Potential Predictors of Motor and Functional Outcomes After Distributed Constraint-Induced Therapy for Patients With Stroke

 Hopefully your doctor did nothing with this. You don't want predictions of failure to recover. Scream at your doctor; 'WHERE ARE MY 100% RECOVERY PROTOCOLS?' and keep screaming until they acknowledge that they incompetently don't have any.  Then fire them and move to a place that does have recovery protocols. The keyword there is protocols, NOT GUIDELINES! You want exact instructions on how to recover, not guesses, or I think this might work.

Potential Predictors of Motor and Functional Outcomes After Distributed Constraint-Induced Therapy for Patients With Stroke

2008, Neurorehabilitation and Neural Repair

From the School of Occupational Therapy, College of Medicine, National Taiwan University, and Division of Occupational Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei (KCL,YWH), and Department of Occupational Therapy and Graduate Institute of Clinical Behavioral Science, Chang Gung University, Taoyuan, Taiwan (CYW); and Department of Occupational Therapy, College of Health and Human Services, California State University, Dominguez Hills, Carson, California (YHH). Address correspondence to Ching-yi Wu, ScD, OTR, Department of Occupational Therapy, Chang Gung University, 259 Wen-hwa 1st Rd, Kwei-shan, Taoyuan, Taiwan. E-mail: cywu@mail.cgu.edu.tw.
 


Keh-chung Lin, ScD, OTR, Yan-hua Huang, PhD, OTR, Yu-wei Hsieh, MS, and Ching-yi Wu, ScD, OTR
 Background
 
Selection of patients who are most and least likely to benefit from constraint-induced therapy (CIT) for the upper extremity is uncertain.
Objective. 

This study investigated demographic and clinical characteristics that may predict outcomes for a distributed form of CIT.
 Methods. 

A group of 57 patients were treated with distributed CIT, and 7 potential predictors were identified, including age, sex, side of stroke, time since stroke, spasticity, neurologic status, and movement performance of the distal part of the upper extremity. Treatment outcome was assessed in terms of motor performance, perceived functional ability of the affected hand, and functional performance of daily activities, mea-sured by Fugl-Meyer Assessment (FMA), Motor Activity Log (MAL), and Functional Independence Measure (FIM), respectively.
 Results. 

Motor ability of the distal part of the upper extremity and time since stroke were significantly predictive of outcomes on the FMA (adjusted;R>2= 0.18,P= .002) and the MAL subtest quality of movement (adjusted R2= 0.43,P< .0001). Motor ability and age were significant predictors of amount of use measured by the MAL (adjusted R2= 0.20,P= .001). None of the variables exhibited a predictive relationship with the FIM.
Conclusions. 

The best predictor for motor outcomes after distributed CIT was greater motor ability of the distal part of the upper extremity, which is consistent with the presence of residual motor pathways that may respond to training. The FMA may be of value in stratifying patients for their likelihood to benefit from distributed CIT protocols.
 Keywords:
Stroke; Rehabilitation; Constraint-induced therapy; Outcome prediction; Hemiplegia; Upper extremity
 .
Approximately 30% to 66% of stroke survivors experience persistently impaired upper extremity (UE) movement.¹;Residual motor deficits in the UE frequently cause disability and permanent dependency on community care.²;Constraint-induced therapy (CIT) has been advocated as means to improve motor recovery of the UE and functional use of the affected limb among patients after stroke. Constraint-induced therapy involves restraint of the unaffected UE (eg, during 90% of the hours the patient is awake per day for 2 weeks), forcing the use of the affected UE (eg, 6 h/d on 10 consecutive weekdays), and massed task-related training of the affected UE.³;Because the acceptance of CIT among therapists and patients remains poor due to prolonged practice and restraint,⁴;different forms of CIT have been developed. For example, the distributed forms of CIT (distributed CIT) involved 2 to 3 hour training of the affected arm with 6- to 9-hour restraint of the unaffected arm for 2 to 4 weeks.^5-11;Numerous studies^5,6,12-14;involving stroke patients have shown that various forms of CIT can enhance motor performance and functional ability of the affected UE. However, possible predictors related to distributed CIT outcome remain unknown. The identification of potential predictors for distributed CIT outcome helps
underscore the factors that may affect treatment outcomes and target individuals who benefit the most from the therapy.Evidence regarding predictors of optimal outcomes in stroke patients after CIT is limited.^15-18;For example, Fritz et al¹⁵;examined the 6 demographic and clinical characteristics of side of stroke, time since stroke, hand dominance, age, sex, and ambulatory status as predictors of functional outcomes of CIT and found that age is the only significant predictor of the amount of use in the affected UE after CIT. Rijntjes et al¹⁷;also demonstrated that age is related to the quality of move-ment after CIT. A recent study by Langan and van Donkelaar¹⁸;found that hand dominance does not influence response to CIT. Other clinical and demographic characteristics of stroke, such as side of stroke, time since stroke, and sex, were not found to be good predictors of CIT outcome.Nevertheless, Ploughman and Corbett,¹⁹;using one principle of CIT (restraint of the unaffected hand), mentioned that patients with left hemiplegia appeared to benefit from treatment differ-ently from those with right hemiplegia. In addition, Rijntjes et al¹⁷;demonstrated greater improvement in fine motor control after CIT for patients with right hemiplegia than for those with left hemiplegia. Time since stroke and sex are often used or

proposed as predictors for recovery or rehabilitation outcomes in stroke patients.^20,21;These potential predictors warrant further scrutiny in the context of outcome studies of CIT. Fritz et al¹⁵ suggest that other potential predictors such as neurologic status might be included in outcome research on stroke rehabilitation.Another work by Fritz et al¹⁶investigated several measures of motor status to predict CIT outcome. They found that active finger extension was the only significant predictor of move-ment capacity outcome. However, they did not consider indi-cators of spasticity. Neurophysiologic measures²² and the degree of spasticity measured clinically²³ have also been proposed as predictors for training-related stroke recovery.^22,23 The studies discussed are not fully comparable,^15-18 possibly owing to differences in potential predictors, outcome measures, and statistical analyses. Fritz et al¹⁵ used demographic and clinical characteristics without UE performance, whereas in another study, Fritz et al¹⁶only included motor performance without demographic characteristics. Langan and van Donkelaar¹⁸ only examined the demographic characteristic of hand dominance. Meanwhile, although Rijntjes et al¹⁷;comprehensively examined 14 factors possibly influencing CIT outcomes, they performed statistical analysis for each factor without considering their pos-sible interactions or correlations. This study included demo-graphic and clinical characteristics (primarily involving movement performance of the distal part of UE and spasticity) in the predictive model to make it more inclusive and allow study of the possible relations among these factors.The outcomes of motor performance and functional capacity after CIT used in these studies were primarily assessed using the Wolf Motor Function Test and the Motor Activity Log (MAL).^15-18;Additional outcome measures of motor and functional performance commonly reported in CIT studies included measurement tools such as the Fugl-Meyer Assess-ment (FMA) and the Functional Independence Measure (FIM).^5,6,12,13,19;Whether the outcomes after CIT can be pre-dicted by demographic and clinical characteristics awaits investigation. Furthermore, studied factors that are predictive of positive treatment outcomes are limited to CIT delivery.^15,16;These factors may not be appropriate predictors of success in distributed CIT delivery,¹⁶;which is in a less intense manner and for a different duration compared with CIT.This study aimed to identify predictors of distributed CIT out-comes, including movement performance, perceived functional ability of the affected hand, and functional performance of daily activities measured by FMA, MAL, and FIM. The potential predictors selected in this study were age, sex, side of stroke, time since stroke, spasticity, neurologic status, and the movement per-formance of the distal part of the upper extremity.