CRITICALLY APPRAISED PAPER (CAP) Wu, C. Y., Wang, T. N., Chen, Y. T., Lin, K. C., Chen, Y. A., Li, H. T., & Tsai, P. L. (2013). Effects of constraint-induced therapy combined with eye patching on functional outcomes and movement kinematics in poststroke neglect. American Journal of Occupational Therapy, 67(2), 236 245. https://doi.org/10.5014/ajot.2013.006486 CLINICAL BOTTOM LINE Stroke is a leading cause of long-term disability among adults. Stroke often results in longstanding physical, cognitive, and psychological impairments that affect the individual s functional performance and independence in daily activities. After stroke, survivors may experience a condition known as unilateral neglect, which impairs the individual s perception of stimuli on the contralateral side of the brain lesion. Unilateral neglect increases safety risks and challenges for individuals during participation in activities. This article is within the scope of occupational therapy practice because it examines the efficacy of three different techniques that occupational therapists can use to address unilateral neglect: constraint-induced therapy (CIT), CIT combined with eye patching (CIT+EP), and traditional occupational therapy treatment. All participants received 2 hours of one-on-one therapy 5 days/week for 3 weeks. In the CIT intervention group, the unaffected upper extremity was restricted by a mitt, and participants were forced to use the affected upper extremity during functional tasks. In the CIT+EP intervention group, participants completed the previously described CIT while wearing glasses with a patch that blocked visual stimuli from the ipsilesional visual field; this induced participants to receive visual stimuli from the neglected, contralesional visual field. Traditional occupational therapy (control group) included functional training, strengthening, stretching, and weight bearing of the affected upper extremity only. This article is the first to study these comparisons in a single-blinded randomized controlled trial. The authors found that CIT and CIT+EP both improved daily function more than traditional occupational therapy. CIT was more effective for increasing visual fixation points in the neglected (left) visual field and shortening reaction time, whereas CIT+EP was more effective in developing preplanned motor control and decreasing rightward trunk leaning. This study used a reliable and valid primary outcome measure (Catherine Bergego Scale) and analysis of covariance (ANCOVA) statistical analysis. Its limitation is that the trial had a small sample size of 24 participants, which limits power and generalizability. However, the study 1
provides insight into strategies and outcome measures that practitioners can use to address specific aspects of vision deficits and unilateral-neglect stroke rehabilitation. RESEARCH OBJECTIVE(S) Determine the effect of a combined CIT+EP intervention, CIT alone, and conventional occupational therapy treatment on functional performance, eye movement, and trunk arm kinematics among stroke patients with unilateral-neglect syndrome DESIGN TYPE AND LEVEL OF EVIDENCE Level I: Single-blinded randomized controlled trial PARTICIPATION SELECTION Stroke patients with neglect were recruited from eight medical centers and rehabilitation clinics in Taiwan, Republic of China. The institutional review board approved all of the clinical settings, and participants provided informed consent. Participants were randomly assigned to an intervention group with a random number scale; therapists were informed of the intervention allocation and delivered therapy accordingly. Convenience sampling might have been used. INCLUSION CRITERIA Right-side cerebral stroke Neglect syndrome, as demonstrated on at least two of the four tests: double simultaneous stimulation test, line bisection test, random shape cancellation test, and random Chinese word cancellation test Brunnstrom s Stage II or higher for proximal and distal upper extremity Considerable nonuse of the more-affected upper extremity EXCLUSION CRITERIA Excessive spasticity in the affected arm ( 2 on the Modified Ashworth Scale in any joint) Severe cognitive impairment (inability to show awareness or respond to oral instructions) Severe impairment of visual acuity after rectification Participation in any experimental rehabilitation or drug studies during study period PARTICIPANT CHARACTERISTICS N= (Number of participants taking part in the study) 24 #/ (%) Male 17/(71%) #/ (%) Female 7/(29%) Ethnicity NR 2
Disease/disability diagnosis Right-side cerebral stroke INTERVENTION(S) AND CONTROL GROUPS Group 1: CIT+EP Brief description of the intervention How many participants in the group? Where did the intervention take place? Who Delivered? How often? For how long? 7 CIT: Participants wore a mitt on their unaffected hand and wrist for 6 hours/day during the 3-week study period and completed a daily compliance log. Therapists assigned homeskill activities with CIT in daily life and assisted with problem solving. Patients completed shaping-skills tasks during therapy sessions. EP: Participants wore glasses with a right lens patch (blocked right visual stimuli, forcing stimulus from the left visual field). Participating hospital and clinic settings Occupational therapists who were trained in the administration of the CIT+EP protocol and had passed a written competency test 2-hours therapy, 5 days/week 3 weeks Group 2: CIT Brief description of the intervention CIT: Participants wore a mitt on their unaffected hand and wrist for 6 hr/day during the 3-week study period and completed a daily compliance log. Therapists assigned home-skill activities with CIT in daily life and assisted with problem solving. Patients completed shaping-skills tasks during therapy sessions. No eye patching How many participants in the group? Where did the intervention take place? Who Delivered? How often? For how long? 8 Participating hospital and clinic settings Occupational therapists who were trained in the administration of the CIT protocol and had passed written a competency test 2-hours therapy, 5 days/week 3 weeks Group 3: Control group Brief description of the Participants in the control group received traditional occupational 3
intervention therapy (stretching, weight bearing, improving range of motion, muscle strengthening, bilateral task practice). No CIT or EP interventions How many participants in the group? Where did the intervention take place? Who Delivered? How often? For how long? 9 Participating hospital and clinic settings Occupational therapists trained in interventions to improve function of affected upper extremity (stretching, weight bearing, improving range of motion, strengthening, bilateral task practice) 2-hours therapy, 5 days/week 3 weeks Intervention Biases: Check yes, no, or NR and explain, if needed. Contamination: Co-intervention: Comment: Comment: Patients who participated in the study continued to receive other routine rehabilitation services (e.g., speech therapy and physical therapy). Timing: Site: Comment: The study period was relatively short only 3 weeks. Comment: Although there were eight sites, patients were recruited at medical centers and rehabilitation centers. There was no specification of whether the patients were inpatient or outpatient. Use of different therapists to provide intervention: Comment: Occupational therapists received training and were required to pass a competency test before being assigned to administer a treatment intervention protocol. 4
MEASURES AND OUTCOMES Complete for each measure relevant to occupational therapy: Measure 1: Catherine Bergego Scale Name/type of Catherine Bergego Scale measure used: What outcome was measured? Effect of neglect on an individual s daily life functions, based on evaluator s observation and evaluation of 10 situations, on a 4-point scale reliable? valid? When is the Before and after 3-week intervention measure used? Measure 2: Eye movement analysis Name/type of ClearView 2.0 eye tracker system measure used: What outcome was measured? Analyzed eye movement and its variables (line bisection task, with analysis on left fixation points, fixation amplitudes, and left fixation time) NR reliable? valid? NR When is the Before and after 3-week intervention measure used? Measure 3: Kinematic analysis Name/type of measure used: What outcome was measured? reliable? valid? When is the measure used? Kinematic task of using the index finger of the unaffected upper extremity to press a task bell as quickly as possible; motion was analyzed by a seven-camera motion analysis system Kinematic analysis of upper extremity and trunk movement: reaction time, normalized movement time, normalized total distance, percentage of movement time during peak velocity, and trunk lateral shift NR NR Before and after 3-week intervention Measurement Biases Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain. Comment: The three occupational therapist evaluators were trained and blinded to group allocations. Interrater reliability was high. 5
Recall or memory bias. Check yes, no, or NR, and if yes, explain. Comment: Others (list and explain): RESULTS List key findings based on study objectives Include statistical significance where appropriate (p < 0.05) Include effect size if reported Using ANCOVA for statistical analysis, the researchers found that the Catherine Bergego Scale results were significant (p =.006), with a large effect size (η² =.40; η².14 is considered large). Post hoc analysis identified that functional performance improved with both the CIT+EP and the CIT groups, compared with the control group. For eye-movement analysis, left (neglected) fixation point results had a significant and large effect (p =.036; η² =.28), whereas amplitude and left fixation time results did not. Post hoc analyses showed that the CIT and control protocols were more beneficial in increasing fixation points in the neglected (left) field than the CIT+EP protocol. For kinematic analysis, ANCOVA identified significant changes in reaction time (p =.029; η² =.30); percentage of movement time in peak velocity, which suggests preplanned motor control (p =.013; η² =.35); and trunk lateral shift (p =.034; η² =.29). Post hoc analyses demonstrated that the CIT group was more effective in shortening reaction time, compared with the control group. However, the CIT+EP group was more effective in percentage of movement time in peak velocity and increasing trunk lateral shift toward the neglected side. These varying findings suggest that CIT+EP and CIT interventions may benefit different aspects of unilateral-neglect syndrome. Was this study adequately powered (large enough to show a difference)? Check yes, no, or NR, and if no, explain. Comment: Small sample size for overall study Were appropriate analytic methods used? Check yes, no, or NR, and if no, explain. Comment: Were statistics appropriately reported (in written or table format)? Check yes or no, and if no, explain. Comment: 6
Was the percent/number of subjects/participants who dropped out of the study reported? Limitations: What are the overall study limitations? The small sample size of the study limits power and generalizability of the results regarding these treatment interventions for stroke patients with neglect syndrome. The authors also reported the study s limitation in investigating the interventions effects on the complex subtypes of neglect syndrome. CONCLUSIONS State the authors conclusions related to the research objectives. The authors concluded that CIT+EP and CIT were both more effective than traditional occupational therapy interventions in treating neglect syndrome seen among stroke patients. CIT+EP and CIT both help improve daily functions, CIT may improve eye movement and limb initiation, and CIT+EP may improve preplanned control and trunk control. Future research should include studies with a larger sample size and follow-up for long-term benefits. Future studies should also investigate intervention strategies for different subtypes of neglect syndrome among stroke patients. This work is based on the evidence-based literature review completed by Claire Lin, MA, OTR/L. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, and M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 7