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Evidence-Based Medicine Comes to Neurorehabilitation. Welcome.

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welcome

Welcome

Presenters:Stephen E. Nadeau, MD.Medical Director BRRC, Chief of Neurology Malcom Randal NF/SG VAMCUniversity of Florida Neurology [email protected] E. Davis, Research P.T. BRRCUniversity of Florida Physical [email protected] G. Richards, OTR/L, PhDResearch Scientist BRRCUniversity of Florida Occupational [email protected]

objectives
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
slide5

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.
first identify individuals for cimt
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 al1999Minimum 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
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
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 drinkTask Practice: Functionally based activities performed continuously 15-20 minutes or until the task is attained.Example: fix a sandwich & eat lunchMore general feedback & graded progressionTo Progress:Add specific challenges i.e.speed, height, distance, weight, #’s, dual task, quality of movement
design cimt menu of unique tasks
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
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
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
Compliance Measures
  • Translational PackageMorris,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
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 therapy16

Behavioral

suppression

Unsuccessful

attempts

to move

Punishment

(pain, can’t)

Compensatory

behavior

strengthened

Compensatory

Behavior

patterns

Positive

Reinforcement

Constraint Induced Movement Therapy
  • Developed to improve motor skill and to decrease learned non-use

Injury

slide18
(Dettmers, et al., 2005)

Does it need to be given 6 hours every day?

slide19

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

slide20

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
Cortical Map Reorganization

Proximal

Distal

(Kleim et al, 2004)

is there evidence that cimt changes the brain
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
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
CIMT now Paired
  • With other Therapies:* Drugs* Strengthening* Rhythm Cues
remaining questions
Remaining Questions
  • Future Research Needs to Demonstrate* What is the Best CIMT Schedule:- Distributed versus Massed- # of Hours- Maintenance of the gains
summary
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
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
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