Constraint-Induced Movement therapy (CI therapy) is shown to reduce disability, increase use of the more affected arm/hand, and promote brain plasticity for individuals with upper extremity hemiparesis post-stroke. Randomized controlled trials consistently demonstrate that CI therapy is superior to other rehabilitation paradigms, yet it is available to only a small minority of the estimated 1.2 million chronic stroke survivors with upper extremity disability. The current study aims to establish the comparative effectiveness of a novel, patient-centered approach to rehabilitation utilizing newly developed, inexpensive, and commercially available gaming technology to disseminate CI therapy to underserved individuals. Video game delivery of CI therapy will be compared against traditional clinic-based CI therapy and standard upper extremity rehabilitation. Additionally, individual factors that differentially influence response to one treatment versus another will be examined. This protocol outlines a multi-site, randomized controlled trial with parallel group design. Two hundred twenty four adults with chronic hemiparesis post-stroke will be recruited at four sites. Participants are randomized to one of four study groups: (1) traditional clinic-based CI therapy, (2) therapist-as-consultant video game CI therapy, (3) therapist-as-consultant video game CI therapy with additional therapist contact via telerehabilitation/video consultation, and (4) standard upper extremity rehabilitation. After 6-month follow-up, individuals assigned to the standard upper extremity rehabilitation condition crossover to stand-alone video game CI therapy preceded by a therapist consultation. All interventions are delivered over a period of three weeks. Primary outcome measures include motor improvement as measured by the Wolf Motor Function Test (WMFT), quality of arm use for daily activities as measured by Motor Activity Log (MAL), and quality of life as measured by the Quality of Life in Neurological Disorders (NeuroQOL). This multi-site RCT is designed to determine comparative effectiveness of in-home technology-based delivery of CI therapy versus standard upper extremity rehabilitation and in-clinic CI therapy. The study design also enables evaluation of the effect of therapist contact time on treatment outcomes within a therapist-as-consultant model of gaming and technology-based rehabilitation. Clinicaltrials.gov, NCT02631850 .

Constraint-Induced Movement Therapy (CI therapy) refers to a family of treatments for motor disability that combines constraint of movement, massed practice, and shaping of behavior to improve the amount of use of the targeted limb. CI therapy has controlled evidence for efficacy that supports its benefit for patients with chronic disability following central nervous system injury, regardless of their age or the interval since illness onset. Furthermore, the benefits transfer to real-world measures of limb use. Significant functional improvement may occur even after the patient has been treated with conventional physical therapy. In this paper we review the evidence for the efficacy of CI therapy, particularly for chronic stroke hemiparesis, but also for diverse other chronic disabling illnesses, including non-motor disorders such as phantom limb pain and aphasia. The adaptation of the therapy to the stroke clinic is described, along with a review of the neurophysiologic mechanisms that are postulated to underlie the treatment benefit (overcoming learned nonuse, plastic brain reorganization). Critical to the success of CI therapy is its modification according to disease factors, economic considerations, limitations of the practice setting, and the cognitive and physical status of the patient. We conclude by recommending future areas for research on CI therapy.

Background: Some studies have suggested that in stroke patients, spatial inattention on the cancellation test is closely related to disorganized visual search. However, methods to assess spatial aspects of search organization on cancellation tests have not been well developed. In this study the authors design and evaluate new methods to quantify strategies of spatial exploration on the cancellation test in stroke patients who showed a broad range of spatial attentional abilities, and test whether disorganization and inattention are related. Methods: Twenty stroke patients were videotaped while they performed a cancellation test. Several variables that reflect spatial aspects of search organization were measured through subsequent video playback. Two patients with severe neglect were excluded from further analysis to avoid constraining the spatial expression of search organization. Spearman correlations were used to assess whether severity of spatial inattention correlated with the individual search organization measures. Results: Of the 18 remaining patients, 10 had mild-moderate spatial neglect (pathologic inattention), while the other 8 omitted at most one target (normal performance). There were no significant correlations between the number of targets omitted and any of the search organization measures. Conclusions: Spatial inattention on cancellation due to neglect following stroke is not closely related to the organization of visual search. Instead, search disorganization during cancellation may reflect disturbance of an unspecified executive control mechanism.

Methods have not been well developed and tested to predict the extent of remote degeneration in the central nervous system that follows cerebral infarction. We hypothesized that the extent of infarction overlap with the cerebral hemispheric course of the corticospinal tract (CST) on structural MR imaging predicts the extent of ipsilateral cerebral peduncular atrophy in patients with chronic stroke. Hemiparetic patients (n = 34) with supratentorial unilateral infarctions who were at least 1 year poststroke onset and enrolled in research protocols of Constraint-Induced Movement therapy underwent volumetric T1 MR imaging of the brain. The following measures were calculated for each patient: 1) the maximal proportion of the CST in the cerebral hemisphere on axial section that was overlapped by infarction, 2) total infarction volume, and 3) the ratio of the cross-sectional area of the ipsilateral cerebral peduncle to the area of the contralateral cerebral peduncle (peduncular asymmetry ratio). Correlation analyses evaluated the predictive value of CST injury or infarction volume for the peduncular asymmetry ratio. CST injury correlated significantly with the peduncular asymmetry ratio (r = -0.65; P < .001), whereas infarction volume did not (r = -0.31; P = .09). The extent of postinfarction CST injury in the cerebral hemisphere predicts the extent of ipsilateral cerebral peduncular atrophy. More generally, the findings suggest that the extent of remote wallerian degeneration of a fiber tract is strongly related to its extent of injury directly at the site of infarction.

This article reviews the impact of unilateral spatial neglect on daily living ("functional") activities. Its disturbances on basic functional activities, such as feeding, grooming, and locomotion, are easily identifiable. Patients with neglect frequently lack insight into their disorder and do not initiate compensatory behaviors, which probably impedes recovery. Simple standard tests of neglect during visual exploration correlate with impaired recovery of functional skills acutely following brain injury. However, unilateral neglect resolves in most individuals, yet many patients remain chronically impaired during daily living activities. This suggests that some other disorder associated with neglect may contribute to the failure to regain functional independence. A candidate disorder is general (non-spatial) inattention. However, cognitive studies in stroke are biased toward assessing neglect and are usually insensitive to other disorders that may accompany stroke, such as general inattention and executive dysfunction. Therefore, the contribution of unilateral neglect toward functional status relative to diverse other cognitive disorders after stroke is unclear. Treatments for unilateral neglect have been largely unsuccessful or impractical, or they were not evaluated in controlled studies. Intensive practice of scanning appears to benefit, but this observation needs to be replicated in a controlled manner. A recently developed treatment that involves wearing prisms to shift the view ipsilaterally has been associated with transfer of training effects to untreated spatial activities and prolonged improvement of neglect. However, despite some promising lines of investigation in neglect rehabilitation, further research is required to understand where neglect stands in relation to other cognitive disturbances that follow stroke with respect to functional significance and recovery, to decide what disorders should be targeted for rehabilitation.