Constraint-Induced Movement Therapy After Stroke: Efficacy for Patients With Minimal Upper-Extremity Motor Ability

Validity and reliability of the functional test for hemiplegic upper Extremity-Thai version

Background

There are very few standard instruments currently available for measuring upper extremity (UE) functions for patients with stroke in Thailand.

Objectives

This study aims to examine the concurrent validity, construct validity, and stability reliability of the Functional Test for Hemiplegic Upper Extremity (FTHUE)-Thai version for patients with stroke.

Methods

Thirty hemiplegic participants from five community rehabilitation centers in Chiang Mai province and 30 healthy subjects were recruited. The FTHUE-Thai version and the Fugl-Meyer Assessment for the Upper Extremity (FMA-UE) were the instruments used. Concurrent validity was determined by investigating the relationship between the FTHUE-Thai version and the FMA-UE. Construct validity was investigated by comparing the performance of FTHUE-Thai version between stroke participants and healthy subjects. The stability reliability of the FTHUE-Thai version, which measured the UE function of stroke participants twice in a two-week's period, was also investigated. The statistics used were Spearman's correlation coefficient and the Mann-Whitney test.

Results

There were significant correlations between the UE function, as measured by the FTHUE-Thai version, and the arm, and hand sub-scores, as well as the total scores of the FMA-UE (r = 0.93, r = 0.84, and r = 0.95, respectively), indicating good concurrent validity. Stability reliability was also good (r = 0.98, weighted kappa = 0.94). A known group technique test revealed significantly different scores between stroke patients and healthy subjects (p < .001), indicating good construct validity.

Conclusion

The FTHUE-Thai version could be a reliable measurement tool for the UE function in stroke patients in the Thai context.

Combining Cyproheptadine Hydrochloride With Targeted Muscle Activation Training to Treat Upper Extremity Stroke: A Randomized, Placebo-Controlled Trial

OBJECTIVE

To examine a treatment for upper extremity impairment in stroke survivors that combines administration of cyproheptadine hydrochloride with repetitive practice focused on control of muscle activation patterns.

DESIGN

Double-blind, randomized controlled trial.

SETTINGS

Laboratory within a free-standing rehabilitation hospital.

PARTICIPANTS

A total of 94 stroke survivors with severe, chronic hand impairment were randomly assigned to 1 of 4 treatment groups.

INTERVENTIONS

Participants received either a placebo or cyproheptadine hydrochloride in identical pill form. The daily dosage of cyproheptadine/placebo was gradually increased from 8 to 24 mg/d over 3 weeks and then maintained over the next 6 weeks while participants completed 18 therapy sessions. Therapy consisted of either (1) active practice of muscle activation patterns to play "serious" computer games or control a custom hand exoskeleton or (2) passive, cyclical finger stretching imposed by the exoskeleton.

MAIN OUTCOME MEASURES

Hand control was evaluated with the primary outcome measure of time to complete the Graded Wolf Motor Function Test (GWMFT) and secondary outcome measures including finger strength and spasticity.

RESULTS

Across the 88 participants who completed the study, a repeated-measures analysis of variance revealed a significant effect of GroupxEvaluation interaction on GWMFT (F=1.996, P=.026). The 3 groups receiving cyproheptadine and/or actively practicing muscle activation pattern control exhibited significant reduction in mean time to complete the GWMFT tasks; roughly one-third of these participants experienced at least a 10% reduction in completion time. Gains were maintained at the 1-month follow-up evaluation. The group receiving placebo and passive stretching did not show improvement. No significant differences among groups were observed in terms of changes in strength or spasticity.

CONCLUSIONS

Despite chronic, severe impairment, stroke survivors were able to complete the therapy focused on muscle activations and achieved statistically significant improvement in hand motor control. Cyproheptadine hydrochloride is a potential complementary treatment modality for stroke survivors with hand impairment.

How does combining physical therapy with transcranial direct stimulation improve upper-limb motor functions in patients with stroke? A theory perspective

More than half of stroke survivors suffer from upper-limb dysfunction that persists years after stroke, negatively impacting patients' independence and, therefore, affecting their quality of life. Intense motor rehabilitation is required after a stroke to facilitate motor recovery. More importantly, finding new ways to maximize patients' motor recovery is a core goal of stroke rehabilitation. Thus, researchers have explored the potential benefits of combining the effects of non-invasive brain stimulation with physical therapy rehabilitation. Specifically, combining transcranial direct stimulation (tDCS) with neurorehabilitation interventions can boost the brain's responses to interventions and maximize the effects of rehabilitation to improve upper-limb recovery post-stroke. However, it is still unclear which modes of tDCS are optimal for upper-limb motor recovery in patients with stroke when combined with physical therapy interventions. Here, the authors review the existing literature suggesting combining physical therapy rehabilitation with tDCS can maximize patients' motor recovery using the Interhemispheric Competition Model in Stroke. The authors focus on two main rehabilitation paradigms, which are constraint-induced movement therapy (CIMT) and Mirror therapy with and without tDCS. The authors also discuss potential studies to elucidate further the benefit of using tDCS adjunct with these upper-limb rehabilitation paradigms and its effectiveness in patients with stroke, with the ultimate goal of maximizing patients' motor recovery.

Global research hotspots and trends in constraint-induced movement therapy in rehabilitation over the past 30 years: a bibliometric and visualization study

Background

Stroke is a cerebrovascular disease with high prevalence and mortality, and upper limb hemiparesis is a major factor limiting functional recovery in stroke patients. Improvement of motor function in stroke patients through various forms of constraint-induced movement therapy (CITM) has been recognized as safe and effective in recent years. This research field lacks a comprehensive systematic and clear vein combing analysis, analyzing the literature research of CIMT in the field of rehabilitation in the past three decades, summarizing the research hotspots and cutting-edge trends in this field, in an effort to offer ideas and references for subsequent researchers.

Methods

Relevant literature on CIMT in rehabilitation was collected from 1996 to 2024 within the Web of Science database's core dataset by using CiteSpace6.1, VOSviewer1.6.18, R-bibliometrix4.6.1, Pajek5.16, Scimago Graphica 1.0.26 software for visualization and analysis.

Results

There were 970 papers in all United States was ranked first with 401 papers. Alabama Univ was ranked first for institutions with 53 papers. Neurorehabilitation and Neural Repair was ranked first for journals with 78 papers, and Taub E was ranked first for author publications with 64 papers. Research keywords were CIMT, stroke rehabilitation, upper extremity function, lower extremity gait balance, randomized controlled trials, physical therapy techniques (transcranial magnetic stimulation and sensory amplitude electrical stimulation), primary motor cortex plasticity, lateral dominance (spatial behaviors), cerebral vascular accidents, activities of daily living, hand function, disability, functional restoration, bimanual training, aphasia, acquired invalidity, type A Botulinum toxin and joystick riding toys.

Conclusion

The current state of research shows that CIMT still has a vast potential for development in the field of rehabilitation research. The research hotspots are the clinical efficacy of CIMT combined with other therapies (botulinum toxin type A, transcranial direct current stimulation, virtual reality, mirror therapy, robotic-assisted) to enhance the functionality of upper limb hemiparesis in stroke patients, the mechanism of CIMT to improve the plasticity of the motor cortex through electrophysiological and imaging methods, and improvement of lower limb gait balance function in stroke patients and aphasia applications, the optimal intervention time and dose, and exploration of CIMT in new settings such as robot-assisted, telemedicine, and home rehabilitation.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Recovery of Patients With Upper Limb Paralysis Due to Stroke Who Underwent Intervention Using Low-Frequency Repetitive Transcranial Magnetic Stimulation Combined With Occupational Therapy: A Retrospective Cohort Study

OBJECTIVES

The combination of repetitive transcranial magnetic stimulation (rTMS) and motor practice is based on the theory of neuromodulation and use-dependent plasticity. Predictive planning of occupational therapy (OT) is important for patients with rTMS conditioning. Recovery characteristics based on the severity of pretreatment upper extremity paralysis can guide the patient's practice plan for using the paretic hand. Therefore, we evaluated the recovery of patients with upper limb paralysis due to stroke who underwent a novel intervention of rTMS combined with OT (NEURO) according to the severity of upper limb paralysis based on the scores of the Fugl-Meyer assessment for upper extremity (FMA-UE) with recovery in proximal upper extremity, wrist, hand, and coordination.

MATERIALS AND METHODS

In this multicenter retrospective cohort study, the recovery of 1397 patients with upper limb paralysis was analyzed by severity at six hospitals that were accredited by the Japanese Stimulation Therapy Society for treatment. The delta values of the FMA-UE scores before and after NEURO were compared among the groups with severe, moderate, and mild paralysis using the generalized linear model.

RESULTS

NEURO significantly improved the FMA-UE total score according to the severity of paralysis (severe = 5.3, moderate = 6.0, and mild = 2.9). However, when the FMA-UE subscores were analyzed separately, the results indicated specific improvements in shoulder/elbow, wrist, fingers, and coordination movements, depending on the severity.

CONCLUSIONS

This study had enough patients who were divided according to severity and stratified by lesion location and handedness parameters. Our results suggest that independently of these factors, the extent of recovery of upper limb motor parts after NEURO varies according to the severity of paralysis.

Effects of virtual reality training in the upper limb motor coordination of individuals post- stroke: a systematic review with meta-analysis

ABSTRACT After a stroke, 75% of people are affected in their upper limbs, remaining with sequelae at these limbs. Results from recent clinical trials have been contradictory regarding the effectiveness of Virtual Reality (VR) therapy in rehabilitating upper limb motor coordination in this population. This study aimed to perform a systematic literature review with meta-analysis to investigate the effects of VR training on upper limb motor coordination in patients post-stroke. Searches were performed in the electronic databases PubMed, LILACS, SciELO, PEDro, in addition to manual searches. The whole process was performed by two independent raters. The methodological quality of the studies was assessed by the PEDro scale. In total, we selected 18 studies, out of which only 13 were included in the meta-analysis. In general, VR training was effective in improving upper limb motor coordination (SMD 0.32; 95% CI 0.08-0.56; I2=42%; p<0.01). When subgroup analysis assessed control group type, VR training was superior than no intervention (SMD 0.36; 95% CI: 0.06-0.66; p<0.05). However, when compared to other interventions, we found no significant difference (SMD 0.26; 95% CI: −0.12-0.64; p=0.18). Overall, VR training is effective in improving upper limb motor coordination in post-stroke individuals compared to no intervention. However, it shows no superiority when compared to other types of intervention used in the rehabilitation of upper limb motor coordination in these patients.

Efeitos do treino de realidade virtual na coordenação motora dos membros superiores de indivíduos após acidente vascular encefálico: uma revisão sistemática com meta-análise

RESUMO Após um acidente vascular encefálico (AVE), 75% das pessoas tem o membro superior acometido, permanecendo com sequelas nessa extremidade. Resultados de ensaios clínicos recentes são contraditórios quanto à eficácia da terapia de realidade virtual (RV) na reabilitação da coordenação motora dos membros superiores dessa população. Assim, o objetivo deste trabalho foi realizar uma revisão sistemática da literatura, com meta-análise, a fim de investigar os efeitos do treinamento com RV na coordenação motora dos membros superiores em pacientes pós-AVE. Para isso, foram feitas buscas nas bases de dados PubMed, LILACS, SciELO, PEDro e buscas manuais. Esse processo foi realizado por dois avaliadores independentes, e a qualidade metodológica dos estudos foi avaliada pela escala PEDro. Foram selecionados 18 estudos, sendo que apenas 13 foram incluídos na meta-análise. De forma geral, o treino de RV se mostrou eficaz na melhora da coordenação motora dos membros superiores da população (SMD 0,32; IC95% 0,08 a 0,56; I2=42%; p<0,01). Após uma análise de subgrupos, o treino de RV demonstrou ser superior quando comparado a nenhuma intervenção (SMD 0,36; IC95% 0,06 a 0,66; p<0,05). No entanto, quando comparado a outras intervenções, não houve diferença significativa (SMD 0,26; IC95% −0,12 a 0,64; p=0,18). De forma geral, o treino de RV é eficaz na melhora da coordenação motora dos membros superiores de indivíduos pós-AVE em comparação a nenhuma intervenção. No entanto, não é superior quando comparado a outros tipos de intervenção utilizados na reabilitação da coordenação motora dos membros superiores dos pacientes.

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

Background:

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

Objective:

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

Methods:

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

Results:

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

Conclusions:

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

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.

The reliability of the graded Wolf Motor Function Test for stroke

Introduction

The graded Wolf Motor Function Test assesses upper limb function following stroke. Clinical utility is limited by the requirement to video record for scoring purposes. This study aimed to (a) assess whether video recording is required through examination of inter-rater reliability and agreement; and (b) assess intra-rater reliability and agreement.

Method

A convenience sample of 30 individuals were recruited following stroke. The graded Wolf Motor Function Test was administered within 2 weeks of rehabilitation commencement and at 3 months. Two occupational therapists scored participants through either direct observation or video. Inter- and intra-rater reliability and agreement were examined for item-level and summary scores.

Results

Excellent inter-rater reliability ( n = 28) was found between scoring through direct observation and by video (intraclass correlation coefficients >0.9), and excellent intra-rater reliability ( n = 21) was found (intraclass correlation coefficients >0.9) for item-level and summary scores. Low agreement was found between raters at the item level. Adequate agreement was found for total functional ability, with increased measurement error found for total performance time.

Conclusion

The graded Wolf Motor Function Test is a reliable measure of upper limb function. Video recording may not be required by therapists. In view of low agreement, future studies should assess the impact of standardised training.

Reliability, validity and discriminant ability of a robotic device for finger training in patients with subacute stroke

Background

The majority of stroke survivors experiences significant hand impairments, as weakness and spasticity, with a severe impact on the activity of daily living. To objectively evaluate hand deficits, quantitative measures are needed. The aim of this study is to assess the reliability, the validity and the discriminant ability of the instrumental measures provided by a robotic device for hand rehabilitation, in a sample of patients with subacute stroke.

Material and methods

In this study, 120 patients with stroke and 40 controls were enrolled. Clinical evaluation included finger flexion and extension strength (using the Medical Research Council, MRC), finger spasticity (using the Modified Ashworth Scale, MAS) and motor control and dexterity during ADL performance (by means of the Frenchay Arm Test, FAT). Robotic evaluations included finger flexion and extension strength, muscle tone at rest, and instrumented MAS and Modified Tardieu Scale. Subjects were evaluated twice, one day apart, to assess the test-retest reliability of the robotic measures, using the Intraclass Correlation Coefficient (ICC). To estimate the response stability, the standard errors of measurement and the minimum detectable change (MDC) were also calculated. Validity was assessed by analyzing the correlations between the robotic metrics and the clinical scales, using the Spearman’s Correlation Coefficient (r). Finally, we investigated the ability of the robotic measures to distinguish between patients with stroke and healthy subjects, by means of Mann-Whitney U tests.

Results

All the investigated measures were able to discriminate patients with stroke from healthy subjects (p < 0.001). Test-retest reliability was found to be excellent for finger strength (in both flexion and extension) and muscle tone, with ICCs higher than 0.9. MDCs were equal to 10.6 N for finger flexion, 3.4 N for finger extension, and 14.3 N for muscle tone. Conversely, test-retest reliability of the spasticity measures was poor. Finally, finger strength (in both flexion and extension) was correlated with the clinical scales (r of about 0.7 with MRC, and about 0.5 with FAT).

Discussion

Finger strength (in both flexion and extension) and muscle tone, as provided by a robotic device for hand rehabilitation, are reliable and sensitive measures. Moreover, finger strength is strongly correlated with clinical scales. Changes higher than the obtained MDC in these robotic measures could be considered as clinically relevant and used to assess the effect of a rehabilitation treatment in patients with subacute stroke.

Post-stroke motor recovery and cortical organization following Constraint-Induced Movement Therapies: a literature review

[Purpose] This review synthesizes findings from studies on two forms of Constraint-Induced Movement Therapies: the original Constraint-Induced Movement Therapy and the modified Constraint-Induced Movement Therapy, in adult stroke patients including the evidence, current limitations and future directions. [Methods] We critically reviewed studies evaluating the effectiveness of Constraint-Induced Movement Therapies in chronic stoke focusing on the functional (i.e. motor recovery) and the neural (i.e. cortical organization) levels. [Results] Constraint-Induced Movement Therapies seemed to improve the upper limb functional usage in chronic stoke with no reliable neurophysiological underlying mechanisms. The Motor Activity Log was the common outcome measuring motor recovery. The work that has been done on modified Constraint-Induced Movement Therapy was far less than the work done on the original Constraint-Induced Movement Therapy. [Conclusion] Evident lack of understanding of the association between changes in motor recovery and the underlying neural mechanisms in-terms of measures of assessing and defining functional recovery (i.e Motor Activity Log) that lacks sufficient sensitivity to characterize changes in movement strategies and thereby lack of distinction between recovery and behavioral compensation. Future studies should employ using kinematic metrics to quantify and explain the training-related changes in behavior following Constraint-Induced Movement Therapies in chronic stroke.

A systematic review of the application and psychometric properties of the graded Wolf Motor Function Test

Introduction

Adapted from the Wolf Motor Function Test, the graded Wolf Motor Function Test is an upper limb activity assessment for use following stroke and brain injury. The aim of this systematic review was to identify and appraise evidence where the test has been used or has undergone psychometric evaluation.

Method

A systematic review of five databases was conducted to identify studies reporting the graded Wolf Motor Function Test using a keyword search. Intervention and clinical measurement studies were eligible for inclusion. Data quality was assessed using the adapted Critical Appraisal Skills Programme questions and the Consensus-based Standards for the Selection of Health Measurement Instruments Risk of Bias checklist.

Results

Twelve studies, of mostly low quality, were included. Studies included one randomised controlled trial, 10 pre- and post-studies and one clinical measurement study. All studies involved participants following stroke. Reliability was the only measurement property assessed in two studies, which were of a ‘doubtful’ and ‘poor’ quality.

Conclusion

Low quality studies impede the ability of clinicians and researchers to best determine the applicability of the graded Wolf Motor Function Test to patient groups and research contexts. Further exploration of the psychometric properties of the graded Wolf Motor Function Test is recommended across stroke populations using rigorous design methods.

Motor-imagery ability and function of hemiplegic upper limb in stroke patients

Objectives

We quantitatively examined the motor‐imagery ability in stroke patients using a bimanual circle‐line coordination task (BCT) and clarified the relationship between motor‐imagery ability and motor function of hemiplegic upper limbs and the level of use of paralyzed limbs.

Methods

We enrolled 31 stroke patients. Tasks included unimanual‐line (U‐L)—drawing straight lines on the nonparalyzed side; bimanual circle‐line (B‐CL)—drawing straight lines with the nonparalyzed limb while drawing circles with the paralyzed limb; and imagery circle‐line (I‐CL)—drawing straight lines on the nonparalyzed side during imagery drawing on the paralyzed side, using a tablet personal computer. We calculated the ovalization index (OI) and motor‐imagery ability (image OI). We used the Fugl–Meyer motor assessment (FMA), amount of use (AOU), and quality of motion (QOM) of the motor activity log (MAL) as the three variables for cluster analysis and performed mediation analysis.

Results

Clusters 1 (FMA <26 points) and 2 (FMA ≥26 points) were formed. In cluster 2, we found significant associations between image OI and FMA, AOU, and QOM. When AOU and QOM were mediated between image OI and FMA, we observed no significant direct association between image OI and FMA, and a significant indirect effect of AOU and QOM.

Interpretation

In stroke patients with moderate‐to‐mild movement disorder, image OI directly affects AOU of hemiplegic upper limbs and their QOM in daily life and indirectly influences the motor functions via those parameters.

Effects of task-oriented training on upper extremity functional performance in patients with sub-acute stroke: a randomized controlled trial

[Purpose] The present study aimed to determine the effects of a task-oriented training on paretic upper extremity functional performance in patients with subacute stroke. [Participants and Methods] Twenty-eight subacute stroke sufferers (mean age: 50.07, standard deviation 9.31 years; mean time since stroke 11.11, standard deviation 6.73 weeks) were randomly allocated to task-oriented training (n=14) or conventional exercise program (n=14) group. They were trained as a hospital-based, individualized training 1 hour a session, 5 sessions a week for 4 weeks. Wolf Motor Function Test (primary outcome), motor portion of Fugl-Meyer assessment upper extremity, and hand function domain of Stroke Impact Scale were assessed at baseline, after 2 and 4 weeks of training. [Results] All participants completed their training programs. At all post-training assessments, the task-oriented training group showed significantly more improvements in all outcomes than the conventional exercise program group. No serious adverse effects were observed during or after the training. [Conclusion] Task-oriented training produced statistically significant and clinically meaningful improvements of paretic upper extremity functional performance in patients with subacute stroke. These beneficial effects were observed after 2 weeks (10 hours) of training. Future investigation is warranted to confirm and expand these findings.

Validation of the efficiency of a robotic rehabilitation training system for recovery of severe plegie hand motor function after a stroke

We have developed a rehabilitation training system called the Useful and Ultimate Rehabilitation System PARKO (UR System PARKO) to promote the recovery of motor function of the severe chronic plegic hand of stroke patients. This system was equipped with two functions to realize two conditions: (1) fixing of all fingers to a hyperextended position and (2) extending the elbow joint while applying resistance load to the fingertips. A clinical test was conducted with two patients to determine the therapeutic effect of the UR System PARKO for severe plegic hand. In both patients, the active ranges of motion of finger extension improved after training with the UR System PARKO. Moreover, the Modified Ashworth scale scores of finger extension increased. Thus, training reduced the spastic paralysis. These results suggest the effectiveness of training with the UR System PARKO for recovery of motor function as reflected in the finger extension of the severe plegic hand.

Observational Study of 180° Turning Strategies Using Inertial Measurement Units and Fall Risk in Poststroke Hemiparetic Patients

Objective

We analyzed spontaneous 180° turning strategies in poststroke hemiparetic patients by using inertial measurement units (IMUs) and the association of turning strategies with risk of falls.

Methods

We included right paretic (RP) and left paretic (LP) post-stroke patients, and healthy controls (HCs) from a physical and rehabilitation department in France between July 2015 and October 2015. All subjects were right-handed and right-footed for mobilization tasks. Participants were instructed to turn 180° in a self-selected direction after a 10-m walk while wearing three IMUs on their trunk and both feet. We defined three turning patterns based on the number of external steps (pattern I = 1; II = 2–4 steps; and III ≥ 5) and four turning strategies based on the side chosen to turn (healthy or paretic) and the stance limb used during the first step of the turn (healthy or paretic). Falls in the 6 months after measurement were investigated.

Results

We included 17 RP [mean (SD) age 57.5 (9.5) years (range 43–73)], 20 LP patients [mean age 60.7 (8.8) years (range 43–63)], and 15 HCs [mean age 56.7 (16.1) years (range 36–83)]. The LP and RP groups behaved similarly in turning patterns, but 90% of LP patients turned spontaneously to the paretic side versus 59% of RP patients. This difference increased with turning strategies: 85% of LP versus 29% of RP patients used strategy 4 (paretic turn side with paretic limb). Patients using strategy 4 had the highest rate of falls.

Conclusion

We propose to consider spontaneous turning strategies as new indicators to evaluate the risk of fall after stroke. IMU could be routinely used to identify this risk and guide balance rehabilitation programs.

Effects of observation of hand movements reflected in a mirror on cortical activation in patients with stroke

[Purpose] The purpose of this study was to examine what changes occur in brain waves when patients with stroke receive mirror therapy intervention. [Subjects and Methods] The subjects of this study were 14 patients with stroke (6 females and 8 males). The subjects were assessed by measuring the alpha and beta waves of the EEG (QEEG-32 system CANS 3000). The mirror therapy intervention was delivered over the course of four weeks (a total of 20 sessions). [Results] Relative alpha power showed statistically significant differences in the F3, F4, O1, and O2 channels in the situation comparison and higher for hand observation than for mirror observation. Relative beta power showed statistically significant differences in the F3, F4, C3, and C4 channels. [Conclusion] This study analyzed activity of the brain in each area when patients with stroke observed movements reflected in a mirror, and future research on diverse tasks and stimuli to heighten activity of the brain should be carried out.

Constraint-Induced Movement Therapy Combined with Transcranial Direct Current Stimulation over Premotor Cortex Improves Motor Function in Severe Stroke: A Pilot Randomized Controlled Trial

Objective. We compared the effects of transcranial direct current stimulation at different cortical sites (premotor and motor primary cortex) combined with constraint-induced movement therapy for treatment of stroke patients. Design. Sixty patients were randomly distributed into 3 groups: Group A, anodal stimulation on premotor cortex and constraint-induced movement therapy; Group B, anodal stimulation on primary motor cortex and constraint-induced movement therapy; Group C, sham stimulation and constraint-induced movement therapy. Evaluations involved analysis of functional independence, motor recovery, spasticity, gross motor function, and muscle strength. Results. A significant improvement in primary outcome (functional independence) after treatment in the premotor group followed by primary motor group and sham group was observed. The same pattern of improvement was highlighted among all secondary outcome measures regarding the superior performance of the premotor group over primary motor and sham groups. Conclusions. Premotor cortex can contribute to motor function in patients with severe functional disabilities in early stages of stroke. This study was registered in ClinicalTrials.gov database (NCT 02628561).

Usability Evaluation of a VibroTactile Feedback System in Stroke Subjects

Background

To increase the functional capabilities of stroke subjects during activities of daily living, patients receive rehabilitative training to recover adequate motor control. With the goal to motivate self-training by use of the arm in daily life tasks, a sensor system (Arm Usage Coach, AUC) was developed that provides VibroTactile (VT) feedback if the patient does not move the affected arm above a certain threshold level. The objective of this study is to investigate the usability of this system in stroke subjects.

Method

The study was designed as a usability and user acceptance study of feedback modalities. Stroke subjects with mild to moderate arm impairments were enrolled. The subjects wore two AUC devices one on each wrist. VT feedback was given by the device on the affected arm. A semi-structured interview was performed before and after a measurement session with the AUC. In addition, the System Usability Scale (SUS) questionnaire was given.

Results

Ten ischemic chronic stroke patients (39 ± 38 months after stroke) were recruited. Four out of 10 subjects have worn the VT feedback on their dominant, affected arm. In the pre-measurement interview, eight participants indicated a preference for acoustic or visual over VT feedback. In the post evaluation interview, nine of 10 participants preferred VT over visual and acoustic feedback. On average, the AUC gave VT feedback six times during the measurement session. All participants, with the exception of one, used their dominant arm more then the non-dominant. For the SUS, eight participants responded above 80%, one between 70 and 80%, and one participant responded below 50%.

Discussion

More patients accepted and valued VT feedback after the test period, hence VT is a feasible feedback modality. The AUC can be used as a telerehabilitation device to train and maintain upper extremity use in daily life tasks.

Translation, cultural adaptation and reliability of the brazilian version of the Graded Wolf Motor Function Test in adults with severe hemiparesis

Abstract Introduction : The Graded Wolf Motor Function Test (GWMFT) was developed as a modification of the Wolf Motor Function Test (WMFT), designed to address moderate-to-severe upper-extremity motor impairment, consequent to a stroke or brain injury, by combining time and quality of movement measures in both isolated movements and functional tasks. Objectives : To translate and adapt the GWMFT form and instructions manual to Brazilian Portuguese and evaluate the inter-rater reliability. Materials and methods : Ten individuals, mean age 53.2 ± 11.39 (range: 28-72) years and a mean time since stroke onset of 82.5 ± 85.83 (16-288) months participated in the study. After translation and cultural adaptation, two independent evaluators, based on the instructions manual information, administered GWMFT. Video observations were used to rate the time and the compensatory movements in the Functional Ability Scale (FAS). Intra-class Correlation Coefficients (ICCs) and Bland-Altman plots were calculated to examine the inter-rater reliability for performance time and FAS. Results : The translated and adapted version obtained a total ICC inter-rater time 0.99 (0.95-1.00), showing less reliability in the task of lifting a pen, with ICC = 0.71 (- 0.15-0.93). The ICC of the total FAS was 0.98 (0.92-0.99) and the task of elbow extension has shown the lowest ICC rate = 0.83 (0.31-0.96). Conclusion : The GWMFT scale reliability proved to be appropriate to evaluate the paretic upper limb in individuals with chronic hemiparesis post severe stroke.

Hand Rehabilitation Following Stroke: A Pilot Study of Assisted Finger Extension Training in a Virtual Environment

BACKGROUND AND PURPOSE

The purpose of this pilot study was to investigate the impact of assisted motor training in a virtual environment on hand function in stroke survivors.

PARTICIPANTS

Fifteen volunteer stroke survivors (32-88 years old) with chronic upper extremity hemiparesis (1-38 years post incident) took part.

METHOD

Participants had 6 weeks of training in reach-to-grasp of virtual and actual objects. They were randomized to one of three groups: assistance of digit extension provided by a novel cable orthosis, assistance provided by a novel pneumatic orthosis, or no assistance provided. Hand performance was evaluated at baseline, immediately following training, and 1 month after completion of training. Clinical assessments included the Wolf Motor Function Test (WMFT), Box and Blocks Test (BB), Upper Extremity Fugl-Meyer Test (FM), and Rancho Los Amigos Functional Test of the Hemiparetic Upper Extremity (RLA). Biomechanical assessments included grip strength, extension range of motion and velocity, spasticity, and isometric strength.

RESULTS

Participants demonstrated a significant decrease in time to perform functional tasks for the WMFT (p = .02), an increase in the number of blocks successfully grasped and released during the BB (p = .09), and an increase for the FM score (p = .08). There were no statistically significant changes in time to complete tasks on the RLA or any of the biomechanical measures. Assistance of extension did not have a significant effect.

DISCUSSION AND CONCLUSION

After the training period, participants in all 3 groups demonstrated a decrease in time to perform some of the functional tasks. Although the overall gains were slight, the general acceptance of the novel rehabilitation tools by a population with substantial impairment suggests that a larger randomized controlled trial, potentially in a subacute population, may be warranted.

Sequencing bilateral and unilateral task-oriented training versus task oriented training alone to improve arm function in individuals with chronic stroke

BACKGROUND

Recovering useful hand function after stroke is a major scientific challenge for patients with limited motor recovery. We hypothesized that sequential training beginning with proximal bilateral followed by unilateral task oriented training is superior to time-matched unilateral training alone. Proximal bilateral training could optimally prepare the motor system to respond to the more challenging task-oriented training.

METHODS

PARTICIPANTS

Twenty-six participants with moderate severity hemiparesis Intervention: PARTICIPANTS received either 6-weeks of bilateral proximal training followed sequentially by 6-weeks unilateral task-oriented training (COMBO) or 12-weeks of unilateral task-oriented training alone (SAEBO). A subset of 8 COMB0 and 9 SAEBO participants underwent three functional magnetic resonance imaging (fMRI) scans of hand and elbow movement every 6 weeks.

MAIN OUTCOME MEASURES

Fugl-Meyer Upper extremity scale, Modified Wolf Motor Function Test, University of Maryland Arm Questionnaire for Stroke, Motor cortex activation (fMRI).

RESULTS

The COMBO group demonstrated significantly greater gains between baseline and 12-weeks over all outcome measures (p = .018 based on a MANOVA test) and specifically in the Modified Wolf Motor Function test (time). Both groups demonstrated within-group gains on the Fugl-Meyer Upper Extremity test (impairment) and University of Maryland Arm Questionnaire for Stroke (functional use). fMRI subset analyses showed motor cortex (primary and premotor) activation during hand movement was significantly increased by sequential combination training but not by task-oriented training alone.

CONCLUSIONS

Sequentially combining a proximal bilateral before a unilateral task-oriented training may be an effective way to facilitate gains in arm and hand function in those with moderate to severe paresis post-stroke compared to unilateral task oriented training alone.

CI Therapy is Beneficial to Patients with Chronic Low-Functioning Hemiparesis after Stroke

CI therapy is effective in patients with relatively good levels of residual arm function but its applicability to patients with low-functioning hemiparesis is not entirely clear. In the present study, we examined the feasibility and efficacy of the CI therapy concept in patients with very limited upper arm function prior to treatment, and further tested how the length of daily shaping training and constraining the good arm affects treatment outcome. In a baseline-controlled design, 65 chronic patients were treated with 2 weeks of modified CI therapy. Patients were randomly allocated to four treatment groups receiving 90 or 180 min of daily shaping training applied with or without constraint, respectively. Outcome was measured through the Reliable Change Index, which was calculated for parameters of motor function, health, and psychological wellbeing. Follow-up data were collected at 6 and 12 months. Two analyses were conducted, a whole-group analysis across all 65 participants and a sub-group analysis contrasting the four treatment variants. The whole-group analysis showed a significant treatment effect, which was largely sustained after 1 year. The sub-group analysis revealed a mixed picture; while improvements against the baseline period were observed in all four subgroups, 180 min of daily shaping training coupled with the constraint yielded better outcome on the MAL but not the WMFT, while for 90 min of training the level of improvement was similar for those who wore the constraint and those who did not. Together these results suggest that, at least in those patients available for follow-up measures, modified CI therapy induces sustained improvements in motor function in patients with chronic low-functioning hemiparesis. The absence of clear differences between the four treatment variants points to a complex relationship between the length of daily shaping training and the constraint in this patient group, which is likely to be mediated by fatigue and/or compliance with the constraint.

Effect of constraint-induced movement therapy and mirror therapy for patients with subacute stroke

OBJECTIVE

To evaluate the effectiveness of constraint-induced movement therapy (CIMT) and combined mirror therapy for inpatient rehabilitation of the patients with subacute stroke.

METHODS

Twenty-six patients with subacute stroke were enrolled and randomly divided into three groups: CIMT combined with mirror therapy group, CIMT only group, and control group. Two weeks of CIMT for 6 hours a day with or without mirror therapy for 30 minutes a day were performed under supervision. All groups received conventional occupational therapy for 40 minutes a day for the same period. The CIMT only group and control group also received additional self-exercise to substitute for mirror therapy. The box and block test, 9-hole Pegboard test, grip strength, Brunnstrom stage, Wolf motor function test, Fugl-Meyer assessment, and the Korean version of Modified Barthel Index were performed prior to and two weeks after the treatment.

RESULTS

After two weeks of treatment, the CIMT groups with and without mirror therapy showed higher improvement (p<0.05) than the control group, in most of functional assessments for hemiplegic upper extremity. The CIMT combined with mirror therapy group showed higher improvement than CIMT only group in box and block test, 9-hole Pegboard test, and grip strength, which represent fine motor functions of the upper extremity.

CONCLUSION

The short-term CIMT combined with mirror therapy group showed more improvement compared to CIMT only group and control group, in the fine motor functions of hemiplegic upper extremity for the patients with subacute stroke.

Effect of mental practice on the improvement of function and daily activity performance of the upper extremity in patients with subacute stroke: a randomized clinical trial

OBJECTIVES

More than 50% of patients with upper limb paresis after stroke face long-term impaired arm function and ensuing disability in daily life. This study aims to evaluate the effectiveness of a task-oriented mental practice (MP) approach as an addition to regular arm-hand therapy in patients with subacute stroke.

METHODS

A multicenter, prospective, single-blind, randomized clinical trial was performed. Patients trained for 6 weeks, at least 3 times per day. In the experimental group, patients performed video-instructed MP. In the control group, patients performed neurodevelopmental therapy-based exercise therapy. The primary outcome measures are Fugl-Meyer test, Frenchay arm test, Wolf motor function test, and accelerometry.

RESULTS

The patients did improve over time on Fugl-Meyer test and Wolf motor function test in both the control and the experimental group. A significant improvement on the Frenchay arm test was found after training (which was maintained at 12-month follow-up) only in the experimental group. However, no difference in training effects between groups was demonstrated.

CONCLUSIONS

Training effects were demonstrated after MP training in patients with subacute stroke. However, the results of this study do not corroborate the hypothesis that the use of MP in addition to therapy as usual in patients with subacute stroke has an additional effect over neurodevelopmental therapy in addition to therapy as usual.

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.

Improvement after constraint-induced movement therapy: recovery of normal motor control or task-specific compensation?

BACKGROUND

Constraint-induced movement therapy (CIMT) has proven effective in increasing functional use of the affected arm in patients with chronic stroke. The mechanism of CIMT is not well understood.

OBJECTIVE

To demonstrate, in a proof-of-concept study, the feasibility of using kinematic measures in conjunction with clinical outcome measures to better understand the mechanism of recovery in chronic stroke patients with mild to moderate motor impairments who undergo CIMT.

METHODS

A total of 10 patients with chronic stroke were enrolled in a modified CIMT protocol over 2 weeks. Treatment response was assessed with the Action Research Arm Test (ARAT), the Upper-Extremity Fugl-Meyer score (FM-UE), and kinematic analysis of visually guided arm and wrist movements. All assessments were performed twice before the therapeutic intervention and once afterward.

RESULTS

There was a clinically meaningful improvement in ARAT from the second pre-CIMT session to the post-CIMT session compared with the change between the 2 pre-CIMT sessions. In contrast, FM-UE and kinematic measures showed no meaningful improvements.

CONCLUSIONS

Functional improvement in the affected arm after CIMT in patients with chronic stroke appears to be mediated through compensatory strategies rather than a decrease in impairment or return to more normal motor control. We suggest that future large-scale studies of new interventions for neurorehabilitation track performance using kinematic analyses as well as clinical scales.

Barriers to the implementation of constraint-induced movement therapy into practice

BACKGROUND AND PURPOSE

Constraint-induced movement therapy (CIMT) has been studied for many years in the treatment of the hemiplegic upper extremity (UE). However, there has been limited adoption of the protocol in daily practice.

METHODS

In this article, we review the CIMT literature specifically for meta-analysis, randomized controlled trials (RCTs), recent case reports, case series, and pilot studies of CIMT in the adult poststroke population to identify barriers to implementation.

RESULTS

The following barriers have been identified: (a) limited generalizability, (b) resource intensity, (c) therapist factors, (d) patient factors, and (e) uncertainty regarding the emerging debate that the gains seen may be a result of intense, task-specific therapy focused on the use of the more affected UE and not specific to the protocol.

CONCLUSIONS

CIMT has positive outcomes in the treatment of a select group of stroke survivors. Many national guidelines of stroke rehabilitation recommend that CIMT be used when appropriate, however adoption into practice has been limited. The issue of generalizability is being addressed by expanding protocol application to other populations. Resource intensity, with respect to cost and therapist time, is a major concern and has lead to the development of novel modes of service delivery. The benefit seen with CIMT may actually be the result of exposure to intense, task-specific therapy with a focus on the use of the more affected UE, but more research into this area is needed.

Constraint-Induced Movement Therapy (CIMT): Current Perspectives and Future Directions

Constraint-induced movement therapy (CIMT) has gained considerable popularity as a treatment technique for upper extremity rehabilitation among patients with mild-to-moderate stroke. While substantial evidence has emerged to support its applicability, issues remain unanswered regarding the best and most practical approach. Following the establishment of what can be called the "signature" CIMT approach characterized by intense clinic/laboratory-based practice, several distributed forms of training, collectively known as modified constraint therapy (mCIMT), have emerged. There is a need to examine the strengths and limitations of such approaches, and based upon such information, develop the components of a study that would compare the signature approach to the best elements of mCIMT, referred to here as "alternative" CIMT. Based upon a PEDro review of literature, limitations in mCIMT studies for meeting criteria were identified and discussed. A suggestion for a "first effort" at a comparative study that would both address such limitations while taking practical considerations into account is provided.

Changes in the brain activation balance in motor-related areas after constraint-induced movement therapy; a longitudinal fMRI study

PRIMARY OBJECTIVE

This study investigated the longitudinal changes in brain activation balance in motor-related areas after Constraint-Induced Movement Therapy (CIMT).

METHODS AND PROCEDURES

The subjects included seven ischemic stroke patients with mild right hemiparesis. Eight normal subjects were also included. The patients underwent functional MRI and motor function tests (Fugl-Meyer Assessment; FMA, modified Wolf Motor Function Test; mWMFT) both before and immediately after CIMT and also after a 3-month follow-up.

RESULTS

The motor function test scores improved immediately after CIMT; moreover, these scores were either maintained or improved even at the 3-month follow-up. In a comparison of the chronological data of the contralaterality index of the affected hand movement, the cerebellar activity changed significantly to ipsilateral activation immediately after CIMT and thereafter the cerebellar activity further changed to ipsilateral activation at the 3-month follow-up. A correlation was observed among the contralateral activation, FMA and mWMFT scores in SM1 and the ipsilateral activation and in the mWMFT scores in the cerebellum at the 3-month follow-up examinations.

CONCLUSION

The participation of the contralateral SM1 and the ipsilateral cerebellum is thus considered to play an important role in the satisfactory recovery of the motor function after CIMT intervention.

Screening for cognitive decline following single known stroke using the Mini-Mental State Examination

BACKGROUND

Progressive cognitive decline develops in a nontrivial minority of stroke survivors. Although commonly used to identify cognitive decline in older stroke survivors, the usefulness of the Mini-Mental State Examination (MMSE) as a screening tool for post-stroke cognitive decline across a wider range of ages is not well established. This study therefore investigated the usefulness of the MMSE for this purpose.

METHODS

Twenty-seven subjects, aged 18-82 years, with a single known remote stroke were assessed using the MMSE. The frequency of cognitive impairment was determined by comparison of MMSE scores with population-based norms. Relationships between cognitive performance, motor impairments, age, gender, handedness, stroke laterality, and time since stroke also were explored.

RESULTS

Age-adjusted MMSE scores identified mild cognitive impairment in 22.2% and moderate-to-severe cognitive impairment in 7.4% of subjects. Raw and age-adjusted MMSE scores were inversely correlated with time since stroke, but not with other patient or stroke characteristics.

CONCLUSION

A relationship between time since single known stroke and MMSE performance was observed in this study. The proportion of subjects identified as cognitively impaired in this group by Z-transformation of MMSE scores using previously published normative data for this measure comports well with the rates of late post-stroke cognitive impairment reported by other investigators. These findings suggest that the MMSE, when normatively interpreted, may identify cognitive decline in the late period following single known stroke. Additionally, the lack of a relationship between MMSE and Fugl-Meyer scores suggests that the severity of post-stroke motor impairments is unlikely to serve as a clinically useful indicator of the need for cognitive assessment. A larger study of stroke survivors is needed to inform more fully on the usefulness of normatively interpreted MMSE scores as a method of screening for post-stroke cognitive decline.

Effects of robotic-aided rehabilitation on recovery of upper extremity function in chronic stroke: a single case study

The objective of the study was to examine the results of robotic therapy in a single client. A 48-year-old female client 15 months post-stroke, with right hemiparesis, received robotic therapy as an outpatient in a large Midwestern rehabilitation hospital. Robotic therapy was provided three times a week for 6 weeks. Robotic therapy consisted of goal-directed, robotic-aided reaching tasks to exercise the hemiparetic shoulder and elbow. No other therapeutic intervention for the affected upper extremity was provided during the study or 3 months follow-up period. The outcome measures included the Fugl-Meyer, graded Wolf motor function test (GWMFT), motor activity log, active range of motion and Canadian occupational performance measure. The participant made gains in active movement; performance; and satisfaction of functional tasks, GWMFT and functional use. Limitations involved in this study relate to the generalizability of the sample size, effect of medications, expense of robotic technologies and the impact of aphasia. Future research should incorporate functional use training along with robotic therapy.

Coordination changes demonstrated by subjects with hemiparesis performing hand-arm training using the NJIT-RAVR robotically assisted virtual rehabilitation system

Various authors have described pre and post testing improvements in upper limb coordination as a result of intensive upper limb interventions. While the ability to alter coordination patterns as a result of repetitive hand-arm movement is established, patterns of change in the relationship between proximal and distal effectors of the UE over the course of multiple sessions of training have not been described in the rehabilitation literature. In this study eight subjects (5 male, 3 female) with a mean age of 56.4 years (SD=14.2) and a mean time since CVA of 54.7 months post-stroke (SD=51.7) were trained for eight, 2-3 hour sessions on four robotically facilitated virtual rehabilitation activities. This paper will present 1) Functional performance and pre and post testing kinematic analysis for the eight subjects 2) More extensive analysis of the change in hand and arm coordination over the course of the eight session intervention demonstrated by one of the subjects from this sample 3) Kinematic analysis of another subject from this sample performing an un-trained reaching and grasping activity, before and after training.

Group Constraint-Induced Movement Therapy: Motor and Functional Outcomes in Individuals with Stroke

Background

Strokes frequently cause limitations of the upper extremity and in performance of activities of daily living (ADL). Constraint-induced movement therapy (CIMT) is designed to enhance the use of the hemiplegic arm.

Purpose

To assess the effects of group CIMT on upper-extremity motor function and performance level of motor and process skills for instrumental activities in daily living (IADL) in community-dwelling individuals whose stroke occurred at least six months earlier.

Methods

Eight adults with stroke participated in this study. Group-based CIMT was administered for two weeks, five times per week, with two-hour intensive daily training.

Findings

The Fugl-Meyer Assessment (FMA) score and the Assessment of Motor and Process Skills (AMPS) scores improved after intervention.

Implications

The results of this study suggest that relatively brief group-based CIMT may be an effective intervention for improving motor function of the affected upper-limb and the level of IADL in individuals who have had stroke.

Constraint-induced movement therapy for upper extremities in stroke patients

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Technology-assisted training of arm-hand skills in stroke: concepts on reacquisition of motor control and therapist guidelines for rehabilitation technology design

Background

It is the purpose of this article to identify and review criteria that rehabilitation technology should meet in order to offer arm-hand training to stroke patients, based on recent principles of motor learning.

Methods

A literature search was conducted in PubMed, MEDLINE, CINAHL, and EMBASE (1997–2007).

Results

One hundred and eighty seven scientific papers/book references were identified as being relevant. Rehabilitation approaches for upper limb training after stroke show to have shifted in the last decade from being analytical towards being focussed on environmentally contextual skill training (task-oriented training). Training programmes for enhancing motor skills use patient and goal-tailored exercise schedules and individual feedback on exercise performance. Therapist criteria for upper limb rehabilitation technology are suggested which are used to evaluate the strengths and weaknesses of a number of current technological systems.

Conclusion

This review shows that technology for supporting upper limb training after stroke needs to align with the evolution in rehabilitation training approaches of the last decade. A major challenge for related technological developments is to provide engaging patient-tailored task oriented arm-hand training in natural environments with patient-tailored feedback to support (re) learning of motor skills.

Effects of Constraint-Induced Therapy Versus Bilateral Arm Training on Motor Performance, Daily Functions, and Quality of Life in Stroke Survivors

Background and Objective. This study investigated the relative effects of distributed constraint-induced therapy (CIT) and bilateral arm training (BAT) on motor performance, daily function, functional use of the affected arm, and quality of life in patients with hemiparetic stroke. Methods. A total of 60 patients were randomized to distributed CIT, BAT, or a control intervention of less specific but active therapy. Each group received intensive training for 2 hours/day, 5 days/week, for 3 weeks. Pretreatment and posttreatment measures included the Fugl—Meyer Assessment (FMA), Functional Independence Measure (FIM), Motor Activity Log (MAL), and Stroke Impact Scale (SIS). The proximal and distal scores of FMA were used to examine separate upper limb (UL) elements of movement. Results . The distributed CIT and BAT groups showed better performance in the overall and the distal part score of the FMA than the control group. The BAT group exhibited greater gains in the proximal part score of the FMA than the distributed CIT and control groups. Enhanced performance was found for the distributed CIT group in the MAL, the subtest of locomotion in the FIM, and certain domains of the SIS (eg, ADL/IADL). Conclusion. BAT may uniquely improve proximal UL motor impairment. In contrast, distributed CIT may produce greater functional gains for the affected UL in subjects with mild to moderate chronic hemiparesis.

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

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

Potential predictors of motor and functional outcomes after distributed constraint-induced therapy for patients with stroke

BACKGROUND

Selection of patients who are most and least likely to benefit from constraint-induced therapy (CIT) for the upper extremity is uncertain.

OBJECTIVE

This study investigated demographic and clinical characteristics that may predict outcomes for a distributed form of CIT.

METHODS

A group of 57 patients were treated with distributed CIT, and 7 potential predictors were identified, including age, sex, side of stroke, time since stroke, spasticity, neurologic status, and movement performance of the distal part of the upper extremity. Treatment outcome was assessed in terms of motor performance, perceived functional ability of the affected hand, and functional performance of daily activities, measured by Fugl-Meyer Assessment (FMA), Motor Activity Log (MAL), and Functional Independence Measure (FIM), respectively.

RESULTS

Motor ability of the distal part of the upper extremity and time since stroke were significantly predictive of outcomes on the FMA (adjusted R(2) = 0.18, P = .002) and the MAL subtest quality of movement (adjusted R( 2) = 0.43, P < .0001). Motor ability and age were significant predictors of amount of use measured by the MAL (adjusted R(2) = 0.20, P = .001). None of the variables exhibited a predictive relationship with the FIM.

CONCLUSIONS

The best predictor for motor outcomes after distributed CIT was greater motor ability of the distal part of the upper extremity, which is consistent with the presence of residual motor pathways that may respond to training. The FMA may be of value in stratifying patients for their likelihood to benefit from distributed CIT protocols.

Mental practice-based rehabilitation training to improve arm function and daily activity performance in stroke patients: a randomized clinical trial

Background

Over 50% of patients with upper limb paresis resulting from stroke face long-term impaired arm function and ensuing disability in daily life. Unfortunately, the number of effective treatments aimed at improving arm function due to stroke is still low. This study aims to evaluate a new therapy for improving arm function in sub-acute stroke patients based on mental practice theories and functional task-oriented training, and to study the predictors for a positive treatment result. It is hypothesized that a six-week, mental practice-based training program (additional to regular therapy) targeting the specific upper extremity skills important to the individual patient will significantly improve both arm function and daily activity performance, as well as being cost effective.

Methods/design

One hundred and sixty sub-acute stroke patients with upper limb paresis (MRC grade 1–3) will participate in a single-blinded, multi-centre RCT. The experimental group will undertake a six-week, individually tailored therapy regime focused on improving arm function using mental practice. The control group will perform bimanual upper extremity exercises in addition to regular therapy. Total contact time and training intensity will be similar for both groups. Measurements will be taken at therapy onset, after its cessation and during the follow-up period (after 6 and 12 months). Primary outcome measures will assess upper extremity functioning on the ICF level of daily life activity (Wolf Motor Function Test, Frenchay Arm Test, accelerometry), while secondary outcome measures cover the ICF impairment level (Brunnstrom-Fu-Meyer test). Level of societal participation (IPA) and quality of life (EuroQol; SS-Qol) will also be tested. Costs will be based on a cost questionnaire, and statistical analyses on MAN(C)OVA and GEE (generalized estimated equations).

Discussion

The results of this study will provide evidence on the effectiveness of this mental practice-based rehabilitation training, as well as the cost-effectiveness.

Trial registration

Current Controlled Trials [ISRCTN33487341)