(Stroke. 1999;30:586-592.)
© 1999 American Heart Association, Inc.
Original Contribution |
Effects of Constraint-Induced Movement Therapy on Patients With Chronic Motor Deficits After Stroke
A Replication
From the Departments of Biological and Clinical Psychology (W.H.R.M., H.B., M.S.) and Neurology (C.D.), Friedrich-Schiller University of Jena, Germany, and the Department of Psychology, University of Alabama at Birmingham (E.T.).
Correspondence and reprint requests to Wolfgang H.R. Miltner, PhD, Department of Biological and Clinical Psychology, Friedrich-Schiller-University of Jena, Am Steiger 3, Haus 1, D-07743 Jena, Germany. E-mail miltner{at}biopsy.uni-jena.de
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Abstract |
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Background and Purpose—Constraint-induced movement therapy (CI therapy) has previously been shown to produce large improvements in actual amount of use of a more affected upper extremity in the "real-world" environment in patients with chronic stroke (ie, >1 year after the event). This work was carried out in an American laboratory. Our aim was to determine whether these results could be replicated in another laboratory located in Germany, operating within the context of a healthcare system in which administration of conventional types of physical therapy is generally more extensive than in the United States.
Methods—Fifteen chronic stroke patients were given CI therapy, involving restriction of movement of the intact upper extremity by placing it in a sling for 90% of waking hours for 12 days and training (by shaping) of the more affected extremity for 7 hours on the 8 weekdays during that period.
Results—Patients showed a significant and very large degree of improvement from before to after treatment on a laboratory motor test and on a test assessing amount of use of the affected extremity in activities of daily living in the life setting (effect sizes, 0.9 and 2.2, respectively), with no decrement in performance at 6-month follow-up. During a pretreatment control test-retest interval, there were no significant changes on these tests.
Conclusions—Results replicate in Germany the findings with CI therapy in an American laboratory, suggesting that the intervention has general applicability.
Key Words: arm • rehabilitation • physical therapy • motor activity
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Constraint-induced movement therapy (CI therapy) is a new intervention that has, to date, been used mainly for the treatment of the upper extremities of stroke patients.1 2 3 4 5 Most of those treated successfully thus far have been chronic patients who experienced stroke at least 1 year before the start of CI therapy. It is estimated that patients amenable to substantial improvement as a result of CI therapy represent at least 50% of the total stroke population.5 Most of the work with CI therapy has involved constraining use of the unaffected upper extremity for a period of approximately 2 weeks, while giving the affected arm substantial practice in a variety of motor tasks. Training of the affected arm has frequently included a behavioral technique termed "shaping." Research has demonstrated that CI therapy produces great improvement of motor function within a period of 2 weeks, that the treatment effect remains stable for many months after the end of therapy, and that it transfers into the everyday lives of patients. A review of treatment approaches in rehabilitation medicine6 concluded that CI therapy represents one of the few methods of rehabilitation that has demonstrated efficacy in controlled experiments and whose therapeutic effects transfer into the "real-world" environment.
The principles of CI therapy are based on earlier basic research with monkeys1 7 in whom somatic sensation was surgically abolished from a single upper extremity by dorsal rhizotomy. The monkeys stopped using the affected extremity immediately after deafferentation and never spontaneously regained use of it. However, use of the deafferented arm could be induced either by immobilizing the intact arm for a period of consecutive days or by training the affected arm. The resulting extensive reuse of the deafferented arm was permanent, persisting for the rest of the animal's life. Experimental evidence indicated that the loss of motor function due to deafferentation was the result of a learned behavioral suppression termed "learned nonuse."1 7
The same mechanism is thought to apply to humans who suffer mild to moderate hemiparesis after stroke. Despite the fact that patients are often capable of using their affected extremity with reasonably good quality of movement (QOM) when asked to carry out tasks in the laboratory, many of them exhibit relative or sometimes essentially complete nonuse of their paretic limb, beginning in the early poststroke period and continuing for the rest of their lives.5 8
It was felt that the techniques that overcome learned nonuse in monkeys after unilateral deafferentation might also uncover latent motor potentials of many stroke patients and thereby constitute a potential treatment to increase upper-limb use. Multiple experiments2 3 4 5 that have applied the unaffected-arm constraint and affected-arm training techniques to stroke patients have supported this hypothesis. Somatosensory deafferentation and stroke obviously involve very different types of lesions. However, the nature of the learned-nonuse mechanism is such that it will come into operation whenever there is an injury resulting in a large initial deficit followed by a period of prolonged recovery. Learning to not try to use an extremity would appear to occur in the initial postinjury period, whatever the nature of the lesion or the consequent deficit, and having developed it tends to persist. The mechanism is viewed as being general, operating within the context of many types of insult to the central nervous system.
CI therapy constitutes a family of treatments. The most frequently used variant involves motor restriction of the unaffected upper extremity by a resting hand splint and sling and training of the affected extremity. However, there are other related variants that are also effective.4 5 The effective common factor in all forms of CI therapy appears to be inducing patients to repeatedly practice use of the paretic arm for many hours a day for a period of consecutive days. This massed practice of skills is likely to be responsible for the occurrence of use-dependent increase in cortical reorganization demonstrated with transcranial magnetic stimulation in the patients in this study.9 This CI therapy–induced cortical plasticity is presumed to be the basis for the long-term increase in the amount of use (AOU) of the affected extremity. The repetitive training model of CI therapy has received support from recent seminal studies from the laboratory of Mauritz,10 11 in which substantial therapeutic effects were obtained in stroke patients with repetitive concentrated interventions.
Though the results from the application of CI therapy to date are suggestive and encouraging, they must be replicated in other laboratories before therapeutic efficacy can be considered to have been demonstrated conclusively. The question addressed in the current study was whether the results of CI therapy would be the same as in earlier work if it were carried out (1) in a different setting, (2) by different personnel, and (3) in a country where the healthcare system is dissimilar from that in the United States and where patients receive more conventional therapy after stroke. A further difference from earlier work is that patients were accepted for CI therapy as early as one-half year after stroke, rather than 1 year as previously done. The therapy was administered and testing carried out by investigators who received training at the CI Therapy Laboratory (University of Alabama at Birmingham) of one of the coauthors. However, he was not involved in the supervision or collection of data for this experiment. To enable comparison across laboratories, the measurement instruments used here were the same as in previous research. The experimental protocol was approved by this institution's ethics committee.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Subjects
The subjects were 15 adults (6 female; mean age, 54 years; range, 33 to 73 years) (see Table 1
). Twelve patients were married,
and 3 lived alone. The patients had experienced an average of 1.2 CVAs
(range, 1 to 2 CVAs); mean chronicity since (last) CVA was 5.1 years
(range, 0.5 to 17 years). Nine patients exhibited hemiparesis on the
right and 6 on the left side; all reported being right-arm dominant
before stroke. All patients had received extensive physical therapy,
beginning with a mean of 8.4 weeks of inpatient medical rehabilitation
in the acute/subacute period and followed by a range of 20 to 300
half-hour sessions per year over the entire period since the time of
stroke. Each patient either met or exceeded a minimum motor criterion
of at least 20° extension of the affected wrist and 10° of each
finger. Other inclusion criteria were the following: no balance
problems sufficient to compromise safety when wearing the
project's constraint device (3 subjects used a straight cane and
no sling while walking in the street but not indoors; the other
patients did not use assist devices); no serious cognitive problems
(ie, aphasia, attention deficits, visual neglect, disorders of
reasoning, and memory; patients were not allowed to score below the
sixtieth percentile on tests for these functions [see below]); no
serious uncontrolled medical problems; limited spasticity and pain; and
a maximum score of 3.0 on the Motor Activity Log (see below), to
exclude patients whose good motor functioning was too close to a
ceiling for them to be benefited by the therapy. Subjects were
recruited by referral from neurologists and personal physicians and by
advertisements and an article in a local newspaper. They were screened
for suitability by telephone. All patients received separate
examinations by a neurologist and a physical therapist to determine
that all inclusion criteria were met.
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Intervention
Treatment consisted of 2 main elements: (1) restriction of
movement of the unaffected upper extremity by placing it in a resting
hand splint/sling ensemble for 90% of the hours spent awake for a
period of 12 days and (2) training of the affected arm by a procedure
termed "shaping" for approximately 7 h/d on the 8 weekdays during
that period.
Movement Restriction
The ventrum of the affected lower arm and hand was placed in a
resting hand splint that was fastened across its dorsal surface by
Velcro straps; it does not permit wrist flexion and grasp and thus
prevents the manipulation of objects. The arm in the resting hand
splint was then placed inside a sling. Learning to put on and remove
the splint/sling ensemble usually required no more than one-half hour
of instruction before subjects could accomplish these tasks by
themselves without difficulty. A formal behavioral contract with the
subject was set up detailing the agreed-upon activities the patient
would carry out while not wearing the constraint ensemble (eg, bathing,
washing, some aspects of dressing, and any activity in which safety
would be compromised) and the activities that the patient would carry
out while wearing the resting hand splint and sling (eg, grooming,
household tasks, eating).
Shaping
This is a commonly used operant conditioning method in which a
behavioral objective (in this case movement) is approached in small
steps of progressively increasing difficulty.12 13 14 The
subject is rewarded with enthusiastic approval for improvement but is
never blamed (punished) for failure. A basic principle is to keep
extending motor capacity a small increment beyond the
performance level already achieved. A battery of approximately
50 tasks was used for shaping, from which a subset of 15 to 20 was
selected for individual subjects. Task objects were frequently used
household objects (eg, jars, eating utensils, spring-loaded
clothespins), children's toys (eg, building blocks, marbles), and
standard devices used in physical and occupational therapy.
Testing
Before pretreatment testing and after posttreatment testing,
EMG, EEG, MRI, and transcranial magnetic stimulation
studies were carried out; their results will be reported elsewhere.
Each subject received a neuropsychological battery, which consisted of
the following tests: Aachener Aphasie Test,15 Attentional
Deficit Test Battery,16 BIT-Sternchen Test,17
Leistungs-Prüf-Serie (LPS),18 and Word Association
Test (WAT).19
A distinction was drawn in this study between motor performance carried out at the experimenter's request in the laboratory and use of the affected extremity in the real-world setting. Laboratory motor function was determined by means of the Wolf Motor Function Test (WMFT),2 3 20 a 16-item instrument consisting of 13 timed, 2 maximum force exertion, and 1 signature task. The timed tasks were also rated according to 6-step scales (0 to 5) for functional ability (FA) and QOM. The rating scales were developed for use with the Arm Motor Ability Test,21 in which they have been found to have high reliability and validity.21 22 Real-world outcome was assessed by the Motor Activity Log (MAL), which is a semistructured interview that obtains information about 20 important activities of daily living (ADL) carried out outside the laboratory, from such areas as feeding, dressing, and grooming.3 20 Depending on the time of administration, information was obtained about the previous day, weekend, or week. For the last 6 subjects tested, a device (Miltner Constraint Compliance Device) became available for measuring subject compliance with the instruction to wear the movement constraint ensemble for 90% of the waking time spent outside the laboratory (W.H.R. Miltner, S. Franz, E. Taub, unpublished data, 1998).
Procedure
After telephone screening or referral, subjects were brought
into the laboratory, usually several months before project intake,
for a physical therapy examination to determine their eligibility for
the experiment. If subjects were deemed appropriate, they received an
explanation of project procedures and signed an informed consent. A
structured MAL interview was then carried out to determine the AOU and
QOM of the affected arm for the 2 weeks before the "first contact."
Fifteen days before the beginning of treatment, subjects received a
second MAL interview ("baseline"), and they were also given the
WMFT. The MAL and WMFT were administered again on the day before
treatment initiation ("pretreatment"). The repetition of these
tests after a 2-week interval without treatment was designed as a
control procedure to determine whether the simple lapse of time after
an intensive testing contact with the project and for the same
2-week period required by the treatment protocol was sufficient to
produce a treatment effect. On the day before treatment, the cognitive
test battery was presented; in addition, an MAL was
administered in a separate room to a subject's significant other. A
medical/neurological examination was carried out, usually before the
baseline testing day or a few days afterward (in 2 cases). On the day
after the completion of treatment ("posttreatment"), the WFMT and
MAL were repeated, as was an independently administered MAL for the
subject's significant other. The patients returned to the laboratory 4
weeks after treatment ("post-4") and 6 months after treatment
("follow-up") for further testing with the MAL and WMFT and, in
addition, were given the MAL by phone for the first 3 weeks after
treatment ("post-1" to "post-3"). At the time of this writing,
all subjects had completed 1-month follow-up testing, and 12 had
completed their 6-month follow-up testing (there was 1 death before the
6-month time point). The MAL was divided into 2 roughly equivalent
halves. Before and after treatment, both parts of the MAL were
administered on each testing occasion and both the QOM and AOU scales
were used. During treatment, only 1 part of the MAL was used on
individual days (to avoid patient boredom due to repetition). In
addition, just the QOM scale was given during treatment; when use of
the unaffected arm is prevented, the AOU scale for the affected arm
yields an artificially inflated score.
Treatment days began with administration of the MAL, followed by discussion of the amount of compliance since the last treatment day and how compliance could be improved. Shaping of performance on a variety of tasks was then carried out for the remainder of the morning and for a 4-hour period in the afternoon. Eating lunch in the university cafeteria was carried out with the more-affected hand; the subject was helped to the extent required to enable eating (eg, carrying a tray, cutting meat).
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Motor Activity Log
Table 2
displays individual test
scores of the 2 MAL measures obtained at first contact, baseline,
pretreatment and posttreatment, and at post-4 and follow-up.
Figure 1 presents the group means and
SEs of the 2 MAL scores at each of the main time points of the
experimental procedure for all 15 subjects up to the 1-month follow-up
point and for the 12 subjects who had reached the 6-month follow-up at
the time of this writing. Figure 1 also contains the data from
the patients' significant others. Separate repeated-measures ANOVAs
for AOU and QOM scales with side of hemiparesis as a between-subjects
factor revealed significant differences for both scales from first
contact to 6-month follow-up for the 12 subjects who reached that time
point [FAOU (5,55)=62.07, P<0.0001,
=.397; FQOM (5,55)=75.66,
P<0.0001, =.519]. Additional separate analyses
of contrasts indicated that there was a significant treatment effect
from first contact to follow-up [FAOU
(1,11)=121.9, P<0.0001; FQOM (1,11)=
154.74, P<0.0001], and from pretreatment to the fourth
week post-treatment [FAOU (1,11)=98.46,
P<0.0001; FQOM (1,11)= 121.69,
P>0.0001]. However, the scores did not change
significantly between first contact and baseline, between baseline and
pretreatment, or between post-4 and follow-up. No main effect was found
for side of hemiparesis, nor was there a significant interaction
between side of hemiparesis and treatment in this analysis or
any of those reported below.
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All 15 subjects had reached the fourth week of posttreatment. ANOVAs
indicated that there was a significant difference in both AOU and QOM
scores between first contact and post-4 [FAOU
(4,56)=88.49, P<0.0001, =.568;
FQOM (4,56)=82.35, P<0.0001,
=.597]. However, again, AOU and QOM scores did not change
significantly between first contact and baseline and between baseline
and pretreatment.
Paired t tests were carried out for the 11 significant
others for whom complete data were available. They confirmed a
treatment effect from pretreatment to posttreatment for both AOU
[tAOU (10)=-5.64, P<0.0002] and
QOM [tQOM (10)=-7.69, P<0.0001].
The scores for the significant others are presented in Figure 1
as unfilled bars at pretreatment, posttreatment, and
follow-up, the times at which these data were collected. The closeness
of the agreement between the data of the significant others and the
subjects may be noted.
Wolf Motor Function Test
Individual data for the WMFT scores obtained at baseline,
pretreatment, posttreatment, and follow-up are displayed in
Table 3, and group data for all 3 WMFT
measures are presented in Figure 2. ANOVAs on the WMFT scores for the 9
subjects for whom data were available for all observation periods
indicated that there was a significant difference for FA and QOM and a
trend for performance time from baseline to follow-up
[FFA (3,24)=11.28, P<0.004, =.46;
FQOM (3,24)=25.00, P<0.0001,
=.541; Ftime (3,24)=3.29, P=0.095,
=.409]. Additional separate analyses of contrasts showed
that the overall improvement in motor function was due to the change in
scores from pretreatment to posttreatment [FFA
(1,8)=10.00, P<0.02; FQOM
(1,8)=22.84, P<0.0015; Ftime
(1,1)=4.54, P=0.076]. No change was observed from baseline
to pretreatment or from posttreatment to follow-up for any of the 3
measures.
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ANOVAs for each of the 3 WMFT measures for the 13 patients for whom
data were available from baseline, pretreatment, and posttreatment
indicated a significant overall effect for these time points
[FFA (2,24)=41.63, P<0.0001,
=.95; FQOM (2,24)=29.46, P<0.0001,
=.87; Ftime (2,24)=6.24, P<0.009,
=.91]. Separate analyses of contrasts showed that each
measure improved significantly from pretreatment to post-4
[FFA (1,12)=74.89, P<0.0001;
FQOM (1,12)=36.89, P<0.0001;
Ftime (1,12)=7.58, P<0.013], but the
differences in scores between baseline and pretreatment were not
significant.
Other Parameters: Chronicity, Amount of Prior
Treatment, Compliance
Separate ANCOVAs using the variables chronicity and amount of
prior treatment as covariates failed to show a significant impact of
either variable on any of the outcome scores for any period of
observation. In addition, there were no significant correlations
between either of these variables and any of the outcome measures.
It is of interest that the 2 subjects who had suffered a stroke less
than 1 year before to project intake (6 months in both cases) did
approximately as well as the more-chronic subjects. For example, on
MAL-QOM, 1 of these individuals tied for the top score while the other
subject scored at approximately the group mean. Both subjects scored
below the group mean on the MAL-AOU measure, but there were 3
more-chronic subjects who scored lower.
Effect Size
Table 4 contains the effect
sizes for the MAL and WMFT at different time points. The effect sizes
for the MAL measures are extremely large, ranging from 1.33 to 2.98 at
different time points, with a mean of 2.15. The effect sizes for the
WMFT measures are also substantial; however, they are smaller than
those for the MAL scores, ranging from 0.72 to 1.25, with a mean of
1.02. The study-wide effect size was 1.59.
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Discussion |
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The results indicate that CI therapy is a powerful treatment for improving the rehabilitation of movement of the affected upper extremity in chronic stroke patients. The mean effect size for the 2 MAL measures was 2.15, while the mean effect size for the 3 WMFT measures was 1.02. In the meta-analysis literature, effect sizes of 0.2 are considered small, effect sizes of 0.4 to 0.6 are deemed moderate, and effect sizes of
0.8 are judged to be
large.23 Thus, the magnitude of the effect sizes here must
be considered extremely large by the standards of the field. For
example, the mean MAL-AOU scores went from 1.7 at first contact to 3.7
at post-4. A score of 1.7 lies between "very rarely" (a score of 1
indicates virtually not used) and "rarely" (2, used the affected
extremity), while a score of 3.7 is two thirds to three quarters of the
way to "nearly normal" AOU. These are group values; 6 of the 15
subjects scored above 4 ("nearly normal" AOU) at post-4. These data
replicate in almost all respects the data obtained previously with CI
therapy.3 5 The effect sizes for the different
parameters are very similar. Thus, CI therapy may be seen
to produce similar therapeutic gains in 2 different laboratories
located in countries with different healthcare systems. Two aspects of the data from different periods of the experiment time line should be noted. The MAL and WMFT values did not differ significantly between baseline and pretreatment. These time points were separated by 2 weeks in which no therapy was administered. It is the same interval separating pretreatment and posttreatment testing, between which large differences were observed. The baseline testing thus serves as a control procedure indicating that the simple lapse of time, test practice effects, and expectancy of treatment do not alter test scores and therefore cannot account for the experimental results. These data (baseline versus pretreatment) also indicate that the MAL and WMFT have a good intertest reliability. There was also no diminution in test scores between posttreatment, post-4, and follow-up. This supports previous findings that CI therapy produces a long-term improvement in motor function.5
It might intuitively seem that side of hemiparesis could be an important factor in determining the effect of the therapy, with subjects having greater motivation to regain use of a premorbid dominant upper extremity than a premorbid nondominant extremity. This, however, did not prove to be the case. All subjects were right-arm dominant before stroke, and subjects with paresis of the left, nondominant limb exhibited as large a treatment effect as subjects with right hemiparesis. This result suggests that the motivation to use a nondominant limb is sufficiently great to yield a full treatment outcome. The effective factor in producing a rehabilitative improvement would seem to be simply the AOU that the affected extremity engages in during the intervention period.
It was not anticipated that amount of prior conventional therapy would have an impact on the effect of CI therapy.6 This expectation was borne out. In addition, the time since stroke was found to make no difference in the motor improvement produced by CI therapy for the patient population defined by the inclusion criteria of this study. Two aspects of this lack of relationship are particularly noteworthy, relating to the 2 ends of the dimension of chronicity studied in the present work. First, mean chronicity was 5.1 years, with 4 subjects being at 9 or more years after the event. The traditional view in the rehabilitation field, supported by numerous studies, is that patients reach a plateau in their motor recovery at 6 months to 1 year after stroke from which there will be little or no further improvement for the rest of their lives.24 The subjects in this study, however, all showed a very substantial improvement in motor function compared with the motor plateau that each of them had presumably reached before the beginning of CI therapy. Moreover, the 4 subjects with the longest postevent times (9, 9, 14, and 17 years) exhibited a mean improvement on both the AOU and QOM scales of the MAL that was greater than the mean score for the group. Thus, even very chronic stroke survivors are amenable to CI therapy and do as well as individuals who are much closer in time to the focal event. Chronic stroke patients are rarely given therapy to improve motor function because the evidence to date indicates that it is of little value.6 However, the present data demonstrate that CI therapy can benefit very chronic stroke survivors who have had a stroke as many as 17 years earlier.
At the other end of the chronicity spectrum, it was found that the 2 subacute patients who suffered a stroke just 6 months before the initiation of CI therapy received as much benefit from the therapy as more-chronic patients. In the past, the effect of CI therapy has been studied with patients who are >1 year poststroke. However, the present results strongly suggest that CI therapy is also effective for subacute patients. This has practical importance, because subacute patients are much more likely to already be in the treatment system than more-chronic patients and are therefore more accessible to clinicians; moreover, they would often still be eligible for reimbursement for therapy and for the provision of services by medical treatment payers in the United States.
Finally, it should be noted that within the range of patients accepted
for treatment in this study (ie, those who met or exceeded the minimum
motor criterion but did not exceed a score of 3.0 on the QOM scale of
the MAL), initial level of motor ability did not correlate with
treatment outcome. The 2 subjects at project intake who scored 
80
on the Barthel ADL Scale showed treatment gains on the AOU and QOM
scales of the MAL that were slightly greater than the group means, as
did the 4 subjects whose median pretreatment performance time
on the WMFT was greatest (10 seconds); for the 3 subjects who scored
35 on the Copenhagen Stroke Scale, the mean improvement was either as
great (AOU) or a little greater (QOM) than the mean group improvement.
Thus, for the subgroup of stroke survivors defined by the inclusion
criteria of this study, neither level of initial motor ability, amount
of chronicity, amount of prior therapy, nor side of hemiparesis
affected the very substantial amount of improvement in motor ability
produced by CI therapy.
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Acknowledgments |
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Research was supported by the Kuratorium ZNS, Bonn, Germany, grant 95013 (to Dr Miltner), and grant B95-975 R from the Rehabilitation Research Service of the Veterans Administration (to Dr Taub).
Received July 27, 1998; revision received December 1, 1998; accepted December 1, 1998.
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 A. Cacchio, E. De Blasis, V. De Blasis, V. Santilli, and G. Spacca Mirror Therapy in Complex Regional Pain Syndrome Type 1 of the Upper Limb in Stroke Patients Neurorehabil Neural Repair, October 1, 2009; 23(8): 792 - 799. [Abstract] [PDF]
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S. L. Fritz, S. Blanton, G. Uswatte, E. Taub, and S. L. Wolf Minimal Detectable Change Scores for the Wolf Motor Function Test Neurorehabil Neural Repair, September 1, 2009; 23(7): 662 - 667. [Abstract] [PDF]
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 C. Brogardh, U.-B. Flansbjer, and J. Lexell What is the long-term benefit of constraint-induced movement therapy? A four-year follow-up Clinical Rehabilitation, May 1, 2009; 23(5): 418 - 423. [Abstract] [PDF]
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M. Rijntjes, K. Haevernick, A. Barzel, H. van den Bussche, G. Ketels, and C. Weiller Repeat Therapy for Chronic Motor Stroke: A Pilot Study for Feasibility and Efficacy Neurorehabil Neural Repair, March 1, 2009; 23(3): 275 - 280. [Abstract] [PDF]
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K.-c. Lin, C.-y. Wu, J.-s. Liu, Y.-t. Chen, and C.-j. Hsu Constraint-Induced Therapy Versus Dose-Matched Control Intervention to Improve Motor Ability, Basic/Extended Daily Functions, and Quality of Life in Stroke Neurorehabil Neural Repair, February 1, 2009; 23(2): 160 - 165. [Abstract] [PDF]
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M. Rabadi, M. Galgano, D. Lynch, M Akerman, M. Lesser, and B. Volpe A pilot study of activity-based therapy in the arm motor recovery post stroke: a randomized controlled trial Clinical Rehabilitation, December 1, 2008; 22(12): 1071 - 1082. [Abstract] [PDF]
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J. Langan and P. van Donkelaar The Influence of Hand Dominance on the Response to a Constraint-Induced Therapy Program Following Stroke Neurorehabil Neural Repair, June 1, 2008; 22(3): 298 - 304. [Abstract] [PDF]
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S. Page and P. Levine Author Response Physical Therapy, May 1, 2008; 88(5): 684 - 688. [Full Text] [PDF]
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 M. Richter, W. H. R. Miltner, and T. Straube Association between therapy outcome and right-hemispheric activation in chronic aphasia Brain, May 1, 2008; 131(5): 1391 - 1401. [Abstract] [Full Text] [PDF]
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S. J Page, P. Levine, A. Leonard, J. P Szaflarski, and B. M Kissela Modified Constraint-Induced Therapy in Chronic Stroke: Results of a Single-Blinded Randomized Controlled Trial Physical Therapy, March 1, 2008; 88(3): 333 - 340. [Abstract] [Full Text] [PDF]
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K. Dunning, A. Berberich, B. Albers, K. Mortellite, P. G Levine, V. A Hill Hermann, and S. J Page A Four-Week, Task-Specific Neuroprosthesis Program for a Person With No Active Wrist or Finger Movement Because of Chronic Stroke Physical Therapy, March 1, 2008; 88(3): 397 - 405. [Abstract] [Full Text] [PDF]
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J. M. W. W. Myint, G. F. C. Yuen, T. K. K. Yu, C. P. L. Kng, A. M. Y. Wong, K. K. C. Chow, H. C. K. Li, and Chun Por Wong A study of constraint-induced movement therapy in subacute stroke patients in Hong Kong Clinical Rehabilitation, February 1, 2008; 22(2): 112 - 124. [Abstract] [PDF]
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M. Caimmi, S. Carda, C. Giovanzana, E. S. Maini, A. M. Sabatini, N. Smania, and F. Molteni Using Kinematic Analysis to Evaluate Constraint-Induced Movement Therapy in Chronic Stroke Patients Neurorehabil Neural Repair, February 1, 2008; 22(1): 31 - 39. [Abstract] [PDF]
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 S. L. Wolf, C. J. Winstein, J. P. Miller, E. Taub, G. Uswatte, D. Morris, C. Giuliani, K. E. Light, D. Nichols-Larsen, and for the EXCITE Investigators Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. JAMA, November 1, 2006; 296(17): 2095 - 2104. [Abstract] [Full Text] [PDF]
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E. M Frick and J. L Alberts Combined Use of Repetitive Task Practice and an Assistive Robotic Device in a Patient With Subacute Stroke Physical Therapy, October 1, 2006; 86(10): 1378 - 1386. [Abstract] [Full Text] [PDF]
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S.-F. Sun, C.-W. Hsu, C.-W. Hwang, P.-T. Hsu, J.-L. Wang, and C.-L. Yang Application of Combined Botulinum Toxin Type A and Modified Constraint-Induced Movement Therapy for an Individual With Chronic Upper-Extremity Spasticity After Stroke Physical Therapy, October 1, 2006; 86(10): 1387 - 1397. [Abstract] [Full Text] [PDF]
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J. Underwood, P. C Clark, S. Blanton, D. M Aycock, and S. L Wolf Pain, Fatigue, and Intensity of Practice in People With Stroke Who Are Receiving Constraint-Induced Movement Therapy Physical Therapy, September 1, 2006; 86(9): 1241 - 1250. [Abstract] [Full Text] [PDF]
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S. L Fritz, K. E Light, S. N Clifford, T. S Patterson, A. L Behrman, and S. B Davis Descriptive Characteristics as Potential Predictors of Outcomes Following Constraint-Induced Movement Therapy for People After Stroke Physical Therapy, June 1, 2006; 86(6): 825 - 832. [Abstract] [Full Text] [PDF]
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C. Brogardh and B. H Sjolund Constraint-induced movement therapy in patients with stroke: a pilot study on effects of small group training and of extended mitt use Clinical Rehabilitation, March 1, 2006; 20(3): 218 - 227. [Abstract] [PDF]
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 E. Taub, P. S. Lum, P. Hardin, V. W. Mark, and G. Uswatte AutoCITE: Automated Delivery of CI Therapy With Reduced Effort by Therapists Stroke, June 1, 2005; 36(6): 1301 - 1304. [Abstract] [Full Text] [PDF]
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S. L. Fritz, K. E. Light, T. S. Patterson, A. L. Behrman, and S. B. Davis Active Finger Extension Predicts Outcomes After Constraint-Induced Movement Therapy for Individuals With Hemiparesis After Stroke Stroke, June 1, 2005; 36(6): 1172 - 1177. [Abstract] [Full Text] [PDF]
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S. L Fritz, Y.-P. Chiu, M. P Malcolm, T. S Patterson, and K. E Light Feasibility of Electromyography-Triggered Neuromuscular Stimulation as an Adjunct to Constraint-Induced Movement Therapy Physical Therapy, May 1, 2005; 85(5): 428 - 442. [Abstract] [Full Text] [PDF]
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V. M. Pomeroy, C. A. Clark, J. S. G. Miller, J.-C. Baron, H. S. Markus, and R. C. Tallis The Potential for Utilizing the "Mirror Neurone System" to Enhance Recovery of the Severely Affected Upper Limb Early after Stroke: A Review and Hypothesis Neurorehabil Neural Repair, March 1, 2005; 19(1): 4 - 13. [Abstract] [PDF]
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S. J. Page, P. Levine, and A. C. Leonard Modified Constraint-Induced Therapy in Acute Stroke: A Randomized Controlled Pilot Study Neurorehabil Neural Repair, March 1, 2005; 19(1): 27 - 32. [Abstract] [PDF]
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L. Koski, T. J. Mernar, and B. H. Dobkin Immediate and Long-Term Changes in Corticomotor Output in Response to Rehabilitation: Correlation with Functional Improvements in Chronic Stroke Neurorehabil Neural Repair, December 1, 2004; 18(4): 230 - 249. [Abstract] [PDF]
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J. E Sullivan and L. D Hedman A Home Program of Sensory and Neuromuscular Electrical Stimulation With Upper-Limb Task Practice in a Patient 5 Years After a Stroke Physical Therapy, November 1, 2004; 84(11): 1045 - 1054. [Abstract] [Full Text] [PDF]
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J. C. Grotta, E. A. Noser, T. Ro, C. Boake, H. Levin, J. Aronowski, and T. Schallert Constraint-Induced Movement Therapy Stroke, November 1, 2004; 35(11_suppl_1): 2699 - 2701. [Abstract] [Full Text] [PDF]
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A. J Turton and S. R Butler A multiple case design experiment to investigate the performance and neural effects of a programme for training hand function after stroke Clinical Rehabilitation, July 1, 2004; 18(7): 754 - 763. [Abstract] [PDF]
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S. E. Fasoli, H. I. Krebs, M. Ferraro, N. Hogan, and B. T. Volpe Does Shorter Rehabilitation Limit Potential Recovery Poststroke? Neurorehabil Neural Repair, June 1, 2004; 18(2): 88 - 94. [Abstract] [PDF]
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J.H. van der Lee, H. Beckerman, D.L. Knol, H.C.W. de Vet, and L.M. Bouter Clinimetric Properties of the Motor Activity Log for the Assessment of Arm Use in Hemiparetic Patients Stroke, June 1, 2004; 35(6): 1410 - 1414. [Abstract] [Full Text] [PDF]
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W.-R. Schabitz, C. Berger, R. Kollmar, M. Seitz, E. Tanay, M. Kiessling, S. Schwab, and C. Sommer Effect of Brain-Derived Neurotrophic Factor Treatment and Forced Arm Use on Functional Motor Recovery After Small Cortical Ischemia Stroke, April 1, 2004; 35(4): 992 - 997. [Abstract] [Full Text] [PDF]
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N. Byl Dr. Byl Responds Neurorehabil Neural Repair, March 1, 2004; 18(1): 9 - 11. [PDF]
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 M. Kobayashi, S. Hutchinson, H. Theoret, G. Schlaug, and A. Pascual-Leone Repetitive TMS of the motor cortex improves ipsilateral sequential simple finger movements Neurology, January 13, 2004; 62(1): 91 - 98. [Abstract] [Full Text] [PDF]
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R. J Siegert, S. Lord, and K. Porter Constraint-induced movement therapy: time for a little restraint? Clinical Rehabilitation, January 1, 2004; 18(1): 110 - 114. [Abstract] [PDF]
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S. R. Pierce, K. G. Gallagher, S. W. Schaumburg, A. M. Gershkoff, J. P. Gaughan, and L. Shutter Home Forced Use in an Outpatient Rehabilitation Program for Adults with Hemiplegia: A Pilot Study Neurorehabil Neural Repair, December 1, 2003; 17(4): 214 - 219. [Abstract] [PDF]
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S. C DeLuca, K. Echols, S. L. Ramey, and E. Taub Pediatric Constraint-Induced Movement Therapy for a Young Child With Cerebral Palsy: Two Episodes of Care Physical Therapy, November 1, 2003; 83(11): 1003 - 1013. [Abstract] [Full Text] [PDF]
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A. Sterr and S. Freivogel Motor-improvement following intensive training in low-functioning chronic hemiparesis Neurology, September 23, 2003; 61(6): 842 - 844. [Abstract] [Full Text] [PDF]
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N. Byl, J. Roderick, O. Mohamed, M. Hanny, J. Kotler, A. Smith, M. Tang, and G. Abrams Effectiveness of Sensory and Motor Rehabilitation of the Upper Limb Following the Principles of Neuroplasticity: Patients Stable Poststroke Neurorehabil Neural Repair, September 1, 2003; 17(3): 176 - 191. [Abstract] [PDF]
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E. Lackner and H. Hummelsheim Motor-evoked potentials are facilitated during perceptual identification of hand position in healthy subjects and stroke patients Clinical Rehabilitation, June 1, 2003; 17(6): 648 - 655. [Abstract] [PDF]
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S. B. DeBow, M. L.A. Davies, H. L. Clarke, and F. Colbourne Constraint-Induced Movement Therapy and Rehabilitation Exercises Lessen Motor Deficits and Volume of Brain Injury After Striatal Hemorrhagic Stroke in Rats Stroke, April 1, 2003; 34(4): 1021 - 1026. [Abstract] [Full Text] [PDF]
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J. D. Schaechter, E. Kraft, T. S. Hilliard, R. M. Dijkhuizen, T. Benner, S. P. Finklestein, B. R. Rosen, and S. C. Cramer Motor Recovery and Cortical Reorganization after Constraint-Induced Movement Therapy in Stroke Patients: A Preliminary Study Neurorehabil Neural Repair, December 1, 2002; 16(4): 326 - 338. [Abstract] [PDF]
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 W. M. Landau and S. A. Sahrmann Preservation of Directly Stimulated Muscle Strength in Hemiplegia Due to Stroke Arch Neurol, September 1, 2002; 59(9): 1453 - 1457. [Abstract] [Full Text] [PDF]
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 J. K. Willis, A. Morello, A. Davie, J. C. Rice, and J. T. Bennett Forced Use Treatment of Childhood Hemiparesis Pediatrics, July 1, 2002; 110(1): 94 - 96. [Abstract] [Full Text] [PDF]
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M. Hallett Recent Advances in Stroke Rehabilitation Neurorehabil Neural Repair, June 1, 2002; 16(2): 211 - 217. [PDF]
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S. J Page, P. Levine, S. Sisto, Q. Bond, and M. V Johnston Stroke patients' and therapists' opinions of constraint-induced movement therapy Clinical Rehabilitation, January 1, 2002; 16(1): 55 - 60. [Abstract] [PDF]
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C. S. Constantinescu and I. Gottlob Possible Role of Corticosteroids in Nervous System Plasticity: Improvement in Amblyopia After Optic Neuritis in the Fellow Eye Treated with Steroids Neurorehabil Neural Repair, September 1, 2001; 15(3): 223 - 227. [Abstract] [PDF]
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J. M. Meythaler, S. Guin-Renfroe, R. C. Brunner, M. N. Hadley, and G. E. Francisco Intrathecal Baclofen for Spastic Hypertonia From Stroke Editorial Comment Stroke, September 1, 2001; 32(9): 2099 - 2109. [Abstract] [Full Text] [PDF]
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B. B. Johansson, E. Haker, M. von Arbin, M. Britton, G. Langstrom, A. Terent, D. Ursing, and K. Asplund Acupuncture and Transcutaneous Nerve Stimulation in Stroke Rehabilitation : A Randomized, Controlled Trial Stroke, March 1, 2001; 32(3): 707 - 713. [Abstract] [Full Text] [PDF]
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A. W. Dromerick, D. F. Edwards, and M. Hahn Does the Application of Constraint-Induced Movement Therapy During Acute Rehabilitation Reduce Arm Impairment After Ischemic Stroke? Stroke, December 1, 2000; 31(12): 2984 - 2988. [Abstract] [Full Text] [PDF]
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J. H van der Lee, H. Beckerman, G. J Lankhorst, L. M Bouter, S. Blanton, and S. L Wolf Constraint-Induced Movement Therapy Physical Therapy, July 1, 2000; 80(7): 711 - 713. [Full Text]
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J. Liepert, H. Bauder, W. H. R. Miltner, E. Taub, and C. Weiller Treatment-Induced Cortical Reorganization After Stroke in Humans Stroke, June 1, 2000; 31(6): 1210 - 1216. [Abstract] [Full Text] [PDF]
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B. T. Volpe, H. I. Krebs, N. Hogan, L. Edelstein, C. Diels, and M. Aisen A novel approach to stroke rehabilitation: Robot-aided sensorimotor stimulation Neurology, May 23, 2000; 54(10): 1938 - 1944. [Abstract] [Full Text] [PDF]
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S. T. Bland, T. Schallert, R. Strong, J. Aronowski, J. C. Grotta, and D. M. Feeney Early Exclusive Use of the Affected Forelimb After Moderate Transient Focal Ischemia in Rats : Functional and Anatomic Outcome Editorial Comment: Functional and Anatomic Outcome Stroke, May 1, 2000; 31(5): 1144 - 1152. [Abstract] [Full Text] [PDF]
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E. Taub, G. Uswatte, J. H. van der Lee, G. J. Lankhorst, L. M. Bouter, and R. C. Wagenaar Constraint-Induced Movement Therapy and Massed Practice • Response Stroke, April 1, 2000; 31 (4): 983 - 991. [Full Text]
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B. T. Volpe, H. I. Krebs, N. Hogan, L. Edelsteinn, C. M. Diels, and M. L. Aisen Robot training enhanced motor outcome in patients with stroke maintained over 3 years Neurology, November 1, 1999; 53(8): 1874 - 1874. [Abstract] [Full Text]
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J. H. van der Lee, R. C. Wagenaar, G. J. Lankhorst, T. W. Vogelaar, W. L. Deville, and L. M. Bouter Forced Use of the Upper Extremity in Chronic Stroke Patients : Results From a Single-Blind Randomized Clinical Trial Stroke, November 1, 1999; 30(11): 2369 - 2375. [Abstract] [Full Text] [PDF]
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S. Blanton and S. L Wolf An Application of Upper-Extremity Constraint-Induced Movement Therapy in a Patient With Subacute Stroke Physical Therapy, September 1, 1999; 79(9): 847 - 853. [Abstract] [Full Text] [PDF]
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