Posts Tagged constraint induced movement therapy

[WEB PAGE] An expert opinion: upper limb rehabilitation after stroke

Key take home messages

  1. Clinically meaningful improvements are possible in chronic stroke patients
  2. The dose of rehabilitation treatment needs to be larger than currently delivered
  3. Rehabilitation is a complex intervention that cannot be reduced to a single element

Somewhere between 50-80% of stroke survivors have upper limb symptoms after acute stroke1 and persistent difficulty in using the upper limb is a major contributor to ongoing physical disability.2 A commonly held view is that most recovery from stroke occurs over the first three to six months after which little improvement is possible, especially at the level of impairment.3-6 We argue that this may be a self-fulfilling prophecy resulting in lack of provision of potentially helpful rehabilitation.

What is the best way to promote upper limb recovery after stroke? Most studies of behavioural interventions have investigated forms of constraint induced movement therapy (CIMT),7,8 repetitive task training (RTT)9 or robotics,10 each of which focuses on increasing the activity of the affected limb. Kwakkel et al8suggested that motor function, arm-hand activities and self-reported arm-hand functioning in daily life, improved immediately after CIMT and at long-term follow-up, but the comparison was often with usual care. It is worth noting that CIMT approaches were said to be more likely to be successful in promoting long term benefits if the protocol included shaping, massed practice and a behavioural transfer package, whereas simple forced use therapy was ineffective.8 RTT also has some evidence to support benefits over what is described as usual care, but the evidence for benefits over ‘matched therapy’ is less strong.9 The use of robotics can increase the number of movement repetitions, but has failed to produce clinically meaningful effects.10 Indeed, the recent RATULS study showed that compared with usual care, approximately 23 hours of robot-assisted training and matched dose ‘upper limb therapy’ did not improve upper limb function.11Overall, it would appear that asking patients to make simple repetitions of movement, however meaningful the task, is relatively ineffective without some way of actively translating any improvements into activities of daily living. Simply increasing the number of repetitions does not appear to be effective,12 and this in itself should give us pause for thought.

A few studies have tested more complex therapies incorporating a number of different elements. The ICARE study13 of upper limb treatment after stroke went beyond simple repetitions, using a structured, task-oriented motor training programme that was impairment focused, task specific, intense, engaging, collaborative, self-directed, and patient centred, starting about six weeks post-stroke. Outcomes were not improved by this approach, but on reflection it is likely that, as with many of the studies, the dose of 30 hours over ten weeks was too low (the usual care group received 11.2 hours over ten weeks). Despite scepticism that stroke patients would be able to ‘tolerate’ much higher doses,12 one study managed to deliver 300 hours of upper limb therapy to chronic stroke patients over twelve weeks and reported changes in measures of both impairment and activity that were far greater than those in lower dose studies,14 and in fact the findings of this study have recently been replicated by the same group.15 We recently reported the findings of the Queen Square Upper Limb (QSUL) Neurorehabilitation programme,16 a single centre clinical service that provides 90 hours of treatment focusing on the post-stroke upper limb. Most patients entering the programme were in the chronic stage (> 6 months post-stroke), but were able to complete the 90 hours of the programme, even though they exhibited a wide range of impairments and fatigue levels. Despite the time since stroke (median = 18 months) we observed (i) large clinically meaningful improvements in upper limb impairment and activity (of a magnitude similar to those reported by McCabe et al.), and importantly (ii) that these changes were maintained, or even improved upon, six months after treatment.

The first lesson to take from these studies is that post-stroke rehabilitation programmes and clinical trials are almost certainly under dosing patients. In future, clinical trials must investigate the effects of much higher doses than are currently being used. The second question to be raised is what are the key ‘active ingredients’ of an upper limb rehabilitation treatment? Whilst it is not clear what the optimal behavioural approach for promoting upper limb recovery should be, it is clear that simple protocol driven approaches have not led to large or sustained effects,17 both of which are necessary to produce a step change in stroke recovery. Successful post-stroke neurorehabilitation is likely to require a combination of complimentary approaches. If we accept this premise, then we are unlikely to determine the optimal combination of active ingredients simply by studying each approach in isolation, because the interactions between these elements will also have to be considered.

So how do we work out what the ‘active ingredients’ of upper limb rehabilitation are? A more sensible way forward is to look at interventions that have already demonstrated a high level of efficacy and then begin to work out their key components. Here, it is important to say that we need to start with treatments that have a high chance of achieving minimum clinically important differences (MCID) rather than small changes that might be statistically significant. Both McCabe et al14 and Daly et al,15 as well as the QSUL programme,16 produced large improvements on both impairment and activity limitation and both involved more complex treatment approaches, not restricted to one element. It is worth considering these in more detail.

  • Analysis of movement and performance in activities of daily living. The initial assessment is crucial. The question, ‘why does this person’s hand and arm not work’ should never be answered with ‘because they have had a stroke’. There needs to be an appreciation of the range of potential contributory impairments (patterns of weakness, spasticity, loss of joint range, shoulder restriction and pain, sensory loss, apraxia, cognitive deficits, depression, apathy, fatigue etc.) because each of these becomes a therapeutic target. Our view is that without informed clinical reasoning based on the presence or absence of specific impairments, the correct treatment approach is unlikely to be selected.
  • Identify and treat barriers. Avoid complications that will prevent participation in an active rehabilitation programme. We commonly see loss of passive joint range preventing people accessing finger or thumb movement, due to either spasticity or non-neural shortening. This can happen at most joints, but particularly in the hand. As well as increased finger flexion, be alert to loss of flexion at MCP joints which makes it difficult to shape the hand properly. Treatment involves splinting and optimal spasticity management. We also see pain and restriction of range in the shoulder. Restriction of external rotation in particular should raise the possibility of adhesive capsulitis. Despite the lack of a clear evidence base for treating post-stroke adhesive capsulitis, anecdotally we have had success with capsular hydrodilatation followed by physiotherapy.
  • Preparation. Manual techniques are used to optimise and improve baseline at an impairment level, for example mobilising joints to improve range, lengthening and strengthening muscles to ensure they are at a biomechanical advantage to generate force, training sensory discrimination and improving postural control and balance.
  • Reduction of impairment and re-education of quality and control of movement within activities of daily living. Individualised meaningful tasks are practiced repeatedly in order to facilitate task mastery with a focus on quality of movement. This is achieved through (i) adaptation of the task, e.g. decomposing tasks into individual components to be practiced; (ii) adaptation of the environment, e.g. fabrication of functional splints and adaptation of tools such as cutlery or screwdrivers, to enable integration of the affected hand in meaningful activities; (iii) assistance, e.g. de-weighting the arm to allow strengthening and training of movement quality and control through increased range.
  • Coaching (involving instruction, supervision, reinforcement) was considered a key component of the QSUL programme, used throughout to embed new skills and knowledge into individual daily routines. Consequently, individuals increase participation and confidence in their desired goals, enhancing self-efficacy and motivation to sustain behavioural change beyond the end of the active treatment period.
  • Sustaining change. Our view is that the approach described, delivered at a high dose is most likely to achieve clinically meaningful improvement together with improved self-efficacy and behaviour change that results in retention of gains or further improvement (something not routinely seen with many upper limb interventions that have been investigated).

Rehabilitation is often criticised for not following standardised approaches that lend themselves to investigation through clinical trials. However, when single elements are then studied in isolation the results are often not clinically meaningful and are not sustained.18,19 Looking at the difference between these approaches and those taken by McCabe et al14, Daly et al15 and QSUL16 should be informative, with a view to formally describing the key elements of a successful treatment. Whilst approaches at the activity and participation level will vary as they are tailored to an individual’s specific meaningful goals, the overall therapeutic approach taken towards specific impairments should be the same across all patients. Ideally, it should be possible to describe the principles of an optimal intervention using a format such as the TIDIER guidelines.18,19

There is a way to go before we can really say we understand both the treatment itself and the effects of the treatment on individuals. This will require careful assessment of both the ‘input’ (the nature of the behavioural intervention) and of the ‘output’ (the resulting behavioural change) at a level of fine-grained detail that is not currently achieved on a regular basis, for example using kinematic20 or neurophysiological21 assessment. In addition, this input-output relationship will be modulated by a number of patient characteristics, which could relate to behavioural characteristics (e.g. severity, presence of multiple impairments) or to biological characteristics (e.g. the nature and extent of brain damage, time since stroke, age, medication).

Overall, our experience suggests that much higher doses and intensity of upper limb neurorehabilitation can be delivered with beneficial effects. We have highlighted the need to consider the dose and the nature of the intervention as well as appropriate patient stratification in informing future clinical trial design.

Figure 1. Outcome scores for all patients on the Queen Square Upper Limb Rehabilitation programme. Each data point represents a single patient. Top row shows individual scores at admission, discharge, six weeks and six months after discharge. Bottom row shows the individual difference scores for admission to discharge, admission to six weeks post-discharge, and admission to six months post-discharge. Scores are shown for modified Fugl-Meyer (upper limb), Action Research Arm Test and Chedoke Arm and Hand Activity Inventory (CAHAI). Median (solid line) and upper and lower quartiles (dotted lines) are shown. (Reproduced with permission from Ward et al, J Neurol Neurosurg Psychiatry. 2019 May;90(5):498-506).


References

  1. Lawrence ES et al. Estimates of the prevalence of acute stroke impairments and disability in a multiethnic population. Stroke. 2001;32:1279–1284.
  2. Broeks JG, Lankhorst GJ, Rumping K, Prevo AJ. The long-term outcome of arm function after stroke: results of a follow-up study. Disabil Rehabil. 1999;21:357–364.
  3. Kwakkel G, Kollen BJ, van der Grond J, Prevo AJH. Probability of regaining dexterity in the flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. Stroke. 2003;34:2181–2186.
  4. Nakayama H, Jørgensen HS, Raaschou HO, Olsen TS. Recovery of upper extremity function in stroke patients: the Copenhagen Stroke Study. Arch Phys Med Rehabil. 1994;75:394–398.
  5. Sunderland A et al. Enhanced physical therapy for arm function after stroke: a one year follow up study. J. Neurol. Neurosurg. Psychiatr. 1994;57:856–858.
  6. Wade DT, Langton-Hewer R, Wood VA, Skilbeck CE, Ismail HM. The hemiplegic arm after stroke: measurement and recovery. J. Neurol. Neurosurg. Psychiatr. 1983;46:521–524 .
  7. Corbetta D, Sirtori V, Castellini G, Moja L, Gatti R. Constraint-induced movement therapy for upper extremities in people with stroke. Cochrane Database Syst Rev CD004433 (2015). doi:10.1002/14651858.CD004433.pub3
  8. Kwakkel G, Veerbeek J, van Wegen EEH, Wolf SL. Constraint-induced movement therapy after stroke. Lancet Neurol. 2015;14:224–234.
  9. French B et al. Repetitive task training for improving functional ability after stroke. Cochrane Database Syst Rev. 2016;11:CD006073.
  10. Veerbeek JM, Langbroek-Amersfoort AC, van Wegen, EEH, Meskers CGM, Kwakkel G. Effects of Robot-Assisted Therapy for the Upper Limb After Stroke. Neurorehabil Neural Repair. 2017;31: 107–121.
  11. Rodgers H et al. Robot assisted training for the upper limb after stroke (RATULS): a multicentre randomised controlled trial. Lancet (2019). doi:10.1016/S0140-6736(19)31055-4.
  12. Lang CE et al. Dose response of task-specific upper limb training in people at least 6 months poststroke: A phase II, single-blind, randomized, controlled trial. Ann. Neurol. 2016;80:342–354.
  13. Winstein CJ et al. Effect of a Task-Oriented Rehabilitation Program on Upper Extremity Recovery Following Motor Stroke: The ICARE Randomized Clinical Trial. JAMA. 2016;315:571–581.
  14. McCabe J, Monkiewicz M, Holcomb J, Pundik S, Daly JJ. Comparison of robotics, functional electrical stimulation, and motor learning methods for treatment of persistent upper extremity dysfunction after stroke: a randomized controlled trial. Arch Phys Med Rehabil. 2015; 96:981–990.
  15. Daly JJ et al. Long-Dose Intensive Therapy Is Necessary for Strong, Clinically Significant, Upper Limb Functional Gains and Retained Gains in Severe/Moderate Chronic Stroke. Neurorehabil Neural Repair. 1545968319846120 (2019). doi:10.1177/1545968319846120.
  16. Ward NS, Brander F, Kelly K. Intensive upper limb neurorehabilitation in chronic stroke: outcomes from the Queen Square programme. J Neurol Neurosurg Psychiatry jnnp-2018-319954 (2019). doi:10.1136/jnnp-2018-319954
  17. Pollock A et al. Interventions for improving upper limb function after stroke. Cochrane Database Syst Rev. CD010820 (2014). doi:10.1002/14651858.CD010820.pub2
  18. Hoffmann TC et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348;g1687.
  19. Walker MF et al. Improving the Development, Monitoring and Reporting of Stroke Rehabilitation Research: Consensus-Based Core Recommendations from the Stroke Recovery and Rehabilitation Roundtable. Neurorehabil Neural Repair. 2017;31:877–884.
  20. Balasubramanian S, Colombo R, Sterpi I, Sanguineti V, Burdet E. Robotic assessment of upper limb motor function after stroke. Am J Phys Med Rehabil. 2012;91:S255-269.
  21. Cheung VCK et al. Muscle synergy patterns as physiological markers of motor cortical damage. Proc. Natl. Acad. Sci. U.S.A. 2012;109:14652–14656.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Correspondence to: Nick Ward, The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG.
Conflict of interest statement: None declared.
Provenance and peer review: Submitted and externally reviewed.
Date first submitted: 15/4/19
Date resubmitted after peer review: 10/6/19
Acceptance date: 11/6/19
To cite: Ward NS, Kelly K, Brander F. ACNR 2019;18(4):20-22
Published online: 1/8/19

via An expert opinion: upper limb rehabilitation after stroke | ACNR | Online Neurology Journal

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[ARTICLE] Stroke patients’ and non-professional coaches’ experiences with home-based constraint-induced movement therapy: a qualitative study – Full Text

To investigate the experiences of chronic stroke patients and non-professional coaches with home-based constraint-induced movement therapy (homeCIMT).

Qualitative study embedded within a cluster randomized controlled trial investigating the efficacy of homeCIMT to improve the use of the affected arm in daily activities.

Patients’ home environment.

13 stroke patients and 9 non-professional coaches’ alias family members who had completed the four-week homeCIMT programme in the context of the HOMECIMT trial.

Semi-structured interviews; qualitative data were analysed using the methodology of the hermeneutic phenomenological data analysis.

We identified six themes in the qualitative analysis describing the experiences of patients and non-professional coaches with homeCIMT: (1) homeCIMT can be integrated into everyday life with varying degrees of success; (2) training together may produce positive experiences as well as strain; (3) self-perceived improvements during and following homeCIMT; (4) using the affected arm in everyday life is challenging; (5) subjective evaluation of and experiences with homeCIMT-specific exercises; and (6) impact of professional therapists’ guidance and motivation during homeCIMT. Statements regarding theme five and six were only provided by patients, whereas the other themes contain both, the experiences of stroke patients and non-professional coaches.

Patients’ and non-professional coaches’ narratives offer a detailed insight into the manifold experiences with the practical implementation of homeCIMT that may help improve implementing the homeCIMT programme and similar approaches involving increased training duration and intensity and/or involvement of family members.

 

In stroke rehabilitation, repetitive, task-specific training is one of the key principles.1,2 For stroke patients with upper limb dysfunction, constraint-induced movement therapy and its modifications are one of the most promising techniques taking this principle into account.14 To induce the use of the affected arm in everyday life,5 constraint-induced movement therapy comprises an intensive motor training, the use of adherence-enhancing behavioural methods and the immobilization of the non-affected hand.5,6 A four-week home-based training in conjunction with the support of a non-professional coach (e.g. family member) and reduced professional assistance to meet ambulatory care conditions (home-based constraint-induced movement therapy (homeCIMT)) is one way to deliver constraint-induced movement therapy to patients in long-term care.7 The HOMECIMT trial showed homeCIMT to be superior to conventional therapies with regard to the self-perceived use of the stroke-affected arm in daily activities.8

HomeCIMT and other forms of constraint-induced movement therapy have been shown to be particularly effective in improving upper limb function post stroke.1,3 However, these interventions will only work if patients adhere to them. Constraint-induced movement therapy requires numerous hours of repetitive exercises, which are likely to present a challenge for patients.9,10 Regarding homeCIMT, the involvement of a non-professional coach might be an additional challenging aspect for both, patients and non-professional coaches. Thus, it is vital to better understand the users’ experiences with different forms of constraint-induced movement therapies in order to adapt the way how we deliver these interventions and maximize adherence to them. However, there are only few investigations with the users’ perspectives on constraint-induced movement therapies. We are only aware of three minor qualitative studies investigating the experiences of two or three patients with modified constraint-induced movement therapies.1113 A qualitative research approach, in particular, provides information about the users’ experiences with the practical application of a therapy.14,15

In addition to the cluster randomized controlled HOMECIMT trial, we conducted a comprehensive qualitative study to explore the users’ perspectives on homeCIMT following the driving question: What are the experiences of chronic stroke patients and non-professional coaches with homeCIMT?[…]

 

Continue —> Stroke patients’ and non-professional coaches’ experiences with home-based constraint-induced movement therapy: a qualitative study – Anne Stark, Christine Färber, Britta Tetzlaff, Martin Scherer, Anne Barzel, 2019

Figure 1. Themes regarding the experiences of patients and non-professional coaches with homeCIMT.

 

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[WEB SITE] Constraint Induced Movement Therapy

WHAT IS CIMT?

taub2Constraint-Induced Movement therapy (CIMT/ CIT) or CI therapy is a new therapeutic approach to rehabilitation of hand and arm movement after stroke, cerebral palsy, brachial plexus injury, multiple sclerosis (MS) and traumatic brain injury (TBI). CI therapy consists of a family of treatments that teach the brain to “rewire” itself following a neurological injury. CI therapy is based on research by Prof. Edward Taub and his collaborators at the University of Alabama at Birmingham, USA that showed that patients can learn to improve movement of the weaker part of their bodies.CIMT is a 2-3 week treatment program that includes restraint of the non-affected hand for most of the waking hours and intensive practice of the affected one for specific hours per day. Practice is focused on everyday activities that are important for the patient and takes place in the clinic and at home. The daily home-based program is tailor made to match each person’s

HOW CIMT WORKS

CIMT includes restraint of the non-affected hand and intensive, everyday practice to the affected arm and hand.

CIMT’s functional effects have been observed as early as on the 3rd-4th day of the program. Improvements have been recorded to last for years after termination of therapy; the reason for this is that CIMT eventually increases the spontaneous use of the affected hand. That is directly linked to research studies showing that CIMT is the only rehabilitation technique to markedly change the organization of activity in the brain and remodel brain structures.

EFFECTIVENESS

CIMT is the only rehabilitative technique that is evidence based to substantially improve arm and hand movement in both adults and children in a 2-3 week period. A large, supporting body of research studies is available, some of which are large sampled randomized controlled trials. The most important finding from research studies and clinical observations is that improvements last for months or years after termination of the CIMT program.

CONDITIONS CIMT IS SUITABLE FOR

CIMT is suitable for adults and children that face movement difficulties (mostly) with their one arm and hand. This might have been the result of a central or peripheral neurological damage.

Although CIMT has been primarily designed for hemiplegia (muscle weakness and movement difficulties of the one side of the body), it can also be effective in quadriplegia when the one side of the body is the one that causes the main dysfunction. In general, CIMT is suitable for any case that non-use of the one arm/ hand affects the person’s independency in everyday activities.

To determine whether CIMT might be suitable for you, our therapists will apply a thorough functional evaluation.

The usual conditions that we treat are the following:

Cerebral Palsy

Cerebral palsy (CP) is the result of damage to the premature brain, either during pregnancy, birth or early infant years. CP can lead to muscle weakness, incoordination of movements and affected muscle tone. CP can affect all four limbs (quadriplegia), lower limbs only (diplegia) or one side of the body (hemiplegia). CIMT is suitable for hemiplegic CP and specific quadriplegic cases.

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Cerebrovascular Accident (Stroke)

A stroke usually results in movement difficulties in one side of the body (hemiplegia). Early after the incident, movement of the affected hand is clumsy and inefficient leading to unconscious avoidance of this part of the body and use of the healthy hand throughout most everyday activities. This compensation leads to further functional decrements as the muscles lose more of their strength, being underused.

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Brachial plexus injury-BPI (Obstetrical Palsy)

The brachial plexus is responsible for sensory and movement innervation of the entire upper limb. Lesions of the brachial plexus can lead to severe functional impairment. Obstetrical Palsy is a special type of BPI that occurs during the birthing process and affects all or part of the infant’s arm and hand.

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Multiple Sclerosis (MS)

Multiple Sclerosis is a chronic, auto-immune condition which means that for some unidentified reason the body triggers an inflammatory response affecting the nerves in the brain and/ or spinal cord. This can affect a person’s movements as the brain is unable to effectively transmit the messages to the nerves supplying the muscles. Movements may be slower and uncoordinated leading to functional problems with one or both arms during everyday activities.

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Traumatic Brain Injury (TBI)

Traumatic brain injury may occur in the area of the brain responsible for controlling movements in the arm and hand, leading to hemiplegia. It is known that people who have arm and hand weakness are more likely to compensate during functional activities by using their stronger arm. The reason for this is that movement of the weaker arm and hand may be slower or demanding greater effort, thus causing frustration. This condition progressively results in “forgetting” use of the weaker hand and spontaneously using only the healthy hand to accomplish everyday activities. This compensation leads to further functional decrements as the muscles lose more of their strength, being underused.

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For more visit site —>  Constraint Induced Movement Therapy | Constraint Induced Movement Therapy

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[ARTICLE] Assessment of the Efficacy of ReoGo-J Robotic Training Against Other Rehabilitation Therapies for Upper-Limb Hemiplegia After Stroke: Protocol for a Randomized Controlled Trial – Full Text

Background: Stroke patients experience chronic hemiparesis in their upper extremities leaving negative effects on quality of life. Robotic therapy is one method to recover arm function, but its research is still in its infancy. Research questions of this study is to investigate how to maximize the benefit of robotic therapy using ReoGo-J for arm hemiplegia in chronic stroke patients.

Methods: Design of this study is a multi-center parallel group trial following the prospective, randomized, open-label, blinded endpoint (PROBE) study model. Participants and setting will be 120 chronic stroke patients (over 6 months post-stroke) will be randomly allocated to three different rehabilitation protocols. In this study, the control group will receive 20 min of standard rehabilitation (conventional occupational therapy) and 40 min of self-training (i.e., sanding, placing and stretching). The robotic therapy group will receive 20 min of standard rehabilitation and 40 min of robotic therapy using ReoGo®-J device. The combined therapy group will receive 40 min of robotic therapy and 20 min of constraint-induced movement therapy (protocol to improve upper-limb use in ADL suggests). This study employs the Fugl-Meyer Assessment upper-limb score (primary outcome), other arm function measures and the Stroke Impact Scale score will be measured at baseline, 5 and 10 weeks of the treatment phase. In analysis of this study, we use the mixed effects model for repeated measures to compare changes in outcomes between groups at 5 and 10 Weeks. The registration number of this study is UMIN000022509.

Conclusions: This study is a feasible, multi-site randomized controlled trial to examine our hypothesis that combined training protocol could maximize the benefit of robotic therapy and best effective therapeutic strategy for patients with upper-limb hemiparesis.

Introduction

Severe, persistent paresis occurs in over 40% of stroke patients (1) and is reported to significantly decrease their quality of life (2). Thus, much research has been conducted to develop interventions, with many specifically targeting upper extremity hemiplegia. Among the many examples of neuroscience-based rehabilitation (neuro-rehabilitation) strategies, there is strong evidence supporting robotic therapy, constraint-induced movement therapy (CIMT), and task-oriented training (34).

Robotic therapy is considered an effective intervention for mild to severe hemiplegic arm (56), and is cost-effective for chronic stroke patients in terms of both manpower and medical costs (78). However, its effects may be limited for some patients. Some researchers have found that robotic therapy effectively improves arm function as measured by the Fugl-Meyer Assessment (FMA) (9) and Action research arm test (ARAT) (10), but does not improve the use of the affected arm in activities of daily living (ADL) as measured by the Motor activity log (MAL)-14 (11) and by analysis of data from an accelerometer attached to the affected arm (61214).

On the contrary, CIMT is the most well-established intervention for improving the use of the affected arm in ADL (15). CIMT consists of three components: (1) a repeated task-oriented approach, (2) a behavioral approach to transfer the function gained during training to actual life (also called the “transfer package”), and (3) constraining use of the affected arm. Some researchers consider the transfer package the most important component of CIMT. In fact, research has shown that usage of the affected arm in daily life is significantly different between patients treated with and without the transfer package component (1617). However, many therapists question whether CIMT could benefit their patients because of the shortage of sites possessing the clinical resources to provide the intervention for the long duration required for effectiveness (18).

Therefore, there is an urgent need to establish an effective therapeutic approach, especially for upper-limb hemiplegia during the chronic stage of stroke recovery for which there are few clinical resources (In Japan, the insurance system only allows 260 min per month). Therefore, we will compare the efficacy of several therapy methods. As a control, we will monitor changes in arm function in patients undergoing a short, standard rehabilitation by a therapist and standard self-training (control group). This will be compared to similar self-training including robotic therapy with the ReoGo-J device as an adjuvant therapy (RT group). Finally, the robotic therapy will be compared to combined therapy including robotic therapy and CIMT (CT group). Through these comparisons, we will investigate the effect of robotic therapy, both alone and in combination with CIMT, which we hypothesize will complement each other in chronic stroke rehabilitation. Here, we report the structure and protocol of a multi-center, randomized controlled trial.[…]

 

Continue —> Frontiers | Assessment of the Efficacy of ReoGo-J Robotic Training Against Other Rehabilitation Therapies for Upper-Limb Hemiplegia After Stroke: Protocol for a Randomized Controlled Trial | Neurology

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[Abstract] Assessment of the Efficacy of ReoGo-J Robotic training against other rehabilitation therapies for Upper-Limb Hemiplegia after Stroke: Protocol for a Randomized Controlled Trial

Background: Stroke patients experience chronic hemiparesis in their upper extremities leaving negative effects on quality of life. Robotic therapy is one method to recover arm function, but its research is still in its infancy. Research questions of this study is to investigate how to maximize the benefit of robotic therapy using ReoGo-J for arm hemiplegia in chronic stroke patients.

Method: Design of this study is a multi-center parallel group trial following the prospective, randomized, open-label, blinded endpoint (PROBE) study model. Participants and setting will be 120 chronic stroke patients (over 6 months post-stroke) will be randomly allocated to three different rehabilitation protocols. In this study, the control group will receive 20 minutes of standard rehabilitation (conventional occupational therapy) and 40 minutes of self-training (i.e., sanding, placing and stretching). The robotic therapy group will receive 20 minutes of standard rehabilitation and 40 minutes of robotic therapy using ReoGo®-J device. The combined therapy group will receive 40 minutes of robotic therapy and 20 minutes of constraint-induced movement therapy (protocol to improve upper-limb use in ADL suggests). This study employs the Fugl-Meyer Assessment upper-limb score (primary outcome), other arm function measures and the Stroke Impact Scale score will be measured at baseline, 5 weeks, and 10 weeks of the treatment phase. In analysis of this study, we use the mixed effects model for repeated measures to compare changes in outcomes between groups at Week 5 and 10. The registration number of this study is UMIN000022509.

Conclusion: This study is a feasible, multi-site randomized controlled trial to examine our hypothesis that combined training protocol could maximize the benefit of robotic therapy and best effective therapeutic strategy for patients with upper-limb hemiparesis.

via Frontiers | Assessment of the Efficacy of ReoGo-J Robotic training against other rehabilitation therapies for Upper-Limb Hemiplegia after Stroke: Protocol for a Randomized Controlled Trial | Neurology

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[BLOG POST] Repetition Improves Stroke Recovery Time – Saebo

In all stages of growth and development, repetition is key to successful long-term learning and information retention. Repetition is especially beneficial for stroke survivors who seek to regain motor function, strength, and coordination. Consistent repetition that re-establishes communication between the damaged parts of the brain and the body is crucial in stroke rehabilitation.

The brain is our most complex organ and scientists still don’t fully understand it, but we have extensive evidence of one amazing capability called “neuroplasticity.” Neuroplasticity is the brain’s ability to form new synapses, or connections between neurons, especially in response to a brain injury. The nervous system compensates for damage by reorganizing the neurons that remain intact. To form new connections, the involved neurons must be stimulated through consistent activity. Fully understanding this process—and why it works—motivates and clarifies the essential role of repetition in post-stroke rehabilitation.

Neuroplasticity Is The Ability To Heal

For our bodies to perform even the simplest tasks, networks of nerve cells, or neurons, must act in tandem to stimulate the correct parts of our bodies. However, when a stroke causes damage to an area of the brain, damaged neurons become unable to send out signals to the corresponding regions of the body. Although a stroke survivor may appear to have suffered damage to an area of the body—for example, the right arm and leg might be paralyzed—the issue actually stems from damage in the brain.

Amazingly, the brain compensates for these losses through various regenerative strategies. A common process, neuroplasticity, is something that the brain undergoes whenever we learn a new piece of information. As our environments and daily routines change throughout life, we create new synapses, or neural connections. During a healing process, the brain is even more engaged when building these new networks. Synaptic pathways are restructured to work around damaged neurons and may even relocate to entirely different areas of the brain.

Under the right circumstances, the brain can even create new neurons in a process known as neurogenesis. Any healing process requires a healthy body, to support the regeneration of cells, and neurogenesis is no different—the regenerating areas of the brain must be healthy, with the proper blood and oxygen supply, and must be activated consistently. Stroke survivors can encourage neurogenesis through frequent therapy, as well as at-home practice. Careful, diligent practice also ensures that new synapses and neurons do not lead to additional issues or symptoms.

Research has shown that stroke survivors who use repetition to promote neuroplasticity enjoy significant progress in their recovery. In one study, patients who initially struggled with grasp-and-release exercises demonstrated increased cortical reorganization after adhering to a repetitive rehabilitation regimen.

Visualize Progress And Challenge Yourself

We are only just beginning to discover the magnitude of the brain’s capabilities. Not only can the brain heal itself through proper support and repetitive exercises, but it can also respond positively to diligent and focused visualization of those same exercises. People who visualize a process can strengthen the involved synapses without performing the actual, physical motion. Visualization is a great introduction to rehabilitation for those who cannot physically complete the motions. In the early stages of regaining motor function or range-of-motion in an affected limb, it is important for stroke survivors to apply themselves to visualization with the same commitment as they would a physical exercise.

Ia 1995 study, synapses strengthened in participants who imagined completing a particular piano exercise. Even though they were not performing any physical motions, their brains still registered and retained the musical information. This principle is vital for those in the early stages of stroke recovery. Visualization bridges the gap between the motivational difficulties inherent to the early stages of rehabilitation and the more physically intense practices later on in recovery.

The transition between visualization and physical performance can be challenging. Supportive tools such as the SaeboMAS provide support to the affected limb while relieving stress from the joints and muscles involved in the exercise. By guiding the arm through its first physical motions, SaeboMAS helps the brain transition from visualization to independent task completion. Tools like SaeboMAS also encourage consistency in motion, a crucial factor when attempting such intensely repetitive action.

Once you master a repetitive action, it’s important to continue challenging yourself with an exercise routine. This is against human nature because once a task feels easy, we feel that we have succeeded; however, repetitions while on autopilot are far less beneficial than when the individual is actively focused on performing each repetition. It takes self-discipline to continue increasing the difficulty of an exercise but you can derive motivation from the support of a therapist, friends or family.

CIMT—or Constraint Induced Movement Therapy— allows for personal adjustments to the difficulty of an exercise. It’s common for those healing from motor function difficulties to avoid challenging the affected limb, overcompensating with the healthy limb to the point that the affected limb begins to deteriorate further due to non-use. Once the patient can comfortably rely on the affected limb, CIMT introduces “shaping” or “adaptive task practice”: the deconstruction of complex physical tasks into manageable steps that are added one at a time. This gradual addition of challenges deters the patient from switching to autopilot during long, repetitive sets.

A motivated and clear mindset is crucial, therefore the exercises themselves must follow a natural progression to become more challenging, while not being too frustrating. This balance comes from respecting each motion—no matter how small—as an important building block in the healing process. By remaining present in the repetitions, the brain picks up on more detailed messages from the body about what it needs. Any associated soreness or pain should be discussed with professionals to ensure that exercises are promoting healing and not inadvertently causing further damage.

Practice With Purpose

As mindfulness increases, it will become clearer which exercises are right for each particular day, depending on how the body feels. By honoring your body as your guide, you will improve your motivation and the physical progression of neuroplasticity. However, sensing what is best for the body is a tricky practice. Harder tasks may challenge a wider variety of neural networks, speeding up the healing process even when the exercise itself feels less successful.

Overall, it’s better to challenge the brain by moving beyond repetition that no longer inspires further improvement. Start small by mastering simpler tasks and skills, then immediately move on to slightly harder versions of those actions. Always maintain the same level of consistency, but with added restraint or weight. Without added challenges, the progress made through rehabilitation can be lost. It may help to view this healing process as a long-term, ongoing journey with the goal of fully rebuilding and re-strengthening connections that would otherwise be lost.

Canadian psychologist Dr. Donald Hebb claimed that “neurons that fire together, wire together,” in his 1949 book, “The Organization of Behavior.” Long before today’s societal focus on mindfulness, Dr. Hebb recognized the occurrence of neurological regrowth when an activity or thought process is repeated diligently. This observation is pertinent to unlearning less helpful habits or thought patterns, as well. If someone in rehabilitation develops a bad habit, such as injuring a healthy limb through overuse, the brain can unlearn these habits through careful repetition.

Mindfulness Leads To Motivation

The benefits of mindfulness are open to all kinds of learning. Intentional focus during practice is the only way to ensure the brain is fully present and supported for neuroplasticity and neurogenesis. During visualization, each movement should be imagined with extreme specificity as well; awareness that is too unspecific can lead to apathy and lack of concentration. Visualization can be motivating, pushing the person in rehabilitation past the plateau stage—a dispiriting time in the process in which progress stalls. Overall, the trick is to keep exercises from becoming routine. When each day is different or challenging in a new way, the brain stays engaged in ways more conducive to synaptic rehabilitation.

You Need To Move

The most important mantra for post-stroke recovery is to keep moving. Once an intention or goal has been set, consistent movement is the key to warding off muscular atrophy. As mentioned earlier, even before physical movement is possible, exercises can be completed in the brain through visualization. Begin as soon as possible after the injury to take full advantage of early neurogenesis before entering the plateau phase. Whether visualizing or physically completing an action, repetition  is the most important factor in long-term recovery.

How Much Is Enough?

The question remains, how many repetitions are enough to regain full health during stroke rehabilitation? The number of repetitions required to establish a neural pathway depends on multiple factors:

  • the type of exercise
  • the area of the body
  • the current health of the muscles, nerves, and joints

Consistent, dedicated repetition is the most important priority. Without this, the brain cannot complete the rebuilding of the neurons, networks, and capabilities it lost during the stroke.

Quality of repetitions is just as important as quantity. Practice is helpful only while remaining mindful and fully present. Concentration also bolsters motivation, especially when progress plateaus.

Together, mindfulness and repetition move those in rehabilitation past initial discomfort more quickly by strengthening the affected muscles and neurons. We now know that visualization and drive have a psychosomatic effect, speeding up rehabilitation while the brain is most susceptible to healing. Visit the Saebo blog for more information about healing after a stroke.


All content provided on this blog is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your doctor or 911 immediately. Reliance on any information provided by the Saebo website is solely at your own risk.

via Repetition Improves Stroke Recovery Time | Saebo

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

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

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

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

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

 

via Neurophysiological effects of constraint-induced movement therapy and motor function: A systematic review | International Journal of Therapy and Rehabilitation | Vol 25, No 4

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[Abstract] Efficacy of upper limb constraint-induced movement therapy in patients with stroke and impact on community activities: Outcomes of a pilot phase study

Abstract

Introduction

Constraint-Induced Movement Therapy (CIMT) is one of the techniques used to promote sensory-motor recovery of the upper limb in patients with stroke. The aim of this study was to design a pilot phase randomized controlled clinical trial to assess the efficacy of CIMT in the motor performance, and the incorporation of the affected upper limb in community tasks in stroke patients with less than 3 months of evolution.

Materials and methods

The sample was randomly assigned to either CIMT (n = 7) or a control group (n = 6). The outcome measures were assessed pre- and post-intervention by using the Fugl-Meyer Motor Assessment (FMA); dynamometry; Functional Independence Measure (FIM); Arm Motor Ability Test (AMAT); Motor Activity Log (MAL); and Community Activities Scale (CAS).

Results

Both groups were similar on demographics, clinical and baseline outcome scales. Significant effects were noted post-intervention in the CIMT group on AMAT (P<.05), MAL (p<.05), and CAS (P=.05). There were no differences on FMA (P=.880), dynamometry (P=.356), and FIM (P=.508) scores. CAS scale was correlated with tests for assessing the functionality of the upper limb. The relationship was high with the FMA scale (rho=.673) and time (rho = –.627), functional ability (rho=.784) and quality of movement (rho = 735) subscales of AMAT.

Conclusions

CIMT is effective to improve the integration and quality of movement of the affected upper limb in daily life activities and community tasks in individuals with stroke.

 

via Eficacia de la terapia de movimiento inducido por restricción para miembros superiores en pacientes con accidente cerebrovascular y su impacto en actividades de la comunidad: resultados de la fase piloto – ScienceDirect

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[ARTICLE] The Functional Recovery and the Associated Cortical Reorganization Following Constraint-Induced Movement Therapies (CIMTs) in Stroke. – Full Text PDF

Abstract

Constraint-Induced Movement Therapies (CIMTs) including the original Constraint- Induced Movement Therapy (CIMT) and the Modified Constraint-Induced Movement Therapy (mCIMT) gained considerable popularity as a treatment approach for upper extremity rehabilitation among patients with mild-to-moderate stroke.

However, a major barrier in rehabilitation generally and in CIMTs specifically; is the limited objectivity of some commonly used outcome measures and lack sensitivity to define “True” recovery vs. compensation. Thereby, they may not sufficiently detect of long term consequences and the associated neurological recovery. An essential approach to overcome such barrier is to better understand functional motor recovery, associated neural changes and how they may relate to recovery of the pre-morbid movement pattern.

Such Understanding for these relationships would add more in-depth insights on the
functional relevance of plastic brain changes in stroke following CIMTs to optimize the field of neuro-rehabilitation. This review synthesizes findings from studies to on the use of the CIMTs including CIMT and mCIMT as efficient practice in the management of upper limb dysfunction following a stroke. The analysis will include (1) the functional recovery and (2) the cortical reorganization following the use of mCIMT and CIMT on patients in the chronic stage following stroke.

Introduction

Stroke is considered the fifth leading cause of death in the United
States [1]. To date, stroke affects at least 6.4 million persons in the United
States [2]. Projections show that by 2030, an additional 3.4 million
people above 18 years will have had a stroke which is approximately a
20.5% increase in prevalence from 2012 statistics [1]. Stroke is a leading
cause of serious long-term disability in the United States [1].

Arm paresis is one of the most common impairments after stroke
[3,4]. After six months, about two-thirds of patients continue to suffer
from arm sensorimotor impairment that impacts the individual’s
activities of daily living [5]. Motor deficits consist of weakness of
specific muscles [6], abnormal muscle tone [7-9], abnormal postural
adjustments [10], abnormal movement synergies [11], lack of mobility
between structures at the shoulder girdle [10] and incorrect timing
of components within a movement pattern [12]. As a result of such
impairment, patients may progressively avoid using the affected arm in
favor of the unaffected arm for successful ADL, resulting in a learned
non-use phenomenon [13].[…]

Full Text PDF

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[Abstract] Occupational therapy for the upper limb after stroke: implementing evidence-based constraint induced movement therapy into practice. – Doctoral thesis

Abstract

Background
Constraint induced movement therapy (CIMT), an intervention to increase upper limb (UL) function post-stroke, is not used routinely by therapists in the United Kingdom; reasons for this are unknown. Using the Promoting Action on Research Implementation in Health Services (PARIHS) framework to analyse CIMT research and context, a series of related studies explored implementation of CIMT into practice.

Methods and Findings
Systematic review: nineteen CIMT randomised controlled trials found evidence of effectiveness in sub-acute stroke, but could not determine the most effective evidence-based protocols. Further review of qualitative data found paucity of evidence relating to acceptability and feasibility of CIMT.
Focus group: perceptions of the feasibility, including facilitators and barriers, of implementing CIMT into practice were explored in a group of eight therapists. Thematic analysis identified five themes: personal characteristics; setting and support; ethical considerations; education and training; and practicalities, which need to be addressed prior to implementation of CIMT.

Mixed-methods, pilot study (three single cases): pre- and post-CIMT (participant preferred protocol) interviews explored perceptions and experiences of CIMT, with pre- and post-CIMT measurement of participation and UL function. Findings indicated: (i) provision of evidence-based CIMT protocols was feasible, although barriers persisted; (ii) piloted data collection and analysis methods facilitated exploration of stroke survivors’ perceptions and experiences, and recorded participation and UL function.

Conclusions
Findings traversed PARIHS elements (evidence, context, facilitation), and should be considered prior to further CIMT implementation. Future studies of CIMT should explore: effects of CIMT protocol variations; characteristics of stroke survivors most likely to benefit from CIMT; interactions between CIMT and participation.

Source: Keele Research Repository – Keele University

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