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The Cochrane Database of Systematic... Oct 2015In people who have had a stroke, upper limb paresis affects many activities of daily life. Reducing disability is therefore a major aim of rehabilitative interventions.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
In people who have had a stroke, upper limb paresis affects many activities of daily life. Reducing disability is therefore a major aim of rehabilitative interventions. Despite preserving or recovering movement ability after stroke, sometimes people do not fully realise this ability in their everyday activities. Constraint-induced movement therapy (CIMT) is an approach to stroke rehabilitation that involves the forced use and massed practice of the affected arm by restraining the unaffected arm. This has been proposed as a useful tool for recovering abilities in everyday activities.
OBJECTIVES
To assess the efficacy of CIMT, modified CIMT (mCIMT), or forced use (FU) for arm management in people with hemiparesis after stroke.
SEARCH METHODS
We searched the Cochrane Stroke Group trials register (last searched June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library Issue 1, 2015), MEDLINE (1966 to January 2015), EMBASE (1980 to January 2015), CINAHL (1982 to January 2015), and the Physiotherapy Evidence Database (PEDro; January 2015).
SELECTION CRITERIA
Randomised control trials (RCTs) and quasi-RCTs comparing CIMT, mCIMT or FU with other rehabilitative techniques, or none.
DATA COLLECTION AND ANALYSIS
One author identified trials from the results of the electronic searches according to the inclusion and exclusion criteria, three review authors independently assessed methodological quality and risk of bias, and extracted data. The primary outcome was disability.
MAIN RESULTS
We included 42 studies involving 1453 participants. The trials included participants who had some residual motor power of the paretic arm, the potential for further motor recovery and with limited pain or spasticity, but tended to use the limb little, if at all. The majority of studies were underpowered (median number of included participants was 29) and we cannot rule out small-trial bias. Eleven trials (344 participants) assessed disability immediately after the intervention, indicating a non-significant standard mean difference (SMD) 0.24 (95% confidence interval (CI) -0.05 to 0.52) favouring CIMT compared with conventional treatment. For the most frequently reported outcome, arm motor function (28 studies involving 858 participants), the SMD was 0.34 (95% CI 0.12 to 0.55) showing a significant effect (P value 0.004) in favour of CIMT. Three studies involving 125 participants explored disability after a few months of follow-up and found no significant difference, SMD -0.20 (95% CI -0.57 to 0.16) in favour of conventional treatment.
AUTHORS' CONCLUSIONS
CIMT is a multi-faceted intervention where restriction of the less affected limb is accompanied by increased exercise tailored to the person's capacity. We found that CIMT was associated with limited improvements in motor impairment and motor function, but that these benefits did not convincingly reduce disability. This differs from the result of our previous meta-analysis where there was a suggestion that CIMT might be superior to traditional rehabilitation. Information about the long-term effects of CIMT is scarce. Further trials studying the relationship between participant characteristics and improved outcomes are required.
Topics: Exercise Movement Techniques; Humans; Immobilization; Paresis; Randomized Controlled Trials as Topic; Stroke; Stroke Rehabilitation; Time Factors; Upper Extremity
PubMed: 26446577
DOI: 10.1002/14651858.CD004433.pub3 -
The Cochrane Database of Systematic... Mar 2012Mirror therapy is used to improve motor function after stroke. During mirror therapy, a mirror is placed in the patient's midsagittal plane, thus reflecting movements of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Mirror therapy is used to improve motor function after stroke. During mirror therapy, a mirror is placed in the patient's midsagittal plane, thus reflecting movements of the non-paretic side as if it were the affected side.
OBJECTIVES
To summarise the effectiveness of mirror therapy for improving motor function, activities of daily living, pain and visuospatial neglect in patients after stroke.
SEARCH METHODS
We searched the Cochrane Stroke Group's Trials Register (June 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), MEDLINE (1950 to June 2011), EMBASE (1980 to June 2011), CINAHL (1982 to June 2011), AMED (1985 to June 2011), PsycINFO (1806 to June 2011) and PEDro (June 2011). We also handsearched relevant conference proceedings, trials and research registers, checked reference lists and contacted trialists, researchers and experts in our field of study.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) and randomised cross-over trials comparing mirror therapy with any control intervention for patients after stroke.
DATA COLLECTION AND ANALYSIS
Two review authors independently selected trials based on the inclusion criteria, documented the methodological quality of studies and extracted data. We analysed the results as standardised mean differences (SMDs) for continuous variables.
MAIN RESULTS
We included 14 studies with a total of 567 participants that compared mirror therapy with other interventions. When compared with all other interventions, mirror therapy may have a significant effect on motor function (post-intervention data: SMD 0.61; 95% confidence interval (CI) 0.22 to 1.0; P = 0.002; change scores: SMD 1.04; 95% CI 0.57 to 1.51; P < 0.0001). However, effects on motor function are influenced by the type of control intervention. Additionally, mirror therapy may improve activities of daily living (SMD 0.33; 95% CI 0.05 to 0.60; P = 0.02). We found a significant positive effect on pain (SMD -1.10; 95% CI -2.10 to -0.09; P = 0.03) which is influenced by patient population. We found limited evidence for improving visuospatial neglect (SMD 1.22; 95% CI 0.24 to 2.19; P = 0.01). The effects on motor function were stable at follow-up assessment after six months.
AUTHORS' CONCLUSIONS
The results indicate evidence for the effectiveness of mirror therapy for improving upper extremity motor function, activities of daily living and pain, at least as an adjunct to normal rehabilitation for patients after stroke. Limitations are due to small sample sizes of most included studies, control interventions that are not used routinely in stroke rehabilitation and some methodological limitations of the studies.
Topics: Activities of Daily Living; Exercise Movement Techniques; Functional Laterality; Humans; Paresis; Randomized Controlled Trials as Topic; Recovery of Function; Stroke; Stroke Rehabilitation
PubMed: 22419334
DOI: 10.1002/14651858.CD008449.pub2 -
BMJ Case Reports Mar 2017A man aged 77 years sustained a left-hemisphere stroke with right hemiparesis. After spending 10 days in the hospital, he was referred to an area rehabilitation...
A man aged 77 years sustained a left-hemisphere stroke with right hemiparesis. After spending 10 days in the hospital, he was referred to an area rehabilitation centre. There he carried out daily physical, occupational and speech therapy, with an emphasis on task-oriented treatment. The patient's upper-extremity motor performance was evaluated at admission to the rehabilitation centre and before leaving the hospital by 3 different measurement tools: the upper-extremity motor part of the Fugl-Meyer assessment scale, electromyography in hand-reach and grasp and object manipulation and handwriting tasks. Significant improvement in hand function was observed in proximal as well as in distal skills. Significant improvement in handwriting skills and decreased impairment level of the upper extremity had considerable effects on the quality of life of the patient. The case report emphasises the importance of intensive task-oriented training during the first 3 months after stroke to support the natural recovery of the lesioned area.
Topics: Aged; Arm; Exercise Therapy; Hand; Hand Strength; Humans; Male; Paresis; Recovery of Function; Stroke; Stroke Rehabilitation
PubMed: 28314812
DOI: 10.1136/bcr-2017-219250 -
BMJ Open Jan 2019The Children with Hemiparesis Arm and Movement Project (CHAMP) addresses two pressing issues concerning paediatric constraint-induced movement therapy (CIMT): effects of... (Comparative Study)
Comparative Study Randomized Controlled Trial
Children with Hemiparesis Arm and Movement Project (CHAMP): protocol for a multisite comparative efficacy trial of paediatric constraint-induced movement therapy (CIMT) testing effects of dosage and type of constraint for children with hemiparetic cerebral palsy.
INTRODUCTION
The Children with Hemiparesis Arm and Movement Project (CHAMP) addresses two pressing issues concerning paediatric constraint-induced movement therapy (CIMT): effects of two dosages and two types of constraint on functional outcomes. Systematic reviews conclude that CIMT is one of the most efficacious treatments, but wide variations in treatment protocols, outcome measures and patient characteristics have prevented conclusions about potential effects of dosage levels and constraint methods.
METHODS AND ANALYSIS
CHAMP is a multisite comparative efficacy randomised controlled trial of 135 children (2-8 years) with hemiparetic cerebral palsy. The 2×2 factorial design tests two dosage levels-60 hours (3.0 hours/day, 5 days/week × 4 weeks) and 30 hours (2.5 hours/day, 3 days/week × 4 weeks) and two constraint conditions-full-arm, full-time cast and part-time splint, plus usual and customary (UCT) controls, yielding five groups: (1) 60 hours CIMT+full-time cast, (2) 60 hours CIMT+part-time splint, (3) 30 hours CIMT+full-time cast, (4) 30 hours CIMT+part-time splint and (5) UCT. Trained therapists deliver the standardised ACQUIREc protocol for CIMT. Blinded assessments at baseline, end of treatment, and 6 and 12 months post treatment include the Assisting Hand Assessment, and subscales from the Peabody Developmental Motor Scales-2 and modified Quality of Upper Extremity Skills Test. Parents complete the Pediatric Motor Activity Log and Pediatric Evaluation of Disability Inventory. A new Fidelity of Implementation Rehabilitation Measure monitors treatment delivery. Data analyses involve repeated-measures multivariate analysis of co-variance controlling for selected baseline variables.
ETHICS AND DISSEMINATION
Ethics boards at site universities approved the study protocol. To promote equipoise, parents of UCT controls are offered ACQUIREc after 6 months. A Data Safety and Monitoring Committee reviews results regularly, including measures of child and family stress. We will disseminate CHAMP results via peer-reviewed publications and presentations to professional and advocacy organisations.
TRIAL REGISTRATION NUMBER
NCT01895660; Pre-results.
Topics: Arm; Cerebral Palsy; Child; Child, Preschool; Exercise Movement Techniques; Humans; Paresis; Time Factors; Treatment Outcome
PubMed: 30782701
DOI: 10.1136/bmjopen-2018-023285 -
Physical Therapy Oct 2016Poststroke guidelines recommend moderate-intensity, continuous aerobic training (MCT) to improve aerobic capacity and mobility after stroke. High-intensity interval... (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND
Poststroke guidelines recommend moderate-intensity, continuous aerobic training (MCT) to improve aerobic capacity and mobility after stroke. High-intensity interval training (HIT) has been shown to be more effective than MCT among healthy adults and people with heart disease. However, HIT and MCT have not been compared previously among people with stroke.
OBJECTIVE
The purpose of this study was to assess the feasibility and justification for a definitive randomized controlled trial (RCT) comparing HIT and MCT in people with chronic stroke.
DESIGN
A preliminary RCT was conducted.
SETTING
The study was conducted in a cardiovascular stress laboratory and a rehabilitation research laboratory.
PATIENTS
Ambulatory people at least 6 months poststroke participated.
INTERVENTION
Both groups trained 25 minutes, 3 times per week, for 4 weeks. The HIT strategy involved 30-second bursts at maximum-tolerated treadmill speed alternated with 30- to 60-second rest periods. The MCT strategy involved continuous treadmill walking at 45% to 50% of heart rate reserve.
MEASUREMENTS
Measurements included recruitment and attendance statistics, qualitative HIT acceptability, adverse events, and the following blinded outcome variables: peak oxygen uptake, ventilatory threshold, metabolic cost of gait, fractional utilization, fastest treadmill speed, 10-Meter Walk Test, and Six-Minute Walk Test.
RESULTS
During the 8-month recruitment period, 26 participants consented to participate. Eighteen participants were enrolled and randomly assigned to either the HIT group (n=13) or the MCT group (n=5). Eleven out of the 13 HIT group participants attended all sessions. Participants reported that HIT was acceptable and no serious adverse events occurred. Standardized effect size estimates between groups were moderate to very large for most outcome measures. Only 30% of treadmill speed gains in the HIT group translated into overground gait speed improvement.
LIMITATIONS
The study was not designed to definitively test safety or efficacy.
CONCLUSIONS
Although further protocol optimization is needed to improve overground translation of treadmill gains, a definitive RCT comparing HIT and MCT appears to be feasible and warranted.
Topics: Adult; Aged; Chronic Disease; Exercise Therapy; Exercise Tolerance; Feasibility Studies; Female; Heart Rate; Humans; Male; Middle Aged; Oxygen Consumption; Paresis; Stroke; Stroke Rehabilitation; Treatment Outcome; Walking
PubMed: 27103222
DOI: 10.2522/ptj.20150277 -
Journal of Rehabilitation Medicine Mar 2005To assess the reliability of 6 gait performance tests in individuals with chronic mild to moderate post-stroke hemiparesis.
OBJECTIVE
To assess the reliability of 6 gait performance tests in individuals with chronic mild to moderate post-stroke hemiparesis.
DESIGN
An intra-rater (between occasions) test-retest reliability study.
SUBJECTS
Fifty men and women (mean age 58+/-6.4 years) 6-46 months post-stroke.
METHODS
The Timed "Up & Go" test, the Comfortable and the Fast Gait Speed tests, the Stair Climbing ascend and descend tests and the 6-Minute Walk test were assessed 7 days apart. Reliability was evaluated with the intraclass correlation coefficient (ICC(2,1)), the Bland & Altman analysis, the standard error of measurement (SEM and SEM%) and the smallest real difference (SRD and SRD%).
RESULTS
Test-retest agreements were high (ICC(2,1) 0.94-0.99) with no discernible systematic differences between the tests. The standard error of measurement (SEM%), representing the smallest change that indicates a real (clinical) improvement for a group of individuals, was small (< 9%). The smallest real difference (SRD%), representing the smallest change that indicates a real (clinical) improvement for a single individual, was also small (13-23%).
CONCLUSION
These commonly used gait performance tests are highly reliable and can be recommended to evaluate improvements in various aspects of gait performance in individuals with chronic mild to moderate hemiparesis after stroke.
Topics: Activities of Daily Living; Aged; Female; Gait; Humans; Male; Middle Aged; Outcome and Process Assessment, Health Care; Paresis; Recovery of Function; Reproducibility of Results; Stroke; Stroke Rehabilitation; Walking
PubMed: 15788341
DOI: 10.1080/16501970410017215 -
PloS One 2018Virtual reality-based training has found increasing use in neurorehabilitation to improve upper limb training and facilitate motor recovery. (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND
Virtual reality-based training has found increasing use in neurorehabilitation to improve upper limb training and facilitate motor recovery.
OBJECTIVE
The aim of this study was to directly compare virtual reality-based training with conventional therapy.
METHODS
In a multi-center, parallel-group randomized controlled trial, patients at least 6 months after stroke onset were allocated either to an experimental group (virtual reality-based training) or a control group receiving conventional therapy (16x45 minutes within 4 weeks). The virtual reality-based training system replicated patients´ upper limb movements in real-time to manipulate virtual objects. Blinded assessors tested patients twice before, once during, and twice after the intervention up to 2-month follow-up for dexterity (primary outcome: Box and Block Test), bimanual upper limb function (Chedoke-McMaster Arm and Hand Activity Inventory), and subjective perceived changes (Stroke Impact Scale).
RESULTS
54 eligible patients (70 screened) participated (15 females, mean age 61.3 years, range 20-81 years, time since stroke 3.0±SD 3 years). 22 patients were allocated to the experimental group and 32 to the control group (3 drop-outs). Patients in the experimental and control group improved: Box and Block Test mean 21.5±SD 16 baseline to mean 24.1±SD 17 follow-up; Chedoke-McMaster Arm and Hand Activity Inventory mean 66.0±SD 21 baseline to mean 70.2±SD 19 follow-up. An intention-to-treat analysis found no between-group differences.
CONCLUSIONS
Patients in the experimental and control group showed similar effects, with most improvements occurring in the first two weeks and persisting until the end of the two-month follow-up period. The study population had moderate to severely impaired motor function at entry (Box and Block Test mean 21.5±SD 16). Patients, who were less impaired (Box and Block Test range 18 to 72) showed higher improvements in favor of the experimental group. This result could suggest that virtual reality-based training might be more applicable for such patients than for more severely impaired patients.
TRIAL REGISTRATION
ClinicalTrials.gov NCT01774669.
Topics: Adult; Aged; Aged, 80 and over; Female; Humans; Male; Middle Aged; Paresis; Recovery of Function; Single-Blind Method; Stroke; Stroke Rehabilitation; Treatment Outcome; Upper Extremity; Virtual Reality; Virtual Reality Exposure Therapy; Young Adult
PubMed: 30356229
DOI: 10.1371/journal.pone.0204455 -
Nature Medicine Mar 2023Cerebral strokes can disrupt descending commands from motor cortical areas to the spinal cord, which can result in permanent motor deficits of the arm and hand. However,...
Cerebral strokes can disrupt descending commands from motor cortical areas to the spinal cord, which can result in permanent motor deficits of the arm and hand. However, below the lesion, the spinal circuits that control movement remain intact and could be targeted by neurotechnologies to restore movement. Here we report results from two participants in a first-in-human study using electrical stimulation of cervical spinal circuits to facilitate arm and hand motor control in chronic post-stroke hemiparesis ( NCT04512690 ). Participants were implanted for 29 d with two linear leads in the dorsolateral epidural space targeting spinal roots C3 to T1 to increase excitation of arm and hand motoneurons. We found that continuous stimulation through selected contacts improved strength (for example, grip force +40% SCS01; +108% SCS02), kinematics (for example, +30% to +40% speed) and functional movements, thereby enabling participants to perform movements that they could not perform without spinal cord stimulation. Both participants retained some of these improvements even without stimulation and no serious adverse events were reported. While we cannot conclusively evaluate safety and efficacy from two participants, our data provide promising, albeit preliminary, evidence that spinal cord stimulation could be an assistive as well as a restorative approach for upper-limb recovery after stroke.
Topics: Humans; Cervical Cord; Paresis; Spinal Cord; Spinal Cord Injuries; Spinal Cord Stimulation; Stroke; Upper Extremity; Female; Adult; Middle Aged
PubMed: 36807682
DOI: 10.1038/s41591-022-02202-6 -
Journal of Rehabilitation Medicine Jan 2008To evaluate the effects of progressive resistance training on muscle strength, muscle tone, gait performance and perceived participation after stroke. (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To evaluate the effects of progressive resistance training on muscle strength, muscle tone, gait performance and perceived participation after stroke.
DESIGN
A randomized controlled trial.
SUBJECTS
Twenty-four subjects (mean age 61 years (standard deviation 5)) 6-48 months post-stroke.
METHODS
The training group (n = 15) participated in supervised progressive resistance training of the knee muscles (80% of maximum) twice weekly for 10 weeks, and the control group (n = 9) continued their usual daily activities. Both groups were assessed before and after the intervention and at follow-up after 5 months. Muscle strength was evaluated dynamically and isokinetically (60 degrees /sec) and muscle tone by the Modified Ashworth Scale. Gait performance was evaluated by Timed "Up & Go", Fast Gait Speed and 6-Minute Walk tests, and perceived participation by Stroke Impact Scale.
RESULTS
Muscle strength increased significantly after progressive resistance training with no increase in muscle tone and improvements were maintained at follow-up. Both groups improved in gait performance, but at follow-up only Timed "Up & Go" and perceived participation were significantly better for the training group.
CONCLUSIONS
Progressive resistance training is an effective intervention to improve muscle strength in chronic stroke. There appear to be long-term benefits, but further studies are needed to clarify the effects, specifically of progressive resistance training on gait performance and participation.
Topics: Activities of Daily Living; Aged; Exercise Therapy; Female; Follow-Up Studies; Gait; Humans; Male; Middle Aged; Muscle Strength; Muscle, Skeletal; Outcome Assessment, Health Care; Paresis; Prospective Studies; Stroke; Stroke Rehabilitation
PubMed: 18176736
DOI: 10.2340/16501977-0129 -
Annals of Physical and Rehabilitation... Nov 2019This paper revisits the taxonomy of the neurophysiological consequences of a persistent impairment of motor command execution in the classic environment of sensorimotor... (Review)
Review
This paper revisits the taxonomy of the neurophysiological consequences of a persistent impairment of motor command execution in the classic environment of sensorimotor restriction and muscle hypo-mobilization in short position. Around each joint, the syndrome involves 2 disorders, muscular and neurologic. The muscular disorder is promoted by muscle hypo-mobilization in short position in the context of paresis, in the hours and days after paresis onset: this genetically mediated, evolving myopathy, is called spastic myopathy. The clinician may suspect it by feeling extensibility loss in a resting muscle, although long after the actual onset of the disease. The neurologic disorder, promoted by sensorimotor restriction in the context of paresis and by the muscle disorder itself, comprises 4 main components, mostly affecting antagonists to desired movements: the first is spastic dystonia, an unwanted, involuntary muscle activation at rest, in the absence of stretch or voluntary effort; spastic dystonia superimposes on spastic myopathy to cause visible, gradually increasing body deformities; the second is spastic cocontraction, an unwanted, involuntary antagonist muscle activation during voluntary effort directed to the agonist, aggravated by antagonist stretch; it is primarily due to misdirection of the supraspinal descending drive and contributes to reducing movement amplitude; and the third is spasticity, one form of hyperreflexia, defined by an enhancement of the velocity-dependent responses to phasic stretch, detected and measured at rest (another form of hyperreflexia is "nociceptive spasms", following flexor reflex afferent stimulation, particularly after spinal cord lesions). The 3 main forms of overactivity, spastic dystonia, spastic cocontraction and spasticity, share the same motor neuron hyperexcitability as a contributing factor, all being predominant in the muscles that are more affected by spastic myopathy. The fourth component of the neurologic disorder affects the agonist: it is stretch-sensitive paresis, which is a decreased access of the central command to the agonist, aggravated by antagonist stretch. Improved understanding of the pathophysiology of deforming spastic paresis should help clinicians select meaningful assessments and refined treatments, including the utmost need to preserve muscle tissue integrity as soon as paresis sets in.
Topics: Humans; Motor Neurons; Muscle Contraction; Muscle Spasticity; Muscle, Skeletal; Paresis
PubMed: 30500361
DOI: 10.1016/j.rehab.2018.10.004