Iris Brunner

Is modified constraint-induced movement therapy more effective than bimanual training in improving arm motor function in the subacute phase post stroke? A randomized controlled trial

Objective: To compare the effect of modified constraint-induced movement therapy (mCIMT) to bimanual task-related training for patients in the subacute phase post stroke. Design: A single-blinded randomized controlled trial. Settings: Inpatient and outpatient rehabilitation clinics and the patient’s home. Subjects: Thirty patients in the subacute phase post stroke (2–16 weeks) were randomized to modified constraint-induced movement therapy with an emphasis on unimanual tasks, or bimanual task-related training, emphasizing bimanual tasks. All trained with a therapist 4 hours a week for four weeks, followed by a 2–3 hours daily self-training program. Patients in the modified constraint-induced movement therapy group were supposed to wear a restraining mitt on the unaffected hand for 4 hours a day for four weeks. Main measures: Blinded assessments at pre and post treatment and after three months with Action Research Arm Test as a primary outcome measure, Nine-Hole Peg Test and Motor Activity Log. Results: Power calculations suggested an inclusion of 60 patients, but due to recruitment difficulties the trial was stopped after an interim analysis at 30 patients. There was no difference in change (P > 0.05) between the groups on any of the measures, neither at post treatment nor at follow-up assessments. From pre-intervention to follow-up assessment the modified constraint-induced movement therapy group obtained a mean change score of 17.77 (14.66) on Action Research Arm Test, the bimanual group 15.47 (13.59). Conclusion: Bimanual training was as effective as modified constraint-induced movement therapy in improving arm motor function. Wearing a mitt seems unnecessary for most patients in the subacute phase post stroke when focused affected arm training is provided.

Virtual reality training for upper extremity in subacute stroke (VIRTUES): study protocol for a randomized controlled multicenter trial

BackgroundNovel virtual reality rehabilitation systems provide the potential to increase intensity and offer challenging and motivating tasks. The efficacy of virtual reality systems to improve arm motor function early after stroke has not been demonstrated yet in sufficiently powered studies. The objective of the study is to investigate whether VR training as an adjunct to conventional therapy is more effective in improving arm motor function in the subacute phase after stroke than dose-matched conventional training, to assess patient and therapist satisfaction when working with novel virtual reality training and to calculate cost-effectiveness in terms of resources required to regain some degree of dexterity.Methods/DesignRandomized controlled observer-blind trial.One hundred and twenty patients up to 12 weeks after stroke will be randomized to either a group receiving VR training or dose-matched and therapist attention-matched conventional arm training in addition to standard rehabilitation. During a period of four weeks the patients will be offered additional 4–5 training sessions a week of 45–60 minutes duration by a physiotherapist or an occupational therapist.Study outcomes: Arm motor function, dexterity and independence in daily life activities will be evaluated at baseline, post treatment and three months follow-up assessments with the Action Research Arm Test, Box and Blocks Test and the Functional Independence Measure, respectively. Patient and therapist satisfaction with the implementation of a VR rehabilitation system will also be assessed with questionnaires and interviews.DiscussionVirtual reality systems are promising tools for rehabilitation of arm motor function after stroke. Their introduction in combination with traditional physical and occupational therapy may enhance recovery after stroke, and at the same time demand little personnel resources to increase training intensity. The VIRTUES trial will provide further evidence of VR-based treatment strategies to clinicians, patients and health economists.Trial registrationClinicalTrials.gov NCT02079103

Recovery of upper extremity motor function post stroke with regard to eligibility for constraint-induced movement therapy.

Abstract Purpose: To examine eligibility for modalities such as constraint-induced movement therapy (CIMT) and modified CIMT (mCIMT) in the subacute phase after stroke and to define the share of patients who should be offered this treatment. Methods: A prospective, repeated-measures design was used. A total of 100 consecutive patients with arm paresis 1 to 2 weeks post stroke were screened. Eligible for CIMT were patients who were cognitively intact, medically stable, and able to extend the wrist and 3 fingers 10° as a lower limit. The active range of motion was registered, and motor function was assessed by the Action Research Arm Test (ARAT) and the Nine Hole Peg Test at 1 to 2 weeks, 4 weeks, and 3 months post stroke. Results: From 100 patients, 54 were excluded from motor assessment, mostly due to cognitive impairments. Of the remaining 46 patients, 21 (46%) were eligible according to motor function of the hand at 1 to 2 weeks post stroke, whereas in the other patients motor function was either too good or too poor. The share of patients eligible declined to 31% after 4 weeks and 15% after 3 months. Within 3 months, 60% reached reasonable dexterity, expressed by an ARAT score > 51, all receiving standard rehabilitation. Conclusion: Results indicate that eligibility for CIMT or mCIMT should not be considered before 4 weeks post stroke because much improvement in arm function was shown to occur during the first month post stroke with standard rehabilitation.PURPOSE To examine eligibility for modalities such as constraint-induced movement therapy (CIMT) and modified CIMT (mCIMT) in the subacute phase after stroke and to define the share of patients who should be offered this treatment. METHODS A prospective, repeated-measures design was used. A total of 100 consecutive patients with arm paresis 1 to 2 weeks post stroke were screened. Eligible for CIMT were patients who were cognitively intact, medically stable, and able to extend the wrist and 3 fingers 10° as a lower limit. The active range of motion was registered, and motor function was assessed by the Action Research Arm Test (ARAT) and the Nine Hole Peg Test at 1 to 2 weeks, 4 weeks, and 3 months post stroke. RESULTS From 100 patients, 54 were excluded from motor assessment, mostly due to cognitive impairments. Of the remaining 46 patients, 21 (46%) were eligible according to motor function of the hand at 1 to 2 weeks post stroke, whereas in the other patients motor function was either too good or too poor. The share of patients eligible declined to 31% after 4 weeks and 15% after 3 months. Within 3 months, 60% reached reasonable dexterity, expressed by an ARAT score ≯ 51, all receiving standard rehabilitation. CONCLUSION Results indicate that eligibility for CIMT or mCIMT should not be considered before 4 weeks post stroke because much improvement in arm function was shown to occur during the first month post stroke with standard rehabilitation.

Plasticity and Response to Action Observation A Longitudinal fMRI Study of Potential Mirror Neurons in Patients With Subacute Stroke

Background. Action observation has been suggested as a possible gateway to retraining arm motor function post stroke. However, it is unclear if the neuronal response to action observation is affected by stroke and if it changes during the course of recovery. Objective. To examine longitudinal changes in neuronal activity in a group of patients with subacute stroke when observing and executing a bimanual movement task. Methods. Eighteen patients were examined twice using 3-T functional magnetic resonance imaging; 1 to 2 weeks and 3 months post stroke symptom onset. Eighteen control participants were examined once. Image time series were analyzed (SPM8) and correlated with clinical motor function scores. Results. During action observation and execution, an overlap of neuronal activation was observed in the superior and inferior parietal lobe, precentral gyrus, insula, and inferior temporal gyrus in both control participants and patients (P < .05; false discovery rate corrected). The neuronal response in the observation task increased from 1 to 2 weeks to 3 months after stroke. Most activated clusters were observed in the inferior temporal gyrus, the thalamus and movement-related areas, such as the premotor, supplementary and motor cortex (BA4, BA6). Increased activation of cerebellum and premotor area correlated with improved arm motor function. Most patients had regained full movement ability. Conclusions. Plastic changes in neurons responding to action observation and action execution occurred in accordance with clinical recovery. The involvement of motor areas when observing actions early and later after stroke may constitute a possible access to the motor system.

Virtual Reality Training for Upper Extremity in Subacute Stroke (VIRTUES) A multicenter RCT

Objective: To compare the effectiveness of upper extremity virtual reality rehabilitation training (VR) to time-matched conventional training (CT) in the subacute phase after stroke. Methods: In this randomized, controlled, single-blind phase III multicenter trial, 120 participants with upper extremity motor impairment within 12 weeks after stroke were consecutively included at 5 rehabilitation institutions. Participants were randomized to either VR or CT as an adjunct to standard rehabilitation and stratified according to mild to moderate or severe hand paresis, defined as ≥20 degrees wrist and 10 degrees finger extension or less, respectively. The training comprised a minimum of sixteen 60-minute sessions over 4 weeks. The primary outcome measure was the Action Research Arm Test (ARAT); secondary outcome measures were the Box and Blocks Test and Functional Independence Measure. Patients were assessed at baseline, after intervention, and at the 3-month follow-up. Results: Mean time from stroke onset for the VR group was 35 (SD 21) days and for the CT group was 34 (SD 19) days. There were no between-group differences for any of the outcome measures. Improvement of upper extremity motor function assessed with ARAT was similar at the postintervention (p = 0.714) and follow-up (p = 0.777) assessments. Patients in VR improved 12 (SD 11) points from baseline to the postintervention assessment and 17 (SD 13) points from baseline to follow-up, while patients in CT improved 13 (SD 10) and 17 (SD 13) points, respectively. Improvement was also similar for our subgroup analysis with mild to moderate and severe upper extremity paresis. Conclusions: Additional upper extremity VR training was not superior but equally as effective as additional CT in the subacute phase after stroke. VR may constitute a motivating training alternative as a supplement to standard rehabilitation. ClinicalTrials.gov identifier: NCT02079103. Classification of evidence: This study provides Class I evidence that for patients with upper extremity motor impairment after stroke, compared to conventional training, VR training did not lead to significant differences in upper extremity function improvement.

Predicting shoulder function after constraint-induced movement therapy: a retrospective cohort study

ABSTRACT Background Several predictors have been associated with upper extremity (UE) recovery after stroke, but characteristics that predict shoulder function after constraint-induced movement therapy (CIMT) have not yet been identified. Objectives To identify predictors associated with satisfactory shoulder function in patients with reduced shoulder function at admission to CIMT. Methods One hundred and seventy five patients were treated using CIMT while in a specialized inpatient hospital. Satisfactory shoulder function was defined according to the functional ability scale of the Wolf Motor Function test. Predictors of satisfactory shoulder function after CIMT were identified using multivariable logistic regression. Results Better distal arm function and good proximal shoulder function on admission to CIMT were strong predictors of satisfactory shoulder function, while age and time of admission to CIMT since stroke were not. Seventeen percent of all CIMT-participants with reduced shoulder function pre-CIMT reached a level of satisfactory shoulder function after CIMT. Discussion A substantial part of patients with reduced shoulder function reached a level of satisfactory shoulder function after CIMT. Intensive CIMT training, comprising tasks that require both distal and proximal UE function, may increase shoulder function in patients with a potential functional reserve.