Repeat therapy for chronic motor stroke: a pilot study for feasibility and efficacy.

BACKGROUND: . Therapeutic interventions improve outcomes in the acute and chronic phase after motor stroke, but a significant amount of this improvement is usually lost after more than 1 year. Patients might profit from a second course of intensive physiotherapy, but this has not been investigated. OBJECTIVE: . The feasibility and effect of a second phase of physiotherapy was examined 2 years after the first one. METHODS: . A total of 12 patients with chronic stroke were instructed to wear a constraining splint on the affected elbow and hand while awake for 4 weeks and practice individually tailored tasks 2 hours per day. Motor tests for assessment included the Motor Activity Log, Wolf Motor Function Test, and 9-Hole Peg Test. RESULTS: . In the 11 patients who were available for postintervention assessment, the deterioration in the amount and quality of movement that had occurred since the first therapy was largely recouped. Patients who wore the constraint more than 80% of waking hours during the second therapy showed a clear secondary improvement in all tests, in some surpassing the level reached after the first therapy. CONCLUSIONS: . A repeated bout of home-based CIMT 2 years after initial training is feasible with relatively little time and effort provided by a therapist and can lead to further improvement.

Enhancing activities of daily living of chronic stroke patients in primary health care by modified constraint-induced movement therapy (HOMECIMT): study protocol for a cluster randomized controlled trial.

BACKGROUND: Stroke leads to constant rehabilitation needs even at the chronic stage. However, although many stroke patients receive physical or occupational therapy in primary health care, treatment prescriptions do not generally specify therapeutic goals; in particular, participation is not established as an explicit therapeutic goal in the ambulatory setting. The primary aim of this study is to evaluate the efficacy of a therapy regimen for chronic stroke patients (modified 'constraint-induced movement therapy (CIMT) at home') with impaired hand or arm function with regard to the prerequisites of participation in everyday activities: a sufficient arm and hand function. 'CIMT at home' will be compared with conventional physical and occupational therapy ('therapy as usual'). METHODS/DESIGN: The study is a parallel cluster randomized controlled trial with therapy practices as clusters (n = 48). After written consent from the patients (n = 144), the therapists will be randomly assigned to treat either the intervention or the control group. Blinded external assessors will evaluate the patients using standardized outcome measures before and after the intervention, and six months later. The two coprimary endpoint assessments of arm and hand function as prerequisites for participation (defined as equal involvement in activities of daily living) are the motor activity log (quality of arm and hand use) and the Wolf motor function test (arm and hand function). These assessments are made four weeks post-treatment and relativized to baseline performance. Changes in primary outcomes will be analyzed with mixed models, which consider the hierarchical structure of the data and will be adjusted to the baseline measurements and sex. The primary analysis will be the comparison of the two randomized groups, with respect to the adjusted averages for each of the two coprimary endpoints. To keep an overall significance level of 5%, the two endpoints will be tested at the significance level of 5% each in hierarchical order. DISCUSSION: A modification of the CIMT, feasible in the patients' homes (CIMT at home), appears to be a promising therapeutic approach in the ambulatory care of chronic stroke patients. With proven efficacy and practicality, a participation-oriented, stroke-specific treatment would be available in primary care. TRIAL REGISTRATION: ClinicalTrials.gov NCT01343602.

Comparison of two types of Constraint-Induced Movement Therapy in chronic stroke patients: A pilot study.

UNLABELLED: Several studies showed that Constraint-Induced Movement Therapy (CIMT) leads to a lasting improvement of upper extremity function in chronic stroke patients. The original technique includes an intensive 2-week program with 6 hours of daily physiotherapy. Due to high expenses it is difficult to implement this concept in outpatient care. PURPOSE: The objective of this study was to evaluate the effects of a 4-week homebased CIMT program among chronic stroke patients and to compare them with a 2-week CIMT program, based on the original technique. METHODS: Seven adults with chronic stroke completed a newly developed variant of CIMT, performed at patients' homes (group1, CIMThome), supervised by an instructed family member, constraint of unaffected hand for a target of 60% of waking hours. The intervention was analysed with pre-, post-treatment and 6-month follow-up measurements. Effects on improvement in upper extremity function were compared with patients treated according to the original protocol (group2, CIMTclassic), supervised by a physiotherapist, constraint of unaffected hand for a target of 90% of waking hours. RESULTS: Patients from both groups showed almost identical improvement of their motor function according to scores on the Wolf Motor Function Test (WMFT) and the Motor Activity Log (MAL) immediately after the treatment period as well as at follow-up after 6 months. CONCLUSIONS: Our study suggests that CIMThome is not only feasible but also as effective as CIMTclassic. This finding should be replicated in a larger prospective randomized trial to perform a non-inferiority analysis.

The surround inhibition determines therapy-induced cortical reorganization.

Rehabilitation can induce cortical reorganization in chronic stroke patients. In this study we investigated the mechanisms underlying treatment-associated plasticity. Eight patients with a stroke >6 months earlier participated in a 4-week period of physiotherapy based on a forced use concept. Before and after treatment, focal transcranial magnetic stimulation over the affected hemisphere was used to assess the motor output map of the paretic first dorsal interosseous muscle. Using a paired pulse paradigm, intracortical inhibition was investigated at the center of the cortical output map (CoG) and one cm anterior, posterior, lateral and medial of that position. Motor function was evaluated with the Motor Activity Log and the Wolf Motor Function Test. After therapy, the cortical representation size of the affected hand muscle was increased. In each patient, the CoG moved in the direction where intracortical inhibition had been lowest prior to therapy. Significant correlations were found between motor function tests and changes of output map size and CoG shifts, respectively. We conclude that treatment-associated cortical reorganization is influenced by the distribution of inhibitory properties within the representation area prior to therapy, since the CoG moved in the direction of lowest inhibition. The correlations between motor functions and electrophysiological results indicate a functional relevance of the observed reorganization pattern.