Umeå University's logo

Lower- extremity constraint-induced movement therapy (LE-CIMT) has proven effective in overcoming physical disabilities. Participating in the LE-CIMT requires some independent walking ability without aids that indicates a higher level of motor function than for the entire stroke population. However, only few studies evaluated health-related quality of life (HRQoL) after LE-CIMT. This study aimed to compare HRQoL of people who had participated in LE-CIMT post-stroke to the general population and evaluate whether descriptive characteristics and clinical result were associated with their HRQoL. An observational survey study with a questionnaire including the Swedish RAND-36 and Saltin–Grimby Physical Activity Level Scale was sent to 162 people. Reference data from the Mid-Health Survey in Sweden was used for norm-based comparisons of RAND-36. Respondents’ result from six-minute walk test post-LE-CIMT were used in the univariate analyse. The response rate was 65% (n=106; 69 males and 37 females with a mean age of 62±12 years). Ninety percent of the respondents could move around indoors and outdoors independently, despite this, 21% considered themselves physically inactive. The respondents had significantly reduced HRQoL compared to the general population in four of eight domains in the RAND-36: physical functioning (p=0.001), role-functioning (physical; p<0.001), general health (p=0.010), and social functioning (p<0.001). Regression analysis showed that longer walking distance significantly was associated with the RAND-36 physical functioning domain (β=6.45, 95% confidence interval=2.03–10.87, p=0.005). People in the chronic phase post-stroke who had previously participated in LE- CIMT had reduced HRQoL compared to the general population regarding physical functioning, role-functioning physical, general health, and social functioning. A longer walking distance was associated with higher HRQoL in physical functioning domain, emphasising the importance of mobility training in post-stroke rehabilitation.

Objective: To investigate whether high-intensity lower extremity constraint-induced movement therapy can improve balance, leg strength, and dual-task ability.

Design: A longitudinal cohort study in a real-world outpatient clinic.

Patients: 147 community-dwelling participants in the subacute and chronic poststroke phases.

Methods: Participants received lower extremity constraint-induced movement therapy for 6 hours/day during 2 consecutive weeks, including balance, strength, and functional training. The Berg Balance Scale (BBS), Single-Leg-Stance (SLS) bilaterally, one Repetition Maximum (1RM) in a leg press, symmetry of leg strength (Diff-1RM), Timed Up and Go (TUG), and the TUG Manual test were assessed before, after, and 3 months after lower extremity constraint-induced movement therapy.

Results: Compared with preintervention data, statistically significant improvements after lower extremity constraint-induced movement therapy (p < 0.001) were demonstrated for balance with an absolute value in BBS at 1.9 points (effect size 0.38) and SLS at 2.4 s (effect size 0.24), and for leg strength at 10.2 kg (effect size 0.54) for the affected leg. Diff 1RM decreased significantly at 5.8 kg (effect size 0.39) and improvements on dual-task ability at 2.7 s were significant (effect size 0.14). The effects persisted at the 3-month follow-up.

Conclusions: High-intensity lower extremity constraint-induced movement therapy may be a feasible treatment option for middle-aged stroke patients to affect balance, leg strength, and dual-task ability positively in an out-patient clinical setting.

Background: The long-term sequelae after COVID-19 constitute a challenge to public health and increased knowledge is needed. We investigated the prevalence of self-reported persistent symptoms and reduced health-related quality of life (HRQoL) in relation to functional exercise capacity, 6 months after infection, and explored risk factors for COVID-19 sequalae.

Methods: This was a prospective, multicenter, cohort study including 434 patients. At 6 months, physical exercise capacity was assessed by a 1-minute sit-to-stand test (1MSTST) and persistent symptoms were reported and HRQoL was evaluated through the EuroQol 5-level 5-dimension (EQ-5D-5L) questionnaire. Patients with both persistent symptoms and reduced HRQoL were classified into a new definition of post-acute COVID syndrome, PACS+. Risk factors for developing persistent symptoms, reduced HRQoL and PACS+ were identified by multivariable Poisson regression.

Results: Persistent symptoms were experienced by 79% of hospitalized, and 59% of non-hospitalized patients at 6 months. Hospitalized patients had a higher prevalence of self-assessed reduced overall health (28 vs. 12%) and PACS+ (31 vs. 11%). PACS+ was associated with reduced exercise capacity but not with abnormal pulse/desaturation during 1MSTST. Hospitalization was the most important independent risk factor for developing persistent symptoms, reduced overall health and PACS+.

Conclusion: Persistent symptoms and reduced HRQoL are common among COVID-19 survivors, but abnormal pulse and peripheral saturation during exercise could not distinguish patients with PACS+. Patients with severe infection requiring hospitalization were more likely to develop PACS+, hence these patients should be prioritized for clinical follow-up after COVID-19.

BACKGROUND: To regain the ability to walk is one of the most commonly stated goals for people who have had a stroke due to its importance in everyday life. Walking ability affects patients’ mobility, self-care, and social lives. Constraint-induced movement therapy (CIMT) is known to be effective in improving upper extremity outcomes post-stroke. However, there is insufficient evidence regarding its efficacy in improving lower extremity outcomes.AIM: To investigate whether a highly intensive CIMT for lower extremity (LE-CIMT) function post-stroke can improve motor function, functional mobility, and walking ability. Furthermore, it also aimed to investigate whether age, gender, stroke type, more-affected side, or time after stroke onset affect the efficacy of LE-CIMT on walking ability outcomes.

DESIGN: Longitudinal cohort study.

SETTING: Outpatient clinic in Stockholm, Sweden.

POPULATION: A total of 147 patients mean age 51 years (68% males; 57% right-sided hemiparesis), at the sub-acute or chronic phases post-stroke who had not previously undergone LE-CIMT.

METHODS: All patients received LE-CIMT for 6 hours per day over 2 weeks. The Fugl-Meyer Assessment (FMA) of the lower extremity, Timed Up and Go (TUG) test, Ten-Meter Walk Test (10MWT), and six-Minute Walk Test (6MWT) were used to assess functional outcomes before and directly after the 2-week treatment was complete as well at 3-month post-intervention.

RESULTS: Compared to baseline values, FMA (P<0.001), TUG (P<0.001), 10MWT (P<0.001) and 6MWT (P<0.001) scores were statistically significantly improved directly after the LE-CIMT intervention. These improvements persisted at the 3-month post-intervention follow-up. Those who completed the intervention 1-6 months after stroke onset had statistically significant larger improvements in 10MWT compared to those who received the intervention later than 6 months after stroke onset. Age, gender, stroke type, and more-affected side did not impact 10MWT results.

CONCLUSIONS: In an outpatient clinic setting, high-intensity LE-CIMT statistically significant improved motor function, functional mobility, and walking ability in middle-aged patients in the sub-acute and chronic post-stroke phases. However, studies with more robust designs need to be conducted to deepen the understanding of the efficacy of LE-CIMT.

CLINICAL REHABILITATION IMPACT: High-intensity LE-CIMT may be a feasible and useful treatment option in outpatient clinics to improve post-stroke walking ability.

Background: Stroke is the third-leading cause of disability worldwide, and there are rehabilitation needs not only in the first year but throughout the lifetime. The ability to walk is crucial in everyday life since it affects mobility, self-care, and social activities. National guidelines recommend treating impairments with repetitive task- and goal-oriented exercises. One form of highly intensive and task-specific treatment is constraint-induced movement therapy (CIMT), a treatment method developed based on understanding brain plasticity with a behavioural explanatory model. There is insufficient evidence regarding CIMT for the lower extremities (LE-CIMT) since it has only been investigated in a few published studies involving only a small number of participants.

Aim: The overall aims of this thesis were to explore the extent to which LE-CIMT (six hours per day for two weeks) can improve impaired body functions and limited activities, describe how the treatment is experienced, and investigate whether it affects the health-related quality of life (HRQoL) in individuals with stroke.

Methods: This thesis contains five papers that analysed data from two study populations using quantitative and qualitative research methods. A single-subject experimental study with five subjects and a longitudinal uncontrolled cohort study with 147 subjects with stroke treated with LECIMT and follow-up after three and six months were conducted. Subjects were assessed with Fugl–Meyer assessment, the Berg balance scale (BBS), single-leg stance, step test, timed up and go with and without dual-task, ten-metre (10MWT) and six-minute (6MWT) walk tests, one repetition maximum, and weight-bearing standing on two scales. Data were analysed with the two-standard deviation band method and linear mixed modelling, controlling for heterogeneity. Seven individual semistructured interviews were performed and analysed with qualitative content analysis to explore LE-CIMT experiences. Finally, a questionnaire including RAND-36 was sent out to former LE-CIMT participants, with 106 responses (response rate 65%). Data were compared with norm-baseddata and analysed with the summary independent-samples t-test. Univariable analysis was performed to investigate the linear relationships between RAND-36 health domain scores and the 6MWT result per 100meters, time since treatment, living alone, and need for home care. Independent t-tests were used for drop-out analyses.

Results: Highly intensive LE-CIMT significantly improved motor function, strength, balance, dual-task ability, mobility, and walking ability in individuals in the sub-acute and chronic post-stroke phases. They maintained or improved their weight bearing on the more affected leg to provide a more symmetric distribution. The improvements remained at the three- and six-month follow-up. There was a significant interaction for time and age. Those who completed LE-CIMT within six months after their stroke onset had significantly greater improvements in 10MWT self-selected speed during the follow-up than those who completed LE-CIMT after at least seven months. Younger participants had higher BBS scores than older participants. The informants’ experiences generated the overall theme that LE-CIMT gave them knowledge about themselves and how their body works, facilitating the opportunity to live life more easily. There was still hope and opportunity for functional improvements to increase their independence and self-esteem. While LE-CIMT was intense and challenging, it was experienced as entirely necessary. The participants had significantly reduced HRQoL, overall and by sex in physical functioning, role-functioning physical, general health (not females), and social functioning compared to the general population. A significant relationship existed between their previous 6MWT result and the HRQoL physical functioning domain. Every 100-metre improvement in the 6MWT led to a 6.45 higher physical functioning score. No other significant associations were found. The dropout analysis showed no significant differences in characteristics between the participants and those who did not complete all three assessments or answer the questionnaire.

Conclusion: LE-CIMT seems helpful in improving lower extremity body functioning and activities, even a long time after the stroke, leading to persistent improvements. The patients perceived LE-CIMT as entirely necessary. LE-CIMT may be a feasible treatment option and could be conducted in both day hospital rehabilitation and outpatient settings. Six minutewalk performance predicts physical functioning in HRQoL, emphasising the importance of mobility and gait training in rehabilitation after stroke.

Rehabilitation after stroke has changed and more studies with intensive therapy have been conducted. When a new method – here lower-limb constraint-induced movement therapy (CIMT) – is introduced, it is important to investigate participants’ own experience of the therapy. The present purpose was accordingly to describe stroke patients’ experience of training with lower-limb CIMT. Qualitative interviews with seven stroke patients who had participated in lower-limb CIMT were conducted. The interviews were transcribed verbatim and analysed with qualitative content analysis. One theme, knowledge of myself and my prospects for leading an easier life, emerged. Two main categories were found: the therapy and me and my body, with four and three categories respectively. The therapy comprised the informants’ experience of preparation for CIMT, the actual intensive training and its effects, and their views on the physiotherapists involved. Me and my body comprised the informants’ reflections on their own significance for the therapy, how the reflections had affected them and what insight into their condition CIMT had given. The informants reported that CIMT for the lower extremity gave them knowledge of their body and their prospects for leading an easier life. The intensive training instilled hope, since the functional improvements showed the possibilities of improvements, increasing the respondents’ independence and self-esteem. Even though the intensive training is tough, it was experienced as entirely necessary.

OBJECTIVE: To investigate the effects of two weeks of intensive mass practice with a constraint-induced movement therapy approach for the lower extremity in five chronic poststroke patients, and the persistence of effects at three and six months.

DESIGN: A single-subject experimental design (SSED) was used with an AB design and follow-ups three and six months later.

SETTING: Outpatient rehabilitation at Torsby Hospital in Sweden.

MAIN MEASURES: Motor function in lower extremity, mobility, dynamic balance, weight-bearing symmetry and walking ability were measured on six occasions during two weeks (A phase), with the Fugl-Meyer assessment for lower extremity, the Timed Up and Go, the Step Test, the Timed Walking Test and the Six-Minute Walk Test. During the intervention's B phase, six measurements were performed with the same time intervals as in the A phase. There were follow-ups three and six months later.

INTERVENTION: The intervention (B phase) consisted of bicycling, training in water, strength training, standing weight-bearing, walking up and down stairs, walking indoors and outdoors and flexibility training of the lower extremity, on all weekdays, 6 h a day for two weeks.

RESULTS: The results showed improvements in 23/30 variables (77%), 12 of them statistically significant (52%). At follow-up, 22/23 improvements persisted. For example, three of five subjects walked significantly further after the intervention and the follow-ups showed that they still walked further than before the intervention.

CONCLUSION: Intensive mass practice with constraint-induced movement therapy for the lower extremity can improve motor function, mobility, dynamic balance, weight-bearing symmetry and walking ability in chronic poststroke patients. Long-term follow-up showed that the effects persisted for these five subjects.