Edward Taub - US grants

In this laboratory we have developed a new set of techniques that preliminary studies suggest can substantially reduce the incapacitating motor deficit of many elderly stroke patients and lessen their dependence. The techniques involve "constraint-induced" (CI) facilitation of impaired movement and include prolonged motor restriction of the unaffected upper extremity by a sling while at the same time training the affected upper limb. Initial results indicate that old age, per se, is not an important factor in limiting the final level of motor recovery attainable. Limitations of the work previously carried out in this laboratory were the small sample size and a control intervention that was not equal in credibility to the experimental intervention. Aim 1 of the proposed research will be to address these two issues. The sample size will be increased. In addition, the interventions employed in two physical therapy comparison groups have been redesigned so that they will be equal in credibility to that employed with the CI group. Aim 2 of the project is to determine whether aging is a factor in the speed or extent to which the motor impairment of the upper extremity in chronic stroke patients can be reduced by CI techniques. Aim 3 of the study is to ascertain through the use of magnetic resonance imaging whether there is some commonality in the location or extent of the lesions that characterize patients who benefit most from use of CI techniques. The goal of Aim 4 is to assess in a controlled study whether either the intensive or conventional physical therapy we propose to employ is effective in improving the upper extremity motor status of chronic stroke patients. The research team is interdisciplinary and includes three psychologists (with the emphasis of different individuals being in rehabilitation and motor control, statistics and gerontology), a neurologist and two physical therapists. The experimental design will involve 80 subjects randomly assigned to four groups (with blocking based on age). One group will receive movement restriction of the impaired upper extremity for a period of two weeks and training of the unaffected upper extremity. These results will be compared with those of a group of subjects receiving intensive physical therapy, a group of subjects receiving conventional physical therapy and a group of subjects on a waiting list. Each group of 20 will have equal numbers of persons with left - and right - brain strokes. The motor function, amount of limb use and range of motion of these individuals will be assessed before and after intervention and during followup, both in the laboratory and in the life situation.

In this laboratory we have developed a new set of techniques that preliminary studies suggest can substantially reduce the incapacitating motor deficit of many elderly stroke patients and lessen their dependence. The techniques involve "constraint-induced" (CI) facilitation of impaired movement and include prolonged motor restriction of the unaffected upper extremity by a sling while at the same time training the affected upper limb. Initial results indicate that old age, per se, is not an important factor in limiting the final level of motor recovery attainable. Limitations of the work previously carried out in this laboratory were the small sample size and a control intervention that was not equal in credibility to the experimental intervention. Aim 1 of the proposed research will be to address these two issues. The sample size will be increased. In addition, the interventions employed in two physical therapy comparison groups have been redesigned so that they will be equal in credibility to that employed with the CI group. Aim 2 of the project is to determine whether aging is a factor in the speed or extent to which the motor impairment of the upper extremity in chronic stroke patients can be reduced by CI techniques. Aim 3 of the study is to ascertain through the use of magnetic resonance imaging whether there is some commonality in the location or extent of the lesions that characterize patients who benefit most from use of CI techniques. The goal of Aim 4 is to assess in a controlled study whether either the intensive or conventional physical therapy we propose to employ is effective in improving the upper extremity motor status of chronic stroke patients. The research team is interdisciplinary and includes three psychologists (with the emphasis of different individuals being in rehabilitation and motor control, statistics and gerontology), a neurologist and two physical therapists. The experimental design will involve 80 subjects randomly assigned to four groups (with blocking based on age). One group will receive movement restriction of the impaired upper extremity for a period of two weeks and training of the unaffected upper extremity. These results will be compared with those of a group of subjects receiving intensive physical therapy, a group of subjects receiving conventional physical therapy and a group of subjects on a waiting list. Each group of 20 will have equal numbers of persons with left - and right - brain strokes. The motor function, amount of limb use and range of motion of these individuals will be assessed before and after intervention and during followup, both in the laboratory and in the life situation.

[unreadable] DESCRIPTION (provided by applicant): The overall objective of this research is to test the efficacy of a new form of pediatric rehabilitation therapy -namely, Pediatric CI therapy - to promote new and improved motor behavior in young children with hemiparesis associated with cerebral palsy. This is based on a theoretically-grounded therapy shown to be effective with adult patients with chronic stroke and to produce cortical reorganization (cf. Taub et al., 1993; Liepert et al., 2000). Pediatric Cl therapy involves (1) total restraint of the unaffected upper extremity and (2) repetitive use of the affected extremity, using intensive shaping procedures for 6 hours/day for 21 consecutive days. The proposed research builds on findings from a preliminary study that demonstrated significant gains in young children's upper extremity skills following Pediatric Cl therapy. We propose to conduct a prospective, randomized controlled study with 52 children (ages 2-6) with hemiparetic cerebral palsy. The specific aims are:(1) to test the efficacy of Pediatric Cl therapy compared to Conventional therapy to improve upper extremity movement and functional use;(2) to evaluate whether improvement (if detected) is sustained over the next 12 months; and(3) to assess whether Pediatric Cl therapy is associated with significant gains in other adaptive behavior domains (e.g., trunk control, mobility, communication, and self-help skills).This research is of paramount significance because there currently are no forms of pediatric rehabilitation proven efficacious (Barry, 2001), despite widespread use of physical and occupational therapy in treatment of young children with cerebral palsy (Ramey et al; 2000).

ABSTRACT Many individuals with cognitive impairment experience decrements in everyday function that can signal encroaching dementia. For every year that cognitive decline is delayed there is substantial savings in patient care costs and inestimable savings in quality of life for patients and family members. The prevalence of cognitive impairment in chronic stroke is approximately 50%. A number of techniques have been found to improve various aspects of cognition in the training situation. However, their transfer to everyday situations outside the training setting has been limited as is retention. They are therefore of reduced or narrow practical value. A cognitive ability that is improved but not used to enhance real-world performance has limited significance. Pilot work has been carried out here with a novel intervention designed to fill these crucial gaps. The results are very promising. The purpose of the proposed research is to carry out a randomized controlled trial (RCT) with a large enough sample to rigorously evaluate these preliminary results. The new treatment to be tested combines two repeatedly validated rehabilitation methods: the Transfer Package of CI Movement Therapy and Speed of Cognitive Processing Training. The purpose of doing so is to produce a marked enhancement in the transfer of cognitive improvement from the training setting to instrumental activities of daily living (IADL) in everyday situations. Both halves of the new combination therapy are founded on the investigators' own basic research. In both cases, efficacy is supported by positive results from multiple single-site RCTs and a large multisite RCT. However, the effect of Speed of Processing Training has been found to have limited generalization to cognitive-based IADL in everyday situations. In contrast, one of the main strengths of CI Therapy is that it produces a robust and extensive transfer of treatment effect to everyday life situations by means, in part, of its Transfer Package. A second strength of the Transfer Package of CI Therapy is long-term retention of its effect. In our initial work, the Transfer Package procedures that this lab has used effectively to transfer motor gains from the treatment to everyday setting were adapted to transfer cognitive gains from the treatment to the everyday setting. We propose here an RCT with 2 arms: Speed of Processing Training (SOPT) in the lab combined with the TP (TP+) and SOPT in the lab but without the TP (TP-). Participants will be 120 adults more than 1-year post-stroke with mild to moderate cognitive impairment. Performance on cognitive-based tasks will be measured in daily life and in the lab before and after baseline, after treatment, and 6- and 12-months afterwards. This design will permit rigorous testing of the value of the Transfer Package with an adequate sample size, objective measurement, blinding, and between-subjects control for amount and intensity of training and therapist contact.