Phase II Randomized Controlled Trial of Constraint-Induced Movement Therapy in Multiple Sclerosis. Part 2: Effect on White Matter Integrity

Advanced neuroimaging techniques to explore the effects of motor and cognitive rehabilitation in multiple sclerosis

INTRODUCTION

Progress in magnetic resonance imaging (MRI) technology and analyses is improving our comprehension of multiple sclerosis (MS) pathophysiology. These advancements, which enable the evaluation of atrophy, microstructural tissue abnormalities, and functional plasticity, are broadening our insights into the effectiveness and working mechanisms of motor and cognitive rehabilitative treatments.

AREAS COVERED

This narrative review with selected studies discusses findings derived from the application of advanced MRI techniques to evaluate structural and functional neuroplasticity modifications underlying the effects of motor and cognitive rehabilitative treatments in people with MS (PwMS). Current applications as outcome measure in longitudinal trials and observational studies, their interpretation and possible pitfalls and limitations in their use are covered. Finally, we examine how the use of these techniques could evolve in the future to improve monitoring of motor and cognitive rehabilitative treatments.

EXPERT COMMENTARY

Despite substantial variability in study design and participant characteristics in rehabilitative studies for PwMS, improvements in motor and cognitive functions accompanied by structural and functional brain modifications induced by rehabilitation can be observed. However, significant enhancements to refine rehabilitation strategies are needed. Future studies in this field should strive to implement standardized methodologies regarding MRI acquisition and processing, possibly integrating multimodal measures. This will help identifying relevant markers of treatment response in PwMS, thus improving the use of rehabilitative interventions at individual level. The combination of motor and cognitive strategies, longer periods of treatment, as well as adequate follow-up assessments will contribute to enhance the quality of evidence in support of their routine use.

Pertinence of Constraint-Induced Movement Therapy in Neurological Rehabilitation: A Scoping Review

Constraint-induced movement therapy (CIMT) is a neurorehabilitation technique that aims to restore motor function in patients with central nervous system injuries. Based on behavioral research conducted, CIMT has been found effective in restoring motor function in various conditions including stroke, cerebral palsy, traumatic brain injury (TBI), and more. The therapy combines neurological and behavioral mechanisms to induce neuroplastic changes and overcome learned nonuse. Modified CIMT (mCIMT) is a variant that focuses on sensorimotor functioning in the affected limb. This review summarizes studies on CIMT and mCIMT, with a focus on stroke, cerebral palsy, and other conditions. Results show that CIMT and mCIMT demonstrate significant improvements in motor function and quality of life. The studies underscore the importance of long-term research, comparative or combined therapies, and exploration of less-studied conditions like multiple sclerosis (MS) and brachial plexus injury. Overall, CIMT and mCIMT hold promise for neurorehabilitation, emphasizing the need for further investigation to enhance their effectiveness and application.

Effects of constraint induced movement therapy in patients with multiple sclerosis: A systematic review

BACKGROUND

Multiple sclerosis (MS) is a chronic neurodegenerative disorder of the central nervous system (CNS) that commonly affects young and middle-aged adults. Neurodegeneration of the CNS affects its functions such as sensorimotor, autonomic and cognitive functions. Affectation of motor function can result in disability in performance of daily life activities. Thus, effective rehabilitation interventions are needed to help prevent disability in patients with MS. One of these interventions is the constraint induced movement therapy (CIMT). The CIMT is used to improve motor function in patients with stroke and other neurological conditions. Recently, its use in patients with MS is gaining ground. The aim of this study is to carry out a systematic review and meta-analysis to determine from the literature, the effects of CIMT on upper limb function in patients with MS.

METHODS

PubMED, Embase, Web of Science (WoS), PEDro, and CENTRAL were searched until October 2022. Randomized controlled trials in patients with MS who were 18 years and above were included. Data on the characteristics of the study participants such as disease duration, type of MS, the mean scores of the outcomes of interest such as motor function and use of the arm in daily activities, and white matter integrity were extracted. Methodological quality and risks of bias of the included studies were assessed using PEDro scale and Cochrane risks of bias tool. The data was analysed using both narrative and quantitative syntheses. In the quantitative synthesis, random effect model meta-analysis of the mean and standard deviation of the scores on the outcomes of interest and the study sample size (for both the CIMT and the control group) post intervention was carried out. In addition, percentage of variation across the studies due to heterogeneity (I²) was considered significant when it is between 50% and 90% at p < 0.05.

RESULTS

Two studies comprising of 4 published articles with good methodological quality were included in the study. The results showed that, CIMT is safe and improved white matter integrity, motor function, muscle strength, dexterity, real-world arm use and biomechanical parameters post intervention. However, although there was a trend towards better improvement in the CIMT group in all the outcomes, there was no statistically significant difference between groups in motor function (SMD=0.44, 95% CI=-0.20 to 1.07, p = 0.18) and quality of movement (SMD=0.96, -1.15 to 3.07, p = 0.37).

CONCLUSION

CIMT can be used in patients with MS since it is safe as well as effective at improving functional outcomes. However, more studies are required to confirm its safety and effectiveness.

The Mechanism and Clinical Application of Constraint-Induced Movement Therapy in Stroke Rehabilitation

Constraint-induced movement therapy (CIMT) has been widely applied in stroke rehabilitation, and most relevant studies have shown that CIMT helps improve patients' motor function. In practice, however, principal issues include inconsistent immobilization durations and methods, while incidental issues include a narrow application scope and an emotional impact. Although many studies have explored the possible internal mechanisms of CIMT, a mainstream understanding has not been established.

Functional neurological disorder: Extending the diagnosis to other disorders, and proposing an alternate disease term—Attentionally-modifiable disorder

BACKGROUND: The term “functional neurological disorder,” or “FND,” applies to disorders whose occurrence of neurological symptoms fluctuate with the patient’s attention to them. However, many other disorders that are not called “FND” nonetheless can also follow this pattern. Consequently, guidelines are unclear for diagnosing “FND.” OBJECTIVE: To review the neurological conditions that follow this pattern, but which have not so far been termed “FND,” to understand their overlap with conditions that have been termed “FND,” and to discuss the rationale for why FND has not been diagnosed for them. METHOD: A systematic review of the PubMed literature registry using the terms “fluctuation,” “inconsistency,” or “attention” did not yield much in the way of these candidate disorders. Consequently, this review instead relied on the author’s personal library of peer-reviewed studies of disorders that have resembled FND but which were not termed this way, due to his longstanding interest in this problem. Consequently, this approach was not systematic and was subjective regarding disease inclusion. RESULTS: This review identified numerous, diverse conditions that generally involve fluctuating neurological symptoms that can vary with the person’s attention to them, but which have not been called “FND.” The literature was unclear for reasons for not referring to “FND” in these instances. CONCLUSION: Most likely because of historical biases, the use of the term “FND” has been unnecessarily restricted. Because at its core FND is an attentionally-influenced disorder that can respond well to behavioral treatments, the field of neurological rehabilitation could benefit by extending the range of conditions that could be considered as “FND” and referred for similar behavioral treatments. Because the term “FND” has been viewed unfavorably by some patients and clinical practitioners and whose treatment is not implied, the alternative term attentionally-modifiable disorder is proposed.

Personalized prediction of rehabilitation outcomes in multiple sclerosis: a proof-of-concept using clinical data, digital health metrics, and machine learning

Predicting upper limb neurorehabilitation outcomes in persons with multiple sclerosis (pwMS) is essential to optimize therapy allocation. Previous research identified population-level predictors through linear models and clinical data. This work explores the feasibility of predicting individual neurorehabilitation outcomes using machine learning, clinical data, and digital health metrics. Machine learning models were trained on clinical data and digital health metrics recorded pre-intervention in 11 pwMS. The dependent variables indicated whether pwMS considerably improved across the intervention, as defined by the Action Research Arm Test (ARAT), Box and Block Test (BBT), or Nine Hole Peg Test (NHPT). Improvements in ARAT or BBT could be accurately predicted (88% and 83% accuracy) using only patient master data. Improvements in NHPT could be predicted with moderate accuracy (73%) and required knowledge about sensorimotor impairments. Assessing these with digital health metrics over clinical scales increased accuracy by 10%. Non-linear models improved accuracy for the BBT (+ 9%), but not for the ARAT (-1%) and NHPT (-2%). This work demonstrates the feasibility of predicting upper limb neurorehabilitation outcomes in pwMS, which justifies the development of more representative prediction models in the future. Digital health metrics improved the prediction of changes in hand control, thereby underlining their advanced sensitivity.

Graphical Abstract

Neuroplasticity and Motor Rehabilitation in Multiple Sclerosis: A Systematic Review on MRI Markers of Functional and Structural Changes

Background: Motor rehabilitation is routinely used in clinical practice as an effective method to reduce progressive disability gain in multiple sclerosis (MS), but rehabilitation approaches are typically unstandardized, and only few studies have investigated the impact of rehabilitation on brain neuroplasticity. Objective: To summarize and critically analyze studies applying MRI markers of functional connectivity and structural changes to assess the effect of motor rehabilitation on brain neuroplasticity in MS. Methods: Literature search was performed using PubMed and EMBASE, selecting studies having as a subject motor rehabilitation and advanced MRI techniques investigating neuroplasticity in adult patients affected by MS. Results: Seventeen out of 798 papers were selected, of which 5 applied structural MRI (4 diffusion tensor imaging, 1 volumetric measurements), 7 applied functional fMRI (5 task-related fMRI, 2 resting-state fMRI) whereas the remaining 5 applied both structural and functional imaging. Discussion: The considerable data heterogeneity and the small sample sizes characterizing the studies limit interpretation and generalization of the results. Overall, motor rehabilitation promotes clinical improvement, paralleled by positive adaptive brain changes, whose features and extent depend upon different variables, including the type of rehabilitation approach. MRI markers of functional and structural connectivity should be implemented in studies testing the efficacy of motor rehabilitation. They allow for a better understanding of neuroplastic mechanisms underlying rehabilitation-mediated clinical achievements, facilitating the identification of rehabilitation strategies tailored to patients' needs and abilities.

The Role of White Matter in the Neural Control of Swallowing: A Systematic Review

Background: Swallowing disorders (dysphagia) can negatively impact quality of life and health. For clinicians and researchers seeking to improve outcomes for patients with dysphagia, understanding the neural control of swallowing is critical. The role of gray matter in swallowing control has been extensively documented, but knowledge is limited regarding the contributions of white matter. Our aim was to identify, evaluate, and summarize the populations, methods, and results of published articles describing the role of white matter in neural control of swallowing.

Methods: We completed a systematic review with a multi-engine search following PRISMA-P 2015 standards. Two authors screened articles and completed blind full-text review and quality assessments using an adapted U.S. National Institute of Health's Quality Assessment. The senior author resolved any disagreements. Qualitative synthesis of evidence was completed.

Results: The search yielded 105 non-duplicate articles, twenty-two of which met inclusion criteria. Twenty were rated as Good (5/22; 23%) or Fair (15/22; 68%) quality. Stroke was the most represented diagnosis (n = 20; 91%). All studies were observational, and half were retrospective cohort design. The majority of studies (13/22; 59%) quantified white matter damage with lesion-based methods, whereas 7/22 (32%) described intrinsic characteristics of white matter using methods like fractional anisotropy. Fifteen studies (68%) used instrumental methods for swallowing evaluations. White matter areas commonly implicated in swallowing control included the pyramidal tract, internal capsule, corona radiata, superior longitudinal fasciculus, external capsule, and corpus callosum. Additional noteworthy themes included: severity of white matter damage is related to dysphagia severity; bilateral white matter lesions appear particularly disruptive to swallowing; and white matter adaptation can facilitate dysphagia recovery. Gaps in the literature included limited sample size and populations, lack of in-depth evaluations, and issues with research design.

Conclusion: Although traditionally understudied, there is sufficient evidence to conclude that white matter is critical in the neural control of swallowing. The reviewed studies indicated that white matter damage can be directly tied to swallowing deficits, and several white matter structures were implicated across studies. Further well-designed interdisciplinary research is needed to understand white matter's role in neural control of normal swallowing and in dysphagia recovery and rehabilitation.

Rehabilitation in multiple sclerosis in 2021

Patients with multiple sclerosis, despite advances in therapy, often suffer from locomotor impairment that limits their mobility and affect quality of life. Rehabilitation is part of the treatment of MS and has shown its beneficial effects in numerous studies. While traditional rehabilitation techniques remain in the limelight, new technologies are emerging and make it possible to improve the management of disabling symptoms. The aim of this update is to synthesize the new therapy techniques proposed in rehabilitation for patients with multiple sclerosis according to the symptoms as balance, gait, upper limb disorders, fatigue, spasticity and disease progression published over the past 5 years. With regard to balance and walking disorders, neuromotor rehabilitation, physical exercise, rhythmic auditory stimulation, gait robot training and exergaming are effective. Only physical exercise has shown a positive effect on fatigue management. Spasticity is improved by classic rehabilitation techniques however non-invasive brain stimulation are promising. The rehabilitation of upper limb dysfunctions uses various effective techniques such as the repetition of functional tasks in real or virtual situations. In case of a more severe disability, arm robots can be used to relearn the impaired movement. Action observation training in real or virtual situations is also effective. Finally, under certain conditions the constraint induced movement therapy is proposed. The effects of rehabilitation are not only positive on the pyramidal symptoms and fatigue but also increase neuroplasticity and perhaps a neuroprotective effect as shown in some studies.

Retention of Physical Gains in the Community Following Physical Training for Multiple Sclerosis: A Systematic Review and Implications

Multiple sclerosis (MS) is a progressive neurological illness whose typically young adult onset results in a nearly entire lifetime of worsening disability. But despite being an unrelenting neurodegenerative disease, numerous clinical trials over the past 40 years for MS have vigorously attempted to improve or at least stabilize declining physical function. Although the vast majority of the studies assessed training effects only within controlled laboratory or clinic settings, in recent years a growing interest has emerged to test whether newer therapies can instead benefit real-life activities in the community. Nonetheless, comparatively little attention has been paid to whether the training gains can be retained for meaningful periods. This review discusses the comparative success of various physical training methods to benefit within-community activities in MS, and whether the gains can be retained long afterward. This review will suggest future research directions toward establishing efficacious treatments that can allow persons with MS to reclaim their physical abilities and maximize functionality for meaningful periods.

A Three-Arm Parallel-Group Exploratory Trial documents balance improvement without much evidence of white matter integrity changes in people with multiple sclerosis following two months ambulatory neuroproprioceptive "facilitation and inhibition" physical therapy

BACKGROUND

Changes of white matter integrity in people with multiple sclerosis (MS) were documented following mainly motor/skill acquisitions physical therapy, while following neuroproprioceptive "facilitation, inhibition" (neurofacilitation) only by two pilot studies. Neurofacilitation has potential to induce white matter changes due to possibility to interfere with the neuronal tactility threshold, but stronger evidence is missing.

AIM

This study investigates whether neurofacilitation (three physical therapy types) induce white matter changes and if they relate to clinical improvement.

DESIGN

The Three-Arm Parallel-Group Exploratory Trial (NCT04355663).

SETTING

Each group underwent different kind of two months ambulatory therapy (Motor Program Activating Therapy, Vojta's reflex locomotion, and Functional Electric Stimulation in Posturally Corrected Position).

POPULATION

MS people with moderate disability.

METHODS

At baseline and after the program, participants underwent magnetic resonance diffusion tensor imaging (DTI) and clinical assessment. Fractional anisotropy maps obtained from DTI were further analyzed using tract-based spatial statistic exploring the mean values in the whole statistic skeleton. Moreover, additional exploratory analysis in 48 regions of white matter was done.

RESULTS

92 people were recruited. DTI data from 61 were analysed. The neurofacilitation (irrespective type of therapy) resulted in significant improvement on the Berg Balance Scale (p=0.0089), mainly driven by the Motor Program Activating Therapy. No statistically significant change in the whole statistic skeleton was observed (only a trend for decrement of fractional anisotropy after Vojta's reflex locomotion). Additional exploratory analysis confirmed significant decrement of fractional anisotropy in the right anterior corona radiata.

CONCLUSIONS

Neurofacilitation improved balance without much evidence of white matter integrity changes in people with MS.

CLINICAL REHABILITATION IMPACT

The study results point to the importance of neuroproprioceptive "facilitation and inhibition" physical therapy in management of balance in people with multiple sclerosis and the potential to induce white matter changes due to possibility to interfere with the neuronal tactility threshold.

Beyond clinical changes: Rehabilitation-induced neuroplasticity in MS

BACKGROUND

Neural plasticity represents the substrate by which the damaged central nervous system (CNS) re-learns lost behaviors in response to rehabilitation. In persons with multiple sclerosis (MS), rehabilitation can therefore exploit the potential of neural plasticity to restore CNS functions beyond the spontaneous mechanisms of recovery from MS-related damage.

METHODS

Here, we reviewed the currently available evidence on the occurrence of mechanisms of structural and functional plasticity following rehabilitation, motor, and/or cognitive training. We presented both data gained from basic laboratory research on animal models and data on persons with MS obtained by advanced magnetic resonance imaging (MRI) techniques.

RESULTS

Studies on physical and environmental enrichment in experimental MS models showed beneficial effects mediated by both immune modulation and activity-dependent plasticity, lowering tissue destruction and restoring of CNS network function. Translational researches in MS people demonstrated structural and/or functional MRI changes after various interventions, but their heterogeneity and small sample sizes (5-42 patients) raise concerns about the interpretation and generalization of the obtained results.

DISCUSSION

We highlighted the limitations of published studies, focusing on the knowledge gaps to be filled in terms of neuropathological correlations between changes detected in animal models and changes detected in vivo by neuroimaging.

Constraint-Induced Movement Therapy for Lower Extremity Function: Describing the LE-CIMT Protocol

Constraint-induced movement therapy (CIMT) is comprised of a set of techniques shown to produce significant changes in upper extremity (UE) function following stroke and other disorders. The significant positive results obtained with the UE protocol have led to the development of LE-CIMT, an intervention to improve lower extremity (LE) function. However, some modifications of the UE protocol were needed, including omitting use of a restraint device, development of supervised motor training tasks to emphasize movement of the lower limb, and adaptation of the UE Motor Activity Log for the lower extremity. The LE-CIMT protocol includes: (1) intensive supervised training delivered for 3.5 h/d for 10 consecutive weekdays, (2) use of shaping as a strategy for motor training, (3) application of a transfer package, and (4) strongly encouraging use of the more-affected LE with improved coordination. The transfer package consists of several strategies to facilitate transfer of the improved motor skills developed during supervised treatment to everyday situations. Research to date has yielded positive results. However, the intervention protocol continues to evolve. The purpose of this article is to describe the components of the complete LE-CIMT protocol to promote further development and investigation of this approach.

Constraint-Induced Movement Therapy in multiple sclerosis: Safety and three-dimensional kinematic analysis of upper limb activity. A randomized single-blind pilot study

BACKGROUND

There are few evidences on safety of Constraint-Induced Movement Therapy (CIMT), as well as its effects in neurological conditions, including multiple sclerosis (MS).

OBJECTIVE

To evaluate safety and effectiveness of a 2-week CIMT protocol on upper limb activity of progressive MS patients through a three-dimensional (3D) kinematic analysis.

METHODS

In this randomized single-blind pilot study, we randomly allocated patients affected by progressive MS reporting a reduced use of one upper limb into two different groups: CIMT group (less affected limb blocked by a splint) and control group (undergoing bi-manual treatment). Primary outcome was CIMT safety. Furthermore, we assessed CIMT effects through clinical outcomes (hand grip strength, HGS, and 9 Hole Peg Test, 9HPT) and 3D kinematic analysis (normalized jerk, number of movement units, going phase duration, mean velocity, endpoint error). All evaluations were performed at baseline (T0) and after 2 weeks of treatment (T1) for both arms in both groups.

RESULTS

Ten MS patients, mean aged 51.0±7.7 years, were randomly allocated in the 2 groups. After treatment, no differences were found in the blocked arm. Furthermore, CIMT group showed significant improvements in clinical and kinematic parameters.

CONCLUSIONS

CIMT might be considered a safe and effective technique in MS patients.

Performance Measures for Upper Extremity Functions in Persons with Multiple Sclerosis

Recent studies suggest that upper extremity dysfunction is a quite common symptom in multiple sclerosis (MS), and affects adversely the activities of daily living even in the early stages of the disease. It is an undeniable fact that assessment is a crucial component for a disease management. The performance is defined as "what an individual does in his or her current environment" according to the International Classification of Functioning, Disability and Health (ICF). Performance measures for upper extremity have been used relatively recent in persons with MS. ABILHAND, Manual Ability Measurement (MAM), Disabilities of the Arm Shoulder and Hand Outcome Measure, and Motor Activity Log are commonly used perceived performance measures for upper extremity functions in persons with MS. Because of their modern psychometric properties, ABILHAND and MAM stands out from other measures. Only available actual performance measures for upper extremity functions in persons with MS are accelerometers. In addition to their advantages, they have some disadvantages waiting to be solved.