Background and Purpose Constraint-Induced Movement therapy is a set of treatments for rehabilitating motor function after CNS damage. We assessed the roles of its two main components. Methods A 2×2 factorial components analysis with random assignment was conducted. The two 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 post-stroke with hemiparesis. The different treatments, which in each case targeted the more-affected arm, lasted 3.5 hr/day 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 (MAL) and the Wolf Motor Function Test (WMFT), respectively. Results Use of the TP, regardless of the type of training received, resulted in MAL 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 WMFT (Ps<0.05). The MAL gains were retained without loss one year post-treatment. An additional substudy (N=10) showed that a single component of the TP, weekly telephone contact with participants for one month after treatment, doubled MAL 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.

Background and Purpose-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. Methods-Chronic stroke patients were randomly assigned to receive either constraint-induced movement therapy (nϭ16) or a comparison therapy (nϭ20). Longitudinal voxel-based morphometry was performed on structural MRI scans obtained immediately before and after patients received therapy. Results-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. Conclusions-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. Key Words: constraint-induced movement therapy Ⅲ hemiplegia Ⅲ imaging Ⅲ motor activity Ⅲ MRI Ⅲ stroke rehabilitation Ⅲ voxel-based morphometry M erzenich et al 1 and other investigators 2 showed in animals that altering behaviorally relevant afferent input to the central nervous system can produce plastic changes in the function and organization of the brain. Sustained increased use of a body part by an animal leads to an increase in the brain's cortical representation of that body part, 3 whereas decreased input reduces the representational zone of that body part, as occurs after amputation of a digit 1 or somatosensory deafferentation of an entire forelimb in monkeys. 4 Similar phenomena have been demonstrated in humans after both increased use 5 and decreased use resulting from upper extremity amputation 6 or stroke 7 using functional imaging or mapping techniques.A neurorehabilitation technique termed Constraint-Induced Movement therapy (CI therapy) was developed in this laboratory from basic research with monkeys. 8 This treatment has been shown to substantially increase the amount of use of an affected upper extremity after stroke 9 -12 and also greatly alter the size of the regional brain activity or activation pattern associated with the more affected arm. 7,[13][14][15] Until now, neuroanatomical evaluations of treatment changes in humans have relied solely on funct...

Patients with hemispatial neglect fail to cancel lines distributed on one side of a piece of paper. This defect is thought to be induced by a deficit in the neuronal systems that mediate attention, intention, and exploration toward and in the hemispace contralateral to the lesion. However, an alternate (but not mutually exclusive) interpretation is that the patients are either strongly attracted to or impaired in disengaging from the stimuli occupying the other, non-neglected hemispace. We tested ten patients with neglect on two versions of a cancellation test. In the control test they cancelled lines by drawing over them, and in the experimental test they erased lines. There were significantly more omissions in the drawing-over task than in the erasing task. The improved performance when lines were cancelled by removal instead of by marking them suggests that hemispatial neglect is influenced by the presence of stimuli in the non-neglected hemispace.

Background and Purpose Although the motor deficit following stroke is clearly due to the structural brain damage that has been sustained, this relationship is attenuated from the acute to chronic phases. We investigated the possibility that motor impairment and response to Constraint-Induced Movement therapy (CI therapy) in chronic stroke patients may relate more strongly to the structural integrity of brain structures remote from the lesion than to measures of overt tissue damage. Methods Voxel-based morphometry (VBM) analysis was performed on MRI scans from 80 chronic stroke patients to investigate whether variations in grey matter density were correlated with extent of residual motor impairment or with CI therapy-induced motor recovery. Results Decreased grey matter density in non-infarcted motor regions was significantly correlated with magnitude of residual motor deficit. In addition, reduced grey matter density in multiple remote brain regions predicted a lesser extent of motor improvement from CI therapy. Conclusions Atrophy in seemingly healthy parts of the brain that are distant from the infarct accounts for at least a portion of the sustained motor deficit in chronic stroke.

This third paper discusses the evidence for the rehabilitation of the most common movement disorders of the upper extremity. We also present a framework, building on the CAP model, for incorporating some of the principles discussed in the two previous papers by Frey et al. and Sathian et al. in the practice of rehabilitation, and for discussing potentially helpful interventions based on emergent neuroscience principles.