1

Introduction
- Regaining walking ability is a commonly stated rehabilitation goal for post-
stroke patients.

- gait in post-stroke patients

- over 60% have abnormal gait patterns & reduced walking ability
- abnormal patterns also occur in unaffected side (compensatory movements
- slower, higher energy consumption, risks of fall-down higher, easily fatigue
→ limiting participation, reducing QoL

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Introduction
- Constraint-induced movement therapy (CIMT)
- based on the brain’s plasticity & reorganizing ability
- effective in improving upper extremity outcomes post-stroke
- the four components
■ intensive training of the more affected side
■ shaping (behavior training technique)
■ transfer package (problem solving in ADL)
■ restraint of the less affected side for 90% of waking hours

- CIMT for the lower extremities (LE-CIMT)

- insufficient evidence regarding the efficacy, as limited studies investigating this have
been published, with small number of participants 3
Introduction
- Clinical question:
This study aims to investigate whether LE-CIMT (highly intensive task-specific training
for the lower extremity) can improve motor function, functional mobility, and walking
ability among post-stroke patients in an outpatient clinical setting?

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Methods
- Longitudinal cohort study conducted (2003-2018) at an outpatient clinic in
Stockholm, Sweden
- Data from patients who had received LE-CIMT
■ between 2003-2014: collected retrospectively from medical record
■ between 2014-2018: collected prospectively
- all patients were followed prospectively
- only patients who provided written consent were included

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Methods
- Inclusion criteria
- adults with a stroke diagnosed at the time of study inclusion
- able to walk indoors without aid
- able to understand verbal and/or written instructions
- had not previously received intensive training
(6 hr/day for 2 wks or 3 hr/day for 3 wks)

- Exclusion criteria
- patients who had unstable cardiovascular disease

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Methods
- Intervention: highly intensive task-specific training w/ modified LE-CIMT
- every weekday, 6 hr/day, for 2 wks; each session lasted 45-60 mins
- in groups of 3-4, treated by the same PT
- individually designed programs, w/ difficulty increased based on progress
strength, balance, gait, & functional training were used in different orders
■ cycling w/ only the more-affected leg
■ functional training in different starting positions & on different surfaces
■ load exercises w/ weight transfer
■ walking indifferent directions
■ treadmill training
■ stair training
■ running
■ leg press strength training
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Methods
- Intervention: highly intensive task-specific training w/ modified LE-CIMT
- verbal feedback on how well participants performed the tasks (shaping)
- participants were encouraged to use their more-affected leg as much as possible
during ADL over the weekend
- after the intervention, participants received individual home-training programs for 3
months (data not reported in this study)
- A knee orthosis (Knee Immo Art. No 47500, Camp Scandinavia AB , Helsingborg, Sweden) ,
where the knee was constantly extended, was used for restraining the unaffected leg
in walking exercises
■ The orthosis was often used at the beginning of the walking sessions for 5-10 mins. If the
walking pattern was positively impacted, the procedure was repeated.
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Methods
- Outcome measures
assessed at 1 wk pre-intervention, post-intervention, 3 month follow-up

- Motor function & functional mobility

■ Fugl-Meyer Assessment (FMA) subscale E for lower extremities
measures voluntary motor function, max. score = 22,
minimal clinically important difference = 6, minimal detectable change = 4
■ Timed Up and Go (TUG) Test
minimal detectable change = 8 sec

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Methods
- Outcome measures
- Walking ability
patients were allowed to use a AFO when necessary, but no walking aid
■ 10-meter walk test (10MWT)
patients were instructed to walk at a self-selected speed and then as fast as they could

minimal detectable change = > 0.30 m/s walking without assistance at a self-selected
speed
■ 6-minute walk test (6MWT)
minimal detectable change for chronic stroke patients = 28 to 42 meters

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Methods

- Data synthesis & Analysis:

- Data were analyzed using the SPSS v. 26.0
- A two-tailed P value of <0.05 was considered significant
- drop-out analysis: t-test
- MDs between pre-treatment, post-treatment, follow-up: linear mixed model
- the effect of heterogeneity on 10MWT results: additional corresponding linear mixed
models were used
■ age, gender, stroke type, more-affected side, time to intervention
■ participants were divided into 3 groups: those who completed the intervention 1-6
months (sub-acute phase), 7-12 months (chronic phase) and ≥13 months (late chronic
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phase) after stroke onset
Results
- Flow of participants through the study

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Results
- Characteristics of the participants
- 40 participants did not complete the 3-month follow-up. There were no statistically
significant differences in the descriptive characteristics of the 40 participants who did not
complete the follow-up and those who did

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Results
- Improvements in motor function and functional mobility
FMA demonstrated statistically significant improvements.
- FMA: MD in pre-compared to post-intervention scores was 1.5 points (95% CI 1.2-
1.9, P<0.001) and 1.7 points (CI 1.2-2.2, P<0.001) for follow-up

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Results
- Improvements in motor function and functional mobility
TUG demonstrated statistically significant improvements.
- TUG: MD in pre-compared to post-intervention scores was 2.6 sec (CI 1.5-3.6,
P<0.001) and 2.7 sec (CI 1.6-3.8, P<0.001) for follow-up

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Results
- Improvements in walking ability
Statistically significant improvements in walking ability were demonstrated.
- 10MWT self-selected speed improvement: MD in pre- compared to post-
intervention speed was +0.11 m/s (CI 0.08-0.14, P<0.001) and +0.14 m/s (CI 0.09-
0.18, P<0.001) for follow-up
- 10MWT at fastest, time improvement: MD in pre- compared to post-intervention
speed was -1.2 sec (CI 0.7-1.7, P<0.001) and -1.1 sec (CI 0.3-1.9, P=0.005) for
follow-up

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Results
- Improvements in walking ability
Statistically significant improvements in walking ability were demonstrated.
- 6MWT distance improvement: MD in pre- compared to post-intervention speed
was +50 meters (CI 41-59, P<0.001) and +58 meters (CI 43-72, P<0.001) for follow-
up

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Results
- Heterogeneity analysis for the 10MWT
Only the time between the stroke onset & intervention demonstrated a
significant interaction with the 10MWT self-selected speed results (P<0.001).
- patients in the subacute phase had statistically significant larger improvements at
follow-up, c/w patients in the chronic (P=0.01) & late chronic (P=0.03) phases

- age (P=0.07), gender (P=0.48), stroke type (P=0.61), and more-affected side
(P=0.83) did not demonstrate significant interaction with the 10MWT results

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Discussion
- The results demonstrated statistically significant improvements in motor
function, functional mobility, and walking ability directly after the LE-
CIMT intervention, and also at 3-month follow-up.

- previous studies also noted motor function & functional mobility improvements
from LE-CIMT & UE-CIMT

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Discussion
- however, constraints for LE cannot be used to the same extent as UE
- MD in FMA smaller than previously reported minimal detectable change, however a
complete FMA-LE was not performed → not comparable
- MD in TUG also smaller than previously reported minimal detectable change
→ may be due to floor effect
■ mean time in healthy adults = 8.46 sec, minimal detectable change = 8 sec
(current study) mean time in stroke patients = 15.1 sec
if 15.1 - 8 = 7.1 sec
- the improvements persisted at the 3-month follow-up
→ the effects of LE-CIMT on functional mobility were retained
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Discussion
- LE-CIMT is a feasible treatment option in a real-world OPD setting
- could be used as an alternative to other types of post-stroke rehabilitation for patients
with diversified characteristics

- participants relatively young (mean age = 51 yro), approximately ⅔ were male

- LE-CIMT does improve motor function & walking ability, even when delivered
during the sub-acute and chronic stroke stages, at least among some young stroke
survivors

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Discussion
- participants who received LE-CIMT earlier post-stroke onset showed
statistically better walking ability compared to those who received the therapy
later
- supports the importance of the recovery time window
- it is never too late to reap the benefits of training
- persistent improvements at the 3-month follow-ups were observed
- may be attributable to the 60 hr of exercise each participant carried out
- the participants also received home training programs
- home training program compliance was not evaluated
- functional improvements increased independence and self-esteem
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Discussion
- Strengths
- sample size relatively large
- repeated outcome measures reported by a experienced PT
→ enhanced consistency in treatment delivery & assessment provision
- Limitations
- longitudinal cohort design used, causal effects difficult to establish
- no control group
- the PT who conducted the intervention also performed the assessments →
risks of detection bias → statistical analysis done by an independent researcher
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Discussion
- Limitations
- the significance of group treatments was not evaluated

- Implications of future studies

- future studies should develop and use a standard LE-CIMT protocol
- further studies that use robust designs are required to further evaluate LE-
CIMT’s efficacy

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KEY POINTS
High intensity LE-CIMT may significantly improve motor function, functional
mobility, and walking ability in middle-aged sub-acute or chronic phase stroke patients
in an outpatient setting.

The improvements in walking speed and distance persisted at the 3-month post-
intervention follow-up.

Those who completed the intervention 1-6 months post-stroke showed statistically
significant larger improvements in 10MWT results compared to those who received the
intervention more than 6 months post-stroke. 25
ABSTRACT

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Thank
you !!

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