Peter Levine

Modified constraint-induced therapy in acute stroke: a randomized controlled pilot study.

To determine modified constraint-induced therapy (mCIT) feasibility and compare its efficacy to traditional rehabilitation (TR) in acute stroke patients exhibiting upper limb hemiparesis. Method. Before-after, multiple baseline, randomized controlled pilot study. Setting. Rehabilitation hospital. Patients. Ten stroke patients < 14 d poststroke and exhibiting upper limb hemiparesis and affected limb nonuse. Interventions. Five patients were administered mCIT, consisting of structured therapy emphasizing more affected arm use in valued activities 3 d/week for 10 weeks and less affected arm restraint 5 d/week for 5 h. Five other patients received 1/2 sessions of traditional motor rehabilitation for the affected arm, which included affected limb manual dexterity exercises and stretching, as well as compensatory strategies with the unaffected limb. The TR regimens occurred 3 d/week for 10 weeks. Main Outcome Measures. The Fugl-Meyer Assessment of Motor Recovery (Fugl-Meyer), Action Research Arm Test (ARA), and Motor Activity Log (MAL). Results. Before intervention, all patients exhibited stable motor deficits and more affected arm nonuse. After intervention, mCIT patients displayed increased affected arm use (+ 2.43 on the MAL amount of use scale), uniformly exhibited increases on the Fugl-Meyer and ARA (mean change scores = + 18.7 and + 21.7, respectively), and were able to again perform valued activities. TR patients exhibited nominal change in affected limb use (+ 0.07 on the MAL amount of use scale) and modest changes on the Fugl-Meyer and ARA (+ 4.4 and + 4.8, respectively). Fugl-Meyer and ARA changes were significant for the mCIT group only (P < 0.01). Conclusions. mCIT is a promising regimen for improving more affected limb use and function in acute cerebrovascular accident. However, larger confirmatory studies need to be performed.

Home-based electromyography-triggered stimulation in chronic stroke

Objectives: (1) To determine the feasibility of a home-based electromyography triggered neuromuscular stimulation (ETMS) programme; and (2) to determine ETMS efficacy in increasing affected wrist extension and reducing affected arm impairment. Design: Randomized, controlled, pre-lpost, cross-over design. Setting: Outpatient rehabilitation hospital. Patients: Twelve chronic stroke patients with palpable muscle contraction in their affected wrist extensors but no movement (7 males; mean age=59.75 years, age range 44-75 years; mean time since stroke=52.75 months, range 13-131 months). Intervention: Subjects were randomly assigned to receive either: (a) ETMS use twice every weekday in 35-min increments during an eight-week period followed by an eight-week home exercise programme (ETMS/home exercise programme) (n=8); or (b) an eight-week home exercise programme followed by use of ETMS twice every weekday in 35-min increments during an eight-week period (home exercise programme) (n=4). Main outcome measures: The Fugl-Meyer, Action Research Arm Test and goniometry. Results: After home exercise programme participation, subjects showed nominal or no changes on any of the outcome measures. After ETMS, patients showed modest impairment reductions, as shown by the Fugl-Meyer, and no Action Research Arm Test changes. However, both groups showed a 218 increase in active affected wrist extension after ETMS use. Conclusion: ETMS use is feasible in the home environment. Neither participation in a traditional home exercise programme nor ETMS use conveyed changes on the Fugl-Meyer or Action Research Arm Test. However, ETMS use increased active affected limb extension. This new movement may provide a potential pathway for subjects to participate in other interventions, such as modified constraint induced therapy.

Modified Constraint-Induced Therapy: A Promising Restorative Outpatient Therapy

Abstract Background and Purpose: Stroke is the leading cause of disability in the United States, and upper limb hemiparesis is a primary impairment resulting in this disability. However, there remains a paucity of scientifically validated treatment regimens for hemiparesis. Data from randomized controlled studies suggest the effectiveness and efficacy of modified constraint-induced therapy (mCIT), a reimbursable, outpatient, upper limb training regimen. The purpose of this article is to review evidence and discuss the theoretical bases of mCIT for stroke-induced hemiparesis. The objective is to make stroke practitioners aware of the mCIT theoretical bases and of this clinically practical, efficacious protocol. Conclusions: mCIT is solidly grounded in motor learning principles, is practical and safe, and is both efficacious and effective. mCIT studies have shown efficacy using rigorous randomized controlled methods in both subacute and chronic stroke and have shown high effect sizes that have been independently confirmed. It thus seems reasonable to recommend mCIT for clinical application.

Reaching kinematics to measure motor changes after mental practice in stroke.

Abstract Objective: To examine mental practice (MP) efficacy using a new kinematics reaching model. Method: This was a prepost, case series conducted at an outpatient rehabilitation hospital of 5 patients who experienced stroke >1 year before study entry (3 males; mean age = 52.6 ± 15.4 years [range, 38–76 years]; mean time since stroke = 51.2 months [range, 13–126 months]) exhibiting upper limb hemiparesis on their dominant sides. Participants received 30-minute therapy sessions emphasizing activities of daily living (ADLs) using their affected arms, which occurred 2 days/week for 6 weeks. After therapy, participants received 30-minute MP sessions requiring MP of the ADLs. The main outcome measure was 3-D Motion Analysis (kinematics), in which patients performed 2 functional reaching tasks consisting of reaching and grasping a plastic cylinder positioned at either elbow height (reach out) or shoulder height (reach up). Dependent variables included horizontal reaching distance, hand velocity, elbow range of motion, and shoulder range of motion. Results: Prior to intervention, the mean horizontal reaching distance was 8.3 ± 1.7 cm and 10.9 ± 2.2 cm for the reach-up and reach-out tasks, respectively. Upon completion of the intervention, ability to reach up significantly improved to 9.9 ± 1.6 cm (p <.001). Horizontal reach distance also improved during the reach-out task (11.7 ± 2.2 cm, p = .366). No statistically significant change was observed in linear hand velocity. Patients also exhibited greater shoulder flexion and elbow extension during both the posttest reach-up and posttest reach-out tasks. Discussion and Conclusion: Kinematics appears to offer a precise, objective way of quantifying MP-induced motor changes during ADL performance. MP appears to improve several aspects of affected arm reaching.

Orthotic functional electrical stimulation following botulinum toxin for a young adult with severe hand impairment due to childhood stroke

ABSTRACT This case report describes the outcomes of a task-specific training protocol using functional electrical stimulation for a young adult with severe hand impairment from a childhood stroke who had a history of tendon transfer and a recent botulinum toxin injection. A 22-year-old female who had a hemorrhagic stroke at age 5, a tendon transfer at 18, and a botulinum toxin injection 6 weeks before study entry, participated in a home- and clinic-based task-specific training program using a functional electrical stimulation orthosis. Training was 30–90 minutes per day, 4 days per week, for 4 weeks. Stroke-specific outcomes were measured before and after intervention. Increases occurred in the following scores: Action Research Arm Test, Stroke Impact Scale Hand Function Domain, and Canadian Occupational Performance Measure. A task-specific training protocol using orthotic functional electrical stimulation appears to have increased hand function and quality of life for an adult with chronic, childhood-onset stroke. To our knowledge, this is the first study to investigate the efficacy of functional electrical stimulation for such an individual.