Motor Learning
Motor Learning, Sprig 2017
Question Set 2
Your answers to the following questions should be based on the research articles listed below (listed in the order discussed) and class discussion. In order to
receive full credit your answers must be written in essay format (APA format is required).
1. Krakauer, J. W. (2015). The applicability of motor learning to neurorehabilitation. In; Dietz, V. and Ward, N., ed. Oxford Textbook of Neurorehabilitation (p.
55-65). Oxford University Press, USA.
2. Kitago et al. (2013). Improvement after constraint-induced movement therapy: recovery of normal motor control or task-specific compensation? Neural
rehabilitation and Neural Repair, 2, 99-109.
1. What is CIMT and why is early, intense neurorehabilitation considered an important post-stroke intervention? Explain. 3 points
2. Why has the role of instruction and knowledge for motor learning been neglected? Explain. 3 points
3. What is motor recovery and compensation and why is the distinction between motor recovery and compensation important? Explain. 4 points
Please refer to Kitago et al., 2013 for the following questions:
4. Describe the rationale for including both clinical and kinematic assessments. 4 points
5. Describe 4 weaknesses of the study that limit both the generalization of the results and the scientific progression of knowledge regarding CIMT as a successful
neurorehabiliation technique. Explain. 8 points
6. Describe the effectiveness of CIMT based on the results and discuss how the findings advanced our knowledge of CIMT. 8 points
7. Design a future study that would successfully advance our knowledge about CIMT as a post-stroke intervention. (Make sure to provide a rationale for each
component of your design). 20 points
http://nnr.sagepub.com/ Repair Neurorehabilitation and Neural
http://nnr.sagepub.com/content/27/2/99 The online version of this article can be found at:
DOI: 10.1177/1545968312452631 2013 27: 99 originally published online 13 July 2012Neurorehabil Neural Repair Randolph S. Marshall, Pietro Mazzoni, Laura Lennihan and
John W. Krakauer Tomoko Kitago, Johnny Liang, Vincent S. Huang, Sheila Hayes, Phyllis Simon, Laura Tenteromano, Ronald M. Lazar, Task-Specific Compensation?
Improvement After Constraint-Induced Movement Therapy: Recovery of Normal Motor Control or
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Neurorehabilitation and Neural Repair 27(2) 99 –109 © The Author(s) 2013 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI:
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Clinical Research Articles
Introduction
Stroke occurs in approximately 795 000 Americans a year and is the leading cause of adult disability.1 Between 30% and 66% of patients are left with limited arm
function 6 months after stroke.2 There is clearly a need for interven- tions that can improve arm function beyond what is regained through spontaneous recovery and
conventional rehabilita- tion. Constraint-induced movement therapy (CIMT) has emerged as a promising intervention in subacute3,4 and chronic5,6 stroke. In CIMT, the
unaffected arm is restrained for a majority of waking hours while the affected arm under- goes task-based practice.7 The mechanisms underlying the functional
improvement seen with CIMT are not well under- stood at either the neural or the behavioral level.8,9 Are patients regaining more normal control of their affected arm
after CIMT, or are they learning to use compensatory strate- gies?
The distinction between motor recovery and compensa- tion is often not addressed in rehabilitation studies.10,11 We define motor recovery as the reemergence of
movement kinematics similar to those of healthy age-matched con- trols, resulting from a decrease in impairment, whereas compensation involves the use of the
unaffected limb or alternative muscle groups on the affected side to accom- plish a task. For example, with hemiparesis patients may
452631NNR27210.1177/1545968312452631Kita go et alNeurorehabilitation and Neural Repair 2013© The Author(s) 2010
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1 Columbia University College of Physicians and Surgeons, New York, NY, USA 2Helen Hayes Hospital, West Haverstraw, NY, USA 3Johns Hopkins University, Baltimore, MD,
USA
Corresponding Author: Tomoko Kitago, MD, Neurological Institute, Department of Neurology, Columbia University College of Physicians and Surgeons, 710 West 168th
Street, New York, NY 10032, USA Email: tk2229@columbia.edu
Improvement After Constraint-Induced Movement Therapy: Recovery of Normal Motor Control or Task-Specific Compensation?
Tomoko Kitago, MD1, Johnny Liang, MS1, Vincent S. Huang, PhD1, Sheila Hayes2, Phyllis Simon, MS2, Laura Tenteromano2, Ronald M. Lazar, PhD1, Randolph S. Marshall,
MD1, Pietro Mazzoni, MD, PhD1, Laura Lennihan, MD1, 2, and John W. Krakauer, MD1, 3
Abstract Background. Constraint-induced movement therapy (CIMT) has proven effective in increasing functional use of the affected arm in patients with chronic stroke.
The mechanism of CIMT is not well understood. Objective. To demonstrate, in a proof- of-concept study, the feasibility of using kinematic measures in conjunction with
clinical outcome measures to better understand the mechanism of recovery in chronic stroke patients with mild to moderate motor impairments who undergo CIMT. Methods.
A total of 10 patients with chronic stroke were enrolled in a modified CIMT protocol over 2 weeks. Treatment response was assessed with the Action Research Arm Test
(ARAT), the Upper-Extremity Fugl-Meyer score (FM-UE), and kinematic analysis of visually guided arm and wrist movements. All assessments were performed twice before
the therapeutic intervention and once afterward. Results. There was a clinically meaningful improvement in ARAT from the second pre-CIMT session to the post-CIMT
session compared with the change between the 2 pre-CIMT sessions. In contrast, FM-UE and kinematic measures showed no meaningful improvements. Conclusions. Functional
improvement in the affected arm after CIMT in patients with chronic stroke appears to be mediated through compensatory strategies rather than a decrease in impairment
or return to more normal motor control. We suggest that future large-scale studies of new interventions for neurorehabilitation track performance using kinematic
analyses as well as clinical scales.
Keywords stroke, constraint-induced movement therapy, rehabilitation, kinematics, reaching
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100 Neurorehabilitation and Neural Repair 27(2)
engage excessive truncal or scapular movement while reaching12,13 or use alternative grasp strategies14 to pick up objects. A concern that has been raised is that
emphasis on the use of compensatory strategies to achieve immediate functional gains may be detrimental to long-term motor recovery,13,15,16 although this has not been
systematically examined. Most studies of CIMT have used self-reported question- naires or functional scales that are unable to distinguish between improvements
resulting from motor recovery and those attributable to compensation.17 The primary outcome measures in the largest randomized controlled trial of CIMT to date were a
patient questionnaire (Motor Activity Log) and a functional arm test (Wolf Motor Function Test) involving timed and strength tasks.4 A few studies have also
investigated the effect of CIMT on tests of arm impairment in chronic stroke patients, most commonly using the Upper- Extremity Fugl-Meyer Assessment (FM-UE), with
variable results.5,18-22 Mean changes in FM-UE scores in these stud- ies ranged from 3 to 19, with the larger changes occurring with lower-intensity, longer-duration
treatment protocols.20,21 Limitations of the FM-UE as an impairment assessment tool include a ceiling effect in patients with mild deficits and its 3-graded scale,
which may limit its responsiveness to change.23 Kinematic analysis can provide objective, quantitative, fine-grained measures of arm motor impair- ment after stroke,24
with the ability to detect and quantify even subtle differences in movement patterns, which is crucial for a mechanistic understanding of this increasingly popular
therapy. The few studies that have assessed kinematics before and after CIMT17,18,25,26 have shown reduced reaction time,18 reduced movement duration,17,18,26
increased smoothness,26 reduced path length,18 and reduced trajectory variability.17,26 Massie et al17 found that patients used more shoulder abduc- tion to reach
after CIMT, which suggests that some of the functional improvements seen with CIMT may be a result of compensatory strategies rather than reacquisition of normal
motor control. These prior kinematic studies charac- terized unrestrained 3-dimensional movements and so did not test patients’ abilities to perform tasks under
conditions that do not allow the use of compensatory strategies. Indeed, patients may continue to use compensatory habits despite a degree of neural recovery that
would actually allow for a more normal movement pattern if they were to attempt it.27 Therefore, we argue that patients’ level of impairment should be tested on a
constrained kinematic task designed to preclude the use of compensation. In the current study, compensatory strategies were mini- mized in the kinematic tasks through
the use of constraints, with the aim of capturing measures reflecting “true” impair- ment. For example, the arm task used in the current study required planar reaching
movements (hand, elbow, and shoulder had to be level), with participants seated in a setup
that limited trunk and shoulder movement (Figure 1). When reaching movements are planar, there is only a single joint angle solution pair at the elbow and shoulder for
a given end point. Thus, in our tasks, patients could not use compensa- tory strategies that take advantage of the multiple degrees of freedom available when
performing 3-dimensional reach- ing movements. That is to say, we tested for impairment in a system that does not have redundancy that can be exploited by
compensation.14,28 Our tasks were relatively simple movements designed to test an elementary level of motor control in the proximal arm and wrist and can be considered
the arm and wrist analogues of quantitative tests of finger individuation.29 That these tasks capture an elementary level of multijoint limb control is supported by
the observa- tion that healthy participants are able to perform them mak- ing movements with straight trajectories and high end-point accuracy30 with minimal practice
despite having little expe- rience with planar reaching or isolated visually guided wrist movements in everyday activities.31 Previous kinematic studies in patients
with hemiparesis have shown deficits in trajectory and end-point control, with increased initial directional error,32 path curvature,33 end-point error,34 and
segmentation.33,35 These are the 4 kinematic outcome mea- sures that we used in the current study to assay for reduc- tions in arm impairment. A recent meta-analysis
found a graded effect of modified CIMT, with the largest effects on arm function (measured by the Action Research Arm Test [ARAT]), significant but smaller effects on
arm impairment (measured by the FM-UE), and improvements in some kinematic variables but not others.36 However, no single study has compared improvements at all 3
levels, as was done in the current study, in which patients with chronic stroke participated in
Figure 1. Setup for the arm reaching task: participants were seated with the shoulder, elbow, and hand aligned in the same plane, and the their trunk was secured
between the table and chair to limit truncal displacement. The wrist, hand, and fingers were immobilized with a splint, thus confining movements to the shoulder and
elbow, and the forearm was supported on an air-sled system, which removed friction. Participants viewed a mirror that reflected an LCD display, and the arm was
obscured from view
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Kitago et al 101
a modified CIMT program and were evaluated with clinical scales of motor function and impairment as well as with kinematic analysis of arm and wrist movements. We
hypothesized here that the main effect of CIMT is to pro- mote functional use of the affected arm primarily through compensatory strategies and not through a reduction
in impairment (ie, motor recovery), given the task-oriented nature of the training intervention and findings of a prior study17 of CIMT. Therefore, we predicted that
we would see the greatest improvements in the ARAT and more modest, if any, improvements in the FM-UE and in kine- matic variables.
Methods Study Participants
A total of 10 patients with chronic stroke were recruited from a local rehabilitation hospital and outpatient neurological practices between May 2005 and February
2007. Participants met the following inclusion criteria: (1) ischemic or hemor- rhagic stroke at least 6 months prior to enrollment, (2) motor deficit involving 1 arm
with the ability to perform at least 20° wrist extension and 10° finger extension, (3) significant unaffected hand use for activities of daily living, and (4) ARAT
score <50 in the affected arm. Inclusion criteria (2) and (3) are similar to those used in previous studies of CIMT that demonstrated functional motor improvements,4
and we required patients to have a demonstrable deficit on the ARAT to avoid a potential ceiling effect. Patients were excluded if they had only ataxia or sensory
symptoms, were unable to give informed consent or were unable to participate in train- ing because of aphasia or cognitive impairment, had signifi- cant pain or
musculoskeletal problems that would interfere with intensive training, or were receiving ongoing physical therapy for the arm. All participants signed a written
consent form that was approved by the local institutional human research review board.
Intervention All patients completed 2 weeks of CIMT at home under the supervision of a licensed physical therapist, with a goal of 4 hours a day for 10 consecutive
weekdays. This was a modified version of the original CIMT protocol, which consisted of 6 hours of therapy a day for 10 consecutive weekdays.4 Therapy sessions began
with active range of motion and/or stretching exercises, then proceeded to task- based activities that were individualized based on the patient’s goals and interests.
Activities included folding clothes, eating, writing, throwing a ball, and playing games (eg, chess and Jenga). Task difficulty was adjusted for indi- vidual patients
to be sufficiently challenging as determined by the therapist, and shaping techniques were incorporated,
with increasing task difficulty over successive sessions. Verbal feedback was provided to participants during task practice. The time spent in each activity ranged
from 1 to 15 minutes, depending on the patient’s level of interest and endurance. The total activity time was recorded for each session by the therapist. Participants
were also encouraged to wear the mitt on their unaffected hand outside of therapy and reported their compliance.
Study Design Clinical and kinematic assessments were performed at 3 time points: (1) 3 weeks prior to therapy, (2) 1 week prior to therapy, and (3) within 2 weeks
after completion of therapy. Two assessments were performed prior to the CIMT inter- vention to reduce the impact of improvements caused by practice effects,
particularly in our kinematic tasks.
Clinical Outcome Measures All clinical assessments were performed by a single physi- cal therapist blinded to the patients’ performance during therapy. The primary
clinical outcome measures were the ARAT37 and the FM-UE scale,38 which have been shown to have good reliability, validity, and responsiveness to motor change in
patients with chronic stroke.23,39-41 The ARAT is an instrument that tests arm function and consists of 19 items in 4 domains: grasp, grip, pinch, and gross movement.
Each domain contains items arranged into hierarchical order of difficulty such that success at the most difficult item of a specific subclass assumes success for all
items lower in the hierarchy of the same class. Each item is scored on a 4-point ordinal scale (0 = cannot perform, 1 = per- forms test partially, 2 = completes test
but takes abnormally long time or has great difficulty, and 3 = performs test nor- mally), with a maximum score of 57. The ARAT is a functional measure with limited
ability to discriminate between “normal” movements and the use of compensatory strategies.10 Arm impairment was assessed using the FM-UE. The FM-UE is scored using a
3-point ordinal scale (0 = cannot perform, 1 = can perform partially, 2 = can perform fully) on 22 items in 4 sections: arm, wrist, hand, and coordination, for a
maximum score of 66. This test specifies that all limb subcomponents move in a qualitatively normal manner for a normal performance score to be given. We further
subdi- vided the FM-UE into proximal (first 18 items, maximum score 36), wrist (next 5 items, maximum score 10), hand (next 7 items, maximum score 14), and
coordination (last 3 items, maximum score 6).
Kinematics: Arm Reaching Task Participants moved a cursor by making reaching move- ments over a glass-surface table (Figure 1). Hand position,
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102 Neurorehabilitation and Neural Repair 27(2)
calibrated to the position of the fingertip, was monitored using a Flock of Birds (Ascension Technology, Burlington, VT) magnetic movement recording system at a
frequency of 120 Hz. The experimental computer converted this infor- mation online into hand, elbow, and shoulder positions using custom routines in RealBasic (Real
Software, Austin, TX). The computer used real-time hand position informa- tion to control the visual display and to provide visual feedback. The target set consisted
of 8 radially arrayed circles with a 1-cm radius, 45° apart, 8 cm from a center start circle. Each trial began after the participant held the cursor inside the start
circle for 750 ms. Participants were instructed to make straight, out-and-back movements with a sharp rever- sal within the target, when they were ready to move after
the target appeared. To ensure that movements were made quickly and to ensure consistency between trials and ses- sions, the black cursor froze at its position at 200
ms, and the reversal point was indicated by a white square.42 This time requirement also allowed us to focus on deficits in patients’ feed-forward control by
minimizing online correc- tions. Participants were given 1 or 2 practice runs of 88 movements for each arm to become familiar with the task. They completed 2
experimental runs, each comprising 11 cycles of 8 targets presented in random order, for each arm.
Kinematics: Wrist Pointing Task Participants sat in a chair with their forearm placed in a rigid splint that maintained the elbow at a 90° angle and the forearm midway
between pronation and supination. The participant’s hand was lightly taped in a fist, and a 1.5-cm spherical reflective marker was attached over the index finger’s
first interphalangeal joint. The hand was hidden from view. Participants were instructed to make pointing movements through combinations of abduction-adduction and
flexion-extension movements around the wrist, so as to point the marker at targets projected onto a vertical com- puter screen. The position of the marker was
monitored using a Qualysis ProReflex video camera (model MCU 240; Qualisys, Gothenburg, Sweden) equipped with an infrared strobe coupled to a video digitizer, which
recorded the marker’s position in the vertical plane at a frequency of 100 Hz. The target set for the wrist task consisted of 4 radially arrayed circles, separated by
90°, at a distance, which required a 2-cm movement of the infrared marker. Similarly to the arm reaching task, participants were instructed to make out and back
movements, placing both the cursor, which froze after 100 ms, and a white reversal square in the center of the target. They completed 1 familiarization run and 2
experimental runs for each wrist, which consisted of 22 cycles of 4 targets presented in random order.
Analysis of Kinematics
We analyzed hand and wrist position data using custom routines within the IGOR analysis software package (Wavemetrics, Lake Oswego, OR). Position time series were
low-pass filtered (Butterworth filter) at 8 Hz for the arm task and 14 Hz for the wrist task and differentiated to yield tangential velocity and acceleration. The
first velocity peak above a threshold (10 cm/s for the arm and 5 cm/s for the wrist) was identified for each trial. These thresholds were chosen to exclude small
movements made by some participants who had difficulty stabilizing their hand within the start circle. The start of the movement was defined as either the point at
which the velocity crossed 1 cm/s or the first velocity minimum prior to the first veloc- ity peak, whichever was later. The end point of the outward movement was
defined as the reversal point—that is, the point where distance from the origin stopped increasing. The movements were further divided into submovements based on their
acceleration profiles. The first submovement was defined as the movement up until the first zero crossing of acceleration from negative to positive.43 Each subsequent
submovement was defined as the movement between zero crossings of acceleration from negative to positive. We calculated the following variables for the outward
movement: (1) movement time; (2) peak velocity; (3) abso- lute initial directional error, which is the angle between the vector from start position to target and the
vector from start position to cursor position at 120 ms after movement start; (4) path curvature, the unsigned area between hand path and the shortest possible path (a
straight line joining the start and end points of the movement), divided by the area of a semicircle with the shortest possible path as its diameter; (5) systematic
error, the distance between the average end- point position and target center; (6) end-point variance, the determinant of the covariance matrix of the end points cor-
rected for the number of observations and averaged across targets; and (7) number of submovements. The following kinds of trials were excluded: anticipatory movements,
movements that did not reach 30% of the distance to the target, movements without reversals, and spatial outliers (in which the movement direction was >90° from the
target direction). Anticipatory movements were defined as those with reaction times less than 200 ms, based on the fastest reaction times seen in a similar task when
healthy participants were instructed to move “as soon as possible.”44
Statistical Analysis All statistical analyses were performed on average group data. One-tailed, paired t tests were performed using Excel (Microsoft, Redmond, WA) on
the differences between the
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Kitago et al 103
change from session 1 to 2 (Δ1) and the change from ses- sion 2 to 3 (Δ2). We chose to compare the changes in values in order to minimize the possible confound of task
practice on our measures across sessions and chose 1-tailed tests because our hypotheses were based on improvements in our clinical and kinematic variables. We
performed post hoc power analyses to assess the false-negative rate for each of our comparisons. Meaningful effect size was chosen as 10% of the maximum possible score
for the clinical measures.23,41 The study was powered at 0.83 for ARAT, 0.86 for FM total, 0.78 for FM arm, and 0.52 for FM wrist. For the kinematic measures, we used
50% of the patients’ mean deficit (the difference between the patients’ affected side and values obtained for elderly controls in an ongoing study). The magnitude of
improve- ment in our kinematic tasks that would be associated with a clinically meaningful reduction in impairment is not known, but we presumed that significant
recovery would be accom- panied by a larger percentage improvement in the more sen- sitive45 and responsive46 kinematic measures compared with the clinical scales. For
the arm kinematic measures, the study was powered at 0.55 for path curvature, 0.65 for ini- tial directional error, 0.48 for systematic error, 0.45 for end- point
variance, and 0.48 for number of submovements. For wrist movements, the study was powered at 0.51 for path curvature, 0.99 for initial directional error, 0.88 for
system- atic error, 0.96 for end-point variance, and 0.55 for number of submovements.
Results A total of 10 patients with chronic stroke participated in the study, but 1 patient was excluded from the analysis because he did not meet inclusion criteria.
Table 1 summarizes patient demographics and stroke location. The mean age of patients was 70 years, and mean time elapsed since stroke was 34.3 months (range = 10-162
months). Of the 9 patients, 7 had ischemic strokes, 5 involved the dominant
hemisphere, and lesions included both cortical and subcor- tical areas. For the study intervention, patients spent on average 2.45 hours practicing activities (range =
1.84-2.89 hours) with the therapist each day. By self-report, they spent an average of 61 min/d (range = 0-251 min/d) wear- ing the mitt outside of therapy. However, 5
of the patients did not wear the mitt at all outside of therapy because of safety concerns. No adverse events were reported during the study.
Clinical Outcomes At baseline, patients were moderately affected, with a mean ARAT score of 31.3 and mean total FM-UE score of 44.3 (Table 2). Clinical outcome
measures are summa- rized in Figure 2. Arm function as measured by the ARAT improved significantly more after CIMT than between the 2 pre-CIMT sessions (−0.8 vs 5.4, P
= .004). Δ2 was also significantly larger than Δ1 for the total FM-UE (−0.9 vs 4.1, P = .018), FM wrist score (-0.2 vs 0.9, P = .027), and FM coordination score (−0.2
vs 0.9, P = .014) but not for the FM arm (−0.4 vs 1.4, P = .087) or FM hand (−0.1 vs 0.9, P = .148).
Table 1. Patient Demographics and Clinical Characteristics
Patient Sex Age (years) Months Since Stroke Stroke Type Affected Arm Stroke Location P1 M 66 49 H ND R BG P2 M 57 162 I D L MCA and BG P3 F 77 17 H D L BG P4 M 58 10 I
ND R frontal P5 F 77 10 I D L pons P6 F 81 15 I D L MCA and BG P7 M 83 14 I ND R frontal P8 F 59 22 I ND R pons P9 M 72 10 I D L MCA and pons
Abbreviations: M, male; F, female; I, ischemic; H, hemorrhagic; D, dominant; ND, nondominant; R, right; L, left; BG, basal ganglia; MCA, middle cerebral artery
territory.
Table 2. Patient Baseline Clinical Assessments
Patient ARAT FM-UE Total FM-UE Arm FM-UE Wrist P1 39 48 23 9 P2 44 56 33 9 P3 38 48 25 9 P4 18 30 13 5 P5 32 53 27 10 P6 22 36 19 5 P7 40 55 30 8 P8 23 40 17 9 P9 26
33 15 5 Abbreviations: ARAT, Action Research Arm Test; FM-UE, Fugl-Meyer Upper Extremity Assessment.
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104 Neurorehabilitation and Neural Repair 27(2)
Arm Kinematics
Hand trajectories for the arm reaching task in a healthy control and a patient are shown in Figures 3A to 3C. There was no significant improvement from Δ1 to Δ2 for
the per- centage of rejected moves, movement times, or peak velocities. Kinematic outcomes are shown in Figure 4. There were no significant improvements from Δ1 and Δ2
for path curvature, initial directional error, systematic error, or variable error.
Wrist Kinematics Trajectories for the wrist pointing task in a healthy control and patient are shown in Figures 3D to 3F. There were no significant improvements from
Δ1 to Δ2 for the percentage of rejected moves, movement times, or peak velocities. There were also no significant improvements from Δ1 to Δ2 for path curvature,
initial directional error, systematic error, or variable error in the affected wrist (Figure 4).
Discussion Improvements in function can result from a reduction in impairment, the use of compensatory strategies at a fixed
level of impairment, or a combination of both.10,11,16,47 The objective of this study was to use clinical and kinematic assessments of upper-extremity movements to
better under- stand the contributions of compensation and recovery to the functional improvements seen after CIMT in patients with chronic stroke. We found
statistically significant improve- ments in arm function and a statistically significant but very small reduction in impairment after CIMT. Assuming a 10% change in
these scales to be clinically meaningful,23,41 we conclude that the CIMT intervention resulted in an improvement in arm function that was close to reaching clini- cal
relevance (9.5%) but no meaningful improvement in over- all arm impairment (6.2%). Our results are consistent with the findings of a recent meta-analysis of modified
CIMT.36 The magnitude of functional arm improvement seen in our study was somewhat smaller compared with those in other studies of modified CIMT protocols in patients
with chronic stroke that used similar assessments of arm func- tion and found differences ranging from 7 to 10 in ARAT after CIMT.19,20 These studies used a modified
CIMT proto- col with shorter sessions of CIMT but over a longer period of time. The modified CIMT protocol in our study was similar to the original CIMT protocol used
in the EXCITE trial4 but with 4 h/d of therapy, rather than 6 h/d, for 10 consecutive weekdays, and our patients wore the mitt out- side therapy for only an average of
61 min/d. The optimal dosing for CIMT is still not well established,17 but it is likely that the patients in our study were relatively under- dosed. We should stress,
however, that we were interested in the weighting of compensation versus true recovery for a given amount of therapy. It is possible that a more pro- longed or more
intensive CIMT intervention program would have resulted in greater gains in function accompa- nied by reduction in impairment, but it is also possible that further
gains at the functional level via compensation would not be accompanied by reductions in impairment. We chose the FM-UE and constrained pointing tasks with the arm and
wrist as our measures of arm impairment. The FM-UE is one of the most widely used measures of motor impairment after stroke23 and has been used as a pri- mary outcome
measure to evaluate the effect of upper- extremity rehabilitative techniques. Previous studies of CIMT in patients with chronic stroke have found variable effects on
FM-UE scores.5,18-22 Page et al21 found signifi- cant changes in ARAT scores without corresponding changes in FM-UE scores and speculated that their results were a
result of the greater reliance of the ARAT on distal upper-extremity function, which may be emphasized more heavily than the proximal arm in activities practiced
during CIMT. In our study, we found small improvements in the overall FM-UE score, with increases distributed across all subsections, although some of these were not
statistically significant. Therefore, it is unlikely that the more substan- tial changes in ARAT than in FM-UE scores after CIMT were a result of greater effects on
the distal limb.
Figure 2. Mean scores on the (A) ARAT and (B) FM-UE for each session, with error bars representing SD. For (B), total FM-UE (in black) is further subdivided into
proximal arm (white), wrist (oblique stripes), hand (gray), and coordination (vertical stripes) Abbreviations: ARAT, Action Research Arm Test; CIMT, constraint-
induced movement therapy; SD, standard deviation; FM-UE, Upper- Extremity Fugl-Meyer Assessment.
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Kitago et al 105
Detailed movement analysis in nonhuman animals48,49 and humans13,16 has been used to differentiate functional gains resulting from compensation from those indicating
recovery. The arm reaching and wrist pointing tasks in this study were designed to minimize compensatory strat- egies by restricting degrees of freedom available to
the patient to accomplish the task. Constrained tasks such as these, although not routinely used in everyday activities, are valuable assays of impairment and motor
control of the arm, analogous in our view to the finger individuation index that has been developed for the hand.29 Healthy individuals make accurate straight planar
reaching move- ments within a few trials when they first encounter the reaching task,30,50 which indicates that it is not a task that needs to be learned—it is easy if
baseline motor control is intact. It is interesting to note that we found a small increase in FM-UE total without significant changes in our kinematic variables, even
though both are measures of impairment.
The increase in FM-UE may reflect coarse improvements in impairment that are not sufficient to induce improvements in fine motor control of the arm and wrist required
for visu- ally guided prehension. Indeed, the magnitude of change in FM-UE is small and not likely to be functionally relevant, as evidenced by studies of robotic
rehabilitation that have elicited comparable changes in FM-UE scores without an effect on arm function or activities of daily living.51 If this interpretation is
correct, it implies that CIMT causes func- tional improvements in parallel with, but unrelated to, smaller reductions in impairment. One potential objection to the
apparent dissociation between function and impairment might be that CIMT resulted in task-specific improvements in motor control that did not generalize to our novel
kinematic tasks. It is impor- tant to emphasize that we consider our kinematic tests assays for rudimentary baseline motor control rather than specialized tasks per
se. Healthy individuals can perform planar reaches and make wrist pointing movements with no
Figure 3. Trajectories for randomly selected participants performing the arm reaching and wrist pointing tasks: (A) control, dominant arm; (B) patient, affected arm,
pre-CIMT 2; (C) patient, affected arm, post-CIMT; (D) control subject, dominant wrist; (E) patient, affected wrist, pre-CIMT 2; and (F) patient, affected wrist, post-
CIMT 2. Trajectories of healthy controls are presented for illustrative purposes Abbreviation: CIMT, constraint-induced movement therapy.
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106 Neurorehabilitation and Neural Repair 27(2)
need for extended practice because these tasks probe for basic motor control capacities that healthy individuals already have. We consider it highly unlikely that
these indi- viduals could recover more normal control in more ecologi- cal and challenging everyday tasks but fail to generalize to our more basic kinematic tests.
This would be akin to say- ing that a patient could become better at typing without showing any improvement on a finger individuation index.52 In the specific case of
planar reaching, such a view would imply that patients could show improved control of 3-dimensional arm movements but not of 2-dimensional arm movements. Again, we
consider this highly unlikely, especially as it has been shown that when the effects of gravity are removed, patients with stroke greatly increase
the range of their 2-dimensional planar movements,53 which implies that patients find control easier when the gravita- tional challenge of 3-dimensional movements is
removed. Nevertheless, an interesting future direction would be to combine kinematic assessments of constrained and free movements to quantify both impairment and the
compensa- tory mechanisms contributing to functional gains. We also recognize this study’s small sample size and lack of power to detect changes in some of our
kinematic variables. With regard to the issue of power, however, it should be empha- sized that some measures were adequately powered and that none of these showed
improvement. One of the points of this study is to encourage the use of kinematic measures in future larger-scale studies.
Figure 4. Kinematic outcomes for (A) movement time, (B) initial directional error, (C) path curvature, (D) number of submovements, (E) systematic error, and (F)
variable error in the arm and wrist tasks. Scores for each session are shown: 1 (black), 2 (white), and 3 (gray). Performance of elderly controls in a separate study
are shown to the right. Values are mean with error bars depicting standard deviation
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Kitago et al 107
Our interpretation of the current data is that CIMT induces task-specific compensatory strategies through prac- tice in the chronic stage of stroke despite an
invariant impairment level. CIMT could have a qualitatively different effect if applied very early after stroke if larger reductions in impairment than expected from
spontaneous recovery occurred.54 Then, patients would not resort to compensatory strategies. Although early CIMT did not show a benefit in 1 trial, impairment was not
assessed.55 Our study and others demonstrate the feasibility of using kinematic analysis to obtain more detailed, objective measures of movement patterns and motor
performance in studies of novel neurorehabilitative interventions.56-58 Analysis at the kinematic level will provide us with the ability to differentiate between
functional gains achieved through compensation versus those achieved through true recovery of motor control.45 At the current time, conven- tional therapy has largely
focused on teaching compensa- tory strategies, with a goal of achieving early functional independence. As mentioned above, early focus on com- pensation may limit
long-term recovery.13,14,16 Even in the acute stroke period, patients may learn not to use or explore more normal movements with the affected limb because of habitual
reliance on compensatory strategies and thus miss out on a time window of plasticity within which true recovery could be maximized11. Detailed kinematic assess- ments
of the kind used here could contribute to a better understanding of the interactions between spontaneous recovery, the development of compensatory behaviors, and
rehabilitation and their relative contributions to long- term outcome.16,59
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this
article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The work was supported by
the following grants: National Institutes of Health Grant Number K02-NS048099 and the Suellen Jones Saunders Memorial Fund.
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