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Lower-extremity constraint-induced movement therapy in individuals with stroke: improvements, experiences, and health-related quality of life
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Rehabilitation Medicine. Region Värmland.ORCID iD: 0000-0002-1719-9816
2023 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Intensiv och uppgiftsspecifik behandling med CI-terapi för nedre extremitet hos personer med stroke : förbättringar, upplevelser och hälsorelaterad livskvalitet (Swedish)
Abstract [en]

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.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2023. , p. 70
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2260
Keywords [en]
Stroke, rehabilitation, high-intensity, lower-extremity, constraint-induced movement therapy, physiotherapy, experiences, qualitative content analysis, health-related quality of life
National Category
Physiotherapy
Research subject
Rehabilitation Medicine
Identifiers
URN: urn:nbn:se:umu:diva-215882ISBN: 9789180701761 (print)ISBN: 9789180701778 (electronic)OAI: oai:DiVA.org:umu-215882DiVA, id: diva2:1807834
Public defence
2023-11-24, Aula Biologica, Biologihuset, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2023-11-03 Created: 2023-10-27 Last updated: 2023-11-16Bibliographically approved
List of papers
1. Effects of lower limb intensive mass practice in poststroke patients: single-subject experimental design with long-term follow-up
Open this publication in new window or tab >>Effects of lower limb intensive mass practice in poststroke patients: single-subject experimental design with long-term follow-up
2006 (English)In: Clinical Rehabilitation, ISSN 0269-2155, E-ISSN 1477-0873, Vol. 20, no 7, p. 568-576Article in journal (Refereed) Published
Abstract [en]

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.

Place, publisher, year, edition, pages
Sage Publications, 2006
National Category
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-22801 (URN)10.1191/0269215506cr973oa (DOI)000239895800002 ()16894799 (PubMedID)2-s2.0-33746898595 (Scopus ID)
Available from: 2009-05-19 Created: 2009-05-19 Last updated: 2023-10-30Bibliographically approved
2. Lower-extremity constraint-induced movement therapy improved motor function, mobility, and walking after stroke
Open this publication in new window or tab >>Lower-extremity constraint-induced movement therapy improved motor function, mobility, and walking after stroke
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2023 (English)In: European Journal of Physical and Rehabilitation Medicine, ISSN 1973-9087, E-ISSN 1973-9095, Vol. 59, no 2, p. 136-144Article in journal (Refereed) Published
Abstract [en]

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.

Place, publisher, year, edition, pages
Edizioni Minerva Medica, 2023
Keywords
Stroke rehabilitation, Exercise, Lower extremity, Physical therapy modalities
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-207044 (URN)10.23736/S1973-9087.23.07683-9 (DOI)000983180600002 ()36892520 (PubMedID)2-s2.0-85153120897 (Scopus ID)
Funder
Region VärmlandRegion VästerbottenUmeå UniversityThe Swedish Stroke Association
Available from: 2023-04-25 Created: 2023-04-25 Last updated: 2023-10-30Bibliographically approved
3. Improved balance, leg strength, and dual-task ability after lower extremity constraint-induced movement therapy in stroke patients: a longitudinal cohort study
Open this publication in new window or tab >>Improved balance, leg strength, and dual-task ability after lower extremity constraint-induced movement therapy in stroke patients: a longitudinal cohort study
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(English)Manuscript (preprint) (Other academic)
National Category
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-215887 (URN)
Available from: 2023-10-27 Created: 2023-10-27 Last updated: 2023-10-30
4. "I got knowledge of myself and my prospects for leading an easier life": stroke partients' experience of training with lower-limb CIMT
Open this publication in new window or tab >>"I got knowledge of myself and my prospects for leading an easier life": stroke partients' experience of training with lower-limb CIMT
2010 (English)In: Advances in Physiotherapy, ISSN 1403-8196, E-ISSN 1651-1948, Vol. 12, no 3, p. 134-141Article in journal (Refereed) Published
Abstract [en]

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.

Place, publisher, year, edition, pages
Informa Healthcare, 2010
Keywords
constraint-induced movement therapy, interview, qualitative content analysis, rehabilitation
National Category
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-22807 (URN)10.3109/14038190903141048 (DOI)000217388800004 ()2-s2.0-77955935760 (Scopus ID)
Note

Originally included in lic. thesis with title: "I got knowledge of myself and my prospects for leading an easier life: stroke partients' experience of training with lower-limb CIMT". 

Available from: 2009-05-19 Created: 2009-05-19 Last updated: 2023-10-30Bibliographically approved
5. Six minute walk performance predicts physical functioning in health related quality of life after lower-extremity constraint-induced movement therapy post-stroke: a cross-sectional survey study
Open this publication in new window or tab >>Six minute walk performance predicts physical functioning in health related quality of life after lower-extremity constraint-induced movement therapy post-stroke: a cross-sectional survey study
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-215906 (URN)
Available from: 2023-10-27 Created: 2023-10-27 Last updated: 2023-10-30

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