EFFECTIVENESS OF LONG DURATION- SHORT TERM VERSUS SHORT DURATION-LONG TERM MODIFIED CONSTRAINT INDUCED MOVEMENT THERAPY IN IMPROVING THE FUNCTIONAL OUTCOME OF UPPER EXTREMITY IN SUBACUTE STROKE PATIENTS.MASTER OF PHYSIOTHERAPY (NEUROLOGY) 2009

Dr.P.k.sethi HOD Neurology (SGRH Hospital)

Shubham Singh Dr.K.S Anand Dr .Deepti Parashar, HOD Neurology Lecturer,FIT (RML Hospital) (MPT Neuro,)

Hemiparesis is among the most common deficits after stroke,

leading in many cases to disability and permanent dependency on community care in various developed and developing countries, various physiotherapeutic treatments are applied to improve chronic hemiparesis, however, controlled evaluation studies indicate that the effectiveness of these treatments is minor or moderate at best. This finding is especially true for the transfer of therapeutic effects into the home environment real-world outcome5. Owing to high incidence of Middle cerebral artery strokes, Upper Extremity is frequently more affected than Lower Extremity. About 20% of individuals paralyzed by stroke fail to regain any functional use of the affected Upper Extremity 28 .

Endurance after stroke is compromised to a level

that limits basic daily functioning .Therapy in clinical practice often lasts only a few weeks and lacks progression in intensity and task complexity . Rehabilitation services for stroke survivors are increasingly constrained by the cost concerns, with pressure to discharge individuals from acute rehabilitation earlier when recovery and function have not yet stabilized6. . Stroke survivors are often deconditioned predisposed to a sedentary lifestyle that limits performance of ADL(activities of daily living) , increases the risks of fall and may contribute to a heightened risk of recurrent stroke and cardiovascular disease. Clearly stroke survivors can benefit from counseling on participation in physical activity and exercise training9.

Furthermore, treatment options for stroke are fewer in developing

countries like India. Well-organized stroke services and emergency transport services are lacking and many treatments are unaffordable. Also, sociocultural factors may influence access to medical care for many stroke victims. Most stroke centers are currently in the private sector and

establishing such centers in the public sector will require enormous capital investment. Given the limited resources available for hospital treatments, it would be logical to place a greater emphasis on effective population wide interventions to control or reduce exposure to leading stroke risk factors. There also needs to be a concerted effort to ensure access to stroke care programs that are tailored to suit Indian communities and are accessible to the large majority of the population, namely the poor8.

The term function of Upper Extremity

covers a large spectrum from the ability to lift the arm when dressing ,to the ability to lift a cup from a table , to write etc10. Recently alternative approaches which use repetitive training or forced-use procedures, have been applied with increasing success. A new family of rehabilitation, termed as Constraint induced movement therapy or, CIMT therapy has been developed that controlled experiments have shown is effective in producing large improvements in limb use in the real world environment after cerebrovascular accidents {CVA} 11.

Constraint induced movement therapy can improve chronic hemiparesis,

but this technique has proven difficult to transfer into clinical practice. The signature therapy involves constraining movements of less affected arm with a sling for 90% of waking hours, while intensively training the use of the more affected limb. The common therapeutic factor in all the Constraint induced movement therapy techniques would appear to be inducing concentrated, repetitive practice of use of the more affected limb12.

Modified Constraint induced movement therapy, as developed by Page

and colleagues, represents a distributed practice pattern in which the mitt is worn for several hours each day over a 10-week period and this homebased practice is supplemented with outpatient therapy several times each week13. The relative costs for providing the signature Constraint induced movement therapy approach are high. Modified Constraint induced movement therapy, which represents a distributed practice and treatment pattern, and forced use, in which a patient works primarily in the home environment and has far fewer treatments, are less expensive. However, there still is a need to subject this intervention to a costeffectiveness analysis. To date, this task has not been undertaken formally14.

Because stroke patients with poorer physical condition have less

capacity for demanding activities, a 6-hours a day training schedule may be too strenuous for them .the demanding nature of behavioral intervention techniques can be a major concern in stroke patients ; it may also act against the therapys effectiveness ,when a patient is pushed beyond his/her endurance limits and becomes fatigued 15,46,47. Also when constrained induced movement therapy was described in an excerpt from a case report ,more than 80% of the patients felt that if the protocol lasted for several more weeks ,with shorter physical therapy and occupational therapy sessions, and/or fewer hours of wearing the restrictive device ,and the number of practice hours would be more acceptable by them. Moreover ,over 70%of the therapist felt that most facilities did not have the resources needed to implement Constraint induced movement therapy . In reference to the restrictive device use schedule ,therapists were

concerned with compromises in independent activities and safety.

Also , with regard to the practice component they noted some clinics

may lack adequate resources or personnel to engage patients for 6 hours per day16.

Studying the effects of enrichment on recovery from brain

lesions in animals, Wil et al found that ,enrichment of 2 hours a day was beneficial as 24 hours a day. Thus ,a question arises: what might be the optimal amount of training be?17 Thus, the main goal of the present study was to compare the efficacy of the two, long duration -short term modified constraint induced movement therapy and short durationlong term modified constraint induced movement therapy in improving the upper extremity function and control in sub-acute stroke patients which would guide the physical therapist as to design an effective Constraint induced movement therapy protocol which could be implemented according to the needs of the patient and resources available.

Statement

Of Problem Till date there have been a number of studies explaining the efficacy of modified constrained induced movement therapy ,however there exists a dearth of clinical trials comparing Long duration- short term over Short duration-long term modified constrained induced movement therapy in improving the functional outcome of upper extremity in sub-acute stroke patients. Aim To establish the effectiveness of Long duration short term versus short duration long term modified constraint induced movement therapy in improving the functional outcome of upper extremity in sub-acute stroke patients.

Purpose of study

To assess the effectiveness of daily training of Long durationshort term over Short duration-long term modified constraint induced movement therapy in improving the functional outcome of upper extremity in sub-acute stroke patients.Hypothesis Research hypothesis 1: Both, Long duration - short term and

Short duration -long term modified constraint induced movement therapy ,will be equally effective in improving upper extremity function in sub acute stroke patient. Research hypothesis 2: Both, Long duration -short term and Short duration - long term modified constraint induced movement therapy, will have different effects in improving the upper extremity function in sub acute stroke patients

Significance Of The Study

This study evaluates the effectiveness of the 2 modified Constraint induced movement therapy protocols i.e., Long duration- short term modified constrained induced movement therapy and Short duration-long term modified constrained induced movement therapy in improving the functional outcome of upper extremity in sub-acute stroke patients. Thus, it would enable to design an effective modified Constraint induced movement therapy protocol that features treatment parameters within the managed care limits and that is implementable on an out patient basis, according to the convenience of the therapist and patient both.

Operational Definitions Long duration- short term modified constrained induced

movement therapy-modified Constraint induced movement therapy = 2 hours for 15 days . Short duration-long term modified constrained induced movement therapy- modified Constraint induced movement therapy =1 hour for 30 days.

Stroke Stroke is defined as rapidly developing clinical signs of focal or global disturbances

of cerebral function lasting for more than 24 hours, with no apparent cause other than of vascular origin 2,18

Epidemiology Richard F. Gillum (1999)states that stroke is the third leading cause of death in black

women and the sixth in black men in the United States in 1996, stroke accounted for 10 509 deaths in women and 7972 in men among blacks: 7.92% and 5.33%, respectively, of the total deaths. Age-adjusted death rates per 100 000 were black women, 39.2; white women, 22.9; black men, 50.9; and white men, 26.319.

Stroke represents 1.2% of total deaths in India .T. K. Banerjee (2006) shows that the

age-adjusted annual incidence rate is 105/100,000 in the urban community of Kolkata and 262/100,000 in a rural community of Bengal 20. prevalence in various studies because of the differences in diagnostic criteria, medical facilities, age and sex distribution and screening procedures21. Naik M (1984) suggests infarction is more common than hemorrhage as the cause of stroke22.K. Srinivasan (1997) reports 15% of cerebrovascular strokes occur in those below 40 years of age, cerebral venous thrombosis and arterial thrombosis in puerperium5. According to Gobindram Arjundas (2006), Maximum frequency (73%) is seen in the 51 to 70 year age group and 14% occurs in the below 40 years age group. The maximum incidence is between 4 am and 12 pm (48% of cases). There is also a second peak time between 4 pm and 8 pm23.

Rajinder K Dhamija (2000), concluded that it is difficult to compare stroke

Risk factors and recommendations Helen Rodgers,FRCP, Jane Greenway, MSc et al (2004);concluded that, classic risk factors such as atrial fibrillation , history of hypertension , TIA ,CVD , current smoking ,systolic blood pressure , and increasing age increase the risk of stroke in older people24 . Didier Leys (2002) discusses about the risk factors and recommendations25 arterial Hypertension26,51, hypercholesterolemia26, cigarette smoking27 diabetes mellitus26, hormone replacement therapy, -oral contraceptive therapy, -alcohol abuse27, physical inactivity

Xin Hua Zhang et al (1995)concluded that the sex ratio of stroke mortality is

increasing with time and decreasing with age. Differences in lifestyle among countries and over the last three decades may contribute partially to these differences in sex ratio30. Sarah E. Vermeer et al (2006),concluded that Impaired glucose tolerance is an

independent risk factor for future stroke in nondiabetic patients with TIA or minor ischemic stroke31 . Zoltn Vok et al (1999) found a continuous increase in stroke incidence with

increasing blood pressure in nontreated subjects. In treated subjects, they found a J-shaped relation between blood pressure and the risk of stroke. In the lowest category of diastolic blood pressure, the increase of stroke risk was statistically significant compared with the reference category. Hypertension and isolated systolic hypertension are strong risk factors for stroke in the elderly. The increased stroke risk in the lowest stratum of blood pressure in treated hypertensive patients may indicate that the therapeutic goal of "the lower the better" is not the optimal strategy in the elderly32 .

Pathophysiology Osullivan reveals that Interruption of blood flow for only few minutes set in motion serious

pathoneurological events. Complete cerebral circulation arrest results in irreversible cellular damage with a core area of focal infraction with in minutes. The area surrounding the core is termed as the ischemic penumbra and consists of viable but metabolically lethargic cells. The ischemia triggers a number of damaging and potentially reversible events including the release of cascades of chemicals 28-29 .

Following Ischemia , brain edema begins with in minutes of the insult and reaches maximum by 3-4 days. It is

the result of tissue necrosis and widespread rupture of cell membrane with movement of water from blood to brain tissue. The swelling gradually subsides and disappear in 3 weeks.. Significant edema can elevate the Intra Cranial Pressure and leading to secondary brain damage. Alien Turton (2002) suggests that physical therapy in first few days after stroke should be given in the context of optimum physiological basic care29 .

Clinical Features Neil F Gordon ,et al (2004);concluded that Body structure and function effects (known as

impairments ,such as hemiplegia ,spasticity and aphasia are the primary neurological disorders that are caused by stroke. Activity limitations (also referred to as (disabilities) are manifested by reduced ability to perform daily functions such as dressing , bathing , or walking.A diminished self efficacy , greater dependence on others for activities of daily living , and reduced ability for normal societall interaction can have profound negative psychological impact38 . Richard T Katz , MD ,W. Zev Rymer , MD ,PhD. (1989) concluded ,Spastic hypertonia is a

component of upper motor neuron syndrome ,whose features include loss of dexterity ,weakness , fatigability, and various reflex release phenomenon .these other features of upper motor neuron syndrome may well be more disabling to the patient than changes in muscle tone33 .

Pamela Duncan, PhD , FAPTA; Stephanie Studenski , MD , MPH , Lorie Richards

,PhD et al (2003);concluded that endurance after stroke is compromised to a level that limits basic daily functioning 34 . According to Bruce H. Dobkin et al,(2008 ) fatigue is a common symptom of patients with any neurological impairment when defined as a subjective lack of physical and mental energy that interferes with usual activities. Some complaints may, however, arise from fatigability ,an objective decline in strength as routine use of muscle groups proceeds.15 According to Robert H. Jebsen ,MD .Ernest R et al (april 1971)Decrement in hand function may result from motor deficits on the normal side secondary to destruction of the upper motor neurons which remains ipsilateral throughout their course ,destruction of ipsilateral ascending sensory fibers or a disturbance of integration between the two hemispheres35 . Zackowski KM, et al (2004) concluded that the deficit in joint individuation reflects a fundamental motor control problem that largely explains some aspects of voluntary reaching deficits of hemiparetic subjects.Hemiparetic subjects tended to produce concurrent flexion motions of shoulder and elbow joints when attempting any movement, henceforth they were better at the 'reach up' than the 'reach out' task 36 .

Takeuchi N et al (2007) concluded that the inhibitory function of the PMC

(premotor cortex)was disturbed in patients with poor motor function. Stroke patients with poor motor ability appeared to depend not only on the motor pathway from M1 (primary motor cortex) but also on other parallel motor circuits to move the paretic side. However, this brain reorganization might result in the sacrifice of function of the affected hand.37 is a reduction in the number of functioning motor units . the loss of functioning motor units does not commence until after the second month of illness , and was relatively abrupt ,being complete by the sixth month ,and that the loss must have resulted from trans synaptic degeneration. After a hemiplegic episode , a substantial proportion of motor neurons innervating the paralyzed limbs cease to function.39 tasks with hemiparetic arm .the reduced ability to recruit and modulate agonist muscle in the hemiparetic arm was a result of reduced agonist activity ,not co contraction. In majority of patients of upper motor neuron syndrome , whether they have developed spasticity or not , the major defects in function are negative not positive. Cerebral shock , weakness , and loss of dexterity are greater problems than are spasticity and the resistance to movement attributable to co- contraction of the agonist and antagonist muscles40.

A.J McComas ,et al(1973), concluded that after an upper motor neuron lesion , there

Gowland et al, looked the ability of the clients with stroke to perform functional

According to Disa K. Sommerfeld (2004), stroke give arise to upper motor

neuron syndrome, including positive and negative features. Positive feature include spasticity and abnormal posture. Negative feature includes loss of strength and dexterity, adaptive feature includes physiological, mechanical and functional changes in muscles and other soft tissues might also develop41 . According to Joann E Gallichio (2004), Spasticity simply refers to a velocitydependent resistance to movement. In 1980, Lance published this frequently cited definition: "Spasticity is a motor disorder characterized by a velocitydependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyper-excitability of the stretch reflex, as one component of the upper motoneuron syndrome42 . Ing-Shiou Hwang (2005) considered that one of the characteristic outcomes of stroke is the unintended activation of one limb when the homologous part of the opposite limb is active. This phenomenon has long been documented with various associated termssuch as "global synkinesis" (GS) "mirror movement, motor overflow and "contralateral irradiation 43 .

Alan Sunderland , PhD , et al 1999;Concluded that, Subtle impairments in dexterity of the ipsilateral hand are common within 1 month of stroke . ipsilateral sensorimotor losses may contribute to these impairements , but the major factor appears to be the presence of cognitive deficits affecting perception and control of action. The nature of these deficits varies with side of brain damage44 . Alice S . Ryan, PhD , et al ,2002,concluded that Lean tissue mass is lower and fat deposition within the muscle is higher in the hemiparetic limb than in the non affected limb in chronic stroke patients. These abnormalities may contribute to the functional disability and increased risk for recurrent stroke by their association with insulin resistance.45 According to Marleen H De Groot , Msc, Stephen J Philips , MB , Gail A Eskes , Phd. (2003);Post stroke fatigue is common 47.Eva Lotta Glader , MD , Birgitta Stegmayr , PhD , Kjell Asplund , MD ,PhD (2002) ,suggests that fatigue after stroke results from a combination of organic brain lesion and psychosocial stress related to adjustment to a new life situation46. Severe spasticity of the upper extremity is a common complication after stroke , and is usually a major contributor to the motor function disability170

Diagnostic testsOSullivan reveals a number of routine laboratory and

diagnostic test like Urinalysis, blood analysis, blood sugar level, blood chemistry profile, blood cholesterol and lipid profile, radiograph of chest, ECG, CT SCAN, MRI, positron emission topography, ultrasound Transcranial Doppler and cerebral angiography48

Pharmacology Management Didier Leys (2002) discusses about the various drug therapies25 . Primary

prevention trails for Arterial Hypertension are Antihypertensive therapies, Diuretics (Hydrocholorothiazide), Both (beta) blocker and high dose diuretics, Angiotensin converting enzyme inhibitors, Nitrondipine, a calcium antagonist, Calcium channel blockers Secondary prevention by the use of perindopril (4 mg daily) alone or in combination with indapamide (2.5 mg daily). Joann E Gallichio .(Oct 2004) states that Several options exists for the pharmacological management of spasticity after stroke 49 , ranging from oral drug therapy with diazepam, dantrolene sodium, baclofen; intrathecal baclofen therapy; and other focal treatment options such as chemical neurolytics (for example , phenol, and ethyl alcohol );phenol injections ;botulinum toxin; each with its own potential benefits and drawbacks . the decisions regarding whether ,when ,and how to manage spasticity is influenced by many factors .factors to consider include distribution of spasticity , chronicity , severity , cause , concomitant medical conditions , and cost .hence forth the goals of intervention must be clearly established prior to choosing the intervention

Motor Recovery And Stroke According to Rita Formisano, MD , PhD , Patrizia Pantano , MD , PhD , M.

Gabriella Buzzi , MD , PhD , et al (2005); Rehabilitation of stroke patients is more effective in the first months after the event rather than later ,considering the significant correlation observed between motor recovery and time elapsed since stroke. Flaccid patients appear to need 3 months or more before reaching the final plateau , because motor recovery occurs later and / or proceeds more slowly ,whereas for spastic patients with spasticity appear to occur in the first months after stroke. 49. variable , is possible after stroke.50 According to M.M Paithankar, R.D Dabhi . (2003 ), The neurological recovery after an ischemic stroke depends on many patient and disease related variables and also on acute therpeutic interventions and rehabilitative measures .significant neurological recovery occurs in the initial 3-4 weeks after the stroke.51 Prognosis is better in deep hemispheric infarcts and patients with larger infarct have a poorer outcome.

Bronwyn K Williams , et al (2001)Concluded ,recovery of upper limb , although

Ruth Bonita MPH,PhD, and Robert beaglehole, MD, FRACP. (1988);concluded

that Recovery of motor function is associated with the stroke severity but not with age or sex ;patients with a mild motor deficit at onset were 10 times more likely to recover their motor function than those with severe stroke.52 Peter Hans Stern , MD , (1971) , showed that self care function is correlated to the motor acts but there is no congruence with motor deficits53 Abraham Adunsky , MD,et al (1992),concluded that For young stroke patients

admitted to a rehabilitation ward shortly after the event , prognosis in terms of survival and functional outcome is favorable , and independent of precipitating factors ,age ,sex or side of weakness.54

According to Jean Pierre Brion , MD , et al 1989.Functional recovery appears to depend upon the cortical reorganization involving both the hemispheres ,particularly in both the parietal regions ,in the sub groups of patients with cortico- sub cortical lesions.55

According to Darcy S Reisman , John P Scholz. et al (March 2007), The

normal magnitude and timing of surface production during reaching beyond arms length are altered in people with even mild hemiparesis after stroke ,particularly during reaching towards the hemiparetic side.56 atrophy and more fat within the muscle ,factors that may contribute to the functional disability and increased cardiovascular disease risk in chronic hemi paretic stroke patients.57

Alice S . Ryan, PhD , et al (2002),showed Hemiparetic skeletal muscle

Hirofumi Nakayama , MD, et al (1994) ;concluded that although age is not

related to the type of lesion , it influences several aspects of stroke outcome mostly in ADL related aspects :initial ADL, and neurological status ,discharge ADL status , and improvement in ADL status.58 Rita Formisano, MD , PhD , Patrizia Pantano , MD , PhD , M. Gabriella Buzzi , MD , PhD , et al ( 2005);suggests that Both the time interval from stroke to the beginning of rehabilitation and the changes in muscle tone after stroke {flaccidity vs. spasticity} appear to condition the extent and time course of motor recovery in the late phase after stroke59 . According to Javier Carod Artal , MD ,Phd; Jose Antonio Egido , MD et al

( 2000);Functional status and depression were identified as predictors of quality of life60 .

Lynn M Maher ,Leslie J.G Rothi , Kenneth M Heilman. (1997) found that

the patients with left hemisphere lesions did demonstrate deficient praxis ;that is ;ideomotor apraxia, while right hemisphere does not play a crucial role in praxis .The left hemisphere brain damage group tended to make more errors with the selection ,activation and stabilization of joints , confirming the role of left hemisphere in the regulation of joints in the motor program. while both the hemispheres contribute the same information with respect to amplitude.61 proximal and distal arm weakness in the ipsilateral upper limb were maximally recovered within one month following the onset of hemispheric stroke but their weakness was not completely recovered .also the amount of their recoveries were different from each other. these results indicate that the ipsilateral upper limb weakness is not a temporary event , and that motor function of the proximal and distal arm might be mediated by different neuronal circuits.62 Okubu ,MD et al (1994);Investigated the association between location of lesion and discharge status of ADL, measured by Barthel index in first stroke patients , and concluded that only one selected location , the right parietal lobe lesion , was negatively associated with the discharge Barthel index.63

Han Young Jung , Joon Shik Yoon and Bong Soon Park (2002) found that

Satoru Saeki , MD , Hajime Ogata , MD , Kenji Hachisuka ,MD ,Toshiteru

According to Cinzia Calautii,MD, Jean Claude Baron , MD ,FRCP.

(2003);Both cross sectional and longitudinal studies demonstrated that damaged adult brain is able to reorganize to compensate for motor deficits .rather than a complete substitution of function , the main mechanism underlying recovery of motor abilities involves enhanced activity in preexisting networks , including the disconnected motor cortex in subcortical stroke and the infarct rim after cortical stroke. 64. ,concurrent disability , and physical impairment were more important determinants of handicap than the other demographic factors or initial stroke severity. Because depression and anxiety were more independently associated with handicap , their treatment may potentially reduce handicap in stroke patients65. CBF{cerebral blood flow} and CMRGlu{glucose metabolism} may serve as indicators of regional neuronal activity and may provide tools for functional brain imaging of cerebral plasticity following central nervous system injury66. .recruitment of cortical regions involving the non damaged brain side , as well as extension of activated areas adjacent to the lesions may participate in the process of functional reorganization.

Jonathan.W Sturm , Phd , Geoffrey A. et al ,(2004) concluded that Age

Ulrich Rocelcke, Klaus L Leenders ,Armin Curt ,( 1998)found that both

Annette Sterr, Phd , and Susanna Freivogel, PT (2003)found that After

MCA stroke , PET and fMRI studies during movement of the paretic arm have found abnormally increased activation in the contralateral M1, bilateral premotor areas , SMA, and parietal cortex , suggesting the involvement of a widespread recovery. 67 damage to the motor cortex ,rehabilitative training can shape subsequent reorganization in the adjacent intact cortex and that the undamaged motor cortex may play an important role in motor recovery. valuable role in rehabilitation. Certain drugs may affect this process either positively or negativly for example : amphetamine might be able to help patients by improving motivation and this might help improve skills , such as mobility , and self care. some centrally acting drugs may impair the recovery .noradrenergic blockers for example , may be one such class. Much of the recovery after stroke is due to brain plasticity. The recovery of lost function after stroke occurs predominantly during the intial weeks to months following the ictal episode. 68.

Mark Hallet , Eric M Wasswermann ,et al (1998).Suggest that after local

Patterns of use can influence the cortical reorganization and plays a

Rdiger J. Seitz et al ,(1999) concluded that motor recovery after hemiparetic brain

infarction is subserved by brain structures in locations remote from the stroke lesion. The topographic overlap of the lesion-affected and recovery-related networks suggests that diaschisis may play a critical role in stroke recovery. 70. Alexander W. Dromerick (1995) found that For patients with HHH {hemiparesis, hemisensory loss, and hemianopsia }deficits, the anatomic location of the lesion {cortical (C) versus subcortical (S)versus mixed (M)} does not affect functional outcome . 71 Steven C. Cramer, et al (1997), used functional magnetic resonance imaging to compare brain activations in normal controls and subjects who recovered from hemiparetic stroke and found that recovered finger-tapping by stroke subjects activated the same motor regions as controls but to a larger extent, particularly in the unaffected hemisphere. Increased reliance on these motor areas may represent an important component of motor recovery. Functional magnetic resonance imaging studies of subjects who recovered from stroke provide evidence for several processes that may be related to restoration of neurologic function. 73. Rdiger J. Seitz et al ,(1998), concluded motor recovery after cortical infarction in the middle cerebral artery territory appears to rely on activation of premotor cortical areas of both cerebral hemispheres. Thereby, short-term output from motor cortex is likely to be initiated. 72 .

Alexander W. Dromerick (1995) found that For patients with HHH

{hemiparesis, hemisensory loss, and hemianopsia }deficits, the anatomic location of the lesion {cortical (C) versus subcortical (S)versus mixed (M)} does not affect functional outcome . 71 to compare brain activations in normal controls and subjects who recovered from hemiparetic stroke and found that recovered finger-tapping by stroke subjects activated the same motor regions as controls but to a larger extent, particularly in the unaffected hemisphere. Increased reliance on these motor areas may represent an important component of motor recovery. Functional magnetic resonance imaging studies of subjects who recovered from stroke provide evidence for several processes that may be related to restoration of neurologic function. 73.

Steven C. Cramer, et al (1997), used functional magnetic resonance imaging

Rdiger J. Seitz et al ,(1998), concluded motor recovery after cortical

infarction in the middle cerebral artery territory appears to rely on activation of premotor cortical areas of both cerebral hemispheres. Thereby, short-term output from motor cortex is likely to be initiated. 72. mediated by cerebral reorganization. Stroke is a powerful model to study these processes in the human brain, since middle cerebral artery infarction is a common neurological disease with a clearly defined onset of a lateralized sensorimotor deficit syndrome74.

Seitz RJ.et al,(2005) ;Recovery after focal brain lesions is supposed to be

Ftima de N. A. P. Shelton et al (2001), in a study assessed the effects of

stroke involvement of primary and secondary hemispheric motor systems and corticofugal tracts on arm and hand recovery with neuroimaging studies performed >48 hours of stroke and concluded that the probability of recovery of isolated UL movement decreases progressively with lesion location as follows: cortex, corona radiata, and PLIC( posterior limbs of the internal capsule). This is consistent with our current understanding of redundant cortical motor representation and convergence of corticofugal motor efferents as they pass through the corona radiata to the PLIC. 75 Kwakkel G, et al (1996),suggests that the following variables are valid

predictors for functional recovery after stroke: age; previous stroke; urinary continence; consciousness at onset; disorientation in time and place; severity of paralysis; sitting balance; admission ADL score; level of social support and metabolic rate of glucose outside the infarct area in hypertensive patients. 76

Zackowski KM, (et al )2004 concluded that the deficit in joint individuation reflects a

fundamental motor control problem that largely explains some aspects of voluntary reaching deficits of hemiparetic subjects.the hemiparetic subjects tended to produce concurrent flexion motions of shoulder and elbow joints when attempting any movement, henceforth they were better at the 'reach up' than the 'reach out' task . 77. Hirofumi nakayama et al ( 1994) ,concluded that recovery of Upper extremity related ADL function mainly takes place within the first 2 months after stroke; the few patients who experience functional recovery after that are patients with severe paresis of the affected Upper extremity . 78. Further Functional recovery should not be expected later than 11 weeks after stroke. Axel R Fugyl meyer and Lisbeth jaasko, suggests that the final stage of motor recovery in

hemiplegia is a significant predictor for self care ADL. 79. Andrew heller et al, (1987) concluded that recovery of arm function is concentrated in the first 3 months. 80. According to W.-R. Schbitz,et al ,(2004), Postischemic intravenous brain-derived neurotrophic

factor (BDNF) treatment improves functional motor recovery after photothrombotic stroke and induces widespread neuronal remodeling. Early forced arm use (FAU) treatment after stroke does not increase infarct size, impairs sensorimotor function, but leaves motor function unchanged. Postischemic astrogliosis was reduced by both treatments. 81.

Cinzia Calautti,et al (2003);concluded that rather than a complete

substitution of function, the main mechanism underlying recovery of motor abilities involves enhanced activity in preexisting networks, including the disconnected motor cortex in subcortical stroke and the infarct rim after cortical stroke. 82. Raimondo Traversa, et al. (1997); confirm the existence in adults of a "plasticity" in the central nervous system that is still operating between 2 and 4 months from the acute ictal episode. 83. According to Deborah S, et al , (2005); The association of age and gender with all of the Stroke Impact Scale {SIS} domains indicates the powerful influence that these demographic variables have overall on the quality of life of stroke survivors. Other factors influencing Health-related quality of life { HRQOL} across domains were stroke type, concordance, and upperextremity motor function. Previous studies have also reported that age, gender, disability, and diabetes (as a common comorbidity ) negatively influence HRQOL. 84. Ernst Fischer (1967) says that motor learning capacity improves from adolescence up to late 20s then under goes a minor decline until the middle age and a considerable and quick decline thereafter. Motor learning factually defined means that with reported trials the movements become less erratic, smoother, quicker and less tense as well as powerful when needed 85

Wolfgang Fries (1993) says that partial and selective damage

to one motor area has a good prognosis for functional recovery. The more motor areas or their descending pathways are affected, the lesser becomes the potential for neural functional substitution and poorer the outcomes will be in term of motor deficit 86 Gregory Bard (1965) studied the recovery of voluntary motion in the hemiplegic arm. Most of subjects regain full active motion by first to third month. Those who attain only partial voluntary motion or recover more slowly and their ability to perform active motion tends to fluctuate, most of them reach a maximum during sixth and seventh month 87.

Twitchell (1951) says that common course of recovery shows a regular

sequence of reflex changes, each of which is associated with a corresponding increase in ability for willed movement. The process of recovery may become arrested at any stage in this sequence. After the initial phase of depression of all motor function, the proprioceptive responses become abnormally active .If motor function recovers following the hemiplegia caused by a lesion of the cerebrum, These proprioceptive responses do not constitute a simple entity, for they are modified and conditioned by other factors, such as stretch on associated muscles, the position of the patient's head in relation to his body, and the position of the body in relation to the supporting surface, and later by certain contactual stimulation. As the recovery process proceeds, the more elementary proprioceptive responses become subordinated to special exteroceptive stimulation. Voluntary movement appears as a further facilitation of the available responses at each stage. It is not a separate entity, but from its first appearance it takes the form of conditioned proprioceptive and contactual responses88. correlate well with an improvement of motor performances, which confirm the existence of plasticity" in the central nervous system89,90.

The presence of a rearrangement of the motor cortical output area and

Exercise And Stroke According to Marilyn J . Mackay Lyons , PhD , et al (2002) Exercise capacity

approximately 1 month after stroke was compromised91 . Neil F Gordon ,et al (2004);states that Exercise is a normal human function that can be undertaken with a high level of safety by most people , including stroke survivors .however exercise is not without risks , and the recommendation that stroke survivor participate in an exercise program is based on the premise that the benefits outweigh the risks .therefore , the fore most priority in formulating the exercise prescription is to minimize the potential adverse effects of exercise via appropriate screening , program design , monitoring , and patient education. Before embarking on a physical conditioning regimen , it is recommended that all stroke survivors undergo a complete medical history , usually the most important part of the pre-exercise evaluation , and a physical examination aimed at the identification of the neurological complications and other medical conditions that require special consideration or constitute a contraindication to exercise. Prescribing exercise for the stroke patients is comparable in many ways to prescribing medications ;that is one recommends an optimal dosage according to individual needs , and limitations. 92

Stroke Rehabilitation And Facts Related To Stroke

In addition to the components of pre-exercise evaluation , the neurological

examination should clarify the cognitive state, and the Folstein Mini mental status examination can be useful ancillary in this regard to facilitate optimal outcomes from an exercise -based stroke rehabilitation program , an assessment of familial support should be undertaken92. Peter Hans Stern , MD , (1971) , concluded that elaborate and expensive rehabilitation methods do not offer more benefits to the stroke patients , than simple , functional oriented programs which should be begun as soon as a definitive diagnosis has been established and the general medical condition is stable. 96

Ailie Turton and Valerie Pomeroy. (2002) in a paper considers the physiology of

the brain in acute stroke and evaluates the evidence for and against the early intensive activity of the upper limb as an essential precursor to any decision to invest in increased activity. This review has highlighted the paucity of the clinical research in examining the optimal time of intensive arm training for recovery of hand function after stroke. More research is clearly needed to answer this question. meanwhile it is clear that there is a period of a few days when the ischemic penumbra may be on the edge of anoxic cell death. Reducing the demands on penumbral tissue and the establishing control of the other physiological factors may be crucial determinants of outcome. physical therapy for the first few days after stroke should be given in context of optimum physiological basic care and should not undermine these considerations . however for the first few weeks it is likely that patients are suffering from too little practice of movements using the affected harm to optimize their recovery. 97 According to Lara A Boyd and Carolee J Winstein Lara (2003);Explicit

information was detrimental for implicit motor -sequence learning following MCA stroke .rehabilitation outcomes may benefit from the consideration of stroke location when determining the degree to which explicit information can augment the implicit motor skill learning. 108

Colleen A. Hanlon, BS;et al (2005 ); confirms

Bihemispheric reorganization in motor system after a focal right hemisphere lesion. Attentional demands of self monitored movement may be much greater than visually guided movement in patients ,possibly impacting rehabilitation protocols for MCA stroke patients. 94.

Ellen M Frick and Jay L Alberts . (Oct 2006),in case report describes a training

comprising of the combined use of repetitive task practice and robotic therapy for a patient with subacute stroke and resultant impaired function, and describes it as an effective method to improve function in paretic UE97Michelle Ploughman , PT , Msc ,et al ( 2004),Suggests Forced use therapy is a practical method to apply constraint principles in the acute rehabilitation phase of stroke.93 According to Jacob L . Halberstam , PhD, and Herbert H. Zarestsky, PhD.( march

1969)both aged and the brain damaged patients appear to have learning potential that does not differ from that of the younger rehabilitation patients, although special conditions may be needed in order to make maximal use of this potential. Among these special conditions should be included such as variables , as the elimination of the time limits for assigned tasks, a positive emotional milieu, and above all the structuring of the rehabilitation program into progressive tasks , the accomplishment of which is intrinsically rewarded. 98. Sarah A .Maulden , MD,MS et al , (2005);confirms that For moderately and

severely impaired patients with stroke fewer days from stroke symptom onset to rehabilitation admission is associated with better functional outcome at discharge and shorter length of stay. 99.

According to Hirofumi Nakayama , MD et al , 1994 -Age

influences initial stroke severity and ADL recovery but does not influence neurological recovery , suggesting poor compensatory ability in elderly stroke patients. henceforth , the rehabilitation of the elderly stroke patients should be focused on the ADL and compensation rather than recovery of neurological status ,and age itself should not be a selection criteria for rehabilitation. 100. Amy L . Alderson , PhD , et al (2003) concluded that Measurement of orientation and higher neuro cognitive processes are important aspects of early Neuro rehabilitation101 Kjell Asplund , MD ,PhD. (2002 ),Fatigue often interferes with the rehabilitation process and impairs the patients ability to regain functions lost because of stroke. 102. Marleen H De Groot , Msc, Stephen J Philips , MB , Gail A Eskes , Phd. (2003);confirms ,The recognition of fatigue as a genuine post stroke disorder requiring assessment and treatment is the first step to the development of a comprehensive therapeutic program to address the problem. 103.

According to Eva Lotta Glader , MD , Birgitta Stegmayr , PhD ,

Hild Fjaertoft ,RPT; Bent Indredavik ,MD ,PHD ;Stian Lydersen, PhD .

(2003) found that Stroke service based on treatment in stroke unit combined with early supported discharge appears to improve the long term clinical outcome compared with ordinary stroke unit. 105. muscle strength improves in stroke patients with hemiplegia undergoing rehabilitation. 106.Antonio Di Carlo , MD ;Maria Lamassa , MD ;Giovanni Pracucci , MD , Anna Maria Basile , MD ,et al (1999)concluded that In very old , both medical socio -demographic factors may significantly influence stroke outcome. 107. MPH , Lorie Richards ,PhD et al( 2003);Persons with sub acute stroke may benefit from more highly structured , intensive , and progressive therapeutic exercise. 109

Richard W . Bohannon And Melissa B . Smith. (April 1987),states that

According to Pamela Duncan, PhD , FAPTA; Stephanie Studenski , MD ,

E. Badics , A Wittmann, M.Rupp ,B Stabauer and U.A Zilfko.

(1997); confirms that Strength training significantly increased muscle power in patients with muscle weakness of central origin without any negative effects on spasticity. 110. Graded resistive exercise is not detrimental to post stroke spastic muscle , and should be considered as a possible remediation for deficits of muscle weakness and reduced function in post stroke individuals .the individuals that may most benefit from this type of training may include those clients who have pre morbid reduced levels of peak force which may further be accentuated by stroke. 111

Gloria J.T Miller , Kathye E. Light. (1997);concluded that

According to Gert kwakkel,Phd, Robert C Wagenaar Phd,Johan C Koetsier ,MD,et

al . (1999);Greater intensity of leg rehabilitation improves functional recovery and health related functional status , whereas greater intensity of arm rehabilitation results in small improvements in dexterity , providing further evidence that exercise therapy primarily induces treatment effects on the abilities at which training is specially aimed. 112. training increases spasticity and leads to the development of pathologic movement patterns, a concern often raised by Bobath trained therapists . the authors used a baseline control repeated measures test to study 29 patients with chronic upper limb hemiparesis who received daily shaping training and suggested that training has no adverse effects on the muscle tone and movement quality. 113

Annette Sterr, Phd , and Susanna Freivogel, PT.(2004);Assessed whether intensive

Ng YS, Stein J, et al (2007); in a study compared the demographics and functional

outcomes of patients with stroke in a variety of vascular territories who underwent inpatient rehabilitation and concluded that Patients with stroke made significant functional gains and should be offered rehabilitation regardless of stroke vascular territory. The initial functional status at admission, rather than the stroke subgroup, better predicts discharge functional outcomes post rehabilitation. 117.

Cheol E Han et al, (2008) ;found that Motor training with the upper limb

affected by stroke partially reverses the loss of cortical representation after lesion and has been proposed to increase spontaneous arm use. Moreover, repeated attempts to use the affected hand in daily activities create a form of practice that can potentially lead to further improvement in motor performance. thus they hypothesized that if motor retraining after stroke increases spontaneous arm use sufficiently, then the patient will enter a virtuous circle in which spontaneous arm use and motor performance reinforce each other. In contrast, if the dose of therapy is not sufficient to bring spontaneous use above threshold, then performance will not increase and the patient will further develop compensatory strategies with the less affected hand. 116. forced use therapy on the dexterity of the affected arm (ARA) and a temporary clinically relevant effect on the amount of use of the affected arm during activities of daily living (MAL amount of use). The effect of forced use therapy was clinically relevant in the subgroups of patients with sensory disorders and hemineglect, respectively114.

Van der Lee JH et al ,(1999);in a study showed a small but lasting effect of

.

Ole Morten Rnninget al (1998) concluded that Subacute rehabilitation of

stroke patients in a hospital-based rehabilitation unit improves outcome. Patients with moderate or severe stroke appear to benefit most. 116.Cirstea MC et al (2002)suggests the use of compensatory strategies may be related to the degree of motor impairment: severely to moderately impaired subjects recruited new degrees of freedom to compensate for motor deficits while mildly impaired subjects tended to employ healthy movement patterns, also, that stroke subjects may be able to exploit effectively the redundancy of the motor system115. improvement in performance and in plasticity of the motor cortex. Also ,Use-dependent plasticity was reduced substantially by dextromethorphan (an N-methyl-d-aspartate receptor blocker) and by lorazepam [a gammaaminobutyric acid (GABA) type A receptor-positive allosteric modulator]. mechanisms operating in use-dependent plasticity in intact human motor cortex and point to similarities in the mechanisms underlying this form of plasticity and long-term potentiation 118.

Btefisch CM,et al ( 2000); concluded that Practicing movements results in

N-methyl-d-aspartate receptor activation and GABAergic inhibition as

Lalit Kalra,et al( 2007) states that the basis of all stroke rehabilitation is the

assumption that patients will improve with spontaneous recovery, learning and practice. Recent studies show that reorganization in the brain can occur with both recovery and learning but improves significantly in both with practice. retention of motor learning is best accomplished with variable training schedules and, for optimal results, rehabilitation techniques need to be geared toward patients specific motor deficits. Several promising new rehabilitation approaches have been developed on theories of motor learning and include impairment-oriented training, constraint-induced movement therapy, electromyogram-triggered neuromuscular stimulation, robotic interactive therapy and virtual reality.Stroke rehabilitation is based on the concepts of neuroplasticity and reorganization of cerebral activity, the validity of which has been strongly supported in many functional MRI studies over the last decade. 119. practice in 2 feedback conditions (knowledge of results [KR]; knowledge of performance, [KP]) on reacquisition of reaching and concluded that Use of KP during repetitive movement practice resulted in better motor outcomes. 121. Stroke severity together with cognitive impairments are important factors for choosing motor rehabilitation interventions after stroke.Lumy Sawaki, et al( 2006), concluded that PNS (Peripheral nerve stimulation )applied to the paretic limb paired with motor training enhances training effects on cortical plasticity in stroke patients120..

C.M. Cirstea,. et al (2006), analyzed the effects of repetitive movement

Susan d horn et al ( 2005); concluded that specific therapy activities

and interventions are associated with better outcomes. earlier initiation of rehabilitation admission , more time spent per day in higher level activities such as gait , upper extremity control and problem solving early in rehabilitation process ,tube feeding , and newer medications are associated with better stroke rehabilitation outcomes . 122.Neil F Gordon ,et al 2004;Traditional stroke rehabilitation programs emphasize functional training as a means to help the individual gain and maintain as much as independence as possible. training in the performance of mobility and personal care tasks , together with attempts to improve muscle strength and coordination , continue to form the central area of focus of most rehabilitation programs123. with initial severe upper extremity paresis may benefit from rehabilitation focusing on compensation by unaffected side .Teaching of compensatory strategies is of great importance in the patients with severe UE paresis , and should be given high priority when planning rehabilitation124..

Hirofumi nakayama,et al (1994), concluded that majority of patients

Stephen Bagg, et al,(2002) concluded that although age itself may not be

a significant factor in identifying who will benefit from the rehabilitation , it may nevertheless serve as an indicator of those who will fail to retain the maximum benefit of rehabilitation125. often recommended as stroke patients become more chronic , and / or when they fail to respond positively to motor rehabilitation .managed -care programs frequently reinforce this practice by restricting care to patients who respond to therapy and / or to the most acute patients126. .

Stephen j page , (2004) , found that termination of motor rehabilitation is

The higher intensity of upper and lower limb function training during the

first 6 months after stroke did not result in significant gains at 1 year , even though this training accelerated speed of functional recovery and improved health functional status during the first 3 months after stroke. 127. may augment movement capabilities, at least as well as exercise regimens, data relating neuromuscular changes to function are limited. 128.

Steven L Wolf ,(September 1983),states that Although EMG biofeedback

According to Lalit Kalra et al ;(2007); Recent transcranial magnetic stimulation studies have shown that

regression of perilesional inhibition and intracortical disinhibition of the motor cortex contralateral to the infarction play an important part in this reorganization. At the cellular level, ischemia appears to induce a unique microenvironment for surviving axons to sprout new connections and establish novel projection patterns in the first month after stroke. Post-stroke neuronal regeneration may involve orchestrated waves of cellular and molecular events characterized by a reduction in growth-inhibitory molecules and activation of growth-promoting genes by neurons. In addition, there are waves of migration of immature neurons from their origin in the subventricular zone into peri-infarct cortex, partly mediated by the cytokine erythropoietin. These findings suggest that modulation of electrophysiological activity and/or manipulation of cellular and molecular events by novel therapies has the potential of improving recovery after stroke. 129. The basis of all stroke rehabilitation is the assumption that patients will improve with spontaneous recovery, learning and practice. Recent studies show that reorganization in the brain can occur with both recovery and learning but improves significantly in both with practice .

According to Andrew J Butler and Steven L Wolf ;(June 2007),

Transcranial magnetic stimulation (TMS), has become a suitable, noninvasive, and painless technique that can be applied to detect changes in cortical excitability as an indicator of neurological changes. Furthermore, repetitive trains of TMS themselves can induce plasticity. 78. involving teamwork by members of several professions. During the course of rehabilitation, patient spends time with their therapists and their interaction is likely to affect the rehabilitation process 130-131 .C Bro Kleheurst (1978) believed physical therapy, occupational therapy and speech therapy is the basis of stroke rehabilitation .Two developments are necessary, firstly a reliable method of predicting prognosis with stroke secondly a clear appraisal is needed of the objectives of the physiotherapy and of alternative for the longer term treatment of those patients with stroke whose disability is greater and recovery poor 132 . J.F Lehmann (1975) said functional gain is achieved and retained after rehabilitation 133 .

Annica Wohlin (2007) says stroke rehabilitation is a complex process

Gert Kwakkel (1997) concluded a small but statistically significant

intensity-effect relationship in the rehabilitation of stroke patients 134. Nancy A. (1999) said that client would elicit improved co-ordination of movement in task that use real objects and also create argument for increased use of goal directed activity in case of CVA135. Leeanne M. (1993) disclose some facts about training of tactile and proprioceptive discrimination tasks, effects are obtained despite variation in lesion site, lesion severity, and time from onset of stroke, degree of motor impairment in upper limb, cognitive status, age and prior occupation 136.John V. Basmajian (1987) compared EMGBF favorably with traditional exercise therapy based on bobath techniques 137. intensive exercise and electric stimulation 138. Jane E Sullinian (2004) confirmed that patient with a lesion in the somato sensory cortex might not be able to accurately interpret afferent inputs. Cortical representation areas are constantly modified by experience induced afferent inputs. Electrical stimulation may enhance afferent input to the cortex in multiways 139. John Chae (1998) reports that surface neuromuscular stimulation enhances the upper extremity motor recovery of acute stroke survivor and the affect is maintained for up to 3 months after completion of treatment 140.

Thomas Sinkjaer (2005) states that cortical plasticity could be promoted by

Joanne M Wagner (2007) states upper limb strength deficits are most

common predictors of the variance in reaching performance during first 3 months after stroke 141 . Darcy S. Reismen (2007) verdict the normal magnitude and timing of surface force production during reaching beyond arms length are altered even in people with mild hemiparesis after stroke 142 . Qing Ping Tang (2005) suggest that regardless of a persons cognitive function problem oriented willed movement intervention is effective in improving lower extremity more then upper extremity 143

Marilyn J. (2002) illustrates exercise capacity approximately 1 month

after stroke is compromised. Respiratory function after hemispheric stroke is often only modestly affected 145 .David C. Osmon (1993) be evidence for the hand dominance; left sidestroke group is impaired than the orthopedic group on the comprehension, naming, memory and similarities scale. The right group is worse then orthopedic group on naming and constructions scale. The two-stroke groups do not differ from each other on any scale146

Constraint Induced Movement TherapyAnnette Sterr, Phd , and Susanna Freivogel, PT, (2003)-Studied the

benefits of a modified regimen designed to be applicable in clinical environment . Affected arm movements were trained 90 minutes /day for 3 weeks using the learning principle shaping the outcome measures indicated a significant increase in performance after the intervention compared with the performance during the 3 week baseline interval. 150.

Constraint-Induced Movement therapy (CI therapy) is a recognized

rehabilitation approach for persons having stroke with mild to moderately severe motor upper extremity deficits.

Mary H. Bowman,et al( 2006) in a case report describes treatment of a

chronic stroke participant with a plegic hand using a CI therapy protocol that combines CI therapy with selected occupational and physical therapy techniques. Treatment consisted of six sessions of adaptive equipment and upper extremity orthotics training followed by a three-week, six-hour daily intervention of CI therapy plus neurodevelopmental treatment. Outcome measures included the Motor Activity Log for very low functioning patients (Grade 5 MAL), upper extremity portion of the Fugl-Meyer Motor Assessment, Graded Wolf Motor Function Test for very low functioning patients (gWMFT- Grade 5), and Modified Ashworth Scale. The participant showed improvement on each outcome measure with the largest improvement on the Grade 5 MAL. In follow-up, the participant had good retention of his gains in motor performance and use of his more affected arm for real world activities after 3 months; after a one-week brush-up at 3 months, and at one year post-treatment. 152.

Lorie Richards (2006) Compared the outcomes in motor skill, perceived

amount of use and ability of the paretic arm in daily activities between traditional Constraint-Induced Movement Therapy, consisting of 6 hours of in-clinic, therapist-guided task practice, and a shortened Constraint-Induced Movement Therapy, consisting of 1 hour of in clinic, therapist-guided task practice coupled with 5 hours of unsupervised practice at home .the Wolf Motor Function Test was used to assess motor skill and the Motor Activity Log amount of use and quality of movement scales were used to assess perceived amount of use and ability respectively and concluded that 6 hours of therapist-guided practice may not be necessary to facilitate motor skill gains, but may influence patterns of use. 153

Edward Taub, et al ( 2006). conducted a placebo-controlled trial of CI

therapy in patients with mild to moderate chronic (mean=4.5 years after stroke) motor deficit after stroke. The CI therapy group received intensive training (shaping) of the more affected upper extremity for 6 hours per day on 10 consecutive weekdays, restraint of the less affected extremity for a target of 90% of waking hours during the 2-week treatment period, and application of a number of other techniques designed to produce transfer to the life situation. The placebo group received a program of physical fitness, cognitive, and relaxation exercises for the same length of time and with the same amount of therapist interaction as the experimental group . results showed that patients receiving CI therapy showed large to very large increases in spontaneous use of their more impaired arm in the real-world environment, as indexed by the effect size of the change in MAL scores, and moderate improvement in more-impaired arm motor ability, as shown by a laboratory motor performance test (WMFT). In contrast, patients given a credible placebo intervention did not show a significant change in either of these measures. 154After CI therapy, patients showed large (Wolf Motor Function Test) to very large improvements in the functional use of their more affected arm in their daily lives (Motor Activity Log; P