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Constraint Induced Movement Therapy: influence of restraint and type of training on performance and on brain plasticity
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation.
2006 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Partial paralysis of the hand is one of the main impairments after stroke. Constraint Induced Movement Therapy (CIT) is a new treatment technique that appears to improve upper extremity function after stroke. CIT consists of 6 hours of training/day for the affected arm (mainly with shaping exercises) and of restraint (mitt) of the non affected arm for two weeks. There are concerns about the practicality and resource issues in carrying out CIT according to the original model. In this thesis the benefit of modifications of CIT, of an assessment tool and of two common types of hand training have been evaluated.

 

CIT (n=16) administered in groups for two weeks (paper I) seems to be a feasible alternative to improve upper limb motor function after chronic stroke. The arm/hand motor performance improved significantly on Motor Assessment Scale (MAS; p= 0.003) and on Sollerman hand function test (p= 0.037). The median self reported motor ability (MAL) also improved (p < 0.001). No additional effect was seen from wearing a mitt for an extended period of three months. The reliability of the Sollerman hand function test (paper II) was studied in patients with chronic stroke. Three examiners observed 24 patients at three experimental sessions. There was agreement (kappa ≥ 0.4) between the examiners for 15/20 subtests. Using total sum scores, the agreement within the examiners was higher than 0.96 (for Spearman’s rhos and ICCs) and agreement between the examiners was higher than 0.96 (Spearman’s rhos) and 0.92 (ICCs), respectively. In a cohort of 24 patients with subacute stroke (paper III) forced use therapy (FUT; mitt use and 3 hours of training/day for 2 weeks) improved arm/hand function, but not more than regular arm therapy given to the control group. Significant improvements in arm/hand motor performance were found in the FUT group (n=12) as well as in the control group (n=12) on the Sollerman hand function test (p= 0.001), on MAS (p< 0.05) and on MAL (p < 0.05). No significant differences were seen between the groups pre- or post training or at three months follow up, demonstrating that the mitt had limited importance. In a separate study on 30 healthy subjects (paper IV), employing transcranial magnetic brain stimulation (TMS), we found that shaping exercises but not general activity training increased dexterity (p<0.05; Purdue peg board test) of the trained non dominant hand. After shaping exercises the cortical motor map shifted forwardly into the premotor area but did not expand. After general activity training the cortical motor map expanded significantly (p=0.03) in the posterior (sensory) direction. Shift of location of active TMS positions rather than their numbers might therefore be a critical factor for the interpretation of cortical plasticity.

 

In conclusion, the studies in this thesis have shown that less resource consuming modifications of CIT may be feasible to improve upper limb motor function after stroke. The type and amount of training for the more affected arm seems to be an important factor rather than the mitt use in itself. Shaping exercises, at least in healthy people, are effective in improving dexterity and the Sollerman hand function test reliable to evaluate arm/hand function after stroke.

Place, publisher, year, edition, pages
Umeå: Samhällsmedicin och rehabilitering , 2006. , 45 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1025
Keyword [en]
Medicine, Constraint induced movement therapy, hand, stroke, group practise, reliability, mode of training, dexterity, brain plasticity
Keyword [sv]
Medicin
Research subject
Rehabilitation Medicine
Identifiers
URN: urn:nbn:se:umu:diva-763ISBN: 91-7264-071-5 (print)OAI: oai:DiVA.org:umu-763DiVA: diva2:144461
Public defence
2006-05-12, Hörsal b, 9 tr, Tandläkarhögskolan, Norrlands universitetssjukhus, Umeå, 13:00 (English)
Opponent
Supervisors
Available from: 2006-04-21 Created: 2006-04-21 Last updated: 2016-02-22Bibliographically approved
List of papers
1. Constraint Induced Movement Therapy in patients with stroke: A pilot study on effects of small group training and of extended mitt use
Open this publication in new window or tab >>Constraint Induced Movement Therapy in patients with stroke: A pilot study on effects of small group training and of extended mitt use
2006 (English)In: Clinical Rehabilitation, ISSN 0269-2155, E-ISSN 1477-0873, Vol. 20, no 3, 218-227 p.Article in journal (Refereed) Published
Identifiers
urn:nbn:se:umu:diva-5086 (URN)10.1191/0269215506cr937oa (DOI)16634340 (PubMedID)
Available from: 2006-04-21 Created: 2006-04-21 Last updated: 2016-02-22Bibliographically approved
2. Intra- and inter-rater reliability of the Sollerman hand function test in patients with chronic stroke.
Open this publication in new window or tab >>Intra- and inter-rater reliability of the Sollerman hand function test in patients with chronic stroke.
2007 (English)In: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165, Vol. 29, no 2, 145-154 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE: To examine whether the Sollerman hand function test is reliable in a test-retest situation in patients with chronic stroke. METHOD: Three independent examiners observed each patient at three experimental sessions; two days in week 1 (short-term test-retest) and one day in week 4 (long-term test-retest). A total of 24 patients with chronic stroke (mean age; 59.7 years, mean time since stroke onset 29.6 months) participated. The examiners simultaneously assessed the patients' ability to perform 20 subtests. Both ordinal data (generalized kappa) and total sum scores (Spearman's rank correlation coefficient (Spearman's rho), intra class correlation coefficient (ICC2, 1) and mean differences) were used in the statistical analysis. RESULTS: There was agreement (kappa >or= 0.4) between the examiners for 15 out of the 20 subtests. Using total sum scores, the agreement within the examiners, both short- and long-term, was higher than 0.96 (for Spearman's rho and ICC, respectively). The mean differences were 0.29 - 1.0/80 points within each examiner. Agreement between the examiners at each session was higher than 0.96 (Spearman's rho) and 0.92 (ICC), respectively. Systematic differences (p < 0.05) were, however, found between examiners A and B/C for all sessions. CONCLUSIONS: The Sollerman hand function test seems to be a reliable test in patients with chronic stroke, but we recommend that the same examiner evaluates a patient's hand function pre- and post-treatment.

Identifiers
urn:nbn:se:umu:diva-26225 (URN)10.1080/09638280600747603 (DOI)17364764 (PubMedID)
Available from: 2009-09-30 Created: 2009-09-30 Last updated: 2016-02-22
3. Forced use therapy in patients with subacute stroke: The mitt can be thrown!: A randomised controlled study with blinded observers
Open this publication in new window or tab >>Forced use therapy in patients with subacute stroke: The mitt can be thrown!: A randomised controlled study with blinded observers
(English)Manuscript (preprint) (Other academic)
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-5088 (URN)
Available from: 2006-04-21 Created: 2006-04-21 Last updated: 2016-02-22Bibliographically approved
4. Mode of hand training determines cortical reorganisation: A randomized controlled study in healthy adults
Open this publication in new window or tab >>Mode of hand training determines cortical reorganisation: A randomized controlled study in healthy adults
2010 (English)In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 42, no 8, 789-794 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To evaluate two commonly used forms of hand training with respect to influence on dexterity and cortical reorganization.

Subjects: Thirty healthy volunteers (mean age 24.2 years).

Methods: The subjects were randomized to 25 min of shaping exercises or general activity training of the non-dominant hand. The dexterity and the cortical motor maps (number of excitable positions) of the abductor pollicis brevis muscle were evaluated pre- and post-training by the Purdue Peg Board test and transcranial magnetic stimulation, respectively.

Results: After shaping exercises the dexterity increased significantly (p ≤ 0.005) for both hands, mostly so in the non-dominant hand. The cortical motor map of the abductor pollicis brevis muscle shifted forwardly into the pre-motor area without expanding. After general activity training, no significant improvements in dexterity were found for the non-dominant hand. The cortical motor map of the non-dominant abductor pollicis brevis muscle expanded significantly (p = 0.03) in the posterior (sensory) direction.

Conclusion: These results indicate that shaping exercises, but not general activity training, increase dexterity of the trained non-dominant hand in parallel with a shift of location of active transcranial magnetic stimulation positions. Shifts of active cortical areas might be important for the interpretation of brain plasticity in common behavioural tasks.

Place, publisher, year, edition, pages
Foundation for rehabilitation information, 2010
Keyword
dexterity, hand training, healthy subjects, transcranial magnetic stimulation; plasticity, cortical shift
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-5089 (URN)10.2340/16501977-0588 (DOI)000281927000013 ()
Available from: 2006-04-21 Created: 2006-04-21 Last updated: 2016-02-22Bibliographically approved

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