Function In Chronic Stroke Patients Research Articles

The effect of an intensive exercise programme on leg function in chronic stroke patients: a pilot study with one-year follow-up

Objective: To investigate the effect of two weeks of intensive exercise on leg function in chronic stroke patients and to evaluate the feasibility of an intensive exercise programme in a group setting. Design: Pilot study with one-group pre-test post-test design with two pre-tests and one-year follow-up. Setting: Inpatient rehabilitation hospital. Subjects: Twelve hemiparetic patients completed the intervention. Ten patients participated at one-year follow-up. Intervention: Six hours of daily intensive exercise for two weeks with focus on weight-shifting towards the affected side and increased use of the affected extremity during functional activities. An insole with nubs in the shoe of the non-paretic limb was used to reinforce weight-shift toward the affected side. Main measures: Timed Up and Go, Four Square Step Test, gait velocity, gait symmetry and muscle strength in knee and ankle muscles. Results: Maximal gait velocity (P = 0.002) and performance time (seconds) on Timed Up and Go (mean, SD; 12.2, 3.8 vs. 9.4, 3.2) and Four Square Step Test improved from pre- to post-test (P = 0.005). Improvements remained significant at follow-up. Preferred gait velocity and gait symmetry remained unchanged. Knee extensor (P<50.009) and flexor (P<50.001) strength increased bilaterally from pre- to post-test but only knee flexor strength remained significant at follow-up. Ankle dorsi flexor (P = 0.02) and plantar flexor (P<0.001) strength increased on paretic side only (not tested at follow-up). Conclusion: Intensive exercise for lower extremity is feasible in a group setting and was effective in improving ambulatory function, maximal gait velocity and muscle strength in chronic stroke patients. Most improvements persisted at the one-year follow-up.

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

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. 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. 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. 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. 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.

Constraint-induced movement therapy after injection of Botulinum toxin improves spasticity and motor function in chronic stroke patients

Does injection of Botulinum toxin followed by constraint-induced movement therapy improve spasticity and upper limb motor function more than the same injection followed by rehabilitation based on neurodevelopmental techniques? Randomised trial with concealed allocation and blinded outcome assessment. Rehabilitation department of a tertiary hospital in Taiwan. Adults at least one year after a stroke with a Modified Ashworth Scale (MAS) score of 3 or more in the elbow, wrist, or finger flexors, and with at least 10 degrees of active interphalangeal and metacarpophalangeal extension and 20 degrees of wrist extension. Fixed contractures, major co-morbidities, and previous Botulinum toxin injection or surgery for spasticity were exclusion criteria. Randomisation of 32 participants allotted 16 to each group. Both groups received a total dose of 1000 units of Botulinum toxin type A, injected at standard muscular sites in the affected upper limb, and commenced their 3-month rehabilitation regimen the following day. The intervention group underwent intensive training of the affected upper limb for 2 hours, 3 times per week, while the non-affected upper limb was restrained for at least 5 hours per day. Selected tasks were progressed in complexity, with some assistance with movements and verbal feedback and encouragement. The control group received 1 hour each of physiotherapy and occupational therapy, 3 times per week. Therapy was based on neurodevelopmental techniques, focusing on normalising tone, and movement patterns. The primary outcome was the MAS (0 = no spasticity, 4 = rigid in flexion or extension). Secondary outcomes included the Motor Activity Log (MAL), comprising two 6-point scales of amount of use and quality of movement, and the Action Research Arm Test (ARAT), which rates 19 tasks from 0 (no movement possible) to 3 (normal movement), to give a total score out of 57. 29 participants completed the study. At 6 months, the treatment group had significantly greater reduction in MAS scores for the elbow (0.7, 95% CI 0.1 to 1.3), wrist (0.7, 95% CI 0.2 to 1.2), and fingers (1.2, 95% CI 0.9 to 1.5). Also at 6 months, the treatment group had significantly greater improvement in amount of use (1.1, 95% CI 0.8 to 1.4), quality of movement (0.9, 95% CI 0.6 to 1.2), and ARAT scores (7, 95% CI 4 to 10). Injection of Botulinum toxin followed by constraint-induced movement therapy improves spasticity and upper limb motor function more than the same injection followed by rehabilitation based on neurodevelopmental techniques.

Poster 19: Double-Blind Crossover Assessment of Botulinum Toxin Type A Combined With Therapy as Compared With Dosed Therapy to Improve Upper-Extremity Function in Chronic Stroke Patients With Spastic Hypertonia

Poster 19: Double-Blind Crossover Assessment of Botulinum Toxin Type A Combined With Therapy as Compared With Dosed Therapy to Improve Upper-Extremity Function in Chronic Stroke Patients With Spastic Hypertonia

Priming the motor system enhances the effects of upper limb therapy in chronic stroke

After stroke, the function of primary motor cortex (M1) between the hemispheres may become unbalanced. Techniques that promote a re-balancing of M1 excitability may prime the brain to be more responsive to rehabilitation therapies and lead to improved functional outcomes. The present study examined the effects of Active-Passive Bilateral Therapy (APBT), a putative movement-based priming strategy designed to reduce intracortical inhibition and increase excitability within the ipsilesional M1. Thirty-two patients with upper limb weakness at least 6 months after stroke were randomized to a 1-month intervention of self-directed motor practice with their affected upper limb (control group) or to APBT for 10-15 min prior to the same motor practice (APBT group). A blinded clinical rater assessed upper limb function at baseline, and immediately and 1 month after the intervention. Transcranial magnetic stimulation was used to assess M1 excitability. Immediately after the intervention, motor function of the affected upper limb improved in both groups (P < 0.005). One month after the intervention, the APBT group had better upper limb motor function than control patients (P < 0.05). The APBT group had increased ipsilesional M1 excitability (P < 0.025), increased transcallosal inhibition from ipsilesional to contralesional M1 (P < 0.01) and increased intracortical inhibition within contralesional M1 (P < 0.005). None of these changes were found in the control group. APBT produced sustained improvements in upper limb motor function in chronic stroke patients and induced specific and sustained changes in motor cortex inhibitory function. We speculate that APBT may have facilitated plastic reorganization in the brain in response to motor therapy. The utility of APBT as an adjuvant to physical therapy warrants further consideration.

Inhibition of the unaffected motor cortex by 1 Hz repetitive transcranical magnetic stimulation enhances motor performance and training effect of the paretic hand in patients with chronic stroke

Recent reports demonstrated that low-frequency repetitive transcranial magnetic stimulation (rTMS) over the unaffected hemisphere improved the affected hand function in chronic stroke patients. We investigated whether 1 Hz rTMS improved the motor learning of the affected hand in patients after stroke. A double-blind study. Twenty patients with chronic subcortical stroke. The patients were randomly assigned to receive either a sub-threshold rTMS over the unaffected hemisphere (1 Hz, 25 minutes) or sham stimulation, and all patients performed a pinching task after stimulation. We evaluated the motor function of the affected hand and the excitatory and inhibitory function of the affected motor cortex by transcranial magnetic stimulation. Compared with sham stimulation, rTMS induced an increase in the excitability of the affected motor cortex(p < 0.001) and an improvement in acceleration of the affected hand (p = 0.006). Moreover, the effect of motor training on pinch force was enhanced by rTMS (p < 0.001). These improvement in the motor function lasted for one week after rTMS and motor training (p < 0.001). rTMS improved the motor learning of the affected hand in patients after stroke; thus, it can apply as anew rehabilitation strategy for patients after stroke.

Exploring Theta Burst Stimulation as an intervention to improve motor recovery in chronic stroke

ObjectiveTo explore the effects of a single session of repetitive Transcranial Magnetic Stimulation, given as Theta Burst Stimulation, on behavioural and physiological measures of hand function in chronic stroke patients. MethodsSix chronic stroke patients with incomplete recovery of the hand were tested under three conditions: excitatory TBS over the stroke hemisphere (iTBSSH), inhibitory TBS (cTBSIH) over the intact hemisphere and sham stimulation. Behavioural outcomes included simple and choice reaction time paradigms. Physiological effects were assessed using single pulse TMS on both sides. Changes were sought for up to 40min after TBS. ResultsImmediately after iTBSSH simple reaction times in the paretic hands were decreased and, compared to sham stimulation, remained significantly shorter throughout the testing period. The amplitude of the MEPs at rest and during background contraction and the area under the Input–Output curves were also increased on the stroke side after iTBSSH. cTBSIH suppressed the MEPs evoked in the healthy hands but did not change motor behaviour or the electrophysiology of the paretic hands. No side effects were encountered. ConclusionsTBS seems safe in chronic stroke patients. iTBS over the stroke hemisphere transiently improved motor behaviour and corticospinal output in the paretic hands. SignificanceExcitatory TBS may represent a useful rTMS protocol to apply to the stroke hemisphere in future longer term therapy trials.

Bilateral and unilateral movement training on upper limb function in chronic stroke patients: A TMS study

The use of activity-dependent interventions has shown some success in promoting recovery of upper limb function in chronic stroke patients. This study compared the neurophysiological and behavioural changes associated with two such rehabilitation protocols: unilateral and bilateral movement training. Twelve chronic stroke patients were randomly assigned to the two training protocols involving six daily practice sessions. Each session consisted of 50 trials of a dowel placement task performed either with both impaired and unimpaired arm moving synchronously (bilateral training group) or with only the impaired arm moving (unilateral training). Kinematic measurements of upper limb movements were made in four unilateral test trials performed prior to and following each practice session. Functional assessments of the impaired upper limb and neurophysiological assessments, using transcranial magnetic stimulation (TMS), of the affected and non-affected cortical hemispheres were made prior to and following the intervention sessions. Individuals receiving bilateral training showed a reduction in movement time of the impaired limb and increased upper limb functional ability compared to individuals receiving unilateral training. In some patients changes to upper limb function were associated with changes to the cortical representation of a target muscle in the non-affected hemisphere. Overall, these findings suggest that a short-term bilateral training intervention may be effective in facilitating upper limb motor function in chronic stroke patients.

Does motor imagery training improve hand function in chronic stroke patients? A pilot study.

To assess the efficacy of motor imagery training for arm function in chronic stroke patients. The relation between mental processes such as attentional and perceived personal control over recovery, and motor imagery was additionally investigated. Twenty patients with long-term motor impairments (mean two years post stroke), were assessed before and after four weeks of training. Ten patients mentally rehearsed movements with their affected arm. Their recovery was compared with patients who performed nonmotor imagery (n =5), or who were not engaged in mental rehearsal (n=5). Patients were recruited from the stroke database of Ninewells Hospital, Dundee. Assessment and training were performed at the patients' home. The motor imagery group was asked to practise daily imagining moving tokens with their affected arm. The nonmotor imagery group rehearsed visual imagery of previously seen pictures. All patients practised physically moving the tokens. The following variables were assessed before and after training: motor function (training task, pegboard and dynamometer), perceived locus of control, attention control and ADL independence. All patient groups improved on all motor tasks except the dynamometer. Improvement was greater for the motor imagery group on the training task only (average of 14% versus 6%). No effect of motor imagery training was found on perceived or attentional control. Motor imagery training without supervision at home may improve performance on the trained task only. The relation between movement imagery, attention and perceived personal control over recovery remained unclear.

Imagery Improves Upper Extremity Motor Function in Chronic Stroke Patients: A Pilot Study

After medical stabilization, stroke patients receive rehabilitation during a period that is considered subacute. The traditional view of neurologic rehabilitation is that it reduces impairment and minimizes disability. However, intensive rehabilitation is expensive and there are limited and diminishing financial resources to pay for therapy after stroke. Imagery improves motor learning and performance. Studies report increased blood flow, electromyographic activity during imagery, and subsequent changes in organization of the motor cortex in stroke patients following imagery. Since these events usually precede reacquisition of function, it has been suggested that imagery may be beneficial in reacquisition of function following stroke. To test this, 8 chronic stroke patients with right-arm hemiparesis were provided a four-week program combining occupational therapy and imagery (OT + I), while 8 controls received a program consisting only of OT. Scores on the upper extremity section of the Fugl-Meyer Assessment of Sensorimotor Recovery indicated that those receiving OT + I exhibited significantly more improved function than those receiving OT ( F [1,14] −14.71; p &lt; .05). Findings suggest that imagery may be an inexpensive, noninvasive compliment to OT for hemiparesis in stroke. The researchers encourage further investigation of OT + I in stroke.