Article

Constraint-Induced Movement Therapy for the Lower Extremities in Multiple Sclerosis: Case Series With 4-Year Follow-Up

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Abstract

Objective: To evaluate in a preliminary manner the feasibility, safety, and efficacy of Constraint-Induced Movement therapy (CIMT) of persons with impaired lower extremity use from multiple sclerosis (MS). Design: Clinical trial with periodic follow-up for up to 4 years. Setting: University-based rehabilitation research laboratory. Participants: A referred sample of ambulatory adults with chronic MS (N=4) with at least moderate loss of lower extremity use (average item score ≤6.5/10 on the functional performance measure of the Lower Extremity Motor Activity Log [LE-MAL]). Interventions: CIMT was administered for 52.5 hours over 3 consecutive weeks (15 consecutive weekdays) to each patient. Main outcome measures: The primary outcome was the LE-MAL score at posttreatment. Secondary outcomes were posttreatment scores on laboratory assessments of maximal lower extremity movement ability. Results: All the patients improved substantially at posttreatment on the LE-MAL, with smaller improvements on the laboratory motor measures. Scores on the LE-MAL continued to improve for 6 months afterward. By 1 year, patients remained on average at posttreatment levels. At 4 years, half of the patients remained above pretreatment levels. There were no adverse events, and fatigue ratings were not significantly changed by the end of treatment. Conclusions: This initial trial of lower extremity CIMT for MS indicates that the treatment can be safely administered, is well tolerated, and produces substantially improved real-world lower extremity use for as long as 4 years afterward. Further trials are needed to determine the consistency of these findings.

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... In 2013, a case series was published which had been conducted on multiple sclerosis patients with a 4-year follow-up. At the end of the protocol they observed that these patients showed a notable improvement in Lower Extremity Motor Activity Log (LE-MAL) [25]. ...
... The scale for subscale B (self-initiated device-assistance) relevant to a given task can be either the assistive device subscale (B1) or the environmental support subscale (B2). Subscale C (person assistance) is the same for every item [25,47,48]. ...
... It is important to clarify that when we first put this protocol into practice, we maintained the first study published by the group. At that time, the protocol was performed with 15 days of intervention [25]. Following information updates about the protocol from Dr Taub and colleagues at the University of Alabama in Birmingham to use 10 days of training, we decided to continue with the initial methodology plan as the protocol is still evolving and, in this way, offers us an opportunity to discuss the optimum amount of LE-CIT. ...
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Background Protocols involving intensive practice have shown positive outcomes. Constraint induced movement therapy (CIT) appears to be one of the best options for better outcomes in upper limb rehabilitation, but we still have little data about lower extremity constraint-induced movement therapy (LE-CIT) and its effects on gait and balance. Objective To evaluate the effects of an LE-CIT protocol on gait functionality and balance in chronic hemiparetic patients following a stroke. Methods The study adopts a randomized, controlled, single-blinded study design. Forty-two patients, who suffered a stroke, who were in the chronic phase of recovery (>6 months), with gait disability (no community gait), and who were able to walk at least 10 m with or without the advice or support of 1 person, will be randomly allocated to 2 groups: the LE-CIT group or the control group (intensive conventional therapy). People will be excluded if they have speech deficits that render them unable to understand and/or answer properly to evaluation scales and exercises selected for the protocol and/or if they have suffered any clinical event between the screening and the beginning of the protocol. Outcome will be assessed at baseline (T0), immediately after the intervention (T1), and after 6 months (T2). The outcome measures chosen for this trial are as follows: 6-min walk test (6minWT), 10-m walk test (10mWT), timed up and go (TUG), 3-D gait analysis (3DGA), Mini Balance Evaluation Systems Test (Mini-BESTest), and as a secondary measure, Lower Extremity Motor Activity Log will be evaluated (LE-MAL). The participants in both groups will receive 15 consecutive days of daily exercise. The participants in the LE-CIT group will be submitted to this protocol 2.5 h/day for 15 consecutive days. It will include (1) intensive supervised training, (2) use of shaping as strategy for motor training, and (3) application of a transfer package (plus 30 min). The control group will receive conventional physiotherapy for 2.5 h/day over 15 consecutive days (the same period as the CIT intervention). Repeated measures analyses will be made to compare differences and define clinically relevant changes between groups. Results Data collection is currently on-going and results are expected in 2021. Discussion LE-CIT seems to be a good protocol for inclusion into stroke survivors’ rehabilitation as it has all the components needed for positive results, as well as intensity and transference of gains to daily life activities. Trial registration www.ensaiosclinicos.gov.br RBR-467cv6 . Registered on 10 October 2017. “Effects of Lower Extremities - Constraint Induced Therapy on gait and balance function in chronic hemipretic post-stroke patients”.
... Spooren A et al. (2012) indicated the restorative potential of UL function in pwMS after motor training programs. Moreover, based on our own systematic literature review performed in our first master year, we reported that sensory education [13], Constraint Induced Movement Therapy (CIMT) [14], aquatic training [15] and traditional rehabilitation strategies such as Bobath, resistance and endurance training [16][17][18] may improve UL function in pwMS. We also found UL training with robotic modalities to be an upcoming trend in UL rehabilitation in a neurological population [19][20][21][22]. ...
... This could be due to experienced fluctuations in fatigue feelings, perhaps due to uncontrolled preceding daily life activities, which was also indicated by the low ICC. Another intervention study [14], that investigated the effects of CIMT in pwMS, also used perceived fatigue as one of the outcome measures. They included only 5 participants of which 4 felt mostly no fatigue, which was not the case in our group of participants. ...
... The FMS values of the WMFT correspond to the WMFT time values and resulted that the participants also reached statistically significant improvements after treatment. From our review of UL intervention studies in pwMS, we found one study [14] that also included the WMFT time as outcome measure. Participants of this study [14] improved in the WMFT time after treatment, but in contrast to our study, without statistically significant effect. ...
Thesis
Deze studie heeft betrekking tot robot geassisteerde bovenste lidmaat revalidatie bij personen met Multiple Sclerosis
... CIMT was designed to overcome learned non-use in chronic hemiparesis, i.e. behavioral suppression of purposeful movement of the more affected upper extremity in real-life situations, with compensation, during ADL, by the less affected upper extremity; this suppression is believed to be maintained chronically, although many patients can nevertheless complete common ADL with the paretic limb upon request (Taub et al., 1999;Sterr et al., 2002). Only a few studies -all performed by the same group -have evaluated the effects of CIMT in patients with MS (Mark et al., 2008(Mark et al., , 2013(Mark et al., , 2018Barghi et al., 2018). In a pilot study, Mark et al. showed safety, tolerability, and real-world functional efficacy of CIMT in hemiparetic MS patients (Mark et al., 2008). ...
... Indeed, at the end of the two-week treatment these participants had significantly greater muscle strength and dexterity compared with T0, performing the 9HPT in a significantly shorter time, although there were no differences between the groups at T1. Over the last few years, CIMT has been a focus of increasing attention in the scientific literature as a promising rehabilitation technique in stroke patients (Taub et al., 1999;Sterr et al., 2002;Morris DM et al., 2006;Peurala et al., 2012;Smania et al., 2012) and recently also in patients affected by MS (Mark et al., 2008(Mark et al., , 2013(Mark et al., , 2018Barghi et al., 2018). This pilot study suggests that CIMT had positive effects in the treatment of progressive MS patients and the technique appears to be effective, safe and tolerated in these patients. ...
Article
Multiple sclerosis (MS) is a chronic disease of the central nervous system, characterized by demyelinization and axonal loss resulting, in 66% of cases, in upper limb motor impairment. The effects of constraint-induced movement therapy (CIMT) have recently been investigated in MS patients. The aim of this randomized single-blind pilot study was to assess the effects of CIMT on upper limb activity, specifically smoothness of movement, in patients affected by progressive MS. Patients affected by MS, and reporting reduced use primarily of one upper limb, were enrolled and randomly allocated to two different groups: a CIMT group, where treatment was performed with the less affected limb immobilized by a splint, and a control group, submitted to intensive bi-manual treatment. All evaluations were performed at baseline (T0) and after two weeks of treatment (T1) by an operator unaware of the patients' allocation. The primary outcome was the difference in movement smoothness, measured by means of a bidimensional kinematic evaluation. Secondary outcomes were: endpoint error and arm trajectory mean speed. Furthermore, patients performed the Hand Grip Strength Test (HGS) and 9-Hole Peg Test (9HPT), for both arms, at both time points. Ten patients with MS (4 males, 6 females; mean age 51.0±7.7 years) were randomly allocated to the CIMT group (n=5) and control group (n=5). There were no significant differences between groups in any of the data assessed at baseline. In the CIMT group subjects, the treatment effect, in terms of movement smoothness, was significant at the more affected limb (p=0.0376). The CIMT group displayed statistically significant improvements, versus the baseline values, in muscle strength (HGS:22.4±8.3 vs 26.0±6.0; p<0.05) and dexterity (9HPT: 31.8±6.1 vs 27.4±4.9; p<0.05) of the more affected limb. A positive, although not significant, trend in terms of muscle strength and upper limb dexterity was observed, for both limbs, in the control group after the two-week treatment. Bi-dimensional kinematic evaluation demonstrated that the CIMT group showed a significant reduction of endpoint error and higher mean speed for the more affected arm; these data are in line with the significant improvements recorded on the HGS and 9HPT. Moreover, in the CIMT group, a non-significant worsening of muscle strength was recorded for the less affected upper limb.
... Indeed, up to date, only few studies have assessed how CIMT might be effective on upper limb activity and function on selected patients with MS with a hemiparetic presentation of the disease (Mark et al., 2008(Mark et al., , 2013(Mark et al., , 2018Barghi et al., 2018). Mark et al. in the most recent randomized controlled trial (RCT) demonstrated that CIMT could improve the use of the more affected arm in terms of ADL in these specific patients (Mark et al., 2018). ...
... Over the last decade, CIMT has been proven to be useful as rehabilitation behavior-based technique improving the motor function in different neurologic diseases, including stroke Sterr et al., 2002;Morris et al., 2006;Peurala et al., 2012;Smania et al., 2012) and recently also MS (Mark et al., 2008(Mark et al., , 2013(Mark et al., , 2018Barghi et al., 2018). Although CIMT might be a promising rehabilitation technique in rehabilitation of MS, there are some concerns regarding patient compliance, muscle soreness resulting in stiffness and discomfort in the involved upper extremity as well as skin lesions and skin burns. ...
Article
Background: There are few evidences on safety of Constraint-Induced Movement Therapy (CIMT), as well as its effects in neurological conditions, including multiple sclerosis (MS). Objective: To evaluate safety and effectiveness of a 2-week CIMT protocol on upper limb activity of progressive MS patients through a three-dimensional (3D) kinematic analysis. Methods: In this randomized single-blind pilot study, we randomly allocated patients affected by progressive MS reporting a reduced use of one upper limb into two different groups: CIMT group (less affected limb blocked by a splint) and control group (undergoing bi-manual treatment). Primary outcome was CIMT safety. Furthermore, we assessed CIMT effects through clinical outcomes (hand grip strength, HGS, and 9 Hole Peg Test, 9HPT) and 3D kinematic analysis (normalized jerk, number of movement units, going phase duration, mean velocity, endpoint error). All evaluations were performed at baseline (T0) and after 2 weeks of treatment (T1) for both arms in both groups. Results: Ten MS patients, mean aged 51.0±7.7 years, were randomly allocated in the 2 groups. After treatment, no differences were found in the blocked arm. Furthermore, CIMT group showed significant improvements in clinical and kinematic parameters. Conclusions: CIMT might be considered a safe and effective technique in MS patients.
... Previous studies on TOCT highlighted positive effects on restoring mobility in stroke survivors including a wide range of exercise doses and intensities [16]. To our knowledge (except for treadmill, body-weight support treadmill and robot-assisted gait training [34]), the only attempts to apply a taskoriented training for mobility impairments in PwMS were done by Mark et al. [35] who proposed a Constraint-Induced Movement Therapy (CIMT) for the lower extremities and Salbach et al. [36] who tested a community exercise program for people with stroke, acquired brain injury and MS. CIMT was administered to a small sample (n = 4) showing positive effects on real-world lower extremity use up to four years. ...
... CIMT was administered to a small sample (n = 4) showing positive effects on real-world lower extremity use up to four years. Compared to our TOCT, CIMT protocol was much more intense (3.5 h/d for 3 wk), trained 15 different tasks (compared to 7) and a "transfer package" to deliver gains into the real world was administered [35]. The community exercise program was delivered to 2 MS subjects twice/week for 12 weeks with no effects on walking endurance [36]. ...
Article
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The aim of this study was to evaluate the safety, feasibility and preliminary effects of a high-intensity rehabilitative task-oriented circuit training (TOCT) in a sample of multiple sclerosis (MS) subjects on walking competency, mobility, fatigue and health-related quality of life (HRQoL). 24 MS subjects (EDSS 4.89 ± 0.54, 17 female and 7 male, 52.58 ± 11.21 years, MS duration 15.21 ± 8.68 years) have been enrolled and randomly assigned to 2 treatment groups: (i) experimental group received 10 TOCT sessions over 2 weeks (2 hours/each session) followed by a 3 months home exercise program, whereas control group did not receive any specific rehabilitation intervention. A feasibility patient-reported questionnaire was administered after TOCT. Functional outcome measures were: walking endurance (Six Minute Walk Test), gait speed (10 Meter Walk Test), mobility (Timed Up and Go test) and balance (Dynamic Gait Index). Furthermore, self-reported questionnaire of motor fatigue (Fatigue Severity Scale), walking ability (Multiple Sclerosis Walking Scale – 12) and health-related quality of life (Multiple Sclerosis Impact Scale – 29) were included. Subjects’ assessments were delivered at baseline (T0), after TOCT (T1) and 3 months of home-based exercise program (T2). After TOCT subjects reported a positive global rating on the received treatment. At 3 months, we found a 58.33% of adherence to the home-exercise program. After TOCT, walking ability and health-related quality of life were improved (p < 0.05) with minor retention after 3 months. The control group showed no significant changes in any variables. This two weeks high-intensity task-oriented circuit class training followed by a three months home-based exercise program seems feasible and safe in MS people with moderate mobility impairments; moreover it might improve walking abilities. Trial registration NCT01464749
... The lower extremity CIMT protocol includes (1) intensive practice of the functional activities, (2) limiting reliance on the unimpaired lower limb, (3) transfer of the gains from the training session to the family or community rehabilitation with a "transfer package" and (4) strong encouragement to use the impaired lower limb with improved coordination (17). However, unlike upper extremity CIMT, which uses a substantial constraint on the unimpaired lower limb (e.g., a padded mitt), the "constraint" for lower extremity CIMT can be behavioral, physical, or both (18). To stimulate walking ability and to overcome general inactivity, lower extremity CIMT consists of massed or repetitive practice of lower limb tasks (e.g., treadmill walking, over-ground walking, sit-to-stand, lie-tosit, step climbing, and various balance and support exercises) (19). ...
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Objective Constraint-induced movement therapy (CIMT) is a common treatment for upper extremity motor dysfunction after a stroke. However, whether it can effectively improve lower extremity motor function in stroke patients remains controversial. This systematic review comprehensively studies the current evidence and evaluates the effectiveness of CIMT in the treatment of post-stroke lower extremity motor dysfunction. Methods We comprehensively searched randomized controlled trials related to this study in eight electronic databases (PubMed, Embase, The Cochrane Library, Web of Science, CBM, CNKI, WAN FANG, and VIP). We evaluated CIMT effectiveness against post-stroke lower extremity motor dysfunction based on the mean difference and corresponding 95% confidence interval (95% CI). We assessed methodological quality based on the Cochrane Bias Risk Assessment Tool. After extracting the general information, mean, and standard deviation of the included studies, we conducted a meta-analysis using RevMan 5.3 and Stata 16.0. The primary indicator was the Fugl-Meyer Assessment scale on lower limbs (FMA-L). The secondary indicators were the Berg balance scale (BBS), 10-meter walk test (10MWT), gait speed (GS), 6-min walk test (6MWT), functional ambulation category scale (FAC), timed up and go test (TUGT), Brunnstrom stage of lower limb function, weight-bearing, modified Barthel index (MBI), functional independence measure (FIM), stroke-specific quality of life questionnaire (SSQOL), World Health Organization quality of life assessment (WHOQOL), and National Institute of Health stroke scale (NIHSS). Results We initially identified 343 relevant studies. Among them, 34 (totaling 2,008 patients) met the inclusion criteria. We found that patients treated with CIMT had significantly better primary indicator (FMA-L) scores than those not treated with CIMT. The mean differences were 3.46 (95% CI 2.74–4.17, P < 0.01, I2 = 40%) between CIMT-treated and conventional physiotherapy-treated patients, 3.83 (95% CI 2.89–4.77, P < 0.01, I2 = 54%) between patients treated with CIMT plus conventional physiotherapy and patients treated only with conventional physiotherapy, and 3.50 (95% CI 1.08–5.92, P < 0.01) between patients treated with CIMT plus western medicine therapy and those treated only with western medicine therapy. The secondary indicators followed the same trend. The subgroup analysis showed that lower extremity CIMT with device seemed to yield a higher mean difference in FMA-L scores than lower extremity CIMT without device (4.52, 95% CI = 3.65–5.38, P < 0.01 and 3.37, 95% CI = 2.95–3.79, P < 0.01, respectively). Conclusion CIMT effectively improves lower extremity motor dysfunction in post-stroke patients; however, the eligible studies were highly heterogeneous. Systematic review registration : https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=277466 .
... Zhu et al. (2016) evaluated the COM displacement and basic gait parameters of stroke patients and proposed that mCIMT intervention improved the COM displacement and improved hemiplegic gait parameters in stroke patients. Mark et al. (2013) found that CIMT was a safe and well-tolerated treatment for motor dysfunction of the lower extremities in patients with multiple sclerosis and significantly improved lower extremity function in 4 years. ...
Article
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Constraint-induced movement therapy (CIMT) has been widely applied in stroke rehabilitation, and most relevant studies have shown that CIMT helps improve patients’ motor function. In practice, however, principal issues include inconsistent immobilization durations and methods, while incidental issues include a narrow application scope and an emotional impact. Although many studies have explored the possible internal mechanisms of CIMT, a mainstream understanding has not been established.
... As an example for how CIMT can be adapted for other forms of physical training for MS, a published case series adapted CIMT procedures to increase lower extremity use in four persons with chronic MS who reported having disabled walking (mean EDSS ¼ 6.0; potential scores can be 0--10). 88 The treatment was given as 52.5 training hours over 3 consecutive weeks. The study obtained a posttreatment ES ¼ 3.3 (very large) on the LE MAL. ...
Article
Multiple sclerosis (MS) is a progressive neurological illness whose typically young adult onset results in a nearly entire lifetime of worsening disability. But despite being an unrelenting neurodegenerative disease, numerous clinical trials over the past 40 years for MS have vigorously attempted to improve or at least stabilize declining physical function. Although the vast majority of the studies assessed training effects only within controlled laboratory or clinic settings, in recent years a growing interest has emerged to test whether newer therapies can instead benefit real-life activities in the community. Nonetheless, comparatively little attention has been paid to whether the training gains can be retained for meaningful periods. This review discusses the comparative success of various physical training methods to benefit within-community activities in MS, and whether the gains can be retained long afterward. This review will suggest future research directions toward establishing efficacious treatments that can allow persons with MS to reclaim their physical abilities and maximize functionality for meaningful periods.
... The scope of this method is extensive in that it can be applied not only in neurological pathologies that affect walkingstroke, multiple sclerosis (Mark et al., 2011), Parkinson (Lee, Lee, & Hwang, 2011), Guillain-Barré syndrome etc., but also in post-traumatic osteoarticular sequelae (ankle/knee sprain). Within the method, the therapeutic program involves restraining the degree of mobility of the healthy lower limb while thoroughly practicing through intense strain of the impaired lower limb, by performing functional therapeutic tasks relevant to everyday life. ...
... Our laboratory has previously shown that Constraint-Induced Movement Therapy (CIMT) significantly improves upper extremity motor disability following stroke, [6][7][8][9][10][11] cerebral palsy, 12 traumatic brain injury, 13 and multiple sclerosis. 14 The treatment effect is associated with substantial structural changes in grey matter (GM) in bilateral sensorimotor cortices, more anterior motor areas, and hippocampi. [15][16][17][18] However, to determine the neuro-metabolic changes produced by CIMT or other treatments, it is important to first evaluate the normal variation and reproducibility of candidate 1 H-MRS techniques in healthy subjects. ...
Article
To date, single voxel spectroscopy (SVS) is the most commonly used MRS technique. SVS is relatively easy to use and provides automated and immediate access to the resulting spectra. However, it is also limited in spatial coverage. A new and very promising MRS technique allows for whole-brain MR spectroscopic imaging (WB-MRSI) with much improved spatial resolution. Establishing the reproducibility of data obtained using SVS and WB-MRSI is an important first step for using these techniques to evaluate longitudinal changes in metabolite concentration. The purpose of this study was to assess and directly compare the reproducibility of metabolite quantification at 3T using SVS and WB-MRSI in ‘hand-knob’ areas of motor cortices and hippocampi in healthy volunteers. Ten healthy adults were scanned using both SVS and WB-MRSI on three occasions one week apart. N-acetyl aspartate (NAA), creatine (Cr), choline (Cho) and myo-inositol (mI) were quantified using SVS and WB-MRSI with reference to both Cr and H2O. The reproducibility of each technique was evaluated using the coefficient of variation (CV), and the correspondence between the two techniques was assessed using Pearson correlation analysis. The measured mean (range) intra-subject CVs for SVS were 5.90 (2.65-10.66)% for metabolites (i.e. NAA, Cho, mI) relative to Cr, and 8.46 (4.21-21.07)% for metabolites (NAA, Cr, Cho, mI) relative to H2O. The mean (range) CVs for WB-MRSI were 7.56 (2.78-11.41)% for metabolites relative to Cr, and 7.79 (4.57-14.11)% for metabolites relative to H2O. Significant positive correlations were observed between metabolites quantified using SVS and WB-MRSI techniques when the Cr but not H2O reference was used. The results demonstrate that reproducibilities of SVS and WB-MRSI are similar for quantifying the four major metabolites (NAA, Cr, Cho, mI); both SVS and WB-MRSI exhibited good reproducibility. Our findings add reference information for choosing the appropriate ¹H-MRS technique in future studies.
... One of these methods is Constraint-Induced Movement Therapy (CIMT) for which more than 350 studies were published worldwide that confirm beneficial effects on motor and in part also on somatosensory recovery Liepert, 2010Reiss, Wolf, Hammel, McLeod, & Williams, 2012;Taub, 2012;. Besides that, this approach was also documented as very effective in the treatment of multiple sclerosis (Mark et al., 2008(Mark et al., , 2013Rickards et al., 2012), focal hand dystonia (Candia et al., 1999(Candia et al., , 2005, phantom limb pain Weiss, Miltner, Adler, Bruckner, & Taub, 1999), and aphasia (Kurland, Pulvermueller, Silva, Burke, & Andrianopoulos, 2012;Pulvermuller & Berthier, 2008;Pulvermuller et al., 2001). ...
... 6 In CIMT, the term constraint has been changed to cover both mechanical limitation on the nonparalyzed side using tools and action limitation, including compensatory strategies and lower extremity treatments, and such a device is not used for lower extremity CIMT because both lower extremities must be simultaneously engaged for weight-bearing on massed practice tasks. 20 To However, several limitations of CIMT have been raised. 21 In this study, the aim was to increase weight bearing and use of the paralyzed lower extremity by increasing sensitivity of the nonparalyzed lower extremity. ...
Article
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Objective: The aims of this work were to determine whether game-based constraint-induced movement therapy (CIMT) is effective at improving balance ability in patients with stroke, and to provide clinical knowledge of game-based training that allows application of CIMT to the lower extremities. Design: Thirty-six patients with chronic stroke were randomly assigned to game-based CIMT (n = 12), general game-based training (n = 12), and conventional (n = 12) groups. All interventions were conducted 3 times a week for 4 weeks. The static balance control and weight-bearing symmetry were assessed, and the Functional Reach Test (FRT), modified Functional Reach Test (mFRT), and Timed Up and Go (TUG) test were performed to evaluate balance ability. Results: All 3 groups showed significant improvement in anterior-posterior axis (AP-axis) distance, sway area, weight-bearing symmetry, FRT, mFRT, and TUG test after the intervention (P < 0.05). Post hoc analysis revealed significant differences in AP-axis, and sway area, weight-bearing symmetry of the game-based CIMT group compared with the other group (P < 0.05). Conclusions: Although the general game-based training and the game-based CIMT both improved on static and dynamic balance ability, game-based CIMT had a larger effect on static balance control, weight-bearing symmetry, and side-to-side weight shift.
... Other efficacious extensions of the basic protocol have been to the upper extremity in young children with cerebral palsy (Taub & Crago, 1995; Taub, Ramey, Echols, & DeLuca, 2004), multiple sclerosis (M.S.)(Mark et al., 2008), and focal hand dystonia (Candia et al., 1999). We have also worked with the lower extremities of patients with stroke, spinal cord injury (Taub et al., 1999), and M.S. (Mark et al., 2013). In addition, we have shown that CI therapy produces a large effect on the function (Liepert, Bauder, Miltner, Taub, & Weiller, 2000) and structure (Gauthier et al., 2008) of the brain and that the magnitude of the treatment effect is strongly correlated with the magnitude of the amount of increase of grey matter in motor areas of the cerebral cortex. ...
Article
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Dr. Edward Taub has developed an effective therapy for stroke victims called Constraint-Induced Movement therapy. The foundation of this therapy is based entirely on behavior analysis principles, and intervention is a matter of applying contingencies of reinforcement for improving the movement of limbs impaired by different types of central nervous system damage. The result is a very efficacious therapy that produces large and clinically significant gains in performance that have been replicated numerous times across patients, clinics, and countries. Dr. Taub answers questions regarding the development of this therapy, which started with animal models, and offers insight into implementing behavior-analysis based treatments in medical settings.
... Также представлены первые результаты применения этой технологии для тренировки паретичной ноги у 4 больных [27]. Тренировка проводилась в течение 3 нед по будням (в среднем по 3,5 ч в день). ...
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In a chronic and disabling disease like multiple sclerosis, rehabilitation programs are of major importance for the preservation of physical, physiological, social and professional functioning and improvement of quality of life. Currently, it is generally assumed that physical activity is an important component of non-pharmacological rehabilitation in multiple sclerosis. Properly organized exercise is a safe and efficient way to induce improvements in a number of physiological functions. A multidisciplinary rehabilitative approach should be recommended. The main recommendations for the use of exercise for patients with multiple sclerosis have been listed. An important aspect of the modern physical rehabilitation in multiple sclerosis is the usage of high-tech methods. The published results of robot-assisted training to improve the hand function and walking impairment have been represented. An important trend in the rehabilitation of patients with multiple sclerosis is the reduction of postural disorders through training balance coordination. The role of transcranial magnetic stimulation in spasticity reducing is being investigated. The use of telemedicine capabilities is quite promising. Due to the fact that the decline in physical activity can lead to the deterioration of many aspects of physiological functions and, ultimately, to mobility decrease, further research of the role of physical rehabilitation as an important therapeutic approach in preventing the progression of disability in multiple sclerosis is required.
... The CI therapy protocol has been applied with success to traumatic brain injury [71], upper and lower extremity in multiple sclerosis [46,47], cerebral palsy and pedi-atric motor disorders of neurological origin across the full range of age from one year old through the teenage years [88,89,94], focal hand dystonia in musicians [8,9], and the increased use element of CI therapy has been effective for phantom limb pain after amputation [114]. ...
Article
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Constraint-Induced Movement Therapy or CI Therapy is an approach to physical rehabilitation elaborated from basic neuroscience and behavioral research with primates. The application of the CI therapy protocol to humans began with the upper-extremity after stroke and was then modified and extended to cerebral palsy in young children, traumatic brain injury, and multiple sclerosis. A form of CI therapy was developed for the lower extremities and has been used effectively after stroke, spinal cord injury, fractured hip, multiple sclerosis, and cerebral palsy. Adaptations of the CI therapy paradigm have also been developed for aphasia (CI Aphasia Therapy or CIAT), focal hand dystonia in musicians, and phantom limb pain. The range of these applications indicates that CI therapy is not only a treatment for stroke, which is its most common application, but for overcoming learned nonuse in general, a phenomenon which manifests as excess disability after different types of CNS injury which until now have been largely refractory to treatment. CI therapy in all of its forms consists of four major components: 1) intensive training of an impaired function for several hours a day for multiple days, 2) training by the behavioral technique termed shaping, 3) a set of behavioral techniques, the transfer package, designed to transfer gains from the treatment setting to daily activities in the life situation, and 4) "constraining? or discouraging compensatory patterns of movement developed in the early post-injury period to substitute for loss of function. CI therapy for the upper-extremity in adults and children has been shown to produce an increase in the volume of grey matter in motor areas of the brain and there is evidence that CI Aphasia Therapy has a similar effect in language-related regions.
... 93,94 Improvements in real-world limb use may remain for as much as 4-5 years following the single course (2 or 3 weeks) of treatment. 94,95 Moreover, a recent randomized controlled trial of upper-extremity CIMT versus a program of holistic physical complementary and alternative medicine treatments (massage, yoga, relaxation exercises, aquatic therapy) indicated superiority of CIMT not only for improving real-world paretic arm use but also for inducing increased cortical gray-matter structure on MRI, 96 thus suggesting that CIMT may have a neuromodulatory effect by stimulating structural CNS plasticity. ...
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Tong Chao Geng,1 Victor W Mark2 1Department of Neurology, Yuquan Hospital of Tsinghua University, Beijing, People's Republic of China; 2Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, AL, USA Abstract: With the chronic progress of the disease, the majority of patients with multiple sclerosis will eventually become severely disabled and unable to live independently. Neurorestorative strategies, including cell therapy and neuromodulation, combined with neurorehabilitation, have shown encouraging signs that may benefit multiple sclerosis patients. This review indicates current progress in this area. Keywords: demyelinating disease, immunosuppression, cell therapy, neuromodulation, neurorehabilitation
... Single limb exercise 21) or unilateral step training 22) have also been used to work the affected lower limb intensively. Furthermore, intensive, practice of gait-related activities without restraint of the unaffected limb has improved the gait performance of individuals with multiple sclerosis to a certain degree 23) . However, owing to the bipedal nature of human locomotion and mobility, forced-use by constraint of the unaffected limb or intensive unilateral use of the affected limb may actually prevent walking or functional mobility performance or practice in task-oriented ways. ...
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[Purpose] The purpose of this study was to investigate the effects of a forced-use training program on gait, mobility and quality of life of post-acute stroke patients. [Subjects] Twenty-one individuals with unilateral stroke participated in this study. All participants had suffered from first-ever stroke with time since onset of at least 3 months. [Methods] A single-blinded, non-equivalent, pre-post controlled design with 1-month follow-up was adopted. Participants received either a forced-use or a conventional physical therapy program for 2 weeks. The main outcomes assessed were preferred and fastest walking velocities, spatial and temporal symmetry indexes of gait, the timed up and go test, the Rivermead Mobility Index, and the Stroke-Specific Quality of Life Scale (Taiwan version). [Results] Forced-use training induced greater improvements in gait and mobility than conventional physical therapy. In addition, compared to pre-training, patients in the conventional physical therapy group walked faster but more asymmetrically after training. However, neither program effectively improved in-hospital quality of life. [Conclusion] The forced-use approach can be successfully applied to the lower extremities of stroke patients to improve mobility, walking speeds and symmetry of gait.
... The pediatric motor deficits treated included those resulting from TBI, brachial plexus injury, congenital brain malformations, and hemispherectomy (Taub et al., 2009). An adaptation of CI therapy for the lower extremity has been carried out in adults not only after stroke, but also after spinal cord injury and fractured hip and MS (Mark et al., 2013). Both in our adult and pediatric clinics we have also worked with numerous cases of brain resection and obtained results comparable to those with stroke when the initial motor deficits were similar . ...
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We address here the question of whether the techniques of CI therapy, a family of treatments that has been employed in the rehabilitation of movement and language after brain damage might apply to the rehabilitation of such visual deficits as unilateral spatial neglect and visual field deficits. CI therapy has been used successfully for the upper and lower extremities after chronic stroke, cerebral palsy (CP), multiple sclerosis (MS), other CNS degenerative conditions, resection of motor areas of the brain, focal hand dystonia, and aphasia. Treatments making use of similar methods have proven efficacious for amblyopia. The CI therapy approach consists of four major components: intensive training, training by shaping, a “transfer package” to facilitate the transfer of gains from the treatment setting to everyday activities, and strong discouragement of compensatory strategies. CI therapy is said to be effective because it overcomes learned nonuse, a learned inhibition of movement that follows injury to the CNS. In addition, CI therapy produces substantial increases in the grey matter of motor areas on both sides of the brain. We propose here that these mechanisms are examples of more general processes: learned nonuse being considered parallel to sensory nonuse following damage to sensory areas of the brain, with both having in common diminished neural connections (DNC) in the nervous system as an underlying mechanism. CI therapy would achieve its therapeutic effect by strengthening the diminished neural connections. Use-dependent cortical reorganization is considered to be an example of the more general neuroplastic mechanism of brain structure repurposing (BSR). If the mechanisms involved in these broader categories are involved in each of the deficits being considered, then it may be the principles underlying efficacious treatment in each case may be similar. The lessons learned during CI therapy research might then prove useful for the treatment of visual deficits
... An adaptation of CI therapy has been used to treat lower limb impairments, first after stroke, then after spinal cord injury, fractured hip (summarized in Taub et al., 1999) and multiple sclerosis (Mark et al., 2013). Approximately 90% of patients with chronic CVA ambulate but may do so with a degraded pattern of coordination. ...
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For the nineteenth and the better part of the twentieth centuries two correlative beliefs were strongly held by almost all neuroscientists and practitioners in the field of neurorehabilitation. The first was that after maturity the adult CNS was hardwired and fixed, and second that in the chronic phase after CNS injury no substantial recovery of function could take place no matter what intervention was employed. However, in the last part of the twentieth century evidence began to accumulate that neither belief was correct. First, in the 1960s and 1970s, in research with primates given a surgical abolition of somatic sensation from a single forelimb, which rendered the extremity useless, it was found that behavioral techniques could convert the limb into an extremity that could be used extensively. Beginning in the late 1980s, the techniques employed with deafferented monkeys were translated into a rehabilitation treatment, termed Constraint Induced Movement therapy or CI therapy, for substantially improving the motor deficit in humans of the upper and lower extremities in the chronic phase after stroke. CI therapy has been applied successfully to other types of damage to the CNS such as traumatic brain injury, cerebral palsy, multiple sclerosis, and spinal cord injury, and it has also been used to improve function in focal hand dystonia and for aphasia after stroke. As this work was proceeding, it was being shown during the 1980s and 1990s that sustained modulation of afferent input could alter the structure of the CNS and that this topographic reorganization could have relevance to the function of the individual. The alteration in these once fundamental beliefs has given rise to important recent developments in neuroscience and neurorehabilitation and holds promise for further increasing our understanding of CNS function and extending the boundaries of what is possible in neurorehabilitation.
... The CI Therapy approach has been applied successfully to treatment of the upper extremities in patients with chronic and subacute CVA [6], patients with chronic traumatic brain injury [7], for the lower limb of patients with multiple sclerosis [8], and individuals with incomplete spinal cord injury and fractured hip [9]. The approach has recently been extended to focal hand dystonia of musicians and phantom limb pain [10]. ...
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Main goals of rehabilitation are to help patients to reach the fullest physical, physiological, social, vocational and avocational potential consistent with their level of impairment, desires and life plans [1]. Rehabilitation involves medical, social, educational, and vocational measures used to optimize neurologic recovery, teach compensatory strategies for residual deficits, and teach Activities of Daily Living (ADLs) and skills required for community living [2]. The majority of rehabilitation approaches that involve physical therapy are based on providing a patient with a positive re-enforcement of the patient’s performance by the physical therapist who conducts the treatment or a by a computerized device used in rehabilitation. Thus, positive feedback is used in gait re-education of individuals with Parkinson Disease [3], in improving of pointing movements in individuals with stroke [4], in enhancement of postural control in individuals with traumatic brain injury and cerebrovascular accident [5]. Such positive re-enforcement helps a patient to focus on the quality of the produced movement, ambulation, or the body posture. While the positive re-enforcement approach is extensively used in rehabilitation one can ask a question of whether rehabilitation based on using a positive feedback is the most efficient (and the only) way of restoring the lost ability to perform daily tasks or learning new movements and skills. We contend that the rehabilitation of patients could also be efficient when they are subjected to a discomfort leading to a need to overcome it. The support for the above statement comes from a number of studies that use a negative feedback to improve the patient’s body posture, gait pattern, or use of his/her affected extremity. Among them is the Constraint-Induced Movement Therapy (CI) therapy that involves constraining movements of the less-affected arm with a sling while intensively training use of the more-affected arm [6]. While the literature reports the common therapeutic factor in all CI Therapy techniques as inducing concentrated, repetitive practice of use of the more-affected limb, we argue that CI therapy also creates a discomfort due to inability of a patient to use the less affected arm. Such a discomfort could also serve as a negative feedback that promotes the use of the affected upper extremity. The CI Therapy approach has been applied successfully to treatment of the upper extremities in patients with chronic and subacute CVA [6], patients with chronic traumatic brain injury [7], for the lower limb of patients with multiple sclerosis [8], and individuals with incomplete spinal cord injury and fractured hip [9]. The approach has recently been extended to focal hand dystonia of musicians and phantom limb pain [10].
... The CI therapy protocols, that is, upper-and lower-extremity interventions, for adults with stroke have been applied with similar success to the upper extremity in traumatic brain injury (Shaw et al., 2003 ) and to the upper and lower extremity in multiple sclerosis (Mark et al., 2008Mark et al., , 2013). Results as good as or better than with adults after stroke have also been obtained for the upper extremity in children with cerebral palsy and other pediatric motor disorders of neurological origin across the full range of childhood years, that is, from 1 year through the teens (Taub et al., 2004Taub et al., , 2007Taub et al., , 2011). ...
Article
Constraint-Induced Movement therapy or CI therapy is an approach to physical rehabilitation elaborated from basic neuroscience and behavioral research with primates. The application of the CI therapy protocol to humans began with the upper extremity after stroke and was then modified and extended to cerebral palsy in young children, traumatic brain injury, and multiple sclerosis. A form of CI therapy was developed for the lower extremities and has been used effectively after stroke, spinal cord injury, fractured hip, multiple sclerosis, and cerebral palsy. Adaptations of the CI therapy paradigm have also been developed for aphasia, focal hand dystonia in musicians, and phantom limb pain. Human and animal studies using a variety of methods provide evidence that CI therapy produces marked neuroplastic changes in the structure and function of the CNS. Moreover, these changes appear to be important for the intervention's therapeutic effect.
... The first use of clinical constraint-induced (CI) therapy treatment principles and procedures was for the improvement of upper extremity motor deficit after stroke (Taub et al., 1993 ). Modifications have been applied to the upper extremities after traumatic brain injury (Shaw et al., 2005 ); in individuals with multiple sclerosis (Mark et al., 2008); in young children with cerebral palsy (Taub et al., 2011; Taub, Ramey, Echols, & DeLuca, 2004); and to the lower extremities after stroke, spinal cord injury, fractured hip (Taub, Uswatte, & Pidikiti, 1999), and multiple sclerosis (Mark et al., 2013). Constraint-induced movement therapy (CIMT) is said to be efficacious for improving the motor deficit of the extremities , in part because it overcomes a learned inhibition of limb use, termed learned nonuse, that develops in the acute period after different types of substantial neurological injury. ...
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The initial version of Constraint-Induced Aphasia Therapy (CIAT I) consisted of a single exercise. This study sought to evaluate the feasibility for future trials of an expanded and restructured protocol designed to increase the efficacy of CIAT. The subjects were four native English-speakers with chronic stroke who exhibited characteristics of moderate Broca's aphasia. Treatment was carried out for 3.5 hr/d for 15 consecutive weekdays. It consisted of: 1) intensive training by a behavioral method termed shaping using a number of expressive language exercises in addition to the single original language card game, 2) strong discouragement of attempts to use gesture or other non-verbal means of communication, and 3) a transfer package of behavioral techniques to promote transfer of treatment gains from laboratory to life situation. Participation in speech in the life situation improved significantly after treatment. The effect sizes, i.e., d', in this domain were ≥ 2.2; d' values ≥ .8 are considered large. Improvement in language ability on a laboratory test, WAB-R, did not achieve statistical significance, although the effect size was large, i.e., 1.3 (13.1 points). These pilot results suggest in preliminary fashion that CIAT II may produce significant improvements in everyday speech.
... Case series support the efficacy of CI therapy for rehabilitating upper-extremity function in traumatic brain injury (TBI) 3 and multiple sclerosis (MS) 4 and lower-extremity function in chronic stroke, 5 TBI, 6 and MS. 7 The magnitude of the treatment effect that has been reported, however, has been markedly variable. ...
Article
Background and purpose: Constraint-induced movement therapy is a set of treatments for rehabilitating motor function after central nervous system damage. We assessed the roles of its 2 main components. Methods: A 2 × 2 factorial components analysis with random assignment was conducted. The 2 factors were type of training and presence/absence of a set of techniques to facilitate transfer of therapeutic gains from the laboratory to the life situation (Transfer Package; TP). Participants (N=40) were outpatients ≥ 1-year after stroke with hemiparesis. The different treatments, which in each case targeted the more affected arm, lasted 3.5 hours/d for 10 weekdays. Spontaneous use of the more affected arm in daily life and maximum motor capacity of that arm in the laboratory were assessed with the Motor Activity Log and the Wolf Motor Function Test, respectively. Results: Use of the TP, regardless of the type of training received, resulted in Motor Activity Log gains that were 2.4 times as large as the gains in its absence (P<0.01). These clinical results parallel previously reported effects of the TP on neuroplastic change. Both the TP and training by shaping enhanced gains on the Wolf Motor Function Test (P<0.05). The Motor Activity Log gains were retained without loss 1 year after treatment. An additional substudy (N=10) showed that a single component of the TP, weekly telephone contact with participants for 1 month after treatment, doubled Motor Activity Log scores at 6-month follow-up. Conclusions: The TP is a method for enhancing both spontaneous use of a more affected arm after chronic stroke and its maximum motor capacity. Shaping enhances the latter.
... One of these methods is Constraint-Induced Movement Therapy (CIMT) for which more than 350 studies were published worldwide that confirm beneficial effects on motor and in part also on somatosensory recovery Liepert, 2010Reiss, Wolf, Hammel, McLeod, & Williams, 2012;Taub, 2012;. Besides that, this approach was also documented as very effective in the treatment of multiple sclerosis (Mark et al., 2008(Mark et al., , 2013Rickards et al., 2012), focal hand dystonia (Candia et al., 1999(Candia et al., , 2005, phantom limb pain Weiss, Miltner, Adler, Bruckner, & Taub, 1999), and aphasia (Kurland, Pulvermueller, Silva, Burke, & Andrianopoulos, 2012;Pulvermuller & Berthier, 2008;Pulvermuller et al., 2001). ...
Article
Stroke patients in the chronic phase received constraint-induced (CI) movement therapy. The motor cortex was spatially mapped using focal transcranial magnetic stimulation (TMS) before and after 2 weeks of treatment. Motor-output areas of the abductor pollicis brevis muscle, motor evoked potential (MEP) amplitudes and location of centre of gravity (CoG) of motor cortex output were studied. After CI therapy, motor performance improved substantially in all patients. There was also an increase of motor output area size and MEP amplitudes, indicating enhanced neuronal excitability in the damaged hemisphere for the target muscles. The mean centre of gravity of the motor output maps was shifted considerably after the rehabilitation, indicating the recruitment of motor areas adjacent to the original location. Thus, even in chronic stroke patients, reduced motor cortex representations of an affected body part can be enlarged and increased in level of excitability by an effective rehabilitation procedure. The data therefore demonstrate a CNS correlate of therapy-induced recovery of function after nervous system damage in humans.
Chapter
Neurofunctional approaches play the paramount functions in management of neurological disorders to improve the functional capability after impairments and activity limitations. These interventional approaches aligned with the neuroplasticity theories and all rely on repetition matters to build up engrams for the change of the brain function and activity performance. Affolter approach guides cognitive perceptual interaction through tactile-kinesthetic inputs. Neuromuscular facilitation relays the periphery information to the central nervous system by joint and muscle stimulus by using different techniques such stretching, irradiation, traction and approximation. Neurodevelopmental therapy manages the abnormal movement and postures through hands on facilitation of normal movement and inhibiting abnormal patterns movement. Roods approaches focus on the primitive reflexes through sensory stimuli to the targeted sensory receptors to initiate the appropriate motor pattern development. Brunnstrom approaches build on the synergies to provoke the engagement of the affected limbs. Task-oriented approaches are based on motor learning and involve repeat training with task-oriented activities. It is effective for improvement of the functional performance. It is a training method for encouraging functional movement with an interesting task. And also it improved the dexterity when applied using mixed interventions in hemiplegic.
Chapter
During the past century, we have seen the development of several therapeutic approaches for the treatment of adults with various neurological deficits. In the early to the middle part of the twentieth century, therapeutic approach for handling neurological conditions was largely orthopedic that emphasized on surgery, strengthening the weak muscles, and use of splints. By the late 1940s to early 1960s, a swing towards a neurological emphasis characterized by development of techniques based on neurophysiological and motor learning principles was observed. Approaches developed by Rood, Brunnström, Bobath and Bobath, and Knot and Voss were instances for the same. From the 1980s the emphasis moved away from the neurodevelopmental approaches towards non-neurodevelopmental approaches like motor relearning program and constraint-induced movement therapy and currently, the technological advancement has paved the way to novel concepts like the use of virtual reality, transcranial magnetic stimulation, and robotics in the field of neurological rehabilitation. As yet, there is no scientific evidence that clearly supports that any standalone approach is superior to another. The gamut of research including systematic and meta-analysis studies has shown minimal to moderate improvement for few approaches when delivered as a standalone treatment and for most the sample size or methodology was not rigorous enough to demand a change in practice. Therapists must have adequate knowledge, both theoretical and practical, about various therapeutic approaches to provide an eclectic treatment program. Since all these approaches have strengths and weaknesses of their own and collectively have the edge over a standalone, an eclectic approach makes it all the more meaningful to tackle most of the sensorimotor dysfunctions among patients. The author believes that the knowledge earned from each scientific therapeutic approach must serve as a reservoir from which a clinician can wisely choose the necessary tools to customize the eclectic treatment program to suit the specific needs of patients. Choosing the best treatment methods to address the patient’s sensorimotor issues must be the most rational approach when substantial evidence for the effectiveness of any single approach over the others is unavailable. Based on the patient’s abilities and requirements, the therapists need to carefully select the strategies that have the greatest chance of successfully remediating existing impairments and promoting functional recovery.
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Objective To assess the personal perspectives of persons with multiple sclerosis (MS) on the acceptability of a novel physical therapy program that is designed to transfer gains from the clinic to their real-world lower extremity (LE) use, termed LE Constraint-Induced Therapy (CIT). The program includes several Behavior Change techniques (prescribed home exercises, daily structured therapist interviews and problem-solving for LE activities, keeping an activity diary) and a concentrated physical treatment schedule. Design Anonymous internet survey. Setting Participants accessed the survey from computers in the community. Participants Five hundred adults were recruited from an MS support organization's registry for having indicated from mild to total limb spasticity, because they were anticipated to have markedly impaired LE use in the community. Interventions Not applicable. Main Outcome Measures Participants were offered the options on a non-numerical Likert scale of “Very likely,” “Likely,” “Neutral,” “Unlikely,” or “Very unlikely” to indicate their personal acceptability for each of five different key treatment procedures after these were explained. Totals for each option within each key procedure were analyzed for their acceptability. Results Of the 281 persons who responded, 90% expressed interest in participating in LE CIT. A large majority of persons who completed the survey selected either “Very likely” or “Likely” for each key procedure, median = 88%, range = 65-90%, p’s < 0.01. This indicated strong acceptance for the procedures of LE CIT. In addition, more respondents who already had had previous physical therapy accepted LE CIT than did respondents who had not had physical therapy, p < 0.01. Conclusions The results suggest there is strong acceptance of CIT for mobility with preliminary evidence of benefiting community LE use for persons with MS. The results support further clinical trials of LE CIT for persons with MS.
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Background Protocols involving intensive practice have shown positive outcomes. Constraint Induced Movement Therapy (CIT) appears to be one of the best options for better outcomes in upper limb rehabilitation, but we still have little data about Lower Extremities - Constraint Induced Movement Therapy (LE-CIT) and its effects on gait and balance.Objective To evaluate the effects of an LE-CIT protocol on gait functionality and balance in chronic hemiparetic patients following a stroke.Methods The study adopts a randomized, controlled, single-blinded study design. 42 patients who suffered a stroke event, in the chronic phase of recovery (>6 months), with gait disability (no community gait), able to walk at least 10 meters with or without the advice or support of 1 person, will be randomly allocated to 2 groups: the LE-CIT Group or the Control Group (Intensive Conventional Therapy). People will be excluded if they have speech deficits that render them unable to understand and/or answer properly to evaluation scales and exercises selected for the protocol and/or if they have suffered any clinical event between the screening and the beginning of the protocol. Outcome will be assessed at baseline (T0), immediately after the intervention (T1), and after 6 months (T2). The outcome measures chosen for this trial are: 6 minute walk test (6minWT), 10 meter walk test (10mWT), Timed Up and Go (TUG), 3-D gait analysis (3DGA), Mini Balance Evaluation Systems Test (Mini-BESTest) and, as a secondary measure, Lower Extremity Motor Activity Log will be evaluated (LE-MAL). The participants in both groups will receive 15 followed days of daily exercise. The participants in the LE-CIT Group will be submitted to this protocol 2.5 hour/day for 15 followed days. It will include: 1) intensive supervised training, 2) use of shaping as strategy for motor training, and 3) application of a transfer package (plus 30 minutes). The Control Group will receive conventional physiotherapy for 2.5 hours/day over 15 followed days (the same period as the CIT intervention). Repeated measures analyses will be made to compare differences and define clinically relevant changes between groups.ResultsData collection is currently on-going and results are expected in 2021.Discussion: LE-CIT seems to be a good protocol for inclusion into stroke survivors’ rehabilitation as it has all the components needed for positive results, as well as intensity and transference of gains to daily life activities.Trial Registration: www.ensaiosclinicos.gov.br (Register Number: RBR-467cv6). Date of registration: October 10, 2017. “Effects of Lower Extremities - Constraint Induced Therapy on gait and balance function in chronic hemipretic post-stroke patients”.
Article
Objectives: To determine the test-retest reliability and validity of the Lower Extremity Motor Activity Log (LE-MAL) for assessing LE use in the community in adults with multiple sclerosis (MS). Design: Prospective analysis of measures conducted by trained examiners. Setting: Participants were evaluated by telephone on several measures of LE use. Participants: Adults with MS (NZ43). Interventions: Not applicable. Main Outcome Measures: The LE-MAL has 3 subscales (Assistance, Functional Performance, and Confidence). It was administered twice, at least 2 weeks apart. The Multiple Sclerosis Walking Scale (MSWS-12), Patient Determined Disease Steps (PDDS), and Mobility Scale were only administered during the first call. Results: The test-retest reliability of the composite and the 3 subscale LE-MAL scores were high (intraclass correlation, >0.94). The composite and subscale LE-MAL scores were strongly correlated with the MSWS-12, PDDS, and Mobility Scale scores (rZe0.56 to e0.77; P<.001). Conclusion: This initial study suggests that the LE-MAL reliably and validly measures LE use in the community in adults with MS.
Preprint
Objectives To determine the test-retest reliability and validity of the Lower Extremity Motor Activity Log (LE-MAL) for assessing LE use in the community in adults with multiple sclerosis (MS). Design Prospective analysis of measures conducted by trained examiners. Setting Participants were evaluated by telephone on several measures of LE use. Participants Adults with MS (N=43). Interventions Not applicable. Main Outcome Measures The LE-MAL has 3 subscales (Assistance, Functional Performance, and Confidence). It was administered twice, at least 2 weeks apart. The Multiple Sclerosis Walking Scale (MSWS-12), Patient Determined Disease Steps (PDDS), and Mobility Scale were only administered during the first call. Results The test-retest reliability of the composite and the 3 subscale LE-MAL scores were high (intraclass correlation, >0.94). The composite and subscale LE-MAL scores were strongly correlated with the MSWS-12, PDDS, and Mobility Scale scores (r=–0.56 to –0.77; P<.001). Conclusion This initial study suggests that the LE-MAL reliably and validly measures LE use in the community in adults with MS.
Article
Constraint-Induced Movement Therapy (CIMT) is comprised of a set of techniques shown to produce significant changes in upper extremity (UE) function following stroke and other disorders. The significant positive results obtained with the UE protocol has led to the development of LE-CIMT, an intervention to improve lower extremity (LE) function. However, some modifications of the UE protocol were needed including: omitting use of a restraint device, development of supervised motor training tasks to emphasize movement of the lower limb, and adaptation of the UE Motor Activity Log (MAL) for the lower-extremity (LE-MAL). The LE-CIMT protocol includes: 1) intensive supervised training delivered for 3.5 h/day for10 consecutive weekdays, 2) use of shaping as a strategy for motor training, 3) application of a transfer package, and 4) strongly encouraging use of the more affected LE with improved coordination. The transfer package consists of several strategies to facilitate transfer of the improved motor skills developed during supervised treatment to everyday situations. Research to date has yielded positive results. However, the intervention protocol continues to evolve. The purpose of this article is to describe the components of the complete LE-CIMT protocol in order to promote further development and investigation of this approach.
Article
Constraint-induced movement therapy (CIMT) has been a well-established rehabilitative method for upper limb paralysis in patients post-stroke. In recent years, its application to lower limb paralysis (Lower limb CIMT, L-CIMT) has been reported. However, the reported intensive lower limb trainings do not seem enough to target behavioral modifications in an individual's daily life. In this study, we investigated the effects of L-CIMT including the transfer package to induce behavioral transformation in normal daily life of patients with lower limb paralysis. The L-CIMT including the transfer package was administered to three patients with chronic-phase stroke without any constraint on the healthy lower limb for 3.5 hours a day, 5 days a week for 3 weeks. As a result, standing balance and walking ability were improved immediately and within 6 months after the intervention, respectively. All three cases experienced increased daily opportunities for standing and walking. We believe that L-CIMT including the transfer package can bring both short- and long-term improvements in standing balance and walking ability. This can lead to an increase in the frequency of standing and walking in daily living, along with an expanded range of action in ADL and IADL in patients with chronic-phase stroke.
Chapter
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Stroke is increasingly becoming a global health problem. This is because it may lead to death, Long-term disability such as in motor function, and significant burden to the patients and their families. The disability can be prevented or rehabilitated using a physiotherapy technique known as constraint-induced movement therapy (CIMT). The CIMT comprises of task practice with the affected limb, constraint of the unaffected limb, and transfer package to foster compliance and increase the amount of task repetition. It helps to reestablish normal motor control through facilitating changes in physiological functions of the brain, improvement in real-world arm use, and movement precision and quality. However, its protocols vary. Some protocols use number of hours and others use number of repetitions to determine the intensity or the amount of task practice. This chapter argued that CIMT is effective, but the protocols that use a number of hours of task practice are not clear and are resource intensive; and as such they could interfere with the process of clinical decision making. Consequently, it proposed the use of a number of repetitions of task practice to determine the intensity or the amount of task practice and extending the application of CIMT to those with severe impairments after stroke.
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While early medical treatment has proven effective in MS, early-phase MS rehabilitation has not gained much attention in MS research and clinical practice. Exercise therapy is one of the most promising treatment strategies in MS rehabilitation. Here, we provide a topical review investigating when exercise therapy is initiated in existing MS studies, showing that exercise is initiated at a rather late disease stage, where it predominantly serves as a symptomatic treatment. Recent findings in MS suggest that exercise may have neuroprotective and disease-modifying effects. Such findings along with the findings from medical trials that an early-stage “window of opportunity” exists leads to the proposal that early exercise therapy should be an increased focus in research and clinical practice for persons with MS. A further perspective relates to other rehabilitation interventions that are also initiated at a later disease stage, as these may also take advantage of an early-phase approach.
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Background Constraint-Induced Movement therapy (CIMT) has controlled evidence of efficacy for improving real-world paretic limb use in non-progressive physically disabling disorders (stroke, cerebral palsy). Objective This study sought to determine whether this therapy can produce comparable results with a progressive disorder such as multiple sclerosis (MS). We conducted a preliminary Phase II randomized controlled trial of CIMT vs. a program of Complementary and Alternative Medicine (CAM) treatments for persons with MS, to evaluate their effect on real-world disability. Methods Twenty adults with hemiparetic MS underwent 35 hours of either CIMT or CAM over 10 consecutive weekdays. The primary clinical outcome was change from pretreatment on the Motor Activity Log (MAL). Results The CIMT group improved more on the MAL (2.7 points, 95% confidence interval 2.2-3.2) than did the CAM group (0.5 points, 95% confidence interval -0.1-1.1; p < 0.001). These results did not change at 1-year follow-up, indicating long-term retention of functional benefit for CIMT. The treatments were well tolerated and without adverse events. Conclusion These results suggest that CIMT can increase real-world use of the more-affected arm in patients with MS for at least one year.
Chapter
In this chapter we highlight the main characteristics of gait and balance in multiple sclerosis, and the assessment and rehabilitation treatment of these disorders. The main scientific evidence on the rehabilitation treatment is described, with a focus on the innovative approaches and technologies. Finally, the prognostic factors on rehabilitation outcome are discussed.
Article
There is a built-in reluctance in clinical fields to accept or endorse for administration a new intervention, even when demonstrations of clinical efficacy have been carried out that conform to the conventional standards of proof that have developed in those clinical fields. This resistance to new approaches, such as those based on behavior analysis principles, is greatly strengthened when the evidence for efficacy is generated by studies with experimental designs that diverge from those that have been employed before and that are conventionally viewed as acceptable in a clinical field. Constraint-Induced (CI therapy) is a family of neurorehabilitation treatments based on the use of behavior analysis techniques for the rehabilitation of functional deficits produced by damage to the central nervous system. Notwithstanding the fact that there are a large number of studies demonstrating the efficacy of CI therapy, many using conventional designs and measures, clinical acceptance of these treatments has been slow over the past 20 years, and it is by no means universal at present. In the last few years, though, acceptance has been accelerating. Thus, the example of CI therapy may hold some lessons that may be of use for other clinical applications of behavior analysis principles. The organizers of the conference at which this paper was presented requested that I discuss some of these considerations. Other relevant issues are addressed in a recent videotaped interview (Iversen, 2013; current issue).
Article
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In hemiplegic gait the paretic lower limb provides less muscle power and shows a briefer stance compared with the unaffected limb. Yet, a longer stance and a higher power can be obtained from the paretic lower limb if gait speed is increased. This supports the existence of a 'learned non-use' phenomenon, similar to that underlying some asymmetric impairments of the motion of the eyes and of the upper limbs. Crouch gait (CG) (bent-hip bent-knee, about 30° minimum knee flexion) might be an effective form of 'forced-use' treatment of the paretic lower limb. It is not known whether it also stimulates a more symmetric muscle power output. Gait analysis on a force treadmill was carried out in 12 healthy adults and seven hemiplegic patients (1-127 months after stroke, median: 1.6). Speed was imposed at 0.3 m/s. Step length and single and double stance times, sagittal joint rotations, peak positive power, and work in extension of the hip, knee, and ankle (plantar flexion), and surface electromyography (sEMG) area from extensor muscles during the generation of power were measured on either side during both erect and crouch walking. Significance was set at P less than 0.05; corrections for multiplicity were applied. Patients, compared with healthy controls, adopted in both gait modalities and on both sides a shorter step length (61-84%) as well as a shorter stance (76-90%) and swing (63-83%) time. As a rule, they also provided a higher muscular work (median: 137%, range: 77-250%) paralleled by a greater sEMG area (median: 174%, range: 75-185%). In erect gait, the generation of peak extensor power across hip, knee, and ankle joints was in general lower (83-90%) from the paretic limb and higher (98-165%) from the unaffected limb compared with control values. In CG, peak power generation across the three lower limb joints was invariably higher in hemiparetic patients: 107-177% from the paretic limb and 114-231% from the unaffected limb. When gait shifted from erect to crouch, only for hemiplegic patients, at the hip, the paretic/unaffected ratio increased significantly. For peak power, work, sEMG area, and joint rotation, the paretic/unaffected ratio increased from 55 to 85%, 56 to 72%, 68 to 91%, and 67 to 93%, respectively. CG appears to be an effective form of forced-use exercise eliciting more power and work from the paretic lower limb muscles sustained by a greater neural drive. It also seems effective in forcing a more symmetric power and work from the hip extensor muscles, but neither from the knee nor the ankle.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/.
Chapter
Motor impairments are very common in multiple sclerosis (MS), leading to a reduced Quality of Life and active participation. In the past decades, new insights into the functional reorganization processes that occur after a brain injury have been introduced. Specifically, the motor practice seems to be determinant to induce neuroplastic changes and motor recovery. More recently, these findings have been extended to multiple sclerosis, in particular, it has been hypothesized that disease progression, functional reorganization and disability are mutually related. For this reason, neuroplasticity-based technologies and interventions have been rapidly introduced in MS rehabilitation. Constraint-induced movement therapy (CIMT), robotics and virtual reality training are new rehabilitative interventions that deliver an intensive e task-specific practice, which are two critical factors associated with functional improvements and cortical reorganization. Another promising strategy for enhancing neuroplastic changes is non-invasive brain stimulation that can be used with a priming effect on motor training. The aims of this chapter are to review the evidence of neuroplastic changes in multiple sclerosis and to present technologies and interventions that have been tested in clinical trials.
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This paper outlines some actual developments in the behavioral treatment and rehabilitation of stroke and other brain injuries in post-acute and chronic conditions of brain lesion. It points to a number of processes that demonstrate the enormous plasticity and reorganization capacity of the human brain following brain lesion. It also highlights a series of behavioral and neuroscientific studies that indicate that successful behavioral rehabilitation is paralleled by plastic changes of brain structures and by cortical reorganization and that the amount of such plastic changes is obviously significantly determining the overall outcome of rehabilitation.
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Constraint-Induced Movement therapy (CI therapy) has been demonstrated to improve motor function and upper extremity (UE) use of persons with hemiparesis resulting from chronic stroke through two separate but linked mechanisms, overcoming learned nonuse, and facilitating use-dependent cortical reorganization. The principles of CI therapy and adaptations of the basic techniques have been used successfully with diagnostic categories other than stroke that involve disability greater than what is warranted by the organic condition of the individual. Because neuroimaging and transcranial magnetic stimulation studies indicate that many of these conditions involve abnormalities of cortical organization, CI therapy might therefore be viewed as a technique that achieves clinical efficacy by correcting disorders of brain plasticity. CI therapy constitutes a new approach to neurorehabilitation and, with continued investigation, elaboration, and application to clinical settings, it seems to hold considerable promise.
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Objective: Research on monkeys with a forelimb from which sensation is surgically abolished demonstrates that such animals do not use their deafferented limb even though they possess sufficient motor ability to do so, a phenomenon labeled learned nonuse. This dissociation also occurs after neurological injury in humans. Instruments that measure these 2 aspects of motor function are discussed, and the implications of this work for cognitive assessment are explored. Study Design: Literature review. Results and Conclusions: The effects of a neurological injury may differ widely in regard to motor ability assessed on a laboratory performance test in which movements are requested and actual spontaneous use of an extremity in real-world settings, indicating that these parameters need to be evaluated separately. The methods used in Constraint-Induced Movement therapy research to independently assess these 2 domains are reliable and valid. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Few research in multiple sclerosis (MS) has focused on physical rehabilitation of upper limb dysfunction, though the latter strongly influences independent performance of activities of daily living. Upper limb rehabilitation technology could hold promise for complementing traditional MS therapy. Consequently, this pilot study aimed to examine the feasibility of an 8-week mechanical-assisted training program for improving upper limb muscle strength and functional capacity in MS patients with evident paresis. A case series was applied, with provision of a training program (3×/week, 30 minutes/session), supplementary on the customary maintaining care, by employing a gravity-supporting exoskeleton apparatus (Armeo Spring). Ten high-level disability MS patients (Expanded Disability Status Scale 7.0-8.5) actively performed task-oriented movements in a virtual real-life-like learning environment with the affected upper limb. Tests were administered before and after training, and at 2-month follow-up. Muscle strength was determined through the Motricity Index and Jamar hand-held dynamometer. Functional capacity was assessed using the TEMPA, Action Research Arm Test (ARAT) and 9-Hole Peg Test (9HPT). Muscle strength did not change significantly. Significant gains were particularly found in functional capacity tests. After training completion, TEMPA scores improved (p = 0.02), while a trend towards significance was found for the 9HPT (p = 0.05). At follow-up, the TEMPA as well as ARAT showed greater improvement relative to baseline than after the 8-week intervention period (p = 0.01, p = 0.02 respectively). The results of present pilot study suggest that upper limb functionality of high-level disability MS patients can be positively influenced by means of a technology-enhanced physical rehabilitation program.
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Resistance training studies in multiple sclerosis (MS) often use short intervention periods. Furthermore, training efficiency could be optimized by unilateral training and/or electrical stimulation. To examine the effect(s) of unilateral long-term (20 weeks) standardized resistance training with and without simultaneous electro-stimulation on leg muscle strength and overall functional mobility. A randomized controlled trial involving 36 persons with MS. At baseline (PRE) and after 10 (MID) and 20 (POST) weeks of standardized (ACSM) light to moderately intense unilateral leg resistance training (RES(O), n = 11) only or resistance training with simultaneous electro-stimulation (RES(E), n = 11, 100 Hz, biphasic symmetrical wave, 400 µs), maximal isometric strength of the knee extensors and flexors (45°, 90° knee angle) and dynamic (60-180°/s) knee-extensor strength was measured and compared with a control group (CON, n = 14). Functional mobility was evaluated using the Timed Get Up and Go, Timed 25 Foot Walk, Two-Minute Walk Test, Functional Reach and Rivermead Mobility Index. Maximal isometric knee extensor (90°, MID: +10 ± 3%, POST: +10  ±  4%) in RES(O) and knee flexor (45°, POST: +7 ± 4%; 90°, POST: +9  ±  5%) in RES(E) strength increased (p < 0.05) compared with CON but RES(O) and RES(E) did not differ. Also, impaired legs responded positively to resistance training (unilateral leg strength analysis) and functional reaching increased significantly in RES(O) (+18%) compared with CON. Dynamic muscle strength and the remaining functional mobility tests did not change. Long-term light to moderately intense resistance training improves muscle strength in persons with MS but simultaneous electro-stimulation does not further improve training outcome.
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This systematic review summarizes evidence for intensity of treatment and constraint-induced language therapy (CILT) on measures of language impairment and communication activity/participation in individuals with stroke-induced aphasia. A systematic search of the aphasia literature using 15 electronic databases (e.g., PubMed, CINAHL) identified 10 studies meeting inclusion/exclusion criteria. A review panel evaluated studies for methodological quality. Studies were characterized by research stage (i.e., discovery, efficacy, effectiveness, cost-benefit/public policy research), and effect sizes (ESs) were calculated wherever possible. In chronic aphasia, studies provided modest evidence for more intensive treatment and the positive effects of CILT. In acute aphasia, 1 study evaluated high-intensity treatment positively; no studies examined CILT. Four studies reported discovery research, with quality scores ranging from 3 to 6 of 8 possible markers. Five treatment efficacy studies had quality scores ranging from 5 to 7 of 9 possible markers. One study of treatment effectiveness received a score of 4 of 8 possible markers. Although modest evidence exists for more intensive treatment and CILT for individuals with stroke-induced aphasia, the results of this review should be considered preliminary and, when making treatment decisions, should be used in conjunction with clinical expertise and the client's individual values.
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Fatigue is a prominent disabling symptom in a variety of medical and neurologic disorders. To facilitate research in this area, we developed a fatigue severity scale, subjected it to tests of internal consistency and validity, and used it to compare fatigue in two chronic conditions: systemic lupus erythematosus and multiple sclerosis. Administration of the fatigue severity scale to 25 patients with multiple sclerosis, 29 patients with systemic lupus erythematosus, and 20 healthy adults revealed that the fatigue severity scale was internally consistent, correlated well with visual analogue measures, clearly differentiated controls from patients, and could detect clinically predicted changes in fatigue over time. Fatigue had a greater deleterious impact on daily living in patients with multiple sclerosis and systemic lupus erythematosus compared with controls. The results further showed that fatigue was largely independent of self-reported depressive symptoms and that several characteristics could differentiate fatigue that accompanies multiple sclerosis from fatigue that accompanies systemic lupus erythematosus. This study demonstrates (1) the clinical and research applications of a scale that measures fatigue severity and (2) helps to identify features that distinguish fatigue between two chronic medical disorders.
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A new approach to the rehabilitation of movement, based primarily on the principles of operant conditioning, was derived from research with deafferented monkeys. The analysis suggests that a certain proportion of excess motor disability after certain types of injury involves a learned suppression of movement and may be termed learned nonuse. Learned nonuse can be overcome by changing the contingencies of reinforcement so that they strongly favor use of an affected upper extremity in the chronic postinjury situation. The techniques employed here involved 2 weeks of restricting movement of the opposite (unaffected) extremity and training of the affected limb. Initial work with humans has been with chronic stroke patients for whom the approach has yielded large improvements in motor ability and functional independence. We report here preliminary data suggesting that shaping with verbal feedback further enhances the motor recovery.
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A new family of rehabilitation techniques, termed Constraint-Induced Movement Therapy or CI Therapy, has been developed that controlled experiments have shown is effective in producing large improvements in limb use in the real-world environment after cerebrovascular accident (CVA). The signature therapy involves constraining movements of the less-affected arm with a sling for 90% of waking hours for 2 weeks, while intensively training use of the more-affected arm. The common therapeutic factor in all CI Therapy techniques would appear to be inducing concentrated, repetitive practice of use of the more-affected limb. A number of neuroimaging and transcranial magnetic stimulation studies have shown that the massed practice of CI Therapy produces a massive use-dependent cortical reorganization that increases the area of cortex involved in the innervation of movement of the more-affected limb. The CI Therapy approach has been used successfully to date for the upper limb of patients with chronic and subacute CVA and patients with chronic traumatic brain injury and for the lower limb of patients with CVA, incomplete spinal cord injury, and fractured hip. The approach has recently been extended to focal hand dystonia of musicians and possibly phantom limb pain.
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A volunteer sample of 22 participants with chronic traumatic brain injury (TBI) (onset >1 year) and relative hemiplegia that revealed moderate disability in the more-affected upper limb (UL) participated. Constraint-induced (CI) movement therapy (CI therapy) was employed for a 2-week period; treatments included massed practice, shaping of the more-affected UL, behavioral contracts, and other behavioral techniques for affecting transfer to a real-world setting. We used the Wolf Motor Function Test, the Fugl-Meyer Motor Performance Assessment, and the Motor Activity Log to measure outcomes. All outcome measures improved significantly as a result of the intervention. More-adherent participants had more improvement compared with less-adherent participants. These preliminary results suggest that CI therapy may be effective for improving UL motor function following chronic TBI.
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To evaluate in a preliminary fashion whether several standard cognitive assessments predict treatment outcomes on real-world functional activities following Constraint-Induced Movement therapy (CI therapy) for either the upper extremity (UE) or the lower extremity (LE) for chronic stroke hemiparesis in the outpatient therapy clinic. 15 UE and 14 LE patients in the clinic underwent a short battery of cognitive assessments that evaluated sustained attention, episodic memory, executive control abilities, and general cognitive function. Spearman correlation analysis was used to evaluate whether each cognitive test predicted treatment outcome on the limb-specific Motor Activity Log (MAL). Two assessments (delayed verbal memory and Trail Making Test form B) significantly correlated with LE MAL change that followed therapy. We tentatively conclude from this exploratory and preliminary study that cognitive performance may predict treatment changes in response to CI therapy for the LE. Moderate to large correlations that we observed between other cognitive assessments and CI therapy outcomes recommend replicating this study with a larger and more cognitively diverse sample of stroke patients to learn if these findings are generalizable.
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Constraint-induced movement therapy (CI therapy) is a rehabilitation treatment approach that improves more-affected extremity use following a stroke, especially in the life situation. The originators of the approach describe CI therapy as consisting of a family of therapies including a number of treatment components and subcomponents. When thinking of CI therapy, rehabilitation researchers and clinicians frequently cite a restraining mitt on the less affected arm as the main active ingredient behind improvements in motor function. However, substantial data suggest that restraint makes actually a relatively small contribution to treatment outcome. This paper provides a detailed description of the multiple treatment elements included in the CI therapy protocol as used in our research laboratory. Our aim is to improve understanding of CI therapy and the research supporting its use.
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Research on monkeys with a single forelimb from which sensation is surgically abolished demonstrates that such animals do not use their deafferented limb even though they possess sufficient motor innervation to do so, a phenomenon labeled learned nonuse. This dissociation also occurs after neurological injury in humans. Instruments that measure these two aspects of motor function are discussed. The effects of a neurological injury may differ widely in regard to motor ability assessed on a laboratory performance test in which movements are requested and actual spontaneous use of an extremity in real-world settings, indicating that these parameters need to be evaluated separately. The methods used in Constraint-Induced Movement therapy (CI therapy) research to independently assess these two domains are reliable and valid. We suggest that these tests have applicability beyond studies involving CI therapy for stroke and may be of value for determining motor status in other types of motor disorders and with other types of treatment. The learned nonuse formulation also predicts that a rehabilitation treatment may have differential effects on motor performance made on request and actual spontaneous amount of use of a more affected upper extremity in the life situation. CI therapy produces improvements in the former, but focuses attention on the latter and, in fact, spontaneous use of the limb is where this intervention has by far its greatest effect. The evidence suggests that this result is driven by use of a ''transfer package'' of techniques, which can be used with other therapies to increase the transfer of improvements made in the clinic to the life situation. The use of CI therapy in humans began with the upper extremity after stroke and was then extended for the upper extremity to cerebral palsy in young children (8 months to 8 years old) and traumatic brain injury. A form of CI therapy was developed for the lower extremities and was used effectively after stroke, spinal cord injury, and fractured hip. Adaptations of CI therapy have also been developed for aphasia (CI aphasia therapy), focal hand dystonia in musicians and phantom limb pain. The range of these applications suggests that CI therapy is not only a treatment for stroke, for which it is most commonly used, but for learned nonuse in general, which manifests as excess motor disability in a number of conditions which until now have been refractory to treatment.
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Single-site studies suggest that a 2-week program of constraint-induced movement therapy (CIMT) for patients more than 1 year after stroke who maintain some hand and wrist movement can improve upper extremity function that persists for at least 1 year. To compare the effects of a 2-week multisite program of CIMT vs usual and customary care on improvement in upper extremity function among patients who had a first stroke within the previous 3 to 9 months. The Extremity Constraint Induced Therapy Evaluation (EXCITE) trial, a prospective, single-blind, randomized, multisite clinical trial conducted at 7 US academic institutions between January 2001 and January 2003. Two hundred twenty-two individuals with predominantly ischemic stroke. Participants were assigned to receive either CIMT (n = 106; wearing a restraining mitt on the less-affected hand while engaging in repetitive task practice and behavioral shaping with the hemiplegic hand) or usual and customary care (n = 116; ranging from no treatment after concluding formal rehabilitation to pharmacologic or physiotherapeutic interventions); patients were stratified by sex, prestroke dominant side, side of stroke, and level of paretic arm function. The Wolf Motor Function Test (WMFT), a measure of laboratory time and strength-based ability and quality of movement (functional ability), and the Motor Activity Log (MAL), a measure of how well and how often 30 common daily activities are performed. From baseline to 12 months, the CIMT group showed greater improvements than the control group in both the WMFT Performance Time (decrease in mean time from 19.3 seconds to 9.3 seconds [52% reduction] vs from 24.0 seconds to 17.7 seconds [26% reduction]; between-group difference, 34% [95% confidence interval {CI}, 12%-51%]; P<.001) and in the MAL Amount of Use (on a 0-5 scale, increase from 1.21 to 2.13 vs from 1.15 to 1.65; between-group difference, 0.43 [95% CI, 0.05-0.80]; P<.001) and MAL Quality of Movement (on a 0-5 scale, increase from 1.26 to 2.23 vs 1.18 to 1.66; between-group difference, 0.48 [95% CI, 0.13-0.84]; P<.001). The CIMT group achieved a decrease of 19.5 in self-perceived hand function difficulty (Stroke Impact Scale hand domain) vs a decrease of 10.1 for the control group (between-group difference, 9.42 [95% CI, 0.27-18.57]; P=.05). Among patients who had a stroke within the previous 3 to 9 months, CIMT produced statistically significant and clinically relevant improvements in arm motor function that persisted for at least 1 year. Trial Registration clinicaltrials.gov Identifier: NCT00057018.
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Physical deconditioning is involved in the impaired exercise tolerance of patients with multiple sclerosis (MS), but data on the effects of aerobic training (AT) in this population are scanty. The purpose of this study was to compare the effects of an 8-week AT program on exercise capacity-in terms of walking capacity and maximum exercise tolerance, as well as its effects on fatigue and health-related quality of life-as compared with neurological rehabilitation (NR) in subjects with MS. Nineteen subjects (14 female, 5 male; mean age [X+/-SD]=41+/-8 years) with mild to moderate disability secondary to MS participated in a randomized crossover controlled study. Eleven subjects (8 female, 3 male; mean age [X+/-SD]=44+/-6 years) completed the study. After AT, but not NR, the subjects' walking distances and speeds during a self-paced walk were significantly improved, as were their maximum work rate, peak oxygen uptake, and oxygen pulse during cardiopulmonary exercise tests. The increases in peak oxygen uptake and maximum work rate, but not in walking capacity, were significantly higher after AT, as compared with after NR. Additionally, the subjects who were most disabled tended to benefit more from AT. There were no differences between AT and NR in effects on fatigue, and the results showed that AT may have partially affected health-related quality of life. The results suggest that AT is more effective than NR in improving maximum exercise tolerance and walking capacity in people with mild to moderate disability secondary to MS.
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Individuals with multiple sclerosis (MS) are more sedentary than the general population, increasing their propensity for reduced functional ability, mobility, and activities of daily living. Self-efficacy has been one of the most consistent determinants of physical activity across populations, including those with MS. However, no studies exist that have attempted to influence self-efficacy in MS patients, in an effort to improve physical activity participation. We conducted a three-month randomised, controlled trial (n=26), contrasting the effects of an efficacy-enhancement exercise condition and a control exercise condition on exercise adherence, well-being, and affective responses to exercise. Analyses indicated that individuals in the efficacy enhancement condition attended more exercise sessions, reported greater levels of well-being and exertion, and felt better following exercise than individuals in the standard care condition. Regardless of treatment condition, individuals with a stronger sense of exercise self-efficacy, who reported more enjoyment following the exercise sessions, demonstrated significantly greater adherence with the exercise program. We believe this to be the first empirical attempt to change physical activity behavior in persons with MS using a well-established theoretical framework to drive the intervention. Continued examination of self-efficacy as a determinant of behavior change in individuals with MS is needed.
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In this laboratory we have developed a set of techniques that randomized controlled studies and a multisite randomized controlled trial have shown can substantially reduce the motor deficit of adult patients with mild to severe chronic strokes. Equivalent results have been obtained with adult patients after traumatic brain injury and brain resection. The basic technique, termed Constraint-Induced Movement therapy or CI therapy was derived directly from basic research with monkeys with mature motor systems and with monkeys given surgical intervention either on their day of birth or prenatally by intrauterine surgical procedures. We report here the results of two randomized controlled trials of CI therapy with young children with asymmetric upper extremity motor deficits of varied etiologies from 8 months to 8 years of age in one study and with children with hemiparesis consequent to prenatal, perinatal, or early antenatal stroke from 2 to 6 years old in a second study. The procedures used with children are very similar to those used with adults and diverge simply to make the basic techniques age-appropriate. All forms of CI therapy for the upper extremity to date involve 3 main elements: (1) intensive training of the more affected extremity, (2) prolonged restraint of the less affected extremity, (3) a 'transfer package' of techniques to induce transfer of therapeutic gains achieved in the laboratory to the life situation. The results in children with cerebral palsy are considerably better than those obtained in adults. Marked changes were observed in the quality of movement in the laboratory scored by masked observers from videotape; actual amount of use of the more affected arm in the life situation; active range of motion; and emergence of new classes of behaviour never performed before, such as in individual cases, fine thumb-forefinger grasp, supination, and use of the more affected extremity in crawling with palmar placement and rhythmic alteration. In the second experiment, the control group, after receiving usual and customary care for 6 months, was crossed over to receive CI therapy and exhibited results that were as good as those for the children receiving CI therapy first. Retention of treatment gains was approximately 70% at 6 months after the end of treatment. For some children there was no decrement in retention while for others there was a marked drop-off. One of the important factors contributing to good retention was the compliance of parents with the recommended post-treatment regimen. When retention is poor, brush-up periods may be of value. In the first experiment children were treated for 6 hr/day for 21 consecutive days, while in the second experiment treatment occurred only on the weekdays of the 3-wk treatment period (15 days). The results were at least as good with 15 days of treatment as with 21 consecutive days, thereby allowing the protocol to be fit into the usual therapist work week and making it more practical and less expensive for clinical use. CI therapy does not make movement normal in children with cerebral palsy with asymmetric upper extremity motor disorders. However, as carried out in this laboratory, it can produce a substantial improvement in a majority of cases.
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Studies on adult stroke patients have demonstrated functional changes in cortical excitability, metabolic rate, or blood flow after motor therapy, measures that can fluctuate rapidly over time. This study evaluated whether evidence could also be found for structural brain changes during an efficacious rehabilitation program. Chronic stroke patients were randomly assigned to receive either constraint-induced movement therapy (n=16) or a comparison therapy (n=20). Longitudinal voxel-based morphometry was performed on structural MRI scans obtained immediately before and after patients received therapy. The group receiving constraint-induced movement therapy exhibited far greater improvement in use of the more affected arm in the life situation than the comparison therapy group. Structural brain changes paralleled these improvements in spontaneous use of the more impaired arm for activities of daily living. There were profuse increases in gray matter in sensory and motor areas both contralateral and ipsilateral to the affected arm that were bilaterally symmetrical, as well as bilaterally in the hippocampus. In contrast, the comparison therapy group failed to show gray matter increases. Importantly, the magnitude of the observed gray matter increases was significantly correlated with amount of improvement in real-world arm use. These findings suggest that a previously overlooked type of brain plasticity, structural remodeling of the human brain, is harnessed by constraint-induced movement therapy for a condition once thought to be refractory to treatment: motor deficit in chronic stroke patients.
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To evaluate whether Constraint-Induced Movement therapy (CI therapy) may benefit chronic upper extremity hemiparesis in progressive multiple sclerosis (MS). Five patients with progressive MS, who had chronic upper extremity hemiparesis and evidence for learned non-use of the paretic limb in the life situation, underwent 30 hours of repetitive task training and shaping for the paretic limb over 2-10 consecutive weeks, along with physical restraint of the less-affected arm and a "transfer package" of behavioral techniques to reinforce treatment adherence. The patients showed significantly improved spontaneous, real-world limb use at post-treatment and 4 weeks post-treatment, along with improved fatigue ratings and maximal movement ability displayed in a laboratory motor test. Conclusions The findings suggest for the first time that slowly progressive MS may benefit from CI therapy. Further studies are needed to determine the retention of treatment responses.
Article
In a chronic and disabling disease like multiple sclerosis, rehabilitation becomes of major importance in the preservation of physical, psychological and social functioning. Approximately 80% of patients have multiple sclerosis for more than 35 years and most will develop disability at some point of their lives, emphasising the importance of rehabilitation in order to maintain quality of life. An important aspect of multiple sclerosis rehabilitation is the preservation of physical functioning. Hot topics in the rehabilitation of physical function include (1) exercise therapy, (2) robot-assisted training and (3) pharmacological interventions. Exercise therapy has for many years been a controversial issue in multiple sclerosis rehabilitation and the advice generally given to patients was not to participate in physical exercise, since it was thought to lead to a worsening of symptoms or fatigue. However, a paradigm shift is taking place and it is now increasingly acknowledged that exercise therapy is both safe and beneficial. Robot-assisted training is also attracting attention in multiple sclerosis rehabilitation. Several sophisticated commercial robots exist, but so far the number of scientific studies that have evaluated these is limited, although some promising results have been reported. Finally, recent studies have shown that certain pharmacological interventions have the potential to improve functional capacity substantially, with the potassium channel blocker fampridine being one of the most promising. This drug has been shown to improve walking ability in some patients with multiple sclerosis, associated with a reduction of patients' self-reported ambulatory disability. Rehabilitation strategies involving these different approaches, or combinations of them, may be of great use in improving everyday functioning and quality of life in patients with MS.
Article
Our previous research indicated that an Internet intervention was effective in increasing self-reported physical activity in persons with multiple sclerosis (MS). The present study examined the efficacy of the same Internet intervention in persons with MS by using both objective and self-report measures of physical activity. Participants (N = 21) wore an accelerometer around the waist for 7 days and then completed the International Physical Activity Questionnaire (IPAQ) and Godin Leisure-Time Exercise Questionnaire (GLTEQ) before and after receiving the 12-week Internet intervention. The Internet intervention resulted in moderate increases in accelerometer activity counts (d = 0.68) and steps counts (d = 0.60), and this was paralleled by small increases in IPAQ (d = 0.43) and GLTEQ (d = 0.34) scores. The number of weeks that persons logged on was correlated with change in accelerometer activity counts (r = 0.42) and step counts (r = 0.37) but not change in IPAQ (r = 0.10) or GLTEQ (r = 0.08) scores. The novel contribution of this study was the observation that an Internet intervention was efficacious for increasing physical activity in persons with MS by using both objective and self-report measures.
Article
Approaches for treating poststroke language impairments (aphasia) based on constraint-induced (CI) principles were first introduced in 2001. CI principles as previously applied to upper extremity and locomotor retraining in stroke survivors were derived from basic neuroscience. They comprise forced-use of the affected modality, a gradual rebuilding of targeted functions using a highly intensive treatment protocol, administered in a behaviorally relevant context. CI-based approaches have stimulated considerable neurorehabilitation research interest in the past decade. The original CI aphasia treatment protocol was tailored to improve functional communication in chronic aphasia (ie, 6-12mo after stroke) and more recently, it has been adapted to treat language impairments in acute stroke survivors as well. Moreover, CI therapy applied to aphasia has been used as a model to assess language network plasticity in response to treatment using functional imaging techniques. In the following article, we review the first 10 years of behavioral and functional brain imaging research on CI-based approaches for aphasia rehabilitation.
Article
Ambulation impairment is a major component of physical disability in multiple sclerosis (MS) and a major target of rehabilitation programs. Outcome measures commonly used to evaluate walking capacities suffer from several limitations. To define and validate a new test that would overcome the limitations of current gait evaluations in MS and ultimately better correlate with the maximum walking distance (MWD). The authors developed the Timed 100-Meter Walk Test (T100MW), which was compared with the Timed 25-Foot Walk Test (T25FW). For the T100MW, the subject is invited to walk 100 m as fast as he/she can. In MS patients and healthy control volunteers, the authors measured the test-retest and interrater intraclass correlation coefficient. Spearman rank correlations were obtained between the T25FW, the T100MW, the Expanded Disability Status Scale (EDSS), and the MWD. The coefficient of variation, Bland-Altman plots, the coefficient of determination, and the area under the receiver operator characteristic curve were measured. The mean walking speed (MWS) was compared between the 2 tests. A total of 141 MS patients and 104 healthy control volunteers were assessed. Minor differences favoring the T100MW over the T25FW were observed. Interestingly, the authors demonstrated a paradoxically higher MWS on a long (T100MW) rather than on a short distance walk test (T25FW). The T25FW and T100MW displayed subtle differences of reproducibility, variability, and correlation with MWD favoring the T100MW. The maximum walking speed of MS patients may be poorly estimated by the T25FW since MS patients were shown to walk faster over a longer distance.
Article
To compare the effect of inpatient physiotherapy in a warm versus cold climate in short- and long-term perspectives. Sixty multiple sclerosis (MS) patients with gait problems, without heat intolerance, were included in a randomized cross-over study of 4-week inpatient physiotherapy in warm (Spain) and cold (Norway) climate. The primary outcome, 6-min walk test (6MWT), and secondary physical performance and self-reported measures were scored at screening, baseline, after treatment and at 3 and 6 months of follow-up. Treatment effects were analysed by mixed models. After treatment, the mean walking distance had increased by 70 m in Spain and 49 m in Norway (P = 0.060). Improvement in favour of warm climate was demonstrated at 6 months of follow-up, 43 m (Spain) compared to 20 m (Norway) (P = 0.048). The patients reported less exertion after walking (6MWT) in favour of treatment in Spain at all time points (P < 0.05). No significant differences in change were detected for the other physical performance measures. Most self-reported measures showed more improvement after treatment in Spain, but these improvements were not sustained at follow-up. The results indicate that MS patients without heat intolerance have additional benefits from physiotherapy in a warm climate.
Article
Few studies have evaluated the contribution of individual symptoms and impairments to the burden of multiple sclerosis (MS). This article reviews the contribution of walking impairment, fatigue, spasticity, depression, and pain, to quality of life (QOL) of the patient and economic burden of MS. Studies for inclusion were chosen from the literature that reported on QOL and costs in patients with MS, identified through PubMed searches (main search terms: "multiple sclerosis" combined with "quality of life," "costs," or "burden"). Articles were selected based on whether the analyses included evaluation of symptoms and impairments as contributory factors to QOL or costs. Impaired mobility was ranked to be of high concern, and was suggested to be an important contributory factor to QOL, having a greater impact on physical components than mental components. Fatigue was associated with QOL, with effects on both physical and mental components of QOL, independent of disability level. Depression was inversely associated with QOL. Spasticity may affect physical components of QOL, and daily activities may be impacted in as many as 44% of patients with MS. Pain, occurring in up to 86% of patients with MS, impacts daily function and QOL across the range of physical and mental domains. The contribution of these impairments and symptoms to the economic burden has been less well characterized, although the importance of mobility to employment and productivity has been suggested by several studies. Evidence suggests that impaired mobility and symptoms such as fatigue, pain, depression, and spasticity are important contributory factors to the observed reduction in QOL, and in some cases, increased costs, associated with MS. There is a need for greater recognition of the presence and effects of these disabilities, and effective targeted treatment options for specific impairments, potentially resulting in improved QOL and reduced indirect costs.
Article
Multiple sclerosis (MS) is frequently diagnosed during a person's most productive years, and because life expectancy for patients with MS approaches that of the general population, MS is associated with a considerable economic burden from medical costs and lost productivity. In addition, there is a substantial negative impact on quality of life (QOL) and activities of daily living (ADL). While change in walking ability often is the most visible sign of MS, and the classic clinical manifestation, few studies have evaluated the relationship between mobility impairment and patient-reported outcomes like ADL and QOL. The purpose of this article is to review the contribution of mobility impairment to patient-reported outcomes in persons with MS. Searches of PubMed were performed to identify studies from the MS literature, from January 1980 through November 2008, that evaluated the contribution of mobility to the patient burden of disease. Abstracts identified using the search terms 'multiple sclerosis AND (walking OR mobility)' in combination with the terms 'burden,' 'costs,' 'quality of life,' 'activities of daily living,' 'independence,' and 'productivity' were reviewed for relevancy for inclusion. Although impaired mobility is more apparent with greater disease duration and at higher levels of disability, it may be present even in the early stages of MS. Maintaining mobility is ranked as one of the highest priorities among patients with MS, regardless of disease duration or disability level. Several studies have demonstrated that loss of mobility contributes to a substantial patient burden. The statistical technique of path analysis has shown how difficulty walking significantly affects physical activity in patients with MS. Impaired mobility is associated with reductions in QOL, ADL, and productivity. The primary concern related to patient independence among persons with MS, regardless of their status, is loss of mobility. It should be noted that limitations inherent in some of the studies, including heterogeneity in methodology and MS populations, may limit their generalizability. These findings highlight the need for more comprehensive assessments of walking impairment in patients with MS and further evaluation from the patient's perspective.
Article
To examine the relationship among 4 clinical measures of walking ability and the outputs of the StepWatch Activity Monitor in participants with stroke. Correlational study. Clinic and participants' usual environments. Fifty participants more than 6 months after stroke were recruited. All participants were able to walk independently, but with some residual difficulty. Not applicable. Rivermead Mobility Index (RMI), Rivermead Motor Assessment (RMA), six-minute walk test (6MWT), ten-meter walk test (10MWT), StepWatch outputs (based on daily step counts and stepping rates). The correlations between the RMA and all StepWatch outputs were low (rho=0.36-0.48; P<.05), as were most for the RMI (rho=0.31-0.52; P<.05). The 10MWT and 6MWT had moderate to high correlations (rho=0.51-0.73; P<.01) with most StepWatch outputs. Multiple regression showed that the 6MWT was the only significant predictor for most StepWatch outputs, accounting for between 38% and 54% of the variance. Age and the RMI were further significant predictors of 1 and 2 outputs, respectively. The 6MWT has the strongest relationship with the StepWatch outputs and may be a better test than the 10MWT to predict usual walking performance. However, it should be remembered that the 6MWT explains only half the variability in usual walking performance. Thus, activity monitoring captures aspects of walking performance not captured by other clinical tests and should be considered as an additional outcome measure in stroke rehabilitation.
Article
. Therapeutic interventions improve outcomes in the acute and chronic phase after motor stroke, but a significant amount of this improvement is usually lost after more than 1 year. Patients might profit from a second course of intensive physiotherapy, but this has not been investigated. . The feasibility and effect of a second phase of physiotherapy was examined 2 years after the first one. . A total of 12 patients with chronic stroke were instructed to wear a constraining splint on the affected elbow and hand while awake for 4 weeks and practice individually tailored tasks 2 hours per day. Motor tests for assessment included the Motor Activity Log, Wolf Motor Function Test, and 9-Hole Peg Test. . In the 11 patients who were available for postintervention assessment, the deterioration in the amount and quality of movement that had occurred since the first therapy was largely recouped. Patients who wore the constraint more than 80% of waking hours during the second therapy showed a clear secondary improvement in all tests, in some surpassing the level reached after the first therapy. . A repeated bout of home-based CIMT 2 years after initial training is feasible with relatively little time and effort provided by a therapist and can lead to further improvement.
Article
Twenty-eight subjects were randomly allocated to either a nicotine fading or a maintenance condition. The maintenance condition utilized behavioral contracting and extended treatment in addition to the nicotine fading to improve treatment outcome and avoid relapse. The maintenance condition achieved superior outcome on smoking measures at post-treatment and follow-up periods for self-reported smoking levels. Carbon monoxide levels were significantly lower for the maintenance condition at post-treatment, three month and six month follow-up. Saliva thiocyanate levels were significantly lower for the maintenance condition at the three month follow-up. Changes in health functioning indicated significantly lower diastolic and systolic blood pressure at six month follow-up for the maintenance condition. Additional research on nicotine regulation during nicotine fading and thiocyanate levels during experimental smoking would be useful. The use of behavioral contracting to enhance maintenance without therapeutic support warrants further research as well.
Article
One method of evaluating the degree of neurologic impairment in MS has been the combination of grades (0 = normal to 5 or 6 = maximal impairment) within 8 Functional Systems (FS) and an overall Disability Status Scale (DSS) that had steps from 0 (normal) to 10 (death due to MS). A new Expanded Disability Status Scale (EDSS) is presented, with each of the former steps (1,2,3 . . . 9) now divided into two (1.0, 1.5, 2.0 . . . 9.5). The lower portion is obligatorily defined by Functional System grades. The FS are Pyramidal, Cerebellar, Brain Stem, Sensory, Bowel & Bladder, Visual, Cerebral, and Other; the Sensory and Bowel & Bladder Systems have been revised. Patterns of FS and relations of FS by type and grade to the DSS are demonstrated.
Article
The unaffected upper extremity of chronic stroke patients was restrained in a sling during waking hours for 14 days; on ten of those days, these patients were given six hours of practice in using the impaired upper extremity. An attention-comparison group received several procedures designed to focus attention on use of the impaired upper extremity. The restraint subjects improved on each of the laboratory measures of motor function used--in most cases markedly. Extensive improvement, from a multi-year plateau of greatly impaired motor function, was also noted for the restraint group in the life situation and these gains were maintained during a two-year period of follow-up. For the comparison group only one measure showed small to moderate improvement, and this was lost during the follow-up period; there was essentially no overlap between the individuals of the two groups. Thus, prolonged restraint of an unaffected upper extremity and practice of functional movements with the impaired limb proved to be an effective means of restoring substantial motor function in stroke patients with chronic motor impairment identified by the inclusion criteria of this project.
Article
To describe the association between impairment and disability during stroke rehabilitation and to examine the effects of rehabilitation by studying the degree of disability reduction experienced by stroke patients who did not have significant reductions in impairment levels. Statistical analysis of items from a database of prospectively collected information on stroke patients admitted for rehabilitation. Large urban academic freestanding rehabilitation facility. Four hundred two patients consecutively admitted for comprehensive acute stroke inpatient rehabilitation. The National Institutes of Health Stroke Scale (NIHSS) was used to measure impairment and the Functional Independence Measure (FIM) was used to measure disability. Motor and cognitive subscales of the FIM instrument were evaluated. Raw NIHSS and FIM scores were converted to linear measures using Rasch analysis. Relationships were studied between converted NIHSS and the two FIM subscales for admission, discharge, and change scores using linear regression analysis. In a second analysis, two groups of patients were identified; the 342 patients who experienced no substantial reduction of impairment comprised the "no impairment reduction (NIR) group," and the 60 patients who had a significant reduction of impairment level comprised the "impairment reduction (IR) group." Multivariate analysis of variance was used to determine and compare the amount of change in motor and cognitive FIM measures over time for each of the two groups. NIHSS correlated significantly with motor and cognitive FIM subscores for admission, discharge, and change measures; R2 values ranged between .02 and .36. Both the NIR group and the IR group experienced significant decreases in disability during rehabilitation. The differences in discharge FIM measures between the two groups were relatively small. Although stroke-related impairment and disability are significantly correlated with each other, reduced impairment level alone does not fully explain the reduced disability that occurs during rehabilitation. Even patients without substantial impairment reduction demonstrate disability reduction during rehabilitation, suggesting that rehabilitation has an independent role in improving function beyond that explained by neurologic recovery alone.
Article
To assess the effect of a combined exercise and motivation program on the compliance and level of disability of patients with chronic and recurrent low back pain. A double-blind prospective randomized controlled trial. Physical therapy outpatient department, tertiary care. Ninety-three low back pain patients were randomly assigned to either a standard exercise program (n = 49) or a combined exercise and motivation program (n = 44). Patients were prescribed 10 physical therapy sessions and were advised to continue exercising after treatment termination. The motivation program consisted of five compliance-enhancing interventions. Follow-up assessments were performed at 3 1/2 weeks, 4 months, and 12 months. Disability (low back outcome score), pain intensity, physical impairment (modified Waddell score, fingertip-to-floor distance, abdominal muscle strength), working ability, motivation, and compliance. The patients in the motivation group were significantly more likely to attend their exercise therapy appointments (p = .0005). Four and 12 months after study entry there was a significant difference in favor of the motivation group with regard to the disability score (p = .004) and pain intensity (p < or = .026). At 4 months, there was a significant advantage for the motivation group in the fingertip-to-floor distance (p = .01) and in abdominal muscle strength (p = .018). No significant differences were found in motivation scores, self-reported compliance with long-term exercise, and modified Waddell score. In terms of working ability, there was a trend favoring the combined exercise and motivation program. The combined exercise and motivation program increased the rate of attendance at scheduled physical therapy sessions, ie, short-term compliance, and reduced disability and pain levels by the 12-month follow-up. However, there was no difference between the motivation and control groups with regard to long-term exercise compliance.
Article
This article provides a complete report of outcome data from a study of behavioral marital therapy (BMT) with and without additional couples relapse prevention (RP) sessions. (See J. Stud. Alcohol 54: 652-666, 1993, for an earlier partial report.) Fifty-nine couples with an alcoholic husband, after receiving weekly BMT couples sessions for 5-6 months, were assigned randomly to get or not get 15 additional couples relapse prevention (RP) sessions over the next 12 months. Outcome measures were collected before and after BMT and at quarterly intervals for the 30 months after BMT. BMT-plus-RP produced more days abstinent and greater use of the Antabuse Contract than BMT-only; and these superior drinking outcomes for BMT-plus-RP lasted through 18-month follow-up (i.e., 6 months after the end of RP). BMT-plus-RP had better wives' marital adjustment than BMT-only throughout the 30 months of follow-up, with the superiority of BMT-plus-RP over BMT-only being greatest for wives with poorer pretreatment marital adjustment during the later months of follow-up. BMT-plus-RP also maintained their improved marriages longer (through 24-month follow-up) than BMT-only (through 12-month follow-up). Irrespective of treatment condition, more use of BMT-targeted marital behaviors (e.g., shared recreational activities, constructive communication) was associated with better marital and drinking outcomes throughout the 30-month follow-up period whereas more use of the Antabuse contract was associated with better marital and drinking outcomes through 12-month follow-up. Alcoholics with more severe marital problems had more abstinent days and maintained relatively stable levels of abstinence if they received BMT-plus-RP, while their counterparts who received BMT-only had fewer abstinent days and showed a steep decline in abstinent days during the 30 months of follow-up. Furthermore, alcoholics with more severe alcohol problems used the Antabuse contract more and showed a less steep decline in use of the Antabuse contract in the 30 months of follow-up if they received BMT-plus-RP than if they received BMT-only. For the entire sample, BMT-plus-RP produced better marital outcomes throughout the 30 months of follow-up and better drinking outcomes during and for the 6 months following RP sessions, relative to BMT-only outcomes. For alcoholics with more severe marital and drinking problems, BMT-plus-RP produced better drinking outcomes than BMT-only throughout the 30-month follow-up period.
Article
To be useful for clinical research, an outcome measure must be feasible to administer and have sound psychometric attributes, including reliability, validity, and sensitivity to change. This study characterizes the psychometric properties of the Stroke Impact Scale (SIS) Version 2.0. Version 2.0 of the SIS is a self-report measure that includes 64 items and assesses 8 domains (strength, hand function, ADL/IADL, mobility, communication, emotion, memory and thinking, and participation). Subjects with mild and moderate strokes completed the SIS at 1 month (n=91), at 3 months (n=80), and at 6 months after stroke (n=69). Twenty-five subjects had a replicate administration of the SIS 1 week after the 3-month or 6-month test. We evaluated internal consistency and test-retest reliability. The validity of the SIS domains was examined by comparing the SIS to existing stroke measures and by comparing differences in SIS scores across Rankin scale levels. The mixed model procedure was used to evaluate responsiveness of the SIS domain scores to change. Each of the 8 domains met or approached the standard of 0.9 alpha-coefficient for comparing the same patients across time. The intraclass correlation coefficients for test-retest reliability of SIS domains ranged from 0.70 to 0.92, except for the emotion domain (0.57). When the domains were compared with established outcome measures, the correlations were moderate to strong (0.44 to 0.84). The participation domain was most strongly associated with SF-36 social role function. SIS domain scores discriminated across 4 Rankin levels. SIS domains are responsive to change due to ongoing recovery. Responsiveness to change is affected by stroke severity and time since stroke. This new, stroke-specific outcome measure is reliable, valid, and sensitive to change. We are optimistic about the utility of measure. More studies are required to evaluate the SIS in larger and more heterogeneous populations and to evaluate the feasibility and validity of proxy responses for the most severely impaired patients.
Article
Patients with chronic aphasia were assigned randomly to a group to receive either conventional aphasia therapy or constraint-induced (CI) aphasia therapy, a new therapeutic technique requiring intense practice over a relatively short period of consecutive days. CI aphasia therapy is realized in a communicative therapeutic environment constraining patients to practice systematically speech acts with which they have difficulty. Patients in both groups received the same amount of treatment (30 to 35 hours) as 10 days of massed-practice language exercises for the CI aphasia therapy group (3 hours per day minimum; 10 patients) or over a longer period of approximately 4 weeks for the conventional therapy group (7 patients). CI aphasia therapy led to significant and pronounced improvements on several standard clinical tests, on self-ratings, and on blinded-observer ratings of the patients' communicative effectiveness in everyday life. Patients who received the control intervention failed to achieve comparable improvements. Data suggest that the language skills of patients with chronic aphasia can be improved in a short period by use of an appropriate massed-practice technique that focuses on the patients' communicative needs.
Article
Self-reported capability in physical functioning has long been considered an important focus of research for older persons. Current measures have been criticized, however, for conceptual confusion, lack of sensitivity to change, poor reproducibility, and inability to capture a wide range of upper and lower extremity functioning. Using Nagi's disablement model, we wrote physical functioning questionnaire items that assessed difficulty in 48 common daily tasks. We constructed the instrument using factor analysis and Rasch analytic techniques and evaluated its validity and test-retest reliability with 150 ethnically and racially diverse adults aged 60 years and older who had a range of functional limitations. Our analyses resulted in a 32-item function component with three dimensions--upper extremity, basic lower extremity, and advanced lower extremity functions. Expected differences in summary scores of known-functional limitation groups support its validity. Test-retest stability over a 1- to 3-week period was extremely high (intraclass correlation coefficients =.91 to.98). The Late-Life Function and Disability Instrument has potential to assess activity concepts related to upper and lower extremity functioning across a wide variety of daily physical tasks and individual levels of physical functioning.
Article
Efforts to evaluate the effectiveness of clinical and community-based interventions designed to impact late-life disability have been hindered significantly by limitations in current instrumentation. More conceptually sound and responsive measures of disability are needed. Applying Nagi's disablement model, we wrote questionnaire items that assessed disability in terms of frequency and limitation in performance of 25 life tasks. We evaluated their validity and test-retest reliability with 150 ethnically and racially diverse adults aged 60 and older who had a range of functional limitations, using factor analysis and Rasch analytic techniques to examine and refine the instrument. Our analyses resulted in a 16-item disability component with two dimensions, one focused on frequency of performance and the other addressing limitation in performance of life tasks, with two disability domains within each dimension. The frequency dimension consisted of a personal and a social role domain, and the limitation dimension consisted of an instrumental and a management role domain. Expected differences in summary scores of known-functional limitation groups support the validity of this instrument. Test-retest intraclass correlations of the reproducibility of each overall dimension summary score were moderate to high (intraclass correlation coefficients .68-.82). The Late-Life Function and Disability Instrument has potential to assess meaningful concepts of disability across a wide variety of life tasks with relatively few items.