Randomized Trial of Distributed Constraint-Induced Therapy Versus Bilateral Arm Training for the Rehabilitation of Upper-Limb Motor Control and Function After Stroke

Chang Gung University, Taoyuan, Taiwan.
Neurorehabilitation and neural repair (Impact Factor: 3.98). 10/2010; 25(2):130-9. DOI: 10.1177/1545968310380686
Source: PubMed


This study compared the efficacy of distributed constraint-induced therapy (dCIT), bilateral arm training (BAT), and control treatment (CT) on motor control and functional performance of the upper limb in stroke patients.
A total of 66 patients with mean stroke onset of 16.20 months and mild to moderate motor impairment were randomized to dCIT, BAT, or CT groups. Each group received treatment for 2 h/d and 5 d/wk for 3 weeks. Pretreatment and posttreatment measures included reaching kinematic variables in unilateral and bilateral tasks, the Wolf Motor Function Test (WMFT), and the Motor Activity Log (MAL).
The dCIT and BAT groups had smoother reaching trajectories in the unilateral and bilateral tasks than the CT group. The BAT group, but not the dCIT group, generated greater force at movement initiation than the CT group during the unilateral and bilateral tasks. The dCIT patients had decreased WMFT time and higher functional ability scores than the CT patients. MAL results pointed to better performance in the amount and quality of use of the affected arm than BAT and CT patients.
BAT and dCIT exhibited similar beneficial effects on movement smoothness but differential effects on force at movement initiation and functional performance. Therefore, BAT is a better option if improvement of force generation is the treatment goal, and dCIT is more appropriate for improving functional ability and use of the affected arm in daily life. These findings may assist in the planning of individually tailored rehabilitation therapies.

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    • "It is known that this technique provides positive results regarding the improvement of the affected upper limb, resulting in increased quality of life for the patient [5]. Researchers relate these behavioral gains with enlargement of the cortical excitability area [7] [8], and neurophysiologic principles and neuroimaging tools promote an understanding of how this reorganization of the central nervous system influences the recovery process of the individual [9]. "
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    ABSTRACT: Stroke has been considered as one of the main causes ofdeath and of motor and cognitive sequels. Especially, many patients with upper limb hemiparesis improved their motor action and showed meaningful cortical changes after treatment with constraint-induced movement therapy. Therefore, this review aims toverify the literature about neuroimaging and behavioral evidences in the cortical reorganization through the use of the constraint-induced movement therapy. So, we conducted the literature research in indexed journalsfrom many databases like Pubmed, Medline, Cochrane Database, Lilacs and Scielo. We concluded that the behavioral and neuroimaging studies using traditional and modified constraint-induced movement therapy promote cortical reorganization.
    Full-text · Article · Dec 2013 · Neuroscience & Medicine
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    • "Several studies have used functional task protocols to compare the relative effects of unilateral vs. bilateral arm training [27-35], and debate continues whether and in which cases one approach could be superior to the other [23,24]. Three studies [27-29] revealed that unilateral arm training produced greater functional gains and use of the paretic arm in daily life, whereas bilateral arm training improved proximal upper limb motor impairment and force generation or increased movement smoothness. "
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    ABSTRACT: Although the effects of robot-assisted arm training after stroke are promising, the relative effects of unilateral (URT) vs. bilateral (BRT) robot-assisted arm training remain uncertain. This study compared the effects of URT vs. BRT on upper extremity (UE) control, trunk compensation, and function in patients with chronic stroke. This was a single-blinded, randomized controlled trial. The intervention was implemented at 4 hospitals. Fifty-three patients with stroke were randomly assigned to URT, BRT, or control treatment (CT). Each group received UE training for 90 to 105 min/day, 5 days/week, for 4 weeks. The kinematic variables for arm motor control and trunk compensation included normalized movement time, normalized movement units, and the arm-trunk contribution slope in unilateral and bilateral tasks. Motor function and daily function were measured by the Wolf Motor Function Test (WMFT), Motor Activity Log (MAL), and ABILHAND Questionnaire. The BRT and CT groups elicited significantly larger slope values (i.e., less trunk compensation) at the start of bilateral reaching than the URT group. URT led to significantly better effects on WMFT-Time than BRT. Differences in arm control kinematics and performance on the MAL and ABILHAND among the 3 groups were not significant. BRT and URT resulted in differential improvements in specific UE/trunk performance in patients with stroke. BRT elicited larger benefits than URT on reducing compensatory trunk movements at the beginning of reaching. In contrast, URT produced better improvements in UE temporal efficiency. These relative effects on movement kinematics, however, did not translate into differential benefits in daily functions. Trial registration NCT00917605.
    Full-text · Article · Apr 2013 · Journal of NeuroEngineering and Rehabilitation
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    • "In humans, bilateral movement training improves the balance of excitability in both hemispheres [75, 76] and is effective for improving motor function in stroke patients [77]. However, bilateral training may facilitate more recruitment of ipsilateral motor projections [78, 79] and thus may be more advantageous for proximal arm function than for hand function [80]. Considering these reports, bilateral training may prevent learned nonuse but enhance maladaptive plasticity of the distal side. "
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    ABSTRACT: Many studies in human and animal models have shown that neural plasticity compensates for the loss of motor function after stroke. However, neural plasticity concerning compensatory movement, activated ipsilateral motor projections and competitive interaction after stroke contributes to maladaptive plasticity, which negatively affects motor recovery. Compensatory movement on the less-affected side helps to perform self-sustaining activity but also creates an inappropriate movement pattern and ultimately limits the normal motor pattern. The activated ipsilateral motor projections after stroke are unable to sufficiently support the disruption of the corticospinal motor projections and induce the abnormal movement linked to poor motor ability. The competitive interaction between both hemispheres induces abnormal interhemispheric inhibition that weakens motor function in stroke patients. Moreover, widespread disinhibition increases the risk of competitive interaction between the hand and the proximal arm, which results in an incomplete motor recovery. To minimize this maladaptive plasticity, rehabilitation programs should be selected according to the motor impairment of stroke patients. Noninvasive brain stimulation might also be useful for correcting maladaptive plasticity after stroke. Here, we review the underlying mechanisms of maladaptive plasticity after stroke and propose rehabilitation approaches for appropriate cortical reorganization.
    Full-text · Article · Jun 2012 · Neural Plasticity
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