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- Brogårdh, Christina, 1968-
(författare)
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Constraint Induced Movement Therapy : influence of restraint and type of training on performance and on brain plasticity
- 2006
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- 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.
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| 2. |
- Brogårdh, Christina, et al.
(författare)
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Constraint-induced movement therapy in patients with stroke: a pilot study on effects of small group training and of extended mitt use
- 2006
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Ingår i: Clinical Rehabilitation. - : SAGE Publications. - 1477-0873 .- 0269-2155. ; 20:3, s. 218-227
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Tidskriftsartikel (refereegranskat)abstract
- Objective: (1) To evaluate constraint-induced movement therapy for chronic stroke patients modified into group practice to limit the demand on therapist resources. (2) To explore whether extended mitt use alone may enhance outcome. Design: A combined case-control and randomized controlled study with pre- and post-treatment measures by blinded observers. Setting: A university hospital rehabilitation department. Participants: Sixteen stroke patients (nine men and seven women; mean age 56.7 years; on average 28.9 months post stroke, five of whom were 6-9 months post stroke) with moderate motor impairments in the contralateral upper limb. Intervention: Constraint-induced therapy (mitt on the less affected hand 90% of waking hours for 12 days) with 2-3 patients per therapist and 6 h of group training per day. After the training period, the patients were randomized either to using the mitt at home every other day for two-week periods for another three months (in total 21 days) or to no further treatment. Outcome measures: Modified Motor Assessment Scale, Sollerman Hand Function Test, Two-Point Discrimination test and Motor Activity Log. Results: The mean motor performance improved significantly after two weeks of constraint-induced group therapy on Motor Assessment Scale (1.44 (95% confidence interval (95% CI) 0.59-2.28) points; P = 0.003) and on Sollerman Hand Function Test (3.81 (95% CI 0.26-7.36) points; P = 0.037) but showed no sensory change in the Two-Point Discrimination Test (P = 0.283). The median difference in self-reported motor ability (Motor Activity Log) also improved (P < 0.001). However, no additional effect was seen from wearing a mitt for another three months. Conclusion: Constraint-induced group therapy, allowing several patients per therapist, seems to be a feasible alternative to improve upper limb motor function. The restraint alone, extended in time, did not enhance the treatment effect.
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| 3. |
- Brogårdh, Christina, et al.
(författare)
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Intra- and inter-rater reliability of the Sollerman hand function test in patients with chronic stroke
- 2007
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Ingår i: Disability and Rehabilitation. - : Informa UK Limited. - 0963-8288 .- 1464-5165. ; 29:2, s. 145-154
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Tidskriftsartikel (refereegranskat)abstract
- 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 I (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 >= 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.
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| 4. |
- Brogårdh, Christina, et al.
(författare)
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Shortened constraint-induced movement therapy in subacute stroke - no effect of using a restraint : a randomized controlled study with independent observers
- 2009
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Ingår i: Journal of Rehabilitation Medicine. - : Stiftelsen Rehabiliteringsinformation. - 1650-1977 .- 1651-2081. ; 41:4, s. 231-236
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Tidskriftsartikel (refereegranskat)abstract
- Objective: To examine the effect of using a mitt during shortened constraint-induced movement therapy for patients in the subacute phase after stroke.Subjects: Twenty-four patients with stroke (mean age 57.6 (standard deviation 8.5) years; average 7 weeks post-stroke) with mild to moderate impaired hand function.Methods: The patients were randomized to mitt use or no mitt use on the less affected hand for 90% of waking hours for 12 days. All patients received 3 h of arm and hand training per day for 2 weeks. Assessments were made by blinded observers using the modified Motor Assessment Scale, the Sollerman hand function test, the 2-Point Discrimination test and Motor Activity Log test.Results: Patients in both groups showed significant improvements in arm and hand motor performance and on self-reported motor ability after 2 weeks of therapy and at 3 months follow-up. However, no statistically significant differences between the groups were found in any measures at any point in time.Conclusion: In this study, no effect of using a restraint in patients with subacute stroke was found. Thus, this component in the constraint-induced therapy concept seems to be of minor importance for the outcome.
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| 5. |
- Brogårdh, Christina, et al.
(författare)
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What is the long-term benefit of constraint-induced movement therapy? A four-year follow-up.
- 2009
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Ingår i: Clinical Rehabilitation. - : SAGE Publications. - 1477-0873 .- 0269-2155. ; 23, s. 418-423
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Tidskriftsartikel (refereegranskat)abstract
- Objective: To evaluate the long-term benefits of constraint-induced movement therapy in chronic stroke.Design: A four-year follow-up after constraint-induced group therapy assessing arm and hand function and self-reported daily hand use.Subjects: Fourteen post-stroke individuals (six women and eight men; mean age 59.6 +/- 12.7 years, range 23-75 years) with mild to moderate impairments of hand function. OUTCOME MEASURES: The Sollerman hand function test and the Motor Activity Log test.Results: Four years after constraint-induced group therapy the participants had maintained their hand function, as measured by the Sollerman hand function test. The self-reported use and quality of movements of the more affected hand, as measured by the Motor Activity Log test, had decreased compared to post-treatment and three months follow-up (P < 0.01), but was still significantly higher than pre-treatment (P < 0.05).Conclusion: There seems to be a long-term benefit of constraint-induced group therapy. Hand function was maintained over time and daily hand use had increased compared to pre-treatment. To provide guidelines about the clinical use of constraint-induced movement therapy further, larger and controlled studies are needed.
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