage, followed by graded dexterity training in real-world tasks. We also exposed participants to 3 weeks of sham training to control for the non-specific effects of therapy visits and interactions. We conducted five test-sessions: two pre-tests and three post-tests. Our results indicate substantial improvements in the less-impaired arm performance, without detriment to the paretic arm that transferred to improved functional independence in all three posttests, indicating durability of training effects for at least 3 weeks. We provide evidence for establishing the basis of a rehabilitation approach that includes evaluation and remediation of the ipsilesional arm in moderately to severely impaired stroke survivors. This study was originally a crossover design; however, we were unable to complete the second arm of the study due to the COVID-19 pandemic. We report the results from the first arm of the planned design as a longitudinal study.

Five Features to Look for in Early-Phase Clinical Intervention Studies

Neurorehabilitation relies on core principles of neuroplasticity to activate and engage latent neural connections, promote detour circuits, and reverse impairments. Clinical interventions incorporating these principles have been shown to promote recovery and demote compensation. However, many clinicians struggle to find interventions centered on these principles in our nascent, rapidly growing body of literature. Not to mention the immense pressure from regulatory bodies and organizational balance sheets that further discourage time-intensive recovery-promoting interventions, incentivizing clinicians to prioritize practical constraints over sound clinical decision making. Modern neurorehabilitation practices that result from these pressures favor strategies that encourage compensation over those that promote recovery. To narrow the gap between the busy clinician and the cutting-edge motor recovery literature, we distilled 5 features found in early-phase clinical intervention studies-ones that value the more enduring biological recovery processes over the more immediate compensatory remedies. Filtering emerging literature through this lens and routinely integrating promising research into daily practice can break down practical barriers for effective clinical translation and ultimately promote durable long-term outcomes. This perspective is meant to serve a new generation of mechanistically minded and caring clinicians, students, activists, and research trainees, who are poised to not only advance rehabilitation science, but also erect evidence-based policy changes to accelerate recovery-based stroke care.

Effect of Modified Constrain Induced Movement Therapy on Fatigue and Motor Performance in Sub Acute Stroke

OBJECTIVES

There is a little available information about the fatigue status among people receiving modified constraint induced movement therapy. The study examined such changes. The effect of using restraint on motor performance was also evaluated in sub acute phase after stroke.

MATERIALS AND METHODS

The study was designed as two group pretest and post-test study. The experimental design included a pretest and post test measures of dependent variables fatigue and motor function. All patients were recruited from the Safdurjung Hospital. 20 patients in subacute phase of stroke (3-9 months), (N = 10) mean age±SD 51.90±15.27, MAS score mean ± SD 1.90±.316 and post stroke duration mean ±SD 6.45±2.26 were included in the experimental group and (N = 10) mean age ± SD 54.10±17.42, MAS score mean ±SD 1.52±0.52 and post stroke duration mean±SD score 4.55± 2.52 were included in the control group. The subjects in the experimental group were restrained for six hours every week day with task training for 2 h per day five times a week for three weeks and the subjects in the controlled group received task training for 2 h per day five times a week for three weeks with no restrain. Motor Performance and fatigue were measured on day to day basis by Wolf Motor Function Test Scores (WMFT) and 11th item of Barrow Neurological Institute (BNI) scale in both experimental and controlled group.

RESULTS

The restraint group exhibited significant better motor performance than the controlled group. Mean difference between Pre- WMFT scores and Post WMFT scores were (0.533±.362) as compared to controlled group (0.192±.23). No significant statistical difference was observed in the difference of mean Pre- BNI and Post - BNI scores in either of the two groups (p = .57). Difference between the experimental and controlled group in motor performance and fatigue scores were nonsignificant.

CONCLUSIONS

Restraint improves motor performance in subacute therapy group and the intensive practice associated with m-CIMT may be administered without the exacerbation of fatigue.

Training in a cooperative bimanual skilled reaching task, the popcorn retrieval task, improves unimanual function after motor cortical infarcts in rats

Disuse of the paretic hand after stroke is encouraged by compensatory reliance on the nonparetic hand, to exacerbate impairment and potentially constrain motor rehabilitation efficacy. Rodent stroke model findings support that learning new unimanual skills with the nonparetic forelimb diminishes functional improvements that can be driven by rehabilitative training of the paretic forelimb. The influence of learning new ways of skillfully using the two hands together on paretic side function is much less clear. To begin to explore this, we developed a new cooperative bimanual skilled reaching task for rats, the Popcorn Retrieval Task. After motor cortical infarcts impaired an established unimanual reaching skill in the paretic forelimb, rats underwent a 7 week period of de novo bimanual training (BiT) or no-training control procedures (Cont). Probes of paretic forelimb unimanual performance revealed significant improvements during and after the training period in BiT vs. Cont. We additionally observed a striking change in the bimanual task strategy over training days: a switch from the paretic to the nonparetic forelimb for initiating reach-to-grasp sequences. This motivated another study to test whether rats that established the bimanual skill prior to the infarcts would similarly switch handedness, which they did not, though paretic paw use for manipulative movements diminished. These results indicate that unimanual function of the paretic side can be improved by novel bimanual skill practice, even when it involves compensatory reliance on the nonparetic hand. They further support the suitability of the Popcorn Retrieval Task for studying bimanual skill learning effects in rats.

Combined effects of Telehealth and Modified Constraint-Induced Movement Therapy for Individuals with Chronic Hemiparesis

Telehealth use allows improved access to services and results in potential cost savings. The purpose of this study was to examine the effectiveness of a combined modified Constrained Induced Movement Therapy (mCIMT) program using telehealth and in-person sessions, for participants with higher (Group 1) and lower (Group 2) functional ability of the hemiparetic upper extremity. Using a pre-experimental design with a 6-week intervention, 28 participants were assessed twice on use of upper extremity via subjective and objective measures. For the Motor Activity Log, the amount of use and quality of use were significant for Groups 1 and 2. Significant improvements were shown on the Wolf Motor Function Test (WMFT), the Fugl-Meyer UE, and the Functional Independence Measure (FIM) for both groups except for the strength subtest on the WMFT and the timed portion for Group 1. Percentages of attendance for telehealth and in-person sessions were also compared. Telehealth sessions had a higher attendance rate (84.5%) than in-person sessions (75.3%) (p=.004). The combined mCIMT program of telerehabilitation and in-person group sessions was effective in improving functional ability after a stroke.

Predictors of Arm Nonuse in Chronic Stroke: A Preliminary Investigation

Background. Nonuse (NU) after stroke is characterized by failure to use the contralesional arm despite adequate capacity. It has been suggested that NU is a consequence of the greater effort and/or attention required to use the affected limb, but such accounts have not been directly tested, and we have poor understanding of the predictors of NU. Objective. We aimed to provide preliminary evidence regarding demographic, neuropsychological (ie, apraxia, attention/arousal, neglect), and psychological (ie, self-efficacy) factors that may influence NU in chronic stroke. Methods. Twenty chronic stroke survivors with mild to moderate sensory-motor impairment characterized by the Upper-Extremity Fugl-Meyer (UEFM) were assessed for NU with a modified version of the Actual Amount of Use Test (AAUT), which measures the disparity between amount of use in spontaneous versus forced conditions. Participants were also assessed with measures of limb apraxia, spatial neglect, attention/arousal, and self-efficacy. Using stepwise multiple regression, we determined which variables predicted AAUT NU scores. Results. Scores on the UEFM as well as attention/arousal predicted the degree of NU (P < .05). Attention/arousal predicted NU above and beyond UEFM (P < .05). Conclusions. The results are consistent with the importance of attention and engagement necessary to fully incorporate the paretic limb into daily activities. Larger-scale studies that include additional behavioral (eg, sensation, proprioception, spasticity, pain, mental health, motivation) and neuroanatomical measures (eg, lesion volume and white matter connectivity) will be important for future investigations.

Contralesional motor cortex is causally engaged during more dexterous actions of the paretic hand after stroke-A Preliminary report

Bilateral activation in motor cortex is observed during paretic hand performance after stroke; however the functional significance of contralesional motor cortex (C-M1) activation is highly debated. Particularly, it is not known if task characteristics such as dexterity influence the causal engagement of C-M1 during paretic hand performance. Transcranial magnetic stimulation (TMS) was used to quantify motor corticospinal physiology of the CM1 projecting to the contralateral resting extensor carpi radialis brevis (ECRB) and first dorsal interosseous (FDI) while eleven participants with unilateral stroke performed unimanual tasks of differing dexterity with their paretic hand. The novel finding was that compared to rest and less dexterous task (LDT), more dexterous task (MDT) performance led to increased corticospinal excitability and decreased intracortical inhibition of the C-M1 projecting to the resting FDI, but not resting ECRB. Further, using trains of repetitive TMS during MDT and LDT, we tested the behavioral relevance of C-M1 for paretic hand performance. Online rTMS perturbation to C-M1, but not to the vertex or sham stimulation led to significantly more movement errors during MDT without consistently affecting LDT performance. The present results argue for a beneficial role of C-M1 for accurate performance during dexterous motor actions with the paretic hand after stroke.

Thumb and finger movement is reduced after stroke: An observational study

Hand motor impairment is common after stroke but there are few comprehensive data on amount of hand movement. This study aimed to compare the amount of thumb and finger movement over an extended period of time in people with stroke and able-bodied people. Fifteen stroke subjects and 15 able-bodied control subjects participated. Stroke subjects had impaired hand function. Movement of the thumb and index finger was recorded using stretch sensors worn on the affected hand (stroke subjects) or the left or right hand (control subjects) for ∼4 hours during the day. A digit movement was defined as a monotonic increase or decrease in consecutive sensor values. Instantaneous digit position was expressed as a percentage of maximal digit flexion. Mixed linear models were used to compare the following outcomes between groups: (1) average amplitude of digit movement, (2) digit cadence and average digit velocity, (3) percentage of digit idle time and longest idle time. Amplitude of digit movement was not different between groups. Cadence at the thumb (between-group mean difference, 95% CI, p value: -0.6 movements/sec, -1.0 to -0.2 movements/sec, p = 0.003) and finger (-0.5 movements/sec, -0.7 to -0.3 movements/sec, p<0.001) was lower in stroke than control subjects. Digit velocity was not different between groups. Thumb idle time was not different between groups, but finger idle time was greater in stroke than control subjects (percentage of idle time: 6%, 1 to 11%, p = 0.02; longest idle time: 375 sec, 29 to 721 sec, p = 0.04). Rehabilitation after stroke should encourage the performance of functional tasks that involve movements at faster cadences, and encourage more frequent movement of the digits with shorter periods of inactivity.

Putting the "Sensory" Into Sensorimotor Control: The Role of Sensorimotor Integration in Goal-Directed Hand Movements After Stroke

Integration of sensory and motor information is one-step, among others, that underlies the successful production of goal-directed hand movements necessary for interacting with our environment. Disruption of sensorimotor integration is prevalent in many neurologic disorders, including stroke. In most stroke survivors, persistent paresis of the hand reduces function and overall quality of life. Current rehabilitative methods are based on neuroplastic principles to promote motor learning that focuses on regaining motor function lost due to paresis, but the sensory contributions to motor control and learning are often overlooked and currently understudied. There is a need to evaluate and understand the contribution of both sensory and motor function in the rehabilitation of skilled hand movements after stroke. Here, we will highlight the importance of integration of sensory and motor information to produce skilled hand movements in healthy individuals and individuals after stroke. We will then discuss how compromised sensorimotor integration influences relearning of skilled hand movements after stroke. Finally, we will propose an approach to target sensorimotor integration through manipulation of sensory input and motor output that may have therapeutic implications.

Self-powered robots to reduce motor slacking during upper-extremity rehabilitation: a proof of concept study

BACKGROUND

Robotic rehabilitation is a highly promising approach to recover lost functions after stroke or other neurological disorders. Unfortunately, robotic rehabilitation currently suffers from "motor slacking", a phenomenon in which the human motor system reduces muscle activation levels and movement excursions, ostensibly to minimize metabolic- and movement-related costs. Consequently, the patient remains passive and is not fully engaged during therapy. To overcome this limitation, we envision a new class of body-powered robots and hypothesize that motor slacking could be reduced if individuals must provide the power to move their impaired limbs via their own body (i.e., through the motion of a healthy limb).

OBJECTIVE

To test whether a body-powered exoskeleton (i.e. robot) could reduce motor slacking during robotic training.

METHODS

We developed a body-powered robot that mechanically coupled the motions of the user's elbow joints. We tested this passive robot in two groups of subjects (stroke and able-bodied) during four exercise conditions in which we controlled whether the robotic device was powered by the subject or by the experimenter, and whether the subject's driven arm was engaged or at rest. Motor slacking was quantified by computing the muscle activation changes of the elbow flexor and extensor muscles using surface electromyography.

RESULTS

Subjects had higher levels of muscle activation in their driven arm during self-powered conditions compared to externally-powered conditions. Most notably, subjects unintentionally activated their driven arm even when explicitly told to relax when the device was self-powered. This behavior was persistent throughout the trial and did not wane after the initiation of the trial.

CONCLUSIONS

Our findings provide novel evidence indicating that motor slacking can be reduced by self-powered robots; thus demonstrating promise for rehabilitation of impaired subjects using this new class of wearable system. The results also serve as a foundation to develop more sophisticated body-powered robots (e.g., with controllable transmissions) for rehabilitation purposes.

"Remind-to-Move" for Promoting Upper Extremity Recovery Using Wearable Devices in Subacute Stroke: A Multi-Center Randomized Controlled Study

This paper examined the effects of "Remind-to-Move" (RTM) via vibration cueing using wearable devices to increase the use of the affected upper limb and integrate upper limb activities undertaken at home in patients with subacute stroke after inpatient discharge. In a multi-centered randomized controlled trial, 84 eligible patients from four general hospitals, who had a first stroke in the last six months, were randomly allocated to either an experimental, sham, or control group, stratified by arm function levels. Patients in the experimental group were treated by RTM, using wearable devices for three consecutive hours daily, over four weeks. The sham group used sham devices, and the control group received usual care alone. A masked assessor evaluated the patients at 0th, 4th, 8th, and 12th weeks using outcome measures included arm function tests, motor activity log, and movement recorded by the devices. Results showed that there was a significant group by time interaction, and the average movement amount and Action Research Arm Test score in the experimental group were significantly higher than in the sham group. This paper demonstrates that RTM via wearable devices used for the hemiplegic upper extremities could promote more arm recovery than the sham or control and, hence, produce an optimal functional improvement for subacute stroke patients.

Bimanual coordination: A missing piece of arm rehabilitation after stroke

Inability to use the arm in daily actions significantly lowers quality of life after stroke. Most contemporary post-stroke arm rehabilitation strategies that aspire to re-engage the weaker arm in functional activities have been greatly limited in their effectiveness. Most actions of daily life engage the two arms in a highly coordinated manner. In contrast, most rehabilitation approaches predominantly focus on restitution of the impairments and unilateral practice of the weaker hand alone. We present a perspective that this misalignment between real world requirements and intervention strategies may limit the transfer of unimanual capability to spontaneous arm use and functional recovery. We propose that if improving spontaneous engagement and use of the weaker arm in real life is the goal, arm rehabilitation research and treatment need to address the coordinated interaction between arms in targeted theory-guided interventions. Current narrow focus on unimanual deficits alone, difficulty in quantifying bimanual coordination in real-world actions and limited theory-guided focus on control and remediation of different coordination modes are some of the biggest obstacles to successful implementation of effective interventions to improve bimanual coordination in the real world. We present a theory-guided taxonomy of bimanual actions that will facilitate quantification of coordination for different real-world tasks and provide treatment targets for addressing coordination deficits. We then present evidence in the literature that points to bimanual coordination deficits in stroke survivors and demonstrate how current rehabilitation approaches are limited in their impact on bimanual coordination. Importantly, we suggest theory-based areas of future investigation that may assist quantification, identification of neural mechanisms and scientifically-based training/remediation approaches for bimanual coordination deficits post-stroke. Advancing the science and practice of arm rehabilitation to incorporate bimanual coordination will lead to a more complete functional recovery of the weaker arm, thus improving the effectiveness of rehabilitation interventions and augmenting quality of life after stroke.

The use and effect of video game design theory in the creation of game-based systems for upper limb stroke rehabilitation

Upper limb exercise is often neglected during post-stroke rehabilitation. Video games have been shown to be useful in providing environments in which patients can practise repetitive, functionally meaningful movements, and in inducing neuroplasticity. The design of video games is often focused upon a number of fundamental principles, such as reward, goals, challenge and the concept of meaningful play, and these same principles are important in the design of games for rehabilitation. Further to this, there have been several attempts for the strengthening of the relationship between commercial game design and rehabilitative game design, the former providing insight into factors that can increase motivation and engagement with the latter. In this article, we present an overview of various game design principles and the theoretical grounding behind their presence, in addition to attempts made to utilise these principles in the creation of upper limb stroke rehabilitation systems and the outcomes of their use. We also present research aiming to move the collaborative efforts of designers and therapists towards a model for the structured design of these games and the various steps taken concerning the theoretical classification and mapping of game design concepts with intended cognitive and motor outcomes.

Cerebral palsy in adult patients: constraint-induced movement therapy is effective to reverse the nonuse of the affected upper limb

OBJECTIVE

To determine if the original protocol of Constraint-Induced Movement Therapy (CIMT), is adequate to reverse the nonuse of the affected upper limb (AUL) in patients with Cerebral Palsy (CP) in adulthood.

METHOD

The study included 10 patients diagnosed with CP hemiparesis had attended the adult protocol CIMT, from January/August 2009/2014.

RESULTS

Average age 24.6 (SD 9.44); MAL average pretreatment How Often (HO) = 0.72 and How Well (HW) = 0.68 and post-treatment HO = 3.77 and HW = 3.60 (p ≤ 0.001) and pretreatment WMFT average = 21.03 and post-treatment average = 18.91 (p = 0.350).

CONCLUSION

The constraint-induced movement therapy is effective to reverse the nonuse learn of the AUL in adult patients with CP.

The Efficacy of Wii-Based Movement Therapy for Upper Limb Rehabilitation in the Chronic Poststroke Period: A Randomized Controlled Trial

Background

More effective and efficient rehabilitation is urgently needed to address the prevalence of unmet rehabilitation needs after stroke. This study compared the efficacy of two poststroke upper limb therapy protocols.

Aims and/or hypothesis

We tested the hypothesis that Wii-based movement therapy would be as effective as modified constraint-induced movement therapy for post-stroke upper-limb motor rehabilitation.

Methods

Forty-one patients, 2–46 months poststroke, completed a 14-day program of Wii-based Movement Therapy or modified Constraint-induced Movement Therapy in a dose-matched, assessor-blinded randomized controlled trial, conducted in a research institute or patient's homes. Primary outcome measures were the Wolf Motor Function Test timed-tasks and Motor Activity Log Quality of Movement scale. Patients were assessed at prebaseline (14 days pretherapy), baseline, post-therapy, and six-month follow-up. Data were analyzed using linear mixed models and repeated measures analysis of variance.

Results

There were no differences between groups for either primary outcome at any time point. Motor function was stable between prebaseline and baseline ( P > 0·05), improved with therapy ( P < 0·001); and improvements were maintained at six-months ( P > 0·05). Wolf Motor Function Test timed-tasks log times improved from 2·1 ± 0·22 to 1·7 ± 0·22 s after Wii-based Movement Therapy, and 2·6 ± 0·23 to 2·3 ± 0·24 s after modified Constraint-induced Movement Therapy. Motor Activity Log Quality of Movement scale scores improved from 67·7 ± 6·07 to 102·4 ± 6·48 after Wii-based Movement Therapy and 64·1 ± 7·30 to 93·0 ± 5·95 after modified Constraint-induced Movement Therapy (mean ± standard error of the mean). Patient preference, acceptance, and continued engagement were higher for Wii-based Movement Therapy than modified Constraint-induced Movement Therapy.

Conclusions

This study demonstrates that Wii-based Movement Therapy is an effective upper limb rehabilitation poststroke with high patient compliance. It is as effective as modified Constraint-induced Movement Therapy for improving more affected upper limb movement and increased independence in activities of daily living.

Proximal Fugl-Meyer Assessment Scores Predict Clinically Important Upper Limb Improvement After 3 Stroke Rehabilitative Interventions

OBJECTIVE

To identify the baseline motor characteristics of the patients who responded to 3 prominent intervention programs.

DESIGN

Observational cohort study.

SETTING

Outpatient rehabilitation clinics.

PARTICIPANTS

Individuals with chronic stroke (N=174).

INTERVENTIONS

Participants received 30 hours of constraint-induced movement therapy (CIMT), robot-assisted therapy, or mirror therapy (MT).

MAIN OUTCOME MEASURES

The primary outcome measure was the change score of the Upper Extremity Fugl-Meyer Assessment (UE-FMA). The potential predicting variables were baseline proximal, distal, and total UE-FMA and Action Research Arm Test scores. We combined polynomial regression analyses and the minimal clinically important difference to stratify the patients as responders and nonresponders for each intervention approach.

RESULTS

Baseline proximal UE-FMA scores significantly predicted clinically important improvement on the primary outcome measure after all 3 interventions. Participants with baseline proximal UE-FMA scores of approximately <30 benefited significantly from CIMT and robot-assisted therapy, whereas participants with scores between 21 and 35 demonstrated significant improvement after MT. Baseline distal and total UE-FMA and Action Research Arm Test scores could also predict upper limb improvement after CIMT and MT, but not after robot-assisted therapy.

CONCLUSIONS

This study could inform clinicians about the selection of suitable rehabilitation approaches to help patients achieve clinically meaningful improvement in upper extremity function.

Nasogastric feeding for stroke patients: practice and education

BACKGROUND AND AIMS

Dysphagia is common after stroke, so feeding through a nasogastric (NG) tube may be necessary. These tubes are frequently dislodged, causing interruption to feeding and hydration, and potential aspiration of feed or fluids into the lungs. Interventions to prevent this may include taping tubes to the face; the application of hand mittens or bandaging patients' hands; inserting the NG tube into the nostril on the stroke-affected side; and nasal bridles. The aims of this survey were to investigate the management of NG feeding for stroke patients, including current tube confirmation and securing techniques, and associated nurse education. This was part of a three-phased sequential mixed-methods study. This paper reports on the second quantitative phase.

METHODS

A quantitative postal survey, based on initial qualitative findings, was sent to registered nurses (n=528) from the National Stroke Nurses Forum and Scottish Stroke Nurses Forum, in addition to registered nurses working on stroke units within the local health board.

RESULTS

The overall response rate was 59% (n=314/528). Tape was the most commonly used method for securing tube position, followed by inserting the tube on the stroke-affected side. Hand mittens were used more frequently than the nasal bridle; bandaging hands was reported once. Taping was considered to be more acceptable and safer than hand mittens or the nasal bridle, but less effective. Training in inserting NG feeding tubes was received by 56% (n=176/314). Methods used for confirming tube position included aspiration and X-ray. Provision of training in confirmation techniques varied.

CONCLUSIONS

This study shows that the management of NG feeding for dysphagic stroke patients requires standardisation, as does the education for nurses to ensure that this intervention is carried out safely, effectively and acceptably.

Being deliberate in postacute stroke: strategies to redeem the time

Physical rehabilitation post stroke is key to minimizing impairments, restoring functional mobility, and returning individuals to their life roles. The reimbursable time allotted to attain those goals in the current health care environment is limited and is not projected to increase. It is critical, therefore, for rehabilitation professionals to re-evaluate how they use their limited time with clients. Repetition is the foundation for changes in representational organization of the motor cortex and for motor skill learning. Drawing from animal and human motor learning literature as well as completed clinical trials, we delineate strategies that can be implemented with individual patients to most prudently redeem the time spent with them and to best steward their recovery.

Upper limb rehabilitation following stroke: current evidence and future perspectives

Stroke is a leading cause of disability worldwide, with its risk increasing with age. Upper limb hemiparesis is common and associated with persistent impairments and associated disabilities. Older stroke populations often suffer multiple comorbidities and restoring independence is complex. Recovery of upper limb function can be crucial for individuals to return to independent living and to participate in community life. This review describes upper limb recovery post-stroke, and some of the new therapeutic approaches available to promote recovery. Technologies (including virtual reality and telehealth) offer the opportunity for more home-based therapies, longer programs and greater access to rehabilitation for older individuals. However, the trials continue to exclude older individuals, so acceptability is poorly understood. Upper limb rehabilitation remains a research frontier, which has been energized by new technologies, but is grounded by the basic need to find ways to allow older individuals to recover independence. This paper aims to review the applicability and generalizability of current research to the older stoke survivor. Future research priorities need to be tailored to consider the older mean age of individuals in stroke rehabilitation.

Stroke-related motor outcome measures: do they quantify the neurophysiological aspects of upper extremity recovery?

Various stroke rehabilitation outcome measures are used in clinical and research practice. Severe upper extremity paresis serves as a challenge for the selection of an appropriate outcome measure. No single measure is universally acceptable and sufficient to record the minute clinically important changes. The objectives of the present review were to explore the stroke-specific upper extremity motor outcome measures and to better understand those measures' ability to quantify upper extremity motor recovery. Seven outcome measures were selected for this review. The criteria used to select outcome measures for this review included performance-based tools that assessed the upper extremity's voluntary motor control and outcome measures which had been used for the past 10 years. A critical review that referred to motor recovery stages and volitional control was performed. The upper extremity components of each measure were compared with the neurophysiological aspects of recovery (Brunnstrom Recovery Stages) and analyzed for their clinical relevance. The concepts of minimal detectable change and minimal clinically important difference were also considered while examining the outcome measures. The findings of this review reveal that there were very few measures available to precisely assess the upper extremity motor components and volitional control. Most of the measures are functional and performance-based. Only Fugl-Meyer Assessment was found to explore the individual joint motor control as per the sequential recovery stages. Further, there is a need to develop stroke-specific upper extremity outcome measures. Scoring criteria of the acceptable measures may be modified to discern precise and progressive, but clinically significant motor changes.

MRI predicts efficacy of constraint-induced movement therapy in children with brain injury

Using resting state (RS) functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI), we identified the predictors of clinical improvement following constraint-induced movement therapy (CIMT) in pediatric patients with chronic hemiplegia.From 14 children with congenital or acquired brain injury and 10 sex- and age-matched healthy controls, brain dual-echo, DTI and RS fMRI sequences were acquired before CIMT. The Quality of Upper Extremities Skills Test and the Gross Motor Function Measure (GMFM) were administered at baseline, at the end of CIMT (10 weeks), and after 6 months. Mean diffusivity and fractional anisotropy (FA) were measured in the lesion responsible for the clinical symptomatology, the affected and unaffected corticospinal tract (CST), motor transcallosal fibers, and uncinate fasciculus (as an internal control). Independent component analysis was used to identify the sensorimotor RS network. The ability of baseline MRI variables to predict clinical changes over time was assessed using multivariate linear models. At baseline, patients had increased mean diffusivity in the symptomatic lesion and decreased FA in the symptomatic lesion, affected corticospinal tract, and motor transcallosal fibers. A reduced RS functional connectivity was found in the bilateral cerebellum, left precentral gyrus, and right secondary sensorimotor cortex. At follow up, Quality of Upper Extremities Skills Test and GMFM scales improved significantly. Baseline average lesion FA predicted clinical improvement at week 10, and baseline functional connectivity of the right secondary sensorimotor cortex and cerebellum predicted GMFM improvement at month 6. DTI and RS fMRI offer promising and objective markers to predict clinical outcomes following CIMT in pediatric patients with congenital or acquired hemiplegia.

Motor system plasticity in stroke models: intrinsically use-dependent, unreliably useful

Background and Purpose

The natural response to disability in one limb is to learn new ways of using the other limb. This compensatory behavioral strategy after stroke has long been thought to contribute to persistent dysfunction in the paretic limb by encouraging its disuse. Our recent findings suggest that it goes beyond the encouragement of disuse to disrupt neural substrates of paretic limb functional improvements.

Methods

We overview recent findings from rodent models of chronic upper extremity impairments in which precise control and manipulation of forelimb experiences were used to understand bilateral and interhemispheric contributions to motor functional outcome.

Results

Skill learning with the less-affected (nonparetic) forelimb promotes neural plasticity in the contralesional motor cortex that subserves its function. At the same time, it exacerbates dysfunction and limits the efficacy of rehabilitative training in the paretic limb. The maladaptive effects of skill learning with the nonparetic forelimb are dependent on callosal connections and contralesional motor cortex, and linked with reduced neural activation of peri-infarct motor cortex during rehabilitative training.

Conclusions

These findings suggest that learning to rely on the nonparetic body side has the capacity to disrupt functionality in a region of the injured hemisphere that contributes to outcome of the paretic limb. Whether this effect generalizes across injury loci and functional modalities remains to be tested.

Brain SPECT Analysis After Constraint-Induced Movement Therapy in Young Children with Hemiplegic Cerebral Palsy: Case Report

Constraint-induced movement therapy (CIMT) was shown recently to be promising for improving upper-limb function in children with cerebral palsy (CP). This study investigated the changes in cerebral perfusion with single-photon emission computerized tomography (SPECT) after modified CIMT (child-friendly CIMT) in young hemiplegic girls. Two young children with left hemiplegic CP were studied with SPECT at rest before and after the CIMT period, and they also performed standardized upper motor function tests [Jebsen hand function test, quality of upper extremity skills test (QUEST), and dynamic electromyography (EMG)]. The cerebral perfusion SPECT revealed regional perfusion increase in the motor cortex area in the affected hemisphere, and the changes associated with functional gain. Our cases showed that intensive movement therapy appears to change local cerebral perfusion and SPECT could show these changes in children with hemiplegic CP.

Don't neglect 'neglect'- an update on post stroke neglect

OBJECTIVES

Post-stroke neglect is common and an independent predictor of functional outcome. Assessment of neglect is very demanding, the treatment extremely difficult and the literature vast; we performed a literature search for all aspects of this difficult subject.

METHODS

We searched the PubMed, EMBASE databases and historical manuals for authoritative studies on post stroke neglect between 1951 and 2011.

FINDINGS

There is a great dearth of randomised controlled data on neglect because standardised assessment does not occur frequently. Eighty-eight manuscripts were identified in the literature, which were quite heterogeneous in their content and addressing diverse aspects of this clinical entity.

INTERPRETATION AND IMPLICATIONS

The most important historical papers were selected along with the most widely accepted and proven strategies for assessment and treatment. Standardised assessment of neglect does not always occur, but several useful strategies are available and are described in the following sections.

The EXCITE Trial: reacquiring upper-extremity task performance with early versus late delivery of constraint therapy

OBJECTIVE

This study examines performance of Wolf Motor Function Test (WMFT) tasks in terms of the ability of EXCITE trial participants (who had suffered a stroke 3-9 months before recruitment) to complete the task within the timed interval.

METHODS

Data were collected from participants who received constraint-induced movement therapy (CIMT) 3 to 9 months poststroke (CIMT-I, n = 106) or 15 to 21 months poststroke (CIMT-D, n = 116). Performance on the 15 timed WMFT tasks was converted into binary values, and changes in completion of the tasks were analyzed with generalized estimating equation methods, under the assumption of a binomial or Poisson process for completion.

RESULTS

During CIMT, the CIMT-I group showed significant within-group improvements in 3 fine-movement tasks and in total noncompleted tasks (noncompletes), whereas the CIMT-D group did not (P ≤ .0036). CIMT-I improvement was significantly greater than CIMT-D improvement for the lifting pencil task and total noncompletes. During the year following CIMT, neither group showed significant changes in completion of WMFT tasks. Over all time intervals, only the CIMT-I group displayed significant improvement in several tasks and total noncompletes. Between groups, there were significant and almost-significant differences between the improvements of the 2 groups in 3 tasks requiring fine distal movement.

CONCLUSION

Receiving CIMT earlier appears to improve reacquisition and retention of WMFT tasks, especially those requiring fine motor skills. Combined with earlier findings, these results indicate that improvements in existing motor abilities are possible with both immediate and delayed CIMT, but early CIMT is necessary for significant reacquisition of tasks.

Unimanual and bimanual intensive training in children with hemiplegic cerebral palsy and persistence in time of hand function improvement: 6-month follow-up results of a multisite clinical trial

This study aims to compare in hemiplegic children the effectiveness of intensive training (unimanual and bimanual) versus standard treatment in improving hand function, assessing the persistence after 6 months. A multicenter, prospective, cluster-randomized controlled clinical trial was designed comparing 2 groups of children with hemiplegic cerebral palsy, treated for 10 weeks (3 h/d 7 d/wk; first with unimanual constraint-induced movement therapy, second with intensive bimanual training) with a standard treatment group. Children were assessed before and after treatment and at 3 and 6 months postintervention using Quality of Upper Extremity Skills Test (QUEST) and Besta Scales. One hundred five children were recruited (39 constraint-induced movement therapy, 33 intensive bimanual training, 33 standard treatment). Constraint-induced movement therapy and intensive bimanual training groups had significantly improved hand function, showing constant increase in time. Grasp improved immediately and significantly with constraint-induced movement therapy, and with bimanual training grasp improved gradually, reaching the same result. In both, spontaneous hand use increased in long-term assessment.

Distal forelimb representations in primary motor cortex are redistributed after forelimb restriction: a longitudinal study in adult squirrel monkeys

Primary motor cortex (M1) movement representations reflect acquired motor skills. Representations of muscles and joints used in a skilled task expand. However, it is unknown whether motor restriction in healthy individuals results in complementary reductions in M1 representations. With the use of intracortical microstimulation techniques in squirrel monkeys, detailed maps of movement representations in M1 were derived before and up to 35 wk after restriction of the preferred distal forelimb (DFL) by use of a soft cast. Although total DFL area and movement threshold remained constant, casting resulted in a redistribution of digit and wrist/forearm representations. Digit representations progressively decreased, whereas wrist/forearm representations progressively increased in areal extent. In three of four monkeys, hand preference returned to normal by the end of the postcast recovery period, and postrecovery maps demonstrated reversal of restriction-induced changes. However, in one monkey, a chronic motor impairment occurred in the casted limb. Rehabilitation via a forced-use paradigm resulted in recovery in use and skill of the impaired limb, as well as restoration of normal motor maps. These results demonstrate that plasticity in motor representations can be induced by training or restricting movements of the limb. Physiological changes induced by restriction appear to be reversible, even in the case of adverse motor outcomes. The respective contributions of both disuse and lost motor skills are discussed. These results have relevance for clinical conditions requiring forelimb casting as well as interpreting the differential effects of injury and disuse that are necessarily intertwined after cortical injury, as occurs in stroke.

ENGAGE: Guided Activity-Based Gaming in Neurorehabilitation after Stroke: A Pilot Study

Introduction. Stroke is a leading cause of disability in healthy adults. The purpose of this pilot study was to assess the feasibility and outcomes of a novel video gaming repetitive practice paradigm, (ENGAGE) enhanced neurorehabilitation: guided activity-based gaming exercise. Methods. Sixteen individuals at least three months after stroke served as participants. All participants received concurrent outpatient therapy or took part in a stroke exercise class and completed at least 500 minutes of gaming. Primary baseline and posttest outcome measures included the Wolf motor function test (WMFT) and the Fugl-Meyer assessment (FMA). ENGAGE uses a game selection algorithm providing focused, graded activity-based repetitive practice that is highly individualized and directed. The Wilcoxon signed ranks test was used to determine statistical significance. Results. There were improvements in the WMFT (P = 0.003) and the FMA (P = 0.002) that exceeded established values of minimal clinically important difference. Conclusions. ENGAGE was feasible and an effective adjunct to concurrent therapy after stroke.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of reinforcement history on hand choice in an unconstrained reaching task

Choosing which hand to use for an action is one of the most frequent decisions people make in everyday behavior. We developed a simple reaching task in which we vary the lateral position of a target and the participant is free to reach to it with either the right or left hand. While people exhibit a strong preference to use the hand ipsilateral to the target, there is a region of uncertainty within which hand choice varies across trials. We manipulated the reinforcement rates for the two hands, either by increasing the likelihood that a reach with the non-dominant hand would successfully intersect the target or decreasing the likelihood that a reach with the dominant hand would be successful. While participants had minimal awareness of these manipulations, we observed an increase in the use of the non-dominant hand for targets presented in the region of uncertainty. We modeled the shift in hand use using a Q-learning model of reinforcement learning. The results provided a good fit of the data and indicate that the effects of increasing and decreasing the rate of positive reinforcement are additive. These experiments emphasize the role of decision processes for effector selection, and may point to a novel approach for physical rehabilitation based on intrinsic reinforcement.

Movement therapy induced neural reorganization and motor recovery in stroke: a review

This paper is a review conducted to provide an overview of accumulated evidence on contemporary rehabilitation methods for stroke survivors. Loss of functional movement is a common consequence of stroke for which a wide range of interventions has been developed. Traditional therapeutic approaches have shown limited results for motor deficits as well as lack evidence for their effectiveness. Stroke rehabilitation is now based on the evidence of neuroplasticity, which is responsible for recovery following stroke. The neuroplastic changes in the structure and function of relevant brain areas are induced primarily by specific rehabilitation methods. The therapeutic method which induces neuroplastic changes, leads to greater motor and functional recovery than traditional methods. Further, the recovery is permanent in nature. During the last decade various novel stroke rehabilitative methods for motor recovery have been developed. This review focuses on the methods that have evidence of associated cortical level reorganization, namely task-specific training, constraint-induced movement therapy, robotic training, mental imaging, and virtual training. All of these methods utilize principles of motor learning. The findings from this review demonstrated convincing evidence both at the neural and functional level in response to such therapies. The main aim of the review was to determine the evidence for these methods and their application into clinical practice.

Anatomy of stroke injury predicts gains from therapy

BACKGROUND AND PURPOSE

Many therapies are emerging that aim to improve motor function in people with stroke. Identifying key biological substrates needed for treatment gains would help to predict treatment effects and to maximize treatment impact. The current study addressed the hypothesis that behavioral gains from therapy targeting distal upper extremity are predicted by the structural integrity of key motor system white matter tracts.

METHODS

Twenty-three subjects with chronic left-sided stroke underwent robotic therapy targeting the distal right upper extremity. MRI was obtained at baseline and used to outline the infarct. For each subject, the degree to which stroke injured each of 4 descending white matter tracts (from the primary motor cortex, supplementary motor area, dorsal premotor cortex, and ventral premotor cortex, respectively) was determined. Correlations between tract-specific injury and behavioral gains from therapy were then examined.

RESULTS

Numerous examples were found whereby tract-specific injury predicted treatment gains. The strongest correlations pertained to stroke injury to tracts descending from the primary motor cortex and dorsal premotor cortex. Infarct volume and baseline behavior were weak predictors of treatment gains.

CONCLUSIONS

Extent of injury to specific motor tracts predicts behavioral gains from treatment in subjects with chronic stroke. This supports a role for these tracts in mediating treatment effects and reinforces the importance of lesion location in stroke. Tract-specific injury was stronger than infarct volume or baseline clinical status at predicting gains, identifies subjects with sufficient biological substrate to improve from therapy, and so might be useful as an entry criterion in repair-based trials.

Randomized trial of distributed constraint-induced therapy versus bilateral arm training for the rehabilitation of upper-limb motor control and function after stroke

BACKGROUND AND OBJECTIVE

This study compared the efficacy of distributed constraint-induced therapy (dCIT), bilateral arm training (BAT), and control treatment (CT) on motor control and functional performance of the upper limb in stroke patients.

METHODS

A total of 66 patients with mean stroke onset of 16.20 months and mild to moderate motor impairment were randomized to dCIT, BAT, or CT groups. Each group received treatment for 2 h/d and 5 d/wk for 3 weeks. Pretreatment and posttreatment measures included reaching kinematic variables in unilateral and bilateral tasks, the Wolf Motor Function Test (WMFT), and the Motor Activity Log (MAL).

RESULTS

The dCIT and BAT groups had smoother reaching trajectories in the unilateral and bilateral tasks than the CT group. The BAT group, but not the dCIT group, generated greater force at movement initiation than the CT group during the unilateral and bilateral tasks. The dCIT patients had decreased WMFT time and higher functional ability scores than the CT patients. MAL results pointed to better performance in the amount and quality of use of the affected arm than BAT and CT patients.

CONCLUSIONS

BAT and dCIT exhibited similar beneficial effects on movement smoothness but differential effects on force at movement initiation and functional performance. Therefore, BAT is a better option if improvement of force generation is the treatment goal, and dCIT is more appropriate for improving functional ability and use of the affected arm in daily life. These findings may assist in the planning of individually tailored rehabilitation therapies.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN AND SETTING

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

PARTICIPANTS

Seventeen individuals who were 3 to 9 months poststroke participated.

INTERVENTION

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

MEASUREMENTS

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

RESULTS

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

CONCLUSION

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

Bilateral movement therapy post-stroke: underlying mechanisms and review

Aims

Up to 66% of individuals with stroke never regain functional use of their upper extremities. Bilateral movement training (BMT) is a task-specific rehabilitation technique that has recently been investigated for its influence on upper extremity recovery in individuals post-stroke. BMT is thought to affect the hemiparetic upper extremity by a phenomenon referred to as cross education, or the cross transfer effect.

Methods

This article reviews the theoretical accounts underlying the cross transfer effect and explain the means by which BMT may facilitate recovery of function in the hemiparetic arm. The current research evidence supporting the use of BMT as a therapeutic approach to stroke rehabilitation is discussed, and implications for clinical practice and recommendations for further research are presented.

Findings

Evidence is emerging that BMT improves impairments and function in people with hemiparesis after stroke. The main limitations of existing research on BMT include small sample sizes, varying initial impairment levels, and lack of control groups.

Conclusions

Future research needs to establish which individuals are most likely to benefi tfrom BMT, as well as the optimal dose of BMT, and whether BMT can be used as an adjunct to existing rehabilitation approaches for upper extremity rehabilitation.

Pediatric constraint-induced movement therapy: a promising intervention for childhood hemiparesis

Experimental and clinical evidence is accumulating that supports the assertion that the damaged human brain is capable of responding to sensory stimulation in a sufficient manner to result in sustainable and useful benefits. The intensity and duration of therapeutic maneuvers that elicit improvement are under active investigation. Recent studies in animals, adults, and children with hemiparesis have shown that constraint of the less involved upper limb coupled with a behavioral program that repetitively encourages graded unilateral movements can result in long-term "new" functional activities. Constraint-induced movement therapy (CIMT) is a promising approach for treatment of children with stroke-related hemiparesis from either prenatal or postnatal causes due to the enhanced neuroplasticity of the brain during early life.

A functional threshold for long-term use of hand and arm function can be determined: predictions from a computational model and supporting data from the Extremity Constraint-Induced Therapy Evaluation (EXCITE) Trial

BACKGROUND

Although spontaneous use of the more-affected arm and hand after stroke is an important determinant of participation and quality of life, a number of patients exhibit decreases in use following rehabilitative therapy. A previous neurocomputational model predicted that if the dose of therapy is sufficient to bring performance above a certain threshold, training can be stopped.

OBJECTIVE

The aim of this study was to test the hypothesis that there exists a threshold for function of the paretic arm and hand after therapy. If function is above this threshold, spontaneous use will increase in the months following therapy. In contrast, if function is below this threshold, spontaneous use will decrease.

METHODS

New computer simulations are presented showing that changes in arm use following therapy depend on a performance threshold. This prediction was tested by reanalyzing the data from the Extremity Constraint-Induced Therapy Evaluation (EXCITE) trial, a phase III randomized controlled trial in which participants received constraint-induced movement therapy for 2 weeks and were tested both 1 week and 1 year after therapy.

RESULTS

The results demonstrate that arm and hand function measured immediately after therapy predicts, on average, the long-term change of arm use. Above a functional threshold, use improves. Below this threshold, use decreases.

LIMITATIONS

The reanalysis of the EXCITE trial data provides a "group" threshold above which a majority of patients, but not all, improve spontaneously. A goal of future research is to provide the means to assess when patients reach their individual threshold.

CONCLUSION

Understanding of the causal and nonlinear relationship between limb function and daily use is important for the future development of cost-effective interventions and prevention of "rehabilitation in vain."

Bound for success: a systematic review of constraint-induced movement therapy in children with cerebral palsy supports improved arm and hand use

BACKGROUND

Constraint-induced movement therapy (CIMT) is a potentially effective intervention for children with hemiplegic cerebral palsy (CP).

PURPOSE

The objectives of this systematic review are: (1) to investigate whether CIMT is supported with valid research of its effectiveness and (2) to identify key characteristics of the child and intervention protocol associated with the effects of CIMT.

DATA SOURCES AND STUDY SELECTION

A search of MEDLINE (1966 through March 2009), Entrez PubMed (1966 through March 2009), EMBASE (1980 through March 2009), CINAHL (1982 through March 2009), PsychINFO (1887 through March 2009), and Web of Science (1900 through March 2009) produced 23 relevant studies.

DATA EXTRACTION AND SYNTHESIS

The 2 objectives of the review were addressed by: (1) scoring the validity and level of evidence for each study and calculating evidence-based statistics, if possible, and (2) recording and summarizing the inclusion and exclusion criteria, type and duration of constraint, intervention and study durations, and outcomes based on the International Classification of Functioning, Disability and Health (ICF).

LIMITATIONS

Only studies published in journals and in English were included in the systematic review.

CONCLUSIONS

Studies varied widely in type and rigor of design; subject, constraint, and intervention characteristics; and ICF level for outcome measures. One outcome measure at the body functions and structure level and 4 outcome measures at the activity level had large and significant treatment effects (d > or = .80), and these findings were from the most rigorous studies. Evidence from more-rigorous studies demonstrated an increased frequency of use of the upper extremity following CIMT for children with hemiplegic CP. The critical threshold for intensity that constitutes an adequate dose cannot be determined from the available research. Further research should include a priori power calculations, more-rigorous designs and comparisons of different components of CIMT in relation to specific children, and measures of potential impacts on the developing brain.