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Evidence-Based Medicine Comes to
NeurorehabilitationBrain 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
WelcomePresenters:
Stephen E. Nadeau, MD.Medical Director BRRC, Chief of Neurology
Malcom Randal NF/SG VAMCUniversity of Florida Neurology
Sandra E. Davis, Research P.T. BRRCUniversity of Florida Physical Therapy
Lorie G. Richards, OTR/L, PhDResearch Scientist BRRC
University of Florida Occupational [email protected]
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 TRIALWolf 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 goalExample: 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 lunchMore 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 & QualityBox and Blocks Fugl Meyer Wolf Motor FunctionKinematicsActual Amount Use TestAccelerometryQuality of MotionQoL- SISCaregiver 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
InjuryUnsuccessful attempts to move
Punishment (pain, can’t)
Behavioral suppression
Positive Reinforcement
Compensatorybehavior strengthened
CompensatoryBehaviorpatterns
00.5
11.5
22.5
33.5
44.5
5
pre post f/u
MAL-6
MAL-3
-3
-2
-1
0
1
2
3
4
5
MAL Wolf time
(Sterr, et al., 2002)
(Dettmers, et al., 2005)
3.1
3.15
3.2
3.25
3.3
3.35
3.4
Sco
res
on t
he
Wol
f F
un
ctio
nal
Ab
ility
Sca
le
Baseline Midpoint Post 6-months
0
0.5
1
1.5
2
2.5
3
3.5
Scor
es o
n th
e A
mou
nt o
f U
se S
cale
(M
AL
)Baseline Midpoint Post 6-months
Does it need to be given 6 hours every day?
Page, et al., 2005
ACUTE STROKE
Traditional therapy: Compensatory ADLs, ROM, strengthening, dexterity practice
mCIMT – 1/2 hrs/d 3x/wk shaping, 5 hr/d mitt
Dromerick, et al., 2009
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
(Kleim et al, 2004)
Cortical Map Reorganization
Proximal
Distal
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 lesioned M1 and disturbed MEPs at baseline
Participants with intact M1 and 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 [email protected] 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
