Posts Tagged Sequential combination therapy
[ARTICLE] Sequencing bilateral robot-assisted arm therapy and constraint-induced therapy improves reach to press and trunk kinematics in patients with stroke | Full Text
Posted by Kostas Pantremenos in Constraint induced movement therapy CIMT, Paretic Hand, Rehabilitation robotics on March 23, 2016
Journal of NeuroEngineering and Rehabilitation (JNER)
Published: 22 March 2016
Abstract
Background
The combination of robot-assisted therapy (RT) and a modified form of constraint-induced therapy (mCIT) shows promise for improving motor function of patients with stroke. However, whether the changes of motor control strategies are concomitant with the improvements in motor function after combination of RT and mCIT (RT + mCIT) is unclear. This study investigated the effects of the sequential combination of RT + mCIT compared with RT alone on the strategies of motor control measured by kinematic analysis and on motor function and daily performance measured by clinical scales.
Methods
The study enrolled 34 patients with chronic stroke. The data were derived from part of a single-blinded randomized controlled trial. Participants in the RT + mCIT and RT groups received 20 therapy sessions (90 to 105 min/day, 5 days for 4 weeks). Patients in the RT + mCIT group received 10 RT sessions for first 2 weeks and 10 mCIT sessions for the next 2 weeks. The Bi-Manu-Track was used in RT sessions to provide bilateral practice of wrist and forearm movements. The primary outcome was kinematic variables in a task of reaching to press a desk bell. Secondary outcomes included scores on the Wolf Motor Function Test, Functional Independence Measure, and Nottingham Extended Activities of Daily Living. All outcome measures were administered before and after intervention.
Results
RT + mCIT and RT demonstrated different benefits on motor control strategies. RT + mCIT uniquely improved motor control strategies by reducing shoulder abduction, increasing elbow extension, and decreasing trunk compensatory movement during the reaching task. Motor function and quality of the affected limb was improved, and patients achieved greater independence in instrumental activities of daily living. Force generation at movement initiation was improved in the patients who received RT.
Conclusion
A combination of RT and mCIT could be an effective approach to improve stroke rehabilitation outcomes, achieving better motor control strategies, motor function, and functional independence of instrumental activities of daily living.
Trial registration
ClinicalTrials.gov. NCT01727648
Background
Stroke remains a leading cause of permanent motor disability worldwide [1]. Persistent impairment of the upper extremity (UE) occurs in up to two-thirds of patients after stroke [2]. UE paresis can lead to deficits in motor control [3], motor dysfunction [4], and participation in activities of daily living (ADL) [5]. Developing and providing effective therapeutic techniques to improve UE motor control and recovery is crucial.
Robot-assisted therapy (RT) is an emerging intervention approach that provides high-intensity, high-repetition, and task-specific training to enhance motor learning and control in patients with stroke [6, 7]. Systemic reviews have indicated that RT improves UE muscle strength and motor function of patients with moderate to severe motor impairment after stroke [8,9]. A recent review suggested that the assessment of movement kinematics should be included in RT studies to identify modulation in motor control strategies [10]. Previous studies found that RT can improve motor control strategies in patients with stroke, including greater movement efficacy [11–13], better movement smoothness of the affected UE [13], and more use of the preplanned control strategy [13]. However, no consistent findings on patients’ participation in ADL were observed after RT [8, 14–17]. How to optimize or transfer the treatment benefits of RT on motor function and motor control strategies into participation in ADL warrants further investigation. An approach using RT monotherapy may not optimally address this need.
Constraint-induced therapy (CIT), one most investigated approaches to rehabilitation, was developed to overcome the learned nonuse phenomenon and enhance functional use of the affected arm after stroke [18, 19]. Treatment components of CIT include repetitive and intensive task practice, behavioral shaping techniques, restraint of the unaffected UE, and transfer package [20, 21]. Modified and distributed CIT, which are not as intensive as the original CIT, have been developed and validated [20, 22, 23]. The benefits of the original CIT and its modified versions have been well demonstrated to improve motor function, arm-hand activities, and daily performance of patients with stroke [19, 24, 25].
Therapies that combine RT with other rehabilitation approaches have been developed to optimize the treatment effects of RT [26–29]. The combination of RT and conventional therapy led to significant gains in arm function of patients, but different combination sequences showed benefits in different outcomes [27]. In addition, RT combined with repetitive task practice was effective in enhancing hand function and stroke recovery of patients [28]. To the best of our knowledge, only one study has investigated the treatment effects of sequencing the combination of RT and a modified form of CIT (mCIT) in patients with stroke [29]. The results indicated that the sequential combination of RT and mCIT led to better motor and functional ability measured by clinical scales compared with RT alone or conventional rehabilitation [29]. However, whether the changes in motor control strategies are responsible for the improvements in motor function after the sequential combination therapy remains unclear.
Kinematic analysis has been recommended as a sound measure to provide objective and sensitive evaluations on spatial and temporal characteristics of UE movements [8]. More importantly, kinematics can capture motor control strategies that cannot be detected by clinical scales [30]. Thus, kinematic analysis enables us to understand whether the behavioral improvement is due to a true change in the end point control and joint motion or is a result of compensation. Kinematic measures, along with clinical assessments, can better clarify the motor control strategies underlying the motor improvements of stroke patients [31, 32].
This study investigated the effects of the sequential combination of RT and mCIT (RT + mCIT), compared with RT alone, focusing on motor control strategies measured by kinematic analysis and on motor and ADL functions using clinical measures. We hypothesized that (1) RT + mCIT would lead to different benefits on the motor control strategies compared with and RT alone and that (2) RT + mCIT would contribute to better performances in ADL than RT alone.
Fig. 1 Graphic representation of the angular strategy variables: (a) shoulder flexion (ShFlex) in the sagittal plane and elbow extension (ElbExt) in the sagittal plane; (b) shoulder abduction (ShAbd) in the frontal plane; and (c) trunk flexion in sagittal (TrunkFlex) plane
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