CRITICALLY APPRAISED TOPIC

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1 TITLE CRITICALLY APPRAISED TOPIC The use of constraint-induced movement therapy versus bilateral arm training in adults with upper extremity hemiparesis following a stroke to improve perception of upper extremity improvement during activities daily living AUTHOR Prepared by address James Casey Whorton OTS, and Carrie Ciro PhD, OTR/l, FAOTA James-whorton@ouhsc.edu Date 5 September 2013 Review date 27 September 2013 CLINIAL SCENARIO Every year, more than 795,000 people in the United States experience a cerebrovascular accident (CVA), and more than 85% of patients following a stroke have significantly impaired upper extremity functioning (Nichols-Larsen, Zeringue, Greenspan & Blanton, 2005). Hemiparesis is the most common upper extremity impairment experienced by individuals following a stroke and refers to one-sided weakness that can impact arms, hands, legs, and facial muscles. Regaining arm function is vital for independence in activities of daily living and can be attributed to a diminished health related quality of life. Clinicians incorporate a wide range of interventions to address upper extremity hemiplegia following a stroke but evidence supporting a superior one remains unclear (Hayner, Gibson & Giles, 2010). Constraint-Induced Motion Therapy (CIMT) refers to the restraint of the unaffected upper extremity and the incorporation of an intense training schedule of the affected upper extremity. The signature form of CIMT typically involves six hours of affect UE training daily for duration of two weeks and restraint of the unaffected upper extremity for up to 90% of waking hours (Wolf, Winstein, Miller, Taub, Uswatte, Morris & Nichols-Larsen, 2006). However, various CIMT training regimes have been developed that use less intensive training and shorter restraint times. These forms of CIMT decreased training sessions to hours daily, 5-9 hours per day with longer trail durations of 3-10 weeks. CIMT involves repetitive practice of functional activities using the involved arm that may lead cortical changes in the brain, resulting in improvement in gross and fine motor function of the upper extremity. Functional activities refer to task or activity such as picking up a penicils or moving beans between containers, not real life activities such as bathing. In contrast, Bilateral Arm Training (BAT) has been used as an upper extremity rehabilitation intervention for individuals with stroke at all levels of severity (Stewart, Cauraugh & Summers, 2006). BAT emphasizes symmetrical bilateral movements of the upper extremities due to the nature of many daily activities that require the use of bilateral arm movement. Cooking, cleaning, selffeeding, and toileting are examples are bilateral arm skills addressed during BAT training sessions. Training schedules for many BAT studies consist of 15 minutes to 2.25 hours daily and 3 to 5 times weekly for 2 to 8 weeks severity (Stewart et al., 2006). Despite some research investigating the differences between CIMT and BAT treatment outcomes for individuals with upper extremity impairment post stroke, the effectiveness of CIMT and BAT on an individual s perception of upper extremity improvement during daily activities with hemiparesis following a stroke is unclear. FOCUSED CLINICAL QUESTION For adults above the age of 50 with upper extremity hemiparesis due to stroke, resulting in a loss of hand function is constraint induced movement therapy more effective than bilateral arm training for perceived improvement of upper extremity function in activities of daily living?

2 SUMMARY OF SEARCH [Best evidence appraised and key findings] Reports from three studies are included in this review. One study investigated the efficacy of CIMT, BAT, and control treatment (CT) on movement strategies of the affected upper extremity and functional outcome in stoke patients (Wu, Chuang, Lin, Chen & Tsay, 2011). The second study investigated the effects of CIMT and BAT on motor performance, daily function, functional use of the affected arm, and quality of life in patients with hemiparetic stroke (Lin, Chang, Wu & Chen, 2009). The last study evaluated the effectiveness of CIMT with bilateral treatment of equal intensity for chronic upper extremity dysfunction caused by a cerebrovascular accident (CVA). Collectively, These studies found that high intensity CIMT and BAT exhibit similar beneficial effects in improving perception of upper extremity use during functional activities in individuals post stroke. However, none of the studies were able to show significant differences between the two interventions. CLINICAL BOTTOM LINE Evidence suggests that constraint-induced movement therapy and bilateral arm training result in increased use of affected upper extremity (UE) and individuals with UE hemiparesis perception of use during daily activities. However, there remains no clear superior intervention between CIMT and BAT for improving perceived upper extremity use during ADL following a stroke. Important note on the limitation of this CAT This critically appraised paper (or topic) has been peer-reviewed by one other independent professor. SEARCH STRATEGY Terms used to guide the search strategy Patient/Client Group: Adults above the age of 50 with upper extremity hemiparesis due to stroke resulting in a loss of hand function Intervention (or Assessment): Constraint-Induced Movement Therapy Comparison Bilateral Arm Training Outcome(s): Improved perception of upper extremity functioning during daily activities Databases and Sites Searched Search Terms Limits Used General databases: Medline EBSCO OVID AJOT Search PubMed Aged OR elderly OR older adults OR frail OR older people OR older persons OR geriatric AND Constraint-Induced Motion Therapy, Modified Constraint- Induced Motion Therapy, Movement Therapy, Unilateral Required : Constraint Induced Motion Therapy, Movement Therapy, Bilateral Arm Training, Forced Use Therapy, Simultaneous Arm Training, cerebrovascular accident, stroke, hemiparesis Publications written in English

3 Google Scholar Arm training, Bilateral Arm training, Forced Use Therapy, and Simultaneous arm training, AND cerebrovascular accident, stroke, hemiplegia, hemiparesis, upper extremity function, weakness, arm/ hand function Publication dates Where possible-systematic Reviews and RCT s were selected in limits INCLUSION and EXCLUSION CRITERIA Inclusion Criteria Studies that directly compared the use of Constraint-Induced Movement Therapy and Bilateral Arm Training for adults with a mean age over 50 experiencing upper extremity impairment following a stroke Studies that included outcome measures individuals perception of upper extremity function pre and post Constraint-Induced Movement Therapy and Bilateral Arm Training Interventions Samples with adults over the age of 50 with upper extremity hemiparesis or impairment following a stroke Studies with a mean onset of stroke of 6 months or greater Exclusion Criteria Samples with severe upper extremity impairment or paralysis Studies that did not target specific outcomes related to improve UE function and bilateral UE use, improved perception of UE function, and greater satisfaction with daily use following intervention Studies published in languages other than English Studies published prior to 2000 RESULTS OF SEARCH A total of 6 relevant articles were located and categorized based on the adapted version of the American Occupational Therapy Association Literature Review Project for OT outcomes research (Lieberman, D., & Scheer, J., 2002) where:

4 Table 1: Summary of Study Designs of Articles Retrieved Study Design/Methodology of Articles Retrieved Randomized Control Trial (n 20), Systematic Reviews Level Number Located Author (Year) 1A 5 Nichols-Larsen, D. S., Clark, P. C., Zeringue, A., Greenspan, A., & Blanton, S. (2005). Wolf, S. L., Winstein, C. J., Miller, J. P., Taub, E., Uswatte, G., Morris, D.,... & Nichols-Larsen, D. (2006). Stewart, K. C., Cauraugh, J. H., & Summers, J. J. (2006) Wu, C. Y., Chuang, L. L., Lin, K. C., Chen, H. C., & Tsay, P. K. (2011) Lin, K. C., Chang, Y. F., Wu, C. Y., & Chen, Y. A. (2009). Randomized Control Trial (n<20) 1B 1 Hayner, K., Gibson, G., & Giles, G. M. (2010). BEST EVIDENCE The following papers were identified as the best evidence and selected for critical appraisal. Wu et al. (2011), Lin et al. (2009), and Hayner et al. (2010). Reason for selecting these studies were: The studies focused and compared the use of CIMT and BAT in individuals with upper extremity hemiparesis or impairment following a stroke Outcome measures assessed upper extremity function, perception, functional performance, and satisfaction. Highest level of evidence that specifically addressed the research question SUMMARY OF BEST EVIDENCE Table 2: Description and appraisal of Randomized trial of distributed constraint-induced therapy versus bilateral arm training for the rehabilitation of upper-limb motor control and function after stroke by Wu et al. (2011) Aim/Objective of the Study/Systematic Review: The aim of this study was to compare the efficacy of constraint-induced movement therapy (CIMT), bilateral arm training (BAT), and control treatment (CT) on movement strategies of the affected UE and

5 functional outcome in stroke patients (Wu et al., 2011). Study Design A randomized pre-test and post-test control group design where eligible participants were randomized using a computerized block randomization scheme into CIMT, BAT, or control treatment (CT) groups. All interventions were conducted during regular scheduled occupational therapy sessions by five certified occupational therapists trained to administer CIMT, BAT, and CT protocols by the investigators. Kinematic analysis and outcome measures were conducted before and after the three week intervention period and administered by two certified occupational therapists that were blinded to the experimental groups. Setting Four participating hospitals stroke rehabilitation units where each of the three interventions were administered during regularly scheduled occupational therapy sessions. Participants This study recruited 66 stroke patients with a mean age of years and a stroke onset of months, from 4 stroke rehabilitation units. Patients had undergone unilateral strokes that were identified by brain imaging, and received independent examinations by a physiatrist and an occupational therapist to determine their eligibility for inclusion. Inclusion was determined by the following criteria: more than 6 months after onset of an ischemic or haemorrhagic stroke, Brunnstrom stage III or above for proximal or distal parts of UE, considerable non-use of affected UE, no serious cognitive deficits (Mini-Mental State Examination 23), no participation with experimental drugs, or balance problems that would comprise safety during intervention. Intervention Investigated Control The control group consisted of 22 randomly assigned participants. Approximately 75% of the intervention provided in the control group was based on principals used in neurodevelopmental treatment (NDT) and 25% addressed compensatory strategies. The NDT principals included functional task practice, UE coordination, balance, stretching, and weight bearing of the affected UE. The compensatory strategies group of the control intervention focused on compensation of the affected limb and unaffected limbs during functional tasks. This treatment regime received therapy 2 hours daily for 5 weeks for 3 consecutive weeks. The intervention was provided by five certified occupational therapists that were trained in the administration of CIMT, BAT, and CT protocols by the primary investigators. Experimental The experimental group was divided into two interventions consisting of CIMT or BAT. Each intervention group had 22 randomly assigned participants. The CIMT intervention group focused on using a mitt to restrict the unaffected for 6 hours daily and under intensive treatment to train the affected UE in functional tasks, including reaching to move a cup, pick up coins, picking up utensil to use for self-feeding, grasping/releasing various sized blocks, and other functional daily tasks. Hours of mitten use were recorded by the patients and confirmed by the caregivers. The BAT intervention group focused on simultaneous symmetrical movements and alternating patterns of both UE s in functional tasks. These tasks included, lifting 2 cups, picking up 2 peg, grasping/releasing 2 towels, wiping tables with 2 hands, etc. The intervention was provided by five certified occupational therapists that were trained in the administration of CIMT, BAT, and CT protocols by the primary investigators.

6 Outcome Measures (Primary and Secondary) The Motor Activity Log (MAL) examines how much and how well the subject uses their more-affected arm outside of the laboratory setting. Participants are asked standardized questions about the amount of use of their more-affected arm (Amount Scale or AS) and the quality of their movement (How Well Scale or HW) during the functional activities indicated. According to Uswatte, Taub, Morris, Vignolo, & McCulloch (2005) the MAL is reliable and valid measure of real world upper extremity use for stroke survivors undergoing CIMT. This study suggests the MAL is internally consistent, reliable and responsive to the amount of use (AOU) and quality of use (QOU) in stroke survivors with upper extremity impairment.the rating scales for the MAL (AS) and (HW) are both administered during all tests except during periodic testing, when only the HW rating scale is used. Participants should be informed that they are able to use half scores if these accurately reflect their ratings. A mean MAL score is calculated for both scales by adding the rating scores for each scale and dividing by the number of items asked. Furthermore, the administrator should avoid asking the participant to rate the more affected UE on the HW scale if previous given a score of 0 on the AS scale.the MAL amount scale is as follows: Amount Scale (AS) Rating Interpretation 0 Did not use my weaker arm 1 Occasionally used my weaker arm but only very rarely (very rarely) 2 Sometimes used my weaker arm but did the activity most with my stronger arm 3 Used my weaker arm about half as much as before the stroke 4 Used my weaker arm almost as much as before the stroke (3/4 pre-stroke) 5 Used my weaker arm as often as before the stroke (same as pre-stroke) How Well (HW) Scale Rating Interpretation 0 My weaker arm was not used at all during the activity 1 My weaker arm was moved during the activity but not helpful My weaker arm was of some use during that activity but needed some help from the stronger arm, moved very slowly, or with difficulty My weaker arm was used for that activity but the movements were slow or were made only with some effort (fair) The movements made by my weaker arm for that activity were almost normal but not quite as fast or accurate as normal The ability to use my weaker arm for that activity was as good as before the stroke Secondary Outcome Measures: Wolf Motor Function Test Kinematic analysis variables for unilateral and bilateral tasks Main Findings The participants in the CIMT group produced significant grains in the MAL Amount of Use (AOU) rating scale (p=.002 for CIMT vs CT); and( p=0.10 for CIMT vs BAT). In addition, significant improvements in the MAL Quality of Use (QOU) rating scale were observed (p=.036 for CIMT vs CT; p=.005 for CIMT vs BAT). The table below from Wu et al. (2011), page 135, shows the CIMT group rated both amount and quality of use for the MAL higher after the trial the intervention. No significant differences between

7 the CT and the BAT groups for any of the clinical measures administered in this study were found. Table taken from (Wu et al., 2011) demonstrates the MAL scores for the CIMT and BAT groups pre and post-treatment (p.135). Original Authors Conclusions This study provided further insight into the relative effects of CIMT and BAT on upper extremity movement performance in people after experiencing a stroke. Results from this study suggest that participants receiving CIMT and BAT exhibit the ability to generalize the trained skills of the affected limb to both unilateral and bilateral tasks. However, the investigators suggest the participants in the CIMT group demonstrated improved performance of functional upper extremity tasks and quality of use of the affected limb, measured by the MAL scale than the BAT or CT groups. Critical Appraisal Validity External validity: The investigators used a randomized control design, strict inclusion criteria, reported no drop outs, and used multiple relevant outcome measures. However, a lack of participant demographic information (gender, ethnicity, comorbidities, and socioeconomic status) was noted during the critical appraisal and affects the generalizability of the results. Internal validity: Interventions were applied in a consistent, uniform, and realistic manner. The standardized outcomes measures were administered by certified, trained occupational therapist that were blinded to the participant group. Lastly, the investigators trained the five certified occupational therapist who administered the interventions to ensure consistent intervention protocols. The primary purpose of this study and high internal validity make this study applicable to the clinical question. Interpretation of Results.

8 The current study demonstrated favourable results regarding the focused clinical question. The outcome of this study showed significant gains in the MAL-AOU than the CT and BAT groups (P=0.02 for CIMT vs. CT; P=.010 for CIMT vs. BAT). Furthermore, MAL-QOM scores showed greater improvements in the CIMT vs. CT (P=.036) and CIMT vs. BAT (P=.005). There were no significant differences between the CT and BAT groups in any of the clinical measures. Given the strengths of the interval validity of this study, useful information on the administration and implementation of a CIMT was obtained. There is some evidence that constraint-induced movement therapy improves the perception of upper extremity function in adults with hemiparesis due to stroke. Summary/Conclusion The overall results of this study show benefits of both CIMT and BAT for individuals following stroke on movement strategies and functional outcomes. Regarding the clinical question, CIMT participants achieved better performance in the amount and quality of use of the affected UE, measured by the MAL than the CT or BAT groups. This study provides further evidence that CIMT programs can have significant impacts on functional improvement of affected UE. Overall, this study reports on all factors in the clinical question and provides further evidence for CIMT being superior in improving perception of upper extremity improvement with stroke survivors. SUMMARY OF BEST EVIDENCE Table 2: Effects of constraint-induced therapy versus bilateral arm training on motor performance, daily functions, and quality of life in stroke survivors by Lin et al. (2009) Aim/Objective of the Study/Systematic Review: The aim of this study was to compare the effects of constraint-induced movement therapy versus bilateral arm training verses a control intervention on motor capacity, functional performance, and quality of life. The researchers hypothesized that both CIMT and BAT would have better performance than the control intervention. Furthermore, CIMT and BAT would display differential benefits regarding specific outcomes measures. Study Design A randomized pre-test and post-test control group design with sixty participants who were randomized into CIT, BAT, or control intervention (CT) groups via a computer randomization scheme. Participants received independent examinations by an occupational therapist to determine eligibility in the trial. Each intervention group consisted of 20 participants and received equal intervention durations throughout the study. Each intervention received training for 2 hours daily, 5 days days/week, for 3 three weeks. These interventions were completed during regularly scheduled occupational therapy sessions with concurrent interdisciplinary stroke rehabilitation continuing as usual. Pre and post-test clinical evaluations of the Fugel-Meyer Assessment (FMA), Functional Independence Measure (FIM), Motor Activity Log (MAL), and Stroke Impact Scale (SIS) were administered by three blinded rates that were trained to properly administer the outcome measures. Setting One participating hospitals stroke rehabilitation unit where each of the three interventions were administered during regularly scheduled occupational therapy sessions. Participants Sixty participants (34 men, 26 women) with a mean age of years diagnosed with unilateral stroke.

9 All participants attended an outpatient rehabilitation program and received an independent examination by a certified occupational therapist to determine eligibility.. Inclusion was determined by the following criteria: more than 6 months after onset of an ischemic or haemorrhagic stroke, Brunnstrom stage III or above for proximal or distal parts of UE, considerable non-use of affected UE, no serious cognitive deficits (Mini-Mental State Examination), no participation in experimental drugs, or balance problems that would comprise safety during intervention. All participants were blinded to the studies hypotheses and no drop out were reported. Intervention Investigated Control Intervention involved intense training for hand function, coordination, balance, and movements of the affected upper extremity, in addition to compensatory practice on functional tasks using both affected and unaffected UE s. Experimental CIMT: The participants in this group were fitted with a restrictive mitt on the unaffected hand to hinder movement and use. The mitt was wore on the unaffected hand for six hours a day while participants underwent intensive training of the affected upper extremity during functional tasks two hours daily during the weekdays for three weeks. Functional tasks included reaching forward and upward to move a cup, picking up coins, picking up a utensil for food prep, grasping/releasing various blocks, and other functional activities related to daily living. Participants recorded the hours the mitt was worn per day and confirmed by caregivers. BAT: This intervention group focused on simultaneous movements of both the unaffected and affected UE in functional tasks. These movements were to be completed in symmetric or alternating patterns for two hours daily during weekdays for three weeks. Examples of functional tasks the BAT group completed were lifting two cups, picking up two pegs, reaching forward or upward to move blocks, and grasping/releasing two towels. However, this group did not have required at-home practice in comparison to the CIMT group. Outcome Measures (Primary and Secondary) The Motor Activity Log (MAL) examines how much and how well the subject uses their more-affected arm outside of the laboratory setting. Participants are asked standardized questions about the amount of use of their more-affected arm (Amount Scale or AS) and the quality of their movement (How Well Scale or HW) during the functional activities indicated. According to Uswatte, Taub, Morris, Vignolo, & McCulloch (2005) the MAL is reliable and valid measure of real world upper extremity use for stroke survivors undergoing CIMT. This study suggests the MAL is internally consistent, reliable and responsive to the amount of use (AOU) and quality of use (QOU) in stroke survivors with upper extremity impairment.the rating scales for the MAL (AS) and (HW) are both administered during all tests except during periodic testing, when only the HW rating scale is used. Participants should be informed that they are able to use half scores if these accurately reflect their ratings. A mean MAL score is calculated for both scales by adding the rating scores for each scale and dividing by the number of items asked. Furthermore, the administrator should avoid asking the participant to rate the more affected UE on the HW scale if previous given a score of 0 on the AS scale.the MAL amount scale is as follows: Amount Scale (AS) Rating Interpretation 0 Did not use my weaker arm 1 Occasionally used my weaker arm but only very rarely (very rarely) 2 Sometimes used my weaker arm but did the activity most with my

10 stronger arm 3 Used my weaker arm about half as much as before the stroke 4 Used my weaker arm almost as much as before the stroke (3/4 pre-stroke) 5 Used my weaker arm as often as before the stroke (same as pre-stroke) How Well (HW) Scale Rating Interpretation 0 My weaker arm was not used at all during the activity 1 My weaker arm was moved during the activity but not helpful Secondary Outcome Measures: Fugel-Meyer Assessment Functional Independence Measure Stroke Impact Scale Main Findings My weaker arm was of some use during that activity but needed some help from the stronger arm, moved very slowly, or with difficulty My weaker arm was used for that activity but the movements were slow or were made only with some effort (fair) The movements made by my weaker arm for that activity were almost normal but not quite as fast or accurate as normal The ability to use my weaker arm for that activity was as good as before the stroke The table below from Lin et al. (2009), page 445, shows the constraint-induced movement therapy rated both amount and quality of use higher after intervention in comparison to the bilateral arm training and control treatment group. Table taken from Lin et al. (2009, p. 445)

11 Original Authors Conclusions These investigators concluded that BAT may have the ability to improve proximal upper extremity motor impairment compared to CIMT. However, CIMT demonstrated significantly greater improvement in functional use of the affected upper extremity in daily life. In addition, participants in the CIMT group demonstrate improved functional independence and quality of life. Critical Appraisal Validity External Validity: A randomized trial consisting of three comparison groups but had a small sample size, which negatively influenced the studies external validity. The inclusion and exclusion criteria for this study were well define and reported no drops before, during, or after intervention. However, limited demographics given regarding subjects including only age, gender, and diagnosis. These factors may limit the generalizability of results. Internal Validity: The investigators clearly defined and monitored the methods of the three designated interventions. All subjects included in this study were recruited prospectively. A single site conducted the study. The samples of participants were selected from attendees of an outpatient rehabilitation program. The standardized outcomes measures were administered by certified, trained occupational therapists that were blinded to the participant group. Lastly, the investigators trained the three certified occupational therapist who administered the interventions to ensure consistent intervention protocols. Interpretation of Results Overall, CIMT demonstrated greater gains in perceived functional use of the affected upper extremity in daily life, increased functional independence, and positively influenced quality of life of CIMT participants. Furthermore, BAT and CIMT both improved overall upper extremity motor skills and functioning. However, CIMT could be a superior approach to improving non-use of affected arm and

12 increasing daily function, perception of improvement, and quality of life than BAT or control treatments. The results of this study are readily generalizable to other individuals with upper extremity hemiparesis following a stroke and CIMT trials performed in past studies. Summary/Conclusion This study provides significant evidence supporting CIMT effect on stroke survivor s perception of improvement with upper extremity functioning during daily living. The authors conclude that CIMT can have a significant impact on daily use and quality of life of those individuals with upper extremity impairments due to stroke. In addition, this article also demonstrated the value of BAT on motor function and how each intervention could benefit stroke survivors with upper extremity hemiparesis or impairment. This study used the MAL as an outcome measure, which includes the participant s perception of amount and quality of movement in relation to the focussed clinical question. The participants in the CIMT group exhibited greater improvements at post-test in comparison to the BAT or control treatment group. Table 2: Comparison of constraint-induced movement therapy and bilateral treatment of equal intensity in people with chronic upper-extremity dysfunction after cerebrovascular accident by Hayner et a. (2010) Aim/Objective of the Study/Systematic Review: The author s objectives for this study were to further understand CIMT through comparison of bilateral arm training, both of which are two common treatments for chronic UE dysfunction in people post stroke. Furthermore, equal intensity interventions of CIMT and BAT were explored to gain a better perspective on whether one treatment was superior to the other for chronic UE dysfunction following a stroke. Lastly, the authors hypothesized that all participants would demonstrate improved scores on the Canadian Occupational Performance Measure and maintain these gains at the follow up six months after post-test. Study Design This study was a stratified, randomized control trial with pre-test and post-test controls. All assessments were administered or supervised by a licensed occupational therapist. Participants were stratified as having more or less UE dysfunction, which was determined by their performance on the Wolf Motor Function Test (WMFT) and then blindly randomized into either the CIMT or BAT group. The outcome measures used in this study include the WMFT and the Canadian Occupational Performance Measure (COPM). All participants were treated simultaneously, in the same location, and by the same therapist to ensure interventions in both groups were of the same intensity and avoid confounding variables. The authors conducted a follow up six months after the post-test, which the raters were not blinded. The intervention was provided by three occupational therapy researchers, seven second-year masters of occupational therapy students, and four first year masters of occupational therapy students. Setting The study took place in a health sciences training facility at Samuel Merritt University, in Oakland California. Participants There were 12 participants who met the inclusion criteria set forth by the authors. Six participants were assigned to the CIMT intervention group and six to the BAT intervention group. The eligible participants were recruited from the Samuel Merritt clinic, various clinics nearby, and a local CVA support group. A two stage screening processes was initiated, which included a telephone interview to determine English speaking skills and an in-person screening consisting of the Mini-Mental Status Exam (MMSE), with a score 23. Inclusion criteria included being between 18 and 100 years old, at least 6 months post CVA with related UE dysfunction, sufficient endurance, could walk without an aid, and were available for the

13 entire duration of the study. Intervention Investigated Experimental CIMT intervention group: The participants in the CIMT group were asked to wear a padded mitt on the unaffected hand and to practice functional activities using only the affected UE. Functional tasks completed by the CIMT group included stabilizing objects, chopping vegetables, washing hands, self-feeding. The CIMT participants were allowed to use assistive devices were required to accomplish a task with one hand. An example would be the use of a universal cuff for self-feeding and scrub brush with suction cups for hand washing. Intervention was provided with six hours of occupational therapy for 10 consecutive days plus additional practice at home. The BAT intervention group: The participants in the BAT intervention group were given repetitive and intrusive cuing to use both hands during all functional activities. The authors used repetitive cueing for bilateral use of the UE even during tasks under normal circumstance would be considered unilateral. Assistive technology was not made available to the BAT group in comparison to the CIMT group. Intervention was provided with six hours of occupational therapy for 10 consecutive days plus additional practice at home. Outcome Measures (Primary and Secondary) Canadian Occupational Performance Measure (COPM) The Canadian Occupational Performance Measure (COPM) is useful to guide client-centered care by patients and therapists together identifying occupational performance problem areas with level of performance and satisfaction ratings for those areas. The various sections of the COPM includes: personal care, functional mobility, community management, work, household management, and leisure. The client rates each problem area on a 1-10 point scale, with 1 being not able or not satisfied and 10 being able to do well or extremely satisfied. Then the therapist and patient prioritize the top five areas to use as goals for therapy. The test-retest reliability for stoke on the COPM is excellent, r=0.87 for performance, and r=0.88 for satisfaction. The validity of the COPM was measured by comparison to other outcome measures that explore life satisfaction ratings. The COPM measures the participants self-rated goals of therapy in the categories of self-care, productivity, and leisure. The participant s goals were then rated on two 10 point scales describing Performance and Satisfaction with Performance. The participant rates Other Outcome Measures used: Wolf Motor Function Test Main Findings The authors reported no significant differences between the CIMT and BAT groups for descriptive statistics such as age, balance, MMSE, date of onset of CVA. In addition, no significant differences were reported on any of the pre-test assessments between the CIMT and BAT groups. For the COPM ratings of Performance and Satisfaction with Performance represented below in tables 3 and 4, significant effects were observed. For the CIMT group, the more and less impaired UE functioning groups were significantly different on the post-test (p=.026) and the follow-up test (p=.023). However, in the BAT group, the more and less impaired UE functioning groups did not have significant effects on the COPM, pre-test (p=.08) and post-test (p=.091). Furthermore, the CIMT group demonstrated a significant difference on the post-test of the COPM Satisfaction with Performance rating seen in Table 4 below. The main effects were (p=.031) post-test and during the follow an effect of (p=0.34) were reported. Lastly, both more and less impaired Bat groups reported more time spent practicing at home than either CIMT

14 group. Below are the tables 3 &4 taken from Hayner et al. (2010), describing the COPM results for Performance and Satisfaction With Performance. Original Authors Conclusions The authors concluded that both CIMT and BAT treatments appear to be an effective in improving perception of UE motor function in people post CVA with chronic UE dysfunction. According to the authors, treatment intensity rather than physical restraint of the unimpaired UE being the critical factor in improving UE dysfunction. Overall, CIMT and BAT of same frequency, duration, and intensity during functional activities are effective in increasing UE movement in people post CVA and their perception of UE use. Critical Appraisal Validity External Validity: The criterion of inclusion and exclusion were well-defined in this study. Dropouts were accounted for and well described during methods section. There was no control group in this study and the sample size was small. Furthermore, blinded randomization of participants was incorporated in the study design. However, raters during the follow up test were not blinded. Follow up was consistent between trials and all patients recruited in this study were accounted for at post-intervention

15 Internal Validity: The authors clearly describe in detail and monitor the administration of outcomes and methods of the two interventions groups. Participants were recruited in this study prospectively. Author s clearly state who administered the assessments and interventions. Furthermore, each intervention group received same intensity of treatment due to the authors treating all participants simultaneously, in same location, and by the same therapists. Patients level of UE functioning were clearly defined in the methods as either more or less impaired. Interpretation of Results The results of this study were favourable. The CIMT group exhibited significant effects on the COPM for Performance and Satisfaction with Performance in both the more and less impaired groups at post-test and six month follow-up (p=.026) and (p=.023).results from this study indicate CIMTs effectiveness for the perceived improvement of upper extremity functioning after intervention. Due to the In addition, this study demonstrated that both CIMT and BAT treatments can improve UE function in people following a stroke. These results interpreted with the validity of this study, including higher level of evidence using randomization, concise list of therapeutic activities that mimic ADLs, and multiple outcome measures, point to the benefits of therapeutic activities for intervention Summary/Conclusion This study provides evidence regarding CIMT effectiveness in improving individuals with upper extremity impairment and dysfunctions perception of improvement during functional activities. The inclusion/exclusion criteria were well defined and intervention methodology was detailed and easily replicable. This study suggests that treatment intensity is the critical therapeutic factor for improving UE dysfunction and perception among stroke survivors instead of restraint of unaffected limb. This study further investigated the effectiveness of CIMT and BAT for UE impairments in stroke survivors using comparable dosages of both interventions to reduce confounding variables. Overall, this study applies to my focused clinical question and provides evidence for CIMT and BAT as interventions for adults perception of improvement with UE impairments following a CVA. Table [x]: Characteristics of included studies Study 1 Study 2 Study 3 Wu et al., (2011) Lin et al., (2009) Hayner et al., (2010) Intervention investigated Constraint-induced movement therapy Constraint-induced movement therapy Constraint-induced movement therapy Comparison intervention Bilateral Arm Training and Control Treatment Bilateral Arm Training and Control Treatment Bilateral Arm Training Outcomes used Motor Activity Log Wolf Motor Function Test Motor Activity Log Fugel-Meyer Assessment Functional Independence Measure Stroke Impact Scale Canadian Occupational Performance Measure Wolf Motor Function Test

16 Findings The participants in the CIMT group had significantly better outcomes regarding performance and amount and quality of use of the affected UE measured by the Motor Activity Log compared to BAT or CT. The Motor Activity Log test results demonstrate enhanced perceived performance in functional activities for participants in the CIMT group. In addition, CIMT may produce greater perceived functional gains for the affected UE for stroke survivors with mild to moderate chronic hemiparesis. Gains in the COPM measures of Performance and Satisfaction with Performance at posttest experienced a slight decrease at the time of follow-up. IMPLICATIONS FOR PRACTICE, EDUCATION and FUTURE RESEARCH The evidence reviewed in this appraisal supports the use of constraint-induced movement therapy (CIMT) to address and improve stroke survivors with upper extremity hemiparesis arm functioning during daily living. In addition, evidence found in Wu et al. (2011), Lin et al. (2010), and Hayner et al.. (2010) demonstrated the overall effectiveness of BAT and CIMT for the improvement of UE dysfunction and impairment for stroke survivors. However, no evidence was found regarding the effectiveness of BAT on improved perception of upper extremity functioning in stroke survivors. Practice Clinicians should find the results of this CAT promising. More clinicians should consider using CIMT during stroke rehabilitation in adults to facilitate improved outcomes regarding patient s perception of UE improvement during ADL. Modified CIMT is feasible to provide in the clinic and may provide unique benefits to participants following a stroke that may not be addressed using bilateral arm training. To maximize validity of the protocol, occupational therapists can create and present CIMT activities, which are purposeful and meaningful in a contextually-appropriate environment. For example, instead of moving beans from one container to another, patients can repetitively practice feeding his/herself in a kitchen environment. Furthermore, outcome measures including the Motor Activity Log and COPM may be practical to administer to gain a better understanding of patients self-reported perception of recovery and improvement. Education Educational programs and occupational therapists who are not familiar with the CIMT treatment protocol should seek the appropriate continuing education for incorporating this intervention strategy into practice. Incorporating CIMT into our normal occupational based intervention for survivors of stroke is feasible for practice and may provide benefits normal stroke rehabilitation does not. It is important that occupational therapy students seek training in CIMT so that our future practice will be enhanced and patients receive the best services following a stroke. Research The evidence provided in the above studies and findings of related studies have yet to provide a concrete intervention protocol for CIMT, which clearly defines the minimum dosage and restraint necessary for clinical effectiveness at each stage post stroke. More research needs to be conducted over the effectiveness of CIMT versus BAT in adults with UE dysfunction following a stroke related to broader outcomes such as fine motor control and overall hand function as present studies typically focus on gross

17 motor control. Lastly, the barriers to implementation of a CIMT protocol such as resource intensity, patient/therapist factors, and uncertainty regarding the emerging debate that the gains seen may be a result of intense, task-specific therapy focused on the use of the more affected UE and not specific to the protocol should be further examined to ensure that patients are given access to participant in CIMT. REFERENCES Hayner, K., Gibson, G., & Giles, G. M. (2010). Comparison of constraint-induced movement therapy and bilateral treatment of equal intensity in people with chronic upper-extremity dysfunction after cerebrovascular accident. The American Journal of Occupational Therapy, 64(4), Lieberman, D., & Scheer, J. (2002). AOTA s evidence-based literature review project. An overview. Evidence-Based Practice Forum, 56(3), Lin, K. C., Chang, Y. F., Wu, C. Y., & Chen, Y. A. (2009). Effects of constraint-induced therapy versus bilateral arm training on motor performance, daily functions, and quality of life in stroke survivors. Neurorehabilitation and Neural Repair, 23(5), Nichols-Larsen, D.S., Clark, P.C., Zeringue, A., Greenspan, A., & Blanton, S. (2005). Factors influencing stroke survivors quality of life during subacute recovery. Stroke, 36(7), Stewart, K. C., Cauraugh, J. H., & Summers, J. J. (2006). Bilateral movement training and stroke rehabilitation: a systematic review and meta-analysis. Journal of the neurological sciences, 244(1), Uswatte, G., Taub, E., Morris, D., Vignolo, M., & McCulloch, K. (2005). Reliability and validity of the upper-extremity Motor Activity Log-14 for measuring real-world arm use. Stroke, 36(11), Wolf, S. L., Winstein, C. J., Miller, J. P., Taub, E., Uswatte, G., Morris, D.,... & Nichols-Larsen, D. (2006). Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke. JAMA: the journal of the American Medical Association, 296(17), Wu, C. Y., Chuang, L. L., Lin, K. C., Chen, H. C., & Tsay, P. K. (2011). Randomized trial of distributed constraint-induced therapy versus bilateral arm training for the rehabilitation of upper-limb motor control and function after stroke. Neurorehabilitation and neural repair, 25(2),