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Running head: EFFECTS OF CONSTRAINT-INDUCED MOVEMENT THERAPY
The Effects of Constraint-Induced Movement Therapy on Proprioception
Britany Brissette, Colleen Mrozinski, and Tyler Simpson
Saginaw Valley State University
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Abstract
Purpose: This mixed method, quasi-experimental, nonequivalent two-group pretest-posttest
study was to examine the effects of CIMT and mCIMT on proprioceptive functioning within
individuals who sustained chronic hemiparesis status post CVA.
Methods: The quantitative methodology included the use of a researcher designed
proprioceptive assessment administered pre and post intervention. Qualitative data was gathered
through semi structured focus groups with themes being established from resulting answers,
journals kept by participants, and conversation.
Results: The results suggest that there were improvements that participants experienced in
proprioception after participation in CIMT/mCIMT treatment.
Conclusion: This study suggests that, CIMT/mCIMT may be an effective treatment intervention
for CVA survivors who have proprioceptive deficits.
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The Effects of Constraint-Induced Movement Therapy on Proprioception
Cerebral vascular accident (CVA), or stroke, is the leading cause of disability in the
United States (Gillot, Holder-Walls, Kurtz, & Varley, 2002), with more than 730,000 Americans
experiencing a new or recurring stroke each year (Wolf, 2006). CVAs may result in variety of
symptoms and functional deficits. The symptoms and deficits experienced depend on which
blood vessels are occluded, and in what location (Gillot, et al, 2002). Among other issues, CVAs
can result in impaired arm function and impaired proprioception. Proprioception is a sense of
the movements and positions of the body and its limbs in space, independent of vision (Piper,
2006). These proprioception deficits can range from mild to severe. Many survivors of CVAs
report diminished levels of independence, self-care and a decreased quality of life, in part due to
decreased upper extremity function, hemiparesis, and/or proprioception deficits (Flinn, 2005).
Different types of rehabilitation approaches have been developed to help address these
deficits, and increase survivors’ levels of independence in activities of daily living, instrumental
activities of daily living, work, education, leisure, and play. In stable patients, traditional
rehabilitation begins 48 hours after onset of a CVA (Dobkin, 2004), and often emphasizes
compensatory methods using the non-affected arm, rather than spending time to strengthen and
reeducate the affected arm (Young & Kong, 2007). While traditional rehabilitation has been used
as treatment for various CVA-related deficits, controlled studies have shown this approach to
post CVA rehabilitation has been found to be ineffective (Wolf et al., 2006).
In recent years research has supported the effectiveness of one type of therapy known as
constraint-induced movement therapy (CIMT) in addressing CVA-related deficits(Dobkin,
2004). This treatment method involves repetitive training to the affected upper extremity. This
repetitive training involves intense movement and exercise of the affected upper extremity to
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enhance functioning. CIMT has been shown to be effective in rehabilitation of various deficits
experienced by CVA survivors (Wolf et al, 2006).
Research Problem
Among post CVA clients, deficits may be observed in proprioceptive functioning. This
may result in issues such as clients’ inability to identify where their affected extremity is in
space. Current methods of rehabilitation are limited in the treatment of proprioceptive deficits in
these clients. CIMT has been shown as an effective method in the rehabilitation of post CVA
clients (Freeland, et al., 2006). According to Freeland, et al., CIMT improved functioning on
post CVA clients. This study suggests that CIMT would be an effective treatment on
proprioceptive deficits. There was preliminary evidence that supports Thus it appears that CIMT
could potentially be useful in improving proprioception in these clients. However, there is
limited evidence supporting the effects of CIMT on improving proprioception.
Purpose of the Study
The purpose of this mixed method, quasi-experimental, nonequivalent two-group pretest-
posttest study was to explore the effects of CIMT/mCIMT treatment on proprioception among
post CVA clients. Specifically, the goal of this research project was to build on previously
conducted research to determine if CIMT/mCIMT improves proprioceptive functioning in the
affected extremity of clients that have experienced a CVA.
Research Questions and Hypotheses
The research questions and hypotheses to be explored in this study are as follows:
1. Is CIMT an effective method for improving proprioception in the affected upper
extremity among people with chronic hemiparesis status post CVA?
The null and alternate hypotheses for CIMT study are as follows:
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Null hypothesis: There is no significant difference in the pre-to post-test scores of the
Researcher-designed Proprioception Assessment among participants involved in a CIMT
program.
Ho: µ1 = µ2, where
µ1 = Researcher designed proprioception assessment pretest scores
µ2 = Researcher designed proprioception assessment posttest scores
Alternate Hypothesis: There is a significant difference in the pre to post test scores of the
Researcher-designed Proprioception Assessment among participants involved in a CIMT
program.
HA: µ1 ≠ µ2
2. Is mCIMT an effective method for improving proprioception in the affected upper
extremity among people with chronic hemiparesis status post CVA?
The null and alternate hypotheses for mCIMT are as follows:
Null hypothesis: There is no significant difference in the pre-to post-test scores of the
Researcher-designed Proprioception Assessment among participants involved in a mCIMT
program.
Ho: µ1 = µ2, where
µ1 = Researcher designed proprioception assessment pretest scores
µ2 = Researcher designed proprioception assessment posttest scores
Alternate Hypothesis: There is a significant difference in the pre to post test scores of the
Researcher-designed proprioception assessment among participants involved in a mCIMT
program.
HA: µ1 ≠ µ2
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Definition of Terms
Constraint-induced movement therapy (CIMT). An approach to rehabilitation that
addresses lowered upper extremity function through use of a constraint on the unaffected side to
elicit movement from the affected side (Porter, 2004).
Cerebral vascular accident (CVA). CVA is “an occlusion of blood flow to the brain
which often results in motor impairments for the individual” (Freeland, et.al, 2006, p. 3).
Proprioception. As described by Westlake and Culham, proprioception is a component
providing orientation information regarding “passive and active movements and positions of the
joints” (2007, p.1275).
Significance of the Study
This research adds to the limited body of evidence concerning the use of CIMT as an
approach to address deficits in proprioception among persons who have experienced a CVA.
The results of this project demonstrated that CIMT may have a positive impact on proprioception
among persons experiencing upper extremity hemiparesis post CVA. This study will provide a
basis for further research to be done on how CIMT addresses deficits in proprioception in
individuals who have suffered a CVA.
Literature Review
Proprioceptive deficits have severe effects on individuals who have suffered a CVA. This
review of literature revealed much information regarding CIMT and its effects on upper
extremity function. However, there is no information relevant to CIMT and proprioceptive
deficits. This literature review will provide an overview of information regarding learned non-
use, “shaping”, CIMT with primates, CIMT versus mCIMT, effectiveness of CIMT, and
proprioception deficits. The first topic that will be discussed in the review is learned non-use,
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with a focus on early research with primates. Second, shaping methods in CIMT treatment will
be covered. Next, the protocols for CIMT and mCIMT will be discussed. After that, research
supporting the effectiveness of CIMT with primates and with humans, and current approaches to
rehabilitation of proprioceptive deficits, will be explored in CVA survivors. Finally, an overview
of proprioceptive deficits among elderly individuals will be provided.
Learned Non-use
After a CVA, many, post-stroke patients may lose upper extremity function and develop
a “learned non-use” behavior as a result of trying to compensate for issues with the use of their
affected limb by using their good limb. If learned non-use becomes an established habit in an
individual, it may disrupt the possible recovery of functional mobility in the impaired limb.
CIMT encourages the use of the affected extremity to regain function (Personal communication,
Early, May, 2009).
Dr. Edward Taub conducted the first research on CIMT, the Silver Springs Monkey
Experiement, in the late 1970s and 1980s. This research focused on exploring the efficacy of
rehabilitation interventions focused on enhancing motor function among CVA survivors. In his
initial experiements, Taub performed dorsal rhizotomies on primates to deprive their upper
extremities of somatic sensation, resulting in a “deadening” of the affected limb. Taub then
immobilized the non-affected limb of the animal using a constraint (Grotta, et al, 2004). This
study supports the hypothesis that decline is due to diminished recognition in the sensory-motor
strip in the brain rather than change in context interference (Personal communication, Earley,
May, 2009). This intervention promoted the animal’s use of the affected limb for functional
purposes (Grotta, et al, 2004).
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Based upon the results of studies such as this, Taub began experimenting with the use of
CIMT on humans in the late 1990’s. Since then the use of CIMT has proved to be an effective
form of rehabilitation for many CVA patients experiencing a decrease in upper extremity
function (Taub, Uswatte & Pidikiti, 1999).
“Shaping”
Shaping is a protocol of repetitive exercises which can be modified to increase the
intensity while the therapist uses positive reinforcement. Porter and Lord conducted a study in
2004 exploring functional mobility of CVA patients, using CIMT and shaping as treatment.
CIMT involves intense intervention, which is performed to enhance the functional ability of the
affected extremity of stroke patients. In the exercise program there is a “shaping” method used,
which utilizes positive encouragement by the therapists while actively participating in a
repetitive exercise protocol (Porter & Lord, 2004). Repetitive tasks are tasks in which basic
movements are repeated, this may include tasks such as eating or grooming. Tasks can be
modified to make it easier or harder for the individual. Adaptive tasks also involve repetitious
movements but of a defined movement such as picking up blocks. A defined movement involves
using a certain hand position required to pick up blocks. Each task has a certain time limit, or
number of successful attempts. The individual is responsible for decreasing their time or
increasing their number of successful attempts (Wolf, 2007).Some treatment interventions used
in the exercise programs in CIMT are as follows: peg board exercises, playing cards, and puzzle
activities, stacking blocks, lining up dominos, and working on jigsaw puzzles (Porter & Lord,
2004).
CIMT vs. mCIMT
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The CIMT protocol calls for a 14 day procedure where a splint or cast was worn on the
non-affected limb to promote the use of the affected limb (Porter & Lord, 2004). CIMT also
involves one on one therapy for six hours a day. The mCIMT protocol involves wearing the mitt
for several hours each day over a ten week period. The individual is also given a home-based
practice to supplement their therapy in the clinic. These protocols are similar because they both
involve one on one therapy in a clinic. The mCIMT protocol differs because it involves wearing
the constraint for several hours a day in the clinic versus six hours like the CIMT protocol.
Effectiveness of CIMT. Flinn conducted a study involving a CIMT protocol in 2005. This
study showed the effectiveness of CIMT in CVA survivors. People that suffer CVA’s can have
long-term disability and impaired arm function, which can result in decreased well-being,
decreased independent self-care, and decreased quality of life for stroke patients. CIMT is
utilized to enhance functioning and quality of life by using intense movement exercises
involving the impaired limb (Flinn, Schamburg, Fetrow, & Flanigan, 2005).
Another benefit of CIMT is that it can also promote the growth of new connections in the
brain. This is known as neuroplasticity. As a result of neuroplasticity the neurons in the brain
grow dendrites post trauma. These dendrites help the neuropathways to become stronger
(Personal communication, Earley, May, 2009). One research study was conducted regarding
neuroplasticity in monkey’s. For example, an experiment was done on a monkey where the nerve
to the monkey’s hand was severed. After a month, the neurons in the brain that had once
received input from that nerve changed (Research Library, 1992). An 8 to 10 milimeter wide
area of the brain that was once responsible for sensation of the hand, had reorganized itself to
receive input from the face. This was the first report of brain reorganization after deafferentation
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(Anderson, 1990). This finding gave an idea that plasticity can occur in adult brains as well
(Research Library, 1992).
If neuroplasticity can occur in adult brains through CIMT intervention, then this is a
enormous finding in the medical field. As related to occupational therapy, there is a distinct
interest in the effect of CIMT in reducing issues with occupation performance of stroke patients.
The Flinn, Schamburg, Fetrow, and Flanigan study in particular only required 3 ½ hours of
treatment per day, so there were improvements made but they were less effective than 24-hour
treatments. In conclusion, CIMT is effective and can improve the lives and satisfaction of stroke
survivors (Flinn, Schamburg, Fetrow, & Flanigan, 2005). CIMT has been proven to be effective
in remediation of many deficits experienced by post stroke individuals with hemiperiesis.
However, no studies have been conducted using CIMT in the improvement of proprioception,
although studies not related to CIMT have been done (Beaver & Hamilton, 2007). The following
section will discuss proprioception, proprioception deficits, and how these deficits affect
function in CVA survivors.
Propriocetive Deficits Post-CVA
Proprioception is a sense at the subconscious level which perceives movements and
positions of limbs without the use of vision. Proprioceptive deficits can cause a decline in
function in individuals. These deficits affect areas such as grooming, eating, dressing, and
toileting. They can also affect the individual’s ability to work, manage money, and participate in
home maintenance. The individual may also be unable to participate in their usual leisure
activities.
Another study was completed regarding how proprioceptive deficits affect functioning in
CVA survivors. This study was done by Smith, Akhtar, and Garraway in 1983 to examine how
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proprioception may impact functioning after a stroke. They noted that proprioceptive deficits
present at the onset of a stroke lead to a poor recovery. In particular, proprioceptive deficits can
result in difficulty in using postural mechanisms, poor muscle coordination, and a gait
disturbance. Individuals with proprioceptive deficits also frequently have deficits in other
purposeful movements which can affect occupational functioning (Smith, Akhtar, &Garraway,
1983).
Some research has been conducted regarding proprioception input and position in space.
For instance, Ochi, Morioka, Kataoka, and Toboaka completed a study involving individuals
possessing proprioceptive deficits. The purpose of this study was to see whether or not there is a
difference in the accuracy of visual and proprioceptive input when the individual is on an
inclined seat. This descriptive study included six hemiplegic stroke participants and six healthy
individuals as the control group. The participants sat on a laterally rotating seat where the angle
could be manually controlled by a handle. The participants were asked to tell the researchers
when they were aligned with the visual cue. A horizontal stand was placed in front of the
participants and the clients were started at a fifteen degree angle. The seat was rotated until the
participant stated that they thought they were aligned with the horizontal stand. The results of
this study indicated that, although there were no significant differences between the control and
experimental groups for the horizontal position of the sitting position support (Ochi, Morioka,
Kataoka & Taboaka, 2008), the stroke survivors still showed deficits in proprioception related to
their body angle.
One research study has been conducted to address proprioception in older adults. For
instance, Westlake and Culham conducted a study addressing proprioception with older adults.
This study explored the effect of sensory specific balance training on proprioception
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reintegration in older adults, using a randomized controlled trial method. Age-related alterations
in assessment of proprioception in relation to sensory input become evident when proprioception
inputs become distorted. This study explored the impact of environmental constantly changing
conditions on proprioception and the adjustments that older individuals need to make in order to
re-orient themselves to changes reduce the risk of falls. Treatment consisted of sensory specific
training classes which focused on static and dynamic balance exercises. The results of this study
found that older adults are able to improve proprioception through sensory specific training. This
can help to improve safety in individuals with proprioceptive deficits (Westlake & Culham,
2007).
Some research has been conducted to explore treatment for proprioceptive deficits. For
example, Carey, Matyas, and Oke conducted a study exploring assessment and treatment of
proprioception deficits. To evaluate the participant’s proprioception deficits, they were placed in
a splint that aligned their forearm with their wrist. This splint also had a lever that passively
placed the wrist in different positions. The wrist was placed in 20 different positions of flexion
and extension. Treatment consisted of discrimination tasks which uses odd surfaces to improve
texture discrimination and proprioception. The results of this study indicated that participants
with severe proprioceptive deficits were able to return to an almost normal level of
proprioception function treatment. These participants were also able to maintain the gains that
were made in treatment (Carey, Matyas, & Oke, 1993).
Proprioceptive deficits have severe effects on individuals who have suffered a CVA and
their ability to regain occupational function. Some studies have been conducted regarding
treatment for proprioception deficits, although these treatments are not very effective. Since,
CIMT has been shown to be a successful intervention for improvement of upper extremity
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function in individuals who have suffered a CVA, one could speculate that CIMT may also be a
good intervention for proprioception. In conclusion, data supports the use of CIMT as an
effective treatment for improving upper extremity function in individuals that had suffered a
CVA, but more research needs to be done regarding the effectiveness of CIMT on improvements
in proprioception deficits.
Method
Research Design
A mixed methods approach, consisting of qualitative and quantitative methodology, was
used. The quantitative portion of the study involved use of a quasi-experimental, nonequivalent,
two-group pretest-posttest design (as described in Portney & Watkins, 2008). This approach
allowed the researchers to examine the effects of CIMT and mCIMT on proprioception.
Subjects were not randomly assigned to groups, nor was a control group be used. Rather,
treatment groups were determined via participants’ preference (CIMT vs. mCIMT protocol), as
well as participants’ individual capabilities and therapeutic tolerance for the requirements of each
protocol. The qualitative portion of this study included review of data collected from journals
kept by the participants throughout therapy, and a pre and post-treatment focus group.
Participants
The total sample size for the research study included eight participants, four of them
participating in the CIMT program and four of them participating in the mCIMT program. In
order to participate in this research study, participants were required to have a diagnosis of a
previous cerebral vascular accident that resulted in a hemiplegic or hemiparetic upper extremity.
Participants had to be a minimum of 6 months post CVA to participate in the program.
Participants could not have history of diagnosis such as recent heart attack, seizures, and/or
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severe osteoporosis that would interfere with CIMT treatment. A prescription was required from
a physician stating the client was able to participate in therapy. Other conditions that excluded
participants from the study were bursitis, rotator cuff injuries, and tendonitis. Shoulder pain,
with the exception of arthritis, did not exclude participants (Freeland, et al.).
Additionally, to be included in this study, participants had to be able to follow
instructions in verbal or written form, and have adequate levels of activity tolerance. If
individuals required ambulatory devices such as a cane, they were not excluded from the
program. It was also required that participants possess strength and motivation sufficient to
complete therapeutic treatment activities each day while in the program.
In order to participate in the study, each person had to have a minimal level of function in
the affected upper extremity (as discussed by Blanton and Wolf, 1999): 45-90 degrees of active
range of motion of shoulder flexion and abduction; 45 degrees of external rotation; normal active
elbow extension; 45 degrees of supination and pronation of the forearm, 5 degrees wrist
extension to neutral, and 5 degrees of digit extension especially thumb, index and middle finger.
(Blanton & Wolf).
Instrumentation
Background information regarding participants’ past medical history and current living
situation was gathered through use of a researcher-designed Intake Interview (Attachment 1).The
Mini-Mental State Examination (MMSE) was used as a screening assessment for cognition. This
test was administered during the initial assessment phase. According to Wolf et al., persons who
score less than a 23/30 on the Mini-Mental State Examination are not appropriate for
participation in CIMT/mCIMT treatment programs (2006).
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A researcher-designed Proprioceptive Assessment tool (Appendix A) was used to evaluate
proprioception in the affected upper extremities pre- and post- intervention. This tool was
developed by occupational therapy students, with guidance from occupational therapy professors
with experience in stroke rehabilitation. This tool assessed the accuracy of participants’
proprioception skills in selected joints, using a five point scale. The movements that were
assessed were shoulder flexion, shoulder abduction, shoulder external rotation, elbow flexion,
forearm pronation, and wrist extension.
The qualitative portion of this study included a review of data collected from journals kept
by the participants throughout therapy, and a post-treatment focus group. The focus group was
held in a quiet room with the participating members of CIMT and mCIMT and the student
researchers. The focus group was performed post-treatment and followed-up 3 months post-
CIMT treatment be means of telephone. Questions asked of the participants can be found in
appendix B.
Procedures
Study site. Data collection and analysis took place on the campus of a medium sized public
university in the Midwestern United States. Treatment activities took place in a variety of
locations on campus including, the occupational therapy lab, hallways, the lunch area, and the
grounds of the campus.
Data collection. Quantitative data was collected prior to beginning the program, and at
the conclusion of the study. All assessments and reassessments were conducted by graduate
occupational therapy students with training in the administration and interpretation of the
assessment tools. Supervision was provided by registered occupational therapists (OTRs). The
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Mini Mental State Examination (MMSE) was utilized to screen the clients to determine
eligibility for participation in the study.
The researcher-designed Proproiceptive Assessment tool was administered to the
participants after the completion of the consent process. During the assessment, participants
were asked to close their eyes and their affected arm was placed in a specific position. The
participants were then asked to position their non-affected arm so that it mirrored (matched) the
position of the affected arm. They were then scored on a five point scale with one being not
close to mirroring the affected arm and five being a perfect match of the placement of the
affected arm.
Qualitative data was gathered by means of a semi-structured focus group conducted at
the conclusion of the two and four week studies. During the focus group, participants were
encouraged to respond to questions regarding their pre-stroke lifestyle, self-perceptions of
themselves following participation in CIMT/mCIMT and satisfaction with the results of
participation in CIMT/mCIMT. This allowed the participants to reflect on their feelings,
thoughts, and perceptions of the treatment process, as well as the effects of intervention on their
daily lives. Additional questions were addressed along with the following previously stated.
Intervention. All participants received one-on-one therapy in a group setting with a
graduate student who had received training in the use of CIMT/mCIMT interventions. All
students and participants received direct, on-site supervision from a Registered Occupational
Therapist (OTR) with specialized training in CIMT/mCIMT. Participants assigned to the
traditional CIMT treatment group received intervention following a traditional CIMT protocol
(CIMT). These participants received six hours of therapy, five days a week, for two weeks.
Outside of therapy, participants in the CIMT group were required to wear a constraint for 90% of
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their waking hours. Participants in the modified CIMT (mCIMT) group received three hours of
therapy, five days a week, for four weeks (Early, 2008). Participants in this group were required
to wear a constraint for the top five to six arm use hours every day outside of therapy.
Prior to initiating treatment each day as the clients arrived, they participated in stretching
activities for the affected arm. Stretches were performed on major joints such as the shoulder,
elbow, wrist and fingers in all major planes of motion. Warm-up activities worked with items
such as thera-band and/or weighted balls. These activities were done in a variety of gravity and
gravity-eliminated planes. These activities helped to prepare clients for the various activities of
the day and assisted in getting the upper extremity loose.
Repetitive training tasks are specific motor activities that assist clients in the improvement
of the functional abilities. Some repetitive training tasks completed by clients included but were
not limited to; placing pegs, moving loops on the Velcro wall, moving loops in a semi circular
manor on the hula loop, therapy putty, juxtacisor, gripper, checkers, card games, the washer
dowel board, ring tree and the Minnesota Rate of Manipulation board subtests. Participants who
possessed higher functioning were encouraged to wear wrist weights to give the just right
challenge. Repetitive activities integrating blocked and random practice of basic movements
were used to facilitate smooth, controlled movements in the affected extremity. Repetitive
activities included use of table top activities such as pegboards, placing clothespins on dowel
rods, sorting mail into slots, and locking and unlocking common household locks. These tasks
were performed either in standing or sitting. Functional activities were integrated throughout
therapy to encourage consistent use of the affected extremity in daily activities, and included
tasks such as using a handheld vacuum, or preparing and eating a light meal. Participants were
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closely monitored throughout all treatment activities for signs of fatigue, and allowed to take rest
breaks as necessary.
Therapy itself consisted of participation in repetitive and/or functional tasks designed to
promote increased use of the affected extremity in functional activities. Participants were
required to wear their constraints throughout therapy unless removal was required for safety
reasons.
Purposeful activities were client-centered tasks that assisted in the engagement and
motivation of clients, which ultimately helped to improve functional task performance.
Purposeful activities were based on individual goals for the client written by the student
therapists. Some purposeful activities that were completed during treatment included vacuuming,
dusting, cooking, feeding, planting tasks, virtual tasks using the computer, writing tasks and
other cleaning tasks. These tasks included washing tables, dishes and windows, cooking light
breakfasts for the group, planting seeds in pots, typing recipes and eating lunch/snacks.
Individual and group activities that were completed while in the CIMT/mCIMT program
were designed using input from each participant. The activities were then tailored to promote
increased function to reach desired goals set by the student therapist. All activities listed were
performed with each client wearing the constraint.
Participants in the two week program (CIMT) were instructed to wear the constraint for 90
percent of their waking hours outside of therapy, for the duration of the program, Participants
involved in the two week program were to wear the constraint for a total of 14 days, including
two weekends. Participants in the four week program (mCIMT) were instructed to wear the
constraint every day, for the top five or six arm use hours outside of therapy, for the duration of
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the program, Participants involved in the four week program were to wear the constraint for a
total of 28 days, including four weekends.
Participants were also asked to keep a daily treatment journal throughout the course of
therapy. Participants were asked to record information about their thoughts and feelings about
participating in the therapy protocol, as well as any significant changes they notice as a result of
participation in therapy. The journals enabled the researchers to monitor the clients’ perceptions
regarding their overall progress throughout therapy.
Data Analysis. All statistical analyses were completed Microsoft Excel software.
The researchers were unable to use inferential statistics due to the small sample size. so
descriptive statistics were used in place. Therefore descriptive statistics were used to describe
changes in proprioception scores pre- to post-intervention among participants in each treatment
group. Frequency distributions were used to assist in sorting the data and to allow the
recognition of trends. Results of frequency distributions were displayed on bar graphs.
Qualitative data was gathered through the participant’s journals, daily notes and through the
focus group. This information was reviewed, coded, and organized into themes. The student
therapists independently reviewed the content of the focus group and used peer review and
investigator triangulation to decrease the likelihood of researcher bias influencing outcomes, and
to ensure that comments were not misinterpreted by individual researchers. This type of
triangulation requires that more than one researcher analyzes the data.
Qualitative data was gathered through the participant’s journals and through the focus
group. This information was reviewed, coded, and organized into themes. The student therapists
independently reviewed the content of the focus group and used peer review triangulation to
decrease the likelihood of researcher bias influencing outcomes, and to ensure that comments
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were not misinterpreted by individual researchers. The forms of triangulation support validity of
our finding because there was more than one source of data used, more than one data collection,
and more than one set of researchers.
Trustworthiness
Trustworthiness is a tool that is utilized to determine if a study is “worthy of confidence”
(Kreftings, 1991). In this research the main criterion of trustworthiness included credibility and
dependability. To attain credibility of the qualitative data, researchers asked open-ended
questions to participants clarifying their thoughts and feelings about the focus group questions.
Dependability is how reliable the data that is retrieved will be in comparison with other similar
studies. Dependability strategy involves an external auditor having the capabilities to follow the
protocol to understand methodology performed and arrives at the same conclusion (Kreftings,
1991). Dependability was addressed by participating a in an extensive CIMT/mCIMT training
program, which assisted in the dependability of the qualitative data that was retrieved from
participants during the focus groups.
Quantitative Results
The researcher-designed Proprioceptive Assessment tool suggests that CIMT/mCIMT is an
effective treatment method for individuals post CVA. Pre and post test scores for each
movement on the researcher-designed to Proprioceptive Assessment tool (shoulder flexion,
shoulder abduction, shoulder external rotation, elbow flexion, forearm pronation, and wrist
extension) were calculated for each group.
Out of the four participants in the CIMT program, improvements were seen in one
participant. The mean pre-test score for shoulder flexion was 5 and the mean post-test score was
5. The mean pre-test score for shoulder abduction was 5 and the mean post-test score was 5.
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The mean pre-test score for shoulder external rotation was 5 and the mean post-test score was 5.
The mean pre-test elbow flexion score was 4. The mean pre-test score for forearm pronation was
5 and the mean post-test score was 5. The mean pre-test score for wrist extension was 5 and the
mean post-test score was 5. No deficits were seen in three of the four participants following pre-
test screening.
In the mCIMT protocol improvements were seen in all four participants. The mean scores
for participants in the mCIMT program showed improvements. The mean pre-test score for
shoulder flexion was 4.5 and the mean post-test score was 5. The mean pre-test score for
shoulder abduction was 4.5 and the mean post-test score was 5. The mean pre-test score for
shoulder external rotation was 2.5 and the mean post-test score was 4.75. The mean pre-test
score for elbow flexion was 3 and the mean post-test score was 5. The mean pre-test score for
forearm pronation was 3.5 and the mean post-test score was 5. The mean pre-test score for wrist
extension was 2 and the mean post-test score was 3.75. No deficits were seen in one of the
participants following the pre-test screening.
Qualitative Results
Seven themes were developed from the data analysis of the qualitative portion of this study.
The data was gained from the focus group from the CIMT and mCIMT programs following
treatment. The identified themes were: 1) change of lifestyle; 2) positive hand use improvement;
3) Determination; 4) expectation; 5) outgoing; 6) “It’s like having a job again”; and 7)
enjoyment. These themes are described in the following paragraphs using summaries and direct
quotes from the participants included in the study.
Change of Lifestyle
CIMT - 22
The participants were asked how about how their lifestyle changed post CVA. A common
theme that was found in responses from participants was a complete change of lifestyle. One of
the participants stated that his/her “lifestyle changed quite a bid, I can not do things that I use to
do, and this treatment has been a life-changing experience. The participants overall felt that
through intervention within the CIMT/mCIMT program, they felt more comfortable in the areas
of work and leisure.
Positive Hand Use Improvement
The participants were asked what their overall perception of the treatment in the
CIMT/mCIMT program. One participant stated that he/she “found myself using my affected
hand more. One other participant stated “ I feel better and make a point ot use my affected hand.
I have saw good improvements since I have been here.” Another participant shared that others
noticed his/her changes. With the concept of forced non-use and the reinforcement of that
concept throughout the program, the participants began to use their affected hand more.
Confidence was built in the participants that they could still use their hand, only it might just take
more time and patience to do so.
Determination
“I want to see how far I can go” was one of the participant’s comments when asked for a
final evaluation of perception of function following the CIMT/mCIMT program. The comments
regarding this question were positive and negative. Many participants were driven to see how far
they could go to better their hand function. “I will keep working at it and I want to see how far
forward I can go” was a comment made while “I cannot get past it; I feel people are looking at
me” were negative comments made.
Expectation
CIMT - 23
The next question that was asked was the participants if they were satisfied with the results
that were obtained from participation in the CIMT/mCIMT program. The overall answer from
each participant was “yes”. One of the clients explained that “I got what I expected.”
Participants were grateful for the gain in function that was seen while in treatment in this
program. Participants seemed pleased with the progress they were making during treatment;
when the program was completed they could see by assessments completed on them that their
numbers had changed. Many participants exclaimed that they would enjoy participating in
another program if it were to be offered.
Outgoing
“I am not as shy as I used to be” was the comment made by a participant. Upon admission
into the program, some participants were reserved. They did not feel the need to talk with the
other participants. A safe place was set with their therapist; therefore their communication was
generally with the therapist. Upon completion of the program the participants were very
comfortable with each other, and they were encouraging each other to go a bit further. The
shyness disappeared as their function was increased.
“It’s like having a job again”
The participants were asked what aspect of their life was most affected by their CVA, and if
that aspect of their life was affected positively by participation in the CIMT/mCIMT program.
The participants felt as if they were working again while in the program. The program set a
daily schedule for the participants to follow. They were sent home with a program to work on in
the evening and a program was set-up for the weekends. These qualities of therapy are some of
the same in a work environment.
Enjoyment
CIMT - 24
The participants were asked whether or not they enjoyed the treatment activities. Each of
them responded in a positive manner. One of the participants stated “I enjoyed it, you guys
made it fun.” Another participant stated “It makes me want to get better”. As the program went
on, participants worked hard having a good time as they worked. For the participants to
verbalize that they enjoyed the program was inspiring for the therapists to hear. With the
participants stating that they enjoyed the program and wanted to come back helped to make this
program a success. With the participants helping each other and playing games with each other,
they were able to give each other encouragement.
In summary to the themes collected from the participants no questions were asked directly
on the participants perception of increased proprioceptive functioning. When focusing on
increased hand function it could be inferred that an increased was accomplished by the
participants. The results show that some increase was made from multiple participants, but no
comments were made directly regarding proprioception.
Discussion
The purpose of this study was to determine if clients post CVA who possessed
proprioception deficits in their affected upper extremity, showed improvements in proprioceptive
function while completing a CIMT/mCIMT program. Results of the researcher designed
proprioceptive assessment indicated that CIMT/mCIMT improved proprioception in four of the
eight participants.
The data analysis gained from the focus groups developed themes which overall stated
that participants enjoyed being in CIMT/mCIMT program. The participants have become more
confident in using their hand and thinking about using the hand. They were happy with the
overall affect of the program.
CIMT - 25
This study is similar to a study conducted by Freeland et al. The CIMT/mCIMT program
that was conducted by Freeland in 2007 was similar to this study in that the protocols were
followed consistently. In that study it was recommended for a future study to be done involving
CIMT/mCIMT and the effects of this treatment on proprioception. This study showed that
CIMT/mCIMT may have a positive effective treatment for individuals post CVA.
After reviewing the quantitative data from the researcher designed proprioceptive
assessment it can be suggested that the participants showed improvements in proprioceptive
deficits. This study shows that CIMT/mCIMT does have an effect on proprioceptive deficits,
however more research is needed to gain more information in the area of proprioception and its
remediation with CIMT/mCIMT.
A study conducted by Flinn in 2005 found that CIMT helped improve affected upper
extremity function and quality of life in individuals who have experienced a CVA. This
proprioceptive study used similar repetitive tasks involving the impaired limb with the idea that
proprioceptive functioning would be improved. Unlike the study conducted by Smith , Akhtar,
and Garraway in 1983, poor recovery was made with proprioception as a result of a CVA.
Limitation.
Limitations to this study include a small sample size. The participants did not always
understand the context of the questions being asked during the focus group. The issues with the
question context was attempted to be addressed during the session by on-the-spot rewording of
the questions, but some participants still didn’t answer the questions to our satisfaction due to
confusion. In addition, when participating in the focus group the participants seemed to lose
sight of the question being asked because they would go more into depth about their personal
situation and talk amongst other group members, allowing the discussion to be taken off track.
CIMT - 26
This was also attempted to be addressed during the focus group by the student therapists
reiterating the questions throughout discussion. The answers given to various questions did not
pertain to the questions resulting in the invalidation of the question with the inability to use the
data. This led to questions being thrown out of the qualitative data. The tool that was used to
gain qualitative data analysis gave limited information to determine if proprioception was
affected by the CIMT/mCIMT. The diversity between the CIMT and mCIMT group was good.
We had an even number of subjects in each protocol. The consistency of scoring of the
assessment was a limitation of this study. The researchers were trained how to complete the
assessment, but interpretation of the score could be different between researchers. The
assessment posed strong intra-rater reliability but had very low inter-rater reliability.
Recommendations for future research
A larger sample size is recommended for future study on CIMT/mCIMT and the effects on
proprioception. This larger sample size should include more participants who have
proprioception deficits and that fit the inclusion and exclusion criteria. Another recommendation
is to develop an assessment battery for proprioception. Having a stronger assessment battery
would allow a better conclusion that CIMT/mCIMT is an effective treatment in improvement of
proprioceptive function.
Conclusions
The purpose of this mixed method quasi-experimental, nonequivalent, two-group pretest-
posttest study was to explore the effects of CIMT/mCIMT treatment on function among post
CVA clients who possessed proprioception deficits in the affected upper extremity. The
quantitative research shows that CIMT improved proprioception. The identified themes
developed from the focus groups were: 1) change of lifestyle; 2) positive hand use improvement;
CIMT - 27
3) Determination; 4) expectation; 5) outgoing; 6) “It’s like having a job again”; and 7)
enjoyment. The results of this study suggest that CIMT/mCIMT could be an effective treatment
for individuals post CVA. Further research is needed to determine if CIMT/mCIMT is an
effective treatment to address proprioceptive deficits.
CIMT - 28
Acknowledgments
We would like to thank the participants for their dedication to this program while the study
was conducted. We would also like to thank the occupational therapy professors and lab
assistant for their help and guidance throughout the research and implementation of the study.
CIMT - 29
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Appendix A:
1. What was your pre-stroke lifestyle like? How has it changed since your CVA?
2. How has participation in the overall CIMT/mCIMT program affected your performance
of daily activities?
3. How do you perceive yourself now, compared to before your participation in the
CIMT/mCIMT program?
4. Are you satisfied with the results of the intervention?
5. How has the intervention affected your social network?
6. What aspects of your life have been most affected by your participation in the
CIMT/mCIMT program?
7. Did you enjoy the treatment activities used in the CIMT/mCIMT program?
8. How has this program improved your ability to participate in social activities?
9. How do you feel about your future potential for completing functional activities?
10. How confident were you in using your affected arm prior to intervention? Upon
completion of the intervention?
\
CIMT - 35
Appendix B: Researcher Designed Proprioceptive Assessment
This assessment measures the improvement of proprioception on a five point scale. This assessment will be administered by two evaluators. One evaluator will place the affected in the position while the other measures the degrees of movement of the unaffected with a goniometer. Each point given represents degrees in motion seen by the evaluator. 1 point is given if no movement is seen. 2 points are given if 25% of the full range of motion is seen. 3 points are given for half of the full range of motion is seen. 4 points are given if 75% of the full range of motion is seen. 5 points are given if the full range of motion is seen. The scale lists each movement that will be evaluated and lists the normal range of motion.
Shoulder Flexion
Normal 90 degrees
1 point
0 degrees of motion
2 points
22 degrees of
motion
3 points
45 degrees of motion
4 points
67 degrees of motion
5 points
90 degrees of motion
Trial 1 Trial 2
Shoulder Abduction
normal 120
degrees
1 point
0 degrees of motion
2 points
30 degrees of
motion
3 points
60 degrees of motion
4 points
90 degrees of motion
5 points
120 degrees of
motion
Shoulder external rotation
normal 80 degrees
1 point
0 degrees of motion
2 points
20 degrees of
motion
3 points
40 degrees of motion
4 points
60 degrees of motion
5 points
80 degrees of motion
Elbow flexion
normal 30 degrees
1 point
0 degrees of motion
2 points
10 degrees of
motion
3 points
15 degrees of motion
4 points
25 degrees of motion
5 points
30 degrees of motion
Forearm pronation normal 80 degrees
1 point
0 degrees of motion
2 points
26 degrees of
motion
3 points
40 degrees of motion
4 points
66 degrees of motion
5 points
80 degrees of motion
Wrist extension normal 45 degrees
1 point
0 degrees of motion
2 points
15 degrees of
motion
3 points
23 degrees of motion
4 points
38 degrees of motion
5 points
45 degrees of motion
CIMT - 36
Appendix C:
Table 1: Proprioceptive Assessment Tool pre-test
Participant
Number
Shoulder
Flexion
Shoulder
Abduction
Shoulder
External
Rotation
Elbow
Flexion
Forearm
Pronation
Wrist
Extension
CIMT
7 5 5 5 4 5 5
2 5 5 5 5 5 5
3 5 5 5 5 5 5
10 5 5 5 5 5 5
mCIMT
4 4 4 3 4 4 3
5 4 4 2 3 5 0
8 5 5 0 0 0 0
9 5 5 5 5 5 5
CIMT - 37
Table 2: Proprioceptive Assessment Tool post-test
Participant
Number
Shoulder
Flexion
Shoulder
Abduction
Shoulder
External
Rotation
Elbow
Flexion
Forearm
Pronation
Wrist
Extension
CIMT
7 5 5 5 5 5 5
2 5 5 5 5 5 5
3 5 5 5 5 5 5
10 5 5 5 5 5 5
mCIMT
4 5 5 5 5 5 5
5 5 5 4 5 5 0
8 5 5 5 5 5 5
9 5 5 5 5 5 5
