Rehabilitation of arm function after stroke. Literature review

IntroductionIn the recent literature we can find many articles dealing with upper extremity rehabilitation in stroke patients. New techniques, still under evaluation, are becoming the practical applications for the concept of post-stroke brain plasticity.MethodsThis literature review focuses on controlled randomized studies, reviews and meta-analyses published in the English language from 2004 to 2008. The research was conducted in MEDLINE with the following keywords: “upper limb”, “stroke”, “rehabilitation”.ResultsWe reviewed 66 studies. The main therapeutic strategies are: activation of the ipsilesional motor cortex, inhibition of the contralesional motor cortex and modulation of the sensory afferents. Keeping a cortical representation of the upper limb distal extremity could prevent the learned non-use phenomenon. The modulation of sensory afferents is then proposed: distal cutaneous electrostimulation, anesthesia of the healthy limb, mirror therapy, virtual reality. Intensifying the rehabilitation care means increasing the total hours of rehabilitation dedicated to the paretic limb (proprioceptive stimulation and repetitive movements). This specific rehabilitation is facilitated by robot-aided therapy in the active-assisted mode, neuromuscular electrostimulation and bilateral task training. Intensifying the rehabilitation training program significantly improves the arm function outcome when performed during subacute stroke rehabilitation (< six months). Ipsilesional neurostimulation as well as mental practice optimize the effect of repetitive gestures for slight motor impairments. Contralesional neurostimulation or anesthesia of the healthy hand both improve the paretic hand's dexterity via a decrease of the transcallosal inhibition. This pathophysiological mechanism could also explain the positive impact of constraint-induced movement therapy (CI therapy) in an environmental setting for chronic stroke patients.ConclusionTo ensure a positive functional outcome, stroke rehabilitation programs are based on task-oriented repetitive training. This literature review shows that exercising the hemiparetic hand and wrist is essential in all stages of a stroke rehabilitation program. New data stemming from neurosciences suggest that ipsilesional corticospinal excitability should be a priority.     

Distributed form of constraint-induced movement therapy improves functional outcome and quality of life after stroke

OBJECTIVE: To evaluate the effectiveness of a distributed version of constraint-induced movement therapy (CIMT). DESIGN: Within-subjects control intervention study. SETTING: Outpatient rehabilitation center. PARTICIPANTS: Eleven persons with chronic stroke. All had active extension of at least 20 degrees at the wrist and at least 10 degrees for each finger of the more-affected hand. INTERVENTIONS: Intensive motor training of the more-affected arm for 3 hours a day for 20 days; restraint of the other arm for 9.3 hours daily to limit its use. This intervention provides the same amount of training as provided in the conventional CIMT therapy protocol (60 h) but distributes training time over twice the number of days. MAIN OUTCOME MEASURES: Real-world (Motor Activity Log) and laboratory motor activity (Wolf Motor Function Test, Frenchay Arm Test, Nine Hole Peg Test), strength (grip force) and spasticity (Ashworth Scale), and quality of life (QOL; Stroke Impact Scale) were assessed. RESULTS: Participants showed significant improvements in more-affected arm real-world motor activity, laboratory motor activity, strength and spasticity, as well as in some aspects of QOL, up to 6 months after treatment ( P .05). CONCLUSIONS: Distributed CIMT is a promising intervention for improving motor function and QOL in patients with chronic stroke.     

The Application of the Principles and Procedures of PNF for the Care of Lumbar Spinal Instabilities

Abstract

Proprioceptive Neuromuscular Facilitation (PNF) is a dynamic manual approach to the evaluation and treatment of the neuromusculoskeletal system. This treatment approach has broad application for patients with both neurological and orthopedic problems. The authors have developed a systematic protocol using the philosophy and procedures of PNF integrated with other manual therapy procedures for the care of lumbar instabilities. This article will present the history, philosophy, basic principles, and procedures of PNF and their use in the treatment of lumbar spine instabilities.     

Botulinum toxin a, evidence-based exercise therapy, and constraint-induced movement therapy for upper-limb hemiparesis attributable to stroke: a preliminary study

OBJECTIVE: To determine whether the combination of botulinum toxin A (BTX-A) treatment for the upper limb and a 4-wk course of exercise therapy could improve motor function sufficiently to allow those with poststroke hemiparesis and spasticity to achieve the minimal motor criteria (MMC) to be enrolled in constraint-induced movement therapy (CIMT), and to determine the feasibility of enrolling participants into CIMT if they meet MMC after treatment with a combination of BTX-A plus exercise therapy. DESIGN: Twelve individuals received BTX-A and exercise therapy for 1 hr/day, three times per week, for 4 wks. Those who met MMC were enrolled in 2 wks of CIMT, and the rest received a home exercise program. Outcome measures included the Ashworth Scale, Wolf Motor Function Test (WMFT), the Motor Activity Log (MAL), the Box and Blocks Test (BBT), and the upper-extremity subtest of the Fugl-Meyer Assessment of Motor Function (FM-UE). RESULTS: Ashworth Scale scores declined from a mean score of 2.0-1.2 (P = 0.01). Four of 12 subjects were able to achieve MMC (P = 0.026). CIMT participants improved in the BBT, the MAL, and the WMFT compared with their own baseline. Gains achieved during CIMT receded by week 24 as spasticity returned. CONCLUSION: BTX-A plus exercise therapy shows potential to improve function for those with severe hand paresis and spasticity after stroke. Those who meet MMC may initially realize further modest gains through CIMT. However, gains are likely to recede as spasticity returns. Adding medications or modifying the therapy protocol to include activities such as functional neuromuscular stimulation or robotic training may yield a more potent effect.     

The effect of modified constraint-induced movement therapy on spasticity and motor function of the affected arm in patients with chronic stroke

Purpose: The purpose of this study was to explore the effect of modified constraint-induced movement therapy (CIMT) in a real-world clinical setting on spasticity and functional use of the affected arm and hand in patients with spastic chronic hemiplegia.Method: A prospective consecutive quasi-experimental study design was used. Twenty patients with spastic hemiplegia (aged 22-67 years) were tested before and after 2-week modified CIMT in an outpatient rehabilitation clinic and at 6 months. The Modified Ashworth Scale (MAS), active range of motion (AROM), grip strength, Motor Activity Log (MAL), Sollerman hand function test, and Box and Block Test (BBT) were used as outcome measures.Results: Reductions (p<0.05-0.001) in spasticity (MAS) were seen both after the 2-week training period and at 6-month follow-up. Improvements were also seen in AROM (median change of elbow extension 5°, dorsiflexion of hand 10°), grip strength (20?Newton), and functional use after the 2-week training period (MAL: 1 point; Sollerman test: 8 points; BBT: 4 blocks). The improvements persisted at 6-month follow-up, except for scores on the Sollerman hand function test, which improved further.Conclusion: Our study suggests that modified CIMT in an outpatient clinic may reduce spasticity and increase functional use of the affected arm in spastic chronic hemiplegia, with improvements persisting at 6 months.     

Effect of coordination movement using the PNF pattern underwater on the balance and gait of stroke patients

[Purpose] To investigate the effect of coordination movement using the Proprioceptive Neuromuscular Facilitation pattern underwater on the balance and gait of stroke patients. [Subjects and Methods] Twenty stroke patients were randomly assigned to an experimental group that performed coordination movement using the Proprioceptive Neuromuscular Facilitation pattern underwater and a control group (n =10 each). Both the groups underwent neurodevelopmental treatment, and the experimental group performed coordination movement using the Proprioceptive neuromuscular facilitation pattern underwater. Balance was measured using the Berg Balance Scale and Functional Reach Test, and gait was measured using the 10-Meter Walk Test and Timed Up and Go Test. To compare in-group data before and after the intervention, paired t-test was used. Independent t-test was used to compare differences in the results of the Berg Balance Scale, Functional Reach Test, 10-Meter Walk Test, and Timed Up and Go Test before and after the intervention between the groups. [Results] Comparison within the groups showed significant differences in the results of the Berg Balance Scale, Functional Reach Test, 10-Meter Walk Test, and Timed Up and Go Test before and after the experimental intervention. On comparison between the groups, there were greater improvements in the scores of the Berg Balance Scale, Functional Reach Test, 10-Meter Walk Test, and Timed Up and Go Test in the experimental group. [Conclusion] The findings demonstrate that coordination movement using the Proprioceptive Neuromuscular Facilitation pattern under water has a significant effect on the balance and gait of stroke patients.Key words: Coordination movement using the PNF pattern, Balance, Gait     

The immediate effect of neuromuscular joint facilitation (NJF) treatment on the standing balance in younger persons

[Purpose] The aim of this study was to investigate the change in standing balance of younger persons after neuromuscular joint facilitation (NJF) treatment. [Subjects] The subjects were 57 healthy young people, who were divided into three groups: The NJF group, and the Proprioceptive Neuromuscular Facilitation (PNF) group and the control group. [Methods] Functional reach test and body sway were measured before and after intervention in three groups. Four hip patterns of NJF or PNF were used. Two-way ANOVA and multiple comparisons were performed. [Results] The rate of change of FRT in the NJF group increased than the PNF group. The root mean square area at NJF and PNF group increased than control group. [Conclusion] The results suggest that caput femoris rotation function can be improved by NJF treatment, and that improvement of caput femoris rotation contributes to improve dynamic balance.Key words: Neuromuscular joint facilitation, Proprioceptive neuromuscular facilitation, Balance     

Cortical Alpha Rhythms Are Related to the Anticipation of Sensorimotor Interaction Between Painful Stimuli and Movements: A High-Resolution EEG Study

We tested whether cortical activation anticipating painful stimuli is reduced more by integrative processes on somatosensory painful and motor information relative to the same hand than when that information refers to different hands. In 3 conditions, visual warning stimuli were followed by visual target stimuli associated with an electrical painful stimulation at left index finger. In the Pain (control) condition, no task was required after the target stimuli. In the “Pain + ipsilateral movement” condition, the subjects had to perform a movement of the left index finger. In the “Pain + contralateral movement” condition, they had to perform a movement of the right index finger. Meanwhile, electroencephalographic data were recorded (n = 18) from 128 scalp electrodes. Off line, these data were spatially enhanced by surface Laplacian transformation. Sensorimotor cortical activation before the painful stimulation was probed by the percentage power reduction of alpha rhythms at approximately 8 to 12 Hz (event-related desynchronization, ERD). Results showed that the subjects perceived a lower stimulus intensity in both “Pain + ipsilateral” and “Pain + contralateral” conditions compared with the control “Pain” condition. Furthermore, wide anticipatory alpha ERD (approximately 10–12 Hz) was lower in amplitude in the “Pain + ipsilateral” than in the “Pain + contralateral” condition. These results suggest that modulation of alpha rhythms is a putative physiological mechanism underlying anticipatory processes preceding the integration of painful and motor information at cortical level. Furthermore, these processes show a marked interference (“gating”) when the sensorimotor integration refer to the same hand as opposed to both hands.PerspectiveWe showed that cortical alpha rhythms preceding painful stimulation are influenced by the preparation of contralateral and ipsilateral finger movements. These results motivate further investigation for testing the hypothesis that chronic pain patients might exaggerate the anticipatory activation of sensorimotor cortex to negligible pain stimuli.     

A 1-Year Follow-Up After Shortened Constraint-Induced Movement Therapy With and Without Mitt Poststroke

Brogårdh C, Lexell J. A 1-year follow-up after shortened constraint-induced movement therapy with and without mitt poststroke.

Objective

To explore the long-term benefits of shortened constraint-induced movement therapy (CIMT) in the subacute phase poststroke.

Design

A 1-year follow-up after shortened CIMT (3h training/d for 2wk) where the participants had been randomized to a mitt group or a nonmitt group.

Setting

A university hospital rehabilitation department.

Participants

Poststroke patients (N=20, 15 men, 5 women; mean age 58.8y; on average 14.8mo poststroke) with mild to moderate impairments of hand function.

Interventions

Not applicable.

Main Outcome Measures

The Sollerman hand function test, the modified Motor Assessment Scale, and the Motor Activity Log test. Assessments were made by blinded observers.

Results

One year after shortened CIMT, participants within both the mitt group and the nonmitt group showed statistically significant improvements in arm and hand motor performance and on self-reported motor ability compared with before and after treatment. No significant differences between the groups were found in any measure at any time.

Conclusions

Shortened CIMT seems to be beneficial up to 1 year after training, but the restraint may not enhance upper motor function. To determine which components of CIMT are most effective, larger randomized studies are needed.     

Short- and long-term outcome of constraint-induced movement therapy after stroke: a randomized controlled feasibility trial

OBJECTIVE: Constraint-induced movement therapy (CIMT) is a method to improve motor function in the upper extremity following stroke. The aim of this trial was to determine the effect and feasibility of CIMT compared with traditional rehabilitation in short and long term. DESIGN: A randomized controlled trial. SETTING: An inpatient rehabilitation clinic. SUBJECTS: Thirty patients with unilateral hand impairment after stroke. INTERVENTION: Six hours arm therapy for 10 consecutive weekdays, while using a restraining mitten on the unaffected hand. MAIN MEASURES: The patients were assessed at baseline, post-treatment and at six-month follow-up using the Wolf Motor Function Test as primary outcome measure and the Motor Activity Log, Functional Independence Measure and Stroke Impact Scale as secondary measurements. RESULTS: The CIMT group (n=18) showed a statistically significant shorter performance time (4.76 seconds versus 7.61 seconds, P= 0.030) and greater functional ability (3.85 versus 3.47, P= 0.037) than the control group (n=12) on the Wolf Motor Function Test at post-treatment assessment. There was a non-significant trend toward greater amount of use (2.47 versus 1.97, P= 0.097) and better quality of movement (2.45 versus 2.12, P=0.105) in the CIMT group according to the Motor Activity Log. No such differences were seen on Functional Independence Measure at the same time. At six-month follow-up the CIMT group maintained their improvement, but as the control group improved even more, there were no significant differences between the groups on any measurements. CONCLUSIONS: CIMT seems to be an effective and feasible method to improve motor function in the short term, but no long-term effect was found.     

Constraint-induced motor relearning after stroke: a naturalistic case report

Constraint-induced movement therapy (CIMT) is a promising approach to promoting recovery of functional arm movement after stroke. However, controlled studies have been limited to persons who sustained strokes at least 1 year before beginning the treatment protocol. This case study documents the neurologic history and motor recovery of a woman whose natural circumstances lend support to the principles of CIMT. The patient sustained a right midpontine vascular infarct and fell simultaneously, fracturing her right humerus. Orthopedic intervention for the fracture mirrored the protocol suggested by proponents of CIMT by immobilizing her right arm. Her significant recovery of left arm use over a 1-year period was more extensive than what would be typically expected after the type of cerebral infarct she incurred. Her case provides the first evidence in the literature that supports the principles of CIMT when it is applied immediately poststroke.     

神经肌肉本体促通技术对偏瘫患者立位平衡极限的影响

目的观察神经肌肉本体促通技术 (PNF)对偏瘫患者立位平衡极限能力的影响。方法 18例脑卒中恢复期患者分为 :治疗组 (9例 )使用PNF手法 ;对照组 (9例 )采用Bobath、运动再学习等康复技术。均治疗 3个月结果治疗组患者立位平衡极限能力优于对照组 (P <0 0 5 -0 0 1)。结论利用PNF技术对提高偏瘫患者平衡极限能力有明显的效果。     

Case report: ICF-level changes in a preschooler after constraint-induced movement therapy

The authors examined changes associated with constraint-induced movement therapy (CIMT) provided to a preschool-aged child with right spastic hemiplegia. This case study design used a 2-week pretest measure baseline period, 2 weeks of CIMT, and postmeasures at 1 week and 3 months. Measures were chosen to document changes at the different levels of International Classification of Functioning, Disability and Health (ICF), including the Canadian Occupational Performance Measure (COPM), Pediatric Evaluation of Disability Inventory (PEDI) Self-Care Section, Melbourne Assessment of Unilateral Upper Limb Function, and grip and pinch strength. Results showed increases on COPM-identified goals of increased independence with bilateral hand play and participation in gross motor play with friends. Changes were also documented in self-care, arm function, and grip strength. Another unexpected association reported by parents and professionals was increased speech intelligibility. Potential implications of implementing CIMT with young children are presented.     

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.     

External biomechanical constraints impair maximal voluntary grip force stability post-stroke

BackgroundGrip strength is frequently measured as a global indicator of motor function. In clinical populations, such as hemiparesis post-stroke, grip strength is associated with upper-extremity motor impairment, function, and ability to execute activities of daily living. However, biomechanical configuration of the distal arm and hand may influence the magnitude and stability of maximal voluntary grip force and varies across studies. The influence of distal arm/hand biomechanical configuration on grip force remains unclear. Here we investigated how biomechanical configuration of the distal arm/hand influence the magnitude and trial-to-trial variability of maximal grip force performed in similar positions with variations in external constraint.MethodsWe studied three groups of 20 individuals: healthy young, healthy older, and individuals post-stroke. We tested maximal voluntary grip force in 4 conditions: 1: self-determined/“free”; 2: standard; 3: fixed arm-rest; 4: gripper fixed to arm-rest, using an instrumented grip dynamometer in both dominant/non-dominant and non-paretic/paretic hands.FindingsRegardless of hand or group, maximal voluntary grip force was highest when the distal limb was most constrained (i.e., Condition 4), followed by the least constrained (i.e., Condition 1) (Cohen's f = 0.52, P's < 0.001). Coefficient of variation among three trials was greater in the paretic hand compared with healthy individuals, particularly in more (Conditions 3 and 4) compared to less (Conditions 1 and 2) constrained conditions (Cohen's f = 0.29, P's < 0.05).InterpretationThese findings have important implications for design of rehabilitation interventions and devices. Particularly in individuals post-stroke, external biomechanical constraints increase maximal voluntary grip force variability while fewer biomechanical constraints yield more stable performance.     

Essential Role of Social Context and Self-Efficacy in Daily Paretic Arm/Hand Use After Stroke: An Ecological Momentary Assessment Study With Accelerometry

ObjectiveTo determine the momentary effect of social-cognitive factors, in addition to motor capability, on post-stroke paretic arm/hand use in the natural environment.DesignA 5-day observational study in which participants were sent 6 Ecological Momentary Assessment (EMA) prompts/day.SettingParticipants’ daily environment.ParticipantsCommunity-dwelling, chronic stroke survivors with right-dominant, mild-moderate upper extremity paresis (N=30).InterventionsNot applicable.Main Outcome MeasuresTime duration of bimanual and unimanual paretic arm/hand use indexed by accelerometry; social-cognitive factors (social context, self-efficacy, mood) captured by EMA; motor capability of the paretic limb measured by Fugl-Meyer Upper Extremity Motor Assessment (FM).ResultsAfter accounting for participants’ motor capability, we found that momentary social context (alone or not) and self-efficacy significantly predicted post-stroke paretic arm/hand use behavior in the natural environment. When participants were not alone, paretic arm/hand movement increased both with and without the less-paretic limb (bimanual and unimanual movements, P=.018 and P<.001, respectively). Importantly, participants were more likely to use their paretic arm/hand (unimanually) if they had greater self-efficacy for limb use (P=.042). EMA repeated-measures provide a real-time approach that captures the natural dynamic ebb and flow of social-cognitive factors and their effect on daily arm/hand use. We also observed that people with greater motor impairments (FM<50.6) increase unimanual paretic arm/hand movements when they are not alone, regardless of motor capability.ConclusionsIn addition to motor capability, stroke survivors’ momentary social context and self-efficacy play a role in paretic arm/hand use behavior. Our findings suggest the development of personalized rehabilitative interventions which target these factors to promote daily paretic arm/hand use. This study highlights the benefits of EMA to provide real-time information to unravel the complexities of the biopsychosocial (ie, motor capability and social-cognitive factors) interface in post-stroke upper extremity recovery.     

Constraint-induced movement therapy after stroke: efficacy for patients with minimal upper-extremity motor ability

OBJECTIVE: To examine the effects of constraint-induced movement therapy (CIMT) on chronic moderate-to-severe upper-extremity motor impairment after stroke. DESIGN: Within-subjects design; pre- and posttesting as well as 1-month follow-up. SETTING: Outpatient clinic within a rehabilitation hospital. PARTICIPANTS: Twenty participants, each greater than 12 months poststroke. INTERVENTION: Three weeks of CIMT including restraint of the nonparetic upper extremity and 6 hours of training a day. MAIN OUTCOME MEASURES: Fugl-Meyer Assessment (FMA), Graded Wolf Motor Function Test (GWMFT), and Motor Activity Log (MAL). RESULTS: There was a statistically significant effect of treatment on upper-extremity motor impairment as assessed by the FMA, the MAL, and the functional ability scale of the GWMFT. There was a trend toward an effect of CIMT on mean speed of performance on the GWMFT. Post hoc analysis showed significant differences between motor impairment scores between pretreatment and posttreatment assessments, and improvements in motor impairment scores remained stable 1 month after completion of formal treatment. Improvements appeared to be mostly in the use of the involved upper extremity for bimanual activities. CONCLUSIONS: CIMT conferred significant changes in objective measures in subjects with chronic moderate-to-severe impairments after stroke. Additional studies of long-term benefits of this treatment on poststroke motor impairments and related functional disabilities are warranted.     

强制性使用运动疗法对慢性期脑卒中患者上肢运动功能的康复疗效

目的 探讨强制性使用运动疗法（CIMT）对慢性期脑卒中患者上肢运动功能的康复疗效。方法 15例慢性期脑卒中偏瘫患者（平均病程13．5个月）在CIMT治疗期间健侧穿戴吊带和夹板限制肢体动作，每天清醒时固定时间不少于90％，连续12d；同时接受塑形训练，密集训练患侧肢体活动，完成日常生活动作，连续两周共10个工作日。在CIMT治疗前2周的基线期、治疗前和治疗后采用上肢功能测验（UEFT）和简易上肢机能检查（STEF）评价患者的上肢运动功能。结果 患者在CIMT治疗前2周的基线期内，UEFT和STEF显现出微小改善（ES；0．11，0．13）；接受2周CIMT治疗后，UEFT和STEF显现出较为明显的改善（ES：0．8，0．5）。结论 C1MT是改善慢性期脑卒中患者上肢运动功能的一种有效治疗方法，短期CIMT介入可以促进患侧上肢功能多方面的改善。