[109] A NEW TECHNIQUE FOR IMPROVING REHABILITATION OF MOVEMENT AFTER STROKE
Rama D. Pidikiti, MD; Edward Taub, PhD
Physical Medicine and Rehabilitation Service, VA Medical
Center, Birmingham, AL 35233; Department of Psychology,
University of Alabama at Birmingham, Birmingham, AL 35294;
email: Etaub@uab.edu
Sponsor: Department of Veterans Affairs, VA
Rehabilitation Research and Development Service, Washington,
DC 20420
(Project #B1692-RA)
PURPOSE--We have developed a new approach to rehabilitation, Constraint-Induced (CI) Movement Therapy. Controlled studies indicate that our technique can substantially reduce the incapacitating motor deficit of the affected upper limb in persons with mild-to-moderate chronic strokes and can greatly increase their functional independence.
METHODOLOGY--In its signature variant, CI consists of restricting the movement of the affected arm for 90 percent of waking hours in a sling for 2 wks; for the 10 weekdays during that period, the patient is given training of the affected arm for 6 hrs per day.
The main purpose of the current research is to further evaluate the clinical efficacy of CI for upper limb rehabilitation. There were two specific objectives:
Previously we had worked only with patients who reached or exceeded a minimum motor criterion that included 20-25 percent of patients with chronic stroke with motor deficit. In the current work we wished to determine whether the next lowest functioning 20-25 percent of patients with chronic stroke were also amenable to substantial improvement with CI. The main inclusion criterion for this group was ability to extend at the wrist between 10 and 20°, abduct the thumb at least 10°, and extend any two other fingers at least 10°.
We also wished to compare our previous CI results against matched subjects given a credible placebo control therapy. After 3 mo of follow-up, these subjects were to be crossed over to CI Therapy. The placebo intervention was termed a General Fitness Group; patients were given exercises (such as walking, aquatic therapy, balance training, word and attention games) to increase their endurance, stamina, and alertness. However, they received no exercises for the upper limb.
PROGRESS--Eleven lower functioning patients have been treated to date. These patients have responded as well to treatment as the higher functioning patients (20° extension at wrist and 10° extension at all fingers) we had previously worked with. Thus, it would appear that CI is applicable to at least 40-50 percent of patients with chronic stroke.
In the General Fitness (control) Group, 19 subjects have been tested to date. The intervention has a face credibility, as indicated by scores on an "expectancy and self-efficacy" questionnaire administered before and after treatment. However, the placebo treatment did not produce a significant effect on the Wolf Motor Function Test or on two real-world outcome measures. After cross over to CI 3 mo after the end of the placebo intervention, 10 subjects (to date) showed the same significant and large effects in improving arm function as observed on our previous work. The results make more conclusive our earlier findings that CI Therapy can significantly improve the amount of upper limb use in persons whose functional independence has been significantly compromised by motor deficits resulting from stroke.
FUTURE PLANS--We shall seek to determine whether the CI Therapy approach will be as useful for the rehabilitation of lower limb function after stroke as it is for that of the upper.
[110] FADING-IN OF RIGHT HEMISPATIAL INFORMATION IN THE TREATMENT OF UNILATERAL NEGLECT
Jeffrey S. Webster, PhD; Mark R. Levenstein, MD;
Payandeh Abadee, MD
Psychology, Geriatric Evaluation & Management, Physical
Medicine & Rehabilitation Services, VA Medical Center, 5901
E. Seventh Street Long Beach, CA 90822; email:
webster.jeffrey_s@long-beach.va.gov
Sponsor: Department of Veterans Affairs, VA
Rehabilitation Research and Development Service, Washington,
DC 20420
(Project #C2180-RA)
PURPOSE--Persons with right hemisphere stroke (R-CVA) along with left unilateral neglect sustain more accidents and respond less well to therapy than all other stroke patients undergoing rehabilitation. In our recent research, we developed a computer-assisted program to train these persons to compensate for unilateral neglect during simulated high-risk activities (i.e., wheelchair propulsion). We found that the program reduced symptoms of neglect in all but those subjects whose symptoms were most severe. These subjects were not globally demented, as they performed well on our screening tests of verbal memory. Rather, it appeared that their right hemisphere deficits were so severe that they could not benefit from training at the time of our intervention. The present research is designed to investigate a technique that may help to improve performance in severely impaired neglect patients. This technique involves first eliminating stimuli in right hemispace (the intact attentional area) and then gradually fading it back in as the subject learns to respond adequately to information in left hemispace.
METHODOLOGY--The present research compares two techniques for fading in right hemispatial information. The first, Environmental Fading (EF), involves placing sheets of neutral density filter paper over the right side of the computer training task. The paper is replaced by a less dense filter paper as the subject attains and maintains good performance in left hemispace. The goal of training is to have the subject perform well in left hemispace without any filter. The second technique, Visual Fading (VF), is similar to EF except that the subject wears the filter on his glasses. Filters are attached to the nasal portion of the left lens and the temporal portion of the right lens.
Subjects are randomly assigned to either the EF group or the VF group. All are then trained on number reading, visual tracking, and computer-simulated wheelchair driving tasks, receiving a maximum of 15 training sessions. Data from these groups will be compared with results from a matched group of unilateral neglect subjects, trained without fading. ANOVA analyses will be used to compare the groups on various pre-post neuropsychological measures sensitive to unilateral neglect and various outcome measures of training (e.g., number of training sessions to complete the program, skill mastery).
PROGRESS--Our study began in February 1998. One research assistant was hired at that time and another in September. Since start-up, we have been developing the technology to perform the EF and VF procedures mentioned above. We have also screened 22 R-CVA patients and piloted 7 of them using the two procedures to fade in right hemispatial stimuli. At present, we are recruiting subjects for participation in our treatment study.
FUTURE PLANS--We plan to collect data on 24 subjects (12 in each treatment group), and compare the two groups on our outcome measures. If the EF group performs significantly better on our outcome measures than the VF group, then this procedure will be used to train patients on in-vivo rehabilitation tasks (i.e., wheelchair navigation, using utensils/eating, kitchen safety). If the EF group does not perform better than the VF group, or the two groups do not differ significantly on our measures, then the VF procedure will be used to train subjects on real-life tasks, as this procedure will be more adaptable to in-vivo training. A Fading Treatment group (using either EF or VF) will then be compared to a Standard Treatment group (no fading) on several outcome measures to determine whether fading procedures facilitate training of unilateral neglect patients on rehabilitation tasks.
[111] GRADED WEIGHT-BEARING EXERCISE FOR IMPROVED AMBULATION AFTER STROKE
Charles G. Burgar, MD; David A. Brown, PhD, PT
VA Palo Alto Health Care System, Rehabilitation Research
and Development Center, Palo Alto, CA 94304
Sponsor: Department of Veterans Affairs, VA
Rehabilitation Research and Development Service, Washington,
DC 20420
(Project #B2005-2RA)
PURPOSE--The purpose of this study is to test the efficacy of a new exercise regime, graded weight-bearing (GWB), for improving lower limb function in persons with post-stroke hemiplegia. The exercise involves dynamic alternating lower limb movements with the amount of weight-bearing graded according to the level of recovery of the subject and is performed by pedaling an ergometer. Instead of sitting on a bicycle seat, the subject stands safely in the pedals and is partially supported by a tiltable backboard. The angle of the backboard determines the portion of body weight that must be supported by the legs. The goal of the current proposal is to demonstrate improved lower limb strength, improved weight-bearing capability, and improved functional ambulation in a group of chronic hemiplegic subjects training with GWB pedaling as compared with those of conventional therapeutic (CT) exercise techniques during a 12-week period.
METHODOLOGY--Post-stroke hemiplegic subjects are randomly selected from volunteer chronic stroke patients (>6 mo since onset) and will undergo initial (4 and 1 week prior to intervention), interim (6 weeks after initiation of intervention), and final measurements (1 and 4 weeks post-intervention) of lower-limb strength, weight-bearing capability, and functional ambulation. The CT group undergoes a thrice weekly, 12-week protocol of therapeutic exercises aimed at improving lower-limb strength and weight-bearing capability. The GWB pedaling group participates in a thrice weekly 12-week regimen of non-seated pedaling. In addition, both groups undergo functional gait training therapy in the remaining 2 days of each week. Statistical analyses are used to determine whether significant differences are present in the changes in the strength, weight-bearing capability, and functional ambulation tests performed either with CT or GWB intervention.
PROGRESS--To date, we have recruited 19 subjects to participate in the program. Ten have undergone the CT, and 9 the GWB, regimen. Initial data processing has begun on the outcome measures associated with strength, weight-bearing capability, and functional ambulation. Reliability of these measures is also currently being examined.
FUTURE PLANS--We will continue to recruit up to 8 more subjects for the study. Ultimately, we will propose studies to investigate the efficacy of GWB pedaling in enhancing and accelerating the pace of functional recovery in patients during the acute phase of post-stroke hemiplegia.
[112] MECHANICALLY ASSISTED UPPER LIMB MOVEMENT FOR ASSESSMENT AND THERAPY
Charles Burgar, MD; Machiel Van der Loos, PhD; Peter
Lum, PhD; Peggy Shor, OT
Palo Alto VA Rehabilitation Research and Development
Center, Palo Alto, CA 94304
Sponsor: Department of Veterans Affairs, VA
Rehabilitation Research and Development Service, Washington,
DC 20420
(Project #B2056-RA)
PURPOSE--We are attempting to evaluate the efficacy of robot-aided exercise for the recovery of upper limb motor function in chronic stroke subjects in a clinical trial comparing a robot-aided upper limb exercise program (MIME) with a conventional neurodevelopmental therapy (NDT) program.
METHODOLOGY--Chronic stroke subjects are randomly assigned to a test, or a control, group. Both groups receive 24 one-hour sessions over a 2-mo period. The test group practices reaching movements (tabletop and vertical) and planar tracing of circles and polygons. The movements are performed in three modes: passive (the limb is moved by the robot), active (the robot provides a viscous resistance in the direction of movement and spring-like loads in all other directions), and bilateral (the subject performs bilateral mirror-image movements while the paretic limb is assisted by the robot that is slaved to movement of the contralateral limb). Forces from the paretic limb are measured throughout. The control group receives conventional NDT. A blinded therapist evaluates all subjects pre- and post-treatment with standard clinical scales.
PROGRESS--Improvements in the design and implementation of the MIME apparatus have been completed. The robotic manipulator has been upgraded to a PUMA 560. The ability to perform programmed and patient-controlled, mirror-image movements in 3-D space has been added. Both right and left hemiplegia can now be accommodated. Several safety features have been added. The software has been extensively revised and tested. Clinical trials are in progress, and we are concluding testing of the third group of subjects.
PRELIMINARY RESULTS--All subjects tested so far have shown improved Fugl-Meyer scores following treatment. Other data, including kinetic and kinematic data from the exercise sessions and the between-group differences will be analyzed after completion of the study.
FUTURE PLANS--In future studies, the clinical utility of upper limb rehabilitation using MIME very early after the onset of hemiplegia (when it may have even greater beneficial effects on functional outcomes) will be investigated. Interaction forces during assisted movement will be used to help model and understand unilateral and bimanual motor functions and their recovery after stroke. Our long-term objectives are to develop improved treatment methods for hemiplegia and to develop a musculoskeletal model of the upper limb that enhances our understanding of motor impairment. We will validate the model using the kinematics and kinetics of active assisted movements, along with muscle electromyographic measurements.
[113] CORTICAL CONTRIBUTION TO THE RECOVERY OF MOTOR FUNCTION
Peter L. Strick, PhD; Donna S. Hoffman, PhD; Nathalie
Picard, PhD
Research Service (151S), VA Medical Center, Syracuse, NY
13210; email: strickp@vax.cs.hscsyr.edu
Sponsor: Department of Veterans Affairs, VA
Rehabilitation Research and Development Service, Washington,
DC 20420
(Project #B2013-RA)
PURPOSE--Our goals in these experiments are to identify the cortical areas involved in the generation and control of hand movements, and to determine which of them is responsible for the remarkable recovery of motor function that follows some cortical strokes. We have focused on hand movements because they are so essential to the normal daily function of humans. We have studied normal laboratory primates and human subjects, as well as laboratory primates with experimentally produced removal of a specific motor area of the brain, and humans with naturally occurring strokes.
METHODOLOGY--The primary motor cortex has long been thought to be the major motor area in the frontal lobe for the generation and control of voluntary movement. In laboratory primates, removal of the arm area of the primary motor cortex initially produced a profound paralysis of wrist movements. However, we found that a remarkable recovery of motor function was possible in these animals. Recovery took place over the course of approximately 1 yr with daily training of wrist movements. However, even after this period, some deficits remained. The wrist movements of animals with motor cortex lesions were slower than those of normal monkeys, and, in addition, movements in some directions were performed in multiple steps, rather than in a single smooth step to the target. The relative timing of activation of agonist and synergistic muscles also was disrupted. These observations led us to conclude that the primary motor cortex is responsible for the precise spatio-temporal patterning of muscle activity required for normal movement.
We also used 14C labeled 2-deoxyglucose (2-DG) to examine the pattern of functional activation in the motor areas of monkeys that recovered motor function after motor cortex lesions. 2-DG is taken up by the synapses and cell bodies of neurons that are metabolically active. Preliminary analysis suggests that 2-DG uptake was elevated in some of the premotor areas of the hemisphere ipsilateral to the primary motor cortex lesion. One of the premotor areas on the medial wall of the hemisphere, the dorsal cingulate motor area, was particularly active. On the other hand, activation in the opposite hemisphere did not appear to be higher than in normal animals. These preliminary observations suggest that the recovery of motor function following damage to the primary motor cortex depends on the increased involvement of specific premotor areas in the generation and control of movement.
RESULTS--Our studies in humans with cortical strokes have led to the surprising observation that a stroke on one side of the brain not only caused the expected problems in the control of contralateral wrist movements, but also disrupted wrist movements on the ipsilateral side. For example, nonimpaired human subjects perform accurate step-tracking movements of the wrist in a single step from one position to another. In contrast, in stroke patients, step-tracking movements of the wrist ipsilateral to a cortical stroke were performed in multiple steps with a zig-zagging trajectory. The normal pattern of agonist and antagonist muscle activity also was disrupted in the stroke patients. Overall, the effects of a cortical stroke in humans on movements of the wrist ipsilateral to the stroke were surprisingly similar to the effects of a lesion of the primary motor cortex in monkeys on contralateral wrist movements.
IMPLICATIONS--The outcome of our research could have an important impact on the methods used to evaluate and treat stroke patients. Our results should lead to a clearer definition of the short- and long-term deficits that are caused by a lesion of the primary motor cortex. In addition, our data should enable clinicians to make more accurate predictions about the potential for, and time course of, functional recovery after a cortical stroke. Specifically, our initial results suggest that the integrity of certain premotor areas in the frontal lobe is essential to the recovery of motor function of the hand following damage to the primary motor cortex. The potential for recovery may be good if these areas are not involved in the disease process and may be limited if these areas are involved. This information could be critical to attempts to rehabilitate stroke patients.
[114] CULTURAL INFLUENCE ON APHASIA IN AFRICAN-AMERICANS
Robert T. Wertz, PhD; Sandra B. Chapman, PhD; Hanna K.
Ulatowska, PhD
Audiology and Speech Pathology, VA Medical Center,
Nashville, TN 37212; University of Texas, Dallas, Dallas, TX
75235; email: wertz.robert_t.@nashville.va.gov
Sponsor: Department of Veterans Affairs, VA
Rehabilitation Research and Development Service, Washington,
DC 20420
(Project #C888-2RA)
PURPOSE--We are determining whether traditional aphasia tests are culturally biased and are developing culturally appropriate measures for aphasia. We seek answers to two research questions: Does performance by neurologically normal African-Americans (AA) differ from performance by neurologically normal Caucasian-Americans (CA) on traditional aphasia tests, culturally appropriate discourse measures, and a functional communication profile? Are there differences in the severity and profile of language deficits between aphasic AAs and aphasic CAs on traditional aphasia tests, culturally appropriate discourse measures, and a functional communication profile?
METHODOLOGY--Study participants will be 35 normal AAs; 35 normal CAs; 35 aphasic AAs; and 35 aphasic CAs. Normal subjects will have no history of neurological impairment. Aphasic subjects will be aphasic subsequent to a left hemisphere cerebral vascular accident and at least 3 mo postonset. All subjects will be administered: Two aphasia tests, the Western Aphasia Battery and the Token Test from the Neurosensory Center Comprehensive Examination for Aphasia; a discourse battery that includes four culturally appropriate tasks designed to elicit narrative discourse, and a functional communication profile that rates communication competence in a variety of functional communication activities. To answer the primary research questions, analyses of variance and covariance and Chi Square analyses will be used to compare normal AAs and CAs and aphasic AAs and CAs on the traditional aphasia tests, discourse measures, and functional communication profile.
PROGRESS--Discourse stimuli and tasks have been developed and pilot-tested for validity and reliability. Study participants are being recruited and evaluated. To date, 19 AA aphasic patients (AAA) and 22 AA control (AAC) subjects have been evaluated. Both groups produced relatively high amounts of language with good coherence on the discourse tasks. AAA patients showed significantly lower quantity of narrative (p<0.005) than AAC subjects. AAA patients differ significantly from AAC subjects in producing gists (p<0.002) and in interpreting proverbs (p<0.0001). The aphasia quotient on the Western Aphasia Battery is significantly lower (p<0.0001) in AAA patients, and comprehension on the Token Test is significantly lower (p<0.001). We continue to recruit and enter additional subjects in all groups to meet the prescribed sample size.
[115] CONTINUOUSLY INFUSED INTRATHECAL BACLOFEN (ITB) FOR SPASTIC/SYSTONIC HEMIPLEGIA
J.M. Meythaler, MD
University of Alabama at Birmingham, Spain
Rehabilitation Center, Birmingham, AL 35233; email:
meythaler@sun.rehabm.uab.edu
Sponsor: University of Alabama at Birmingham, Birmingham, AL 35233
PURPOSE--The Research goal is to determine if the continuous intrathecal delivery of baclofen (ITB) will control spastic hypertonia due to long-standing hemiplegia from acquired brain injury.
METHODOLOGY--In a tertiary care outpatient and inpatient rehabilitation center directly attached to a university hospital, we consecutively recruited persons who have had hemiplegia for more than 6 mo with intractable spasticity and dystonia. Subjects were screened via a randomized double blind, placebo-controlled crossover design to receive a bolus injection of either intrathecal normal saline or 50 µg of baclofen. Data for Ashworth rigidity scores, spasm scores, and deep tendon reflex scores were collected on the affected upper (UL) and lower (LL) limb side. Those who dropped an average of two points on their affected LL side Ashworth scores were then offered computer-controlled pump implantation for continuous ITB. Differences over time were assessed via descriptive statistics and Wilcoxon signed-rank.
PROGRESS--We recruited six subjects (average age 50, range 42-66 yr) for the ITB regimen.
RESULTS--Following 3 mo of treatment the average LL Ashworth on the affected side score decreased from 3.7±1.0 to 1.9±0.6 (p<0.0001), spasm score from 1.5±1.0 to 0.5±1.2 (p=0.138), and reflex score from 1.7±1.2 to 0.5±0.8 (p=0.0262). The average UL Ashworth score on the affected side decreased from 3.2±1.1 to 2.1±0.9 (p=0.0005), spasm score from 0.8±1.3 to 0±0 (p=0.1797), and reflex score from 2.3±0.5 to 1.7±0.5 (p=0.1088). On the non-hemiparetic side the only objective finding was drop in the LL reflexes from 1.5±0.7 to 0.2±0.4. The average ITB dose required to attain these effects was 205.3 µg continuously infused over 24 hr.
FUTURE PLANS--We shall continue enrolling subjects described in protocol for data collections.
IMPLICATIONS--Continuous intrathecal infusion of baclofen is capable of maintaining a reduction in the dystonia on the hemiparetic side without significantly affecting motor strength on the normal side.
[116] LONG-TERM CONTINUOUSLY INFUSED BACLOFEN (ITB) FOR SPASTIC-DYSTONIC HYPERTONIA IN TRAUMATIC BRAIN INJURY
J.M. Meythaler, MD
University of Alabama at Birmingham, Spain
Rehabilitation Center, Birmingham, AL 35233; email:
meythaler@sun.rehabm.uab.edu
Sponsor: University of Alabama at Birmingham, Birmingham, AL 35233
PURPOSE--The purpose of this research is to determine whether the long-term use of continuously infused intrathecal baclofen (ITB) over a 1-year period will control spastic-dystonic hypertonia in traumatic brain injury (TBI).
METHODOLOGY--Setting: tertiary care outpatient and inpatient rehabilitation center directly attached to a university hospital. Subjects: persons with TBI and intractable spasticity and dystonia for over 6 mo duration recruited in a consecutive manner. Design: subjects were admitted to the study after screening via a bolus injection of either intrathecal normal saline or 50 mg of baclofen. Data for Ashworth rigidity scores, spasm scores, and deep tendon reflex scores were collected for both the upper (UL) and lower (LL) limbs. Those who dropped an average of two points on their lower extremity Ashworth scores were then offered computer controlled pump implantation for continuous ITB. Changes over time were assessed statisticaly via Friedman's analysis for ordinal data and ANOVA for linear data. Differences between set points in time were also assessed via Wilcoxon signed-rank.
PROGRESS--We treated 17 subjects (mean age=29±11 yrs) with spasticity and/or dystonia over 1 yr via a computer-controllable system for the delivery of ITB, after which the average LL Ashworth score decreased from 3.5±1.3 to 1.7±0.9 (p<0.0001), spasm score from 1.8±1.3 to 0.2±0.5 (p<0.0001), and reflex score from 2.5SD±1.1 to 0.1±0.3 (p<0.0001). The average UE Ashworth score decreased from 2.9±1.5 to 1.6±1.0 (p<0.0001), spasm score from 1.2±1.5 to 0.2±0.6 (p<0.0001), and reflex score from 2.2±0.5 to 1.0±0.8 (p<0.0001). The average ITB dose required to attain these effects was 302 µg continuously infused per day.
FUTURE PLANS--Continue enrolling subjects described in protocol for data collections.
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