Sandra Davis

Active Finger Extension Predicts Outcomes After Constraint-Induced Movement Therapy for Individuals With Hemiparesis After Stroke

Background and Purpose— Constraint-induced movement therapy (CIMT) is a rehabilitative strategy used primarily with the post-stroke population to increase the functional use of the neurologically weaker upper extremity through massed practice while restraining the lesser involved upper extremity. Whereas research evidence supports CIMT, limited evidence exists regarding the characteristics of individuals who benefit most from this intervention. The goal of this study was to investigate the potential of 5 measures to predict functional CIMT outcomes. Methods— A convenience sample of 55 individuals, >6 months after stroke, was recruited that met specific inclusion/exclusion criteria allowing for individuals whose upper extremity was mildly to severely involved. They participated in CIMT 6 hours per day. Pretest, post-test, and follow-up assessments were performed to assess the outcomes for the Wolf Motor Function Test (WMFT). The potential predictors were minimal motor criteria (active extension of the wrist and 3 fingers), active finger extension/grasp release, grip strength, Fugl–Meyer upper extremity motor score, and the Frenchay score. A step-wise regression analysis was used in which the potential predictors were entered in a linear regression model with simultaneous entry of the dependent variables’ pretest score as the covariate. Two regressions models were determined for the dependent variable, for immediate post-test, and for follow-up post-test. Results— Finger extension was the only significant predictor of WMFT outcomes. Conclusions— When using finger extension/grasp release as a predictor in the regression equations, one can predict individual’s follow-up scores for CIMT. This experiment provides the most comprehensive investigation of predictors of CIMT outcomes to date.

Effects of trunk restraint combined with intensive task practice on poststroke upper extremity reach and function: a pilot study.

Background. Poststroke reaching is characterized by excessive trunk motion and abnormal shoulder—elbow coordination. Little attention is typically given to arm—trunk kinematics during task practice. Preventing compensatory trunk motion during short-term practice immediately improves kinematics, but effects of longer-term practice are unknown. Objective. This study compared the effects of intensive task practice with and without trunk restraint on poststroke reaching kinematics and function. Methods. A total of 11 individuals with chronic stroke, baseline Fugl-Meyer Upper Extremity Assessment scores 26 to 54, were randomized to 2 constraint-therapy intervention groups. All participants wore a mitt on the unaffected hand for 90% of waking hours over 14 days and participated in 10 days/6 hours/day of supervised progressive task practice. During supervised sessions, one group trained with a trunk restraint (preventing anterior trunk motion) and one group did not. Tasks for the trunk-restraint group were located to afford repeated use of a shoulder flexion—elbow extension reaching pattern. Outcome measures included kinematics of unrestrained targeted reaching and tests of functional arm ability. Results. Posttraining, the trunk-restraint group demonstrated straighter reach trajectories (P = .000) and less trunk displacement (P = .001). The trunk-restraint group gained shoulder flexion (P = .006) and elbow extension (P = .022) voluntary ranges of motion, the nonrestraint group did not. Posttraining angle—angle plots illustrated that individuals from the trunk-restraint group transitioned from elbow flexion to elbow extension during mid-reach; individuals in the nonrestraint group retained pretraining movement strategies. Both groups gained functional arm ability (P < .05 all tests). Conclusion. Intensive task practice structured to prevent compensatory trunk movements and promote shoulder flexion—elbow extension coordination may reinforce development of “normal” reaching kinematics.

Bilateral Arm Training With Rhythmic Auditory Cueing in Chronic Stroke: Not Always Efficacious

Objective. Bilateral arm training with rhythmic auditory cueing (BATRAC) has been reported to be efficacious in promoting upper-extremity (UE) recovery in chronic stroke. We tested a modified form of BATRAC (modBATRAC) in a new group of participants with a condensed treatment regime to determine whether we could replicate these reported results. Methods. Fourteen subjects with chronic stroke completed 2 weeks of 2.25 hours per session, 4 sessions per week of modBATRAC. Results. No significant changes were observed in UE Fugl-Meyer or Wolf Motor Function Test scores. Subjects did report increased paretic UE use on the Motor Activity Log (mean change, 0.50; SD = 0.70). Conclusions. The results of this study offer only partial support for the efficacy of modBATRAC. As in previous trials, modBATRAC facilitated increased use of the paretic arm, but unlike previous trials, it did not increase motor performance. These differences may reflect a more temporally condensed training schedule and less impaired patients.

Limited dose response to Constraint-Induced Movement Therapy in patients with chronic stroke

Objective: To compare outcomes in motor skill, perceived amount of use and ability of the paretic arm in daily activities between traditional Constraint-Induced Movement Therapy, consisting of 6 hours of in-clinic, therapist-guided task practice, and a shortened Constraint-Induced Movement Therapy, consisting of 1 hour of in clinic, therapist-guided task practice coupled with 5 hours of unsupervised practice at home. Design: A secondary analysis of two previous randomized, controlled, double-blind, parallel group studies. Setting: A research clinic. Participants: Thirty-nine individuals with hemiparesis from a chronic unilateral stroke who were able to extend the wrist 10° and the fingers and thumb 10° from a flexed position and were participants in one of the two studies examining the efficacy of adding neuroplasticity adjuvants to Constraint-Induced Movement Therapy. Main outcome measures: The Wolf Motor Function Test was used to assess motor skill and the Motor Activity Log amount of use and quality of movement scales were used to assess perceived amount of use and ability respectively. Interventions: Constraint-Induced Movement Therapy plus donepezil in the CIMT-6 study (the traditional 6 hours of in-clinic task practice) and Constraint-Induced Movement Therapy plus repetitive transcranial magnetic stimulation in the CIMT-1 study (1 hour of in-clinic task practice). Results: Motor skill gains after two weeks of therapy were equivalent for both groups (n=39; mean difference=2.81, P>0.22), but gains were not maintained six months later with either intervention protocol. Despite this, participants in the CIMT-6 group reported greater use (mean difference=1.52, P<0.001) and movement quality (mean difference=0.95, P<0.004) than those with less therapist-guided practice. Both groups had regressed somewhat in use and ability at the six-month follow-up. Conclusion: These results suggest that 6 hours of therapist-guided practice may not be necessary to facilitate motor skill gains, but may influence patterns of use.

Response to Intensive Upper Extremity Therapy by Individuals with Ataxia from Stroke

Abstract Objective: This study investigated whether or not individuals with ataxia from stroke improve their upper extremity motor function with intense motor practice. Method: Three individuals with ataxia from chronic stroke completed modified constraint-induced movement therapy (CIMT) protocols. Stroke Participants 1 and 2 completed 60 hours and Stroke Participant 3 completed 30 hours of graded task practice while being asked to wear a mitt on the nonparetic arm for 90% of waking hours. Outcome measures were the upper extremity subscale of the Fugl-Meyer Motor Assessment, Wolf Motor Function Test, Motor Activity Log, and kinematics of reaching. Results: All stroke participants improved on either the Fugl-Meyer or the Wolf tests and increased their daily use of the paretic upper extremity. Participants 1 and 2 also improved on all kinematic measures: maximum velocity and time to maximum velocity increased, while index of curvature, number of peaks in the velocity profile, and trunk movement decreased. Participant 3 improved on some kinematic measures (smoother velocity profile, increased time to maximum velocity, decreased number of peaks in the velocity profile) but not all (decreased maximum velocity, increased index of curvature). Conclusion: Individuals with ataxia from stroke can improve their motor function with intense motor practice.

Generalization of a modified form of repetitive rhythmic bilateral training in stroke

OBJECTIVE To determine if a modified form of repetitive rhythmic bilateral training will generalize to two reach to target tasks. SETTING Testing and training were performed at the Brain Rehabilitation Research Center, Malcom Randall VAMC in Gainesville, Florida. SUBJECTS Fourteen subjects with chronic stroke completed this study: 9 male, 5 female, mean age 64.4years, and a mean of 5.5years post-stroke. INTERVENTION Modified Bilateral Arm Training with Rhythmic Auditory Cueing (modBATRAC) was performed 4 sessions/week of 2.25h/session for 2weeks. MAIN MEASURES End-point kinematic measures; hand path curvature, time to peak velocity, peak velocity, smoothness of the curve and acceleration using the Vicon motion analysis system during two reach to target tasks: (1) similar spatial demands (2) dissimilar spatial demands. An individual analysis was performed to investigate if there was any pattern of responding. Additionally, correlation analyses of kinematic and functional measures taken pre- and post-test were performed. RESULTS Improvements were found at post-test for hand path curvature, smoothness of the curve, and peak velocity and were equivalent across two reach to target tasks. DISCUSSION Generalization was found for both reach to target tasks for end-point kinematic aspects (PV, HPC, and number of Peaks) during modBATRAC training. There was a positive correlation with the significant kinematic variables (HPC and PV) and the functional measures used pre- and post-test in this study. This suggests that generalization may be possible through the practice of basic coordinated movements after stroke. These basic movements may provide the building blocks for more complex movement behaviors.

The social organization in constraint-induced movement therapy

Ethnographic data were collected at two rehabilitation facilities conducting ongoing research to evaluate functional and neurological outcomes of constraint-induced movement therapy (CIMT). Our findings indicate that several patterns of behavior occur during participant/therapist interaction in therapy sessions: coaching, cheerleading, reminding, changing, and contemplating. These interaction patterns indicate that learned nonuse of an affected limb does not exist in social isolation and that people who participate in CIMT routinely consider the balance of any improvement against the costs of using an affected limb that is still not fully functional. These patterns of social interaction that occur during therapy--which often influence a participants hope for future physical progress--are an important part of CIMT that may not be fully acknowledged in the clinical training of therapists.

Telehealth and constraint-induced movement therapy (CIMT) : An intensive case study approach

Abstract Stroke is the leading cause of disability in the United States. Stroke survivors often experience motor sequelae characterized by hemiparesis in the upper extremity contralateral to the brain lesion. Constraint-Induced Movement Therapy (CIMT) is an effective treatment for post-stroke hemiparesis. In this study, two stroke survivors completed clinic-based CIMT and, subsequently, a home-based CIMT trial (tele-CIMT) incorporating telecommunications technology. Outcome measures were administered at pre-, post-, and follow-up time points. Partial confirmation was obtained for the effectiveness of tele-CIMT as an alternate mode of treatment. Improvements in motor skills were evidenced across both clinic- and tele-CIMT modalities, from baseline to follow up, for both participants. Future research directions are addressed, especially studies comparing the efficacy and cost-effectiveness of tele-CIMT versus standard clinic CIMT.