Carolee J. Winstein

Retention of upper limb function in stroke survivors who have received constraint-induced movement therapy: the EXCITE randomised trial

BACKGROUND The aim of constraint-induced movement therapy (CIMT) is to promote use of a limb that is functionally impaired after a stroke. In one form of CIMT to treat upper limb impairment, use of the less severely affected arm is restricted for many hours each weekday over 2 consecutive weeks. The EXCITE trial has previously shown the efficacy of this intervention for patients 3-9 months poststroke who were followed-up for the next 12 months. We assessed the retention of improvements 24 months after the intervention. METHODS In the EXCITE trial, 106 of 222 participants who had mild to moderate poststroke impairments were randomly assigned to receive CIMT rather than usual and customary care. We assessed this group of patients every 4 months for the primary outcome measure of impaired upper limb function, as measured with the Wolf motor function test (WMFT) and the motor activity log (MAL). Health-related quality of life, measured with the stroke impact scale (SIS), was a secondary outcome measure. Analysis was per protocol. This trial is registered with ClinicalTrials.gov, number NCT00057018. FINDINGS The effects at 24 months after treatment did not decline from those at 12 months for time taken to complete the WMFT (-0.32 s, 95% CI -3.70 to 3.06), for weight lifted in the WMFT (-1.39 kg, -2.74 to -0.04), for WMFT grip strength (-4.39 kg, -6.91 to -1.86), for amount of use in the MAL (-0.17, -0.38 to 0.04), or for how well the limb was used in the MAL (-0.14, -0.34 to 0.06). The additional changes were in the direction of increased therapeutic effect. For the strength components of the WMFT, p<0.0001. INTERPRETATION Patients who have mild to moderate impairments 3-9 months poststroke have substantial improvement in functional use of the paretic upper limb and quality of life 2 years after a 2-week CIMT intervention. Thus, this intervention has persistent benefits.

Methods for a Multisite Randomized Trial to Investigate the Effect of Constraint-Induced Movement Therapy in Improving Upper Extremity Function among Adults Recovering from a Cerebrovascular Stroke

This article describes the study design, methodological considerations, and demographic characteristics of a phase III RCT to determine if 1) constraint-induced therapy (CI therapy) can be applied with therapeutic success 3 to 9 months after stroke across different sites, 2) gains that might occur persist over 2 years, 3) initial level of motor ability determines responsiveness to CI therapy, and 4) the treatment effect differs between those treated before 9 months and after 1 year. Six sites will screen and recruit poststroke survivors stratified on initial level of motor ability and after randomization allocate participants to immediate or delayed intervention. Primary outcomes include a laboratory-based measure of function (Wolf Motor Function Test [WMFT]) and a real-world participant-centered functional use measure (Motor Activity Log [MAL]). Secondary outcomes concern function, behavior, and compliance. This is the first multisite, single-blind RCT of a formal training intervention for upper extremity rehabilitation in subacute stroke in the United States.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association

Purpose— The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke. Methods— Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council’s Scientific Statement Oversight Committee and the AHA’s Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. Results— Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential. Conclusions— As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.)

Effects of unilateral brain damage on the control of goal-directed hand movements

Insight into the functional neural substrates associated with the control of goal-directed purposive movements can be obtained through the study of the performance of individuals with brain damage. The control of rapid reciprocal aiming was investigated by comparing ipsilateral limb performance of subjects with unilateral brain damage to that of controls performing with the same limb. Thirty right-hand-dominant individuals, ten with right hemisphere stroke, ten with left hemisphere stroke, and ten age-matched controls performed unconstrained alternating tapping movements under three conditions of task complexity. The path of the stylus was recorded by video using two-dimensional kinematic techniques. Key kinematic features of the vertical and horizontal components of the trajectories were analyzed using both quantitative and qualitative methods. All subjects with brain damage showed prolonged movement times; however, the locus of the slowing depended on lesion side. Specifically, subjects with left stroke showed deficits in the open-loop component of the movement across all three conditions of task complexity, and a prolonged reversal phase surrounding target impact, particularly in the most complex condition. In contrast, subjects with right stroke showed deficits in the closed-loop phase of the movement prior to target impact, particularly in the most complex condition when visual information was necessary for accuracy. Together, these results suggest that for the control of rapid goal-directed aiming movements, the left hemisphere is dominant for task-relevant aspects of processing associated with the ballistic component and the timing or triggering of sequential movements. In contrast, the right hemisphere is dominant for processing associated with rapid, on-line visual information even when target location is known and direction is certain.

The EXCITE trial: attributes of the Wolf Motor Function Test in patients with subacute stroke.

The Wolf Motor Function Test (WMFT) has been used in rehabilitation studies of chronic stroke patients, but until now its psychometric properties have not been evaluated in patients with subacute stroke. Two hundred twenty-nine participants with subacute stroke (3-9 months postinjury) at 7 research sites met inclusion criteria for the EXCITE Trial and were randomized into immediate or delayed (by 1 year) constraint-induced movement therapy treatment. All evaluations were undertaken by assessors standardized in the administration of the WMFT and masked to treatment designation. Participants were also assessed using the Fugl Meyer Motor Assessment (FMA). Delayed group members had measurements repeated 2 weeks following baseline assessment to determine learning or exposure effects. The results demonstrate that the WMFT differentiated higher from lower functioning participants across sites; scores were uninfluenced by hand dominance or affected side. Women exhibited slower performance times than men. The Functional Ability scale (FAS) portion of the WMFT also revealed lower scores among lower functioning participants and women. Minimal changes were observed after repeating the WMFT among delayed group participants 2 weeks later. The FMA revealed similar results when the total group was divided into higher and lower functional levels at its midpoint score of 33. The WMFT discriminates higher from lower functioning participants tested across research sites. Comparable findings using the FMA support the criterion validity of the WMFT.

Motor learning after unilateral brain damage.

Forty adults, post-stroke from anterior circulation unilateral cerebrovascular accident (approximately 2 years post onset) and 40 age-matched controls (M = 57 years) practiced a rapid, spatially and temporally constrained programmed action under one of two augmented feedback practice conditions. Participants in the stroke group used the upper limb ipsilateral to the lesion. After an extended practice period (198 trials), acquisition, retention, and reacquisition performance was assessed for accuracy and consistency and compared over trials, between groups and feedback conditions. Both stroke and control groups demonstrated significant improvement in accuracy and consistency over practice with relative persistence of these changes during retention. There were no differences between groups (stroke vs control) in performance patterns across trials for acquisition, retention, or reacquisition phases. In addition, there were no differential effects of the two augmented feedback conditions on performance and no interactions of feedback condition with group. However, independent of feedback condition, the stroke group performed with more error than did the control group during all experimental phases (i.e., acquisition, retention, reacquisition). These results suggest that unilateral stroke-related damage in the sensorimotor areas primarily effects the processes underlying the control and execution of motor skills but not the learning of those skills. Implications of these findings for physical rehabilitation are discussed.

Effects of Task-Specific Locomotor and Strength Training in Adults Who Were Ambulatory After Stroke: Results of the STEPS Randomized Clinical Trial

Background and Purpose: A phase II, single-blinded, randomized clinical trial was conducted to determine the effects of combined task-specific and lower-extremity (LE) strength training to improve walking ability after stroke. Subjects: The participants were 80 adults who were ambulatory 4 months to 5 years after a unilateral stroke. Method: The exercise interventions consisted of body-weight–supported treadmill training (BWSTT), limb-loaded resistive leg cycling (CYCLE), LE muscle-specific progressive-resistive exercise (LE-EX), and upper-extremity ergometry (UE-EX). After baseline assessments, participants were randomly assigned to a combined exercise program that included an exercise pair. The exercise pairs were: BWSTT/UE-EX, CYCLE/UE-EX, BWSTT/CYCLE, and BWSTT/LE-EX. Exercise sessions were 4 times per week for 6 weeks (total of 24 sessions), with exercise type completed on alternate days. Outcomes were self-selected walking speed, fast walking speed, and 6-minute walk distance measured before and after intervention and at a 6-month follow-up. Results: The BWSTT/UE-EX group had significantly greater walking speed increases compared with the CYCLE/UE-EX group; both groups improved in distance walked. All BWSTT groups increased walking speed and distance whether BWSTT was combined with LE strength training or not. Discussion and Conclusion: After chronic stroke, task-specific training during treadmill walking with body-weight support is more effective in improving walking speed and maintaining these gains at 6 months than resisted leg cycling alone. Consistent with the overtraining literature, LE strength training alternated daily with BWSTT walking did not provide an added benefit to walking outcomes.

Effects of Physical Guidance and Knowledge of Results on Motor Learning: Support for the Guidance Hypothesis

The guidance hypothesis (Schmidt, 1991) predicts that the guiding properties of augmented feedback are beneficial for motor learning when used to reduce error, but detrimental when relied upon. Therefore, a heavily guiding form of feedback might be detrimental for learning. In addition, the guidance hypothesis predicts that practice with a high relative frequency of augmented feedback would be detrimental for learning. An experiment is described that crossed two forms of feedback with two levels of relative frequency. Subjects practiced movements to a target with either physical guidance or knowledge of results, and with either a high or faded relative frequency. The high frequency physical guidance condition resulted in the poorest retention, and both high frequency feedback conditions resulted in the least accuracy in transfer. These results provide support for the guidance hypothesis and suggest consideration of the combined effects on learning of the type and relative frequency of augmented feedback and acquisition-test conditions.

Learning–performance distinction and memory processes for motor skills: A focused review and perspective

Behavioral research in cognitive psychology provides evidence for an important distinction between immediate performance that accompanies practice and long-term performance that reflects the relative permanence in the capability for the practiced skill (i.e. learning). This learning-performance distinction is strikingly evident when challenging practice conditions may impair practice performance, but enhance long-term retention of motor skills. A review of motor learning studies with a specific focus on comparing differences in performance between that at the end of practice and at delayed retention suggests that the delayed retention or transfer performance is a better indicator of motor learning than the performance at (or end of) practice. This provides objective evidence for the learning-performance distinction. This behavioral evidence coupled with an understanding of the motor memory processes of encoding, consolidation and retrieval may provide insight into the putative mechanism that implements the learning-performance distinction. Here, we propose a simplistic empirically-based framework--motor behavior-memory framework--that integrates the temporal evolution of motor memory processes with the time course of practice and delayed retention frequently used in behavioral motor learning paradigms. In the context of the proposed framework, recent research has used noninvasive brain stimulation to decipher the role of each motor memory process, and specific cortical brain regions engaged in motor performance and learning. Such findings provide beginning insights into the relationship between the time course of practice-induced performance changes and motor memory processes. This in turn has promising implications for future research and practical applications.

Motor Cortex Activation During Treatment May Predict Therapeutic Gains in Paretic Hand Function After Stroke

Background and Purpose— Functional brain imaging after stroke offers insight into motor network adaptations. This exploratory study examined whether motor cortical activation captured during arm-focused therapy can predict paretic hand functional gains. Methods— Eight hemiparetic patients had serial functional MRI (fMRI) while performing a pinch task before, midway, and after 2 weeks of constraint-induced therapy. The Wolf Motor Function Test (WMFT) was performed before and after intervention. Results— There was a linear reduction in ipsilateral (contralesional) primary motor (M1) activation (voxel counts) across time. The midpoint M1 Laterality Index anticipated post-therapeutic change in time to perform the WMFT. The change in ipsilateral M1 voxel count (pre- to mid-) correlated with the change in mean WMFT time (pre- to post-). Conclusions— The relationship between brain activation during treatment and functional gains suggests a use for serial fMRI in predicting the success and optimal duration for a focused therapeutic intervention.