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Objective: To evaluate in a preliminary fashion whether several standard cognitive assessments predict treatment outcomes on real-world functional activities following Constraint-Induced Movement therapy (CI therapy) for either the upper extremity (UE) or the lower extremity (LE) for chronic stroke hemiparesis in the outpatient therapy clinic. Methods: 15 UE and 14 LE patients in the clinic underwent a short battery of cognitive assessments that evaluated sustained attention, episodic memory, executive control abilities, and general cognitive function. Spearman correlation analysis was used to evaluate whether each cognitive test predicted treatment outcome on the limb-specific Motor Activity Log (MAL). Results: Two assessments (delayed verbal memory and Trail Making Test form B) significantly correlated with LE MAL change that followed therapy. Conclusions: We tentatively conclude from this exploratory and preliminary study that cognitive performance may predict treatment changes in response to CI therapy for the LE. Moderate to large correlations that we observed between other cognitive assessments and CI therapy outcomes recommend replicating this study with a larger and more cognitively diverse sample of stroke patients to learn if these findings are generalizable. [ABSTRACT FROM AUTHOR]

Constraint-Induced Movement therapy (CI therapy) is a recognized rehabilitation approach for persons having stroke with mild to moderately severe motor upper extremity deficits. To date, no rehabilitation treatment protocol has been proven effective that addresses both motor performance and spontaneous upper extremity use in the life situation for chronic stroke participants having severe upper extremity impairment with no active finger extension or thumb abduction. This case report describes treatment of a chronic stroke participant with a plegic hand using a CI therapy protocol that combines CI therapy with selected occupational and physical therapy techniques. Treatment consisted of six sessions of adaptive equipment and upper extremity orthotics training followed by a three-week, six-hour daily intervention of CI therapy plus neurodevelopmental treatment. Outcome measures included the Motor Activity Log for very low functioning patients (Grade 5 MAL), upper extremity portion of the Fugl-Meyer Motor Assessment, Graded Wolf Motor Function Test - for very low functioning patients (gWMFT- Grade 5), and Modified Ashworth Scale. The participant showed improvement on each outcome measure with the largest improvement on the Grade 5 MAL. In follow-up, the participant had good retention of his gains in motor performance and use of his more affected arm for real world activities after 3 months; after a one-week brush-up at 3 months, and at one year post-treatment. [ABSTRACT FROM AUTHOR]

The great prevalence of traumatic brain injury (TBI) and its high economic costs make reducing TBI-related disability a national health care priority. In our research laboratory, CI therapy has been found to significantly improve upper extremity function for persons with chronic TBI. The results have suggested that persons with TBI are less likely to adhere to critical components of the CI therapy protocol than participants with stroke in other studies. Treatment outcomes have also been more variable. Our findings suggest that some cognitive skills appear related to treatment outcome. In addition, cognitive and behavioral deficits, commonly seen with participants with TBI, challenge the delivery of the standard CI therapy protocol with some persons. We discuss the implications of these neuropsychological factors for CI therapy used for chronic TBI and propose further research to more thoroughly investigate these issues. [ABSTRACT FROM AUTHOR]

Background: The term "functional neurological disorder," or "FND," applies to disorders whose occurrence of neurological symptoms fluctuate with the patient's attention to them. However, many other disorders that are not called "FND" nonetheless can also follow this pattern. Consequently, guidelines are unclear for diagnosing "FND.", Objective: To review the neurological conditions that follow this pattern, but which have not so far been termed "FND," to understand their overlap with conditions that have been termed "FND," and to discuss the rationale for why FND has not been diagnosed for them., Method: A systematic review of the PubMed literature registry using the terms "fluctuation," "inconsistency," or "attention" did not yield much in the way of these candidate disorders. Consequently, this review instead relied on the author's personal library of peer-reviewed studies of disorders that have resembled FND but which were not termed this way, due to his longstanding interest in this problem. Consequently, this approach was not systematic and was subjective regarding disease inclusion., Results: This review identified numerous, diverse conditions that generally involve fluctuating neurological symptoms that can vary with the person's attention to them, but which have not been called "FND." The literature was unclear for reasons for not referring to "FND" in these instances., Conclusion: Most likely because of historical biases, the use of the term "FND" has been unnecessarily restricted. Because at its core FND is an attentionally-influenced disorder that can respond well to behavioral treatments, the field of neurological rehabilitation could benefit by extending the range of conditions that could be considered as "FND" and referred for similar behavioral treatments. Because the term "FND" has been viewed unfavorably by some patients and clinical practitioners and whose treatment is not implied, the alternative term attentionally-modifiable disorder is proposed.

Background: Functional movement disorders (FMDs) are a common cause of disability. With an increasing research interest in FMD, including the emergence of intervention trials, it is crucial that research methodology be examined, and standardized protocols be developed., Objective: To characterize the current inclusion criteria used to select patients for FMD research studies and review the consistency and appropriateness of these criteria., Methods: We identified studies of potential biomarkers for FMD that were published over the last two decades and performed a qualitative analysis on the finally included studies., Results: We identified 79 articles and found inconsistent inclusion criteria. The Fahn-Williams and DSM-IV criteria were the most commonly applied, but neither accounted for the majority (Fahn-Williams 46%, DSM-IV 32% of the total). The selection of the inclusion criteria depended in part on the phenotype of FMD under investigation. We also identified inclusion methodologies that were not appropriate, such as the inclusion of low-certainty diagnoses and diagnosing by excluding specific biomarkers rather than including patients based on clinical characteristics that commonly are thought to suggest FMD., Conclusions: Significant variability exists with the inclusion criteria for FMD research studies. This variability could limit reproducibility and the appropriate aggregation of data for meta-analysis. Advancing FMD rehabilitation research will need standardized inclusion criteria. We make some suggestions.

Background: Although Constraint-Induced Movement therapy (CIMT) has been deemed efficacious for adults with persistent, mild-to-moderate, post-stroke upper-extremity hemiparesis, CIMT is not available on a widespread clinical basis. Impediments include its cost and travel to multiple therapy appointments. To overcome these barriers, we developed an automated, tele-health form of CIMT., Objective: Determine whether in-home, tele-health CIMT has outcomes as good as in-clinic, face-to-face CIMT in adults ≥1-year post-stroke with mild-to-moderate upper-extremity hemiparesis., Methods: Twenty-four stroke patients with chronic upper-arm extremity hemiparesis were randomly assigned to tele-health CIMT (Tele-AutoCITE) or in-lab CIMT. All received 35 hours of treatment. In the tele-health group, an automated, upper-extremity workstation with built-in sensors and video cameras was set-up in participants' homes. Internet-based audio-visual and data links permitted supervision of treatment by a trainer in the lab., Results: Ten patients in each group completed treatment. All twenty, on average, showed very large improvements immediately afterwards in everyday use of the more-affected arm (mean change on Motor Activity Log Arm Use scale = 2.5 points, p < 0.001, d' = 3.1). After one-year, a large improvement from baseline was still present (mean change = 1.8, p < 0.001, d' = 2). Post-treatment outcomes in the tele-health group were not inferior to those in the in-lab group. Neither were participants' perceptions of satisfaction with and difficulty of the interventions. Although everyday arm use was similar in the two groups after one-year (mean difference = -0.1, 95% CI = -1.3-1.0), reductions in the precision of the estimates of this parameter due to drop-out over follow-up did not permit ruling out that the tele-health group had an inferior long-term outcome., Conclusions: This proof-of-concept study suggests that Tele-AutoCITE produces immediate benefits that are equivalent to those after in-lab CIMT in stroke survivors with chronic upper-arm extremity hemiparesis. Cost savings possible with this tele-health approach remain to be evaluated.

Purpose: The purpose of this feasibility study was to assess whether combined intermittent theta burst suppression (iTBS) applied to the ipsilesional hemisphere and modified constraint-induced aphasia therapy (mCIAT) are safe and logistically feasible within the time interval associated with iTBS induced long-term potentiation in patients with post-stroke aphasia. We also wanted to determine whether combining priming with iTBS and CIAT improves language functions after treatment., Methods: Twelve participants received fMRI (semantic decision/tone decision task) and neuropsychological testing of language skills at three time points - before starting the iTBS/mCIAT intervention (T1), immediately after completing 2-week long course of intervention (T2), and at 3-months follow-up (T3). ITBS was applied to the individually determined fMRI language "hot spot" located in the left fronto-temporal regions., Results: There were no serious adverse events, and all mCIAT group therapy sessions (3-4 subjects each) were initiated within 30 minutes of the first group subject receiving iTBS. Neuropsychological assessments of language showed a significant effect of session on Western Aphasia Battery aphasia quotient (WAB-AQ; p = 0.04) and spontaneously correct responses on Boston Naming Test (BNT; p = 0.002), with improvement noted at T2 (p = 0.002) and T3 (p = 0.05) versus T1. FMRI showed significant changes between all timepoints. Post-hoc correlations showed associations between improvements in WAB-AQ from T2 to T3 and decreased BOLD signal in left inferior parietal lobe, and improvements in BNT from T1 to T3 with decreased signal in right inferior frontal gyrus., Conclusion: This study shows feasibility and safety for combining behavioral and neurostimulation interventions for chronic post-stroke aphasia. Observed changes in linguistic measures were relatively small. However, they were statistically significant and associated with parallel changes observed in the neuroimaging. Our findings support further development and testing of the combined mCIAT and iTBS protocol and comparisons to either CIAT/mCIAT or iTBS applied alone for the treatment of post-stroke aphasia.

Background: Infarct size and location account for only a relatively small portion of post-stroke motor impairment, suggesting that other less obvious factors may be involved., Objective: Examine the relationship between white matter hyperintensity (WMH) load among other factors and upper extremity motor deficit in patients with mild to moderate chronic stroke., Methods: The magnetic resonance images of 28 patients were studied. WMH load was assessed as total WMH volume and WMH overlap with the corticospinal tract in the centrum semiovale. Hemiparetic arm function was measured using the Motor Activity Log (MAL) and Wolf Motor Function Test (WMFT)., Results: Hierarchical multiple regression models found WMH volume predicted motor deficits in both real-world arm use (MAL;ΔR2 = 0.12, F(1, 22) = 4.73, p = 0.04) and in arm motor capacity as measured by a laboratory motor function test (WMFT;ΔR2 = 0.18, F(1, 22) = 6.32, p = 0.02) over and above age and lesion characteristics. However, these models accounted for less than half of the variance in post-stroke motor deficits., Conclusion: The results suggest that WMH may be an important factor to consider in stroke-related upper extremity motor impairment. Nonetheless, the basis of the largest part of the post-stroke motor deficit remains unaccounted for by structural CNS factors. This component may be behavioral or learned, involving learned nonuse.

Purpose: To evaluate the efficacy of an expanded form of Constraint-Induced Movement Therapy (eCIMT) that renders CIMT, originally designed for treating mild-to-moderate upper-extremity hemiparesis, suitable for treating severe hemiparesis., Methods: Twenty-one adults ≥1 year after stroke with severe upper-extremity hemiparesis (with little or no capacity to make movements with the more-affected hand) were randomly assigned to eCIMT (n = 10), a placebo-control procedure (n = 4), or usual care (n = 7). The participants who received usual care were crossed over to eCIMT four months after enrollment. The CIMT protocol was altered to include fitting of orthotics and adaptive equipment, selected neurodevelopmental techniques, and electromyography-triggered functional electrical stimulation. Treatment was given for 15 consecutive weekdays with 6 hours of therapy scheduled daily for the immediate eCIMT group and 3.5 hours daily for the cross-over eCIMT group., Results: At post-treatment, the immediate eCIMT group showed significant gains relative to the combination of the control groups on the Grade-4/5 Motor Activity Log (MAL; mean = 1.5 points, P < 0.001, f = 4.2) and a convergent measure, the Canadian Occupational Performance Measure (COPM; mean = 2.3, P = 0.014, f = 1.1; f values ≥0.4 are considered large, on the COPM changes ≥2 are considered clinically meaningful). At 1-year follow-up, the MAL gains in the immediate eCIMT group were only 13% less than at post-treatment. The short and long-term outcomes of the crossover eCIMT group were similar to those of the immediate eCIMT group., Conclusions: This small, randomized controlled trial (RCT) suggests that eCIMT produces a large, meaningful, and persistent improvement in everyday use of the more-affected arm in adults with severe upper-extremity hemiparesis long after stroke. These promising findings warrant confirmation by a large RCT.

Purpose: The purpose of this study was to delineate the relationship between several types of T1-weighted MRI pathology and motor rehabilitation potential following Constraint Induced Movement therapy (CI therapy) in chronic stroke., Methods: Stepwise regression was employed (n = 80) to identify predictors of motor recovery (prior to therapy) and of response to Constraint-Induced Movement therapy [measured via the Wolf Motor Function Test (WMFT) and Motor Activity Log (MAL)] from among the following: age, side of motor deficit, chronicity, gender, lesion volume, peri-infarct damage volume, white matter hypointensity volume, ventricular asymmetry, and lesion location., Results: Although extent of total stroke damage weakly correlated with poorer performance on the WMFT prior to therapy, this relationship was mediated by the location of the damage. No metric of tissue damage examined here was associated with real-world arm use at baseline (MAL at pre-treatment) or with CI therapy-induced improvement in either best motor performance upon request (WMFT) or spontaneous arm use for daily activities (MAL)., Conclusions: In sum, the extent of brain tissue damage of any type examined here poorly predicted motor function and response to rehabilitation in chronic stroke.

Background and Purpose: Infarct volume and location have a weak relationship with motor deficit in patients with chronic stroke. Recent research has focused on the relationship between spared or seemingly "healthy" neural tissue and motor function. In this study we examined MRI scans of patients with chronic stroke to determine if characteristics of seemingly normal parenchyma could predict either response to different forms of upper extremity physical rehabilitation or to pre-treatment motor status., Methods: Individuals with chronic stroke (ages 60.6 ± 11.9 years) and mild/moderate upper extremity hemiparesis were administered either CI therapy (n = 14) or a comparison therapy (n = 29). The patients were assessed prior to and following therapy with MRI scans and the Wolf Motor Function Test (WMFT) Performance Time measure. Total voxels in combined grey matter (GM) and white matter (WM) segments (parenchymal volume) were divided by total voxels in GM, WM, and cerebrospinal fluid segments (intracranial volume) to obtain the brain parenchymal fraction (BPF)., Results: BPF correlated with treatment gains on the WMFT (r(43) = -0.31, p = 0.04). Significant correlations between pre-treatment motor function and BPF were not observed., Conclusions: Individuals with greater BPFs after stroke show larger arm function gains after CI therapy, suggesting that reductions in volume of normal-appearing tissue may relate to ability to benefit from rehabilitation therapy in chronic stroke.

Purpose: To evaluate the effect of total cerebral infarction volume on motor status and treatment responses to Constraint-Induced Movement therapy (CI therapy) in patients with chronic post-stroke hemiparesis and limb nonuse. In most studies of clinical-radiological correspondences, infarct volume has been found to predict clinical status., Methods: 60 adult patients who met inclusion criteria for CI therapy underwent standard structural brain MRI around the time of treatment. We tested whether the total volume of infarcted tissue predicted pre-treatment values and pre- to post-treatment changes on standard assessments of laboratory- and real-world-based upper extremity movement., Results: The patients significantly improved from baseline clinical motor measures after CI therapy. The range of infarction volumes was comparable to those of other stroke studies. In contrast, total infarction volume was not correlated with any of the motor measures. The absence of correlation was maintained even when evaluating only patients with either unilateral or solitary cerebral infarctions, or with respect to severity of baseline motor impairment or variations in the forms of therapy., Conclusion: The findings suggest that certain standard motor measures in chronic hemiparetic stroke (limb movement in the laboratory, limb use in the life situation, changes in these measures following efficacious CI therapy) are insensitive to infarction load. Our findings are consistent with the hypothesis that plastic brain reorganization after stroke attenuates the effect of infarct volume on purposive limb movement. However, we cannot exclude the possibilities that the specific methods we used to assess upper limb status may be generally insensitive to infarction load, or that the stringent inclusion criteria for this research precluded detecting an effect of infarction load. Further study to evaluate these relationships in the acute-subacute stroke phases and among patients with more severe motor deficits would help to clarify the basis for the lack of an infarction load effect.

Constraint-Induced Movement Therapy (CI therapy) refers to a family of treatments for motor disability that combines constraint of movement, massed practice, and shaping of behavior to improve the amount of use of the targeted limb. CI therapy has controlled evidence for efficacy that supports its benefit for patients with chronic disability following central nervous system injury, regardless of their age or the interval since illness onset. Furthermore, the benefits transfer to real-world measures of limb use. Significant functional improvement may occur even after the patient has been treated with conventional physical therapy. In this paper we review the evidence for the efficacy of CI therapy, particularly for chronic stroke hemiparesis, but also for diverse other chronic disabling illnesses, including non-motor disorders such as phantom limb pain and aphasia. The adaptation of the therapy to the stroke clinic is described, along with a review of the neurophysiologic mechanisms that are postulated to underlie the treatment benefit (overcoming learned nonuse, plastic brain reorganization). Critical to the success of CI therapy is its modification according to disease factors, economic considerations, limitations of the practice setting, and the cognitive and physical status of the patient. We conclude by recommending future areas for research on CI therapy.