The learned nonuse phenomenon: implications for rehabilitation.

Research on monkeys with a single forelimb from which sensation is surgically abolished demonstrates that such animals do not use their deafferented limb even though they possess sufficient motor innervation to do so, a phenomenon labeled learned nonuse. This dissociation also occurs after neurological injury in humans. Instruments that measure these two aspects of motor function are discussed. The effects of a neurological injury may differ widely in regard to motor ability assessed on a laboratory performance test in which movements are requested and actual spontaneous use of an extremity in real-world settings, indicating that these parameters need to be evaluated separately. The methods used in Constraint-Induced Movement therapy (CI therapy) research to independently assess these two domains are reliable and valid. We suggest that these tests have applicability beyond studies involving CI therapy for stroke and may be of value for determining motor status in other types of motor disorders and with other types of treatment. The learned nonuse formulation also predicts that a rehabilitation treatment may have differential effects on motor performance made on request and actual spontaneous amount of use of a more affected upper extremity in the life situation. CI therapy produces improvements in the former, but focuses attention on the latter and, in fact, spontaneous use of the limb is where this intervention has by far its greatest effect. The evidence suggests that this result is driven by use of a ''transfer package'' of techniques, which can be used with other therapies to increase the transfer of improvements made in the clinic to the life situation. The use of CI therapy in humans began with the upper extremity after stroke and was then extended for the upper extremity to cerebral palsy in young children (8 months to 8 years old) and traumatic brain injury. A form of CI therapy was developed for the lower extremities and was used effectively after stroke, spinal cord injury, and fractured hip. Adaptations of CI therapy have also been developed for aphasia (CI aphasia therapy), focal hand dystonia in musicians and phantom limb pain. The range of these applications suggests that CI therapy is not only a treatment for stroke, for which it is most commonly used, but for learned nonuse in general, which manifests as excess motor disability in a number of conditions which until now have been refractory to treatment.

Constraint-Induced Movement Therapy: a new family of techniques with broad application to physical rehabilitation--a clinical review.

A new family of rehabilitation techniques, termed Constraint-Induced Movement Therapy or CI Therapy, has been developed that controlled experiments have shown is effective in producing large improvements in limb use in the real-world environment after cerebrovascular accident (CVA). The signature therapy involves constraining movements of the less-affected arm with a sling for 90% of waking hours for 2 weeks, while intensively training use of the more-affected arm. The common therapeutic factor in all CI Therapy techniques would appear to be inducing concentrated, repetitive practice of use of the more-affected limb. A number of neuroimaging and transcranial magnetic stimulation studies have shown that the massed practice of CI Therapy produces a massive use-dependent cortical reorganization that increases the area of cortex involved in the innervation of movement of the more-affected limb. The CI Therapy approach has been used successfully to date for the upper limb of patients with chronic and subacute CVA and patients with chronic traumatic brain injury and for the lower limb of patients with CVA, incomplete spinal cord injury, and fractured hip. The approach has recently been extended to focal hand dystonia of musicians and possibly phantom limb pain.

Poststroke cerebral peduncular atrophy correlates with a measure of corticospinal tract injury in the cerebral hemisphere.

BACKGROUND AND PURPOSE: Methods have not been well developed and tested to predict the extent of remote degeneration in the central nervous system that follows cerebral infarction. We hypothesized that the extent of infarction overlap with the cerebral hemispheric course of the corticospinal tract (CST) on structural MR imaging predicts the extent of ipsilateral cerebral peduncular atrophy in patients with chronic stroke. MATERIALS AND METHODS: Hemiparetic patients (n = 34) with supratentorial unilateral infarctions who were at least 1 year poststroke onset and enrolled in research protocols of Constraint-Induced Movement therapy underwent volumetric T1 MR imaging of the brain. The following measures were calculated for each patient: 1) the maximal proportion of the CST in the cerebral hemisphere on axial section that was overlapped by infarction, 2) total infarction volume, and 3) the ratio of the cross-sectional area of the ipsilateral cerebral peduncle to the area of the contralateral cerebral peduncle (peduncular asymmetry ratio). Correlation analyses evaluated the predictive value of CST injury or infarction volume for the peduncular asymmetry ratio. RESULTS: CST injury correlated significantly with the peduncular asymmetry ratio (r = -0.65; P < .001), whereas infarction volume did not (r = -0.31; P = .09). CONCLUSIONS: The extent of postinfarction CST injury in the cerebral hemisphere predicts the extent of ipsilateral cerebral peduncular atrophy. More generally, the findings suggest that the extent of remote wallerian degeneration of a fiber tract is strongly related to its extent of injury directly at the site of infarction.

Constraint-Induced Movement therapy can improve hemiparetic progressive multiple sclerosis. Preliminary findings.

OBJECTIVE: To evaluate whether Constraint-Induced Movement therapy (CI therapy) may benefit chronic upper extremity hemiparesis in progressive multiple sclerosis (MS). METHODS: Five patients with progressive MS, who had chronic upper extremity hemiparesis and evidence for learned non-use of the paretic limb in the life situation, underwent 30 hours of repetitive task training and shaping for the paretic limb over 2-10 consecutive weeks, along with physical restraint of the less-affected arm and a "transfer package" of behavioral techniques to reinforce treatment adherence. RESULTS: The patients showed significantly improved spontaneous, real-world limb use at post-treatment and 4 weeks post-treatment, along with improved fatigue ratings and maximal movement ability displayed in a laboratory motor test. Conclusions The findings suggest for the first time that slowly progressive MS may benefit from CI therapy. Further studies are needed to determine the retention of treatment responses.

The Motor Activity Log-28: assessing daily use of the hemiparetic arm after stroke.

BACKGROUND: Data from monkeys with deafferented forelimbs and humans after stroke indicate that tests of the motor capacity of impaired extremities can overestimate their spontaneous use. Before the Motor Activity Log (MAL) was developed, no instruments assessed spontaneous use of a hemiparetic arm outside the treatment setting. OBJECTIVE: To study the MAL's reliability and validity for assessing real-world quality of movement (QOM scale) and amount of use (AOU scale) of the hemiparetic arm in stroke survivors. METHODS: Participants in a multisite clinical trial completed a 30-item MAL before and after treatment (n = 106) or an equivalent no-treatment period (n = 116). Participants also completed the Stroke Impact Scale (SIS) and wore accelerometers that monitored arm movement for three consecutive days outside the laboratory. All were 3 to 12 months post-stroke and had mild to moderate paresis of an upper extremity. RESULTS: After an item analysis, two MAL tasks were eliminated. Revised participant MAL QOM scores were reliable (r =0.82). Validity was also supported. During the first observation period, the correlation between QOM and SIS Hand Function scale scores was 0.72. The corresponding correlation for QOM and accelerometry values was 0.52. Participant QOM and AOU scores were highly correlated (r = 0.92). CONCLUSIONS: 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.

The reliability of the wolf motor function test for assessing upper extremity function after stroke.

OBJECTIVE: To examine the reliability of the Wolf Motor Function Test (WMFT) for assessing upper extremity motor function in adults with hemiplegia. DESIGN: Interrater and test-retest reliability. SETTING: A clinical research laboratory at a university medical center. PATIENTS: A sample of convenience of 24 subjects with chronic hemiplegia (onset >1yr), showing moderate motor impairment. INTERVENTION: The WMFT includes 15 functional tasks. Performances were timed and rated by using a 6-point functional ability scale. The WMFT was administered to subjects twice with a 2-week interval between administrations. All test sessions were videotaped for scoring at a later time by blinded and trained experienced therapists. MAIN OUTCOME MEASURE: Interrater reliability was examined by using intraclass correlation coefficients and internal consistency by using Cronbach's alpha. RESULTS: Interrater reliability was.97 or greater for performance time and.88 or greater for functional ability. Internal consistency for test 1 was.92 for performance time and.92 for functional ability; for test 2, it was.86 for performance time and.92 for functional ability. Test-retest reliability was.90 for performance time and.95 for functional ability. Absolute scores for subjects were stable over the 2 test administrations. CONCLUSION: The WMFT is an instrument with high interrater reliability, internal consistency, test-retest reliability, and adequate stability.

Objective measurement of functional upper-extremity movement using accelerometer recordings transformed with a threshold filter.

BACKGROUND AND PURPOSE: The consensus is that the most important outcome for rehabilitation is functional activity in the life situation. Constraint-Induced Movement Therapy, a new treatment that transfers in-clinic gains to the life situation, demands objective measurement of real-world movement. However, direct, objective, and accurate measures of arm use in the real world are not available. Previous attempts to use accelerometry to measure extremity movement have failed because of unacceptable variability. This problem has been addressed here by use of a threshold filter. METHODS: Nine stroke patients and 1 healthy individual wearing accelerometers were videotaped while they carried out their usual activities at home or in the clinic; the duration of their arm, torso, and ambulatory movements was judged by 2 observation teams. In addition, 11 college students performed 5 standardized activities of daily living for varying durations in the laboratory. The accelerometer data were transformed; the raw value recorded for a given epoch was set to a constant if it exceeded a low threshold. RESULTS: The threshold-filtered recordings measured the duration of movement accurately and with very little variability. Correlations between the threshold-filtered recordings and the observer ratings of the duration of arm, torso, and ambulatory movements were 0.93, 0.93 and 0.99, respectively; the corresponding correlations for the raw values were -0.17, 0.34, and 0.85. CONCLUSIONS: These results present initial evidence for the validity of threshold-filtered accelerometer recordings for objectively measuring the amount of real-world upper-extremity movement as an index of treatment outcome for rehabilitation patients.