Everyday movement and use of the arms: Relationship in children with hemiparesis differs from adults

PURPOSE

In adults with hemiparesis amount of movement of the more-affected arm is related to its amount of use in daily life. In children, little is known about everyday arm use. This report examines the relationships between everyday movement of the more-affected arm and its (a) everyday use and (b) motor capacity in children with hemiparesis.

METHODS

Participants were 28 children with a wide range of upper-extremity hemiparesis subsequent to cerebral palsy due to pre- or peri-natal stroke. Everyday movement of the more-affected arm was assessed by putting accelerometers on the children's forearms for three days. Everyday use of that arm and its motor capacity were assessed with the Pediatric Motor Activity Log-Revised and Pediatric Arm Function Test, respectively.

RESULTS

Intensity of everyday movement of the more-affected arm was correlated with its motor capacity (rs ≥ 0.52, ps ≤ 0.003). However, everyday movement of that arm was not correlated with its everyday use (rs ≤ 0.30, ps ≥ $ 0.126).

CONCLUSIONS

In children with upper-extremity hemiparesis who meet the study intake criteria amount of movement of the more-affected arm in daily life is not related to its amount to use, suggesting that children differ from adults in this respect.

Implications of CI therapy for visual deficit training

We address here the question of whether the techniques of Constraint Induced (CI) therapy, a family of treatments that has been employed in the rehabilitation of movement and language after brain damage might apply to the rehabilitation of such visual deficits as unilateral spatial neglect and visual field deficits. CI therapy has been used successfully for the upper and lower extremities after chronic stroke, cerebral palsy (CP), multiple sclerosis (MS), other central nervous system (CNS) degenerative conditions, resection of motor areas of the brain, focal hand dystonia, and aphasia. Treatments making use of similar methods have proven efficacious for amblyopia. The CI therapy approach consists of four major components: intensive training, training by shaping, a "transfer package" to facilitate the transfer of gains from the treatment setting to everyday activities, and strong discouragement of compensatory strategies. CI therapy is said to be effective because it overcomes learned nonuse, a learned inhibition of movement that follows injury to the CNS. In addition, CI therapy produces substantial increases in the gray matter of motor areas on both sides of the brain. We propose here that these mechanisms are examples of more general processes: learned nonuse being considered parallel to sensory nonuse following damage to sensory areas of the brain, with both having in common diminished neural connections (DNCs) in the nervous system as an underlying mechanism. CI therapy would achieve its therapeutic effect by strengthening the DNCs. Use-dependent cortical reorganization is considered to be an example of the more general neuroplastic mechanism of brain structure repurposing. If the mechanisms involved in these broader categories are involved in each of the deficits being considered, then it may be the principles underlying efficacious treatment in each case may be similar. The lessons learned during CI therapy research might then prove useful for the treatment of visual deficits.

The functional significance of cortical reorganization and the parallel development of CI therapy

For the nineteenth and the better part of the twentieth centuries two correlative beliefs were strongly held by almost all neuroscientists and practitioners in the field of neurorehabilitation. The first was that after maturity the adult CNS was hardwired and fixed, and second that in the chronic phase after CNS injury no substantial recovery of function could take place no matter what intervention was employed. However, in the last part of the twentieth century evidence began to accumulate that neither belief was correct. First, in the 1960s and 1970s, in research with primates given a surgical abolition of somatic sensation from a single forelimb, which rendered the extremity useless, it was found that behavioral techniques could convert the limb into an extremity that could be used extensively. Beginning in the late 1980s, the techniques employed with deafferented monkeys were translated into a rehabilitation treatment, termed Constraint Induced Movement therapy or CI therapy, for substantially improving the motor deficit in humans of the upper and lower extremities in the chronic phase after stroke. CI therapy has been applied successfully to other types of damage to the CNS such as traumatic brain injury, cerebral palsy, multiple sclerosis, and spinal cord injury, and it has also been used to improve function in focal hand dystonia and for aphasia after stroke. As this work was proceeding, it was being shown during the 1980s and 1990s that sustained modulation of afferent input could alter the structure of the CNS and that this topographic reorganization could have relevance to the function of the individual. The alteration in these once fundamental beliefs has given rise to important recent developments in neuroscience and neurorehabilitation and holds promise for further increasing our understanding of CNS function and extending the boundaries of what is possible in neurorehabilitation.

An enhanced protocol for constraint-induced aphasia therapy II: a case series

PURPOSE

The initial version of Constraint-Induced Aphasia Therapy (CIAT I) consisted of a single exercise. This study sought to evaluate the feasibility for future trials of an expanded and restructured protocol designed to increase the efficacy of CIAT I.

METHOD

The subjects were 4 native English speakers with chronic stroke who exhibited characteristics of moderate Broca's aphasia. Treatment was carried out for 3.5 hr/day for 15 consecutive weekdays. It consisted of 3 components: (a) intensive training by a behavioral method termed shaping using a number of expressive language exercises in addition to the single original language card game, (b) strong discouragement of attempts to use gesture or other nonverbal means of communication, and (c) a transfer package of behavioral techniques to promote transfer of treatment gains from the laboratory to real-life situations.

RESULTS

Participation in speech in the life situation improved significantly after treatment. The effect sizes (i.e., d') in this domain were ≥ 2.2; d' values ≥ 0.8 are considered large. Improvement in language ability on a laboratory test, the Western Aphasia Battery-Revised (Kertesz, 2006), did not achieve statistical significance, although the effect size was large--that is, 1.3 (13.1 points).

CONCLUSION

These pilot results suggest in preliminary fashion that CIAT II may produce significant improvements in everyday speech.

Diffusion tensor imaging study of the response to constraint-induced movement therapy of children with hemiparetic cerebral palsy and adults with chronic stroke

OBJECTIVE

To investigate the relationship of white matter integrity and path of the corticospinal tract (CST) on arm function before and after constraint-induced (CI) movement therapy in children with hemiparetic cerebral palsy (CP) and adults with chronic stroke.

DESIGN

Study 1 used a multiple-baseline pre-post design. Study 2 was a randomized controlled trial.

SETTING

Outpatient rehabilitation laboratory.

PARTICIPANTS

Study 1 included children with hemiparetic CP (n=10; mean age ± SD, 3.2±1.7y). Study 2 included adults with chronic stroke (n=26; mean age ± SD, 65.4±13.6y) who received either CI therapy or a comparison therapy.

INTERVENTIONS

Children in study 1 received CI therapy for 3.5h/d for 15 consecutive weekdays. Adults in study 2 received either CI therapy or a comparison therapy for 3.5h/d for 10 consecutive weekdays.

MAIN OUTCOME MEASURES

Diffusion tensor imaging was performed to quantify white matter integrity. Motor ability was assessed in children using the Pediatric Motor Activity Log-Revised and Pediatric Arm Function Test, and in adults with the Motor Activity Log and Wolf Motor Function Test.

RESULTS

Participants in both studies improved in real-world arm function and motor capacity. Children and adults with disrupted/displaced CSTs and children with reduced fractional anisotropy values were worse on pretreatment tests of motor function than participants with unaltered CSTs. However, neither integrity (fractional anisotropy) nor distorted or disrupted path of the CST affected motor improvement after treatment.

CONCLUSIONS

Participants who had reduced integrity, displacement, or interruption of their CST performed worse on pretreatment motor testing. However, this had no effect on their ability to benefit from CI therapy. The results for children and adults are consistent with one another.

Promoting physical activity: fertile ground for rehabilitation psychology

Comments on the article by Schmacher et al. (see record 2013-06066-009). Readers of Rehabilitation Psychology might be surprised, or maybe even alarmed, to find an article on promoting physical activity in able-bodied people between the covers of their latest issue. This commentary contends that this area of research and practice might be one into which rehabilitation psychologists want to venture. Schumacher and coworkers describe a field test (N = 216) of a token system for reinforcing stair taking. The setting was an eight-story office building housing a single company in a midsized city in the southeastern United States. Schumacher et al. report an increase from 39 stair transactions per day by all study participants in the 6 months before implementation of the intervention to 301 transactions in the 6 months after the implementation of the intervention, which represents a 600% increase. The cost of the intervention was only $17 per person. Although replication of these results in a study with additional sources of control would increase confidence in the validity of the findings, the size of the gains in stair taking, the number of participants in the study, the length of the baseline and implementation periods, and the objective measurement of outcome warrant attention.

Structural neuroplastic change after constraint-induced movement therapy in children with cerebral palsy

Research from the present laboratory with adult stroke patients showed that structural neuroplastic changes are correlated with clinical improvements due to constraint-induced movement (CI) therapy. This pilot study evaluated whether comparable changes occur in children receiving CI therapy. Ten children (6 boys) with congenital hemiparesis (mean age: 3 years, 3 months) underwent MRI scans 3 weeks before, immediately before, and immediately after receiving 3 weeks of CI therapy. Longitudinal voxel-based morphometry was performed on MRI scans to determine gray matter change. In addition, the Pediatric Motor Activity Log-Revised was administered at these time points to assess arm use in daily life before and after treatment. Children exhibited large improvements after CI therapy in spontaneous use of the more-affected arm (P < .001, d' = 3.24). A significant increase in gray matter volume occurred in the sensorimotor cortex contralateral to the more-affected arm (P = .04); there was a trend for these changes to be correlated with motor improvement (r = 0.63, P = .063). Trends were also observed for increases in gray matter volume in the ipsilateral motor cortex (P = .055) and contralateral hippocampus (P = .1). No significant gray matter change was seen during the 3 weeks before treatment. These findings suggest that CI therapy produces gray matter increases in the developing nervous system and provide additional evidence that CI therapy is associated with structural remodeling of the human brain while producing motor improvement in patients with disabling central nervous system diseases.

Method for enhancing real-world use of a more affected arm in chronic stroke: transfer package of constraint-induced movement therapy

BACKGROUND AND PURPOSE

Constraint-induced movement therapy is a set of treatments for rehabilitating motor function after central nervous system damage. We assessed the roles of its 2 main components.

METHODS

A 2 × 2 factorial components analysis with random assignment was conducted. The 2 factors were type of training and presence/absence of a set of techniques to facilitate transfer of therapeutic gains from the laboratory to the life situation (Transfer Package; TP). Participants (N=40) were outpatients ≥ 1-year after stroke with hemiparesis. The different treatments, which in each case targeted the more affected arm, lasted 3.5 hours/d for 10 weekdays. Spontaneous use of the more affected arm in daily life and maximum motor capacity of that arm in the laboratory were assessed with the Motor Activity Log and the Wolf Motor Function Test, respectively.

RESULTS

Use of the TP, regardless of the type of training received, resulted in Motor Activity Log gains that were 2.4 times as large as the gains in its absence (P<0.01). These clinical results parallel previously reported effects of the TP on neuroplastic change. Both the TP and training by shaping enhanced gains on the Wolf Motor Function Test (P<0.05). The Motor Activity Log gains were retained without loss 1 year after treatment. An additional substudy (N=10) showed that a single component of the TP, weekly telephone contact with participants for 1 month after treatment, doubled Motor Activity Log scores at 6-month follow-up.

CONCLUSIONS

The TP is a method for enhancing both spontaneous use of a more affected arm after chronic stroke and its maximum motor capacity. Shaping enhances the latter.

Pediatric Arm Function Test: reliability and validity for assessing more-affected arm motor capacity in children with cerebral palsy

OBJECTIVE

Although there are several validated upper-extremity measures in young children with cerebral palsy, none of these primarily assess the capacity to carry out actions and tasks with the more-affected arm. To address this need, we developed the Pediatric Arm Function Test (PAFT), which involves the behavioral observation of how children use their more-affected arm during structured play in a laboratory or clinic. This article evaluates the reliability and validity of the PAFT Functional Ability scale.

DESIGN

In study 1, a total of 20 children between 2 and 8 yrs old with a wide range of upper-extremity hemiparesis caused by cerebral palsy completed the PAFT on two occasions separated by 3 wks. In study 2, a total of 41 children between 2 and 6 yrs old with similar characteristics completed the PAFT and received a grade reflecting the severity of more-affected arm motor impairment.

RESULTS

In study 1, the PAFT test-retest reliability correlation coefficient was 0.74. In study 2, convergent validity was supported by a strong inverse correlation (r = -0.6, P < 0.001) between the PAFT scores and the grade of impairment.

CONCLUSIONS

The PAFT Functional Ability scale is a reliable and valid measure of more-affected arm motor capacity in children between 2 and 6 yrs old with cerebral palsy. It can be used to measure upper-extremity neurorehabilitation outcome.

The pediatric motor activity log-revised: assessing real-world arm use in children with cerebral palsy

OBJECTIVE

Widely accepted models of disability suggest that actual use of an impaired upper extremity in everyday life frequently deviates from its motor capacity, as measured by laboratory tests. Yet, direct measures of real-world use of an impaired upper extremity are rare in pediatric neurorehabilitation. This paper examines how well the Pediatric Motor Activity Log-Revised (PMAL-R) measures this parameter, when the PMAL-R is administered as a structured interview as originally designed.

DESIGN

Parents of 60 children between 2 and 8 years of age with upper-extremity hemiparesis due to cerebral palsy completed the PMAL-R twice. Additionally, the children were videotaped during play structured to elicit spontaneous arm use. More-affected arm use was scored by masked raters; it was thought to reflect everyday activity since no cues were given about which arm to employ. Testing sessions were separated by 3 weeks, during which 29 children received upper-extremity rehabilitation and 31 did not.

RESULTS

The PMAL-R had high internal consistency (Cronbach's alpha = .93) and test-retest reliability (r = .89). Convergent validity was supported by a strong correlation between changes in PMAL-R scores and more-affected arm use during play, r(53) = .5, p < .001.

CONCLUSIONS

The PMAL-R interview is a reliable and valid measure of upper-extremity pediatric neurorehabilitation outcome.

Constraint-induced movement therapy for the lower extremities in multiple sclerosis: case series with 4-year follow-up

OBJECTIVE

To evaluate in a preliminary manner the feasibility, safety, and efficacy of Constraint-Induced Movement therapy (CIMT) of persons with impaired lower extremity use from multiple sclerosis (MS).

DESIGN

Clinical trial with periodic follow-up for up to 4 years.

SETTING

University-based rehabilitation research laboratory.

PARTICIPANTS

A referred sample of ambulatory adults with chronic MS (N=4) with at least moderate loss of lower extremity use (average item score ≤6.5/10 on the functional performance measure of the Lower Extremity Motor Activity Log [LE-MAL]).

INTERVENTIONS

CIMT was administered for 52.5 hours over 3 consecutive weeks (15 consecutive weekdays) to each patient.

MAIN OUTCOME MEASURES

The primary outcome was the LE-MAL score at posttreatment. Secondary outcomes were posttreatment scores on laboratory assessments of maximal lower extremity movement ability.

RESULTS

All the patients improved substantially at posttreatment on the LE-MAL, with smaller improvements on the laboratory motor measures. Scores on the LE-MAL continued to improve for 6 months afterward. By 1 year, patients remained on average at posttreatment levels. At 4 years, half of the patients remained above pretreatment levels. There were no adverse events, and fatigue ratings were not significantly changed by the end of treatment.

CONCLUSIONS

This initial trial of lower extremity CIMT for MS indicates that the treatment can be safely administered, is well tolerated, and produces substantially improved real-world lower extremity use for as long as 4 years afterward. Further trials are needed to determine the consistency of these findings.

Constraint-induced movement therapy combined with conventional neurorehabilitation techniques in chronic stroke patients with plegic hands: a case series

OBJECTIVE

To determine whether the combination of Constraint-Induced Movement Therapy (CIMT) and conventional rehabilitation techniques can produce meaningful motor improvement in chronic stroke patients with initially fisted hands.

DESIGN

Case series.

SETTING

University hospital outpatient laboratory.

PARTICIPANTS

Consecutive sample (N=6) >1 year poststroke with plegic hands.

INTERVENTIONS

Treatment consisted of an initial period of 3 weeks (phase A) when adaptive equipment in the home, orthotics, and splints were employed to improve ability to engage in activities of daily living. This was continued in phase B, when CIMT and selected neurodevelopmental treatment techniques were added.

MAIN OUTCOME MEASURES

Motor Activity Log (MAL), accelerometry, Fugl-Meyer Motor Assessment (F-M).

RESULTS

Patients exhibited a large improvement in spontaneous real-world use of the more-affected arm (mean lower-functioning MAL change=1.3±0.4 points; P<.001; d'=3.0) and a similar pattern of increase in an objective measure of real-world more-affected arm movement (mean change in ratio of more- to less-affected arm accelerometer recordings=0.12±0.1 points; P=.016; d'=1.2). A large improvement in motor status was also recorded (mean F-M change=5.3±3.3 points; P=.005; d'=1.6).

CONCLUSIONS

The findings of this pilot study suggest that stroke patients with plegic hands can benefit from CIMT combined with some conventional rehabilitation techniques, even long after brain injury. More research is warranted.

Sensor-enabled RFID system for monitoring arm activity: reliability and validity

After stroke, capacity to complete tasks in the treatment setting with the more-affected arm is an unreliable index of actual use of that extremity in daily life. Available objective methods for monitoring real-world arm use rely on placing movement sensors on patients. These methods provide information on amount but not type of arm activity, e.g., functional versus nonfunctional movement. This paper presents an approach that places sensors on patients and household objects, overcoming this limitation. An accelerometer and the transmitter component of a radio-frequency proximity sensor are attached to objects; the receiver component is attached to the arm of interest. The receiver triggers an on-board radio-frequency identification tag to signal proximity when that arm is within 23 cm of an instrumented object. In benchmark testing, this system detected perfectly which arm was used to move the target object on 200 trials. In a laboratory study with 35 undergraduates, increasing the amount of time target objects were moved with the arm of interest resulted in a corresponding increase in system output . Moreover, measurement error was low ( ≤ 2.5%). The results support this system's reliability and validity in individuals with unimpaired movement; testing is now warranted in stroke patients.

A telerehabilitation platform for home-based automated therapy of arm function

Constraint-Induced Movement Therapy (CI therapy) has been shown to be an effective approach for improving arm function in stroke survivors with mild to severe hemiparesis. Given the time-intensive nature of the intervention, and the inherent costs and travel required to receive in-clinic treatment, the accessibility and availability of CI therapy is limited. To facilitate home-based CI therapy, a telerehabilitation platform has been developed. It consists of a table-top workstation configured with a range of physical task devices (e.g. pegboard, object flipping, threading, vertical reaching). A desktop PC is used to acquire data from sensors embedded in the task devices; display visual instructions, stimuli, and feedback to the patient during tasks; and provide videoconferencing and remote connection capabilities so the therapist can interact with and monitor the patient during at-home therapy sessions. This system has potential to greatly expand access to CI therapy and make it a more realistic option for a larger number of stroke survivors with upper extremity impairment.

Atrophy of spared gray matter tissue predicts poorer motor recovery and rehabilitation response in chronic stroke

BACKGROUND AND PURPOSE

Although the motor deficit after stroke is clearly due to the structural brain damage that has been sustained, this relationship is attenuated from the acute to chronic phases. We investigated the possibility that motor impairment and response to constraint-induced movement therapy in patients with chronic stroke may relate more strongly to the structural integrity of brain structures remote from the lesion than to measures of overt tissue damage.

METHODS

Voxel-based morphometry analysis was performed on MRI scans from 80 patients with chronic stroke to investigate whether variations in gray matter density were correlated with extent of residual motor impairment or with constraint-induced movement therapy-induced motor recovery.

RESULTS

Decreased gray matter density in noninfarcted motor regions was significantly correlated with magnitude of residual motor deficit. In addition, reduced gray matter density in multiple remote brain regions predicted a lesser extent of motor improvement from constraint-induced movement therapy.

CONCLUSIONS

Atrophy in seemingly healthy parts of the brain that are distant from the infarct accounts for at least a portion of the sustained motor deficit in chronic stroke.

Treatment of congenital hemiparesis with pediatric constraint-induced movement therapy

To determine efficacy of pediatric Constraint-Induced Movement therapy, 20 children with congenital hemiparesis (ages 2 to 6 years) were randomly assigned to receive the treatment or usual care. Controls crossed over to the therapy after 6 months. Children receiving the therapy first exhibited emergence of more new classes of motor patterns and skills (eg, crawling, thumb-forefinger prehension; 6.4 vs 0.02, P < .0001, effect size d = 1.3), and demonstrated significant gains in spontaneous use of the more affected arm at home (2.2 vs 0.1, P < .0001, d = 3.8) and in a laboratory motor function test. Depending on the measure, benefits were maintained (range, no loss to 68% retention over 6 months). When controls crossed over to the therapy, they exhibited improvements as great as or greater than those receiving therapy first. Thus, Constraint-Induced Movement therapy appears to be efficacious for young children with hemiparesis consequent to congenital stroke.

Sensor-enabled RFID system for monitoring arm activity in daily life

After stroke, capacity to carry out tasks in the treatment setting with the more-affected arm is a poor index of actual use of that extremity in daily life. However, objective methods currently available for monitoring real-world upper-extremity use only provide information on amount of activity. These methods, which rely on movement sensors worn by patients, do not provide information about type of activity (e.g., functional vs. nonfunctional movement). The benchmark testing reported here evaluated an approach that involves placing sensors on patients and objects. An accelerometer and the transmitter component of a prototype radio frequency proximity sensor were attached to household objects. The receiver component was placed on the experimenter's right arm. This device triggered an on-board radio frequency identification tag to signal proximity when that arm was within 23 cm of the objects. The system detected > 99% of 6 cm or greater movements of objects. When handling of objects by the right or left arm was determined randomly, 100% of right arm trials were detected. No signals were recorded when objects were at rest or moved by the left arm. Testing of this approach, which monitors manipulation of objects (i.e., functional movement), is now warranted in stroke patients.

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Measurement structure of the Wolf Motor Function Test: implications for motor control theory

BACKGROUND

Tools chosen to measure poststroke upper-extremity rehabilitation outcomes must match contemporary theoretical expectations of motor deficit and recovery because an assessment's theoretical underpinning forms the conceptual basis for interpreting its score.

OBJECTIVE

The purpose of this study was to investigate the theoretical framework of the Wolf Motor Function Test (WMFT) by (1) determining whether all items measured a single underlying trait and (2) examining the congruency between the hypothesized and the empirically determined item difficulty orders.

METHODS

Confirmatory factor analysis (CFA) and Rasch analysis were applied to existing WMFT Functional Ability Rating Scale data from 189 participants in the EXCITE (Extremity Constraint-Induced Therapy Evaluation) trial. Fit of a 1-factor CFA model (all items) was compared with the fit of a 2-factor CFA model (factors defined according to item object-grasp requirements) with fit indices, model comparison test, and interfactor correlations.

RESULTS

One item was missing sufficient data and therefore removed from analysis. CFA fit indices and the model-comparison test suggested that both models fit equally well. The 2-factor model yielded a strong interfactor correlation, and 13 of 14 items fit the Rasch model. The Rasch item difficulty order was consistent with the hypothesized item difficulty order.

CONCLUSION

The results suggest that WMFT items measure a single construct. Furthermore, the results depict an item difficulty hierarchy that may advance the theoretical discussion of the person ability versus task difficulty interaction during stroke recovery.