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(Stroke. 2000;31:2984.)
© 2000 American Heart Association, Inc.
Original Contributions |
Does the Application of Constraint-Induced Movement Therapy During Acute Rehabilitation Reduce Arm Impairment After Ischemic Stroke?
From the Department of Neurology and Program in Occupational Therapy, Washington University School of Medicine, St Louis, Mo.
Correspondence and reprint requests to Alexander Dromerick, MD, Campus Box 8111, 660 South Euclid Ave, St Louis, MO 63110. E-mail dromericka{at}neuro.wustl.edu
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Abstract |
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Background and Purpose—Motor dysfunction after unilateral deafferentation in primates can be overcome by restraining the unaffected limb. We asked whether a constraint-induced movement (CIM) program could be implemented within 2 weeks after stroke and whether CIM is more effective than traditional upper-extremity (UE) therapies during this period.
Methods—Twenty-three persons were enrolled in a pilot randomized, controlled trial that compared CIM with traditional therapies. A blinded observer rated the primary end point, the Action Research Arm Test (ARA). Inclusion criteria were the following: ischemic stroke within 14 days, persistent hemiparesis, evidence of preserved cognitive function, and presence of a protective motor response. Differences between the groups were compared by using Student’s t tests, ANCOVA, and Mann-Whitney U tests.
Results—Twenty subjects completed the 14-day treatment. Two adverse outcomes, a recurrent stroke and a death, occurred in the traditional group; 1 CIM subject met rehabilitation goals and was discharged before completing 14 inpatient days. The CIM treatment group had significantly higher scores on total ARA and pinch subscale scores (P<0.05). Differences in the mean ARA grip, grasp, and gross movement subscale scores did not reach statistical significance. UE activities of daily living performance was not significantly different between groups, and no subject withdrew because of pain or frustration.
Conclusions—A clinical trial of CIM therapy during acute rehabilitation is feasible. CIM was associated with less arm impairment at the end of treatment. Long-term studies are needed to determine whether CIM early after stroke is superior to traditional therapies.
Key Words: cerebrovascular disorders • controlled clinical trials • motor activity • neuronal plasticity • rehabilitation
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Stroke has recently been estimated to affect 730 000 persons per year in the United States, with cost estimates ranging from $13 to $30 billion.1 Although most stroke survivors recover to some degree, many survivors are left with significant sensorimotor and cognitive deficits. These deficits produce long-term need for assistance from caregivers and society. Most stroke treatment research has focused on minimizing brain injury in the acute phase, promoting early reperfusion of ischemic brain, developing neuroprotection strategies, and treating cerebral edema.
Another treatment strategy is to promote clinical improvement despite neurological deficit. One potential method to improve sensorimotor recovery after stroke is constraint-induced movement (CIM), or "forced use."2 3 Most rehabilitation treatments of the hemiplegic patient focus on compensation rather than restoration of upper-extremity (UE) function. Patients are taught to use the unaffected UE for activities of daily living (ADL). In contrast, CIM treatment discourages the use of the unaffected extremity and encourages active use of the hemiplegic arm. The goal is to maximize or restore motor function.
A series of animal studies have shown that the reduced motor activity associated with unilateral deafferentation can be overcome by restraining the unaffected limb to force the animal to use the affected limb. Lesioned animals treated with CIM incorporate these motor gains into functional activities, such as feeding and grooming.3 4 Human studies of CIM treatment in persons with hemiplegia of 6 months’ to decades’ duration2 5 6 7 8 report that this treatment improves objective measures of dexterity and motor function.
Taub and colleagues2 3 have suggested that "learned nonuse" could account for improvements from CIM. In their model, the patient (or lesioned animal) who has difficulty using the affected side will quickly learn to compensate by using the unaffected side. Because the patient or animal continues to use compensatory strategies, the intrinsic recovery that occurs remains "masked." Forcing the animal or patient to use the impaired UE reinforces the long-term use of the UE in ADL.3
Recent findings regarding neuroplasticity and cortical reorganization might also explain the reported effectiveness of CIM. Nudo and others9 10 11 12 13 14 15 describe cortical representation shrinking after lesioning or sensory/motor deprivation. Changes in representational areas were prevented or reversed by focused motor training in primates with concurrent improvements in motor function.9 10 11 12 13 14 15 In addition, functional imaging studies in humans with stroke have found recovery to be associated with shifts of activation during motor tasks involving the affected hand to ipsilateral secondary and tertiary motor areas and to contralateral homologous motor areas.16 17 CIM might be more effective than traditional therapies in promoting these representational changes.18 Finally, the differential effect of CIM could result from superior motor learning in animal subjects—similar to techniques of massed practice or task-specific therapy.19 20 21
No human studies have compared CIM to traditional UE occupational therapy treatment during the first few weeks after stroke, when rehabilitation is typically delivered. Previous studies involved CIM treatment after standard therapies were completed.
We sought to determine, by executing a pilot clinical trial, whether CIM could be implemented during the acute rehabilitation stay (1 to 2 weeks after stroke) and whether CIM is more effective than traditional UE therapies during this time. We hypothesized that hemiplegic stroke patients, treated with CIM rehabilitation within 2 weeks of stroke onset, would show significantly less UE impairment after 14 days of treatment than patients who received traditional rehabilitation treatment.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Design
This was a prospective, randomized, controlled clinical trial, with a blinded observer used to measure the primary end point. The baseline measures were collected after informed consent was obtained. Subjects were individually randomized into experimental or control groups by using a table of random numbers. Study treatment protocols were initiated by rehabilitation day 3. To equalize treatment intensity, the same number of therapy sessions was provided to both groups. When 2 or more study subjects were on the rehabilitation floor at the same time, they were assigned rooms in different hallways and received therapy at different times to prevent unintended crossover. Only persons who completed 14 days of inpatient study treatment were included in the analysis.
Subjects
The Human Studies Committee approved this protocol,
and all subjects gave informed consent. Subjects were drawn from the
acute stroke and brain injury rehabilitation service, a 32-bed unit
admitting more than 250 ischemic stroke survivors yearly. The
average inpatient stay is 18 days. The majority of patients are
admitted to inpatient rehabilitation within 7 days of stroke onset.
Consecutively admitted patients were evaluated for participation in the
study. Persons with hemorrhagic stroke were excluded. Screening
assessments were administered within 2 days of admission to the
rehabilitation floor. Study participants met the following inclusion
criteria: (1) admission to inpatient rehabilitation within 14 days of
ischemic stroke; (2) persistent hemiparesis leading to impaired
UE function, as indicated by a score of 1 or 2 on the motor arm item of
the National Institutes of Health Stroke Scale (NIHSS); (3) evidence of
preserved cognitive function, as indicated by 0 or 1 on the
consciousness, communication, and neglect items of the NIHSS; (4)
presence of a protective response, as indicated by scores of 
3 on the
upper-arm item of the Motor Assessment Scale (MAS); and (5) no UE
injury or conditions that limited use before the
stroke.
Measures
Screening Measures
The
NIHSS22 23
was used as a screening tool (see inclusion criteria) and a measure of
stroke severity. The upper-arm function item of the MAS was used as a
screening tool for
inclusion.24 The
test measures impairment and disability on a 6-point ordinal scale and
includes measures of volitional arm and hand movements, tone, and
mobility. For this study, section 2 in the upper-arm function portion
was applied. We used this measure to eliminate persons without UE
protective reactions.
Primary Outcome Measures
The primary end point for this study was the total
Action Research Arm Test (ARA) score after 14 days of treatment.
Reliability, construct validity, and predictive validity of the ARA
have been well
established.25 26
The ARA has been used in other recent clinical trials of motor
therapies.8 25 27
The ARA is a functional assessment of UE strength, dexterity, and
coordination. Derived from the Fugl-Meyer scale, the ARA includes 19
items divided into 4 subscales: grasp, grip, pinch, and gross
movement.26 The
performance of each motor task is rated on a 4-point scale,
ranging from 0 (no movement possible) to 3 (movement performed
normally). Scores on individual items are added, with a maximum score
per arm of 57.
Secondary Outcome Measures
The Barthel Index (BI) at discharge from inpatient
rehabilitation was used as the measure of basic ADL
function.28 The
Functional Independence
Measure29 (FIM)
includes 5 items that specifically assess UE function (eating,
grooming, bathing, UE dressing, and lower-extremity dressing. Each item
is scored on a 7-point ordinal scale. The BI score, and the score of
each of the 5 individual UE ADL items at discharge, were used as
secondary end points.
Treatment
Treatment regimens were designed to ensure that
patients in both groups received equivalent time and intensity of
treatment directly supervised by the occupational therapist. All
subjects received routine interdisciplinary stroke rehabilitation,
except for the study treatment that occurred during the regularly
scheduled occupational therapy sessions. Individualized and
circuit-training techniques were used in control and experimental
groups. All subjects received study treatment for 2 hours per day, 5
days per week, for 2 consecutive weeks.
Control (Traditional) Occupational Therapy
Treatment
The control group received standard occupational
therapy treatment that included compensatory techniques for ADL, UE
strength and range of motion, and traditional positioning. Subjects
also participated in a circuit-training program allowing patients to
perform bilateral self-range of motion and functional activities in a
supervised setting.
Experimental (CIM) Therapy Treatment
Subjects in the experimental group received a CIM
intervention that directed subject attention and effort toward the
hemiparetic UE and minimized the use of the uninvolved UE during
functional activities. To discourage the use of the unaffected hand
outside of therapy sessions, subjects wore a padded mitten for at least
6 hours per day during the 14-day treatment period. This method allowed
subjects to use the unaffected arm to prevent a fall. Occupational
therapy treatment focused on ADLs, UE training which used the affected
UE as much as possible. The CIM circuit training encouraged the use of
the hemiplegic arm with a variety of UE and functional
tasks.
Analysis
All data analyses were computed with
STATISTICA version 5.1 (Stat-Soft Inc, 1997). Descriptive statistics
were computed for each of the variables included in the study. For
between-group comparisons of continuous variables,
t tests were used. Mann-Whitney U
tests and 
2 analyses were used
when appropriate. ANCOVA was computed to test the study
hypothesis.
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Of the 23 persons enrolled in the study, 20 completed the 14-day treatment. The characteristics of the remaining study participants are shown in Table 1
. Mean time to randomization was 6±2.6 days (range
4 to 14 days). The mean age of the traditional group was almost 10
years greater than that of the subjects in the CIM group, but this
difference was not statistically significant
(t=-1.92, P<0.07). There were no
significant differences between the groups for lesion location (left
versus right), Mini-Mental State Examination scores, or NIHSS scores.
The gender distributions were unequal between the groups (there were
more men in the CIM group); however, this difference was not
statistically significant (2=1.65,
P<0.19).
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As expected, total ARA scores for the unimpaired extremities
were normal for both groups at each time of testing. All posttreatment
assessments were performed by blinded testers on study day 15. The
pretest and posttest ARA scores are presented in
Table 2. The pretest total ARA score was used as a
covariate, and ANCOVA was computed for the posttest total ARA scores.
After the 14 days of treatment, the mean total ARA score was
significantly higher in patients who received CIM treatment than in
patients in the traditional treatment group
(F1,15=11.70, P<0.003). Thus,
the study hypothesis was supported; effect size was
r=0.66.
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The posttest grip, pinch, grasp, and gross motor scores for
each group were compared by using Mann-Whitney U
tests. These findings are presented in
Table 2
. All mean posttreatment ARA subtest scores were
higher for patients in the CIM group; only the pinch subtest scores
achieved statistical significance (U=13.50,
P<0.03). BI and FIM scores at discharge were used as
secondary end points for the study. The BI and FIM item scores are
presented in
Table 3. There were no significant differences in BI scores
at discharge (t=1.14, P<0.27). The 5
FIM UE item scores at discharge were also compared. On each item, the
mean scores were higher for the CIM group. The only significant
difference occurred on the UE dressing item (t= 2.16,
P<0.04).
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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CIM, or "forced-use," treatment may be an appropriate method to improve sensorimotor recovery after stroke.2 3 Most rehabilitation treatments for hemiplegic patients focus on compensatory strategies to promote independence in ADL by any means rather than restoration of UE function. Typically, patients are taught to use the unaffected UE and various assistive devices for ADL. In contrast, CIM treatment discourages the use of the unaffected UE and encourages the use of the hemiplegic arm. The goal of this treatment is to maximize or restore motor function. Before the present study, no studies had tested this treatment in the acute phase of stroke recovery during inpatient stroke rehabilitation.
This pilot study demonstrates that a clinical trial of CIM therapy during acute rehabilitation is feasible. We found a statistically significant improvement in our primary end point, the total ARA score, at the end of 14 days of treatment compared with the standard occupational therapy treatment. All subjects tolerated the treatment, and there was no evidence of excess disability associated with CIM treatment. We emphasize that both groups received the same amount of time with the occupational therapy staff, and so the CIM treatment did not involve more therapy resources than routinely used in our unit.
This pilot trial involved a relatively small number of subjects and did not address the persistence of any treatment effect. Although there was no statistically significant difference in age between the 2 treatment groups, the trend toward younger age in the CIM group could have affected the results of this study. Caution must be used in making any statements about the effectiveness of CIM in the acute rehabilitation setting. We found statistically significant differences using the prespecified end point of the total ARA score. While this result is subject to all the vagaries of a small trial, there was nonetheless a moderate-to-large effect size (r=0.66) for this treatment. Other analyses of the data also support this finding. The CIM group had higher scores on all the ARA subscales, though only the pinch scale achieved statistical significance. There was no difference in overall disability as measured by the BI. However, the CIM group had higher scores on the 5 FIM items that require the use of the arms.
Several safety concerns have been postulated regarding CIM treatment in the acute rehabilitation setting. Painful overuse syndromes and the frustration of focusing on a weak and clumsy limb have been raised as potential problems. No subjects withdrew from the study, suggesting that overuse and frustration are not obstacles to the use of this treatment during acute rehabilitation. Another concern about early use of CIM is that the emphasis on motor restoration might compromise compensatory techniques and thus lead to excess disability. Our study found no suggestion that patients who received CIM were less independent in ADL at the end of the treatment period.
Another safety concern arises from animal studies showing that very intense motor activity, early after lesion, increased stroke lesion volume. Lesion enlargement has been reported in rats placed in conditions that force immediate and extreme overuse of the affected forelimb.30 31 32 This lesion enlargement has been attributed to excitotoxicity33 or exercise-induced hyperthermia.30 34 On the other hand, enriched environments that encourage motor activity improved outcome without increasing lesion volume in rodents.35 Our study tested treatment intensities that were much lower than those used in the animal studies, and all subjects received the routine amounts of therapy delivered in our clinical service. Our subjects were neurologically stable when study treatments were initiated.
The relevance of the animal data to the clinical rehabilitation setting is unknown, but our results are reassuring. The relative improvement in the CIM group does not directly address the question of activity-dependent lesion enlargement in humans. However, even if such enlargement were to occur, the improvements in motor outcomes seen in this trial would call into question the biological significance of any enlargement.
The "best" primary end point for a UE motor intervention has not been established. Even after dozens of acute stroke trials, no single measure is widely accepted as the "best" end point for hyperacute stroke intervention trials.36 37 Most disability measures do not distinguish unilateral from bilateral accomplishment of ADL tasks and would be insensitive to the expected results of a UE motor intervention trial. Other studies have used subject self-reports3 ; we did not choose this method because of the uncertain validity of such reports in the rehabilitation setting and because self-report would circumvent the blinding process. The ultimate goal of treatment is to maximize social participation and quality of life. However, in the early phase of treatment development, it seemed most reasonable to use measures that directly assessed the mechanism by which gains in social participation and quality of life would be achieved.
Several lines of reasoning support early implementation of CIM. From a motor learning perspective, early implementation might minimize learned nonuse. It might be easier to prevent behaviors than attempt to extinguish them once they are established. Primate data also suggest that early implementation of motor training could prevent shrinkage of cortical representational areas. There might also be a window of opportunity after brain injury. Rodent studies suggest a defined period after injury during which synaptic arborization and pruning occur. Although preliminary, our findings suggest that CIM, during acute stroke rehabilitation, could improve motor function without increasing treatment time. Previous CIM studies included persons with chronic hemiplegia, typically 6 months to many years after stroke onset. Chronic CIM trials represent an added period of treatment that requires new resources for implementation.
This investigation demonstrates that a randomized controlled trial of this nonpharmacologic stroke therapy is feasible even under the clinical conditions currently found in the United States. The results of our study are promising enough to justify further clinical studies. A larger sample size and community follow-up would allow the definitive determination of whether early CIM provides long-term and clinically significant benefits versus traditional UE therapies.
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Acknowledgments |
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This study was supported by a Beginning Grant-in-Aid from the American Heart Association, Missouri Affiliate, and by grant JSMF 98:32 CRH-QUA11; Improving Cognitive Performance: Cognition, Neurobiological Mechanisms, Treatment, and Community Reintegration, from the James S. McDonnell Foundation. The authors acknowledge the support of the therapists and nurses involved and the Rehabilitation Service Line of the Barnes-Jewish Hospital.
Received March 27, 2000; revision received August 29, 2000; accepted August 29, 2000.
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References |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
1. Broderick J, Brott T, Kothari R, Miller R, Khoury J, Pancioli A, Mills D, Minneci L, Shukla R. The Greater Cincinnati/Northern Kentucky Stroke Study. Stroke. 1998;29:415–421.
2. Taub E, Miller NE, Novack TA, Cook IEW, Fleming WC, Nepomuceno CS, Connel JS, Crago JE. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil. 1993;74:347–354.[Medline] [Order article via Infotrieve]
3. Taub E, Uswatte G. A new approach to treatment and measurement in physical rehabilitation: constraint-induced (CI) movement therapy. In: Frank R, Elliott T, eds. Handbook of Rehabilitation Psychology. Washington, DC: American Psychological Association; 2000.
4. Ogden R, Franz SI. On cerebral motor control: the recovery from experimentally produced hemiplegia. Psychobiology. 1917;1:33–49.
5. Wolf SL, Lecraw DE, Barton LA, Jann BB. Forced use of hemiplegic upper extremities to reverse the effect of learned nonuse among chronic stroke and head-injured patients. Exp Neurol. 1989;104:125–132.[Medline] [Order article via Infotrieve]
6.
Miltner
WHR, Bauder H, Sommer M, Dettmers C, Taub E. Effects of
constraint-induced movement therapy on patients with chronic motor
deficits after stroke: a replication. Stroke. 1999;30:586–592.
7. Willis J, Bennett J, Nicholl J, Lilien D, Morello A, Davie A, Rice J. Forced-use treatment of childhood hemiparesis. Ann Neurol. 1998;44:992–992. Abstract.
8.
van der
Lee JH, Wagenaar RC, Lankhorst GJ, Vogelaar TW, Deville WL, Bouter LM.
Forced use of the upper extremity in chronic stroke patients.
Stroke. 1999;30:2369–2375.
9. Friel KM, Nudo RJ. Recovery of motor function after focal cortical injury in primates: compensatory movement patterns used during rehabilitative training. Somatosens Motor Res. 1998;15:173–189.[Medline] [Order article via Infotrieve]
10.
Kleim
JA, Barbay S, Nudo RJ. Functional reorganization of the rat motor
cortex following motor skill learning. J
Neurophysiol. 1998;80:3321–3325.
11.
Nudo
RJ, Milliken GW. Reorganization of movement representations in
primary motor cortex following focal ischemic infarcts in adult
squirrel monkeys. J Neurophysiol. 1996;75:2144–2149.
12. Nudo RJ, Wise BM, SiFuentes F, Milliken GW. Neural substrates for the effects of rehabilitative training on motor recovery after ischemic infarct. Science. 1996;272:1791–1794.[Abstract]
13.
Xerri
C, Merzenich MM, Jenkins W, Santucci S. Representational
plasticity in cortical area 3b paralleling tactual-motor skill
acquisition in adult monkeys. Cereb Cortex. 1999;9:264–276.
14.
Xerri
C, Merzenich MM, Peterson BE, Jenkins W. Plasticity of primary
somatosensory cortex paralleling sensorimotor skill recovery from
stroke in adult monkeys. J Neurophysiol. 1998;79:2119–2148.
15. Nudo RJ, Milliken GW. Reorganization of movement representations in primary motor cortex following focal ischemic infarcts in adult squirrel monkeys. J Neurophysiol. 1996;75:2144–2149.
16. Sabatini U, Toni D, Pantano P, Brughitta G, Padovani A, Bozzao L, Lenzi GL. Motor recovery after early brain damage: a case of brain plasticity. Stroke. 1994;25:514–517.[Abstract]
17. Weiller C, Ramsay SC, Wise RJS, Friston KJ, Frackowiak RSJ. Individual patterns of functional reorganization in the human cerebral cortex after capsular infarction. Ann Neurol. 1993;33:181–189.[Medline] [Order article via Infotrieve]
18.
Liepert
J, Bauder H, Miltner WHR, Taub E, Weiller C. Treatment-induced cortical
reorganization after stroke in humans. Stroke. 2000;31:1210–1216.
19. Hanlon RE. Motor learning following unilateral stroke. Arch Phys Med Rehabil. 1996;77:811–815.[Medline] [Order article via Infotrieve]
20. Butefisch C, Hummelschein H, Denzler P, Mauritz K-H. Repetitive training of isolated movements improves the outcome of motor rehabilitation of the centrally paretic hand. J Neurol Sci. 1995;130:59–68.[Medline] [Order article via Infotrieve]
21.
Hesse
S, Bertelt C, Jahnke MT, Schaffrin A, Baake P, Malezic M, Mauritz K-H.
Treadmill training with partial body weight support compared with
physiotherapy in nonambulatory hemiparetic stroke patients.
Stroke. 1995;26:976–981.
22.
Brott
T, Adams HP, Olinger CP, Marler JR, Barsan WG, Biller J, Spilker J,
Holleran R, Eberle R, Hertzberg V, et al. Measurement of acute cerebral
infarction: a clinical examination scale. Stroke. 1989;20:864–870.
23.
Goldstein
LB, Bertels C, Davis JN. Interrater reliability of the NIH stroke
scale. Arch Neurol. 1989;46:660–662.
24. Carr JH, Shepherd RB, Nordholm L, Lynne D. Investigation of a new motor assessment scale for stroke patients. Phys Ther. 1985;65:175–180.
25. Lyle RC. A performance test for assessment of upper limb function in physical rehabilitation treatment and research. Int J Rehabil Res. 1981;4:483–492.[Medline] [Order article via Infotrieve]
26. de Weerdt CJ, Harrison MA. Measuring recovery of arm-hand function in stroke patients: a comparison of the Brunnstrom-Fugl-Meyer test and the Action Research Arm Test. Physiother Can. 1986;37:65–70.
27. Kwakkel G, Wagenaar RC, Twisk JWR, Lankhorst GJ, Koestier JC. Intensity of leg and arm training after primary middle-cerebral-artery stroke: a randomised trial. Lancet. 1999;354:191–196.[Medline] [Order article via Infotrieve]
28. Mahoney F, Barthel D. Functional evaluation: the Barthel Index. Md Med J. 1965;2:61–65.
29. Granger CV, Hamilton BB, Sherwin FS. Guide for the Use of the Uniform Data Set for Medical Rehabilitation. Buffalo, NY: Buffalo General Hospital, Uniform Data System for Medical Rehabilitation Project Office; 1986.
30. Risedal A, Zeng J, Johansson BB. Early training may exacerbate brain damage after focal brain ischemia in the rat. J Cereb Blood Flow Metab. 1999;19:997–1003.[Medline] [Order article via Infotrieve]
31. Humm JL, Kozlowski DA, James DC, Gotts JE, Schallert T. Use-dependent exacerbation of brain damage occurs during an early post-lesion vulnerable period. Brain Res. 1998;783:286–292.[Medline] [Order article via Infotrieve]
32.
Kozlowski
DA, James DC, Schallert T. Use-dependent exaggeration of neuronal
injury after unilateral sensorimotor cortex lesions. J
Neurosci. 1996;16:4776–4786.
33. Humm JL, Kozlowski DA, Bland ST, James DC, Schallert T. Use-dependent exaggeration of brain injury: is glutamate involved? Exp Neurol. 1999;157:349–358.[Medline] [Order article via Infotrieve]
34.
Bland
ST, Schallert T, Strong R, Aronowski J, Grotta JC. Early exclusive use
of the affected forelimb after moderate transient focal
ischemia in rats: functional and anatomic outcome.
Stroke. 2000;31:1144–1152.
35. Johansson BB, Ohlsson A-L. Environment, social interaction, and physical activity as determinants of functional outcome after cerebral infarction in the rat. Exp Neurol. 1996;139:322–327.[Medline] [Order article via Infotrieve]
36.
Lyden
PD, Lau GT. A critical appraisal of stroke evaluation and rating
scales. Stroke. 1991;22:1345–1352.
37.
Wardlaw
JM, Sandercock PAG, Warlow CP, Lindley R. Trials of
thrombolysis in acute ischemic stroke: does the
choice of a primary outcome measure really matter?
Stroke. 2000;31:1133–1135.
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 S. L Wolf Revisiting Constraint-Induced Movement Therapy: Are We Too Smitten With the Mitten? Is All Nonuse "Learned"? and Other Quandaries Physical Therapy, September 1, 2007; 87(9): 1212 - 1223. [Abstract] [Full Text] [PDF]
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B. Hemmen and H.A.M. Seelen Effects of movement imagery and electromyography-triggered feedback on arm hand function in stroke patients in the subacute phase Clinical Rehabilitation, July 1, 2007; 21(7): 587 - 594. [Abstract] [PDF]
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P. L Scheets, S. A Sahrmann, and B. J Norton Use of Movement System Diagnoses in the Management of Patients With Neuromuscular Conditions: A Multiple-Patient Case Report Physical Therapy, June 1, 2007; 87(6): 654 - 669. [Abstract] [Full Text] [PDF]
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S. L Fritz, S. Z George, S. L Wolf, and K. E Light Participant Perception of Recovery as Criterion to Establish Importance of Improvement for Constraint-Induced Movement Therapy Outcome Measures: A Preliminary Study Physical Therapy, February 1, 2007; 87(2): 170 - 178. [Abstract] [Full Text] [PDF]
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B. H. Dobkin Confounders in Rehabilitation Trials of Task-Oriented Training: Lessons From the Designs of the EXCITE and SCILT Multicenter Trials Neurorehabil Neural Repair, January 1, 2007; 21(1): 3 - 13. [Abstract] [PDF]
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C. Boake, E. A. Noser, T. Ro, S. Baraniuk, M. Gaber, R. Johnson, E. T. Salmeron, T. M. Tran, J. M. Lai, E. Taub, et al. Constraint-Induced Movement Therapy During Early Stroke Rehabilitation Neurorehabil Neural Repair, January 1, 2007; 21(1): 14 - 24. [Abstract] [PDF]
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J. M. Wagner, C. E. Lang, S. A. Sahrmann, Q. Hu, A. J. Bastian, D. F. Edwards, and A. W. Dromerick Relationships between Sensorimotor Impairments and Reaching Deficits in Acute Hemiparesis Neurorehabil Neural Repair, September 1, 2006; 20(3): 406 - 416. [Abstract] [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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N. Sharma, V. M. Pomeroy, and J.-C. Baron Motor Imagery: A Backdoor to the Motor System After Stroke? Stroke, July 1, 2006; 37(7): 1941 - 1952. [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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J. Higgins, N. M Salbach, S. Wood-Dauphinee, C. L Richards, R. Cote, and N. E Mayo The effect of a task-oriented intervention on arm function in people with stroke: a randomized controlled trial Clinical Rehabilitation, April 1, 2006; 20(4): 296 - 310. [Abstract] [PDF]
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M. Rijntjes, V. Hobbeling, F. Hamzei, S. Dohse, G. Ketels, J. Liepert, and C. Weiller Individual Factors in Constraint-Induced Movement Therapy after Stroke Neurorehabil Neural Repair, September 1, 2005; 19(3): 238 - 249. [Abstract] [PDF]
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B. Bates, J. Y. Choi, P. W. Duncan, J. J. Glasberg, G. D. Graham, R. C. Katz, K. Lamberty, D. Reker, and R. Zorowitz Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care: Executive Summary Stroke, September 1, 2005; 36(9): 2049 - 2056. [Abstract] [Full Text] [PDF]
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P. W. Duncan, R. Zorowitz, B. Bates, J. Y. Choi, J. J. Glasberg, G. D. Graham, R. C. Katz, K. Lamberty, and D. Reker Management of Adult Stroke Rehabilitation Care: A Clinical Practice Guideline Stroke, September 1, 2005; 36(9): e100 - e143. [Full Text] [PDF]
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J. Desrosiers, D. Bourbonnais, H. Corriveau, S. Gosselin, and G. Bravo Effectiveness of unilateral and symmetrical bilateral task training for arm during the subacute phase after stroke: a randomized controlled trial Clinical Rehabilitation, June 1, 2005; 19(6): 581 - 593. [Abstract] [PDF]
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 B. H. Dobkin Rehabilitation after Stroke N. Engl. J. Med., April 21, 2005; 352(16): 1677 - 1684. [Full Text] [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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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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R P. Van Peppen, G Kwakkel, S Wood-Dauphinee, H J. Hendriks, P. J Van der Wees, and J Dekker The impact of physical therapy on functional outcomes after stroke: what's the evidence? Clinical Rehabilitation, August 1, 2004; 18(8): 833 - 862. [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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C. G Canning, L. Ada, R. Adams, and N. J O'Dwyer Loss of strength contributes more to physical disability after stroke than loss of dexterity Clinical Rehabilitation, March 1, 2004; 18(3): 300 - 308. [Abstract] [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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 M. Ferraro, J. J. Palazzolo, J. Krol, H. I. Krebs, N. Hogan, and B. T. Volpe Robot-aided sensorimotor arm training improves outcome in patients with chronic stroke Neurology, December 9, 2003; 61(11): 1604 - 1607. [Abstract] [Full Text] [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. Barreca, S. L. Wolf, S. Fasoli, and R. Bohannon Treatment Interventions for the Paretic Upper Limb of Stroke Survivors: A Critical Review Neurorehabil Neural Repair, December 1, 2003; 17(4): 220 - 226. [Abstract] [PDF]
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C. J. Winstein, J. P. Miller, S. Blanton, E. Taub, G. Uswatte, D. Morris, D. Nichols, and S. Wolf Methods for a Multisite Randomized Trial to Investigate the Effect of Constraint-Induced Movement Therapy in Improving Upper Extremity Function among Adults Recovering from a Cerebrovascular Stroke Neurorehabil Neural Repair, September 1, 2003; 17(3): 137 - 152. [Abstract] [PDF]
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H. Rodgers, J. Mackintosh, C. Price, R. Wood, P. McNamee, T. Fearon, A. Marritt, and R. Curless Does an early increased-intensity interdisciplinary upper limb therapy programme following acute stroke improve outcome? Clinical Rehabilitation, June 1, 2003; 17(6): 579 - 589. [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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M. Ferraro, J. H. Demaio, J. Krol, C. Trudell, K. Rannekleiv, L. Edelstein, P. Christos, M. Aisen, J. England, S. Fasoli, et al. Assessing the Motor Status Score: A Scale for the Evaluation of Upper Limb Motor Outcomes in Patients after Stroke Neurorehabil Neural Repair, September 1, 2002; 16(3): 283 - 289. [Abstract] [PDF]
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S. J. Page, S. Sisto, M. V. Johnston, and P. Levine Modified Constraint-Induced Therapy after Subacute Stroke: A Preliminary Study Neurorehabil Neural Repair, September 1, 2002; 16(3): 290 - 295. [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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 R. D Herbert, C. G Maher, A. M Moseley, and C. Sherrington Regular review: Effective physiotherapy BMJ, October 6, 2001; 323(7316): 788 - 790. [Full Text] [PDF]
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