BACKGROUND

Motor disability following stroke is common and results in difficulty performing everyday tasks such as dressing and meal preparation. Constraint-induced movement therapy (CIMT) is unique among motor rehabilitation paradigms because it employs intensive motor practice to build strength and function and also incorporates behavioral techniques to maximize use of the more-impaired arm during daily activities (self-monitoring of arm use, goal-setting, and guided problem-solving to overcome barriers to not using a hemiparetic arm). Randomized controlled trials (RCTs) consistently show that CIMT is superior at producing improvements in daily arm use, yet it has only minimally penetrated clinical practice because of cost and its demanding treatment schedule. With the advent of new camera sensors, it became possible to program video games for rehabilitation that use a person's own body movements to drive game play. Rehabilitation gaming provides a solution for making the intensive training and behavioral techniques of CIMT more accessible to underserved individuals. A previous pilot study established the feasibility of this treatment approach, but a definitive trial of the comparative effectiveness of this novel model of CIMT delivery is needed to guide clinical decision-making.

OBJECTIVES

This multisite RCT aimed to (1) establish the comparative effectiveness of 2 different implementations of an in-home video game delivery model of CIMT vs traditional clinic-based CIMT and vs standard care; and (2) examine individual factors that may differentially influence response to 1 treatment vs another.

METHODS

In total, 193 individuals with chronic stroke were randomly assigned to 1 of 4 interventions that occurred over a 3-week period: (1) traditional CIMT (35 therapist/client contact hours over 10 sessions); (2) therapist-as-consultant Gaming CIMT (5 therapist/client contact hours over 4 sessions and 15 hours of independent game play at home); (3) therapist-as-consultant Gaming CIMT with additional teleconsultation (5 therapist/client contact hours over 4 sessions, 6 additional video conference “check-ins,” and 15 hours of independent game play in the home); and (4) standard occupational therapy (5 hours over 4 sessions plus a home exercise program). The gaming system logged active play time to monitor adherence to the prescribed unsupervised in-home game play. Motor function/speed (Wolf Motor Function Test [WMFT]) and self-reported daily use of the more-affected hand (Motor Activity Log [MAL]) served as the primary outcome measures. Participants were assessed immediately before treatment, after 3 weeks of treatment, and 6 months later. Between-group differences in treatment response/maintenance were assessed through intent-to-treat analyses using linear mixed models. Initial motor ability, cognition, tactile sense, use of the more-affected arm for daily activities (outside the clinic), treatment adherence, age, sex, and chronicity were examined as potential moderators of motor outcome.

RESULTS

Of 193 participants who consented to the study, 168 started treatment, 150 completed treatment, and 113 completed 6-month follow-up assessment. All 3 treatments incorporating a form of CIMT (both game-based CIMT groups and traditional in-clinic CIMT) produced clinically meaningful improvements in (MAL), whereas standard care did not. Between-group differences (95% CIs) relative to standard care were 0.8 points (0.5-1.0), 1.0 points (0.8-1.3), and 1.2 points (1.0-1.5) for the gaming, gaming with teleconsultation, and in-clinic CIMT groups, respectively. Retention of MAL gains at 6 months posttreatment was 57%. Regarding gains in (WMFT), all groups attained clinically meaningful improvements that were maintained 6 months later (median proportional improvements of about 20%). There were also marginally significant ( = .05-.08) comparative treatment effects immediately posttreatment whereby in-clinic CIMT produced greater improvements in natural log-transformed WMFT scores during the treatment period than Gaming and Standard Care; between-group differences were −0.18 (−0.37 to 0.00) and −0.17 (−0.36 to 0.02), respectively, which corresponds to a performance time decrease of 0.85 seconds per task for in-clinic CIMT relative to both Gaming and Standard Care. These marginally significant comparative treatment effects can likely be attributed to greater dosing of motor practice in the in-clinic CIMT group. Comparative treatment effects on the WMFT were absent in follow-up. Poorer motor ability at baseline was associated with significantly greater improvements in motor function and poorer improvements in daily arm use.

CONCLUSIONS

Superior gains in were achieved from all CIMT and gaming CIMT interventions in which the therapist delivered behavioral interventions compared with standard care (in which therapy time focused primarily on motor practice). Clinically meaningful long-term gains in were roughly equivalent between groups, suggesting that survivors of chronic stroke can continue to make meaningful improvements in motor function regardless of how they access motor practice (ie, whether through virtual reality, CIMT, or standard care). Video games can thus provide a vehicle for therapists to monitor and encourage in-home intensive motor rehabilitation while freeing up therapist time to conduct the critical behavioral elements of CIMT. This therapist-supported self-management model maximizes both motor function and daily arm use within the typical constraints of managed care.

LIMITATIONS

Adherence to in-home gaming rehabilitation was imperfect, particularly for the gaming group that received fewer therapist consultations. Thus, a comparison of the efficacy of game-based vs in-clinic CIMT for promoting motor restoration could not be achieved from this pragmatic study design. Follow-up data should be cautiously interpreted given substantial and unequal attrition between groups in follow-up.