Grade-4/5 motor activity log-Brazil for post-stroke individuals with a severely impaired upper limb: a validity, reliability and measurement error study

PURPOSE

This study examined the clinimetrics of the Brazilian-Portuguese translation of the Grade-4/5 Motor Activity Log (MAL 4/5), which assesses everyday use of the more affected upper-limb (UL) in stroke survivors with moderate/severe or severe motor impairment.

MATERIALS AND METHODS

The translated MAL 4/5 was administered to 47 stroke survivors with moderate/severe or severe UL motor impairment. Accelerometers were worn on participants' wrists for five days on average prior to the first assessment. Test-retest and inter-rater reliabilities were assessed using the intraclass correlation coefficient (ICC), internal consistency using Cronbach's α, and construct validity was tested with correlations with the accelerometry. The measurement error (SEM) and the minimal detectable change (MDC) were calculated.

RESULTS

MAL4/5-Brazil's test-retest reliability (AOU: ICC = 0.84; QOU: ICC = 0.90), inter-rater reliability (AOU: ICC = 0.83; QOU: ICC = 0.91), internal consistency (Cronbach's α = 0.91 and 0.95 for AOU and QOU scales, respectively), the SEM and MDC were 0.3 and 0.8 points for the AOU subscale and 0.2 and 0.5 points for the QOU subscale, respectively. The construct validity (AOU scale: r = 0.67; QOU scale: r = 0.76) was high.

CONCLUSION

Grade-4/5 Motor Activity Log-Brazil is a reliable and valid instrument for assessing the more-affected UL use of stroke patients with moderate/severe or severe UL motor impairments.

The Immediate Effects of Different Types of Augmented Feedback on Fast Walking Speed Performance and Intrinsic Motivation After Stroke

Objective

To examine the immediate effects of different types of augmented feedback on walking speed and intrinsic motivation post-stroke.

Design

A within-subjects repeated-measures design.

Setting

A university rehabilitation center.

Participants

Eighteen individuals with chronic stroke hemiparesis with a mean age of 55.67±13.63 years and median stroke onset of 36 (24, 81) months (N=18).

Interventions

Not applicable.

Primary outcome

Fast walking speed measured on a robotic treadmill for 13 meters without feedback and 13 meters with augmented feedback on each of the 3 experimental conditions: (1) without virtual reality (VR), (2) with a simple VR interface, and (3) with VR-exergame. Intrinsic motivation was measured using the Intrinsic Motivation Inventory (IMI).

Results

Although the differences were not statistically significant, fast-walking speed was higher in the augmented feedback without VR (0.86±0.44 m/s); simple VR interface (0.87±0.41 m/s); VR-exergame (0.87±0.44 m/s) conditions than in the fast-walking speed without feedback (0.81±0.40 m/s) condition. The type of feedback had a significant effect on intrinsic motivation (P=.04). The post hoc analysis revealed borderline significance on IMI-interest and enjoyment between the VR-exergame condition and the without-VR condition (P=.091).

Conclusion

Augmenting feedback affected the intrinsic motivation and enjoyment of adults with stroke asked to walk fast on a robotic treadmill. Additional studies with larger samples are warranted to examine the relations among these aspects of motivation and ambulation training outcomes.

Tactile Sensation Improves Following Motor Rehabilitation for Chronic Stroke: The VIGoROUS Randomized Controlled Trial

Background. Up to 85% of people with chronic stroke experience somatosensory impairment, which contributes to poor sensorimotor control and non-use of the affected limb. Neurophysiological mechanisms suggest motor rehabilitation may improve tactile sense post-stroke, however, somatosensory recovery has rarely been reported in controlled trials. Objective. To compare the effect of four upper limb motor rehabilitation programs on the recovery of tactile sensation in adults with chronic stroke. Methods. Adults with chronic stroke and mild or moderate upper extremity hemiparesis (n = 167) were enrolled in a multi-site randomized controlled trial. Participants completed three weeks of gaming therapy, gaming therapy with additional telerehabilition, Constraint-Induced Movement therapy, or traditional rehabilitation. Here, we report the results of a secondary outcome, tactile sensation, measured with monofilaments, before and after treatment, and 6 months later. Results. A mixed-effects general linear model revealed similar positive change in tactile sensitivity regardless of the type of training. On average, participants were able to detect a stimulus that was 32% and 33% less after training and at 6-month follow-up, respectively. One-third of participants experienced recategorization of their level of somatosensory impairment (e.g., regained protective sensation) following training. Poorer tactile sensation at baseline was associated with greater change. Conclusions. About one-third of individuals with mild/moderate chronic hemiparesis experience sustained improvements in tactile sensation following motor rehabilitation, regardless of the extent of tactile input in the rehabilitation program. Potential for sensory improvement is an additional motivator for those post-stroke. Characteristics of those who improve and mechanisms of improvement are important future questions. Clinicaltrials.gov NCT02631850.

Video game rehabilitation for outpatient stroke (VIGoROUS): A multi-site randomized controlled trial of in-home, self-managed, upper-extremity therapy

BACKGROUND

Integrating behavioral intervention into motor rehabilitation is essential for improving paretic arm use in daily life. Demands on therapist time limit adoption of behavioral programs like Constraint-Induced Movement (CI) therapy, however. Self-managed motor practice could free therapist time for behavioral intervention, but there remains insufficient evidence of efficacy for a self-management approach.

METHODS

This completed, parallel, five-site, pragmatic, single-blind trial established the comparative effectiveness of using in-home gaming self-management as a vehicle to redirect valuable therapist time towards behavioral intervention. Community-dwelling adults with post-stroke (>6 months) mild/moderate upper extremity hemiparesis were randomized to receive one of 4 different interventions over a 3-week period: 5 h of behaviorally-focused intervention plus gaming self-management (Self-Gaming), the same with additional behaviorally-focused telerehabilitation (Tele-Gaming), 5 h of Traditional motor-focused rehabilitation, or 35 h of CI therapy. Primary outcomes assessed everyday arm use (Motor Activity Log Quality of Movement, MAL) and motor speed/function (Wolf Motor Function Test, WMFT) immediately before treatment, immediately after treatment, and 6 months later. Intent-to-treat analyses were implemented with linear mixed-effects models on data gathered from March 15, 2016 to November 21, 2019. ClinicalTrials.gov, NCT02631850.

RESULTS

Of 193 enrolled participants, 167 began treatment and were analyzed, 150 (90%) completed treatment, and 115 (69%) completed follow-up. Tele-Gaming and Self-Gaming produced clinically meaningful MAL gains that were 1·0 points (95% CI 0·8 to 1·3) and 0·8 points (95% CI 0·5 to 1·0) larger than Traditional care, respectively. Self-Gaming was less effective than CI therapy (-0·4 points, 95% CI -0·6 to -0·2), whereas Tele-Gaming was not (-0·2 points, 95% CI -0·4 to 0·1). Six-month retention of MAL gains across all groups was 57%. All had similar clinically-meaningful WMFT gains; six-month retention of WMFT gains was 92%.

INTERPRETATION

Self-managed motor-gaming with behavioral telehealth visits has outcomes similar to in-clinic CI therapy. It addresses most access barriers, requiring just one-fifth as much therapist time that is redirected towards behavioral interventions that enhance the paretic arm's involvement in daily life.

FUNDING

PCORI, NIH.

A-136 The Transfer of Cognitive Training to Real-World Functioning: Results of our First Six Pilot Subjects at Six-Month Follow-Up

Objective

Currently, the majority of cognitive training research measures treatment efficacy using in-laboratory measures, with minimal focus on real-world treatment changes. This case series demonstrates the feasibility of transferring cognitive improvements from the laboratory into the everyday life setting.

Method

This case series includes 6 chronic post-stroke participants; mild to moderate cognitive impairment. The intervention combines cognitive training with behavioral techniques, known as the Transfer Package (TP). The TP involves components that target functionality on IADLs in the real-world. Performance on cognitively-based IADLs in the real world are measured pre-treatment, post, and 6-month follow-up. Measures of real-world ability are the: Canadian Occupational Performance Measure (COPM), Cognitive Task Activity Log (CTAL) and Inventory of Improved and New Abilities (INCA). In-laboratory measures included the D-KEFS and Timed IADL assessments.

Results

The real-world outcome measures used in this study were the COPM and two measures developed for this study, the CTAL and INCA. The mean change from pre to post on the COPM Performance Scale was 2.18 (SD = 1.33) and the mean change on the COPM Satisfaction Scale was 2.70 (SD = 1.27). The mean change on the CTAL was 1.96 (SD = 0.93). On the INCA, the mean number of improved real-world cognitive activities was 11.8 (SD = 4.9) and the mean number of new cognitive activities was 7.6 (SD = 3.9). Follow-up reported near-perfect retention on CTAL and continued improvement on the INCA. There were minimal changes on in-laboratory measures.

Conclusions

This case series provides a framework for achieving the transfer of cognitive training treatment effects in the real-world life situation by overcoming behavioral barriers to functioning.

Tele-rehabilitation of upper-extremity hemiparesis after stroke: Proof-of-concept randomized controlled trial of in-home Constraint-Induced Movement therapy

BACKGROUND

Although Constraint-Induced Movement therapy (CIMT) has been deemed efficacious for adults with persistent, mild-to-moderate, post-stroke upper-extremity hemiparesis, CIMT is not available on a widespread clinical basis. Impediments include its cost and travel to multiple therapy appointments. To overcome these barriers, we developed an automated, tele-health form of CIMT.

OBJECTIVE

Determine whether in-home, tele-health CIMT has outcomes as good as in-clinic, face-to-face CIMT in adults ≥1-year post-stroke with mild-to-moderate upper-extremity hemiparesis.

METHODS

Twenty-four stroke patients with chronic upper-arm extremity hemiparesis were randomly assigned to tele-health CIMT (Tele-AutoCITE) or in-lab CIMT. All received 35 hours of treatment. In the tele-health group, an automated, upper-extremity workstation with built-in sensors and video cameras was set-up in participants' homes. Internet-based audio-visual and data links permitted supervision of treatment by a trainer in the lab.

RESULTS

Ten patients in each group completed treatment. All twenty, on average, showed very large improvements immediately afterwards in everyday use of the more-affected arm (mean change on Motor Activity Log Arm Use scale = 2.5 points, p < 0.001, d' = 3.1). After one-year, a large improvement from baseline was still present (mean change = 1.8, p < 0.001, d' = 2). Post-treatment outcomes in the tele-health group were not inferior to those in the in-lab group. Neither were participants' perceptions of satisfaction with and difficulty of the interventions. Although everyday arm use was similar in the two groups after one-year (mean difference = -0.1, 95% CI = -1.3-1.0), reductions in the precision of the estimates of this parameter due to drop-out over follow-up did not permit ruling out that the tele-health group had an inferior long-term outcome.

CONCLUSIONS

This proof-of-concept study suggests that Tele-AutoCITE produces immediate benefits that are equivalent to those after in-lab CIMT in stroke survivors with chronic upper-arm extremity hemiparesis. Cost savings possible with this tele-health approach remain to be evaluated.

Acceptability of constraint induced movement therapy: influence of perceived difficulty and expected treatment outcome

BACKGROUND

Constraint-Induced Movement (CI) Therapy has evidence of efficaciously rehabilitating upper-extremity hemiparesis after stroke. Yet, it is not widely used in the United States. One barrier appears to be the perception of its difficulty among stroke care consumers, as reported by two published studies in which the participants had little or no apparent direct exposure to CI Therapy.

OBJECTIVES

Assess the perception of difficulty of CI Therapy by individuals with chronic stroke who have actually undergone CI Therapy.

METHODS

A secondary analysis was conducted of data from two randomized controlled trials of CI Therapy. Participants had chronic, mild-to-moderate upper-extremity hemiparesis after stroke. The Motor Activity Log and Wolf Motor Function Test were used to measure motor function of the more-affected arm. A Patient Opinion Survey assessed participants' perception of difficulty and satisfaction with treatment.

RESULTS

The participants (N = 40) showed large improvements in motor function of their more-affected arm after treatment, p's <001. CI Therapy was perceived to be of only moderate difficulty by participants before treatment (mean = 4.4 out of 7). Perception of its difficulty decreased afterward (mean = 3.7, p = .002). Moreover, participants were highly satisfied with their outcomes (mean = 6.3 out of 7). Satisfaction was positively related to the improvements in more-affected arm use in everyday life, ΔR² = .3, p < .001.

CONCLUSIONS

Chronic stroke survivors who have actually had CI Therapy perceive it to be of only moderate difficulty and are highly satisfied. Negative views about its acceptability warrant reconsideration.

Validity and reliability of the Turkish version of the pediatric motor activity log-revised (PMAL-R) for 2-17 year old children with hemiparetic cerebral palsy

PURPOSE

The Pediatric Upper-extremity Motor Activity Log-Revised (PMAL-R) is a structured interview that measures use of the more-affected arm in daily life in children with cerebral palsy (CP). This study investigated the concurrent validity and test-retest reliability of a Turkish version of the PMAL-R.

MATERIALS AND METHODS

The PMAL-R was translated and cross-culturally adapted to Turkish and administered to parents of eighty children with hemiplegic CP between 2-17 years. Its concurrent validity was examined by correlating scores on the PMAL-R How Well and How Often scales with ABILHAND-Kids scores. Fifty parents were re-interviewed after three weeks to establish test-retest reliability.

RESULTS

PMAL-R scores were strongly correlated with ABILHAND-Kids scores (How Well scale, r = 0.78, p < 0.001; How Often scale, r = 0.59, p < 0.001). PMAL-R test-retest reliability (Intraclass correlation; How Often = 0.98, How Well = 0.99) and internal consistency (Cronbach's α; How Often = 0.96, How Well = 0.97) were high.

CONCLUSIONS

This translation of the PMAL-R has good reliability and validity for measuring everyday use of the more-affected arm in Turkish children with hemiparesis due to CP between 2-17 years. Implications for rehabilitationAn instrument that evaluates real-world arm use in Turkish children with CP.Reliability and concurrent validity of the Turkish PMAL-R is established in 2-17-year old with upper-extremity hemiparesis.Systematic replication of the clinimetric properties of the English PMAL-R is demonstrated in a wider age range than previously, 2-17 years vs. 2-8 years.Reliability and concurrent validity of the PMAL-R is shown in both children with right and left hemiparesis.

Reproducibility of whole-brain temperature mapping and metabolite quantification using proton magnetic resonance spectroscopy

Assessing brain temperature can provide important information about disease processes (e.g., stroke, trauma) and therapeutic effects (e.g., cerebral hypothermia treatment). Whole-brain magnetic resonance spectroscopic imaging (WB-MRSI) is increasingly used to quantify brain metabolites across the entire brain. However, its feasibility and reliability for estimating brain temperature needs further validation. Therefore, the present study evaluates the reproducibility of WB-MRSI for temperature mapping as well as metabolite quantification across the whole brain in healthy volunteers. Ten healthy adults were scanned on three occasions 1 week apart. Brain temperature, along with four commonly assessed brain metabolites-total N-acetyl-aspartate (tNAA), total creatine (tCr), total choline (tCho) and myo-inositol (mI)-were measured from WB-MRSI data. Reproducibility was evaluated using the coefficient of variation (CV). The measured mean (range) of the intra-subject CVs was 0.9% (0.6%-1.6%) for brain temperature mapping, and 4.7% (2.5%-15.7%), 6.4% (2.4%-18.9%) and 14.2% (4.4%-52.6%) for tNAA, tCho and mI, respectively, with reference to tCr. Consistently larger variability was found when using H₂ O as the reference for metabolite quantifications: 7.8% (3.3%-17.8%), 7.8% (3.1%-18.0%), 9.8% (3.7%-31.0%) and 17.0% (5.9%-54.0%) for tNAA, tCr, tCho and mI, respectively. Further, the larger the brain region (indicated by a greater number of voxels within that region), the better the reproducibility for both temperature and metabolite estimates. Our results demonstrate good reproducibility of whole-brain temperature and metabolite measurements using the WB-MRSI technique.

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

BACKGROUND

Constraint-induced movement therapy (CIMT) is a method of physical rehabilitation that has demonstrated clinical efficacy in patients with chronic stroke, cerebral palsy, and multiple sclerosis (MS).

OBJECTIVE

This pilot randomized controlled trial tested whether CIMT can also induce increases in white matter integrity in patients with MS.

METHODS

Twenty adults with chronic hemiparetic MS were randomized to receive either CIMT or complementary and alternative medicine (CAM) treatment (reported in the first article of this pair). Structural white matter change was assessed by tract-based spatial statistics (TBSS); measures included fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD).

RESULTS

CIMT and CAM groups did not differ in pretreatment disability or expectancy to benefit. As noted in the companion paper, the motor activity log (MAL) improved more after CIMT than CAM ( P < .001); the within-group effect size for CIMT was 3.7 (large d' = 0.57), while for CAM it was just 0.7. Improvements in white matter integrity followed CIMT and were observed in the contralateral corpus callosum (FA, P < .05), ipsilateral superior occipital gyrus (AD, P < .05), ipsilateral superior temporal gyrus (FA, P < .05), and contralateral corticospinal tract (MD and RD, P < .05).

CONCLUSION

CIMT produced a very large improvement in real-world limb use and induced white matter changes in patients with hemiparetic MS when compared with CAM. The findings suggest in preliminary fashion that the adverse changes in white matter integrity induced by MS might be reversed by CIMT.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT01081275).

Phase II Randomized Controlled Trial of Constraint-Induced Movement Therapy in Multiple Sclerosis. Part 1: Effects on Real-World Function

BACKGROUND

Constraint-Induced Movement therapy (CIMT) has controlled evidence of efficacy for improving real-world paretic limb use in non-progressive physically disabling disorders (stroke, cerebral palsy).

OBJECTIVE

This study sought to determine whether this therapy can produce comparable results with a progressive disorder such as multiple sclerosis (MS). We conducted a preliminary phase II randomized controlled trial of CIMT versus a program of complementary and alternative medicine (CAM) treatments for persons with MS, to evaluate their effect on real-world disability.

METHODS

Twenty adults with hemiparetic MS underwent 35 hours of either CIMT or CAM over 10 consecutive weekdays. The primary clinical outcome was change from pretreatment on the Motor Activity Log (MAL).

RESULTS

The CIMT group improved more on the MAL (2.7 points, 95% confidence interval 2.2-3.2) than did the CAM group (0.5 points, 95% confidence interval -0.1 to 1.1; P < .001). These results did not change at 1-year follow-up, indicating long-term retention of functional benefit for CIMT. The treatments were well tolerated and without adverse events.

CONCLUSION

These results suggest that CIMT can increase real-world use of the more-affected arm in patients with MS for at least 1 year.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT01081275.

Relation of white matter hyperintensities and motor deficits in chronic stroke

BACKGROUND

Infarct size and location account for only a relatively small portion of post-stroke motor impairment, suggesting that other less obvious factors may be involved.

OBJECTIVE

Examine the relationship between white matter hyperintensity (WMH) load among other factors and upper extremity motor deficit in patients with mild to moderate chronic stroke.

METHODS

The magnetic resonance images of 28 patients were studied. WMH load was assessed as total WMH volume and WMH overlap with the corticospinal tract in the centrum semiovale. Hemiparetic arm function was measured using the Motor Activity Log (MAL) and Wolf Motor Function Test (WMFT).

RESULTS

Hierarchical multiple regression models found WMH volume predicted motor deficits in both real-world arm use (MAL;ΔR2 = 0.12, F(1, 22) = 4.73, p = 0.04) and in arm motor capacity as measured by a laboratory motor function test (WMFT;ΔR2 = 0.18, F(1, 22) = 6.32, p = 0.02) over and above age and lesion characteristics. However, these models accounted for less than half of the variance in post-stroke motor deficits.

CONCLUSION

The results suggest that WMH may be an important factor to consider in stroke-related upper extremity motor impairment. Nonetheless, the basis of the largest part of the post-stroke motor deficit remains unaccounted for by structural CNS factors. This component may be behavioral or learned, involving learned nonuse.

Comparison of reproducibility of single voxel spectroscopy and whole-brain magnetic resonance spectroscopy imaging at 3T

To date, single voxel spectroscopy (SVS) is the most commonly used MRS technique. SVS is relatively easy to use and provides automated and immediate access to the resulting spectra. However, it is also limited in spatial coverage. A new and very promising MRS technique allows for whole-brain MR spectroscopic imaging (WB-MRSI) with much improved spatial resolution. Establishing the reproducibility of data obtained using SVS and WB-MRSI is an important first step for using these techniques to evaluate longitudinal changes in metabolite concentration. The purpose of this study was to assess and directly compare the reproducibility of metabolite quantification at 3T using SVS and WB-MRSI in 'hand-knob' areas of motor cortices and hippocampi in healthy volunteers. Ten healthy adults were scanned using both SVS and WB-MRSI on three occasions one week apart. N-acetyl aspartate (NAA), creatine (Cr), choline (Cho) and myo-inositol (mI) were quantified using SVS and WB-MRSI with reference to both Cr and H₂ O. The reproducibility of each technique was evaluated using the coefficient of variation (CV), and the correspondence between the two techniques was assessed using Pearson correlation analysis. The measured mean (range) intra-subject CVs for SVS were 5.90 (2.65-10.66)% for metabolites (i.e. NAA, Cho, mI) relative to Cr, and 8.46 (4.21-21.07)% for metabolites (NAA, Cr, Cho, mI) relative to H₂ O. The mean (range) CVs for WB-MRSI were 7.56 (2.78-11.41)% for metabolites relative to Cr, and 7.79 (4.57-14.11)% for metabolites relative to H₂ O. Significant positive correlations were observed between metabolites quantified using SVS and WB-MRSI techniques when the Cr but not H₂ O reference was used. The results demonstrate that reproducibilities of SVS and WB-MRSI are similar for quantifying the four major metabolites (NAA, Cr, Cho, mI); both SVS and WB-MRSI exhibited good reproducibility. Our findings add reference information for choosing the appropriate ¹ H-MRS technique in future studies.

Rehabilitation of stroke patients with plegic hands: Randomized controlled trial of expanded Constraint-Induced Movement therapy

PURPOSE

To evaluate the efficacy of an expanded form of Constraint-Induced Movement Therapy (eCIMT) that renders CIMT, originally designed for treating mild-to-moderate upper-extremity hemiparesis, suitable for treating severe hemiparesis.

METHODS

Twenty-one adults ≥1 year after stroke with severe upper-extremity hemiparesis (with little or no capacity to make movements with the more-affected hand) were randomly assigned to eCIMT (n = 10), a placebo-control procedure (n = 4), or usual care (n = 7). The participants who received usual care were crossed over to eCIMT four months after enrollment. The CIMT protocol was altered to include fitting of orthotics and adaptive equipment, selected neurodevelopmental techniques, and electromyography-triggered functional electrical stimulation. Treatment was given for 15 consecutive weekdays with 6 hours of therapy scheduled daily for the immediate eCIMT group and 3.5 hours daily for the cross-over eCIMT group.

RESULTS

At post-treatment, the immediate eCIMT group showed significant gains relative to the combination of the control groups on the Grade-4/5 Motor Activity Log (MAL; mean = 1.5 points, P < 0.001, f = 4.2) and a convergent measure, the Canadian Occupational Performance Measure (COPM; mean = 2.3, P = 0.014, f = 1.1; f values ≥0.4 are considered large, on the COPM changes ≥2 are considered clinically meaningful). At 1-year follow-up, the MAL gains in the immediate eCIMT group were only 13% less than at post-treatment. The short and long-term outcomes of the crossover eCIMT group were similar to those of the immediate eCIMT group.

CONCLUSIONS

This small, randomized controlled trial (RCT) suggests that eCIMT produces a large, meaningful, and persistent improvement in everyday use of the more-affected arm in adults with severe upper-extremity hemiparesis long after stroke. These promising findings warrant confirmation by a large RCT.

Upper extremity motor training of a subject with initially motor complete chronic high tetraplegia using constraint-induced biofeedback therapy

Introduction

The purpose of this case study was to determine if a subject with chronic high tetraplegia (C3 AIS A) could learn to use an initially paralyzed upper extremity on the basis of training procedures alone.

Case presentation

Initially, an AIS examination revealed no purposive movement below the neck other than minimal shoulder movement. Training was carried out weekly over 39 months. Training began based on electromyographic biofeedback; the electrical activity of a muscle (biceps or triceps) was displayed visually on a computer monitor and the subject was encouraged to progressively increase the magnitude of the response in small increments on a trial-by-trial basis (i.e., shaping). When small, overt movements began to appear; these were, in turn, shaped so that their excursion progressively increased. Training then progressed to enable lifting the arm with the aid of the counterweight of a Swedish Help Arm. Mean movement excursions in the best session were: internal rotation 52.5 cm; external rotation 26.9 cm; shoulder extension 22.1 cm; shoulder flexion 15.2 cm; pronation/supination 120°; extension of index finger (D2) 2.5 cm. Movements were initially saltatory, becoming smoother over time. With the Swedish Help Arm, the subject was able to lift her hand an average of 24.3 cm in the best session with 0.7 kg counterweight acting at the wrist (1.9 J of work).

Discussion

Results suggest in preliminary fashion the effectiveness of this approach for improving upper extremity function after motor complete high tetraplegia. Thus, future studies are warranted. Possible mechanisms are discussed.

Relation of depressive symptoms to outcome of CI movement therapy after stroke

OBJECTIVE

Depressive symptoms after stroke have been associated with negative outcomes, including poorer functional ability, less efficient use of rehabilitation services, decreased quality of life, and increased mortality. It has been anecdotally noted that depressive symptoms do not limit motor recovery in patients who undergo Constraint-Induced Movement Therapy (CIMT), an efficacious intervention for chronic poststroke hemiparesis. Here we analyze depressive symptom and motor scores from 40 participants who received CIMT in 2 previously published studies.

METHOD

Adults more than 1-year after stroke with mild to moderate upper-extremity hemiparesis completed the Zung Self-Rating Depression Scale and Motor Activity Log (MAL) before and after CIMT. We used regression analysis to test whether Zung scores predicted response to CIMT and paired t tests to test whether depressive symptoms changed from pre- to posttreatment.

RESULTS

Pretreatment Zung score did not predict outcome on the MAL Arm Use scale, ΔR2 (1, 30) = 0.004, p = .19, after controlling for pretreatment MAL scores. Additionally, participants had a small but statistically significant decrease in Zung score, t(39) = 3.0, p = .005, mean change = -3.6.

CONCLUSION

These results suggest that depressive symptoms do not significantly limit motor recovery in patients treated with CIMT for chronic poststroke hemiparesis. Additionally, treatment with CIMT may improve depressive symptoms. (PsycINFO Database Record

Video Game Rehabilitation for Outpatient Stroke (VIGoROUS): protocol for a multi-center comparative effectiveness trial of in-home gamified constraint-induced movement therapy for rehabilitation of chronic upper extremity hemiparesis

Background

Constraint-Induced Movement therapy (CI therapy) is shown to reduce disability, increase use of the more affected arm/hand, and promote brain plasticity for individuals with upper extremity hemiparesis post-stroke. Randomized controlled trials consistently demonstrate that CI therapy is superior to other rehabilitation paradigms, yet it is available to only a small minority of the estimated 1.2 million chronic stroke survivors with upper extremity disability. The current study aims to establish the comparative effectiveness of a novel, patient-centered approach to rehabilitation utilizing newly developed, inexpensive, and commercially available gaming technology to disseminate CI therapy to underserved individuals. Video game delivery of CI therapy will be compared against traditional clinic-based CI therapy and standard upper extremity rehabilitation. Additionally, individual factors that differentially influence response to one treatment versus another will be examined.

Methods

This protocol outlines a multi-site, randomized controlled trial with parallel group design. Two hundred twenty four adults with chronic hemiparesis post-stroke will be recruited at four sites. Participants are randomized to one of four study groups: (1) traditional clinic-based CI therapy, (2) therapist-as-consultant video game CI therapy, (3) therapist-as-consultant video game CI therapy with additional therapist contact via telerehabilitation/video consultation, and (4) standard upper extremity rehabilitation. After 6-month follow-up, individuals assigned to the standard upper extremity rehabilitation condition crossover to stand-alone video game CI therapy preceded by a therapist consultation. All interventions are delivered over a period of three weeks. Primary outcome measures include motor improvement as measured by the Wolf Motor Function Test (WMFT), quality of arm use for daily activities as measured by Motor Activity Log (MAL), and quality of life as measured by the Quality of Life in Neurological Disorders (NeuroQOL).

Discussion

This multi-site RCT is designed to determine comparative effectiveness of in-home technology-based delivery of CI therapy versus standard upper extremity rehabilitation and in-clinic CI therapy. The study design also enables evaluation of the effect of therapist contact time on treatment outcomes within a therapist-as-consultant model of gaming and technology-based rehabilitation.

Trial registration

Clinicaltrials.gov, NCT02631850.

Assessing the Amount of Spontaneous Real-World Spoken Language in Aphasia: Validation of Two Methods

PURPOSE

The purpose of this article is to present the results of a study evaluating the psychometric properties of 2 new measures that exclusively assess the amount of real-world spoken language in patients with aphasia.

METHOD

Forty individuals with aphasia were evaluated on several measures of spoken language in real-world settings. The Verbal Activity Log (VAL; Johnson et al., 2014) has participants, aided by caregivers, indicate current amount and quality of real-world spoken language compared with before stroke. In addition, digital voice recorders objectively measured the amount of real-world spoken language. The Communicative Effectiveness Index (Lomas et al., 1989), a previously validated measure of functional communication, was used as a comparison measure. Nineteen participants received follow-up assessment ≥ 3 weeks later.

RESULTS

Validity was supported by Pearson correlations between spoken language recordings and the VAL, r(38) = .70, p < .001. Likewise, correlation with the Communicative Effectiveness Index was strong, r(38) = .73, p < .001. Test-retest reliability for both VAL and audio recording was high, with intraclass correlations ≥ .96 and .90, respectively.

CONCLUSIONS

These results present preliminary evidence for the reliability and validity of the VAL and spoken language recording for assessment of the amount of real-world spoken language in aphasia. As a simple patient-reported outcome, the VAL may assist diverse therapies for aphasia.

Translation and cross cultural adaptation of the Pediatric Motor Activity Log-Revised scale

ABSTRACT The standardized instrument developed to assess the use of the affected upper limb in children with cerebral palsy (CP) is the Pediatric Motor Activity Log Revised (PMAL-R). Objectives To translate PMAL-R and adapt for the Brazilian culture; analyze the reliability and the internal consistency of the Brazilian version. Method Translation of PMAL-R to the Portuguese-Brazil and back translation. The back-translated version was revised by the authors of the scale. The final version was administered to a sample of 24 patients with spastic hemiparesis CP between 2–8 years. Results The reliability intra and inter-rater were suitable (how often = 0.97 and 0.98, how well = 0.98 and 0.99 respectively) and so the internal consistency (0.98). Conclusion The Brazilian version of PMAL-R has adequate internal consistency, reliability intra and inter raters and can be used to assess the spontaneous use of the upper limb of children with CP type spastic hemiparesis, aged 2–8 years.

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.

Motor recovery from constraint induced movement therapy is not constrained by extent of tissue damage following stroke

PURPOSE

The purpose of this study was to delineate the relationship between several types of T1-weighted MRI pathology and motor rehabilitation potential following Constraint Induced Movement therapy (CI therapy) in chronic stroke.

METHODS

Stepwise regression was employed (n = 80) to identify predictors of motor recovery (prior to therapy) and of response to Constraint-Induced Movement therapy [measured via the Wolf Motor Function Test (WMFT) and Motor Activity Log (MAL)] from among the following: age, side of motor deficit, chronicity, gender, lesion volume, peri-infarct damage volume, white matter hypointensity volume, ventricular asymmetry, and lesion location.

RESULTS

Although extent of total stroke damage weakly correlated with poorer performance on the WMFT prior to therapy, this relationship was mediated by the location of the damage. No metric of tissue damage examined here was associated with real-world arm use at baseline (MAL at pre-treatment) or with CI therapy-induced improvement in either best motor performance upon request (WMFT) or spontaneous arm use for daily activities (MAL).

CONCLUSIONS

In sum, the extent of brain tissue damage of any type examined here poorly predicted motor function and response to rehabilitation in chronic stroke.

Everyday movement and use of the arms: Relationship in children with hemiparesis differs from adults

PURPOSE

In adults with hemiparesis amount of movement of the more-affected arm is related to its amount of use in daily life. In children, little is known about everyday arm use. This report examines the relationships between everyday movement of the more-affected arm and its (a) everyday use and (b) motor capacity in children with hemiparesis.

METHODS

Participants were 28 children with a wide range of upper-extremity hemiparesis subsequent to cerebral palsy due to pre- or peri-natal stroke. Everyday movement of the more-affected arm was assessed by putting accelerometers on the children's forearms for three days. Everyday use of that arm and its motor capacity were assessed with the Pediatric Motor Activity Log-Revised and Pediatric Arm Function Test, respectively.

RESULTS

Intensity of everyday movement of the more-affected arm was correlated with its motor capacity (rs ≥ 0.52, ps ≤ 0.003). However, everyday movement of that arm was not correlated with its everyday use (rs ≤ 0.30, ps ≥ $ 0.126).

CONCLUSIONS

In children with upper-extremity hemiparesis who meet the study intake criteria amount of movement of the more-affected arm in daily life is not related to its amount to use, suggesting that children differ from adults in this respect.

Implications of CI therapy for visual deficit training

We address here the question of whether the techniques of Constraint Induced (CI) therapy, a family of treatments that has been employed in the rehabilitation of movement and language after brain damage might apply to the rehabilitation of such visual deficits as unilateral spatial neglect and visual field deficits. CI therapy has been used successfully for the upper and lower extremities after chronic stroke, cerebral palsy (CP), multiple sclerosis (MS), other central nervous system (CNS) degenerative conditions, resection of motor areas of the brain, focal hand dystonia, and aphasia. Treatments making use of similar methods have proven efficacious for amblyopia. The CI therapy approach consists of four major components: intensive training, training by shaping, a "transfer package" to facilitate the transfer of gains from the treatment setting to everyday activities, and strong discouragement of compensatory strategies. CI therapy is said to be effective because it overcomes learned nonuse, a learned inhibition of movement that follows injury to the CNS. In addition, CI therapy produces substantial increases in the gray matter of motor areas on both sides of the brain. We propose here that these mechanisms are examples of more general processes: learned nonuse being considered parallel to sensory nonuse following damage to sensory areas of the brain, with both having in common diminished neural connections (DNCs) in the nervous system as an underlying mechanism. CI therapy would achieve its therapeutic effect by strengthening the DNCs. Use-dependent cortical reorganization is considered to be an example of the more general neuroplastic mechanism of brain structure repurposing. If the mechanisms involved in these broader categories are involved in each of the deficits being considered, then it may be the principles underlying efficacious treatment in each case may be similar. The lessons learned during CI therapy research might then prove useful for the treatment of visual deficits.

The functional significance of cortical reorganization and the parallel development of CI therapy

For the nineteenth and the better part of the twentieth centuries two correlative beliefs were strongly held by almost all neuroscientists and practitioners in the field of neurorehabilitation. The first was that after maturity the adult CNS was hardwired and fixed, and second that in the chronic phase after CNS injury no substantial recovery of function could take place no matter what intervention was employed. However, in the last part of the twentieth century evidence began to accumulate that neither belief was correct. First, in the 1960s and 1970s, in research with primates given a surgical abolition of somatic sensation from a single forelimb, which rendered the extremity useless, it was found that behavioral techniques could convert the limb into an extremity that could be used extensively. Beginning in the late 1980s, the techniques employed with deafferented monkeys were translated into a rehabilitation treatment, termed Constraint Induced Movement therapy or CI therapy, for substantially improving the motor deficit in humans of the upper and lower extremities in the chronic phase after stroke. CI therapy has been applied successfully to other types of damage to the CNS such as traumatic brain injury, cerebral palsy, multiple sclerosis, and spinal cord injury, and it has also been used to improve function in focal hand dystonia and for aphasia after stroke. As this work was proceeding, it was being shown during the 1980s and 1990s that sustained modulation of afferent input could alter the structure of the CNS and that this topographic reorganization could have relevance to the function of the individual. The alteration in these once fundamental beliefs has given rise to important recent developments in neuroscience and neurorehabilitation and holds promise for further increasing our understanding of CNS function and extending the boundaries of what is possible in neurorehabilitation.

An enhanced protocol for constraint-induced aphasia therapy II: a case series

PURPOSE

The initial version of Constraint-Induced Aphasia Therapy (CIAT I) consisted of a single exercise. This study sought to evaluate the feasibility for future trials of an expanded and restructured protocol designed to increase the efficacy of CIAT I.

METHOD

The subjects were 4 native English speakers with chronic stroke who exhibited characteristics of moderate Broca's aphasia. Treatment was carried out for 3.5 hr/day for 15 consecutive weekdays. It consisted of 3 components: (a) intensive training by a behavioral method termed shaping using a number of expressive language exercises in addition to the single original language card game, (b) strong discouragement of attempts to use gesture or other nonverbal means of communication, and (c) a transfer package of behavioral techniques to promote transfer of treatment gains from the laboratory to real-life situations.

RESULTS

Participation in speech in the life situation improved significantly after treatment. The effect sizes (i.e., d') in this domain were ≥ 2.2; d' values ≥ 0.8 are considered large. Improvement in language ability on a laboratory test, the Western Aphasia Battery-Revised (Kertesz, 2006), did not achieve statistical significance, although the effect size was large--that is, 1.3 (13.1 points).

CONCLUSION

These pilot results suggest in preliminary fashion that CIAT II may produce significant improvements in everyday speech.

Diffusion tensor imaging study of the response to constraint-induced movement therapy of children with hemiparetic cerebral palsy and adults with chronic stroke

OBJECTIVE

To investigate the relationship of white matter integrity and path of the corticospinal tract (CST) on arm function before and after constraint-induced (CI) movement therapy in children with hemiparetic cerebral palsy (CP) and adults with chronic stroke.

DESIGN

Study 1 used a multiple-baseline pre-post design. Study 2 was a randomized controlled trial.

SETTING

Outpatient rehabilitation laboratory.

PARTICIPANTS

Study 1 included children with hemiparetic CP (n=10; mean age ± SD, 3.2±1.7y). Study 2 included adults with chronic stroke (n=26; mean age ± SD, 65.4±13.6y) who received either CI therapy or a comparison therapy.

INTERVENTIONS

Children in study 1 received CI therapy for 3.5h/d for 15 consecutive weekdays. Adults in study 2 received either CI therapy or a comparison therapy for 3.5h/d for 10 consecutive weekdays.

MAIN OUTCOME MEASURES

Diffusion tensor imaging was performed to quantify white matter integrity. Motor ability was assessed in children using the Pediatric Motor Activity Log-Revised and Pediatric Arm Function Test, and in adults with the Motor Activity Log and Wolf Motor Function Test.

RESULTS

Participants in both studies improved in real-world arm function and motor capacity. Children and adults with disrupted/displaced CSTs and children with reduced fractional anisotropy values were worse on pretreatment tests of motor function than participants with unaltered CSTs. However, neither integrity (fractional anisotropy) nor distorted or disrupted path of the CST affected motor improvement after treatment.

CONCLUSIONS

Participants who had reduced integrity, displacement, or interruption of their CST performed worse on pretreatment motor testing. However, this had no effect on their ability to benefit from CI therapy. The results for children and adults are consistent with one another.

Promoting physical activity: fertile ground for rehabilitation psychology

Comments on the article by Schmacher et al. (see record 2013-06066-009). Readers of Rehabilitation Psychology might be surprised, or maybe even alarmed, to find an article on promoting physical activity in able-bodied people between the covers of their latest issue. This commentary contends that this area of research and practice might be one into which rehabilitation psychologists want to venture. Schumacher and coworkers describe a field test (N = 216) of a token system for reinforcing stair taking. The setting was an eight-story office building housing a single company in a midsized city in the southeastern United States. Schumacher et al. report an increase from 39 stair transactions per day by all study participants in the 6 months before implementation of the intervention to 301 transactions in the 6 months after the implementation of the intervention, which represents a 600% increase. The cost of the intervention was only $17 per person. Although replication of these results in a study with additional sources of control would increase confidence in the validity of the findings, the size of the gains in stair taking, the number of participants in the study, the length of the baseline and implementation periods, and the objective measurement of outcome warrant attention.

Structural neuroplastic change after constraint-induced movement therapy in children with cerebral palsy

Research from the present laboratory with adult stroke patients showed that structural neuroplastic changes are correlated with clinical improvements due to constraint-induced movement (CI) therapy. This pilot study evaluated whether comparable changes occur in children receiving CI therapy. Ten children (6 boys) with congenital hemiparesis (mean age: 3 years, 3 months) underwent MRI scans 3 weeks before, immediately before, and immediately after receiving 3 weeks of CI therapy. Longitudinal voxel-based morphometry was performed on MRI scans to determine gray matter change. In addition, the Pediatric Motor Activity Log-Revised was administered at these time points to assess arm use in daily life before and after treatment. Children exhibited large improvements after CI therapy in spontaneous use of the more-affected arm (P < .001, d' = 3.24). A significant increase in gray matter volume occurred in the sensorimotor cortex contralateral to the more-affected arm (P = .04); there was a trend for these changes to be correlated with motor improvement (r = 0.63, P = .063). Trends were also observed for increases in gray matter volume in the ipsilateral motor cortex (P = .055) and contralateral hippocampus (P = .1). No significant gray matter change was seen during the 3 weeks before treatment. These findings suggest that CI therapy produces gray matter increases in the developing nervous system and provide additional evidence that CI therapy is associated with structural remodeling of the human brain while producing motor improvement in patients with disabling central nervous system diseases.

Method for enhancing real-world use of a more affected arm in chronic stroke: transfer package of constraint-induced movement therapy

BACKGROUND AND PURPOSE

Constraint-induced movement therapy is a set of treatments for rehabilitating motor function after central nervous system damage. We assessed the roles of its 2 main components.

METHODS

A 2 × 2 factorial components analysis with random assignment was conducted. The 2 factors were type of training and presence/absence of a set of techniques to facilitate transfer of therapeutic gains from the laboratory to the life situation (Transfer Package; TP). Participants (N=40) were outpatients ≥ 1-year after stroke with hemiparesis. The different treatments, which in each case targeted the more affected arm, lasted 3.5 hours/d for 10 weekdays. Spontaneous use of the more affected arm in daily life and maximum motor capacity of that arm in the laboratory were assessed with the Motor Activity Log and the Wolf Motor Function Test, respectively.

RESULTS

Use of the TP, regardless of the type of training received, resulted in Motor Activity Log gains that were 2.4 times as large as the gains in its absence (P<0.01). These clinical results parallel previously reported effects of the TP on neuroplastic change. Both the TP and training by shaping enhanced gains on the Wolf Motor Function Test (P<0.05). The Motor Activity Log gains were retained without loss 1 year after treatment. An additional substudy (N=10) showed that a single component of the TP, weekly telephone contact with participants for 1 month after treatment, doubled Motor Activity Log scores at 6-month follow-up.

CONCLUSIONS

The TP is a method for enhancing both spontaneous use of a more affected arm after chronic stroke and its maximum motor capacity. Shaping enhances the latter.

Pediatric Arm Function Test: reliability and validity for assessing more-affected arm motor capacity in children with cerebral palsy

OBJECTIVE

Although there are several validated upper-extremity measures in young children with cerebral palsy, none of these primarily assess the capacity to carry out actions and tasks with the more-affected arm. To address this need, we developed the Pediatric Arm Function Test (PAFT), which involves the behavioral observation of how children use their more-affected arm during structured play in a laboratory or clinic. This article evaluates the reliability and validity of the PAFT Functional Ability scale.

DESIGN

In study 1, a total of 20 children between 2 and 8 yrs old with a wide range of upper-extremity hemiparesis caused by cerebral palsy completed the PAFT on two occasions separated by 3 wks. In study 2, a total of 41 children between 2 and 6 yrs old with similar characteristics completed the PAFT and received a grade reflecting the severity of more-affected arm motor impairment.

RESULTS

In study 1, the PAFT test-retest reliability correlation coefficient was 0.74. In study 2, convergent validity was supported by a strong inverse correlation (r = -0.6, P < 0.001) between the PAFT scores and the grade of impairment.

CONCLUSIONS

The PAFT Functional Ability scale is a reliable and valid measure of more-affected arm motor capacity in children between 2 and 6 yrs old with cerebral palsy. It can be used to measure upper-extremity neurorehabilitation outcome.

The pediatric motor activity log-revised: assessing real-world arm use in children with cerebral palsy

OBJECTIVE

Widely accepted models of disability suggest that actual use of an impaired upper extremity in everyday life frequently deviates from its motor capacity, as measured by laboratory tests. Yet, direct measures of real-world use of an impaired upper extremity are rare in pediatric neurorehabilitation. This paper examines how well the Pediatric Motor Activity Log-Revised (PMAL-R) measures this parameter, when the PMAL-R is administered as a structured interview as originally designed.

DESIGN

Parents of 60 children between 2 and 8 years of age with upper-extremity hemiparesis due to cerebral palsy completed the PMAL-R twice. Additionally, the children were videotaped during play structured to elicit spontaneous arm use. More-affected arm use was scored by masked raters; it was thought to reflect everyday activity since no cues were given about which arm to employ. Testing sessions were separated by 3 weeks, during which 29 children received upper-extremity rehabilitation and 31 did not.

RESULTS

The PMAL-R had high internal consistency (Cronbach's alpha = .93) and test-retest reliability (r = .89). Convergent validity was supported by a strong correlation between changes in PMAL-R scores and more-affected arm use during play, r(53) = .5, p < .001.

CONCLUSIONS

The PMAL-R interview is a reliable and valid measure of upper-extremity pediatric neurorehabilitation outcome.

Constraint-induced movement therapy for the lower extremities in multiple sclerosis: case series with 4-year follow-up

OBJECTIVE

To evaluate in a preliminary manner the feasibility, safety, and efficacy of Constraint-Induced Movement therapy (CIMT) of persons with impaired lower extremity use from multiple sclerosis (MS).

DESIGN

Clinical trial with periodic follow-up for up to 4 years.

SETTING

University-based rehabilitation research laboratory.

PARTICIPANTS

A referred sample of ambulatory adults with chronic MS (N=4) with at least moderate loss of lower extremity use (average item score ≤6.5/10 on the functional performance measure of the Lower Extremity Motor Activity Log [LE-MAL]).

INTERVENTIONS

CIMT was administered for 52.5 hours over 3 consecutive weeks (15 consecutive weekdays) to each patient.

MAIN OUTCOME MEASURES

The primary outcome was the LE-MAL score at posttreatment. Secondary outcomes were posttreatment scores on laboratory assessments of maximal lower extremity movement ability.

RESULTS

All the patients improved substantially at posttreatment on the LE-MAL, with smaller improvements on the laboratory motor measures. Scores on the LE-MAL continued to improve for 6 months afterward. By 1 year, patients remained on average at posttreatment levels. At 4 years, half of the patients remained above pretreatment levels. There were no adverse events, and fatigue ratings were not significantly changed by the end of treatment.

CONCLUSIONS

This initial trial of lower extremity CIMT for MS indicates that the treatment can be safely administered, is well tolerated, and produces substantially improved real-world lower extremity use for as long as 4 years afterward. Further trials are needed to determine the consistency of these findings.

Constraint-induced movement therapy combined with conventional neurorehabilitation techniques in chronic stroke patients with plegic hands: a case series

OBJECTIVE

To determine whether the combination of Constraint-Induced Movement Therapy (CIMT) and conventional rehabilitation techniques can produce meaningful motor improvement in chronic stroke patients with initially fisted hands.

DESIGN

Case series.

SETTING

University hospital outpatient laboratory.

PARTICIPANTS

Consecutive sample (N=6) >1 year poststroke with plegic hands.

INTERVENTIONS

Treatment consisted of an initial period of 3 weeks (phase A) when adaptive equipment in the home, orthotics, and splints were employed to improve ability to engage in activities of daily living. This was continued in phase B, when CIMT and selected neurodevelopmental treatment techniques were added.

MAIN OUTCOME MEASURES

Motor Activity Log (MAL), accelerometry, Fugl-Meyer Motor Assessment (F-M).

RESULTS

Patients exhibited a large improvement in spontaneous real-world use of the more-affected arm (mean lower-functioning MAL change=1.3±0.4 points; P<.001; d'=3.0) and a similar pattern of increase in an objective measure of real-world more-affected arm movement (mean change in ratio of more- to less-affected arm accelerometer recordings=0.12±0.1 points; P=.016; d'=1.2). A large improvement in motor status was also recorded (mean F-M change=5.3±3.3 points; P=.005; d'=1.6).

CONCLUSIONS

The findings of this pilot study suggest that stroke patients with plegic hands can benefit from CIMT combined with some conventional rehabilitation techniques, even long after brain injury. More research is warranted.

Sensor-enabled RFID system for monitoring arm activity: reliability and validity

After stroke, capacity to complete tasks in the treatment setting with the more-affected arm is an unreliable index of actual use of that extremity in daily life. Available objective methods for monitoring real-world arm use rely on placing movement sensors on patients. These methods provide information on amount but not type of arm activity, e.g., functional versus nonfunctional movement. This paper presents an approach that places sensors on patients and household objects, overcoming this limitation. An accelerometer and the transmitter component of a radio-frequency proximity sensor are attached to objects; the receiver component is attached to the arm of interest. The receiver triggers an on-board radio-frequency identification tag to signal proximity when that arm is within 23 cm of an instrumented object. In benchmark testing, this system detected perfectly which arm was used to move the target object on 200 trials. In a laboratory study with 35 undergraduates, increasing the amount of time target objects were moved with the arm of interest resulted in a corresponding increase in system output . Moreover, measurement error was low ( ≤ 2.5%). The results support this system's reliability and validity in individuals with unimpaired movement; testing is now warranted in stroke patients.

A telerehabilitation platform for home-based automated therapy of arm function

Constraint-Induced Movement Therapy (CI therapy) has been shown to be an effective approach for improving arm function in stroke survivors with mild to severe hemiparesis. Given the time-intensive nature of the intervention, and the inherent costs and travel required to receive in-clinic treatment, the accessibility and availability of CI therapy is limited. To facilitate home-based CI therapy, a telerehabilitation platform has been developed. It consists of a table-top workstation configured with a range of physical task devices (e.g. pegboard, object flipping, threading, vertical reaching). A desktop PC is used to acquire data from sensors embedded in the task devices; display visual instructions, stimuli, and feedback to the patient during tasks; and provide videoconferencing and remote connection capabilities so the therapist can interact with and monitor the patient during at-home therapy sessions. This system has potential to greatly expand access to CI therapy and make it a more realistic option for a larger number of stroke survivors with upper extremity impairment.

Atrophy of spared gray matter tissue predicts poorer motor recovery and rehabilitation response in chronic stroke

BACKGROUND AND PURPOSE

Although the motor deficit after stroke is clearly due to the structural brain damage that has been sustained, this relationship is attenuated from the acute to chronic phases. We investigated the possibility that motor impairment and response to constraint-induced movement therapy in patients with chronic stroke may relate more strongly to the structural integrity of brain structures remote from the lesion than to measures of overt tissue damage.

METHODS

Voxel-based morphometry analysis was performed on MRI scans from 80 patients with chronic stroke to investigate whether variations in gray matter density were correlated with extent of residual motor impairment or with constraint-induced movement therapy-induced motor recovery.

RESULTS

Decreased gray matter density in noninfarcted motor regions was significantly correlated with magnitude of residual motor deficit. In addition, reduced gray matter density in multiple remote brain regions predicted a lesser extent of motor improvement from constraint-induced movement therapy.

CONCLUSIONS

Atrophy in seemingly healthy parts of the brain that are distant from the infarct accounts for at least a portion of the sustained motor deficit in chronic stroke.

Treatment of congenital hemiparesis with pediatric constraint-induced movement therapy

To determine efficacy of pediatric Constraint-Induced Movement therapy, 20 children with congenital hemiparesis (ages 2 to 6 years) were randomly assigned to receive the treatment or usual care. Controls crossed over to the therapy after 6 months. Children receiving the therapy first exhibited emergence of more new classes of motor patterns and skills (eg, crawling, thumb-forefinger prehension; 6.4 vs 0.02, P < .0001, effect size d = 1.3), and demonstrated significant gains in spontaneous use of the more affected arm at home (2.2 vs 0.1, P < .0001, d = 3.8) and in a laboratory motor function test. Depending on the measure, benefits were maintained (range, no loss to 68% retention over 6 months). When controls crossed over to the therapy, they exhibited improvements as great as or greater than those receiving therapy first. Thus, Constraint-Induced Movement therapy appears to be efficacious for young children with hemiparesis consequent to congenital stroke.

Sensor-enabled RFID system for monitoring arm activity in daily life

After stroke, capacity to carry out tasks in the treatment setting with the more-affected arm is a poor index of actual use of that extremity in daily life. However, objective methods currently available for monitoring real-world upper-extremity use only provide information on amount of activity. These methods, which rely on movement sensors worn by patients, do not provide information about type of activity (e.g., functional vs. nonfunctional movement). The benchmark testing reported here evaluated an approach that involves placing sensors on patients and objects. An accelerometer and the transmitter component of a prototype radio frequency proximity sensor were attached to household objects. The receiver component was placed on the experimenter's right arm. This device triggered an on-board radio frequency identification tag to signal proximity when that arm was within 23 cm of the objects. The system detected > 99% of 6 cm or greater movements of objects. When handling of objects by the right or left arm was determined randomly, 100% of right arm trials were detected. No signals were recorded when objects were at rest or moved by the left arm. Testing of this approach, which monitors manipulation of objects (i.e., functional movement), is now warranted in stroke patients.

The EXCITE stroke trial: comparing early and delayed constraint-induced movement therapy

BACKGROUND AND PURPOSE

Although constraint-induced movement therapy (CIMT) has been shown to improve upper extremity function in stroke survivors at both early and late stages after stroke, the comparison between participants within the same cohort but receiving the intervention at different time points has not been undertaken. Therefore, the purpose of this study was to compare functional improvements between stroke participants randomized to receive this intervention within 3 to 9 months (early group) to participants randomized on recruitment to receive the identical intervention 15 to 21 months after stroke (delayed group).

METHODS

Two weeks of CIMT was delivered to participants immediately after randomization (early group) or 1 year later (delayed group). Evaluators blinded to group designation administered primary (Wolf Motor Function Test, Motor Activity Log) and secondary (Stroke Impact Scale) outcome measures among the 106 early participants and 86 delayed participants before delivery of CIMT, 2 weeks thereafter, and 4, 8, and 12 months later.

RESULTS

Although both groups showed significant improvements from pretreatment to 12 months after treatment, the earlier CIMT group showed greater improvement than the delayed CIMT group in Wolf Motor Function Test Performance Time and the Motor Activity Log (P<0.0001), as well as in Stroke Impact Scale Hand and Activities domains (P<0.0009 and 0.0214, respectively). Early and delayed group comparison of scores on these measures 24 months after enrollment showed no statistically significant differences between groups.

CONCLUSIONS

CIMT can be delivered to eligible patients 3 to 9 months or 15 to 21 months after stroke. Both patient groups achieved approximately the same level of significant arm motor function 24 months after enrollment. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00057018.

Measurement structure of the Wolf Motor Function Test: implications for motor control theory

BACKGROUND

Tools chosen to measure poststroke upper-extremity rehabilitation outcomes must match contemporary theoretical expectations of motor deficit and recovery because an assessment's theoretical underpinning forms the conceptual basis for interpreting its score.

OBJECTIVE

The purpose of this study was to investigate the theoretical framework of the Wolf Motor Function Test (WMFT) by (1) determining whether all items measured a single underlying trait and (2) examining the congruency between the hypothesized and the empirically determined item difficulty orders.

METHODS

Confirmatory factor analysis (CFA) and Rasch analysis were applied to existing WMFT Functional Ability Rating Scale data from 189 participants in the EXCITE (Extremity Constraint-Induced Therapy Evaluation) trial. Fit of a 1-factor CFA model (all items) was compared with the fit of a 2-factor CFA model (factors defined according to item object-grasp requirements) with fit indices, model comparison test, and interfactor correlations.

RESULTS

One item was missing sufficient data and therefore removed from analysis. CFA fit indices and the model-comparison test suggested that both models fit equally well. The 2-factor model yielded a strong interfactor correlation, and 13 of 14 items fit the Rasch model. The Rasch item difficulty order was consistent with the hypothesized item difficulty order.

CONCLUSION

The results suggest that WMFT items measure a single construct. Furthermore, the results depict an item difficulty hierarchy that may advance the theoretical discussion of the person ability versus task difficulty interaction during stroke recovery.