Treatment-Induced Cortical Reorganization After Stroke in Humans
TL;DR: This is the first demonstration in humans of a long-term alteration in brain function associated with a therapy-induced improvement in the rehabilitation of movement after neurological injury.
Abstract: Background and Purpose—Injury-induced cortical reorganization is a widely recognized phenomenon. In contrast, there is almost no information on treatment-induced plastic changes in the human brain. The aim of the present study was to evaluate reorganization in the motor cortex of stroke patients that was induced with an efficacious rehabilitation treatment. Methods—We used focal transcranial magnetic stimulation to map the cortical motor output area of a hand muscle on both sides in 13 stroke patients in the chronic stage of their illness before and after a 12-day-period of constraint-induced movement therapy. Results—Before treatment, the cortical representation area of the affected hand muscle was significantly smaller than the contralateral side. After treatment, the muscle output area size in the affected hemisphere was significantly enlarged, corresponding to a greatly improved motor performance of the paretic limb. Shifts of the center of the output map in the affected hemisphere suggested the recru...
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TL;DR: 10 principles of experience-dependent neural plasticity and considerations in applying them to the damaged brain are reviewed from the perspective of basic neuroscientists but in a manner intended to be useful for the development of more effective clinical rehabilitation interventions.
Abstract: Purpose This paper reviews 10 principles of experience-dependent neural plasticity and considerations in applying them to the damaged brain. Method Neuroscience research using a variety of models o...
1,907 citations
Cites background from "Treatment-Induced Cortical Reorgani..."
...…arm in humans with unilateral strokes improves the function of the impaired limb and promotes greater movementassociated activation in the remaining cortex of the injured hemisphere (e.g., Liepert et al., 2000; Sterr et al., 2002; Taub, 2000; Taub, Uswatte, & Morris, 2003; Wolf et al., 1989)....
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TL;DR: The Extremity Constraint Induced Therapy Evaluation (EXCITE) trial as mentioned in this paper showed that a 2-week program of constraint-induced movement therapy (CIMT) for patients more than 1 year after stroke who maintain some hand and wrist movement can improve upper extremity function that persists for at least 1 year.
Abstract: ContextSingle-site studies suggest that a 2-week program of constraint-induced movement therapy (CIMT) for patients more than 1 year after stroke who maintain some hand and wrist movement can improve upper extremity function that persists for at least 1 year.ObjectiveTo compare the effects of a 2-week multisite program of CIMT vs usual and customary care on improvement in upper extremity function among patients who had a first stroke within the previous 3 to 9 months.Design and SettingThe Extremity Constraint Induced Therapy Evaluation (EXCITE) trial, a prospective, single-blind, randomized, multisite clinical trial conducted at 7 US academic institutions between January 2001 and January 2003.ParticipantsTwo hundred twenty-two individuals with predominantly ischemic stroke.InterventionsParticipants were assigned to receive either CIMT (n = 106; wearing a restraining mitt on the less-affected hand while engaging in repetitive task practice and behavioral shaping with the hemiplegic hand) or usual and customary care (n = 116; ranging from no treatment after concluding formal rehabilitation to pharmacologic or physiotherapeutic interventions); patients were stratified by sex, prestroke dominant side, side of stroke, and level of paretic arm function.Main Outcome MeasuresThe Wolf Motor Function Test (WMFT), a measure of laboratory time and strength-based ability and quality of movement (functional ability), and the Motor Activity Log (MAL), a measure of how well and how often 30 common daily activities are performed.ResultsFrom baseline to 12 months, the CIMT group showed greater improvements than the control group in both the WMFT Performance Time (decrease in mean time from 19.3 seconds to 9.3 seconds [52% reduction] vs from 24.0 seconds to 17.7 seconds [26% reduction]; between-group difference, 34% [95% confidence interval {CI}, 12%-51%]; P<.001) and in the MAL Amount of Use (on a 0-5 scale, increase from 1.21 to 2.13 vs from 1.15 to 1.65; between-group difference, 0.43 [95% CI, 0.05-0.80]; P<.001) and MAL Quality of Movement (on a 0-5 scale, increase from 1.26 to 2.23 vs 1.18 to 1.66; between-group difference, 0.48 [95% CI, 0.13-0.84]; P<.001). The CIMT group achieved a decrease of 19.5 in self-perceived hand function difficulty (Stroke Impact Scale hand domain) vs a decrease of 10.1 for the control group (between-group difference, 9.42 [95% CI, 0.27-18.57]; P=.05).ConclusionAmong patients who had a stroke within the previous 3 to 9 months, CIMT produced statistically significant and clinically relevant improvements in arm motor function that persisted for at least 1 year.Trial Registrationclinicaltrials.gov Identifier: NCT00057018
1,662 citations
01 Jan 2006
TL;DR: The Extremity Constraint Induced Therapy Evaluation (EXCITE) trial as discussed by the authors was designed to compare the effects of a 2-week multisite program of CIMT vs usual andcustomary care.
Abstract: Context Single-sitestudiessuggestthata2-weekprogramofconstraint-inducedmove-ment therapy (CIMT) for patients more than 1 year after stroke who maintain somehand and wrist movement can improve upper extremity function that persists for atleast 1 year.Objective To compare the effects of a 2-week multisite program of CIMT vs usualandcustomarycareonimprovementinupperextremityfunctionamongpatientswhohad a first stroke within the previous 3 to 9 months.Design and Setting The Extremity Constraint Induced Therapy Evaluation(EXCITE) trial, a prospective, single-blind, randomized, multisite clinical trial con-ducted at 7 US academic institutions between January 2001 and January 2003.Participants Twohundredtwenty-twoindividualswithpredominantlyischemicstroke.Interventions Participants were assigned to receive either CIMT (n=106; wearinga restraining mitt on the less-affected hand while engaging in repetitive task practiceandbehavioralshapingwiththehemiplegichand)orusualandcustomarycare(n=116;rangingfromnotreatmentafterconcludingformalrehabilitationtopharmacologicorphysiotherapeutic interventions); patients were stratified by sex, prestroke dominantside, side of stroke, and level of paretic arm function.Main Outcome Measures The Wolf Motor Function Test (WMFT), a measure oflaboratory time and strength-based ability and quality of movement (functional abil-ity),andtheMotorActivityLog(MAL),ameasureofhowwellandhowoften30com-mon daily activities are performed.Results From baseline to 12 months, the CIMT group showed greater improve-ments than the control group in both the WMFT Performance Time (decrease inmean time from 19.3 seconds to 9.3 seconds [52% reduction] vs from 24.0 sec-onds to 17.7 seconds [26% reduction]; between-group difference, 34% [95% con-fidence interval {CI}, 12%-51%];
1,494 citations
TL;DR: Compared with conventional treatment, robot-assisted movements had advantages in terms of clinical and biomechanical measures and was justified into the use of robotic manipulation for motor rehabilitation.
1,111 citations
TL;DR: The current "state of the art" for virtual reality (VR) applications in the field of motor rehabilitation is reviewed and movements learned by people with disabilities in VR transfer to real world equivalent motor tasks in most cases, and in some cases even generalize to other untrained tasks.
Abstract: In this paper, the current "state of the art" for virtual reality (VR) applications in the field of motor rehabilitation is reviewed. The paper begins with a brief overview of available equipment options. Next, a discussion of the scientific rationale for use of VR in motor rehabilitation is provided. Finally, the major portion of the paper describes the various VR systems that have been developed for use with patients, and the results of clinical studies reported to date in the literature. Areas covered include stroke rehabilitation (upper and lower extremity training, spatial and perceptual-motor training), acquired brain injury, Parkinson's disease, orthopedic rehabilitation, balance training, wheelchair mobility and functional activities of daily living training, and the newly developing field of telerehabilitation. Four major findings emerge from these studies: (1) people with disabilities appear capable of motor learning within virtual environments; (2) movements learned by people with disabilities in VR transfer to real world equivalent motor tasks in most cases, and in some cases even generalize to other untrained tasks; (3) in the few studies (n = 5) that have compared motor learning in real versus virtual environments, some advantage for VR training has been found in all cases; and (4) no occurrences of cybersickness in impaired populations have been reported to date in experiments where VR has been used to train motor abilities.
1,094 citations
References
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Book•
01 Dec 1969TL;DR: The concepts of power analysis are discussed in this paper, where Chi-square Tests for Goodness of Fit and Contingency Tables, t-Test for Means, and Sign Test are used.
Abstract: Contents: Prefaces. The Concepts of Power Analysis. The t-Test for Means. The Significance of a Product Moment rs (subscript s). Differences Between Correlation Coefficients. The Test That a Proportion is .50 and the Sign Test. Differences Between Proportions. Chi-Square Tests for Goodness of Fit and Contingency Tables. The Analysis of Variance and Covariance. Multiple Regression and Correlation Analysis. Set Correlation and Multivariate Methods. Some Issues in Power Analysis. Computational Procedures.
115,069 citations
TL;DR: The results suggest that the representation of different parts of the body in the primary somatosensory cortex of humans depends on use and changes to conform to the current needs and experiences of the individual.
Abstract: Magnetic source imaging revealed that the cortical representation of the digits of the left hand of string players was larger than that in controls. The effect was smallest for the left thumb, and no such differences were observed for the representations of the right hand digits. The amount of cortical reorganization in the representation of the fingering digits was correlated with the age at which the person had begun to play. These results suggest that the representation of different parts of the body in the primary somatosensory cortex of humans depends on use and changes to conform to the current needs and experiences of the individual.
1,821 citations
TL;DR: The results suggest that, after local damage to the motor cortex, rehabilitative training can shape subsequent reorganization in the adjacent intact cortex, and that the undamaged motor cortex may play an important role in motor recovery.
Abstract: Substantial functional reorganization takes place in the motor cortex of adult primates after a focal ischemic infarct, as might occur in stroke. A subtotal lesion confined to a small portion of the representation of one hand was previously shown to result in a further loss of hand territory in the adjacent, undamaged cortex of adult squirrel monkeys. In the present study, retraining of skilled hand use after similar infarcts resulted in prevention of the loss of hand territory adjacent to the infarct. In some instances, the hand representations expanded into regions formerly occupied by representations of the elbow and shoulder. Functional reorganization in the undamaged motor cortex was accompanied by behavioral recovery of skilled hand function. These results suggest that, after local damage to the motor cortex, rehabilitative training can shape subsequent reorganization in the adjacent intact cortex, and that the undamaged motor cortex may play an important role in motor recovery.
1,821 citations
TL;DR: A very strong direct relationship is reported between the amount of cortical reorganization and the magnitude of phantom limb pain (but not non-painful phantom phenomena) experienced after arm amputation, indicating that phantom-limb pain is related to, and may be a consequence of, plastic changes in primary somatosensory cortex.
Abstract: Although phantom-limb pain is a frequent consequence of the amputation of an extremity, little is known about its origin. On the basis of the demonstration of substantial plasticity of the somatosensory cortex after amputation or somatosensory deafferentation in adult monkeys, it has been suggested that cortical reorganization could account for some non-painful phantom-limb phenomena in amputees and that cortical reorganization has an adaptive (that is, pain-preventing) function. Theoretical and empirical work on chronic back pain has revealed a positive relationship between the amount of cortical alteration and the magnitude of pain, so we predicted that cortical reorganization and phantom-limb pain should be positively related. Using non-invasive neuromagnetic imaging techniques to determine cortical reorganization in humans, we report a very strong direct relationship (r = 0.93) between the amount of cortical reorganization and the magnitude of phantom limb pain (but not non-painful phantom phenomena) experienced after arm amputation. These data indicate that phantom-limb pain is related to, and may be a consequence of, plastic changes in primary somatosensory cortex.
1,692 citations
"Treatment-Induced Cortical Reorgani..." refers background or methods in this paper
...Exclusion criteria were (1) serious uncontrolled medical conditions, (2) global aphasia or cognitive impairments that might interfere with understanding instructions for motor testing, (3) anything in the head that contained metal, (4) pregnancy, (5) epilepsy, and (6) cardiac pacemaker....
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...Treatment efficacy was evaluated with the motor activity log (MAL), 34 which tracked arm use in 20 common and important activities of daily living (ADL) performed outside the laboratory (1) for the week before the subject’s visit to the laboratory 2 weeks before the beginning of treatment, (2) for the week before the beginning of treatment, (3) 1 day after treatment, and (4) 4 weeks and (5) 6 months after the end of treatment (follow-up)....
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Journal Article•
TL;DR: Extensive restraint of an unaffected upper extremity and practice of functional movements with the impaired limb proved to be an effective means of restoring substantial motor function in stroke patients with chronic motor impairment identified by the inclusion criteria of this project.
1,566 citations