Constraint-induced movement therapy: a narrative review

Objectives

To identify factors relevant to implementing constraint-induced movement therapy (CIMT) within the clinical setting.

Data sources

AMED (1995-January 2007), CINHAL (1982-January 2007), Medline (1996-January 2007) and EMBASE (1996-January 2007) were searched to identify relevant studies.

Review methods

Criteria for inclusion of trials in this study were that trial participants were over 18 years of age, had had a stroke, and CIMT or modified CIMT was compared with either no intervention, modified CIMT or alternative treatment. Modified CIMT had to include both constraint and training components. The study design was either a quasi-randomised controlled trial or a randomised controlled trial. Trials had to be published in English and score 4 or more on the PEDro scale.

Results

Twelve eligible studies were identified. The quality of the studies varied, although there was evidence that this improved with more recent studies achieving higher PEDro scores. Patient selection criteria and the components related to the delivery of CIMT were identified as relevant factors. Thirteen different patient selection criteria were identified: age; length of time post stroke; specified side of hemiplegia; hand dominance; spasticity; pain; balance and mobility; hand function; range of active and passive movement; cognitive impairment; perception; sensation; and communication. Ten components were identified as being relevant to the actual delivery of CIMT: type of CIMT; type of constraint; constraint wear time; excluded activities; shaping; shaping dosage; group versus individual treatment; environment; potential harms of CIMT; and compliance. A third relevant consideration was the selection of outcome measures. Significant variability was identified in many aspects of CIMT, although there was evidence of greater standardisation in more recent studies.

Conclusion

The development of CIMT for stroke patients has provided clinicians with a treatment technique for a defined patient group that is now supported by a considerable evidence base. CIMT is a complex intervention and the optimum intensity and length of treatment remains unknown. Transferring CIMT into the clinical environment has been hampered by the lack of standardisation in many aspects of the intervention. However, there is evidence that this is improving. Implementation and evaluation in the clinical environment would strengthen the evidence base.     

The Effects of Constraint-Induced Therapy on Kinematic Outcomes and Compensatory Movement Patterns: An Exploratory Study

Massie C, Malcolm MP, Greene D, Thaut M. The effects of constraint-induced therapy on kinematic outcomes and compensatory movement patterns: an exploratory study.

Objective

To determine changes in kinematic variables and compensatory movement patterns of survivors of stroke completing constraint-induced therapy (CIT).

Design

Pre-post, case series.

Setting

Clinical rehabilitation research laboratory.

Participants

Men (n=7) and women (n=3) with unilateral stroke occurring at least 9 months prior to study entry with moderate, stable motor deficits.

Intervention

Participants completed 10 consecutive weekdays of CIT for 6 hours a day comprised of trainer-supervised, functionally based activities using massed practice.

Main Outcome Measures

Kinematic measures included movement time, average velocity, trajectory stability, shoulder abduction, and segmental contribution. Functional measures included Wolf Motor Function Test (WMFT) performance time and functional ability scores and Motor Activity Log (MAL) “how-well” scores. All measures were administered before and after the 2-week CIT intervention.

Results

Movement time, average velocity, and trajectory stability significantly improved after CIT. Participants used more shoulder flexion to reach after CIT, but also demonstrated increased compensatory shoulder abduction. Functional scores also significantly improved, including WMFT performance time and functional ability and MAL scores. There was no change in trunk movement or amount of elbow extension.

Conclusions

CIT improved motor capacities in the hemiparetic arm as reflected in the functional outcomes and in some kinematic measures. Participants' reliance on common compensatory movements was not beneficially affected by CIT. The results of this study demonstrate that while functional capacity and some movement strategies in the hemiparetic arm improve after CIT, participants may not overcome their reliance on common compensatory movement patterns. Based on these findings, this study suggests that CIT may encourage subjects to generate movement through compensatory and/or synergy-dominated movement rather than promote the normalization of motor control. This outcome highlights the need to develop CIT further as an intervention that improves functional capacity and more normative movement strategies.     

A Method for Standardizing Procedures in Rehabilitation: Use in the Extremity Constraint Induced Therapy Evaluation Multisite Randomized Controlled Trial

Morris DM, Taub E, Macrina DM, Cook EW, Geiger BF. A method for standardizing procedures in rehabilitation: use in the Extremity Constraint Induced Therapy Evaluation multisite randomized controlled trial.

Objective

An enduring problem in the field of rehabilitation has been the lack of standardization in the protocols of treatments and tests. To develop a process evaluation method to standardize the administration of rehabilitation procedures used in the Extremity Constraint Induced Therapy Evaluation (EXCITE) Trial, a randomized controlled trial of upper-extremity constraint-induced therapy implemented across 7 sites.

Design

Process evaluation.

Setting

Research laboratory.

Participants

Convenience sample or research personnel.

Interventions

Not applicable.

Main Outcome Measures

Checklist scoring sheets were developed to rate videotapes using systematic application of prescribed steps for each of 5 procedures across 3 time periods. Time periods were immediately after training, and 1 and 2 years later. A performance score of at least 90% was required before individual research personnel were allowed to participate in the trial.

Results

Overall performance scores ranged from 85.8% to 95% of performance items correctly executed. There was a significant improvement in standard performance of procedures between the first time period (immediately after training) and each of the subsequent time periods for all but 1 procedure. The scoring of standardized performance when carried out with routine participant testing and training did not differ significantly from scoring from videotaped sessions submitted for standardization rating for 2 of the procedures, suggesting adequate validity of scoring from videotape.

Conclusions

The present method was successful in assessing protocol fidelity for the EXCITE research personnel and represents 1 means of addressing the longstanding problem in rehabilitation of the lack of standardization in administering different treatments and tests.     

Estimating minimal clinically important differences of upper-extremity measures early after stroke

Lang CE, Edwards DF, Birkenmeier RL, Dromerick AW. Estimating minimal clinically important differences of upper-extremity measures early after stroke.

Objective

To estimate minimal clinically important difference (MCID) values of several upper-extremity measures early after stroke.

Design

Data in this report were collected during the Very Early Constraint-induced Therapy for Recovery of Stroke trial, an acute, single-blind randomized controlled trial of constraint-induced movement therapy. Subjects were tested at the prerandomization baseline assessment (average days poststroke, 9.5d) and the first posttreatment assessment (average days poststroke, 25.9d). At each time point, the affected upper extremity was evaluated with a battery of 6 tests. At the second assessment, subjects were also asked to provide a global rating of perceived changes in their affected upper extremity. Anchor-based MCID values were calculated separately for the affected dominant upper extremities and the affected nondominant upper extremities for each of the 6 tests.

Setting

Inpatient rehabilitation hospital.

Participants

Fifty-two people with hemiparesis poststroke.

Interventions

Not applicable.

Main Outcome Measures

Estimated MCID values for grip strength, composite upper-extremity strength, Action Research Arm Test (ARAT), Wolf Motor Function Test (WMFT), Motor Activity Log (MAL), and duration of upper-extremity use as measured with accelerometry.

Results

MCID values for grip strength were 5.0 and 6.2kg for the affected dominant and nondominant sides, respectively. MCID values for the ARAT were 12 and 17 points, for the WMFT function score were 1.0 and 1.2 points, and for the MAL quality of movement score were 1.0 and 1.1 points for the 2 sides, respectively. MCID values were indeterminate for the dominant (composite strength), the nondominant (WMFT time score), and both affected sides (duration of use) for the other measures.

Conclusions

Our data provide some of the first estimates of MCID values for upper-extremity standardized measures early after stroke. Future studies with larger sample sizes are needed to refine these estimates and to determine whether MCID values are modified by time poststroke.     

Neutral functional realignment orthosis prevents hand pain in patients with subacute stroke: a randomized trial

Bürge E, Kupper D, Finckh A, Ryerson S, Schnider A, Leemann B. Neutral functional realignment orthosis prevents hand pain in patients with subacute stroke: a randomized trial.

Objective

To quantify the preventive effect of a neutral functional realignment orthosis on pain, mobility, and edema of the hand in subacute hemiparetic poststroke patients with severe motor deficits.

Design

Randomized trial.

Setting

Rehabilitation center.

Participants

Poststroke patients (N=30) with subacute hemiparesis and severe deficits of the upper limb were enrolled. Fifteen patients were randomized to a standard rehabilitation program without orthosis and 15 patients received an experimental orthosis in addition to their standard rehabilitation program.

Intervention

The orthosis group wore the neutral functional realignment orthosis for at least 6 hours daily.

Main Outcome Measures

Hand pain at rest (visual analog scale), wrist range of motion (Fugl-Meyer Assessment subscale), and edema of hand and wrist (circumferences). Outcome measures were assessed at time of randomization and after 13 weeks between groups.

Results

At baseline, 2 patients in each group complained about a painful hand. After 13 weeks, 8 subjects in the control group and 1 subject in the orthosis group complained of hand pain (P=.004). Mobility and edema evolved similarly in both groups.

Conclusions

Neutral functional realignment orthoses have a preventive effect on poststroke hand pain, but not on mobility and edema in the subacute phase of recovery.     

The Influence of Applying Additional Weight to the Affected Leg on Gait Patterns During Aquatic Treadmill Walking in People Poststroke

Jung T, Lee D, Charalambous C, Vrongistinos K. The influence of applying additional weight to the affected leg on gait patterns during aquatic treadmill walking in people poststroke.

Objective

To investigate how the application of additional weights to the affected leg influences gait patterns of people poststroke during aquatic treadmill walking.

Design

Comparative gait analysis.

Setting

University-based aquatic therapy center.

Participants

Community-dwelling volunteers (n=22) with chronic hemiparesis caused by stroke.

Interventions

Not applicable.

Main Outcome Measures

Spatiotemporal and kinematic gait parameters.

Results

The use of an ankle weight showed an increase in the stance phase percentage of gait cycle (3%, P=.015) when compared with no weight. However, the difference was not significant after a Bonferroni adjustment was applied for a more stringent statistical analysis. No significant differences were found in cadence and stride length. The use of an ankle weight showed a significant decrease of the peak hip flexion (7.9%, P=.001) of the affected limb as compared with no weight condition. This decrease was marked as the reduction of unwanted limb flotation because people poststroke typically show excessive hip flexion of the paretic leg in the late swing phase followed by fluctuating hip movements during aquatic treadmill walking. The frontal and transverse plane hip motions did not show any significant differences but displayed a trend of a decrease in the peak hip abduction during the swing phase with additional weights. The use of additional weight did not alter sagittal plane kinematics of the knee and ankle joints.

Conclusions

The use of applied weight on the affected limb can reduce unwanted limb flotation on the paretic side during aquatic treadmill walking. It can also assist the stance stability by increasing the stance phase percentage closer to 60% of gait cycle. Both findings can contribute to the development of more efficient motor patterns in gait training for people poststroke. The use of a cuff weight does not seem to reduce the limb circumduction during aquatic treadmill walking.     

Cortical Reorganization Induced by Body Weight-Supported Treadmill Training in Patients With Hemiparesis of Different Stroke Durations

Yang Y-R, Chen I-H, Liao K-K, Huang C-C, Wang R-Y. Cortical reorganization induced by body weight-supported treadmill training in patients with hemiparesis of different stroke durations.

Objective

To investigate corticomotor changes induced by body weight-supported treadmill training (BWSTT) in patients with short or long poststroke duration.

Design

Single-blinded and randomized controlled trial.

Setting

Neurologic physical therapy research laboratory.

Participants

Hemiparesis patients (N=18) whose motor-evoked potentials could be induced participated in this study. Subjects in each hemiparesis postonset of short (<6mo) or long (>12mo) duration group were randomly assigned to either the control or experimental group.

Interventions

Subjects in the experimental groups participated in BWSTT for 4 weeks. Those in the control groups received the general exercise program.

Main Outcome Measures

The primary outcomes were motor threshold and map size of the abductor hallucis muscle in the ipsilesional hemisphere. The secondary outcome was Fugl-Meyer Assessment. Outcome measures were blindly assessed before and after completing the 4 weeks of training.

Results

The 4-week BWSTT resulted in a decrease of motor threshold and an increase of map size in subjects with hemiparesis of short duration, whereas only the expansion of the map size was noted in subjects with hemiparesis of long duration. Improvement of motor control occurred in subjects with hemiparesis of both short and long duration after BWSTT.

Conclusions

The BWSTT results in similar improvement in motor control but different patterns of treatment-induced cortical reorganization in subjects with different poststroke durations.     

Repeated treatments with botulinum toxin type a produce sustained decreases in the limitations associated with focal upper-limb poststroke spasticity for caregivers and patients

Elovic EP, Brashear A, Kaelin D, Liu J, Millis SR, Barron R, Turkel C. Repeated treatments with botulinum toxin type A produce sustained decreases in the limitations associated with focal upper-limb poststroke spasticity for caregivers and patients.

Objective

To assess the safety and evaluate the effects of repeated treatments with botulinum toxin type A (BTX-A) on functional disability, quality of life (QOL), and muscle tone of patients with upper-limb poststroke spasticity, as well as its effect on caregivers.

Design

Multicenter, open-label, repeated-dose study.

Setting

Thirty-five clinical sites in North America.

Participants

Patients (N=279) with upper-limb poststroke spasticity at 6 months or more poststroke.

Intervention

Up to 5 intramuscular injections of BTX-A (200-400U) divided among the wrist, finger, thumb, and elbow flexors, with at least 200U in the wrist and finger flexors. Retreatment was permitted at 12 weeks or more after the last treatment.

Main Outcome Measures

Investigators rated disability using the Disability Assessment Scale and muscle tone using the Ashworth Scale. Each patient's health-related QOL was assessed by using the Stroke Adapted Sickness Impact Profile and the visual analog scale of the European Quality of Life−5 Dimensions questionnaires.

Results

Patients treated with BTX-A reported improvements in muscle tone, disability, and ability to function that were statistically significant and clinically meaningful. Significant improvements were observed at week 30 and at subsequent time points in QOL in the overall group and the high-dose group.

Conclusions

Up to 5 treatments with BTX-A every 12 weeks for up to 56 weeks in patients with poststroke spasticity was well tolerated and significantly improved muscle tone, lessened disability, and improved patients' QOL. Further research is required to examine the effectiveness of repeated injections of BTX-A in patients with poststroke spasticity.     

Development and Validation of Participation and Positive Psychologic Function Measures for Stroke Survivors

Bode RK, Heinemann AW, Butt Z, Stallings J, Taylor C, Rowe M, Roth EJ. Development and validation of participation and positive psychologic function measures for stroke survivors.

Objective

To evaluate the reliability and validity of Neurologic Quality of Life (NeuroQOL) item banks that assess quality-of-life (QOL) domains not typically included in poststroke measures.

Design

Secondary analysis of item responses to selected NeuroQOL domains.

Setting

Community.

Participants

Community-dwelling stroke survivors (n=111) who were at least 12 months poststroke.

Interventions

Not applicable.

Main Outcome Measures

Five measures developed for 3 NeuroQoL domains: ability to participate in social activities, satisfaction with participation in social activities, and positive psychologic function.

Results

A single bank was developed for the positive psychologic function domain, but 2 banks each were developed for the ability-to-participate and satisfaction-with-participation domains. The resulting item banks showed good psychometric properties and external construct validity with correlations with the legacy instruments, ranging from .53 to .71. Using these measures, stroke survivors in this sample reported an overall high level of QOL.

Conclusions

The NeuroQoL-derived measures are promising and valid methods for assessing aspects of QOL not typically measured in this population.     

Light Touch Cue Through a Cane Improves Pelvic Stability During Walking in Stroke

Boonsinsukh R, Panichareon L, Phansuwan-Pujito P. Light touch cue through a cane improves pelvic stability during walking in stroke.

Objective

To examine the effect of a light touch cue provided through a cane on mediolateral (ML) pelvic stability during walking in subjects poststroke.

Design

Crossover trial examining ML pelvic stability during walking using a cane with the force contact and touch contact methods.

Setting

Physical therapy clinic, tertiary care center.

Participants

Subacute patients (N=40) with stroke with a mean age of 59.6 years and mean stroke duration of 46.8 days. The average gait speed with a cane was .13m/s (.05-.29m/s).

Intervention

Using a cane with the force contact and touch contact methods during walking.

Main Outcome Measures

ML pelvic stability as measured by averaged peak-to-peak pelvic acceleration, muscle activation of bilateral tensor fascia latae (TFL), semitendinosus (ST), and vastus medialis (VM) using an electromyography system, and vertical cane force.

Results

The average amount of cane force during touch contact and force contact cane use conditions was 2.3N and 49.3N, respectively. A light touch cue through a cane was required only when the paretic leg accepted the body weight, and this cue can provide ML pelvic stability (.16g of average pelvic acceleration) during walking to the same degree as the force contact method of cane use. However, significant increases in single-limb support duration with higher activations of TFL, VM, and ST muscles on the paretic leg were found during the paretic stance phase when using a cane in the touch contact fashion (P<.05).

Conclusions

A light touch cue can be provided during walking through the use of a cane. This augmented somatosensory information provides lateral stability during walking for subjects with stroke by facilitating the activations of weight-bearing muscles on the paretic leg during the stance phase.     

Demographic and Clinical Variation in Veterans Health Administration Provision of Assistive Technology Devices to Veterans Poststroke

Hubbard Winkler SL, Cowper Ripley DC, Wu S, Reker DM, Vogel B, Fitzgerald SG, Mann WC, Hoenig H. Demographic and clinical variation in Veterans Health Administration provision of assistive technology devices to veterans poststroke.

Objectives

To examine variation in provision of assistive technology (AT) devices and the extent to which such variation may be explained by patient characteristics or Veterans Health Administration (VHA) administrative region.

Design

Retrospective population-based study.

Setting

VHA.

Participants

Veterans poststroke in fiscal years 2001 and 2002 (N=12,046).

Interventions

Not applicable.

Main Outcome Measure

Provision of 8 categories of AT devices.

Results

There was considerable regional variation in provision of AT. For example, differences across administrative regions in the VHA ranged from 5.1 to 28.1 standard manual wheelchairs per 100 veterans poststroke. Using logistic regression, with only demographic variables as predictors of standard manual wheelchair provision, the c statistic was .62, and the pseudo R² was 2.5%. Adding disease severity increased the c statistic to .67 and the pseudo R² to 6.2%, and adding Veteran Integrated Network System further increased the c statistic to .72 and pseudo R² to 9.8%.

Conclusions

Our research showed significant variation in the provision of AT devices to veterans poststroke, and it showed that patient characteristics accounted for only 6.2% of the variation. VHA administrative region and disability severity accounted for equivalent amounts of the variation. Our findings suggest the need for improvements in the process for providing AT and/or provider education concerning device provision.     

Functional significance of ipsilesional motor deficits after unilateral stroke

Chestnut C, Haaland KY. Functional significance of ipsilesional motor deficits after unilateral stroke.

Objective

To determine whether ipsilesional motor skills, which have been related to independent functioning, are present chronically after unilateral stroke and are more common in people with apraxia than in those without apraxia.

Design

Observational cohort comparing the performance of an able-bodied control group, stroke patients with left- or right-hemisphere damage matched for lesion volume, and left-hemisphere stroke patients with and without ideomotor limb apraxia.

Setting

Primary care Veterans Affairs and private medical center.

Participants

Volunteer right-handed sample; stroke patients with left- or right-hemisphere damage about 4 years poststroke; a control group of demographically matched, able-bodied adults.

Interventions

Not applicable.

Main Outcome Measures

Total time to perform the (1) Williams doors test and the (2) timed manual performance test (TMPT), which includes parts of the Jebsen-Taylor Hand Function Test.

Results

Ipsilesional motor deficits were present after left- or right-hemisphere stroke when using both measures, but deficits were consistently more common in patients with limb apraxia only for the TMPT.

Conclusions

These findings add to a growing literature that suggests that ipsilesional motor deficits may have a functional impact in unilateral stroke patients, especially in patients with ideomotor limb apraxia.     

Use of the six-minute walk test poststroke: is there a practice effect?

Liu J, Drutz C, Kumar R, McVicar L, Weinberger R, Brooks D, Salbach NM. Use of the six-minute walk test poststroke: is there a practice effect?

Objectives

To determine whether a practice effect occurs across 2 trials of the six-minute walk test (6MWT) among community-dwelling people within 1 year poststroke and to identify characteristics distinguishing people who show a practice effect from those who do not.

Design

Secondary analysis of scores on 2 trials of the 6MWT administered approximately 30 minutes apart at baseline in a randomized controlled trial.

Setting

General community.

Participants

People (N=91) living in the community with a residual walking deficit within the first year of a first or recurrent stroke.

Interventions

Not applicable.

Main Outcome Measure

Distance walked on the 6MWT.

Results

Mean 6MWT scores ± SD for trials 1 and 2 were 196±119m and 197±126m, respectively (n=83). The mean difference in 6MWT performance across trials was 0±35m (95% confidence interval [CI], -7 to 8m). The Pearson correlation coefficient between 6MWT distances was .96 (P<.001), and the intraclass correlation coefficient was .98 (95% CI, .97-.99). The Bland-Altman plot showed no clear pattern. Participants whose improvement was equal to or greater than the minimal detectable change of 29m between trials (14%) did not significantly differ from those in the rest of the study sample; however, they tended to be younger (P=.05) and more likely to have a mild or moderate gait deficit (P=.06).

Conclusions

Findings do not support a practice effect across 2 trials of the 6MWT in individuals within 1 year poststroke. Thus, a practice walk does not appear necessary. Further research is recommended to evaluate the influence of young age, acute stroke, and mild-to-moderate gait deficit on practice effects.     

The efficacy of telephone counseling for health promotion in people with multiple sclerosis: a randomized controlled trial

Bombardier CH, Cunniffe M, Wadhwani R, Gibbons LE, Blake KD, Kraft GH. The efficacy of telephone counseling for health promotion in people with multiple sclerosis: a randomized controlled trial.

Objective

To determine if motivational interviewing-based telephone counseling increases health promotion activities and improves other health outcomes in people with multiple sclerosis (MS).

Design

Randomized controlled trial with wait-list controls and single-blinded outcome assessments conducted at baseline and at 12 weeks.

Setting

MS research and training center in the Pacific Northwest.

Participants

Community-residing persons (N=130) with physician confirmed MS aged 18 or older who were able to walk unassisted at least 90m (300ft).

Intervention

A single in-person motivational interview followed by 5 scheduled telephone counseling sessions to facilitate improvement in 1 of 6 health promotion areas: exercise, fatigue management, communication and/or social support, anxiety and/or stress management, and reducing alcohol or other drug use.

Main Outcome Measures

Health Promotion Lifestyle Profile II plus fatigue impact, subjective health, and objective measures of strength, fitness, and cognition. Intent-to-treat analyses of change scores were analyzed using nonparametric tests.

Results

Seventy persons were randomized to treatment and 60 to the control condition. The treatment group reported significantly greater improvement in health promotion activities, including physical activity, spiritual growth, and stress management as well as in fatigue impact and mental health compared with controls. In addition, the exerciser subgroup showed greater improvement than controls in self-selected walking speed.

Conclusions

A less intensive, more accessible approach to health promotion based on telephone counseling and motivational interviewing shows promise and merits further study.     

Effects of Motor Imagery on Hand Function During Immobilization After Flexor Tendon Repair

Stenekes MW, Geertzen JH, Nicolai J-P, De Jong BM, Mulder T. Effects of motor imagery on hand function during immobilization after flexor tendon repair.

Objective

To determine whether motor imagery during the immobilization period after flexor tendon injury results in a faster recovery of central mechanisms of hand function.

Design

Randomized controlled trial.

Setting

Tertiary referral hospital.

Participants

Patients (N=28) after surgical flexor tendon repair were assigned to either an intervention group or a control group.

Intervention

Kinesthetic motor imagery of finger flexion movements during the postoperative dynamic splinting period.

Main Outcome Measures

The central aspects of hand function were measured with a preparation time test of finger flexion in which subjects pressed buttons as fast as possible following a visual stimulus. Additionally, the following hand function modalities were recorded: Michigan Hand Questionnaire, visual analog scale for hand function, kinematic analysis of drawing, active total motion, and strength.

Results

After the immobilization period, the motor imagery group demonstrated significantly less increase of preparation time than the control group (P=.024). There was no significant influence of motor imagery on the other tested hand function (P>.05). All tests except kinematic analysis (P=.570) showed a significant improvement across time after the splinting period (P≤.001).

Conclusions

Motor imagery significantly improves central aspects of hand function, namely movement preparation time, while other modalities of hand function appear to be unaffected.     

Rehabilitation of the Elbow Extension With Motor Imagery in a Patient With Quadriplegia After Tendon Transfer

Grangeon M, Guillot A, Sancho P-O, Picot M, Revol P, Rode G, Collet C. Rehabilitation of the elbow extension with motor imagery in a patient with quadriplegia after tendon transfer.

Objective

To test the effect of a postsurgical motor imagery program in the rehabilitation of a patient with quadriplegia.

Design

Crossover design with kinematic analysis.

Setting

Rehabilitation Hospital of Lyon. Study approved by the local Human Research Ethics Committee.

Participants

C6-level injured patient (American Spinal Injury Association Impairment Scale grade A) with no voluntary elbow extension (triceps brachialis score 1).

Intervention

The surgical procedure was to transfer the distal insertion of the biceps brachii onto the triceps tendon of both arms. The postsurgical intervention on the left arm included 10 sessions of physical rehabilitation followed by 10 motor imagery sessions of 30 minutes each. The patient underwent 5 sessions a week during 2 consecutive weeks. The motor imagery content included mental representations based on elbow extension involved in goal-directed movements. The rehabilitation period of the right arm was reversed, with motor imagery performed first, followed by physical therapy.

Main Outcome Measures

The kinematics of upper-limb movements was recorded (movement time and variability) before and after each type of rehabilitation period. A long-term retention test was performed 1 month later.

Results

Motor imagery training enhanced motor recovery by reducing hand trajectory variability—that is, improving smoothness. Motor performance then remained stable over 1 month.

Conclusions

Motor imagery improved motor recovery when associated with physical therapy, with motor performance remaining stable over the 1-month period. We concluded that motor imagery should be successfully associated with classic rehabilitation procedure after tendon transfer. Physical sessions may thus be shortened if too stressful or painful.     

A Specific Home Care Program Improves the Survival of Patients With Chronic Obstructive Pulmonary Disease Receiving Long Term Oxygen Therapy

Rizzi M, Grassi M, Pecis M, Andreoli A, Taurino AE, Sergi M, Fanfulla F. A specific home care program improves the survival of patients with chronic obstructive pulmonary disease receiving long term oxygen therapy.

Objectives

To analyze the influence of a home care (HC) program on outcomes of patients with chronic obstructive pulmonary disease (COPD) receiving long-term oxygen therapy (LTOT) in comparison with outcomes of patients receiving standard care (SC).

Design

A 10-year follow-up study with 2 parallel cohorts (HC vs SC).

Setting

University hospital.

Participants

One hundred and eight patients in the HC program and 109 patients managed conventionally.

Interventions

The HC program consisted of outpatient clinical and functional evaluations every 6 months, and domiciliary assessments by a specific team including a pneumologist, a respiratory nurse, and a rehabilitation therapist every 2 to 3 months or more, as needed.

Main Outcome Measures

Mortality; exacerbation, hospital and intensive care unit admission rate.

Results

One hundred and eight patients entered the HC program and 109 patients were managed conventionally. The 2 groups of patients did not differ for age, sex, body mass index, COPD severity or comorbid conditions. The overall mortality during the follow-up was 63% and the median survival was 96±38 months. The survival curves for HC and SC patients were statistically significantly different (log-rank, −16.04; P=.0001). In the Cox proportional hazards model, inclusion in the HC program was associated with an increased survival rate, whereas comorbid conditions and requirement of mechanical ventilation during the follow-up were associated with a decreased survival rate. During the entire follow-up, HC patients had a lower number of exacerbations/year than SC patients.

Conclusions

A disease-oriented HC program is effective in reducing mortality and hospital admissions in COPD patients requiring LTOT.     

Evaluation of postural control in quiet standing using center of mass acceleration: comparison among the young, the elderly, and people with stroke

Yu E, Abe M, Masani K, Kawashima N, Eto F, Haga N, Nakazawa K. Evaluation of postural control in quiet standing using center of mass acceleration: comparison among the young, the elderly, and people with stroke.

Objective

To determine center of mass (COM) acceleration usefulness in the evaluation of postural control during quiet standing.

Design

Three-group comparison design.

Setting

A research laboratory.

Participants

Poststroke subjects (n=12), healthy elderly subjects (n=22), and healthy young subjects (n=25).

Interventions

Not applicable.

Main Outcome Measures

With a force platform, postural sway was evaluated by using the standard deviations of COM acceleration and center of pressure (COP) and COM (COP-COM) in which COP-COM represents the distance between the COP and the COM.

Results

COM acceleration and COP-COM variables were greater in the poststroke group than in the healthy groups (elderly and young) in the mediolateral (ML) direction. Both variables in the anteroposterior (AP) direction were greater in the poststroke group and the elderly group than in the young group. Furthermore, the correlations between COM acceleration and COP-COM in each group in each direction were shown to be significantly high (r range, .906-.979; P<.001).

Conclusions

COM acceleration was useful in the evaluation of postural control during quiet standing when comparing the young, the elderly, and poststroke patients. Additionally, COM acceleration and COP-COM in both the AP and ML directions during quiet standing were significantly and highly correlated. Thus, we proposed that COM acceleration can be an alternative and convenient measure instead of COP-COM in the evaluation of postural control.