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Advisory Committee Chair

Gitendra Uswatte

Advisory Committee Members

Victor Mark

David Morris

Edward Taub

Rex Wright

Document Type

Dissertation

Date of Award

2016

Degree Name by School

Doctor of Philosophy (PhD) College of Arts and Sciences

Abstract

Constraint-Induced Movement therapy, or CI therapy, is one of the few techniques that controlled, randomized studies show to substantially reduce the incapacitating motor deficit of the more-affected upper-extremity of patients with mild to moderately severe hemiparesis. The therapy for individuals with mild to moderate motor impairment of their more-affected arm involves a) training of more-affected arm for 3.5 hours per day for 10 consecutive weekdays, b) following shaping principles when conducting the training, c) restraining the less-affected arm for a target of 90% of waking hours, and d) administering a package of behavioral techniques designed to transfer gains to daily life. Imaging techniques for studying structural neuroplastic changes after CI therapy show substantial increases in contralateral primary sensorimotor cortex and motor areas anterior to these loci, equivalent changes in the ipsilateral cortex, and the hippocampus after CI therapy. It is thought that one mechanism responsible for the large gains in everyday use of the more-affected arm may be that the increase in central nervous system (CNS) representation makes movement of the more-affected arm less effortful and less demanding of attention. The effect of CI therapy on effort required to move the more-affected arm during an upper-extremity motor task was examined in two studies in patients with mild-to-moderate upper-extremity hemiparesis. Effort was measured by systolic blood pressure (SBP), heart rate (HR), and the Category Ratio Scale (CR10). In the first study, chronic stroke patients (n = 21) received either a telerehabilitation form or CI therapy or standard CI therapy. In the second study, multiple sclerosis (MS) patients (n = 17) received standard CI therapy or Complementary Alternative Medicine treatments. Participants in both studies moved a peg from a starting hole to a target hole and back with their more-affected arm for 60 s in for each of four increasing levels of task difficulty. In addition, attention required to move the more-affected arm was studied using a dual-attention task, i.e., upper-extremity pegboard and arithmetic tasks, performed simultaneously. In the first study with chronic stroke patients, participants in both CI therapy groups showed very large gains in the quality of movement of the more-affected arm use as measured by the MAL, F(1, 14) = 200.5, p < .0001, d' = 2.9. In the second study with MS patients, participants in the CI therapy group showed very large MAL gains, F(1, 8) = 151.6, p < .0001, d' = 4.6. However, participants that received CAM treatments (e.g. massage, yoga) showed substantially smaller gains, F (1, 7) = 7.5, p < .05, d' = .6. The effort data from both studies indicated that the two testing paradigms functioned as intended, i.e., the difficult task levels required more effort than the easy ones, and performance of the motor and cognitive tasks in the dual-task compared to single-task condition was more demanding. In both stroke patients and MS patients, all three of the indices of effort increased monotonically with task difficulty, p's < .05. Correlations among the three indices of effort, CR10, SBP, and HR responses, however, did not behave as expected. Although SBP and CR10 values were correlated in stroke patients, r(16) = .66, p< .01, HR values were not significantly correlated with either of the two indices. In MS patients, none of the three indices were correlated with another. For stroke patients, the results indicated perceived effort to move the more-affected arm during the motor task decreased after CI therapy, F(4, 56) = 3.3, p< .02. There was also a reduction in attention required to perform the motor and arithmetic tasks together, F(1, 11) = 5.5, p = .04, and a concomitant decrease in perceived effort, F(1, 12) = 14.3, p = .003, for the dual-attention task, relative to the single-tasks, after CI therapy. There were no significant improvements in any of the measures of effort or attention after CI therapy in the MS patients. The stroke study findings warrant testing in a study with a more rigorous design and larger sample size.

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