9/9/2016. By: Erica Ogilvie Rehab 540 Stroke Rehab University of Alberta Northwestern Ontario Regional Stroke Network

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1 By: Erica Ogilvie Rehab 540 Stroke Rehab University of Alberta Northwestern Ontario Regional Stroke Network Referred to as J.S. 60 year old Caucasian female 6 weeks post ischemic stroke Middle Cerebral Artery (MCA) infarct in the motor cortex Contralateral hemiparesis Right hand dominant Candidate for tpa PmHx: hypertension, dyslipidemia, smoker SHx: retired teacher and enjoys sewing and playing the guitar Independent with ADLs/IADLs prior to admission 1

2 Upper-Extremity Outcome Measures Fugl-Meyer Assessment (FMA)- upper-extremity section Nine Hole Peg Test (NHPT) Chedoke McMaster Arm and Hand Activity Inventory (CAHAI) Scores Right hand= 50/66 Left hand= 65/66 Right hand= 145 seconds Left hand= 20 seconds Right hand= 40/91 Left hand= 91/91 Intact gross motor movements Limited manual dexterity skills Good static and dynamic balance No cognitive or speech deficits Goals: return to sewing, playing guitar, and writing o OT interested in trialing mcimt to improve manual dexterity skills. 2

3 CIMT was developed by Edward Taub and colleagues in Based on the theory of neuroplasticity and cortical reorganization to treat learned non-use phenomenon. Forced use of the affected upper-limb through the use of a restraint (i.e. sling or splint) for at least 90% of the individual s waking hours and intense massed/functional practice 6 hours a day for 2-3 weeks. mcimt is a less intense treatment (i.e. less therapy and restraint time) compared to traditional CIMT. 3

4 How effective is modified constraint-induced movement therapy (mcimt) compared to traditional therapies in improving manual dexterity in adults with upper-extremity hemiparesis as a result of a subacute ischemic or hemorrhagic stroke postintervention? 4

5 1 Guideline 3 Systematic Reviews 2 Single Blinded Randomized Control Trials 1 Cohort Study 2015 Canadian Stroke Best Practice Recommendations LOE: Early-Level A; Late-Level A Support demonstrated for the use of CIMT and mcimt protocols in rehabilitation. Appropriate for individuals who have some active wrist and finger movements. Not appropriate for individual s who have sensory or cognitive deficits. Stage of stroke recovery is not defined. 5

6 3 Systematic Reviews Each SR selected examined the effects of mcimt during the subacute phase. Action Research Arm Test (ARAT) most commonly used outcome measure in each trial selected to detect changes in grasp, grip, and pinch movements (i.e. manual dexterity skills). Modified constraint-induced movement therapy versus traditional rehabilitation in patients with upper-extremity dysfunction after stroke: A systematic review and metaanalysis Published in 2011 by Shi, Tian, Yang, & Zhao. LOE: level 1a. Examined mcimt versus TR in patients with a paretic upperextremity within the acute, subacute, or chronic stage of stroke recovery. 5 RCTs included in this review measured changes on the ARAT between the two study groups in the subacute phase. Results demonstrated a higher ARAT score in the mcimt group post-intervention favouring the experimental group. Stage of stroke recovery benefited most from mcimt intervention not outlined. 6

7 Constraint-induced movement therapy for the upper paretic limb in acute or sub-acute stroke: A systematic review Published in 2011 by Nijland, Kwakkel, Bakers, and van Wegen. LOE: level 1a. Studied the effectiveness of CIMT and mcimt compared to traditional therapy during the acute or subacute phase. Significant effect favouring CIMT/mCIMT groups demonstrated within the subacute phase. mcimt is more beneficial during the acute and subacute phase of recovery due to protocol feasibility and participant compliance. Modified constraint-induced movement therapy for upper extremity recovery post stroke: What is the evidence? Published in 2014 by Fleet et al. LOE: level 3a. 4 RCT s compared mcimt to traditional therapy in the subacute phase of stroke recovery. mcimt protocol 30 minute sessions, 3 times per week, and over a 10-week period. Significant effect demonstrated within the mcimt group 10 weeks post intervention. 7

8 Pre- to posttest change scores for the Action Research Arm Test (ARAT) for studies examining patients in the chronic (A), subacute (B), and acute (C) stage of recovery. The dashed line represents the minimal clinically important difference (MCID), with inverted triangles, squares, and circles representing the mcimt, usual care therapy, and no-therapy groups, respectively. Note: Atteya35 used a no-therapy group, but did not report the scores. Figure 1 obtained from systematic review by Fleet et al. (2014). Modified constraint-induced movement therapy improved upper limb function in subacute post-stroke patients: A small-scale clinical trial Published in 2012 by Treger, I., Aidinof, L., Lehrer, H., & Kalichman, L. LOE: level 1b. Compared mcimt to a standard rehabilitation group to improve paretic arm function in patients during the subacute period. Three functional tasks assessed: 1) transferring pegs from a saucer to a pegboard, 2) grasp, carry, and release a hard rubber ball, 3) eating using a spoon. Statistically significant differences (P-value <0.05) were demonstrated 1 month post-intervention within the mcimt group and between the two study conditions. 8

9 A study of constraint-induced movement therapy in subacute stroke patients in Hong Kong Published in 2008 by Myint et al. LOE: level 1b. Compared the effectiveness of mcimt compared to TR postintervention (2 weeks) and at 12 weeks. NHPT outcome measure selected. Post-intervention: 16 individuals in the mcimt group and 9 patients in the control were able to complete NHPT assessment (P-value= 0.022) statistically significant effect. 12 weeks: 18 individuals in the mcimt group and 10 in the control group could complete NHPT (P-value ) statistically significant effect. Limitation: Not true mcimt protocol as participants were expected to be in the restraint 90% of the time. Outcome Measure Nine Hole Peg Test Able to complete test at baseline Able to complete test postintervention Able to complete test at 12 week follow-up mcimt Control Test for difference between groups 9 (34.8%) 6 (30%) Chisquare= (69.9%) 9 (45%) Chi-square= (78.3%) 10 (50%) Chi-square= 4.77 *= Statistically Significant Obtained from RCT by Treger et al. (2008). P-value * * 9

10 Recovery of upper extremity motor function post stroke with regard to eligibility for constraintinduced movement therapy. Published in 2011 by Brunner et al. LOE: level 2b. Conducted to determine if CIMT and mcimt are appropriate interventions to use in the subacute phase. NHPT conducted at baseline and 2 weeks postintervention. Significant effect demonstrated (P-value of <.001) regarding dexterity skills of the paretic upper-limb from baseline to post-intervention. No control used in this study. Clinical Case J.S. OT should trial mcimt intervention with J.S. to improve manual dexterity skills as statistically significant improvements favouring mcimt over TR in the subacute phase were found in the literature. mcimt will increase her participation in sewing activities, writing, and playing the guitar. Limitation: unclear which mcimt protocol would be most beneficial to use with J.S. at this time. 10

11 Increased mcimt studies within the acute/subacute stroke populations Large RCTs> 100 participants Standardized mcimt protocol Long-term effects of mcimt Questions?? 11

12 Aloraini, S. M., Mackay-Lyons, M., Boe, S., & McDonald, A. (2014). Constraint-induced movement therapy to improve paretic upper-extremity motor skills and function of a patient in the subacute stage of stroke. Physiotherapy Canada.Physiotherapie Canada, 66(1), doi: /ptc [doi] Atteya, A. A. (2004). Effects of modified constraint induced therapy on upper limb function in subacute stroke patients. Neurosciences (Riyadh, Saudi Arabia), 9(1), doi: [pii] Brunner, I. C., Skouen, J. S., & Strand, L. I. (2011). Recovery of upper extremity motor function post stroke with regard to eligibility for constraint-induced movement therapy. Topics in Stroke Rehabilitation, 18(3), doi: /tsr [doi] Dromerick, A. W., Edwards, D. F., & Hahn, M. (2000). Does the application of constraint-induced movement therapy during acute rehabilitation reduce arm impairment after ischemic stroke? Stroke; a Journal of Cerebral Circulation, 31(12), Dromerick, A. W., Lang, C. E., Birkenmeier, R. L., Wagner, J. M., Miller, J. P., Videen, T. O., et al. (2009). Very early constraint-induced movement during stroke rehabilitation (VECTORS): A single-center RCT. Neurology, 73(3), doi: /wnl.0b013e3181ab2b27 [doi] Fleet, A., Page, S. J., MacKay-Lyons, M., & Boe, S. G. (2014). Modified constraint-induced movement therapy for upper extremity recovery post stroke: What is the evidence? Topics in Stroke Rehabilitation, 21(4), doi: /tsr [doi] Hebert, D., Lindsay, M. P., McIntyre, A., Kirton, A., Rumney, P. G., Bagg, S., et al. (2016). Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update International Journal of Stroke : Official Journal of the International Stroke Society, 11(4), doi: / [doi] Myint, J. M., Yuen, G. F., Yu, T. K., Kng, C. P., Wong, A. M., Chow, K. K., et al. (2008 February). A study of constraint-induced movement therapy in subacute stroke patients in Hong Kong. Clinical Rehabilitation, 22(2), Nijland, R., Kwakkel, G., Bakers, J., & van Wegen, E. (2011). Constraint-induced movement therapy for the upper paretic limb in acute or subacute stroke: A systematic review. International Journal of Stroke : Official Journal of the International Stroke Society, 6(5), doi: /j x [doi] Page, S. J., Levine, P., Leonard, A., Szaflarski, J. P., & Kissela, B. M. (2008). Modified constraint-induced therapy in chronic stroke: Results of a single-blinded randomized controlled trial. Physical Therapy, 88(3), doi: /ptj [doi] Page, S. J., Levine, P., & Leonard, A. C. (2005). Modified constraint-induced therapy in acute stroke: A randomized controlled pilot study. Neurorehabilitation and Neural Repair, 19(1), doi:19/1/27 [pii] Page, S. J., Sisto, S., Johnston, M. V., & Levine, P. (2002). Modified constraint-induced therapy after subacute stroke: A preliminary study. Neurorehabilitation and Neural Repair, 16(3), Page, S. J., Sisto, S., Johnston, M. V., Levine, P., & Hughes, M. (2002). Modified constraint-induced therapy in subacute stroke: A case report. Archives of Physical Medicine and Rehabilitation, 83(2), doi:s [pii] Page, S. J., Sisto, S. A., Levine, P., Johnston, M. V., & Hughes, M. (2001). Modified constraint induced therapy: A randomized feasibility and efficacy study. Journal of Rehabilitation Research and Development, 38(5), Stroke Engine. (2016). Constraint Induced Movement Therapy (CIMT). Shi, Y. X., Tian, J. H., Yang, K. H., & Zhao, Y. (2011). Modified constraint-induced movement therapy versus traditional rehabilitation in patients with upper-extremity dysfunction after stroke: A systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation, 92, Treger, I., Aidinof, L., Lehrer, H., & Kalichman, L. (2012). Modified constraint-induced movement therapy improved upper limb function in subacute poststroke patients: A small-scale clinical trial. Topics in Stroke Rehabilitation, 19(4), doi: /tsr [doi] 12