Lower-extremity constraint-induced movement therapy in individuals with stroke : improvements, experiences, and health-related quality of life

Abstract: Background: Stroke is the third-leading cause of disability worldwide, and there are rehabilitation needs not only in the first year but throughout the lifetime. The ability to walk is crucial in everyday life since it affects mobility, self-care, and social activities. National guidelines recommend treating impairments with repetitive task- and goal-oriented exercises. One form of highly intensive and task-specific treatment is constraint-induced movement therapy (CIMT), a treatment method developed based on understanding brain plasticity with a behavioural explanatory model. There is insufficient evidence regarding CIMT for the lower extremities (LE-CIMT) since it has only been investigated in a few published studies involving only a small number of participants.Aim: The overall aims of this thesis were to explore the extent to which LE-CIMT (six hours per day for two weeks) can improve impaired body functions and limited activities, describe how the treatment is experienced, and investigate whether it affects the health-related quality of life (HRQoL) in individuals with stroke.Methods: This thesis contains five papers that analysed data from two study populations using quantitative and qualitative research methods. A single-subject experimental study with five subjects and a longitudinal uncontrolled cohort study with 147 subjects with stroke treated with LECIMT and follow-up after three and six months were conducted. Subjects were assessed with Fugl–Meyer assessment, the Berg balance scale (BBS), single-leg stance, step test, timed up and go with and without dual-task, ten-metre (10MWT) and six-minute (6MWT) walk tests, one repetition maximum, and weight-bearing standing on two scales. Data were analysed with the two-standard deviation band method and linear mixed modelling, controlling for heterogeneity. Seven individual semistructured interviews were performed and analysed with qualitative content analysis to explore LE-CIMT experiences. Finally, a questionnaire including RAND-36 was sent out to former LE-CIMT participants, with 106 responses (response rate 65%). Data were compared with norm-baseddata and analysed with the summary independent-samples t-test. Univariable analysis was performed to investigate the linear relationships between RAND-36 health domain scores and the 6MWT result per 100meters, time since treatment, living alone, and need for home care. Independent t-tests were used for drop-out analyses.Results: Highly intensive LE-CIMT significantly improved motor function, strength, balance, dual-task ability, mobility, and walking ability in individuals in the sub-acute and chronic post-stroke phases. They maintained or improved their weight bearing on the more affected leg to provide a more symmetric distribution. The improvements remained at the three- and six-month follow-up. There was a significant interaction for time and age. Those who completed LE-CIMT within six months after their stroke onset had significantly greater improvements in 10MWT self-selected speed during the follow-up than those who completed LE-CIMT after at least seven months. Younger participants had higher BBS scores than older participants. The informants’ experiences generated the overall theme that LE-CIMT gave them knowledge about themselves and how their body works, facilitating the opportunity to live life more easily. There was still hope and opportunity for functional improvements to increase their independence and self-esteem. While LE-CIMT was intense and challenging, it was experienced as entirely necessary. The participants had significantly reduced HRQoL, overall and by sex in physical functioning, role-functioning physical, general health (not females), and social functioning compared to the general population. A significant relationship existed between their previous 6MWT result and the HRQoL physical functioning domain. Every 100-metre improvement in the 6MWT led to a 6.45 higher physical functioning score. No other significant associations were found. The dropout analysis showed no significant differences in characteristics between the participants and those who did not complete all three assessments or answer the questionnaire.Conclusion: LE-CIMT seems helpful in improving lower extremity body functioning and activities, even a long time after the stroke, leading to persistent improvements. The patients perceived LE-CIMT as entirely necessary. LE-CIMT may be a feasible treatment option and could be conducted in both day hospital rehabilitation and outpatient settings. Six minutewalk performance predicts physical functioning in HRQoL, emphasising the importance of mobility and gait training in rehabilitation after stroke.