MODIFIED CONSTRAINT INDUCED MOVEMENT THERAPY TO IMPROVE UPPER EXTREMITY FUNCTION POST-STROKE IN CANADIAN NEUROLOGICAL REHABILITATION

Abstract

Recovery of upper extremity (UE) function after stroke is often incomplete. Incorporating evidence-based treatments early in rehabilitation can promote better recovery. One intervention, constraint induced movement therapy (CIMT), has been shown to promote UE recovery after stroke better than usual care. While research has examined CIMT effectiveness, there are gaps in the literature regarding how the therapy is being used and implemented, as well as reviews summarizing the evidence in support of any one CIMT protocol. Also, there is a need to examine the feasibility and effectiveness of CIMT in the acute and subacute stage of stroke recovery in the context of the healthcare system in which it is intended to be delivered. To address these gaps, this research examines the clinical utilization of CIMT, derives the level of evidence in support of its use, and lastly examines, in a preliminary manner, the effectiveness and feasibility of CIMT acutely post-stroke.

While CIMT appears within the literature to be a viable treatment option, little is known about how therapists use it, nor what therapist characteristics predict who would use it. A national survey of therapists working in neurological rehabilitation identified CIMT parameters of treatment and barriers to use (including therapist lack of knowledge and a lack of institutional resources). Methods to overcome barriers to CIMT use are addressed in order to increase its clinical application.

A systematic review of the mCIMT literature, one of the most researched protocols that follows a distributed practice schedule, showed an intermediate level of evidence in support of its use. Specifically, mCIMT appears to be effective at improving UE function, reducing impairment and increasing activity. While these treatment effects were observed across all stages of recovery, most of the literature is based on chronic stroke populations. Summarizing a body of literature related to a treatment is important for clinicians as it helps evaluate the evidence in support of the therapy, aiding with treatment decisions.

Lastly, preliminary findings of the clinical trial (based on a case study) support the effectiveness of mCIMT to improve UE function acutely post-stroke. Post-treatment, the subject receiving mCIMT demonstrated clinically significant improvements in UE function and activity, and maintained these changes at the 6-month follow-up. While the results may be promising, a number of challenges (for patients and therapists) to mCIMT implementation are discussed along with possible mechanisms to overcome them.

Identifying barriers to mCIMT use is a first step to developing administrative-, education-, and intervention-based solutions to improve clinical utilization. Solutions may be to alter the personnel delivering treatment, providing resource materials to inform clinical practice, and to investigate the minimum required components of mCIMT. If shown that mCIMT is effective and feasible to use in Canada, we can increase its use, in-turn improving the recovery of patients who have had a stroke.