#cimt le #taylor & Francis #pubmed #scopus #gait disorder #CONSTRAINT INDUCED MOVEMENT THERAPY #NON PARETIC LOWERELIMB #RCT #NIHSS #FAC

1. Welcome to the Journal
Club
Presented by –Suparna Bandyopadhyay
2nd year MPT(Neurology)
Moderator- DR. Answesh Pradhan
Associate professor, NIHS, Kolkata
Dr. Namita Kaushik
Assistant professor, NIHS, Kolkata

2. TRIAL DETAILS
Trial
Name:
Authors:
Journal:
Year of
Publicatio
n:
Contact
Informatio
n:
2
Effects of constraint-induced movement therapy for lower limbs on
measurements of functional mobility and postural balance in subjects
with stroke: a randomized controlled trial
Emília Márcia Gomes de Souza e Silva et. al
Taylor & Francis online
2017
rcia Gomes de Souza E Silva
Emilia.marciagss@hotmail.com

3. TRIAL DETAILS
9/3/20XX Presentation Title 3
Trial
Dates:
DOI:
Country
ISSN:
Ethical
Approval:
doi.org/10.1080/10749357.2017.1366011
Brazil
1074-9357
Research Ethics Committee
of the Federal University of Rio Grande do Norte
(Natal, Brazil)

4. 9/3/20XX Presentation Title 4
Journal Details
Impact Factor : 4.231 (2020)
Indexing:
Google
scholar
Web of science
DOAJ
PubMed
PubMed
central
Scopus

5. According to a data published in 2010 Stroke is the 3rd leading cause of disability-adjusted life years
worldwide. Worldwide Incidence of stroke is about 795000 per year
Gait disorder following stroke
Uncoordinated gait after stroke prevents turning from being done properly, making fall episodes eight
times more common during turning than in straight walking
Stroke patients, are unable to stabilize the center of mass movement during walking results in a less
stable gait pattern and it is difficult for them to carry out their ADLs, and change direction while walking
Weight bearing asymmetry further contributes to the increasing dynamic postural instability of these
patients
9/3/20XX Presentation Title 5
INTRODUCTION:

6. INTRODUCTION
Constraint-induced movement therapy (CIMT) is an approach that stimulates the use of the paretic limb
through restraining the non-paretic limb, to reduce the effects of learned disuse and make the function of
limbs more symmetrical
Regnaux and co-workers were the first to propose the use of load as a restraint for the NPLL of subacute
stroke patients. In that study, improved gait speed, cadence, and kinematics of the paretic limb were
observed after restraining the NPLL using an ankle mass in a single session of treadmill training
Bonnyaud and colleagues used the same protocol but for chronic stroke patients, and did not observe
specific effects of the restraint on gait parameters of the paretic limb
The purpose of this study was to examine the effects of load addition used as a restraint to using the NPLL
during treadmill gait training on measures of functional mobility and postural balance in subjects with
subacute stroke
29.09.23 Journal club 6

7. Methods
Study design:
Number of
participants
Allocation Duration
9/3/20XX Presentation Title 7
Two arm
Randomized trial
38 subjects
Experimental group-
19
Control group -19
Sample size was
calculated by adopting
a symmetry ratio of
swing time as the
primary outcome
measure, according to
a randomized clinical
trial
Subjects were
randomly allocated,
using a computer-
generated
(Randomization.com
website. Available
at:
http://www.randomiz
ation.com/.)
randomization
schedule done by a
researcher who was
not involved in the
study
Two weeks
(9 sessions)

8. 9/3/20XX Presentation Title 8
Inclusion Criteria
Stroke survivors (between 21 and 70
years old)
Clinical diagnosis of their first stroke
(ischemic or hemorrhagic)
All the participants could walk at least 10
m independently (without walking aids)
Exhibiting slow or moderate gait speed
(less than 0.8 m/s)
Were able to understand simple
command
Exclusion Criteria
Instability of heart conditions
Other adverse clinical conditions affecting balance
and/or gait, pain and/or discomfort that could impede
completion of the training
Changes in blood pressure
 Before, during or after training, and submaximal heart rate (HR) above the allowed values during
training (75% of HR)
 Subjects were not actively involved in any kind of exercise program involving lower limbs during the
study period. Participants did not use gait orthosis during interventions

9. Intervention
Neurological
status
• NIHSS
Cognitive
status
• MMSE
Gait ability
• Functional
ambulatory
scale
9/3/20XX Presentation Title 9
Outcome measure
Static dynamic
postural balance
• BBS
Mobility skill
• TUG
Kinematic turning
parameters
• Qualisys
Motion System
Baseline Data

10. Intervention
Experimental group Control group
9/3/20XX Presentation Title 10
 Training sessions (days 1–9) consisted of 30-minute
treadmill training (Gait Trainer System 2 )Biodex
Medical Systems Inc, Shirley, New York. The
experimental group performed treadmill training
using a mass attached around the non-paretic ankle,
with a load equivalent to 5% of the individual body
weigh
 Treadmill training (Gait Trainer System 2 )Biodex
Medical Systems Inc, Shirley, New York. The
experimental
 All the participants were instructed to use their usual footwear during the training. Subjects used a harness for
stabilization (without unweighting) while walking on a treadmill. On day 1, patients were told to hold on to the
front bar of the treadmill with the non-paretic hand, being encouraged to withdraw this support in subsequent
days. The speed of the treadmill was set at the highest comfortably tolerated by the subject.30 Once the subject
stopped using the support of the treadmill bar, speed could be increased at the beginning of each new therapy
session, according to individual tolerance
 Therapists monitored the posture and body alignment of participants, but without providing manual assistance.
However, verbal corrections and incentives were given as deemed necessary

11. Intervention
Home exercise (Load discharge exercise)
Both groups were instructed to perform load discharge exercises every day at
home, so that patients could stimulate the paretic limb even during activities
outside the laboratory (“transfer package”). Load discharge exercises involved
the transfer of body weight on the paretic limb in both the antero-posterior and
latero-lateral direction in the standing position, consisting of 3 sets of 10
repetitions in each direction. In each training session, subjects were asked
about the performed exercises and the instructions were reinforced,
representing behavioral strategies according to the concepts of CIMT
9/3/20XX Presentation Title 11

12. Flowchart
9/3/20XX Presentation Title 12

13. Data analysis
9/3/20XX Presentation Title 13
Data analysis was carried out by a researcher blind to group
allocation, using statistical software (Statistical Package for
the Social Science version 20.0 (SPSS, IBM®, USA) and
considering α level of .05 for all analyses
Result
Improvement
observed in
TUG,BBS and
turning
parameters in
both group
No adverse
event were
reported
36 completed
the protocol

14. Data analysis
9/3/20XX Presentation Title 14
Baseline data BBS
TUG test
Kinematic turning

15. Discussion
9/3/20XX Presentation Title 15
Both the experimental and control group shows improvement on postural balance and functional mobility. But there was no
statistical difference between the group
Uswatte and co-workers 33 observed a similar improvement using massive practice of functional activities, with and without
upper limb restraint. Restraint has less essential role in gains from CIMT
This protocol was innovative in several ways: (1) A 5% body weight load, based on previous studies but chosen as a percentage
of body weight, according to our pilot study; (2) Time of intervention, with 9 sessions for 2 consecutive weeks, to observe long
term effects, and (3) Adding a “transfer package,” to reinforce learning and patient adherence to therapy.
Lack of difference between groups is that the load used may have been insufficient for satisfactorily restraining the NPLL in
long-term training
Treadmill training allows repetitive, rhythmic, and task-oriented movements, which favor interlimb symmetry, leading to
increased dynamic stability while walking. In our study, treadmill training was undertaken daily for two weeks, associated with
home-based practice exercises; this provided more practice for the participants, and should have optimized the results

16. 9/3/20XX Presentation Title 16
Discussion
Improved postural balance was observed with only one week of training, which was maintained in following
assessments
Treadmill training induces changes in corticomotor excitability, probably related to improved balance and gait
performance after stroke
Furthermore, studies have reported that early after stroke, treadmill training promotes significant improvements
in clinical measures of balance
Improved postural balance may have had an impact on functional mobility, considering that the reduced time
spent on the TUG test occurred in the second week of training,
Moreover, as gait is one of the components of the TUG, the improvement observed in this test may also have
been due to the task-specific training provided by the treadmill. Less time spent on TUG test is important
because it reflects greater independence and a lower risk of falls in patients with neurological disorders
Chen and colleagues42 compared two groups of stroke subjects: one group underwent turning-based treadmill
training and other underwent regular treadmill training. Both groups showed increased turn speed, straight-
walking cadence, and stride length, indicating that improving intrinsic gait components can also increase the
ability to perform gait-related action

17. 9/3/20XX Presentation Title 17
Our results suggest that turning performance became not only faster, but also safer (less asymmetric)
after interventions, although the symmetry ratio of swing time did not improve. Previous studies have
also indicated a higher resistance to change of the temporal symmetry, showing minimal or
statistically non-significant improvements even with specific training to improve this parameter
Discussion

18. Conclusion
9/3/20XX Presentation Title 18
Two weeks of daily gait training on a treadmill associated with home-
based exercises appears to be effective in improving postural balance
and functional mobility in subacute stroke subjects. However, load
addition did not provide additional benefits to training
Limitation
The added load may not have been enough, so that other
load percentages should be tested
the intervention time may not be sufficient to cause greater
changes through restraint on the analyzed parameter

19. 9/3/20XX Presentation Title 19