Is there a dose-dependent effect of modified constraint-induced movement therapy in patients with hemiplegia?

Abstract

BACKGROUND:

Impairment of upper extremity function is a common sequelae of stroke. It has been reported that modified constraint-induced movement therapy (mCIMT) could prove to be effective.

OBJECTIVE:

To investigate the relationship between the intensity of rehabilitation such as treatment and constraining time, and the functional outcome for the paretic upper extremity in stroke patients through mCIMT.

METHODS:

We conducted an observational prospective study of 31 patients with hemiplegia and subacute or chronic stroke. The mCIMT was performed for two weeks. Rehabilitation time and constraining time were variable among patients. The rehabilitation time included an individualized task-oriented program and conventional occupation treatment with an individualized therapist. The constraining time, with mit or splint, was also asked to self-record individually. The outcome was evaluated on the more affected side by the Wolf Motor Function Test, Fugl-Meyer Assessment, Motor Activity Log 14, and Functional Independence Measure for self-care tasks after the therapy.

RESULTS:

All participants after the modified constraint-induced movement therapy program for two weeks improved on the evaluated outcome measures (P < 0.05). No significant correlation was found between the dose-dependent treatment or constraining time and outcomes. Comparisons improvement with subgroups based on the duration from onset, constraining component, dominant hand consistent with lesion side of stroke, and initial medical research council score for muscle strength, also showed no significant differences.

CONCLUSIONS:

This is the first study on the effects of intensity of mCIMT with respect to time-dosage. Although all patients in this study showed improved functional status, no significant correlation between dose-dependent rehabilitation or constraining time and outcomes was seen.

Keywords

mCIMT hemiplegia rehabilitation time constraining time outcome

1 Introduction

Stroke is one of the principal causes of mortality and morbidity around the world (Mehndiratta et al., 2015; Doussoulin et al., 2016). Impairment of upper extremity function is a common sequelae of stroke. Approximately, 30–66% of stroke survivors suffer loss of functional ability in the more affected arm and hand (Uswatte et al., 2006).

Constraint-induced movement therapy (CIMT) has been reported to improve functional use of the upper extremity with level of evidence “A” in evidence-based practice after stroke (Winstein et al., 2016). CIMT involves treatment for 3 to 6 h/d for 5 d/wk for two weeks and application of constrain for up to 90% of the waking hours to the less affected upper extremity (Kwakkel et al., 2015). Patients with chronic and subacute stroke showed improved functional use in the real world, through overcoming “learned nonuse” (Morris et al., 2006; Sterr & Saunders, 2006). There were two factors based on the mechanism of CIMT-deafferentation of constraint of the less affected limb and treatment time (Taub, 1976). To explain this, studies have explored the constraining component, such as mitt, splint, or sling by the forced use method (Sterr & Saunders, 2006). Treatment time was decided either based on convention or according to the self-task time, such as the shaping task which progressively increases in difficulty to improve brain plasticity or repetitive tasks for improved skill (Kwakkel et al., 2015). However, the massive treatment dose can cause patients to drop out from a CIMT study (Page et al., 2002b), so massive method is still limited in clinical settings because of human resources, clinical resources, and restriction schedules (Fleet et al., 2014).

It has been reported that modifying the therapy could prove to be effective; thus modified CIMT (mCIMT) intervention (Page et al., 2002a; Taub et al., 2002; Wang et al., 2011), which was composed 1 h/d for 3 d/wk for 10 weeks, has been proposed (Kwakkel et al., 2015). The mCIMT protocols were executable and tolerable in stroke patients (Souza et al., 2015). A previous randomized controlled trial showed that mCIMT might be more beneficial for usability and time efficacy than traditional rehabilitation therapy, except for kinematic improvement (Page, 2007; Wu et al., 2007; Shi et al., 2011). In addition, original CIMT and mCIMT showed no significant difference of outcome (Wang et al., 2011).

Most studies have focused on the intervention of mCIMT program in finding threshold to start functional improvement and efficacy (Page et al., 2004; Morris et al., 2006; Uswatte et al., 2006; Kwakkel et al., 2015; Seok et al., 2016; Gee et al., 2018). Regarding the mCIMT protocol, studies on treatment time, restrain time, treatment methods, and overall duration were preceded. According to the 62 studies related to CIMT (Souza et al., 2015), 27.4% of the articles studied various intensities with less than 90% of waking time. The duration ranged from 2 to 10 weeks, and individual received therapy was ranged from 1 to 7 days per week. Morris et al. considered shaping or task practice, adherence-enhancing strategy, and constraining mitt or splint to get the maximum effect in CIMT or mCIMT (Morris et al., 2006). There were many related studies, but adequate parameters were not presented. There is no consensus on the type, intensity of practice, or the schedule of mCIMT that has the potential to improve functional outcomes (Gee et al., 2018). A recent study suggests that mCIMT consisting of a “therapeutic package” i.e. a number of different components, may improve functional ability (Morris et al., 2006; Gee et al., 2018).

The aim of this study is to investigate the relationship between the intensity of rehabilitation such as treatment and constraining time, and the functional outcome for the paretic upper extremity in stroke patients through modified constraint-induced movement therapy.

2 Methods

2.1 Participants

Individuals with subacute or chronic stroke were recruited by clinicians during the in-patient rehabilitation period between September 2016 and March 2018 at Bundang Jesaeng General Hospital. The main inclusion criteria (Winstein et al., 2016) were 1) hemiplegia caused by unilateral stroke, 2) more than one month post onset, 3) ability to lift two fingers on the table or to extend the wrist at least 10°, and 4) ability to follow two-step command. The main exclusion criteria were: 1) modified ashworth scale score > 2, 2) relapsed stroke, 3) hemispatial neglect, 4) sensory disorder, and 5) refusal to participate. The study protocol was approved by the Institutional Review Board of Bundang Jesaeng General Hospital (No. RM16-06).

2.2 Intervention

The mCIMT program was conducted for two weeks. All patients were asked to choose a constraining component in unaffected arm, which was described as either a splint or mitt. The splint was short arm cast, which limited motion of wrist and hand. The mitt had a component of extended plate from midportion of volar forearm to finger tip (Fig. 1). Patients with mitt were required to constrain unaffected arm as much as possible during their waking hours (Morris et al., 2006; Kwakkel et al., 2015).

Fig.1

Constraining Method with (a) short arm splint, and (b) mitt.

All patients had conventional occupational therapy for 30 minutes daily on weekdays, administered by individual occupational therapist (James, 2001). In addition, they was asked to do as much self-tasks as possible. The self-tasks were programmed to be task-oriented repetitive and shaping hand exercise based on the individual function and goal. A clinician has chosen several tasks, and these examples were attached to Table 1.

Table 1

The examples of the self-tasks

Build domino

Color a picture

Overturn water-bottle

Write a diary in fixed space

Put on the back of one space and catch a bean bag

Bounce small ball in two lines

Put vinyl gloves in your hand

Put and pull off the rubber band on your fingers

Cut paper with scissors

Fix papers with stapler

Hand over each bookcase one by one

Pick and subtract small balls

Put a ball in the cup

Computer gaming by exoskeletal smart glove

A self-recording diary for constraining time (CT) and amount of time of self-task was completed by patients. Based on the diary, the total rehabilitation time (TT) was defined as the summation of the occupational therapy time with occupational therapist plus the variable time of self-tasks. The clinician gave positive feedback to the patient on the ability to perform self-tasks and adherence to the intervention after one week. They received feedback through video record, which contained movement of the patient attempting a given self-task before the start of mCIMT. The patient and the clinician have either reset the goal or performed with or without additional tasks for the remaining a week.

2.3 Outcome measures

All patients were assessed before they entered into the intervention and at 14 days after the intervention. All study measures were conducted by blinded occupational therapists who had formal certified training.

The primary outcome measures included upper extremity motor function with Wolf Motor Function Test (WMFT), a measure of impairment with upper extremity motor subsection of the Fugl-Meyer Assessment (FMA), a structured interview to assess the real-world arm function with Motor Activity Log 14 (MAL), and daily task performance (self-care subgroup of the Functional Independence Measure, FIM).

The WMFT comprises of 15 items scored on a 6-point scale and two strength tasks (lifting weighted sand bag using a limb and grip strength). The scale ranged from 0 to 75, except for the two strength tasks. The test has established high validity and reliability in stroke populations (Morris et al., 2001; Yu et al., 2017).

The FMA includes 33 items scored on a 3-point ordinal scale of the upper arm, wrist and hand function for a possible score from 0 to 66. Previous studies demonstrated high interrater and intrarater reliability and good establish validity (Platz et al., 2005; Thrane et al., 2015).

The MAL is a patient-rated questionnaire in which the subject makes a direct judgement and subjective report. The score ranges from 0 to 70 where patients rate the amount of use of the affected arm when completing 14 common daily tasks. The tool is commonly used in CIMT studies (Uswatte et al., 2005; Yu et al., 2017).

The FIM evaluate functional independence in daily activities through 18 items, 13 related to motor activity and 5 with cognitive function. In this study, only the self-care area representing upper limb function was specified and evaluated. The self-care subgroup of the FIM is rated on a 7-point scale from 6 to 42 by summing the 6 items. It was assumed that the higher the score, the better is the function (Heinemann et al., 1994; Doussoulin et al., 2017).

2.4 Statistical analysis

All statistical analyses were performed using SPSS for Windows, Version 22.0 (IBM SPSS Inc, Chicago, IL, USA). All data were expressed as mean±standard deviation. Statistical significance was defined as a P-value of < 0.05. Paired-sample t tests were conducted to compare within-group changes in outcome measures between pre-treatment and post-treatment evaluations. A linear regression model for changes of outcome measures within group was established by using independent variables including TT and CT, as well as, correlation analysis. For the comparison of the outcome measure among the subgroups, such as duration from onset, dominant hand consistent with lesion side of stroke, and initial Medical Research Council for muscle strength of upper extremity (MRC), the Mann Whitney U-test was used for analysis.

3 Results

3.1 Characteristics of subjects

In total, 34 participants with hemiplegia were participated, but 3 patients withdrew from the study after starting treatment. One person had deep vein thrombosis with cerebral hemorrhage, so she was transferred to the cardiology department, and others were transferred to other rehabilitation center (Fig. 2). Participant characteristics were summarized in Table 2. The age of subjects was 52.7±19.9 years (male: female = 14 : 17), and duration from onset was 184.5±296.8 days. Two groups by constraining method, the splint (n = 5) and the mitt group (n = 26), had no significant differences for any of the baseline variables.

Fig.2

Flow diagram.

Table 2

Baseline characteristics before intervention

	mCIMT (n = 31)	range
Age (years)	52.7±19.9
Sex (male:female)	14:17
Stroke type (infarction:hemorrhage)	12:19
Side of lesion (left:right)	16:15
Duration from onset (days)	184.5±296.8	(30∼1590)
Initial MRC (score)	9±2.10

mCIMT = Modified Constraint-Induced Movement Therapy; MRC = Medical Research Council for muscle strength. Values are mean±SD.

3.2 Functional outcome measures after intervention

TT was 1193.2±643.6 minutes (range = 473 – 3495 minutes) and CT was 7002.6±6074.3 minutes (range = 3360 – 20160 minutes) for two weeks. All outcome measures had significantly been improved from baseline to posttreatment (Table 3); WMFT (P < 0.04), FMA (P < 0.03), MAL (P < 0.0008), and self-care (P < 0.001).

Table 3
Functional outcomes after intervention

pre-intervention post-intervention p

WMFT (score) 52.6±14.1 59.0±14.8 0.04^*

FMA (score) 45.1±12.4 51.0±11.6 0.03^*

MAL (score) 22.3±14.8 36.2±18.2 0.0008^*

self-care of FIM (score) 25.3±7.7 31.5±7.4 0.001^*

	pre-intervention	post-intervention	p
WMFT (score)	52.6±14.1	59.0±14.8	0.04^*
FMA (score)	45.1±12.4	51.0±11.6	0.03^*
MAL (score)	22.3±14.8	36.2±18.2	0.0008^*
self-care of FIM (score)	25.3±7.7	31.5±7.4	0.001^*

WMFT = Wolf Motor Function Test; FMA = Fugl-Meyer Assessment; MAL = Motor Activity Log 14; self-care subgroup of the FIM = Functional Independence Measure. Values are mean±SD. p < 0.05.

3.3 Dose-dependent effect of treatment or constraining time

There was no correlation according to the linear regression model between improvement of outcome measure and the independent variables, TT or CT (Table 4). The analysis showed negative results for the dose-dependent effect of rehabilitation or constraining time on function. With respect to the intensity, which is TT multiplied by the CT, no significant correlation between intensity and functional outcome was observed (Fig. 3). There were no adverse effects such as burns, skin lesion, and shoulder pain in this study.

Table 4
Linear regression analysis between the intensity and outcome

ΔWMFT ΔFMA ΔMAL ΔFIM

Total rehabilitation time (minutes) 0.52 (0.13) 0.29 (0.38) 0.56 (0.088) –0.04 (0.90)

Constraining time (minutes) 0.87 (0.10) 0.32 (0.53) 0.98 (0.057) 0.14 (0.79)

Intensity (TT^*CT) –1.02 (0.10) –0.11 (0.86) –0.89 (0.14) –0.035 (0.96)

	ΔWMFT	ΔFMA	ΔMAL	ΔFIM
Total rehabilitation time (minutes)	0.52 (0.13)	0.29 (0.38)	0.56 (0.088)	–0.04 (0.90)
Constraining time (minutes)	0.87 (0.10)	0.32 (0.53)	0.98 (0.057)	0.14 (0.79)
Intensity (TT^*CT)	–1.02 (0.10)	–0.11 (0.86)	–0.89 (0.14)	–0.035 (0.96)

WMFT = Wolf Motor Function Test; FMA = Fugl-Meyer Assessment; MAL = Motor Activity Log 14; self-care subgroup of the FIM = Functional Independence Measure; TT = total rehabilitation time; CT = constraining time. Values are co-efficient values β of the linear regression model. p < 0.05.

Fig.3

Outcome Measures of Intensity through Total Rehabilitation Time Multiplication Constraining Time from Pretreatment to Posttreatment within the mCIMT. WMFT = Wolf Motor Function Test; FMA = Fugl-Meyer Assessment; MAL = Motor Activity Log 14; self-care subgroup of the FIM = Functional Independence Measure; Intensity = Total Rehabilitation Time ^* Constraining Time.

3.4 Relations between the outcome measure and the duration from onset, constraining component, dominant hand consistent with lesion side of stroke, and initial MRC

The subjects was regrouped based on if the duration from onset was within three months, splint or mitt, non-dominant or dominant side, and within an initial MRC score of 9. There were no significant differences of outcome measure between the subgroups classified based on the characteristics of the patients (Table 5).

Table 5
Comparisons with outcome among the subgroups

ΔWMFT’ p ΔFMA’ p ΔMAL’ p ΔFIM’ p

Duration from onset

≤3 month (n = 17) 6.6±5.0 0.82 6.7±4.9 0.22 14.3±9.4 0.81 6.4±5.2 0.59

>3 month (n = 14) 6.2±4.0 4.9±2.0 13.4±10.3 5.5±2.8

Constraint

splint (n = 5) 6.6±4.0 0.92 7.8±5.0 0.25 19.2±10.9 0.19 6.6±3.2 0.72

mitt (n = 26) 6.4±4.7 5.5±3.7 12.9±9.3 5.8±4.4

Consistence with dominant hand

consistence (n = 17) 6.6±4.7 0.82 5.8±3.6 0.83 12.1±8.9 0.25 5.8±3.4 0.77

non-consistence (n = 14) 6.2±4.5 6.1±4.4 16.1±10.4 6.2±5.2

Initial MRC

≤9 (n = 20) 6.5±4.5 0.96 6.4±4.2 0.35 12.1±9.1 0.17 5.3±3.7 0.24

>10 (n = 11) 6.4±4.8 5.0±3.3 17.2±10.2 7.2±5.0

	ΔWMFT’	p	ΔFMA’	p	ΔMAL’	p	ΔFIM’	p
Duration from onset
≤3 month (n = 17)	6.6±5.0	0.82	6.7±4.9	0.22	14.3±9.4	0.81	6.4±5.2	0.59
>3 month (n = 14)	6.2±4.0		4.9±2.0		13.4±10.3		5.5±2.8
Constraint
splint (n = 5)	6.6±4.0	0.92	7.8±5.0	0.25	19.2±10.9	0.19	6.6±3.2	0.72
mitt (n = 26)	6.4±4.7		5.5±3.7		12.9±9.3		5.8±4.4
Consistence with dominant hand
consistence (n = 17)	6.6±4.7	0.82	5.8±3.6	0.83	12.1±8.9	0.25	5.8±3.4	0.77
non-consistence (n = 14)	6.2±4.5		6.1±4.4		16.1±10.4		6.2±5.2
Initial MRC
≤9 (n = 20)	6.5±4.5	0.96	6.4±4.2	0.35	12.1±9.1	0.17	5.3±3.7	0.24
>10 (n = 11)	6.4±4.8		5.0±3.3		17.2±10.2		7.2±5.0

WMFT = Wolf Motor Function Test; FMA = Fugl-Meyer Assessment; MAL = Motor Activity Log 14; self-care subgroup of the FIM = Functional Independence Measure; MRC = Medical Research Council for muscle strength. Values are mean±SD. p < 0.05.

4 Discussion

This study is the first to evaluate the effects of intensity through time dosage within mCIMT. Although the mCIMT program in this study showed significantly improved functional outcomes, this study did not present the relationship between constraining and rehabilitation time with functional outcome after two weeks performing mCIMT in patients with stroke.

On the basis of evidence-based practice, two critical components - constraining of the unaffected limb and treatment time are essential for mCIMT intervention in terms of deafferentation (Taub, 1976). That was why signature form (Taub et al., 2002; Wolf et al., 2006) of original CIMT was programmed to constrain the unaffected arm at least 90% of waking time and intensive practice to improve functional use of the affected arm after stroke. However, its massive treatment method is still limited in clinical settings and consequently limiting the effectiveness (Fleet et al., 2014). This study also showed that most of the subjects chose mitt as a constraint method. This is consistent with the overall shift from CIMT to mCIMT approach. It is also an important consideration for an effective program that the majority of patients choose more easy-to-access mitt than splint. Morris et al. reported the constraint of the affected arm was not only to restrain the less affected arm, but also to encourage the use by the more affected arm during activities of function (Morris et al., 2006). The constraint is one of the important components in mCIMT. Therefore, this study attempted to determine if much of the restraint resulted in better outcomes.

This study showed that CT did not affect functional outcome according to the regression analysis. In spite of importance of restraining component, a few studies proposed that the constraining alone (forced use therapy) was not necessary for promoting use of the affected arm (Wu et al., 2011; Gee et al., 2018). Kwakkel et al. (2015) investigated that forced use therapy did not show an added effect for amount and quality of affected arm based on previous randomized controlled trials. From the results of this study, it could not be guaranteed that the more restraint, the better the functional outcome. However, the number of subjects with splint was small. In addition, there was an interval in the constraining time, although there was no valid outcome difference between the two groups by constraining methods. Subjects using mitt were restrained from 4hours to 10hours per day; splint group were restrained from 24hours per day. Since there were no functional outcomes between 10 and 24hours for constraining time, it was possible that the results were affected. The restrain within 4hours was also not included in the study results, thus further study is needed considering this point.

We expected that the treatment intensity, which was composed of both TT and CT, would be associated with the outcome, similar to linear graph with plateau or inverted U-shaped curve with some intensity observed better performance. However, no such correlation was seen with the intensity, which is TT multiplied by CT, according to the regression model and correlation analysis. Our patients had lower functionality, thus they were more vulnerable to fatigue and pain. In addition, some patients could have had a lower threshold for self-satisfaction. Since individual threshold might not be directly related to the intensity and threshold value was individually variable, there was no statistically significant relationship between treatment intensity and outcome.

We did not find evidence that TT, including self-task practice and conventional therapy, was linear related to the outcome. It was consistent with previous meta-analysis; sensitivity analysis presented no significant differences between dose of mCIMT (5 to 60hours, mean 46.8hours) (Kwakkel et al., 2015), which supported the theoretical basis of mCIMT. Also, Dromerick et al. (2009) proposed, like drug interventions, dose higher than a proper range might be less successful than lower dose. In one study, therapy with repetitive tasks and treatment time for 10 minutes per day for two weeks did not show better functional outcome compared with occupational and physiotherapy (Woldag et al., 2003). There may be a minimum amount of treatment that affects the outcome, but the amount of treatment does not seem to directly affect the outcome by the linear graph. Quality of self-task or human resources might be considered to effect on functional outcome.

The mCIMT program in this study showed significantly improved functional outcomes. In this study, there was no control group and patients with subacute stroke were included. Hence, it was not possible to rule out the possibility of functional improvement by natural recovery. However, we presented that there was no statistically significant difference when compared within or beyond 3 months after onset. This was speculated to effect of mCIMT beyond natural recovery. In addition, in contrast to previous similar mCIMT or conventional CIMT programs, our mCIMT program presented that patients had improved by approximately 50% with respect to the MAL score and by 12% from the initial functional ability score with respect to WMFT. This study showed more affected functional outcome than several previous studies (Uswatte et al., 2006; Wu et al., 2011; Liu et al., 2016), and they supported the positive impact of mCIMT. According to the previously described minimal clinically important differences (https://www.sralab.org/rehabilitation-measures), the changes in WMFT and FMA were significant (WMFT reference values: dominant 1, non-dominant 1.2 vs. WMFT values in this study: dominant 6.59, non-dominant 6.21; FMA reference values: 5.25 vs. FMA value in this study: 5.90). Minimal clinically important difference has not been reported for other metrics, such as MAL, and self-care of FIM; however, 6–10% of the highest measures on the scale were achieved in this study (Angst et al., 2017).

Considering the above, other parameters associated with characteristics of the patients, which were expected to affect the function, were investigated; the duration from onset, constraining component, dominant hand consistent with lesion side of stroke, and initial MRC, had no significant differences in terms of the outcome measures.

Wolf et al. showed that the effects of CIMT dose were confused by the initial severity of motor impairment (Wolf et al., 2007). However, patients in this study proved that there were no differences of improvement on initial motor impairment whether within MRC 9 score or not. The MRC for muscle strength of upper extremity measured sum of each part, wrist, elbow, and shoulder from 0 to 5 score. The cut score 9 means each part of upper extremity can be movable against gravity. This demonstrated that physicians should consider patient capacity and outcomes might be more multiply affected by other factors, such as in the laboratory, contract, caregiver, and problem solving to overcome obstacles.

The finding in the present study that the mechanism of mCIMT was improvement in the smoothness of their motor performance (van Kordelaar et al., 2014) and learning to optimize the use of intact compensatory skills affected their outcomes to patients with subacute and chronic stroke (Liepert et al., 1998; Sawaki et al., 2008; van Kordelaar et al., 2013), is also consistent with the findings in previous reports. Contextual learning factors resulted in improvement of functional ability. It was consistent with that mCIMT is more appropriate for improving functional ability and use than for greater force at movement initiation (Wu et al., 2011).

This study had an advantage of individually goal-oriented tasks with shaping and repetitive methods conducted by a clinician. The clinician gave positive feedbacks in a video record at one week post initiation of the program for positive reinforcement and encourage. They repeatedly practiced a variety of functional tasks and were required to undergo dexterity training along with functional training. As a result, the patients could be adhered to their training for the entire intervention duration. In order to enhance the adherence to the training, we applied behavioral strategies, including a self-recording diary, daily clinician contact, and problem solving to overcome apparent barriers to the use of the more affected upper extremity in the real-world situation for two weeks. In addition, we speculated that the shaping method, which had tasks with progressively increasing difficulty, improved neurophysiological adaptation with cortical reorganization as discussed by Page et al. (2002a).

Not only the amount of treatment, but also the quality and efficiency of treatment are important for functional improvement. Further more diverse approach intervention will be needed to determine what can lead to treatment outcomes. In addition, it is necessary to investigate what factors are affected by the intensity, how much intensity is suitable, and the specific mechanism of mCIMT program. Doussoulin et al. (2018) rated that group therapy focusing on motivation improved the functional use more in contrast to individual intervention in mCIMT. They focused on moving to real-life patients, social support, stimulating physical and mood function and adherence (Page et al., 2005; Leung et al., 2009; Doussoulin et al., 2017). Further research will be required to establish dose-response relationships, optimal and threshold levels for therapeutic efficacy.

5 Limitation

The primary limitation is the small sample size, especially, with respect to splint application. In addition, the follow up period is short. Although mCIMT has been proved to be significantly effective in patients with subacute and chronic stroke, we need to evaluate the long-term effects of mCIMT.

In terms of the mCIMT program, all patients who had consistently maintained the self-diary about CT and self-task time, showed a non-blinded bias towards the clinician. Also, the results were not verified that were less than the amount of TT or CT performed by their own. Hence, further studies are needed to evaluate the effect with rehabilitation and constraint for less amount of time. Although there was no control group, it would have been ethical to not apply even with treatment of strong evidence.

In comparison to other studies, the MAL value was significantly improved, which might be a subjective assessment tool. In general, a positive assessment of treatment is intended to be overestimated because it may also affect their behavioral evaluation.

6 Conclusion

This is the first study on the effects of intensity related to deafferentation with respect to time dosage of mCIMT. All patients in this study showed improved functional status with respect to the outcome measures of WMFT, FMA, MAL, and self-care of FIM. However, there was no significant correlation between dose-dependent rehabilitation or constraining time and functional outcomes. The mCIMT has strong evidence in treatment for strokes; however, the critical therapeutic factor of mCIMT is still unknown. The underlying mechanism for the functional improvements seen in case of mCIMT is still poorly understood. Further research is warranted to explore other parameters such as motivation, behavior, and the psychological aspect of patient rehabilitation, as key factors.

Conflict of interest

The authors declare no conflict of interest. There was also no funding proved for the project.

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Is there a dose-dependent effect of modified constraint-induced movement therapy in patients with hemiplegia?

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1 Introduction

2 Methods

2.1 Participants

2.2 Intervention

2.4 Statistical analysis

3 Results

3.1 Characteristics of subjects

Table 3 Functional outcomes after intervention pre-intervention post-intervention p WMFT (score) 52.6±14.1 59.0±14.8 0.04* FMA (score) 45.1±12.4 51.0±11.6 0.03* MAL (score) 22.3±14.8 36.2±18.2 0.0008* self-care of FIM (score) 25.3±7.7 31.5±7.4 0.001*

5 Limitation

6 Conclusion

Conflict of interest

References

Table 3
Functional outcomes after intervention

pre-intervention post-intervention p

WMFT (score) 52.6±14.1 59.0±14.8 0.04^*

FMA (score) 45.1±12.4 51.0±11.6 0.03^*

MAL (score) 22.3±14.8 36.2±18.2 0.0008^*

self-care of FIM (score) 25.3±7.7 31.5±7.4 0.001^*