1 Title: Modified constraint-induced movement therapy is effective for improving functional ability of the affected upper limb in comparison to traditional rehabilitation for adults following a cerebrovascular accident more than one year ago. Prepared by: Kassi Mikshowsky (mikshows.kass@uwlax.edu) Date: December 9, 2010 Review date: December 9, 2012 CLINICAL SCENARIO: Client population: Adults who have suffered a cerebrovascular accident more than one year ago Treatment context: Outpatient clinic Problem/condition: The problem/condition for this CAT is hemiplegia/hemiparesis which leads to decreased functional use of the client s affected upper extremity. Explain why problem is so important for occupational therapists to treat: According to Pendleton (2006), Each year, 700,000 people suffer a new or recurrent stroke. Approximately 500,000 strokes are first attacks, and 200,000 are recurrent. And among the long-term care clients who have sustained a stroke, 50% have hemiparesis (p. 803). Hemiplegia/hemiparesis in cerebrovascular accident patients is an area that occupational therapy can help treat through the use of modified constraint-induced movement therapy. This is important for occupational therapists to treat because only having the ability to complete daily tasks with one functional hand decreases performance. They can help to improve functional use of the affected upper extremity, and in turn occupational performance, through the use of this intervention. In addition to this, focusing on a client s purposeful and meaningful occupations will help to improve his/her quality of life as well. Explain what the intervention actually is and how it is thought to work: In modified constraint-induced movement therapy the non-affected limb is restrained through the use of a mitt and a sling. This is to ensure the client does not use this hand to aid the affected limb with activities and occupations. With time, the affected limb is used less and less which leads to a phenomenon known as learned non-use. This is when the affected limb progressively decreases its function and the non-affected limb does more and more, eventually leading to the affected limb doing very little in daily life. The mitt is worn on the non-affected limb for about 5-6 hours per day during a time noted as frequent use (this is done at home on the client s own time and usually involves supervision from a caregiver). With the nonaffected limb restrained, it is thought that the affected limb will relearn certain movements and tasks. During this period of restraint, the affected limb is put through intense therapy 3-5 days per week while working on reaching/grasping activities, strengthening, and motor control to help regain function. Identify an Occupational Therapy theoretical basis for the intervention:
2 The Motor Control and Motor Learning Frame of Reference provides a good foundation for modified constraint-induced movement therapy. Motor learning can be defined as the acquisition and modification of learned movement patterns over time (Pedretti, 2006). It involves practice and repetition, which both aid in the body s ability to produce sufficient movement. This will lead to the body s ability to respond to the requirements of occupational performance. This supports mcimt because the affected limb is going through an intense therapy program (practice and repetition) that will help to increase the motor pathways and therefore motor movements. Motor control occurs after motor learning and is continuously developed. Purposeful movements are produced according to the different activities and environmental demands that are placed on the body. With the non-affected limb restrained, the affected limb will also receive more input from the environment providing more sensory feedback. This will help to further improve the affected limb s function. Also, the movements that have been re-learned will be refined over time with the additional practice and experience provided. Explain the science behind the intervention (what is happening in the body with this intervention? When an individual suffers a stroke, one or both sides of the brain are severely deprived of oxygen (due to an embolus or thrombosis) which may lead to paralysis on the contralateral side of the body. The hemiplegia/hemiparesis is due to the inability of the motor cortex to function correctly and properly send neuronal signals to the opposite side of the body. When modified constraint-induced movement therapy is used, the individual s non-affected side is restrained so the client is unable to use it. The learned nonuse of the affected limb is counteracted when it is forced to be used. This is thought to create new neuronal pathways in the brain (brain plasticity). Modified constraint-induced movement therapy promotes increased use of a weak or paralysed arm and has been credited with speeding up the cortical map reorganization process in humans (Pedretti, 2006). When the client is forced to use his/her affected limb he/she is receiving many sensory inputs (vision, proprioception, and kinaesthesia) that help to create/modify the new pathways. FOCUSED CLINICAL QUESTION: Patient/Client Group: Adults who have undergone a stroke more than one year ago Intervention: Modified constraint-induced movement therapy Comparison Intervention: Traditional therapy Outcome(s): Improved functional ability of the affected upper limb SUMMARY: Is modified constraint-induced movement therapy found to be effective for improving functional ability of the affected upper limb in comparison to traditional rehabilitation for adults following a cerebrovascular accident more than one year ago? Search: Six databases were searched in order to complete this CAT Seven relevant articles were located One randomized control trial article was critiqued and it had a strength of 1a There were three reviewed articles and these were selected based on the amount of time since stroke (more than one year post-stroke) and also how recent the articles
3 were published. Page & Levine (2007), Lin, Wu, Wei, & Lee (2007), and Page, Sisto, Levine, & McGrath (2004) were the three articles selected to be reviewed. The article by Lin et al., (2007) is the article chosen for the article critique. CLINICAL BOTTOM LINE: Modified constraint-induced movement therapy was found to be an effective intervention for improving functional ability of the affected upper limb in comparison to traditional rehabilitation for adults who have suffered a stroke more than one year ago.
4 SEARCH STRATEGY: Table 1: Search Strategy Databases Searched EBSCOHost Rehabdata Database Search Terms Limits used Inclusion and Exclusion Criteria Cerebrovascular accident Constraint-induced movement therapy And Or English-only articles Full-Text AOTA (American Journal of Occupational Therapy) Health Professions Database via EBSCOHost PsychInfo Cochrane Collection Plus Modified constraint-induced movement therapy Stroke CIMT mcimt CIT M-CIT Related to stroke RESULTS OF SEARCH Table 2: Summary of Study Designs of Articles Retrieved Level Study Design/ Methodology of Articles Retrieved Number Located Source Citation (Name, Year) SR Systematic Review (articles) 1 Australian Journal of Physiotherapy Hakkennes, S. (2005). Level 1 Randomized Control Trials 4 1. Physical Therapy 2. Clinical Rehabilitation 3. Archives of Physical Medicine and Rehabilitation 4. Archives of Physical Medicine and Rehabilitiation 1. Page, S. J. (2008) 2. Lin, K. (2007) 3. Wu C.-y. (2007) 4. Page S. J. (2004)
5 Level 2 Non-randomized control group (two groups) Level 3 Non-randomized control group (one group) 2 1.Human Movement Science 2. Physical Therapy 1. Leung, D. P. (2009) 2. Page, S. J. (2007) Level 4 Single-subject/Repeated Measures Designs Level 5 Qualitative, Case Study STUDIES INCLUDED: 1. Page, S. J., & Levine, P. (2007). Modified constraint-induced therapy in patients with chronic stroke exhibiting minimal movement ability in the affected arm. Physical Therapy, 87(7), 872-878 2. Lin, K, Wu, C., Wei, T., & Lee, C. (2007). Effects of modified constraint-induced movement therapy on reach-to-grasp movements and functional performance after chronic stroke: A randomized controlled study. Clinical Rehabilitation, 21(12), 1075-1086 3. Page, S. J., Sisto, S., Levine, P., McGrath, R. E. (2004). Efficacy of modified constraintinduced movement therapy in chronic stroke: A single-blinded randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 85(1), 14-18 Table 3: Summary of Included Studies (add more columns if necessary) Study 1 Study 2 Study 3 Intervention Investigated Comparison Intervention Outcome variables and Modified constraintinduced therapy. Non-affected side=wearing mitt for 5 hours for 5 days/week for 10 weeks. Affected side=1/2-hour therapy sessions 3 times/week for 10 weeks. Modified constraintinduced movement therapy. Non-affected side=wearing mitt for 6 hours/day for 3 weeks. Affected side=intense training for 2 hours/weekday for 3 weeks. Not applicable Traditional Rehabilitation Use of affected limb and quality of movement (Motor Functional ability (Motor Activity Log and Modified constraintinduced movement therapy Non-affected side=wearing mitt for 5 hours/weekday for 10 weeks. Affected side=1/2-hour therapy sessions 3 times/week for 10 weeks. Traditional Rehabilitation Control group (no therapy) Affected upper limb impairment (Fugl- Meyer Assessment
6 measures Activity Log) Impairment of affected limb (Fugl- Meyer Assessment of Motor Recovery) Distal movement ability of affected limb (Action Research Arm Test) Findings Improved fine motor skills as measured by the Action Research Arm Test) Increased movement and quality of movement in affected arm as measured by the Motor Activity Log. Decreased impairment as measured by the Fugl-Meyer Assessment of Motor Recovery Functional Independence Measure) Control of reaching and grasping (Kinematic Analysis) The treatment group preplanned reaching and grasping and depended more on feedforward control of reaching than traditional rehab. The treatment group showed significant improvement on functional performance on the Motor Activity Log and the Functional Independence Measure. of Motor Recovery) Arm mobility (Action Research Arm Test) Functional ability (Motor Activity Log: on both the amount of use and the quality of use) The treatment group displayed significantly greater improvements on the Fugl-Meyer Assessment of Motor Recovery and the Action Research Arm Test than traditional or control groups. Amount of use measured by Motor Activity Log improved only in treatment group.
7 SYNTHESIS: Is modified constraint-induced movement therapy effective for improving functional ability of the affected upper limb in comparison to traditional rehabilitation for adults following a cerebrovascular accident more than one year ago? Overall Conclusions: Two of the three articles listed in the CAT were randomized controlled trials while the other was a single-blinded case series. All three of the articles found similar results supporting modified constraint-induced movement therapy to be effective in improving function ability of the affected upper limb. The first randomized controlled trial (Lin, Wu, Wei, & Lee, 2007) found significant and moderate-large effects on the amount of use (.0.67) and quality of movement (0.70) scales for the Motor Activity Log. The second randomized controlled trial (Page, Sisto, Levine, & McGrath, 2004) found the amount of use and quality of movement increased more in the treatment group than in the control or traditional therapy group as well. Similar results were also noted in the case series article (Page & Levine, 2007); marked improvement on the amount of use and quality of movement in the affected upper limb as reported by the participant. The case-series article (Page et al., 2007) and one randomized controlled trial (RCT) (Page et al., 2004) lasted for a total of ten weeks, whereas the other randomized controlled trial (Lin et al., 2007) lasted for only three weeks. Even though this is a rather significant time difference, all three studies showed similar results regarding improved function of affected upper limb. Another aspect that differed between the studies was the time requirements for wearing the mitt on the non-affected hand and the amount of therapy received. One RCT (Lin et al., 2007) required that all participants wear the mitt for a total of six hours per day during times of frequent use and received intense training on affected limb for two hours per weekday for a total of three weeks. The other RCT (Page et al., 2004) and the caseseries study (Page et al., 2007) had the same requirements and treatment times; each participant had to wear the mitt for a total of five hours per weekday and had half-hour therapy sessions three times per week for a total of ten weeks. Once again, even though the time requirements were different, this did not have an impact on the results. Boundaries: These three articles primarily focused on individuals diagnosed as having a chronic stroke and therefore it is outside the scope of this CAT to say if this treatment can be generalized to other populations other than people between the ages of 37-81 years or if it is effective for people who are not categorized as having a chronic stroke (less than one year post-stroke); such as an acute or subacute stroke. The results between these three studies applied to individuals between the ages of 37 and 81 with chronic strokes. The case-series study (Page et al., 2007) mentioned how participants were able to generalize their gains to other contexts and areas of their lives such as; eating finger foods, tying shoes, reaching for and grabbing a cup, and grasping an eating utensil and bringing it to the mouth. These were all performed with the affected hand that has regained movement, while the other two studies did not mention how successes were transferred to other areas of the participant s lives.
8 None of the three studies looked at the long-term effects of the intervention. One study administered the posttest one week after therapy was completed, and the other two studies did not mention the exact time lapse but stated the posttest was completed after the intervention. It would be beneficial to know how long this intervention remains effective for improving functional ability in a client s affected limb. Implications for Practice: In the article by Lin et al. (2007) they noted that as clients will present with a variety of levels of hand function, it is important to keep in mind that this will affect how each individual client will respond to modified constraint-induced movement therapy. Not all patients who choose to use modified constraint-induced movement therapy will yield the same results and progress. They also noted that it may make it easier to distinguish differences among pre-treatment to post-treatment if the size of the objects were varied more during the grasping tasks. Page et al. (2007) discussed how modified constraint-induced movement therapy may also be effective for those who do not meet the conventional inclusion criteria for appropriate wrist and finger extension, instead of for just those who do. This is important to note because it may increase the number of potential candidates for this intervention. It was also noted that modified constraint-induced movement therapy can be used in conjunction with other therapies to further the benefits of this intervention such as; electrical stimulation and botulinum toxin A. According to Page et al. (2004) it is important to participate in repeated, functional, task-specific practice of valued ADLs to induce cortical reorganization and meaningful functional improvements (p. 17). Performing a task that is functional and meaningful will help to give the client motivation to continue on with it. This can be done through modifying the client s present tasks to help meet the previously stated criteria.
9 Articles Reviewed: Lin, K., Wu, C., Wei, T., & Lee, C. (2007). Effects of modified constraint-induced movement therapy on reach-to-grasp movements and functional performance after chronic stroke: a randomized controlled study. Clinical Rehabilitation, 21, 1075-1086. doi: 10.1177/0269215507079843 Permalink: https://libweb.uwlax.edu/login?url=http://search.ebscohost.com/login.aspx?direct= true&db=a9h&an=27631300&site=ehost-live Page, S. J., & Levine, P. (2007). Modified constraint-induced therapy in patients with chronic stroke exhibiting minimal movement ability in the affected arm. Physical Therapy, 87(7), 872-878 Permalink: https://libweb.uwlax.edu/login?url=http://search.ebscohost.com/login.aspx?direct=t rue&db=a9h&an=25657243&site=ehost-live Page, S. J., Sisto, S., Levine, P., & McGrath, R. E. (2004). Efficacy of modified constraintinduced movement therapy in chronic stroke: A single-blinded randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 85(1), 14-18. doi: 10.1016/S0003-9993(03)00481-7 Related Articles: Hakkennes, S., & Keating, J. L. (2005). Constraint-induced movement therapy following stroke: A systematic review of randomized controlled trials. Australian Journal of Physiotherapy, 51(4), 221-231. Retrieved from http://svc019.wic048p.serverweb.com/ajp/vol_51/4/austjphysiotherv51i4hakkennes.pdf Leung, D. P., Ng, A. K., & Fong, K. N. (2009). Effect of a small group treatment of the modified constraint induced movement therapy for clients with chronic stroke in a community setting. Human Movement Science, 28(6), 798-808. doi: 10.1016/j.humov.2009.04.006 Page, S. J., Levine, P., Leonard, A., Szaflarski, J. P., & Kissela, B. M. (2008). Modified constraint induced movement therapy in chronic stroke: Results of a single-blinded randomized controlled trial. Physical Therapy, 88(3), 333-340. doi: 10.2522/ptj.20060029 Wu, C. Y., Chen, C. I., Tsai, W. C., Lin K. C., & Chou, S. H. (2007). A randomized controlled trial of modified constraint-induced movement therapy for elderly stroke survivors: Changes in motor impairment, daily functioning, and quality of life. Archives of Physical Medicine and Rehabilitation, 88(3), 273-278. doi: 10.1016/j.apmr.2006.11.021 Other Sources: Pendleton, H. M., & Winifred, S. (2006). Pedretti s Occupational Therapy: Practice Skills for Physical Dysfunction (6 th ed., pp. 793-803). St. Louis, MO: Mosby-Elsevier.
10 APPENDIX (Article Critique) Title: Lin, K., Wu, C., Wei, T., & Lee, C. (2007). Effects of modified constraint-induced movement therapy on reach-to-grasp movements and functional performance after chronic stroke: a randomized controlled study. Clinical Rehabilitation, 21, 1075-1086 Permalink: https://libweb.uwlax.edu/login?url=http://search.ebscohost.com/login.aspx?direc t=true&db=a9h&an=27631300&site=ehost-live Purpose of the Study: The purpose of this study is to determine the effectiveness of modified constraintinduced movement therapy in motor control of the affected upper limb on a function reach-to-grasp activity and on the ability to perform activities of daily living functionally in participants with chronic strokes. Hypothesis: o Lin, Wu, Wei, & Lee (2007) hypothesized that, compared with traditional rehabilitation, modified constraint-induced movement therapy would have beneficial effects on both functional ability (improved performance on the Motor Activity Log and Function Independence Measure) and the control of reaching and grasping (i.e. shift from temporal inefficiency toward increased efficiency and from feedback to feedforward control) (p. 1077). Study Design: Level 1 Two-group randomized controlled trial Pretreatment and post-treatment measures Modified constraint-induced movement therapy group (treatment group) and a traditional rehabilitation group (control group) Setting: Outpatient rehabilitation clinic This intervention also took place in the client s home when he/she needed to wear the mitt and sling on own time during hours noted as frequent use. Participants: Originally there were 17 participants in the traditional intervention group and 17 participants in the modified constraint-induced movement therapy group. However, two participants from the traditional intervention group dropped out due to unstable medical conditions. Then during the analysis two participants data (one from each group) could not be used because the markers on the thumb and index finger were obscured during the recording phase of the kinematics testing. This left a total of 14 participants in the traditional intervention group and 16 participants in the modified constraint-induced movement therapy group to be analyzed. Participants were recruited from the rehabilitation departments of three participating hospitals while attending outpatient therapy. Inclusion criteria according to Lin et al. (2007) were:
11 Inclusion criteria according to Lin et al. (2007) were: (1) 12 month single unilateral stroke experience, neurologically stable, able to participate in modified constraintinduced movement therapy training and evaluation before study enrollment; (2) able to reach Brunnstrom stage III or above in the proximal and distal parts of arm; (3) considerable non0use of the affected arm (amount-of-use <2.5 on the Motor Activity Log); (4) mo balance problems sufficient to compromise safety; (5) no serious cognitive deficits (modified Mini-Mental Status Examination score=70); (6) no excessive spasticity in the affected arm, including the shoulder, elbow, wrist and fingers (Modified Ashworth Scale score=2 in any joint). Exclusion criteria included history of stroke or other neurological, neuromuscular or orthopaedic disease (p. 1077). The participants were aware of which group they were placed in, but they were blinded to the hypotheses of the study. Convenience sampling was used because the researcher recruited certain participants based on the convenience and ease of accessibility to them. Key demographics: o 21 men, 11 women o Mean age=57.89 years; range=43-81 years o Mean time since first-ever stroke=16.27 months; range=13-26 months Participants were comparable at baseline across the two groups with no statistically significant differences. Intervention Investigated: The participants were randomly assigned to two different groups; a control (traditional rehabilitation) and a treatment group (modified constraint-induced movement therapy) o The participants were first separated based on the side of their stroke (left of right side). o Next sealed envelopes were used to determine what group each participant was assigned to. A table of random numbers was utilized to ensure randomization of groups. o After the randomization process took place, 17 people were assigned to the modified constraint-induced movement therapy group and 15 people were assigned to the traditional rehabilitation group. The intervention was provided at three different hospitals that all chose to participate in this study by three different occupational therapists. o The three occupational therapists underwent the same training on how to properly administer modified constraint-induced movement therapy. After the training, the three therapists took a written test to ensure competency of administration. The investigators of the study were the ones who provided the training and also thoroughly reviewed the therapist s daily notes throughout the duration of the study. The treatment phases for both groups lasted a total of three weeks. The two main components of the modified constraint-induced movement therapy group:
12 o The unaffected hand was placed in a mitt for six hours per day during a time of frequent use. This was monitored and recorded by the participants themselves, and confirmed by the participants caregiver. o An intensive training program was designed and implemented for each participant to go through for two hours each weekday. Some examples of practice activities according to Lin et. al (2007) included; picking up marbles, flipping cards, stacking blocks, combing hair, writing, and other similar activities of daily living (p. 1078). These activities were all graded based on the participant s progress, improvements made, as well as concepts from the motor learning theory. The traditional rehabilitation was five days/week for two hours/day. The traditional therapy involved: o Strengthening o Balance o Fine motor dexterity training o Functional task practice o Stretching/weight bearing by the affected arm Dependent Variables: Depend Outcome ent Measure Variable Amount of use of arm in daily life tasks Quality of use of arm in daily life tasks Acvities of daily living (ADL) Motor Control Motor Acivity Log (MAL) Motor Acivity Log (MAL) Functional Independence Measure (FIM) Data Type Ordinal data Ordinal data Ordinal data Scoring Higher score=better performance. Use a 6-point scale (score range 0-5). Higher score=better performance. Use a 6-point scale (score range 0-5). Higher score = more independent. Six subscales with 18 items each. Each item is rated from 1 to 7. 1=complete assistance to 7=complete independence. Kinematic Analysis Reaction time Ratio Faster reaction time=higher efficiency Movement Ratio Less movement time ICF Level Body structur e and function impairm ent Body structur e and function impairm ent Activitie s and Participa tion Body structur e and OT Framewo rk Terms Performa nce Skills: Motor and Praxis Skills Performa nce Skills: Motor and Praxis Skills Areas of Occupatio n: ADLs Performa nce Skills: Motor
13 time % of movement time where peak velocity occurs Movement units Maximum grip aperture % of movement time where maximum grip aperture occurs Ratio Ratio Ratio Ratio is better/more efficient Higher percentage=better feedforward control Fewer movement units are better Smaller grip aperture=better feedforward control Greater percentage= better feedforward control function impairm ent and Praxis Skills *The Motor Activity Log (MAL), Functional Independence Measure (FIM), and Kinematic Analysis were all administered before and after the assigned interventions. The MAL and FIM were performed by two occupational therapists that were blind as to which group each participant belonged to. These two occupational therapists underwent a four hour training session on the administration of the MAL and FIM that was conducted by the primary evaluator who has five years experience in administering both of them. The Kinematic Analysis was conducted by the evaluators who were specifically trained in the administration details of the measure. The participants were advised to not tell which intervention they had been assigned to. Main Findings: Lin et al. (2007) hypothesized that compared with traditional rehabilitation, modified constraint-induced movement therapy would have beneficial effects on both functional ability (improved performance on the Motor Activity Log and Functional Independence Measure) and the control of reaching and grasping (i.e. shifting from temporal inefficiency toward increased efficiency and from feedback to feedforward control) (p. 1077). *Statistical significance was set at P<0.05 (one-tail). Statistics for kinematic variables and clinical measures: o Motor Activity Log and Functional Independence Measure Pretreatment Posttreatment P- r mcimt Traditional mcimt Traditional values Amount of 0.64 0.69 (0.91) 2.04 (1.04) 0.93 (1.03) <0.0001 0.67 Use (AOU) (0.71) Quality of 0.75 0.78 (1.13) 2.30 (1.04) 0.99 (0.97) <0.0001 0.70 use (QOU) (0.93) Functional 104.00 102.00 113.06 105.67 0.016 0.43
14 Independen ce Measure (13.60) (17.8) (10.55) (15.85) o Kinematic Analysis Variable Pretreatment Posttreatment P- r mcimt Traditional mcimt Traditional values Reaction 0.71 + 0.49 0.58 + 0.22 0.52 + 0.21 0.56 + 0.17 0.018 0.38 Time Movement 0.085 + 0.11 + 0.10 0.049 + 0.059 + 0.19 0.17 Time 0.046 0.0070 0.0080 % of 21.65 + 28.41+ 29.20 + 24.08 + 9.67 0.046 0.31 movement time where peak velocity occurs 8.44 15.84 12.47 Motor 0.66 + 0.57 0.91 + 0.94 0.31 + 0.20 0.44 + 0.50 0.18 0.18 Units maximum grip aperture % of movement time where maximum grip aperture occurs 10.88 + 1.99 (n=16) 61.45 + 16.95 (n=16) 9.65 + 2.78 (n=14) 54.77 + 22.66 (n=14) 11.30 + 1.87 (n=16) 67.89 + 14.66 (n=16) 11.05 + 2.11 (n-14) 58.46 + 13.04 (n=14) Original Author s Conclusions: The author s of this article found modified constraint-induced movement therapy to be more effective in helping regain functional movement as well as motor control in comparison with traditional rehabilitation. The Motor Activity Log (use and quality of movement) showed there to be greater improvements in functional ability during daily activities than the control group. The Functional Independence Measure also showed more improvements in functional use of the affected limb than did the traditional rehabilitation group. The motor areas that Lin et al. (2007) stated to be more successful for participants in the modified constraint-induced movement therapy group included; more efficient preplanning of activities, better reaching and grasping tactics (shorter reaction time), as well as a greater shift towards a feedforward planning system as opposed to a feedback system (a higher percentage of movement time where peak velocity occurs) (p. 1082). One area the authors recommend to change if this study were to be redone would be to vary the size of the objects used with the grasping tasks. This may have made it easier to help distinguish the changes from pre-treatment to post-treatment. If the size of the objects had been varied more, it may have made a more significant difference on 0.066 0.28 0.063 0.29
15 the maximum grip aperture (MGA) as well as the percentage of movement time where maximum grip aperture occurs (PMGA). Validity: Rigour of the methodology o This study was done exceptionally well. Even though participants and therapists could not be blinded to what group they were assigned (due to wearing a mitt or not wearing a mitt), they were blind as to what the study s hypothesis was. Also, the occupational therapists who provided the interventions underwent training on how to administer the modified constraint-induced movement therapy to ensure it was all being done the same way. Lastly, to help control biases occupational therapists who were blind to which group the participants were in evaluated the participants before and after treatment (Motor Activity Log, Functional Independence Measure and the Kinematic Analysis). They had undergone an intense 4- hour training session to help ensure consistency between therapists. PEDro scale 1. Subjects were randomly allocated to groups (in a crossover study, Yes subjects were randomly allocated an order in which treatments were received) 2. Allocation was concealed Yes 3. The groups were similar at baseline regarding the most important Yes prognostic indicators 4. There was blinding of all subjects No 5. There was blinding of all therapists who administered the therapy No 6. There was blinding of all assessors who measured at least one key Yes outcome 7. Measures of at least one key outcome were obtained from more Yes than 85% of the subjects initially allocated to groups 8. All subjects for whom outcome measures were available received No the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analysed by intention to treat. 9. The results of between-group statistical comparisons are reported Yes for at least one key outcome 10. The study provides both point measures and measures of Yes variability for at least one key outcome o 7/10 o Numbers 4 and 5 were scored as 0 because of inability to blind the participants and the therapists. With this intervention, participants are required to wear a mitt, which is a physical object and this does not permit blinding of the participants and therapists as to which group they have been assigned. o Number 8 was also scored as a 0 because it did not specifically state whether or not an intention to treat analysis was performed. Interpretation of Results:
16 This study did find modified constraint-induced movement therapy to be an effective method for improving functional use and motor control in the affected limb of people who have undergone a stroke more than one year ago in comparison to traditional rehabilitation. There were statistically significant effects found for the reaction time improvement (P=0.018) and for improving the percentage of reach where peak velocity occurs (P=0.046). There were also statistically significant effects found for the Amount of Use (P<0.0001) and Quality of Movement (P<0.0001) subscales of the Motor Activity Log, as well as for improvements on the Functional Independence Measure (P=0.016). A shorter reaction time helps to indicate a feedforward control has been utilized over a feedback control. This is important because it allows the participant to have smoother and more efficient arm movements. The treatment group used the affected side of his/her body for a total of 18 activities before intervention (on average) and for a total of 25 activities after intervention. The control group used the affected side of his/her body for a total of 17 (on average) activities before intervention and for a total of 22 activities after the intervention. This is important because it shows that the treatment group has gained significantly better functional ability with the use of the affected limbs. Significant and large effects were found on the Amount of Use (P<0.0001) and on the Quality of Movement (P<0.0001). Summary/Conclusion (Take Away Message) Modified constraint-induced movement therapy has been found to have statistically significant effects in increasing functional ability and motor control in adults who have suffered a stroke over a year ago. When an occupational therapist has undergone the proper training of m-cimt and has developed an appropriate understanding of the science behind m-cimt, this intervention can be very beneficial to the client and can help him/her gain back several functional abilities; such as reaching and grasping and help him/her to have better control of movements. It is also important for the client to comply with the necessary guidelines including wearing the mitt for the appropriate time per day (six hours), during the correct part of the day, while participating in intense training program for the affected arm for two hours per weekday.