Background

Acknowledgements

Clinical Scenario

References

The Effectiveness of Modified Constraint-Induced Movement Therapy (mCIMT) on Increasing Upper Extremity Function in Adults Post- Stroke

Methods

Implications for Research and Practice

Results

Limitations

• About 795,000 Americans are affected by stroke each year.

• Healthcare expenditures for stroke patients in the United States amounted to $73.7 billion in 2010.

• Occupational therapists are trained to provide client-centered, evidence-based interventions which establish, restore, and/or maintain body functions and body structures.

Mr. E is a 61-year-old man who experienced a stroke 8 months ago, resulting in left hemiparesis. He desires to go back to work as a construction worker to support his wife and two children.

The occupational therapist working with Mr. E decides to research the evidence for modified constraint-induced movement therapy in improving upper extremity (UE) function in patients following stroke.

Thank you to the following peers for their contribution: Minnie Chan, BA; Beth Fong, BS; Angelie Ornopia, BS

What is a Critically Appraised Topic (CAT): In a CAT, current research is selected and briefly reviewed to help answer a clinical question. The search strategy is reproducible, and the appraisal of the selected literature is structured.

Search Strategy: SEARCH TERMS: “stroke” (MeSH) OR “cerebrovascular accident” OR “hemiparesis” OR “hemiplegia” (MeSH) AND “modified constraint-induced movement therapy” OR “modified constraint-induced therapy”AND “upper extremity function” OR “recovery of function” (MeSH) OR “motor recovery stroke”

INCLUSION CRITERIA: Limited to meta-analyses (MA), systematic reviews (SR), randomized controlled trials (RCT), and all adults >19 years. Only studies published prior to April 2012 were included.

STUDY SELECTION: The initial search resulted in 22 articles; upon review, 3 articles were selected. Included articles were of the highest level of evidence and published within the last 5 years.

AUTHOR YEAR SAMPLE INTERVENTION OUTCOME

Page, S. J., et al.

2008 Level I RCTn = 35; patients with chronic stroke

mCIMT, non-affected arm constrained for 5 hours, 5 days/week for 10 weeks

Significant improvement in UE function (ARAT and MAL) in favor of mCIMT

Shi, Y. X., et al.

2011 Level I SR & MAn = 13 RCTs, 278 patients with stroke of all levels

mCIMT, non-affected arm constrained for 30 minutes to 3 hours/day, 3-5 days/week for 2-10 weeks

Statistical improvement in favor of mCIMT for clinical variables (MAL, ARAT, and Fugl Meyer) but not for some kinematic variables

Wang, Q., et al.

2011 Level I RCTn = 30; patients with sub-acute stroke

mCIMT, non-affected arm constrained for 3 hours, 5 days/week for 4 weeks

No significant difference between mCIMT and intensive therapy on UE function (WMFT), but only mCIMT showed systematic effect

• mCIMT was significantly and positively associated with greater UE motor recovery for patients with stroke compared to conventional rehabilitation.

• It is unclear to what extent these effects were due to the constraint component or the greater intensity of training.

• The studies had small sample sizes and variations in mCIMT intervention protocols.

• mCIMT is reimbursable, may show earlier gains in UE motor function, and has no reported adverse effects. Consequently, mCIMT can be recommended for Mr. E.

• Further research is needed to investigate the specific protocols for mCIMT intervention with larger sample sizes.

• Occupational therapists should consider implementing mCIMT in addition to standard rehabilitation treatment with careful monitoring of patient progress.

• Limited focused question and studies that met certain inclusion/exclusion criteria.

• Only included PubMed search results.

Study Question

In patients with post-stroke hemiparesis, what is the effect of modified constraint-induced movement therapy (mCIMT) on upper extremity functioning compared with standard occupational therapy?

Page, S. J., Levine, P., Leonard, A., Szaflarski, J. P., & Kissela, B. M. (2008). Modified constraint-induced therapy in chronic stroke: results of a single-blinded randomized controlled trial. Journal of American Physical Therapy Association, 88(3), 333–40. Shi, Y. X., Tian, J. H., Yang, K. H., & Zhao, Y. (2011). Modified constraint-induced movement therapy versus traditional rehabilitation in patients with upper-extremity dysfunction after stroke: a systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation, 92(6), 972–82. University of Southern California Division of Occupational Science and Occupational Therapy. Critically appraised topics (CAT). Retrieved March 2, 2013, from http://ot.usc.edu/research/student-researchWang, Q., Zhao, J.L., Zhu, Q.X., Li, J., & Meng, P.P. (2011). Comparison of conventional therapy, intensive therapy and modified constraint-induced movement therapy to improve upper extremity function after stroke. Journal of Rehabilitation Medicine, 43(7), 619–25.

Ulrike Willwerth, MA, OTS; Kamaljit Bains, BS, OTS; Alla Berger, BA, OTS; Emi Ito, BA, BS, OTS