Improvement of gait and balance function in chronic post-stroke patients induced by Lower Extremity - Constraint Induced Movement Therapy: a randomized controlled clinical trial.

OBJECTIVE: To evaluate the effects of Lower Extremity - Constraint Induced Movement Therapy on gait function and balance in chronic hemiparetic patients. METHODS: Randomized, controlled, single-blinded study. We recruited chronic post stroke patients and allocated them to Lower Extremity - Constraint Induced Movement Tharapy (LE-CIMT) or Control Group. The LE-CIMT group received this protocol 2.5 hour/day for 15 followed days, including: 1) intensive supervised training, 2) use of shaping as a strategy for motor training, and 3) application of a transfer package. The control group received conventional physiotherapy for 2.5 hours/day for 15 followed days. Outcomes were assessed at baseline, after the interventions, and after 6 months, through 6-minute walk test and Mini-Balance Evaluation Systems Test; 10-meter walk test, Timed Up and Go, 3-D gait analysis, and Lower Extremity - Motor Activity Log. RESULTS: LE-CIMT was superior on the Assistance and confidence subscale of Lower Extremity - Motor Activity Log, Mini-BESTest and 6-minute walk test. The effect size for all outcomes was small when comparing both groups. LE-CIMT showed clinically significant differences in daily activities, balance, and gait capacity, with no clinically significant difference for spatiotemporal parameters. CONCLUSION: The LE-CIMT protocol had positive outcomes on balance, performance, and confidence perception.

The effect of constraint-induced movement therapy assessed by accelerometry: the impact on daytime activity and sleep in children with cerebral palsy / O efeito da terapia por contensão induzida avaliada por meio de acelerômetros: o impacto na atividade diurna e no sono em crianças com paralisia cerebral

Abstract Introduction Spastic hemiparetic cerebral palsy (CP) is the most prevalent type of CP. Children with spastic hemiparesis experience difficulties when using their affected upper extremities, and one effective treatment is the Constraint-Induced Movement Therapy (CIMT). The study of rest-activity patterns provides information on children's daily activities with spastic hemiparetic CP during the day and sleep. Objective To investigate the effect of CIMT on the rest-activity patterns in children with spastic hemiparetic CP vs in a healthy group. Methods Nonrandomized controlled trial was conducted at the Neuropediatric Center of the Hospital de Clínicas Complex, in Curitiba, Brazil. Children with spastic hemi-paretic CP between 5 and 16 years old participated in the study group and receive the CIMT. The healthy group was composed of children between 5 and 15 years old. Both groups used accelerometer to record rest-activity patterns, that may be studied through nonparametric variables of accelerometer: M10 (an individual's most active 10h); L5 (an individual's least active 5h); and RA (relative amplitude of the circadian rest-activity patterns). Results Forty-five children were recruited, and 38 were included in the analyses (19 allocated to each group). In the study group, there was a significant increase in M10 and L5 (p < 0.001) after CIMT. The values of M10 and L5 were significantly higher (p < 0.001) in the healthy group compared to the study group after CIMT. Conclusion Our results showed that children with spastic hemiparetic CP became more active and participant in their daily life during the day as well as more efficient sleeping.

Resumo Introdução A paralisia cerebral (PC) hemiparética espástica é o tipo de PC mais prevalente. Crianças com hemiparesia es-pástica apresentam dificuldades ao usar as extremidades superiores afetadas e um tratamento eficaz é a Terapia por Contensão Induzida (TCI). O estudo dos padrões de atividade-repouso fornece informações sobre as atividades diárias de crianças com PC hemiparética espástica durante o dia e o sono. Objetivo Investigar o efeito da TCI nos padrões de repouso-atividade em crianças com PC hemiparética espástica versus um grupo saudável. Métodos Realizou-se um ensaio controlado não randomizado no Centro de Neuropediatria do Complexo do Hospital de Clínicas, Curitiba, Brasil. Crianças com PC hemi-parética espástica entre 5 e 16 anos participaram do grupo de estudo e receberam a TCI. O grupo saudável foi composto por crianças entre 5 e 15 anos. Ambos os grupos utilizaram um acelerômetro para registrar padrões de atividade-repouso, os quais podem ser estudados através de variáveis não paramé-tricas do acelerômetro: M10 (10h mais ativas de um indivíduo); L5 (5h menos ativas de um indivíduo); e AR (amplitude rela-tiva dos padrões de atividade-repouso). Resultados Foram recrutadas 45 crianças e 38 foram incluídas nas análises (19 alocadas em cada grupo). No grupo de estudo, houve aumento significativo de M10 e L5 (p < 0,001) após TCI. Os valores de M10 e L5 foram significativamente maiores (p < 0,001) no grupo saudável em comparação ao grupo de estudo após TCI. Conclusão Os resultados do presente estudo mostraram que crianças com PC hemiparética espástica tornaram-se mais ativas e participantes de sua vida diária durante o dia, bem como dormiram mais eficientemente.

Aphasia improvement without logotherapy during motor neurorehabilitation of post-stroke hemiparesis using virtual reality or modified constraint-induced movement therapy: A retrospective cohort.

BACKGROUND: Some research suggests that post-stroke aphasia can recover "on its own", however, there is evidence of a common neural substrate for motor and language systems. We hypothesize, that motor neurorehabilitation of hemiparesis could be related to simultaneous improvement in aphasia. OBJECTIVE: To measure changes in post-stroke aphasia and its relation with hemiparesis treated with different therapies. METHODS: Database information (n = 32) on post-stroke hemiparesis (Fugl-Meyer Scale evaluated) managed with virtual reality (VR) versus modified constraint-induced movement therapy (mCIMT) or regular therapy (rPT/OT) was analyzed. None received logotherapy (LT) by appointment at four months. INCLUSION CRITERIA: < 3 months after the stroke, aphasia severe (Boston Aphasia Intensity Scale), and all three evaluations. RESULTS: Twenty-one patient records met inclusion criteria (71,4% women and mean age 66,67±3,13 years) who received VR, mCIMT, or rPT/OT (n = 6, 8, and 7, respectively). There was continuous intra-groups improvement in aphasia (p < 0.05), but inter-groups the greater aphasia recovery (p = 0.05) and hemiparesis (p = 0.02) were in VR, with a high correlation in evolution between them (r = 0.73; p = 0.047). CONCLUSION: High clinical correlation between aphasia, without LT, and hemiparesis evolution during motor neurorehabilitation would support common neural connections stimulation. We will conduct a clinical trial, with a larger sample size to contrast our hypothesis.

Neurophysiological biomarkers of motor improvement from Constraint-Induced Movement Therapy and Robot-Assisted Therapy in participants with stroke.

Background: The mechanism of stroke recovery is related to the reorganization of cerebral activity that can be enhanced by rehabilitation therapy. Two well established treatments are Robot-Assisted Therapy (RT) and Constraint-Induced Movement Therapy (CIMT), however, it is unknown whether there is a difference in the neuroplastic changes induced by these therapies, and if the modifications are related to motor improvement. Therefore, this study aims to identify neurophysiological biomarkers related to motor improvement of participants with chronic stroke that received RT or CIMT, and to test whether there is a difference in neuronal changes induced by these two therapies. Methods: This study included participants with chronic stroke that took part in a pilot experiment to compare CIMT vs. RT. Neurophysiological evaluations were performed with electroencephalography (EEG) and transcranial magnetic stimulation (TMS), pre and post rehabilitation therapy. Motor function was measured by the Wolf Motor Function Test (WMFT) and Fugl-Meyer Assessment Upper Limb (FMA-UL). Results: Twenty-seven participants with chronic stroke completed the present study [mean age of 58.8 years (SD ± 13.6), mean time since stroke of 18.2 months (SD ± 9.6)]. We found that changes in motor threshold (MT) and motor evoked potential (MEP) in the lesioned hemisphere have a positive and negative correlation with WMFT improvement, respectively. The absolute change in alpha peak in the unlesioned hemisphere and the absolute change of the alpha ratio (unlesioned/lesioned hemisphere) is negatively correlated with WMFT improvement. The decrease of EEG power ratio (increase in the lesioned hemisphere and decrease in the unlesioned hemisphere) for high alpha bandwidths is correlated with better improvement in WMFT. The variable "type of treatment (RT or CIMT)" was not significant in the models. Conclusion: Our results suggest that distinct treatments (RT and CIMT) have similar neuroplastic mechanisms of recovery. Moreover, motor improvements in participants with chronic stroke are related to decreases of cortical excitability in the lesioned hemisphere measured with TMS. Furthermore, the balance of both EEG power and EEG alpha peak frequency in the lesioned hemisphere is related to motor improvement.

Effects of constraint-induced movement therapy on activity and participation after a stroke: Systematic review and meta-analysis.

Introduction: Hemiparesis is the main sensorimotor deficit after stroke. It can result in limitations in Activities of Daily Living (ADL) and social participation. Hemiparesis can be treated with behavioral techniques of intensive use of the affected arm, such as constraint-induced movement therapy (CIMT), however, it remains unclear whether motor improvement can lead to increases in the domains of activity and participation. Objective: Identify whether CIMT is superior to usual techniques to enhance activity and participation outcomes in stroke survivors. Methods: A systematic review with meta-analysis was conducted, based on the PRISMA guidelines. Search databases were: PubMed, LILACS, Embase, SciELO, Cochrane Library, Scopus, Medline, and Web of Science, with no language restriction. Meta-analysis was performed with Review Manager (version 5.3), significance level p ≤ 0.05. Results: A total of 21 articles were included for analysis. Superior effects were observed on motor function and performance in activities of daily living of individuals treated with CIMT. The outcomes measures utilized were: Fugl-Meyer Assessment (p = 0.00001); Wolf motor function test (p = 0.01); Modified Barthel Index (p = 0.00001); Motor Activity log (MAL) Amount of use (AOU) (p = 0.01); MAL Quality of movement (QOM) (p = 0.00001); Action Research Arm Test-ARAT (p = 0.00001); and FIM (p = 0.0007). Conclusion: Our results show that CIMT results in more significant gains in the functional use of the upper limb in ADL and functional independence, demonstrating superior activity and participation results in stroke survivors when compared to conventional therapies.

Robot-Assisted Therapy and Constraint-Induced Movement Therapy for Motor Recovery in Stroke: Results From a Randomized Clinical Trial.

Background: Stroke is one of the leading causes of adult disability, and up to 80% of stroke survivors undergo upper extremity motor dysfunction. Constraint-Induced Movement Therapy (CIMT) and Robot-Assisted Therapy (RT) are used for upper limb stroke rehabilitation. Although CIMT and RT are different techniques, both are beneficial; however, their results must be compared. The objective is to establish the difference between RT and CIMT after a rehabilitation program for chronic stroke patients. Method: This is a randomized clinical trial, registered at ClinicalTrials.gov (ID number NCT02700061), in which patients with stroke received sessions of RT or CIMT protocol, combined with a conventional rehabilitation program for 12 weeks. The primary outcome was measured by Wolf Motor Function Test (WMFT) and Fugl-Meyer Assessment-Upper Limb (FMA-UL). Activities of daily living were also assessed. Results: Fifty one patients with mild to moderate upper limb impairment were enrolled in this trial, 25 women and 26 men, mean age of 60,02 years old (SD 14,48), with 6 to 36 months after stroke onset. Function significantly improved regardless of the treatment group. However, no statistical difference was found between both groups as p-values of the median change of function measured by WMFT and FMA were 0.293 and 0.187, respectively. Conclusion: This study showed that Robotic Therapy (RT) was not different from Constraint-Induced Movement Therapy (CIMT) regardless of the analyzed variables. There was an overall upper limb function, motor recovery, functionality, and activities of daily living improvement regardless of the interventions. At last, the combination of both techniques should be considered in future studies.

Effects of lower extremity constraint-induced movement therapy on gait and balance of chronic hemiparetic patients after stroke: description of a study protocol for a randomized controlled clinical trial.

BACKGROUND: Protocols involving intensive practice have shown positive outcomes. Constraint induced movement therapy (CIT) appears to be one of the best options for better outcomes in upper limb rehabilitation, but we still have little data about lower extremity constraint-induced movement therapy (LE-CIT) and its effects on gait and balance. OBJECTIVE: To evaluate the effects of an LE-CIT protocol on gait functionality and balance in chronic hemiparetic patients following a stroke. METHODS: The study adopts a randomized, controlled, single-blinded study design. Forty-two patients, who suffered a stroke, who were in the chronic phase of recovery (>6 months), with gait disability (no community gait), and who were able to walk at least 10 m with or without the advice or support of 1 person, will be randomly allocated to 2 groups: the LE-CIT group or the control group (intensive conventional therapy). People will be excluded if they have speech deficits that render them unable to understand and/or answer properly to evaluation scales and exercises selected for the protocol and/or if they have suffered any clinical event between the screening and the beginning of the protocol. Outcome will be assessed at baseline (T0), immediately after the intervention (T1), and after 6 months (T2). The outcome measures chosen for this trial are as follows: 6-min walk test (6minWT), 10-m walk test (10mWT), timed up and go (TUG), 3-D gait analysis (3DGA), Mini Balance Evaluation Systems Test (Mini-BESTest), and as a secondary measure, Lower Extremity Motor Activity Log will be evaluated (LE-MAL). The participants in both groups will receive 15 consecutive days of daily exercise. The participants in the LE-CIT group will be submitted to this protocol 2.5 h/day for 15 consecutive days. It will include (1) intensive supervised training, (2) use of shaping as strategy for motor training, and (3) application of a transfer package (plus 30 min). The control group will receive conventional physiotherapy for 2.5 h/day over 15 consecutive days (the same period as the CIT intervention). Repeated measures analyses will be made to compare differences and define clinically relevant changes between groups. RESULTS: Data collection is currently on-going and results are expected in 2021. DISCUSSION: LE-CIT seems to be a good protocol for inclusion into stroke survivors' rehabilitation as it has all the components needed for positive results, as well as intensity and transference of gains to daily life activities. TRIAL REGISTRATION: www.ensaiosclinicos.gov.br RBR-467cv6 . Registered on 10 October 2017. "Effects of Lower Extremities - Constraint Induced Therapy on gait and balance function in chronic hemipretic post-stroke patients".

Electromyographic analysis of constraint-induced movement therapy effects in patients after stroke in chronic course.

[Purpose] The purpose is to analyze the effects of Constraint-induced Movement Therapy in post stroke patients in chronic course. [Subjects and Methods] This is a Quasi-experiment study and the adopted protocol consisted of a three-hour therapy for ten consecutive working days applied to a constraint intact upper limb. Surface Electromyography, Motor Activity Log, Wolf Motor Function Test and Functional Independence Measure were used for evaluating the experiment. [Results] The individuals showed reduction in the degree of spasticity, confirmed by Surface Electromyography. In relation to Motor Activity Log this study showed an increase in amount and in quality of the paretic upper limb movement. The Wolf Motor Function Test showed reduction in the average time to perform the tasks and a functional improvement was identified through the Functional Independence Measure. [Conclusion] Constraint Induced Movement Therapy proved to be a relevant method to improve motor function in chronic hemiparesis post stroke reducing the spasticity, maximizing and improving the use of committed upper limb.

Efeitos da terapia por contensão induzida nas lesões encefálicas adquiridas / The effects of constraint induced movement therapy in acquired brain injuries

Introdução: A Terapia por Contensão Induzida (TCI) é uma técnica de reabilitação que tem como objetivo melhora da função do membro superior acometido. Objetivos: Determinar se o protocolo da TCI é adequado para a reabilitação do membro superior em adultos com Lesões Encefálicas Adquiridas (LEA). analisar a manutenção dos resultados e identificar possíveis preditores de eficácia da técnica. Método: Estudo retrospectivo, 40 pacientes. As escalas utilizadas foram Motor Activity Log (MAL), Quantidade (QT) e Qualidade (QL) de movimento do membro superior acometido e Wolf Motor Function Test (WMFT). Resultados e discussão: As médias de QT e QL do membro superior acometido no pré e pós-tratamento tiveram um aumento significativo (p < 0,001), enquanto as do WMFT apresentaram uma redução significativa do tempo (p <0,001), o que representa uma melhora na habilidade motora e maior uso fora do ambiente terapêutico. Os ganhos foram mantidos após 12 meses do termino do protocolo, e não foi evidenciado nenhum preditor de evolução. Conclusão: A TCI demonstrou eficácia na melhora da habilidade motora e reversão do não uso aprendido do membro superior acometido, estes resultados foram mantidos após um ano da intervenção. Não foi evidenciado no estudo nenhum fator preditor de eficácia da técnica. (AU)

Introduction:The Constraint Induced Therapy (CIT) is a rehabilitation techique that aims to improve the function of the impaired upper limb. Objectives: To determine if the CIT protocol is suitable for rehabilitation of the upper limb in adults with brain injury, if if the results are maintained and identify possible predictors of technique effectiveness. Method: Retrospective study, 40 patients. The Scales used were Motor Motor Activity Log (MAL), How often (HO) and How Well (HW) of movement of affected upper limb and Wolf Motor Function Test (WMFT). Results and discussion: The averages of HO and HW of the affected upper limb in pre and post-treatment had a significant increase (p <0.001), and the WMFT showed a significant decrease of time (p < 0.001), which represents an improvement of motor skill, and more use out of therapeutic environment. The gains were kept after 12 months after the end of the protocol, and did not show any predictor of unfavorable outcome. Conclusion: The CIT demonstrated effectiveness in improving motor skills and reversal learned non-use of affected upper limb; these results were kept after one year of intervention. This study did not show any predictor of the technique effectiveness. (AU)

Cerebral palsy in adult patients: constraint-induced movement therapy is effective to reverse the nonuse of the affected upper limb / A eficácia da terapia por contensão induzida em pacientes adultos com paralisia cerebral

ABSTRACT Objective To determine if the original protocol of Constraint-Induced Movement Therapy (CIMT), is adequate to reverse the nonuse of the affected upper limb (AUL) in patients with Cerebral Palsy (CP) in adulthood. Method The study included 10 patients diagnosed with CP hemiparesis had attended the adult protocol CIMT, from January/August 2009/2014. Results Average age 24.6 (SD 9.44); MAL average pretreatment How Often (HO) = 0.72 and How Well (HW) = 0.68 and post-treatment HO = 3.77 and HW = 3.60 (p ≤ 0.001) and pretreatment WMFT average = 21.03 and post-treatment average = 18.91 (p = 0.350). Conclusion The constraint-induced movement therapy is effective to reverse the nonuse learn of the AUL in adult patients with CP.

RESUMO Objetivo Determinar se o protocolo original da Terapia por Contensão Induzida (TCI), é adequado para reverter o não uso do membro superior afetado (MSA) em pacientes com Paralisia Cerebral (PC) na fase adulta. Método Foram incluídos no estudo 10 pacientes com diagnóstico de PC hemiparéticos que haviam realizado o protocolo adulto da TCI, no período de janeiro/2009 a agosto/2014. Resultados Média de idade 24,6 (DP 9,44); MAL média pré-tratamento Quantidade (QT) = 0,72 e Qualidade (QL) = 0,68 e no pós-tratamento QT = 3,77 e QL = 3,60 (p ≤ 0,001) e WMFT média pré-tratamento = 21,03 e média pós-tratamento = 18,91 (p = 0,350). Conclusão A terapia por contensão induzida é eficaz para reverter o não uso do MSA em pacientes adultos com PC.

The impact of transcranial direct current stimulation (tDCS) combined with modified constraint-induced movement therapy (mCIMT) on upper limb function in chronic stroke: a double-blind randomized controlled trial.

PURPOSE: This pilot double-blind sham-controlled randomized trial aimed to determine if the addition of anodal tDCS on the affected hemisphere or cathodal tDCS on unaffected hemisphere to modified constraint-induced movement therapy (mCIMT) would be superior to constraints therapy alone in improving upper limb function in chronic stroke patients. METHODS: Twenty-one patients with chronic stroke were randomly assigned to receive 12 sessions of either (i) anodal, (ii) cathodal or (iii) sham tDCS combined with mCIMT. Fugl-Meyer assessment (FMA), motor activity log scale (MAL), and handgrip strength were analyzed before, immediately, and 1 month (follow-up) after the treatment. Minimal clinically important difference (mCID) was defined as an increase of ≥5.25 in the upper limb FMA. RESULTS: An increase in the FMA scores between the baseline and post-intervention and follow-up for active tDCS group was observed, whereas no difference was observed in the sham group. At post-intervention and follow-up, when compared with the sham group, only the anodal tDCS group achieved an improvement in the FMA scores. ANOVA showed that all groups demonstrated similar improvement over time for MAL and handgrip strength. In the active tDCS groups, 7/7 (anodal tDCS) 5/7 (cathodal tDCS) of patients experienced mCID against 3/7 in the sham group. CONCLUSION: The results support the merit of association of mCIMT with brain stimulation to augment clinical gains in rehabilitation after stroke. However, the anodal tDCS seems to have greater impact than the cathodal tDCS in increasing the mCIMT effects on motor function of chronic stroke patients. IMPLICATIONS FOR REHABILITATION: The association of mCIMT with brain stimulation improves clinical gains in rehabilitation after stroke. The improvement in motor recovery (assessed by Fugl-Meyer scale) was only observed after anodal tDCS. The modulation of damaged hemisphere demonstrated greater improvements than the modulation of unaffected hemispheres.

Addition of trunk restraint to home-based modified constraint-induced movement therapy does not bring additional benefits in chronic stroke individuals with mild and moderate upper limb impairments: A pilot randomized controlled trial.

BACKGROUND: People with stroke excessively move their trunk, when reaching and grasping objects. OBJECTIVE: To determine if the addition of trunk restraint to modified constraint-induced movement therapy (mCIMT) was better than mCIMT alone in improving strength, function, and quality of life after stroke. METHODS: A pilot randomized double-blinded clinical trial was conducted. Twenty-two participants with chronic stroke were randomly assigned to an experimental group that received mCIMT plus trunk restraint, or a control group (only mCIMT). Primary outcomes were the amount of use and quality of movement of the paretic upper limb (UL), determined by the Motor Activity Log (MAL) scores. Secondary outcomes included the observed performance of the paretic UL during unimanual and bimanual tasks, kinematics of reaching, strength, and quality of life. RESULTS: Both groups demonstrated significant improvements in the MAL scores and in the time to perform bimanual activities immediately after the interventions. However, no between-group differences were observed. CONCLUSIONS: The addition of trunk restraint to mCIMT resulted in no additional benefits, compared with mCIMT alone with stroke individuals with mild to moderate impairments. Unimanual and bimanual improvements were observed after mCIMT, regardless of trunk restraint, and the intervention did not adversely affect their reaching patterns.

Eficacia de la terapia restrictiva sobre funcionalidad de la extremidad superior en niños de 3 a 8 años con parálisis cerebral hemiparética: un ensayo clínico experimental / Efficacy of constraint-induced movement therapy on upper limb function in children with hemiparetic cerebral palsy from 3 to 8 years old. A pilot randomized clinical trial

Introducción: Los niños con hemiparesia presentan disminución de habilidades motrices y funcionales de la extremidad afectada, con escasa integración de ésta en actividades cotidianas; la terapia restrictiva ha sido escasamente estudiada en la realidad nacional. Objetivo: Evaluar eficacia de terapia restrictiva con yeso y terapia restrictiva más infiltración de onabotulinumtoxinA (Botox®), en funcionalidad de extremidad superior parética, en niños de 3-8 años de edad, con hemiparesia y compromiso funcional leve o moderado del Instituto Teletón Valparaíso-Chile. Método: Estudio experimental, controlado, aleatorio, simple ciego en 42 pacientes con consentimiento informado. Se distribuyen en tres grupos: sólo terapia convencional (control); con terapia convencional más restricción de extremidad indemne con yeso y terapia convencional con restricción de extremidad indemne con yeso más infiltración de onabotulinumtoxinA. Concluyen el estudio 29 niños, sometidos a tratamiento durante 6 semanas, con 3 sesiones semanales de 45 min cada una. Un terapeuta ocupacional ciego al grupo de pertenencia del paciente, evalúa calidad de movimiento (prueba Quest), actividades de la vida diaria (WeeFIM) y posicionamiento del pulgar (prueba House) al inicio, final del tratamiento y seguimiento en 3 meses. Resultados: Dentro de los grupos experimentales, las medianas de las pruebas WeeFIM y Quest, disminuyen al término del tratamiento y al seguimiento en relación al momento basal. La prueba House no cambia durante el proceso. No se registran diferencias significativas respecto del grupo control. Conclusión: No se comprueba mejoría de funcionalidad motriz de la extremidad superior parética y nivel de independencia en las AVD, con terapia restrictiva y adicionada con onabotulinumtoxina .

Introduction: Children with hemiparetic cerebral palsy show decreased motor and functional skills of their paretic extremity, along with scarce integration of it in daily activities. Constraint-induced movement therapy has been scantily studied in our country. Objective: To assess the effectiveness of plaster constraint-induced movement therapy alone and plaster constraint-induced movement therapy plus a onabotulinumtoxinA (Botox®) infiltration, on paretic upper limb function, in children from 3 to 8 years old, with hemiparetic cerebral palsy, and mild or moderate functional impairment, all patients at Valparaíso’s Teleton Institute in Chile. Method: An experimental, controlled, randomized and simple blind clinical trial was conducted with 42 patients who were distributed into three groups: only conventional therapy (control); conventional therapy with plaster constraint of undamaged upper extremity; and conventional therapy with plaster constraint of undamaged upper extremity plus a onabotulinum toxin A (Botox) infiltration.The protocol was completed by 29 children who participated during 6 weeks of treatment, with three 45 minutes sessions each week. A blind occupational therapist assessed quality of movement (QUEST), daily live activities (WEE FIM) and position of thumb at onset and end of treatment; and at 3 months follow-up. Results: WEE FIM and QUEST median scores for the experimental groups declined by the end of treatment and at follow-up, when compared to baseline measures. HOUSE test results showed no improvement either. No differences between control and experimental groups were observed. Conclusion: Motor functionality improvement of hemiparetic upper extremity and level of independence in daily activities, was not demonstrated for plaster constraint induced movement therapy alone or with infiltration of onabotulinumtoxinA (Botox).

Comparison of Structured Skill and Unstructured Practice During Intensive Bimanual Training in Children With Unilateral Spastic Cerebral Palsy.

UNLABELLED: Background High-intensity training aims to improve hand function in children with unilateral spastic cerebral palsy (USCP). However, the extent to which skill training is required is not known. Objectives To compare the effects of intensive bimanual training with and without structured progression of skill difficulty, on manual dexterity, bimanual hand use, daily functioning, and functional goals in children with USCP. Method Twenty-two children were randomized to structured practice group (SPG) or unstructured practice group (UPG), and received 6 h/d training during 15 days. Children from the SPG were engaged in fine and gross motor bimanual activities, with skill progression and goal training. Children from UPG performed the same activities without skill progression or goal training. Participants were evaluated before, immediately and 6 months after training by a physical therapist blinded to group allocation. The primary outcomes were the Jebsen-Taylor Test of Hand Function (JTTHF) and Assisting Hand Assessment (AHA). Secondary outcomes included the Canadian Occupational Performance Measure (COPM), Pediatric Evaluation of Disability Inventory (PEDI), and ABILHAND-Kids. Results Both groups showed similar improvements in the JTTHF, AHA, ABILHAND-Kids, COPM-satisfaction, and PEDI (P < .05). A significant interaction in the COPM-performance scale (P = .03) showed superior improvements of the SPG immediately, but not 6 months, after the intervention. CONCLUSIONS: Children from both groups demonstrated improvements in dexterity and functional hand use. This suggests that for intensive bimanual approaches, intensive training at such high doses may not require structured practice to elicit improvements. However, there may be immediate added benefit of including goal training.

Terapia de movimento induzido por restrição (cimt) em uma criança com paralisia cerebral espástica hemiparética: relato de caso / Constraint-induced movement therapy (CIMT) in a child with cerebral palsy with hemiparesis: A case report

Crianças com paralisia cerebral (PC) espástica hemiparética podem apresentar dificuldades em realizar atividades diárias, principalmente tarefas bimanuais. A terapia de movimento induzido por restrição (CIMT) é uma intervenção de alta intensidade e pode ser utilizada para melhorar a funcionalidade da criança com PC. O objetivo deste estudo foi avaliar os efeitos de uma versão modificada da CIMT na função motora manual e no desempenho de atividades funcionais em uma criança com PC espástica hemiparética esquerda, com idade de 3 anos, e Classificação da Função Manual (Manual Ability Classification System – MACS) nível III. Um protocolo adaptado da CIMT foi utilizado. As avaliações foram feitas antes e após a intervenção, com as seguintes medidas de desfecho: Medida Canadense de Desempenho Ocupacional (COPM), Pediatric Evaluation of Disability Inventory (PEDI), Quality of Upper Extremity Skills Test (QUEST), Child Arm Use Test (CAUT) e uma entrevista não estruturada com a mãe. Os resultados mostraram aumento de até 60% nos escores das subescalas do QUEST. No CAUT, observou-se melhora na participação, na qualidade e na espontaneidade quanto ao uso do membro afetado. As pontuações referentes à satisfação da mãe e ao desempenho da criança, segundo a COPM, também apresentaram aumento. Os escores brutos das escalas de autocuidado do PEDI evidenciaram ganho após a intervenção. A entrevista não estruturada com a mãe identificou percepções positivas. O protocolo adaptado da CIMT favoreceu o ganho de habilidades manuais e pode estar relacionado a ganhos em atividades funcionais.

Children with spastic hemiplegic cerebral palsy (CP) may show difficulties in performing daily activities, especially bimanual tasks. Constraint induced movement therapy (CIMT) is a high intensity intervention which can be used to improve functioning in children with CP. The objective of this study was to evaluate the effects of a modified version of CIMT on manual function and functional activity performance of a child with spastic left hemiplegia CP, of 3 years of age and Manual Classification Function (Manual Ability Classification System - MACS) level III. An adapted protocol of CIMT was used. Assessments were conducted before and after intervention, with the following outcome measures: Canadian Measure of Occupational Performance (COPM), Pediatric Evaluation of Disability Inventory (PEDI), Quality of Upper Extremity Skills Test (QUEST), Child Arm Use Test (CAUT) and an unstructured interview with the child’s mother. Increase of up to 60% on the QUEST subscales was observed. There was improvement in the CAUT’s participation, quality and willingness to use the affected arm. Scores from mother’s satisfaction and perception of child’s performance, using the COPM, showed increase. The raw scores from the PEDI self-care scales also indicated gain after intervention. The interview with the mother identified positive perceptions. The adapted CIMT protocol favored gain in manual skills and may be related to gains in functional activities.

Terapia de movimento induzido por restrição (cimt) em uma criança com paralisia cerebral espástica hemiparética: relato de caso / Constraint-induced movement therapy (CIMT) in a child with cerebral palsy with hemiparesis: A case report

Crianças com paralisia cerebral (PC) espástica hemiparética podem apresentar dificuldades em realizar atividades diárias, principalmente tarefas bimanuais. A terapia de movimento induzido por restrição (CIMT) é uma intervenção de alta intensidade e pode ser utilizada para melhorar a funcionalidade da criança com PC. O objetivo deste estudo foi avaliar os efeitos de uma versão modificada da CIMT na função motora manual e no desempenho de atividades funcionais em uma criança com PC espástica hemiparética esquerda, com idade de 3 anos, e Classificação da Função Manual (Manual Ability Classification System – MACS) nível III. Um protocolo adaptado da CIMT foi utilizado. As avaliações foram feitas antes e após a intervenção, com as seguintes medidas de desfecho: Medida Canadense de Desempenho Ocupacional (COPM), Pediatric Evaluation of Disability Inventory (PEDI), Quality of Upper Extremity Skills Test (QUEST), Child Arm Use Test (CAUT) e uma entrevista não estruturada com a mãe. Os resultados mostraram aumento de até 60% nos escores das subescalas do QUEST. No CAUT, observou-se melhora na participação, na qualidade e na espontaneidade quanto ao uso do membro afetado. As pontuações referentes à satisfação da mãe e ao desempenho da criança, segundo a COPM, também apresentaram aumento. Os escores brutos das escalas de autocuidado do PEDI evidenciaram ganho após a intervenção. A entrevista não estruturada com a mãe identificou percepções positivas. O protocolo adaptado da CIMT favoreceu o ganho de habilidades manuais e pode estar relacionado a ganhos em atividades funcionais.(AU)

Children with spastic hemiplegic cerebral palsy (CP) may show difficulties in performing daily activities, especially bimanual tasks. Constraint induced movement therapy (CIMT) is a high intensity intervention which can be used to improve functioning in children with CP. The objective of this study was to evaluate the effects of a modified version of CIMT on manual function and functional activity performance of a child with spastic left hemiplegia CP, of 3 years of age and Manual Classification Function (Manual Ability Classification System - MACS) level III. An adapted protocol of CIMT was used. Assessments were conducted before and after intervention, with the following outcome measures: Canadian Measure of Occupational Performance (COPM), Pediatric Evaluation of Disability Inventory (PEDI), Quality of Upper Extremity Skills Test (QUEST), Child Arm Use Test (CAUT) and an unstructured interview with the child’s mother. Increase of up to 60% on the QUEST subscales was observed. There was improvement in the CAUT’s participation, quality and willingness to use the affected arm. Scores from mother’s satisfaction and perception of child’s performance, using the COPM, showed increase. The raw scores from the PEDI self-care scales also indicated gain after intervention. The interview with the mother identified positive perceptions. The adapted CIMT protocol favored gain in manual skills and may be related to gains in functional activities.(AU)

Tratamento de restrição e indução do movimento na reabilitação funcional de pacientes pós acidente vascular encefálico: uma revisão bibliográfica / A review about the effectiveness of the constraint induced movement therapy in rehabilitation of patients after stroke

INTRODUÇÃO: O Acidente Vascular Encefálico (AVE) é uma das doenças mais incidentes da hipermodernidade, que resulta em múltiplas sequelas. Uma das mais importantes refere-se à função motora do membro superior afetado que, em geral, é mais lenta que a do membro inferior e não acontece de forma adequada. A Terapia de Restrição e Indução do Movimento (TRIM) tem sido considerada uma técnica de reabilitação da função motora da extremidade hemiparética, capaz de promover melhora funcional deste membro. OBJETIVO: O objetivo deste estudo é realizar uma pesquisa bibliográfica para avaliar a eficácia da TRIM em pacientes acometidos por AVE. Material e Método: o presente estudo é uma revisão bibliográfica de artigos indexados na base de dados PubMed, publicados de janeiro de 2000 a dezembro de 2007, em inglês e português. Na estratégia de busca foram utilizados os unitermos: "cerebrovascular accident", "stroke", "CIMT", "constraint induced movement therapy". RESULTADOS E DISCUSSÃO: de modo geral, as pesquisas demonstram que a TRIM é uma técnica alternativa no campo de reabilitação funcional do membro superior parético, promovendo reorganização cortical, superação do "não uso aprendido" e melhora na quantidade e qualidade de movimentos, e que este efeito é transferido para o dia-a-dia do paciente durante suas atividades de rotina. CONCLUSÃO: a TRIM é um produto do advento científico da fisioterapia que traz benefícios funcionais para os pacientes que se submetem a ela. Porém, faz-se necessário investigar mais detalhadamente essa técnica a fim de reduzir as complicações psicológicas advindas deste tratamento, maximizando, assim, a funcionalidade do membro superior acometido.

INTRODUCTION: The cerebrovascular accident is one of the most incident disease of the modernity, that results in multiple sequels. One of the most important sequel is the impairment of the motor function of the affected upper limb and, usually, the rehabilitation is slower than the lower limb and, often, it does not happen in adequate form. The Constraint Induced Movement Therapy (CIMT) have been considered a rehabilitation technique for the affected upper limb and it’s able to promote the functional recovery of the hemiparetic arm. OBJECTIVE: the aim of this study is conducting a literature search to assess the effectiveness of the CIMT in patients after stroke. Materials and Method: this study is a literature review of articles indexed in the database PubMed, published from 2000 to 2007, in English and Portuguese. In the search strategy was used the following key-words: “cerebrovascular accident”, “stroke”, “constraint induced movement therapy” and “CIMT”. RESULTS AND DISCUSSION: in general, the researches shows that the CIMT is an alternative technique in the field of functional rehabilitation of the paretic arm, promoting cortical reorganization, overcoming of the “learned non-use”, improving the quality of movement and increasing amount of use and, these improvements are transferred to the daily life activities of the patient. CONCLUSION: CIMT is a product of the scientific advent of the physiotherapy that brings functional benefits for the patients after stroke. However, it’s necessary more investigation about this technique to reduce the psychological complications resulting from the treatment, thus maximizing the functionality of the affected upper limb.