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Author Response
Toward Optimizing a Way to "Handle" Force-Use, CIMT, and Unimanual and Bimanual Functional Training
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Ann M. Hammer, Doctoral Student Department of Rehabilitation Medicine, Örebro University Hospital, Örebro, Sweden, Birgitta Lindmark
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ann.hammer{at}orebroll.se Ann M. Hammer, et al.
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We thank Wolf for his interest in our work recently published in PTJ.1 We also thank the editor for giving us an opportunity to respond to Wolf’s comments. The issue of labeling an intervention performed is challenging. The reason for our choice of the term “forced use” is here explained. When our present study was initiated, constraint-induced movement therapy (CIMT) was presented only in the classic version,2 apart from forced use described earlier.3,4 As the idea of our study was to add the sling to the ongoing rehabilitation, we did not think this would qualify the use of the term “CIMT” because the interventions were not intensified or focused exclusively on the upper limb. Other published studies in this area have used terms such as “modified CIMT,”5–7 “distributed CIMT,”8 “shorter CIMT,”9 or “shortened CIMT,”10 always completely focusing the training on the upper limb. Therefore, we believe “forced use” was a more-appropriate label of our intervention. The motor impairment of the people in our study was, to some extent, moderate. However, participants recruited for the EXCITE trial were both higher functioning and lower functioning, based on amount of wrist and digit extension at inclusion.11,12 Our patients were all in the higher-functioning state, fulfilling such inclusion criteria. The Fugl-Meyer test scores presented by Wolf et al12 represent the total means for all patients in the EXCITE trial (42.5 and 41.1), but the mean Fugl-Meyer test score of the patients in the higher-functioning state was 44.9.13 The Motor Activity Log (MAL) scores presented in Figure 2 in the article by Wolf et al12 show that there was close to a 1-point difference at each time point between the lower-functioning and higher-functioning subgroups. Regarding our sample, the mean scores of the scales used (see Tab. 2 in our article1) were within the upper third of these scales’ range of scores. Nevertheless, the results of the 16-hole peg test and the Grippit ratio certainly represent a substantial deficit of motor function. We recently reported on outcome on daily hand use,14 and the MAL scores showed an obviously reduced level of performance in daily life, with a baseline mean score 1 week before intervention of 1.3 on this 0 to 5 scale. Thus, we would say the level of hand use in our patients was similar to that of the higher-functioning subgroup in the EXCITE study.12 Individually, only 3 of the 30 participants in our study had a baseline MAL score higher than 2.5. We would suggest this finding demonstrates that high scores on a motor scale do not tell the whole truth. Patients have much more difficulty making use of their hand in daily functioning, which is captured by a measure of daily hand use. This may be explained by the several extended difficulties encountered when performing a “real-life” task compared with a relatively simple standard test. Additionally, our sample performed a first preintervention test 1 week before the intervention not only of the MAL14 but also of the results for the other measures shown in the Table, indicating a slightly lower motor function than immediately prior to the intervention.1 Table.
a Values are mean (SD). b t test for independent groups. The field of stroke rehabilitation research is immense, and findings are gradually accumulating. To agree with Wolf, we are hopeful for the future with an extended base of knowledge concerning patient-related benefits of rehabilitation-no matter what ingredients of training that will contribute. Ann M. Hammer, Birgitta Lindmark A.M. Hammer, PT, MSc, is Doctoral Student, Department of Rehabilitation Medicine, Örebro University Hospital, and School of Health and Medical Sciences, Örebro University, S-701 85 Örebro, Sweden. Address all correspondence to Ms Hammer at: ann.hammer{at}orebroll.se. B. Lindmark, PhD, is Professor Emeritus, Section of Physiotherapy, Department of Neuroscience, Uppsala University, Uppsala, Sweden. References 1 Hammer AM, Lindmark B. Effects of forced use on arm function in the subacute phase after stroke: a randomized, clinical pilot study. Phys Ther. 2009;89:526–539. 2 Taub E, Miller NE, Novack TA, et al. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil. 1993;74:347–354. 3 Ostendorf CG, Wolf SL. Effect of forced use of the upper extremity of a hemiplegic patient on changes in function: a single-case design. Phys Ther. 1981;61:1022–1028. 4 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. 5 Atteya AA. Effects of modified constraint induced therapy on upper limb function in subacute patients. Neuroscience. 2004;9:24–29. 6 Wu CY, Lin KC, Chen HC, et al. Effects of modified constraint-induced movement therapy on movement kinematics and daily function in patients with stroke: a kinematic study of motor control mechanisms. Neurorehabil Neural Repair. 2007;21:460–466. 7 Page SJ, Levine P, Leonard A, et al. Modified Constraint-induced therapy in chronic stroke: results of a single-blinded randomized controlled trial. Phys Ther. 2008;88:333–340. 8 Dettmers C, Teske U, Hamzei F, et al. Distributed form of constraint-induced movement therapy improves functional outcome and quality of life after stroke. Arch Phys Med Rehabil. 2005;86:204–209. 9 Sterr A, Elbert T, Berthold I, et al. Longer versus shorter daily constraint-induced movement therapy of chronic hemiparesis: an exploratory study. Arch Phys Med Rehabil. 2002;83:1374–1377. 10 Brogardh C, Vestling M, Sjolund BH. Shortened constraint-induced movement therapy in subacute stroke-no effect of using a restraint: a randomized controlled study with independent observers. J Rehabil Med. 2009;41:231–236. 11 Winstein CJ, Miller JP, Blanton S, et al. 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. 2003;17:137–152. 12 Wolf SL, Winstein CJ, Miller JP, et al. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. JAMA. 2006;296:2095–2104. 13 Wolf SL, Thompson PA, Morris DM, et al. The EXCITE trial: attributes of the Wolf Motor Function Test in patients with subacute stroke. Neurorehabil Neural Repair. 2005;19:194–205. 14 Hammer AM, Lindmark B. Is forced use of the paretic upper limb beneficial? A randomized pilot study during subacute post-stroke recovery. Clin Rehabil. 2009;23:424–433. |
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Steven Wolf, physical therapist Dept. Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA
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swolf{at}emory.edu Steven Wolf
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The recent article by Hammer and Lindmark1 is an excellent demonstration of a research design that honors detail to attention in a topic of growing interest within the physical therapy community: upper-extremity stroke rehabilitation. Because my colleagues and I were instrumental in coining the term “forced use” as a treatment mode for home-based and self-directed upper-extremity rehabilitation,2,3 this article is of particular interest to us. Forced use has been differentiated from a more-detailed approach, called “constraint induced movement therapy” (CIMT), in that the former treatment mode does not require individualized training but stipulates home-based task practice, during which time a sling or mitt still supports the less-impaired upper extremity or secures the hand to eliminate grasp for most waking hours. The latter approach includes intense supervised training that emphasizes repetitive task practice and behavioral shaping.4,5 Unlike the apparent description from Hammer and Lindmark, forced use was intended to be undertaken in the home and clinical environments, but, given that the patients were chronic (greater than 1 year poststroke), the approach emphasized home use following initial instruction and weekly review of progress over the 2-week intervention. The present findings1 indicate that the application of forced use yielded outcome measures that were improved but no more so than a standard rehabilitation. Many of the inclusion criteria were comparable to those used in our original studies of forced use3 or in a recently completed clinical multisite clinical trial using CIMT.6 However, some very important differences existed between the patients recruited by Hammer and Lindmark and those recruited in our original forced use studies or the recently completed EXCITE trial.7-9 An important criterion not included in the present work is the mean Motor Activity Log score, which, for the EXCITE studies, had to be less than 2.5 on a 0 to 5 scale. This consideration meant that, on average for the 30 home-based tasks, 10 patients were using their nonimpaired limb to assist the impaired limb. An examination of the EXCITE trial patient group11 using a measure common to the present study and the EXCITE trial, the Fugl-Meyer Upper Extremity Assessment Scale (FMA),12 revealed that a logical “cut point” to differentiate patients who were higher functioning from those who were lower functioning—using movement criteria comparable to those described by Hammer and Lindmark—was 33/66. No FMA data were acquired in the original forced-use group study,3 but there is no doubt that the degree of impairment characterizing those patients and the EXCITE trial participants, as measured by the FMA, was far greater than in the present group. The totality of these observations, using the FMA as a yardstick, would allow us to conclude that the patients recruited for the Hammer and Lindmark study would not have been enrolled our studies because they would have been too “unimpaired.” Hence, one must question whether their work truly is an effectiveness study, given the apparently mild FMA impairment levels and remarkably high baseline scores for several outcome measures. The finding that there were no differences in outcomes between the 2 groups, therefore, is not surprising, because the impact of forced use is most noticeable in patients who are more severely impaired but not profoundly so. This differential also might explain why some forced-use studies have shown favorable outcomes,13 whereas others did not.14 In this context, it is worth noting that Hammer and Lindmark’s comment that “[o]ther research groups also have failed to demonstrate differences in results between CIMT and an equal amount of an alternative intervention, both in the chronic phase15 and in the acute phase16,17”1(p532) is not accurate. The chronic phase study to which they are referring, undertaken by van der Lee and coworkers,15 was not a CIMT study but rather one using forced use as defined in the present study. The results from the comparison between forced use and a neurodevelopmental treatment approach revealed a significant difference between groups when including participants in the forced-use group who had hemi-neglect and sensory compromise. The acute phase studies by the Dromerick et al16 and Boake et al17 were indeed CIMT studies in which the intervention was administered for at least 3 hours per day in patients less than 14 days poststroke. Given that Dromerick et al18 had shown favorable outcomes previously in patients with acute stroke given no more than 2 hours of CIMT per day, the case can be made that for survivors of an acute stroke, too much CIMT (more than 2 hours per day over a 2-week period within 2 weeks of the stroke event) can be counterproductive but not detrimental. Hence, the issue of intensity and timing of CIMT or forced-use training, discussed in detail recently,19,20 may have a strong bearing on treatment effectiveness. Too much CIMT too soon after stroke may not be advisable. In addition, the relative upper-extremity impairment of the patient with stroke must be taken into consideration before definitive conclusions regarding any of form of unimanual task-specific training can be dismissed. In this regard, the comments offered by Cauraugh and Summers21 were particularly intriguing. They appropriately complimented Hammer and Lindmark on the quality of their study and then proceeded to develop a case for bilateral training at the expense of unimanual training. They suggested, “Taken together, the new stroke therapies emphasizing motor learning principles and the comprehensive discussion on current stroke recovery and rehabilitation22-24 clearly show that research is moving away from forced use, as implemented in the laboratory.”21(pp539-540) Review of these citations fails to confirm this assertion. There is little doubt that emphasis on affected arm and hand movement during immobilization of the unaffected limb can produce an interhemispheric inhibition of the intact hemisphere and thus promote the possibility of higher-threshold requirements to engage the intact cortex for bilateral movements; however, the evidence that CIMT does induce appropriate cortical reorganization in the impaired cortex has been demonstrated from both transcranial magnetic stimulation25,26 and functional magnetic resonance imaging27 studies. Thus, improvements in function and associated measures of plasticity have been documented from the same patients receiving CIMT. The evidence that Cauraugh and Summers provided to support the value of bilateral training, including their own studies,28,29 indeed shows that kinematic and movement time aspects of impaired-limb performance can improve, and Whitall and colleagues30-32 have provided evidence for improved use of the impaired limb following bilateral upper-extremity training. Thus, the accumulating information should not be viewed as a definitive “either/or” phenomenon, in which unimanual task training is pitted against bimanual training, but rather one requiring the logical development of sequential and best practice defined by the level of limb impairment severity and relative chronicity. Clinical researchers have a professional duty to embrace such perspectives, especially given the reality that, in upper-extremity stroke rehabilitation, we have yet to encounter an intervention that can be applied universally. This reality needs to be coupled with the pressing need to determine outcomes in terms of acceptably measurable clinical change in addition to the more-traditional statistically significant metric. With respect to the question at hand (ie, the value of forced use, CIMT, or bimanual training), the importance of including functionally related activities is beyond dispute. The extent to which each form of training yields improvements that are clinically relevant requires intense focus. In this regard, work by McCombe Waller and Whitall33 argues for determining appropriate algorithms for sequencing unimanual and bimanual training, and data from a study by Lin and coworkers34 suggest that unimanual training induces changes more prominent in distal rather than proximal control, thus validating our original observations,3 whereas bimanual training appears to promote improvements in more-proximal joint impairments. Unlike most bimanual training studies, most CIMT studies require some distal function as an inclusion criterion; therefore, it is not surprising that the use of CIMT results in outcomes that show the penultimate measure—actual use of the impaired limb to manipulate the environment. To date, the exact extent to which bimanual training results in an array of functionally important and preserved indexes of limb use is unclear. Inevitably, the acceptance of best practice will be extracted from our efforts to decipher the important sequencing of unimanual and bimanual training in light of the prevailing magnitude and longevity of upper-extremity impairment. Until such time, contrary to Cauraugh and Summer’s proclamation,21 the tolling of Hemingway’s bell will continue. Perhaps its sound will not cease but rather ring with greater clarity when all survivors of stroke are able to emit its reverberations with their more-impaired hand. SL Wolf, PT, PhD, FAPTA, FAHA, is Professor, Departments of Rehabilitation Medicine and Medicine, and Associate Professor, Department of Cell Biology, Emory University School of Medicine; Professor, Health and Elder Care, Nell Hodgson Woodruff School of Nursing at Emory University; Senior Research Scientist, Atlanta VA Rehab R&D Center References 1 Hammer AM, Lindmark B. Effects of forced use on arm function in the subacute phase after stroke: a randomized, clinical pilot study. Phys Ther. 2009;89:526–539. 2 Ostendorf CG, Wolf SL. Effect of forced use of the upper extremity of a hemiplegic patient on changes in function: a single-case design. Phys Ther. 1981;61:1022–1028. 3 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. 4 Taub E, Wolf SL. Constraint induction techniques to facilitate upper extremity use in stroke patients. Top Stroke Rehabil. 1997;4:38–61. 5 Wolf SL. Revisiting constraint-induced movement therapy: Are we too smitten with the mitten? Is all nonuse "Learned"? And other quandaries. Phys Ther. 2007;87:1212–1223. 6 Winstein CJ, Miller JP, Blanton S, et al. 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. 2003;17:137–152. 7 Wolf SL, Winstein CJ, Miller JP, et al. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. JAMA. 2006;296:2095–2104. 8 Wolf SL, Winstein CJ, Miller JP, et al. Retention of upper limb function in stroke survivors who have received constraint-induced movement therapy: the EXCITE randomised trial. Lancet Neurol. 2008;7:33–40. 9 Wolf SL, Newton H, Maddy D, et al. The EXCITE trial: relationship of intensity of constraint induced movement therapy to improvement in the Wolf Motor Function Test. Restor Neurol Neurosci. 2007;25:549–562. 10 Taub E, Miller NE, Novack TA, et al. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil. 1993;74:347–354. 11 Wolf SL, Thompson PA, Morris DM, et al. The EXCITE trial: attributes of the Wolf Motor Function Test in patients with subacute stroke. Neurorehabil Neural Repair. 2005;19:194–205. 12 Fugl-Meyer AR, Jaasko L, Leyman I, et al. The post-stroke hemiplegic patient, 1: a method for evaluation of physical performance. Scand J Rehabil Med. 1975;7:13–31. 13 Pierce SR, Gallagher KG, Schaumburg SW, et al. Home forced use in an outpatient rehabilitation program for adults with hemiplegia: a pilot study. Neurorehabil Neural Repair. 2003;17:214–219. 14 Brogardh C, Vestling M, Sjolund BH. Shortened constraint-induced movement therapy in subacute stroke—no effect of using a restraint: a randomized controlled study with independent observers. J Rehabil Med. 2009;41:231–236. 15 van der Lee JH, Wagenaar RC, Lankhorst GJ, et al. Forced use of the upper extremity in chronic stroke patients: results from a single-blind randomized clinical trial. Stroke. 1999;30:2369–2375. 16 Dromerick A, Lang CE, Birkenmeier R, et al. Very Early Constraint-Induced Movement During Stroke Rehabilitation (VECTORS): a single-center RCT. Neurology. 2009 May 20 [Epub ahead of print]. 17 Boake C, Noser EA, Ro T, et al. Constraint-induced movement therapy during early stroke rehabilitation. Neurorehabil Neural Repair. 2007;21:14–24. 18 Dromerick AW, Edwards DF, Hahn M. Does the application of constraint-induced movement therapy during acute rehabilitation reduce arm impairment after ischemic stroke? Stroke. 2000;31:2984–2988. 19 Dobkin BH. Confounders in rehabilitation trials of task-oriented training: lessons from the designs of the EXCITE and SCILT multicenter trials. Neurorehabil Neural Repair. 2007;21:3–13. 20 Wolf SL, Winstein CJ, Miller JP, et al. Looking in the rear view mirror when conversing with backseat drivers: the EXCITE trial revisited. Neurorehabil Neural Repair. 2007;21:379–387. 21 Cauraugh JH, Summers JJ. Invited commentary on “Effects of forced use on arm function in the subacute phase after stroke: a randomized, clinical pilot study.” Phys Ther. 2009;89:539–541. 22 Stein J, Harvey RL, Macko RF, et al. Stroke Recovery and Rehabilitation. New York, NY: Demos Medical Publishing; 2009. 23 Cramer SC, Riley JD. Neuroplasticity and brain repair after stroke. Curr Opin Neurol. 2008;21:76–82. 24 Cramer SC. Repairing the human brain after stroke, I: mechanisms of spontaneous recovery. Ann Neurol. 2008;63:272–287. 25 Liepert J. Motor cortex excitability in stroke before and after constraint-induced movement therapy. Cogn Behav Neurol. 2006;19:41–47. 26 Sawaki L, Butler AJ, Xiaoyan L, et al. Constraint-induced movement therapy results in increased motor map area in subjects 3 to 9 months after stroke. Neurorehabil Neural Repair. 2008;22:505–513. 27 Dong Y, Dobkin BH, Cen SY, et al. Motor cortex activation during treatment may predict therapeutic gains in paretic hand function after stroke. Stroke. 2006;37:1552–1555. 28 Cauraugh JH, Kim S. Two coupled motor recovery protocols are better than one: electromyogram-triggered neuromuscular stimulation and bilateral movements. Stroke. 2002;33:1589–1594. 29 Cauraugh JH, Coombes SA, Lodha N, et al. Upper extremity improvements in chronic stroke: coupled bilateral load training. Restor Neurol Neurosci. 2009;27:17–25. 30 McCombe Waller S, Liu W, Whitall J. Temporal and spatial control following bilateral versus unilateral training. Hum Mov Sci. 2008;27:749–758. 31 Whitall J, McCombe Waller S, Silver KH, Macko RF. Repetitive bilateral arm training with rhythmic auditory cueing improves motor function in chronic hemiparetic stroke. Stroke. 2000;31:2390–2395. 32 Luft AR, McCombe-Waller S, Whitall J, et al. Repetitive bilateral arm training and motor cortex activation in chronic stroke: a randomized controlled trial. JAMA. 2004;292:1853–1861. 33 McCombe Waller S, Whitall J. Bilateral arm training: Why and who benefits? NeuroRehabilitation. 2008;23:29–41. 34 Lin KC, Wu CY, Liu JS, et al. Constraint-induced therapy versus dose-matched control intervention to improve motor ability, basic/extended daily functions, and quality of life in stroke. Neurorehabil Neural Repair. 2009;23:160–165. |
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