Unilateral Versus Bilateral Upper Limb Training After Stroke

Abstract

Background and Purpose-Unilateral and bilateral training protocols for upper limb rehabilitation after stroke represent conceptually contrasting approaches with the same ultimate goal. In a randomized controlled trial, we compared the merits of modified constraint-induced movement therapy, modified bilateral arm training with rhythmic auditory cueing, and a dose-matched conventional treatment. Modified constraint-induced movement therapy and modified bilateral arm training with rhythmic auditory cueing targeted wrist and finger extensors, given their importance for functional recovery. We hypothesized that modified constraint-induced movement therapy and modified bilateral arm training with rhythmic auditory cueing are superior to dose-matched conventional treatment. Methods-Sixty patients, between 1 to 6 months after stroke, were randomized over 3 intervention groups. The primary outcome measure was the Action Research Arm test, which was conducted before, directly after, and 6 weeks after intervention. Results-Although all groups demonstrated significant improvement on the Action Research Arm test after intervention, which persisted at 6 weeks follow-up, no significant differences in change scores on the Action Research Arm test were found between groups postintervention and at follow-up. Conclusions-Modified

Constraint-induced movement therapy after stroke

“…Possible risks of bias, like blinding of assessors, did not seem to influence lack of difference between dose-matched trials and non-dose matched trials. These findings are in agreement with a recent trial(82) and meta-analysis(84) showing that dose-matched trials of mCIMT in which the control group received an equal dose of bilateral arm training failed to report significant differences in overall effect sizes. Despite the finding that (m)CIMT may increase short-term(50, 85) and long-term cortical activation patterns, (42, 50, 86), the underlying mechanisms responsible for improvements require further investigation.…”

“…Interestingly, the 3D-kinematic improvements closely follow the clinical time course of impairments such as synergism(94, 96, 97) and are also restricted to the first 3 months post stroke. (98, 99) Interestingly, the present meta-analysis further suggests that the effects of mCIMT on motor function of the arm such as FMA-arm scores is restricted to trials that started within this time window of 3 months post stroke (Table 1 and supplementary web appendix 6 and 7) (References (34, 45, 49, 50, 82)). This finding is in agreement with the growing evidence from animal studies in which the first weeks after stroke onset are characterized by increased levels of homeostatic neuroplasticity (100)…”

“…CIMT has been investigated in 51 RCTs,(23, 28-31, 33-82) including 1784 patients with adult stroke, but only 15 trials included patients within the first three months post stroke. (34, 45, 47, 49, 50, 52, 53, 56, 59, 66, 67, 69, 76, 78, 82) Panel 1 shows the used search strategy and selection criteria used for this systematic review of the literature.…”

“…(34, 45, 47, 49, 50, 52, 53, 56, 59, 66, 67, 69, 76, 78, 82) Panel 1 shows the used search strategy and selection criteria used for this systematic review of the literature. For details about the search strategy, methods and flow-chart, see supplementary web appendix 2 to 4.…”

“…(23, 31, 33-58, 61-64, 66, 70-78, 80-82) In favor of mCIMT, significant positive small to medium summary effect sizes (SESs) have been found post intervention in terms of motor function of the paretic arm, muscle tone, arm-hand activities, self-reported amount of arm-hand use in daily life, self-reported quality of arm-hand movement in daily life, and basic ADL (Figure 2) (see also supplementary web appendix 6). No significant summary effect sizes were found for grip strength, sensibility, pain, quality of life related to hand function, and quality of life related to ADL (Figure 2) (See supplementary web appendix 6).…”