Similar Effects of Two Modified Constraint-Induced Therapy Protocols on Motor Impairment, Motor Function and Quality of Life in Patients with Chronic Stroke

Neural recovery after cortical injury: Effects of MSC derived extracellular vesicles on motor circuit remodeling in rhesus monkeys

Reorganization of motor circuits in the cortex and corticospinal tract are thought to underlie functional recovery after cortical injury, but the mechanisms of neural plasticity that could be therapeutic targets remain unclear. Recent work from our group have shown that systemic treatment with mesenchymal stem cell derived (MSCd) extracellular vesicles (EVs) administered after cortical damage to the primary motor cortex (M1) of rhesus monkeys resulted in a robust recovery of fine motor function and reduced chronic inflammation. Here, we used immunohistochemistry for cfos, an activity-dependent intermediate early gene, to label task-related neurons in the surviving primary motor and premotor cortices, and markers of axonal and synaptic plasticity in the spinal cord. Compared to vehicle, EV treatment was associated with a greater density of cfos⁺ pyramidal neurons in the deep layers of M1, greater density of cfos⁺ inhibitory interneurons in premotor areas, and lower density of synapses on MAP2+ lower motor neurons in the cervical spinal cord. These data suggest that the anti-inflammatory effects of EVs may reduce injury-related upper motor neuron damage and hyperexcitability, as well as aberrant compensatory re-organization in the cervical spinal cord to improve motor function.

Effectiveness of Constraint-Induced Movement Therapy (CIMT) on Balance and Functional Mobility in the Stroke Population: A Systematic Review and Meta-Analysis

Constraint-induced movement therapy (CIMT) is one of the most popular treatments for enhancing upper and lower extremity motor activities and participation in patients following a stroke. However, the effect of CIMT on balance is unclear and needs further clarification. The aim of this research was to estimate the effect of CIMT on balance and functional mobility in patients after stroke. After reviewing 161 studies from search engines including Google Scholar, EBSCO, PubMed, PEDro, Science Direct, Scopus, and Web of Science, we included eight randomized controlled trials (RCT) in this study. The methodological quality of the included RCTs was verified using PEDro scoring. This systematic review showed positive effects of CIMT on balance in three studies and similar effects in five studies when compared to the control interventions such as neuro developmental treatment, modified forced-use therapy and conventional physical therapy. Furthermore, a meta-analysis indicated a statistically significant effect size by a standardized mean difference of 0.51 (P = 0.01), showing that the groups who received CIMT had improved more than the control groups. However, the meta-analysis results for functional mobility were statistically insignificant, with an effect size of −4.18 (P = 0.16), indicating that the functional mobility improvements in the investigated groups were not greater than the control group. This study’s findings demonstrated the superior effects of CIMT on balance; however, the effect size analysis of functional mobility was statistically insignificant. These findings indicate that CIMT interventions can improve balance-related motor function better than neuro developmental treatment, modified forced-use therapy and conventional physical therapy in patients after a stroke.

Sex differences in recovery of motor function in a rhesus monkey model of cortical injury

BACKGROUND

Stroke disproportionately affects men and women, with women over 65 years experiencing increased severity of impairment and higher mortality rates than men. Human studies have explored risk factors that contribute to these differences, but additional research is needed to investigate how sex differences affect functional recovery and hence the severity of impairment. In the present study, we used our rhesus monkey model of cortical injury and fine motor impairment to compare sex differences in the rate and degree of motor recovery following this injury.

METHODS

Aged male and female rhesus monkeys were trained on a task of fine motor function of the hand before undergoing surgery to produce a cortical lesion limited to the hand area representation of the primary motor cortex. Post-operative testing began two weeks after the surgery and continued for 12 weeks. All trials were video recorded and latency to retrieve a reward was quantitatively measured to assess the trajectory of post-operative response latency and grasp pattern compared to pre-operative levels.

RESULTS

Postmortem analysis showed no differences in lesion volume between male and female monkeys. However, female monkeys returned to their pre-operative latency and grasp patterns significantly faster than males.

CONCLUSIONS

These findings demonstrate the need for additional studies to further investigate the role of estrogens and other sex hormones that may differentially affect recovery outcomes in the primate brain.

Constraint Induced Movement Therapy Increases Functionality and Quality of Life after Stroke

This blind randomized clinical trial evaluated the effect of CIMT on the functionality and quality of life (QOL) of chronic hemiparetics. Thirty volunteers were divided into two groups: Control (CG) and CIMT (CIMTG); evaluated before and after 12 and 24 intervention sessions. The scales used were: adapted Fugl-Meyer Motor Assessment (FMA), Modified Ashworth, Stroke Specific Quality Of Life (SS-QOL) and the Functional Reach Test (FRT). The scores for all FMA variables in the CIMTG increased until the 24th session, differing from the pre-treatment. In the CG, the scores increased for pain, coordination/ speed and sensitivity. In the FRT there was an increase in the scores in both groups; after the 12th and 24th sessions, the result of the CIMTG was superior to the CG. For the SS-QOL in the CIMTG, the general score and most of the variables increased, as well as in the CG. Muscle tone in CIMTG was lower compared to CG after 24 sessions. Both protocols used in the study were effective, the CIMT protocol showed benefits in recovering the functionality of the paretic upper limb, in the functional range and in reducing muscle tone, with a consequent improvement in quality of life.

Group-based constraint-induced movement therapy in the rehabilitation of chronic poststroke patients

BACKGROUND

This study aimed to describe the effects of a 90-minute group-based constraint-induced movement therapy protocol (CIMT) on upper extremity (UE) rehabilitation in poststroke patients.

METHOD

The study was a case series clinical study with 6 patients with chronic stroke admitted to the institutional integrated clinic. Ten 90-minute CIMT sessions were administered, based on the principles of the original therapy. On completion of the protocol, participants underwent group care once a week, for 1 hour a day. For comparison purposes, the Wolf Motor Function Test (WMFT), Motor Activity Log (MAL), and Canadian Occupational Performance Measure (COPM) were applied on admission, shortly after completing the protocol, and 3 months after completion. In addition, the MAL and shaping tasks were applied daily.

RESULTS

There was a statistically significant difference only in the MAL Amount of Use Scale applied daily between the 2nd (3.56) and 9th (3.31) and 2nd and 10th days (4.49) (P = .004), with a moderate effect size (d' = 0.46), and in the average value of shaping repetitions between the 1st (16.10) and 2nd (6.00) and 1st and 10th tasks (7.00) (P = .014), with a moderate effect size (d' = 0.35).

CONCLUSION

The 90-minute CIMT protocol resulted in significant improvements in use of the more affected arm in activities of daily living during the 2-week protocol. Additional research with a larger sample and a control group is needed to confirm its effectiveness.

A method for assessing recovery of fine motor function of the hand in a rhesus monkey model of cortical injury: an adaptation of the Fugl-Meyer Scale and Eshkol-Wachman Movement Notation

Motor dysfunction of the upper extremity can result from stroke, cortical injury and neurological diseases and causes significant disruption of activities of daily living. While some spontaneous recovery in terms of compensatory movements does occur after injury to cortical motor areas, full recovery is rare. The distinction between complete recovery and compensatory recovery is important as the development of compensatory movements in the upper extremity may not translate into full functional use in human patients. However, current animal models of stroke do not distinguish full recovery from compensatory recovery. We have developed a Non-Human Primate Grasp Assessment Scale (GRAS) to quantify the precise recovery of composite movement, individual digit action, and finger-thumb pinch in our rhesus monkey model of cortical injury. To date, we have applied this GRAS scale to assess the recovery of fine motor function of the hand in young control and cell-therapy treated monkeys with cortical injury confined to the hand representation in the dominant primary motor cortex. We have demonstrated that with this scale we can detect and quantify significant impairments in fine motor function of the hand, the development of compensatory function during recovery and finally a return to full fine motor function of the hand in monkeys treated with a cell therapy.

Mesenchymal derived exosomes enhance recovery of motor function in a monkey model of cortical injury

BACKGROUND

Exosomes from mesenchymal stromal cells (MSCs) are endosome-derived vesicles that have been shown to enhance functional recovery in rodent models of stroke.

OBJECTIVE

Building on these findings, we tested exosomes as a treatment in monkeys with cortical injury.

METHODS

After being trained on a task of fine motor function of the hand, monkeys received a cortical injury to the hand representation in primary motor cortex. Twenty-four hours later and again 14 days after injury, monkeys received exosomes or vehicle control. Recovery of motor function was followed for 12 weeks.

RESULTS

Compared to monkeys that received vehicle, exosome treated monkeys returned to pre-operative grasp patterns and latency to retrieve a food reward in the first three-five weeks of recovery.

CONCLUSIONS

These results provide evidence that in monkeys exosomes delivered after cortical injury enhance recovery of motor function.

Hand strengthening exercises in chronic stroke patients: Dose-response evaluation using electromyography

STUDY DESIGN

Cross-sectional.

PURPOSE OF THE STUDY

This study evaluates finger flexion and extension strengthening exercises using elastic resistance in chronic stroke patients.

METHODS

Eighteen stroke patients (mean age: 56.8 ± 7.6 years) with hemiparesis performed 3 consecutive repetitions of finger flexion and extension, using 3 different elastic resistance levels (easy, moderate, and hard). Surface electromyography was recorded from the flexor digitorum superficialis (FDS) and extensor digitorum (ED) muscles and normalized to the maximal electromyography of the non-paretic arm.

RESULTS

Maximal grip strength was 39.2 (standard deviation: 12.5) and 7.8 kg (standard deviation: 9.4) in the nonparetic and paretic hand, respectively. For the paretic hand, muscle activity was higher during finger flexion exercise than during finger extension exercise for both ED (30% [95% confidence interval {CI}: 19-40] vs 15% [95% CI: 5-25] and FDS (37% [95% CI: 27-48] vs 24% [95% CI: 13-35]). For the musculature of both the FDS and ED, no dose-response association was observed for resistance and muscle activity during the flexion exercise (P > .05).

CONCLUSION

The finger flexion exercise showed higher muscle activity in both the flexor and extensor musculature of the forearm than the finger extension exercise. Furthermore, greater resistance did not result in higher muscle activity during the finger flexion exercise. The present results suggest that the finger flexion exercise should be the preferred strengthening exercise to achieve high levels of muscle activity in both flexor and extensor forearm muscles in chronic stroke patients. The finger extension exercise may be performed with emphasis on improving neuromuscular control.

LEVEL OF EVIDENCE

4b.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIM

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

MATERIAL AND METHODS

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

RESULTS AND CONCLUSION

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

The Effects of Modified Constraint-Induced Movement Therapy in Acute Subcortical Cerebral Infarction

Background: Constraint-induced movement therapy (CIMT) promotes upper extremity recovery post stroke, however, it is difficult to implement clinically due to its high resource demand and safety of the restraint. Therefore, we propose that modified CIMT (mCIMT) be used to treat individuals with acute subcortical infarction. Objective: To evaluate the therapeutic effects of mCIMT in patients with acute subcortical infarction, and investigate the possible mechanisms underlying the effect. Methods: The role of mCIMT was investigated in 26 individuals experiencing subcortical infarction in the preceding 14 days. Patients were randomly assigned to either mCIMT or standard therapy. mCIMT group was treated daily for 3 h over 10 consecutive working days, using a mitt on the unaffected arm for up to 30% of waking hours. The control group was treated with an equal dose of occupational therapy and physical therapy. During the 3-month follow-up, the motor functions of the affected limb were assessed by the Wolf Motor Function Test (WMFT) and Motor Activity Log (MAL). Altered cortical excitability was assessed via transcranial magnetic stimulation (TMS). Results: Treatment significantly improved the movement in the mCIMT group compared with the control group. The mean WMF score was significantly higher in the mCIMT group compared with the control group. Further, the appearance of motor-evoked potentials (MEPs) were significantly higher in the mCIMT group compared with the baseline data. A significant change in ipsilesional silent period (SP) occurred in the mCIMT group compared with the control group. However, we found no difference between two groups in motor function or electrophysiological parameters after 3 months of follow-up. Conclusions: mCIMT resulted in significant functional changes in timed movement immediately following treatment in patients with acute subcortical infarction. Further, early mCIMT improved ipsilesional cortical excitability. However, no long-term effects were seen.

Constraint-induced movement therapy in treatment of acute and sub-acute stroke: a meta-analysis of 16 randomized controlled trials

OBJECTIVE:

The aim of this meta-analysis was to evaluate the clinical efficacy of constraint-induced movement therapy in acute and sub-acute stroke.

DATA SOURCES:

The key words were stroke, cerebrovascular accident, constraint-induced therapy, forced use, and randomized controlled trial. The databases, including China National Knowledge Infrastructure, WanFang, Weipu Information Resources System, Chinese Biomedical Literature Database, PubMed, Medline, Embase, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews, were searched for studies on randomized controlled trials for treating acute or sub-acute stroke published before March 2016.

DATA SELECTION:

We retrieved relevant randomized controlled trials that compared constraint-induced movement therapy in treatment of acute or sub-acute stroke with traditional rehabilitation therapy (traditional occupational therapy). Patients were older than 18 years, had disease courses less than 6 months, and were evaluated with at least one upper extremity function scale. Study quality was evaluated, and data that met the criteria were extracted. Stata 11.0 software was used for the meta-analysis.

OUTCOME MEASURES:

Fugl-Meyer motor assessment of the arm, the action research-arm test, a motor activity log for amount of use and quality of movement, the Wolf motor function test, and a modified Barthel index.

RESULTS:

A total of 16 prospective randomized controlled trials (379 patients in the constraint-induced movement-therapy group and 359 in the control group) met inclusion criteria. Analysis showed significant mean differences in favor of constraint-induced movement therapy for the Fugl–Meyer motor assessment of the arm (weighted mean difference (WMD) = 10.822; 95% confidence intervals (95% CI): 7.419–14.226), the action research-arm test (WMD = 10.718; 95% CI: 5.704–15.733), the motor activity log for amount of use and quality of movement (WMD = 0.812; 95% CI: 0.331–1.293) and the modified Barthel index (WMD = 10.706; 95% CI: 4.417–16.966).

CONCLUSION:

Constraint-induced movement therapy may be more beneficial than traditional rehabilitation therapy for improving upper limb function after acute or sub-acute stroke.

Can Short-Term Constraint-Induced Movement Therapy Combined With Visual Biofeedback Training Improve Hemiplegic Upper Limb Function of Subacute Stroke Patients?

Objective

To Investigate the synergic effects of short-term constraint-induced movement therapy (CIMT) and visual biofeedback training (VBT) in subacute stroke patients.

Methods

Thirty-two subacute stroke patients were enrolled and randomly assigned to one of three groups: short-term CIMT with VBT, VBT only, and control groups. We applied CIMT for an hour daily during VBT instead of the ordinary restraint time, referred to as 'short-term' CIMT. Short-term CIMT with VBT group received simultaneous VBT with CIMT, whereas the VBT the only group received VBT without CIMT for an hour a day for 2 weeks. The control group received conventional occupational therapy (OT) alone. Patients underwent the Purdue Pegboard Test, the JAMAR grip strength test, the Wolf Motor Function Test, the Fugl-Meyer Assessment (upper extremity), Motricity index and the Korean version of Modified Barthel Index test to evaluate motor functions of the hemiplegic upper limb at baseline, post-treatment, and 2 weeks after treatment.

Results

No significant differences were observed between short-term CIMT with VBT and VBT only groups. Both groups showed significantly higher scores compared to the control group in the WMFT and FMA tests. However, the short-term CIMT with VBT group showed significant improvement (p<0.05) compared with the control group in both grasp and pad pinch at post-treatment and 2 weeks after treatment while the VBT only group did not.

Conclusion

Short-term CIMT with VBT group did not show significant improvement of hemiplegic upper limb function of subacute stroke patients, compared to VBT only group. Larger sample sizes and different restraint times would be needed to clarify the effect.

Caregiver-mediated exercises for improving outcomes after stroke

BACKGROUND

Stroke is a major cause of long-term disability in adults. Several systematic reviews have shown that a higher intensity of training can lead to better functional outcomes after stroke. Currently, the resources in inpatient settings are not always sufficient and innovative methods are necessary to meet these recommendations without increasing healthcare costs. A resource efficient method to augment intensity of training could be to involve caregivers in exercise training. A caregiver-mediated exercise programme has the potential to improve outcomes in terms of body function, activities, and participation in people with stroke. In addition, caregivers are more actively involved in the rehabilitation process, which may increase feelings of empowerment with reduced levels of caregiver burden and could facilitate the transition from rehabilitation facility (in hospital, rehabilitation centre, or nursing home) to home setting. As a consequence, length of stay might be reduced and early supported discharge could be enhanced.

OBJECTIVES

To determine if caregiver-mediated exercises (CME) improve functional ability and health-related quality of life in people with stroke, and to determine the effect on caregiver burden.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (October 2015), CENTRAL (the Cochrane Library, 2015, Issue 10), MEDLINE (1946 to October 2015), Embase (1980 to December 2015), CINAHL (1982 to December 2015), SPORTDiscus (1985 to December 2015), three additional databases (two in October 2015, one in December 2015), and six additional trial registers (October 2015). We also screened reference lists of relevant publications and contacted authors in the field.

SELECTION CRITERIA

Randomised controlled trials comparing CME to usual care, no intervention, or another intervention as long as it was not caregiver-mediated, aimed at improving motor function in people who have had a stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials. One review author extracted data, and assessed quality and risk of bias, and a second review author cross-checked these data and assessed quality. We determined the quality of the evidence using GRADE. The small number of included studies limited the pre-planned analyses.

MAIN RESULTS

We included nine trials about CME, of which six trials with 333 patient-caregiver couples were included in the meta-analysis. The small number of studies, participants, and a variety of outcome measures rendered summarising and combining of data in meta-analysis difficult. In addition, in some studies, CME was the only intervention (CME-core), whereas in other studies, caregivers provided another, existing intervention, such as constraint-induced movement therapy. For trials in the latter category, it was difficult to separate the effects of CME from the effects of the other intervention.We found no significant effect of CME on basic ADL when pooling all trial data post intervention (4 studies; standardised mean difference (SMD) 0.21, 95% confidence interval (CI) -0.02 to 0.44; P = 0.07; moderate-quality evidence) or at follow-up (2 studies; mean difference (MD) 2.69, 95% CI -8.18 to 13.55; P = 0.63; low-quality evidence). In addition, we found no significant effects of CME on extended ADL at post intervention (two studies; SMD 0.07, 95% CI -0.21 to 0.35; P = 0.64; low-quality evidence) or at follow-up (2 studies; SMD 0.11, 95% CI -0.17 to 0.39; P = 0.45; low-quality evidence).Caregiver burden did not increase at the end of the intervention (2 studies; SMD -0.04, 95% CI -0.45 to 0.37; P = 0.86; moderate-quality evidence) or at follow-up (1 study; MD 0.60, 95% CI -0.71 to 1.91; P = 0.37; very low-quality evidence).At the end of intervention, CME significantly improved the secondary outcomes of standing balance (3 studies; SMD 0.53, 95% CI 0.19 to 0.87; P = 0.002; low-quality evidence) and quality of life (1 study; physical functioning: MD 12.40, 95% CI 1.67 to 23.13; P = 0.02; mobility: MD 18.20, 95% CI 7.54 to 28.86; P = 0.0008; general recovery: MD 15.10, 95% CI 8.44 to 21.76; P < 0.00001; very low-quality evidence). At follow-up, we found a significant effect in favour of CME for Six-Minute Walking Test distance (1 study; MD 109.50 m, 95% CI 17.12 to 201.88; P = 0.02; very low-quality evidence). We also found a significant effect in favour of the control group at the end of intervention, regarding performance time on the Wolf Motor Function test (2 studies; MD -1.72, 95% CI -2.23 to -1.21; P < 0.00001; low-quality evidence). We found no significant effects for the other secondary outcomes (i.e.

PATIENT

motor impairment, upper limb function, mood, fatigue, length of stay and adverse events; caregiver: mood and quality of life).In contrast to the primary analysis, sensitivity analysis of CME-core showed a significant effect of CME on basic ADL post intervention (2 studies; MD 9.45, 95% CI 2.11 to 16.78; P = 0.01; moderate-quality evidence).The methodological quality of the included trials and variability in interventions (e.g. content, timing, and duration), affected the validity and generalisability of these observed results.

AUTHORS' CONCLUSIONS

There is very low- to moderate-quality evidence that CME may be a valuable intervention to augment the pallet of therapeutic options for stroke rehabilitation. Included studies were small, heterogeneous, and some trials had an unclear or high risk of bias. Future high-quality research should determine whether CME interventions are (cost-)effective.

Inosine enhances recovery of grasp following cortical injury to the primary motor cortex of the rhesus monkey

BACKGROUND

Inosine, a naturally occurring purine nucleoside, has been shown to stimulate axonal growth in cell culture and promote corticospinal tract axons to sprout collateral branches after stroke, spinal cord injury and TBI in rodent models.

OBJECTIVE

To explore the effects of inosine on the recovery of motor function following cortical injury in the rhesus monkey.

METHODS

After being trained on a test of fine motor function of the hand, monkeys received a lesion limited to the area of the hand representation in primary motor cortex. Beginning 24 hours after this injury and continuing daily thereafter, monkeys received orally administered inosine (500 mg) or placebo. Retesting of motor function began on the 14th day after injury and continued for 12 weeks.

RESULTS

During the first 14 days after surgery, there was evidence of significant recovery within the inosine-treated group on measures of fine motor function of the hand, measures of hand strength and digit flexion. While there was no effect of treatment on the time to retrieve a reward, the treated monkeys returned to asymptotic levels of grasp performance significantly faster than the untreated monkeys. Additionally, the treated monkeys evidenced a greater degree of recovery in terms of maturity of grasp pattern.

CONCLUSION

These findings demonstrate that inosine can enhance recovery of function following cortical injury in monkeys.