Constraint-Induced Movement Therapy

Effectiveness of modified constraint-induced movement therapy on upper limb function of stroke survivors in inpatient hospital settings: a systematic review and meta-analysis

PURPOSE

To synthesise evidence on the effectiveness of modified constraint-induced movement therapy on upper limb function in stroke survivors within inpatient hospital settings.

METHODS

A systematic review was pre-registered in PROSPERO (CRD42023421715b) and searched six databases (EMBASE, AMED, MEDLINE, CINAHL, Cochrane Library, OTseeker) up to November 2024.

Articles included adults with stroke undergoing modified constraint-induced movement therapy in inpatient hospital settings. Article quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. Homogenous data was synthesised in a meta-analysis and assessed using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Remaining data was synthesised descriptively.

RESULTS

Ten randomised controlled trials (364 participants) were included. Four (191 participants) were analysed in a meta-analysis, showing modified constraint-induced movement therapy improved upper limb function (standardised mean difference (SMD) 0.94, 95% confidence interval (CI) 0.40 to 1.48), based on low-quality evidence. Five articles included follow-up, with two (90 participants) reporting sustained improvements. Five articles assessed activities of daily living, with two (136 participants) reporting positive effects.

CONCLUSION

Modified constraint-induced movement therapy improves upper limb function in the acute and sub-acute stages of stroke recovery within inpatient hospital settings. Sustainability of improvements and the impact on activities of daily living remains uncertain.

Effect of visual biofeedback on fine motor function and activity daily of life in stroke patients: A pilot study

INTRODUCTION

Many stroke patients suffer from dysfunction in their upper limbs, which can lead to difficulties in performing activities of daily living (ADL) as well as social and work interactions. This is particularly true for patients whose dominant side has been affected. The aim of the current study was to explore how effective visual biofeedback could improve fine motor function in the hand and ADL for people suffering from a stroke.

METHODS

Ten individuals who had experienced a stroke with aged from 60 to 74 years old (mean: 64.3 years) were randomly divided into two groups. Patients in study group (n: 5) received 15 sessions of visual biofeedback therapy along with routine occupational therapy. Control group (n: 5) received only routine occupational therapy. Fine motor function was measured by Fugl Meyer Scale (FMS), box and block test (BBT), and Purdue pegboard test (PPBT). Also, ADL was measured by functional independence measure (FIM). These clinical outcomes were evaluated before, after, and 1.5 months following the interventions.

RESULTS

The results showed that the study group experienced a significant increase in fine motor function after receiving visual biofeedback, compared to the control group. The ADL also improved in both the study and control groups after the intervention, but there was no significant difference between the two groups during the intervention and follow-up stages for ADL.

CONCLUSION

It seems that combining biofeedback with routine occupational therapy could be a promising method to enhance fine motor function in individuals with stroke.

Hybrid Brain-Computer Interface Controlled Soft Robotic Glove for Stroke Rehabilitation

Soft robotic glove controlled by a brain-computer interface (BCI) have demonstrated effectiveness in hand rehabilitation for stroke patients. Current systems rely on static visual representations for patients to perform motor imagination (MI) tasks, resulting in lower BCI performance. Therefore, this study innovatively used MI and high-frequency steady-state visual evoked potential (SSVEP) to construct a friendly and natural hybrid BCI paradigm. Specifically, the stimulation interface sequentially presented decomposed action pictures of the left and right hands gripping a ball, with the pictures flashing at specific stimulation frequencies (left: 34 Hz, right: 35 Hz). Integrating soft robotic glove as feedback, we established a comprehensive "peripheral - central - peripheral" hand rehabilitation system to facilitate the hand rehabilitation of patients. Filter bank common spatial pattern (FBCSP) and filter bank canonical correlation analysis (FBCCA) algorithms were used to identify MI and SSVEP signals, respectively. Additionally, we proposed a novel fusion algorithm to decide the final output of the system. The feasibility of the proposed system was validated through online experiments involving 12 healthy subjects and 9 stroke patients, achieving accuracy rates of 95.83 ± 6.83% and 63.33 ± 10.38, respectively. The accuracy of MI and SSVEP in 12 healthy subjects reached 81.67 ± 15.63% and 95.14 ± 7.47%, both lower than the accuracy after fusion, these results confirmed the effectiveness of the proposed algorithm. The accuracy rate was more than 50% in both healthy subjects and patients, confirming the effectiveness of the proposed system.

Effect of different constraint-induced movement therapy protocols on recovery of stroke survivors with upper extremity dysfunction: a systematic review and network meta-analysis

We aimed to assess and rank comparative efficacy of different constraint-induced movement therapy (CIMT) protocols on motor function of upper extremity and activities of daily living (ADL) in stroke survivors. A comprehensive search was conducted in PubMed, EMBASE, Web of Science and Cochrane Library to identify randomized controlled trials on CIMT. Included studies were evaluated using the revised Cochrane risk of bias tool. Then a random-effects network meta-analysis was performed within a frequentist framework using Stata v16.0. Of the 1150 studies retrieved, 44 studies with 1779 participants were included. In terms of motor recovery of upper extremity, CIMT combined with trunk restraint, in which the less affected arm was constrained at least 4 h but no more than 6 h per day, ranked as the most effective intervention for the improvement of the Fugl-Meyer Assessment-Upper Extremity and the Action Research Arm Test score. In terms of ADL improvement, constraining the less affected arm for at least 4 h but no more than 6 h per day in CIMT combined with trunk restraint, was found to significantly improve the Motor Activity Log of quality of movement scale and amount of use scale score. The protocol of CIMT combined with trunk restraint, in which the less affected arm was constrained at least 4 h but no more than 6 h per day, ranked the highest in this analysis and might be considered in practice.

Motor learning in hemi-Parkinson using VR-manipulated sensory feedback

AIMS

Modalities for rehabilitation of the neurologically affected upper-limb (UL) are generally of limited benefit. The majority of patients seriously affected by UL paresis remain with severe motor disability, despite all rehabilitation efforts. Consequently, extensive clinical research is dedicated to develop novel strategies aimed to improve the functional outcome of the affected UL. We have developed a novel virtual-reality training tool that exploits the voluntary control of one hand and provides real-time movement-based manipulated sensory feedback as if the other hand is the one that moves. The aim of this study was to expand our previous results, obtained in healthy subjects, to examine the utility of this training setup in the context of neuro-rehabilitation.

METHODS

We tested the training setup in patient LA, a young man with significant unilateral UL dysfunction stemming from hemi-parkinsonism. LA underwent daily intervention in which he intensively trained the non-affected upper limb, while receiving online sensory feedback that created an illusory perception of control over the affected limb. Neural changes were assessed using functional magnetic resonance imaging (fMRI) scans before and after training.

RESULTS

Training-induced behavioral gains were accompanied by enhanced activation in the pre-frontal cortex and a widespread increase in resting-state functional connectivity.

DISCUSSION

Our combination of cutting edge technologies, insights gained from basic motor neuroscience in healthy subjects and well-known clinical treatments, hold promise for the pursuit of finding novel and more efficient rehabilitation schemes for patients suffering from hemiplegia.Implications for rehabilitationAssistive devices used in hospitals to support patients with hemiparesis require expensive equipment and trained personnel - constraining the amount of training that a given patient can receive. The setup we describe is simple and can be easily used at home with the assistance of an untrained caregiver/family member. Once installed at the patient's home, the setup is lightweight, mobile, and can be used with minimal maintenance . Building on advances in machine learning, our software can be adapted to personal use at homes. Our findings can be translated into practice with relatively few adjustments, and our experimental design may be used as an important adjuvant to standard clinical care for upper limb hemiparesis.

Ipsilesional Motor Cortex Activation with High-force Unimanual Handgrip Contractions of the Less-affected Limb in Participants with Stroke

Stroke is a leading cause of severe disability that often presents with unilateral motor impairment. Conventional rehabilitation approaches focus on motor practice of the affected limb and aim to suppress brain activity in the contralesional hemisphere. Conversely, exercise of the less-affected limb promotes contralesional brain activity which is typically viewed as contraindicated in stroke recovery due to the interhemispheric inhibitory influence onto the ipsilesional hemisphere. Yet, high-force unimanual handgrip contractions are known to increase ipsilateral brain activation in control participants, and it remains to be determined if high-force contractions with the less-affected limb would promote ipsilateral brain activation in participants with stroke (i.e., the ipsilesional hemisphere). Therefore, this study aimed to determine how parametric increases in handgrip force during repeated contractions with the less-affected limb impacts brain activity bilaterally in participants with stroke and in a cohort of neurologically intact controls. Participants performed repeated submaximal contractions at 25%, 50%, and 75% of their maximum voluntary contraction during separate functional magnetic resonance imaging brain scans. Brain activation during the tasks was quantified as the present change from resting levels. In this study, higher force contractions were found to increase brain activation in the ipsilesional (stroke)/ipsilateral (controls) hemisphere in both groups (p = .002), but no between group differences were observed. These data suggest that high-force exercise with the less-affected limb may promote ipsilesional cortical plasticity to promote motor recovery of the affected-limb in participants with stroke.

Contralesional plasticity following constraint-induced movement therapy benefits outcome: contributions of the intact hemisphere to functional recovery

Stroke is a leading cause of death and disability worldwide. A common, chronic deficit after stroke is upper limb impairment, which can be exacerbated by compensatory use of the nonparetic limb. Resulting in learned nonuse of the paretic limb, compensatory reliance on the nonparetic limb can be discouraged with constraint-induced movement therapy (CIMT). CIMT is a rehabilitative strategy that may promote functional recovery of the paretic limb in both acute and chronic stroke patients through intensive practice of the paretic limb combined with binding, or otherwise preventing activation of, the nonparetic limb during daily living exercises. The neural mechanisms that support CIMT have been described in the lesioned hemisphere, but there is a less thorough understanding of the contralesional changes that support improved functional outcome following CIMT. Using both human and non-human animal studies, the current review explores the role of the contralesional hemisphere in functional recovery of stroke as it relates to CIMT. Current findings point to a need for a better understanding of the functional significance of contralesional changes, which may be determined by lesion size, location, and severity as well stroke chronicity.

Low-Cost Robotic Guide Based on a Motor Imagery Brain-Computer Interface for Arm Assisted Rehabilitation

Motor imagery has been suggested as an efficient alternative to improve the rehabilitation process of affected limbs. In this study, a low-cost robotic guide is implemented so that linear position can be controlled via the user’s motor imagination of movement intention. The patient can use this device to move the arm attached to the guide according to their own intentions. The first objective of this study was to check the feasibility and safety of the designed robotic guide controlled via a motor imagery (MI)-based brain–computer interface (MI-BCI) in healthy individuals, with the ultimate aim to apply it to rehabilitation patients. The second objective was to determine which are the most convenient MI strategies to control the different assisted rehabilitation arm movements. The results of this study show a better performance when the BCI task is controlled with an action–action MI strategy versus an action–relaxation one. No statistically significant difference was found between the two action–action MI strategies.

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.

Constraint Induced Movement Therapy as a Rehabilitative Strategy for Ischemic Stroke-Linking Neural Plasticity with Restoration of Skilled Movements

BACKGROUND

Stroke leads to devastating impact on health as well as quality of life making it one of the leading causes of disability. Restoring the functions of upper extremities after ischemic (ISC) stroke is one of the challenges for rehabilitation. Lack of trained professionals and accessibility to rehabilitation centers are limited in many counties. Constraint induced movement therapy (CIMT) has been practiced in regaining the functional activity following stroke. CIMT can be practiced with minimum clinical set up which makes it cost effective. However, the neural plasticity mechanism underlying the recovery with CIMT is not well understood.

METHODS

In the current study, we sought to investigate the extent to which CIMT helps in ameliorating neurological deficits in rat model of ISC stroke, induced by Endothelin-1 (ET-1). As well as to understand the cortical plasticity with Golgi-Cox staining and interhemispheric interaction with biotinylated dextran amine (BDA) following CIMT. Neurological deficits were identified within 24 hours of ET-1 infusion.

RESULTS

CIMT restored the impaired skilled movements after ISC stroke and improved the quality of fine movements. Golgi-Cox staining showed significant decrease in dendritic arborization in the injured motor cortex following ISC stroke. CIMT was efficient in reversing this effect as indicated by increased dendritic arborization especially in layer III pyramidal neurons. Also, the stroke induced asymmetry in dendritic length across both hemispheres was found to be reduced with CIMT. BDA tracing showed a re-establishment of the axonal connections between the hemispheres after CIMT.

CONCLUSIONS

Implications of CIMT can be one of the promising and low cost rehabilitative technique for the individuals with upper limb movement deficits.

Comparison of bilateral and unilateral upper limb training in people with stroke: A systematic review and meta-analysis

Background and objectives

Bilateral upper limb training (BULT) and unilateral upper limb training (UULT) are two effective strategies for the recovery of upper limb motor function after stroke. This meta-analysis aimed to compare the improvements in motor impairment and functional performances of people with stroke after BULT and UULT.

Research design and methods

This systematic review and meta-analysis identified 21 randomized controlled trials (RCTs) met the eligibility criteria from CINAHL, Medline, Embase, Cochrane Library and PubMed. The outcome measures were the Fugl-Meyer Assessment of Upper Extremity (FMA-UE), Wolf Motor Function Test (WMFT), Action Research Arm Test (ARAT) and Box and Block Test (BBT), which are validated measures of upper limb function.

Results

Twenty-one studies involving 842 subjects with stroke were included. Compared with UULT, BULT yielded a significantly greater mean difference (MD) in the FMA-UE (MD = 2.21, 95% Confidence Interval (CI), 0.12 to 4.30, p = 0.04; I² = 86%, p<0.001). However, a comparison of BULT and UULT yielded insignificant mean difference (MD) in terms of the time required to complete the WMFT (MD = 0.44; 95%CI, -2.22 to 3.10, p = 0.75; I² = 55%, p = 0.06) and standard mean difference (SMD) in terms of the functional ability scores on the WMFT, ARAT and BBT (SMD = 0.25; 95%CI, -0.02 to 0.52, p = 0.07; I² = 54%, p = 0.02).

Discussion and implications

Compared to UULT, BULT yielded superior improvements in the improving motor impairment of people with stroke, as measured by the FMA-UE. However, these strategies did not yield significant differences in terms of the functional performance of people with stroke, as measured by the WMFT, ARAT and BBT. More comparative studies of the effects of BULT and UULT are needed to increase the reliability of these conclusions.

Laterality of Damage Influences the Relationship Between Impairment and Arm Use After Stroke

OBJECTIVES

To investigate whether the relationship between arm use and motor impairment post-stroke is influenced by the hemisphere of damage.

METHODS

Right-handed patients with unilateral left hemisphere damage (LHD) or right (RHD) (n=58; 28 LHD, 30 RHD) were recruited for this study. The Arm Motor Ability Test and Functional Impact Assessment were used to derive arm use patterns. The Fugl-Meyer motor assessment scale was used to quantify the level of motor impairment.

RESULTS

A significant interaction between patient group and impairment level was observed for contralesional, but not ipsilesional arm use. For lower impairment levels, contralesional (right arm for LHD and left arm for RHD) arm use was greater in LHD than RHD patients. In contrast, for greater levels of impairment, there were no arm use differences between the two patient groups.

CONCLUSIONS

When motor impairment is significant, it overrides potential effects of stroke laterality on the patterns of arm use. However, a robust influence of hemisphere of damage on the patterns of arm use is evident at lower impairment levels. This may be attributed to previously described arm preference effects. These findings suggest adoption of distinct strategies for rehabilitation following left versus right hemisphere damage in right-handers, at least when the impairment is moderate to low. (JINS, 2019, 25, 470-478).

Analysis of the Factors Related to the Effectiveness of Transcranial Current Stimulation in Upper Limb Motor Function Recovery after Stroke: a Systematic Review

Transcranial direct current stimulation is one of the non-invasive techniques whose main mechanism of action is based on its modulation of cortical excitability. The objective of this study is to analyze the variables (i.e, demographics, clinicals, stimulation parameters) that could influence into the responses during rehabilitation of the upper extremity in patients with stroke. Our systematic review has been performed by searching full-text articles published from January 2008 to December 2018 in Embase, Medline, PubMed and Cochrane Library databases. Studies with adult patients with ischemic or hemorrhagic stroke at any stage of evolution were included. We compared interventions with any type of transcranial direct current stimulation (anodal, cathodal or bihemispheric, also known as dual) regarding improvement of upper extremity motor function. We included 14 studies with 368 patients, of whom almost 89% have ischemic etiology and more than half are males. Most patients were considered subacute or chronic, while only two studies were selected with patients in the acute phase. Different methods of using transcranial direct current stimulation with several complementary therapies were identified, such as virtual reality, robot therapy, Occupational Therapy, Physiotherapy, Constraint Induced Movement Therapy or Peripheral Nerve Stimulation. In conclusion, there is not significant evidence due to heterogeneity of clinical data and therapies. Clinical studies with greater number of participants and protocols standardized could outline this assessment in future studies.

Current knowledge on selected rehabilitative methods used in post-stroke recovery

Understanding brain plasticity after stroke is important in developing rehabilitation strategies. Active movement therapies show considerable promise but their individual application is still not fully implemented. Among the analysed, available therapeutic modalities, some became widely used in therapeutic practice. Thus, we selected three relatively new methods, i.e. mirror therapy, motor imagery and constraint-induced movement therapy (CIMT). Mirror therapy was initially used in the treatment of phantom pain in patients with amputated limbs and later, in stroke patients. Motor imagery is widely used in sport to improve performance, which raises the possibility of applying it both as a rehabilitative method and in accessing the motor network independently of recovery. Whereas CIMT is based on the paradigm that impairment of arm function is exacerbated by learned non-use and that this, in turn, leads to loss of cortical representation in the upper limb.

Training of the impaired forelimb after traumatic brain injury enhances hippocampal neurogenesis in the Emx1 null mice lacking a corpus callosum

Unilateral brain injury is known to disrupt the balance between the two cortices, as evidenced by an abnormally high interhemispheric inhibitory drive from motor cortex M1_intact to M1_lesioned transmitted transcallosally. Our previous work has shown that the deletion of homeobox gene Emx1 not only led to the agenesis of the corpus callosum (cc), but also to reduced hippocampal neurogenesis. The current study sought to determine whether lacking the cc affected the recovery of forelimb function and hippocampal plasticity following training of the affected limb in mice with unilateral traumatic brain injuries (TBI). One week after TBI, produced by a controlled cortical impact to impair the preferred limb, Emx1 wild type (WT) and knock out (KO) mice were subjected to the single-pellet reaching task with the affected limb for 4 weeks. Both TBI and Emx1 deletion had overall adverse effects on the successful rate of reaching. However, TBI significantly affected reaching performance only in the WT mice and not in the KO mice. Both TBI and Emx1 gene deletion also negatively affected hippocampal neurogenesis, demonstrated by a reduction in doublecortin (DCX)-expressing immature neurons, while limb training enhanced DCX expression. However, limb training increased DCX cells in KO mice only in the TBI-treated group, whereas it induced neurogenesis in both WT mice groups regardless of the treatment. Our finding also suggests that limb training enhances neuroplasticity after brain injury at functionally remote regions including the hippocampus, which may have implications for promoting overall recovery of function after TBI.

Daily repetitive sensory stimulation of the paretic hand for the treatment of sensorimotor deficits in patients with subacute stroke: RESET, a randomized, sham-controlled trial

Background

Repetitive sensory stimulation (RSS) adapts the timing of stimulation protocols used in cellular studies to induce synaptic plasticity. In healthy subjects, RSS leads to widespread sensorimotor cortical reorganization paralleled by improved sensorimotor behavior. Here, we investigated whether RSS reduces sensorimotor upper limb impairment in patients with subacute stroke more effectively than conventional therapy.

Methods

A single-blinded sham-controlled clinical trial assessed the effectiveness of RSS in treating sensorimotor deficits of the upper limbs. Patients with subacute unilateral ischemic stroke were randomly assigned to receive standard therapy in combination with RSS or with sham RSS. Patients were masked to treatment allocation. RSS consisted of intermittent 20 Hz electrical stimulation applied on the affected hand for 45 min/day, 5 days per week, for 2 weeks, and was transmitted using custom-made stimulation-gloves with built-in electrodes contacting each fingertip separately. Before and after the intervention, we assessed light-touch and tactile discrimination, proprioception, dexterity, grip force, and subtasks of the Jebsen Taylor hand-function test for the non-affected and the affected hand. Data from these quantitative tests were combined into a total performance index serving as primary outcome measure. In addition, tolerability and side effects of RSS intervention were recorded.

Results

Seventy one eligible patients were enrolled and randomly assigned to receive RSS treatment (n = 35) or sham RSS (n = 36). Data of 25 patients were not completed because they were transferred to another hospital, resulting in n = 23 for each group. Before treatment, sensorimotor performance between groups was balanced (p = 0.237). After 2 weeks of the intervention, patients in the group receiving standard therapy with RSS showed significantly better restored sensorimotor function than the control group (standardized mean difference 0.57; 95% CI -0.013–1.16; p = 0.027) RSS treatment was superior in all domains tested. Repetitive sensory stimulation was well tolerated and accepted, and no adverse events were observed.

Conclusions

Rehabilitation including RSS enhanced sensorimotor recovery more effectively than standard therapy alone. Rehabilitation outcome between the effects of RSS and standard therapy was largest for sensory and motor improvement; however, the results for proprioception and everyday tasks were encouraging warranting further studies in more severe patients.

Trial registration

The trial was retrospectively registered January 31, 2012 under DRKS00003515 (https://www.drks.de/drks_web/navigate.do;jsessionid=AEE2585CCB82A22A2B285470B37C47C8?navigationId=results).

Using Virtual Reality to Transfer Motor Skill Knowledge from One Hand to Another

As far as acquiring motor skills is concerned, training by voluntary physical movement is superior to all other forms of training (e.g. training by observation or passive movement of trainee's hands by a robotic device). This obviously presents a major challenge in the rehabilitation of a paretic limb since voluntary control of physical movement is limited. Here, we describe a novel training scheme we have developed that has the potential to circumvent this major challenge. We exploited the voluntary control of one hand and provided real-time movement-based manipulated sensory feedback as if the other hand is moving. Visual manipulation through virtual reality (VR) was combined with a device that yokes left-hand fingers to passively follow right-hand voluntary finger movements. In healthy subjects, we demonstrate enhanced within-session performance gains of a limb in the absence of voluntary physical training. Results in healthy subjects suggest that training with the unique VR setup might also be beneficial for patients with upper limb hemiparesis by exploiting the voluntary control of their healthy hand to improve rehabilitation of their affected hand.

Patient Engagement Is Related to Impairment Reduction During Digital Game-Based Therapy in Stroke

OBJECTIVE

Upper limb impairment in the chronic phase of stroke recovery is persistent, disabling, and difficult to treat. The objectives of this study were to determine whether therapeutic enjoyment is related to clinical improvement after upper limb rehabilitation and to assess the feasibility of a therapy gaming system.

MATERIALS AND METHODS

Ten chronic stroke survivors with persistent upper limb impairment were enrolled in the study. Upper limb impairment was evaluated by using the Fugl-Meyer Assessment of Upper Extremity Function (FMA-UE). The Physical Activity Enjoyment Scale (PACES) assessed the level of therapy enjoyment, and the System Usability Scale (SUS) measured the ease of operation of the game. Upper limb therapy involved 30 minutes of novel digital gaming therapy, three times per week, for 6 weeks.

RESULTS

The average improvement in the FMA-UE after the digital gaming therapy was 2.8 (±2.1) points. Participants scored the digital gaming system as having good usability (SUS: 72 ± 7.9), and the physical activity as enjoyable (PACES: 65.8 ± 10.6). There was a strong positive correlation between improvement in the FMA-UE score and the PACES (Spearman's Rho = 0.84; P < 0.002).

CONCLUSION

This pilot study demonstrates the feasibility and potential for improvements in upper limb motor function by using digital gaming in the chronic stroke patient population. The positive correlation found between therapy enjoyment and clinical gains highlights the importance of engagement in therapy to optimize outcomes in chronic stroke survivors.

Buyang Huanwu decoction facilitates neurorehabilitation through an improvement of synaptic plasticity in cerebral ischemic rats

BACKGROUND

Loss of neural function is a critical but unsolved issue after cerebral ischemia insult. Neuronal plasticity and remodeling are crucial for recovery of neural functions after brain injury. Buyang Huanwu decoction, which is a classic formula in traditional Chinese medicine, can positively alter synaptic plasticity. This study assessed the effects of Buyang Huanwu decoction in combination with physical exercise on neuronal plasticity in cerebral ischemic rats.

METHODS

Cerebral ischemic rats were administered Buyang Huanwu decoction and participated in physical exercise after the induction of a permanent middle cerebral artery occlusion. The neurobehavioral functions and infarct volumes were evaluated. The presynaptic (SYN), postsynaptic (GAP-43) and cytoskeletal (MAP-2) proteins in the coronal brain samples were evaluated by immunohistochemistry and western blot analyses. The ultrastructure of the neuronal synaptic junctions in the same region were analyzed using transmission electron microscopy.

RESULTS

Combination treatment of Buyang Huanwu decoction and physical exercise ameliorated the neurobehavioral deficits (p < 0.05), significantly enhanced the expression levels of SYN, GAP-43 and MAP-2 (p < 0.05), and maintained the synaptic ultrastructure.

CONCLUSIONS

Buyang Huanwu decoction facilitated neurorehabilitation following a cerebral ischemia insult through an improvement in synaptic plasticity. Graphical abstract The Buyang Huanwu decoction (BYHWD) combined with physical exercise (PE) attenuates synaptic disruption and promotes synaptic plasticity following cerebral ischemia (stroke).

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).

Efficacy of Modified Constraint Induced Movement Therapy in the Treatment of Hemiparetic Upper Limb in Stroke Patients: A Randomized Controlled Trial

INTRODUCTION

Paretic upper limb in stroke patients has a significant impact on the quality of life. Modified Constraint Induced Movement Therapy (mCIMT) is one of the treatment options used for the improvement of the function of the paretic limb.

AIM

To investigate the efficacy of four week duration mCIMT in the management of upper extremity weakness in hemiparetic patients due to stroke.

MATERIALS AND METHODS

Prospective single blind, parallel randomized controlled trial in which 30 patients received conventional rehabilitation programme (control group) and 30 patients participated in a mCIMT programme in addition to the conventional rehabilitation programme (study group). The mCIMT included three hours therapy sessions emphasizing the affected arm use in general functional tasks, three times a week for four weeks. Their normal arm was also constrained for five hours per day over five days per week. All the patients were assessed at baseline, one month and three months after completion of therapy using Fugl-Meyer Assessment (FMA) score for upper extremity and Motor Activity Log (MAL) scale comprising of Amount of Use (AOU) score and Quality of Use (QOU) score.

RESULTS

All the 3 scores improved significantly in both the groups at each follow-up. Post-hoc analysis revealed that compared to conventional rehabilitation group, mCIMT group showed significantly better scores at 1 month {FMA1 (p-value <0.0001, es0.2870), AOU1 (p-value 0.0007, es0.1830), QOU1 (p-value 0.0015, es0.1640)} and 3 months {FMA3 (p-value <.0001, es0.4240), AOU3 (p-value 0.0003, es 0.2030), QOU3 (p-value 0.0008, es 0.1790)}.

CONCLUSION

Four weeks duration for mCIMT is effective in improving the motor function in paretic upper limb of stroke patients.

Exercise Training Inhibits the Nogo-A/NgR1/Rho-A Signals in the Cortical Peri-infarct Area in Hypertensive Stroke Rats

OBJECTIVE

The aim of this study was to test the hypothesis that exercise training promotes motor recovery after stroke by facilitating axonal remodeling via inhibition of the Nogo-A/NgR1 and Rho-A pathway.

DESIGN

A distal middle cerebral artery occlusion model was generated in stroke-prone renovascular hypertensive rats. Stroke-prone renovascular hypertensive rats were randomly divided into a control group, an exercise training group, and a sham group. Motor function was measured using the grip strength test. Axon and myelin remodeling markers, growth-associated protein 43, myelin basic protein, Tau, and amyloid precursor protein were detected by immunofluorescence. The expression of Nogo-A, NgR1, and Rho-A was demonstrated by immunofluorescence and Western blotting in the peri-infarction area at 7, 14, 28, and 52 days after distal middle cerebral artery occlusion.

RESULTS

Grip strength was higher in the exercise training group (P < 0.05). Exercise training increased the expression of growth-associated protein 43, myelin basic protein (at 7, 14, and 28 days), and Tau (at 7 and 14 days), and decreased the expression of axonal damage amyloid precursor protein (at 7 and 14 days), compared with the control group. The protein levels of Nogo-A (at 7 and 14 days), NgR1 (at 7, 14, and 28 days), and Rho-A (at 14 and 28 days) were reduced after exercise training.

CONCLUSIONS

Exercise training promotes axonal recovery, which is associated with functional improvement after cerebral infarction. Down-regulation of the Nogo-A/NgR1/Rho-A may mediate the axonal remodeling induced by exercise training.

Stroke Treatment Associated with Rehabilitation Therapy and Transcranial DC Stimulation (START-tDCS): a study protocol for a randomized controlled trial

Background

Traditional treatment for motor impairment after stroke includes medication and physical rehabilitation. The transcranial direct current stimulation associated with a standard physical therapy program may be an effective therapeutic alternative for these patients.

Methods

This study is a sham-controlled, double-blind, randomized clinical trial aiming to evaluate the efficacy of transcranial direct current stimulation in activities of daily living and motor function post subacute stroke. In total there will be 40 patients enrolled, diagnosed with subacute, ischemic, unilateral, non-recurring stroke. Participants will be randomized to two groups, one with active stimulation and the other with a placebo current. Patients and investigators will be blinded. Everyone will receive systematic physical therapy, based on constraint-induced movement therapy. The intervention will be applied for 10 consecutive days. Patients will undergo three functional assessments: at baseline, week 2, and week 4. Neuropsychological tests will be performed at baseline and week 4. Adverse effects will be computed at each session. On completion of the baseline measures, randomization will be conducted using random permuted blocks. The randomization will be concealed until group allocation.

Discussion

This study will investigate the combined effects of transcranial direct current stimulation and physical therapy on functional improvement after stroke. We tested whether the combination of these treatments is more effective than physical therapy alone when administered in the early stages after stroke.

Trial registration

NCT02156635 - May 30, 2014. Randomization is ongoing (40 participants randomized as of the end of December 2015).

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

OBJECTIVE

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

DESIGN

Observational cohort study.

SETTING

Outpatient rehabilitation clinics.

PARTICIPANTS

Individuals with chronic stroke (N=174).

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Functional recovery in upper limb function in stroke survivors by using brain-computer interface A single case A-B-A-B design

Resent studies suggest that brain-computer interface (BCI) training for chronic stroke patient is useful to improve their motor function of paretic hand. However, these studies does not show the extent of the contribution of the BCI clearly because they prescribed BCI with other rehabilitation systems, e.g. an orthosis itself, a robotic intervention, or electrical stimulation. We therefore compared neurological effects between interventions with neuromuscular electrical stimulation (NMES) with motor imagery and BCI-driven NMES, employing an ABAB experimental design. In epoch A, the subject received NMES on paretic extensor digitorum communis (EDC). The subject was asked to attempt finger extension simultaneously. In epoch B, the subject received NMES when BCI system detected motor-related electroencephalogram change while attempting motor imagery. Both epochs were carried out for 60 min per day, 5 days per week. As a result, EMG activity of EDC was enhanced by BCI-driven NMES and significant cortico-muscular coherence was observed at the final evaluation. These results indicate that the training by BCI-driven NMES is effective even compared to motor imagery combined with NMES, suggesting the superiority of closed-loop training with BCI-driven NMES to open-loop NMES for chronic stroke patients.

Emerging treatments for motor rehabilitation after stroke

Although numerous treatments are available to improve cerebral perfusion after acute stroke and prevent recurrent stroke, few rehabilitation treatments have been conclusively shown to improve neurologic recovery. The majority of stroke survivors with motor impairment do not recover to their functional baseline, and there remains a need for novel neurorehabilitation treatments to minimize long-term disability, maximize quality of life, and optimize psychosocial outcomes. In recent years, several novel therapies have emerged to restore motor function after stroke, and additional investigational treatments have also shown promise. Here, we familiarize the neurohospitalist with emerging treatments for poststroke motor rehabilitation. The rehabilitation treatments covered in this review will include selective serotonin reuptake inhibitor medications, constraint-induced movement therapy, noninvasive brain stimulation, mirror therapy, and motor imagery or mental practice.

A novel functional electrical stimulation-control system for restoring motor function of post-stroke hemiplegic patients

Hemiparesis is one of the most common consequences of stroke. Advanced rehabilitation techniques are essential for restoring motor function in hemiplegic patients. Functional electrical stimulation applied to the affected limb based on myoelectric signal from the unaffected limb is a promising therapy for hemiplegia. In this study, we developed a prototype system for evaluating this novel functional electrical stimulation-control strategy. Based on surface electromyography and a vector machine model, a self-administered, multi-movement, force-modulation functional electrical stimulation-prototype system for hemiplegia was implemented. This paper discusses the hardware design, the algorithm of the system, and key points of the self-oscillation-prone system. The experimental results demonstrate the feasibility of the prototype system for further clinical trials, which is being conducted to evaluate the efficacy of the proposed rehabilitation technique.

Brain-computer interface with somatosensory feedback improves functional recovery from severe hemiplegia due to chronic stroke

Recent studies have shown that scalp electroencephalogram (EEG) based brain-computer interface (BCI) has a great potential for motor rehabilitation in stroke patients with severe hemiplegia. However, key elements in BCI architecture for functional recovery has yet to be clear. We in this study focused on the type of feedback to the patients, which is given contingently to their motor-related EEG in a BCI context. The efficacy of visual and somatosensory feedbacks was compared by a two-group study with the chronic stroke patients who are suffering with severe motor hemiplegia. Twelve patients were asked an attempt of finger opening in the affected side repeatedly, and the event-related desynchronization (ERD) in EEG of alpha and beta rhythms was monitored over bilateral parietal regions. Six patients were received a simple visual feedback in which the hand open/grasp picture on screen was animated at eye level, following significant ERD. Six patients were received a somatosensory feedback in which the motor-driven orthosis was triggered to extend the paralyzed fingers from 90 to 50°. All the participants received 1-h BCI treatment with 12–20 training days. After the training period, while no changes in clinical scores and electromyographic (EMG) activity were observed in visual feedback group after training, voluntary EMG activity was newly observed in the affected finger extensors in four cases and the clinical score of upper limb function in the affected side was also improved in three participants in somatosensory feedback group. Although the present study was conducted with a limited number of patients, these results imply that BCI training with somatosensory feedback could be more effective for rehabilitation than with visual feedback. This pilot trial positively encouraged further clinical BCI research using a controlled design.

Reducing Abnormal Muscle Coactivation After Stroke Using a Myoelectric-Computer Interface: A Pilot Study

Background A significant factor in impaired movement caused by stroke is the inability to activate muscles independently. Although the pathophysiology behind this abnormal coactivation is not clear, reducing the coactivation could improve overall arm function. A myoelectric computer interface (MCI), which maps electromyographic signals to cursor movement, could be used as a treatment to help retrain muscle activation patterns. Objective To investigate the use of MCI training to reduce abnormal muscle coactivation in chronic stroke survivors. Methods A total of 5 healthy participants and 5 stroke survivors with hemiparesis participated in multiple sessions of MCI training. The level of arm impairment in stroke survivors was assessed using the upper-extremity portion of the Fugl-Meyer Motor Assessment (FMA-UE). Participants performed isometric activations of up to 5 muscles. Activation of each muscle was mapped to different directions of cursor movement. The MCI specifically targeted 1 pair of muscles in each participant for reduction of coactivation. Results Both healthy participants and stroke survivors learned to reduce abnormal coactivation of the targeted muscles with MCI training. Out of 5 stroke survivors, 3 exhibited objective reduction in arm impairment as well (improvement in FMA-UE of 3 points in each of these patients). Conclusions These results suggest that the MCI was an effective tool in directly retraining muscle activation patterns following stroke.

Plasticity in the Injured Brain

Changes in brain circuits occur within specific paradigms of action in the adult brain. These paradigms include changes in behavioral activity patterns, alterations in environmental experience, and direct brain injury. Each of these paradigms can produce axonal sprouting, dendritic morphology changes, and alterations in synaptic connectivity. Activity-, experience-, and injury-dependent plasticity alter neuronal network function and behavioral output, and in the case of brain injury, may produce neurological recovery. The molecular substrate for adult neuronal plasticity overlaps in these three paradigms in key signaling pathways. These common pathways for adult plasticity suggest common mechanisms for activity-, experience-, and injury-dependent plasticity. These common pathways may also interact to enhance or impede each other during adult recovery of function after injury. This review focuses on common molecular changes evoked during the process of adult neuronal plasticity, with a focus on neural repair in stroke.

Long-term sensory stimulation therapy improves hand function and restores cortical responsiveness in patients with chronic cerebral lesions. Three single case studies

Rehabilitation of sensorimotor impairment resulting from cerebral lesion (CL) utilizes task specific training and massed practice to drive reorganization and sensorimotor improvement due to induction of neuroplasticity mechanisms. Loss of sensory abilities often complicates recovery, and thus the individual's ability to use the affected body part for functional tasks. Therefore, the development of additional and alternative approaches that supplement, enhance, or even replace conventional training procedures would be advantageous. Repetitive sensory stimulation protocols (rSS) have been shown to evoke sensorimotor improvements of the affected limb in patients with chronic stroke. However, the possible impact of long-term rSS on sensorimotor performance of patients with CL, where the incident dated back many years remains unclear. The particular advantage of rSS is its passive nature, which does not require active participation of the subjects. Therefore, rSS can be applied in parallel to other occupations, making the intervention easier to implement and more acceptable to the individual. Here we report the effects of applying rSS for 8, 36, and 76 weeks to the paretic hand of three long-term patients with different types of CL. Different behavioral tests were used to assess sensory and/or sensorimotor performance of the upper extremities prior, after, and during the intervention. In one patient, the impact of long-term rSS on restoration of cortical activation was investigated by recording somatosensory evoked potentials (SEP). After long-term rSS all three patients showed considerable improvements of their sensory and motor abilities. In addition, almost normal evoked potentials could be recorded after rSS in one patient. Our data show that long-term rSS applied to patients with chronic CL can improve tactile and sensorimotor functions, which, however, developed in some cases only after many weeks of stimulation, and continued to further improve on a time scale of months.

Constraint-induced movement therapy for the upper paretic limb in acute or sub-acute stroke: a systematic review

Constraint-induced movement therapy is a commonly used intervention to improve upper limb function after stroke. However, the effectiveness of constraint-induced movement therapy and its optimal dosage during acute or sub-acute stroke is still under debate. To examine the literature on the effects of constraint-induced movement therapy in acute or sub-acute stroke. A literature search was performed to identify randomized, controlled trials; studies with the same outcome measure were pooled by calculating the mean difference. Separate quantitative analyses for high-intensity and low-intensity constraint-induced movement therapy were applied when possible. Five randomized, controlled trials were included, comprising 106 participants. The meta-analysis demonstrated significant mean differences in favor of constraint-induced movement therapy for the Fugl-Meyer arm, the Action Research Arm Test, the Motor Activity Log, Quality of Movement and the Grooved Pegboard Test. Nonsignificant mean difference in favor of constraint-induced movement therapy were found for the Motor Activity Log, Amount of Use. Separate analyses for high-intensity and low-intensity constraint-induced movement therapy resulted in significant favorable mean differences for low-intensity constraint-induced movement therapy for all outcome measures, in contrast to high-intensity constraint-induced movement therapy. This meta-analysis demonstrates a trend toward positive effects of high-intensity and low-intensity constraint-induced movement therapy in acute or sub-acute stroke, but also suggests that low-intensity constraint-induced movement therapy may be more beneficial during this period than high-intensity constraint-induced movement therapy. However, these results were based on a small number of studies. Therefore, more trials are needed applying different doses of therapy early after stroke and a better understanding is needed about the different time windows in which underlying mechanisms of recovery operate.

Parietofrontal integrity determines neural modulation associated with grasping imagery after stroke

Chronic stroke patients with heterogeneous lesions, but no direct damage to the primary sensorimotor cortex, are capable of longitudinally acquiring the ability to modulate sensorimotor rhythms using grasping imagery of the affected hand. Volitional modulation of neural activity can be used to drive grasping functions of the paralyzed hand through a brain-computer interface. The neural substrates underlying this skill are not known. Here, we investigated the impact of individual patient's lesion pathology on functional and structural network integrity related to this volitional skill. Magnetoencephalography data acquired throughout training was used to derive functional networks. Structural network models and local estimates of extralesional white matter microstructure were constructed using T(1)-weighted and diffusion-weighted magnetic resonance imaging data. We employed a graph theoretical approach to characterize emergent properties of distributed interactions between nodal brain regions of these networks. We report that interindividual variability in patients' lesions led to differential impairment of functional and structural network characteristics related to successful post-training sensorimotor rhythm modulation skill. Patients displaying greater magnetoencephalography global cost-efficiency, a measure of information integration within the distributed functional network, achieved greater levels of skill. Analysis of lesion damage to structural network connectivity revealed that the impact on nodal betweenness centrality of the ipsilesional primary motor cortex, a measure that characterizes the importance of a brain region for integrating visuomotor information between frontal and parietal cortical regions and related thalamic nuclei, correlated with skill. Edge betweenness centrality, an analogous measure, which assesses the role of specific white matter fibre pathways in network integration, showed a similar relationship between skill and a portion of the ipsilesional superior longitudinal fascicle connecting premotor and posterior parietal visuomotor regions known to be crucially involved in normal grasping behaviour. Finally, estimated white matter microstructure integrity in regions of the contralesional superior longitudinal fascicle adjacent to primary sensorimotor and posterior parietal cortex, as well as grey matter volume co-localized to these specific regions, positively correlated with sensorimotor rhythm modulation leading to successful brain-computer interface control. Thus, volitional modulation of ipsilesional neural activity leading to control of paralyzed hand grasping function through a brain-computer interface after longitudinal training relies on structural and functional connectivity in both ipsilesional and contralesional parietofrontal pathways involved in visuomotor information processing. Extant integrity of this structural network may serve as a future predictor of response to longitudinal therapeutic interventions geared towards training sensorimotor rhythms in the lesioned brain, secondarily improving grasping function through brain-computer interface applications.

An intensive intervention for improving gait, balance, and mobility in individuals with chronic incomplete spinal cord injury: a pilot study of activity tolerance and benefits

OBJECTIVE

To determine the tolerance to and benefits of an intensive mobility training (IMT) approach for individuals with incomplete spinal cord injury (ISCI).

DESIGN

Prospective pretest-posttest study with 6-month follow-up.

SETTING

University research laboratory.

PARTICIPANTS

A volunteer sample of individuals with ISCI (N=15; >6 mo postinjury and able to walk at least 3.05 m with or without assistance). Follow-up data were collected for 10 of the participants.

INTERVENTIONS

Participants received IMT for 3h/d for 10 weekdays, participating in activities that encouraged repetitive, task-specific training of their lower extremities in a massed practice schedule.

MAIN OUTCOME MEASURES

Amount of time spent in therapeutic activities and rest was used to assess participants' tolerance to the intervention. Treatment outcomes were assessed pretest, posttest, and 6 months after the intervention and included the Berg Balance Scale (BBS), Dynamic Gait Index (DGI), 6-minute walk test, gait speed, and Spinal Cord Injury Functional Ambulation Inventory.

RESULTS

Individuals in the higher functioning ISCI group (BBS score ≥45 and gait speed ≥0.6 m/s) spent more time in the intensive therapy on average than individuals in the lower functioning ISCI group. Effect sizes were comparable for changes in balance and mobility assessments between the lower and higher functioning groups, with the largest effect sizes observed for the DGI.

CONCLUSIONS

This dosage of IMT may be a more appropriate treatment approach for higher functioning ISCI individuals, as they were better able to tolerate the length of the session and demonstrated higher effect sizes postintervention.

Clinical study of neurorehabilitation in stroke using EEG-based motor imagery brain-computer interface with robotic feedback

This clinical study investigates the ability of hemiparetic stroke patients in operating EEG-based motor imagery brain-computer interface (MI-BCI). It also assesses the efficacy in motor improvements on the stroke-affected upper limb using EEG-based MI-BCI with robotic feedback neurorehabilitation compared to robotic rehabilitation that delivers movement therapy. 54 hemiparetic stroke patients with mean age of 51.8 and baseline Fugl-Meyer Assessment (FMA) 14.9 (out of 66, higher = better) were recruited. Results showed that 48 subjects (89%) operated EEG-based MI-BCI better than at chance level, and their ability to operate EEG-based MI-BCI is not correlated to their baseline FMA (r=0.358). Those subjects who gave consent are randomly assigned to each group (N=11 and 14) for 12 1-hour rehabilitation sessions for 4 weeks. Significant gains in FMA scores were observed in both groups at post-rehabilitation (4.5, 6.2; p=0.032, 0.003) and 2-month post-rehabilitation (5.3, 7.3; p=0.020, 0.013), but no significant differences were observed between groups (p=0.512, 0.550). Hence, this study showed evidences that a majority of hemiparetic stroke patients can operate EEG-based MI-BCI, and that EEG-based MI-BCI with robotic feedback neurorehabilitation is effective in restoring upper extremities motor function in stroke.

Peripherally induced movement disorders

Peripherally induced movement disorders may be defined as involuntary or abnormal movements triggered by trauma to the cranial or peripheral nerves or roots. Although patients often recall some history of trauma before the onset of a movement disorder, determining the true relationship of the disorder to the earlier trauma is often difficult. The pathophysiology of these disorders is reviewed.

Constraint-induced movement therapy (CIMT): pediatric applications

The purpose of this article is to describe theoretical and research bases for constraint-induced movement therapy (CIMT), to discuss key features and variations in protocols currently in use with children, and to review the results of studies of efficacy. CIMT has been found to be an effective intervention for increasing functional use of the hemiparetic upper extremity in adults with chronic disability from stroke. CIMT developed out of behavioral research on the phenomenon of "learned nonuse" of an upper extremity, commonly observed following sensory and/or motor CNS injury, in which failure to regain use persists even after a period of partial recovery. CIMT includes three key elements: (1) constraining the use of the less-impaired upper extremity (UE); (2) intensive, repetitive daily therapist-directed practice of motor movements with the impaired UE for an extended period (2-3 weeks); and (3) shaping of more complex action patterns through a process of rewarding successive approximations to the target action. Mechanisms responsible for success are thought to be separate but complementary, that is, operant conditioning (reversal of learned nonuse) and experience-driven cortical reorganization. CIMT has recently been extended to children with hemiparesis secondary to perinatal stroke or other CNS pathology. Numerous case studies, as well as a small number of randomized controlled or controlled clinical trials have reported substantial gains in functional use of the hemiplegic UE following CIMT with children. Protocols vary widely in terms of type of constraint used, intensity and duration of training, and outcome measures. In general, all report gains in functional use, with minimal or no adverse effects. Continued research is needed, to clarify optimal protocol parameters and to further understand mechanisms of efficacy.

The effect of an intensive exercise programme on leg function in chronic stroke patients: a pilot study with one-year follow-up

OBJECTIVE

To investigate the effect of two weeks of intensive exercise on leg function in chronic stroke patients and to evaluate the feasibility of an intensive exercise programme in a group setting.

DESIGN

Pilot study with one-group pre-test post-test design with two pre-tests and one-year follow-up.

SETTING

Inpatient rehabilitation hospital.

SUBJECTS

Twelve hemiparetic patients completed the intervention. Ten patients participated at one-year follow-up.

INTERVENTION

Six hours of daily intensive exercise for two weeks with focus on weight-shifting towards the affected side and increased use of the affected extremity during functional activities. An insole with nubs in the shoe of the non-paretic limb was used to reinforce weight-shift toward the affected side.

MAIN MEASURES

Timed Up and Go, Four Square Step Test, gait velocity, gait symmetry and muscle strength in knee and ankle muscles.

RESULTS

Maximal gait velocity (P = 0.002) and performance time (seconds) on Timed Up and Go (mean, SD; 12.2, 3.8 vs. 9.4, 3.2) and Four Square Step Test improved from pre- to post-test (P = 0.005). Improvements remained significant at follow-up. Preferred gait velocity and gait symmetry remained unchanged. Knee extensor (P<50.009) and flexor (P<50.001) strength increased bilaterally from pre- to post-test but only knee flexor strength remained significant at follow-up. Ankle dorsi flexor (P = 0.02) and plantar flexor (P<0.001) strength increased on paretic side only (not tested at follow-up).

CONCLUSION

Intensive exercise for lower extremity is feasible in a group setting and was effective in improving ambulatory function, maximal gait velocity and muscle strength in chronic stroke patients. Most improvements persisted at the one-year follow-up.

A mobile robot therapist for under-supervised training with robot/computer assisted motivating systems

Robot assisted therapy is a new and promising area in stroke rehabilitation and has shown to be effective in reducing motor impairment, but is a costly solution for home rehabilitation. High medical costs could be reduced if we could improve rehabilitation exercise in unsupervised environments such as the home. Hence, there is an augmented need for a cost effective rehabilitation system that can be used outside the clinic. This paper presents the design concept for an autonomous robotic assistant that is low-cost and effective in engaging the users while assisting them with therapy in any under-supervised area. We investigated how the robot assistant can support TheraDrive, our low-cost therapy system. We present the design methods and a case study demonstrating the arm and video collection system.

Responsiveness and validity of three outcome measures of motor function after stroke rehabilitation

BACKGROUND AND PURPOSE

This study investigated and compared the responsiveness and validity of the Fugl-Meyer Assessment (FMA), the Action Research Arm Test (ARAT), and the Wolf Motor Function Test (WMFT) for patients after stroke rehabilitation.

METHODS

A total of 57 patients with stroke received 1 of 3 rehabilitation treatments for 3 weeks. At pretreatment and posttreatment, the 3 outcome measures, as well as the Functional Independence Measure (FIM) as the external criterion, were administered. The standardized response mean (SRM) and the Wilcoxon signed rank test were used to examine the responsiveness. Construct validity and predictive validity were examined by the Spearman correlation coefficient (rho).

RESULTS

The responsiveness of the FMA, ARAT, and WMFT functional ability scores was large (SRM=0.95-1.42), whereas the WMFT performance time score was small (SRM=0.38). The responsiveness of the FMA was significantly larger than those of the ARAT and the WMFT-TIME, but not the WMFT functional ability scores. With respect to construct validity, correlations between the FMA and other measures were relatively high (rho=0.42-0.76). The FMA and the WMFT performance time scores at pretreatment had moderate predictive validity with the FIM scores at posttreatment (rho=0.42-0.47). In addition, the ARAT and the WMFT functional ability scores revealed a low predictive validity with the FIM (rho=0.17-0.26).

CONCLUSIONS

The results support the FMA and the WMFT-FAS are suitable to detect changes over time for patients after stroke rehabilitation. While simultaneously considering the responsiveness and validity attributes, the FMA may be a relatively sound measure of motor function for stroke patients based on our results. Further research based on a larger sample is needed to replicate the findings.

Short- and long-term outcome of constraint-induced movement therapy after stroke: a randomized controlled feasibility trial

Objective: Constraint-induced movement therapy (CIMT) is a method to improve motor function in the upper extremity following stroke. The aim of this trial was to determine the effect and feasibility of CIMT compared with traditional rehabilitation in short and long term.

Design: A randomized controlled trial.

Setting: An inpatient rehabilitation clinic.

Subjects: Thirty patients with unilateral hand impairment after stroke.

Intervention: Six hours arm therapy for 10 consecutive weekdays, while

using a restraining mitten on the unaffected hand.

Main measures: The patients were assessed at baseline, post-treatment and at six-month follow-up using the Wolf Motor Function Test as primary outcome measure and the Motor Activity Log, Functional Independence Measure and Stroke Impact Scale as secondary measurements.

Results: The CIMT group (n=18) showed a statistically significant shorter performance time (4.76 seconds versus 7.61 seconds, P= 0.030) and greater functional ability (3.85 versus 3.47, P= 0.037) than the control group (n=12) on the Wolf Motor Function Test at post-treatment assessment. There was a non-significant trend toward greater amount of use (2.47 versus 1.97, P= 0.097) and better quality of movement (2.45 versus 2.12, P=0.105) in the CIMT group according to the Motor Activity Log. No such differences were seen on Functional Independence Measure at the same time. At six-month follow-up the CIMT group maintained their improvement, but as the control group improved even more, there were no significant differences between the groups on any measurements.

Conclusions: CIMT seems to be an effective and feasible method to improve motor function in the short term, but no long-term effect was found.

Constraint-induced movement therapy for severe upper-extremity impairment after stroke in an outpatient rehabilitation setting: a case report

PURPOSE

Laboratory studies confirm that constraint-induced movement therapy (CIMT) improves upper-extremity (UE) function after stroke. Due to strict patient criteria and the intensive resources required, CIMT has been slow to become part of rehabilitation practice. Our purpose was to determine the feasibility and effectiveness of an adapted experimental protocol within an outpatient clinical setting for a patient with moderate to severe UE impairment who did not meet traditional CIMT criteria.

PATIENT DESCRIPTION

AJ, a 16-year-old male, experienced a left middle cerebral artery ischemic stroke due to carotid artery dissection one year before beginning CIMT. He demonstrated some proximal movement but no wrist or finger extension. He had received intensive rehabilitation for 12 months prior to beginning CIMT.

INTERVENTION

Two occupational therapists and two physiotherapists collaborated to provide CIMT task training for 6 hours daily for 2 weeks. A knitted mitten extending to the elbow restrained the less-involved UE during 90% of waking hours. Tasks were tailored to AJ's interests, with the goal of integrating his affected UE into his behavioural repertoire. MEASURES AND OUTCOMES: After 2 weeks of CIMT, AJ improved in all measures (grip and lateral pinch strength, Action Research Arm Test [ARAT], and Box and Block Test) except the Chedoke McMaster Impairment Inventory. Greatest gains were seen at 6 months in the ARAT and Box and Block Test, which coincided with patient and family reports of AJ's using his arm in everyday functional tasks.

IMPLICATIONS

Shared workload, emphasis on relevant functional tasks, and complete family participation likely influenced the success of CIMT. Our findings suggest that the strict CIMT criteria used in previous studies may exclude patients who might benefit from the treatment. Controlled trials should be undertaken to examine the effects of CIMT in patients with moderate to severe UE impairment.