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

Modified-constraint movement induced therapy versus neuro-developmental therapy on reaching capacity in children with hemiplegic cerebral palsy

BACKGROUND AND OBJECTIVE

Upper extremity impairment is one of the complications in hemiplegic children. The purpose of modified constraint-induced movement therapy (mCIMT) is to improve the function of impaired arms and hands in these children. This study compared the efficacy of mCIMT and the approach of neurodevelopmental therapy (NDT) on reaching capacity in children with spastic hemiplegia.

METHODS

Fifty-two spastic hemiplegic children ranging in age from four to 6 years were selected for this study from an outpatient clinic and biomechanical lab (Prince Sattam bin Abdulaziz University, KSA). They were randomly divided into two experimental groups: group I received NDT and group II received mCIMT for the involved upper limb and restriction of the uninvolved arm movements for 12 weeks (three times per week). Both groups received a conventional exercise program in addition to experimental one. Active elbow extension range of motion and three-dimensional motion analysis of the reaching task were measured before and after 3 months of treatment.

RESULTS

Significant enhancement in all pre-treatment and post-treatment outcomes was observed in both groups by a two-way mixed MANOVA; furthermore, Group II (mCIMT) showed the most significant improvement (elbow extension, percentage of reach to peak velocity, movement time and movement units) when comparing the post-treatment outcomes between the two groups (p < 0.001).

IMPLICATION FOR PHYSIOTHERAPY PRACTICE

Addition of mCIMT to a conventional exercise was superior to adding NDT exercise therapy in promoting the performance of reaching pattern in hemiplegic children.

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.

Progress in the clinical application of constraint-induced therapy following stroke since 2014

Stroke is a group of cerebrovascular diseases with high prevalence and mortality rate. Stroke can induce many impairments, including motor and cognitive dysfunction, aphasia/dysarthria, dysphagia, and mood disorders, which may reduce the quality of life among the patients. Constraint-induced therapy has been proven to be an effective treatment method for stroke rehabilitation. It has been widely used in the recovery of limb motor dysfunction, aphasia, and other impairment like unilateral neglect after stroke. In recent years, constraint-induced therapy can also combine with telehealth and home rehabilitation. In addition, constraint-induced therapy produces significant neuroplastic changes in the central nervous system. Functional magnetic resonance imaging, diffusion tensor imaging, and other imaging/electrophysiology methods have been used to clarify the mechanism and neuroplasticity. However, constraint-induced therapy has some limitations. It can only be used under certain conditions, and the treatment time and effectiveness are controversial. Further research is needed to clarify the mechanism and effectiveness of CI therapy.

Proprioceptive based training or modified constraint-induced movement therapy on upper extremity motor functions in chronic stroke patients: A randomized controlled study

BACKGROUND: The Modified Constraint-Induced Movement Therapy (mCIMT) method is a unilateral training that respectively avoids and activates less affected and affected sides of upper extremities; however, the selected options are not typically ideal. Proprioceptive based training (PT) includes bilateral training methods and influencing proprioceptive receptors. OBJECTIVE: The primary purpose was to determine if conventional therapy and PT or conventional therapy and mCIMT therapy show similar improvement in patients with chronic stroke. The secondary purpose was to investigate the effectiveness of conventional therapy and PT or mCIMT therapy in patients with chronic stroke and to compare which of the two interventions is more effective. METHODS: Forty patients with chronic stroke were randomly allocated to only conventional therapy (PTR, n = 14), conventional therapy plus proprioception training (PTR-PT, n = 13), and mCIMT (PTR-mCIMT, n = 13) groups. Evaluations were assessed before and 6 weeks after treatment. RESULTS: Intragroup evaluations revealeda significant improvement in the all scores in the PTR-PT and PTR-mCMIT groups (p = 0.006 < 0.001). Intergroup comparisons demonstrated that the PTR-mCIMT group had a significant improvement in spasticity and motor function scores compared to the PTR (p < 0.001) and the PTR-PT groups (p = 0.006–0.015). CONCLUSIONS: PT and mCMIT applied in addition to conventional therapy in patients with chronic stroke were more effective than only conventional therapy. Additionally, mCMIT showed greater improvement in spasticity and motor function scales than PT.

Effects of Intensive Vibratory Treatment with a Robotic System on the Recovery of Sensation and Function in Patients with Subacute and Chronic Stroke: A Non-Randomized Clinical Trial

Background: Sensory–motor deficits are frequent and affect the functionality after stroke. The use of robotic systems to improve functionality and motor performance is advisable; therefore, the aim of the present study was to evaluate the effects of intensive, high-frequency vibration treatment administered with a robotic system in subacute and chronic stroke patients in terms of upper limb sensitivity, motor function, quantity and quality of movement, and quality of life. Methods: A simple-blind, non-randomized controlled trial was conducted. The control group received conventional rehabilitation treatment and the experimental group received robotic treatment with an Amadeo^® robot in addition to their conventional rehabilitation sessions. Results: Intragroup analysis identified significant improvements in the experimental group in hand (p = 0.012), arm (p = 0.018), and shoulder (p = 0.027) sensitivity, as well as in motor function (FMA-UEmotor function, p = 0.028), integration of the affected limb (MAL-14amount scale, p = 0.011; MAL-14How well scale, p = 0.008), and perceived quality of life (SIS-16, p = 0.008). The measures between the control and experimental groups showed statistically significant differences in motor performance and spontaneous use of the affected limb (MAL-14amount scale, p = 0.021; MAL-14How well scale, p = 0.037). Conclusions: Intensive, high-frequency vibration with a robotic system, in combination with conventional intervention, improves the recovery of upper limb function in terms of quantity and quality of movement in patients with subacute and chronic stroke.

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.

Effect of Edaravone Combined with Anticoagulant Therapy on the Serum hs-CRP, IL-6, and TNF-α Levels and Activity of Daily Living in Patients with Acute Cerebral Infarction

Objective

To explore the effect of edaravone combined with anticoagulant therapy on the serum hs-CRP, IL-6, and TNF-α levels and the activity of daily living (ADL) in patients with acute cerebral infarction (ACI).

Methods

The clinical data of 84 ACI patients treated in our hospital from August 2020 to August 2021 were retrospectively analyzed, and they were divided into the routine group (n = 42) and the combined group (n = 42) according to the order of admission. Both groups were treated with routine clinical treatment, and the combined group was additionally treated with edaravone combined with anticoagulant therapy. Serum samples were collected from both groups after treatment. ELISA was used to detect the serum inflammatory factor levels, and the modified Barthel index score was used to evaluate the ADL of patients.

Results

Compared with the routine group, the combined group achieved obviously lower levels of PMA, CD62p, and serum inflammatory factors after treatment (P < 0.001), higher modified Barthel score after treatment (P < 0.001), lower plasma viscosity, platelet aggregation rate, and plasma fibrinogen level after treatment (P < 0.001), and higher clinical overall efficacy (P < 0.05).

Conclusion

Edaravone combined with anticoagulant therapy is a reliable method to enhance ADL and reduce the inflammatory response of ACI patients. This strategy greatly reduces the platelet-activating factor levels of patients and improves the comprehensive clinical efficacy, and its further research will help to establish a better solution for these patients.

Constraint-induced movement therapy protocols using the number of repetitions of task practice: a systematic review of feasibility and effects

BACKGROUND

High repetitions of task practice is required for the recovery of the motor function during constraint-induced movement therapy (CIMT). This can be achieved into ways: when the task practice is measured in hours of practice or when the number of repetitions is counted. However, it has been argued that using hours of task practice as a measure of practice does not provide a clear instruction on the dose of practice.

AIM

The aim of this study is to determine the feasibility and effects of the CIMT protocol that uses the number of repetitions of task practice.

MATERIALS/METHOD

The study was a systematic review registered in PROSPERO (CRD42020142140). Five databases, PubMED, CENTRAL, PEDro, OTSeeker and Web of Science, were searched. Studies of any designs in adults with stroke were included if they used the number of repetitions of task practice as a measure of dose. The methodological quality of the included studies was assessed using Modified McMaster critical review form. The results were analysed using qualitative synthesis.

RESULTS

Eight studies (n = 205) were included in the study. The number of task repetitions in the studies ranges between 45 and 1280 per day. The results showed that CIMT protocol using the number of repetitions of task practice was feasible and improved outcomes such as motor function, quality of life, functional mobility and spasticity.

CONCLUSION

The number of repetitions of task practice as a measure of CIMT dose can be used in place of the existing protocol that uses the number of hours of task practice.

Treadmill exercise attenuates cerebral ischaemic injury in rats by protecting mitochondrial function via enhancement of caveolin-1

AIMS

Exercise training has a neuroprotective effect against ischaemic injury, but the underlying mechanism is not completely clear. This study explored the potential mechanisms underlying the protective effects of treadmill training and caveolin-1 regulation against mitochondrial dysfunction in cerebral ischaemic injury.

MAIN METHODS

After middle cerebral artery occlusion (MCAO) surgery, rats were subjected to treadmill training and received daidzein injections and combined therapy. A series of analyses, including neurological function scoring; body weight measurement; Nissl, haematoxylin and eosin staining; cerebral infarction volume assessment; mitochondrial morphology examination; caveolin-1, cytoplasmic and mitochondrial cytochrome C (CytC), and translocase of outer membrane 20 (TOM20) expression analysis; apoptosis index analysis; and transmission electron microscopy were conducted.

KEY FINDINGS

Treadmill training increased caveolin-1 expression, reduced neurobehavioral scores and cerebral infarction volumes, improved tissue morphology, reduced neuronal loss, inhibited mitochondrial outer membrane permeabilization (MOMP) through the caveolin-1 pathway, prevented excessive Cyt-C release from mitochondria, and reduced the degrees of apoptosis and mitochondrial damage. In addition, treadmill training increased the expression of TOM20 through the caveolin-1 pathway and maintained import signal function, thereby protecting mitochondrial integrity.

SIGNIFICANCE

Treadmill exercise protected mitochondrial integrity and inhibited the endogenous mitochondrial apoptosis pathway. The damage of cerebral ischaemia was alleviated in rats through enhancement of caveolin-1 by treadmill exercise.

Combined effects of Telehealth and Modified Constraint-Induced Movement Therapy for Individuals with Chronic Hemiparesis

Telehealth use allows improved access to services and results in potential cost savings. The purpose of this study was to examine the effectiveness of a combined modified Constrained Induced Movement Therapy (mCIMT) program using telehealth and in-person sessions, for participants with higher (Group 1) and lower (Group 2) functional ability of the hemiparetic upper extremity. Using a pre-experimental design with a 6-week intervention, 28 participants were assessed twice on use of upper extremity via subjective and objective measures. For the Motor Activity Log, the amount of use and quality of use were significant for Groups 1 and 2. Significant improvements were shown on the Wolf Motor Function Test (WMFT), the Fugl-Meyer UE, and the Functional Independence Measure (FIM) for both groups except for the strength subtest on the WMFT and the timed portion for Group 1. Percentages of attendance for telehealth and in-person sessions were also compared. Telehealth sessions had a higher attendance rate (84.5%) than in-person sessions (75.3%) (p=.004). The combined mCIMT program of telerehabilitation and in-person group sessions was effective in improving functional ability after a stroke.

Neurobiology of Recovery of Motor Function after Stroke: The Central Nervous System Biomarker Effects of Constraint-Induced Movement Therapy

Recovery of motor function after stroke involves many biomarkers. This review attempts to identify the biomarker effects responsible for recovery of motor function following the use of Constraint-Induced Movement Therapy (CIMT) and discuss their implications for research and practice. From the studies reviewed, the biomarker effects identified include improved perfusion of motor areas and brain glucose metabolism; increased expression of proteins, namely, Brain-Derived Neurotrophic Factor (BDNF), Vascular Endothelial Growth Factor (VEGF), and Growth-Associated Protein 43 (GAP-43); and decreased level of Gamma-Aminobutyric Acid (GABA). Others include increased cortical activation, increased motor map size, and decreased interhemispheric inhibition of the ipsilesional hemisphere by the contralesional hemisphere. Interestingly, the biomarker effects correlated well with improved motor function. However, some of the biomarker effects have not yet been investigated in humans, and they require that CIMT starts early on poststroke. In addition, one study seems to suggest the combined use of CIMT with other rehabilitation techniques such as Transcortical Direct Stimulation (tDCs) in patients with chronic stroke to achieve the biomarker effects. Unfortunately, there are few studies in humans that implemented CIMT during early poststroke. Thus, it is important that more studies in humans are carried out to determine the biomarker effects of CIMT especially early on poststroke, when there is a greater opportunity for recovery. Furthermore, it should be noted that these effects are mainly in ischaemic stroke.

Early Path Nursing on Neurological Function Recovery of Cerebral Infarction

Purpose

to study the application of path type early rehabilitation nursing in the nursing of patients with cerebral infarction and to explore its impact on the recovery of neurological function.

Methods

Patients with acute cerebral infarction in our hospital were randomly divided into two groups. The control group used conventional treatment methods. The experimental group used path type early rehabilitation care based on conventional treatment methods and observed the curative effect.

Results

The NIHSS scores in the experimental group were significantly lower than those in the control group, and the P value was less than 0.05, which was statistically significant.

Conclusion

Path type early rehabilitation nursing has a positive effect on the treatment of patients with cerebral infarction, which contributes to the recovery of neurological function of patients and is worthy of promotion in treatment.

Is there a dose-dependent effect of modified constraint-induced movement therapy in patients with hemiplegia?

BACKGROUND

Impairment of upper extremity function is a common sequelae of stroke. It has been reported that modified constraint-induced movement therapy (mCIMT) could prove to be effective.

OBJECTIVE

To investigate the relationship between the intensity of rehabilitation such as treatment and constraining time, and the functional outcome for the paretic upper extremity in stroke patients through mCIMT.

METHODS

We conducted an observational prospective study of 31 patients with hemiplegia and subacute or chronic stroke. The mCIMT was performed for two weeks. Rehabilitation time and constraining time were variable among patients. The rehabilitation time included an individualized task-oriented program and conventional occupation treatment with an individualized therapist. The constraining time, with mit or splint, was also asked to self-record individually. The outcome was evaluated on the more affected side by the Wolf Motor Function Test, Fugl-Meyer Assessment, Motor Activity Log 14, and Functional Independence Measure for self-care tasks after the therapy.

RESULTS

All participants after the modified constraint-induced movement therapy program for two weeks improved on the evaluated outcome measures (P < 0.05). No significant correlation was found between the dose-dependent treatment or constraining time and outcomes. Comparisons improvement with subgroups based on the duration from onset, constraining component, dominant hand consistent with lesion side of stroke, and initial medical research council score for muscle strength, also showed no significant differences.

CONCLUSIONS

This is the first study on the effects of intensity of mCIMT with respect to time-dosage. Although all patients in this study showed improved functional status, no significant correlation between dose-dependent rehabilitation or constraining time and outcomes was seen.

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.

Effects of modified constraint-induced movement therapy on upper extremity function and occupational performance of stroke patients

[Purpose] The purpose of this research was to examine the effectiveness of modified constraint-induced movement therapy (mCIMT) on the upper extremity function and occupational performance of stroke patients. [Participants and Methods] An experimental study was carried out on two groups of 7 participants selected by a specific criterion. The experimental group received the mCIMT as well as the conventional rehabilitation therapy (CRT) for 5 days per week over a 2 week period. The control group received only the CRT. Outcome measures included the Manual Function Test (MFT), Motor Activity Log (MAL), and Canadian Occupational Performance Measure (COPM). [Results] Average amount of changes in the MAL and COPM is different in statistical analysis between the mCIMT and the CRT groups before and after the intervention. The mCIMT group showed significant improvements on MFT, MAL, and COPM before and after the intervention. [Conclusion] We suggest that the mCIMT improves the upper extremity function and occupational performance of stroke patients better than the CRT alone.

Neurophysiological effects of constraint-induced movement therapy and motor function: A systematic review

Background/Aims:

There is a claim that improvements in motor function in people with stroke following constraint-induced movement therapy (CIMT) is due to compensation but not actually neurorestoration. However, few studies have demonstrated improvements in neurophysiological outcomes such as increased motor map size and activation of primary cortex, or their positive correlations with motor function, following CIMT. The aim of this study was to carry out a systematic review of CIMT trials using neurophysiological outcomes, and a meta-analysis of the relationship between the neurophysiological outcomes and motor function.

Methods:

The PubMed, PEDro and CENTRAL databases, as well as the reference lists of the included studies, were searched. The included studies were randomised controlled trials comparing the effect of CIMT on neurophysiological outcomes compared with other rehabilitation techniques, conventional therapy, or another variant of CIMT. Methodological quality was assessed using the PEDro scale. The data extracted from the studies were sample size, eligibility criteria, dose of intervention and control, outcome measurements, and time since stroke.

Findings:

A total of 10 articles (n=219) fulfilled the study inclusion criteria, all of which were used for narrative synthesis, and four studies were used in the meta-analysis. The methodological quality of the studies ranged from low to high. Strong, positive, and significant correlations were found between the neurophysiological and motor function outcomes in fixed effects (z=3.268, p=0.001; r=0.52, 95% confidence interval (CI) 0.227–0.994) and random-effects (z=2.106, p=0.035; r=0.54, 95% CI 0.0424–0.827) models.

Conclusions:

Randomised controlled trials evaluating the effects of CIMT on neurophysiological outcomes are few in number. Additionally, these studies used diverse outcomes, which makes it difficult to draw any meaningful conclusion. However, there is a strong positive correlation between neurophysiological and motor function outcomes in these studies.

Early Rehabilitation After Stroke: a Narrative Review

PURPOSE OF REVIEW

Despite current rehabilitative strategies, stroke remains a leading cause of disability in the USA. There is a window of enhanced neuroplasticity early after stroke, during which the brain's dynamic response to injury is heightened and rehabilitation might be particularly effective. This review summarizes the evidence of the existence of this plastic window, and the evidence regarding safety and efficacy of early rehabilitative strategies for several stroke domain-specific deficits.

RECENT FINDINGS

Overall, trials of rehabilitation in the first 2 weeks after stroke are scarce. In the realm of very early mobilization, one large and one small trial found potential harm from mobilizing patients within the first 24 h after stroke, and only one small trial found benefit in doing so. For the upper extremity, constraint-induced movement therapy appears to have benefit when started within 2 weeks of stroke. Evidence for non-invasive brain stimulation in the acute period remains scant and inconclusive. For aphasia, the evidence is mixed, but intensive early therapy might be of benefit for patients with severe aphasia. Mirror therapy begun early after stroke shows promise for the alleviation of neglect. Novel approaches to treating dysphagia early after stroke appear promising, but the high rate of spontaneous improvement makes their benefit difficult to gauge. The optimal time to begin rehabilitation after a stroke remains unsettled, though the evidence is mounting that for at least some deficits, initiation of rehabilitative strategies within the first 2 weeks of stroke is beneficial. Commencing intensive therapy in the first 24 h may be harmful.