BACKGROUND Constraint-induced (CI) movement therapy (also called forced use by some investigators and clinicians) has gained increasing popularity as a treatment mode for restoring function in the upper extremities of patients with stroke. The purpose of this article is to review the concept of constraint-induced movement therapy and provide a critical analysis of the existing data. REVIEW SUMMARY The evidence to date offers encouragement for the application of this procedure for patients who have some movement recovery out of synergy. Success may be contingent on patient cooperation and intense repetitive use with applications of retraining through practice and shaping. The extent to which each of the latter elements influences the magnitude of recovery is still unclear. However, task novelty and challenge seem important to recovery of function. There are several methods used to map cortical changes after stroke. At this time, transcranial magnetic stimulation is the primary vehicle used to assess motor cortical reorganization after CI therapy in humans. CONCLUSIONS Accumulating data indicate that the size of a cortical area representative of a muscle does expand and its center of gravity does change with CI therapy.

Background Constraint-Induced Movement therapy (CIMT) uses a variety of treatment components, including restricted use of the better upper extremity, to promote increased use of the contralesional limb for many hours each weekday over two consecutive weeks. The EXCITE Trial demonstrated the efficacy of this intervention for patients 3-9 months post-stroke who were followed for the next 12 months. We assessed the retention of improvements through 24 months. Method Measurements were made every four months for impaired upper extremity function (Wolf Motor Function Test - WMFT and Motor Activity Log - MAL) and health related quality of life (Stroke Impact Scale - SIS) amongst 106/222 participants randomized into one arm of the EXCITE Trial in which they received CIMT rather than usual and customary care. Findings There was no observed regression from the treatment effects observed at 12 months after treatment during the next 12 months for the primary outcome measures of WMFT and MAL. In fact, the additional changes were in the direction of increased therapeutic effect. For the strength components of the WMFT the changes were significant (P < .05) Secondary outcome variables, including the SIS, exhibited a similar pattern. Interpretation Mild to moderately impaired patients who are 3-9 months post-stroke demonstrate substantial improvement in functional use of the paretic upper extremity and quality of life 2 years after receiving a 2-week CIMT intervention. Thus this intervention has persistent benefits.

The authors examined serial changes in optical topography in a stroke patient performing a functional task, as well as clinical and physiologic measures while undergoing constraint-induced therapy (CIT). A 73-year-old right hemiparetic patient, who had a subcortical stroke 4 months previously, received 2 weeks of CIT. During the therapy, daily optical topography imaging using near-infrared light was measured serially while the participant performed a functional key-turning task. Clinical outcome measures included the Wolf Motor Function Test (WMFT), Motor Activity Log (MAL), and functional key grip test. Transcranial magnetic stimulation (TMS) and functional magnetic resonance imaging (fMRI) were also used to map cortical areas and hemodynamic brain responses, respectively. Optical topography measurement showed an overall decrease in oxy-hemoglobin concentration in both hemispheres as therapy progressed and the laterality index increased toward the contralateral hemisphere. An increased TMS motor map area was observed in the contralateral cortex following treatment. Posttreatment fMRI showed bilateral primary motor cortex activation, although slightly greater in the contralateral hemisphere, during affected hand movement. Clinical scores revealed marked improvement in functional activities. In one patient who suffered a stroke, 2 weeks of CIT led to improved function and cortical reorganization in the hemisphere contralateral to the affected hand.

EMG and kinetic measures have been primary tools in the study of movement and have provided the foundation for much of the work presented in this journal. Recently, novel ways of combining these tools have provided opportunities to examine elements of motor learning and brain plasticity. This presentation reviews the quantification of EMG within the context of transcranial magnetic stimulation. This vehicle permits acquisition of measures that are fundamental to examining prospects for cortical reorganization among patients with stroke and employs a therapeutic approach called “constraint induced therapy” as a model to demonstrate the interpretation of changes in EMG measures among patients with stroke. Moreover, interfacing novel uses of kinetic measurements during functional task performances is highlighted to illustrate how EMG and kinetics can provide further insight into mechanisms related to reacquisition of movement and concomitant changes in plasticity. Clinicians and researchers interested in expanding their use of these measurement tools are encouraged to learn more about application possibilities.

Background: Despite intensive rehabilitation efforts, most stroke survivors have persistent functional disability of the paretic arm and hand. These motor impairments may be due in part to maladaptive changes in structural and functional connections between brain regions. The following early stage clinical trial study protocol describes a noninvasive brain stimulation approach to target transcallosally mediated interhemispheric connections between the ipsi- and contralesional motor cortices (iM1 and cM1) using corticocortical paired associative stimulation (ihPAS). This clinical trial aims to characterize ihPAS-induced modulation of interhemispheric connectivity and the effect on motor skill performance and learning in chronic stroke survivors. Methods/Design: A repeated-measures, cross-over design study will recruit 20 individuals post-stroke with chronic mild-moderate paretic arm impairment. Each participant will complete an active ihPAS and control ihPAS session. Assessments of cortical excitability and motor skill performance will be conducted prior to and at four time points following the ihPAS intervention. The primary outcome measures will be: TMS-evoked interhemispheric motor connectivity, corticomotor excitability, and response time on a modified serial reaction time task. Discussion/Conclusion: The findings from this single-site early stage clinical trial will provide foundational results to inform the design of larger-scale, multisite clinical trials to evaluate the therapeutic potential of ihPAS-based neuromodulation for upper limb recovery after stroke. This trial is registered with NCT02465034.

Constraint-induced movement therapy (CIMT) has gained considerable popularity as a treatment technique for upper extremity rehabilitation among patients with mild-to-moderate stroke. While substantial evidence has emerged to support its applicability, issues remain unanswered regarding the best and most practical approach. Following the establishment of what can be called the “signature” CIMT approach characterized by intense clinic/laboratory-based practice, several distributed forms of training, collectively known as modified constraint therapy (mCIMT), have emerged. There is a need to examine the strengths and limitations of such approaches, and based upon such information, develop the components of a study that would compare the signature approach to the best elements of mCIMT, referred to here as “alternative” CIMT. Based upon a PEDro review of literature, limitations in mCIMT studies for meeting criteria were identified and discussed. A suggestion for a “first effort” at a comparative study that would both address such limitations while taking practical considerations into account is provided.

BACKGROUND: The use of transcranial magnetic stimulation (TMS) to evaluate corticomotor excitability of lower limb (LL) muscles can provide insights about neuroplasticity mechanisms underlying LL rehabilitation. However, to date, a majority of TMS studies have focused on upper limb muscles. Posture-related activation is an important under-investigated factor influencing corticomotor excitability of LL muscles. OBJECTIVE: The purpose of this study was to evaluate effects of posture and background activation on corticomotor excitability of ankle muscles. METHODS: Fourteen young neurologically-unimpaired participants (26.1±4.1 years) completed the study. TMS-evoked motor evoked potentials (MEPs) were recorded from the tibialis anterior (TA) and soleus during 4 conditions - standing, standing coactivation, sitting, and sitting coactivation. TA and soleus MEP amplitudes were compared during: (1) standing versus sitting;(2) standing coactivation (standing while activating both TA and soleus) versus sitting coactivation; and (3) standing coactivation versus standing. For each comparison, background EMG for TA and soleus were matched. Trial-to-trial coefficient of variation of MEP amplitude and coil-positioning errors were additional dependent variables. RESULTS: No differences were observed in TA or soleus MEP amplitudes during standing versus sitting. Compared to sitting coactivation, larger MEPs were observed during standing coactivation for soleus but not TA. Compared to standing, the standing coactivation task demonstrated larger MEPs and reduced trial-to-trial MEP variability. CONCLUSION: Our findings suggest that incorporation of measurements in standing in future TMS studies may provide novel insights into neural circuits controlling LL muscles. Standing and standing coactivation tasks may be beneficial for obtaining functionally-relevant neuroplasticity assessments of LL musculature.

Background and Purpose Although constraint-induced movement therapy (CIMT) has been shown to improve upper extremity function in stroke survivors at both early and late stages post-stroke, the comparison between participants within the same cohort but receiving the intervention at different time points has not been undertaken. Therefore, the purpose of this study was to compare functional improvements between stroke participants randomized to receive this intervention within 3–9 months (early group)to participants randomized upon recruitment to receive the identical intervention 15–21 months post-stroke(delayed group). Methods Two weeks of CIMT was delivered to participants immediately after randomization (early group) or one year later (delayed group). Evaluators blinded to group designation administered primary (Wolf Motor Function Test [WMFT], Motor Activity Log [MAL]) and secondary (Stroke Impact Scale [SIS]) outcome measures among the 106 early participants and 86 delayed participants prior to delivery of CIMT, two weeks thereafter and 4, 8 and 12 months later. Results While both groups showed significant improvements from pretreatment to 12 months post-treatment, the earlier CIMT group showed greater improvement than the delayed CIMT group in WMFT Performance Time and the MAL (P’s < .0001) as well as in Stroke Impact Scale Hand and Activities domains (P <. 0009 and .0214, respectively). Early and delayed group comparison of scores on these measures 24 months after enrollment, showed no statistically significant differences between groups. Conclusions CIMT can be delivered to eligible patients 3 to 9 months or 15 to 21 months following stroke. Both patient groups achieved approximately the same level of significant arm motor function 24 months after enrollment. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00057018

Background Although principles based in motor learning, rehabilitation, and human-computer interfaces can guide the design of effective interactive systems for rehabilitation, a unified approach that connects these key principles into an integrated design, and can form a methodology that can be generalized to interactive stroke rehabilitation, is presently unavailable. Results This paper integrates phenomenological approaches to interaction and embodied knowledge with rehabilitation practices and theories to achieve the basis for a methodology that can support effective adaptive, interactive rehabilitation. Our resulting methodology provides guidelines for the development of an action representation, quantification of action, and the design of interactive feedback. As Part I of a two-part series, this paper presents key principles of the unified approach. Part II then describes the application of this approach within the implementation of the Adaptive Mixed Reality Rehabilitation (AMRR) system for stroke rehabilitation. Conclusions The accompanying principles for composing novel mixed reality environments for stroke rehabilitation can advance the design and implementation of effective mixed reality systems for the clinical setting, and ultimately be adapted for home-based application. They furthermore can be applied to other rehabilitation needs beyond stroke.

Background Residual disability after stroke is substantial; 65% of patients at 6 months are unable to incorporate the impaired upper extremity into daily activities. Task-oriented training programs are rapidly being adopted into clinical practice. In the absence of any consensus on the essential elements or dose of task-specific training, an urgent need exists for a well-designed trial to determine the effectiveness of a specific multidimensional task-based program governed by a comprehensive set of evidence-based principles. The Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) Stroke Initiative is a parallel group, three-arm, single blind, superiority randomized controlled trial of a theoretically-defensible, upper extremity rehabilitation program provided in the outpatient setting. The primary objective of ICARE is to determine if there is a greater improvement in arm and hand recovery one year after randomization in participants receiving a structured training program termed Accelerated Skill Acquisition Program (ASAP), compared to participants receiving usual and customary therapy of an equivalent dose (DEUCC). Two secondary objectives are to compare ASAP to a true (active monitoring only) usual and customary (UCC) therapy group and to compare DEUCC and UCC. Methods/design Following baseline assessment, participants are randomized by site, stratified for stroke duration and motor severity. 360 adults will be randomized, 14 to 106 days following ischemic or hemorrhagic stroke onset, with mild to moderate upper extremity impairment, recruited at sites in Atlanta, Los Angeles and Washington, D.C. The Wolf Motor Function Test (WMFT) time score is the primary outcome at 1 year post-randomization. The Stroke Impact Scale (SIS) hand domain is a secondary outcome measure. The design includes concealed allocation during recruitment, screening and baseline, blinded outcome assessment and intention to treat analyses. Our primary hypothesis is that the improvement in log-transformed WMFT time will be greater for the ASAP than the DEUCC group. This pre-planned hypothesis will be tested at a significance level of 0.05. Discussion ICARE will test whether ASAP is superior to the same number of hours of usual therapy. Pre-specified secondary analyses will test whether 30 hours of usual therapy is superior to current usual and customary therapy not controlled for dose. Trial registration http://www.ClinicalTrials.gov webcite Identifier: NCT00871715