Evidence-Based Medicine
Comes to
Neurorehabilitation
Brain Rehabilitation Research Center:
A VA Rehabilitation R&D Center of Excellence
Malcolm Randall VAMC (151- A)
1601 S.W. Archer Road
Gainesville, Florida 32608
352-374-6181  Fax 352-379-2332
www.va.gov/brrc
Welcome
Presenters:
Stephen E. Nadeau, MD.
Medical Director BRRC, Chief of Neurology
Malcom Randal NF/SG VAMC
University of Florida Neurology
snadeau@ufl.edu
Sandra E. Davis, Research P.T. BRRC
University of Florida Physical Therapy
sandra.davis2@va.gov
Lorie G. Richards, OTR/L, PhD
Research Scientist BRRC
University of Florida Occupational Therapy
lrichard@phhp.ufl.edu
Objectives
• As a Participant you will be able to:
* describe EBM in stroke rehabilitation
* identify individuals for constraint induced
movement therapy (CIMT)
* list key components of CIMT
* implement a CIMT session
* explain the scientific basis for CIMT
* identify limitations in evidence for CIMT
Introduction to Constraint
Induced Movement Therapy
CIMT
EXCITE TRIAL
Wolf SL et al. Effect of constraint-induced movement therapy on upper
extremity function 3 to 9 months after stroke. JAMA 2006;296:2095-2104
• Prospective, randomized, parallel group, multicenter,
phase III, single blind trial of 2 weeks of CIMT,
3 & 9 months after acute stroke
• Subjects:
– CIMT: N = 106
– Usual and customary care : N = 116
• Inclusion criteria:
– High functioning: 20˚ wrist ext, 10˚ finger ext.
– Low functioning: 10˚ wrist ext, 10˚ ext. thumb & ≥ 2 other fingers.
– Motor Activity Log (MAL) < 2.5
• CIMT: up to 6 hrs/day + mitt worn 90% of waking hrs.
• Outcome measures: Wolf Motor Function Test
MAL- Quality of motion at 1-year.
EXCITE Trial
First: Identify Individuals for
CIMT
• CIMT is a beneficial treatment for patients post stroke
exhibiting some active wrist and hand movement.
Wolf et al 2006,Dromerick et al 2000, Van der Lee et al1999
Minimum Motor Criteria:
Active extension must be repeated 3x in one minute:
From a relaxed resting position,
Not from a neutral wrist position.
At least 10 degrees: wrist, thumb and 2 digits
Include Key Components of
CIMT
• Add these elements to each session:
* Massed Repetition
* Graded/progressed activities
* Objective Feedback
* Restraint of the less involved UE
* Intensive Practice:
Original CIMT included 6 hours/day for 5 days a week for 2 weeks
What does a CIMT Session
Look Like?
• Choose Shaping (lower functioning) or
Task Practice (higher functioning)
Shaping: Components of the task are made more difficult
in a more structured way to attain the task.
Detailed feedback & progress only when attain set goal
Example: reach - to grasp - to lift a glass – to drink
Task Practice: Functionally based activities performed
continuously 15-20 minutes or until the task is attained.
Example: fix a sandwich & eat lunch
More general feedback & graded progression
To Progress:
Add specific challenges i.e.
speed, height, distance, weight, #’s, dual task, quality of movement
Choose CIMT tasks to match the
Individual
Design CIMT Menu of
Unique Tasks
• To meet the unique individual’s needs:
* impairment level
* interests
* roles inventory
* meaningful activities
* functional needs
* strength
* coordination
* range of motion
* sensation
* personal goals
* endurance
* sense of humor
Creative Considerations for
CIMT and modified mCIMT
*Setting
*Acuity
*Length of Stay
*Staffing
*Support
*Modifications
*Home Program
*Charge and Reimbursement
*Legal and Ethical considerations
Standardized tests to take to clinic
• Measure your
Outcomes!
MAL- Amount & Quality
Box and Blocks
Fugl Meyer
Wolf Motor Function
Kinematics
Actual Amount Use Test
Accelerometry
Quality of Motion
QoL- SIS
Caregiver Strain
Compliance Measures
• Translational Package
Morris,Taub,Mark,2006
* Contract 90% mitt wearing
* Diary
* Coach agreement
* Daily cues: Motor Activity Log
* Home Practice
* Weekend Practice
* Daily Schedule
* Agreed upon appointments
* Agreed upon time to remove mitt
Constraint Induced Movement
Therapy
• A family of therapies
• Developed from deafferented monkey studies
(Knapp, Taub, et al., 1958; Taub, 1976, 1977)
– Without sensation, monkey did not use the limb
– Would use the arm if the other arm were restrained
– Restraint of 1-2 days = revert after restraint removal,
but not after 1-2 weeks
– Shaping also increased ability and use of limb
Constraint Induced Movement
Therapy
• Developed to improve motor skill and to
decrease learned non-use
Injury
Compensatory
Behavior
patterns
Unsuccessful
attempts
to move
Positive
Reinforcement
Punishment
(pain, can’t)
Behavioral
suppression
Compensatory
behavior
strengthened
5
4
3
2
1
0
-1
-2
-3
MAL
Wolf time
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
MAL-6
MAL-3
pre
post
f/u
(Sterr, et al., 2002)
Does it need to be given 6 hours every day?
3.4
Scores on the Amount of Use Scale (MAL)
Scores on the Wolf Functional Ability Scale
3.5
3.35
3.3
3.25
3.2
3.15
3
2.5
2
1.5
1
0.5
0
Baseline
3.1
Baseline
Midpoint
Post
Midpoint
Post
6-months
(Dettmers, et al.,
2005)
6-months
ACUTE STROKE
Traditional therapy:
Compensatory ADLs, ROM,
strengthening, dexterity practice
mCIMT – 1/2 hrs/d 3x/wk
shaping, 5 hr/d mitt
Page, et al., 2005
ACUTE STROKE
Traditional therapy:
Compensatory ADLs, ROM,
strengthening
Low CIMT – 2 hrs/d shaping, 5
hr/d mitt
High CIMT – 3 hr/d shaping, mitt
90% waking hrs
Dromerick, et al., 2009
Cortical Map Reorganization
Proximal
Distal
(Kleim et al, 2004)
Is there evidence that CIMT
changes the brain?
• 2 most common methods:
– Transcranial Magnetic Stimulation
(TMS)
– Functional Magnetic Resonance Imaging
(fMRI)
Is there evidence that CIMT
changes the brain?
(Hamzei, et al., 2006)
Participants with
intact M1 and MEPs
at baseline
Participants
with lesioned
M1 and
disturbed MEPs
at baseline
CIMT now Paired
• With other Therapies:
* Drugs
* Strengthening
* Rhythm Cues
Remaining Questions
• Future Research Needs to Demonstrate
* What is the Best CIMT Schedule:
- Distributed versus Massed
- # of Hours
- Maintenance of the gains
Summary
• Evidence shows:
- CIMT is efficacious
- Variations of the original protocol are
efficacious and can translate to clinic
- More therapy is generally better
- CIMT is reimbursable
Thank you!
Questions & Discussion
CE Credit
• For any questions about the monthly GRECC
Audio Conference Series please contact Tim
Foley at tim.foley@va.gov or call (734) 222-4328
• To evaluate this conference for CE credit please
obtain a ‘Satellite Registration’ form and a
‘Faculty Evaluation’ form from the Satellite
Coordinator at you facility. The forms must be
mailed to EES within 2 weeks of the broadcast