Does the Application of Constraint-Induced Movement Therapy During Acute Rehabilitation Reduce Arm Impairment After Ischemic Stroke?

Dromerick, Alexander W.; Edwards, Dorothy Farrar; Hahn, Michele

doi:10.1161/01.str.31.12.2984

Cited by 359 publications

(244 citation statements)

References 43 publications

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“…30 Clinical trials indicate that patients who practice at this intensity increase the amount and efficiency of use of the affected hand by 20 to 50 percent, whether therapy is begun while they are inpatients or a year after the stroke. 31,32 Many technology-assisted approaches to improve the functional use of a hand have been tried. In small trials, electromyographic biofeedback, which is used to help patients focus on increasing the force of contraction necessary to move a paretic wrist or to improve pinching and grasping, has increased movement but has less often improved the functional use of the hand.…”

Section: Targeted Therapymentioning

confidence: 99%

Rehabilitation after Stroke

2005

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A 66-year-old man was suddenly unable to speak, follow directions, or move his right arm and leg. He received tissue plasminogen activator within 90 minutes. Four days later, his speech was limited to effortful answers of yes or no. He could not walk or use his right arm, and self-care tasks required maximal assistance. What advice would you offer him and his family regarding rehabilitation for his disabilities? THE CLINICAL PROBLEMApproximately 400 persons per 100,000 population over the age of 45 years have a first stroke each year in the United States, Europe, and Australia. Stroke is the most frequent cause of adult-onset disability among people in the United States, and the cost of related care is among the fastest-growing expenses for Medicare. 1 The likelihood of improvement after stroke varies with the nature and severity of the initial deficit. Approximately 35 percent of survivors with initial paralysis of the leg do not regain useful function, and 20 to 25 percent of all survivors are unable to walk without full physical assistance. 2 Six months after stroke, about 65 percent of patients cannot incorporate the affected hand into their usual activities. Poor upper-extremity outcomes are probable after a hemispheric infarction when the leg cannot move by two weeks and the hand has no movement or only slight finger flexion with no opening by four weeks, consistent with considerable damage to the corticospinal tract. 3 Patients who survive a stroke almost always have less physical disability by the end of the first three months. Functional scales, such as the Barthel Index and the Functional Independence Measure (which measure the physical assistance or supervision needed for self-care, including using the toilet, dressing, bathing, eating, and mobility), tend to show a plateau of gains by three to four months after stroke, partly owing to insensitivity of the scale to further improvements. Patients who no longer require assistance at that point may still be unable to use the affected hand, walk at speeds and distances that permit activities outside the home, or live alone. Only 25 percent of patients return to the level of everyday participation and physical functioning of community-matched persons who have not had a

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Section: Targeted Therapymentioning

confidence: 99%

Rehabilitation after Stroke

2005

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“…The beneficial effect of CI therapy on the functioning of the upper extremities has been replicated in several laboratories for the chronic symptoms of stroke [42][43][44][45] and for acute symptoms in the period beginning 7-14 days after stroke 46 . A six-site randomized US clinical trial of CI therapy in the subacute period is now underway.…”

Section: From Deafferentation To CI Therapymentioning

confidence: 99%

New treatments in neurorehabiliation founded on basic research

2002

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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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“…Gowland stated that only 5 percent of persons who receive intensive therapy for severe upper-limb weakness poststroke regain functional use of their paretic upper limb during rehabilitation [4]. Several approaches to provide upperlimb exercise after stroke have been studied, including constraint-induced movement therapy (CIMT) [6][7][8][9][10]. While CIMT appears to be a promising therapy, it requires a significant level of residual motor function and is not feasible for individuals with more severe weakness after stroke.…”

Section: Weaknessmentioning

confidence: 99%

Motions or muscles? Some behavioral factors underlying robotic assistance of motor recovery

Hogan

Krebs²,

Rohrer³

et al. 2006

JRRD

327

200

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Abstract-Robotics and related technologies have begun to realize their promise to improve the delivery of rehabilitation therapy. However, the mechanism by which they enhance recovery remains unclear. Ultimately, recovery depends on biology, yet the details of the recovery process remain largely unknown; a deeper understanding is important to accelerate refinements of robotic therapy or suggest new approaches. Fortunately, robots provide an excellent instrument platform from which to study recovery at the behavioral level. This article reviews some initial insights about the process of upper-limb behavioral recovery that have emerged from our work. Evidence to date suggests that the form of therapy may be more important than its intensity: muscle strengthening offers no advantage over movement training. Passive movement is insufficient; active participation is required. Progressive training based on measures of movement coordination yields substantially improved outcomes. Together these results indicate that movement coordination rather than muscle activation may be the most appropriate focus for robotic therapy.

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Does the Application of Constraint-Induced Movement Therapy During Acute Rehabilitation Reduce Arm Impairment After Ischemic Stroke?

Cited by 359 publications

References 43 publications

Rehabilitation after Stroke

Rehabilitation after Stroke

New treatments in neurorehabiliation founded on basic research

Motions or muscles? Some behavioral factors underlying robotic assistance of motor recovery

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