Mental Practice–Triggered Electrical Stimulation in Chronic, Moderate, Upper-Extremity Hemiparesis After Stroke Stephen J. Page, Peter Levine, Valerie Hill
MeSH TERMS electric stimulation hemiplegia mental processes motor skills disorders stroke
OBJECTIVE. To determine the feasibility and impact of home-based, mental practice–triggered electrical stimulation among stroke survivors exhibiting moderate upper-extremity (UE) impairment. METHOD. Five participants with moderate, stable UE hemiparesis were administered the Fugl-Meyer Assessment, the Box and Block Test, and the Activities of Daily Living, Hand Function, and overall recovery domains of the Stroke Impact Scale (Version 3). They were then administered an 8-wk regimen consisting of 1 hr of mental practice–triggered electrical stimulation every weekday in their home. At the end of every 2 wk, participants attended supervised stimulation to progress therapeutic exercises and stimulation levels and monitor compliance. RESULTS. Six instances of device noncompliance were reported. Participants exhibited reduced UE motor impairment and increased UE dexterity and participation in valued activities. CONCLUSION. The regimen appears feasible and had a substantial impact on UE impairment, dexterity, and participation in valued activities as well as perceptions of recovery. Page, S. J., Levine, P., & Hill, V. (2015). Mental practice–triggered electrical stimulation in chronic, moderate, upperextremity hemiparesis after stroke. American Journal of Occupational Therapy, 69, 6901290050. http://dx.doi.org/ 10.5014/ajot.2015.014902
Stephen J. Page, PhD, MS, OTR/L, FAHA, FACRM, is Director, Better Rehabilitation and Assessment for Improved Neuro-recovery (B.R.A.I.N.) Laboratory, and Associate Professor, Division of Occupational Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus; [email protected] Peter Levine, PTA, is Director, Synaps Together, LLC, Cincinnati, OH. Valerie Hill, PhD, OTR/L, is Postdoctoral Fellow, University of Southern California, Los Angeles.
The American Journal of Occupational Therapy
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troke remains a leading cause of disability, with the number of survivors exhibiting residual deficits expected to increase over the next decade (Go et al., 2014). Motor impairments are common and profoundly undermine occupational performance and independence (Broeks, Lankhorst, Rumping, & Prevo, 1999; Mayo, Wood-Dauphinee, Coˆte´, Durcan, & Carlton, 2002). Because functional practice integrating the paretic upper extremity (UE) appears to be critical to reduction of motor deficits (Nudo, 2006), many contemporary rehabilitative approaches emphasize repetitive, task-specific practice (RTP) integrating the paretic UE (e.g., Page, Levine, & Leonard, 2007; Wolf et al., 2006). Yet, most of these therapies are efficacious only in clients exhibiting active distal UE movement, a minority of the stroke survivor population. Mental practice (MP) is one example of a promising UE therapy that incorporates RTP but that currently offers only limited application because of its requirement for distal UE movement. Its use in stroke rehabilitation has long been supported by evidence showing that MP triggers the same neural areas and musculature as physical practice of the same tasks (e.g., Decety, 1996; Decety & Ingvar, 1990; Weiss et al., 1994). The primary author’s laboratory was the first to show that repetitive MP use consistently reduces UE impairment (Page, 2000) and causes cortical reorganizations similar to those brought about by motor practice (Page, Szaflarski, Eliassen, Pan, & Cramer, 2009) and that addition of MP to physical practice significantly increases paretic UE use and function (e.g., 6901290050p1
Page et al., 2007; Page, Dunning, Hermann, Leonard, & Levine, 2011), a finding subsequently replicated by others (for a review, see Cha, Yoo, Jung, Park, & Park, 2012). However, MP combined with RTP is also limited in that survivors must exhibit active paretic wrist and finger flexion to be eligible. To address this challenge, an innovative electrical stimulation device was developed that is triggered by the minute muscle activations occurring during MP. The stimulation is activated only when the client’s electromyographic (EMG) activity during MP attains a preset EMG threshold level displayed on the device’s screen. When this level is reached, the client receives electrical stimulation via surface electrodes on the paretic UE musculature. Moreover, when the client is repeatedly successful at attaining a certain threshold, the threshold level can be increased, thereby increasing the level of challenge for the client. In addition to movement repetition, such progressive challenge is a prerequisite for plasticity and UE motor return (Nudo, 2006). Use of this device—called the Mentamove (Mentamove Deutschland, Karlsfeld, Germany)—has the potential to expand MP’s use to the large number of stroke survivors exhibiting only trace UE movement—a group that is not eligible for traditional MP protocols and that cannot activate stimulation devices predicated on substantial active limb movements as a trigger. The primary study objective was to estimate the impact of Mentamove use on UE motor impairment in stroke survivors exhibiting trace movement in the distal areas of their paretic UEs. We chose a cohort of chronic stroke survivors (>6 mo postictus) because they were likely to be neurologically stable and not receiving other rehabilitative interventions that could contaminate the findings of this pilot study. An additional, unique study facet was that the intervention was mostly home based. This aspect was consistent with other home-based electrical stimulation studies that we had conducted (e.g., Gabr, Levine, & Page, 2005; Page, Levin, Hermann, Dunning, & Levine, 2012), and we felt it was highly relevant to occupational therapy practice given the diminishing amount of clinical contact time available to intervene with the growing population of clients with poststroke UE deficits. Given that the regimen was mostly home based and that this was the first application of MP-triggered stimulation to the paretic UE poststroke, we monitored patient compliance and adverse events—important information for a pilot study that would inform, in part, whether the intervention should move forward to testing in subsequent Phase 1b and Phase 2 work. 6901290050p2
Method Participants Participants were recruited through presentations provided to local stroke support groups and by distributing advertisements approved by the local institutional review board to local therapists during continuing education events or via mail. To be eligible for the study, volunteers had to meet the following inclusion criteria: 1. In the paretic UE, ³20˚ of active shoulder flexion, ³20˚ of active internal and external humeral rotation, ³20˚ active elbow flexion, and ³15˚ of passive wrist flexion and extension. The latter motor criterion was intended to ensure that participants exhibited sufficient passive range of motion without contractures or discomfort such that their fingers could be moved by the stimulation. 2. Manual muscle test of 1/5 in the paretic wrist flexors and extensors, indicative of a palpable muscle contraction. Minimal active joint movement could be exhibited in the paretic wrist or metacarpophalangeals but was not a requirement. The movement had to be 6 mo poststroke and who exhibited moderately severe UE hemiparesis. • Although the MP-triggered electrical stimulation was mostly home based, participants displayed favorable compliance. Behavioral strategies were used to increase compliance and comprehension of the study protocol. The American Journal of Occupational Therapy
These strategies included compliance visits, a 1-hr education session, and home use diaries.
Conclusion Poststroke UE motor recovery frequently necessitates many long hours of task-specific practice to elicit neuroplastic and motor changes. With diminishing contact time and funding available for rehabilitation, high-duration protocols and protocols requiring expensive equipment are often not feasible. MP-triggered electrical stimulation offers the possibility of repetitive, home-based practice and appears to increase gross dexterity, UE recovery, and participation in valued activities even years poststroke. The innovative integration of behavioral techniques to enhance protocol compliance and client understanding of this homebased approach appears promising and should be further investigated in future trials. s
References American Occupational Therapy Association. (2007). AOTA’s Centennial Vision and executive summary. American Journal of Occupational Therapy, 61, 613–614. http://dx.doi. org/10.5014/ajot.61.6.613 Barry, J. G., Ross, S. A., & Woehrle, J. (2012). Therapy incorporating a dynamic wrist-hand orthosis versus manual assistance in chronic stroke: A pilot study. Journal of Neurologic Physical Therapy, 36, 17–24. http://dx.doi.org/10.1097/ NPT.0b013e318246203e Bohannon, R. W., & Smith, M. B. (1987). Interrater reliability of a modified Ashworth scale of muscle spasticity. Physical Therapy, 67, 206–207. Broeks, J. G., Lankhorst, G. J., Rumping, K., & Prevo, A. J. (1999). The long-term outcome of arm function after stroke: Results of a follow-up study. Disability and Rehabilitation, 21, 357–364. http://dx.doi.org/10.1080/096382899297459 Butler, A., Blanton, S., Rowe, V., & Wolf, S. (2006). Attempting to improve function and quality of life using the FTM Protocol: Case report. Journal of Neurologic Physical Therapy, 30, 148–156. http://dx.doi.org/10.1097/01.NPT.0000281952. 93934.6b Cauraugh, J. H., & Kim, S. B. (2003). Chronic stroke motor recovery: Duration of active neuromuscular stimulation. Journal of the Neurological Sciences, 215, 13–19. http://dx. doi.org/10.1016/S0022-510X(03)00169-2 Cha, Y. J., Yoo, E. Y., Jung, M. Y., Park, S. H., & Park, J. H. (2012). Effects of functional task training with mental practice in stroke: A meta analysis. NeuroRehabilitation, 30, 239–246. Decety, J. (1996). Do imagined and executed actions share the same neural substrate? Brain Research in Cognitive Brain Research, 3, 87–93. Decety, J., & Ingvar, D. H. (1990). Brain structures participating in mental simulation of motor behavior: A neuropsychological interpretation. Acta Psychologica, 73, 13–34. http://dx.doi.org/10.1016/0001-6918(90)90056-L 6901290050p7
Duncan, P. W., Bode, R. K., Min Lai, S., & Perera, S.; Glycine Antagonist in Neuroprotection Americans Investigators. (2003). Rasch analysis of a new stroke-specific outcome scale: The Stroke Impact Scale. Archives of Physical Medicine and Rehabilitation, 84, 950–963. http://dx.doi.org/ 10.1016/S0003-9993(03)00035-2 Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-Mental State”: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198. http://dx.doi.org/10.1016/ 0022-3956(75)90026-6 Fugl-Meyer, A. R., Ja¨a¨sko¨, L., Leyman, I., Olsson, S., & Steglind, S. (1975). The post-stroke hemiplegic patient: 1. A method for evaluation of physical performance. Scandinavian Journal of Rehabilitation Medicine, 7, 13–31. Gabr, U., Levine, P., & Page, S. J. (2005). Home-based electromyography-triggered stimulation in chronic stroke. Clinical Rehabilitation, 19, 737–745. http://dx.doi.org/ 10.1191/0269215505cr909oa Go, A. S., Mozaffarian, D., Roger, V. L., Benjamin, E. J., Berry, J. D., Blaha, M. J., . . . Turner, M. B.; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. (2014). Heart disease and stroke statistics—2014 update. Circulation, 129, e28–e292. http://dx.doi.org/10.1161/01.cir.0000441139.02102. 80journal Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub. L. 104–191, 42 U.S.C. x 300gg, 29 U.S.C x 1181-1183, and 42 USC 1320d-1320d9. Mayo, N. E., Wood-Dauphinee, S., Coˆte´, R., Durcan, L., & Carlton, J. (2002). Activity, participation, and quality of life 6 months poststroke. Archives of Physical Medicine and Rehabilitation, 83, 1035–1042. http://dx.doi.org/10.1053/ apmr.2002.33984 Nudo, R. J. (2006). Plasticity. NeuroRx, 3, 420–427. http://dx. doi.org/10.1016/j.nurx.2006.07.006 Page, S. J. (2000). Imagery improves motor function in chronic stroke patients with hemiplegia: A pilot study. OTJR: Occupation, Participation and Health, 20, 200–215. Page, S. J., Boe, S., & Levine, P. (2013). What are the “ingredients” of modified constraint-induced therapy? An evidencebased review, recipe, and recommendations. Restorative Neurology and Neuroscience, 31, 299–309.
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Page, S. J., Dunning, K., Hermann, V., Leonard, A., & Levine, P. (2011). Longer versus shorter mental practice sessions for affected upper extremity movement after stroke: A randomized controlled trial. Clinical Rehabilitation, 25, 627–637. http://dx.doi.org/10.1177/0269215510395793 Page, S. J., Fulk, G., & Boyne, P. (2012). Clinically important differences for the upper-extremity Fugl-Meyer Scale in people with minimal to moderate impairment due to chronic stroke. Physical Therapy, 92, 791–798. http://dx. doi.org/10.2522/ptj.20110009 Page, S. J., Levin, L., Hermann, V., Dunning, K., & Levine, P. (2012). Longer versus shorter daily durations of electrical stimulation during task specific practice in moderately impaired stroke. Archives of Physical Medicine and Rehabilitation, 93(2), 200–206. http://dx.doi.org/10.1016/j.apmr. 2011.09.016 Page, S. J., Levine, P., & Khoury, J. C. (2009). Modified constraintinduced therapy combined with mental practice: Thinking through better motor outcomes. Stroke, 40, 551–554. http:// dx.doi.org/10.1161/STROKEAHA.108.528760 Page, S. J., Levine, P., & Leonard, A. (2007). Mental practice in chronic stroke: Results of a randomized, placebo-controlled trial. Stroke, 38, 1293–1297. http://dx.doi.org/10.1161/ 01.STR.0000260205.67348.2b Page, S. J., Szaflarski, J. P., Eliassen, J. C., Pan, H., & Cramer, S. C. (2009). Cortical plasticity following motor skill learning during mental practice in stroke. Neurorehabilitation and Neural Repair, 23, 382–388. http://dx.doi.org/ 10.1177/1545968308326427 Smith, D. A. (1961). The Box and Block test: Normative data for 7, 8, 9 year-old children (Unpublished master’s thesis). University of Southern California, Los Angeles. Weiss, T., Hansen, E., Beyer, L., Conradi, M. L., Merten, F., Nichelmann, C., . . . Zippel, C. (1994). Activation processes during mental practice in stroke patients. International Journal of Psychophysiology, 17, 91–100. http://dx.doi.org/10.1016/ 0167-8760(94)90059-0 Wolf, S. L., Winstein, C. J., Miller, J. P., Taub, E., Uswatte, G., Morris, D., . . . Nichols-Larsen, D.; EXCITE Investigators. (2006). Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: The EXCITE randomized clinical trial. JAMA, 296, 2095–2104. http://dx.doi.org/10.1001/jama.296.17.2095
January/February 2015, Volume 69, Number 1
MeSH TERMS electric stimulation hemiplegia mental processes motor skills disorders stroke
OBJECTIVE. To determine the feasibility and impact of home-based, mental practice–triggered electrical stimulation among stroke survivors exhibiting moderate upper-extremity (UE) impairment. METHOD. Five participants with moderate, stable UE hemiparesis were administered the Fugl-Meyer Assessment, the Box and Block Test, and the Activities of Daily Living, Hand Function, and overall recovery domains of the Stroke Impact Scale (Version 3). They were then administered an 8-wk regimen consisting of 1 hr of mental practice–triggered electrical stimulation every weekday in their home. At the end of every 2 wk, participants attended supervised stimulation to progress therapeutic exercises and stimulation levels and monitor compliance. RESULTS. Six instances of device noncompliance were reported. Participants exhibited reduced UE motor impairment and increased UE dexterity and participation in valued activities. CONCLUSION. The regimen appears feasible and had a substantial impact on UE impairment, dexterity, and participation in valued activities as well as perceptions of recovery. Page, S. J., Levine, P., & Hill, V. (2015). Mental practice–triggered electrical stimulation in chronic, moderate, upperextremity hemiparesis after stroke. American Journal of Occupational Therapy, 69, 6901290050. http://dx.doi.org/ 10.5014/ajot.2015.014902
Stephen J. Page, PhD, MS, OTR/L, FAHA, FACRM, is Director, Better Rehabilitation and Assessment for Improved Neuro-recovery (B.R.A.I.N.) Laboratory, and Associate Professor, Division of Occupational Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus; [email protected] Peter Levine, PTA, is Director, Synaps Together, LLC, Cincinnati, OH. Valerie Hill, PhD, OTR/L, is Postdoctoral Fellow, University of Southern California, Los Angeles.
The American Journal of Occupational Therapy
S
troke remains a leading cause of disability, with the number of survivors exhibiting residual deficits expected to increase over the next decade (Go et al., 2014). Motor impairments are common and profoundly undermine occupational performance and independence (Broeks, Lankhorst, Rumping, & Prevo, 1999; Mayo, Wood-Dauphinee, Coˆte´, Durcan, & Carlton, 2002). Because functional practice integrating the paretic upper extremity (UE) appears to be critical to reduction of motor deficits (Nudo, 2006), many contemporary rehabilitative approaches emphasize repetitive, task-specific practice (RTP) integrating the paretic UE (e.g., Page, Levine, & Leonard, 2007; Wolf et al., 2006). Yet, most of these therapies are efficacious only in clients exhibiting active distal UE movement, a minority of the stroke survivor population. Mental practice (MP) is one example of a promising UE therapy that incorporates RTP but that currently offers only limited application because of its requirement for distal UE movement. Its use in stroke rehabilitation has long been supported by evidence showing that MP triggers the same neural areas and musculature as physical practice of the same tasks (e.g., Decety, 1996; Decety & Ingvar, 1990; Weiss et al., 1994). The primary author’s laboratory was the first to show that repetitive MP use consistently reduces UE impairment (Page, 2000) and causes cortical reorganizations similar to those brought about by motor practice (Page, Szaflarski, Eliassen, Pan, & Cramer, 2009) and that addition of MP to physical practice significantly increases paretic UE use and function (e.g., 6901290050p1
Page et al., 2007; Page, Dunning, Hermann, Leonard, & Levine, 2011), a finding subsequently replicated by others (for a review, see Cha, Yoo, Jung, Park, & Park, 2012). However, MP combined with RTP is also limited in that survivors must exhibit active paretic wrist and finger flexion to be eligible. To address this challenge, an innovative electrical stimulation device was developed that is triggered by the minute muscle activations occurring during MP. The stimulation is activated only when the client’s electromyographic (EMG) activity during MP attains a preset EMG threshold level displayed on the device’s screen. When this level is reached, the client receives electrical stimulation via surface electrodes on the paretic UE musculature. Moreover, when the client is repeatedly successful at attaining a certain threshold, the threshold level can be increased, thereby increasing the level of challenge for the client. In addition to movement repetition, such progressive challenge is a prerequisite for plasticity and UE motor return (Nudo, 2006). Use of this device—called the Mentamove (Mentamove Deutschland, Karlsfeld, Germany)—has the potential to expand MP’s use to the large number of stroke survivors exhibiting only trace UE movement—a group that is not eligible for traditional MP protocols and that cannot activate stimulation devices predicated on substantial active limb movements as a trigger. The primary study objective was to estimate the impact of Mentamove use on UE motor impairment in stroke survivors exhibiting trace movement in the distal areas of their paretic UEs. We chose a cohort of chronic stroke survivors (>6 mo postictus) because they were likely to be neurologically stable and not receiving other rehabilitative interventions that could contaminate the findings of this pilot study. An additional, unique study facet was that the intervention was mostly home based. This aspect was consistent with other home-based electrical stimulation studies that we had conducted (e.g., Gabr, Levine, & Page, 2005; Page, Levin, Hermann, Dunning, & Levine, 2012), and we felt it was highly relevant to occupational therapy practice given the diminishing amount of clinical contact time available to intervene with the growing population of clients with poststroke UE deficits. Given that the regimen was mostly home based and that this was the first application of MP-triggered stimulation to the paretic UE poststroke, we monitored patient compliance and adverse events—important information for a pilot study that would inform, in part, whether the intervention should move forward to testing in subsequent Phase 1b and Phase 2 work. 6901290050p2
Method Participants Participants were recruited through presentations provided to local stroke support groups and by distributing advertisements approved by the local institutional review board to local therapists during continuing education events or via mail. To be eligible for the study, volunteers had to meet the following inclusion criteria: 1. In the paretic UE, ³20˚ of active shoulder flexion, ³20˚ of active internal and external humeral rotation, ³20˚ active elbow flexion, and ³15˚ of passive wrist flexion and extension. The latter motor criterion was intended to ensure that participants exhibited sufficient passive range of motion without contractures or discomfort such that their fingers could be moved by the stimulation. 2. Manual muscle test of 1/5 in the paretic wrist flexors and extensors, indicative of a palpable muscle contraction. Minimal active joint movement could be exhibited in the paretic wrist or metacarpophalangeals but was not a requirement. The movement had to be 6 mo poststroke and who exhibited moderately severe UE hemiparesis. • Although the MP-triggered electrical stimulation was mostly home based, participants displayed favorable compliance. Behavioral strategies were used to increase compliance and comprehension of the study protocol. The American Journal of Occupational Therapy
These strategies included compliance visits, a 1-hr education session, and home use diaries.
Conclusion Poststroke UE motor recovery frequently necessitates many long hours of task-specific practice to elicit neuroplastic and motor changes. With diminishing contact time and funding available for rehabilitation, high-duration protocols and protocols requiring expensive equipment are often not feasible. MP-triggered electrical stimulation offers the possibility of repetitive, home-based practice and appears to increase gross dexterity, UE recovery, and participation in valued activities even years poststroke. The innovative integration of behavioral techniques to enhance protocol compliance and client understanding of this homebased approach appears promising and should be further investigated in future trials. s
References American Occupational Therapy Association. (2007). AOTA’s Centennial Vision and executive summary. American Journal of Occupational Therapy, 61, 613–614. http://dx.doi. org/10.5014/ajot.61.6.613 Barry, J. G., Ross, S. A., & Woehrle, J. (2012). Therapy incorporating a dynamic wrist-hand orthosis versus manual assistance in chronic stroke: A pilot study. Journal of Neurologic Physical Therapy, 36, 17–24. http://dx.doi.org/10.1097/ NPT.0b013e318246203e Bohannon, R. W., & Smith, M. B. (1987). Interrater reliability of a modified Ashworth scale of muscle spasticity. Physical Therapy, 67, 206–207. Broeks, J. G., Lankhorst, G. J., Rumping, K., & Prevo, A. J. (1999). The long-term outcome of arm function after stroke: Results of a follow-up study. Disability and Rehabilitation, 21, 357–364. http://dx.doi.org/10.1080/096382899297459 Butler, A., Blanton, S., Rowe, V., & Wolf, S. (2006). Attempting to improve function and quality of life using the FTM Protocol: Case report. Journal of Neurologic Physical Therapy, 30, 148–156. http://dx.doi.org/10.1097/01.NPT.0000281952. 93934.6b Cauraugh, J. H., & Kim, S. B. (2003). Chronic stroke motor recovery: Duration of active neuromuscular stimulation. Journal of the Neurological Sciences, 215, 13–19. http://dx. doi.org/10.1016/S0022-510X(03)00169-2 Cha, Y. J., Yoo, E. Y., Jung, M. Y., Park, S. H., & Park, J. H. (2012). Effects of functional task training with mental practice in stroke: A meta analysis. NeuroRehabilitation, 30, 239–246. Decety, J. (1996). Do imagined and executed actions share the same neural substrate? Brain Research in Cognitive Brain Research, 3, 87–93. Decety, J., & Ingvar, D. H. (1990). Brain structures participating in mental simulation of motor behavior: A neuropsychological interpretation. Acta Psychologica, 73, 13–34. http://dx.doi.org/10.1016/0001-6918(90)90056-L 6901290050p7
Duncan, P. W., Bode, R. K., Min Lai, S., & Perera, S.; Glycine Antagonist in Neuroprotection Americans Investigators. (2003). Rasch analysis of a new stroke-specific outcome scale: The Stroke Impact Scale. Archives of Physical Medicine and Rehabilitation, 84, 950–963. http://dx.doi.org/ 10.1016/S0003-9993(03)00035-2 Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-Mental State”: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198. http://dx.doi.org/10.1016/ 0022-3956(75)90026-6 Fugl-Meyer, A. R., Ja¨a¨sko¨, L., Leyman, I., Olsson, S., & Steglind, S. (1975). The post-stroke hemiplegic patient: 1. A method for evaluation of physical performance. Scandinavian Journal of Rehabilitation Medicine, 7, 13–31. Gabr, U., Levine, P., & Page, S. J. (2005). Home-based electromyography-triggered stimulation in chronic stroke. Clinical Rehabilitation, 19, 737–745. http://dx.doi.org/ 10.1191/0269215505cr909oa Go, A. S., Mozaffarian, D., Roger, V. L., Benjamin, E. J., Berry, J. D., Blaha, M. J., . . . Turner, M. B.; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. (2014). Heart disease and stroke statistics—2014 update. Circulation, 129, e28–e292. http://dx.doi.org/10.1161/01.cir.0000441139.02102. 80journal Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub. L. 104–191, 42 U.S.C. x 300gg, 29 U.S.C x 1181-1183, and 42 USC 1320d-1320d9. Mayo, N. E., Wood-Dauphinee, S., Coˆte´, R., Durcan, L., & Carlton, J. (2002). Activity, participation, and quality of life 6 months poststroke. Archives of Physical Medicine and Rehabilitation, 83, 1035–1042. http://dx.doi.org/10.1053/ apmr.2002.33984 Nudo, R. J. (2006). Plasticity. NeuroRx, 3, 420–427. http://dx. doi.org/10.1016/j.nurx.2006.07.006 Page, S. J. (2000). Imagery improves motor function in chronic stroke patients with hemiplegia: A pilot study. OTJR: Occupation, Participation and Health, 20, 200–215. Page, S. J., Boe, S., & Levine, P. (2013). What are the “ingredients” of modified constraint-induced therapy? An evidencebased review, recipe, and recommendations. Restorative Neurology and Neuroscience, 31, 299–309.
6901290050p8
Page, S. J., Dunning, K., Hermann, V., Leonard, A., & Levine, P. (2011). Longer versus shorter mental practice sessions for affected upper extremity movement after stroke: A randomized controlled trial. Clinical Rehabilitation, 25, 627–637. http://dx.doi.org/10.1177/0269215510395793 Page, S. J., Fulk, G., & Boyne, P. (2012). Clinically important differences for the upper-extremity Fugl-Meyer Scale in people with minimal to moderate impairment due to chronic stroke. Physical Therapy, 92, 791–798. http://dx. doi.org/10.2522/ptj.20110009 Page, S. J., Levin, L., Hermann, V., Dunning, K., & Levine, P. (2012). Longer versus shorter daily durations of electrical stimulation during task specific practice in moderately impaired stroke. Archives of Physical Medicine and Rehabilitation, 93(2), 200–206. http://dx.doi.org/10.1016/j.apmr. 2011.09.016 Page, S. J., Levine, P., & Khoury, J. C. (2009). Modified constraintinduced therapy combined with mental practice: Thinking through better motor outcomes. Stroke, 40, 551–554. http:// dx.doi.org/10.1161/STROKEAHA.108.528760 Page, S. J., Levine, P., & Leonard, A. (2007). Mental practice in chronic stroke: Results of a randomized, placebo-controlled trial. Stroke, 38, 1293–1297. http://dx.doi.org/10.1161/ 01.STR.0000260205.67348.2b Page, S. J., Szaflarski, J. P., Eliassen, J. C., Pan, H., & Cramer, S. C. (2009). Cortical plasticity following motor skill learning during mental practice in stroke. Neurorehabilitation and Neural Repair, 23, 382–388. http://dx.doi.org/ 10.1177/1545968308326427 Smith, D. A. (1961). The Box and Block test: Normative data for 7, 8, 9 year-old children (Unpublished master’s thesis). University of Southern California, Los Angeles. Weiss, T., Hansen, E., Beyer, L., Conradi, M. L., Merten, F., Nichelmann, C., . . . Zippel, C. (1994). Activation processes during mental practice in stroke patients. International Journal of Psychophysiology, 17, 91–100. http://dx.doi.org/10.1016/ 0167-8760(94)90059-0 Wolf, S. L., Winstein, C. J., Miller, J. P., Taub, E., Uswatte, G., Morris, D., . . . Nichols-Larsen, D.; EXCITE Investigators. (2006). Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: The EXCITE randomized clinical trial. JAMA, 296, 2095–2104. http://dx.doi.org/10.1001/jama.296.17.2095
January/February 2015, Volume 69, Number 1
