Constraint Induced Movement Therapy – Flashcards

Bilateral functional use (of UE) Compensatory mechanisms -- teach these Rote (repetitive) neuromuscular retraining Facilitation of mtr. Control → leads to skilled tasks Strengthening and/or endurance trng. Education

Restraining the uninvolved upper extremity and encouraging movement of the involved upper extremity through massed practice * Not even bring other hand in as a stabilizer * taking unaffected arm out of their environment so they can't use it. mitt glove can be used (most effective) sling can also be used (less effective)

Constraint Induced Therapy Forced use Therapy (FUT) Constraint Induced Movement Therapy (CIMT)

Optimal window of opportunity (soon after a stroke but not too soon) Complex Enriched environment Intense and focused Repetitive (that's how learning occurs) Use of real world objects Motor challenge (maximize motor challenge)

- 70 years of studies looking at this - Failing to use the affected side - Unsuccessful and frustrating → no further attempts - Success with compensatory techniques → reinforcement of nonuse Affected side not reacting the way it used to before, they attempt to use it and it is not effective, so just stop using it = this is referred to as learned non-use Then learn compensatory techniques like learning to use the other hand (esp. nondominant replaces use of dominant hand) and reinforcing the non use, reinforced by the benefit of using the nonaffected extremity Over time stop using affected extremity because it's not effective At the same time, they may start using compensatory techniques - reinforces nonuse

Criteria for appropriateness of CIMT - Actively extend wrist greater than 10 degrees - Actively extend MCP & IP joints of thumb + 2 digits 10 degrees - 90° shoulder flexion & abduction - 45° external rotation - No more than -30° elbow extension - 45° forearm supination and pronation - Wrist extension to neutral - Finger extension (all digits) with no greater than 30° of flexion contracture at MCP & IP joints - 3 to 7 months post stroke - 24/30 on Mini mental exam (ie. cognitively intact) - 2 min. standing balance without UE support - Independent transfers - 18 or older - Not in other rehab. Program The best of the best (finger function) **Qualifying to be a candidate person is the most high level stroke patient and probably going to make gains anyway** they were doing this study on client who would probably incorporate extremity into their activities anyways even if they didn't have intervention and would improve.Hayner's Q: can we lower that criteria and still have benefits?

10 x 10 x 10 - 10 degrees active wrist extension - 10 degrees active thumb abduction - 10 degrees active extension of any other two digits on affected hand focussed on having some finger motion If you have some finger motion, you're already much higher functioning than those with full flexed position

Basic components include: Restraint of unaffected arm for 90% of waking hours 2 to 3 week period, 6 to 7 hours per day of intense therapy on consecutive weekdays Repetitive training of more affected UE Behavioral agreement Treatment diary Restraint: Mitt was on a lot 2 to 3 weeks period: might be just the dosage, Much more intensive that typical. Normal outpatient: 1 hour per week. Comparing apples to oranges Behavioral agreement: Person would participate and keep mitt on 90% of time

very few subjects

CIMT appears to augment rehabilitation -- is beneficial Less improvement in patients experiencing shoulder pain. *Pain is limited ability to participate (pretty much in all interventions) not beneficial for improving pain. But almost no rehab is beneficial for treating pain Primarily used with post stroke clients but is being use with many clients with varying diagnoses to gain control over motor function. (LIKE WITH CEREBRAL PALSY)

Possible potential exaggeration of neuronal injury if used in acute phase *In rat study -- Possible to increase damage, so in acute care not the time to start rehab using CIMT 7 hours a day - start CIMT after in acute stage could increase the damage if you're doing restraint for 6-7 hours a day during acute care stage Estimated length of time for treatment? * Usually 6-7 hours a day, studies with 5 hours, but who is to say if have an 1 not to do it? You can treat for an hour and if safe enough give them a mitt to use and incorporate components into their life if willing and will actually do it Clients willingness & carry through Rote vs. functional activities? * Functional activities sound less boring You can do rote activity where you're reaching over and over (boringgg) or you can do just right challenge with activities Consider safety (using a FWW?)

Consider current research by Psychologists, PhD's, OT's & PT's Is CIMT more effective than other treatments or are the benefits from massed practice? Do massed functional activities improve outcome? Which post stroke patients will benefit the most?

Twelve participants Pre-test, Post-test, 6 month follow-up testing Two comparison groups: (CIMT vs. bilateral hand use) Random assignment * Before randomly assigned determined if highly impaired vs. less impaired so divided 6 higher level and 6 lower level and then randomly assigned for groups of 6 to CIMT vs bilateral hand use * some had isolated finger movement but were slow, others had no isolated movement Treated together- 2 weeks, 6 hours/day 10 weekdays for 6 hours a day Randomly assigned to one of two groups CIMT Bilateral use

Mvmt above trace in affected hand and shoulder Able to use affected UE as stabilizer No smoking for 6-7 hours Balance screened - able to ambulate without a device Just wanted to see a flicker of movement Could they but affected UE on table to use as a stabilizer in any way possible that they wanted to Ambulate without device for safety

Pre-test, post-test design with 6 month follow up Wolf Motor Function Test * functional activities and rate of speed Canadian Occupational Performance Measure (COPM) AROM of UE Videotape of functional tasks * OTs and PTs rated which was better (pre or post)

Group activities to promote function & AROM * Group activities like stretching in chair Purposeful activities, meaningful to the participant * sometimes craft-related, sometimes bingo, sometimes unwrapping parcel cooking Activities graded to the individuals functional ability Homework * Honest responses about participation at home in homework to see if able to do it - Encouraged them to do things at home.Didn't tell them they had to wear mitt for 5 hours. Encouraged to but understand many weren't able toJust tell us what you actually did

Participant criteria lowered for active movement / range Participant criteria lowered for time since stroke * individuals who had been 4+ years after stroke were now allowed Both groups treated the same amount of time Both groups received identical treatments OT focus in treatment activities (functional)

12 subjects total 5 male & 7 female participants Days since CVA: (13 to 79 months) Bilateral mean: 2039 days Mitt mean: 642.3 days Age range: 43 to 81 (mean: 56.75) Side of lesion: 10 left side, 2 right side

Mixed ANOVA Looked at between subjects: -Changes between CIMT & bilateral group - Changes between high and low groups Looked at within subjects: - Data for each subject comparing trails (pre-test, post-test, to follow-up test)

lower score = more impaired The Wolf Pretest score (M = 40.83) was significantly lower than the post-test (M = 46.83; p = .009) and the follow-up test scores (M = 49.42; p = .008) across all groups. (gains were made) The post-test score was significantly lower than the follow-up test score (p = .022). While both groups made significant gains of about the same percentage, the high group made more gains due to starting at a higher functional level. Both groups: ~10% gain. Neither was more effective than the other (CIMT vs. bilateral treatment) gains continued to be made at follow-up probably trying to incorporate gains they'd already made this is a great technique but does not seen more beneficial than others. When you use the same dosage, bilateral is just as effective

that bilateral use and CIMT both effective (equally), CIMT is a tool to use

CIMT appears to be a beneficial treatment option in improving function and use. Bilateral treatment is also a beneficial treatment option for improving function and use.

One is not better than the other. The best treatment will be dependent on: Patients use of arm/hand, balance, safety Ability for carryover Patients desire (CIMT has a lot of press) Time (hrs) available for treatment