Brain parenchymal fraction predicts motor improvement following intensive task-oriented motor rehabilitation for chronic stroke

An Exploration of the Effectiveness of Different Intensity Protocols of Modified Constraint-Induced Therapy in Stroke: A Systematic Review

Purpose

To examine the effectiveness of different modified Constraint-Inuced Therapy (mCIMT) protocol intensities on upper extremity motor function in adults with hemiplegia.

Methods

A search was conducted in PubMed, Scopus, EBSCO, and Cochrane Library for articles published between April 2010 and December 2021. Only randomized controlled trials (RCTs) were included. Studies were excluded if they used a sample of less than five, mCIMT in combination with other therapy, and/or if they were not written in English. Methodologic quality was assessed using the Cochrane collaboration risk of bias tool-2.

Results

Thirty-six RCTs with a total of 721 participants were included. Most researchers followed a moderate to low protocol intensity in terms of total treatment time and moderate to high intensity with regard to restriction time. Almost all of the upper limb motor function measures showed statistically significant improvements (p < .05) after mCIMT, irrespective of the protocol's intensity, but there was lack of high-quality studies. Statistically significant improvements did not always translate to clinical importance.

Conclusions

Low-intensity CIMT protocols may result in comparable improvements to more intensive ones but caution has to be taken when drawing conclusions due to high risk of bias studies.

Bimanual coordination: A missing piece of arm rehabilitation after stroke

Inability to use the arm in daily actions significantly lowers quality of life after stroke. Most contemporary post-stroke arm rehabilitation strategies that aspire to re-engage the weaker arm in functional activities have been greatly limited in their effectiveness. Most actions of daily life engage the two arms in a highly coordinated manner. In contrast, most rehabilitation approaches predominantly focus on restitution of the impairments and unilateral practice of the weaker hand alone. We present a perspective that this misalignment between real world requirements and intervention strategies may limit the transfer of unimanual capability to spontaneous arm use and functional recovery. We propose that if improving spontaneous engagement and use of the weaker arm in real life is the goal, arm rehabilitation research and treatment need to address the coordinated interaction between arms in targeted theory-guided interventions. Current narrow focus on unimanual deficits alone, difficulty in quantifying bimanual coordination in real-world actions and limited theory-guided focus on control and remediation of different coordination modes are some of the biggest obstacles to successful implementation of effective interventions to improve bimanual coordination in the real world. We present a theory-guided taxonomy of bimanual actions that will facilitate quantification of coordination for different real-world tasks and provide treatment targets for addressing coordination deficits. We then present evidence in the literature that points to bimanual coordination deficits in stroke survivors and demonstrate how current rehabilitation approaches are limited in their impact on bimanual coordination. Importantly, we suggest theory-based areas of future investigation that may assist quantification, identification of neural mechanisms and scientifically-based training/remediation approaches for bimanual coordination deficits post-stroke. Advancing the science and practice of arm rehabilitation to incorporate bimanual coordination will lead to a more complete functional recovery of the weaker arm, thus improving the effectiveness of rehabilitation interventions and augmenting quality of life after stroke.

Modification of the ladder rung walking task-new options for analysis of skilled movements

Method sensitivity is critical for evaluation of poststroke motor function. Skilled walking was assessed in horizontal, upward, and downward rung ladder walking to compare the demands of the tasks and test sensitivity. The complete step sequence of a walk was subjected to analysis aimed at demonstrating the walking pattern, step sequence, step cycle, limb coordination, and limb interaction to complement the foot fault scoring system. Rats (males, n = 10) underwent unilateral photothrombotic lesion of the motor cortex of the forelimb and hind limb areas. Locomotion was video recorded before the insult and at postischemic days 7 and 28. Analysis of walking was performed frame-by-frame. Walking along the rung ladder revealed different results that were dependent on ladder inclination. Horizontal walking was found to discriminate lesion-related motor deficits in forelimb, whereas downward walking demonstrates hind limb use most sensitively. A more frequent use of the impaired forelimb that possibly supported poststroke motor learning in rats was shown. The present study provides a novel system for a detailed analysis of the complete walking sequence and will help to provide a better understanding of how rats deal with motor impairments.