Li-ling Chuang

Randomized Trial of Distributed Constraint-Induced Therapy Versus Bilateral Arm Training for the Rehabilitation of Upper-Limb Motor Control and Function After Stroke

Background and Objective. This study compared the efficacy of distributed constraint-induced therapy (dCIT), bilateral arm training (BAT), and control treatment (CT) on motor control and functional performance of the upper limb in stroke patients. Methods. A total of 66 patients with mean stroke onset of 16.20 months and mild to moderate motor impairment were randomized to dCIT, BAT, or CT groups. Each group received treatment for 2 h/d and 5 d/wk for 3 weeks. Pretreatment and posttreatment measures included reaching kinematic variables in unilateral and bilateral tasks, the Wolf Motor Function Test (WMFT), and the Motor Activity Log (MAL). Results. The dCIT and BAT groups had smoother reaching trajectories in the unilateral and bilateral tasks than the CT group. The BAT group, but not the dCIT group, generated greater force at movement initiation than the CT group during the unilateral and bilateral tasks. The dCIT patients had decreased WMFT time and higher functional ability scores than the CT patients. MAL results pointed to better performance in the amount and quality of use of the affected arm than BAT and CT patients. Conclusions. BAT and dCIT exhibited similar beneficial effects on movement smoothness but differential effects on force at movement initiation and functional performance. Therefore, BAT is a better option if improvement of force generation is the treatment goal, and dCIT is more appropriate for improving functional ability and use of the affected arm in daily life. These findings may assist in the planning of individually tailored rehabilitation therapies.

Responsiveness and validity of three dexterous function measures in stroke rehabilitation

In this study, we compared the responsiveness and validity of the Box and Block Test (BBT), the Nine-Hole Peg Test (NHPT), and the Action Research Arm Test (ARAT). We randomized 59 patients with stroke into one of three rehabilitation treatments for 3 weeks. We administered six outcome measures (BBT, NHPT, ARAT, Fugl-Meyer Assessment [FMA], Motor Activity Log [MAL], and Stroke Impact Scale [SIS] hand function domain) pretreatment and posttreatment. We used the standardized response mean (SRM) to examine responsiveness and the Spearman rank correlation coefficient (rho) to examine concurrent validity. The BBT, NHPT, and ARAT were moderately responsive to change and not significantly different (SRM = 0.64-0.79). The correlations within the BBT, NHPT, and ARAT were moderate to good at pretreatment (rho = -0.55 to -0.80) and posttreatment (rho = -0.57 to -0.71). The BBT and ARAT showed fair to moderate correlations with the FMA, MAL, and SIS hand function domain at pretreatment and posttreatment (rho = 0.31-0.59), whereas the NHPT demonstrated low to fair correlations with the FMA and MAL (rho = -0.16 to -0.33) and moderate correlations with the SIS hand function domain (rho = -0.58 to -0.66). Our results indicate that the BBT, NHPT, and ARAT are suitable to detect changes over time. While simultaneously considering the responsiveness and validity attributes, the BBT and ARAT can be considered more appropriate for evaluating dexterous function than the NHPT. Further studies with larger samples are needed to validate these findings.

Reliability, Validity, and Responsiveness of Myotonometric Measurement of Muscle Tone, Elasticity, and Stiffness in Patients With Stroke

OBJECTIVE To assess the metric properties of a myotonometer. DESIGN Metric study. SETTING Three medical centers. PARTICIPANTS Stroke patients (N=67). INTERVENTION Upper-extremity rehabilitation programs. MAIN OUTCOME MEASURES The tone, elasticity, and stiffness of relaxed extensor digitorum, flexor carpi radialis, and flexor carpi ulnaris were measured using the myotonometer. Fifty-eight patients completed the myotonometer measures twice at pretreatment. The myotonometric measurement and the criteria measures, including hand strength (grip, lateral pinch, and palmar pinch strength) and Action Research Arm Test (ARAT) were administered at pretreatment and posttreatment. RESULTS The myotonometer showed high test-retest reliability for muscle properties in 3 muscles. Significant correlations existed between the tone and stiffness of the 3 muscles and palmar pinch strength, between those of the flexor carpi muscles and lateral pinch strength, and between those of the flexor carpi radialis and the ARAT at posttreatment. The posttreatment elasticity of the 2 flexor carpi muscles was significantly correlated with grip strength. The pretreatment elasticity of the flexor carpi ulnaris was significantly correlated with posttreatment grip strength, and the pretreatment muscle tone and stiffness of the flexor carpi radialis were significantly correlated with palmar pinch strength and the ARAT. The responsiveness of the extensor digitorum was higher than that of the flexor carpi radialis and ulnaris. Muscle stiffness was more responsive than tone and elasticity in 3 muscles. CONCLUSIONS Myotonometry can be a reliable, valid, and responsive outcome measure for assessing muscle properties after stroke rehabilitation.

Constraint-induced therapy versus control intervention in patients with stroke: A functional magnetic resonance imaging study

Lin K-C, Chung H-Y, Wu C-Y, Liu H-L, Hsieh Y-W, Chen I-H, Chen C-L, Chuang L-L, Liu J-S, Wai Y-Y: Constraint-induced therapy versus control intervention in patients with stroke: a functional magnetic resonance imaging study. Objective:This study compared the effects of a distributed form of constraint-induced therapy with control intervention in motor recovery and brain reorganization after stroke. Design:A two-group randomized controlled trial with pretreatment and posttreatment measures was conducted. Thirteen patients with stroke were randomly assigned to the distributed form of constraint-induced therapy (n = 5) or the control intervention group (n = 8). Outcome measures included the Fugl-Meyer Assessment, the Motor Activity Log, and functional magnetic resonance imaging examination. The number of activation voxels and laterality index were determined from the functional magnetic resonance imaging data for the study of brain reorganization. Results:The distributed form of constraint-induced therapy group exhibited significantly greater improvements in the Fugl-Meyer Assessment and Motor Activity Log than the control intervention group. The functional magnetic resonance imaging data showed that distributed form of constraint-induced therapy significantly increased activation in the contralesional hemisphere during movement of the affected and unaffected hand. The control intervention group showed a decrease in primary sensorimotor cortex activation of the ipsilesional hemisphere during movement of the affected hand. Conclusions:The preliminary findings indicate that brain adaptation may be modulated by specific rehabilitation practices, although generalization of the functional magnetic resonance imaging findings is limited by sample size. Further research is needed to identify the specific neural correlates of the behavioral gains achieved after rehabilitation therapies.

Effect of Therapist-Based Versus Robot-Assisted Bilateral Arm Training on Motor Control, Functional Performance, and Quality of Life After Chronic Stroke: A Clinical Trial

Background Although bilateral arm training (BAT) has been widely studied, the comparative effects of therapist-based BAT (TBAT) versus robot-assisted BAT (RBAT) remains unknown. Objective This study compared the efficacy of TBAT, RBAT, and a control treatment (CT) on motor control, functional performance, and quality of life after chronic stroke. Design A randomized, pretest-posttest, control group design was used. Methods Forty-two patients (mean age=54.49 years, SD=9.69; mean length of time since stroke onset=17.62 months, SD=10.50) were randomly assigned to TBAT, RBAT, and CT groups. Each group received treatment for 90 to 105 minutes per session, 5 sessions on weekdays, for 4 weeks. Outcome measures included kinematic analyses, the Fugl-Meyer Assessment (FMA), the Motor Activity Log, and the Stroke Impact Scale (SIS). Results Large and significant effects were found in the kinematic variables, distal part of upper-limb motor impairment, and certain aspects of quality of life in favor of TBAT or RBAT. Specifically, the TBAT group demonstrated significantly better temporal efficiency and smoothness, straighter trunk motion, and less trunk compensation compared with the CT and RBAT groups. The RBAT group had increased shoulder flexion compared with the CT and TBAT groups. On the FMA, the TBAT group showed higher distal part scores than the CT group. On the SIS, the RBAT group had better strength subscale, physical function domain, and total scores than the CT group. Limitations This study recruited patients with mild spasticity and without cognitive impairment. Conclusions Compared with CT, TBAT and RBAT exhibited differential effects on outcome measures. Therapist-based BAT may improve temporal efficiency, smoothness, trunk control, and motor impairment of the distal upper limb. Robot-assisted BAT may improve shoulder flexion and quality of life.

Responsiveness and validity of two outcome measures of instrumental activities of daily living in stroke survivors receiving rehabilitative therapies

Objective: To comprehensively investigate and compare the responsiveness and validity of two instrumental activities of daily living (ADL) measures: a modified version of the Nottingham Extended ADL Scale and the Frenchay Activities Index, after stroke rehabilitation. Setting: Rehabilitation clinics. Subjects: Seventy stroke patients received a three-week intervention (mean (SD) age, 55.5 (12.1) years; 46 (65.7%) men; mean (SD) time post stroke, 19.9 (12.5) months). Measures: Four outcome measures (modified Nottingham Extended ADL Scale, Frenchay Activities Index, Stroke Impact Scale and Motor Activity Log) were administered before and after treatment. We used the standardized response mean (SRM) to examine responsiveness and the Spearman correlation coefficient (ρ) to examine concurrent validity. Results: Responsiveness was significantly larger for the modified Nottingham Extended ADL Scale (SRM = 0.9) compared with the Frenchay Activities Index (SRM = 0.5). The correlations between the modified Nottingham Extended ADL Scale and Frenchay Activities Index were good to excellent before (ρ = 0.8) and after treatment (ρ = 0.8). The modified Nottingham Extended ADL Scale and Frenchay Activities Index showed fair correlations with the Stroke Impact Scale ADL/Instrumental ADL domain, Stroke Impact Scale total score and Motor Activity Log before treatment (ρ = 0.3—0.4). After treatment, the modified Nottingham Extended ADL Scale and Frenchay Activities Index demonstrated moderate to good correlations with the Stroke Impact Scale ADL/Instrumental ADL domain (ρ = 0.6) and fair correlations with the Stroke Impact Scale total score and Motor Activity Log (ρ = 0.2—0.5). Conclusions: The modified Nottingham Extended ADL Scale and Frenchay Activities Index are both valid outcome measures but the modified Nottingham Extended ADL Scale is more responsive than the Frenchay Activities Index. While simultaneously considering the properties of responsiveness and validity, the modified Nottingham Extended ADL Scale may be a relatively sound measure of instrumental ADL function in stroke patients receiving rehabilitation.

Quantitative Mechanical Properties of the Relaxed Biceps and Triceps Brachii Muscles in Patients with Subacute Stroke: A Reliability Study of the Myoton-3 Myometer

Objective. Test-retest reliability of the myotonometer was investigated in patients with subacute stroke. Methods. Twelve patients with substroke (3 to 9 months poststroke) were examined in standardized testing position twice, 60 minutes apart, with the Myoton-3 myometer to measure tone, elasticity, and stiffness of relaxed bilateral biceps and triceps brachii muscles. Intrarater reliability of muscle properties was determined using intraclass correlation coefficient (ICC), the standard error of measurement (SEM), and the minimal detectable change (MDC). Results. Intrarater reliability of muscle properties of bilateral biceps and triceps brachii muscles were good (ICCs = 0.79–0.96) except for unaffected biceps tone (ICC = 0.72). The SEM and MDC of bilateral biceps and triceps brachii muscles indicated small measurement error (SEM% <10%, MDC% <25%). Conclusion. The Myoton-3 myometer is a reliable tool for quantifying muscle tone, elasticity, and stiffness of the biceps and triceps brachii in patients with subacute stroke.

Relative and Absolute Reliabilities of the Myotonometric Measurements of Hemiparetic Arms in Patients With Stroke

OBJECTIVE To investigate the relative and absolute reliabilities of the myotonometer. DESIGN Psychometric study. SETTING Three medical centers. PARTICIPANTS Patients with stroke (N=61). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Muscle tone, elasticity, and stiffness of relaxed affected deltoid, triceps brachii, biceps brachii, extensor digitorum, flexor carpi radialis, and flexor carpi ulnaris were measured twice, 30 minutes apart, using the myotonometer. Intraclass correlation coefficient, a relative reliability index, was calculated for 3 muscular properties and for each muscle to examine the degree of consistency and agreement between the 2 test sessions. Absolute reliability indices, including the SEM, smallest real difference, and Bland-Altman limits of agreement, were used to quantify measurement errors and check systematic biases of the 2 test sessions. RESULTS The intraclass correlation coefficients were .83 to .95 for muscle tone, elasticity, and stiffness of all muscle groups. The SEM and the smallest real difference of muscle tone, elasticity, and stiffness of the biceps were the smallest among the 6 muscles tested. The Bland-Altman analyses showed no systematic bias between most of the repeated measurements. Compared with other muscles, biceps had narrower limits-of-agreement ranges, indicating that the myotonometric measurements of the biceps had higher stability and less variation over time. CONCLUSIONS The myotonometer reliably measures muscular properties, with good relative and absolute reliabilities. These findings are useful for clinicians and researchers to assess muscle properties reliably and determine whether a real change has occurred in groups and on individual levels of patients with stroke.

Transcription of Tnfaip3 Is Regulated by NF-κB and p38 via C/EBPβ in Activated Macrophages

Macrophages play a pivotal role in the immune system through recognition and elimination of microbial pathogens. Toll-like receptors (TLRs) on macrophages interact with microbial substances and initiate signal transduction through intracellular adapters. TLR4, which recognizes the lipopolysaccharides (LPS) on Gram-positive and Gram-negative bacteria, triggers downstream signaling mediators and eventually activates IκB kinase (IKK) complex and mitogen-activated protein kinases (MAPKs) such as p38. Previous reports revealed that, in addition to NF-κB, a core transcription factor of the innate immune response, the induction of some LPS-induced genes in macrophages required another transcription factor whose activity depends on p38. However, these additional transcription factors remain to be identified. In order to identify p38-activated transcription factors that cooperate with NF-κB in response to LPS stimulation, microarrays were used to identify genes regulated by both NF-κB and p38 using wild-type, IKK-depleted, and p38 inhibitor-treated mouse bone marrow-derived macrophages (BMDMs). In silico analysis of transcription factor binding sites was used to predict the potential synergistic transcription factors from the co-expressed genes. Among these genes, NF-κB and C/EBPβ, a p38 downstream transcription factor, were predicted to co-regulate genes in LPS-stimulated BMDMs. Based on the subsequent results of a chromatin immunoprecipitation assay and TNFAIP3 expression in C/EBPβ-ablated macrophages, we demonstrated that Tnfaip3 is regulated by both NF-κB and p38-dependent C/EBPβ. These results identify a novel regulatory mechanism in TLR4-mediated innate immunity.

Effects of whole body vibration on spasticity and lower extremity function in children with cerebral palsy.

AIM The aim of this study was to evaluate the effect of whole body vibration (WBV) on lower extremity spasticity and ambulatory function in children with cerebral palsy (CP) with a complete crossover design. METHOD Sixteen participants aged 9.8(2.3) years received a 20-min WBV and a control condition in a counterbalanced order on two separate days. Change scores of each outcome variable were used to show the improvement. RESULTS Repeated-measures analyses revealed significant differences in condition scores among variables including active range-of-motion (active ROM, increased), relaxation index (RI, increased), Modified Ashworth Scale (MAS, decreased), timed up-and-go (TUG, decreased), and Six Minute Walk Test (6MWT, increased). Significant differences were also found in time change scores for MAS and 6MWT. Correlation results revealed that TUG was significantly correlated with RI (r=-.512, p=.042), and 6MWT (r=-.700, p=.003). INTERPRETATION This study suggested that WBV intervention can control the spasticity, enhance ambulatory performance and increase active ROM. Along with previous results, data from this study revealed the potential use of WBV in clinical rehabilitation in children with CP. Future investigations should focus on finding the combination of treatment frequency and duration to achieve an ideal result.