Does the application of constraint-induced movement therapy during acute rehabilitation reduce arm impairment after ischemic stroke?

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.

The Effect of Constraint-Induced Movement Therapy on Arm Function and Activities of Daily Living in Post-stroke Patients: A Systematic Review and Meta-Analysis

This meta-analysis aimed to evaluate the effect of constraint-induced movement therapy (CIMT) on arm function and daily living compared with conventional rehabilitation in stroke patients with hemiplegia. We searched three international electronic databases-MEDLINE, Embase, and the Cochrane Library-for relevant studies. The risk of bias was evaluated using Cochrane's Risk of Bias version 1.0, and the certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations method. A total of 34 randomized controlled trials (RCTs) were included herein. Specifically, 21 RCTs regarding arm motor function, 13 on upper limb motor impairment, and 12 on activities of daily living (ADL) performance were analyzed. The results of the meta-analysis demonstrated that CIMT was significantly more effective than conventional therapy in improving arm motor function, reducing upper limb motor impairment, and enhancing ADL performance. CIMT should be implemented and tailored to the strength of the affected upper limb to improve upper limb function and ADL performance in post-stroke patients with hemiplegia.

Design and application of pneumatic rehabilitation glove system based on brain-computer interface

Stroke has been the second leading cause of death and disability worldwide. With the innovation of therapeutic schedules, its death rate has decreased significantly but still guides chronic movement disorders. Due to the lack of independent activities and minimum exercise standards, the traditional rehabilitation means of occupational therapy and constraint-induced movement therapy pose challenges in stroke patients with severe impairments. Therefore, specific and effective rehabilitation methods seek innovation. To address the overlooked limitation, we design a pneumatic rehabilitation glove system. Specially, we developed a pneumatic glove, which utilizes ElectroEncephaloGram (EEG) acquisition to gain the EEG signals. A proposed EEGTran model is inserted into the system to distinguish the specific motor imagination behavior, thus, the glove can perform specific activities according to the patient's imagination, facilitating the patients with severe movement disorders and promoting the rehabilitation technology. The experimental results show that the proposed EEGTrans reached an accuracy of 87.3% and outperformed that of competitors. It demonstrates that our pneumatic rehabilitation glove system contributes to the rehabilitation training of stroke patients.

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.

Therapeutic Role of Additional Mirror Therapy on the Recovery of Upper Extremity Motor Function after Stroke: A Single-Blind, Randomized Controlled Trial

BACKGROUND

Rehabilitation of upper extremity hemiplegia after stroke remains a great clinical challenge, with only 20% of patients achieving a basic return to normal hand function. How to promote the recovery of motor function at an early stage is crucial to the life of the patient.

OBJECTIVES

To invest the effects of additional mirror therapy in improving upper limb motor function and activities of daily living in acute and subacute stroke patients, and further explore the effects of other factors on the efficacy of MT.

METHODS

Participants who presented with unilateral upper extremity paralysis due to a first ischemic or hemorrhagic stroke were included in the study. They were randomly allocated to the experimental or control group. Patients in the control group received occupational therapy for 30 minutes each session, six times a week, for three weeks, while patients in the experimental group received 30 minutes of additional mirror therapy based on occupational therapy. The primary outcome measures were Fugl-Meyer Assessment-upper extremity (FMA-UE), Action Research Arm Test (ARAT), and Instrumental Activity of Daily Living (IADL) which were evaluated by two independent occupational therapists before treatment and after 3-week treatment. A paired t-test was used to compare the values between pretreatment and posttreatment within an individual group. Two-sample t-test was utilized to compare the changes (baseline to postintervention) between the two groups.

RESULTS

A total of 52 stroke patients with unilateral upper extremity motor dysfunction who were able to actively cooperate with the training were included in this study. At baseline, no significant differences were found between groups regarding demographic and clinical characteristics (P > 0.05 for all). Upper limb motor function and ability to perform activities of daily living of the patients were statistically improved in both groups towards the third week (P < 0.05). In addition, statistical analyses showed more significant improvements in the score changes of FMA-UE and IADL in the experimental group compared to the control group after treatment (P < 0.05), but no significant difference was observed in the ARAT score changes between the two groups (P > 0.05). The subgroup analysis showed that no significant heterogeneity was observed in age, stroke type, lesion side, and clinical stage (P > 0.05).

CONCLUSION

In conclusion, some positive changes in aspects of upper limb motor function and the ability to perform instrumental activities of daily living compared with routine occupational therapy were observed in additional mirror therapy. Therefore, the application of additional mirror therapy training should be reconsidered to improve upper extremity motor in stroke patients.

Effects of Meaningful Action Observation Therapy on Occupational Performance, Upper Limb Function, and Corticospinal Excitability Poststroke: A Double-Blind Randomized Control Trial

Introduction

Action observation therapy (AOT) is a mirror neuron-based approach that has been recently used in poststroke rehabilitation. The main goal of this study was to investigate the effectiveness of AOT of occupations and tasks that are meaningful for chronic stroke patients on occupational performance, upper-extremity function, and corticospinal changes.

Method

A randomized control trial was designed to compare between experimental (n = 13) and control groups (n = 14). In both groups, the execution of meaningful tasks was practiced, but the videos of those tasks were just shown to the experiment group. Instead, patients in the control group watched nature videos as a placebo. Clinical outcomes were evaluated using the Canadian Occupational Performance Measure (COPM), Fugl-Meyer Assessment (FMA), Action Research Arm Test (ARAT), and Box-Block Test (BBT) on 3 occasions: baseline, post (at 4 weeks), and follow-up (at 8 weeks). The assessments of central motor conduction time (CMCT) for abductor policis brevis (APB) and extensor indicis (EI) were only recorded at baseline and posttreatment. Both assessors of clinical and neurophysiological outcomes were blinded to the allocation of subjects.

Result

Finally, the results of outcomes in 24 patients who completed the study were analyzed. In both groups, significant improvements after treatment were seen for most outcomes (p ≤ 0.05). These changes were persistent until follow-up. There were significant differences in COPM performance (p = 0.03) and satisfaction (p = 0.001) between the experimental and control groups. In contrast, other clinical assessments such as FMA, ARAT, and BBT did not show significant differences between the two treatments (p ≥ 0.05). The results of CMCT related to APB showed a more significant change in the experiment group compared to the control group (p = 0.022). There was no difference in change detected between the two groups for CMCT related to EI after treatments.

Conclusion

Observation and execution of meaningful activities can enhance the effects of simply practicing those activities on occupational performance/satisfaction and corticospinal excitability poststroke.

The Effect of Task-Oriented Training on Upper-Limb Function, Visual Perception, and Activities of Daily Living in Acute Stroke Patients: A Pilot Study

This pilot study aimed to investigate the effects of task-oriented training on upper-limb functioning, visual perception, and activities of daily living (ADL) in acute stroke patients. Of 20 participants, 10 were randomly assigned in a 1:1 ratio to experimental and control groups. Task-oriented training and table-top activity training were implemented for 6 weeks. Change in upper-limb functioning was assessed with the Manual Function Test (MFT); visual perceptual skill and ADL performance were evaluated using the Motor-Free Visual Perception Test—Vertical (MVPT-V) and Korean Modified Barthel Index (K-MBI), respectively. There was a significant interaction in the MFT and MBI score between the group and time (p < 0.05), but the group effect was not significant (p > 0.05). The MFT and MBI score significantly increased in both groups after the intervention (p < 0.001), but the effect size was greater in the task-oriented training group than the table-top activity training group. No significant interaction with MVPT-V score was found between the group and time (p > 0.05), and no statistical group difference was found either (p > 0.05). Both groups showed significant improvement in their MVPT-V score after the intervention (p < 0.001). The pilot study findings demonstrate that both task-oriented training and table-top activity training are effective in recovering upper-limb function, visual perception, and ADL in acute stroke patients.

Why Are Stroke Rehabilitation Trial Recruitment Rates in Single Digits?

Background: Recruitment of patients in early subacute rehabilitation trials (<30 days post-stroke) presents unique challenges compared to conventional stroke trials recruiting individuals >6 months post-stroke. Preclinical studies suggest treatments be initiated sooner after stroke, thus requiring stroke rehabilitation trials be conducted within days post-stroke. How do specific inclusion and exclusion criteria affect trial recruitment rates for early stroke rehabilitation trials?

Objectives: Provide estimates of trial recruitment based on screening and enrollment data from a phase II early stroke rehabilitation trial.

Methods: CPASS, a phase II intervention trial screened ischemic stroke patients in acute care (18-months, N = 395) and inpatient rehabilitation (22-months, N = 673). Patients were stratified by upper extremity (UE) impairment into mild (NIHSS motor arm = 0, 1); moderate (NIHSS = 2, 3); severe (NIHSS = 4) and numbers of patients disqualified due to CPASS exclusion criteria determined. We also examined if a motor-specific evaluation (Action Research Arm Test, ARAT) increases the pool of eligible patients disqualified by the NIHSS motor arm item.

Results: CPASS recruitment in acute care (5.3%) and inpatient rehabilitation (5%) was comparable to prior trials. In acute care, a short stay (7–17-days), prior stroke (13.5% in moderately; 13.2% in severely impaired) disqualified the majority. In inpatient rehabilitation, the majority (40.8%) were excluded for “too mild” impairment. The next majority were disqualified for reaching inpatient rehabilitation “too late” to participate in an early stroke trial (15% in moderately; 24% in severely impaired). Mean ARAT in the “too mild” showed significant impairment and potential to benefit from participation in select UE rehabilitation trials.

Conclusions: Screening of ischemic stroke patients while they are still in acute care is crucial to successful recruitment for early stroke rehabilitation trials. A significant proportion of eligible patients are lost to “short length of stay” in acute care, and arrive to inpatient rehabilitation “too late” for an early rehabilitation trial. Additional screening of mildly impaired patients using a motor function specific scale will benefit the trial recruitment and generalizability.

Trial Registration Number:http://www.clinicaltrials.gov Identifier: NCT02235974.

Effect of mirror therapy on hand functions in Egyptian chronic stroke patients

Background

Most stroke survivors (more than 60%) suffer from persistent neurological impairments that significantly affect activities of daily living. Hand functions are essential for doing daily living and working activities. Mirror therapy is shown to be effective in improving hand functional recovery in stroke patients.

Objective

This study aimed to determine the effect of mirror therapy on improving hand functions in Egyptian chronic stroke patients.

Subjects and methods

Thirty chronic ischemic stroke patients from both sexes participated in the study. Their ages ranged from 45 to 65 years. They were randomly assigned into two equal groups: the study group that received a selected physical therapy program in addition to the mirror therapy and the control group that received the same selected physical therapy program but without a mirror therapy. Treatment sessions were conducted three times per week for 8 weeks. Range of motion (ROM) of the wrist extension and forearm supination, hand grip strength, and the time of Jebson Hand Function Test (JHFT) were measured before and after the treatment program.

Results

There were statistically significant increases in the range of motion of the wrist extension and forearm supination and hand grip strength with a decrease in the time of Jebson Hand Function Test in both groups post-treatment. Post-treatment improvement was more significant in the study group compared to the control group.

Conclusion

Mirror therapy had a positive effect on improving hand motor functional skills in a sample of Egyptian chronic stroke patients.

Unimanual Intensive Therapy with or without Unaffected Hand Containment in Children with Hemiplegia. A Randomized Controlled Pilot Study

Children with hemiplegia have lower spontaneous use and quality of movement in the affected upper limb. The modified constraint-induced movement therapy (mCIMT) is applied to improve the affected upper limb function. The objective of this study was to study the efficacy of unaffected hand containment to obtain changes in the function of the affected upper limb after applying two unimanual therapies. A randomized controlled pilot study was performed with 16 children diagnosed with congenital infantile hemiplegia, with eight children randomized in each group (average age: 5.54 years; SD: 1.55). mCIMT and unimanual therapy without containment (UTWC) were applied, with a total of 50 h distributed in five weeks (two h/per day). Two assessments were performed (pre- and post-treatment) to evaluate the affected upper limb spontaneous use, measured with the Shiners Hospital Upper Extremity Evaluation (SHUEE), and the quality of movement, measured with the Quality of Upper Extremity Skills Test (QUEST scale). The progression of the variables was different in both groups. The results are expressed in the median of the improvement percent and interquartile range (IQR). The spontaneous use analysis showed an improvement percent of 31.65 (IQR: 2.33, 110.42) in the mCIMT group with respect to 0.00 (IQR: 0.00, 0.00) in the UTWC group. The quality of movement increased in the mCIMT and UTWC groups, 24.21 (IQR: 13.44, 50.39), 1.34 (IQR: 0.00, 4.75), respectively and the greatest increase was obtained in the grasp variable for both groups. The use of unaffected hand containment in mCIMT would produce improvements in the affected upper limb functionality in children with hemiplegia (4-8 years old) compared to the same protocol without containment (UTWC).

Effects of transcranial direct current stimulation with virtual reality on upper limb function in patients with ischemic stroke: a randomized controlled trial

BACKGROUND

Non-invasive brain stimulation techniques have been shown in several studies to improve the motor recovery of the affected upper-limbs in stroke patients. This study aims to investigate whether or not cathodal transcranial direct current stimulation (c-tDCS), combined with virtual reality (VR), is superior to VR alone in reducing motor impairment and improving upper limb function and quality of life in stroke patients.

METHODS

Forty patients who suffered ischemic stroke between 2 weeks to 12 months were recruited for this single-blind randomized control trial. The patients were randomly assigned either to an experimental group who receiving c-tDCS and VR, or a control group receiving sham stimulation and VR. The cathodal electrode was positioned over the primary motor cortex (M1) of the unaffected hemisphere. The treatment session consisted of 20 min of daily therapy, for 10 sessions over a 2-week period. The outcome measures were the Fugl-Meyer Upper Extremity (FM-UE), the Action Research Arm Test (ARAT) and the Barthel Index (BI).

RESULTS

The two groups were comparable in demographic characteristic and motor impairment. After 2 weeks of intervention, both groups demonstrated significant improvement in FM-UE, ARAT and BI scores (P<0.05).The experiment group demonstrated more improvement in FM-UE than the control group (10.1 vs. 6.4, p = 0.003) and, ARAT (7.0 vs 3.6, p = 0.026) and BI (12.8 vs 8.5, p = 0.043).

CONCLUSIONS

The findings from our study support that c-tDCS, along with VR, can facilitate a stronger beneficial effect on upper limb motor impairment, function and quality of life than VR alone in patients with ischemic stroke.

TRIAL REGISTRATION

The study was registered in the Chinese Clinical Trial Registry (ChiCTR1800019386) in November 8, 2018-Retrospectively registered.

Generalizing movement patterns following shoulder fixation

Generalizing newly learned movement patterns beyond the training context is challenging for most motor learning situations. Here we tested whether learning of a new physical property of the arm during self-initiated reaching generalizes to new arm configurations. Human participants performed a single-joint elbow reaching task and/or countered mechanical perturbations that created pure elbow motion with the shoulder joint free to rotate or locked by the manipulandum. With the shoulder free, we found activation of shoulder extensor muscles for pure elbow extension trials, appropriate for countering torques that arise at the shoulder due to forearm rotation. After locking the shoulder joint, we found a partial reduction in shoulder muscle activity, appropriate because locking the shoulder joint cancels the torques that arise at the shoulder due to forearm rotation. In our first three experiments, we tested whether and to what extent this partial reduction in shoulder muscle activity generalizes when reaching in different situations: 1) different initial shoulder orientation, 2) different initial elbow orientation, and 3) different reach distance/speed. We found generalization for the different shoulder orientation and reach distance/speed as measured by a reliable reduction in shoulder activity in these situations but no generalization for the different elbow orientation. In our fourth experiment, we found that generalization is also transferred to feedback control by applying mechanical perturbations and observing reflex responses in a distinct shoulder orientation. These results indicate that partial learning of new intersegmental dynamics is not sufficient for modifying a general internal model of arm dynamics.NEW & NOTEWORTHY Here we show that partially learning to reduce shoulder muscle activity following shoulder fixation generalizes to other movement conditions, but it does not generalize globally. These findings suggest that the partial learning of new intersegmental dynamics is not sufficient for modifying a general internal model of the arm's dynamics.

Constraint-induced movement therapy for upper limb recovery in adult neurorehabilitation: An international survey of current knowledge and experience

INTRODUCTION

Constraint-induced movement therapy (CIMT) is an effective intervention for upper limb recovery following stroke and traumatic brain injury. Despite strong evidence, the use of CIMT in practice is limited. The aim of this study was to investigate clinician knowledge and experience of delivering CIMT protocols internationally in neurorehabilitation.

METHODS

A cross-sectional survey was conducted online. The survey was distributed through occupational therapy and physiotherapy associations, neurological interest groups and list serves in 11 countries. Passive snowball sampling was used to recruit participants. Descriptive and inferential statistics were used for analysis.

RESULTS

Complete surveys were returned by 169 respondents (64.5% occupational therapists; 34.3% physiotherapists; 1.2% other). Most respondents were from the United Kingdom (36.1%), Australia (28.4%) and Denmark (7.7%). Most participants delivered CIMT to individuals (79.3%) rather than in groups. A modified version of CIMT was used most often (74.6%), with one hour sessions per day (30.2%), provided to stroke survivors (96.4%) and people with traumatic brain injury (37.3%). Most respondents (88.8%) used intensive graded practice as a component of a CIMT program, but only 43.2% reported using a mitt restraint for most waking hours, and only 38.5% used a transfer package.

CONCLUSION

These findings suggest that CIMT is being used globally but not always with fidelity to the original trials. A range of strategies are needed for improving clinicians' knowledge and skills to increase the frequency of program delivery and enhance program delivery with fidelity.

Analysis of Displayable Force Region at Passive-Type Force Display with Redundant Brakes – Development of Rehabilitation System for Upper Limbs mboxPLEMO-Y (Redundant) –

Robotic rehabilitation systems for upper limbs have been developed as two system types: active or passive. Active-type systems use actuators to provide users with varying degrees of force; in contrast, the force available from passive-type systems is limited, although these systems are safer to use. In this paper, a passive-type force display with redundant brakes is proposed to extend the displayable force region of the system. The kinematics and statics are derived, and the reaction force generated by brake torques is clarified. The displayable force region is analyzed in the simulation, and then the experiments are examined to verify the proposed analytical model.

Effectiveness and Superiority of Rehabilitative Treatments in Enhancing Motor Recovery Within 6 Months Poststroke: A Systemic Review

OBJECTIVE

To investigate the effects of various rehabilitative interventions aimed at enhancing poststroke motor recovery by assessing their effectiveness when compared with no treatment or placebo and their superiority when compared with conventional training program (CTP).

DATA SOURCE

A literature search was based on 19 Cochrane reviews and 26 other reviews. We also updated the searches in PubMed up to September 30, 2017.

STUDY SELECTION

Randomized controlled trials associated with 18 experimented training programs (ETP) were included if they evaluated the effects of the programs on either upper extremity (UE) or lower extremity (LE) motor recovery among adults within 6 months poststroke; included ≥10 participants in each arm; and had an intervention duration of ≥10 consecutive weekdays.

DATA EXTRACTION

Four reviewers evaluated the eligibility and quality of literature. Methodological quality was assessed using the PEDro scale.

DATA SYNTHESIS

Among the 178 included studies, 129 including 7450 participants were analyzed in this meta-analysis. Six ETPs were significantly effective in enhancing UE motor recovery, with the standard mean differences (SMDs) and 95% confidence intervals outlined as follow: constraint-induced movement therapy (0.82, 0.45-1.19), electrostimulation (ES)-motor (0.42, 0.22-0.63), mirror therapy (0.71, 0.22-1.20), mixed approach (0.21, 0.01-0.41), robot-assisted training (0.51, 0.22-0.80), and task-oriented training (0.57, 0.16-0.99). Six ETPs were significantly effective in enhancing LE motor recovery: body-weight-supported treadmill training (0.27, 0.01-0.52), caregiver-mediated training (0.64, 0.20-1.08), ES-motor (0.55, 0.27-0.83), mixed approach (0.35, 0.15-0.54), mirror therapy (0.56, 0.13-1.00), and virtual reality (0.60, 0.15-1.05). However, compared with CTPs, almost none of the ETPs exhibited significant SMDs for superiority.

CONCLUSIONS

Certain experimented interventions were effective in enhancing poststroke motor recovery, but little evidence supported the superiority of experimented interventions over conventional rehabilitation.

Rehabilitation Interventions for Upper Limb Function in the First Four Weeks Following Stroke: A Systematic Review and Meta-Analysis of the Evidence

OBJECTIVE

To investigate the therapeutic interventions reported in the research literature and synthesize their effectiveness in improving upper limb (UL) function in the first 4 weeks poststroke.

DATA SOURCES

Electronic databases and trial registries were searched from inception until June 2016, in addition to searching systematic reviews by hand.

STUDY SELECTION

Randomized controlled trials (RCTs), controlled trials, and interventional studies with pre/posttest design were included for adults within 4 weeks of any type of stroke with UL impairment. Participants all received an intervention of any physiotherapeutic or occupational therapeutic technique designed to address impairment or activity of the affected UL, which could be compared with usual care, sham, or another technique.

DATA EXTRACTION

Two reviewers independently assessed eligibility of full texts, and methodological quality of included studies was assessed using the Cochrane Risk of Bias Tool.

DATA SYNTHESIS

A total of 104 trials (83 RCTs, 21 nonrandomized studies) were included (N=5225 participants). Meta-analyses of RCTs only (20 comparisons) and narrative syntheses were completed. Key findings included significant positive effects for modified constraint-induced movement therapy (mCIMT) (standardized mean difference [SMD]=1.09; 95% confidence interval [CI], .21-1.97) and task-specific training (SMD=.37; 95% CI, .05-.68). Evidence was found to support supplementary use of biofeedback and electrical stimulation. Use of Bobath therapy was not supported.

CONCLUSIONS

Use of mCIMT and task-specific training was supported, as was supplementary use of biofeedback and electrical simulation, within the acute phase poststroke. Further high-quality studies into the initial 4 weeks poststroke are needed to determine therapies for targeted functional UL outcomes.

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

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

Constraint-induced movement therapy as a rehabilitation intervention for upper extremity in stroke patients: systematic review and meta-analysis

Constraint-induced movement therapy (CIMT) is a neurorehabilitation technique designed to improve upper extremity motor functions after stroke. This review aimed to investigate evidence of the effect of CIMT on upper extremity in stroke patients and to identify optimal methods to apply CIMT. Four databases (MEDLINE, EMBASE, CINHAL, and PEDro) and reference lists of relevant articles and reviews were searched. Randomized clinical trials that studied the effect of CIMT on upper extremity outcomes in stroke patients compared with other rehabilitative techniques, usual care, or no intervention were included. Methodological quality was assessed using the PEDro score. The following data were extracted for each trial: patients' characteristics, sample size, eligibility criteria, protocols of CIMT and control groups, outcome measurements, and the PEDro score. A total of 38 trials were identified according to the inclusion criteria. The trials included were heterogeneous in CIMT protocols, time since stroke, and duration and frequency of treatment. The pooled meta-analysis of 36 trials found a heterogeneous significant effect of CIMT on upper extremity. There was no significant effect of CIMT at different durations of follow-up. The majority of included articles did not fulfill powered sample size and quality criteria. The effect of CIMT changed in terms of sample size and quality features of the articles included. These meta-analysis findings indicate that evidence for the superiority of CIMT in comparison with other rehabilitative interventions is weak. Information on the optimal dose of CIMT and optimal time to start CIMT is still limited.

Navigated transcranial magnetic stimulation for glioma removal: prognostic value in motor function recovery from postsurgical neurological deficits

OBJECTIVE The aim of the present study was to evaluate the usefulness of navigated transcranial magnetic stimulation (nTMS) as a prognostic predictor for upper-extremity motor functional recovery from postsurgical neurological deficits. METHODS Preoperative and postoperative nTMS studies were prospectively applied in 14 patients (mean age 39 ± 12 years) who had intraparenchymal brain neoplasms located within or adjacent to the motor eloquent area in the cerebral hemisphere. Mapping by nTMS was done 3 times, i.e., before surgery, and 1 week and 3 weeks after surgery. To assess the response induced by nTMS, motor evoked potential (nTMS-MEP) was recorded using a surface electromyography electrode attached to the abductor pollicis brevis (APB). The cortical locations that elicited the largest electromyography response by nTMS were defined as hotspots. Hotspots for APB were confirmed as positive responsive sites by direct electrical stimulation (DES) during awake craniotomy. The distances between hotspots and lesions (D_HS-L) were measured. Postoperative neurological deficits were assessed by manual muscle test and dynamometer. To validate the prognostic value of nTMS in recovery from upper-extremity paresis, the following were investigated: 1) the correlation between D_HS-L and the serial grip strength change, and 2) the correlation between positive nTMS-MEP at 1 week after surgery and the serial grip strength change. RESULTS From the presurgical nTMS study, MEPs from targeted muscles were identified in 13 cases from affected hemispheres. In one case, MEP was not evoked due to a huge tumor. Among 9 cases from which intraoperative DES mapping for hand motor area was available, hotspots for APB identified by nTMS were concordant with DES-positive sites. Compared with the adjacent group (D_HS-L < 10 mm, n = 6), the nonadjacent group (D_HS-L ≥ 10 mm, n = 7) showed significantly better recovery of grip strength at 3 months after surgery (p < 0.01). There were correlations between D_HS-L and recovery of grip strength at 1 week, 3 weeks, and 3 months after surgery (r = 0.74, 0.68, and 0.65, respectively). Postsurgical nTMS was accomplished in 13 patients. In 9 of 13 cases, nTMS-MEP from APB muscle was positive at 1 week after surgery. Excluding the case in which nTMS-MEP was negative from the presurgical nTMS study, recoveries in grip strength were compared between 2 groups, in which nTMS-MEP at 1 week after surgery was positive (n = 9) or negative (n = 3). Significant differences were observed between the 2 groups at 1 week, 3 weeks, and 3 months after surgery (p < 0.01). Positive nTMS-MEP at 1 week after surgery correlated well with the motor recovery at 1 week, 3 weeks, and 3 months after surgery (r = 0.87, 0.88, and 0.77, respectively). CONCLUSIONS Navigated TMS is a useful tool for identifying motor eloquent areas. The results of the present study have demonstrated the predictive value of nTMS in upper-extremity motor function recovery from postsurgical neurological deficits. The longer D_HS-L and positive nTMS-MEP at 1 week after surgery have prognostic values of better recovery from postsurgical neurological deficits.

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

OBJECTIVE:

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

DATA SOURCES:

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

DATA SELECTION:

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

OUTCOME MEASURES:

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

RESULTS:

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

CONCLUSION:

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

Effects of virtual reality training with modified constraint-induced movement therapy on upper extremity function in acute stage stroke: a preliminary study

[Purpose] The purpose of this study was to investigate the effects of virtual reality training combined with modified constraint-induced movement therapy on upper extremity motor function recovery in acute stage stroke patients. [Subjects and Methods] Four acute stage stroke patients participated in the study. A multiple baseline single subject experimental design was utilized. Modified constraint-induced movement therapy was used according to the EXplaining PLastICITy after stroke protocol during baseline sessions. Virtual reality training with modified constraint-induced movement therapy was applied during treatment sessions. The Manual Function Test and the Box and Block Test were used to measure upper extremity function before every session. [Results] The subjects' upper extremity function improved during the intervention period. [Conclusion] Virtual reality training combined with modified constraint-induced movement is effective for upper extremity function recovery in acute stroke patients.

Motor skill changes and neurophysiologic adaptation to recovery-oriented virtual rehabilitation of hand function in a person with subacute stroke: a case study

PURPOSE

The complexity of upper extremity (UE) behavior requires recovery of near normal neuromuscular function to minimize residual disability following a stroke. This requirement places a premium on spontaneous recovery and neuroplastic adaptation to rehabilitation by the lesioned hemisphere. Motor skill learning is frequently cited as a requirement for neuroplasticity. Studies examining the links between training, motor learning, neuroplasticity, and improvements in hand motor function are indicated.

METHODS

This case study describes a patient with slow recovering hand and finger movement (Total Upper Extremity Fugl-Meyer examination score = 25/66, Wrist and Hand items = 2/24 on poststroke day 37) following a stroke. The patient received an intensive eight-session intervention utilizing simulated activities that focused on the recovery of finger extension, finger individuation, and pinch-grasp force modulation.

RESULTS

Over the eight sessions, the patient demonstrated improvements on untrained transfer tasks, which suggest that motor learning had occurred, as well a dramatic increase in hand function and corresponding expansion of the cortical motor map area representing several key muscles of the paretic hand. Recovery of hand function and motor map expansion continued after discharge through the three-month retention testing.

CONCLUSION

This case study describes a neuroplasticity based intervention for UE hemiparesis and a model for examining the relationship between training, motor skill acquisition, neuroplasticity, and motor function changes. Implications for rehabilitation Intensive hand and finger rehabilitation activities can be added to an in-patient rehabilitation program for persons with subacute stroke. Targeted training of the thumb may have an impact on activity level function in persons with upper extremity hemiparesis. Untrained transfer tasks can be utilized to confirm that training tasks have elicited motor learning. Changes in cortical motor maps can be used to document changes in brain function which can be used to evaluate changes in motor behavior persons with subacute stroke.

Constraint-induced movement therapy: time for a little restraint?

Our aim was to consider some issues surrounding constraint-induced movement therapy (CIMT), and in particular, its theoretical basis, effectiveness, utility and composition. We examined selected articles and related publications concerning CIMT. Considerable evidence from case studies and case series has accumulated but only a limited number of randomized controlled trials (RCTs) exist. The two most positive RCTs represent a combined total of 15 people undergoing CIMT. Other issues include: how analogous deafferentation of an upper limb in monkeys is to cerebral infarcts in humans; teasing out the active components of CIMT; a need for replication by groups not already strongly associated with CIMT; and patient/therapist acceptability. CIMT may hold considerable promise, but independent, large-scale, multicentre RCTs comparing its effectiveness with conventional therapy of equal intensity are required, as is the consideration of some associated issues.

Treatment Interventions for the Paretic Upper Limb of Stroke Survivors: A Critical Review

Despite a threefold increase in treatment interventions studies during the past 10 years, “best practice” for the rehabilitation of the paretic upper limb is still unclear. This review aims to lessen uncertainty in the management of the poststroke upper limb. Two separate searches of the scientific literature from 1966-2001 yielded 333 articles. Three referees, using strict inclusion and exclusion criteria, selected 68 relevant references. Cohort studies, randomized control trials, and systematic reviews were critically appraised. Mean randomized control trial quality (n = 33) was 17.1/27 (SD = 5.2, 95% CI = 15.2–19.0, range = 6–26). Mean quality of cohort studies (n = 29) was 11.8/27 (SD = 3.8, 95% CI = 10.4–13.2, range = 4–19). Quantitative syntheses were done using theZ -statistic. This systematic review indicated that sensorimotor training; motor learning training that includes the use of imagery, electrical stimulation alone, or combined with biofeedback; and engaging the client in repetitive, novel tasks can be effective in reducing motor impairment after stroke. Furthermore, careful handling, electrical stimulation, movement with elevation, strapping, and the avoidance of overhead pulleys could effectively reduce or prevent pain in the paretic upper limb. Rehabilitation specialists can use this research synthesis to guide their selection of effective treatment techniques for persons with impairments after stroke.

The effect of a task-oriented intervention on arm function in people with stroke: a randomized controlled trial

Objective: To evaluate the efficacy of a task-oriented intervention in enhancing arm function in people with stroke.

Design: Two-centre, observer-blinded, stratified, block-randomized controlled trial.

Setting: General community.

Patients: Ninety-one individuals within one year of a first or recurrent stroke consented to participate between May 2000 and February 2003.

Interventions: The experimental intervention involved practice of functional, unilateral and bilateral tasks that were designed to improve gross and fine manual dexterity whereas the control intervention was composed of walking tasks. Members in both groups participated in three sessions a week for six weeks.

Main outcome measure(s): The primary test of arm function was the Box and Block Test. Secondary tests included the Nine-Hole Peg Test, maximal grip strength, the Test d'Evaluation des Membres supé rieurs des Personnes Agées (TEMPA) and the Stroke Rehabilitation Assessment of Movement.

Results: Results are for the more affected arm. Baseline performance on the Box and Block Test was an average of 26 blocks (standard deviation (SD=16) in the experimental group (n=47) and 26 blocks (Sd=18) in the control group (n=44). These values represent approximately 40% of age-predicted values. Values for the postintervention evaluation were an average of 28 (SD=17) and 28 (SD=19) blocks for the experimental and control group respectively. No meaningful change on other measures of arm function was observed.

Conclusions: A task-oriented intervention did not improve voluntary movement or manual dexterity of the affected arm in people with chronic stroke.

Effectiveness of unilateral and symmetrical bilateral task training for arm during the subacute phase after stroke: a randomized controlled trial

Objective: To evaluate the effect of an arm training programme combining repetition of unilateral and symmetrical bilateral tasks for people in the subacute phase after stroke.

Design: Randomized controlled trial.

Setting: Inpatient functional rehabilitation unit.

Subjects: Forty-one people who had had a stroke, in the subacute phase, receiving conventional arm occupational and physical therapy, were randomized to an experimental group (n=20) and a control group (n=21).

Interventions: In addition to the usual arm therapy in the rehabilitation unit, the experimental group received an arm therapy programme (15-20 45-min sessions) based on repetition of unilateral and symmetrical bilateral tasks. The control group received additional usual arm therapy of a similar duration and frequency to the experimental treatment.

Main measures: The effect of the programme was judged on the basis of: (1) arm impairments (motor function, grip strength, gross and fine manual dexterity and motor co-ordination), (2) arm disabilities in tasks related to daily activities, and (3) functional independence in activities of daily living (ADL) and instrumental ADL (IADL).

Results: Although both experimental and control groups of participants improved similarly during the study period, the statistical analyses did not show any difference between the groups at the end of the treatment for the different dependent variables evaluated: (1) arm impairments: p=0.43-0.79; (2) arm disabilities: p=0.16-0.90; and (3) functional independence: p=0.63 and 0.90.

Conclusions: An arm training programme based on repetition of unilateral and symmetrical bilateral practice did not reduce impairment and disabilities nor improve functional outcomes in the subacute phase after stroke more than the usual therapy.

Does the use of a constraint mitten to encourage use of the hemiplegic upper limb improve arm function in adults with subacute stroke?

Objective: To evaluate the effect of a constraint mitten, worn on the unaffected upper limb, on the arm and hand function of participants with hemiplegia. To estimate the sample size for a future trial.

Design: An A-B-A design.

Setting: Inpatient, outpatient and domiciliary setting.

Subjects Ten participants with mild to moderate residual upper limb hemiparesis, between 1 and 12 months post stroke.

Intervention: Following a two-week baseline period, 10 participants were advised to wear the constraint mitten on the unaffected upper limb for 9 waking hours/day for two weeks to encourage use of the hemiplegic arm. Existing levels of therapy continued during the whole study.

Main measures: The primary outcome measure was the Action Research Arm Test. At the end of the intervention phase participants completed a questionnaire. Participants also recorded their daily use of the constraint mitten during the intervention phase.

Results: A mean improvement in the Action Research Arm Test score of 4.0 points (95% confidence interval 1.7 to 6.2; P=00.016) was found during the intervention phase after correcting for background recovery. Mean compliance was 6.7 hours/day (74%), 90% of participants were positive about the intervention and would recommend the treatment to other stroke survivors, although 50% were relieved to stop the mitten-wearing phase.

Conclusions: The use of a constraint mitten in upper limb stroke rehabilitation may be a useful adjunct to enhance functional recovery with minimal additional resources. The positive findings from this preliminary study warrant a larger randomized controlled trial of 200 participants in total.

Home Forced Use in an Outpatient Rehabilitation Program for Adults with Hemiplegia: A Pilot Study

The objective of this study was to examine the effectiveness of a program of traditional outpatient neurological rehabilitation that included home forced use. In total, 17 patients with chronic stroke and 1 patient with subacute stroke (mean time poststroke = 27.6 months) completed an individualized program consisting of seven 2-hour treatment sessions composed of 1 hour of occupational therapy and 1 hour of physical therapy. Therapy sessions were completed over a 2- to 3-week period and included instruction on the use of a restraining mitt at home during functional activities. The Wolf Motor Function Test (WMFT) was used to assess upper extremity impairment and function at baseline, midway through treatment, and posttreatment. Patients demonstrated statistically significant improvements (P < 0.05 corrected for multiple comparisons) in mean time for completion in 12 of 17 WMFT subtasks when comparing baseline to posttreatment. The preliminary results suggest that the forced-use component of constraint-induced therapy may be effective when applied within a traditional outpatient rehabilitation program. However, additional investigation is required to examine the effectiveness of using forced use within typical outpatient rehabilitation under more experimentally controlled conditions.

Effects of movement imagery and electromyography-triggered feedback on arm—hand function in stroke patients in the subacute phase

Objective: To investigate the effects of movement imagery-assisted electromyography (EMG)-triggered feedback (focused on paretic wrist dorsiflexors) on the arm—hand function of stroke patients.

Design: Single-blinded, longitudinal, multicentre randomized controlled trial. Measurements were performed (on average) 54 days post stroke (baseline), three months later (post training) and at 12 months post baseline.

Setting: Two rehabilitation centres.

Subjects: Twenty-seven patients with a first-ever, ischaemic, subacute stroke.

Interventions: A reference group received conventional electrostimulation, while the experimental group received arm—hand function training based on EMG-triggered feedback combined with movement imagery. Both groups were trained for three months, 5 days/week, 30 minutes/day, in addition to their therapy as usual.

Main measures: Arm—hand function was evaluated using the upper extremity-related part of the Brunnstrom Fugl-Meyer test and the Action Research Arm test.

Results: During training, Brunnstrom Fugl-Meyer scores improved 8.7 points and Action Research Arm scores by 19.4 points ( P < 0.0001) in both groups relative to baseline results, rising to 13.3 and 28.4 points respectively at one year follow-up ( P < 0.0001). No between-group differences were found at any time.

Conclusions: EMG-triggered feedback stimulation did not lead to more arm—hand function improvement relative to conventional electrostimulation. However, in contrast to many clinical reports, a significant improvement was still observed in both groups nine months after treatment ceased.

Relationships between Sensorimotor Impairments and Reaching Deficits in Acute Hemiparesis

To determine the relationships between sensorimotor impairments and upper extremity reaching performance during the acute phase of stroke and to determine which, if any, measures of sensorimotor impairment can predict variance in reaching performance during this phase. Methods. Sensorimotor impairments of upper extremity (UE) strength, active range of motion, isolated movement control, light touch sensation, joint position sense, spasticity, and shoulder pain were evaluated in a group of 46 individuals with acute hemiparesis (mean time since insult = 9.2 days). Subjects performed a reaching task to a target placed on their affected side. Three-dimensional kinematic analyses were used to assess reaching speed, accuracy, and efficiency. Forward stepwise multiple linear regression analyses were used to determine which impairment was the best predictor of variance in reaching performance. Results. Measures of UE strength predicted the largest proportion of variance in the speed, accuracy, and efficiency of forward reaching. Isolated movement control, somatosensory deficits, and elbow spasticity predicted smaller amounts of variance in reaching performance. Conclusions. The authors’ data show that deficits in strength appear to be the most influential sensorimotor impairment associated with limited reaching performance in subjects with acute hemiparesis.

Does Shorter Rehabilitation Limit Potential Recovery Poststroke?

Objective. To examine retrospectively the recovery of patients engaged in robotic research during a 6- to 7-week course of inpatient rehabilitation. Because timing of the Interim evaluation at 31/2 weeks was comparable to the present length of inpatient stroke rehabilitation, the authors assessed whether significant gains in motor abilities occurred after the time when most stroke patients today are discharged home. Methods. Fifty-six inpatients with a single, unilateral stroke were randomly assigned to a robot therapy or robot exposure group. Therapists blinded to group assignment administered the Fugl-Meyer, Motor Status Score, and MRC motor power test. Results. Significant improvements in upper-limb motor abilities occurred throughout a period approximately twice the present length of stay in inpatient rehabilitation. However, in the latter half of this period, patients who received conventional therapy showed little improvement, whereas patients who received robot training plus conventional therapy continued to improve. Conclusion. Further opportunities for recovery after stroke are possible by extending intensive therapy beyond present inpatient rehabilitation stays.

Methods for a Multisite Randomized Trial to Investigate the Effect of Constraint-Induced Movement Therapy in Improving Upper Extremity Function among Adults Recovering from a Cerebrovascular Stroke

This article describes the study design, methodological considerations, and demographic characteristics of a phase III RCT to determine if 1) constraint-induced therapy (CI therapy) can be applied with therapeutic success 3 to 9 months after stroke across different sites, 2) gains that might occur persist over 2 years, 3) initial level of motor ability determines responsiveness to CI therapy, and 4) the treatment effect differs between those treated before 9 months and after 1 year. Six sites will screen and recruit poststroke survivors stratified on initial level of motor ability and after randomization allocate participants to immediate or delayed intervention. Primary outcomes include a laboratory-based measure of function (Wolf Motor Function Test [WMFT]) and a real-world participant-centered functional use measure (Motor Activity Log [MAI]). Secondary outcomes concern function, behavior, and compliance. This is the first multisite, single-blind RCT of a formal training intervention for upper extremity rehabilitation in subacute stroke in the United States.

Modified Constraint-Induced Therapy in Acute Stroke: A Randomized Controlled Pilot Study

To determine modified constraint-induced therapy (mCIT) feasibility and compare its efficacy to traditional rehabilitation (TR) in acute stroke patients exhibiting upper limb hemiparesis. Method. Before-after, multiple baseline, randomized controlled pilot study. Setting. Rehabilitation hospital. Patients. Ten stroke patients < 14 d poststroke and exhibiting upper limb hemiparesis and affected limb nonuse. Interventions. Five patients were administered mCIT, consisting of structured therapy emphasizing more affected arm use in valued activities 3 d/week for 10 weeks and less affected arm restraint 5 d/week for 5 h. Five other patients received 1/2 sessions of traditional motor rehabilitation for the affected arm, which included affected limb manual dexterity exercises and stretching, as well as compensatory strategies with the unaffected limb. The TR regimens occurred 3 d/week for 10 weeks. Main Outcome Measures. The Fugl-Meyer Assessment of Motor Recovery (Fugl-Meyer), Action Research Arm Test (ARA), and Motor Activity Log (MAL). Results. Before intervention, all patients exhibited stable motor deficits and more affected arm nonuse. After intervention, mCIT patients displayed increased affected arm use (+ 2.43 on the MAL amount of use scale), uniformly exhibited increases on the Fugl-Meyer and ARA (mean change scores = + 18.7 and + 21.7, respectively), and were able to again perform valued activities. TR patients exhibited nominal change in affected limb use (+ 0.07 on the MAL amount of use scale) and modest changes on the Fugl-Meyer and ARA (+ 4.4 and + 4.8, respectively). Fugl-Meyer and ARA changes were significant for the mCIT group only (P < 0.01). Conclusions. mCIT is a promising regimen for improving more affected limb use and function in acute cerebrovascular accident. However, larger confirmatory studies need to be performed.

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).

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.

Constraint-induced movement therapy for upper extremities in people with stroke

BACKGROUND

In people who have had a stroke, upper limb paresis affects many activities of daily life. Reducing disability is therefore a major aim of rehabilitative interventions. Despite preserving or recovering movement ability after stroke, sometimes people do not fully realise this ability in their everyday activities. Constraint-induced movement therapy (CIMT) is an approach to stroke rehabilitation that involves the forced use and massed practice of the affected arm by restraining the unaffected arm. This has been proposed as a useful tool for recovering abilities in everyday activities.

OBJECTIVES

To assess the efficacy of CIMT, modified CIMT (mCIMT), or forced use (FU) for arm management in people with hemiparesis after stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group trials register (last searched June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library Issue 1, 2015), MEDLINE (1966 to January 2015), EMBASE (1980 to January 2015), CINAHL (1982 to January 2015), and the Physiotherapy Evidence Database (PEDro; January 2015).

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

One author identified trials from the results of the electronic searches according to the inclusion and exclusion criteria, three review authors independently assessed methodological quality and risk of bias, and extracted data. The primary outcome was disability.

MAIN RESULTS

We included 42 studies involving 1453 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. The majority of studies were underpowered (median number of included participants was 29) and we cannot rule out small-trial bias. Eleven trials (344 participants) assessed disability immediately after the intervention, indicating a non-significant standard mean difference (SMD) 0.24 (95% confidence interval (CI) -0.05 to 0.52) favouring CIMT compared with conventional treatment. For the most frequently reported outcome, arm motor function (28 studies involving 858 participants), the SMD was 0.34 (95% CI 0.12 to 0.55) showing a significant effect (P value 0.004) in favour of CIMT. Three studies involving 125 participants explored disability after a few months of follow-up and found no significant difference, SMD -0.20 (95% CI -0.57 to 0.16) in favour of conventional treatment.

AUTHORS' CONCLUSIONS

CIMT is a multi-faceted intervention where restriction of the less affected limb is accompanied by increased exercise tailored to the person's capacity. We found that CIMT was associated with limited improvements in motor impairment and motor function, but that these benefits did not convincingly reduce disability. This differs from the result of our previous meta-analysis where there was a suggestion that CIMT might be superior to traditional rehabilitation. Information about the long-term effects of CIMT is scarce. Further trials studying the relationship between participant characteristics and improved outcomes are required.

Effect of shoulder girdle strengthening on trunk alignment in patients with stroke

[Purpose] This study investigated the effect of shoulder girdle strengthening, particularly the scapular muscles, on poststroke trunk alignment. [Subjects and Methods] The study involved 30 patients with residual hemiparesis following cerebrovascular stroke. Patient assessment included measuring shoulder muscle peak torque, scapular muscles peak force, spinal lateral deviation angle, and motor functional performance. Patients were randomly allocated either to the control group or the study group and received an 18-session strengthening program including active resisted exercises for shoulder abductors and external rotators in addition to trunk control exercises. The study group received additional strengthening exercises for the scapular muscles. [Results] The two groups showed significant improvement in strength of all shoulder and scapular muscles, with higher improvement in the study group. Similarly, the lateral spinal deviation angles significantly improved in both groups, with significantly higher improvement in the study group. Transfer activity, sitting balance, upper limb functions, and hand movements significantly improved in the two groups, with higher improvement in the latter two functions in the study group. [Conclusion] Strengthening of shoulder girdle muscles, particularly scapular muscles, can significantly contribute to improving the postural alignment of the trunk in patients with poststroke hemiparesis.

Constraint-induced movement therapy after stroke

Constraint-induced movement therapy (CIMT) was developed to overcome upper limb impairments after stroke and is the most investigated intervention for the rehabilitation of patients. Original CIMT includes constraining of the non-paretic arm and task-oriented training. Modified versions also apply constraining of the non-paretic arm, but not as intensive as original CIMT. Behavioural strategies are mostly absent for both modified and original CIMT. With forced use therapy, only constraining of the non-paretic arm is applied. The original and modified types of CIMT have beneficial effects on motor function, arm-hand activities, and self-reported arm-hand functioning in daily life, immediately after treatment and at long-term follow-up, whereas there is no evidence for the efficacy of constraint alone (as used in forced use therapy). The type of CIMT, timing, or intensity of practice do not seem to affect patient outcomes. Although the underlying mechanisms that drive modified and original CIMT are still poorly understood, findings from kinematic studies suggest that improvements are mainly based on adaptations through learning to optimise the use of intact end-effectors in patients with some voluntary motor control of wrist and finger extensors after stroke.

Differential patterns of cortical reorganization following constraint-induced movement therapy during early and late period after stroke: A preliminary study

OBJECTIVE

Constraint-induced movement therapy (CIMT) has been shown to improve upper extremity voluntary movement and change cortical movement representation after stroke. Direct comparison of the differential degree of cortical reorganization according to chronicity in stroke subjects receiving CIMT has not been performed and was the purpose of this study. We hypothesized that a higher degree of cortical reorganization would occur in the early (less than 9 months post-stroke) compared to the late group (more than 12 months post-stroke).

METHODS

17 early and 9 late subjects were enrolled. Each subject was evaluated using transcranial magnetic stimulation (TMS) and the Wolf Motor Function Test (WMFT) and received CIMT for 2 weeks.

RESULTS

The early group showed greater improvement in WMFT compared with the late group. TMS motor maps showed persistent enlargement in both groups but the late group trended toward more enlargement. The map shifted posteriorly in the late stroke group. The main limitation was the small number of TMS measures that could be acquired due to high motor thresholds, particularly in the late group.

CONCLUSION

CIMT appears to lead to greater improvement in motor function in the early phase after stroke. Greater cortical reorganization in map size and position occurred in the late group in comparison.

SIGNIFICANCE

The contrast between larger functional gains in the early group vs larger map changes in the late group may indicate that mechanisms of recovery change over the several months following stroke or that map changes are a time-dependent epiphenomenon.

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.

Modified constraint-induced movement therapy for clients with chronic stroke: interrupted time series (ITS) design

[Purpose] The purpose of this study was to investigate the impact that modified constraint-induced movement therapy has on upper extremity function and the daily life of chronic stroke patients. [Subjects and Methods] Modified constraint-induced movement therapy was conduct for 2 stroke patients with hemiplegia. It was performed 5 days a week for 2 weeks, and the participants performed their daily living activities wearing mittens for 6 hours a day, including the 2 hours of the therapy program. The assessment was conducted 5 times in 3 weeks before and after intervention. The upper extremity function was measured using the box and block test and a dynamometer, and performance daily of living activities was assessed using the modified Barthel index. The results were analyzed using a scatterplot and linear regression. [Results] All the upper extremity functions of the participants all improved after the modified constraint-induced movement therapy. Performance of daily living activities by participant 1 showed no change, but the results of participant 2 had improved after the intervention. [Conclusion] Through the results of this research, it was identified that modified constraint-induced movement therapy is effective at improving the upper extremity functions and the performance of daily living activities of chronic stroke patients.

Robotic Technology and Stroke Rehabilitation: Translating Research into Practice

Research on the effectiveness of robotic therapy for the paretic upper limb after stroke has shown statistically significant reductions in motor impairment during both acute and chronic phases of recovery. Despite growing empirical support for this technology and a stronger focus on optimizing rehabilitation outcomes and productivity, there continues to be a disconnect between research and clinical practice. We review studies on the use of robot-aided neurorehabilitation for the paretic arm after stroke and discuss ways in which this technology may provide opportunities for intensive training that complement more conventional therapy methods.

Motor Recovery Strategies After Stroke

Impaired motor function after stroke is a major cause of disability in young stroke survivors. The plasticity of the adult human brain provides opportunities to enhance traditional rehabilitation programs for these individuals. Younger stroke patients appear to have a greater ability to recover from stroke and are likely to benefit substantially from treatments that facilitate plasticity-mediated recovery. The use of new exercise treatments, such as constraint-induced movement therapy, robot-aided rehabilitation, and partial body weight supported treadmill training are being studied intensively and are likely to ultimately be incorporated into standard poststroke rehabilitation. Medications to enhance recovery, growth factors, and stem cells will also be components of rehabilitation for the young stroke survivor in the foreseeable future.