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The relative dearth of effective interventions in neurorehabilitation could be partly attributable to the weak contribution that this field has received from basic sciences such as neuroscience and behavioural psychology. Neuroscience holds an important place in the curriculum of physical therapy schools, but its influence has been largely didactic and has had little bearing on clinical practice. Behavioural psychology has contributed much to the treatment of chronic pain 1 , but has little or no place in the curriculum of physical rehabilitation schools or in the development of treatments for movement disorders. In other health-related fields, basic research has, of course, been of inestimable value in enabling the development of new therapeutic interventions. In the neurosciences, the fruitfulness of this approach has been amply shown by the development of treatments for Parkinson's disease and other disorders on the basis of the pioneering work of Carlsson and others on chemical neurotransmission 2,3 . The paradigm shift that is mentioned in the preface refers to the fact that this process of translation of basic research into new treatments is beginning to take place in the field of neurorehabilitation and is proceeding at an accelerating pace.After injury to the central nervous system (CNS), the initial deficit in behaviour, perception and/or cognitive ability is frequently followed by a spontaneous recovery of function. This resiliency may be considered as one type of behavioural plasticity. By apparent contrast, the traditional view in neuroscience during the first threequarters of the last century was that the mature CNS has little capacity to reorganize and repair itself in response to injury. This view extends back into the nineteenth century, promoted initially by Broca's studies on the localization of function within the brain 4 , which emphasized the constancy of organization of the mature CNS even after substantial injury. Although contrary views were expressed 5,6 , the mature CNS was generally believed 7 to show little or no plasticity 8 . Hughlings Jackson's hierarchical view 9 that lower centres of the brain substituted in function for higher damaged centres after CNS insult, together with other related formulations, had an important influence for most of the twentieth century on our thinking about the recovery of function. However, the phenomenon of spontaneous recovery of function was never fully explained and received little experimental attention, largely because the techniques needed to explore this process had not yet been developed. Beginning in the 1970s, research from several laboratories, including those of Merzenich Recent discoveries about how the central nervous system responds to injury and how patients reacquire lost behaviours by training have yielded promising new therapies for neurorehabilitation. Until recently, this field had been largely static, but the current melding of basic behavioural science with neuroscience promises entirely new approaches to improving behavioural, ...

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The participant Motor Activity Log is reliable and valid in individuals with subacute stroke. It might be employed to assess the real-world effects of upper extremity neurorehabilitation and detect deficits in spontaneous use of the hemiparetic arm in daily life.

Background and Purpose-In research on Constraint-Induced Movement (CI) therapy, a structured interview, the Motor Activity Log (MAL), is used to assess how stroke survivors use their more-impaired arm outside the laboratory. This article examines the psychometrics of the 14-item version of this instrument in 2 chronic stroke samples with mild-to-moderate upper-extremity hemiparesis. Methods-Participants (nϭ41) in the first study completed MALs before and after CI therapy or a placebo control procedure. In addition, caregivers independently completed a MAL on the participants. Participants (nϭ27) in the second study completed MALs and wore accelerometers that monitored their arm movements for 3 days outside the laboratory before and after an automated form of CI therapy. Results-Validity

Background and Purpose-Constraint-Induced Movement therapy (CI therapy) is a neurorehabilitation technique developed to improve use of the more affected upper extremity after stroke. A number of studies have reported positive effects for this intervention, but an experiment with a credible placebo control group has not yet been published. Methods-We conducted a placebo-controlled trial of CI therapy in patients with mild to moderate chronic (meanϭ4.5 years after stroke) motor deficit after stroke. The CI therapy group received intensive training (shaping) of the more affected upper extremity for 6 hours per day on 10 consecutive weekdays, restraint of the less affected extremity for a target of 90% of waking hours during the 2-week treatment period, and application of a number of other techniques designed to produce transfer to the life situation. The placebo group received a program of physical fitness, cognitive, and relaxation exercises for the same length of time and with the same amount of therapist interaction as the experimental group. Results-After CI therapy, patients showed large (Wolf Motor Function Test) to very large improvements in the functional use of their more affected arm in their daily lives (Motor Activity Log; PϽ0.0001). The changes persisted over the 2 years tested. Placebo subjects showed no significant changes. Conclusion-The results support the efficacy of CI therapy for rehabilitating upper extremity motor function in patients with chronic stroke.

This article describes the study design, methodological considerations, and demographic characteristics of a phase III RCT to determine if 1) constraint-induced therapy (CI therapy) can be applied with therapeutic success 3 to 9 months after stroke across different sites, 2) gains that might occur persist over 2 years, 3) initial level of motor ability determines responsiveness to CI therapy, and 4) the treatment effect differs between those treated before 9 months and after 1 year. Six sites will screen and recruit poststroke survivors stratified on initial level of motor ability and after randomization allocate participants to immediate or delayed intervention. Primary outcomes include a laboratory-based measure of function (Wolf Motor Function Test [WMFT]) and a real-world participant-centered functional use measure (Motor Activity Log [MAI]). Secondary outcomes concern function, behavior, and compliance. This is the first multisite, single-blind RCT of a formal training intervention for upper extremity rehabilitation in subacute stroke in the United States.

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