Effectiveness of Constraint-Induced Movement Therapy (CIMT) on Balance and Functional Mobility in the Stroke Population: A Systematic Review and Meta-Analysis

Effectiveness of Occupational Therapy Interventions on Activities of Daily Living, Cognitive Function, and Physical Function in Middle-Aged and Older People with Chronic Stroke: A Systematic Review with Meta-Analysis

Background: Occupational therapy (OT) interventions on activities of daily living (ADL), cognitive functions, and physical function in middle-aged and older people with chronic stroke. Methods: A systematic review search until November 2024 using five generic databases: PubMed/Medline, Web of Science, Scopus, ScienceDirect, and OT seeker. The PRISMA checklist, RoB 2 (Cochrane, London, UK), and GRADEpro (Evidence Prime Inc., Hamilton, CA) tools assessed the evidence's methodological quality and certainty. The protocol was registered in PROSPERO (code: CRD42024568225). Results: Of 1733 records were identified across the databases, nine studies were analyzed using the PICOS format. The meta-analysis revealed significant improvements in independent performance of activities of daily living (ADL), as measured by the Canadian Occupational Performance Measure (COPM), in favor of the experimental groups (p = 0.03). No significant differences were found for the other variables analyzed. Conclusions: Performance on ADLs improved significantly according to the COPM, whereas no significant improvements in cognitive or physical function were observed among middle-aged and older chronic stroke survivors. Individual studies highlight the potential benefits of OT interventions that combine cognitive, motor, and technological approaches, such as virtual reality and brain stimulation.

Neuroathletic training in stroke rehabilitation? A single-blind randomized controlled pilot study on the potential of neuroathletic training for balance ability in stroke outpatient rehabilitation

Recently, neuroathletic training has been increasingly applied in competitive sports, in therapy, and in prevention. Scientific evidence on the effectiveness of this approach, however, has been poorly developed. Potentials of neuropathologic perceptual exercises to potentially improve balance control in the context of movement therapy in stroke rehabilitation appear promising. To investigate the possible effects of neuroathletic exercises on the balance ability of poststroke patients with ischemic infarcts and intracerebral hemorrhages, a controlled trial of a standardized protocol of daily neuroathletic exercises compared to traditional movement therapy during a four-week period of medical rehabilitation was conducted (n = 19). Patients were assessed with the Berg-Balance Scale (BBS), which represents the Gold standard for clinical measurement of balance. The results of the prepost BBS measurement showed significant balance improvements in the intervention and control groups, whereas the intervention group reached a higher total score by half the size of the standard deviation. A comparison of the results of both groups supported the general effectiveness of movement therapy for improving balance in stroke rehabilitation. However, neuroathletic training exercises did not lead to a stronger effect. Moreover, the intervention group did not score significantly lower than the control group. A negative influence can therefore not be assumed. For further investigations of neuroathletic training compared to treatment-as-usual training to improve balance in stroke rehabilitation, additional studies with larger sample sizes and longer treatment periods should be conducted.Trial registration United States National Library of Medicine, NCT06391801, date: 04.29.2024.

Positive effects of lower extremity constraint-induced movement therapy on balance, leg strength and dual-task ability in stroke patients: a longitudinal cohort study

OBJECTIVE

To investigate whether high-intensity lower extremity constraint-induced movement therapy can improve balance, leg strength, and dual-task ability.

DESIGN

A longitudinal cohort study in a real-world outpatient clinic.

PATIENTS

147 community-dwelling participants in the subacute and chronic poststroke phases.

METHODS

Participants received lower extremity constraint-induced movement therapy for 6 hours/day during 2 consecutive weeks, including balance, strength, and functional training. The Berg Balance Scale (BBS), Single-Leg-Stance (SLS) bilaterally, one Repetition Maximum (1RM) in a leg press, symmetry of leg strength (Diff-1RM), Timed Up and Go (TUG), and the TUG Manual test were assessed before, after, and 3 months after lower extremity constraint-induced movement therapy.

RESULTS

Compared with preintervention data, statistically significant improvements after lower extremity constraint-induced movement therapy (p < 0.001) were demonstrated for balance with an absolute value in BBS at 1.9 points (effect size 0.38) and SLS at 2.4 s (effect size 0.24), and for leg strength at 10.2 kg (effect size 0.54) for the affected leg. Diff 1RM decreased significantly at 5.8 kg (effect size 0.39) and improvements on dual-task ability at 2.7 s were significant (effect size 0.14). The effects persisted at the 3-month follow-up.

CONCLUSIONS

High-intensity lower extremity constraint-induced movement therapy may be a feasible treatment option for middle-aged stroke patients to affect balance, leg strength, and dual-task ability positively in an out-patient clinical setting.

Effectiveness of Virtual Reality in Occupational Therapy for Post-Stroke Adults: A Systematic Review

Background: In recent years, there has been a growing use of technological advancements to enhance the rehabilitation of individuals who have suffered from cerebrovascular accidents. Virtual reality rehabilitation programs enable patients to engage in a customized therapy program while interacting with a computer-generated environment. Therefore, our goal was to investigate the effectiveness of virtual reality in occupational therapy for people's rehabilitation after a cerebrovascular accident. Methods: We systematically searched databases (Pubmed/Medline, Scopus, Web of Science, and Science Direct) for randomized controlled trials published within the last 10 years. Studies involving adult stroke survivors undergoing virtual reality-based interventions aimed at improving upper-extremity motor function were included. The quality assessment followed PRISMA guidelines, with the risk of bias assessed using the Cochrane tool (version 6.4) and methodological quality evaluated using GRADEpro. Results: We selected sixteen studies that met the main criteria for the implementation of virtual reality technology. The interventions described in the articles focused mainly on the upper extremities and their fine motor skills. Conclusions: When used in conventional treatments to improve people's motor and cognitive functions after a cerebrovascular accident, virtual reality emerges as a beneficial tool. Additionally, virtual reality encourages adherence to the interventional process of rehabilitation through occupational therapy.

Validity of an android device for assessing mobility in people with chronic stroke and hemiparesis: a cross-sectional study

BACKGROUND

Incorporating instrument measurements into clinical assessments can improve the accuracy of results when assessing mobility related to activities of daily living. This can assist clinicians in making evidence-based decisions. In this context, kinematic measures are considered essential for the assessment of sensorimotor recovery after stroke. The aim of this study was to assess the validity of using an Android device to evaluate kinematic data during the performance of a standardized mobility test in people with chronic stroke and hemiparesis.

METHODS

This is a cross-sectional study including 36 individuals with chronic stroke and hemiparesis and 33 age-matched healthy subjects. A simple smartphone attached to the lumbar spine with an elastic band was used to measure participants' kinematics during a standardized mobility test by using the inertial sensor embedded in it. This test includes postural control, walking, turning and sitting down, and standing up. Differences between stroke and non-stroke participants in the kinematic parameters obtained after data sensor processing were studied, as well as in the total execution and reaction times. Also, the relationship between the kinematic parameters and the community ambulation ability, degree of disability and functional mobility of individuals with stroke was studied.

RESULTS

Compared to controls, participants with chronic stroke showed a larger medial-lateral displacement (p = 0.022) in bipedal stance, a higher medial-lateral range (p < 0.001) and a lower cranio-caudal range (p = 0.024) when walking, and lower turn-to-sit power (p = 0.001), turn-to-sit jerk (p = 0.026) and sit-to-stand jerk (p = 0.001) when assessing turn-to-sit-to-stand. Medial-lateral range and total execution time significantly correlated with all the clinical tests (p < 0.005), and resulted significantly different between independent and limited community ambulation patients (p = 0.042 and p = 0.006, respectively) as well as stroke participants with significant disability or slight/moderate disability (p = 0.024 and p = 0.041, respectively).

CONCLUSION

This study reports a valid, single, quick and easy-to-use test for assessing kinematic parameters in chronic stroke survivors by using a standardized mobility test with a smartphone. This measurement could provide valid clinical information on reaction time and kinematic parameters of postural control and gait, which can help in planning better intervention approaches.

Combination of different noninvasive brain stimulation treatments for upper limb recovery in stroke patients: A systematic review

We report a review of Pubmed (Medline), CENTRAL, Web of Science, and Scopus to test the effectiveness of the combined application of repetitive transcranial magnetic stimulation and transcranial direct current stimulation in the improvement of different functional variables of the upper limb in people with stroke. Two independent reviewers assessed eligibility and evaluated the quality of the studies. Five articles were included in the final review according to the inclusion criteria: Most show statistically significant differences in motor function improvement in favor of the experimental group, but not in activity. Due to the heterogeneity of the observed studies, the results should be interpreted with caution-more high-quality studies are needed to investigate the effectiveness of these interventions in different stages of stroke patients.

Multiple Approaches of Neuro-Physiotherapy Used for Improving Balance, Normalizing Tone, and Gait Training in a Child With Ataxic Cerebral Palsy: A Case Report

Cerebral palsy (CP) is a non-progressive developmental delay disorder that mainly affects children. A strategy for enhancing organizational abilities, including practices based on evidence, and improving outcomes is the base of clinical management in physiotherapy. A seven-year-old girl presented with a history of difficulty walking, standing for extended periods, and performing gross and fine motor movements. MRI revealed generalized atrophy of the cerebellum. The child was managed by medications and physiotherapy. Physiotherapy intervention was based on goal-oriented strategies, which include Rood's approach, constraint-induced movement therapy (CIMT), proprioceptive neuromuscular facilitation (PNF), passive stretching, etc. This goal-oriented program showed an improvement in the treatment outcomes of the child. The child was walking independently with a proper gait pattern and was able to maintain both static and dynamic balance. Initial physical therapy management using integrated methods promotes the achievement of developmental milestones like gross motor skills in ataxic cerebral palsy children.

Advances in Stroke Neurorehabilitation

Stroke is one of the leading causes of disability worldwide despite recent advances in hyperacute interventions to lessen the initial impact of stroke. Stroke recovery therapies are crucial in reducing the long-term disability burden after stroke. Stroke recovery treatment options have rapidly expanded within the last decade, and we are in the dawn of an exciting era of multimodal therapeutic approaches to improve post-stroke recovery. In this narrative review, we highlighted various promising advances in treatment and technologies targeting stroke rehabilitation, including activity-based therapies, non-invasive and minimally invasive brain stimulation techniques, robotics-assisted therapies, brain-computer interfaces, pharmacological treatments, and cognitive therapies. These new therapies are targeted to enhance neural plasticity as well as provide an adequate dose of rehabilitation and improve adherence and participation. Novel activity-based therapies and telerehabilitation are promising tools to improve accessibility and provide adequate dosing. Multidisciplinary treatment models are crucial for post-stroke neurorehabilitation, and further adjuvant treatments with brain stimulation techniques and pharmacological agents should be considered to maximize the recovery. Among many challenges in the field, the heterogeneity of patients included in the study and the mixed methodologies and results across small-scale studies are the cardinal ones. Biomarker-driven individualized approaches will move the field forward, and so will large-scale clinical trials with a well-targeted patient population.

Influence of the constraint-induced method of constraint-induced movement therapy on improving lower limb outcomes after stroke: A meta-analysis review

Background

Constraint-induced movement therapy (CIMT) targeting the lower limb function uses various methods. The influence of CIMT methods on lower limb outcomes after stroke has rarely been examined.

Objectives

This study aimed to examine CIMT effects on lower limb outcomes and explore the influence of CIMT methods on treatment effects after stroke, with other potential factors considered as covariates.

Methods

PubMed, Web of Science, Cochrane Library, Academic Search Premier via EBSCOHost, and PEDro databases were searched until September 2022. We included randomized control trials with CIMT targeting the lower limb function and dosage-matched active control. The Cochrane risk-of-bias tool was used to evaluate the methodological quality of each study. Hedges' g was used to quantify the effect size of CIMT on outcomes compared to the active control. Meta-analyses were conducted across all studies. A mixed-variable meta-regression analysis was used to investigate the influence of CIMT methods on treatment effects after stroke, with other potential factors considered as covariates.

Results

Twelve eligible randomized controlled trials with CIMT were included in the meta-analysis, where 10 trials were with a low risk of bias. A total of 341 participants with stroke were involved. For the treatment effects on the lower limb function, CIMT showed a moderate short-term effect size [Hedges' g = 0.567; P &gt; 0.05; 95% confidence interval (CI): 0.203–0.931], but a small and insignificant long-term effect size (Hedges' g = 0.470; P &gt; 0.05; 95%CI: −0.173 to 1.112), compared with conventional treatment. The CIMT method of using a weight strapped around the non-paretic leg and the ICF outcome category of the movement function were identified as significant factors contributing to the heterogeneity of short-term effect sizes across studies (β = −0.854 and 1.064, respectively, R2 = 98%, P &gt; 0.05). Additionally, using a weight strapped around the non-paretic leg had a significant contribution to the heterogeneity of long-term effect sizes across studies as well (β = −1.000, R2 = 77%, P &gt; 0.05).

Conclusion

Constraint-induced movement therapy is superior to conventional treatment for improvement of lower limb function in the short-term but not in the long-term. The CIMT method of using a weight strapped around a non-paretic leg contributed negatively to the treatment effect, and therefore might not be recommended.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, identifier: CRD42021268681.

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.

Combination of noninvasive brain stimulation and constraint-induced movement therapy in patients with stroke: a systematic review and meta-analysis

INTRODUCTION

Constraint-induced movement therapy (CIMT) and noninvasive brain stimulation (NIBS) are used to counteract learned nonuse phenomenon and imbalance in interhemispheric inhibition following stroke. The aim of this study is to summarize the available evidence on the effects of combining NIBS with CIMT in patients with stroke.

METHOD

PubMed, Embase, Web of Science (WoS), PEDro, OTSeeker, and CENTRAL were searched for randomized controlled trials comparing the use of NIBS+CIMT with sham NIBS+CIMT. Data on variables such as time since stroke and mean scores and standard deviations on outcomes assessed such as motor function were extracted. Cochrane risks of bias assessment tool and PEDro scale were used to assess the risk of bias and methodological quality of the included studies.

RESULTS

The results showed that both NIBS+CIMT and sham NIBS+CIMT improved all outcomes post-intervention and at follow-up. However, NIBS+CIMT is superior to sham NIBS+CIMT at improving level of motor impairment (SMD = 1.75, 95% CI = 0.49 to 3.01, P = 0.007) post-intervention and hand function (SMD = 1.21, 95% CI = 0.07 to 2.35, P = 0.04) at follow-up.

CONCLUSIONS

The addition of NIBS to CIMT seems to provide additional benefits to the recovery of function following stroke.

The effect and safety of constraint-induced movement therapy for post-stroke motor dysfunction: a meta-analysis and trial sequential analysis

Background

Due to motor function insufficiency, patients with post-stroke motor dysfunction (PSMD) have limitations in performing an activity, feel restricted during social participation, and feel impaired in their quality of life. Constraint-induced movement therapy (CIMT) is a neurorehabilitation technique, but its effectiveness on PSMD after stroke still remains controversial.

Objective

This meta-analysis and trial sequential analysis (TSA) aimed to comprehensively evaluate the effect and safety of CIMT for PSMD.

Methods

Four electronic databases were searched from their inception to 1 January 2023 to identify randomized controlled trials (RCTs) investigating the effectiveness of CIMT for PSMD. Two reviewers independently extracted the data and assessed the risk of bias and reporting quality. The primary outcome was a motor activity log for the amount of use (MAL-AOU) and the quality of movement (MAL-QOM). RevMan 5.4, Statistical Package for Social Sciences (SPSS) 25.0, and STATA 13.0 software were used for statistical analysis. The certainty of the evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. We also performed the TSA to assess the reliability of the evidence.

Results

A total of 44 eligible RCTs were included. Our results showed that CIMT combined with conventional rehabilitation (CR) was superior to CR in improving MAL-AOU and MAL-QOM scores. The results of TSA indicated that the above evidence was reliable. Subgroup analysis demonstrated that CIMT (≥6 h per day or duration ≤ 20 days) combined with CR was more effective than CR. Meanwhile, both CIMT and modified CIMT (mCIMT) combined with CR were more efficient than CR at all stages of stroke. No severe CIMT-related adverse events occurred.

Conclusion

CIMT may be an optional and safe rehabilitation therapy to improve PSMD. However, due to limited studies, the optimal protocol of CIMT for PSMD was undetermined, and more RCTs are required for further exploration.

Clinical trial registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=143490, identifier: CRD42019143490.

The Mediating Effect of Age, Gender, and Post-Stroke Duration on the Association between Trunk and Upper Limb Recovery in Subacute Stroke Population: A Cross-Sectional Study with Mediation Analysis

BACKGROUND

The trunk acts as proximal support with which limbs execute smooth and purposeful movement. Furthermore, as upper extremity functions are an integral component of daily living activities, exploring the association between trunk and upper extremity recovery will guide therapists in developing appropriate rehabilitation goals and interventions. The objectives of this study were to (1) assess the association between trunk and upper extremity recovery in the subacute stroke population and (2) assess the effect of trunk control on upper extremity impairment and function with age, gender, and duration of stroke as mediators using mediation analysis in subacute stroke individuals.

METHODS

This cross-sectional study included 54 subacute stroke participants with a mean age of 58.37 ± 6.11 years. The trunk impairment scale (TIS) assessed the trunk's stability, mobility, and coordination. The level of upper extremity impairment was evaluated using the Fugl-Meyer Assessment scale (FMA). The quality and quantity of upper limb motor functions were measured using the Wolf motor function test (WMFT).

RESULTS

The TIS exhibited moderate positive correlations with the FMA-UE, WMFT-time scale (TS), and WMFT-functional ability scale (FAS) at p < 0.001. The mediation analysis reported a profound mediation effect of post-stroke duration on the association of trunk and upper limb recovery.

CONCLUSIONS

The study results substantiated that trunk control significantly correlates with upper limb impairment and the quality and quantity of its use in the subacute stroke population. Post-stroke duration proved to mediate the association between trunk and upper limb recovery. Therefore, the assessment and intervention of trunk and upper extremity motor control considering the post-stroke duration is vital and should be incorporated in stroke rehabilitation aiming at functional independence.