[ARTICLE] Counteracting learned non-use in chronic stroke patients with reinforcement-induced movement therapy – Full Text

Abstract

Background

After stroke, patients who suffer from hemiparesis tend to suppress the use of the affected extremity, a condition called learned non-use. Consequently, the lack of training may lead to the progressive deterioration of motor function. Although Constraint-Induced Movement Therapies (CIMT) have shown to be effective in treating this condition, the method presents several limitations, and the high intensity of its protocols severely compromises its adherence. We propose a novel rehabilitation approach called Reinforcement-Induced Movement Therapy (RIMT), which proposes to restore motor function through maximizing arm use. This is achieved by exposing the patient to amplified goal-oriented movements in VR that match the intended actions of the patient. We hypothesize that through this method we can increase the patients self-efficacy, reverse learned non-use, and induce long-term motor improvements.

Methods

We conducted a randomized, double-blind, longitudinal clinical study with 18 chronic stroke patients. Patients performed 30 minutes of daily VR-based training during six weeks. During training, the experimental group experienced goal-oriented movement amplification in VR. The control group followed the same training protocol but without movement amplification. Evaluators blinded to group designation performed clinical measurements at the beginning, at the end of the training and at 12-weeks follow-up. We used the Fugl-Meyer Assessment for the upper extremities (UE-FM) (Sanford et al., Phys Ther 73:447–454, 1993) as a primary outcome measurement of motor recovery. Secondary outcome measurements included the Chedoke Arm and Hand Activity Inventory (CAHAI-7) (Barreca et al., Arch Phys Med Rehabil 6:1616–1622, 2005) for measuring functional motor gains in the performance of Activities of Daily Living (ADLs), the Barthel Index (BI) for the evaluation of the patient’s perceived independence (Collin et al., Int Disabil Stud 10:61–63, 1988), and the Hamilton scale (Knesevich et al., Br J Psychiatr J Mental Sci 131:49–52, 1977) for the identification of improvements in mood disorders that could be induced by the reinforcement-based intervention. In order to study and predict the effects of this intervention we implemented a computational model of recovery after stroke.

Results

While both groups showed significant motor gains at 6-weeks post-treatment, only the experimental group continued to exhibit further gains in UE-FM at 12-weeks follow-up (p<.05). This improvement was accompanied by a significant increase in arm-use during training in the experimental group.

Conclusions

Implicitly reinforcing arm-use by augmenting visuomotor feedback as proposed by RIMT seems beneficial for inducing significant improvement in chronic stroke patients. By challenging the patients’ self-limiting believe system and perceived low self-efficacy this approach might counteract learned non-use.

Trial registration

Clinical Trials NCT02657070.

Background

After stroke, a neural shock leads to a learning process in which the brain progressively suppresses the use of the affected extremity [1]. This phenomenon is commonly referred to as learned non-use [2, 3]. Constraint-Induced Movement Therapy (CIMT) [1] implements a technique that aims to re-integrate the affected arm in the performance of Activities of Daily Living (ADLs) and reduce learned non-use. In order to achieve this goal, CIMT proposes to restrict the movement of the patient’s less-affected arm for about 90 % of the patient’s waking hours, which physically forces the use of the affected arm during performance of ADLs. Although a number of studies have shown the effectivity of CIMT [4], the high intensity of its protocols severely compromises its adherence [5] and can be physically and mentally tiring [6]. Moreover, its application is restricted to patients without severe cognitive impairments and with mild hemiparesis, which only accounts for about 15 % of all stroke cases [7]. Due to this limitations, several studies have tested variants of CIMT with reduced intensity protocols, giving rise to a Modified Constraint-Induced Movement Therapy (mCIMT) [8] and the so called Distributed Constraint-Induced Movement Therapy (dCIMT) [9]. However, the inclusion criteria of this type of therapy still remains excessively stringent [8, 10], and its efficacy at the chronic stage is unclear [11]. Given these limitations, there is a need for developing alternative methods that build on CIMT principles to foster the usage of the paretic limb, while mitigate its limitations.

A better understanding of the different factors determining hand selection could provide valuable insights for the development of new treatments that effectively counteract learned non-use and promote functional recovery. Previous studies have shown that the history of rewards may strongly bias action selection and habit learning [12, 13,14, 15]. Indeed, perceived self-efficacy, i.e. one’s own belief in his or her capabilities to successfully execute actions that are required for a desired outcome [16], appears to be an important driver for health behavior improvements [17]. In addition, the minimization of the expected cost/effort associated to a given action may as well regulate the decision making process [18]. The strong influence of these two factors on hand selection (i.e. expected cost and expected reward) may be sufficient to approximate the prediction of hand selection patterns, and may provide a direct explanation of our general preference for the execution of ipsilateral movements [19]. Following this line of research, we have shown in previous studies that hemiparetic stroke patients may be highly sensitive to failure when using the affected limb, therefore exposure to goal-oriented movement amplification in VR when using the affected extremity may serve as implicit reinforcement and promote arm use [20]. The resulting bias in hand selection patterns may rapidly emerge via action selection mechanisms, both reducing the expected cost and increasing the expected outcome associated to those movements executed with the paretic limb. It is generally known that motor learning is driven by motor error, and the high redundancy of the human motor system allows for the optimization of performance through decision making processes (i.e. effector selection). Thus, by virtually reducing sensorimotor error, these decision making processes can be modulated through intrinsic evaluation mechanisms [21, 22]. Previous studies have further proposed that a successful action outcome might reinforce not only the intended action but also any movement that drives the ideomotor system during the course of its execution [23, 24, 25]. This theory suggests that accidental success after action selection may be an effective mechanism for the spontaneous emergence of compensatory movements [26]. On this basis, by reducing sensorimotor feedback of those goal-oriented movements performed with the paretic limb, we may reinforce the future selection of the executed action. Indeed, a fMRI study on one stroke patient suggests that activations in the sensorimotor cortex of the affected hemisphere (the “inactive” cortex) were significantly increased simply by providing feedback of the contralateral hand [27]. This effect was also observed in healthy subjects [27]. In more recent studies, the effect of visuomotor modulations in motor adaptation has been also explored, showing that diminished error feedback and goal-oriented movement amplification does not necessarily compromise error-based learning [22, 28]. Building on these findings and grounding them on the Distributed Adaptive Control (DAC) theory of mind and brain, which proposes that restoring impaired sensorimotor contingencies is the key for promoting recovery [29], we propose a new motor rehabilitation technique that we term Reinforcement-Induced Movement Therapy (RIMT) [20]. This strategy is a combination of the following methods: 1) Shaping through training, while increasing the task difficulty according the patient’s performance; 2) limiting the use of the non-affected arm by introducing contextual restrictions in VR (i.e. restricted and symmetrically matched workspace for each arm); 3) providing explicit feedback about performance to the patient; and 4) augmenting goal-directed movements of the paretic limb in virtual reality (VR), in such a way that the patient executing the movement is exposed to diminished visuomotor errors, both in terms of distance and directional accuracy, thus increasing the expected action outcome (i.e. expected success) and decreasing the expected action cost (i.e. expected effort) [21]. While principles one to three of RIMT are similarly present in CIMT and Occupational Therapy protocols, the novelty of RIMT resides in its fourth principle: the provision of implicit reinforcement through the reduction of sensorimotor errors. This unique component of RIMT is the only variable that will be manipulated in the present study.

We hypothesize that by reducing visuomotor error within RIMT protocols, we may be able to boost the patients’ perceived performance of the paretic limb, leading to an increased use over time. Consequently, the increased spontaneous use of the paretic limb may facilitate intense practice and induce use-dependent plastic changes, therefore establishing a closed loop of recovery in which arm use and motor recovery reinforce each other. In this vein, a recent computational model of motor recovery suggested that there may be a functional threshold that predicts the use of the paretic limb after therapy [13, 30]. According to this model, only therapies that enable the patient to exceed a given functional threshold will recursively increase the spontaneous use of the paretic limb and induce functional improvement, leading to a complete motor recovery. This principle of use it or loose it can as well predict the effectiveness of RIMT. Furthermore, based on simulations from a computational model, we propose that reinforcement-based and constraint-based protocols can be combined to maximally promote the use of the paretic limb and induce functional gains in the chronic phase after the stroke. To test our hypothesis we conduct a randomized, double-blind, longitudinal clinical study with chronic stroke patients, and we analyze the effects of RIMT intervention on counteracting learned non-use and inducing motor recovery.

Fig. 1 Set-up and scenarios. a RGS setup in the hospital showing the transparent acrylic table in front of which the desktop computer with the Kinect (on a tadpole that elevates it above the screen) is placed. In order to use the second Kinect and the overhead projector on the scaffold above the table for the real world evaluation scenario, a white cover can be placed over the acrylic surface. During a training session, the user sits in a chair facing the screen while resting his/her arms on the table. b Spheroids scenario, where sets of colored spheres are launched towards the player who has to intercept them. c Whack-a-mole scenario, where the user freely chooses which limb to use in order to reach towards an appearing mole. d Collector scenario, where a set of patterned spheroids as indicated in the upper-left corner of the screen need to be collected. e Virtual evaluation scenario, an abstract version of the Whack-a-mole scenario, where the patient has to reach towards an appearing cylinder. f Real-world scenario, where the user has to reach towards randomly appearing dots that are projected from above on the table surface in front of him or her

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[ARTICLE] Neural Plasticity in Rehabilitation and Psychotherapy: New Perspectives and Findings.

Print ISSN: 2190-8370 Online ISSN: 2151-2604 Published in German from 1890 to 2006 and in English since 2007

It is only a short period of time since one of the most basic convictions about the brain, postulated by the Spanish neuroanatomist, Santiago Ramon y Cajal, became undermined by new and opposing discoveries. In 1928, Ramon y Cajal postulated that the neural setup of the human brain would be fixed and unable to change beyond the end of maturation of the brain around the age of 22–24 years. What structure or function of the human brain is not shaped until that time point by an individual’s interaction with her/his physical and social environments and through learning and adaptation would not be changeable any more during the succeeding years of life. The only accepted reason for change was damage of the brain by traumatization and/or inflammation or by changes in genetic functioning. This view of the human brain has changed considerably since the early 1970s and has been replaced by a myriad of experimental evidence demonstrating that the brain’s structure and functions are open to change throughout the whole lifetime.

The terms coined for this form of modification are “neuroplasticity” and “reorganization.” Although there is currently no generally accepted definition of neuroplasticity and reorganization, most contemporary scientists in this field would agree that neuroplasticity refers to a property at all levels of the human brain, that is, from molecules to larger cortical neural networks, to adapt its structures and functions to environmental pressures, experiences, and challenges, including brain damage (Johansson, 2011; Merzenich, Van Vleet, & Nahum, 2014). In addition, neural reorganization refers to the capacity of the brain to extend and/or change the control of behavior, cognition, and emotion by enlarging the neural networks involved through learning-induced response coordination (Merzenich et al., 2014). Other options represent optimization and economizing the activity of neural networks or the transference of the control of behavior and cognition to other structures that formerly did not control these actions (Merzenich, 2013). The latter was often addressed as rewiring the brain.

Three forms of neuroplasticity and reorganization can further be distinguished by: (a) developmental or maturational plasticity, where changes of brain structures and functions occur as a function of natural development and maturation; (b) adaptive neuroplasticity, where plasticity is induced in the course of adaptation to new environmental conditions, by learning and by skill formation, and (c) restorative neuroplasticity, where plasticity and reorganization occur as a consequence of trauma, inflammation, or epigenetic reprogramming (Will, Dalrymple-Alford, Wolff, & Cassel, 2008).

Following the conviction of the Nobel laureate Eric Kandel (1979, 2008) that any positive outcome of therapy and rehabilitative measure will only occur when the interventions significantly change the underlying neural structures and/or functions of the brain, the present topical issue of the Zeitschrift für Psychologie focuses on structural and functional plasticity of the brain as a result of behavioral and cognitive training and training of emotion regulation in several areas of therapy and rehabilitation.

The first article by Thomas Straube (2016) presents recent findings and developments of neuroplasticity in the psychotherapy of anxiety disorders. He summarizes current evidence that cognitive and behavioral interventions have demonstrated massive cortical plasticity of structures and functions that are considered central in the generation and individual expression of anxiety, like the amygdala, the anterior cerebral cortex (ACC), the insula, and the bed nucleus of the stria terminalis. He also presents a number of methodological issues in the use of functional brain imaging techniques that are critical in order to obtain valid experimental results in this field.

Thomas Weiss (2016) comprehensively summarizes current evidence for neural plasticity and cortical reorganization in subjects suffering from chronic pain in the next paper. In contrast to traditional views that postulated changes of peripheral neural systems being central causes of chronicity, he shows that cortical neuroplasticity and reorganization of neural networks in the somatosensory cortex, motor cortex, limbic and cognitive functional structures mainly account for the chronification of pain, and that these structures are also relevant targets for successful interventions in the behavioral and cognitive treatment of pain.

Eckart Altenmüller’s and Christos Ioannou’s paper (Altenmüller & Ioannou, 2016) specifies some negative sides of neuroplasticity, namely that neuroplasticity is not always beneficial but can lead to massive impairments of motor functions. Too intensive behavioral training of musicians in order to master their instruments might induce a serious condition known as musician’s dystonia and related disorders. Altenmüller and Ioannou elegantly show that in most cases such developments are consequences of training-induced maladaptive processes of plasticity in cortical and subcortical networks.

The paper by Wolfgang Miltner (2016) summarizes a number of processes that demonstrate the enormous plasticity and reorganization capacity of the human brain following brain lesion and highlights a series of behavioral and neuroscientific studies that indicate that successful intensive behavioral rehabilitation is paralleled by plastic changes of brain structures and by cortical reorganization. He shows that the amount of such plastic changes is obviously significantly determining the overall outcome of rehabilitation.

In the final review article, Klingner, Brodoehl, Volk, Guntinas-Lichius, and Witte (2016) explore the plasticity which is induced in the brain when it experiences a pronounced disturbance of the expected body responses: within the face, a lesion of the seventh nerve causes a motor paralysis with intact sensory input which is conveyed through the fifth cranial nerve. As a consequence, the intact brain orders a motor command, which is not executed, resulting in a mismatch between perceived and expected sensory information. This mismatch requires a major adaptive plasticity of the brain, which was studied in detail by this group.

Turning to the original articles, firstly Wolfgang Miltner, Heike Bauder, and Edward Taub (2016)present an example how neuroplasticity can be addressed by means of electroencephalographic measures known as Bereitschaftspotential (BP) that normally precede that execution of voluntary movements of, for example, fingers, hands, and legs. This technique was applied in a group of patients with chronic stroke who were given constraint-induced movement therapy (CIMT) over an intensive 2-week course of treatment. The intervention resulted in a large improvement in use of the more affected upper extremity in the laboratory and in the real-world environment. The evaluation of BP showed that the treatment produced marked changes in cortical activity that correlated with the significant rehabilitative effects. The results are consistent with the rehabilitation treatment having produced a use-dependent cortical reorganization and demonstrate where the physiological data interdigitates with and provides additional credibility to the clinical data.

Brodoehl, Klingner, Schaller, and Witte (2016) explore, in the second original article, the adaptation which the brain performs upon eye closure: with closure of the eyes the brain fundamentally alters the processing of afferent information, from a visually dominated multisensory mode to a monosensory mode. This plasticity is independent of the visual information and takes place in complete darkness, indicating that this switch of processing modes is caused by state-dependent, inherent brain plasticity. Based on these observations one can assume that the ability to cause functional reorganizations can be substantially modified by optimized conditions for such learning processes.

In their opinion piece, Otto Witte and Malgorzata Kossut (2016) emphasize the impact of inflammatory factors on brain plasticity: following a stroke or in the aging brain, the inflammatory system is activated and impairs brain plasticity. The analysis of these processes opens a window for therapeutic interventions that may be employed to enhance the efficacy of behavioral and other rehabilitative procedures.

References

Altenmüller, E. & Ioannou, C. I. (2016). Maladaptive plasticity induces degradation of fine motor skills in musicians: Apollo’s curse. Zeitschrigt für Psychologie, 224, 80–90. doi: 10.1027/2151-2604/a000242 Link

Brodoehl, S., Klingner, C. M., Schaller, D. & Witte, O. W. (2016). Plasticity during short-term visual deprivation. Zeitscrift für Psychologie, 224, 125–132. doi: 10.1027/2151-2604/a000246 Link

Johansson, B. B. (2011). Current trends in stroke rehabilitation: A review with focus on brain plasticity. Acta Neurologica Scandinavica, 123, 147–159. CrossRef

Kandel, E. R. (1979). Psychotherapy and the single synapse: The impact of psychiatric thought on neurobiological research. New England Journal of Medicine, 301, 1028–1037. CrossRef

Kandel, E. R. (2008). Psychiatrie, Psychoanalyse und die neue Biologie des Geistes [Psychiatry psychoanalysis, and the new biology of the mind]. Frankfurt/M, Germany: Suhrkamp Verlag.

Klingner, C. M., Brodoehl, S., Volk, G. F., Guntinas-Lichius, O. & Witte, O. W. (2016). Adaptive and maladaptive neural plasticity due to facial nerve palsy: What can we learn from pure deefferentation?Zeitschrift für Psychologie, 224, 102–111. doi: 10.1027/2151-2604/a000244 Link

Merzenich, M. M. (2013). Soft-wired: How the new science of brain plasticity can change your life.San Francisco, CA: Parnassus Publishing.

Merzenich, M. M., Van Vleet, T. M. & Nahum, M. (2014). Brain plasticity-based therapeutics.Frontiers in Human Neuroscience, 8, 385. doi: 10.3389/fnhum.2014.00385 CrossRef

Miltner, W. H. R. (2016). Plasticity and reorganization in the rehabilitation of stroke: The constraint-induced movement therapy (CIMT) example. Zeitschrift für Psychologie, 224, 91–101. doi:10.1027/2151-2604/a000243 Link

Miltner, W. H. R., Bauder, H. & Taub, E. (2016). Change in movement-related cortical potentials following constraint-induced movement therapy (CIMT) after stroke. Zeitschrift für Psychologie, 224,112–124. doi: 10.1027/2151-2604/a000245 Link

Straube, T. (2016). Effects of psychotherapy on brain activation patterns in anxiety disorders.Zeitscrift für Psychologie, 224, 62–70. doi: 10.1027/2151-2604/a000240 Link

Weiss, T. (2016). Plasticity and cortical reorganization associated with pain. Zeitschrift für Psychologie, 224, 71–79. Abstract

Will, B., Dalrymple-Alford, J., Wolff, M. & Cassel, J.-C. (2008). The concept of brain plasticity: Paillard’s systemic analysis and emphasis on structure and function (followed by the translation of a seminal paper by Paillard on plasticity). Behavioural Brain Research, 192, 2–7. doi:10.1016/j.bbr.2007.11.008 CrossRef

Witte, O. W. & Kossut, M. (2016). Impairment of brain plasticity by brain inflammation. Zeitschrift für Psychologie, 224, 133–138. doi: 10.1027/2151-2604/a000247 Link

Correspondence concerning this article shoud be addressed to:

Wolfgang H. R. Miltner

Department of Biological and Clinical Psychology

Friedrich Schiller University (FSU)

Am Steiger 3/1

07743 Jena

Germany

Tel. +49 3641 945140, Fax +49 3641 945142, E-mail wolfgang.miltner@uni-jena.de

Source: Neural Plasticity in Rehabilitation and Psychotherapy: Neural Plasticity in Rehabilitation and Psychotherapy: Zeitschrift für Psychologie: Vol 224, No 2

[Abstract] Plasticity and Reorganization in the Rehabilitation of Stroke. The Constraint-Induced Movement Therapy (CIMT) Example

Print ISSN: 2190-8370 Online ISSN: 2151-2604 Published in German from 1890 to 2006 and in English since 2007

Abstract. This paper outlines some actual developments in the behavioral treatment and rehabilitation of stroke and other brain injuries in post-acute and chronic conditions of brain lesion. It points to a number of processes that demonstrate the enormous plasticity and reorganization capacity of the human brain following brain lesion. It also highlights a series of behavioral and neuroscientific studies that indicate that successful behavioral rehabilitation is paralleled by plastic changes of brain structures and by cortical reorganization and that the amount of such plastic changes is obviously significantly determining the overall outcome of rehabilitation.

References

Source: Plasticity and Reorganization in the Rehabilitation of Stroke: Plasticity and Reorganization in the Rehabilitation of Stroke: Zeitschrift für Psychologie: Vol 224, No 2

[Survey] Use of constraint induced movement therapy (CIMT) in adult neurorehabilitation survey

Use of constraint induced movement therapy (CIMT) in adult neurorehabilitation survey

Thank you for taking the time to complete this voluntary survey, which will will take approximately 20 minutes to complete.

Please read the Participant Information Sheet at the link below before you begin and print a copy for your records.

In this survey, you will tell us about your use of upper limb constraint induced movement therapy (CIMT) in adult neurorehabilitation. This information will help to improve our knowledge of how CIMT is being implemented in practice.

Submitting the completed survey is an indication of your consent to participate. Responses can be changed before submitting the survey. Once your survey has been submitted, responses cannot be withdrawn. We ask that you complete the survey as an individual rather than responding to it as a group. Please complete the survey only once.

How do I find out more about the project? 

Contact Lauren Christie, Masters by Research candidate, The University of Sydney, on +61 426 835 118 or at lchr6636@uni.sydney.edu.au.

The ethical aspects of this study have been approved by the Human Research Ethics Committee (HREC) of The University of Sydney, protocol no: 2016/074.

Page 1 of 4

	Attachment:   Participant Information Sheet- Survey.pdf  (0.15 MB)

Source: Use of constraint induced movement therapy (CIMT) in adult neurorehabilitation survey

[Abstract] Constraint-induced movement therapy as a rehabilitation intervention for upper extremity in stroke patients: systematic review and meta-analysis. – PubMed – NCBI

Abstract

Constraint-induced movement therapy (CIMT) is a neurorehabilitation technique designed to improve upper extremity motor functions after stroke.

This review aimed to investigate evidence of the effect of CIMT on upper extremity in stroke patients and to identify optimal methods to apply CIMT.

Four databases (MEDLINE, EMBASE, CINHAL, and PEDro) and reference lists of relevant articles and reviews were searched. Randomized clinical trials that studied the effect of CIMT on upper extremity outcomes in stroke patients compared with other rehabilitative techniques, usual care, or no intervention were included. Methodological quality was assessed using the PEDro score. The following data were extracted for each trial: patients’ characteristics, sample size, eligibility criteria, protocols of CIMT and control groups, outcome measurements, and the PEDro score. A total of 38 trials were identified according to the inclusion criteria. The trials included were heterogeneous in CIMT protocols, time since stroke, and duration and frequency of treatment. The pooled meta-analysis of 36 trials found a heterogeneous significant effect of CIMT on upper extremity.

There was no significant effect of CIMT at different durations of follow-up. The majority of included articles did not fulfill powered sample size and quality criteria. The effect of CIMT changed in terms of sample size and quality features of the articles included.

These meta-analysis findings indicate that evidence for the superiority of CIMT in comparison with other rehabilitative interventions is weak. Information on the optimal dose of CIMT and optimal time to start CIMT is still limited.

Source: Constraint-induced movement therapy as a rehabilitation intervention for upper extremity in stroke patients: systematic review and meta-analysis. – PubMed – NCBI

[Abstract] Cardiovascular fitness is improved post-stroke with upper-limb Wii-based Movement Therapy but not dose-matched constraint therapy.

Abstract

Introduction: Post-stroke cardiovascular fitness is typically half that of healthy age-matched people. Cardiovascular deconditioning is a risk factor for recurrent stroke that may be overlooked during routine rehabilitation. This study investigated the cardiovascular responses of two upper limb rehabilitation protocols.

Methods: Forty-six stroke patients completed a dose-matched program of Wii-based Movement Therapy (WMT) or modified Constraint-induced Movement Therapy (mCIMT). Heart rate and stepping were recorded during early (day 2)- and late (day 12–14)-therapy. Pre- and post-therapy motor assessments included the Wolf Motor Function Test and 6-min walk.

Results: Upper limb motor function improved for both groups after therapy (WMT p = 0.003, mCIMTp = 0.04). Relative peak heart rate increased from early- to late-therapy WMT by 33% (p < 0.001) and heart rate recovery (HRR) time was 40% faster (p = 0.04). Peak heart rate was higher and HRR faster during mCIMT than WMT, but neither measure changed during mCIMT. Stepping increased by 88% during Wii-tennis (p < 0.001) and 21% during Wii-boxing (p = 0.045) while mCIMT activities were predominantly sedentary. Six-min walk distances increased by 8% (p = 0.001) and 4% (p = 0.02) for WMT and mCIMT, respectively.

Discussion: Cardiovascular benefits were evident after WMT as both a cardiovascular challenge and improved cardiovascular fitness. The peak heart rate gradient across WMT activities suggests this therapy can be further individualized to address cardiovascular needs. The mCIMT data suggest a cardiovascular stress response.

Conclusions: This is the first study to demonstrate a cardiovascular benefit during specifically targeted upper limb rehabilitation. Thus, WMT not only improves upper limb motor function but also improves cardiovascular fitness.

Source: Maney Online – Maney Publishing

[Abstract] Effects of Unilateral Upper Limb Training in Two Distinct Prognostic Groups Early After Stroke

Abstract

Background and Objective. Favorable prognosis of the upper limb depends on preservation or return of voluntary finger extension (FE) early after stroke. The present study aimed to determine the effects of modified constraint-induced movement therapy (mCIMT) and electromyography-triggered neuromuscular stimulation (EMG-NMS) on upper limb capacity early poststroke.

Methods. A total of 159 ischemic stroke patients were included: 58 patients with a favorable prognosis (>10° of FE) were randomly allocated to 3 weeks of mCIMT or usual care only; 101 patients with an unfavorable prognosis were allocated to 3-week EMG-NMS or usual care only. Both interventions started within 14 days poststroke, lasted up until 5 weeks, focused at preservation or return of FE.

Results. Upper limb capacity was measured with the Action Research Arm Test (ARAT), assessed weekly within the first 5 weeks poststroke and at postassessments at 8, 12, and 26 weeks. Clinically relevant differences in ARAT in favor of mCIMT were found after 5, 8, and 12 weeks poststroke (respectively, 6, 7, and 7 points; P < .05), but not after 26 weeks. We did not find statistically significant differences between mCIMT and usual care on impairment measures, such as the Fugl-Meyer assessment of the arm (FMA-UE). EMG-NMS did not result in significant differences.

Conclusions. Three weeks of early mCIMT is superior to usual care in terms of regaining upper limb capacity in patients with a favorable prognosis; 3 weeks of EMG-NMS in patients with an unfavorable prognosis is not beneficial. Despite meaningful improvements in upper limb capacity, no evidence was found that the time-dependent neurological improvements early poststroke are significantly influenced by either mCIMT or EMG-NMS.

Source: Effects of Unilateral Upper Limb Training in Two Distinct Prognostic Groups Early After Stroke

[Abstract] Effect of Constraint Induced Movement Therapy v/s Motor Relearning Program for Upper Extremity Function in Sub Acute Hemiparetic Patients – a Randomized Clinical Trial

Background

Motor impairment after stroke is common, following damage to areas of the brain normally involved in the planning and execution of motor commands. Impaired motor control of the upper extremity is one of the most frequent consequences of stroke.

Objectives

To determine the effect of CIMT and MRP on upper limb function and to compare the effect of both in sub-acute hemiperatic patients.

Method

45 participants were randomly allocated into group A and B. Group A received CIMT technique. The unaffected extremity was restrained for 80 percent of working hours and task oriented training was given for affected extremity for 3 hours daily for 14 days. Group B received the motor relearning program for 14 days. Functions of upper limb were assessed using Nine Hole Peg Test, Motor Activity Log and Fugal Meyer Performance measured at the beginning and after completion of the intervention.

Result

The results of the present study showed statistical significant improvement in MAL (p=0.001) and FMS (p=0.031) in the CIMT group. The MRP group showed significant improvement in MAL (p=<0.001).

Conclusion

Both CIMT and MRP are found effective in improving upper extremity function in patients; however CIMT was more effective than MRP.

Source: Indian Journals

[Abstract] The efficacy of Wii-based Movement Therapy for upper limb rehabilitation in the chronic poststroke period: a randomized controlled trial

Background: More effective and efficient rehabilitation is urgently needed to address the prevalence of unmet rehabilitation needs after stroke. This study compared the efficacy of two poststroke upper limb therapy protocols.

Aims and/or hypothesis: We tested the hypothesis that Wii-based movement therapy would be as effective as modified constraint-induced movement therapy for post-stroke upper-limb motor rehabilitation.

Methods: Forty-one patients, 2–46 months poststroke, completed a 14-day program of Wii-based Movement Therapy or modified Constraint-induced Movement Therapy in a dose-matched, assessor-blinded randomized controlled trial, conducted in a research institute or patient’s homes. Primary outcome measures were the Wolf Motor Function Test timed-tasks and Motor Activity Log Quality of Movement scale. Patients were assessed at prebaseline (14 days pretherapy), baseline, post-therapy, and six-month follow-up. Data were analyzed using linear mixed models and repeated measures analysis of variance.

Results: There were no differences between groups for either primary outcome at any time point. Motor function was stable between prebaseline and baseline (P > 0·05), improved with therapy (P  0·05). Wolf Motor Function Test timed-tasks log times improved from 2·1 ± 0·22 to 1·7 ± 0·22 s after Wii-based Movement Therapy, and 2·6 ± 0·23 to 2·3 ± 0·24 s after modified Constraint-induced Movement Therapy. Motor Activity Log Quality of Movement scale scores improved from 67·7 ± 6·07 to 102·4 ± 6·48 after Wii-based Movement Therapy and 64·1 ± 7·30 to 93·0 ± 5·95 after modified Constraint-induced Movement Therapy (mean ± standard error of the mean). Patient preference, acceptance, and continued engagement were higher for Wii-based Movement Therapy than modified Constraint-induced Movement Therapy.

Conclusions: This study demonstrates that Wii-based Movement Therapy is an effective upper limb rehabilitation poststroke with high patient compliance. It is as effective as modified Constraint-induced Movement Therapy for improving more affected upper limb movement and increased independence in activities of daily living.

Source: The efficacy of Wii-based Movement Therapy for upper limb rehabilitation in the chronic poststroke period: a randomized controlled trial – McNulty – 2015 – International Journal of Stroke – Wiley Online Library

[Abstract] Constraint-induced movement therapy for upper extremities in people with stroke (Cochrane review) [with consumer summary]

BACKGROUND: In people who have had a stroke, upper limb paresis affects many activities of daily life. Reducing disability is therefore a major aim of rehabilitative interventions. Despite preserving or recovering movement ability after stroke, sometimes people do not fully realise this ability in their everyday activities. Constraint-induced movement therapy (CIMT) is an approach to stroke rehabilitation that involves the forced use and massed practice of the affected arm by restraining the unaffected arm. This has been proposed as a useful tool for recovering abilities in everyday activities.

OBJECTIVES: To assess the efficacy of CIMT, modified CIMT (mCIMT), or forced use (FU) for arm management in people with hemiparesis after stroke.

SEARCH METHODS: We searched the Cochrane Stroke Group trials register (last searched June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library issue 1, 2015), MEDLINE (1966 to January 2015), EMBASE (1980 to January 2015), CINAHL (1982 to January 2015), and the Physiotherapy Evidence Database (PEDro; January 2015).

SELECTION CRITERIA: Randomised control trials (RCTs) and quasi-RCTs comparing CIMT, mCIMT or FU with other rehabilitative techniques, or none.

DATA COLLECTION AND ANALYSIS: One author identified trials from the results of the electronic searches according to the inclusion and exclusion criteria, three review authors independently assessed methodological quality and risk of bias, and extracted data. The primary outcome was disability.

MAIN RESULTS: We included 42 studies involving 1,453 participants. The trials included participants who had some residual motor power of the paretic arm, the potential for further motor recovery and with limited pain or spasticity, but tended to use the limb little, if at all. The majority of studies were underpowered (median number of included participants was 29) and we cannot rule out small-trial bias. Eleven trials (344 participants) assessed disability immediately after the intervention, indicating a non-significant standard mean difference (SMD) 0.24 (95% confidence interval (CI) -0.05 to 0.52) favouring CIMT compared with conventional treatment. For the most frequently reported outcome, arm motor function (28 studies involving 858 participants), the SMD was 0.34 (95% CI 0.12 to 0.55) showing a significant effect (P value 0.004) in favour of CIMT. Three studies involving 125 participants explored disability after a few months of follow-up and found no significant difference, SMD -0.20 (95% CI -0.57 to 0.16) in favour of conventional treatment.

AUTHORS’ CONCLUSIONS: CIMT is a multi-faceted intervention where restriction of the less affected limb is accompanied by increased exercise tailored to the person’s capacity. We found that CIMT was associated with limited improvements in motor impairment and motor function, but that these benefits did not convincingly reduce disability. This differs from the result of our previous meta-analysis where there was a suggestion that CIMT might be superior to traditional rehabilitation. Information about the long-term effects of CIMT is scarce. Further trials studying the relationship between participant characteristics and improved outcomes are required.

Source: PEDro – Search Detailed Search Results