Kohei Marumoto

A 6-month follow-up after constraint-induced movement therapy with and without transfer package for patients with hemiparesis after stroke: a pilot quasi-randomized controlled trial

Objective: To investigate the long-term effects of the ‘transfer package’ in constraint-induced movement therapy, which is an optional protocol to facilitate actual use of the trained affected arm in activities of daily living. Design: A pilot quasi-randomized controlled trial with a blinded single assessor with six-month follow-up. Setting: Hospitalized care at university hospital. Subjects: Twenty-one post-stroke patients were quasi-randomized to either a group with transfer package during constraint-induced movement therapy or a control group (without transfer package). Interventions: The transfer package group received 4.5 hours of intensive task training and 0.5 hours of transfer package whereas the control group received 5.0 hours of intensive task training per day during 10 consecutive weekdays. Main measures: Arm function was measured with Fugl-Meyer Assessment and Amount of Use score of Motor Activity Log. Results: Twenty-three patients were quasi-randomized, but data from two patients were missing from the long-term follow-up. Both groups showed increase in arm function postintervention. However, at six months’ follow-up only the transfer package group showed consistent increase in arm function (with transfer package group versus control group; Fugl-Meyer Assessment, mean (± SD) from 48.6 ± 7.8 (preintervention) to 55.7 ± 4.5 (postintervention) and 59.0 ± 3.6 (six months postintervention) versus from 49.1 ± 5.5 to 52.8 ± 6.0 and 53.3 ± 4.9, P= 0.003; Amount of Use scale of Motor Activity Log, mean from 1.3 ± 0.55 (preintervention) to 2.12 ± 0.55 (postintervention) and 2.79 ± 0.98 (six months postintervention) versus from 1.18 ± 0.70 to 1.61 ± 0.54 and 1.65 ± 0.68, P= 0.002). Conclusions: Our results confirmed the long-term effects of the transfer package in constraint-induced movement therapy.

Diffusion tensor imaging in elderly patients with idiopathic normal pressure hydrocephalus or Parkinson’s disease: diagnosis of gait abnormalities

BackgroundGait abnormalities in the elderly, characterized by short steps and frozen gait, can be caused by several diseases, including idiopathic normal pressure hydrocephalus (INPH), and Parkinson’s disease (PD). We analyzed the relationship between these two conditions and their association with gait abnormalities using laboratory test data and findings from diffusion tensor imaging (DTI).MethodsThe study involved 10 patients with INPH, 18 with PD, and 10 healthy individuals (control group). Fractional anisotropy (FA) of five brain areas was measured and compared among the three groups. In addition, the association of INPH and PD with gait capability, frontal lobe function, and FA of each brain area was evaluated.ResultsThe INPH group had significantly lower FA for anterior thalamic radiation (ATR) and forceps minor (Fmin) as compared to the PD group. The gait capability correlated with ATR FA in the INPH and PD groups. We found that adding DTI to the diagnosis assisted the differential diagnosis of INPH from PD, beyond what could be inferred from ventricular size alone.ConclusionsWe expect that DTI will provide a useful tool to support the differential diagnosis of INPH and PD and their respective severities.

Relationship between Diffusion Tensor Fractional Anisotropy and Motor Outcome in Patients with Hemiparesis after Corona Radiata Infarct

This study examined the relationship between fractional anisotropy (FA) values of magnetic resonance-diffusion tensor imaging (DTI) and motor outcome (1 month after onset) in 15 patients with hemiparesis after ischemic stroke of corona radiata lesions. DTI data were obtained on days 14-18. FA values within the cerebral peduncle were analyzed using a computer-automated method. Motor outcome of hemiparesis was evaluated according to Brunnstrom stage (BRS; 6-point scale: severe to normal) for separate shoulder/elbow/forearm, wrist/hand, and lower extremity functions. The ratio of FA values in the affected hemisphere to those in the unaffected hemisphere (rFA) was assessed in relation to the BRS data (Spearman rank correlation test, P<.05). rFA values ranged from .715 to 1.002 (median=.924). BRS ranged from 1 to 6 (median=4) for shoulder/elbow/forearm, from 1 to 6 (median=5) for wrist/hand, and from 2 to 6 (median=4) for the lower extremities. Analysis revealed statistically significant relationships between rFA and upper extremity functions (correlation coefficient=.679 for shoulder/elbow/forearm and .706 for wrist/hand). Although slightly less evident, the relationship between rFA and lower extremity function was also statistically significant (correlation coefficient=.641). FA values within the cerebral peduncle are moderately associated with the outcome of both upper and lower extremity functions, suggesting that DTI may be applicable for outcome prediction in stroke patients with corona radiata infarct.

Diffusion tensor imaging predicts the outcome of constraint-induced movement therapy in chronic infarction patients with hemiplegia: A pilot study.

PURPOSE To test whether diffusion tensor imaging could evaluate potential motor capability of patients with chronic cerebral infarction. METHODS We used constraint-induced movement therapy (CIMT) as a rehabilitation, which reveals potential motor capability. We also investigated the relationship between the outcome of CIMT and the ratio between fractional anisotropy values (rFA) in affected and unaffected sites of the corticospinal tract before CIMT. Imaging was performed in cerebral infarction patients (n = 14) and the rFA of the posterior limb of internal capsule (PLIC) was measured before CIMT. Patients were evaluated before and after CIMT using the Fugl-Meyer (F-M) assessment, Wolf Motor Function Test, Action Research Arm Test, and Motor Activity Log and association between PLIC- rFA and these scores was determined. RESULTS All patients showed an improvement in mobility following the 10-day CIMT session. Strong positive correlation was found only between F-M after CIMT and PLIC-rFA (r = 0.8098, p = 0.0004). A strong linear relationship was observed after CIMT. CONCLUSION These data support PLIC-rFA as a new marker of the CIMT-induced improvement in motor function (F-M).

Relationship between diffusion-tensor fractional anisotropy and long-term outcome in patients with hemiparesis after intracerebral hemorrhage

We assessed the relationship between fractional anisotropy (FA) values of magnetic resonance-diffusion tensor imaging (DTI) and long-term outcome (3-7 months after onset) in patients with hemiparesis after intracerebral hemorrhage (N = 12). DTI data were obtained on days 14-18. FA values within the cerebral peduncle were analyzed using a computer-automated method. Motor outcome of hemiparesis was evaluated using Brunnstrom stage (six-point scale: severe to normal) for separate shoulder/elbow/forearm, wrist/hand, and lower extremity functions when patients were discharged from a long-term rehabilitation facility 3-7 months after onset. In addition, the motor component of the functional independence measure (FIM-motor) was scored. The ratio of FA values in the affected hemisphere to those in the unaffected hemisphere (rFA) was assessed in relation to the clinical data (Spearmans rank correlation test, P < 0.05). Analysis revealed a statistically significant relationship between rFA and upper extremity function (R = 0.863 for shoulder/elbow/forearm; 0.834 for wrist/hand). Although statistically significant, the relationship between rFA and lower extremity function was less evident (R = 0.609). In contrast, analysis of rFA and FIM-motor scores did not reveal statistical significance. FA values within the cerebral peduncle are tightly associated with long-term outcomes of upper extremity function.

A one-year follow-up after modified constraint-induced movement therapy for chronic stroke patients with paretic arm: a prospective case series study

Abstract Background: Despite the confirmed short-term effects of constraint-induced movement therapy, the long-term effects have not been sufficiently verified in terms of functional improvement of the affected arm. Objective: To evaluate the long-term effects and relationship between arm use in activities of daily living and arm improvement with modified constraint-induced movement therapy in chronic stroke patients. Methods: At 1 year after completing modified constraint-induced movement therapy, arm function (Fugl-Meyer Assessment) and amount of daily arm use (motor activity log) were assessed. Results: Fourteen post-stroke patients with mild to moderate impairment of arm function were analyzed. One year after completing modified constraint-induced movement therapy, participants consistently showed improvements in arm function and amount of daily arm use (analysis of variance: Fugl-Meyer Assessment, P < 0.001; Motor Activity Log, P < 0.001). For the Fugl-Meyer Assessment, post-hoc tests detected significant improvements (pre versus post, P = 0.009; pre versus 1 year, P < 0.0001; post versus 1 year, P < 0.036). For the Motor Activity Log, post-hoc tests also detected significant improvements (pre versus post, P = 0.0001; pre versus 1 year, P < 0.0001; post versus 1 year, P = 0.0014). The magnitude of the change in Fugl-Meyer Assessment score correlated significantly with the change in Motor Activity Log score (R = 0.778, P = 0.001). Conclusions: Among post-stroke patients with mild to moderate impairments of arm function, modified constraint-induced movement therapy without any other rehabilitation after intervention may improve arm function and increase arm use for 1 year. In addition, increasing arm use may represent an important factor in improving arm function, and vice versa.

Relationship between Diffusion Tensor Fractional Anisotropy and Long-term Motor Outcome in Patients with Hemiparesis after Middle Cerebral Artery Infarction

BACKGROUND Magnetic resonance diffusion tensor fractional anisotropy (DTI-FA) is often used to characterize neural damage after stroke. Here we assessed the relationship between DTI-FA and long-term motor outcome in patients after middle cerebral artery (MCA) infarction. METHODS Fractional anisotropy (FA) maps were generated from diffusion tensor brain images obtained from 16 patients 14-18 days postinfarction, and tract-based spatial statistics (TBSS) analysis was applied. Regions of interest were set within the right and left corticospinal tracts, and mean FA values were extracted from individual TBSS data. Hemiparesis motor outcome was evaluated according to Brunnstrom stage (BRS: 1-6, severe-normal) for separate shoulder/elbow/forearm, hand, and lower extremity functions, as well as the motor component score of the Functional Independence Measure (FIM-motor: 13-91, null-full) 5-7 months after onset. Ratios between FA values in the affected and unaffected hemispheres (rFA) were assessed by BRS and FIM-motor scores. RESULTS rFA values were .636-.984 (median, .883) and BRS scores were 1-6 (median, 3) for shoulder/elbow/forearm, 2-6 (median, 3) for hand, and 3-6 (median, 5) for the lower extremities. FIM-motor scores were 51-90 (median, 75). Analysis revealed significant relationships between rFA and BRS data (correlation coefficient: .687 for shoulder/elbow/forearm, .579 for hand, and .623 for lower extremities) but no significance relationship between rFA and FIM-motor scores. CONCLUSIONS The results suggest that DTI-FA is applicable for predicting the long-term outcome of extremity functions after MCA infarction.

Constraint-Induced Movement Therapy After Injection of Botulinum Toxin Type A for a Patient With Chronic Stroke: One-Year Follow-up Case Report

Background and Purpose Spasticity, an aspect of upper motor neuron syndrome, is a widespread problem in patients with stroke. To date, no study has reported the long-term (up to 1 year) outcomes of botulinum toxin (BTX) injection in combination with constraint-induced movement therapy in patients with chronic stroke. In this case report, the long-term (1 year) effects of the combination of BTX type A injection and constraint-induced movement therapy on spasticity and arm function in a patient with chronic stroke and arm paresis are described. Case Description The patient was a 66-year-old man who had had an infarction in the right posterior limb of the internal capsule 4 years before the intervention. At screening, the patient was not able to voluntarily extend his interphalangeal or metacarpophalangeal joints beyond the 10 degrees required for constraint-induced movement therapy. From 12 days after BTX type A injection, the patient received 5 hours of constraint-induced movement therapy for 10 weekdays. Outcomes All outcome measures (Modified Ashworth Scale, Fugl-Meyer Assessment, Action Research Arm Test, and amount of use scale of the Motor Activity Log) improved substantially over the 1-year period (before intervention to 1 year after intervention). Repeat BTX type A injections were not necessary because muscle tone and arm function did not worsen during the observation period. Discussion The improved arm function may have reflected improvements in volitional movements and coordination or speed of movements in the paretic arm as a result of a reduction in spasticity, a reduction of learned nonuse behaviors, or use-dependent plasticity after the combination of BTX type A injection and constraint-induced movement therapy. In addition, the possibility of an influence of the passage of time or the Hawthorne effect cannot be ruled out. If this approach proves useful in future controlled studies, it may reduce the rising medical costs of the treatment of stroke.

Differences in neural pathways are related to the short- or long-term benefits of constraint-induced movement therapy in patients with chronic stroke and hemiparesis: a pilot cohort study

Abstract Background No previous studies have determined how the post-stroke integrity of non-corticospinal neural pathways relates to the efficacy of constraint-induced movement therapy (CIMT). Objectives We aimed to clarify the relationship between several non-corticospinal neural pathway integrities and the short- and long-term benefits of CIMT. Methods This was a pilot cohort study (UMIN registration number: R00027136UMIN000023566), for which we enrolled 13 patients with chronic stroke and hemiparesis who had undergone CIMT. We assessed patients’ motor function improvement by comparing the Fugl-Meyer Assessment (FMA) scores, as well as the Amount of Use (AOU) and Quality of Movement (QOM) scales of the Motor Activity Log before, immediately after (short-term), and 6 months after (long-term) CIMT. We assessed neural pathway integrity by calculating fractional anisotropy (FA) in diffusion tensor images acquired before CIMT. We then assessed correlations between FA and short- and long-term post-CIMT motor function improvements. Results The patients showed significant improvements in all functional assessments at both short- and long-term follow-ups. Immediate FMA score improvements were significantly correlated with FA of the affected anterior limb of the internal capsule (ALIC), body of the corpus callosum, column and body of the fornix (CBF), cingulate cortex (CgC), cerebral peduncle (CP), and posterior limb of the internal capsule. Six-month FMA score improvements were significantly correlated with FA of the affected ALIC, CgC, CBF, CP, and superior frontooccipital fasciculus. Conclusions The integrity of the affected corticospinal and non-corticospinal motor pathways was associated with CIMT-induced motor learning at least 6 months after CIMT.