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Background: Constraint-Induced Movement Therapy (CIMT) is a treatment modality originally intended for impaired arm and hand function following unilateral brain damage, such as stroke. Extensive research has shown that CIMT may effectively enhance upper-extremity motor function with a good carry-over effect to activity levels and the improvements sustained at long-term follow-up. However, the impact of CIMT on hemiplegic shoulder pain (HSP) and Health-related Quality of Life (HRQoL) has not been adequately investigated and clinical implementation of CIMT has thus far been limited. The CIMT concept has eventually been adapted to treat lower extremity deficits (LE-CIMT) focusing on gait and balance, however currently with limited evidence.

Aim: The overall aim of this thesis was to investigate treatment effects of CIMT in an outpatient clinical setting with focus on HSP, motor function, balance, leg muscle strength and HRQoL after stroke.

Methods: A longitudinal cohort study was conducted at a physiotherapy clinic in Stockholm between 2000 and 2018. The CIMT treatment was delivered to all participants and consisted of high-intensity, task-specific training, six hours per weekday for two consecutive weeks. Treatment focus was on either arm/hand or gait/balance. Assessments used were the Fugl-Meyer Assessment scale for scoring shoulder pain, goniometry for passive and active shoulder ROM and B. Lindmark Motor Assessment, Berg Balance Scale, Single-Leg-Stance, one Repetition Maximum in a leg press and Timed Up and Go. All assessments were carried out pre- and post-CIMT and at 3-month follow-up. Additionally, the short form-36 (SF-36) Health Survey was administered pre-CIMT and at 3-month follow-up to assess HRQoL.

Results: Study participants were middle-aged and in the subacute and chronic post-stroke phases. In the upper extremities cohort (221 participants, median age 56 years, 62% men) we found significantly reduced shoulder pain alongside improved motor function and active and passive range of motion. Additionally, positive impacts were found on HRQoL at 3-month follow-up post-CIMT. Results demonstrated overall improvements in physical domains, with women improving significantly more in physical domains and men in mental domains.

Regarding participants in lower extremity CIMT (147 participants, median age 53 years, 68% men), the intervention demonstrated enhanced balance, leg strength and dual-task ability. Leg strength improvements were greater in the affected leg, resulting in decreased leg strength asymmetry between affected and non-affected lower extremity. Furthermore, we showed positive impacts on HRQoL, revealing improvements in the Physical Function and Vitality domains after participation in lower extremity CIMT. Improvements after both CIMT and LE-CIMT were maintained at 3-month follow-up.

Conclusion: CIMT and LE-CIMT are clinically applicable treatment modalities in an outpatient clinical setting with positive impacts on HSP, motor function, balance and leg strength as well as improved self-assessed health-related quality of life among predominantly middle-aged individuals in a chronic stage post-stroke.

Introduction: The objective of this study was to evaluate the effects of Constraint-Induced Movement Therapy (CIMT) on hemiplegic shoulder pain (HSP), shoulder range of motion (ROM) and upper extremity motor function in stroke patients.

Methods: This longitudinal intervention cohort study was performed in an outpatient clinic without a control group. Participants underwent individually tailored CIMT with a patient therapist ratio of 4:1 for 6 h/day, 5 days/week for 2 consecutive weeks, including daily shoulder strength and joint motion training. A total of 221 (101 with and 120 without pre-CIMT HSP) middle-aged (median 54 years) persons at sub-acute or chronic phases after stroke were included in the study. The Fugl-Meyer Assessment (FMA) subscale for pain was used for defining and scoring HSP at passive motion (sum of four directions of movement, maximum 8 points indicating no pain). Passive and active shoulder ROM (sum of flexion and abduction) were assessed. Upper extremity motor function was assessed with B. Lindmark Motor Assessment. Assessments were done pre- and post-CIMT and at 3-month follow-up. Comparisons were stratified by subgroups with- and without HSP.

Results: In the subgroup with pre-CIMT HSP, median HSP score at passive movement was reduced (FMA shoulder pain score increased) from pre- to post-CIMT from 5 points to 7 points post-CIMT, (p < 0.001, Effect size (ES) 0.68). Median active ROM increased from 230° to 308° (p < 0.001, ES 0.72) and median passive ROM increased from 350° to 360° (p < 0.001, ES 0.44). Median motor function improved from 42 to 49 points (p < 0.001, ES 0.92). In the subgroup without pre-CIMT HSP no statistically significant increase of HSP was seen and no clinically significant changes observed for active or passive ROM after CIMT. Median motor function improved from 52 to 56 points (p < 0.001, ES 0.71). All improvements persisted at 3-month follow-up.

Conclusion: CIMT in an outpatient clinical setting may be a feasible treatment to decrease HSP and to improve shoulder ROM and upper extremity motor function among middle-aged persons in the subacute and chronic phases after stroke. Results need to be confirmed in an RCT setting.

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: 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.