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      Sequencing bilateral and unilateral task-oriented training versus task oriented training alone to improve arm function in individuals with chronic stroke

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          Abstract

          Background

          Recovering useful hand function after stroke is a major scientific challenge for patients with limited motor recovery. We hypothesized that sequential training beginning with proximal bilateral followed by unilateral task oriented training is superior to time-matched unilateral training alone. Proximal bilateral training could optimally prepare the motor system to respond to the more challenging task-oriented training.

          Methods

          Participants: Twenty-six participants with moderate severity hemiparesis Intervention: Participants received either 6-weeks of bilateral proximal training followed sequentially by 6-weeks unilateral task-oriented training (COMBO) or 12-weeks of unilateral task-oriented training alone (SAEBO). A subset of 8 COMB0 and 9 SAEBO participants underwent three functional magnetic resonance imaging (fMRI) scans of hand and elbow movement every 6 weeks. Main Outcome Measures: Fugl-Meyer Upper extremity scale, Modified Wolf Motor Function Test, University of Maryland Arm Questionnaire for Stroke, Motor cortex activation (fMRI).

          Results

          The COMBO group demonstrated significantly greater gains between baseline and 12-weeks over all outcome measures (p = .018 based on a MANOVA test) and specifically in the Modified Wolf Motor Function test (time). Both groups demonstrated within-group gains on the Fugl-Meyer Upper Extremity test (impairment) and University of Maryland Arm Questionnaire for Stroke (functional use). fMRI subset analyses showed motor cortex (primary and premotor) activation during hand movement was significantly increased by sequential combination training but not by task-oriented training alone.

          Conclusions

          Sequentially combining a proximal bilateral before a unilateral task-oriented training may be an effective way to facilitate gains in arm and hand function in those with moderate to severe paresis post-stroke compared to unilateral task oriented training alone.

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          Most cited references29

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          Repetitive bilateral arm training and motor cortex activation in chronic stroke: a randomized controlled trial.

          Reorganization in central motor networks occurs during early recovery from hemiparetic stroke. In chronic stroke survivors, specific rehabilitation therapy can improve upper extremity function. To test the hypothesis that in patients who have chronic motor impairment following stroke, specific rehabilitation therapy that improves arm function is associated with reorganization of cortical networks. A randomized controlled clinical trial conducted in a US ambulatory rehabilitation program with 21 patients (median [IQR], 50.3 [34.8-77.3] months after unilateral stroke). Data were collected between 2001 and 2004. Patients were randomly assigned to bilateral arm training with rhythmic auditory cueing (BATRAC) (n = 9) or standardized dose-matched therapeutic exercises (DMTE) (n = 12). Both were conducted for 1 hour, 3 times a week, for 6 weeks. Within 2 weeks before and after the intervention, brain activation during elbow movement assessed by functional magnetic resonance imaging (fMRI) and functional outcome assessed using arm function scores. Patients in the BATRAC group but not in the DMTE group increased hemispheric activation during paretic arm movement (P = .03). Changes in activation were observed in the contralesional cerebrum and ipsilesional cerebellum (P = .009). BATRAC was associated with significant increases in activation in precentral (P<.001) and postcentral gyri (P = .03) and the cerebellum (P<.001), although 3 BATRAC patients showed no fMRI changes. Considering all patients, there were no differences in functional outcome between groups. When only BATRAC patients with fMRI response were included (n = 6), BATRAC improved arm function more than DMTE did (P = .02). These preliminary findings suggest that BATRAC induces reorganization in contralesional motor networks and provide biological plausibility for repetitive bilateral training as a potential therapy for upper extremity rehabilitation in hemiparetic stroke.
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            Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, Action Research Arm Test and Box and Block Test: a multicentre study.

            To establish: (1) inter-rater and test-retest reliability of standardized guidelines for the Fugl-Meyer upper limb section, Action Research Arm Test and Box and Block Test in patients with paresis secondary to stroke, multiple sclerosis or traumatic brain injury and (2) correlation between these arm motor scales and more general measures of impairment and activity limitation. Multicentre cohort study. Three European referral centres for neurorehabilitation. Thirty-seven stroke, 14 multiple sclerosis and five traumatic brain injury patients. Scores of the Fugl-Meyer Test (arm section), Action Research Arm Test, and Box and Block Test derived from video information. All three motor tests showed very high inter-rater and test-retest reliability (ICC and rho for main variables > 0.95). Correlation between the motor scales was very high (rho > 0.92). Motor scales correlated moderately highly with the Hemispheric Stroke Scale, a measure of impairment (rho = 0.660-0.689), but not with the Modified Barthel Index, a measure of the ability to cope with basic activities of daily living (rho = 0.044-0.086). The standardized guidelines assured comparability of test administration and scoring across clinical facilities. The arm motor scales provided information that was not identical to information from the Hemispheric Stroke Scale or the Modified Barthel Index.
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              Motor cortex plasticity during constraint-induced movement therapy in stroke patients.

              Stroke patients in the chronic phase received constraint-induced (CI) movement therapy. The motor cortex was spatially mapped using focal transcranial magnetic stimulation (TMS) before and after 2 weeks of treatment. Motor-output areas of the abductor pollicis brevis muscle, motor evoked potential (MEP) amplitudes and location of centre of gravity (CoG) of motor cortex output were studied. After CI therapy, motor performance improved substantially in all patients. There was also an increase of motor output area size and MEP amplitudes, indicating enhanced neuronal excitability in the damaged hemisphere for the target muscles. The mean centre of gravity of the motor output maps was shifted considerably after the rehabilitation, indicating the recruitment of motor areas adjacent to the original location. Thus, even in chronic stroke patients, reduced motor cortex representations of an affected body part can be enlarged and increased in level of excitability by an effective rehabilitation procedure. The data therefore demonstrate a CNS correlate of therapy-induced recovery of function after nervous system damage in humans.
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                Author and article information

                Contributors
                smccombewaller@som.umaryland.edu
                jwhitall@som.umaryland.edu
                tojenkins@som.umaryland.edu
                lmagder@epi.umaryland.edu
                dhanley@jhmi.edu
                agoldber@medicine.umaryland.edu
                andreas.luft@uzh.ch
                Journal
                BMC Neurol
                BMC Neurol
                BMC Neurology
                BioMed Central (London )
                1471-2377
                14 December 2014
                14 December 2014
                2014
                : 14
                : 1
                : 236
                Affiliations
                [ ]School of Medicine, Department of Physical Therapy and Rehabilitation Science, University of Maryland, 100 Penn Street, Baltimore, MD 21201 USA
                [ ]Department of Epidemiology and Public Health, University of Maryland, 660 W. Redwood Street, Baltimore, MD 21201 USA
                [ ]Acute Care Neurology, Director, Division of Brain Injury Outcomes, The Johns Hopkins Medical Institutions, 1550 Orleans Street, Baltimore, MD 21231 USA
                [ ]Geriatric Research, Education and Clinical Center (GRECC), Baltimore VA Medical Center, University of Maryland School of Medicine, 10 North Greene Street, BT/18/GR, Baltimore, MD 21201 USA
                [ ]Department of Neurology, University and University Hospital Zurich, Frauenklinikstrasse 26, Zürich, 8091 Switzerland
                Article
                236
                10.1186/s12883-014-0236-6
                4276071
                25494635
                4d5fa6b5-5baa-4fac-bf8e-98ea04cabe29
                © McCombe Waller et al.; licensee BioMed Central Ltd. 2014

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 10 June 2014
                : 1 December 2014
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2014

                Neurology
                stroke,bilateral arm training,upper extremity,fmri,sequential training
                Neurology
                stroke, bilateral arm training, upper extremity, fmri, sequential training

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