Modified Constraint-Induced Therapy in Subacute Stroke: A Case Report

Transcription

1 286 CLINICAL NOTE Modified Constraint-Induced Therapy in Subacute Stroke: A Case Report Stephen J. Page, PhD, SueAnn Sisto, PhD, PT, Mark V. Johnston, PhD, Peter Levine, BA, PTA, Mary Hughes, OTR ABSTRACT. Page SJ, Sisto S, Johnston MV, Levine P, Hughes M. Modified constraint-induced therapy in subacute stroke: a case report. Arch Phys Med Rehabil 2002;83: Objective: To determine the efficacy of a modified constraint-induced therapy (CIT) protocol administered to a patient with subacute stroke. Design: Multiple-baseline, before-after trial. Setting: Subacute outpatient clinic. Patient: A 68-year-old woman who had a left anterior cerebral artery infarct 5 months before study entry and who exhibited learned nonuse of the affected upper limb. Intervention: Thirty minutes of structured physical therapy and 30 minutes of occupational therapy 3 times a week for 10 weeks, each session emphasizing affected arm use. During the same period, her unaffected arm and hand were restrained 5d/wk during 5 hours initially identified as a time of frequent use. Main Outcome Measures: The Fugl-Meyer Assessment of Motor Recovery (FMA), Action Research Arm Test (ARA), Wolf Motor Function Test (WMFT), and Motor Activity Log (MAL). Results: The patient exhibited substantial improvements on the FMA and ARA. She also improved on the WMFT in her ability to perform tasks and in the time taken to complete the tasks. Amount and quality of arm use also improved, as measured by the MAL. Conclusions: Modified CIT may be an efficacious method of improving function and use of the affected arms of patients with learned nonuse. Key Words: Cerebrovascular accident; Exercise therapy; Rehabilitation by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation UPPER LIMB HEMIPARESIS is a confounding clinical effect of cerebrovascular accident (CVA) and is the primary impairment underlying disability after CVA. 1-3 Because From the Kessler Medical Rehabilitation Research & Education Corp, West Orange, NJ (Page, Sisto, Johnston, Levine); and Physical Medicine and Rehabilitation, University of Medicine and Dentistry New Jersey Medical School, Newark, NJ (Page, Sisto, Johnston). Hughes was formerly affiliated with Kessler Institute for Rehabilitation, Inc, West Orange, NJ. Accepted in revised form March 20, Supported by the American Heart Association, Heritage Affiliate, and the National Institute on Disability and Rehabilitation Research (grant no. H 133P ). Presented in part at the American Congress of Rehabilitation Medicine s annual assembly, October 20, 2000, Hilton Head, SC. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. Reprint requests to Stephen J. Page, PhD, Kessler Medical Rehabilitation Research and Education Corp, 1199 Pleasant Valley Way, West Orange, NJ /02/ $35.00/0 doi: /apmr of its impact on ability to perform activities of daily living (ADLs), interventions to reduce upper limb hemiparesis are a priority. Studies showed that, when a forelimb was deafferented in a monkey, the animal did not make use of it in the free situation. However, the monkey was made to use the deafferented limb by restrainting the intact limb and applying operant conditioning. 4,5 Taub 5 hypothesized that nonuse of the affected upper limb in humans after CVA could result from a similar learned suppression phenomenon, termed learned nonuse. Building on this work, researchers 6-10 restrained the unaffected arms of chronic patients with CVA (patients who had a stroke 1yr before study entry) for approximately 14 hours each day for 2 weeks while patients performed purposeful activities with the affected arm for 6hr/d on 10 consecutive weekdays. These studies and a randomized, controlled study 11 suggest that this constraint-induced movement therapy (CIT) increases use and function of the affected upper limb in chronic CVA. A case study 12 also documented improvements in a patient with subacute CVA who experienced a stroke 4 months before intervention. Although efficacious, findings from a survey 13 measuring patients and therapists opinions of CIT suggest that its clinical implementation is limited. Specifically, when CIT was described in an excerpt from a case report 12 : (1) 68% of patients with CVA said that they would not want to participate in the protocol; (2) two thirds of the patients who said that they would participate in CIT conceded that they were somewhat or extremely unlikely to adhere to the CIT protocol; and (3) more than 80% of the patients felt that, if the protocol lasted for more weeks, with shorter physical therapy (PT) and occupational therapy (OT) sessions, and/or fewer hours wearing the restictive devices, they would participate. Among therapists surveyed, more than 60% felt that patients were extremely unlikely to adhere to such a protocol, with the primary reasons being the amount of time wearing the restictive device and the number of practice hours. Moreover, over 70% of therapists felt that most facilities did not have the resources needed to implement CIT. In reference to the restictive device use schedule, therapists were concerned with compromises in independent activities and safety. With regard to the practice component, they noted that some clinics may lack adequate resources or personnel to engage patients for 6 hours per day. A funded, multicenter CIT trial is underway. Even if convincing data are obtained, however, the intensity of the therapy and restraint components make the CIT protocol less clinically feasible and not reimbursable under many health plans. A CIT protocol that could be implemented would enable more clinics to use the therapy without increasing patient attrition or compromising staffing. Motor learning research suggests that different practice schedules could lead to similar outcomes. 14 We wanted to examine the efficacy of a modified CIT protocol that features treatment parameters within managed care limits and that is implementable on an outpatient basis. Because previous CIT studies in subacute CVA 12 used only the Wolf Motor

2 MODIFIED CONSTRAINT-INDUCED THERAPY, Page 287 Function Test (WMFT) and Motor Activity Log (MAL) as outcome measures, we also wanted to pilot test the sensitivity and acuity of more established outcome measures with a patient with a subacute CVA who had participated in modified CIT. The following data were collected before initiation of a larger study to determine the feasibility and efficacy of a modified CIT protocol with patients with subacute CVA. METHODS Instruments The Fugl-Meyer Assessment of Motor Recovery 15 (FMA) assesses several impairment dimensions and has been extensively used in studies with CVA patients, including the only randomized, controlled CIT trial. 11 We used the 66-point upper extremity FMA motor component. Its specific items were derived from Brunnstrom s 6 stages of post-cva motor recovery, 16 with data derived from a 3-point ordinal scale (0 cannot perform; 1 can perform partially; 2 can perform fully) applied to each item. The FMA has impressive test-retest reliability (total.98.99; subtests ), 17 interrater reliability, 17 and construct validity. 18 The Action Research Arm Test 19 (ARA) is a 19-item test divided into 4 categories (grasp, grip, pinch, gross movement), with each item graded on a 4-point ordinal scale (0 can perform no part of the test; 1 performs test partially; 2 completes test but takes abnormally long time or has great difficulty; 3 performs test normally) for a total possible score of 57. The test is hierarchical in that if a patient is able to perform the most difficult skill in each category, then he/she can perform the other items within the category and, thus, those items need not be tested. The test has high intrarater (r.99) and retest (r.98) reliability, 19 can be quickly completed, correlates highly with many functional outcome measures, 20 and has also been used in CIT research. 11 Using previous studies, 6,7 the WMFT was used to measure the patient s performances on 19 limb movements and tasks with the affected arm. Two items measured strength and 17 items were timed and scored by a blinded rater. The WMFT has also been widely used in CIT studies. 6,7,9,10,12 The MAL is a semistructured interview measuring how patients use their affected limb for ADLs in the home. In separate MAL interviews, patient and caregiver are asked to rate independently how much and how well the patient has used the affected arm for 30 ADLs during the past week. Both patient and caregiver use a 6-point amount of use scale to rate how much the patient is using the affected arm and a 6-point quality of movement scale to rate how well the patient is using it. Tasks include classic ADLs, such as brushing teeth, buttoning a shirt or blouse, and eating with a fork or spoon. Because our patient s caregiver did not speak English, we administered the MAL to the patient only. Case Description Four recruitment letters were sent to patients who had experienced a CVA and had been discharged from outpatient therapy at a rehabilitation hospital. A research assistant screened 2 individuals who responded to the letters; the first respondent did not meet the motor inclusion criteria. Motor inclusion criteria from previous CIT studies 6,7 were applied and included active extension of the affected wrist greater than 10, active extension of the metacarphalangeal and interphalangeal joints of the thumb, and 10 of active extension in at least 2 additional digits. Other inclusion criteria were: (1) CVA experienced between 4 weeks and 6 months before study enrollment; (2) a score of 70 or higher on the Modified Mini-Mental Status Examination 21 ; (3) no hemorrhagic or bilateral lesions; (4) age between 18 and 95 years; (5) no excessive spasticity in the affected limb, as defined by a score of 2 or more on the Modified Ashworth Scale 22 ; (6) no excessive pain in the affected limb, as defined by a score of 4 or more using a visual analog scale; (7) completely discharged from all forms of physical rehabilitation; and (8) not participating in any experimental rehabilitation or drug studies. The participant described here was chosen because she met inclusion criteria, was motivated, and was willing to follow intervention guidelines. The subject was a 68-year-old, right-handed, woman with a history of hypertension, hypercholesteroma, and obesity. Five months prior to study entry, she experienced sudden, rightsided weakness, and some slurring of speech while resting at home. A computed axial tomography revealed a left anterior cerebral artery infarct. At hospital admission, gross motor tests revealed scores of 5/5 in the left extremities, 2/5 in the right biceps, 2/5 in the right triceps, 2/5 in the fingers, 3/5 for right wrist, hip flexion, and knee extension, and 2/5 for right ankle dorsiflexion. After 18 days of inpatient rehabilitation, which included PT, OT, and speech therapy, she was discharged to return home. At discharge, she required assistance with most ADLs, including some grooming activities, as well as feeding, dressing, negotiating stairs, toileting, showering, and transferrings to the bed and wheelchair. Her comprehension, problem solving, and memory were normal. Initial screening determined that her physical and cognitive conditions had not changed since discharge. The patient could move the affected arm outside of synergy, but an informal interview and a formal assessment using the MAL each revealed that she was making few attempts to use the affected arm for ADLs, although she was right side dominant. We concluded that she was exhibiting learned nonuse. 4 Testing and Intervention Procedures After screening for inclusion, the patient signed approved informed consent forms. The FMA and ARA were then administered on 2 occasions during the pretesting period, and the MAL and WMFT were administered during 1 pretesting session. All instruments were administered by a blinded rater. Therapy for more than 70% of outpatients with CVA attending therapy in our hospital is reimbursed by Medicare. Thus, an intervention that fell within the allowable 30-session Medicare limit was a logical choice. Therefore, the intervention consisted of having the patient participate in 30 minutes of PT and 30 minutes of OT 3 times a week for 10 weeks, which equaled the 30-session limit typically allowed by Medicare. Because there is no optimal therapy for patients with CVA, 23,24 and because proprioceptive neuromuscular facilitation (PNF) approaches are frequently applied in our clinic, approximately 80% of each PT and OT session focused on PNF techniques. Most PNF OT concentrated on affected limb use in functional tasks (eg, writing, opening containers, folding clothes, hanging a coat), with some wrist and arm strengthening. Most PT concentrated on affected upper limb stretching, dynamic stand and balance activities, and gait training. Approximately 20% of the therapy sessions focused on compensatory techniques in which the unaffected side was used (eg, reaching and performing functional tasks with the unaffected arm, assisting the weak arm during reaching tasks). Shaping is a commonly used operant conditioning method in which a behavioral objective (in this case, movement) is approached in small steps of progressively increasing difficulty. The participant is rewarded with enthusiastic approval for improvement, but never blamed (punished) for failure. In CIT, a basic principle is to keep extending motor capacity a small increment beyond the performance level already achieved. In addition to other tasks practiced during

3 288 MODIFIED CONSTRAINT-INDUCED THERAPY, Page Table 1: Subject s Scores on the ARA and FMA During Pre- and Posttesting Sessions Measure Pretest Session 1 Pretest Session 2 Posttest FMA (total score, 66) ARA (total score, 57) therapy sessions, the patient identified 2 functional tasks on the WMFT that were highly valued, and these tasks were recorded on the subject data sheet. During therapy sessions, each previously identified skill was practiced for at least 5 minutes. One occupational therapist and 1 physical therapist, each with 10 years experience, administered therapy. Both were blinded to the patient s instructions to wear the sling at home. Previous CIT studies 7,10,11 have provided patients with approximately 140 hours of restriction. Since limb restriction is thought to be an important therapeutic factor, during the same 10-week period, our subject s unaffected arm and hand were restrained every weekday for 5 hours that were initially identified as a time of frequent arm use, resulting in 250 hours of sling use during the 10-week period (25hr/wk 10wk). The arm was restrained using a cotton hemisling. a The sling had a single strap worn around the neck and under the arm, supporting the elbow and the forearm. The hand was placed in a mesh, polystyrene-filled mitt with a Velcro strap around the wrist. a Because the woman wore the restraint devices at home, a log was kept to document actual restriction time and the activities performed during restraint hours. The instruments were administered again by the blinded rater 1 week after therapy termination. RESULTS Scores on the FMA and ARA remained consistent between pretesting sessions. After intervention, there was a 6-point improvement on the ARA and a 20-point improvement on the FMA (table 1). Improvements on the WMFT were seen both in ability to perform tasks and in time taken to complete the tasks (table 2). Table 2: Ratings of Subject s Task Performance and Time Taken to Complete Each Task on the WMFT Task Pretest Posttest Rating Time (s) Rating Time (s) Forearm to table Forearm to box Extend elbow Extend elbow weight Hand to table Hand to box Reach and retrieve Lift can Lift pencil Lift paperclip Stack checkers Flip cards Turn key in lock Fold towel Lift basket lb weight to box Grip strength (kg) NOTE. Patient was given a maximum of 120 seconds to complete tasks. One trial was provided for each task. Table 3: Mean and Change Scores on the MAL Between Pretest and Posttest Pretest Posttest Pretest to Posttest Change Score No. of activities regularly performed (AOU) 8 (.26) 13 (2.43) 5 Average QOU score Abbreviations: AOU, amount of use scale (range, 30); QOU, quality of movement scale. MAL scores improved between pre- and posttesting sessions (table 3). Specifically, before treatment, the patient reported using the affected limb for 8 of 30 functional activities, with an average quality of movement scale score of 2.5 (range, 0 3). After intervention, use of the limb increased to 13 of 30 activities, with an average quality of movement score of 4.3. The quality of movement scores after intervention ranged from 2to5. In-clinic interviews every 2 to 3 weeks, weekly telephone calls to the patient s home, and a restrictive device wear log established that adherence to the restrictive device wear schedule was not an issue. The log also showed that the patient was actively attempting to use her arm when the restrictive devices were being worn for ADLs such as preparing meals, folding laundry, and using the telephone. DISCUSSION The CIT protocol, although efficacious, may be difficult to implement without extra clinical resources, is not reimbursable under many managed care plans, and its restrictive device schedule may be difficult for patients without substantial support. 13 This single-subject trial describes a patient 5 months post-cva who exhibited learned nonuse and stable motor deficits prior to intervention. After intervention, she reported using the affected arm more frequently and effectively, as measured by the MAL. Furthermore, the patient showed substantial reductions in impairment, as measured by the FMA, and improvements in arm function, as measured by the ARA and WMFT. Also on the WMFT, the patient displayed improved speed on 2 tasks, and added 6 tasks as new abilities. Five tasks were completed with improved quality and slower time: time increases were negligible in 2 tasks (hand to table, hand to box), and the patient did not display adequate strength to perform the other 3 quickly (extend elbow with weight, reach and retrieve, lift basket). Although improvements were seen in some gross items on the FMA, ARA, and WMFT, and she showed increased ability to move out of synergy with the affected arm, most improvements were in fine motor skill items (eg, wrist and finger movements on the FMA, gripping and grasping movements on the ARA, folding towels and flipping cards on the WMFT). She also improved on shaping tasks chosen at preintervention (folding towels, playing solitaire with cards). Functionally, after intervention, the patient reported performing ADLs in her home that she could not previously perform, including meal preparation with minimal assistance, telephone use, self-grooming with minimal assistance, feeding herself with minimal assistance, and dressing with minimal assistance. Previous CIT studies 7,12 reported similar functional gains. This study, however, is significant in that it showed that a modified CIT, which can be implemented within most clinics, can overcome learned nonuse and facilitate functional improvements. This is an important contribution that could eventually make CIT accessible to more patients. An additional

4 MODIFIED CONSTRAINT-INDUCED THERAPY, Page 289 Table 4: Comparison of Parameters of CIT Versus Modified CIT Therapy Hours of Practice/d Total Practice Hours Hours of Restrictive Device Use/d Total Hours of Use CIT * 140 Modified CIT * Presumes that the individual is awake for 14hr/d. Amount of restrictive device wear may vary from patient to patient, depending on how long individuals are awake on a given day. contribution of this study is its initial validation of efficacious practice, and restrictive device schedules of shorter daily durations than in previous CIT studies (table 4). This may improve compliance with less motivated patients. Learned nonuse is believed to occur when patients with CVA, after repeated unsuccessful attempts with the affected limb, stop using the affected limb and, instead, concentrate on using the intact limb. Learned nonuse may also be encouraged by therapists who, to diminish length of stay, emphasize compensatory strategies while reducing the focus on affected limb retraining. A plausible explanation for our findings is that through participation in the therapy and sling components, each of which forced use of the affected side, the patient was reconditioned to use the affected limb. This speculation is corroborated by the improved MAL scores on amount of use, and by the patient, who reported using the limb much more at home. Given previous findings of cortical reorganizations after CIT, 25 the possibility of treatment-induced reorganization resulting from forced use cannot be ruled out as a possible factor. We encourage others to investigate the potential reorganizing properties of the protocol described here. The WMFT was again shown to be a useful measure. 7,8,10-12 One purpose of this study was to determine the sensitivity of the FMA and ARA after a patient s exposure to this intervention. Results showed that both instruments were sensitive enough to determine an effect, with the patient showing particular improvement in gross movements with the wrist and arm on the FMA, and in gripping behaviors on the ARA. Given that the FMA places greater emphasis on gross motor tasks, with some attention to fine motor skills, and vice versa for the ARA, these instruments may comprise an optimal package with which to measure the efficacy of a modified CIT, although more investigation is warranted. MAL scores confirmed that the patient was using the affected arm more and using it more effectively. Indeed, prior to intervention, she used her arm for only 8 of the 30 listed activities and her MAL amount of use scores were 1 or lower. After intervention, she reported attempting 13 activities on a regular basis. Improvements in quality of use (table 3) appear to corroborate FMA, ARA, and WMFT scores. However, we also believe that the patient s MAL may not reflect the true changes in her arm use for 3 reasons: (1) many of the tasks most meaningful to her, including cooking and cleaning, are not on the MAL; (2) the MAL applies self-report techniques, making ratings liable to inability to recall limb use; and (3) preand postintervention, the patient had a home health aide performing many of the ADLs that she would otherwise have performed independently. Ability to recall limb use could have been improved, to some extent, had we been able to administer the MAL to the caregiver. Accelerometers offer more accurate, objective assessment of arm use and are a valid measure of activity. 26 We encourage future researchers to use accelerometers to quantify amount of limb use. At study enrollment, medical discharge records, and therapist and physiatrist observations each indicated that the patient was at the same functional level as when she was discharged from the hospital 4 months before the study, suggesting a stable motor deficit. This, combined with the stable scores the patient displayed during preintervention, and her rapid progress in a relatively short time, make it unlikely that her improvement was attributable to natural recovery. CONCLUSION Many facilities may have CVA patients with learned nonuse who are receiving traditional therapy regimens. Study outcomes suggest the efficacy of an alternative CIT protocol for patients seen in clinics where the traditional CIT protocol is not practical. Given the high adherence and positive outcomes, data from this study provide the impetus for randomized, controlled studies of modified CIT with patients with CVA in the subacute phase who exhibit learned nonuse. References 1. Carr J, Shephard R. Neurological rehabilitation: optimizing motor performance. Oxford: Butterworth-Heinemann; Trombley CA. Occupational therapy for physical dysfunction. 4th ed. Baltimore: Williams & Wilkins; O Sullivan SB. Stroke. In: O Sullivan SB, Schmitz TJ, editors. Physical rehabilitation: assessment and treatment. Philadelphia: FA Davis; p Taub E. Motor behavior following deafferentation in the developing and motorically mature monkey. In: Herman R, Grillner S, Stein P, Stuart D, editors. Neural control of locomotion. New York: Plenum; p Taub E. Movement in nonhuman primates deprived of somatosensory feedback. Exerc Sport Sci Rev 1977;4: Wolf S, LeCraw DE, Barton LA, Jann BB. Forced use of hemiplegic upper extremities to reverse the effect of learned nonuse among chronic stroke and head-injured patients. Exp Neurol 1989; 104: Taub E, Miller NE, Novack TA, et al. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil 1993; 74: Miltner W, Bauder H, Sommer M, Dettmers C, Taub E. Effects of constraint-induced movement therapy on patients with chronic motor deficits after stroke: a replication. Stroke 1999;30: Kopp B, Kunkel A, Muhlnickel W, Villringer K, Taub E, Flor H. Plasticity in the motor system related to therapy-induced improvement of movement after stroke. Neuroreport 1999;10: Kunkel A, Kopp B, Muller G, Villringer K, Villringer A, Taub E, et al. Constraint-induced movement therapy for motor recovery in chronic stroke patients. Arch Phys Med Rehabil 1999;80: Van der Lee JH, Wagenaar RC, Lankhorst GJ, Vogelaar TW, Deville WL, Bouter LM. Forced use of the upper extremity in chronic stroke patients: results from a single-blind randomized clinical trial. Stroke 1999;30: Comment in: Stroke 2000; 31: Blanton S, Wolf SL. An application of upper extremity constraintinduced movement therapy in a patient with subacute stroke. Phys Ther 1999;79: Page SJ, Levine P, Sisto S, Bond Q, Johnston M. Stroke patients and therapists opinions of constraint-induced movement therapy. Clin Rehabil In press. 14. Magill R. Motor learning. 5th ed. Boston: WCB/McGraw-Hill; Fugl-Meyer AR, Jääskö L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient. I. A method for evaluation of physical performance. Scand J Rehabil Med 1975;7: Brunnstrom S. Movement therapy in hemiplegia: a neurophysiological approach. New York: Harper & Row; Duncan PW, Propst M, Nelson SG. Reliability of the Fugl-Meyer assessment of sensorimotor recovery following cerebrovascular accident. Phys Ther 1983;63: DiFabio RP, Badke RB. Relationship of sensory organization to balance function in patients with hemiplegia. Phys Ther 1990;70:

5 290 MODIFIED CONSTRAINT-INDUCED THERAPY, Page 19. Lyle RC. A performance test for assessment of upper limb function in physical rehabilitation treatment and research. Int J Rehabil Res 1981;4: DeWeerdt WJ, Harrison MA. Measuring recovery of arm-hand function in stroke patients: a comparison of the Brunnstrom-Fugl- Meyer test and the action research arm test. Physiother Can 1985;37: Teng EL, Chui HC. The Modified Mini-Mental State (3MS) examination. J Clin Psychiatry 1987;48: Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 1987;67: Logigian MK, Samuels MA, Falconer J, Zagar R. Clinical exercise trial for stroke patients. Arch Phys Med Rehabil 1983;64: Lord J, Hall K. Neuromuscular reeducation versus traditional programs for stroke rehabilitation. Arch Phys Med Rehabil 1986; 67: Liepert J, Bauder H, Wolfgang HR, Miltner WH, Taub E, Weiller C. Treatment-induced cortical reorganization after stroke in humans. Stroke 2000;31: Veltnic PH, Bussman HB, de Vries W, Martens WL, Van Lummel RC. Detection of static and dynamic activities using maximal accelerometers. IEEE Trans Rehabil Eng 1996;4: Supplier a. Sammons-Preston, PO Box 5071, Bolingbrook, IL