Constraint-induced movement therapy in patients with stroke: a pilot study on effects of small group training and of extended mitt use

Objective: (1) To evaluate constraint-induced movement therapy for chronic stroke patients modified into group practice to limit the demand on therapist resources. (2) To explore whether extended mitt use alone may enhance outcome. Design: A combined case-control and randomized controlled study with pre- and post-treatment measures by blinded observers. Setting: A university hospital rehabilitation department. Participants: Sixteen stroke patients (nine men and seven women; mean age 56.7 years; on average 28.9 months post stroke, five of whom were 6-9 months post stroke) with moderate motor impairments in the contralateral upper limb. Intervention: Constraint-induced therapy (mitt on the less affected hand 90% of waking hours for 12 days) with 2-3 patients per therapist and 6 h of group training per day. After the training period, the patients were randomized either to using the mitt at home every other day for two-week periods for another three months (in total 21 days) or to no further treatment. Outcome measures: Modified Motor Assessment Scale, Sollerman Hand Function Test, Two-Point Discrimination test and Motor Activity Log. Results: The mean motor performance improved significantly after two weeks of constraint-induced group therapy on Motor Assessment Scale (1.44 (95% confidence interval (95% CI) 0.59-2.28) points; P = 0.003) and on Sollerman Hand Function Test (3.81 (95% CI 0.26-7.36) points; P = 0.037) but showed no sensory change in the Two-Point Discrimination Test (P = 0.283). The median difference in self-reported motor ability (Motor Activity Log) also improved (P < 0.001). However, no additional effect was seen from wearing a mitt for another three months. Conclusion: Constraint-induced group therapy, allowing several patients per therapist, seems to be a feasible alternative to improve upper limb motor function. The restraint alone, extended in time, did not enhance the treatment effect

Shortened constraint-induced movement therapy in subacute stroke - No effect of using a restraint: A randomized controlled study with independent observers.

OBJECTIVE: To examine the effect of using a mitt during shortened constraint-induced movement therapy for patients in the subacute phase after stroke. SUBJECTS: Twenty-four patients with stroke (mean age 57.6 (standard deviation (SD) 8.5) years; average 7 weeks post-stroke) with mild to moderate impaired hand function. METHODS: The patients were randomized to mitt use or no mitt use on the less affected hand for 90% of waking hours for 12 days. All patients received 3 h of arm and hand training per day for 2 weeks. Assessments were made by blinded observers using the modified Motor Assessment Scale, the Sollerman hand function test, the 2-Point Discrimination test and Motor Activity Log test. RESULTS: Patients in both groups showed significant improvements in arm and hand motor performance and on self- notreported motor ability after 2 weeks of therapy and at 3 months follow-up. However, no statistically significant differences between the groups were found in any measures at any point in time. CONCLUSION: In this study, no effect of using a restraint in patients with subacute stroke was found. Thus, this component in the constraint-induced therapy concept seems to be of minor importance for the outcome

Pain when walking: individual sensory profiles in the foot soles of torture victims - a controlled study using quantitative sensory testing

Abstract Background With quantitative sensory testing (QST) we recently found no differences in sensory function of the foot soles between groups of torture victims with or without exposure to falanga (beatings under the feet). Compared to matched controls the torture victims had hyperalgesia to deep mechano-nociceptive stimuli and hypoesthesia to non-noxious cutaneous stimuli. The purpose of the present paper was to extend the group analysis into individual sensory profiles of victims’ feet to explore possible relations between external violence (torture), reported pain, sensory symptoms and QST data to help clarify the underlying mechanisms. Methods We employed interviews and assessments of the pain and sensory symptoms and QST by investigators blinded to whether the patients, 32 male torture victims from the Middle East, had (n=15), or had not (n=17) been exposed to falanga. Pain intensity, area and stimulus dependence were used to characterize the pain. QST included thresholds for touch, cold, warmth, cold-pain, heat-pain, deep pressure pain and wind-up to cutaneous noxious stimuli. An ethnically matched control group was available.The normality criterion, from our control group data, was set as the mean +/− 1.28SD, thus including 80% of all values.QST data were transformed into three categories in relation to our normality range; hypoesthesia, normoesthesia or hyperesthesia/hyperalgesia. Results Most patients, irrespective of having been exposed to falanga or not, reported severe pain when walking. This was often associated with hyperalgesia to deep mechanical pressure. Hypoesthesia to mechanical stimuli co-occurred with numbness, burning and with deep mechanical hyperalgesia more often than not, but otherwise, a hypoesthesia to cutaneous sensory modalities did not co-occur systematically to falanga, pain or sensory symptoms. Conclusion In torture victims, there seem to be overriding mechanisms, manifested by hyperalgesia to pressure pain, which is usually considered a sign of centralization. In addition there was cutaneous hypoesthesia, but since there was no obvious correlation to the localization of trauma, these findings may indicate centrally evoked disturbances in sensory transmission, that is, central inhibition. We interpret these findings as a sign of changes in central sensory processing as the unifying pathological mechanism of chronic pain in these persons.</p